ISSN 2317-1782 (Online version)

Clinical profile and implications of tinnitus in

Original Article
Artigo Original individuals with and without hearing loss

Jaíse Thainara Mores1  Perfil clínico e implicações do zumbido em

Amanda Bozza1 
Cristiana Magni1  indivíduos com e sem perda auditiva
Raquel Leme Casali2 
Maria Isabel Ramos do Amaral2 

Keywords ABSTRACT
Tinnitus Purpose: To compare clinical characteristics of tinnitus and interference in quality of life in individuals with and
Hearing Loss without associated hearing loss, as well as to discuss the association of quantitative measurements and qualitative
instruments. Methods: A quantitative, cross-sectional and comparative study approved by the Research Ethics
Quality of Life Committee (No. 973.314/CAEE: 41634815.3.0000.0106) was carried out. The responses of the psychoacoustic
Normal Hearing assessment of tinnitus (intensity, frequency, minimum masking level and loudness discomfort level for pure
Impairment tone and speech), as well as the Tinnitus Handicap Inventory (THI) questionnaire, and the visual analogue scale
(VAS) were compared between 15 patients with tinnitus and peripheral hearing loss (group I) and 16 adults
with normal hearing (group II). Results: The mean VAS and THI scores obtained in GI were 5.1 (+1.5) and
42.3 (+18), and in GII, 5.7 (+2.6) and 32.7 (+25), respectively. This result suggests moderate GI annoyance and
moderate/mild GII annoyance (p>0.005). There was a positive and moderate correlation between THI and VAS
only in GII. In the psychoacoustic evaluation, significant differences were observed between the groups regarding
the measurement of loudness (*p=0.013) and the minimum masking level (*p=0.001). Conclusion: There was
no direct influence of the presence of hearing loss in relation to the impact of tinnitus. The differences found
between the groups regarding the psychoacoustics measures can be justified by the presence of cochlear damage.
The objective measurement of tinnitus, regardless of the presence or absence of peripheral hearing loss, is an
important instrument to be used along with self-evaluation measures.

Descritores RESUMO
Zumbido Objetivo: comparar as características clínicas do zumbido e interferência na qualidade de vida em indivíduos
Perda Auditiva com e sem perda auditiva associada, bem como discutir a associação de mensurações quantitativas e instrumentos
qualitativos de avaliação. Método: estudo quantitativo, descritivo e de corte transversal aprovado pelo Comitê
Audição de Ética em pesquisa (nº 973.314/2016 CAEE: 41634815.3.0000.0106). Foram comparadas as respostas da
Qualidade de Vida avaliação psicoacústica do zumbido (pesquisa de intensidade, frequência, nível mínimo de mascaramento e limiar
Prejuízo de desconforto para tom puro e fala), bem como questionário Tinnitus Handicap Inventory (THI) e escala visual
analógica (EVA) de 15 sujeitos portadores de zumbido e perda auditiva periférica (grupo GI) e 16 indivíduos
normo-ouvintes (grupo GII). Resultados: O escore médio na EVA e THI no GI foi, respectivamente, de 5,1(+1,5)
e 42,3(+18) e no GII de 5,7(+2.6) e 32,7(+25), sugerindo incômodo moderado no GI e moderado/leve no GII
(p>0,005). Verificou-se correlação moderada entre o THI e EVA apenas no GII. Na avaliação psicoacústica,
observaram-se diferenças significantes entre os grupos referentes à medida da loudness (*p=0,013) e ao nível
mínimo de mascaramento (*p=0,001). Conclusão: a perda auditiva parece não se constituir em um fator
determinante para o maior ou menor impacto do zumbido na qualidade de vida do sujeito. Já as diferenças
encontradas entre os grupos, referentes às medidas psicoacústicas, podem ser justificadas pela presença do dano
coclear em si. A mensuração objetiva do zumbido, independentemente da presença ou não da perda auditiva
periférica, caracteriza-se como um importante instrumento complementar às medidas de auto avaliação.

