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Improvement of Tinnitus following Tympanoplasty and Tympanomastoidectomy Surgeries in Patients with Chronic Otitis Media

Masoumeh Saeedi1, Mohammad Hossein Khosravi 2,3

1 Department of Otorhinolaryngology, Head and Neck Surgery, Faculty of Medicine, Baqiyatallah University of Medical Sciences, Tehran, Iran

2 Students’ Research Committee (SRC), Baqiyatallah University of Medical Sciences, Tehran, Iran

3 International Otorhinolaryngology Research Association (IORA), Universal Scientific Education and Research Network (USERN), Tehran, Iran

Abstract

Background: After otorrhea and hearing loss, Tinnitus is the most common symptom in patients with chronic otitis media (COM). The aim of this study was to evaluate the improvement of tinnitus in COM patients after tympanoplasty and tympanomastoidectomy surgeries. Materials and Methods: This cross-sectional study was conducted on COM patients suffering from Tinnitus referred to Baqiyatallah hospital, Tehran, Iran undergoing tympanoplasty or tympanomastoidectomy surgeries between March 2013 and August 2014. Tinnitus Handicap Inventory (THI) and Visual Analogue Scale (VAS) questionnaires were filled before and two months after surgery by each patient, and considered subjects were compared with each other. Audiometry test was taken from each patient before and two months after surgery. Audiometry results as well as Air-Bone gap were measured and evaluated prior and after surgery. Data were analyzed using SPSS software by ANOVA, sample t-test and Chi-square tests. Results: Eventually, 26 male and 24 female patients with a mean age of 38.62±11.88 years were enrolled. Air conduction at all frequencies was 49.99±17.37 before and 36.98±22.06 after surgery (P<0.001). Severity of tinnitus was 62.92±30.54 before and 30.54±20.08 after surgery based on THI (P<0.001). Also, it was 7.46±1.66 before and 3.5±2.06 after surgery based on VAS evaluations (P<0.001). Tinnitus severity reduction was significantly associated with the improvement of hearing loss and decrement of air-Bone gap (P<0.001). Tinnitus symptoms such as loudness, annoyance, impact on life and perception of Tinnitus significantly reduced after surgery. Moreover, Tympanomastoidectomy was more effective on the improvement of Tinnitus in comparison with Tympanoplasty (P=0.019).Conclusion: It seems that, both tympanomastoidectomy and tympanoplasty surgeries are effective on the improvement of tinnitus in patients with COM; however, Tympanomastoidectom surgery was shown to be more effective.[GMJ.2016;5(2):63-69]

Keywords: Tinnitus; Otitis Media; Tympanoplasty; Tympanomastoidectomy

Correspondence to:

Mohammad Hossein Khosravi, Students’ Research Committee (SRC), Baqiyatallah University of Medical Sciences, Tehran, Iran

Telephone Number: +989126441288

Email Address: dr.mhkhosravi@gmail.com

Introduction

Tinnitus is defined as the perception of a sound in the absence of an apparent acoustic stimulus [1]. Tinnitus is a relatively prevalent condition which involves approximately one fifth of the people 55 to 65 years old [2]. It is more prevalent in men in comparison with women and smokers [2]. About 50 million Americans suffer from Tinnitus [2]. Tinnitus is one of the three main symptoms of ear diseases and vestibulocochlear disorders which is sometimes so disturbing that it influences patients’ hearing. Tinnitus can be triggered anywhere along the auditory pathway and is usually associated with hearing loss [3].

Tinnitus is caused by a wide spectrum of disorders from metabolic (hypo- or hyperthyroidism and hyperlipidemia), pharmacologic (NSAIDs, Aminoglycosides, heavy metals) and neurologic (Meningitis and Multiple Sclerosis) to otosclerosis, chronic otitis media and brain tumors [4-6].

