Clinical associations between tinnitus and chronic pain
JON E. ISAACSON,
MD,
MATTHEW T. MOYER,
MD,
H. GREGG SCHULER,
BA, CRCC,
and GEORGE F. BLACKALL,
PSYD, MBA,
Hershey,
Pennsylvania
OBJECTIVE: We sought to estimate the prevalence
and severity of tinnitus in patients with chronic pain.
STUDY DESIGN AND SETTING: We conducted a prospective nonrandomized study in which a survey
and the Tinnitus Handicap Inventory (THI) were distributed at a tertiary chronic pain clinic.
RESULTS: Seventy-two patients participated. 50
women (mean age, 53 years) and 22 men (mean
age, 47.5 years); 54.2% reported having tinnitus.
There was an even distribution of patients reporting
the onset of tinnitus as before versus after the onset
of pain. Four patients reported a direct association
between tinnitus and pain. The mean THI score was
27 (of 100) (n ⴝ 35). Fifteen subjects scored less
than 16, indicating no handicap, and 4 scored over
58, indicating a severe handicap.
CONCLUSION: The study results suggest a high incidence of tinnitus within this population. There were
few strong associations between pain and tinnitus.
Tinnitus does not significantly handicap the majority
of these patients.
SIGNIFICANCE: Tinnitus is a common symptom in
the chronic pain population but is not a significant
problem for these patients. (Otolaryngol Head
Neck Surg 2003;128:706-10.)
S imilarities exist between chronic tinnitus and
chronic pain. Tonndorf1 and Moller2,3 described
these similarities in detail. Both tinnitus and pain
are subjective sensations initially produced by a
peripheral disruption between efferent and afferFrom the Departments of Surgery (Dr Isaacson), Internal
Medicine (Dr Moyer), and Anesthesia (Drs Schuler and
Blackall), Pennsylvania State University, Milton S. Hershey Medical Center.
Presented at the Annual Meeting of the American Academy
of Otolaryngology–Head and Neck Surgery, San Diego,
CA, September 22-25, 2002.
Reprint requests: Jon E. Isaacson, MD, Department of Surgery, Division of Otolaryngology–Head and Neck Surgery,
Penn State Milton S. Hershey Medical Center, PO Box
850, MC:H091, Hershey, PA 17033; e-mail, jisaacson@
psu.edu.
Copyright © 2003 by the American Academy of Otolaryngology–Head and Neck Surgery Foundation, Inc.
0194-5998/2003/$30.00 ⫹ 0
doi:10.1016/S0194-5998(03)00227-4
706
ent signals. Over time, this disruption triggers a
central nervous system reorganization leading to a
chronic symptom state. The likely site of central
reorganization is the limbic system, where somatic
stimuli are linked with emotional responses.4
Similarities also exist between patients with
chronic tinnitus and patients with chronic pain.
Chronic pain patients have been subjected to numerous psychologic profiles. They are known to
have hypochondriasis, obsessive-compulsive behaviors, increased tendency to self-focus, perceived lack of control over symptoms and life
events, maladaptive coping strategies, and other
conditions. Folmer et al5 recently compared these
characteristics with those of patients with tinnitus
and found that “tinnitus” and “pain” could often
be substituted when describing these patients.
Both groups are caught in a vicious circle whereby
their symptoms lead to increased depression, fatigue, and anxiety, which in turn exacerbate their
symptoms.
In addition, both of these disorders are difficult
to treat, requiring a series of individualized treatment trials. Once first-line therapies for each disorder are exhausted, patients may be offered antidepressants, biofeedback, electrical stimulation, or
acupuncture.
Similarities in neurobiological models, patient
psychologic profiles, and treatment options warrant greater attention. We distributed a 2-part survey to new patients evaluated in a chronic pain
clinic to investigate these similarities. We wanted
to know how many of these patients have tinnitus,
whether tinnitus related to pain in onset or severity, and whether any of the treatments received for
chronic pain affect tinnitus.
