Journal Logo

Viewpoint

Sleep Quality of Tinnitus Patients: Why, How You Should Care

Hébert, Sylvie PhD

Author Information
doi: 10.1097/01.HJ.0000804844.43904.3c
  • Free

Sleep difficulties are the most frequent complaints in adults with tinnitus—from onset to several years after. Sleep difficulties reported by people with tinnitus range from 28% in population-based studies 1 and up to 80% in clinical samples. 2,3 This is not surprising since even the mildest tinnitus can be heard in quiet environments, such as in the bedroom.

F1
www.Shutterstock.com, tinnitus, hearing loss, sleep.
FB1
5 Sleeping Tips for Counseling.

Indeed, falling asleep was the most frequently mentioned difficulty in a survey among members of a tinnitus self-help association. 4 Sleep complaints can include delayed sleep, disrupted sleep (awakening during mid-sleep and early morning), and fatigue. Nearly half of patients report sleep disturbances as a persistent problem five years after their first visit to the clinic 5 and worsening sleep quality in those with chronic tinnitus. 6 Moreover, more severe sleep complaints are correlated with greater tinnitus severity, 7–10 especially in the evening 11 and during the night. 12 In turn, poor sleep quality before the onset of tinnitus may increase the perceived severity of tinnitus at onset. 13 In sum, poor sleep remains an important comorbidity long after tinnitus onset and beyond the period of care by professionals.

CONSEQUENCES OF POOR SLEEP

Healthy sleep, generally defined as sleep of adequate duration, quality, timing, and regularity, plays a fundamental role in physical, cognitive and mental health. Adults aged 18-64 years should get 7-9 hours and those 65 years and older should get 7-8 hours of good quality sleep on a regular basis, with consistent bed and wake-up times. 14 Unequivocal evidence shows that insufficient sleep on a chronic basis is associated with a wide range of adverse health outcomes. Lack of sleep, poor sleep efficiency (time to fall asleep, waking after sleep onset), and low sleep satisfaction/quality can have short- and long-term consequences linked to altered mental (anxiety, depression), cognitive (memory, learning), and physical health (metabolic syndrome, diabetes/impaired glucose metabolism, hypertension, coronary heart disease).

Sleep loss and poor sleep quality have increased worldwide with the emergence of COVID-19, 15 especially among individuals with a preexisting vulnerability to stressors. 16 This is particularly worrisome for individuals with tinnitus, as tinnitus has been linked with abnormal stress reactivity and mental disorders. 17–19 Indeed, individuals with tinnitus have in 2020-2021 experienced greater stress load 20–22 along with tinnitus 23 and worsening sleep. 24 Notwithstanding the COVID-19 pandemic, individuals with tinnitus are exposed to an increased risk of deleterious health outcomes on the long term, over and beyond their tinnitus severity, when their poor sleep status remains undocumented or mismanaged by hearing care professionals. Improving sleep, therefore, should be a priority for clinicians working with this population.

EFFECTS OF INTERVENTIONS

If we “treat” tinnitus, or more precisely manage it, do we improve both tinnitus severity and sleep complaints? Surprisingly very little data are available to answer this question, and the level of evidence is not very high. Two studies investigating the therapeutic effect of counseling with and without sound therapy 25,26 reported improved tinnitus severity and sleep complaints, as did another study investigating the benefits of being fitted with hearing aids. 27 Likewise, targeting either sleep or tinnitus seems to improve tinnitus or self-reported sleep quality. In one study, participants used bedside sound generators for three to 14 weeks and reported improved sleep (tinnitus severity was not assessed). 28 In another study, tinnitus individuals were exposed to sound therapy for ~3 months and those using tinnitus-matched, in-ear customized devices or noise stimuli had improved tinnitus severity over those using bedside sound generator (sleep parameters were not assessed). 29 Using the sleep-inducing drug melatonin, both tinnitus severity and sleep complaints were improved in another study. 30 In a nutshell, there is some low-level evidence that managing tinnitus or sleep in general might improve sleep and/or tinnitus. However, exactly which aspect of sleep (falling asleep, staying asleep, or overall sleep quality) is improved remains unknown.

