Tinnitus prevalence in Europe: a multi-country cross-sectional population study.

BACKGROUND: Tinnitus prevalence studies report large variability across countries that might be due to inconsistent research methods. Our study aimed to report a single Pan-European estimate for tinnitus prevalence and investigate the effect of individual and country-level characteristics on prevalence. We explored the relationships of healthcare resource use and hearing difficulty with tinnitus symptoms. METHODS: Between 2017-2018, a cross-sectional European Tinnitus Survey (ETS) was conducted in 12 European Union nations (Bulgaria, England, France, Germany, Greece, Ireland, Italy, Latvia, Poland, Portugal, Romania, and Spain), using a standardised set of tinnitus-related questions and response options in country-specific languages. We recruited 11,427 adults aged ≥18 years. FINDINGS: Prevalence of any tinnitus was 14·7% (14·0% in men and 15·2% in women), ranging from 8·7% in Ireland to 28·3% in Bulgaria. Severe tinnitus was found in 1·2% participants (1·0% in men and 1·4% in women), ranging from 0·6% in Ireland to 4·2% in Romania. Tinnitus prevalence significantly increased with increasing age and worsening of hearing status. Healthcare resource use for tinnitus increased with increasing tinnitus symptom severity. INTERPRETATION: This is the first multinational report of Pan-European tinnitus prevalence using standardised questions. The overall prevalence estimates refine previous findings, although widespread inter-country heterogeneity was noted. The results indicate that more than 1 in 7 adults in the EU have tinnitus. Extrapolating to the overall population, approximately 65 million adults in EU28 have tinnitus, 26 million have bothersome tinnitus and 4 million have severe tinnitus. FUNDING: National Institute for Health Research, European Union's Horizon 2020, Medical Research Council, and GENDER-Net Co-Plus Fund.

The Glasgow Benefit Inventory: a systematic review of the use and value of an otorhinolaryngological generic patient-recorded outcome measure.

BACKGROUND: The Glasgow Benefit Inventory (GBI) is a validated, generic patient-recorded outcome measure widely used in otolaryngology to report change in quality of life post-intervention. OBJECTIVES OF REVIEW: To date, no systematic review has made (i) a quality assessment of reporting of Glasgow Benefit Inventory outcomes; (ii) a comparison between Glasgow Benefit Inventory outcomes for different interventions and objectives; (iii) an evaluation of subscales in describing the area of benefit; (iv) commented on its value in clinical practice and research. TYPE OF REVIEW: Systematic review. SEARCH STRATEGY: 'Glasgow Benefit Inventory' and 'GBI' were used as keywords to search for published, unpublished and ongoing trials in PubMed, EMBASE, CINAHL and Google in addition to an ISI citation search for the original validating Glasgow Benefit Inventory paper between 1996 and January 2015. EVALUATION METHOD: Papers were assessed for study type and quality graded by a predesigned scale, by two authors independently. Papers with sufficient quality Glasgow Benefit Inventory data were identified for statistical comparisons. Papers with <50% follow-up were excluded. RESULTS: A total of 118 eligible papers were identified for inclusion. A national audit paper (n = 4325) showed that the Glasgow Benefit Inventory gave a range of scores across the specialty, being greater for surgical intervention than medical intervention or 'reassurance'. Fourteen papers compared one form of surgery versus another form of surgery. In all but one study, there was no difference between the Glasgow Benefit Inventory scores (or of any other outcome). The most likely reason was lack of power. Two papers took an epidemiological approach and used the Glasgow Benefit Inventory scores to predict benefit. One was for tonsillectomy where duration of sore throat episodes and days with fever were identified on multivariate analysis to predict benefit albeit the precision was low. However, the traditional factor of number of episodes of sore throat was not predictive. The other was surgery for chronic rhinosinusitis where those with polyps on univariate analysis had greater benefit than those without. Forty-three papers had a response rate of >50% and gave sufficient Glasgow Benefit Inventory total and subscales for meta-analysis. For five of the 11 operation categories (vestibular schwannoma, tonsillectomy, cochlear implant, middle ear implant and stapes surgery) that were most likely to have a single clear clinical objective, score data had low-to-moderate heterogeneity. The value in the Glasgow Benefit Inventory having both positive and negative scores was shown by an overall negative score for the management of vestibular schwannoma. The other six operations gave considerable heterogeneity with rhinoplasty and septoplasty giving the greatest percentages (98% and 99%) most likely because of the considerable variations in patient selection. The data from these operations should not be used for comparative purposes. Five papers also reported the number of patients that had no or negative benefit, a potentially a more clinically useful outcome to report. Glasgow Benefit Inventory subscores for tonsillectomy were significantly different from ear surgery suggesting different areas of benefit CONCLUSIONS: The Glasgow Benefit Inventory has been shown to differentiate the benefit between surgical and medical otolaryngology interventions as well as 'reassurance'. Reporting benefit as percentages with negative, no and positive benefit would enable better comparisons between different interventions with varying objectives and pathology. This could also allow easier evaluation of factors that predict benefit. Meta-analysis data are now available for comparison purposes for vestibular schwannoma, tonsillectomy, cochlear implant, middle ear implant and stapes surgery. Fuller report of the Glasgow Benefit Inventory outcomes for non-surgical otolaryngology interventions is encouraged.

