Recording of tinnitus psychoacoustic measurements: an integrative literature review

ABSTRACT

Purpose:

to review both the national and international literature as well as to describe the methods used to collect psychoacoustic measurements in tinnitus patients.

Methods:

the current integrative review was conducted on articles in specialized national and international journals, in both the Portuguese and English languages, available in the PubMed/Medline, BVS - LILACS and SCIELO databases. The following keywords and descriptors were used: hearing, tinnitus, psychoacoustic measurements, acuphenometry, and assessment, in both the Portuguese and English languages. The retrieved articles were read and selected for the review according to the eligibility criteria, which included the use of psychoacoustic measurements in tinnitus patients and the presence of a detailed methodological description of the protocol employed, in individuals with normal hearing and those with hearing loss.

Results:

a total of 12 articles, in which psychoacoustic measures were used for the characterization and the measurement of tinnitus in individuals with normal hearing and in those with hearing loss, were reviewed. The main findings were associated with the sample characterization and the way in which the psychoacoustic measures were performed. Conclusion:given the grouping of several protocols for tinnitus evaluation, which were determined following an integrative literature review, a great heterogeneity in the methods used to perform psychoacoustic measurements for tinnitus assessment for both clinical and scientific purposes was noted.

Keywords:
Hearing; Tinnitus; Hearing Loss; Psychoacoustics

RESUMO

Objetivo:

revisar a literatura nacional e internacional e descrever os métodos usados para a coleta das medidas psicoacústicas do zumbido.

Métodos:

essa revisão integrativa foi realizada por meio da busca de artigos em periódicos especializados, nacionais e internacionais, nos idiomas português e inglês, disponíveis nas bases de dados: PubMed/Medline, BVS - LILACS e SCIELO. As palavras-chaves e descritores utilizados foram: audição, zumbido, medidas psicoacústicas, acufenometria e avaliação e, seus correspondentes em inglês. Os artigos levantados foram lidos e selecionados para a revisão seguindo os critérios de elegibilidade: aqueles que empregaram medidas psicoacústicas do zumbido e com descrição metodológica detalhada do protocolo empregado, em indivíduos normo-ouvintes e com perda auditiva.

Resultados:

foram revisados 12 artigos nos quais as medidas psicoacústicas foram empregadas para a caracterização e mensuração do zumbido, em indivíduos normo-ouvintes e com perda auditiva. Os principais achados referem-se à caracterização da amostra e modo de realização das medidas psicoacústicas.

Conclusão:

o agrupamento de diversos protocolos para avaliação do zumbido, realizado a partir da revisão integrativa de literatura, evidenciou grande heterogenidade dos métodos de realização das medidas psicoacústicas para a mensuração do zumbido para fins clínicos e científicos.

Descritores:
Audição; Zumbido; Perda Auditiva; Psicoacústica

Introduction

Tinnitus has been previously described in the scientific literature as the perception of sound in the absence of an external environmental source^1,2. More precisely, such a symptom may originate from an injury occurring at any point of the auditory pathway (i.e. outer ear, middle ear, inner ear, auditory nerve, cochlear nucleus, inferior colliculus, and/or the central nervous system)³. The literature⁴ reports that hearing loss, even when temporary, may cause an increase in the sensitivity of the neurons of the subcortical auditory centers, resulting in tinnitus.

While tinnitus may be present in individuals with normal hearing, the perception of such a symptom may vary in location, i.e. either in the ears or in the head⁵.

Although tinnitus is a well-recognized hearing impairment, a method considered as the "gold standard" for its characterization and measurement is yet to be defined. Generally, questionnaires are used to subjectively measure the discomfort and the impact of tinnitus in the patient's quality of life. An example is provided by the Tinnitus Handicap Inventory (THI), which was developed in 1996⁶ and exists in various versions in several languages, including Brazilian Portuguese⁷. Although one of the most common tools for tinnitus evaluation worldwide, questionnaire-based assessments are subjective and are not capable of measuring the magnitude of the patient’s discomfort and the degree of disability caused by the symptom in an objective manner.

Similarly, acuphenometry is one of the oldest methods for evaluating tinnitus and is still widely used. In fact, it can define the frequency (pitch) and intensity (loudness) of the tinnitus, as well as the minimum masking levels⁸ (MML) and the residual inhibition⁹, which are internationally known as the psychoacoustic measures.

One of the first acuphenometry records dates to 1931¹⁰, when a research on the loudness and pitch of tinnitus was performed with an acoustic stimulation of the pure tone type. Furthermore, the loudness balancing technique became widespread in 1938 to test the effect of tinnitus on hearing acuity when the contralateral ear is tested¹¹.

