Association Between Childhood Hearing Disorders and Tinnitus in Adulthood

Research

Original Investigation Association Between Childhood Hearing Disorders and Tinnitus in Adulthood

Lisa Aarhus, MD; Bo Engdahl, PhD; Kristian Tambs, PhD; Ellen Kvestad, MD, PhD; Howard J. Hoffman, MA

IMPORTANCE The association between childhood hearing disorders and adult tinnitus has not been examined in longitudinal cohort studies.

OBJECTIVES To determine the association between different types of childhood hearing loss and tinnitus in adulthood and evaluate whether tinnitus risk is mediated by adult hearing loss.

DESIGN, SETTING, AND PARTICIPANTS Population-based cohort study of 32 430 adults (aged 20-56 years) who underwent pure-tone audiometry and completed a tinnitus questionnaire in the Nord-Trøndelag Hearing Loss Study, which was a part of the Nord-Trøndelag Health Study 2 (HUNT2). The study was conducted from January 1, 2014, to April 1, 2015. Data analysis was performed from April 1, 2014, to April 1, 2015. As children, the same individuals had undergone screening audiometry in a longitudinal primary school hearing investigation, including ear, nose, and throat examinations when indicated.

INTERVENTIONS Pure-tone audiometry, questionnaires, and ear, nose, and throat examinations.

MAIN OUTCOMES AND MEASURES Self-reported tinnitus (yes or no) in adulthood measured by questionnaires.

RESULTS Adults who had hearing loss at the time of the school investigation (n = 3026) reported more tinnitus, measured as odds ratio (95% CI), than did adults with normal childhood hearing (n = 29 404) (1.4 [1.3-1.6]). Childhood hearing disorders associated with tinnitus in adulthood included sensorineural hearing loss, chronic suppurative otitis media, and hearing loss associated with a history of recurrent acute otitis media (2.4 [1.9-3.0], 2.4 [1.5-3.9], and 1.6 [1.3-2.0], respectively). These estimates were adjusted for age, sex, and noise exposure in adulthood. After further analyses that included adjustment for adult hearing threshold, none of these childhood hearing disorders remained positively associated with tinnitus.

CONCLUSIONS AND RELEVANCE Childhood hearing disorders associated with tinnitus in adulthood include sensorineural hearing loss, chronic suppurative otitis media, and hearing loss associated with a history of recurrent acute otitis media. After adjustment for the adult hearing threshold, none of the childhood hearing disorders was positively associated with tinnitus. Hence, it appears that these significant associations are mediated or transmitted through adult hearing loss.

Author Affiliations: Division of Mental Health, Norwegian Institute of Public Health, Oslo, Norway (Aarhus, Engdahl, Tambs, Kvestad); Epidemiology and Statistics Program, National Institute on Deafness and Other Communication Disorders, National Institutes of Health, Bethesda, Maryland (Hoffman). Corresponding Author: Lisa Aarhus, MD, Division of Mental Health, Norwegian Institute of Public Health, JAMA Otolaryngol Head Neck Surg. 2015;141(11):983-989. doi:10.1001/jamaoto.2015.2378 PO Box 4404, Nydalen, 0403 Oslo, Published online November 5, 2015. Norway ([email protected]).

(Reprinted) 983

Downloaded From: https://jamanetwork.com/ on 09/26/2021 Research Original Investigation Association Between Childhood Hearing Disorders and Tinnitus in Adults

