Severe tinnitus: how can we approach it?
Year: 2025
Type: article
Study design: Observational Study
Abstract: INTRODUCTION Tinnitus, the perception of sound without an external source, is a prevalent condition affecting approximately 20% of people worldwide, with 2%–4% experiencing significant distress.[1] Commonly described as ringing, buzzing, hissing, whistling or whooshing sounds, tinnitus is also notable in Singapore, where a community screening programme reported a prevalence of 17% among seniors aged 60 and above.[2] Despite its widespread occurrence, the experience of tinnitus varies greatly. While most individuals can cope with the condition, a small percentage find tinnitus highly distressing. This raises an important question: why do some individuals adapt effortlessly, while others struggle with significant psychological and emotional distress? Tinnitus is associated with a variety of conditions affecting both the peripheral and central auditory systems. It often coexists with hearing loss. However, many individuals with hearing loss do not experience tinnitus, and some patients with tinnitus exhibit no measurable hearing loss. Interestingly, the severity of tinnitus distress is not strongly correlated with its audiological characteristics, such as pitch, loudness or minimum masking levels. These traditional measures fail to capture the subjective aspects of tinnitus, which are more reflective of the level of distress and need for intervention. This suggests that the psychological response to tinnitus, rather than its sensory features, plays a key role in determining the individual impact. METHODS A retrospective study was carried out in a public hospital in Singapore to determine the key factors associated with patients distressed by tinnitus. The data of tinnitus patients who were referred to the audiology department for tinnitus management from 2016 to 2019 were analysed. This study was approved by the Ethics Committee of the National Healthcare Group Domain Specific Review Board (DSRB Ref No.: 2020/00745). All patients filled out the Tinnitus Handicap Inventory (THI) and tinnitus questionnaire as a part of their first tinnitus management session. The THI is a self-reported measure to evaluate the perceived severity of tinnitus and quantify its impact on a patient’s quality of life. It contains 25 items grouped into catastrophic, emotional and functional subscales. The overall score ranges from 0 to 100 and is categorised into five grades of tinnitus severity. A score of 0–16 indicates slight/no handicap, 18–36 indicates mild handicap, 38–56 indicates moderate handicap, 58–76 indicates severe handicap, and 78–100 indicates catastrophic handicap.[3] The tinnitus questionnaire contains questions on the characteristics of the tinnitus. Information on ear symptoms such as ear pain, ear fullness or muffed hearing were solicited. Patients were also asked if they experienced hyperacusis or sound intolerance, recent personal stressors or sleep disturbances. Age, gender, ethnic group and audiometric data were recorded as baseline information. Data from the questionnaires were extracted and tabulated. During data extraction, no patient identifiers were extracted. Anonymisation involves using a random serial number for each patient and de-linking the anonymised data from the collated data. RESULTS From January 2016 to September 2019, 4356 patients attended the Ear, Nose and Throat (ENT) Clinic at Ng Teng Fong General Hospital with otological complaints as the primary concern. Of these, 760 reported tinnitus, and 208 (27.4%) were referred to the tinnitus clinic for management. Prior to their referral, patients would have been examined by an ENT specialist. Patients with medically treatable tinnitus or underlying psychiatric conditions were not referred to the tinnitus clinic and therefore excluded from this study. The median age of the referred patients was 52 ± 16 years (range 18–88), and 52% of patients were male. Audiometric data revealed that 42% had normal hearing, while 58% had hearing loss of varying degrees. Among those with hearing loss, 74% exhibited bilateral sensorineural high-frequency loss, and eight patients had conductive hearing loss. Tinnitus was bilateral in 50% of cases and unilateral in the rest. Tinnitus characteristics were described by patients as high-pitched ringing (54%), cricket-like sound (24%), and other sounds such as buzzing, hissing or roaring (23%). Aural symptoms such as aural fullness and otalgia were reported by 13% of patients, and 8% experienced sound intolerance or hyperacusis, with sounds such as traffic sounds or children crying being triggers. Additionally, 48% and 42% of patients reported personal stressors and sleep disturbances, respectively. Of the 208 patients, 201 completed the THI questionnaire (seven patients could not understand the questions). Among these, 54% had a slight or mild tinnitus handicap, 27% had a moderate handicap, 10% had a severe handicap, and 9% had a catastrophic handicap. Analysis of THI responses revealed that feelings of frustration (30.7%) and feeling upset (28.8%) were the most common emotion reactions. On the catastrophic subscale, 55% felt a loss of control, and 42% felt trapped by the condition. Severe tinnitus-related distress, as indicated by THI scores of 58 and above, was found to be associated with specific factors. Patients presenting with difficulty coping with life stressors and having sleep disturbances had significantly higher THI scores. No significant associations were observed between severe tinnitus distress and gender, hearing status, nature of tinnitus sounds, presence of hyperacusis or other aural symptoms. Multivariate logistic regression showed that patients experiencing life stressors were 3.4 times more likely to report severe tinnitus distress (adjusted odds ratio [AOR] 3.4, 95% confidence interval [CI] 1.54–7.46), while those with sleep disturbances had a 2.8 times higher likelihood of reporting severe distress (AOR 2.79. 