Therapeutic actions are effective when tinnitus is caused by outer and middle ear disorders; while treatment is less effective when Tinnitus is a result of cochlea, vestibulocochlear nerve and CNS problems [7]. Unfortunately, most cases of tinnitus are a result of inner ear or central structure disorders [7]. Several medications have been used for tinnitus but they were not really effective [8]. Some complementary and alternative therapies such as acupuncture, transcranial magnetic stimulation (TMS), Tinnitus retaining therapy (TRT) and biofeedback are suggested for this condition [9-12].

Patients with tinnitus associated with middle ear disorders such as otosclerosis, tympanic perforation and chronic otitis media (COM) may benefit from surgery. COM is a prevalent disease of the middle ear and sometimes patients are more disturbed by Tinnitus than otorrhea and hearing loss. It has been suggested that patients may improve by tympanic repair through Tympanoplasty or Tympanomastoidectomy but it has remained a controversy [13]. Previous studies have shown improvement of tinnitus in conductive hearing loss following tympanoplasty [14].

So, in the present study we aimed to evaluate the improvement of tinnitus in COM patients after tympanoplasty and tympanomastoidectomy surgeries.

Materials and Methods

1. Research Design and Setting

This cross-sectional study was conducted on patients with COM suffering from Tinnitus, referring to Otorhinolaryngology clinic of Baqiyatallah hospital, Tehran, Iran between March 2013 and August 2014.

2. Selection Criteria

2.1. Inclusion Criteria

After signing an informed consent form and confirmation of COM by a single otolaryngologist, patients who had unilateral and constant Tinnitus were assigned to Tympanoplasty or Tympanomastoidectomy surgeries.

2.2. Exclusion Criteria

Patients more than 50 years of age and those with underlying neurologic or psychiatric diseases, clinical or audiological contraindications for surgery and history of surgery in the Tinnitus-affected ear were excluded from the study. Patients with no improvement in tympanic membrane after Tympanoplasty or requiring bone chain repair were excluded from analysis.

3. Data Collection

A pure-tone audiometry (PTA) was taken from each patient prior and two months after surgery. Air and bone conduction levels as well as air-bone gap at 0.5, 1, 2, 4 and 6 kHz frequencies were evaluated in audiometry assessment and results were compared.

A Persian version of Tinnitus Handicap Inventory (THI) validated by Mahmoudian et al. in 19 to 75-year old people [15], and Visual Analog Scale (VAS( Questionnaires for assessing Tinnitus severity, loudness, annoyance and impact on patients’ life and mood were filled before and two months after surgery by each patient and considered subjects were compared with each other.

4. Research Ethics

This study was registered in ethics committee of Baqiyatallah University of Medical Sciences (IR.BMSU.REC.1394.145). Information of all patients remained confidential and all the steps of study were conducted following Helsinki’s declaration.

5. Statistical Analyses

Data were analyzed using Statistical Package for Social Sciences (SPSS) version 16 (SPSS Inc. Chicago, IL) for Windows. Normal distribution variables (approved by one-sample Kolmogorov–Smirnov test) were compared between the groups using independent sample t-test and paired sample t-test within the groups. Chi- square test was also used to compare categorical variables in two groups. A p-value of less than 0.05 was considered statistically significant.

Results

Eventually 50 cases (26 male and 24 female) with amean age of 38.62 ± 11.68 years underwent analysis. Mean age was 37.69±12.97 in male and 39.63±10.77 in female patients (P=0.571). In 13 males and 8 females, left ears were affected by Tinnitus; while 13 males and 16 females had right-ear involvement (P=0.183).

Duration of Tinnitus is summarized in Table-1 regarding gender. A total of 6 patients had Tinnitus less than one year and duration of Tinnitus was significantly higher in male patients (P=0.004).

The results of audiometry test at 0.5, 1, 2, 4 and 6kHz frequencies are summarized in Table-2 regarding air and bone conduction levels. According to audiometry results, air conduction level significantly decreased at 0.5, 1, 2, 4 and 6kHz frequencies after surgery; while bone conduction level did not significantly decrease at any frequency (Table-2). In general, mean air conduction level at all frequencies was 49.99±17.37 dB before and 36.98±22.06 dB after surgery (P<0.001). Mean bone conduction level at all frequencies was 18.55±16.55 dB before and 17.41±12.43 dB after surgery (P=0.243). The mean Air/Bone gap levels (difference between air and bone conduction levels) were 31.44 ± 8.17 dB and 19.57 ± 16.34 dB before and after surgery, respectively (P<0.001).

