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DPOAE in estimation of the function of the cochlea intinnitus patients with normal hearing

Aleksandra Sztuka, Lucyna Pospiech, Wojciech Gawron *, Krzysztof Dudek

Wroclaw Medical University, ENT Department, Borowska 213, Wroclaw, Poland

Received 25 October 2006; accepted 12 May 2009

Available online 26 June 2009

Abstract

Objective: The most probable place generating tinnitus in the auditory pathway is the outer hair cells (OHCs) inside the cochlea. Otoacoustic

emissions are used to assess their activity. The objective of the investigation was to measure the features of distortion product otoacoustic

emissions (DPOAE) in a group of tinnitus patients without hearing loss, estimate the diagnostic value of the parameters for the analysis of

cochlear function in the patients, emphasizing those most useful in localizing tinnitus generators, and determine the hypothetical influence of

hyperacusis and misophony on DPOAE parameters in tinnitus patients.

Patients and methods: The material consisted of 44 patients with tinnitus and without hearing loss. In the control group were 33 patients

without tinnitus with the same state of hearing. The tinnitus patients were divided into three subgroups: those with hyperacusis, those with

misophonia, and those with neither. After collecting medical history and performing clinical examination of all the patients, tonal and

impedance audiometry, ABR, and discomfort level were evaluated. Then DPOAE were measured using three procedures. First the amplitudes

of two points per octave were assessed, second the fine structure method with 1620 points per octave (f2/f1 = 1.22,L1 = L2 = 70 dB), and

the third procedure included recording the growth function in three series for input tones of f2 = 2002, 4004, and 6006 Hz ( f2/f1 = 1.22) and

L1 = L2 levels increasing by increments of 5 dB in each series.

Results and conclusions: Hyperacusis was found in 63% and misophonia in 10% of the tinnitus patients with no hearing loss. DPOAE

amplitudes in recordings with two points per octave and the fine structure method are very valuable parameters for estimating cochlearfunction in tinnitus patients with normal hearing. Function growth rate cannot be the only parameter in measuring DPOAE in tinnitus patients,

including subjects with hyperacusis and misophonia. The markedly higher DPOAE amplitudes in the group of tinnitus patients without

hearing loss suggest that tinnitus may be caused by increased motility of the OHCs induced by decreasing efferent fiber activity, and not by

OHC failure. Hyperacusis significantly increases the amplitude of DPOAE in tinnitus patients with no hearing loss.

# 2009 Elsevier Ireland Ltd. All rights reserved.

Keywords: Tinnitus; Hyperacusis; Misophonia; DPOAE

1. Introduction

Tinnitus is a serious problem, with increasing numbers of

patients, including children, suffering from this disease.About 35% of adults have had some experience with tinnitus

[1]. Tinnitus is defined as a sense of sound without external

stimuli [24]. The opinions about the cause and location of

tinnitus generation are not unanimous, but the cochlea and

outer hair cells (OHCs) probably play a crucial role in its

pathogenesis. It would be interesting to determine whether

otoacoustic emissions are a useful tool in the evaluation

of OHCs as a tinnitus generator. According to Shiomi et al.

[5], measuring distortion product otoacoustic emissions(DPOAE) is the basic method that allows one to evaluate

properly the mechanical activity of the cochlea in tinnitus

patients. Hyperacusis plays an important role in these

patients and it may often be a forerunner of tinnitus [6]. It is

defined as an unpleasant, often painful, feeling caused by

sound due to hyperactivity of the compensatory action of

the central nervous system. Epidemiological data indicate

that about 40% of tinnitus patients worldwide suffer from

hyperacusis [2,7]. Misophonia and phonophobia are

www.elsevier.com/locate/anlAuris Nasus Larynx 37 (2010) 5560

* Corresponding author at: ul. Krzycka 32, 53-020 Wroclaw, Poland.

Tel.: +48 603672132.

E-mail address: [email protected] (W. Gawron).