innitus, a ringing, roaring, or buzzing in the ears or head, Another study18 from the same database (the linkage is a common symptom that can be debilitating. Preva- between the SHINT and NTHLS) reported a super-additive T lence estimates are mixed, but most studies1,2 show effect of childhood high-frequency sensorineural hearing prevalences of bothersome tinnitus (episodes lasting ≥5 min- loss (SNHL) and aging on adult hearing. utes during the past year) between 10% and 15% in the adult population. Baseline Childhood Study Hearing loss is presumably the most important risk factor The late Norwegian ear, nose, and throat (ENT) specialist Hans for tinnitus, but the association is complex. Tinnitus is re- Fredrik Fabritius, MD, and his colleagues conducted an audio- ported in individuals with apparently normal hearing, and only metric screening of almost all 7-, 10-, and 13-year-old school some hearing-impaired persons report tinnitus. One current, children in Nord-Trøndelag County, Norway, from 1954 to 1986. prominent causal theory of tinnitus states that hearing loss is The study did not record information confirming the partici- often the initial source of tinnitus but that subsequent neural pation of children with normal hearing, so the exact number changes in the central auditory system maintain the condition.3 of participants is unknown. The number of children born be- Although the association between hearing loss and tinni- tween 1941 and 1977 in Nord-Trøndelag County (78 524) may tus is well established in children4-9 and adults,1,2,10-12 to our serve as a crude approximation. The children with hearing loss knowledge, the association between childhood hearing dis- identified at screening were invited to a later ENT specialist orders and the prevalence of adult tinnitus has not been ex- examination. Between 1954 and 1962, average attendance at amined previously in longitudinal cohort studies. A history of the ENT examinations was 97%, and we believe this high level recurrent childhood otitis media has been associated with tin- of attendance did not change later.15 A total of 10 269 chil- nitus in adulthood.2,10,11,13 The association may be transmit- dren participated in the specialist examination. ted or mediated through subsequent permanent hearing loss (childhood otitis media influences adult hearing loss, which Follow-up Adult Study in turn influences the occurrence of tinnitus). However, it has The NTHLS (1996-1998) was part of the Nord-Trøndelag Health also been suggested14 that temporary conductive hearing loss Study 2 (HUNT2), a large, general health screening study.19 The in childhood is associated with permanent sound-processing NTHLS included a pure-tone audiometry examination and deficits in the central auditory system, increasing the risk of hearing questionnaires. The present study used question- later tinnitus. To our knowledge, no previous cohort study has naire 1, which contained items about tinnitus. The total adult included information on childhood hearing disorders and both population (aged ≥20 years) from 17 of the 23 municipalities tinnitus and hearing thresholds in adulthood. The aims of this in Nord-Trøndelag County was invited, and valid audiomet- study were to examine the association between different types ric data were collected from 50 723 participants. The partici- of hearing loss in childhood and tinnitus in adulthood and pation rate was 67% except in one municipality where the evaluate whether tinnitus risk is mediated by adult hearing loss. population was invited to the hearing examination after HUNT2 was finished (participation rate, 41%). Among individuals born between 1941 and 1977 (the population cohort for the present Methods study), 87% of the county’s population was invited, with an overall participation rate of 59%. The study was approved by the Norwegian Regional Commit- tee of Medical Ethics and by the Norwegian Data Inspectorate After Linkage and is in agreement with the established Public Health Code Among the 10 269 children with different types of hearing loss of Ethics of the American Health Association. Participants pro- in the SHINT, 3066 attended the NTHLS. Among these, 40 chil- vided written informed consent. There was no financial com- dren did not have a valid questionnaire 1 (which contained the pensation. The study was conducted from January 1, 2014, to tinnitus items) and were excluded. Accordingly, the present April 1, 2015. Data were deidentified. study included 3026 cases. As previously described, the SHINT did not register chil- Sample dren with normal hearing. Thus, as a reference group we in- This study used baseline data from the School Hearing Inves- cluded all participants of the NTHLS who were at primary tigation in Nord-Trøndelag (SHINT), a long-term study (1954- school age during the SHINT (born between 1941 and 1977) and 1986) of the hearing of primary school pupils, and follow-up who were not registered with hearing loss in the SHINT data from the more recent Nord-Trøndelag Hearing Loss Study (n = 29 720). Individuals without a valid questionnaire 1 (NTHLS). Both studies are described elsewhere.15,16 Arelated (n = 316) were excluded. Accordingly, this study included study17 from the same database, using similar methods and 29 404 noncases. analyses to the extent to which childhood otitis media is associated with adult hearing thresholds, has been conducted. Measures The study reported that childhood chronic suppurative oti- Childhood Hearing Loss tis media and childhood hearing loss after recurrent acute A trained hearing assistant or district health nurse performed otitis media were associated with a significant hearing loss the audiometric screening in the SHINT in a quiet location in adulthood: 17, 17, and 20 dB and 7, 7, and 10 dB in the within the school. Air-conduction thresholds were obtained low-, middle-, and high-frequency ranges, respectively. by pure-tone audiometry at 0.25, 0.5, 1.0, 2.0, 4.0, and 8.0 kHz.

