The Nottingham Health Profile (NHP) has been used to investigate the health profiles for many medical conditions, such as herpes zoster infection, migraine, cancer and epilepsy. However, so far, it has not been used to investigate the health profile for patients suffering from Meniere's disease, but only for patients with dizziness, severe hearing loss and tinnitus. Each of these three symptoms have shown to have a significant impact on the quality of life.
In the present study, 116 consecutive patients with Meniere's disease, diagnosed according to the AAO-HNS guidelines, visiting at the department of Audiology were included in the study. The NHP was used to measure the health related quality of life and includes the following subscales: "Sleep", "Energy", "Emotional reaction", "Pain", "Physical mobility", "Social isolation" and items concerning daily activity. The Tinnitus Severity Questionnaire (TSQ) was used to measure symptoms specific to tinnitus.
The results showed that the perceived severity of tinnitus in patients with Meniere's disease had a significant negative influence on their health related quality of life. The patients with Meniere's disease suffered from more sleep disturbances and social isolation than patients referred to our clinic due to tinnitus. The quality of life was, on the whole, worse for patients of working age compared to retired pensioners. Emotional disturbances could explain 40.3 % of the variance of the tinnitus severity in patients with Meniere's disease. This can be compared with 20.6% in patients with tinnitus. This underscores the importance of providing psychological and psychiatric interventions and support to patients with Meniere's disease.
Keywords: Meniere′s disease, tinnitus, Quality of Life, NHP, Tinnitus severity
|How to cite this article:|
Holgers KM, Finizia C. Health profiles for patients with Meniere's disease. Noise Health 2001;4:71-80
| Introduction|| |
Meniere's disease is a clinical disorder with recurrent spontaneous episodic vertigo, hearing loss, aural fulness and tinnitus. According to the AAO-HNS guidelines (Committee on Hearing and Equilibrium of the American Academy of Otolaryngology-Head and Neck Surgery), this disease should also be characterised by either aural fulness or tinnitus being present at the affected side.
The prevalence of Meniere's disease varies between studies and countries. One explanation for this could be the varying availability of medical facilities (Celestino and Ralli, 1991), but there are no doubt many other essential contributory factors.
In an early report, the prevalence of Meniere's disease in Sweden was calculated to be 46 per 100.000 inhabitants (Stahle et al., 1978), which is comparable to the situation in Finland 3849/100.000 (Kotimaki et al., 1999).
In other parts of the world, for example Japan, the annual incidence was reported to be 21.436.6/100.000 (Shojaku and Watanabe, 1997), which is considerably higher than in Northern Europe.
There seems to be a gender related difference in Meniere's disease, as more women than men are affected (Okafor, 1984, WladislavoskyWaserman et al., 1984). In Rochester, Mn, USA, the annual incidence rate was reported to be 15.3/100.000 with a preponderance for women (16.3), the corresponding incidence for men being 13.3. The difference was, however, not statistically significant (WladislavoskyWaserman et al., 1984).
The suffering caused by Meniere's disease is also important to study. In a Swedish study from 1997, 75% of the subjects avoided certain daily activities because of the disease (Hagnebo et al., 1997), and another study has shown the emotional disability to be greater than the physical disability in patients with this condition (Kinney et al., 1997). In a qualitative study including 4 patients with Meniere's disease, recognition of fear and phobic reactions during the vertigo attacks was reported in these patients (Erlandsson et al., 1996). This is consistent with early reports from the late sixties' by Hinchcliffe who described that Meniere's disease could be secondary to the emotional problems or to the impaired quality of life (QoL) in the patients with Meniere's disease (Hinchcliffe, 1967b, Hinchcliffe, 1967a).
The three symptoms included in Meniere's disease, namely: vertigo, hearing impairment and tinnitus have been studied separately and reported to have a strong negative influence on the daily life (Grimby and Rosenhall, 1995, Grimby and Ringdahl, 2000, Holgers et al., 2000).