ASSESSMENT, FOLLOW UP OF SLEEP COMPLAINTS

Clinical guidelines for tinnitus such as the American Speech-Language Hearing Association 31 or the European 32 guidelines recommend using validated questionnaires to assess tinnitus severity. The Tinnitus Reaction Questionnaire, 33 Tinnitus Handicap Inventory, 34 and Tinnitus Handicap Questionnaire 35 have one question each on sleep while the Tinnitus Functional Index (TFI) 36 has three. Although this can serve as an initial indication of sleep problems, one or a few questions do not provide enough detailed information to be useful on the nature of sleep difficulties or for the follow-up of patients. Validated questionnaires targeting sleep more specifically that are quickly administered could, therefore, be used to this purpose.

The Insomnia Severity Index is a seven-item questionnaire assessing perceived severity of insomnia over the past month. 37 It measures difficulties falling asleep, ability to maintain sleep and early morning awakenings, sleep dissatisfaction, and impact of sleep difficulties on daytime functioning. The total score varies between 0 and 28. There are also useful severity categories: absence of insomnia (score of 0-7), subthreshold insomnia (score of 8-14), moderate insomnia (score of 15-21), and severe insomnia (score of 22-28). A score of ≧8 is an indicator of significant sleep difficulties.

Another validated instrument is the Pittsburgh Sleep Quality Index, 38 which assesses subjective sleep quality retrospectively over the past month. A single global index can be obtained from its 19 items, and three domains can be clustered to describe subjective sleep reports more accurately: 1) sleep efficiency, 2) perceived sleep quality, and 3) daily disturbances. A global score of >5 is a sensitive and specific measure of poor sleep quality.

These two questionnaires are sensitive, valid outcomes to measure improvement (or lack thereof) after intervention. In sum, using the right tools has the potential to a) improve the impact of hearing clinicians in their intervention and follow up of patients, and b) help them decide when to refer patients to sleep specialists or medical doctors for more precise diagnosis or intensive support.

COUNSELING TINNITUS PATIENTS

Tinnitus guidelines and experts recommend that sleep disturbances should be explicitly addressed during counseling. 32 Counseling on sleep hygiene should be given since aside from tinnitus, sleep disruptions can happen for many reasons. Before considering any pharmacological approach or cognitive behavioral therapy, basic advice can be recalled to patients reporting poor sleep. They can be summarized as follows:

  • Create a consistent bedtime routine.
  • Make your bedroom a haven for sleep (e.g., sleep on comfortable mattress, maintain a cool and dark bedroom).
  • Establish a positive association between your bed and sleep.
  • Avoid bright light exposure in the evening and night.
  • Watch your caffeine, nicotine, and alcohol intake.
  • Be mindful of what you eat before sleep.
  • Try to exercise regularly.
  • Stay awake during the day.
  • Take some time to relax.

Clinicians should take time to discuss modifiable lifestyle factors with their patients such as caffeine consumption, drinking alcohol in the evening, drug abuse, and so on. Advice regarding sound enrichment should be approached as well, such as using a fan or a bedside sound generator, provided this does not disturb their sleeping partner. In addition, more advanced sleep hygiene instructions derived from the cognitive behavioral therapy for insomnia can be stressed since this is a recognized therapeutic option for insomnia 39 as well as for tinnitus. 40 The recommendations are aimed at reassociating the bed, bedroom, and bedtime stimuli with sleep rather than with the frustration and anxiety associated with sleeplessness (Table). The Canadian 24-Hour Movement Guidelines for Adults 41 offer useful information about physical activity, sedentary behavior, and sleep. Valuable resources for patients can be found on websites such as those of the American Academy of Sleep medicine, https://aasm.org/clinical-resources/patient-info/, the Canadian Sleep Network, https://www.cscnweb.ca/material-for-patients-and-the-public, and the Sleep on It Campaign, https://sleeponitcanada.ca/.