METHODS
Approval for the project was granted by the
institutional review board. A 2-page survey was
distributed to nonrandomized new patients evaluated at a tertiary care pain clinic over a 6-month
period. Demographic data as well as information
regarding otologic health were obtained. Partici-
Otolaryngology–
Head and Neck Surgery
Volume 128 Number 5
pants who denied having tinnitus did not proceed
further; participants who reported having tinnitus
were asked to continue. The remaining questions
on the first page attempted to qualify tinnitus,
identify tinnitus risk factors, and identify associations between tinnitus and pain. An abbreviated
version of the first page appears in the Appendix.
The second page of the survey was the previously
validated Tinnitus Handicap Inventory (THI).6
The purpose of the THI was to objectively quantify the severity of the tinnitus and its impact on
patients’ lives.
Patients were met at the check-in counter of the
clinic and asked to participate. The survey was
then explained, and written informed consent was
obtained. The explanation of the survey included a
brief scripted definition of tinnitus to ensure that
every patient had the same understanding of tinnitus. The surveys were completed and collected
immediately before the clinic visit.
Data were then entered into a computerized
database (Microsoft Excel for Office 2000; Microsoft, Redman, WA), and statistical calculations
were carried out with a statistical software package (Minitab Version 13: Minitab Corp, State College, PA).
RESULTS
A total of 72 patients were asked to fill out the
survey, and all agreed to participate. Not all patients answered all questions, and this is reflected
by changes in n values. Fifty were women (average age, 53 years; age range, 16 to 88 years) and
22 were men (average age, 47.5 years; age range,
24 to 81 years). Duration of pain was most commonly recorded as greater than 5 years (16 of 39,
or 41%). The distribution of pain sites was roughly
equivalent for men and women.
Thirty-nine subjects (n ⫽ 72, or 54.2%) reported having tinnitus; 29 were women (average
age, 52.8 years; age range, 16 to 88 years) and 10
were men (average, 44.3 years; age range, 24 to 67
years). Duration of pain in this group was most
commonly recorded as between 6 months and 5
years. “Back” was most frequently reported as the
primary site of pain (n ⫽ 39, or 53.9%) (Fig 1).
The average pitch of tinnitus was graded as 6.1
on a 10-point scale where a lower score indicates
a lower pitch. The average volume of tinnitus was
ISAACSON et al 707
Fig 1. Site of pain reported by patients with tinnitus.
graded as 4.9 on a 10-point scale where a lower
score indicates a lower volume.
Eighteen subjects reported a previous subjective
hearing loss (n ⫽ 37, or 48.7%). Fifteen subjects
reported a previous history of noise exposure (n ⫽
36, or 41.7%). Only 4 subjects had a history of
previous head injury (n ⫽ 36, or 11.1%). Twentysix subjects drank caffeinated beverages daily (n
⫽ 36, or 72%) with a range of 1 to 8 cups, with 1
subject admitting to drinking 31 cups of coffee per
day. Twenty-two subjects drank 2 or more cups
per day (n ⫽ 36, or 61%). Nine subjects reported
using aspirin or aspirin-containing products regularly (n ⫽ 34, or 26.5%).
The average duration of tinnitus was 13 years
(Table 1). Fifteen subjects reported the onset of
tinnitus before the onset of pain (n ⫽ 31, or
48.4%), 13 subjects reported the onset of tinnitus
after the onset of pain (n ⫽ 31, or 41.9%), and
only 3 (n ⫽ 31, or 9.7%) reported that the 2 began
concurrently (Table 2). Four subjects reported an
association between tinnitus and pain (n ⫽ 31, or
12.9%). Eight subjects (n ⫽ 27, or 9.6%) reported
that a specific pain treatment improved their tinnitus (Table 3).
Scores on the THI were as follows (Table 4).