In 1985, during a Symposium of CIBA-GEIGY (now Novartis), which is headquartered in London, efforts were concentrated on standardizing a protocol for the evaluation of tinnitus, including the measurement of pitch, loudness, minimum masking level, and residual inhibition⁹.

Previous literature reports that the psychoacoustic measures can be obtained through three different methods, i.e. the adjustment, limits, and adaptive methods¹². The adjustment method relies on the patient to adjust the stimulus (pulsatile tone) until the sound that is considered similar to his/her tinnitus is identified. In contrast, in the limits method, the patient is instructed to choose whether the stimulus presented (pulsating tones, ascending and descending, in increments of 1/6 octave) is more bass or treble when compared to his/her tinnitus. Finally, the adaptive method, also referred to as the "Bracketing”, requires the patient to determine whether the acoustic stimulus presented is brass or treble, but with increments of one octave. To guarantee reliable results, the tests are suggested to be repeated seven to nine times, regardless of the method used.

A debate regarding the type of stimulus to be utilized and the question of laterality (i.e. the presentation of the stimulus in an ipsilateral or contralateral way in relation to the ear where the tinnitus occurs) remains. In fact, while some authors use the contralateral measure as it is less confusing for the patient¹³, others prefer the ipsilateral measure to avoid the effects of diplacusis binauralis¹².

Knowing how researchers and clinicians have conducted the audiological psychoacoustic measurements for the assessment of tinnitus will be of great importance to objectively validate this auditory symptom, which is subjective, by definition. Such measures might be important for counseling, follow-ups, treatment-of-choice to be prescribed according to the suspected individualized diagnosis, and specifically for scientific research.

Although the literature categorizes the methods for conducting tests for psychoacoustic measurements, standards to obtain such parameters do not yet exist, in the field of audiology or in scientific research. Given the importance of the standardization of acuphenometry for the diagnosis and characterization of tinnitus, the purpose of this study was to review the national and international literature for methods of implementation of the psychoacoustic measures.

Methods

The current integrative literature review was conducted on the articles present in specialized journals, both national and international in English and Portuguese, which are available in the following databases: US National Library of Medicine (PubMed/Medline), Virtual Health Library - Latin American and Caribbean Literature on Health Sciences (BVS - LILACS) and Scientific Electronic Library Online (SCIELO).

To identify the articles relevant to our study, we considered terms related to the theme of "psychoacoustic measures in tinnitus", found in the Health Sciences Descriptors (DeCS), and the Medical Subject Headings (MeSH), as well as keywords relative to the topic, and combined them with the use of the Boolean operators AND and OR. The terms chosen for the search were used in an isolated and crossed manner (Figure 1). Finally, the filter "word” was used in all the searches.

Figure 1:
Determination of the databases as well as the keywords chosen for the integrative literature review

The main question underlying the present review was: “How are the psychoacoustic measures for the assessment of tinnitus recorded?”. To obtain the answers to this question, a survey of the articles was conducted in the mentioned databases, specific for each database without limiting the search period (Figure 2).

Figure 2:
Selection process of the articles considered for the literature review

Initially, both the inclusion and the exclusion of the articles were based on the information included in their titles and abstracts. However, when the resulting information was not conclusive, the articles were read fully to check if the following eligibility criteria were fulfilled: the utilization of psychoacoustic measures for the measurement of tinnitus, and the presence of a clear explanation of the method used, both in individuals within normal hearing thresholds and in those with hearing loss. Articles were excluded for the following reasons: they quoted the psychoacoustic measures used for the evaluation of tinnitus but did not present their description, they reviewed the literature and/or methodology, they used a software for measuring the characteristics of tinnitus, they employed animals, and when only the summary and/or "abstract" were available.

The selected articles were analyzed, initially by reading the titles and abstracts, followed by a full reading of the articles that met the eligibility criteria. Each article was evaluated by one of the authors and, in case of doubt, a consensus was reached among all the authors regarding the inclusion of the article in the review. The publications which were found eligible for this review were organized into figures to extract the following information: year, author(s) of the research, purpose(s), sample characterization, and evaluation mode of the acuphenometry.

Finally, the articles that resulted from each crossed term (which was repeated in relation to the previous search and was related to the present study) were computed to organize the data.

Literature Review

As a result of the search performed in the Pubmed/Medline, LILACS and SCIELO databases, 133 articles were found (73, 31 and 29, respectively). All the mentioned articles were identified in one or more databases. While reading the abstracts, duplicate articles (i.e. had previously been selected in other databases), those that did not meet the inclusion criteria and those for which the full text was not available during the period of the search were excluded.