Correspondence address: Study conducted at Clínica Escola do Departamento de Fonoaudiologia – CEFONO, Universidade Estadual do
Maria Isabel Ramos do Amaral Centro-Oeste – Unicentro - Irati (PR), Brasil.
Universidade Estadual de Campinas – 1
Departamento de Fonoaudiologia, Universidade Estadual do Centro Oeste – Unicentro - Irati, PR, Brasil.
UNICAMP 2
Departamento de Desenvolvimento Humano e Reabilitação, Faculdade de Ciências Médicas – FCM, Universidade
Rua Tessália Vieira de Camargo, Estadual de Campinas – UNICAMP – Campinas (SP), Brasil.
126, Cidade Universitária Zeferino
Financial support: nothing to declare.
Vaz, Campinas (SP), Brasil, CP 6111,
CEP: 13083-887. Conflict of interests: nothing to declare.
E-mail: mamaral@fcm.unicamp.br

Received: March 18, 2018.

Accepted: February 25, 2019. This is an Open Access article distributed under the terms of the Creative Commons Attribution License, which
permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Mores et al. CoDAS 2019;31(6):e20180029 DOI: 10.1590/2317-1782/20192018029 1/8

INTRODUCTION stand out. The different methods require more or less participation
from the patient, being characterized as complementary clinical
Tinnitus is defined as the conscious perception of a sound instruments.
generated without the presence of an external sound source. Given the above, the present study aimed to compare the
Despite being characterized as a prevalent condition in the main clinical characteristics related to the occurrence of tinnitus
population, it still remains a clinical and scientific challenge(1). and to investigate the interference of this symptom on quality
According to epidemiological studies, it affects between of life in two groups of subjects; with and without hearing loss.
5 and 30% of the population, with greater incidence in men(1). In addition, it discussed the association of quantitative measures
Approximately 15% of cases lead to negative interference in and qualitative instruments in the evaluation of the condition.
daily life, and about 5% are considered disabling(2).
Although there have been advances in the specific literature METHODS
of tinnitus, its pathophysiology and, consequently, its etiology
have not been completely clarified. It is known that its etiology Study type and location
may be multifactorial, being associated with middle ear diseases,
neurological, neurodegenerative, cardiovascular, metabolic This is a retrospective and subsequently prospective,
and psychological disorders or, in the vast majority of cases, cross-sectional, quantitative and descriptive study, approved
sensorineural hearing loss(3). Although these are often concomitant by the Research Ethics Committee of the institution where it
symptoms, tinnitus is known to be perceived as more harmful was conducted, under opinion No. 973.314./2016.
by individuals than the negative implications of hearing loss(4).
Subject selection and sample characterization
Though not as frequently, tinnitus can also be reported by
individuals with normal hearing in about 5 to 10% of cases(1). Initially, the subjects were selected in a retrospective analysis
According to the literature, the condition should be considered a of the medical records of patients subjected to audiological
relevant symptom in these subjects, because it may be a sign of evaluation at the University Clinic of a public institution between
future hearing loss or of an existing abnormality not yet detected 2012 and 2016. For inclusion in the study, we considered only
by conventional methods(5). Some studies have been conducted the medical records that contained all information regarding the
