Tinnitus in children and associated risk factors
Introduction
Children experience tinnitus as frequently as adults, but most of them do not seem to be bothered. In some cases, they might present similar suffering as observed in adults (Martin and Snashall, 1994). Tinnitus can cause a significant influence on children's life which will inevitably affect their families as well (Kentish and Crocker, 2006).
Investigating tinnitus in childhood is challenging because of its subjectivity and because children are different from adults in several ways. Mills et al. (1986) suggested that statistics in children are underestimated due to communication difficulties. Conversely, Stouffer et al. (1991) argued that children have a tendency to over-report tinnitus when inquired to please the questioner. The rate with which children seek professional help might not reveal the true prevalence because children rarely report tinnitus spontaneously (Fowler and Fowler, 1955; Graham, 1965) and presence of tinnitus is seldom an item in routine pediatric otolaryngological examinations.
Population studies on the epidemiology of tinnitus among children have disclosed prevalence rates from 6% to 59% (Table 1). These studies have differed significantly in their methods of data collection, diagnostic criteria, and age groups.
An effort to minimize communicating problems with children was done by Stouffer et al. (1991) who used a questionnaire with different approaches to the same questions to verify the responses. The results of epidemiologic studies of tinnitus among children also depended on how rigorously the examiners applied their criteria (Table 1). Assessing the difference between the perception of a sound, (tinnitus sensation) and the impact of tinnitus on a person (tinnitus suffering) provides information about the prevalence of problematic tinnitus; but that was rarely adopted in the published studies of tinnitus in children (Table 1).
The purposes of present study were (1) to determine the prevalence of tinnitus in a general pediatric population, differentiating sensation from suffering and (2) to determine the importance of risk factors such as noise exposure, history of otitis media, otologic surgery, middle ear alterations, and hyperacusis.
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Methods
A prospective cross-sectional study of the presence of tinnitus among 13,000 children of the public and private elementary schools in Lajeado, a southern Brazilian town of 64,133 inhabitants was done between September 2002 and December 2003.
Selection criteria
Among the 13,000 children, 700 children 5–12 years of age were randomly selected, 516 of the children's parents (75%) returned the informed consent. Ten of them were excluded for the following reasons: fear of performing the evaluation (n=4) and incomplete examination dates after three attempts (n=6). The final sample included 506 children.
Procedure
This sample was selected on a two-stage cluster sampling (Abramson, 2002). The primary units (clusters) were the 44 schools. The sampling frame was all the schools in the town, from which schools were selected using probability proportional to school size. Each school on the list was allocated a weighting equivalent to the number of children enrolled who were eligible to be selected for the study. The proportion of children in public to private schools was 4:1. Therefore, 75% of the sample was
Data collection and design
The present study was approved by the ethics committee of research of the University of São Paulo. Written consent was obtained from all parents and verbal consent from all children. The data were collected in a cross-sectional survey. Questionnaire data were collected from parents, and the interviews were conducted with the children, as well as the otoscopic evaluation and hearing tests. All children were interviewed and examined by the first author and all audiometric tests were performed by
Data analysis
Two pure-tone average (PTA) scores were calculated for each ear one for low frequencies (0.5, 1, and 2 kHz) and one for the high frequencies (3 and 4 kHz). Mean values of both PTAs were used to classify the degree of hearing loss according to Silman and Silverman (1997): normal hearing, 10–15 dB HL; (b) minimum loss, 16–25 dB; (c) mild, 26dB HL; (d) moderate loss, 41–55 dB HL; (e) moderate to severe loss, 56–70 dB HL; (f) severe loss, 71–90 dB HL; and (g) profound loss, >91 dB HL.
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Statistical analysis
Statistical analysis of the collected data were performed by a professional statistician using SAS (version 9.1, SAS Institute, Inc., Cary, NC) software. Chi-square or two-sided Fisher's exact test were used to access bivariate risk factor associations and demographics, as well as symptoms. Unconditional logistic regression was used to examine multiple independent variables for their association with the outcomes. Final multivariate models were designed using a saturated model and manual
Results
There were 240 girls (47.4%) and 266 boys (52.6%), mean age 9.46 (SD=2.09) in the study; 86.2% white, 9.1% mixed, and 4.7% black. Hearing thresholds were classified as normal in 81% (n=411), minimum to mild loss in 14% (n=72), and moderate to profound hearing loss in 4% (n=19) of the children.
Tinnitus sensation was confirmed in 37.5% of the children (n=190) and tinnitus suffering in 19.6% (n=99). The classification criteria are described in Fig. 1. Tinnitus characteristics, location, and
Discussion
When studying tinnitus among children, it should be kept in mind that a child is not a small adult. For example, it has been shown that somatosensory stimulation can change loudness perception in children but that is less likely in adults (Møller and Rollins, 2002) indicating that the nonclassical (extralemniscal) auditory pathways (Møller, 2003) are commonly active in children but rarely in adults. Their auditory pathway and neural connections is under a maturation process (Werner, 1996) and
Prevalence
In this study of children in the age range of 5–12 years the general over all prevalence of tinnitus was 37.5% (n=190) for sensation and 19.6% (n=99) for suffering. Mills et al. (1986) were the first to report prevalence of tinnitus in children using this classification. They found tinnitus sensation in 29% of the sample and suffering in 9.6% among 93 children with age range from 5 to 16 years in a nonrandomized sample. Holgers and Pettersson (2005) showed prevalence for tinnitus perception in
Risk factors associated with tinnitus sensation and suffering
The risk for tinnitus sensation and tinnitus annoyance has been shown to be progressive as age increases with a risk of 1.1 and 1.2 times, respectively for every year raise. Nodar (1972) in a sample from 10 to 18 years and Aksoy et al. (2007) 6 to 16 years, observed a progressive increase in tinnitus incidence until 13 to14 years of age in their studies. This tendency was confirmed in the present study, but we could not verify if the prevalence kept increasing until 14 years because our age
Conclusion
Tinnitus sensation is a common finding among children. In some cases it might cause interference in concentration, sleeping, and hearing and become a problematic symptom. Because children often do not complain about tinnitus, it is likely to be unnoticed by parents and clinicians. Differences in prevalence rates among studies between children can be attributed to different methodologies, questionnaires, and the way tinnitus is defined. Appropriated instruments to evaluate tinnitus annoyance in
Acknowledgments
This study was partially supported by grants from the Fundação de Amparo à Pesquisa de São Paulo (Fapesp 03/00574-5). We are grateful to Sandra Weber, who was responsible for all audiometric evaluations of the children in the study; and Keila Knobel and Matt Gilchrist, who provided very helpful comments on earlier versions of the manuscript. Statistical analysis performed by Ana Capuano was much appreciated.
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