0385-8146/$ see front matter # 2009 Elsevier Ireland Ltd. All rights reserved.

doi:10.1016/j.anl.2009.05.001
mailto:[email protected]://dx.doi.org/10.1016/j.anl.2009.05.001http://dx.doi.org/10.1016/j.anl.2009.05.001mailto:[email protected]


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different from hyperacusis and result from pathological

excitement of the limbic system, which is responsible for

emotions [8,9].

2. Aims of the study

1. To measure the features of DPOAE in tinnitus patients

group without hearing loss;

2. To determine the diagnostic value of DPOAE parameters

for an analysis of cochlear function in the patients,

emphasizing the DPOAE parameters most useful in

localizing tinnitus generators;

3. To determine the influence of hyperacusis and mis-

ophonia on DPOAE parameters in tinnitus patients.

3. Material

The inclusion criterion was neuro-otological tinnitus, but

not tinnitus generated by way of sound conduction to the

cochlea (called otologic tinnitus according to Shulman [10]).

In this way, only patients with tinnitus generated along the

auditory pathway were considered. The study group (NT)

consisted of 44 patients (22 females and 22 males, 75 ears

tested) with tinnitus and audiologically proper hearing

examined in the ENT Department of Wrocaw University

in 20012004. The average age of the NT group was 32 years.

The control group (N) consisted of 33 subjects (16 females

and 17 males, 63 ears tested) without tinnitus and with

audiologically proper hearing. The average age was 35.9

years. The cases with and without hyperacusis andmisophonia were extracted from the NT group. In the

subgroupof normal hearing tinnitus patients with hyperacusis

we included those with a discomfort level lower than 85 dB

SPL for all measured frequencies in accordance with Schaaf

et al. [8] and Bartnik[11]. In the subgroup of tinnitus patients

with misophonia the discomfort level was lower than 85 dB

only for some examined sounds (frequencies) for which they

felt fear (patients with misophonia do not tolerate these

sounds at all) in accordance with Schaaf et al. [8]. Noneof the

subjects in the control group had hyperacusis or misophonia.

4. Method

A detailed history was taken in each case, with particular

attention to ENT diseases, especially tinnitus. In each case a

physical ENT examination was performed to exclude any

pathology that might influence the condition of the hearing

organ. Then a battery of audiological tests was performed in

each case: pure tone audiometry with discomfort level

evaluation, impedance audiometry, and brainstem auditory

evoked potentials. Based on these tests, only patients with

proper hearing were qualified to the individual groups.

Proper hearing was defined in pure tone audiometry at a

hearing threshold of 20 dB nHL for all the frequencies

tested, a BAEP threshold of 20 dB nHL, and in impedance

audiometry type A tympanometry with stapedial muscle

reflex present for all the frequencies.

The DPOAE measurement consisted of three stages [12

14]:

1. A DP-gram with a distribution of two points per octave

with the parameters L1 = L2 = 70 dB, f2/f1 = 1.22, and

measurement of 2f2f1 for f2 = 1001, 1501, 2002, 3003,

4004, 5005, and 6006 Hz;

2. DP-gram fine structure with the parameter L1 = L2

= 70 dB, f2/f1 = 1.22, and measurement of 2f2f1 for

f2 = 10016995 Hz;

3. The growth rate function (input/output) for f2 = 2002,

4004, and 6006 Hz with the parameters f2/f1 = 1.22 and

L1 = L2, with the intensity of the stimulus increased

stepwise from 35 to 70 dB every 5 dB in each measured

series.

Statistical analysis was performed for the measurable

(quantitative) and non-measurable (qualitative) features.

KolmogorovSmirnov and ShapiroWilk tests were applied

to evaluate the consistence of all the measurable features.

Statistical significance was considered for values of p less

than 0.05. Students t test was applied to calculate the

significance of differences in two populations for features

with a normal distribution and homogenous variance. The

homogeneity of the variances was checked with Bartletts

test. The parametric Students t test was used to obtain the

significance of differences for features with a normal

distribution and homogenous variance for two populationsand the non-parametric MannWhitney U test was applied

to calculate the significance of differences in two popula-

tions for features without a normal distribution or

homogenous variance. Estimation of a normal distribution

was elicited with the KolmogorovSmirnov and Shapiro

Wilk tests. As a criterion of relevance, a level p = 0.05 was

admitted. Homogeneity of variance was checked by

Barletts test. One-factor variance analysis (ANOVA) was

applied to verify the significance of differences in average

values in more than two groups of patients for features with a

normal distribution and homogenous variance.