in this population to elucidate the possible relationship between result of the basic audiological evaluation and the presence or
tinnitus and the functioning of central auditory pathways(6), absence of tinnitus reported at the time of the assessment. Based
along with high-frequency audiometry and suppression of on the results of the analysis, the patients were contacted by
otoacoustic emissions(7,8). telephone. Those who showed interest were asked to come to
Nevertheless, there are few studies comparing subjects with the clinic at a scheduled date and time, received explanations
tinnitus, associated or not with sensorineural hearing loss, to about the research and signed the informed consent form.
understand the differences regarding the symptom’s characterization The participants were then divided into two groups, according
and the implications for quality of life. Sanchez et al. (2005)(9) to the following inclusion criteria:
point out the fact that tinnitus may manifest with some similar
clinical characteristics in subjects with and without associated • Group I (GI): participants aged from 20 to 60 years old
hearing loss, such as time of onset and type, ear and frequency who reported tinnitus and had unilateral or bilateral mild
of the condition; on the other hand, negative implications for to moderate sensorineural hearing loss, according to the
aspects of daily life, such as concentration and sleep quality, seem criteria of Silmam and Silverman(11). Those with type A,
to be more evident in the presence of concomitant sensorineural Ar or Ad tympanogram curve and presence or absence of
hearing loss. acoustic reflexes, whether unilaterally or bilaterally, were
It is a fact that often, in the case of individuals who included. The use of individual hearing aid was not an
complain of tinnitus, there is no standardization regarding the exclusion criterion.
procedures that are effectively included in clinical practice, • Group II (GII): participants aged from 20 to 60 years
despite the extensive description of psychoacoustic methods old who reported tinnitus and normal results in the basic
for the objective measurement of the symptom and number audiological evaluation, considering thresholds up to 20dB
of instruments available for identifying complaints and its at the frequencies researched, ranging from 250 to 8000Hz,
impact on daily life(1,10). The difficulty in measuring tinnitus, and type A tympanogram curve with presence of bilateral
in addition to limiting a better understanding of this symptom ipsilateral and contralateral acoustic reflexes(11).
and its relationship with other factors such as hearing loss, for
instance, makes it difficult to evaluate the results of drug therapy The exclusion criteria considered for both groups included
and other types of treatment. patients who reported pulsatile tinnitus, less prevalent in the
In addition to the analysis of clinical history, both quantitative population and of possible vascular etiology, and/or neurological
(objective) and qualitative instruments can be applied for or cognitive disorders that compromised the understanding
the clinical assessment of tinnitus. Quantitative ones include of the procedures to be performed. Subjects with a history of
psychoacoustic measurements, loudness and pitch measurements exposure to occupational noise were not excluded due to the
being the most widespread. As for the qualitative instruments, high prevalence of the onset of sensorineural hearing loss and
Visual Analog Scales (VAS) and self-perception questionnaires tinnitus in this population.

