J Am Acad Audiol 24:920–926 (2013)
Tinnitus Loudness Tracking: A “Type V Be´ke´sy” Pattern Does Not Exist for Pseudotinnitus DOI: 10.3766/jaaa.24.10.4 James R. Steiger*† Emily J. Thielman‡ James A. Henry‡§
Abstract Background: Evaluation tools are lacking for the identification of patients exhibiting pseudotinnitus. It was hypothesized that tinnitus loudness traces might show a separation between continuous and pulsed tones for participants exhibiting pseudotinnitus, that is, the “type V” pattern shown for threshold tracking among participants exhibiting pseudohypacusis. It was further hypothesized that tinnitus loudness tracking might reveal unreliable tinnitus loudness matches among participants exhibiting pseudotinnitus due to their lack of an internal tinnitus standard. Purpose: To determine whether a tinnitus loudness tracking pattern exists for participants exhibiting pseudotinnitus. Research Design: Nonrandomized posttest-only control design. The experimental group participants were those without tinnitus, and the control group participants were those with tinnitus. Study Sample: There were 86 participants, including 45 with tinnitus and 41 without tinnitus. The participants’ hearing varied from normal to severe hearing losses by pure-tone average at 1000, 2000, and 4000 Hz. Intervention: Participants without tinnitus were asked to act as if they had tinnitus and to complete tinnitus loudness matching as if they were trying to convince the test (or computer) that they had tinnitus. Data Analysis: t-tests Results: There were no statistically significant differences between individuals with tinnitus and participants acting out pseudotinnitus for any of six measures: (1) continuous tone tinnitus loudness tracking; (2) pulsed tone tinnitus loudness tracking; (3) differences between continuous and pulsed tone tinnitus loudness tracking; (4) continuous tone excursion width; (5) pulsed tone excursion width; and (6) differences between continuous and pulsed tone excursion width. Conclusions: Tinnitus loudness tracking does not appear to hold promise as a clinical tool for the identification of participants exhibiting pseudotinnitus. Key Words: Tinnitus loudness perception Abbreviations: PTA 5 pure tone average; TES 5 Tinnitus Evaluation System
INTRODUCTION
A
udiologists must be vigilant for pseudohypacusis, which can lead to unnecessary audiological and medical follow up and treatments as well as
unwarranted monetary compensation (Qiu et al, 1998; Balatsouras et al, 2003). An example of this is found in the Veterans Health Administration, where hearing loss and tinnitus are among the most prevalent service-connected disabilities for which veterans were being compensated at
*School of Speech-Language Pathology and Audiology, University of Akron, Akron, OH; †Northeast Ohio AuD Consortium; ‡VA RR&D National Center for Rehabilitative Auditory Research, VA Medical Center, Portland, OR; §Department of Otolaryngology/Head and Neck Surgery, Oregon Health and Science University, Portland, OR James R. Steiger, The Polsky Building 181, University of Akron, Akron, OH 44325-3001; Phone: 330-972-8190; Fax: 330-972-7884; E-mail: [email protected] This material was based on work supported by VHA Rehabilitation Research and Development Service grants (C4698R, F7070S).
920
Tinnitus Loudness Tracking/Steiger et al
the end of 2011 (U.S. Department of Veterans Affairs, Veterans Benefits Administration, 2012). Accordingly, audiologists routinely assess the reliability of audiometric thresholds by observing within- and between-test response reliability and by employing physiologic tests to confirm behavioral test findings. However, both medical and audiological evaluation tools for identifying pseudotinnitus (tinnitus feigning) are lacking (Jacobson et al, 2000; Henry et al, 2009). In routine clinical practice, audiologists accept the validity of tinnitus claims based on symptoms, history, and the reliability of concomitant hearing loss (McShane et al, 1988). However, Mitchell et al (1993) reported that tinnitus reliability can be assessed directly by evaluating the reliability of tinnitus loudness matching. Tinnitus loudness tracking might be a useful tool to assess the reliability of tinnitus loudness as audiometric threshold tracking (i.e., Be´ke´sy audiometry) is a tool used to assess audiometric threshold reliability.
are perceived as louder; therefore, pseudohypacusic patients show differences between continuous and pulsed tones because they are bracketing (judging) suprathreshold loudness and not threshold (Rintelmann and Harford, 1967). Moreover, pseudohypacusic patients must match tone loudness to an arbitrary a priori abovethreshold loudness standard whereas nonpseudohypacusic patients’ standard is audibility. The stability and utility of the two standards might differ. Rintelmann and Harford (1967) studied the audiometric threshold tracking patterns of 33 pseudohypacusic participants in order to better define the type V pattern. They describe a type V pattern as continuous-pulsed tone threshold differences of at least 10 dB for at least two octaves. In addition, pseudohypacusic participants may exhibit excursions greater than 10 dB (Istre and Burton, 1969; Kacker, 1971) whereas participants with sensory hearing loss might show smaller excursion widths (Jerger, 1960, Owens, 1964), perhaps suggesting reduced justnoticeable differences.
Audiometric Threshold Tracking Tinnitus Loudness Tracking Audiometric threshold tracking has been used to assess the reliability of behavioral audiometric thresholds (Reger, 1952; Jerger and Herer, 1961; Resnick and Burke, 1962; Peterson, 1963; Rintelmann and Harford, 1963; Stein, 1963; Hattler, 1970; Ventry, 1971). During audiometric threshold tracking, patients are presented tones that are automatically swept across frequencies (typically from 250–8000 Hz) or at a fixed-frequency swept in intensity over time. Patients use an attenuator to bracket their own hearing thresholds, with results plotted in the form of tracings that reverse downward when tones exceed audiometric thresholds and reverse upward when tones are below auditory thresholds. Audiometric threshold is defined as the midway point between reversals. Audiometric threshold tracking typically yields reliable thresholds that agree with thresholds obtained with standard audiometric techniques (Reger, 1952, Corso, 1956, Burns and Hinchcliff, 1957, Stream and McConnell, 1961). Pseudohypacusic patients, in contrast, show poor threshold reliability when completing the task first with a continuous tone and again with a pulsed tone (Jerger and Herer, 1961; Resnick and Burke, 1962; Peterson, 1963; Istre and Burton, 1969; Kacker, 1971), especially when the pulsed tone is on for 200 msec and off for 800 msec (Martin and Monro, 1975). Specifically, pseudohypacusic patients often exhibit continuous tone thresholds .10 dB lower than pulsed tone thresholds (Rintelmann and Harford, 1967; Martin and Monro, 1975). This pattern was dubbed a type V pattern to differentiate it from diagnostic site-of-lesion patterns I through IV (Jerger and Herer, 1961). The perceptual basis for a type V pattern lies in the loudness of continuous and pulsed tones; supra-threshold continuous tones
