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29
Keypoints
1. Many studies have addressed the prevalence of
tinnitus, but the definition of tinnitus has varied.
2. Some studies have reported that as many as 80%
of the adult population experience tinnitus at some
point.
3. Six large population studies in different countries
reported prevalence of prolonged tinnitus, varying
between 4.4 and 15.1% for adults and between 7.6
and 20.1% for individuals below the age of 50
years. One of the studies reported that 2.4% of the
population responded “yes” to the description of
tinnitus as “tinnitus plagues me all day.”
4. A study in four cities in England found that tinnitus,
on average, occurred in 17.5% of the participants in
the age group of 40–60 years and 22.2% in partici-
pants above the age of 60 years.
5. Since tinnitus has many forms and its prevalence
varies with age and, to some extent, gender, the
prevalence of tinnitus cannot be described by a
single number.
6. The prevalence of tinnitus increases monotoni-
cally up to the age of approximately 70 years,
above which the prevalence either becomes con-
stant or decreases slightly with age.
7. The prevalence of tinnitus is lower in women up
to 75 years, above which the gender difference
becomes small.
8. There is some evidence that noise exposure increases
the risk of tinnitus.
9. The odds of having tinnitus increases with the
degree of hearing loss when measured at 4 kHz.
10. While reported “trouble hearing” increases mono-
tonically with age, “bothersome tinnitus” increases
with age only up to the age group of 65–74, after
which it becomes independent of age or decreases
slightly with age.
Keywords Tinnitus • Epidemiology • Prevalence
• Adults • Hearing loss • Noise exposure
Introduction
Understanding the incidence and prevalence of a
disease in a defined population is important for
improvement of health and prevention of diseases.
Accurate determination of the prevalence of a condi-
tion, such as tinnitus, which does not have objective
signs, depends on the ability to define the disease to
the members of the population that is studied.
Tinnitus affects different groups of people differ-
ently, such as different age groups, and the prevalence
of tinnitus in women and men is also different. This
means that a single number cannot describe the preva-
lence of tinnitus. It is therefore important to define the
part of the population that is studied.
Tinnitus is often accompanied by hyperacusis
(lowered tolerance for sound, see Chaps. 3 and 57),
misophonia (dislike of certain sounds), and phonophobia
(fear of certain sounds); see Chaps. 4 and 57. While the
prevalence of tinnitus, in general, is poorly known,
the prevalence of these symptoms is even less known. The
effect of tinnitus on a person’s quality of life depends
more on the distress it causes and less on how a person
perceives his or her tinnitus. However, the prevalence
of distress from tinnitus is poorly known.
Chapter 5
Epidemiology of Tinnitus in Adults
Aage R. Møller
A.R. Møller (*)
The University of Texas at Dallas, School of Behavioral
and Brain Sciences, GR 41, 800 W Campbell Rd,
Richardson, TX 75080, USA
e-mail: amoller@utdallas.edu
A.R. Møller et al. (eds.), Textbook of Tinnitus,
DOI 10.1007/978-1-60761-145-5_5, © Springer Science+Business Media, LLC 2011
30 A.R. Møller
When discussing the prevalence of tinnitus, it is the
troubled tinnitus that is of the greatest interest because
that is the form of tinnitus that affects the quality of life
and which may have severe consequences for the per-
son who has tinnitus. Troubled tinnitus may result in
the inability to work and may have such a severe effect
on a person that it causes suicide.
This chapter discusses population studies of the
prevalence of tinnitus. Few studies have addressed the
incidence of tinnitus which will not be discussed, and
the natural history of tinnitus is not understood (see
Chaps. 63 and 64) [1].
For studies of the prevalence of tinnitus, the great-
est challenge lies in defining the tinnitus. As has been
discussed in many of the chapters in this book, tinnitus
has many forms (see especially Chaps. 2–4 and 17).
Tinnitus varies widely among individuals not only in
strength but also in character, and many investigators
have proposed different classification schemes for tin-
nitus (for a review see Heller 2003) [2]. An individu-
al’s tinnitus can vary widely from time to time. Many
forms of tinnitus change from day to day and even
change over the course of one day.