Distractions during critical phases of anaesthesia for caesarean section: an observational study.

Aviation's 'sterile cockpit' rule holds that distractions on the flight deck should be kept at a minimum during critical phases of flight. To assess current practice at comparable points during obstetric regional anaesthesia, we measured ambient noise and distracting events during 30 caesarean sections in three phases: during establishment of regional anaesthesia; during testing of regional blockade; and after delivery of the fetal head. Mean (SD) noise levels were 62.5 (3.9) dB during establishment of blockade, 63.9 (4.1) dB during testing and 66.8 (5.0) dB after delivery (p < 0.001). The median rates of sudden, loud (> 70 dB) noises, non-clinical conversations and numbers of staff present in the operating theatre increased during each of the three phases. Conversely, entrances into, and exits from, theatre per minute were highest during establishment of regional anaesthesia and decreased over the subsequent two time periods (p < 0.001).

Health-related quality of life before and after management in adults referred to otolaryngology: a prospective national study.

OBJECTIVE: An assessment of the effect of otolaryngological management on the health-related quality of life of patients. DESIGN: Application of the Health Utilities Index mark 3 (HUI-3) before and after treatment; application of the Glasgow Benefit Inventory (GBI) after treatment. SETTING: Six otolaryngological departments around Scotland. PARTICIPANTS: A 9005 adult patients referred to outpatient clinics. MAIN OUTCOME MEASURES: Complete HUI-3 data was collected from 4422 patients; complete GBI data from 4235; complete HUI-3 and GBI data from 3884. RESULTS: The overall change in health related quality of life from before to after management was just +0.02. In the majority of subgroups of data (classified by type of management) there was essentially no change in HUI-3 score. The major exceptions were those patients provided with a hearing aid (mean change 0.08) and those whose problem was managed surgically (mean change 0.04). The mean GBI score was 5.3 which is low. Those managed surgically reported a higher GBI score of 13.0. CONCLUSION: We found that patients treated surgically or given a hearing aid reported a significant improvement in their health related quality of life after treatment in otolaryngology departments. In general, patients treated in other ways reported no significant improvement. We argue that future research should look carefully at patient groups where there is unexpectedly little benefit from current treatment methods and consider more effective methods of management.

Critical phase distractions in anaesthesia and the sterile cockpit concept.

In aviation, the sterile cockpit rule prohibits non-essential activities during critical phases of flight, takeoff and landing, phases analogous to induction of, and emergence from, anaesthesia. We studied distraction during 30 anaesthetic inductions, maintenances and emergences. Mean (SD) noise during emergence (58.3 (6.2) dB) was higher than during induction (46.4 (4.3) dB) and maintenance (52 (4.5) dB; p<0.001). Sudden loud noises, greater than 70 dB, occurred more frequently at emergence (occurring 34 times) than at induction (occurring nine times) or maintenance (occurring 13 times). The median (IQR [range]) of staff entrances or exits were 0 (0-2 [0-7]), 6 (3-10 [1-18]) and 10 (5-12 [1-20]) for induction, maintenance and emergence, respectively (p<0.001). Conversations unrelated to the procedure occurred in 28/30 (93%) emergences. These data demonstrate increased distraction during emergence compared with other phases of anaesthesia. Recognising and minimising distraction should improve patient safety. Applying aviation's sterile cockpit rule may be a useful addition to our clinical practice.