Tracking audiometry can be used to match tinnitus loudness in a manner similar to that described above for audiometric threshold tracking, that is, by matching tinnitus loudness to the intensity of sweep frequency tones or to fixed frequency tones (Young and Lowry, 1981; George and Kemp, 1989; Steiger et al, 2007). However, the reliability of such measures appears somewhat uncertain. Steiger et al (2007) tracked tinnitus loudness in a participant with objective pulsatile tinnitus that masked his audiometric thresholds. The participant’s tinnitus loudness tracking matches were in rough agreement with his masked audiometric thresholds, suggesting the tinnitus loudness tracking was grossly reliable. However, these authors also observed test-retest differences they felt could reflect practice effect or variability inherent in tinnitus loudness tracking. Young and Lowry (1981) tracked tinnitus loudness in a participant in whom they used loud noise to induce unilateral tinnitus. Subsequently, their participant heard tinnitus sometimes unilaterally and sometimes bilaterally. Young and Lowry (1981) found that when tinnitus was heard only in the ear not exposed to noise his pulsed and continuous tone tinnitus loudness tracking matches were similar. In contrast, when the participant heard tinnitus in both ears or in the tinnitus-induced ear, his pulsed and continuous tone tinnitus loudness tracking matches differed. Though tinnitus loudness tracking reliability might be questionable among participants with tinnitus, tinnitus loudness tracking appears less reliable among participants without tinnitus. For example, George and Kemp (1989) reported that 16 participants who sometimes experience tinnitus could not complete
921
Journal of the American Academy of Audiology/Volume 24, Number 10, 2013
their tinnitus loudness tracking task and that those same participants reported no tinnitus at the time of testing. Furthermore, George and Kemp (1989) also attempted to induce tinnitus using noise, and four participants who reported no resulting tinnitus were unable to perform the tinnitus loudness tracking task. The present authors know of no attempt to compare and contrast tinnitus loudness tracking among tinnitus sufferers and participants exhibiting pseudotinnitus. There are several reasons to consider this testing option. First, Johnson (1987) and Vernon and Meikle (1988) suggested poor within-session reliability might be an indicator that a patient is exhibiting pseudotinnitus. However, Jacobson et al (2000) failed to confirm this and offered that their ascending presentation method might have allowed participants to use audibility as a benchmark that limited variability. They proposed further research using alternately ascending and descending runs. Tinnitus loudness tracking employs alternating ascending and descending runs, and as a computerized method, it also may reduce experimenter bias possible with manual measures (Henry et al, 1999). Second, Jacobson et al (2000) found that loudness matches of participants exhibiting pseudotinnitus differed in sensation level from loudness matches of tinnitus sufferers. They suggested that their tinnitus participants matched tinnitus to low sensation level tones as expected (Meikle and Walsh, 1983), whereas, in contrast, their participants exhibiting pseudotinnitus matched their feigned tinnitus to more clearly audible higher sensation level suprathreshold tones. Tinnitus loudness tracking might allow the researchers to determine whether this finding is replicable. Finally, tinnitus loudness tracking can be conducted with continuous and pulsed tones. Rintelmann and Carhart (1964) reported that normally hearing listeners required less intensity to maintain continuous tones at their suprathreshold most comfortable level, in contrast to the greater intensity needed to maintain pulsed tones at their suprathreshold most comfortable level. Said differently, participants perceived suprathreshold continuous tones as louder than pulsed tones, and recalling that participants exhibiting pseudotinnitus likely match their feigned tinnitus to suprathreshold tones (Jacobson et al, 2000), the current researchers hypothesized that participants exhibiting pseudotinnitus might show continuous- and pulsed-tone tinnitus loudness match separations similar to the type V tracking pattern seen for pseudohypacusic listeners. METHODS
U
sing our computer-automated, self-guided Tinnitus Evaluation System (TES), a series of experiments was conducted to compare responses between
922
participants experiencing chronic tinnitus versus tinnitus-free participants (Henry et al, 2013). This study was conducted in three phases of multiple psychoacoustic tests. Phase 1 included tinnitus loudness match, tinnitus pitch match, minimum masking level, residual inhibition, tinnitus loudness tracking, and forced-choice double staircase. Phase 2 and 3 tests were chosen based on results of the previous phase. The number of individual tests and the overall time of testing decreased during each successive phase. Tinnitus loudness tracking was not conducted during Phases 2 and 3. Study Participants Participants were recruited by advertising in the local newspaper, posting recruitment flyers at the Portland VA Medical Center (PVAMC), and contacting previous research participants at the National Center for Rehabilitative Auditory Research (NCRAR). Interested candidates were telephone-screened by the research coordinator, who used a scripted query: “Tinnitus is ringing, buzzing, humming or other noises in your ears or head. If you listen for tinnitus in a quiet room, how often do you hear it—always, almost always, sometimes, almost never, or never?” A response of “almost never” or “never” identified the caller as not having tinnitus. A response of “almost always” or “always” identified the caller as having tinnitus. A response of “sometimes” excluded the caller from further consideration. Candidates passing telephone screening were informed that the purpose of the study was to develop a new technique for determining whether a person has tinnitus or not. Those who did not have tinnitus were told that they would respond to all testing as if they actually experienced tinnitus. Those who agreed were scheduled for an eligibility appointment. At the eligibility appointment, candidates first signed informed consent; then they received a conventional hearing threshold evaluation. Candidates were not eligible if they were found to have middle or outer ear problems, air-bone gaps of at least 15 dB at two or more frequencies in one ear, or an air-bone gap of at least 20 dB at any frequency. Eligible candidates completed basic questionnaires providing demographic data and characteristics of tinnitus and were enrolled in the study. Study groups were balanced as much as possible with respect to age and degree of hearing loss. In total, 86 participants were recruited, including 45 with tinnitus and 41 without tinnitus. The participants’ hearing varied from normal to severe hearing losses by pure-tone average at 1000, 2000, and 4000 Hz. Participants each received $20. The IRB Committee at the PVAMC approved this study.
Tinnitus Loudness Tracking/Steiger et al
Procedures
Figure 1. Podiometer (“Pod”) that was used by participants to respond to automated testing by turning the encoder dial and depressing the response buttons. The Pod connects to a computer and is hard wired to the ER-4B insert earphones.
Testing Equipment Testing with the TES took place in a double-walled sound-attenuated suite (Acoustic Systems Model RE245S). The TES runs a series of completely automated testing sequences and has been described in detail (Henry et al, 2009; Henry et al, 2013). Briefly, participants faced a computer monitor, and instruction screens guided them through the tests. The TES was configured to test at any or all of 19 available test frequencies: 1/3-octave steps from 250 to 16,000 Hz. Special programming enabled the TES to perform the tinnitus tracking tests (sweep- and discretefrequency testing) in the same frequency range. Using the “Pod” (Fig. 1), participants controlled stimulus parameters and provided responses. ER-4B insert earphones (Etymotic Research, Inc.) are permanently attached to the Pod, which connects to a computer via a USB port. The Pod was calibrated in the laboratory (using a Bruel and Kjaer Type 2231A sound level meter and Type 4157 Ear Simulator) and then delivered to the test booth. Calibration was checked in the booth using an Extech Model 407768 sound level meter. Participants turned a knob/dial on the Pod to control output level or frequency of test stimuli. Four push buttons on the Pod facilitated responses. To enable tinnitus tracking audiometry, a sweep-frequency oscillator was built into the Pod.