In that way, tinnitus has many similarities with pain.
When the task is to obtain accurate information regard-
ing its prevalence of tinnitus and pain, there are many
aspects of these two symptoms that must be taken into
account as has been discussed in Chaps. 14 and 94.
Tinnitus can noticeably decrease the quality of life
or it can just be a small annoyance. In fact, most people
who have tinnitus do not regard it as anything impor-
tant. One study reported that 0.5–1% of individuals
with tinnitus indicated that the condition severely
affected their ability to live a normal life [3]. Other
studies have reported different estimates of prevalence
of such forms of tinnitus.
The degree of distress tinnitus can cause is not
related to the character or the perceived strength of the
disorder as it is described by the persons who have
tinnitus. The perceived severity of tinnitus depends on
many different factors; one being a person’s personal-
ity (see Chaps. 27, 63 and 64). The perception of
tinnitus is also influenced by external circumstances.
These factors all make it difficult to obtain an accurate
estimate of the prevalence of tinnitus that affects a
person’s life. Different definitions of such forms of tin-
nitus have been used by individual investigators. This
is one of the reasons that the results reported by differ-
ent epidemiologic studies differ considerably, and
different studies report prevalence of tinnitus that
varies from study to study. The lack of objective signs
of tinnitus is another source of uncertainty in studies of
this disorder, and only self-reported evaluation of a
person’s tinnitus is available. Most epidemiologic
studies have not attempted to distinguish between the
different origins of the tinnitus, not even distinguish-
ing between objective and subjective tinnitus.
Another source of variation in the results of differ-
ent epidemiologic studies of tinnitus is shared with
other voluntary studies, namely, that not all persons
selected for a study respond. Normally, epidemiologic
studies will spend a considerable effort finding out if
the group of non-responders is different from the group
that responds.
Another reason for varying results in different
studies is that questions are formulated differently.
Some studies have used written questions distributed
to groups of people more or less representative of the
general population. Some studies have enrolled indi-
viduals seeking professional help for their tinnitus.
The participants in some studies must therefore be
regarded as being a selected group of individuals that
may not be representative of the general population.
Tinnitus depends on many factors, which makes it
important to obtain a multi-dimensional description of
its epidemiology. Thus, it is not meaningful to just
describe the prevalence with a single number.
Estimates of the Prevalence of Tinnitus
Data from the National Center for Health Statistics,
US Department of Health, Education, and Welfare
(1968), indicate that 30% of the general population
are affected by tinnitus, and that 6% of them (1.8% of
the general population) have incapacitating symptoms
[2]. Other studies have presented values of prevalence
that vary between 7.6 and 20.1% (see Table 5.1).
Prevalence of Tinnitus as a Function
of Age
One of the main variables in the prevalence of tinnitus is
age, and studies have therefore expressed the prevalence
of tinnitus as a function of age. Table 5.1 compares the
315 Epidemiology of Tinnitus in Adults
reported prevalence in several studies from the United
Kingdom, Sweden, Norway, and the US.
All published studies show values of prevalence of
tinnitus that are not the same for different age groups.
All published studies seem to agree that the risk of get-
ting tinnitus increases with age up to about 65 years,
after which age prevalence is either independent of or
decreases slightly with increasing age.
The design of the studies, the results of which are
shown in Table 5.1, all had differences, which make it
difficult to compare the results. The first study (United
Kingdom National Study of Hearing) used a postal
questionnaire sent to people in Cardiff, Glasgow,
Nottingham, and Southampton in age groups between
17 and more than 80 years. In the questionnaire, tin-
nitus was defined as “prolonged spontaneous tinnitus”
that lasts for more than 5 min and occurs not exclu-
sively after loud sounds [5].
In the study from Gothenburg, Sweden, question-
naires were mailed and had blinded response (no follow-
up of non-responders). Tinnitus was defined as an ear
noise that occurs “often or always” and sounds like a
peep, chirping, roaring, wind blowing in the trees, etc.,
[6]. In the same study, 2.4% of the population suffered
from the worst severity degree defined as “tinnitus
plaques me all day.”