984 JAMA Otolaryngology–Head & Neck Surgery November 2015 Volume 141, Number 11 (Reprinted) jamaotolaryngology.com

Downloaded From: https://jamanetwork.com/ on 09/26/2021 Association Between Childhood Hearing Disorders and Tinnitus in Adults Original Investigation Research

Hearing loss for the screening was defined by thresholds of a pure-tone average at 0.5 to 4.0 kHz and summed. The final 20-dB hearing level (HL) or greater at 3 or more frequencies composite variable was dichotomized at a level correspond- or a 30-dB HL or greater threshold at 1 or more frequencies. ing to the upper 10% of the distribution. All children with hearing loss at screening were invited to a later ENT specialist examination, which took place at 1 of 14 differ- Outcome Measure ent outpatient clinics in Nord-Trøndelag County. In addition, On a questionnaire in the NTHLS, respondents answered at the time of the specialist examination, the parents com- yes, no, or don’t know–maybe to the question, “Are you pleted a questionnaire about their child’s ear problems. The bothered by ringing in the ears?” Missing values and don’t medical examination included family and medical history, know–maybe were treated as no tinnitus. complete ENT examination for the child, and pure-tone audiometry with air- and bone-conduction thresholds. Depend- Statistical Analysis ing on the underlying hearing disorder, the children had 1 or Analysis of Main Effects more examinations. The specialist recorded the history, find- Data analysis was conducted from April 1, 2014, to April 1, 2015. ings, presumed diagnoses, and treatment. We used logistic regression analysis (SPSS, version 20; IBM), Some children had more than 1 diagnosis (eg, SNHL and specifying the statistical significance level at P = .05, to esti- excessive cerumen). In the present study, only the diagnosis mate the odds ratios with 95% CI for each type of childhood considered most severe was registered according to the fol- hearing disorder and adult tinnitus. The predictors were di- lowing hierarchy (definitions by Fabritius15) and as reported agnostic groups (with normal childhood hearing as the refer- elsewhere17: (1) SNHL (air-conduction thresholds in agree- ence category), age (at the follow-up adult study, in years), sex, ment with the bone-conduction thresholds); (2) anomalies of and adult noise exposure (dichotomous; no or medium vs high the outer and/or middle ear; (3) otosclerosis; (4) chronic sup- levels of reported noise exposure). To investigate whether the purative otitis media (chronic infection of the middle ear with risk of adult tinnitus was mediated by adult hearing loss, the eardrum perforation and intermittent secretion, as well as con- analyses were performed both with and without adjustment ductive or mixed hearing loss; (5) hearing loss associated with for adult hearing threshold. a history of recurrent acute otitis media (no middle ear effusion at the examination but a history of recurrent preschool Interaction Analysis ear infections, sometimes also occurring during school years, We tested whether the previously described associations (the mostly including impairment of the eardrum and conductive effect of each childhood hearing disorder on adult tinnitus, with or mixed hearing loss); (6) otitis media with effusion (chronic and without adjustment for adult hearing threshold) were mod- middle ear effusion and reduced mobility of the eardrum tested erated by sex or noise exposure by using interaction terms. The by Brüning’s magnifying glass, without signs or symptoms of logistic regression analysis was repeated, testing one interac- acute infection); (7) acute otitis media (middle ear effusion with tion term at a time (diagnostic group × sex or diagnostic signs and symptoms of acute infection); (8) otitis externa; (9) group × noise exposure level). Because of the high number of foreign body; (10) cerumen; and (11) other (intellectual dis- interaction terms, the statistical significance level used was ability, unknown or no registered etiology, and other). P <.01. Hearing thresholds less than 20-dB HL usually were not registered in the childhood audiograms performed during the ENT clinic examination; therefore, the thresholds for many Results single frequencies were missing. This replacement is described in detail in a related study.17 Descriptive Statistics The present sample included 32 430 adult participants: 29 404 Adult Hearing Thresholds with normal childhood hearing at the school investigation The NTHLS included pure-tone audiometry; air-conduction (46.7% males) and 3026 with various types of childhood hear- thresholds from 0.25 to 8.0 kHz were determined in sound- ing disorders diagnosed (51.1% males). Descriptive statistics of attenuation booths by audiologists or trained assistants in ac- the sample are presented in Table 1. Mean age at the NTHLS cordance with ISO 8253-1.20 We considered hearing thresh- was 40 years (range, 20-56 years) for both cases (95% CI, 39- olds greater than 100-dB HL as equal to 100-dB HL. Adult 40) and noncases (95% CI, 40-40). Tinnitus prevalence was hearing threshold levels were defined as the pure-tone aver- 11% in noncases and 15% in cases. In cases, the mean child- age of 0.5, 1.0, 2.0, and 4.0 kHz in the worse-hearing ear. hood hearing threshold was 22-dB HL (95% CI, 20-23) in participants reporting adult tinnitus and 19-dB HL (95% CI, 18- Noise Exposure 19) in those not reporting adult tinnitus. We used questionnaire data from the NTHLS for the assess- ment of occupational and nonoccupational adult noise expo- Main Results sure, as reported elsewhere.17 A general index based on all of We examined the association between different types of hear- the noise scores was computed to estimate the overall effect ing loss in childhood and tinnitus in adulthood, adjusted for of noise, similar to the one described by Tambs et al.21 The age, sex, and noise exposure in adulthood (model 1) (Table 2). scores for each item were weighted by the respective regres- Childhood hearing disorders associated with tinnitus in adult- sion coefficients in an initial regression analysis predicting hood included SNHL, hearing loss in combination with chronic

jamaotolaryngology.com (Reprinted) JAMA Otolaryngology–Head & Neck Surgery November 2015 Volume 141, Number 11 985