Melody recognition using three types of dichotic-pitch stimulus.

The recognition of 10 different 16-note melodies, constructed using either dichotic-pitch stimuli or diotic pure-tone stimuli, was measured. The dichotic pitches were created by placing a frequency-dependent transition in the interaural phase of a noise burst. Three different configurations for the transition were used in order to give Huggins pitch, binaural-edge pitch, and binaural-coherence-edge pitch. Forty-nine inexperienced listeners participated. The melodies evoked by the dichotic stimuli were consistently identified well in the first block of trials, indicating that the sensation of dichotic pitch was relatively immediate and did not require prolonged listening experience. There were only small improvements across blocks of trials. The mean scores were 97% (pure tones), 93% (Huggins pitch), 89% (binaural-edge pitch), and 77% (binaural-coherence-edge pitch). All pairwise differences were statistically significant, indicating that Huggins pitch was the most salient of the dichotic pitches and binaural-coherence-edge pitch was weakest. To account for these differences in salience, a simulation of lateral inhibition was applied to the recovered spectrum generated by the modified equalization cancellation model [J. F. Culling, A. Q. Summerfield, and D. H. Marshall, J. Acoust. Soc. Am. 103, 3509-3526 (1998)]. The height of the peak in the resulting "edge-enhanced" recovered spectrum reflected the relative strength of the different dichotic pitches.

Functional magnetic resonance imaging measurements of sound-level encoding in the absence of background scanner noise.

Effects of sound level on auditory cortical activation are seen in neuroimaging data. However, factors such as the cortical response to the intense ambient scanner noise and to the bandwidth of the acoustic stimuli will both confound precise quantification and interpretation of such sound-level effects. The present study used temporally "sparse" imaging to reduce effects of scanner noise. To achieve control for stimulus bandwidth, three schemes were compared for sound-level matching across bandwidth: component level, root-mean-square power and loudness. The calculation of the loudness match was based on the model reported by Moore and Glasberg [Acta Acust. 82, 335-345 (1996)]. Ten normally hearing volunteers were scanned using functional magnetic resonance imaging (tMRI) while listening to a 300-Hz tone presented at six different sound levels between 66 and 91 dB SPL and a harmonic-complex tone (F0= 186 Hz) presented at 65 and 85 dB SPL. This range of sound levels encompassed all three bases of sound-level matching. Activation in the superior temporal gyrus, induced by each of the eight tone conditions relative to a quiet baseline condition, was quantified as to extent and magnitude. Sound level had a small, but significant, effect on the extent of activation for the pure tone, but not for the harmonic-complex tone, while it had a significant effect on the response magnitude for both types of stimulus. Response magnitude increased linearly as a function of sound level for the full range of levels for the pure tone. The harmonic-complex tone produced greater activation than the pure tone, irrespective of the matching scheme for sound level, indicating that bandwidth had a greater effect on the pattern of auditory activation than sound level. Nevertheless, when the data were collapsed across stimulus class, extent and magnitude were significantly correlated with the loudness scale (measured in phons), but not with the intensity scale (measured in SPL). We therefore recommend the loudness formula as the most appropriate basis of matching sound level to control for loudness effects when cortical responses to other stimulus attributes, such as stimulus class, are the principal concern.

Sensitivity to brief changes of interaural time and interaural intensity.