Mores et al. CoDAS 2019;31(6):e20180029 DOI: 10.1590/2317-1782/20192018029 2/8

Previous procedures - Psychoacoustic assessment of tinnitus: performed according to
the criteria described by Branco-Barreiro(12). The parameters
The following procedures were performed to confirm the investigated were pitch, loudness, minimum masking level
inclusion criteria and the permanence of tinnitus as an auditory (MML) and loudness discomfort level (LDL), detailed below:
symptom at the moment of evaluation, even if the subject had
been subjected to some kind of medical/otorhinolaryngologic 1) Pitch: the ear contralateral to the one affected by tinnitus,
treatment and/or undergone the hearing aid adaptation process
according to the participant’s report, was exposed to a
between the date of the medical record and the date of the research:
narrowband noise (NBN). In cases of bilateral tinnitus or
- Audiological anamnesis: information about the occurrence perception within the head, the ear exposed was the one
of hearing complaints and symptoms, otological and family contralateral to the most affected. The pitch of the exposure
history, aspects of general health and occupational history was 10dBNS (sensitivity level) at frequencies ranging from
were collected, along with data on the use of hearing aids 250 to 8000Hz, until the individual could identify which
and performance of otorhinolaryngologic follow-up related one was closest to the pitch perceived.
to the complaint of tinnitus and/or hearing loss.
2) Intensity: the side affected by tinnitus was exposed to a
- Meatoscopy: performed to rule out any obstruction of the pure tone with an initial intensity 10dB below the hearing
external acoustic meatus. threshold at the pitch previously estimated by the participant.
- Basic audiological evaluation (BAE): performed to confirm The signal was increased dB by dB until the participant
the hearing thresholds recorded in the previous examination could identify the intensity that was equivalent to the one
documented in the medical record, and to ensure normal perceived. At the end, the difference between the hearing
conditions regarding the functioning of the middle ear at threshold and the intensity found in the survey was estimated
the time of the assessment. It was composed of Pure-Tone in dBNS.
Audiometry (PTA) surveyed at frequencies ranging from 3) Minimum masking level (MML): this measure was performed
250 to 8000Hz in octave intervals, Speech Audiometry to determine the effects of masking noise on the perception
and Immitanciometry (Tympanometry and Acoustic Reflex of tinnitus, which may become more or less intense or even
Research). The equipment used were an Interacoustic DA65
suppressed by its presence. A narrow band noise (NBN),
audiometer with TDH 49 earphones, and an Interacoustics
initially below the hearing threshold of the side affected
AT235 immittance meter, duly calibrated according to the
by tinnitus, was used for this purpose. In cases of bilateral
ISO 389 and IEC 60645 criteria.
tinnitus or perception within the head, the ear with better
Data collection hearing was the one exposed. The noise was increased
5 by 5dB, and its intensity was estimated in dB in relation
After confirming the results of the basic audiological to the participant’s report regarding some kind of change
evaluation, participants who met the inclusion and exclusion in the perception of tinnitus.
criteria previously described were subjected to the following
data collection procedures: 4) Loudness Discomfort Level (LDL): sound tolerance and
dynamic range of hearing were measured with pure pulsed
- Specific tinnitus questionnaire: prepared by the researchers, tone at frequencies ranging from 250 to 8KHz and speech
considering the main aspects to be investigated in the clinical noise (dBSN). For pure tone, the research was based on
history of tinnitus(12). The data collected pertained to the the previously researched threshold, and the stimulus was
symptom’s characterization, time of onset, affected ear and increased 5 by 5dB. For speech, firstly, the signal (“bang
type, worsening and improvement factors, other associated bang bang”) was presented at the comfort level reported
symptoms, including headache, irritation, hyperacusis, by the subject (approximately 30 to 40dB above the mean
autophony, and general health problems, such as hypertension level of frequencies ranging from 500 to 2000Hz). Then,
and renal diseases, hypo or hyperthyroidism, cervical
the intensity of the stimulus was increased 5 by 5dB in both
alterations, among others, in addition to the regularity or
ears. The discomfort level was determined when the subject
lack of practice of physical activity.
reported discomfort for that stimulus (pure tone or speech)
- Tinnitus Handicap Inventory (THI) — version validated in and requested the interruption of the test by raising his/her
Portuguese(13): applied to quantify the annoyance caused by hand.
tinnitus. It consists of 25 questions, divided into three categories:
functional, emotional and catastrophic. The analysis of the After data collection, all participants received the results
result considers a scale ranging from zero (0 — tinnitus does of the evaluations performed and verbal and written guidance
not intervene in daily life) to one hundred (100 — degree on hearing care, factors related to the worsening of symptoms,
of severe discomfort). and the importance of healthy lifestyle habits as well as annual
- Visual Analog Scale (VAS): consists in the application audiological follow-up and monitoring. Those who were already
of a visual graph that determines the level of discomfort being followed-up received the report of the evaluations performed
or annoyance generated by tinnitus on a scale from zero and a request for a follow-up visit with their doctor. Those who
(0 — no discomfort) to ten (10 — maximum discomfort). were not being followed-up were referred.