Downloaded From: https://jamanetwork.com/ on 09/26/2021 Research Original Investigation Association Between Childhood Hearing Disorders and Tinnitus in Adults

Table 1. Baseline Data for the Sample of the Present Studya

Total Sample No Tinnitus in Adulthood Tinnitus in Adulthood Childhood Hearing Childhood Hearing Threshold, Threshold, Childhood Hearing Diagnosis No. (% Male) OR (95% CI)b No. (% Male) OR (95% CI) No. (% Male) Threshold, OR (95% CI) Total 32 430 (47.1) 28 820 (46.0) 3610 (55.4) Reference groupc 29 404 (46.7) Normal 26 241 (45.7) Normal 3163 (54.9) Normal Childhood hearing loss 3026 (51.1) 19 (19-20) 2579 (49.7) 19 (18-19) 447 (58.8) 22 (20-23) Sensorineural hearing 457 (63.7) 31 (29-33) 354 (61.0) 30 (27-32) 103 (72.8) 34 (29-39) loss OM, total 2034 (49.1) 17 (17-17) 1752 (48.2) 17 (17-17) 282 (55.0) 18 (17-19) Chronic suppurative 105 (43.8) 24 (22-26) 81 (45.7) 23 (21-26) 24 (37.5) 28 (23-32) OMd Hearing loss after 602 (51.7) 19 (18-20) 499 (50.1) 19 (18-19) 103 (59.2) 20 (18-21) recurrent acute OM OM with effusion 1242 (48.6) 16 (15-16) 1096 (47.8) 16 (15-16) 146 (54.8) 15 (14-16) Acute OM 85 (44.7) 18 (15-20) 76 (43.4) 18 (15-20) 9 (55.6) 14 (12-17) Cerumen 158 (44.9) 18 (17-19) 144 (45.8) 18 (16-19) 14 (35.7) 20 (14-26) Unknown/no registered 345 (34.4) 16 (15-17) 303 (38.5) 16 (15-17) 42 (16.7) 26 (8-45) diagnosis Other small diagnostic 32 (50.1) 25 (19-32) 26 (48.2) 25 (18-32) 6 (64.3) 17 (15-19) groupse Abbreviations: OM, otitis media; OR, odds ratio. cholesteatoma removal, 13 for myringoplasty, and 7 for a nonspecified ear a This population is the same as that used in a previous related study.17 operation. Nine participants had dry eardrum perforations. e b Pure-tone average at 0.5 to 4.0 kHz in the worse-hearing ear at the last Other diagnostic groups included middle or outer ear anomaly, otosclerosis, audiometric test in the baseline childhood school investigation. otitis externa, foreign body, intellectual disability, and other disorders (all groups with <13 individuals). c Normal hearing threshold at the baseline childhood school investigation. d Of the 105 participants, 4 individuals underwent surgery for radical

suppurative otitis media, and hearing loss associated with a ing screening examinations. For other types of hearing disor- history of recurrent acute otitis media. After additional analy- ders, the significant association disappeared. ses with adjustment for adult hearing threshold, only childhood SNHL was significantly associated with tinnitus; how- Strengths and Limitations of the Study ever, the direction of association was reversed such that Selection Bias childhood hearing loss after adjusting for adult hearing loss had All schools in Nord-Trøndelag County were included in the a reduced risk of adult tinnitus (model 2) (Table 2). SHINT, so we do not suspect a serious selection bias at this We also tested whether the previously described associa- stage. However, there was a loss to follow-up since only 3066 tions were moderated by participants’ sex or noise exposure. of 10 269 childhood hearing loss cases (29.9%) participated in There were no significant interaction terms. the NTHLS. A related study17 explained and examined the general loss to follow-up from the SHINT to the NTHLS. In short, many participants in the SHINT were not invited to enroll in Discussion the NTHLS: 13% lived in a municipality not included in the NTHLS, and some were not old enough to be included. A few Main Findings individuals were lost owing to missing identification num- Adults with hearing loss at the school screening audiometry ber. The participation rate at the NTHLS among individuals (with follow-up ENT clinic visit for hearing threshold deter- aged 56 years or younger (the population of this study) was mination) reported more tinnitus than did adults with nega- 59%. The remaining loss to follow-up (approximately 3300) tive school screening results. Childhood hearing disorders as- is difficult to explain, but emigration from Nord-Trøndelag sociated with tinnitus in adulthood included SNHL, hearing County after the SHINT or death (approximately 2% accord- loss in combination with chronic suppurative otitis media, and ing to Statistics Norway22) are parts of the explanation. How- hearing loss associated with a history of recurrent acute otitis ever, we have no reason to suspect a selective loss to follow- media. This study found no significant association between up. Aarhus et al17 reported no important differences in the adult tinnitus and childhood hearing loss in combination with distribution of risk factors (etiology, childhood hearing thresh- excessive cerumen, an unknown diagnosis, or an “other” di- old, and sex) between childhood hearing loss cases (total of agnosis. Associations were estimated after adjusting for age, 10 269 in the original cohort) who did (n = 3066) or did not sex, and noise exposure in adulthood. After additional adjust- (n = 7203) participate in the NTHLS.17 Finally, the NTHLS was ment for the adult hearing threshold, the positive association part of a large, general health study (HUNT2), so we do not sus- with SNHL was reversed such that children with SNHL had pect that possible occurrence of tinnitus affected the likeli- lower risk of adult tinnitus than did children with normal hear- hood of participation.