The purpose of this study was to measure listeners' abilities to detect brief changes in interaural temporal disparities (ITDs) or interaural intensitive disparities (IIDs) conveyed by bursts of noise (probes) temporally and symmetrically flanked by segments of diotic or uncorrelated noise. Thresholds were measured using a four-interval, two-alternative, forced-choice adaptive task and the total duration of the bursts of noise was either 20, 40, or 100 ms. Probes were temporally centered within each burst and the durations of the probes ranged from 2 to 100 ms, depending upon the duration of the (longer) total burst of noise within which they were embedded. The results indicate that, for a given total duration of noise, there is a rapid decrease in threshold ITD or threshold IID as the duration of the probe is increased so that it occupies a larger portion of the total burst of noise. Mathematical analyses revealed that both threshold ITDs and threshold IIDs could be well accounted for by assuming that the listener processes both types of binaural cues via a single, symmetric, double-exponential temporal window. Interestingly, the shapes of the temporal windows that fit the data obtained from the human listeners resemble the shapes of the temporal windows derived by Wagner [H. Wagner, J. Comp. Physiol. A 169, 281-289 (1991)], who studied the barn owl. The time constants and relative weightings yielded temporal window functions that heavily emphasize information occurring within the very temporal center of the window. This temporal window function was found to be generalizable in the sense that it also accounts for classic data reported by Grantham and Wightman [D.W. Gratham and F.L. Wightman, J. Acoust. Soc. Am. 63, 511-523 (1978)] concerning sensitivity to dynamically changing interaural disparities.

Manipulating the "straightness" and "curvature" of patterns of interaural cross correlation affects listeners' sensitivity to changes in interaural delay.

The purpose of this study was to test the hypothesis that stimuli characterized by "straight" trajectories of their patterns of cross correlation foster greater sensitivity to changes in interaural temporal disparities (ITDs) than do stimuli characterized by more "curved" trajectories of their patterns of cross correlation. To do so, sensitivity to changes in ITD was measured, as a function of duration, using a set of "reference" stimuli that yielded differing relative amounts of straightness within their patterns of cross correlation while keeping the dominant trajectory at or near midline. The relative amounts of straightness were manipulated by employing specific combinations of bandwidth, ITD, and interaural phase disparity (IPD) of Gaussian noises centered at 500 Hz. The results were consistent with expectations in that the patterning of the threshold ITDs revealed increasingly poorer sensitivity as greater and greater curvature was imposed on the dominant, "midline," trajectory. The variations in threshold ITD across the stimulus conditions can be accounted for quite well quantitatively by assuming either that the listeners based their judgments on changes in the position of the most central peak of the cross-correlation function or that they based their judgments on changes in the centroid of a second-level cross-correlation function. In a second experiment, binaural detection was measured using a subset of the reference stimuli as maskers. As expected, sensitivity was poorest with the maskers characterized by the greatest curvature, which were also those having the lowest interaural correlation.

Active control of the volume acquisition noise in functional magnetic resonance imaging: method and psychoacoustical evaluation.

Functional magnetic resonance imaging (fMRI) provides a noninvasive tool for observing correlates of neural activity in the brain while a subject listens to sound. However, intense acoustic noise is generated in the process of capturing MR images. This noise stimulates the auditory nervous system, limiting the dynamic range available for displaying stimulus-driven activity. The noise is potentially damaging to hearing and is distracting for the subject. In an active noise control (ANC) system, a reference sample of a noise is processed to form a sound which adds destructively with the noise at the listener's ear. We describe an implementation of ANC in the electromagnetically hostile and physically compact MRI scanning environment. First, a prototype system was evaluated psychoacoustically in the laboratory, using the electrical drive to a noise-generating loudspeaker as the reference. This system produced 10-20 dB of subjective noise-reduction between 250 Hz and 1 kHz, and smaller amounts at higher frequencies. The system was modified to operate in a real MR scanner where the reference was obtained by recording the acoustic scanner noise. Objective reduction by 30-40 dB of the most intense component in scanner noises was realized between 500 Hz and 3500 Hz, and subjective reduction of 12 dB and 5 dB in tests at frequencies of 600 Hz and at 1.9 kHz, respectively. Although the benefit of ANC is limited by transmission paths to the cochlea other than air-conduction routes from the auditory meatus, ANC achieves worthwhile attenuation even in the frequency range of maximum bone conduction (1.5-2 kHz). ANC should, therefore, be generally useful during auditory fMRI.

The variation across time of sensitivity to interaural disparities: behavioral measurements and quantitative analyses.