Several comprehensive and widely used generic instruments exist for measuring self-rated health assessment. Some of these instruments have been adapted to Swedish conditions, for example; the Nottingham Health Profile (NHP), the SF-36 and the Sickness Impact Profile (Grimby and Rosenhall, 1995, Grimby and Ringdahl, 2000, Soderman and Malchau, 2000, Sullivan et al., 1995, Sullivan and Karlsson, 1998, Persson et al., 1998, Sullivan, 1988).
The NHP has been shown to be a useful instrument in the evaluation of the health related quality of life in many different medical conditions (Herlitz et al., 2000, Loth et al., 1998, Lundstrom et al., 1992, Soderman and Malchau, 2000). Since it has previously been used in patients with dizziness, tinnitus and hearing impairment (Grimby and Rosenhall, 1995, Grimby and Ringdahl, 2000), one could expect that this instrument also could be used in patients with Meniere's disease.
The aim of the present study was to analyse the quality of life and tinnitus suffering in patients with Meniere's disease and compare them with patients suffering from tinnitus.
| Material and Methods|| |
Patients with Meniere's disease
The Meniere's patients were diagnosed according to the AAO-HNS guidelines. The study group included 186 consecutive patients with Meniere's disease, who visited the audiological clinic during a two-year period. A total of 116 patients volunteered to participate in the study, 53 women and 63 men. The mean age was 62 years for both men and women (the range was 24-85 years for the women and 28-83 years for the men).
The Pure Tone Average (PTA) mean value for 0.5, 1, 2 kHz was 37 dB HL ± 19 SD for both women and men. The PTA mean value in the higher frequencies (3, 4, 6 kHz) were 46 dB HL ± 23 SD for men and 55 dB HL ± 21 SD for women, but the differences were not statistically significant. The patients reported a mean value of 3.4 (2.1-4.6 95 % confidence interval) vertigo attacks during a 6 months period previously to the time of investigation.
The dropouts were 44 women and 26 men. The mean age for the women was 59 years (range 3184 years) and 56 years (range 19-81 years) for the men.
Patients with tinnitus
The tinnitus subjects (N=186) participating in the study were 57 females and 129 males. They were a group of consecutive patients visiting the specialist audiological clinic for tinnitus during a period of six months. The mean age of the women (57 years) was significantly higher than for the men (53 years).
The PTA mean value for 0.5, 1, 2 kHz was 20 dB HL ±16 SD for women and 15 dB HL ±16 SD for men. The PTA mean value for the higher frequencies (3, 4, 6 kHz) was 32 dB HL ±23 SD for women and 40 dB HL ±23 SD for men. The hearing parameters did not differ statistically between genders.
The Nottingham Health Profile (NHP)
The Nottingham Health Profile (NHP) is a nondisease-specific questionnaire, which is widely used for health assessment and has been adapted to Swedish conditions (Wiklund and Welin, 1992, Grimby and Rosenhall, 1995, Grimby and Ringdahl, 2000, Soderman and Malchau, 2000). The questionnaire consists of 45 items, divided in two parts (NHP I and II) and dichotomous response choices are present (yes/no). High scores for a NHP domain or an item represent high levels of dysfunction.
NHP I includes 38 items which describes the relative functional limitations across six specified areas within everyday living: energy, pain, emotional reactions, sleep, social isolation and mobility. For each NHP domain, a relative scale score is calculated and expressed as a percentage of total possible dysfunction, where a score of 0 means no reported dysfunction, while a score of 100 indicates maximum dysfunction. NHP II comprises seven items referring to health-related problems in daily life. The psychometric properties of the NHP and the suggested scales have been proved to be satisfactory (Hunt et al., 1981, Hunt et al., 1980).
The Tinnitus Severity Questionnaire (TSQ)
The severity of tinnitus was assessed by the Tinnitus Severity Questionnaire (TSQ) (Baskill, 1991, Coles, 1991). The questionnaire is designed for self-administration and includes 10 items. Single items can be aggregated into three subscales; Q 1; Q 2-7 and Q 8-10 or into a total score (TSQ all). All items are scored on a fourpoint scale (0 = not affected to 4 = always affected). Scoring is carried out by adding the item scores chosen by each respondent.
The maximum score is 40. A higher score indicates greater perceived severity of tinnitus. The items are presented in Appendix A.