986 JAMA Otolaryngology–Head & Neck Surgery November 2015 Volume 141, Number 11 (Reprinted) jamaotolaryngology.com

Downloaded From: https://jamanetwork.com/ on 09/26/2021 Association Between Childhood Hearing Disorders and Tinnitus in Adults Original Investigation Research

Information Bias Table 2. Associations Between Different Types of Hearing Loss in Childhood and Tinnitus in Adulthood Misclassification | For the reference group, we lacked informa- Model, AOR (95% CI) tion confirming participation in the SHINT. We assumed that Diagnosis 1a 2b all persons born between 1941 and 1977 and living in Nord- Normal childhood hearing (n = 29 404) 1 [Reference] 1 [Reference] Trøndelag County as adults attended the SHINT—this is an ap- All childhood hearing disorders 1.4 (1.3-1.6)c 1.0 (0.8-1.1) proximation. Some participants categorized as noncases prob- (n = 3026) ably had undetected childhood hearing loss because they did Sensorineural hearing loss (n = 457) 2.4 (1.9-3.0)c 0.7 (0.6-0.9)c not participate in the SHINT, for example, owing to immigra- Chronic suppurative OM (n = 105) 2.4 (1.5-3.9)c 1.0 (0.6-1.6) tion to Nord-Trøndelag County after primary school age. This Hearing loss after recurrent acute OM 1.6 (1.3-2.0)c 1.1 (0.9-1.4) bias cannot exceed an almost trivial value, however, since the (n = 602) false-negative to true-negative ratio will remain low. From the OM with effusion (n = 1242) 1.1 (0.9-1.3) 1.0 (0.8-1.2) part of the reference group who went to primary school dur- Acute OM (n = 85) 1.1 (0.5-2.1) 0.9 (0.5-1.9) ing the SHINT, nearly all long-standing or permanent hearing Cerumen (n = 158) 0.8 (0.5-1.4) 0.8 (0.5-1.4) loss was probably detected since there were 3 separate hear- Unknown or no registered diagnosis 1.2 (0.8-1.6) 1.0 (0.7-1.4) (n = 345) ing screening examinations (at ages 7, 10, and 13 years). Other small diagnostic groups (n = 32)d 2.1 (0.9-5.1) 1.1 (0.4-2.9) We suspect high diagnostic accuracy since the diagnoses were determined by an ENT specialist after repeated, com- Abbreviations: AOR, adjusted odds ratio; OM, otitis media. plete examinations with both air- and bone-conduction audi- a Odds ratios are adjusted for age, sex, and noise exposure in adulthood. ometry. Considering the course and treatment of otitis media b Odds ratios are adjusted for adult age, sex, noise exposure, and adult hearing threshold. at that time, antibiotics were prescribed and middle ear sur- c P < .05 by logistic regression analysis. gery (eg, tympanostomy, adenotomy, tympanoplastics, and d Other diagnostic groups included middle or outer ear anomaly, otosclerosis, cholesteatoma removal) was performed at the Namsos Hos- otitis externa, foreign body, intellectual disability, and other disorders (all pital. The classifications of various types of otitis media at that groups with <13 individuals). time correspond well with the classifications used today.23 Most of the children with diagnosed otitis media showed a conductive hearing loss (ie, normal bone-conduction thresholds indicating a normal inner ear or sensorineural function). How- tion suggests that the effect of childhood hearing disorders on ever, some of these children also had impaired bone- tinnitus in adulthood is transmitted through adult hearing loss conduction thresholds (mixed hearing loss), indicating some (thus, adult hearing loss underlies the observed associa- degree of SNHL. This SNHL component is probably due to in- tion). This correlational study cannot establish cause and ner ear damage associated with otitis media,24,25 but other effect. However, because this is a longitudinal study, it sources (eg, noise exposure) cannot be excluded. seems unlikely that tinnitus in adulthood could affect childhood ear diseases; therefore, we think it is reasonable to Outcome Variable | The tinnitus measure used in this study is assume this directionality. based on a single questionnaire item. Approximately half of the sample completed a second follow-up hearing question- Childhood Otitis Media naire with a similar question about tinnitus a few weeks after A history of recurrent childhood otitis media has been asso- they participated in the NTHLS hearing examination. The test- ciated with adult tinnitus in previous studies.2,10,11,13 How- retest polychoric correlation was 0.65 (95% CI, 0.63-0.67),26 ever, no cohort study has included information on different which indicates that the reliability is satisfactory. types of childhood otitis media and both tinnitus and hear- Potential differences in tinnitus prevalence might result ing thresholds in adulthood. The present study found that from variations in how the question is phrased. Whereas a re- children with hearing loss in combination with chronic sup- strictive definition of tinnitus results in a lower tinnitus preva- purative otitis media and hearing loss associated with a his- lence, a more liberal definition results in a higher prevalence. tory of recurrent acute otitis media had an increased risk of Hence, the association between adult hearing loss and tinni- tinnitus as adults. There was no evidence indicating that tus might have been weaker for a more liberal tinnitus defini- hearing loss together with the common conditions of otitis tion (eg, experienced tinnitus rather than bothered by tinni- media with effusion and acute otitis media was associated tus). However, the use of the term bothered may imply that the with adult tinnitus. However, studies24,25 indicate that otitis content of the item is conflated with tolerance to tinnitus, that media can be associated with SNHL. Furthermore, recurrent is, with a psychological component. The consequence of this and chronic suppurative otitis media have been associated wording might then have been an attenuated association with hearing loss in adulthood.17 This association could between reported tinnitus and hearing. explain the increased risk of adult tinnitus associated with these conditions. The lack of evidence of a significant asso- Comparison With Other Studies ciation between childhood otitis media and adult tinnitus To our knowledge, the association between childhood hear- after adjustment for adult hearing suggests that the positive ing disorders and tinnitus in adulthood has not been exam- association between some types of otitis media and tinnitus ined previously in longitudinal cohort studies. Our investiga- is mediated by adult hearing loss. This conclusion is not