The United States National Health Interview Survey
(US NHIS) is a household survey with personal inter-
views of non-institutionalized civilians from randomly
chosen areas constituting a nationally representative
sample. The participants in this study had tinnitus that
was defined as “having been bothered by ringing in the
ears or other funny noises in the head in the past
12 months” [7]. The 1994–1995 US NHIS Disability
Supplement study, Phase I, used an impairment and
disability-screening questionnaire. Chronic tinnitus
was defined in the interview as “now having a ringing,
roaring, or buzzing in the ears that has lasted for at
least 3 months” [8, 9].
The participants in the Beaver Dam, WI Hearing
Loss study had significant tinnitus that was defined as
“buzzing, ringing, or noise in the ears in the past year
of at least moderate severity and/or tinnitus that caused
difculty in falling asleep” (Nondahl 2002) [10].
The Nord Trondelag, Norway Hearing Loss study
used a self-administered questionnaire filled out in
study clinics prior to the hearing examination [11].
Tinnitus was defined as “bothered by ringing in the
ears.” The participants in this study were thus individ-
uals who had sought professional help for their tinni-
tus. The results may therefore not be representative of
the general population.
While there are large differences between the values
of prevalence arrived at by different studies, there is
agreement that the prevalence of tinnitus increases
with age. Less clear is the relationship to gender, but
studies show a tendency for tinnitus to occur more fre-
quently in men than in women. Epide miological stud-
ies of prevalence show a slightly larger prevalence of
tinnitus in men, but the results are not consistent.
Most studies show an increase in the prevalence of
tinnitus with age in the age groups up to 65–74 and
considerably lower prevalence in individuals above
75 years than in the age group of 65–74 years. Since
tinnitus of an individual rarely decreases the preva-
lence arrived at in epidemiologic studies, at least up to
Table 5.1 Prevalence of self-reported tinnitus in adults by decade of life from several population-based, epidemiologic studies
Age (year) I (%) II (%) III (%) IV (%) V (%) VI (%)
20–29 5.7 7.5 5.1 1.4 9.8
30–39 7.4 5.8 6.0 2.0 9.6
40–49 9.9 8.9 7.2 3.7 11.8
50–59 12.5 18.6 10.1 5.7 7.3 16.9
60–69 16.3 20.3 13.0 7.9 10.1 20.2
70–79 14.4 21.3 12.6 9.4 8.7 24.0
>80 13.6 14.1 8.3 5.5 22.9
<50 14.2 20.1 12.1 7.6 8.2 20.1
Adult 10.2 14.2 8.4 4.4 15.1
Participants 34,050 2,556 59,343 99,435 3,737 47,410
I: United Kingdom National Study of Hearing (1980–1986); II: Gothenburg, Sweden (1989); III: US NHIS Hearing Supplement
(1990); IV: Disability Supplement (1994–1995); V: Beaver Dam, WI Hearing Loss Study (1993–1995); VI: Nord Trondelag, Norway
Hearing Loss Study (1996–1998)
Data from Hoffmann and Reed [4]
32 A.R. Møller
the age of 70 can be regarded as being cumulative,
above which it does not seem to increase very much.
This pattern of age relations of prevalence of tinni-
tus is clearly seen in the graphic representation of the
results of another study (Fig. 5.1).
This graph shows that the prevalence of tinnitus for
both men and women increases with age and that it
levels out and even decreases above a certain age. The
prevalence of tinnitus is higher for men than for women
up to the age of 75, and the prevalence of tinnitus
reaches its highest value earlier in life for men than for
women. At the age of 75, the prevalence in women
catches up with that of men, and above the age of 75
the prevalence of tinnitus is about the same for men
and women. This pattern is thus similar to that of the
prevalence of cardiovascular disease.
That the prevalence is less in the group of 80 years
of age may have to do with tinnitus being associated
with diseases, which may have caused early death.
