Acute Exacerbation of Chronic Subjective Tinnitus: A Cross-Sectional Study
Tinnitus, the perception of sound in the absence of an external auditory stimulus, is a prevalent condition affecting approximately 10% to 15% of adults. Among these individuals, about 20% find their tinnitus bothersome, significantly impacting their quality of life. The condition is associated with a range of adverse effects, including anxiety, concentration difficulties, impaired intellectual functioning, sleep disturbances, and depression. In severe cases, tinnitus can even lead to suicidal ideation. The incidence of tinnitus is on the rise, driven by factors such as population aging, accelerated lifestyles, increased noise exposure from construction and entertainment activities, and the escalation of armed conflicts in certain regions. Despite its widespread impact, there is a notable lack of research focusing on the exacerbation of tinnitus. This study aims to address this gap by examining the factors associated with the acute exacerbation of chronic subjective tinnitus, with the goal of preventing tinnitus-related comorbidities and improving its management.
The study was conducted at the Department of Otolaryngology-Head and Neck Surgery at The Third Affiliated Hospital of Sun Yat-Sen University in Guangdong, China, between January 2018 and March 2020. A total of 602 patients with chronic subjective tinnitus were recruited for the study. Acute exacerbation of chronic tinnitus was defined as an increase of 6 points or more in the Tinnitus Handicap Inventory (THI) score compared to the previous score. The study received ethical approval, and all participants provided written informed consent.
Participants underwent a comprehensive physical examination during their initial visit. Detailed medical histories were obtained, including demographic characteristics, occupation, smoking and drinking habits, and the duration of tinnitus and associated symptoms. Tinnitus severity was assessed using the THI, while anxiety and depression were evaluated using the Self-rating Anxiety Scale (SAS) and Self-rating Depression Scale (SDS), respectively. Sleep quality was measured using the Pittsburgh Sleep Quality Index (PSQI), with a score greater than 5 indicating a sleep disorder. Stress levels were assessed using the Psychosomatic Tension Relaxation Inventory (PSTRI), with a score of 65 or higher indicating significant stress. Fatigue severity was measured using the Fatigue Severity Scale (FSS). Hearing loss was considered aggravated if the average pure-tone threshold loss was 10 dB or more. Additionally, abrupt changes in barometric pressure, such as those experienced during air travel, were considered potential triggers for tinnitus exacerbation.
The study population was divided into two groups: those with stable chronic subjective tinnitus and those experiencing an acute exacerbation of chronic subjective tinnitus. The stable group consisted of 398 patients (208 females and 190 males) aged 15 to 85 years, while the acute exacerbation group included 204 patients (105 females and 99 males) aged 17 to 84 years. There were no significant differences between the groups in terms of sex distribution, smoking and drinking behavior, and the duration of tinnitus. However, the acute exacerbation group had a higher proportion of young and middle-aged individuals compared to the stable group.
Significant differences were observed between the two groups in several factors, including aggravated hearing loss, fatigue, stress, negative emotions (anxiety and depression), sleep disorders, upper respiratory tract infections, noise exposure, and abrupt changes in barometric pressure. However, there were no significant differences in the frequency of head and neck trauma, use of traditional Chinese medicine, electrical injury, and surgery between the groups.
A decision tree analysis was employed to evaluate the influence of fatigue, stress, negative emotions, and sleep disorders on the acute exacerbation of tinnitus. The analysis revealed that 99% of patients with chronic subjective tinnitus who experienced fatigue, stress, and negative emotions had aggravated tinnitus. Among patients with fatigue, negative emotions, and sleep disorders but no stress, 84% experienced aggravated tinnitus. In contrast, 58% of patients with fatigue and stress but no negative emotions had aggravated tinnitus. A random forest model was used to assess the importance of these factors, with fatigue and stress identified as the most significant contributors, followed by negative emotions and sleep disorders.
The study highlighted the critical role of fatigue and stress in the exacerbation of chronic tinnitus. Patients often report insomnia, short sleep duration, and frequent awakenings, which can lead clinicians to overemphasize the role of sleep disorders while underestimating the impact of fatigue and stress. Stressful events can trigger a psychosocial stress response, leading to functional changes in the immune system, such as alterations in immune defense, homeostasis, and surveillance. These changes may be linked to the onset and worsening of tinnitus. Fatigue and stress can also induce physiological stress responses, affecting the neuroendocrine system and biological factors like gut microbiota in susceptible individuals, ultimately leading to abnormal immune responses.
Sleep disorders, which affect cognitive, emotional, metabolic, and immunological functions, are a major issue in tinnitus patients, particularly during acute exacerbations. The severity of sleep disturbances is positively correlated with the severity of tinnitus. The prevalence of sleep disturbances in tinnitus patients ranges from 25% to 60%. Tinnitus patients with disturbed sleep often experience headaches and memory deficits, and the co-occurrence of migraines is thought to exacerbate tinnitus. Treatment options for insomnia in tinnitus patients include hypnotics, insomnia-specific psychotherapy, and cognitive behavioral therapy.
While most tinnitus patients do not have severe emotional problems, anxiety is common among them. Patients with anxiety often exhibit certain personality traits, such as introversion and dysfunctional cognition. Dysfunctional cognition, which may result from the patient’s thought processes or external influences, can exacerbate the fear that tinnitus will worsen. Concurrent treatment of anxiety and depression is essential for tinnitus patients exhibiting these symptoms, with treatment options including antidepressants and psychotherapeutic approaches. The study found that the coexistence of fatigue, stress, and negative emotions is a key model of worsening tinnitus, underscoring the close relationship between tinnitus and the limbic system. Research suggests that stimulation of the hippocampus may regulate the auditory cortex, providing a potential avenue for therapeutic intervention.
The study also found that increased noise exposure is associated with worsening tinnitus. Prolonged exposure to noisy environments can cause neural degeneration in the central nervous system, altering the balance of excitation and inhibition in auditory pathways and leading to tinnitus. Based on these findings, a new hypothesis termed “bionic active noise reduction” has been proposed, which considers the innate structures in the auditory system that may contribute to noise suppression. If validated, this hypothesis could have significant implications for noise protection in social medical services, particularly in preventing the onset and exacerbation of tinnitus. Additionally, abrupt changes in barometric pressure, such as those occurring during diving or air travel, can cause acute exacerbation of chronic tinnitus. Barotrauma may lead to changes in cochlear fluids, resulting in either temporary or persistent tinnitus.
Headaches are frequently reported by tinnitus patients, but the relationship between the two conditions is not always causal. Current research suggests that headaches and tinnitus may be symptoms of the same underlying condition. Both conditions are associated with a high degree of disability and are often accompanied by psychiatric disorders. They also share common mechanisms related to their tendency to become chronic. However, the study did not evaluate headaches, highlighting a limitation in the current research.
In addressing the exacerbation of chronic subjective tinnitus, it is essential to consider not only hearing loss and tinnitus but also the broader context of social support, work and leisure life, and psychosocial stress. Understanding the intrinsic relationships between these factors and tinnitus can help patients rebuild healthy living habits, improve social and interpersonal relationships, and enhance their ability to cope with stressors. Only by addressing these multifaceted aspects can the prognosis and management of tinnitus be improved.
In conclusion, fatigue, stress, negative emotions, and sleep disorders are the primary manifestations of aggravated chronic tinnitus, often coexisting and influencing each other. To prevent acute exacerbations of chronic tinnitus, it is crucial to assist patients in developing healthy living habits, improving social interactions, and enhancing their ability to manage stress.
doi.org/10.1097/CM9.0000000000001382
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