Mores et al. CoDAS 2019;31(6):e20180029 DOI: 10.1590/2317-1782/20192018029 3/8

Statistical analysis Regarding the data obtained in the specific questionnaire
applied, in both groups, continuous tinnitus was more prevalent than
The Statistical Package for Social Science — SPSS version intermittent tinnitus, without statistical difference (GI=10/66.7%
17 was used to compare the groups regarding their performance and GII=12/75%; p=0.609), as was single compared to multiple
in the psychoacoustic evaluation of tinnitus and the score tinnitus (GI=14/93.3% and GII=14/97.5%; p=0.583). In the
obtained in the questionnaires. These data were presented description of tinnitus regarding hissing or whistling, the type
using descriptive statistics (mean and standard deviation) and most reported by group 1 was whistling (GI=12/83.6%) compared
compared by the ANOVA test. Pearson’s correlation was used to to hissing in group II (GII=11/73.3%), such difference being
verify the relationship between the THI and VAS questionnaires. statistically significant (p=*0.038).
The significance level adopted was 0.05 (5%), and all p-values The results by group regarding the associated health problems
considered statistically significant were marked with (*). are shown in Table 1.
In relation to the report on the moments and factors associated
RESULTS with the worsening of tinnitus, 14 subjects from GI (93.3%)
mentioned nighttime/silence as the worst moment and aggravating
The sample consisted of 31 subjects aged from 20 to 60 years factor, the same period having been mentioned by only 6 subjects
old. In GI (n=15), composed of 8 (53.3%) women and 7 (46.7%) (37.5%) of GII (*p=0.018). Only 1 subject from GI (6.7%)
men, age ranged from 40.9 to 60.7 (mean of 57.7+6.0). In GII mentioned noise exposure as a worsening factor, while in GII,
(n=15), composed of 8 (50%) women and 8 (50%) men, age 5 subjects (31.25%) mentioned it (*p=0.031). The association
ranged from 25.1 to 58.2 (mean of 40.3+10.7). In the comparison with food as trigger was mentioned by only 5 subjects in GII
between groups, it was possible to observe statistically significant (31.25%) (*p<0.001).
differences regarding mean age (*p=<0.001). As for the distribution Regarding the practice of regular physical activity, only 1
of the genders, there were no statistically significant differences subject from GI (6.7%) reported the habit. As for GII, 6 subjects
in the comparison between groups (p=0.853). (37.5%) mentioned physical activity as a healthy habit, this
Regarding the degree of hearing loss of GI subjects, all difference between groups being statistically significant (*p=0.040).
participants (n=15) had mild sensorineural hearing loss, Tables 2 and 3 show the results of both groups regarding
12 (80%) bilateral and 3 (20%) unilateral, and only 2 subjects the characterization of the impact and discomfort caused by
(13.3%) used hearing aids bilaterally, both for a period of less tinnitus, according to the classification obtained with the Tinnitus
than 1 year, with no improvement in the perception of tinnitus. Handicap Inventory (THI) and Visual Analogue Scale (VAS),
All subjects with unilateral hearing loss reported tinnitus on the and the correlation between them, respectively. There were
same side as the side of loss. no significant differences in the distribution of performance
Chart 1 presents the demographic data of GI and GII subjects between groups, considering either THI or VAS. However, a
regarding age and gender, in addition to the side and approximate significant moderate correlation between THI and VAS was
time of onset of the symptom reported by the participant. found only in GII.

Chart 1. Demographic data and characterization of tinnitus for subjects in Group I (n=15) and Group II (n=16)
GI Age Sex Time Side GII Age Sex Time Side
1 59.3 F 5 years Right 1 37.9 M 7 months Right
2 58.3 M 5 years Left 2 36.1 F 2 years Left
3 59.2 F 6 years Bilateral 3 37.5 M 6 months Left
4 60.3 M 12 years Left 4 58.2 F 2 years Left
5 59.1 M 7 years Left 5 55.9 F 5 years Left
6 55.6 F 8 years Left 6 26.3 M 3 years Left
7 57.2 F 9 years Left 7 38.5 F 15 years Bilateral
8 56.6 M 10 years Left 8 30.1 M 2 years Bilateral
9 60.6 M 4 years Bilateral 9 36.11 M 11 years Bilateral
10 49.2 M 6 years Head 10 30.1 F 2 years Right
11 60.7 F 6 years Bilateral 11 51.11 F 3 years Bilateral
12 60.7 F 24 years Bilateral 12 35.2 M 6 months Bilateral/Head
13 52.5 F 3 years Left 13 25.1 F 9 months Right
14 40.9 M 2 years Left 14 43.1 M 11 years Bilateral/Head
15 45.8 F 10 months Left 15 49.9 F 2 months Left
— — — — — 16 53.8 F 5 years Left
Mean: 57.7 — — — 40.3 — — —
SD+: 6 — — — 10.7 — — —
Caption: SD = Standard Deviation

