The Laryngoscope C 2016 The American Laryngological, V
Rhinological and Otological Society, Inc.
Characteristics of Tinnitus in Adolescents and Association With Psychoemotional Factors So Young Kim, MD; Yung Jin Jeon, MD; Jun-Young Lee, MD, PhD; Young Ho Kim, MD, PhD Objectives/Hypothesis: The characteristics and underlying mechanisms of tinnitus remain more elusive in the pediatric population than in adults. We investigated the prevalence of tinnitus, its characteristics, and associated factors, with a focus on psychoemotional problems in adolescents. Study Design: Cross-sectional study Methods: In total, 962 adolescents were surveyed for tinnitus and possibly related otologic and socioeconomic factors. The participants completed a visual analog scale (VAS) pertaining to various aspects of tinnitus, as well as the Tinnitus Handicap Inventory, Children’s Depression Inventory (CDI), State Anxiety Inventory for Children, Trait Anxiety Inventory for Children (TAIC), Internet Addiction Test, Conners’ Abbreviated Parent Rating Scale, and a learning disability score. Characteristics of tinnitus were analyzed, and psychoemotional and other factors were compared between tinnitus and nontinnitus groups. Results: Approximately one-third of subjects reported experiencing tinnitus. A family history of tinnitus, subjective hearing loss, dizziness, and CDI and TAIC abnormalities were significantly associated with tinnitus. In the tinnitus-always group, tinnitus showed significant relationships with subjective hearing loss, bilateral tinnitus, and VAS, CDI, and TAIC scores. Conclusions: The results suggest that about one-third of adolescents experience tinnitus, which may be related to psychoemotional factors. In particular, anxiety and depression may be important factors to consider in managing tinnitus in adolescents. Further study of tinnitus in adolescents, including efforts toward diagnosis and management, is needed to determine whether there is a causal relationship with anxiety and depression, and the extent to which adverse outcomes may be associated with these psychoemotional factors. Key Words: Tinnitus, adolescence, anxiety, depression. Level of Evidence: 4 Laryngoscope, 127:2113–2119, 2017
INTRODUCTION Tinnitus can be considered as one of the most common and disturbing nonthreatening health problems. Despite robust researches regarding tinnitus, the cause and treatment of tinnitus remain unclear. Although some differences in the incidence of tinnitus are seen depending on the study population and definition, the prevalence of tinnitus has been reported to range from 5% to 30%, and that of severe tinnitus ranges from 1% to 7% in the general adult population (mostly from studies conducted in northern Europe and the United States).1–3
From the Department of Otorhinolaryngology–Head and Neck Surgery, CHA Bundang Medical Center, CHA University, Seongnam (S.Y.K.); Department of Otorhinolaryngology, Seoul National University Boramae Medical Center, Seoul (Y.J.J., Y.H.K.); and Department of Psychiatry, Seoul National University Boramae Medical Center, Seoul (J.-Y.L.), South Korea. Editor’s Note: This Manuscript was accepted for publication August 30, 2016. This study was supported by a clinical research grant provided by Seoul National University Boramae Medical Center. The authors have no other funding, financial relationships, or conflicts of interest to disclose. Send correspondence to Young Ho Kim, MD, Department of Otorhinolaryngology–Head and Neck Surgery, Seoul National University Boramae Medical Center, 20, Boramae-Ro 5-gil, Dongjak-Gu, Seoul 156-707, Republic of Korea. E-mail:
[email protected] DOI: 10.1002/lary.26334
Laryngoscope 127: September 2017
Tinnitus in adolescents has been reported to be as common as it is in adults, at a rate of 12.8% to 74.9% (including temporary tinnitus cases).4–7 However, accurately determining the incidence of tinnitus may be difficult, because mild cases will not be included in medical records. Some subjects, especially among the younger population, do not recognize that they have tinnitus until they are questioned about it.8 Additionally, previous studies have reported that adolescents complain less regarding discomfort from tinnitus than do adults.9,10 Therefore, tinnitus in this age group may often be ignored. Nevertheless, understanding tinnitus in adolescents may have important clinical implications, because