LEADING ARTICLE 141

Otology/ have been an underestimate because of

...... difficulties in communicating with the Arch Dis Child: first published as 10.1136/adc.86.3.141 on 1 March 2002. Downloaded from children. A recent study9 considered the prevalence of in a group of 7 Current perspectives on tinnitus year old children in Sweden (n = 120); a prevalence of 12% was determined, D M Baguley, D J McFerran rising to 13% if only normally ...... children were considered. The question of the validity of tinnitus Experience of tinnitus is common in childhood prevalence studies in children was ad- dressed by Stouffer and colleagues.10 This study attempted to determine the preva- innitus in adults has received much being a combination of explaining the scientific and clinical attention of nature and pathogenesis of the condi- lence of tinnitus in normally hearing and late. Traditional theories about the tion, reassurance, counselling, and hearing impaired children, utilising a T test method that also measured the con- pathogenesis of tinnitus concentrated on sound therapy. Initial work to determine the cochlea, but this model had some the efficacy of this approach showed sistency of the child’s responses. Depend- serious shortcomings and could not promise,5 and randomised controlled ing on the level of consistency of explain some clinical findings. A purely trials are now underway. response required, the findings were that cochlear model of tinnitus fails to ex- Tinnitus in childhood has not received 6–13% of normal hearing children and plain those patients who have tinnitus in the same amount of attention as tinnitus 24–29% of hearing impaired children the presence of normal hearing and con- in adulthood despite the fact that a com- reported tinnitus of duration >5 min- versely why many patients with cochlear plaint of persistent tinnitus in a child utes. This is the only study in this field do not have tinnitus. In presents a significant therapeutic chal- that takes account of the effect of addition, symptoms of tinnitus related lenge. This dearth of interest is in part a children’s desire to please adult investi- anxiety, insomnia, and general agitation result of the fact that children rarely gators by agreeing with them. are very common in adults troubled with present clinically with tinnitus. However, tinnitus1 and cannot be ascribed to coch- when children are specifically asked TINNITUS IN CHILDREN WITH A lear dysfunction alone. about the symptom a substantial pro- SIGNIFICANT SENSORINEURAL To explain these seeming paradoxes it portion have tinnitus. To understand HEARING LOSS (SNHL) is necessary to look at what happens to how childhood tinnitus should be man- Several studies have investigated the auditory information in the brain as well aged it is necessary to examine the prevalence of tinnitus in children with as in the . Information is sent from prevalence and incidence of tinnitus in SNHL. Table 1 summarises the results. the cochlea to the brain stem and then to childhood, to consider how children who While there are variations in the meth- the primary and associative auditory complain of tinnitus should be investi- odology of these studies, specifically cortices in the temporal lobes to give the gated, and to decide how tinnitus treat- regarding the age of children studied and conscious sensation of hearing. However, ment strategies should be applied to this the extent of the SNHL, there are indica- information is also sent from brain stem group. tions that: auditory nuclei to the reticular forma- TINNITUS IN NORMALLY • The prevalence of tinnitus in children tion and to the sympathetic autonomic http://adc.bmj.com/ nervous system. These systems are in- HEARING CHILDREN with sensorineural hearing loss ap- volved with reaction to alerting or Research into the prevalence of tinnitus pears greater than that in normally challenging stimuli. In addition infor- in children is difficult as once specific hearing children mation is sent to the limbic system, spe- questions are asked there is a risk that • The prevalence of tinnitus in children cifically the amygdalae, which are in- the child may try to please their adult with profound SNHL appears lower volved in emotional responses. These questioner and in some studies there than in those children with moderate/ connections are vital for the role of hear- may be overestimates. An additional severe SNHL ing as the major alerting and warning issue in interpretation of the literature is • An acquired SNHL is more likely to be on October 4, 2021 by guest. Protected copyright. sense, and a consensus view that the that there is no consensus in inter- associated with tinnitus than a con- mammalian auditory system evolved to national tinnitus research as to what genital loss allow the perception of sounds with sur- constitutes a child, thus in the studies 2 It is rare for a child with SNHL to vival value is now held. If there is an cited below different age ranges are • spontaneously complain of tinnitus. audible threat in the environment the examined and the results may not be brain filters that threat from other audi- comparable. tory information and instigates an ap- In a large well conducted population TINNITUS IN CHILDREN WITH propriate limbic and reticular reaction survey, 10% of adults questioned re- OTHER OTOLOGICAL DISORDERS with a sympathetically mediated fight or ported prolonged (>5 minutes) sponta- Mills and Cherry16 report a series of 66 flight response. Tinnitus distress arises neous tinnitus.6 Accepting the limita- children (aged 5–15 years) presenting to when this response is generated not to tions of studies in children, tinnitus an ear, nose, and throat outpatient facil- an outside stimulus but to internal neu- prevalence childhood shows a not dis- ity with conductive hearing losses ral signals. The auditory system is not an similar picture. Nodar,7 in a survey of caused by secretory . In this electrically quiet system and there are 2000 normally hearing children (aged series 29 children (43.9%) reported many potential tinnitus generating in- 11–18 years) found a tinnitus prevalence tinnitus compared to a control group of ternal signals at both peripheral and of 15%, though no study was made of 44 children with SNHL, in whom 13 central levels. These theories were united severity. Mills et al questioned 93 nor- (29.5%) reported tinnitus. The preva- in a neurophysiological model of tinnitus mally hearing children (aged 5–16 years, lence of tinnitus in the normally hearing by Jastreboff in 1990.3 Treatments deriv- mean age 5.7 years) about tinnitus.8 Of group was 29%. ing from this model have been described, these, 27 (29%) reported tinnitus, and Mills et al considered a group of 403 with the aim of facilitating habituation nine (9.7%) stated that they were “both- children (aged 5–15 years) seen by two to tinnitus. In particular, tinnitus re- ered” by their tinnitus. The authors felt otologists.8 Of these, 267 (66%) were said training therapy4 has been advocated, that this prevalence of tinnitus might to have evidence of ear disease while the