All coaching took place by the research coordinator before the audiologist encountered the participant (Henry et al, 2013). Nontinnitus participants were instructed: “Please respond to the tests on the computer the way you would if you were trying to convince the test (or computer) that you have tinnitus.” The audiologist was blinded as to whether participants had tinnitus or not and treated all participants as if they had tinnitus. A “tinnitus ear” and contralateral “stimulus ear” were assigned to each participant (Vernon and Meikle, 1981; Vernon and Fenwick, 1984). Participants with symmetrical tinnitus were given the choice as to which ear received the stimulus. If one ear (or side of the head) had more predominant tinnitus, that ear was designated the tinnitus ear and the contralateral ear was the stimulus ear. For the nontinnitus participants asked to exhibit pseudotinnitus, if hearing sensitivity seemed symmetrical, they could choose the stimulus ear. If one ear seemed to have better hearing sensitivity, then that ear was designated the stimulus ear. Prior to testing, the audiologist placed the appropriate insert earphone in the stimulus ear. Testing procedures for loudness and pitch matching have been described in a previous publication (Henry et al, 2013). The present study focuses on tinnitus loudness tracking audiometry as conducted during Phase 1 of this study. Tinnitus Loudness Tracking Audiometry To perform Be´ke´sy (tracking) audiometry in either the sweep- or fixed-frequency mode, patients depress a button when a tone is audible and release it when not audible (Be´ke´sy, 1947). For tinnitus-tracking loudness matching in the present study, participants depressed a button on the Pod when the loudness of the tone exceeded their tinnitus loudness, which decreased the tone’s intensity. They released the button when the loudness was below their tinnitus loudness, which increased the intensity. Two discrete-frequency tests and one sweep-frequency test were performed. Discrete-frequency testing utilized a 1 kHz tone for one test and a tone at the PM frequency for the second test. Sweep-frequency testing was performed between 1 and 8 kHz. Each tinnitus-loudness tracking test was conducted once in the continuous mode and once in the pulsed mode (200 msec on and 800 msec off). The order of testing (sweep versus discrete frequency
Table 1. Means of Pure Tone Average (PTA) and Pitch-Match Frequency N PTA at 3, 4, 6 kHz (dB HL) Pitch match in Hz
Tinnitus Sufferers Mean (SD)
Pseudotinnitus Mean (SD)
Significance
45 45.11 (25.07) 4405.8 (3326.1)
41 52.36 (28.65) 3523.3 (2808.6)
NA 0.28 0.2
923
Journal of the American Academy of Audiology/Volume 24, Number 10, 2013
Table 2. Tinnitus Tracking Matches to a 1000 Hz Standard
Continuous tone tinnitus loudness match (dB SPL) Pulsed tone tinnitus loudness match (dB SPL) Difference between continuous tone and pulsed tone loudness matches (dB) Continuous tone tinnitus loudness match excursion width (dB) Pulsed tone loudness match excursion width (dB) Difference between continuous tone and pulsed tone excursion width (dB)
and continuous versus pulsed tones) was randomized and counterbalanced. Data Analysis Measures of central tendency and variance were computed from the tracked-loudness responses in all conditions (continuous and pulse tone responses at both 1 kHz and at the pitch match frequency). Additional metrics were computed by contrasting continuousand pulsed-tone responses. Twelve summary statistics were calculated for each participant’s data. The continuous tone and pulsed tone loudness matches were found by taking the average of all responses made by the participant for the respective test tone. The difference between the continuous and pulsed tone loudness matches is simply the dB difference of the two averages. The excursion width is the distance (in dB) between consecutive reversals, that is, from one peak to the following valley on the graphical representation of the test result. The continuous tone and pulsed tone excursion widths were calculated for each participant as the average distance (in dB) between consecutive reversals in the participant’s responses to the respective tones. The difference between continuous and pulsed tone excursion width was the dB difference of these two averages. Each of these metrics was calculated for the tinnitus loudness tracking match test at 1 kHz and at the pitch match frequency. For each of the 12 statistics, a t-test was used to evaluate the mean differences between the tinnitus and
Tinnitus Sufferers Mean (SD)
Pseudotinnitus Mean (SD)
Significance
41.32 (13.66) 45.18 (15.07) 23.85 (5.45)
38.82 (14.82) 41.39 (16.42) 22.58 (6.67)
0.42 0.27 0.34
10.47 (4.73) 13.47 (6.23) 23.01 (2.69)
11.89 (5.28) 15.16 (5.64) 23.27 (5.11)
0.19 0.19 0.77
nontinnitus groups. In each case, a two-sample t-test was run and a significance value (p-value) found. A multiple comparison adjustment was anticipated but ultimately proved unnecessary as no significant results were found. RESULTS
A
s shown in Table 1, the tinnitus group’s mean pure tone average (PTA) of 45.11 dB HL was not significantly different than the nontinnitus group’s mean PTA of 52.36 dB HL. Similarly, the mean pitch match frequency of 4405.8 Hz for tinnitus group participants was not significantly different than the nontinnitus group participants’ mean pitch match frequency of 3523.3 Hz. These findings suggest that our tinnitus matches in dB SPL were also at similar dB SL. Tinnitus loudness tracking matches to a 1000 Hz standard are shown in Table 2. The tinnitus and nontinnitus group means did not differ significantly (p , .05) for any of six measures: (1) continuous tone tinnitus loudness tracking; (2) pulsed tone tinnitus loudness tracking; (3) continuous tone-pulsed tone tinnitus loudness tracking differences; (4) continuous tone excursion width; (5) pulsed tone excursion width; (6) continuous tone-pulsed tone excursion width differences (see Table 2 for means, standard deviations, and significance values for each comparison). Tinnitus loudness tracking matches obtained at the pitch match frequency are shown in Table 3. The tinnitus
Table 3. Tinnitus Tracking Matches at Pitch-Match Frequency
Continuous tone loudness match (dB SPL) Pulsed tone loudness match (dB SPL) Difference between continuous tone and pulsed tone loudness matches (dB) Continuous tone excursion width (dB) Pulsed tone excursion width (dB) Difference between continuous tone and pulsed tone excursion width (dB)
924
Tinnitus Sufferers Mean (SD)
Pseudotinnitus Mean (SD)
Significance
57 (18.4385) 57.04 (17.22) 20.04 (6.49)
51.03 (19.4298) 50.56 (18.58) 0.47 (5.75)
0.15 0.1 0.7
11.5 (4.46) 14.55 (5.14) 23.05 (4.5)
11.8 (4.85) 15.82 (5.68) 24.02 (3.41)
0.77 0.28 0.26
Tinnitus Loudness Tracking/Steiger et al
and nontinnitus group means did not differ significantly ( p , .05) for any of six measures: (1) continuous tone tinnitus loudness tracking; (2) pulsed tone tinnitus loudness tracking; (3) continuous tone-pulsed tone tinnitus loudness tracking differences; (4) continuous tone excursion width; (5) pulsed tone excursion width; (6) continuous tone-pulsed tone excursion width differences (see Table 3 for means, standard deviations, and significance values for each comparison). DISCUSSION
B
ased on these findings, tinnitus loudness tracking may not hold promise as a clinical tool for the identification of pseudotinnitus. We found no statistically significant differences between tinnitus group participants and nontinnitus group participants for any of six measures: (1) continuous tone tinnitus loudness tracking; (2) pulsed tone tinnitus loudness tracking; (3) continuous tone-pulsed tone tinnitus loudness tracking differences; (4) continuous tone excursion width; (5) pulsed tones excursion width; (6) continuous tone-pulsed tone excursion width differences. It was surprising to the current researchers that our nontinnitus group participants’ pseudotinnitus loudness matches did not differ from the tinnitus matches of true tinnitus sufferers as was shown by Jacobson et al (2000). This could owe in part to our recording of data in dB SPL and not dB SL (hearing thresholds were not obtained prior to the Be´ke´sy tracking tasks). The hearing sensitivity of the tinnitus group was similar to that of the nontinnitus group, and therefore the tinnitus matches in dB SPL were likely at similar dB SL. However, even small variability of hearing thresholds between participants could impact on results; therefore, future researchers should complete tinnitus tracking comparisons on participants in dB SL. It should also be noted that dynamic range may play a role in suprathreshold tasks. For example, Tyler and Conrad-Armes (1983) argued that, because of recruitment, tinnitus sensation level may not be an appropriate measure of tinnitus loudness; low sensation level tinnitus and tones may sound loud to a given listener. This could reduce the loudness match variability, but reduced variability is not evident in our data. Nonetheless, in the future, researchers could compare tinnitus loudness in sones among participants with tinnitus and participants exhibiting pseudotinnitus. Perhaps our findings owe in part to the inherent difficulty of performing tinnitus loudness tracking reliably (Steiger et al, 2007), including when tinnitus is perceived bilaterally (Young and Lowry, 1981), and among participants who are not perceiving tinnitus at the time of testing (George and Kemp, 1989). Evidence of this can be seen in sample data variability. This could have been exacerbated by the fact that our participants were involved in
a two-session, 2 hr multitest evaluation of our Tinnitus Evaluation System and that tinnitus loudness tracking was performed last. The researchers detected participant fatigue during tinnitus loudness tracking, which in turn could have affected their responses. Also, tinnitus tracking runs are alternately ascending and descending, which could have removed the benchmark of audibility that appeared to contribute to response reliability in previous research (Jacobson et al, 2000). However, other than adding to sample data variability, it seems unlikely that fatigue could lead to our nontinnitus group participants’ surprising ability to match their pseudotinnitus to intensities similar to the tinnitus matches of true tinnitus sufferers. At this time, tinnitus loudness tracking cannot be recommended as a test of pseudotinnitus.