jamaotolaryngology.com (Reprinted) JAMA Otolaryngology–Head & Neck Surgery November 2015 Volume 141, Number 11 987

Downloaded From: https://jamanetwork.com/ on 09/26/2021 Research Original Investigation Association Between Childhood Hearing Disorders and Tinnitus in Adults

in accord with animal studies14,27 that have shown that tem- tus, resulting in a lower prevalence of reported tinnitus in adult- porary conductive hearing loss in early life can alter the hood compared with those with later-onset hearing loss (who functional properties of the auditory cortex on a permanent may have had less time for tinnitus habituation). basis, which could increase the risk of later tinnitus. How- Another explanation as to why adults with childhood- ever, our study only included otitis media with hearing loss onset hearing loss could have a lower risk of tinnitus than adults occurring between ages 7 and 13 years, and it is unclear to what with later-onset hearing loss could be that individuals with extent our results can be generalized to otitis media in younger childhood-onset hearing loss are less likely to develop tinni- children whose auditory pathways probably show greater plas- tus, for example, if the causes of childhood SNHL (eg, genetic ticity and may not lead to similar outcomes. and infectious) are less frequently associated with tinnitus than the causes of adult-onset hearing loss, such as excessive noise Childhood SNHL exposure. Because this study did not provide data on tinni- Compared with normal childhood hearing, childhood SNHL was, tus in childhood, safe conclusions on the interpretation of the as hypothesized, associated with an increased risk of tinnitus finding cannot be drawn. in adulthood. However, after including adjustment for adult hearing thresholds, childhood SNHL appeared to protect against adult tinnitus. To our knowledge, the association between time Conclusions of onset of hearing loss (childhood vs adulthood) and tinnitus in adulthood has not been examined previously. There are sev- Childhood hearing disorders associated with tinnitus in adult- eral possible explanations as to why adults with childhood- hood include SNHL, chronic suppurative otitis media, and hear- onset hearing loss could have a lower risk of tinnitus than adults ing loss associated with a history of recurrent acute otitis with later-onset hearing loss. Children, who have more cogni- media. After adjustment for the adult hearing threshold, none tive flexibility than adults, may cope better with their hearing of the childhood hearing disorders was positively associated loss–associated tinnitus and maintain this capacity through- with tinnitus. Hence, it appears that adult hearing loss plays out life. Eventually, they could learn to cope better with tinni- an important role in governing this association.

