2.1

Subjects

Clinical data were collected on child and adolescent patients who visited our tinnitus clinic in Seoul St. Mary’s Hospital with a chief complaint of tinnitus between January 2000 and December 2011. This retrospective study was approved by the institutional review board of our institution. All patients underwent a careful history, a full head and neck examination, otomicroscopy and audiological evaluation including pure tone audiometry and tympanometry. Those who had otitis media with effusion were excluded from data analysis. Pure tone average (PTA) was determined at 0.5, 1, 2, and 4 kHz thresholds, and hearing was considered normal if PTA was ≤ 20 dB.

2.2

Classification of tinnitus

We termed idiopathic subjective otic to categorize tinnitus into otic, myoclonic, and vascular tinnitus. The initial diagnostic approach depended primarily on the tinnitus quality described by the patient. When a patient complained of a rapid clicking or crackling sound, the motion of the tympanic membrane, torus tubarius and soft palate was inspected. If a throbbing, rushing, or humming sound synchronous with the patient’s pulse suggested a vascular etiology, we auscultated around the ear and neck for bruits and checked if the sound was alleviated by head turning or gentle neck compression. A patulous eustachian tube was diagnosed when the eardrum fluctuated with the patient’s forced nasal respiration. The other idiopathic subjective tinnitus was diagnosed as otic tinnitus. In cases of unilateral hearing loss, myoclonus, and vascular tinnitus, CT or MRI was obtained to find the specific pathology and rule out retrocochlear or neurologic disorders. To evaluate the tinnitus severity and annoyance, we asked the children how often tinnitus bothered them or disturbed their daily activities. “Seldom”, “sometimes” or “only when in a quiet place” was considered as mild tinnitus; “always”, “usually” or “often”, as severe or troublesome tinnitus.

2.3

Treatment selection

Each patient was treated according to the tinnitus severity and category. In all categories, children with mild tinnitus received counseling alone from a single physician (the first author). In the counseling session, the physician provided a simple explanation of the origin of tinnitus in relation to the auditory pathways, reassurance, and instructions to prevent the precipitating factors. Normally hearing patients with severe otic tinnitus underwent a simplified form of tinnitus retraining therapy (TRT) modified from the original version . Our simplified TRT was composed of a single session of directive counseling and sound therapy with or without instrumentation. The individualized TRT counseling was conducted by the same physician as above for about 30 min in an appropriate language matched to the cognitive level of the subjects. At the end of the counseling, patients were instructed on the strategy for sound enrichment to increase afferent input and to decrease attention to tinnitus. The use of environmental sound was preferred in children who were bothered only in quiet surroundings. Ear-level sound generators were required in normally hearing patients who were bothered at all times. Those who had hearing loss of 40 dB or more underwent the TRT with hearing aids.

For patients with distressing myoclonic tinnitus, we provided counseling and short-term medications – muscle relaxants or anticonvulsants – for less than 3 months. Patients with intractable myoclonic tinnitus underwent resection of both stapedial and tensor tympani tendons in middle ear myoclonus; injection of botulinum toxin into the soft palate in palatal myoclonus. Patients with distressing vascular tinnitus received the simplified TRT. In one case of patulous eustachian tube with intractable tinnitus, a bone wax-filled catheter was inserted into the eustachian tube through the myringotomy site. Intractable tinnitus requiring invasive therapy was defined as severe, constant tinnitus for > 1 year, which had not been responsive to any treatment in the other otolaryngology clinics. Treatment outcomes were evaluated at 3 months using the patient’s report to the question, “Is your tinnitus better, same, or worse after the treatment?” “Better” was considered a signal for effective relief from their tinnitus. In children aged ≤ 12, the reports were verified by their parents.

Statistical analyses were conducted using SPSS 18.0 (SPSS Inc., Chicago, IL) to compare the clinical features among the three major tinnitus categories. One-way ANOVA and Tukey post hoc test were used for age and PTA; Chi-square test for sex and affected ear; Kruskal–Wallis test for duration — the interval between the onset of tinnitus and the first interview. A significance level was 0.05.