REFERENCES Balatsouras DG, Kaberos A, Korres S, Kandiloros D, Ferekidis E, Economou C. (2003) Detection of pseudohypacusis: a prospective, randomized study of the use of otoacoustic emissions. Ear Hear 24(6):518–527. Be´ke´sy GV. (1947) A new audiometer. Acta Otolaryngol (Stockholm) 35:411–422. Burns W, Hinchcliff R. (1957) Comparison of the auditory threshold as measured by individual pure tone and by Bekesy audiometry. J Acoust Soc Am 29:1274–1277. Corso JF. (1956) Effects of testing methods on hearing thresholds. AMA Arch Otolaryngol 63(1):78–91. George RN, Kemp S. (1989) Investigation of tinnitus induced by sound and its relationship to ongoing tinnitus. J Speech Hear Res 32(2):366–372. Hattler KW. (1970) Lengthened off-time: a self-recording screening device for nonorganicity. J Speech Hear Disord 35(2):113–122. Henry JA, James KE, Owens K, Zaugg T, Porsov E, Silaski G. (2009) Auditory test result characteristics of subjects with and without tinnitus. J Rehabil Res Dev 46(5):619–632. Henry JA, McMillan GP, Thielman E, et al. (2013) Evaluating psychoacoustic measures for establishing presence of tinnitus. J Rehabil Res Dev 50(4):573–584. Istre CO, Burton M. (1969) Automatic audiometry for detecting malingering. Arch Otolaryngol 90(3):326–332. Jacobson GP, Henderson JA, McCaslin DL. (2000) A re-evaluation of tinnitus reliability testing. J Am Acad Audiol 11(3):156–161. Jerger J. (1960) Bekesy audiometry in analysis of auditory disorders. J Speech Lang Hear Res 3:275–287. Jerger J, Herer G. (1961) Unexpected dividend in Bekesy audiometry. J Speech Hear Disord 26:390–391. Johnson RM. (1987) Tinnitus and disability—a method of evaluation. In: Shulman A, Aran J-M, Tonndorf J, Feldmann H, Vernon JA, eds. Tinnitus: Diagnosis/Treatment. Malvern, PA: Lea and Febiger, 444. Kacker SK. (1971) Bekesy audiometry in simulated hearing loss. J Speech Hear Disord 36(4):506–510.
925
Journal of the American Academy of Audiology/Volume 24, Number 10, 2013
Martin FN, Monro DA. (1975) The effects of sophistication on Type V Bekesy patterns in simulated hearing loss. J Speech Hear Disord 40(4):508–513.
Rintelmann WF, Harford ER. (1967) Type V Bekesy pattern: interpretation and clinical utility. J Speech Hear Res 10(4): 733–744.
McShane DP, Hyde ML, Alberti PW. (1988) Tinnitus prevalence in industrial hearing loss compensation claimants. Clin Otolaryngol Allied Sci 13(5):323–330.
Steiger JR, Saccone PA, Watson KN. (2007) Assessment of objective pulsatile tinnitus in a patient with syringohydromyelia. J Am Acad Audiol 18(3):197–205.
Meikle MB, Walsh ET. (1983) Characteristics of tinnitus and related observations in over 1800 tinnitus clinic patients. J Laryngol Otol Suppl 9:17–21.
Stein L. (1963) Some observations on type V Bekesy tracings. J Speech Hear Res 13:339–348.
Mitchell CR, Vernon JA, Creedon TA. (1993) Measuring tinnitus parameters: loudness, pitch, and maskability. J Am Acad Audiol 4(3):139–151. Owens E. (1964) Bekesy tracings and site of lesion. J Speech Lang Hear Disord 29:456–468. Peterson JL. (1963) Non-organic hearing loss in children and Bekesy audiometry. J Speech Lang Hear Disord 28:153–158. Qiu WW, Yin SS, Stucker FJ, Welsh LW. (1998) Current evaluation of pseudohypacusis: strategies and classification. Ann Otol Rhinol Laryngol 107(8):638–647. Reger SN. (1952) A clinical and research version of the bekesy audiometer. Laryngoscope 62(12):1333–1351. Resnick DM, Burke KS. (1962) Bekesy audiometry in nonorganic auditory problems. Arch Otolaryngol 76:38–41.
Stream RW, McConnell F. (1961) A comparison of two methods of administration in Bekesy-type audiometry. J Aud Res 1: 263–271. U.S. Department of Veterans Affairs, Veterans Benefits Administration. (2012) Annual Benefits Report Fiscal Year 2011. Version 3. www.vba.va.gov/REPORTS/abr/2011_abr.pdf (accessed February 11, 2013). Ventry IM. (1971) Bekesy audiometry in functional hearing loss: a case study. J Speech Lang Hear Disord 36:125–141. Vernon J, Fenwick J. (1984) Identification of tinnitus: a plea for standardization. J Laryngol Otol S9:45–53. Vernon JA, Meikle MB. (1988) Measurement of tinnitus: an update. In: Kitahara M, ed. Tinnitus: Pathophysiology and Management. New York: Igaku-Shoin, 36–52.
Rintelmann WF, Carhart R. (1964) Loudness tracking by normal hearers via Bekesy audiometer. J Speech Hear Res 7:79–93.
Vernon JA, Meikle MB, Evered D, Lawrenson G, eds. (1981) Tinnitus masking: unresolved problems. In: Evered D, Lawrenson G, eds. Ciba Foundation Symposium 85—Tinnitus. London: Pitman Books, 239–256.
Rintelmann WF, Harford E. (1963) The detection and assessment of pseudohypacusis among school-age children. J Speech Lang Hear Res 7:79–93.
Young IM, Lowry LD. (1981) Changes of tinnitus localization following exposure to a pure tone. J Acoust Soc Am 70(S1): S104.