The mean Tinnitusseverity score, based on tinnitus handicap inventory (THI), was 62.92 ± 18.69 before and 30.54 ± 20.08 after surgery (P<0.001). Of 50 patients, 46 (92%) had an improvement in Tinnitus after surgery in which 12(24%) patients fully recovered and 34 (68%) mentioned a reduction in Tinnitus; while 4(8%) patients did not mention any changes in their conditions.

Mean visual analogue scale (VAS) score of patients is shown in Table-3. Mean loudness and awareness of Tinnitus scores as well as discomfort, disturbance, sleep alteration and mood change scores due to Tinnitus significantly decreased after surgery (P<0.001).

The mean Tinnitus score and air conduction level showed a decrease of 32.38 ± 21.16 and 13.02 ± 9.26, respectively after surgery. There was a significant correlation between the improvement of Tinnitus and changes in air conduction level (P= 0.036, R= 0.246). The mean bone conduction level improved by 1.14±6.84 after surgery (P=0.243). There was no significant correlation between the improvement of Tinnitus and changes in bone conduction level (P= 0.06, R= 0.68). The mean Air/Bone gap level improved by 11.87 ±12.36 postoperatively. There was a significant relation between Tinnitus improvement and Air/Bone gap level (P=0.018, R=0.33).

Mean air and bone conduction levels decreased by 11.53 ±11.69 dB in patients (N=17) who underwent Tympanoplasty and 12.05 ±12.86 dB in patients (N=33) who underwent Tympanoplasty and Mastoidectomy (P=0.887, Figure-1). Mean Tinnitus severity score decreased by 24±13.62 in patients who underwent Tympanoplasty and by 36.69±23.16 in patients who underwent Tympanoplasty and Mastoidectomy (P=0.019, Figure-2).

Discussion

In the present study, we found significant improvements in air conduction level postoperatively. Also Air/Bone gap level reduced significantly. We found that Tinnitus significantly improved following surgery and the reduction in Tinnitus severity score had a correlation with the improvement of air conduction level and the reduction in Air/Bone gap. Our findings showed that patients who underwent Tympanomastoidectomy had a significantly higher improvement inTinnitus than patients who had received Tympanoplasty.

Saito et al., in a retrospective study, reported that Tinnitus significantly improved after surgery which is in agreement with the present study; however, improvement rate was higher in our study. As well as the retrospective evaluation, they assessed a limited number of patients which could have an influence on the results [16]. The improvement of Tinnitus was also higher in the present study than another similar one by Helms et al. [17].

In a retrospective study, Baba et al. evaluated a larger number of patients than the present study. They applied VAS questionnaire to assess Tinnitus severity and hearing improvement rather than THI that was applied in the present study. Baba et al. reported a lower improvement in hearing following surgery than the present study and the relation between hearing and Tinnitus improvement was not assessed [18].

In concordance with the present study, Lima et al. reported the same improvement in Tinnitus postoperatively considering that they included fewer number of patients than the present study [14]. Lima et al. assessed Tinnitus severity only by VAS score; while we applied both VAS and THI in which it helps with a more accurate and detailed assessment. Their study did not show any significant correlation between the improvement of Tinnitus and hearing which is not in agreement with our study. Pollyanna et al. reported the same result as ours considering that they only applied VAS questionnaire and did not conduct audiometry and calculate Air/Bone gap postoperatively [19].

Kim et al. reported an improvement of Tinnitus in patients after Tympanoplasty surgery which was in accordance with our study [20]. In their study, the improvement of Tinnitus was significantly related to air conduction level improvement but showed no significant correlation with reduced Air/Bone gap.

Habeseglu et al. demonstrated significant improvements in Tinnitus and hearing after Tympanoplasty and also showed a significant relation between these two, confirming our results [21]. Habeseglu et al. evaluated fewer number of patients than the present study and also their patients had different middle ear diseases which might be confounding.