there is little information on therapeutic modalities for tinnitus in this population, or its potential risk factors during the development period. Diagnosing tinnitus is difficult, because the condition may not be detected using objective methods. Attempts have been made to address this problem using brain imaging modalities, such as functional magnetic resonance imaging and electroencephalometry.11,12 These modalities have demonstrated that tinnitus patients show modulated brain activity in nonauditory centers, such as limbic, paralimbic, and even frontal areas, as well as in the auditory centers.11,12 Although there is still some controversy regarding the mechanism underlying tinnitus, these findings indicate that tinnitus may result from altered activity in the central auditory pathways and the various Kim et al.: Tinnitus in Adolescence
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networks that are associated with tinnitus perception and tinnitus-related distress, such as the limbic system, including the amygdala and insula. Thus, it is generally accepted that tinnitus is at least in part influenced by emotional or psychological factors.13 Recently, there have been studies reporting psychoemotional factors related with tinnitus.8,14,15 Especially in younger populations, psychoemotional problems can have detrimental effects on emotional and physical development.16 Unfortunately, it is hard to detect such psychoemotional problems among youths, because they show more somatization symptoms than do adults.17–19 Despite the unique characteristics of the adolescent period, there have been few studies regarding tinnitus in adolescents. The purpose of this study was to investigate the prevalence and characteristics of tinnitus in adolescents, as well as any associated factors, with a particular focus on psychoemotional factors such as anxiety, depression, Internet addiction, and attention deficit. Investigating the characteristics of tinnitus in adolescents, and identifying strongly associated factors, may be helpful in screening potential candidates for severe tinnitus leading to preventing tinnitus-associated morbidities in adulthood.
MATERIALS AND METHODS Study Participants In total, 1,098 students from two middle schools were asked to complete questionnaires on tinnitus and associated factors, including psychoemotional traits. Data from 136 respondents were excluded due to incomplete answers or lack of informed consent. Thus, in total, 962 students (371 males, 591 females) were included in the final analysis. The response rates were 82.9%, 90.1%, and 89.0% in the first, second, and third grades, respectively. This study was approved by the institutional review board (IRB) of the Seoul National University Boramae Medical center (IRB No. 16-2014-83). For every participant, written informed consent was acquired for the enrolled adolescents and their parents.
Questionnaire Items The questionnaire consisted of 170 items: 129 that were applicable to all students, and an additional 41 questions for students with tinnitus. The questionnaire items included demographic factors such as age and gender, and symptoms such as hearing loss, dizziness, headache, and sleep disturbance. For participants with tinnitus, associated characteristics— including laterality, pitch, noise type, triggers, and treatment history—were surveyed. For the assessment of psychoemotional relevance to various aspects of tinnitus emotional problems, a visual analog scale (VAS), plus the Tinnitus Handicap Inventory (THI),20 Children’s Depression Inventory (CDI),21 State Anxiety Inventory for Children (SAIC),22 Trait Anxiety Inventory for Children (TAIC),22 Internet Addiction Test (IAT; Dr. Kimberly Young),23 Conners’ Abbreviated Parent Rating Scale (CAPRS; used for the diagnosis of attention deficit disorder with or without hyperactivity [ADHD]),24 and the learning disability score (LDS) were used. The THI, CDI, SAIC, TAIC, and IAT are self-reported instruments, whereas the CAPRS and LDS were completed by the adolescents’ parents.
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TABLE I. Demographic Characteristics of Enrolled Subjects (N 5 962). Characteristic
Tinnitus (1)
Tinnitus (2)
311
651
Number of subjects
Age, yr, mean 6 SD 14.77 6 0.92 14.67 6 0.96 Gender, % Male
29.1
70.9
Female 34.3 Family history of tinnitus, %
65.7
No
30.7
69.3
Yes
52
48
P
.13 .09