926
Copyright of Journal of the American Academy of Audiology is the property of American Academy of Audiology and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
Tinnitus Loudness Tracking: A “Type V Be´ke´sy” Pattern Does Not Exist for Pseudotinnitus DOI: 10.3766/jaaa.24.10.4 James R. Steiger*† Emily J. Thielman‡ James A. Henry‡§
Abstract Background: Evaluation tools are lacking for the identification of patients exhibiting pseudotinnitus. It was hypothesized that tinnitus loudness traces might show a separation between continuous and pulsed tones for participants exhibiting pseudotinnitus, that is, the “type V” pattern shown for threshold tracking among participants exhibiting pseudohypacusis. It was further hypothesized that tinnitus loudness tracking might reveal unreliable tinnitus loudness matches among participants exhibiting pseudotinnitus due to their lack of an internal tinnitus standard. Purpose: To determine whether a tinnitus loudness tracking pattern exists for participants exhibiting pseudotinnitus. Research Design: Nonrandomized posttest-only control design. The experimental group participants were those without tinnitus, and the control group participants were those with tinnitus. Study Sample: There were 86 participants, including 45 with tinnitus and 41 without tinnitus. The participants’ hearing varied from normal to severe hearing losses by pure-tone average at 1000, 2000, and 4000 Hz. Intervention: Participants without tinnitus were asked to act as if they had tinnitus and to complete tinnitus loudness matching as if they were trying to convince the test (or computer) that they had tinnitus. Data Analysis: t-tests Results: There were no statistically significant differences between individuals with tinnitus and participants acting out pseudotinnitus for any of six measures: (1) continuous tone tinnitus loudness tracking; (2) pulsed tone tinnitus loudness tracking; (3) differences between continuous and pulsed tone tinnitus loudness tracking; (4) continuous tone excursion width; (5) pulsed tone excursion width; and (6) differences between continuous and pulsed tone excursion width. Conclusions: Tinnitus loudness tracking does not appear to hold promise as a clinical tool for the identification of participants exhibiting pseudotinnitus. Key Words: Tinnitus loudness perception Abbreviations: PTA 5 pure tone average; TES 5 Tinnitus Evaluation System
INTRODUCTION
A
udiologists must be vigilant for pseudohypacusis, which can lead to unnecessary audiological and medical follow up and treatments as well as
unwarranted monetary compensation (Qiu et al, 1998; Balatsouras et al, 2003). An example of this is found in the Veterans Health Administration, where hearing loss and tinnitus are among the most prevalent service-connected disabilities for which veterans were being compensated at
*School of Speech-Language Pathology and Audiology, University of Akron, Akron, OH; †Northeast Ohio AuD Consortium; ‡VA RR&D National Center for Rehabilitative Auditory Research, VA Medical Center, Portland, OR; §Department of Otolaryngology/Head and Neck Surgery, Oregon Health and Science University, Portland, OR James R. Steiger, The Polsky Building 181, University of Akron, Akron, OH 44325-3001; Phone: 330-972-8190; Fax: 330-972-7884; E-mail: [email protected] This material was based on work supported by VHA Rehabilitation Research and Development Service grants (C4698R, F7070S).
920
Tinnitus Loudness Tracking/Steiger et al
the end of 2011 (U.S. Department of Veterans Affairs, Veterans Benefits Administration, 2012). Accordingly, audiologists routinely assess the reliability of audiometric thresholds by observing within- and between-test response reliability and by employing physiologic tests to confirm behavioral test findings. However, both medical and audiological evaluation tools for identifying pseudotinnitus (tinnitus feigning) are lacking (Jacobson et al, 2000; Henry et al, 2009). In routine clinical practice, audiologists accept the validity of tinnitus claims based on symptoms, history, and the reliability of concomitant hearing loss (McShane et al, 1988). However, Mitchell et al (1993) reported that tinnitus reliability can be assessed directly by evaluating the reliability of tinnitus loudness matching. Tinnitus loudness tracking might be a useful tool to assess the reliability of tinnitus loudness as audiometric threshold tracking (i.e., Be´ke´sy audiometry) is a tool used to assess audiometric threshold reliability.
are perceived as louder; therefore, pseudohypacusic patients show differences between continuous and pulsed tones because they are bracketing (judging) suprathreshold loudness and not threshold (Rintelmann and Harford, 1967). Moreover, pseudohypacusic patients must match tone loudness to an arbitrary a priori abovethreshold loudness standard whereas nonpseudohypacusic patients’ standard is audibility. The stability and utility of the two standards might differ. Rintelmann and Harford (1967) studied the audiometric threshold tracking patterns of 33 pseudohypacusic participants in order to better define the type V pattern. They describe a type V pattern as continuous-pulsed tone threshold differences of at least 10 dB for at least two octaves. In addition, pseudohypacusic participants may exhibit excursions greater than 10 dB (Istre and Burton, 1969; Kacker, 1971) whereas participants with sensory hearing loss might show smaller excursion widths (Jerger, 1960, Owens, 1964), perhaps suggesting reduced justnoticeable differences.
Audiometric Threshold Tracking Tinnitus Loudness Tracking Audiometric threshold tracking has been used to assess the reliability of behavioral audiometric thresholds (Reger, 1952; Jerger and Herer, 1961; Resnick and Burke, 1962; Peterson, 1963; Rintelmann and Harford, 1963; Stein, 1963; Hattler, 1970; Ventry, 1971). During audiometric threshold tracking, patients are presented tones that are automatically swept across frequencies (typically from 250–8000 Hz) or at a fixed-frequency swept in intensity over time. Patients use an attenuator to bracket their own hearing thresholds, with results plotted in the form of tracings that reverse downward when tones exceed audiometric thresholds and reverse upward when tones are below auditory thresholds. Audiometric threshold is defined as the midway point between reversals. Audiometric threshold tracking typically yields reliable thresholds that agree with thresholds obtained with standard audiometric techniques (Reger, 1952, Corso, 1956, Burns and Hinchcliff, 1957, Stream and McConnell, 1961). Pseudohypacusic patients, in contrast, show poor threshold reliability when completing the task first with a continuous tone and again with a pulsed tone (Jerger and Herer, 1961; Resnick and Burke, 1962; Peterson, 1963; Istre and Burton, 1969; Kacker, 1971), especially when the pulsed tone is on for 200 msec and off for 800 msec (Martin and Monro, 1975). Specifically, pseudohypacusic patients often exhibit continuous tone thresholds .10 dB lower than pulsed tone thresholds (Rintelmann and Harford, 1967; Martin and Monro, 1975). This pattern was dubbed a type V pattern to differentiate it from diagnostic site-of-lesion patterns I through IV (Jerger and Herer, 1961). The perceptual basis for a type V pattern lies in the loudness of continuous and pulsed tones; supra-threshold continuous tones