www.archdischild.com 142 LEADING ARTICLE

Table 1 Studies of tinnitus prevalence in shildren with SNHL Arch Dis Child: first published as 10.1136/adc.86.3.141 on 1 March 2002. Downloaded from Prevalence Author n Ages of tinnitus Notes

Nodar and Lezak11 55 11–18 56% Prevalence in moderate loss 100% Prevalence in profound loss 35%

Reich12 46 39% Quoted in Graham13

Graham13 158 12–18 49% Prevalence in moderate/severe 66% Prevalence in profound 29%

Viani14 102 6–17 23.5% Only 3 children had previously complained of tinnitus Mostly profound losses

Drukier15 331 33% All profound

Stouffer et al10 21 7–10 24–29% Consistency of response determined Hearing loss not detailed

remainder did not: this “ear disease” was shown that information in the auditory clinic. Such clinics exist in most depart- in the main SNHL or secretory otitis pathways does not flow just from the ear ments of otolaryngology, and although media. There was said to be a statistically to the brain: there is also considerable the personnel in the clinic vary from unit significant difference between the preva- flow in the opposite direction from brain to unit, there are generally medical and lence of tinnitus in the ear disease group to ear. This efferent or descending audiological staff, together with speech but figures are not clearly given. Thus it auditory system is hypothesised to have and language therapists and teachers of is difficult to make an inference about a major role in mediating the gain of the the deaf. A full otological examination is the role of secretory otitis media in the human auditory system.23 Dysfunction indicated, as is pure tone audiometry tinnitus experience in children. of the efferent system has been sug- and tympanometry. Tinnitus pitch and Because it is rare for a child to gested as a cause of ,24 as has intensity matching have not been shown complain spontaneously of tinnitus, it is disturbance of 5-HT pathways in the to be predictive of treatment outcome in important to consider the characteristics brain.25 There are no well conducted adults, but may have some therapeutic of those who do. Martin and Snashall17 studies of the prevalence of hyperacusis value in allowing parents to listen to a considered children who had presented in children in the literature but anecdo- match of their child’s tinnitus. History to departments of audiological tally it seems quite common. The com- taking should be careful to elicit infor- with a complaint of tinnitus in five cen- mon initial reaction to hyperacusis is to mation about the onset of tinnitus, any tres in the UK. In this series of 67 cases, try and avoid the sounds that the person associated negative life events, and be- 42 returned a questionnaire. Of these, 35 finds uncomfortable, and in adults and havioural or emotional difficulties re-