The mean THI score was 27 (of a possible 100) (n
⫽ 35; range, 0 to 96), indicating only a mild
handicap for the group as a whole. No handicap
(score, 0 to 16) was demonstrated in 15 (42.9%),
mild handicap (score, 18 to 36) was demonstrated
in 9 (25.7%), moderate handicap (score, 38 to 56)
was demonstrated in 7 (20%), and severe handicap
Otolaryngology–
Head and Neck Surgery
May 2003
708 ISAACSON et al
Table 1. Duration of pain
No. of patients
with tinnitus
(n ⴝ 39)
Duration of pain
⬍6
6 to 5
⬎5
8
15
16
Table 2. Onset of tinnitus in reference to onset of
pain
Onset of pain reference
to onset of pain
No. of patients
Before pain
After pain
Concurrent with pain
15 (48.4%)
13 (41.9%)
3 (9.7%)
Table 3. Treatments that improved tinnitus
Treatment
No. of patients (n ⴝ 8)
NSAIDs
Aspirin
Narcotics
Did not specify
3
2
1
2
NSAID, nonsteroidal anti-inflammatory drug.
Table 4. Results of the Tinnitus Handicap Inventory
(THI)
THI score
interpretation
THI Score
(0–100)
No. of patients
(n ⴝ 35)
No handicap
Mild handicap
Moderated handicap
Severe handicap
0–16
18–36
38–56
⬎58
15
9
7
4
(score, ⬎58) was demonstrated in 4 (11.4%) patients. An analysis of variance failed to find any
significant relationship between handicap from
tinnitus and duration of pain, site of pain, or duration of tinnitus.
DISCUSSION
Much has been written regarding the similarities between tinnitus and pain and the similarities
between the patients who have these symptoms.
von Bekesy7 initially described similarities between perception of sound and skin sensations in
1957. In 1987, Tonndorf8 theorized that tinnitus
production was similar to pain production by
equating inner and outer hair cell function to that
of large and small diameter afferent nerve fibers
described in the “gate control theory of pain.”
Others have also weighed in on the analogy between tinnitus and pain.2-4
Most recently, Folmer et al5 reviewed survey
data from their tinnitus patients, looking for similarities between their patients and pain patients.
They summarized the similarities between tinnitus
and pain, pointing out that both are continuous but
fluctuating subjective sensations, may be masked,
are controlled by the central nervous system, and
are treated peripherally with limited success. They
also stated that both symptoms are accompanied
by a significant amount of psychologic overlay
and that multimodal treatment often is indicated.
They used the existing pain management literature
as their comparator group.
The personalities of patients with chronic pain
and patients with tinnitus have been scrutinized.
Chronic pain patients are noted to have elevations
in hypochondriasis, depression, and hysteria when
evaluated by the Minnesota Mulitphasic Personality Inventory.9,10 They also have obsessive-compulsive tendencies, high degrees of self-focus, perceived lack of control over life events, and
maladaptive coping strategies.5 Personality disorders are present in 31% to 59% of pain patients
compared with 0.5% to 3% of the general population.11
Tinnitus patients have been studied with the use
of the Minnesota Mulitphasic Personality Inventory as well. Meric et al12 evaluated a large group
of French patients with tinnitus in 1998. They
found that although their patients did not differ
significantly from the general population, patients
with severe tinnitus did differ significantly. These
patients had a greater tendency to have depression,
paranoia, hypochondriasis, and anxiety. They
found depression to have the strongest association
with severe tinnitus. This is similar to the findings
in pain patients.
Newman et al13 also looked at the psychologic
make-up of tinnitus patients. They found that patients with increased self-focused attention
showed significantly greater perceived tinnitus
handicap, distress from tinnitus, and depression.
Otolaryngology–
Head and Neck Surgery
Volume 128 Number 5
All of the above-mentioned similarities
prompted us to examine a chronic pain population.
