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Guidelines For the Grading of Tinnitus Severity

The results of a working group commissioned by the British Association of Otolaryngologists, Head and Neck Surgeons, 1999


Members of the group

Chairman - Andrew McCombe MD FRCS (ORL), Consultant ENT Surgeon, Frimley Park Hospital, Surrey.

David Baguley - MSc MBA Audiological Scientist, Cambridge
Ross Coles- MB FRCP(Ed) DLO Audiological Physician, Nottingham
Laurence McKenna PhD Neuro-psychologist, London
Catherene McKinney BSc Audiological Scientist Guy's and St. Thomas' Hospital Trust, Audiology Dept., St. Thomas' Hospital, Lambeth Palace Road, London SE1 7EH
Paul Windle-Taylor- MA, FRCS, MBA, Consultant Otolaryngologist, Derriford Hospital, Plymouth, Devon

Summary

  • Tinnitus is a common experience with up to one third of the adult population experiencing it at some time in their life.
  • Less than 1% of the adult population have tinnitus of sufficient severity to seriously affect their quality of life (although up to 8% may seek medical advice about it).
  • Much of the severity of tinnitus relates to the individuals psychological response to the abnormal tinnitus signal.
  • The prevalence of tinnitus increases in association with high frequency hearing loss.
  • There is unfortunately, no diagnostic test that either confirms the presence of tinnitus or its severity.
  • Currently there is no satisfactory severity grading system.
  • A 5-point severity grading scheme is therefore proposed and the entry criteria detailed. The 5 severity points are: Slight, Mild, Moderate, Severe and Catastrophic.
  • Categorization as Severe or Catastrophic should, by epidemiological definition, be very rare.
  • General guidance, theory and evidential support are contained within the text and a comprehensive bibliography is included.

Introduction

Currently there are a variety of scoring and grading systems available for assessing tinnitus severity. Unfortunately their use is not uniform and in the medico-legal arena the 3-point scale of "mild/moderate/severe" is woefully inadequate. In addition there is on-going debate about the best treatment/management paradigm for tinnitus and a rising tide of medico-legal claims for tinnitus (with or without hyperacusis and often with little in the way of associated hearing loss).

It was against this background that the remit of this group was set: to try and produce guidelines to allow a more accurate and uniform approach to grading of tinnitus severity.

Definition

There are many definitions of tinnitus but a simple and useful one is as follows:
"Tinnitus is the conscious experience of a sound that originates in the head or neck, and without voluntary origin obvious to that person." (McFadden, 1982)

Aetiology and Epidemiology

Tinnitus is a symptom with multiple aetiologies. Perhaps the most comprehensive classification is that provided by Coles (1997)
Figure.

One of the most important works with regard to epidemiology is that of Heller and Bergman (1953) in which 94% of a group of normal hearing young adults experienced a tinnitus like perception when placed in a soundproof room. This would imply that the potential to experience some kind of tinnitus is almost universal in very quiet conditions.

The National Study of Hearing (1985) undertaken by the MRC (Davis, 1989), and other epidemiological studies (Axelsson and Ringdahl, 1989; Coles, 1997; Pilgram et al, 1999 and Smith & Coles, 1987) provide the following information regarding tinnitus in the general population:

1. A third of all adults report having had tinnitus at some time.
2. Ten to fifteen percent of adults report prolonged spontaneous tinnitus (lasting longer than 5 minutes and not immediately following loud noise or oto-toxic drugs).
3. Nearly 5% report troublesome and annoying tinnitus which can affect their ability to get to sleep.
4. 0.5-1% of adults report tinnitus of such severity as to have a significant adverse effect on their quality of life.
5. Self-report and clinical assessment generally demonstrates close agreement.
6. The prevalence of tinnitus increases in association with a high frequency hearing loss (although the association between severity of tinnitus and degree of hearing loss is very weak - McKinney et al, 1999).
7. Tinnitus annoyance and distress tend to become less with the passage of time.
8. Hyperacusis (as distinct from recruitment) is found as an associated symptom in about 40% of tinnitus sufferers. Hyperacusis can be defined as an undue sensitivity and distress to everyday sounds that would not normally trouble a "normal-hearing" individual. This symptom too can vary from very mild to severe and extremely troublesome.

Further useful figures are that approximately 3% of adults will have had a hospital visit for their tinnitus and 8% will have sought medical advice from their GP regarding the condition. It appears that those individuals who have only tinnitus and no complaint of associated hearing loss are less likely to be referred on to a hospital specialist (Coles, 1997). Despite this it is still probably reasonable to assume that it is the more distressing case that will be referred on for hospital assessment or will seek medical attention in the first place.