2.1

Subjects

Clinical data were collected on child and adolescent patients who visited our tinnitus clinic in Seoul St. Mary’s Hospital with a chief complaint of tinnitus between January 2000 and December 2011. This retrospective study was approved by the institutional review board of our institution. All patients underwent a careful history, a full head and neck examination, otomicroscopy and audiological evaluation including pure tone audiometry and tympanometry. Those who had otitis media with effusion were excluded from data analysis. Pure tone average (PTA) was determined at 0.5, 1, 2, and 4 kHz thresholds, and hearing was considered normal if PTA was ≤ 20 dB.

2.2

Classification of tinnitus

We termed idiopathic subjective otic to categorize tinnitus into otic, myoclonic, and vascular tinnitus. The initial diagnostic approach depended primarily on the tinnitus quality described by the patient. When a patient complained of a rapid clicking or crackling sound, the motion of the tympanic membrane, torus tubarius and soft palate was inspected. If a throbbing, rushing, or humming sound synchronous with the patient’s pulse suggested a vascular etiology, we auscultated around the ear and neck for bruits and checked if the sound was alleviated by head turning or gentle neck compression. A patulous eustachian tube was diagnosed when the eardrum fluctuated with the patient’s forced nasal respiration. The other idiopathic subjective tinnitus was diagnosed as otic tinnitus. In cases of unilateral hearing loss, myoclonus, and vascular tinnitus, CT or MRI was obtained to find the specific pathology and rule out retrocochlear or neurologic disorders. To evaluate the tinnitus severity and annoyance, we asked the children how often tinnitus bothered them or disturbed their daily activities. “Seldom”, “sometimes” or “only when in a quiet place” was considered as mild tinnitus; “always”, “usually” or “often”, as severe or troublesome tinnitus.

2.3

Treatment selection

Each patient was treated according to the tinnitus severity and category. In all categories, children with mild tinnitus received counseling alone from a single physician (the first author). In the counseling session, the physician provided a simple explanation of the origin of tinnitus in relation to the auditory pathways, reassurance, and instructions to prevent the precipitating factors. Normally hearing patients with severe otic tinnitus underwent a simplified form of tinnitus retraining therapy (TRT) modified from the original version . Our simplified TRT was composed of a single session of directive counseling and sound therapy with or without instrumentation. The individualized TRT counseling was conducted by the same physician as above for about 30 min in an appropriate language matched to the cognitive level of the subjects. At the end of the counseling, patients were instructed on the strategy for sound enrichment to increase afferent input and to decrease attention to tinnitus. The use of environmental sound was preferred in children who were bothered only in quiet surroundings. Ear-level sound generators were required in normally hearing patients who were bothered at all times. Those who had hearing loss of 40 dB or more underwent the TRT with hearing aids.

For patients with distressing myoclonic tinnitus, we provided counseling and short-term medications – muscle relaxants or anticonvulsants – for less than 3 months. Patients with intractable myoclonic tinnitus underwent resection of both stapedial and tensor tympani tendons in middle ear myoclonus; injection of botulinum toxin into the soft palate in palatal myoclonus. Patients with distressing vascular tinnitus received the simplified TRT. In one case of patulous eustachian tube with intractable tinnitus, a bone wax-filled catheter was inserted into the eustachian tube through the myringotomy site. Intractable tinnitus requiring invasive therapy was defined as severe, constant tinnitus for > 1 year, which had not been responsive to any treatment in the other otolaryngology clinics. Treatment outcomes were evaluated at 3 months using the patient’s report to the question, “Is your tinnitus better, same, or worse after the treatment?” “Better” was considered a signal for effective relief from their tinnitus. In children aged ≤ 12, the reports were verified by their parents.

Statistical analyses were conducted using SPSS 18.0 (SPSS Inc., Chicago, IL) to compare the clinical features among the three major tinnitus categories. One-way ANOVA and Tukey post hoc test were used for age and PTA; Chi-square test for sex and affected ear; Kruskal–Wallis test for duration — the interval between the onset of tinnitus and the first interview. A significance level was 0.05.