Mores et al. CoDAS 2019;31(6):e20180029 DOI: 10.1590/2317-1782/20192018029 4/8

 Finally, the results of the psychoacoustic assessment of tinnitus DISCUSSION
can be seen in Table 4. The statistically significant differences
found were related to the loudness perception measure, higher Considering the fact that GI subjects had tinnitus-associated
in GII in relation to GI, and to the lower minimum masking hearing loss and the known relationship between hearing loss and
levels in GII compared to GI. age(14), the results of the comparison between groups regarding
age showed expected statistical differences, with higher mean in
Table 1. Distribution (%) and comparison between groups regarding GI (*p<0.001). The prevalence of hearing loss, and consequently
health problems of tinnitus, is known to increase with age, regardless of exposure
GI GII to occupational noise or lack thereof(15).
Health condition P-value
N % N % Although advanced age and sensorineural hearing loss may be
Arthrosis/Hypertension 1 6.70% 0 0.00% 0.464 considered aggravating factors for the occurrence of tinnitus(16),
Diabetes 0 0.00% 1 6.30% 0.143 there is no consensus as to whether these variables are directly
Diabetes/Hypertension 1 6.70% 0 0.00% 0.464 related to the degree of severity of the symptom. One hypothesis
Hypertension 4 26.70% 3 18.80% 0.464 relates to the degree of hearing loss, since some studies indicate
Hyperthyroidism 1 6.70% 1 6.30% 0.591 that subjects with mild sensorineural hearing loss may have a
Hyperthyroidism/Anxiety 1 6.70% 0 0.00% 0.464 lower perception of tinnitus annoyance compared to subjects
Hypothyroidism 1 6.70% 0 0.00% 0.464 with more severe hearing loss and advanced age(17,18).
Labyrinthitis 1 6.70% 0 0.00% 0.464 Another important aspect to be considered refers to the
Two-Proportion Equality Test influence of hearing loss on the degree of interference of tinnitus
Table 2. Individuals in Groups I and II according to the score obtained in aspects of daily life. It is hypothesized that the association
in THI (percentage) and VAS (mean score) of the symptom with hearing loss could be a “cofactor” of this
GI GII interference, since the perception and rating attributed to tinnitus
THI Classification P-value
N % N % annoyance would, in most cases, be influenced by limitations
Slight 1 6.70% 4 25.00% 0.165 resulting from hearing loss as well. It is often difficult for the
Mild 6 40.00% 7 43.80% 0.833 patient to dissociate the two aspects(16).
Moderate 4 26.70% 3 18.80% 0.598 However, considering the results of the application of the
Severe 4 26.70% 2 12.50% 0.318 THI and VAS instruments, the findings of the present research
Mean 42.30% 32.7% 0.235 did not show significant differences between groups regarding
Standard Deviation (SD) 18.0% 25.20% the damage caused by tinnitus on a daily basis. Although the
VAS GI GII P-value differences between groups were not significant, the total
N Mean+SD N Mean+SD 0.478 mean THI score was higher in GI compared to GII, the values
15 5.1+1.5 16 5.7+2.6 obtained having corresponded to moderate and mild annoyance,
ANOVA – variance analysis respectively. Regarding VAS, both groups showed results that
Table 3. Correlation between THI and VAS characterize a perception of moderate annoyance. Given these
THI X VAS Corr (r) P-value data, it is not possible to conclude that there was a direct influence
GI -8.10% 0.775 of the presence of hearing loss on this aspect. A sample with a
GII 51.80% *0.04 larger number of participants in both groups would likely show
All 30.90% 0.09 the importance of these findings in a statistically significant way.
Caption: statistical significance Pearson’s Correlation In the comparison of THI with VAS, a moderate positive
correlation between the instruments was found only for group II
(*p=0.04). THI is considered a very complete method for
Table 4. Individuals in Group I and Group II, according to the results of
the psychoacoustic assessment of tinnitus assessing the impact of tinnitus, because its results make it
Psychoacoustic Standard possible to quantify the symptom’s impact on the quality of life
Group n Mean P-value
Measurements Deviation of patients while considering different spheres related to daily
Pitch (Hz) GI 15 5900.0 2508.6 0.380 activities, but it is more difficult to be interpreted and answered
GII 16 6562.5 1547.8 by the subject when compared to the VAS method, requiring
Loudness (dBSL) GI 15 8.6 3.9 *0.013 the help of an evaluator in many cases. VAS is characterized as
GII 16 5.1 3.4 a simpler measure to be assimilated for offering visual support,
MML (dB) GI 15 78.3 12.3 *0.001 being more easily understood and answered by the individual
GII 16 57.5 19.2 without the help of a professional or family member, in addition
LDL (Pure tone — dB) GI 15 92 9.6 0.377 to its shorter application time. Considering the statistical results
GII 16 87.5 17 obtained in the present sample, it is possible to state that the
LDL (Speech – dBSL) GI 15 85 10 1.0 simultaneous application of both instruments contributed to the
GII 16 85 11.4 gathering of more consistent and representative data from both
Caption: MML – Minimum Masking Level; LDL – Loudness Disconfort Level
Hz=Hertz; dB= decibel; SL = sensation level; dBSL= decibel sensation level;
groups, corroborating researches that describe THI and VAS as
ANOVA – variance analysis distinct but complementary instruments(19).