Zurek (1980) measured listeners' sensitivities to interaural disparities conveyed by a 5-ms "probe" segment embedded within a 50-ms burst of otherwise diotic broadband noise [P. M. Zurek, J. Acoust. Soc. Am. 67, 952-964 (1980)]. He found that thresholds for interaural time delay (ITD) and interaural intensitive difference (IID) were markedly elevated when the onset of the probe segment occurred between 1 and 5 ms after the onset of the burst. Zurek postulated that this occurred because the leading portion of the noise briefly inhibited sensitivity to subsequent binaural information. If such inhibition were the primary factor responsible for the elevation in thresholds, then the omission of the portion of the noise trailing the probe segment would be expected to have little, if any, influence on performance. In order to test this hypothesis, listeners' sensitivities to ITD and IID were measured using a paradigm similar to that employed by Zurek. The results revealed that the omission of either the leading or the trailing portions of the diotic noise led to substantial reductions in threshold ITDs and IIDs. The data were successfully accounted for by a model based upon a combination of a temporal window with an equivalent rectangular duration of approximately 10 ms and a weighting function representing a brief loss of binaural sensitivity just after the onset of a sound.

The lateralization of simple dichotic pitches.

A "simple" dichotic pitch arises when a single narrow band possesses a different interaural configuration from a surrounding broadband noise whose interaural configuration is uniform and correlated. Such pitches were created by interaurally decorrelating a narrow band (experiment 1) or by giving a narrow band a different interaural time difference from the noise (experiment 2). Using an adaptive forced-choice procedure, listeners adjusted the interaural intensity difference of "pointers" to match their lateralization to that of the dichotic pitches. The primary determinants of lateralization were the interaural configuration of the broadband noise (experiment 1), the center frequency of the narrow band (experiment 1), and its interaural configuration (experiment 2). The ability of two computational models to predict these results was evaluated. A version of the central-spectrum model [J. Raatgever and F. A. Bilsen, J. Acoust. Soc. Am. 80, 429-441 (1986)] incorporating realistic frequency selectivity accounted for the main results of experiment 1 but not experiment 2. A new "reconstruction-comparison" model accounted for the main results of both experiments. To accommodate the variables shown to influence lateralization, this model segregates evidence of the dichotic pitch from the noise, reconstructs the cross-correlogram of the noise, and compares it with the cross-correlogram of the original stimulus.

Modulation and task effects in auditory processing measured using fMRI.

Active listening has been reported to elicit a different sensory response from passive listening and is generally observed as an increase in the magnitude of activation. Sensory activation differences may therefore be masked by the effect of attention. The present study measured activation induced by static and modulated tones, while controlling attention by using target-discrimination and passive listening tasks. The factorial design enabled us to determine whether the stimulus-induced activation in auditory cortex was independent of the information-processing demands of the task. Contrasted against a silent baseline, listening to the tones induced widespread activation in the temporal cortex, including Heschl's gyrus (HG), planum temporale, superior temporal gyrus (STG), and superior temporal sulcus. No additional auditory areas were recruited in the response to modulated tones compared to static tones, but there was an increase in the response in the STG, anterior to HG. Relative to passive listening, the active task increased the response in the STG, posterior to HG. The active task also recruited regions in the frontal and parietal cortex and subcortical areas. These findings indicate that preferential responses to the changing spectro-temporal properties of the stimuli and to the target-discrimination task involve distinct, non-overlapping areas of the secondary auditory cortex. Thus, in the present study, differences in sensory activation were not masked by the effects of attention.

Integration of monaural and binaural evidence of vowel formants.

The intelligibility of speech is sustained at lower signal-to-noise ratios when the speech has a different interaural configuration from the noise. This paper argues that the advantage arises in part because listeners combine evidence of the spectrum of speech in the across-frequency profile of interaural decorrelation with evidence in the across-frequency profile of intensity. To support the argument, three experiments examined the ability of listeners to integrate and segregate evidence of vowel formants in these two profiles. In experiment 1, listeners achieved accurate identification of the members of a small set of vowels whose first formant was defined by a peak in one profile and whose second formant was defined by a peak in the other profile. This result demonstrates that integration is possible. Experiment 2 demonstrated that integration is not mandatory, insofar as listeners could report the identity of a vowel defined entirely in one profile despite the presence of a competing vowel in the other profile. The presence of the competing vowel reduced accuracy of identification, however, showing that segregation was incomplete. Experiment 3 demonstrated that segregation of the binaural vowel, in particular, can be increased by the introduction of an onset asynchrony between the competing vowels. The results of experiments 2 and 3 show that the intrinsic cues for segregation of the profiles are relatively weak. Overall, the results are compatible with the argument that listeners can integrate evidence of spectral peaks from the two profiles.