Management of sleep complaints in tinnitus remains an unmet therapeutic challenge. Yet, sleep problems are one important factor that will prompt tinnitus individuals to seek help for their tinnitus in comparison to those who will not, 42 and lack of sleep is among the factors clearly identified as aggravating among tinnitus patients. 43 Poor sleep can entail important consequences on both overall health and tinnitus severity.

Acknowledgement: Julie Carrier, PhD, and Victoria Duda, PhD, Université de Montréal, Montreal, Quebec, Canada, contributed to this article.

REFERENCES

1. Izuhara K, et al. Association between tinnitus and sleep disorders in the general Japanese population Ann OtolRhinolLaryngol 2013 122 701 6
2. Inagaki Y, et al. Personality and Sleep Evaluation of Patients with Tinnitus in Japan Psychiatr Q 2021 92 249 257
3. Richter K, et al. Insomnia Associated with Tinnitus and Gender Differences Int J Environ Res Public Health 2021 18 6
4. Tyler RS, Baker LJ Difficulties experienced by tinnitus sufferers J Speech Hear Disord 1983 48 150 4
5. Andersson G, et al. Longitudinal follow-up of tinnitus complaints Arch Otolaryngol Head Neck Surg 2001 127 175 9
6. Muluk NB, Tuna E, Arikan OK Effects of subjective tinnitus on sleep quality and Mini Mental Status Examination scores B-ENT 2010 6 271 80
7. Hébert S, Carrier J Sleep Complaints in Elderly Tinnitus Patients: A Controlled Study Ear Hear 2007 28 649 655
8. Fioretti AB, Fusetti M, Eibenstein A Association between sleep disorders, hyperacusis and tinnitus: evaluation with tinnitus questionnaires Noise Health 2013 15 91 5
9. Schecklmann M, et al. Psychophysiological Associations between Chronic Tinnitus and Sleep: A Cross Validation of Tinnitus and Insomnia Questionnaires Biomed Res Int 2015 2015 461090
10. Alster J, et al. Sleep disturbance associated with chronic tinnitus Biol Psychiatry 1993 34 84 90
11. Hallam RS Correlates of sleep disturbance in chronic distressing tinnitus ScandAudiol 1996 25 263 6
12. Probst T, et al. Does Tinnitus Depend on Time-of-Day? An Ecological Momentary Assessment Study with the "TrackYourTinnitus" Application Front Aging Neurosci 2017 9 253
13. Lu T, et al. Positive Correlation between Tinnitus Severity and Poor Sleep Quality Prior to Tinnitus Onset: a Retrospective Study Psychiatr Q 2020 91 379 388
14. Chaput JP, Carrier J First sleep health guidelines for Canadian adults: implications for clinicians Sleep Med 2021 79 117 118
15. Jahrami H, et al. Sleep problems during the COVID-19 pandemic by population: a systematic review and meta-analysis J Clin Sleep Med 2021 17 299 313
16. Gao C, Scullin MK Sleep health early in the coronavirus disease 2019 (COVID-19) outbreak in the United States: integrating longitudinal, cross-sectional, and retrospective recall data Sleep Med, 2020 73 1 10
17. Hébert S, Lupien SJ The sound of stress: blunted cortisol reactivity to psychosocial stress in tinnitus sufferers Neurosci Lett 2007 411 138 42
18. Betz LT, et al. Stress Reactivity in Chronic Tinnitus Sci Rep 2017 7 41521
19. Reinhart P, Griffin K, Micheyl C Changes in Heart Rate Variability Following Acoustic Therapy in Individuals With Tinnitus J Speech Lang Hear Res 2021 1 7
20. Xia L, et al. COVID-19 associated anxiety enhances tinnitus PLoS One 2021 16 e0246328
21. Schlee W, et al. The Effect of Environmental Stressors on Tinnitus: A Prospective Longitudinal Study on the Impact of the COVID-19 Pandemic J Clin Med 2020 9 9