5. Results

First DPOAE of the right and left ears in the NT and N

groups were compared. No statistically significant differ-

ences were observed between the sides. Further statistical

analysis was therefore performed for both sides together. In

the next step the number of the cases in which DPOAE were

present in the registration of two points per octave as well as

the fine structure in the N and NT groups was evaluated.

Except for two cases, no statistically significant differences

in DPOAE were present between the groups. Otoacoustic

A. Sztuka et al. / Auris Nasus Larynx 37 (2010) 556056


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emission was present more frequently in the NT group than

in the N group for f2 values of 2832 Hz and 6702 Hz

(p < 0.05). Therefore, further analysis of DPOAE ampli-

tude both for the distribution of two points per octave and for

the fine structure in the N and NT groups was performed

only when otoacoustic emission was present. The average

intensity of DPOAE in two points per octave registration in

the NT group was significantly higher than in the control

group for f2 values of 3003, 4004, and 5005 Hz (p < 0.01,

Fig. 1).

Comparing the intensities of otoacoustic emission in the

fine structure function in the NT and N groups, significantly

higher values were detected in the NT group than in control

N group for f2 in medium and high frequencies (2710

6152 Hz, p < 0.05, Fig. 2).

Hyperacusis was present in 63% and misophonia in10% of the cases in the NT group. The analysis of DPOAE

amplitude in the function of two points per octave did not

show any statistically significant differences between cases

in the NT group without hyperacusis and the control group.

However, DPOAE amplitude tended to increase for higher

f2 values in the NT group in the fine structure function.

Analysis of DPOAE in the fine structure function revealed

significantly higher amplitudes for the NT group without

hyperacusis in the medium f2 frequencies from 3088 to

4004 Hz and significantly lower values for an f2 of

1685 Hz than in the control group. Comparing the average

DPOAE intensities in NT patients with misophonia and

patients in the control group, statistically significant

differences were present only for f2 = 2002 Hz in the

two points per octave distribution. The amplitude wassignificantly lower in the NT group with misophonia for

this value. The DPOAE value tended to decrease in this

group, but without statistical significance. Analysis of the

average DPOAE values in the fine structure function in the

NT group with misophonia compared with the control

group also revealed a tendency to decreased amplitude for

lower f2 values. The differences were statistically

significant for f2 = 1661, 1685, and 1758 Hz. For average

f2 values the average intensities of otoacoustic emission in

the NT group with misophonia were higher, statistically

significant for f2 = 3833 Hz. Comparing the values of

DPOAE amplitude in NT patients with hyperacusis and

patients of the control group, significantly higher values

for f2 = 1501, 2002, 3003, 4004, and 5005 Hz were

detected in the NT group. Similar results were obtained in

the analysis of the average DPOAE values in the fine

structure function. The NT group with hyperacusis

presented significantly higher values for most of the f2

frequencies than the control group, especially for the f2

range of 26006152 Hz (Fig. 3).

Comparing the average DPOAE intensities in the NT

group, the following was noted (Fig. 4):

The highest DPOAE values for the low f2 frequencies in

the subgroup with hyperacusis compared with thesubgroup without hyperacusis were for f2 in the range

from 1245 to 2087 Hz (p < 0.05) and compared with the

subgroup with misophonia for f2 from 1184 to 2002 Hz

(p < 0.05);

There were higher DPOAE intensities in the subgroup

without hyperacusis and in the subgroup with hyperacusis

than in the subgroup with misophonia for the high f2

frequencies, but without statistical significance.

A. Sztuka et al./ Auris Nasus Larynx 37 (2010) 5560 57

Fig. 1. . DPOAE amplitude values for two points per the octave for

individual f2 frequencies in NT and N groups.

Fig. 2. Average otoemissionintensity in NTandN groups. The arrows mark

f2 frequencies that differ significantly in the compared groups ( p < 0.05).