A binaural analog of gap detection.

The temporal resolution of the binaural auditory system was measured using a binaural analog of gap detection. A binaural "gap" was defined as a burst of interaurally uncorrelated noise (Nu) placed between two bursts of interaurally correlated noise (N0). The Nu burst creates a dip in the output of a binaural temporal window integrating interaural correlation, analogous to the dip created by a silent gap in the output of a monaural temporal window integrating intensity. The equivalent rectangular duration (ERD) of the binaural window was used as an index of binaural temporal resolution. In order to derive the ERD, both the shortest-detectable binaural gap and the jnd for a reduction in interaural correlation from unity were measured. In experiment 1, binaural-gap thresholds were measured using narrow-band noise carriers as a function of center frequency from 250 to 2000 Hz (fixed 100-Hz bandwidth) and a function of lower-cutoff frequency from 100 to 400 Hz (fixed 500-Hz upper-cutoff frequency). Binaural-gap thresholds (1) increased significantly with increasing frequency in both tasks, and (2) at frequencies below 500 Hz, were shorter than corresponding silent-gap thresholds measured with the same N0 noises. In experiment 2, interaural-correlation jnd's were measured for the same conditions. The jnd's also increased significantly with increasing frequency. The results were analyzed using a temporal window integrating the output of a computational model of binaural processing. The ERD of the window varied widely across listeners, with a mean value of 140 ms, and did not significantly depend on frequency. This duration is about an order of magnitude longer than the ERD of the monaural temporal window and is, therefore, consistent with "binaural sluggishness."

"Sparse" temporal sampling in auditory fMRI.

The use of functional magnetic resonance imaging (fMRI) to explore central auditory function may be compromised by the intense bursts of stray acoustic noise produced by the scanner whenever the magnetic resonance signal is read out. We present results evaluating the use of one method to reduce the effect of the scanner noise: "sparse" temporal sampling. Using this technique, single volumes of brain images are acquired at the end of stimulus and baseline conditions. To optimize detection of the activation, images are taken near to the maxima and minima of the hemodynamic response during the experimental cycle. Thus, the effective auditory stimulus for the activation is not masked by the scanner noise. In experiment 1, the course of the hemodynamic response to auditory stimulation was mapped during continuous task performance. The mean peak of the response was at 10.5 sec after stimulus onset, with little further change until stimulus offset. In experiment 2, sparse imaging was used to acquire activation images. Despite the fewer samples with sparse imaging, this method successfully delimited broadly the same regions of activation as conventional continuous imaging. However, the mean percentage MR signal change within the region of interest was greater using sparse imaging. Auditory experiments that use continuous imaging methods may measure activation that is a result of an interaction between the stimulus and task factors (e.g., attentive effort) induced by the intense background noise. We suggest that sparse imaging is advantageous in auditory experiments as it ensures that the obtained activation depends on the stimulus alone.

A comparison of detection and discrimination of temporal asymmetry in amplitude modulation.

Two compound experiments were performed to compare the detection of amplitude modulation with the discrimination of modulator shape when the modulators have strong temporal asymmetry. In experiment 1, an adaptive procedure was used to measure detection and discrimination as a function of modulation frequency from 4 to 400 Hz. In experiment 2, the method of constant stimuli was used to measure psychometric functions for detection and discrimination at one modulation frequency, 8 Hz. The asymmetric modulators were time-reversed pairs. Thus their envelope spectra are identical and models based on the envelope spectrum would predict no effect of asymmetry on detection or discrimination at any modulation depth. The detection results show, as predicted, that the direction of asymmetry does not affect the detectability of modulation in either experiment. In contrast, the discrimination results show that direction of asymmetry is readily discriminable for modulation frequencies less than about 50 Hz, indicating that envelope-spectrum models will require modification if they are to be extended to include discrimination of temporal asymmetry.