Therefore, those who die before the age of 80 may have
had a higher prevalence of tinnitus than those who live
beyond the age of 80 years. Again, it may suggest that
tinnitus has similar risk factors as diseases that can
cause early death, such as cardiovascular disorders.
Animal studies have shown that rats genetically
predisposed for high blood pressure also acquire more
hearing loss from noise exposure than animals not
genetically predisposed for hypertension (normotensive
rats) [12, 13]. There may also be (unknown) relations
between cardiovascular factors and tinnitus in humans.
Those individuals who survive the age of 80 may,
thus, have fewer risk factors that shorten lifespan and
which are the same risk factors for tinnitus. It may
therefore be more representative to compare the values
for the higher age groups, such as the 60–69 years,
where the prevalence arrived at in different studies
varies between 20.3 and 8.7%.
Other studies found similar trends of prevalence of
tinnitus increasing with age between 50 and 75 years,
above which the prevalence decreased in two different
studies: one from the US and one from Australia
(Table 5.2).
It has been pointed out that the influence on daily
life from tinnitus is different and that the ways in which
questions asked of participants in epidemiologic studies
Fig. 5.1 Age- and sex-specific prevalence (in percentage of total
study population) of chronic tinnitus (“ringing, roaring or buzzing
in the ears or head now that has lasted at least 3 months”), based
on 1994–1995 US National Health Interview Survey Disability
Supplement. The study had 99,435 participants. Reproduced from
Hoffman and Reed [4] with permission by BC Decker Inc.
Table 5.2 Tinnitus prevalence by age and gender (%),
standardized to the Australian population, using 1996 Australian
census data
Age (years) Women Men Participants
< 60 23.6 32.3 28.0
60–69 30.5 35.1 32.7
70–79 28.7 32.7 30.5
80+ 27.7 21.5 25.4
All ages 28.6 32.2 30.3
Data from Sindhusake et al. [14]
33
5 Epidemiology of Tinnitus in Adults
are formulated influence the results. This is one of the
reasons for the difference in results of epidemiologic
studies.
A study from four cities in the UK (Table 5.3) [15],
which reported that tinnitus occurred in an average of
17.5% of individuals, showed that annoyance was clas-
sified to be moderate or severe in 5.3% on average for
the cities studied. This study also showed a similar pat-
tern of age relationship (14.5% in persons younger
than 40 years, 17.5% in the group of 40–60 years, and
22.2% in individuals older than 60 years).
Although the reported prevalence of tinnitus varies
between different studies, twenty percent of people
who say they have tinnitus reported their condition
as “severe tinnitus.” This means that about 80% of
patients with tinnitus suffer little and are not seeking
treatment.
Hearing Loss and Tinnitus
A study shows that the risk of having tinnitus (expressed
as odds ratio1) increases with the degree of hearing loss
at 4 kHz [16] (Fig. 5.2)
Table 5.3 Percentages of adult population reporting tinnitus and its effects
Cardiff Glasgow Nottingham Southampton
Starting number (N) 1035 2,787 1,028 1,954
Usable replies (N) 730 (71%) 2,033 (75%) 726 (71%) 1,511 (77%)
Tinnitus (%) 17.9 18.6 18.1 15.5
Annoyance: moderate (%) 4.1 4.1 4.4 3.8
Severe (%) 0.7 2.8 0.4 0.7
Combined (%) 4.8 6.9 4.8 4.5
Sleep disturbance (%) 3.8 7.3 5.4 4.4
Severe effect on life (%) 0.4 0.5 0.4 0.5
Data from Coles [15]
1Odds ratio: A measure of the size of an effect describing the
strength of association between two binary data values. It is dif-
ferent from the relative risk because it treats the two variables to
be compared symmetrically.
Fig. 5.2 Bar graph showing how the odds of having tinnitus
increase as hearing threshold level (HTL) at 4 kHz increases in
the United Kingdom National Study of Hearing. Because the
prevalence of tinnitus in people with 4 kHz thresholds less than
10 dB (the reference group) was about 1%, the odds ratios in this
case are very close to the actual prevalence rates in percentage.