children reported bothersome tinnitus older children this may result in recourse lated to the tinnitus. http://adc.bmj.com/ (83%). In the total series of 67, a diagno- to earplugs. This is unhelpful, as if sound The initial history, examination, and sis of migraine was made in 13 cases above a certain intensity is avoided the simple audiometric tests will determine (19%), and features suggestive of juve- auditory system reacts by increasing its whether any more involved investiga- nile Meniere’s disease were present in sensitivity. Thus an even quieter sound tions or specific treatments are required. five (7%). Other diagnoses included now seems unpleasantly loud and the When this phase is complete, tinnitus endolymphatic hydrops (three cases), problem escalates. The appropriate man- therapy can be instituted. Care must be chronic suppurative otitis media (three agement of hyperacusis is a gradual, taken to discuss the model of tinnitus in cases), noise induced hearing loss (three controlled reintroduction of sound, fa- age appropriate language. In many cases on October 4, 2021 by guest. Protected copyright. cases), and one case of a brain stem cilitating desensitisation of the auditory the parents will be as anxious and tumour. Other workers have also re- system. distressed as the child. This should be ported a small incidence of more serious openly discussed in the presence of an otological in childhood that TINNITUS MANAGEMENT IN older child, though younger children has tinnitus as a symptom. Additional CHILDHOOD sometimes find this upsetting. Sound cases of juvenile Meniere’s disease have There have been no controlled trials therapy is justified where there is evi- been reported,18 19 as has perilymph determining the efficacy of tinnitus dence of significant distress, the objec- fistula in childhood.19 20 The youngest management strategies in childhood. tive of sound therapy for tinnitus being case of vestibular schwannoma in a large There is also a question as to whether to reduce the contrast of tinnitus against series was aged 13 years21: in such cases any intervention is needed: many chil- the background. This can be accom- neurofibromatosis II is a more likely dren do not find the experience of tinni- plished by the use of wide band noise diagnosis than sporadic vestibular tus distressing, and in many of those generators worn in the ear, though care schwannoma.22 Thus the possibility of who do the symptom resolves with time. should be taken to make these cosmeti- treatable and potentially serious patho- Most adults with severe tinnitus develop cally acceptable and ensure that they do logy in childhood tinnitus should be their tinnitus in adulthood and were not not occlude the ear canal: occluding the borne in mind. childhood tinnitus sufferers. However, external auditory meatus would cause a for the small number of children who which would be HYPERACUSIS present with significant tinnitus, some counterproductive. Alternatively envi- Abnormal sensitivity to sound of moder- form of help is undeniably required. ronmental sound generators can be ate intensity, or hyperacusis has been It is suggested that a child with a per- used. These may be custom built devices noted in 40% of adults with distressing sistent complaint of distressing tinnitus producing repetitive non-intrusive bor- tinnitus.4 Recent advances in the under- should undergo a consultation in a ing sounds or may be something as sim- standing of hearing physiology have multidisciplinary paediatric otology ple and prosaic as a reassuring ticking