Calculations, such as descriptive statistics, group differences and multifactorial analyses, were carried out by using a statistical package, SPSS, for Macintosh. Gender and age-related differences between Meniere's patients and tinnitus patients were analysed by the Student's t-test (2-tailed) and a non-parametric test, Kendall's Correlation Coefficients (Tau).
In order to identify possible predictors of the perceived severity of tinnitus in the Meniere's patients (the total score of the TSQ), a Stepwise Regression analysis was performed. The TSQ, defined as a dependent variable in the regression model, was analysed in association with independent factors, such as health related quality of life assessed by the NHP I and II, and four hearing parameters (Pure Tone Average (dB HL) for low and high frequencies, left and right ear). Correlations were examined using the Pearsons correlation test.
| Results|| |
Patients with Meniere's disease and patients with tinnitus
Compliance with questionnaire responses Patients with Meniere's disease
The set of questionnaires was sent to 186 patients with Meniere's disease. A hundred and sixteen respondents completed and returned the questionnaires (63% return rate), which were used for further evaluation.
Patients with tinnitus
A hundred and eighty-six patients with tinnitus received the set of questionnaires, and 182 patients answered and returned the questionnaires (98% response rate).
TSQ scores and correlations between Hearing thresholds and NHP
The correlations between TSQ, hearing thresholds and NHP part I and II were analysed, [Table - 1]. The statistically significant correlations were thereafter analysed in a stepwise regression model.
"Tinnitus severity" was chosen as the dependent variable in the stepwise regression analysis and was calculated using the summed score of the TSQ. Variables defined as independent were the statistically significant variables from the correlation analyses, which were the six subscales of the NHP I, the NHP II (healthinduced problems) and the hearing thresholds over both ears.
Gender was also included in the regression model but did not turn out to be a significant predictor.
Two dimensions of the NHP I, "Emotional disturbances" and "Sleep disturbances", were found to be statistically significant predictors of "Tinnitus severity", explaining 40.3 and 6.4 per cent respectively of the variance. The NHP II domain "domestic work" also emerge as a significant predictor, and explained 6.1 % of the variance. In total, 52.8 per cent of the variance in "Tinnitus severity" could be explained by the stepwise regression model. The independent variables "Social isolation", "Energy", "Mobility", "Pain" and the other domains in the NHP II did not give any significant contribution to the variance explained by the model, nor did the hearing parameters. All correlations were significant at the one per cent level. The variance is shown in [Figure - 1].
Comparisons between Meniere's and tinnitus patients according to NHP scores
Comparisons of the NHP I and II, TSQ scores and hearing parameters between tinnitus patients and Meniere's patients are shown in [Table - 2]. Due to the limited sample of subjects in the different age groups, we used two groups: working age and retired patients, in order to strengthen our statistical analyses. The results showed a significant difference in the domains "sleep" (p<0.001) and "social isolation" (p<0.01) in which the Meniere's patients of working age had higher scores compared to tinnitus patients of working age.
| Discussion|| |
Previous findings in patients with tinnitus, dizziness in old age, and severe hearing impairment, have shown these symptoms to have a strong negative influence on the daily life, measured by the NHP (Grimby and Rosenhall, 1995, Grimby and Ringdahl, 2000, Holgers et al., 1999, Holgers et al., 2000). Therefore, we used the same QoL instrument for the health assessment in patients with Meniere's disease.
The results showed that both the NHP and the additional questionnaire TSQ were well accepted by the patients, had satisfactory compliance and low missing value rates, which supports the questionnaires´ feasibility in clinical settings.
In our study, the NHP-subscale "Emotional disturbances" emerged as an important factor for the Meniere's patients. This subscale is composed of nine items, were all items can be related to depression (Appendix B). In a recent study including 92 consecutive tinnitus patients with hearing thresholds better than 50 dBHL, seventy-five percent of these patients suffered from anxiety or depressive disorders according to the Diagnostic Statistic Manual of Mental Disorder (DSM III-R) (Holgers et al., 1999). In another report on incapacitating tinnitus defined as "absence from work more than one month, related to tinnitus" the item: "I feel that life is not worth living" was an extremely strong predictor for this severe type of tinnitus (Holgers et al., 2000).