After Coles [16]. Reproduced from Dobie [1] with permission
from BC Decker Inc
10−19 dB: < 10 dB
20−29 dB: < 10 dB
30−39 dB: < 10 dB
40−49 dB: < 10 dB
50−59 dB: < 10 dB
60−69 dB: < 10 dB
70−79 dB: < 10 dB
80+ dB: < 10 dB
611 16 21 26 31
1
Odds Ratio
HTL at 4 kHz in Better Ear
34 A.R. Møller
“Trouble Tinnitus” Compared
with “Trouble Hearing”
There is considerable difference between having
tinnitus and being troubled by tinnitus (having “trouble
tinnitus”). The same is the case for hearing; having
“trouble hearing” is a distinction from just having
hearing loss. In a study based on the US National
Health Interview Survey, participants were asked to
report whether they had a “lot of trouble hearing” or
“any trouble hearing,” and for tinnitus the participants
were asked if they had “bothersome tinnitus.” In this
study, the reported hearing trouble only increased
slightly after age of 65, when self-reported problems
were concerned (Fig. 5.3).
It is evident that while hearing loss increases mono-
tonically with age, the prevalence of bothersome
tinnitus levels off and even decreases after the age of
70 years, thus, in agreement with other studies reported
above. That bothersome tinnitus reaches a level of
about 14% in the 65- to 74-year age group should be
noted.
Can Hearing Loss Cause Tinnitus?
The prevalence of tinnitus increases with age, and it
has been discussed whether hearing loss can be a
contributing cause of this increase in the prevalence of
tinnitus with age. Audiometric data show that hearing
loss increases with age [17, 18] (see Chap. 36) The
results of studies discussed in this chapter show that
the prevalence of tinnitus increases with age, but it is
not known if it is age-related changes in the ear and the
nervous system that cause the tinnitus to increase with
age or if it is the age-related hearing loss that causes
the increase in prevalence of tinnitus. Population stud-
ies have shown that individuals with tinnitus, on aver-
age, have hearing loss affecting mostly high frequencies
[19] (Fig. 5.4).
Other studies (Table 5.4) have confirmed the differ-
ence in prevalence of tinnitus between men and women.
There is considerable evidence that deprivation
of input to the auditory nervous system can cause
tinnitus (see Chaps. 11–13 and 21). There is also evi-
dence that noise exposure can cause hearing loss (see
Chap. 37), but it is not known if it is the noise expo-
sure, as such, or the associated hearing loss that causes
the tinnitus.
The hearing loss shown in Fig. 5.4 is slightly greater
in males than in females, resembling what is found in
population studies of hearing and showing signs of a
4-kHz dip, indicating that some of the hearing loss is
likely to have been caused by noise exposure.
As an example of the diversity of tinnitus, it has
been shown that the type of hearing (shape of the
audiogram) is related to the character of the tinnitus
Fig. 5.3 Prevalence of
self-reported hearing loss (“lot
of trouble hearing” or “any
trouble hearing”) and bother-
some tinnitus. Reproduced from
Hoffmann and Reed [4] with
permission by BC Decker Inc.;
based on US National Health
Interview Survey, Hearing
Supplement 1990
35
5 Epidemiology of Tinnitus in Adults
(Fig. 5.5). Patients with low-pitched tinnitus
(<1,500 Hz) tend to have much more severe hearing
losses, especially in the low frequencies, than do
patients with higher pitched tinnitus.
Again, it must be emphasized that these data are
also from tinnitus clinics, thus, only including people
who have sought professional help. While tinnitus
does occur in individuals with normal hearing, people
with tinnitus usually have hearing loss, and deprivation
of sound activation of the nervous system can cause
tinnitus by activating neural plasticity, as discussed in
Chap. 12. However, the prevalence of troubled tinnitus
does not increase above the age of 65, while audiomet-
ric hearing loss does continue to increase with age
above 65.