Although tinnitus is estimated to afflict between
16% and 35% of the general population of the
United States,4,14 53.9% of our subjects reported
tinnitus. The high prevalence may be due to the
psychologic overlap between groups of patients
with tinnitus and patients with pain. The average
duration of tinnitus appeared long (13 years), but
the number of subjects reporting the pain began
before the tinnitus was roughly the same as that
reporting the pain began after the tinnitus. Only 4
subjects felt that their tinnitus was related in any
way to their pain, and only 8 subjects reported that
their tinnitus improved when their pain was successfully treated. Interestingly, the treatments that
improved their tinnitus are traditionally thought to
worsen tinnitus (ie, aspirin and nonsteroidal antiinflammatory drugs).
Furthermore, tinnitus did not appear to be a
handicap for our particular population. Only 4
subjects scored in the severe handicap range, with
the majority of subjects (n ⫽ 24) scoring in the
mild to no handicap range. We failed to find any
significant relationship between tinnitus handicap
and duration of pain, site of pain, or duration of
tinnitus. We speculate that tinnitus might not be a
significant problem in our population as these patients are so focused on their pain issues that all
other symptoms become secondary. We did not
score intensity or handicap from pain; therefore,
we were not able to look at this in relation to
tinnitus handicap. We also did not include an
instrument to measure depression.
Several factors may have hampered our study.
We did not have a control group and relied on
historical data as a comparator. Our sample was
nonrandomized and fairly small but extended over
a significant time period. It is possible that a larger
sample of patients or a larger sample of patients
with pain at a specific site may reveal a more
convincing association of pain and tinnitus.
CONCLUSION
Tinnitus is found at a high incidence in patients
seen at a pain management clinic in the tertiary
care setting. The tinnitus does not seem to be
directly related to the specific complaint of pain
and may not change despite successful pain man-
ISAACSON et al 709
agement. Tinnitus was not perceived as a significant handicap in our sample of patients experiencing chronic pain.
REFERENCES
1. Tonndorf J. The origin of tinnitus. In: Shulman A, editor.
Tinnitus diagnosis/treatment. San Diego (CA): Singular
Publishing Group, Inc; 1997. p. 41-9.
2. Moller AR. Similarities between chronic pain and tinnitus. Am J Otol 1997;18:577-85.
3. Moller AR. Similarities between severe tinnitus and
chronic pain. J Am Acad Audiol 2000;11:115-25.
4. Jastreboff PJ. Phantom auditory perception (tinnitus):
mechanisms of generation and perception. Neurosci Res
1990;8:221-54.
5. Folmer RL, Griest SE, Martin WH. Chronic tinnitus as
phantom auditory pain. Otolaryngol Head Neck Surg
2001;124:394-400.
6. Newman CW, Sandridge SA, Jacobson GP. Psychometric adequacy of the Tinnitus Handicap Inventory (THI)
for evaluating treatment outcome. J Am Acad Audiol
1998;9:153-60.
7. von Bekesy G. Sensations of the skin similar to directional hearing, beats, and harmonics of the ear. J Acoust
Soc Am 1957;29:489-501.
8. Tonndorf J. The analogy between tinnitus and pain: a
suggestion for a physiological basis of chronic tinnitus.
Hear Res 1987;28:271-5.
9. Hill A. Phantom limb pain: a review of the literature on
attributes and potential mechanisms. J Pain Sympt Mgmt
1999;17:125-42.
10. Vendrig AA. The Minnesota Multiple Personality Inventory and chronic pain, a conceptual analysis of a longstanding but complicated relationship. Clin Psych Rev
2000;20:533-59.
11. Weisberg JN. Personality and personality disorders in
chronic pain. Curr Rev Pain 2000;4:60-70.
12. Meric C, Gartner M, Collet L, et al. Psychopathological
profile of tinnitus sufferers: evidence concerning the relationship between tinnitus features and the impact on
life. Audiol Neurootol 1998;3:240-52.
13. Newman CW, Wharton JA, Jacobson GP. Self-focused
and somatic attention in patients with tinnitus. J Am
Acad Audiol 1997;8:143-9.