Since the study groups consists of patients referred to a specialist clinic one can expect that they would have a higher degree of suffering than those who have had contact with a general practitioner only. The present findings support the suggestion that Meniere's patients as well as tinnitus patients can be in need of psychological and psychiatric support and/or treatment for their improvement.
In a study on consecutive tinnitus patients it was reported that the NHP domain "Emotional disturbances" could explain 20.6 % of the variance of TSQ, in tinnitus patients (Erlandsson and Holgers, 2000). This is in accordance with findings by other researchers, who have shown that the severity of tinnitus is more strongly correlated with psychological factors than with hearing parameters (Attias, 1995, Collet, 1990, Erlandsson, 1992, Gerber, 1985-86, Holgers et al., 2000).
In the Meniere's patients the domain "Emotional disturbances" could explain as much as 40.3 % of the variance in the present study, suggesting that the emotional factors are even greater for the perceived severity of tinnitus in these patients compared to patients without Meniere's disease. In the Meniere's patients, domestic work explained 6.1 % of the variance of tinnitus severity but was not significant in tinnitus patients. One can speculate that this difference between tinnitus and Meniere's disease could be due to the additional symptoms in Meniere's disease.
When patients with Meniere's disease were compared with tinnitus patients, Meniere's patients of working age scored worse than tinnitus patients on five out of six domains and four out of eight daily life problems in the NHP. The results showed a significant difference in the domains "sleep" (p<0.001) and "social isolation" (p<0.01), in which the Meniere's patients of working age hade higher scores.
In general, Meniere's patients of working age had higher mean values, i.e. greater disability, in the NHP domains when compared to Meniere's patients who were retired. This is in contrast to the assessment of QoL in patients with severe hearing impairment. In that report patients who were employed full-time, scored better in all NHP dimensions, than patients with part-time employment or retired pensioners. However, one has to acknowledge the different criteria (age vs. working status) in the different studies.
"Sleep" was the second most important predictor of tinnitus severity in patients with Meniere's disease as well as in tinnitus patients without Meniere's disease. One explanation for the disparity in the NHP results regarding working age versus pensioners could be related to sleep. The Meniere's patients who were working did not have the possibility of resting during the day to the same extent as the patients who were retired pensioners.
The level of hearing, measured by standard audiometric assessments, did not seem to play a significant role for the experience of specific Meniere's related problems. This is in accordance with the findings of other researchers, who have demonstrated weak correlations between hearing parameters and the severity of tinnitus (Attias, 1995, Erlandsson, 1992, Gerber, 1985-86, Holgers et al., 1999). None of the hearing variables contributed significantly to the variance explained in "tinnitus severity". Two of the NHP I domains; "emotional reactions" and "social isolation", showed small but significant correlations with the hearing variables (r= 0.22-0.37). These findings are consistent with the results of patients with severely impaired hearing, where "emotional", "social" and "energy" dimensions in NHP showed significantly lower QoL compared to a normal-hearing population. As expected, patients with Meniere's disease, had even lower QoL according to the NHP, when compared to the reports on patients with severe hearing impairment (Grimby and Rosenhall, 1995, Grimby and Ringdahl, 2000).
In the present study, the correlation between NHP and TSQ was higher than the correlations between NHP and hearing thresholds. These results suggest that the perceived daily life disability measured with NHP is, to a higher extent, explained by the perceived tinnitus severity than by the hearing impairment in patients with Meniere's disease.
In the present study, perceived health-related QoL was found to be worse for patients with Meniere's disease in comparison with tinnitus patients. These results indicate that not only tinnitus patients but also patients with Meniere's disease belong to a risk group for decreased well-being, who may develop a need for psychological, psychiatric support as well as therapeutic interventions (Holgers et al., 1999, Holgers et al., 2000). An instrument such as the NHP, measuring important life fields of activity, may be a good supplement to routine health screenings as well as a useful instrument for early identification of the development of incapacitating Meniere's disease.
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Dept of Audiology, Sahlgrenska University Hospital, S-413 45 Göteborg
Source of Support: None, Conflict of Interest: None
[Figure - 1]
[Table - 1], [Table - 2]