95% CI 1.28–6.06) [Table 1]. Among patients with severe distress, 73% experienced life stressors and 71% insomnia. Comparatively, only 15% of patients with severe tinnitus distress reported hyperacusis, or intolerance to everyday sounds. This underscores the importance of emotional factors in tinnitus distress.Table 1: Factors associated with severe tinnitus distress.DISCUSSION Notwithstanding its retrospective design, which precludes establishing causality between factors and severe tinnitus distress, and its reliance on self-reported measures such as the THI, this study provides important insights into the factors driving severe tinnitus distress. Our findings reveal that psychological and emotional factors, rather than audiological characteristics, predominantly influence the severity of tinnitus-related distress. Notably, 42% of patients with tinnitus had normal hearing and the severity of distress was not correlated with hearing loss, challenging the assumption that tinnitus severity is primarily tied to auditory deficits. Similarly, there appears to be no significant association between the nature of tinnitus sound and the level of distress, reinforcing that sensory characteristics are less critical than subjective responses. In this study, severe tinnitus distress, as indicated by THI scores above 58, was associated with the presence of life stressors and sleep disturbances. Several theories have been proposed to explain how individuals adapt to tinnitus, with three prominent ones being the neurophysiological, habituation and stress-coping models. The neurophysiological model[4] posits that tinnitus is a physiological condition rooted in abnormalities within the auditory system. It emphasises the role of auditory pathways and non-auditory systems, such as the limbic system, in tinnitus perception. Those with distressing tinnitus are thought to have an abnormal ‘gain’ or amplification in these pathways, leading to heightened sensitivity. This model suggests that the inability to habituate to this overactive sensory input contributes to the distress associated with tinnitus. The habituation model[5] compares tinnitus adaptation to how animals adapt to repetitive stimuli through habituation. In humans, this process is influenced by the emotional and physiological states. The level of arousal at the time of exposure to tinnitus plays a significant role in how the brain processes the sound. Lower stress levels and a more relaxed state can facilitate habituation, making the sound less intrusive over time. The stress-coping model[6] frames tinnitus adaptation as a cognitive process tied to stress management. Tinnitus is viewed as a chronic stressor that causes emotional strain when coping resources are insufficient. Individuals who struggle with tinnitus may lack effective coping strategies or use approaches that inadvertently prolong distress. Successful adaptation involves developing better coping mechanisms and reframing the perception of tinnitus-related stress. Our findings support these models that collectively highlight the interplay of cognitive and emotional factors in shaping individual responses to tinnitus. Patients with severe distress often reported maladaptive beliefs, such as a perceived lack of control over tinnitus (55% endorsed THI item 19: “Do you feel that you have no control over your tinnitus?”) or feeling trapped by the condition (42%). These catastrophic cognitions amplify emotional distress and hinder adaptation. Clinically, healthcare professionals should address these beliefs through targeted counselling, challenging notions like “tinnitus will ruin my life” or “I can never cope with this sound.” Providing accurate information about tinnitus and its manageability can reframe these perceptions and reduce distress. For healthcare professionals, managing severe tinnitus requires a multifaceted approach. Beyond ruling out red flags, clinicians should assess for significant life stressors and sleep disturbances, referring patients to tinnitus management programmes when these are present. Given the emotional toll of severe tinnitus, clinicians must also screen for suicidal ideation, particularly in patients with catastrophic THI scores (9% in this study). Urgent referral to psychiatry is warranted if suicidal thoughts or significant distress are identified, ensuring timely intervention. Tinnitus management programmes should integrate cognitive-behavioural strategies to weaken the link between tinnitus and distress, alongside therapeutic sound interventions to promote habituation. The ultimate goal of therapy is learned inhibition, where the link between tinnitus and distress is weakened, even if the perception of tinnitus persists. By targeting cognitive and emotional factors, therapy empowers individuals, minimising tinnitus reaction and its impact on their lives. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.
Source: Singapore Medical Journal
Authors: Gary Jek Chong Lee, Jasmine Jek Peng Liew, Andrew Wei Li Teng
Institution: Ng Teng Fong General Hospital
Language: English
Subfield: Sensory Systems
Field: Neuroscience
Domain: Life Sciences
Open Access status: diamond
OpenAlex ID: W4414629732