22. Chirakkal P, et al. COVID-19 and Tinnitus Ear Nose Throat J 2021 100 2_suppl 160S 162S
23. Narozny W, Tretiakow D, Skorek A Tinnitus in COVID-19 Pandemic Ear Nose Throat J 2021 145561320988364
24. Beukes EW, et al. Changes in Tinnitus Experiences During the COVID-19 Pandemic Front Public Health 2020 8 592878
25. Wakabayashi S, et al. Effects of tinnitus treatments on sleep disorders in patients with tinnitus Int J Audiol 2018 57 110 114
26. Tinnitus Retraining Therapy Trial Research, G., Scherer RW, Formby C Effect of Tinnitus Retraining Therapy vs Standard of Care on Tinnitus-Related Quality of Life: A Randomized Clinical Trial JAMA Otolaryngol Head Neck Surg 2019 145 597 608
27. Zarenoe R, et al. Working Memory, Sleep, and Hearing Problems in Patients with Tinnitus and Hearing Loss Fitted with Hearing Aids J Am Acad Audiol 2017 28 141 151
28. Handscomb L Use of bedside sound generators by patients with tinnitus-related sleeping difficulty: which sounds are preferred and why? Acta Otolaryngol Suppl 2006 556 59 63
29. Theodoroff SM, et al. Randomized Controlled Trial of a Novel Device for Tinnitus Sound Therapy During Sleep Am J Audiol 2017 26 543 554
30. Megwalu UC, Finnell JE, Piccirillo JF The effects of melatonin on tinnitus and sleep Otolaryngol Head Neck Surg 2006 134 210 3
31. Tunkel DE, Jones SL, Rosenfeld RM Guidelines for Tinnitus JAMA 2016 316 1214 1215
32. Cima R, et al. A multidisciplinary European guideline for tinnitus: diagnostics, assessment, and treatment HNO 2019 67 Suppl 1 10 42
33. Wilson PH, et al. Tinnitus reaction questionnaire: psychometric properties of a measure of distress associated with tinnitus J Speech Hear Res 1991 34 197 201
34. Newman CW, Sandridge SA, Jacobson GP Psychometric adequacy of the Tinnitus Handicap Inventory (THI) for evaluating treatment outcome J Am AcadAudiol 1998 9 153 60
35. Kuk FK, et al. The psychometric properties of a tinnitus handicap questionnaire Ear Hear 1990 11 434 45
36. Henry JA, et al. Tinnitus Functional Index: Development, validation, outcomes research, and clinical application Hear Res 2016 334 58 64
37. Morin CM, et al. The Insomnia Severity Index: psychometric indicators to detect insomnia cases and evaluate treatment response Sleep 2011 34 601 8
38. Buysse DJ, et al. The Pittsburgh Sleep Quality Index: a new instrument for psychiatric practice and research Psychiatry Res 1989 28 193 213
39. Morin CM, et al. Cognitive behavioral therapy, singly and combined with medication, for persistent insomnia: a randomized controlled trial JAMA 2009 301 2005 15
40. Hesser H, et al. A systematic review and meta-analysis of randomized controlled trials of cognitive-behavioral therapy for tinnitus distress Clin Psychol Rev 2011 31 545 53
41. Ross R, et al. Canadian 24-Hour Movement Guidelines for Adults aged 18-64 years and Adults aged 65 years or older: an integration of physical activity, sedentary behaviour, and sleep Appl Physiol Nutr Metab 2020 45 10 (Suppl. 2) S57 S102
42. Scott B, Lindberg P Psychological profile and somatic complaints between help-seeking and non-help-seeking tinnitus subjects Psychosomatics 2000 41 347 52
43. Pan T, et al. Differences Among Patients That Make Their Tinnitus Worse or Better Am J Audiol 2015 24 469 76
Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.