Tracking audiometry can be used to match tinnitus loudness in a manner similar to that described above for audiometric threshold tracking, that is, by matching tinnitus loudness to the intensity of sweep frequency tones or to fixed frequency tones (Young and Lowry, 1981; George and Kemp, 1989; Steiger et al, 2007). However, the reliability of such measures appears somewhat uncertain. Steiger et al (2007) tracked tinnitus loudness in a participant with objective pulsatile tinnitus that masked his audiometric thresholds. The participant’s tinnitus loudness tracking matches were in rough agreement with his masked audiometric thresholds, suggesting the tinnitus loudness tracking was grossly reliable. However, these authors also observed test-retest differences they felt could reflect practice effect or variability inherent in tinnitus loudness tracking. Young and Lowry (1981) tracked tinnitus loudness in a participant in whom they used loud noise to induce unilateral tinnitus. Subsequently, their participant heard tinnitus sometimes unilaterally and sometimes bilaterally. Young and Lowry (1981) found that when tinnitus was heard only in the ear not exposed to noise his pulsed and continuous tone tinnitus loudness tracking matches were similar. In contrast, when the participant heard tinnitus in both ears or in the tinnitus-induced ear, his pulsed and continuous tone tinnitus loudness tracking matches differed. Though tinnitus loudness tracking reliability might be questionable among participants with tinnitus, tinnitus loudness tracking appears less reliable among participants without tinnitus. For example, George and Kemp (1989) reported that 16 participants who sometimes experience tinnitus could not complete
921
Journal of the American Academy of Audiology/Volume 24, Number 10, 2013
their tinnitus loudness tracking task and that those same participants reported no tinnitus at the time of testing. Furthermore, George and Kemp (1989) also attempted to induce tinnitus using noise, and four participants who reported no resulting tinnitus were unable to perform the tinnitus loudness tracking task. The present authors know of no attempt to compare and contrast tinnitus loudness tracking among tinnitus sufferers and participants exhibiting pseudotinnitus. There are several reasons to consider this testing option. First, Johnson (1987) and Vernon and Meikle (1988) suggested poor within-session reliability might be an indicator that a patient is exhibiting pseudotinnitus. However, Jacobson et al (2000) failed to confirm this and offered that their ascending presentation method might have allowed participants to use audibility as a benchmark that limited variability. They proposed further research using alternately ascending and descending runs. Tinnitus loudness tracking employs alternating ascending and descending runs, and as a computerized method, it also may reduce experimenter bias possible with manual measures (Henry et al, 1999). Second, Jacobson et al (2000) found that loudness matches of participants exhibiting pseudotinnitus differed in sensation level from loudness matches of tinnitus sufferers. They suggested that their tinnitus participants matched tinnitus to low sensation level tones as expected (Meikle and Walsh, 1983), whereas, in contrast, their participants exhibiting pseudotinnitus matched their feigned tinnitus to more clearly audible higher sensation level suprathreshold tones. Tinnitus loudness tracking might allow the researchers to determine whether this finding is replicable. Finally, tinnitus loudness tracking can be conducted with continuous and pulsed tones. Rintelmann and Carhart (1964) reported that normally hearing listeners required less intensity to maintain continuous tones at their suprathreshold most comfortable level, in contrast to the greater intensity needed to maintain pulsed tones at their suprathreshold most comfortable level. Said differently, participants perceived suprathreshold continuous tones as louder than pulsed tones, and recalling that participants exhibiting pseudotinnitus likely match their feigned tinnitus to suprathreshold tones (Jacobson et al, 2000), the current researchers hypothesized that participants exhibiting pseudotinnitus might show continuous- and pulsed-tone tinnitus loudness match separations similar to the type V tracking pattern seen for pseudohypacusic listeners. METHODS
U
sing our computer-automated, self-guided Tinnitus Evaluation System (TES), a series of experiments was conducted to compare responses between
922
participants experiencing chronic tinnitus versus tinnitus-free participants (Henry et al, 2013). This study was conducted in three phases of multiple psychoacoustic tests. Phase 1 included tinnitus loudness match, tinnitus pitch match, minimum masking level, residual inhibition, tinnitus loudness tracking, and forced-choice double staircase. Phase 2 and 3 tests were chosen based on results of the previous phase. The number of individual tests and the overall time of testing decreased during each successive phase. Tinnitus loudness tracking was not conducted during Phases 2 and 3. Study Participants Participants were recruited by advertising in the local newspaper, posting recruitment flyers at the Portland VA Medical Center (PVAMC), and contacting previous research participants at the National Center for Rehabilitative Auditory Research (NCRAR). Interested candidates were telephone-screened by the research coordinator, who used a scripted query: “Tinnitus is ringing, buzzing, humming or other noises in your ears or head. If you listen for tinnitus in a quiet room, how often do you hear it—always, almost always, sometimes, almost never, or never?” A response of “almost never” or “never” identified the caller as not having tinnitus. A response of “almost always” or “always” identified the caller as having tinnitus. A response of “sometimes” excluded the caller from further consideration. Candidates passing telephone screening were informed that the purpose of the study was to develop a new technique for determining whether a person has tinnitus or not. Those who did not have tinnitus were told that they would respond to all testing as if they actually experienced tinnitus. Those who agreed were scheduled for an eligibility appointment. At the eligibility appointment, candidates first signed informed consent; then they received a conventional hearing threshold evaluation. Candidates were not eligible if they were found to have middle or outer ear problems, air-bone gaps of at least 15 dB at two or more frequencies in one ear, or an air-bone gap of at least 20 dB at any frequency. Eligible candidates completed basic questionnaires providing demographic data and characteristics of tinnitus and were enrolled in the study. Study groups were balanced as much as possible with respect to age and degree of hearing loss. In total, 86 participants were recruited, including 45 with tinnitus and 41 without tinnitus. The participants’ hearing varied from normal to severe hearing losses by pure-tone average at 1000, 2000, and 4000 Hz. Participants each received $20. The IRB Committee at the PVAMC approved this study.
Tinnitus Loudness Tracking/Steiger et al
Procedures
Figure 1. Podiometer (“Pod”) that was used by participants to respond to automated testing by turning the encoder dial and depressing the response buttons. The Pod connects to a computer and is hard wired to the ER-4B insert earphones.
Testing Equipment Testing with the TES took place in a double-walled sound-attenuated suite (Acoustic Systems Model RE245S). The TES runs a series of completely automated testing sequences and has been described in detail (Henry et al, 2009; Henry et al, 2013). Briefly, participants faced a computer monitor, and instruction screens guided them through the tests. The TES was configured to test at any or all of 19 available test frequencies: 1/3-octave steps from 250 to 16,000 Hz. Special programming enabled the TES to perform the tinnitus tracking tests (sweep- and discretefrequency testing) in the same frequency range. Using the “Pod” (Fig. 1), participants controlled stimulus parameters and provided responses. ER-4B insert earphones (Etymotic Research, Inc.) are permanently attached to the Pod, which connects to a computer via a USB port. The Pod was calibrated in the laboratory (using a Bruel and Kjaer Type 2231A sound level meter and Type 4157 Ear Simulator) and then delivered to the test booth. Calibration was checked in the booth using an Extech Model 407768 sound level meter. Participants turned a knob/dial on the Pod to control output level or frequency of test stimuli. Four push buttons on the Pod facilitated responses. To enable tinnitus tracking audiometry, a sweep-frequency oscillator was built into the Pod.