ARTICLE INFORMATION Disclaimer: The views expressed in this article are 4. Stouffer JL, Tyler RS, Booth JC, Buckrell B. Submitted for Publication: November 9, 2014; those of the authors; they do not represent official Tinnitus in normal-hearing and hearing-impaired final revision received July 9, 2015; accepted July policies of the Norwegian and US government children. In: Aran J-M, Dauman R, eds. Tinnitus 91: 15, 2015. agencies. Proceedings of the Fourth International Tinnitus Previous Presentation: This study was presented Seminar. Amsterdam, the Netherlands: Kugler Published Online: November 5, 2015. Publications; 1992:255-258. doi:10.1001/jamaoto.2015.2378. at the 12th Congress of the European Federation of Audiological Societies; May 28, 2015; Istanbul, 5. Tyler RS, Smith RJ. Management of tinnitus in Author Contributions: Dr Engdahl had full access Turkey. children. In: Newton VE, ed. Paediatric Audiological to all the data in the study and takes responsibility Additional Contributions: Wearegratefultothe Medicine. Philadelphia, PA: Whurr Publishers; for the integrity of the data and the accuracy of the 2002:397-404. data analysis. late Hans Fredrik Fabritius, MD, and to Namsos Study concept and design: Aarhus, Engdahl, Tambs. Hospital and Eskil Bjørgan, MD (Namsos Hospital), 6. Kentish RC, Crocker SR. Scary monsters and Acquisition, analysis, or interpretation of data: All for making the School Hearing Investigation in waterfalls: tinnitus narrative therapy for children. authors. Nord-Trøndelag data available to us. They received In: Tyler RS, ed. Tinnitus Treatment Clinical Protocols Drafting of the manuscript: Aarhus, Engdahl. no financial compensation. The Nord-Trøndelag (16). New York, NY: Thieme; 2006:217-229. Critical revision of the manuscript for important Health Study (the HUNT Study) is a collaboration 7. Graham JM. Tinnitus in children with hearing intellectual content: All authors. between the HUNT Research Center, Faculty of loss. Ciba Found Symp. 1981;85:172-192. Medicine, Norwegian University of Science and Statistical analysis: Aarhus, Engdahl, Hoffman. 8. Holgers KM, Juul J. The suffering of tinnitus in Obtained funding: Engdahl, Tambs. Technology, Norwegian Institute of Public Health, and Nord-Trøndelag County Council. The childhood and adolescence. Int J Audiol. 2006;45 Administrative, technical, or material support: (5):267-272. Engdahl, Hoffman. Nord-Trøndelag County health officer and the Study supervision: Engdahl, Tambs, Kvestad. community health officers in Levanger and other 9. Coelho CB, Sanchez TG, Tyler RS. Tinnitus in municipalities provided organizational and other children and associated risk factors. Prog Brain Res. Conflict of Interest Disclosures: None reported. practical support. We also thank the 2007;166:179-191. Funding/Support: The Nord-Trøndelag Hearing Nord-Trøndelag Hearing Loss Study team for their 10. Nondahl DM, Cruickshanks KJ, Huang GH, et al. Loss Study, which is a part of the Nord-Trøndelag diligence. Tinnitus and its risk factors in the Beaver Dam Health Study, was funded by the National Institute Offspring Study. Int J Audiol. 2011;50(5):313-320. on Deafness and Other Communication Disorders, REFERENCES 11. Sindhusake D, Golding M, Newall P, Rubin G, National Institutes of Health research contract 1. Davis A, Rafaie EA. Epidemiology of tinnitus. In: N01-DC-6-2104. This study was supported by Jakobsen K, Mitchell P. Risk factors for tinnitus in a Tyler RS, ed. Tinnitus Handbook. San Diego, CA: population of older adults: the Blue Mountains research contract 2012/FOM9336 to the National Singular Publishing Group; 2000:1-23. Institute of Public Health from the Extra Hearing Study. Ear Hear. 2003;24(6):501-507. Foundation: Health and Rehabilitation through the 2. Hoffman HJ, Reed GW. Epidemiology of tinnitus. 12. Davis AC. The prevalence of hearing impairment member organization, the National Association of In: Snow JB Jr, ed. Tinnitus: Theory and and reported hearing disability among adults in Hard of Hearing. Management. Hamilton, ON: B C Decker Inc; 2004: Great Britain. Int J Epidemiol. 1989;18(4):911-917. 16-41. Role of the Funder/Sponsor: The funding 13. Dawes PJ, Welch D. Childhood hearing and its organizations had no role in the design and conduct 3. Tyler RS. Neurophysiological models, relationship with tinnitus at thirty-two years of age. of the study; collection, management, analysis, and psychological models, and treatments for tinnitus. Ann Otol Rhinol Laryngol. 2010;119(10):672-676. interpretation of the data; preparation, review, or In: Tyler RS, ed. Tinnitus Treatment: Clinical Protocols. New York, NY: Thieme; 2006:1-22. 14. Sun W, Fu Q, Zhang C, Manohar S, Kumaraguru approval of the manuscript; and decision to submit A, Li J. Loudness perception affected by early age the manuscript for publication. hearing loss. Hear Res. 2014;313:18-25.