In contrast with the present study, Pichora-Fuller et al. [22] concluded that there was no significant relation between Tinnitus and audiometry test results. Seemingly, this finding was due to early postoperative evaluation.

The present study has some limitations such as low sample volume. Moreover, the current research design may provide less options for controlling confounders.

Conclusion

In conclusion, both Tympanomastoidectomy and Tympanoplasty surgeries are effective in the improvement of Tinnitus in patients with COM; however, Tympanomastoidectomy surgery was shown to be more effective. Also, it was concluded that Tinnitus severity reduction is associated with the improvement of hearing loss and decrement of Air-Bone gap.

Future studies with a larger sample and prospective design are needed to be conducted regarding all confounding factors. It is also recommended to evaluate Tinnitus improvement rate in different types of surgeries. It is suggested that further studies use objective methods for determining Tinnitus severity and also assess patients in whom Tinnitus gets worse following surgery.

Conflict of Interest

There are no conflicts of interest in terms of the present manuscript.

Table 1. Duration of Tinnitus in Study Individuals

Duration of tinnitus (year)

Male (N %)

Female (N %)

Total (N %)

<1

6(21.3%)

0(0%)

6(12%)

1-3

4(15.4%)

14(58.3%)

18(36%)

3-10

11(42.3%)

6(25%)

17(34%)

>10

5(19.2%)

4(16.7%)

9(18%)

P-Value

0.004

Table 2. Audiometry Test Results in Study Individuals Before and After Surgery

Frequency(kHz)

0.5

Before Surgery (n=50)

After Surgery (n=50)

P-Value

Air Conduction Level (dB)

47.6 ± 17.56

32.7 ± 20.53

<0.001

Bone Conduction Level (dB)

13.72 ± 13.27

12.36 ± 11.09

0.27

1

Air Conduction (dB)

47.86 ± 14.32

33.28 ± 19.29

<0.001

Bone Conduction (dB)

14.36 ± 14.06

13.20 ± 10.77

0.11

2

Air Conduction (dB)

48.9 ± 19.12

34.9 ± 23.11

<0.001

Bone Conduction (dB)

17.86 ± 15.19

15.98 ± 11.01

0.06

4

Air Conduction (dB)

51.8 ± 21.18

38.9 ± 25.89

<0.001

Bone Conduction (dB)

19.98 ± 17.62

19.40 ± 12.84

0.67

6

Air Conduction (dB)

53.80 ± 23.29

45.10 ± 28.49

<0.001

Bone Conduction (dB)

26.84 ± 26.32

26.10 ± 22.66

0.66

Table 3. Mean VAS Score of Patients Before and After Surgery

VAS Score, mean ± SD

Preoperative (n = 50)

Postoperative (n = 50)