All coaching took place by the research coordinator before the audiologist encountered the participant (Henry et al, 2013). Nontinnitus participants were instructed: “Please respond to the tests on the computer the way you would if you were trying to convince the test (or computer) that you have tinnitus.” The audiologist was blinded as to whether participants had tinnitus or not and treated all participants as if they had tinnitus. A “tinnitus ear” and contralateral “stimulus ear” were assigned to each participant (Vernon and Meikle, 1981; Vernon and Fenwick, 1984). Participants with symmetrical tinnitus were given the choice as to which ear received the stimulus. If one ear (or side of the head) had more predominant tinnitus, that ear was designated the tinnitus ear and the contralateral ear was the stimulus ear. For the nontinnitus participants asked to exhibit pseudotinnitus, if hearing sensitivity seemed symmetrical, they could choose the stimulus ear. If one ear seemed to have better hearing sensitivity, then that ear was designated the stimulus ear. Prior to testing, the audiologist placed the appropriate insert earphone in the stimulus ear. Testing procedures for loudness and pitch matching have been described in a previous publication (Henry et al, 2013). The present study focuses on tinnitus loudness tracking audiometry as conducted during Phase 1 of this study. Tinnitus Loudness Tracking Audiometry To perform Be´ke´sy (tracking) audiometry in either the sweep- or fixed-frequency mode, patients depress a button when a tone is audible and release it when not audible (Be´ke´sy, 1947). For tinnitus-tracking loudness matching in the present study, participants depressed a button on the Pod when the loudness of the tone exceeded their tinnitus loudness, which decreased the tone’s intensity. They released the button when the loudness was below their tinnitus loudness, which increased the intensity. Two discrete-frequency tests and one sweep-frequency test were performed. Discrete-frequency testing utilized a 1 kHz tone for one test and a tone at the PM frequency for the second test. Sweep-frequency testing was performed between 1 and 8 kHz. Each tinnitus-loudness tracking test was conducted once in the continuous mode and once in the pulsed mode (200 msec on and 800 msec off). The order of testing (sweep versus discrete frequency
Table 1. Means of Pure Tone Average (PTA) and Pitch-Match Frequency N PTA at 3, 4, 6 kHz (dB HL) Pitch match in Hz
Tinnitus Sufferers Mean (SD)
Pseudotinnitus Mean (SD)
Significance
45 45.11 (25.07) 4405.8 (3326.1)
41 52.36 (28.65) 3523.3 (2808.6)
NA 0.28 0.2
923
Journal of the American Academy of Audiology/Volume 24, Number 10, 2013
Table 2. Tinnitus Tracking Matches to a 1000 Hz Standard
Continuous tone tinnitus loudness match (dB SPL) Pulsed tone tinnitus loudness match (dB SPL) Difference between continuous tone and pulsed tone loudness matches (dB) Continuous tone tinnitus loudness match excursion width (dB) Pulsed tone loudness match excursion width (dB) Difference between continuous tone and pulsed tone excursion width (dB)
and continuous versus pulsed tones) was randomized and counterbalanced. Data Analysis Measures of central tendency and variance were computed from the tracked-loudness responses in all conditions (continuous and pulse tone responses at both 1 kHz and at the pitch match frequency). Additional metrics were computed by contrasting continuousand pulsed-tone responses. Twelve summary statistics were calculated for each participant’s data. The continuous tone and pulsed tone loudness matches were found by taking the average of all responses made by the participant for the respective test tone. The difference between the continuous and pulsed tone loudness matches is simply the dB difference of the two averages. The excursion width is the distance (in dB) between consecutive reversals, that is, from one peak to the following valley on the graphical representation of the test result. The continuous tone and pulsed tone excursion widths were calculated for each participant as the average distance (in dB) between consecutive reversals in the participant’s responses to the respective tones. The difference between continuous and pulsed tone excursion width was the dB difference of these two averages. Each of these metrics was calculated for the tinnitus loudness tracking match test at 1 kHz and at the pitch match frequency. For each of the 12 statistics, a t-test was used to evaluate the mean differences between the tinnitus and
Tinnitus Sufferers Mean (SD)
Pseudotinnitus Mean (SD)
Significance
41.32 (13.66) 45.18 (15.07) 23.85 (5.45)
38.82 (14.82) 41.39 (16.42) 22.58 (6.67)
0.42 0.27 0.34
10.47 (4.73) 13.47 (6.23) 23.01 (2.69)
11.89 (5.28) 15.16 (5.64) 23.27 (5.11)
0.19 0.19 0.77
nontinnitus groups. In each case, a two-sample t-test was run and a significance value (p-value) found. A multiple comparison adjustment was anticipated but ultimately proved unnecessary as no significant results were found. RESULTS
A
s shown in Table 1, the tinnitus group’s mean pure tone average (PTA) of 45.11 dB HL was not significantly different than the nontinnitus group’s mean PTA of 52.36 dB HL. Similarly, the mean pitch match frequency of 4405.8 Hz for tinnitus group participants was not significantly different than the nontinnitus group participants’ mean pitch match frequency of 3523.3 Hz. These findings suggest that our tinnitus matches in dB SPL were also at similar dB SL. Tinnitus loudness tracking matches to a 1000 Hz standard are shown in Table 2. The tinnitus and nontinnitus group means did not differ significantly (p , .05) for any of six measures: (1) continuous tone tinnitus loudness tracking; (2) pulsed tone tinnitus loudness tracking; (3) continuous tone-pulsed tone tinnitus loudness tracking differences; (4) continuous tone excursion width; (5) pulsed tone excursion width; (6) continuous tone-pulsed tone excursion width differences (see Table 2 for means, standard deviations, and significance values for each comparison). Tinnitus loudness tracking matches obtained at the pitch match frequency are shown in Table 3. The tinnitus
Table 3. Tinnitus Tracking Matches at Pitch-Match Frequency
Continuous tone loudness match (dB SPL) Pulsed tone loudness match (dB SPL) Difference between continuous tone and pulsed tone loudness matches (dB) Continuous tone excursion width (dB) Pulsed tone excursion width (dB) Difference between continuous tone and pulsed tone excursion width (dB)
924
Tinnitus Sufferers Mean (SD)
Pseudotinnitus Mean (SD)
Significance
57 (18.4385) 57.04 (17.22) 20.04 (6.49)
51.03 (19.4298) 50.56 (18.58) 0.47 (5.75)
0.15 0.1 0.7
11.5 (4.46) 14.55 (5.14) 23.05 (4.5)
11.8 (4.85) 15.82 (5.68) 24.02 (3.41)
0.77 0.28 0.26
Tinnitus Loudness Tracking/Steiger et al
and nontinnitus group means did not differ significantly ( p , .05) for any of six measures: (1) continuous tone tinnitus loudness tracking; (2) pulsed tone tinnitus loudness tracking; (3) continuous tone-pulsed tone tinnitus loudness tracking differences; (4) continuous tone excursion width; (5) pulsed tone excursion width; (6) continuous tone-pulsed tone excursion width differences (see Table 3 for means, standard deviations, and significance values for each comparison). DISCUSSION
B
ased on these findings, tinnitus loudness tracking may not hold promise as a clinical tool for the identification of pseudotinnitus. We found no statistically significant differences between tinnitus group participants and nontinnitus group participants for any of six measures: (1) continuous tone tinnitus loudness tracking; (2) pulsed tone tinnitus loudness tracking; (3) continuous tone-pulsed tone tinnitus loudness tracking differences; (4) continuous tone excursion width; (5) pulsed tones excursion width; (6) continuous tone-pulsed tone excursion width differences. It was surprising to the current researchers that our nontinnitus group participants’ pseudotinnitus loudness matches did not differ from the tinnitus matches of true tinnitus sufferers as was shown by Jacobson et al (2000). This could owe in part to our recording of data in dB SPL and not dB SL (hearing thresholds were not obtained prior to the Be´ke´sy tracking tasks). The hearing sensitivity of the tinnitus group was similar to that of the nontinnitus group, and therefore the tinnitus matches in dB SPL were likely at similar dB SL. However, even small variability of hearing thresholds between participants could impact on results; therefore, future researchers should complete tinnitus tracking comparisons on participants in dB SL. It should also be noted that dynamic range may play a role in suprathreshold tasks. For example, Tyler and Conrad-Armes (1983) argued that, because of recruitment, tinnitus sensation level may not be an appropriate measure of tinnitus loudness; low sensation level tinnitus and tones may sound loud to a given listener. This could reduce the loudness match variability, but reduced variability is not evident in our data. Nonetheless, in the future, researchers could compare tinnitus loudness in sones among participants with tinnitus and participants exhibiting pseudotinnitus. Perhaps our findings owe in part to the inherent difficulty of performing tinnitus loudness tracking reliably (Steiger et al, 2007), including when tinnitus is perceived bilaterally (Young and Lowry, 1981), and among participants who are not perceiving tinnitus at the time of testing (George and Kemp, 1989). Evidence of this can be seen in sample data variability. This could have been exacerbated by the fact that our participants were involved in
a two-session, 2 hr multitest evaluation of our Tinnitus Evaluation System and that tinnitus loudness tracking was performed last. The researchers detected participant fatigue during tinnitus loudness tracking, which in turn could have affected their responses. Also, tinnitus tracking runs are alternately ascending and descending, which could have removed the benchmark of audibility that appeared to contribute to response reliability in previous research (Jacobson et al, 2000). However, other than adding to sample data variability, it seems unlikely that fatigue could lead to our nontinnitus group participants’ surprising ability to match their pseudotinnitus to intensities similar to the tinnitus matches of true tinnitus sufferers. At this time, tinnitus loudness tracking cannot be recommended as a test of pseudotinnitus.