988 JAMA Otolaryngology–Head & Neck Surgery November 2015 Volume 141, Number 11 (Reprinted) jamaotolaryngology.com

Downloaded From: https://jamanetwork.com/ on 09/26/2021 Association Between Childhood Hearing Disorders and Tinnitus in Adults Original Investigation Research

15. Fabritius HF. Hearing investigations of school 20. International Organization for Standardization. and classification of otitis media. Ann Otol Rhinol children in North Trøndelag County. J Oslo City Hosp. Acoustic—audiometric test methods—part 1: basic Laryngol Suppl. 2002;188:8-18. 1968;18(1):5-44. pure-tone air and bone conduction threshold 24. Paparella MM, Morizono T, Le CT, et al. 16. Engdahl B, Tambs K, Borchgrevink HM, audiometry (ISO 8253-1). http://www.iso.org/iso Sensorineural hearing loss in otitis media. Ann Otol Hoffman HJ. Screened and unscreened hearing /iso_catalogue/catalogue_ics/catalogue_detail_ics Rhinol Laryngol. 1984;93(6, pt 1):623-629. threshold levels for the adult population: results .htm?csnumber=15356. Published 1989. Accessed October 1, 2015. 25. da Costa SS, Rosito LP, Dornelles C. from the Nord-Trøndelag Hearing Loss Study. Int J Sensorineural hearing loss in patients with chronic Audiol. 2005;44(4):213-230. 21. Tambs K, Hoffman HJ, Borchgrevink HM, otitis media. Eur Arch Otorhinolaryngol. 2009;266 17. Aarhus L, Tambs K, Kvestad E, Engdahl B. Holmen J, Engdahl B. Hearing loss induced by (2):221-224. Childhood otitis media: a cohort study with 30-year occupational and impulse noise: results on threshold shifts by frequencies, age and gender 26. Kvestad E, Czajkowski N, Engdahl B, Hoffman follow-up of hearing (the HUNT Study). Ear Hear. HJ, Tambs K. Low heritability of tinnitus: results 2015;36(3):302-308. from the Nord-Trøndelag Hearing Loss Study. Int J Audiol. 2006;45(5):309-317. from the second Nord-Trøndelag health study. Arch 18. Aarhus L, Tambs K, Nafstad P, Bjorgan E, Otolaryngol Head Neck Surg. 2010;136:178-182. 22. Population and population changes. Statistics Engdahl B. Childhood sensorineural hearing loss: 27. Xu H, Kotak VC, Sanes DH. Conductive hearing effects of combined exposure with aging or noise Norway website. https://www.ssb.no /statistikkbanken/SelectVarVal/Define.asp loss disrupts synaptic and spike adaptation in exposure later in life [published online May 15, developing auditory cortex. J Neurosci.2007;27 2015]. Eur Arch Otorhinolaryngol. ?MainTable=Folkemengd1951&KortNavnWeb= folkendrkv&PLanguage=1&checked=true. Accessed (35):9417-9426. 19. Holmen J, Midthjell K, Krüger Ø, et al. The September 30, 2015. Nord-Trøndelag Health Study 1995–97 (HUNT 2): objectives, contents, methods and participation. 23. Gates GA, Klein JO, Lim DJ, et al. Recent Nor Epidemiol. 2003;13(1):19-32. advances in otitis media: 1: definitions, terminology,

jamaotolaryngology.com (Reprinted) JAMA Otolaryngology–Head & Neck Surgery November 2015 Volume 141, Number 11 989

Downloaded From: https://jamanetwork.com/ on 09/26/2021