Mores et al. CoDAS 2019;31(6):e20180029 DOI: 10.1590/2317-1782/20192018029 5/8

 The association between tinnitus and hearing loss is well be still discussed as an aggravating factor of hearing damage
described in the literature, since damage or degeneration of and, consequently, of tinnitus.
the inner ear and the vestibulocochlear nerve can cause the Regarding the psychoacoustic measures researched, the
onset of tinnitus. The symptom would therefore result from data from both groups did not differ and corroborate the greater
changes in the neural network along the auditory pathways occurrence of high-pitched tinnitus, as well as the region of
after the establishment of cochlear damage(20). Despite the hearing loss in the case of GI subjects(21). Although a recent
lower frequency of subjects with tinnitus associated with study demonstrated similar pitch perception results around the
some degree of hearing loss compared to subjects with normal 6000Hz frequency(25), the fact that the high frequencies were
thresholds(5), the presence of the symptom in normal-hearing not included in the present research may justify the fact that
individuals was found to be an important phenomenon to be the mean value found here, in both groups, is considered lower
studied. The hypothesis(21) that subjects with normal peripheral compared to other works, ranging from 10 to 14000Hz(26).
hearing may show hearing abnormalities frequently above the Regarding the assessment of intensity, expressed as sensitivity
8000Hz frequency or central abnormalities seems to justify the level (SL), statistical difference was found between groups
occurrence of the symptom in individuals with normal hearing (*p=0.013), with greater perception of tinnitus by participants
thresholds, in the conventional evaluation. of GI. This result could be partly explained by the occurrence
The results found regarding the factors associated with the of other factors that are directly related to the characteristics
worsening of tinnitus reported by the participants showed significant of this group, such as the presence of hearing damage itself,
differences between groups, and in GI, nighttime/silence was different etiologies of the existing hearing loss, as well as time
the aggravating factor that was most frequently mentioned. It is of the onset of the hearing damage and consequently of tinnitus.
believed that this is related to the fact that noise competition In addition, it is possible to hypothesize that the damage and
caused by a noisy environment can be considered a relief factor communication barriers resulting from the presence of hearing
for disturbing the perception of tinnitus, and that hearing aids loss favor the negative reinforcement of the perception of tinnitus,
can often help mitigate the symptom in individuals with hearing influencing the perception of intensity.
The literature presents several results regarding the intensity
loss(22). In GI, two subjects made use of this resource.
of tinnitus and its relationship with the severity and degree
The differences between groups regarding aggravating
of annoyance. Researchers, even in the 1990s, reported little
factors were exacerbated due to the diversity of other aspects
relation between these factors, as well as correlation of loudness
mentioned more significantly by GII only: noise as worsening
with the stress and handicap caused by tinnitus(27). More recent
factor (*p=0.031) and food triggers (*p<0.001). These differences
studies point to the intensity of tinnitus as a possible predictor
between groups strengthen the multifactorial etiology of tinnitus,
of perception of the symptom’s severity(2,28), as well as moderate
which suffers interference from various associated factors such
correlations between intensity and degree of annoyance(17).
as metabolic issues, dizziness and/or headache, pre-existing
The fact some patients in the present study reported their
diseases and regular practice of physical activity, for example,
perception of intensity as ranging from 1 to 2dBNS, with moderate
conditions that, in the absence of cochlear damage, may be
degree of annoyance, is an important fact, since many individuals
more evident in individuals with tinnitus and normal hearing believe that the intensity of tinnitus is a crucial factor for the
thresholds. A recent study showed this specific population’s symptom’s impact on quality of life, and perceive it as much
difficulty understanding speech in noisy environments, with more intense than most environmental sounds. The absence of
worse performance of these individuals in speech perception objective data regarding intensity in an evaluation process may
tasks compared to those without tinnitus(21). favor the strengthening of the complaint, a factor that promotes
On the other hand, considering factors associated with the development of psychosocial barriers associated with the
tinnitus, the assessment of the subjects’ health problems and/or symptom. Since there is no consensus that the severity of tinnitus
comorbidities showed significant differences (*p=0.049), with is necessarily associated with its intensity(17,27,28), this information
a higher number of reports of general health problems by can also be understood as a tool with which to guide patients
participants of GI. It is believed that the older age of the subjects and plan at least part of treatment. Regardless of whether it
in GI is a determining factor of this finding, as is the practice of is associated with hearing loss or not, the severity of tinnitus
regular physical activity, which, in turn, was reported by more may also be related to the degree of discomfort in daily tasks
participants of GII, a difference that was found to be significant. and other functional impairments, which could lead to mental
Systemic arterial hypertension (SAH), associated or not with disorders such as difficulty concentrating, sleep disorders,
other diseases, was the factor that was most often mentioned anxiety, mood swings and even social isolation(5,17). In this
by both groups. Auditory and vestibular disorders may be scenario, the present study reinforces the fact that the subject’s
secondary to SAH. Abnormalities in the circulatory system and knowledge of the symptom’s psychoacoustic characteristics is
increase in blood viscosity cause a decrease in capillary blood a therapeutic and awareness/guidance tool that should be used
flow and, consequently, oxygen transport, which may damage routinely in clinical practice.
the organ of Corti and generate tinnitus(23). Despite this, based In the Loudness Discomfort Level (LDL) test, there were
on the data presented here, it would not be possible to confirm no statistical differences for neither pure tone nor speech, and
the direct relationship between these variables, corroborating both groups showed values within the acceptable limits of
other findings that did not show this aspect(24). However, it can normality, i.e., variations between 85 and 100dB(29). This result