Successively, the 133 abstracts, which were selected were read and the following were excluded: 30 due to the unavailability of the full text, 33, which only mentioned the psychoacoustic measures that had been used for the evaluation of tinnitus, three that did not address the context of the "psychoacoustic measures and tinnitus”, eight that only measured tinnitus by the use of questionnaires, six, as they were literature review studies, eight that reported studies measuring tinnitus with a software, one that only described the validation of an instrument for the evaluation of tinnitus, and two that were not available in both English and Portuguese. Finally, 29 articles were available in more than one database and were also excluded from the review.

After this detailed analysis, 12 articles that met the criteria for the current review were selected. Specifically, while seven were obtained from international journals, five were published in national journals. A summary of the articles published in the national journals relative to the use of psychoacoustic measures and their method of applicability for the assessment of tinnitus is shown in Figure 3.

Figure 3:
Synthesis of the national articles selected and analyzed for the present review (n=5)

In contrast, a summary of the articles published in the international journals is illustrated in Figure 4.

Figure 4:
Synthesis of the national articles selected and analyzed for the present review (n=7)

This study presents an overview of the research developed under a national and international scope, using psychoacoustic measures to assess and characterize tinnitus, in both individuals with normal hearing and hearing loss. In addition, we have also described the use of these psychoacoustic measures in guiding researchers and professionals in the evaluation of patients with tinnitus.

Based on the studies analyzed, we could infer an absence of consensus on the standardization of the measurement of tinnitus while performing acuphenometry, which may influence the results of the assessment. The divergent results may be caused by extrinsic (how the guidance prior to assessment is made) and intrinsic factors (variation of the loudness intensity in the research). However, most of the studies describe the correspondence between pitch and loudness, as well as the type and intensity of the stimulus presented, according to the severity of the patient’s tinnitus.

With regards to the national literature, pure tone, white noise and narrow band^16,17 stimuli were used to determine both the pitch and loudness of tinnitus. The intensity of both pitch and loudness were found to vary between 5¹⁴, 10¹⁵ and 15dBNS^17,18.

Furthermore, the researchers of two studies measured and characterized tinnitus either in the contralateral ear or in the ear in which the tinnitus was not prevalent^17,18.

In the international literature, pure tone^20,22, noise²⁰ and pulsatile²¹ stimuli were used to determine the pitch and loudness of tinnitus.

Moreover, we observed the applicability of the Minimum Masking Level (MML) in the characterization and the measurement of tinnitus on the different protocols which were found to be used. The MML is a psychoacoustic estimate of the lowest level of broadband noise to minimally mask the tinnitus in the patient²⁶.

Two studies (one national¹⁶ and one international²¹) reported that the measuring the MML of tinnitus could be used as a complementary method to the identification of loudness in acuphenometry. However, the remaining studies only used the correspondence between the pitch and the loudness to perform the acuphenometry, showing great heterogeneity in their protocols.

Conclusion

Given the grouping of several protocols for tinnitus evaluation, which were determined following an integrative literature review, a great heterogeneity in the methods used to perform psychoacoustic measurements for tinnitus assessment for both clinical and scientific purposes was noted.

REFERENCES

• ¹
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  Ibraheem OA, Hassaan MR. Psychoacoustic characteristics of tinnitus versus temporal resolution in subjects with normal hearing sensitivity. Int Arch Otorhinolaryngol. 2017;21(2):144-50.
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  Seimetz BM, Teixeira AR, Rosito LPS, Flores LS, Pappen CH, Dall'igna C. Pitch and Loudness Tinnitus in Individuals with Presbycusis. Int Arch Otorhinolaryngol. 2016;20(4):321-6.
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  Van de Heyning P, Muehlmeier G, Cox T, Lisowska G, Maier H, Morawski K et al. Efficacy and safety of AM-101 in the treatment of acute inner ear tinnitus va double-blind, randomized, placebo-controlled phase ii study. Otol Neurotol. 2014;35(4):589-97.
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  Kroner-Herwig B, Hebing G, Van Rijn-Kalkmann U, Frenzel A, Schilkowsky G, Esser G. The management of chronic tinnitus-comparison of a cognitive-behavioural group training with yoga. J Psychosom Res. 1995;39(2):153-65.
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Publication Dates

• Publication in this collection
  10 Oct 2019
• Date of issue
  2019

History

• Received
  19 Oct 2018
• Accepted
  25 Mar 2019