REFERENCES Balatsouras DG, Kaberos A, Korres S, Kandiloros D, Ferekidis E, Economou C. (2003) Detection of pseudohypacusis: a prospective, randomized study of the use of otoacoustic emissions. Ear Hear 24(6):518–527. Be´ke´sy GV. (1947) A new audiometer. Acta Otolaryngol (Stockholm) 35:411–422. Burns W, Hinchcliff R. (1957) Comparison of the auditory threshold as measured by individual pure tone and by Bekesy audiometry. J Acoust Soc Am 29:1274–1277. Corso JF. (1956) Effects of testing methods on hearing thresholds. AMA Arch Otolaryngol 63(1):78–91. George RN, Kemp S. (1989) Investigation of tinnitus induced by sound and its relationship to ongoing tinnitus. J Speech Hear Res 32(2):366–372. Hattler KW. (1970) Lengthened off-time: a self-recording screening device for nonorganicity. J Speech Hear Disord 35(2):113–122. Henry JA, James KE, Owens K, Zaugg T, Porsov E, Silaski G. (2009) Auditory test result characteristics of subjects with and without tinnitus. J Rehabil Res Dev 46(5):619–632. Henry JA, McMillan GP, Thielman E, et al. (2013) Evaluating psychoacoustic measures for establishing presence of tinnitus. J Rehabil Res Dev 50(4):573–584. Istre CO, Burton M. (1969) Automatic audiometry for detecting malingering. Arch Otolaryngol 90(3):326–332. Jacobson GP, Henderson JA, McCaslin DL. (2000) A re-evaluation of tinnitus reliability testing. J Am Acad Audiol 11(3):156–161. Jerger J. (1960) Bekesy audiometry in analysis of auditory disorders. J Speech Lang Hear Res 3:275–287. Jerger J, Herer G. (1961) Unexpected dividend in Bekesy audiometry. J Speech Hear Disord 26:390–391. Johnson RM. (1987) Tinnitus and disability—a method of evaluation. In: Shulman A, Aran J-M, Tonndorf J, Feldmann H, Vernon JA, eds. Tinnitus: Diagnosis/Treatment. Malvern, PA: Lea and Febiger, 444. Kacker SK. (1971) Bekesy audiometry in simulated hearing loss. J Speech Hear Disord 36(4):506–510.
925
Journal of the American Academy of Audiology/Volume 24, Number 10, 2013
Martin FN, Monro DA. (1975) The effects of sophistication on Type V Bekesy patterns in simulated hearing loss. J Speech Hear Disord 40(4):508–513.
Rintelmann WF, Harford ER. (1967) Type V Bekesy pattern: interpretation and clinical utility. J Speech Hear Res 10(4): 733–744.
McShane DP, Hyde ML, Alberti PW. (1988) Tinnitus prevalence in industrial hearing loss compensation claimants. Clin Otolaryngol Allied Sci 13(5):323–330.
Steiger JR, Saccone PA, Watson KN. (2007) Assessment of objective pulsatile tinnitus in a patient with syringohydromyelia. J Am Acad Audiol 18(3):197–205.
Meikle MB, Walsh ET. (1983) Characteristics of tinnitus and related observations in over 1800 tinnitus clinic patients. J Laryngol Otol Suppl 9:17–21.
Stein L. (1963) Some observations on type V Bekesy tracings. J Speech Hear Res 13:339–348.
Mitchell CR, Vernon JA, Creedon TA. (1993) Measuring tinnitus parameters: loudness, pitch, and maskability. J Am Acad Audiol 4(3):139–151. Owens E. (1964) Bekesy tracings and site of lesion. J Speech Lang Hear Disord 29:456–468. Peterson JL. (1963) Non-organic hearing loss in children and Bekesy audiometry. J Speech Lang Hear Disord 28:153–158. Qiu WW, Yin SS, Stucker FJ, Welsh LW. (1998) Current evaluation of pseudohypacusis: strategies and classification. Ann Otol Rhinol Laryngol 107(8):638–647. Reger SN. (1952) A clinical and research version of the bekesy audiometer. Laryngoscope 62(12):1333–1351. Resnick DM, Burke KS. (1962) Bekesy audiometry in nonorganic auditory problems. Arch Otolaryngol 76:38–41.
Stream RW, McConnell F. (1961) A comparison of two methods of administration in Bekesy-type audiometry. J Aud Res 1: 263–271. U.S. Department of Veterans Affairs, Veterans Benefits Administration. (2012) Annual Benefits Report Fiscal Year 2011. Version 3. www.vba.va.gov/REPORTS/abr/2011_abr.pdf (accessed February 11, 2013). Ventry IM. (1971) Bekesy audiometry in functional hearing loss: a case study. J Speech Lang Hear Disord 36:125–141. Vernon J, Fenwick J. (1984) Identification of tinnitus: a plea for standardization. J Laryngol Otol S9:45–53. Vernon JA, Meikle MB. (1988) Measurement of tinnitus: an update. In: Kitahara M, ed. Tinnitus: Pathophysiology and Management. New York: Igaku-Shoin, 36–52.
Rintelmann WF, Carhart R. (1964) Loudness tracking by normal hearers via Bekesy audiometer. J Speech Hear Res 7:79–93.
Vernon JA, Meikle MB, Evered D, Lawrenson G, eds. (1981) Tinnitus masking: unresolved problems. In: Evered D, Lawrenson G, eds. Ciba Foundation Symposium 85—Tinnitus. London: Pitman Books, 239–256.
Rintelmann WF, Harford E. (1963) The detection and assessment of pseudohypacusis among school-age children. J Speech Lang Hear Res 7:79–93.
Young IM, Lowry LD. (1981) Changes of tinnitus localization following exposure to a pure tone. J Acoust Soc Am 70(S1): S104.
926
Copyright of Journal of the American Academy of Audiology is the property of American Academy of Audiology and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
