The Epidemiology of Hyperacusis and Tinnitus in Children

Transcription

1 The Epidemiology of Hyperacusis and Tinnitus in Children Rachel Humphriss MSc PhD CS Clinical Scientist (Audiology) University Hospitals Bristol NHS Foundation Trust Research Associate School of Social and Community Medicine University of Bristol

2 This afternoon What is epidemiology? Avon Longitudinal Study of Parents and Children 2 studies: Prevalence and risk factors for reduced sound tolerance (hyperacusis) in children. Prevalence and characteristics of spontaneous tinnitus in 11 year old children. Time for questions

3 Epidemiology The study of the distribution and determinants of health-related states or events in specified populations, and the application of this study to the control of health problems. (Last, 2001)

4 ALSPAC Avon Longitudinal Study of Parents and Children Prospective observational study Former Avon region: Population about 1 million Urban, suburbs, rural, small towns All pregnant women in region with expected dates of delivery between April 1 st 1991 and December 31 st 1992 were invited to participate Ethical approval for the study was obtained from the ALSPAC Law and Ethics Committee and the Local Research Ethics Committees.

5 ALSPAC Response rate approx 80% N = 13,971 live infants at age 12 mths Sample considered to be broadly representative of UK population (slightly higher levels of social advantage and lower levels of ethnic minorities) See Boyd et al (2013) for details of cohort

6 Prospective longitudinal studies: ALSPAC Selection of participants Age 7 Age 9 Age 11 Pregnancy TIME Hearing Hearing Hearing Measurement of SES / other exposures Measurement of other risk factors and confounders

7 Hearing assessment session: Age 11 In context of half-day research clinic Pure Tone Audiometry (AC, BC) (BSA recommended procedure) Tympanometry Transient OAEs Questions about sound sensitivity Questions about tinnitus N=7097

8 Non-auditory risk factors Prenatal Smoking in pregnancy Early life Gestational age (<37 weeks, 37 weeks) Birth-weight ( 2500g, >2500g) Gender SCBU Readmission to hospital by 4 weeks Socioeconomic Maternal education level (low/minimal, medium/qualification at 16yrs, high/qualifications obtained at 18yrs) Housing tenure (mortgaged/owned, private rented, council/ha) Occupational social class (Registrar General s Classification)

9 HYPERACUSIS

10 Definitions of hyperacusis Hyperacusis: an abnormal lowered tolerance to sound (Baguley and Andersson, 2007) Phonophobia: the fear of sounds +auditory sensitivity associated with migraine Misophonia: aversive reaction to specific types of soft sound, e.g. eating, respiration Often confused: challenging to distinguish between a subjective increase in perceived intensity and the emotional reaction to this Definition used here: oversensitivity or distress to particular everyday sounds rather than to loud sounds.

11 Proposed mechanism Heterogeneous condition: multiple mechanisms Increased gain of central auditory system May be associated with reduced peripheral auditory sensitivity Often comorbid with tinnitus: hyperacusis suggested as a precursor to tinnitus

12 Associated conditions Williams syndrome High frequency HL Recurrent OME Acoustic reflexes deficient Autistic Spectrum Disorder Auditory hypervigilance? Oversensitivity to light and touch Migraine Depression Post-Traumatic Stress Disorder

13 Previous study of prevalence of hyperacusis in children Coelho et al (2007) Cross-sectional study 506 children (from random selection of 700, one town in Brazil) Age 5 12 years Hyperacusis Are you bothered by any kind of noise? + identify 10/20 sounds from a list as being annoying + lowered LDL (5 th percentile 1 frequency) Prevalence: 3.2% Phonophobia Are you afraid of sounds? Prevalence: 9%

14 Other studies Sattar (2009) 100 normally hearing children from a clinic (undefined) Hyperacusis more common in males 2:1 ratio Most common age of presentation: 3-4yrs Baguley et al (2013) 88 young persons with tinnitus, 4 specialist European centres 39% had decreased sound tolerance

15 ALSPAC hyperacusis study aims To estimate the prevalence of hyperacusis in 11 year old children using data from a prospective UK populationbased study To identify any early life and auditory risk factors for hyperacusis

16 Questions about sound sensitivity Do you ever experience over-sensitivity or distress to particular sounds? Do you stay away from places or activities because of sensitivity to sounds? Do you ever use ear protection from these sounds?