14. Siedman MD, Jacobson GP. Update on tinnitus. Otolaryngol Clin North Am 1996;29:455-60.
APPENDIX: ABRIDGED VERSION OF
TINNITUS SURVEY PAGE 1
Demographic Information
Age: years
Gender: male, female
Site of pain
Symptom-Related Information
Do you have any of the following?
Hearing loss (Y/N)
History of ear infections (Y/N)
Vertigo (Y/N)
Otolaryngology–
Head and Neck Surgery
May 2003
710 ISAACSON et al
Imbalance (Y/N)
Tinnitus (Y/N)
Those without tinnitus stopped here, those with
tinnitus were asked to continue.
Please grade the pitch of your tinnitus:
Low (like a foghorn) 1 2 3 4 5 6 7 8 9 10 High
(like a whistle)
Please grade the volume of your tinnitus:
Very faint 1 2 3 4 5 6 7 8 9 10 Very loud
Have you had a history of noise exposure?
(Y/N) If yes please explain.
Did you wear ear protection? (Y/N)
CORRECTION
Have you had a severe head injury? (Y/N)
How much caffeine do you ingest daily? (please
include cups of coffee and caffeinated soft drinks)
How much aspirin containing products do you
take daily?
How long have you had tinnitus? (in years)
Did it begin before, at the same time, or after
your pain began?
Do you feel it is associated in any way with
your pain?
Do any of the treatments you take for pain
affect your tinnitus?
(continued)
Following are the correct digital object identifier (doi)
numbers for the articles in the April 2003 issue of
Otolaryngology-Head and Neck Surgery.
Hao S-P. The use of the facial translocation technique in the
management of tumors of the paranasal sinuses and skull base.
(Otolaryngol Head Neck Surg 2003;128:571-5) doi:10.1016/
S1094-5998(03)00092-5
Ammari FF. Tuberculosis of the lymph glands of the neck: A
limited role for surgery. (Otolaryngol Head Neck Surg 2003;128:
576-80) doi:10.1016/S1094-5998(03)00121-9
Chen Y-K. Keratoacanthoma of the tongue: A diagnostic problem.
(Otolaryngol Head Neck Surg 2003;128:581-2) doi:10.1016/
S1094-5998(03)00087-1
Moore BA. Maffucci’s syndrome and cartilaginous neoplasms
of the trachea. (Otolaryngol Head Neck Surg 2003;128:583-6)
doi:10.1016/S1094-5998(02)23292-1
Sutay S. Large submandibular gland calculus with performation of
the floor of the mouth. (Otolaryngol Head Neck Surg 2003;128:
587-8) doi:10.1016/S1094-5998(02)23280-5
Wasinwong Y. Eustachian tube mature teratoma. (Otolaryngol
Head Neck Surg 2003;128:589-91) doi:10.1016/S10945998(02)23310-0
Pérez Fernández CA. Sudden deafness as a manifestation of the
rupture of a cerebral arteriovenous malformation. (Otolaryngol
Head Neck Surg 2003;128:592-4) doi:10.1016/S1094-5998(03)
00130-X
Kelly TF. Endoscopic management of an intranasal hemangioma: A
case report and literature review. (Otolaryngol Head Neck Surg
2003;128:595-7) doi:10.1016/S1094-5998(02)23283-0
Nakahara H. Congenital-type nystagmus in Arnold-Chiari malformation. (Otolaryngol Head Neck Surg 2003;128:598-600) doi:
10.1016/S1094-5998(02)23210-6
Vora NM. Metastatic leiomyosarcoma to the tongue. (Otolaryngol
Head Neck Surg 2003;128:601-2) doi:10.1016/S1094-5998(02)
23263-5
Derkay CS. Phonomicrosurgical techniques for treatment of RRP in
children. (Otolaryngol Head Neck Surg 2003;128:603) doi:10.1016/
S1094-5998(03)00006-8
Zeitels SM. In reply to Derkay letter. (Otolaryngol Head Neck Surg
2003;128:603-4) doi:10.1016/S1094-5998(03)00007-X