The fact that tinnitus cannot be measured objec-
tively as can hearing loss means that comparing tinni-
tus with audiometrical hearing loss may be regarded to
be an invalid comparison. However, as seen in Fig. 5.3,
the subjective trouble with hearing also increases with
age while the prevalence of tinnitus is not changing
above the age of 65. This could be because the debut of
tinnitus above that age is rare or that some individuals
who had tinnitus before the age of 65 improve and that
counteracts an increase in the new cases of tinnitus.
This question cannot be answered because the natural
history of tinnitus is poorly known. Studies that have
concerned the natural history of tinnitus have only
reported on the presence of the dis order, not its sever-
ity [20, 21, 22] or how the individuals perceive their
tinnitus. There are two reasons why the prevalence of
tinnitus may be higher in a population of individuals
with hearing loss. One reason is that hearing loss
implies a certain degree of deprivation of input to the
auditory system (see Chap. 11), which is known to be
able to activate neural plasticity, and known to be
involved in many forms of tinnitus (see Chaps. 12 and
13). Another reason that there may be a relationship
between the prevalence of tinnitus and hearing loss is
that the same factors that cause hearing loss may cause
tinnitus. Such common factors may be age, cardiovas-
cular disorders, and noise exposure.
When the kind of tinnitus individuals with hearing
loss have is correlated with the shape of their audio-
grams, it follows that there are distinct correlations
between the pitch of an individual’s tinnitus and the
Fig. 5.4 Mean hearing thresholds in the right ear for female and
male patients with tinnitus. Data are from patients who attended
a tinnitus clinic. From Henry et al. [19]
Table 5.4 Prevalence in percentages for males and females
Age Male (%) Female (%)
18–24 4.3 5.2
25–24 5.8 6.2
45–64 10.6 9.5
65+ 12.3 13.9
Prevalence based on a self report of “bothersome tinnitus” as a
function of age, sex, and percentage of each characteristic in the
population; based on the 1990 Hearing Supplement to the
National Health Interview Survey. Data from Hoffmann and
Reed [4]
Fig. 5.5 Mean hearing threshold of the right ear for individuals
in each group of patients according to the pitch of their tinnitus.
Data are from patients who attended a tinnitus clinic. From
Henry et al. [19]
36 A.R. Møller
individual’s audiogram (Fig. 5.5). This is yet another
complexity of tinnitus that makes it difficult to estab-
lish clear data on its prevalence.
It was shown in a study of patients with tinnitus of
different pitch that patients with low-pitched tinnitus
(less than 1,500 Hz) tend to have much more severe
hearing losses, especially at the low frequencies, than
do patients with higher pitched tinnitus.
The studies reported in the two preceding graphs
concerned patients who had sought help for their tin-
nitus. This means that the participants do not represent
a random selection of people. There are many reasons
why people seek professional help and equally many
reasons why people do not seek professional help.
Other Risk Factors for Tinnitus
Noise exposure and noise that induced hearing loss is
another factor anecdotally reported to cause tinnitus in
individuals.
Risk factors for tinnitus other than age are hearing
loss, diseases such as middle-ear disorders, Ménière’s
disease, cerebrovascular diseases, and, in particular,
hearing loss of various causes and environmental fac-
tors such as exposure to noise and administration of
certain medications such as ototoxic antibiotics and
acetylsalicylate.
Noise exposure increases the risk of tinnitus, and, at
the same time, it causes hearing loss. The question is,
therefore, if the tinnitus from noise exposure is caused
by the hearing loss associated with noise exposure. The
increased prevalence of tinnitus in males may have to
do with the increased noise exposure in males and sub-
sequent higher frequency of hearing loss in men [17].
Tinnitus and Suffering
Tinnitus is a sensation, and suffering may be related to
and possibly a consequence of having tinnitus. The
prevalence of tinnitus, counting all forms, is of little
interest from a health care perspective because most
individuals with tinnitus are not bothered to an extent
that it affects their daily life, and few will seek medical
attention except for those who want to be sure that
their tinnitus is not a sign of a serious disease. In that
way, tinnitus has similarities with pain. Most people
have experienced pain in one form or another, but only
a few have severe pain that causes suffering.
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