17 Results: prevalence of hyperacusis in 11 year old children N= reported oversensitivity to sound Prevalence of hyperacusis = 3.68% [3.25, 4.14] 157 (60.2%) male, 104 (39.8%) female Behavioural avoidance by 112 (42.9% hyperacusic children) 21 (8.0%) used ear protection

18 Association with socioeconomic factors Reports of hyperacusis strongly associated with: Higher maternal education Mat Ed N (%) hyperacusis N (%) remainder of sample Unadj OR [95% CI] P Adj OR [95% CI] P <16yrs 39 (16.3) 1381 (22.1) Ref Ref GCSE 79 (32.9) 2217 (35.5) 1.26 [0.85, 1.86] [0.97, 2.40] A level+ 122 (50.8) 2644 (42.4) 1.63 [1.13, 2.35] [1.08, 2.72] 0.020

19 Association with child factors Reports of hyperacusis strongly associated with: Male gender Adj. OR for hyperacusis, if female = 0.64 [0.49, 0.85], p=0.002 Children re/admitted to hospital in first 4 weeks of life Adj. OR for hyperacusis, if hospital admission = 1.98 [1.20, 3.25], p=0.007 No strong associations with birth-weight, gestational age, admission to SCBU

20 Associations with ASD 29 children with ASD attended the clinic (only about 30% of ALSPAC children diagnosed with ASD) 12 (41.4%) reported hyperacusis OR for hyperacusis = [8.14, 36.88] (adjusted for gender) But small sample size Could we therefore have underestimated the prevalence of hyperacusis?

21 Associations with audiological outcomes PTA: no strong associations Tympanometry: children were not more likely to have OME (at age 11) OAE: children with hyperacusis had increased odds of larger OAEs Largest differences in amplitude at 2kHz Adjusted mean differences at 2kHz for low level stimuli Right ear, 2.69dB [1.39, 3.98] Left ear: 2.32dB [1.03, 3.60]

22 Conclusions: prevalence of hyperacusis ALSPAC is the largest population-based study to look at hyperacusis in children More generalisable than Coelho et al (2007) Prevalence of hyperacusis in 11 year old children is estimated at 3.68% [3.25, 4.14] 42.9% of these children showed avoidance behaviours But only 8% used ear protection More common in boys

23 Conclusions: hyperacusis and SES Associated with social advantage as measured by maternal education Child more articulate? Greater awareness of health issues? Parents more attentive to health needs? Fewer life issues to worry about? Unusual as most health conditions are associated with social disadvantage Socially advantaged sample so may have overestimated prevalence (but small number with ASD may have resulted in under-estimate)

24 Conclusions: hyperacusis and neonatal health Hyperacusis more prevalent in children admitted to hospital in first month of life Causal: Adverse effect on auditory neurodevelopment? Adverse effect on brain development which predisposes child to later behavioural / emotional problems? Non-causal: Parents of child with difficult start in life might be hyper-vigilant about child s health?

25 Conclusions: hyperacusis and auditory risk factors No consistent associations with hearing thresholds No associations with middle ear function (at age 11) Middle ear history not examined early OME may be a risk factor Association with larger OAEs More spontaneous OAEs in hyperacusis group? Increased gain of cochlear amplifier? LDLs not measured: have low sensitivity / specificity for hyperacusis

26 TINNITUS

27 Estimating tinnitus prevalence in children not straightforward Children rarely spontaneously report tinnitus although they might admit to it when questioned The child might over-report as s/he seeks to please the questioner Tinnitus can be very difficult to describe Behavioural changes Educational difficulties Poor sleep Difficult to distinguish tinnitus sensation and tinnitus suffering (many adults report some internal noise) Only 0.6% of children (n=3047, 12-19yrs, Korea) reporting tinnitus complain of severe discomfort (Park et al, 2014)

28 Previous studies of prevalence of tinnitus in children % for any tinnitus in normally hearing or population-based samples Higher in children with hearing loss 2 previous studies of spontaneous tinnitus Holgers (2003): 12.0% (n=964, 7yr olds, Sweden) Juul et al (2012): 27.0% (n=706, 7yr olds, Sweden)

29 ALSPAC Tinnitus study aims To estimate the prevalence of both any spontaneous tinnitus and clinically significant tinnitus in 11 year old children To describe that tinnitus To look for associations with hearing thresholds

30 ALSPAC Questions about tinnitus Do you ever get noises in your ears? (not associated with noise exposure) Can you describe the noise? Is it low or high pitch? Which ear is it in? Is the noise loud or soft? Do you hear the noises: intermittently / continuously / don t know How long do the noises last? How often do you hear the noises? How long have you had the noises? Do the noises bother you?