In summary though it would seem that the experience of tinnitus is common and more so in the presence of a hearing loss, severe tinnitus is fortunately uncommon and even when troublesome, becomes less so with the passage of time.

Severity Grading

1. Overview and problems

The first and probably main problem with tinnitus is that it is a subjective symptom; there is no objective measure. Attempts have previously been made to match tinnitus in pitch, timbre and intensity and make the assumption that the characteristics of an external sound can be meaningfully related to those of an internally generated sound. There is a consensus that psycho-acoustic tests of this kind give no useful information regarding tinnitus severity (Baskill and Coles, 1999) nor is there any relationship between perceived loudness of tinnitus and complaint behaviour (Coles et al., 1990; Hallam et al., 1984).

Even more than the perception, the reaction is subjective. Further, it has become clear in recent years that the "problem" of tinnitus relates far more to the individual's psychological response to the abnormal tinnitus signal than to the signal itself.
Altered mood state (particularly anxiety and depression) is often associated with tinnitus distress (Hazell, 1994; Hiller and Goebel, 1998; Stephens and Hallam, 1985). However in some cases the altered mood state predates tinnitus onset (Hazell, 1994) making it difficult to know whether tinnitus causes psychological disturbance, or whether psychological disturbance facilitates the emergence of tinnitus. High levels of anxiety and depression were also found in tinnitus clinic patients by Hallam et al. using the Crown-Crisp Experiential Index (Hallam et al., 1984).

Hiller and Goebel (1998) have concluded that psychiatric disorders are the most severe side effect resulting from chronic tinnitus. However the fact that psychiatric disorders do not occur in all individuals with tinnitus suggests that some individuals are more vulnerable than others, and that in these vulnerable patients the additional stress of tinnitus may result in a psychiatric disorder. These vulnerable individuals may be the ones with pre-existing psychological disturbance.

McKenna (1997) reported that 45% of individuals complaining of tinnitus had a psychological disorder (in comparison to 64% of those complaining of vertigo and 27% of those complaining of hearing loss). He also found that tinnitus patients experienced more difficulties in concentration and information processing than hearing loss controls.

Consequently one might expect an individuals reaction to a potentially challenging stimulus such as tinnitus to be influenced by that persons mental robustness and well-being, personality and social stress ( Hart and Rubin, 1996). This has two consequences: firstly, in assessing tinnitus severity one may be grading psychological state as much as tinnitus experience, and secondly, the "experienced, intelligent or carefully coached plaintiff" will have an opportunity to exaggerate "true" severity (Hart and Rubin, 1996).

Finally there is the problem of two different requirements for a grading system. On the one hand a fairly robust yet simple scoring system is needed for every day clinical practice and for medico-legal work. On the other hand a more thorough assessment (perhaps with more increments) is needed for research to assess the results of the various tinnitus treatment strategies. A common system that can address the needs of both would, however, have much to commend it.

2. Subjective Measures

Baguley et al (1992) used a simple system to rate tinnitus in a series of 129 patients pre and post removal of vestibular schwannoma.

  • Mild : only perceived when there is no background noise
  • Moderate : perceived over background noise but does not affect sleep
  • Severe: Perceived over background noise, significant effect on sleep with problems getting to sleep or being awakened by tinnitus.

This simple system derived in part from that of Klockoff and Lindblom (1967)

  • Grade I : audible only in silent environments
  • Grade II : audible only in ordinary acoustic environments, but masked by loud environmental sounds; can disturb falling asleep, but not sleep in general
  • Grade III : audible in all acoustic environments, disturbs falling asleep, can disturb sleep in general, and is a dominating problem that affects quality of life

Glorig (1987, see Shulman 1997) proposed a series of questions to quantify the extent to which tinnitus was a problem for the patient. The use of these questions has a fundamental philosophy that "one must accept the answers of the patient as being truthful and correct in any and all patients claiming compensation or liability" (paraphrased by Shulman, 1997). This would be a hard pill to swallow for many familiar with the English legal system.

Thus one flaw in all the grading systems described above is that they allow the subjective view of a patient who has catastrophised their tinnitus experience, either due to psychological factors or a desire for compensation, to express that view within the grading system unchecked.

In a summary of 10 tinnitus questionnaires in use since 1983, Sissons (1996) reported five main categories of complaint contributing to tinnitus distress. These were:

1. Emotional distress and patient's view of tinnitus
2. Sleep disturbance
3. Auditory perceptual difficulties
4. Interference with work and leisure
5. Effects on general health

The most effective way of measuring these variables is to use one of the psychometrically validated questionnaires available. These questionnaires have the advantage over a simple 3 point scoring system of being standardised, and having good reliability and validity. These factors should minimise some of the inaccuracy and bias inherent in subjective assessments. Two such questionnaires are the Tinnitus Handicap Inventory (THI), (Newman, Jacobson and Spitzer, 1996) and the Tinnitus Questionnaire (TQ), (Hallam, Jakes and Hinchcliffe, 1988).