P-value

Loudness

7.46 ± 1.66

3.50 ± 2.06

<0.001

Discomfort

7.28 ± 1.49

3.12 ± 1.75

<0.001

Disturbance

6.82 ± 1.65

2.96 ± 1.79

<0.001

Awareness

7.0 ± 1.86

3.68 ± 2.52

<0.001

Sleep disorder

6.34 ± 2.68

2.78 ± 2.01

<0.001

Mood

6.6 ±1.86

3.22± 1.96

<0.001

Figure 1. Mean Air-Bone Gap Level in Study Individuals Before and After Surgery

Figure 2. Mean THI scores in study individuals before and after surgery

References

  1. Hazell J, Jastreboff P. Tinnitus. I: Auditory mechanisms: a model for tinnitus and hearing impairment. The Journal of otolaryngology. 1990;19(1):1-5.
  2. Shargorodsky J, Curhan GC, Farwell WR. Prevalence and characteristics of tinnitus among US adults. The American journal of medicine. 2010;123(8):711-8.
  3. Melcher J, Sigalovsky I, Guinan J, Levine R. Lateralized tinnitus studied with functional magnetic resonance imaging: abnormal inferior colliculus activation. Journal of neurophysiology. 2000;83(2):1058-72.
  4. Griest SE, Bishop PM. Tinnitus as an early indicator of permanent hearing loss: A 15 year longitudinal study of noise exposed workers. Workplace Health & Safety. 1998;46(7):325.
  5. Nowak K, Banaszewski J, Dabrowski P, Szymiec E, Szyfter W. [Tinnitus in systemic diseases]. Otolaryngologia polska The Polish otolaryngology. 2001;56(2):213-6.
  6. Eggermont JJ, Roberts LE. The neuroscience of tinnitus. Trends in neurosciences. 2004;27(11):676-82.
  7. Sullivan MD, Katon W, Dobie R, Sakai C, Russo J, Harrop-Griffiths J. Disabling tinnitus: association with affective disorder. General hospital psychiatry. 1988;10(4):285-91.
  8. Baldo P, Doree C, Molin P, McFerran D, Cecco S. Antidepressants for patients with tinnitus. The Cochrane Library. 2012.
  9. Langguth B, Hajak G, Kleinjung T, Pridmore S, Sand P, Eichhammer P. Repetitive transcranial magnetic stimulation and chronic tinnitus. Acta Oto-Laryngologica. 2006;126(S556):102-4.
  10. Phillips JS, McFerran D. Tinnitus retraining therapy (TRT) for tinnitus. The Cochrane Library. 2010.
  11. Jastreboff PJ, Hazell JW. A neurophysiological approach to tinnitus: clinical implications. British journal of audiology. 1993;27(1):7-17.
  12. Dobie RA. A review of randomized clinical trials in tinnitus. The Laryngoscope. 1999;109(8):1202-11.
  13. Waldvogel D, Mattle HP, Sturzenegger M, Schroth G. Pulsatile tinnitus—a review of 84 patients. Journal of neurology. 1998;245(3):137-42.
  14. Lima AdS, Sanchez TG, Moraes MFB, Alves SCB, Bento RF. The effect of timpanoplasty on tinnitus in patients with conductive hearing loss: a six month follow-up. Revista Brasileira de Otorrinolaringologia. 2007;73(3):384-9.
  15. Mahmoudian S, Shahmiri E, Rouzbahani M, Jafari Z, Reza Keyhani M, Rahimi F, et al. Persian language version of the” Tinnitus Handicap Inventory”: translation, standardization, validity and reliability. International Tinnitus Journal. 2011;16(2):93.
  16. Saito T, Kimura Y, Yamada T, Kono Y, Tanaka N, Shibamori Y, et al. [Efficacy of middle ear surgery for patients with hearing aids and middle ear disease]. Nihon Jibiinkoka Gakkai Kaiho. 1999;102(3):347-53.
  17. Helms J. [Tympanoplasty and Tinnitus (author’s transl)]. Laryngologie, Rhinologie, Otologie. 1981;60(3):99-100.
  18. Baba S, Yagi T, Fujikura T. Subjective evaluation and overall satisfaction after tympanoplasty for chronic simple suppurative otitis media. Journal of Nippon Medical School. 2004;71(1):17-24.
  19. Sobrinho PG, Oliveira CA, Venosa AR. Long-term follow-up of tinnitus in patients with otosclerosis after stapes surgery. International Tinnitus Journal. 2004;10(2):197-201.
  20. Kim J-I, Choi J-Y, Lee D-H, Choi T-Y, Lee MS, Ernst E. Acupuncture for the treatment of tinnitus: a systematic review of randomized clinical trials. BMC complementary and alternative medicine. 2012;12(1):97.
  21. Habesoglu M, Habesoglu TE, Karatas C, Tosun A, Gursel AO, Oysu C. Is there any predictor for tinnitus outcome in different types of otologic surgery? European Archives of Oto-Rhino-Laryngology. 2013;270(8):2225-9.
  22. Pichora-Fuller MK, Santaguida P, Hammill A, Oremus M, Westerberg B, Ali U, et al. AHRQ Comparative Effectiveness Reviews. Evaluation and Treatment of Tinnitus: Comparative Effectiveness. Rockville (MD): Agency for Healthcare Research and Quality (US); 2013.

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