Mores et al. CoDAS 2019;31(6):e20180029 DOI: 10.1590/2317-1782/20192018029 6/8

did not indicate, therefore, any degree of intolerance to sounds, other. Thus, the possibility of quantification of the symptom
a finding compatible with the absence of complaints, both in GI based on the results of a psychoacoustic assessment, which
and GII, related to hyperacusis, phonophobia or misophonia, is not always performed routinely in patients referred to basic
based on the specific questionnaire applied. audiological evaluation, makes it an important complementary
As for the Minimum Masking Level (MML) test, the findings tool in relation to self-assessment measures of the impact of
showed significant differences between groups, with lower mean tinnitus on daily life.
in GI (p<0.001). The measurement of MML has been used
along with intensity in clinical research with tinnitus patients, CONCLUSION
and some authors show evidence that it may be correlated
with the degree of perception of the level of stress caused The findings of this research allow concluding that the
by tinnitus(30). However, no study was found correlating this presence of hearing loss itself has not been shown to be a single
measurement in patients with and without hearing loss. Since and determining factor of the greater or lesser impact of tinnitus
GI was composed of subjects with sensorineural hearing loss, on quality of life, which is also influenced by other aspects. Thus,
it is believed that the difference in this finding may be related to it is believed that the association of different clinical instruments
existing cochlear damage and loss of outer hair cells, causing a allows a better understanding of the factors that may influence
possible alteration/distortion in the perception of the sensation the impact of tinnitus on subjects with and without associated
of intensity due to the nonlinearity of the cochlea. hearing loss, also supporting the assessment and planning of
Although MML and loudness provide relevant data to be the appropriate treatment for each case.
analyzed, these measures do not take into account the degree
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MIRA participated, as advisor, in the idealization and planning of the study,
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