www.archdischild.com LEADING ARTICLE 143 clock. In children with a hearing impair- same framework as for adults, but using Dauman R, eds. Proceedings of Fourth International Tinnitus Seminar. Kugler, ment, the use of hearing aids is indi- age appropriate language and involving 1992:255–8. Arch Dis Child: first published as 10.1136/adc.86.3.141 on 1 March 2002. Downloaded from cated. This helps to reduce the sensitivity the parents as well as the child. 11 Nodar RH, Lezak MHW. Paediatric tinnitus: of the auditory system by reducing the a thesis revisited. J Laryngol Otol 1984(suppl 9);234–5. need to strain to hear. This in turn ACKNOWLEDGEMENT 12 Reich G. Personal communication. Cited in reduces the awareness of internally gen- Tinnitus research in Cambridge is supported Graham JM. Tinnitus in hearing-impaired erated signals in the auditory pathways. children. In: Hazell JWP, ed. Tinnitus. London: in part by the British Tinnitus Association, Churchill Livingstone, 1987:131,143. In any case, quite separately from the www.tinnitus.org.uk 13 Graham JM. Tinnitus in hearing-impaired tinnitus issue, there is robust evidence children. In: Hazell JWP, ed. Tinnitus. London: Arch Dis Child 2002;86:141–143 Churchill Livingstone, 1987:131,143. that even a mild 14 Viani LG. Tinnitus in children with hearing has adverse educational consequences if ...... loss. J Laryngol Otol 1989;103:142–5. uncorrected.26 15 Drukier GS. The prevalence and Authors’ affiliations Kentish et al noted that sleep distur- characteristics of tinnitus with profound D M Baguley, Audiology, Addenbrooke’s sensorineural hearing impairment. Am Ann bance was the most commonly reported Hospital, Hills Road, Cambridge CB2 2QQ, UK Deaf 1989;134:260–4. concern in a group of 24 children D J McFerran, Essex County Hospital, Lexden 16 Mills RP, Cherry JR. Subjective tinnitus in Road, Colchester, Essex CO3 3NB, UK children with otological disorders. Int J reviewed, having been referred to a Paediatr Otorhinolaryngol 1984;7:21–7. 17 Martin K, Snashall S. Children presenting department of psychology for tinnitus Correspondence to: Dr D M Baguley; management.27 This finding is congruent with tinnitus: a retrospective study. Br J Audiol [email protected] 1994;28:111–15. with findings in adult tinnitus patients. 18 Hausler R, Toupet M, Cuidetti G, et al. Care should therefore be taken to issue Meniere’s disease in children. Am J REFERENCES Otolaryngol 1987;8:187–93. appropriate devices such as bedside wide 1 Tyler RS, Baker LJ Difficulties experienced by 19 Telischi FF, Rodgers GK, Balkany TJ. band noise generators in this group. tinnitus sufferers. J Speech Lang Res Dizziness in childhood. In: Jackler RK, In cases where tinnitus distress ap- 1983;8:150–4. Brackmann DE, eds. . New York: 2 Eggermont JJ. Between sound and Mosby Year Book, 1994:555–66. pears to have been precipitated by perception: reviewing the search for a neural 20 Parnes LS, McCabe BF. Perilymph fistula: an psychological distress, for example as a code. Hear Res 2001;157:1–42. important cause of deafness and dizziness in result of bullying or of bereavement, or 3 Jastreboff PJ. Phantom auditory perception children. Paediatrics 1989;80:524–8. (tinnitus): mechanisms of generation and 21 Moffat DA, Baguley DM, Beynon GJ, where tinnitus is associated with severe perception. Neurosci Res 1990;8:221–54. Da-Cruz M. Clinical acumen and vestibular emotional distress, one should call upon 4 Jastreboff PJ, Gray WC, Gold SL. schwannoma. Am J Otol 1998;19:82–7. the support of child psychologist col- Neurophysiological approach to tinnitus 22 Chang P, Moffat DA. Neurofibromatosis type patients. Am J Otol 1996;17:236–40. 2: a 15 year experience—a current review. leagues. In the authors’ experience such 5 McKinney CJ, Hazell JWP, Graham RL. An Aust J Otolaryngol 2000;3:528–42. colleagues will avow ignorance of tinni- evaluation of the TRT method. In: Hazell JWP, 23 Sahey TL, Nodar RH, Musiek FE. Efferent tus, and joint management is indicated. ed. Proceedings of Sixth International Tinnitus auditory system. San Diego: Singular, 1997. Seminar. London: Tinnitus and Hyperacusis 24 Jastreboff PJ, Hazell, JWP. A Centre,1999:99–105. neurophysiological approach to tinnitus: clinical implications. Br J Audiol CONCLUSION 6 Davis A, El-Refaie EA. Epidemiology of 1993;27:7–17. tinnitus. In: Tyler RS, ed. Tinnitus handbook. Experience of tinnitus appears common 25 Marriage J, Barnes NM. Is central in childhood, as in adults, but remark- San Diego: Singular, 2000. hyperacusis a symptom of 7 Nodar RH. Tinnitus aurium in school age ably few children seem to be upset by 5-hydroxytryptamine (5-HT) dysfunction? J children. J Aud Res 1972;12:133–5. 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