The TQ should take 5 - 15 minutes to complete. It is suggested that the test be completed with someone present to offer encouragement and simple explanation. Internal consistency is high, as is test-retest variability. Scoring takes 10 minutes. The test is available in printed form from the Psychological Corporation. The questionnaire is copyright and non-photocopiable. As the test was produced in the UK it is fully anglicised.

The Tinnitus Handicap Inventory (THI) (Newman et al, 1996, Newman et al, 1998) is a 25 item self-report questionnaire that has Functional, Emotional and Catastrophic subscales. It has excellent convergent validity, construct validity and test-retest reliability. The THI takes 10 minutes to complete, and it is suggested that the test be completed with someone present to offer encouragement and simple explanation. Scoring takes 5-10 minutes with a score of 4 for a "yes", 2 for "sometimes" and 0 for "No". The test is not copyright and can be reproduced. The test was developed for the USA but does not need modification for the UK.

These two questionnaires aim to measure slightly different aspects of tinnitus experience. Work in progress in Cambridge has utilised both questionnaires in a randomised order of presentation (Baguley et al, in preparation). The questionnaires were mailed to the patients before attendance at the Tinnitus Clinic. At the time of writing data is available for analysis on 35 patients wherein a correlation between the total TQ and THI scores of 0.641 and a regression coefficient of p<0.0001 was found. This would seem to indicate therefore that there is little to choose between the two questionnaires in terms of results although there appear to be some slight administrative advantages in using the THI.

3. Objective Measures

Unfortunately there are no objective measures of tinnitus severity. However, there may be some more objective surrogate measures of tinnitus severity, for instance GP or Hospital attendance. It would certainly be useful to see such confirmatory evidence of a problem

Of course an audiogram is not completely objective but does represent a relatively objective measure of hearing status. There should be some role for audiometry in the assessment of tinnitus severity, particularly in the light of the increased prevalence of tinnitus in the presence of a high frequency hearing loss.

Suggested Grading of Tinnitus Severity

The use of the Tinnitus Handicap Inventory (THI -Appendix1) is recommended for research purposes. It may be useful in a clinical setting but its use is NOT recommended in a medico-legal context for reasons that are detailed in the discussion. The presence or absence of hyperacusis may have relevance to the overall condition of the individual concerned but is irrelevant to the severity of any tinnitus.

Grade 1 - slight - (THI 0-16) - Only heard in quiet environment, very easily masked. No interference with sleep or daily activities. This grading should cover most people who are experiencing but are not troubled by tinnitus.

Grade 2 - mild - (THI 18-36) - Easily masked by environmental sounds and easily forgotten with activities. May occasionally interfere with sleep but not daily activities.

Grade 3 - moderate - (THI 38-56) - May be noticed even in the presence of background or environmental noise although daily activities may still be performed. Less noticeable when concentrating. Not infrequently interferes with sleep and quiet activities.

The majority of people suffering tinnitus should fall into Grades 2 & 3.

Grade 4 - severe - (THI 56-100) - Almost always heard, rarely if ever masked. Leads to disturbed sleep pattern and can interfere with ability to carry out normal daily activities. Quiet activities adversely affected. There should be documentary evidence of the complaint being brought to the general (or some other) medical practitioner (prior to any medico-legal claim). Hearing loss is likely to be present but its presence is not essential. Given the epidemiological data, grading in this group should be uncommon.

Grade 5 - catastrophic - (THI 56-100) - All tinnitus symptoms at level of severe or worse. Should be documented evidence of medical consultation. Hearing loss is likely to be present but its presence is not essential. Associated psychological pathology is likely to be found in hospital or general practitioner records. Given the epidemiological data, grading in this group should be extremely rare.

Discussion

As has become clear through this document, the biggest problem facing any attempt to grade tinnitus severity is the lack of any objective measure. We have therefore tried to take the known epidemiological and clinical data and combine that with our own clinical, medico-legal and research experience to produce a severity scale that we hope will have some practical validity and value. Clearly the best way to test this grading system is with use and the best endorsement will be its use.

It is of course axiomatic of good practice that all questions are asked in an open fashion; more store being placed on volunteered information than that provided by leading questions. Symptoms should appear in an appropriate chronological fashion. It must be emphasised that the whole history must "hang together" with the tinnitus having a place both chronologically and in severity that makes clinical sense. This aspect of the examination is really only gained by experience. A skilled practitioner will just get a "feel" for the whole picture.