31 Results: prevalence of tinnitus in 11 year old children N= answered yes to the main tinnitus question Prevalence of any spontaneous tinnitus = 28.1% [27.1, 29.2] Clinically significant tinnitus defined as: duration >seconds AND children slightly/severely bothered 218 children reported tinnitus lasting minutes/hours AND were bothered by it Prevalence of clinically significant spontaneous tinnitus = 3.1% [2.7, 3.5]

32 Results: tinnitus characteristics Characteristic Descriptor % Description Pitch Loudness Duration of noises How bothersome Buzzing Whistling Other Low High Don t Know Loud Soft Don t know Seconds Mins / hours Don t know Not bothered Slightly bothered Severely bothered

33 Results: associations with clinically significant tinnitus Clinically significant tinnitus less likely If children were able to lateralise their tinnitus If tinnitus was soft rather than loud If tinnitus was continuous rather than intermittent Clinically significant tinnitus was more likely If it occurred more than once a week No strong associations with Pitch Length of history Gender

34 Results: associations with PTA Hearing thresholds tend to become poorer as tinnitus category becomes more severe. Ear Clin sig tinn itus N Mean dbhl Non-signif tinnitus N Mean dbhl No tinnitus N Mean dbhl Clin sig minus nonsig tinn dbhl Any tinnitus minus no tinnitus dbhl R * 1.2* L * 1.2* Shows mean PTA, Hz *Kruskall-Wallis test: p<0.0001

35 Conclusions: prevalence of spontaneous tinnitus Any tinnitus: 28.1% [27.1, 29.2] Clinically significant tinnitus: 3.1% [2.7, 3.5] 84% children who said they experienced tinnitus were not bothered by it The high prevalence of tinnitus in childhood may not necessarily indicate large unmet clinical demand Savastano (2007): although 33.7% reported tinnitus, only 6.5% reported it spontaneously Park et al (2014): 17.7% reported tinnitus, but only 0.6% found it annoying

36 Tinnitus: characteristics More likely to be a problem if loud More likely to be a problem if intermittent rather than continuous Start / stop No gender bias Associated with poorer hearing But only 1 2 dbhl statistically but not clinically significant

37 Comorbidity: tinnitus and hyperacusis 109/260 (41.9%) children reporting hyperacusis also reported tinnitus OR for hyperacusis if have tinnitus = 1.88 [1.43, 2.48] p< /218 (9.6%) children with clinically significant tinnitus also reported hyperacusis OR for clinically significant tinnitus (vs. non-signif tinn) if have hyperacusis = 2.10 [1.27, 3.47] Approx. twice as likely to have tinnitus if have hyperacusis and vice-versa

38 Public health implications Expect approx. one child per class to have hyperacusis Expect approx. one child per class to have problematic tinnitus This may be the same child How far should a clinician probe a child for troublesome tinnitus? Is there a danger of overreporting? What do we do about a child with tinnitus / hyperacusis?

39 The Team Amanda Hall - University of Bristol / University Hospitals Bristol NHS Foundation Trust David Baguley - Cambridge University Hospitals NHS Foundation Trust / Anglia Ruskin University Melanie Parker - Weston Area Health Trust Colin Steer University of Bristol rachel.humphriss@uhbristol.nhs.uk

40 Publications Hall A, Humphriss R, Baguley D, Parker M, Steer C. Prevalence and risk factors for reduced sound tolerance (hyperacusis) in children. International Journal of Audiology. In press. Humphriss R, Hall A, Baguley D. Prevalence and characteristics of spontaneous tinnitus in 11 year old children. International Journal of Audiology. In press.

41 References Baguley DM, Bartnik G, Kleinjung T, Savastano M, Hough EA. Troublesome tinnitus in childhood and adolescence: data from expert centres. Int J Ped Otolaryngol (2): Boyd R, Golding J, Macleod J, et al. Cohort profile: the Children of the 90s ; the index offspring of the Avon Longitudinal Study of Parents and Children. Int J Epidemiol 2013; 42: Coelho CB, Sanchez TG, Tyler RS. Hyperacusis, sound annoyance, and loudness hypersensitivity in children. Progress in Brain Research 2007; 166: Chap 15: Holgers KM. Tinnitus in 7-year-old children. Eur J Pediatr 2003; 162: Park B, Choi HG, Lee HJ, et al. Analysis of the prevalence of and risk factors for tinnitus in a young population. Otol Neurotol 2014; 35: Sattar N. A study of hyperacusis in 100 normally-hearing children. Arch Dis Child (Suppl 1): A98 (G251).

42 Acknowledgements We are extremely grateful to all the families who took part in this study, the midwives for their help in recruiting them, and the whole ALSPAC team which includes interviewers, computer and laboratory technicians, clerical workers, research scientists, volunteers, managers, receptionists and nurses. The UK Medical Research Council (Grant ref: 74882), the Wellcome Trust (Grant ref: ) and the University of Bristol provide core support for ALSPAC