Hyperacusis has been found as an additional symptom in approximately 40% of tinnitus sufferers. It is likely that it shares as its cause an undue sensitivity of the auditory pathways. It was not within our remit to grade the severity of hyperacusis and so we have not addressed this issue. Although the presence of this additional symptom may adversely affect the individual's overall condition, it has no impact on the assessment or severity of tinnitus and so should be addressed separately.

It is likely that an additional severity scoring system may be required for hyperacusis but as it seems a relatively new symptom in clinical consciousness, perhaps the passage of a little more time and consequently more experience of it will prove beneficial.

The use of the THI is unlikely to present problems in the research arena. However, its use in the medico-legal context is fraught with risk. It risks "leading" the claimant and there is a widespread feeling that it might encourage exaggeration. Whether it finds regular use in a more general clinical setting would remain to be seen. There would certainly be some merit in investigating whether the "clinical" part of the grading system matches up with the THI scores; the figures chosen were taken from Newman's own analysis of his THI (Newman et al, 1998). There is of course some debate as to whether the UK based tinnitus questionnaire (Hallam, 1996) may be a better choice than the US based THI. Current work on this (Baguley et al, In progress) would indicate little to choose between the two tests and there are certainly some administrative advantages to using the THI in terms of reproduction and copyright, hence our choice.

There is increasing research evidence of a psychological vulnerability towards the development of tinnitus (Windle-Taylor et al, 1995; Hiller et al, 1999). Evidence of this vulnerability can be found from examination of the subject's medical records and from a variety of psychological profile questionnaires. However, although they may demonstrate a propensity towards development of the condition, they do not predict the experience of severity and so we have chosen not to include them in these guidelines.

With regard to our "objective" measures, we have really focused on two areas. The first is the value of an associated hearing loss. We are in no way suggesting that the presence of a hearing loss be required to allow an individual to be graded as severe. However, there is no escaping the epidemiological data that indicates that the prevalence of tinnitus increases with an increasing high frequency hearing loss. In other words, in the presence of a high frequency hearing loss, a parallel complaint of tinnitus is more likely. There is in addition some evidence that in the presence of a significant hearing loss, tinnitus severity tends to be greater (McKinney, 1999).

Our second thrust has been the presence in the medical notes of a complaint of tinnitus. Again this is not essential to allow a "severe" grading; there are of course many reasons why an individual should fail to seek medical help for their problem. There is though evidence to support the fact that most individuals with distressing tinnitus will seek medical help (Pilgram et al, 1999).

Once again these factors really need to be seen in context of the subject and his complaint; for the examiner the findings must all hang together to allow a reliable severity grading.

Finally, given the epidemiological data available to us it can be appreciated that tinnitus is not often a severe problem and for this reason the majority of sufferers should be found in Grades 2 & 3. A grading of 4 should be uncommon and 5 should be very rare. A Grade 1 score reflects an experience of tinnitus without any distress and so represents a non-pathological state.

The aetiology of tinnitus is irrelevant, as the experience should be the same regardless.

This document refers to adults and not children.

References

Axelsson A, Ringdahl A, 1987. The occurrence and severity of tinnitus - a prevalence study. In: Feldmann H, ed. Proceedings of the Third International tinnitus Seminar Munster. Karlsruhe: Harsch Verlag, 1987.

Baguley DM, Moffat DA and Hardy DG (1992) What is the effect of translabyrinthine acoustic schwannoma removal upon tinnitus? Journal of Laryngology and Otology, 106, 329-331

Baguley DM, Stoddart RL, Hodgson C (In preparation) A comparison of the Tinnitus Questionnaire and the Tinntus Handicap Inventory.

Baskill JL and Coles RRA, 1999. Relationship between Tinnitus Loudness and severity. In Proceedings of the Sixth International Tinnitus Seminar, Cambridge, UK, 1999.

Coles RRA, 1984. Epidemiology of tinnitus: (1) Prevalence. Journal of Laryngology and Otology, (Suppl.9): 7-15.

Coles RRA, Smith P, Davis A. The relationship between noise-induced hearing loss and tinnitus and its management. In: Berglund G, Lindval T, eds. Noise as a Public Health Problem, vol.4: New advances in Noise Research part 1. Stockholm: Swedish Council for Building Research, 1990: 87-112.

Coles RRA, 1997. Tinnitus. Chapter 18 in Scott-Brown's Otolaryngology 6th Edition, Volume 2, Adult Audiology. D Stephens (Ed). Butterworth-Heinemann, London.

Davis A, 1989. The prevalence of hearing Impairment and reported hearing disability among adults in Great Britain. International Journal of Epidemiology, 18, 911-917.

Glorig A ( 1987 ) Tinnitus: suggested guidelines for determining impairment, handicap, disability . Cited in Shulman, 1997

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