Fig. 3. Average otoemission intensity in patients from the NT group with

hyperacusis and in patients from the N group. The arrows indicate f2 ranges

for which the differences are statistically significant (p < 0.05).


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There was no relationship between the shape of the

growth rate function and tinnitus. Analysis of the average

input intensities as the otoacoustic emission threshold in the

growth rate function in the tinnitus patients in the NT group

compared with the control group did not reveal any

significant differences for the individual f2 values 2002z,

4004, and 6006 Hz. Analysis of the average input values in

the individual subgroups of patients divided according to the

presence of hyperacusis and misophonia revealed statisti-

cally significant differences (p < 0.05). The NT subgroup

with misophonia presented significantly higher input values

than the control group for f2 = 2002 Hz (p < 0.05). The NT

group with misophonia also presented significantly higher

average input values than the NT subgroup with hyperacusis

for f2 = 2002 and 6006 Hz.

6. Discussion

Tinnitus is complex in its genesis, perception, and

interpretation of the patient. It is generated not only in the

inner ear, but also in some parts of the limbic system

(mostly the amygdaloid nucleus), thalamus nuclei,

hippocampus, and hypothalamic paraventricular nucleus

take part in the process [7,11,1520]. Activation of the

auditory cortex and other parts of the central nervous

system is also crucial in tinnitus detection, although,

according to Bartnik [2], tinnitus may only be partially

controlled after it reaches the cortex. An increase in

glucose metabolism in the transversal and upper gyrus of

the dominant brain hemisphere (usually the left one) was

demonstrated in tinnitus patients independently of the

lateralization of the symptoms [15,21]. On the other hand,

an increase in emotional stress caused by tinnitus may

sensitize cochlear cells to an impairment. This handicaps

the limbic system and modifies the serotonin release

cascade and, consequently, through the regulation of the

acetylcholine concentration in the efferent system, changes

the function of the outer hair cells [22]. By this mechanism,

almost every central dysfunction may influence the outer

hair cells function.

Spontaneous otoacoustic emissions (SOAE) were not

obtained because authors suggest [23] that tinnitus can be

generated by SOAE only in 2% of normally hearing patients

and, according to Penner [24], they sound rather like ringing.

The frequencies of SOAE are in the range of 12 kHz [25]and the frequencies of the most common tinnitus are above

4 kHz. Even if SOAE can influence DPOAE amplitude, it

could happen only at frequencies of 12 kHz. The frequency

range of our investigations was 10016995 Hz. The

influence of SOAE on the investigated phenomena is slight,

so this parameter was not measured.

In our report there were no statistically significant

differences in DPOAE amplitude in all the tinnitus groups

between the right and left ear, both in two points per octave

and fine structure registration. The results confirm those

reported by Wasniewska et al. [26]. The average DPOAE

intensities for frequencies of 3003, 4004, and 5005 Hz in the

registration of two points per octave in the patients with

tinnitus and proper hearing were higher than in the control

group. Similar results were obtained in the fine structure

recordings, but the f2 values for which the DPOAE

amplitude was higher in the NT group than in the control

group were expanded to values higher than 2710 Hz.

Similarly higher DPOAE values in tinnitus patients with

normal hearing compared with patients with adequate

hearing and without tinnitus were detected by Gouviers et al.

[27]. The differences were present only at higher f2 values,

in the range of 46.3 kHz; for an f2 range of 16502400 Hz

the DPOAE values were significantly lower in the tinnitus

patients. This is not consistent with the results of Shiomiet al. [5]. The authors reported lower DPOAE amplitudes in

93.3% of the cases with tinnitus and proper hearing in

comparison with a group without tinnitus, especially for

frequencies of 47 kHz. Stimuli of L1 = L2 = 75 dB SPL

intensity were used to perform these investigations, so the

non-linear cochlear response connected with outer hair cell

mobility was less involved. Other authors also reported

lower DPOAE amplitudes in patients with proper hearing

and tinnitus, with a simultaneous higher percentage of

neurotic personalities among those subjects [2830].

None of these authors distinguished patients with

hyperacusis, which is perhaps the reason for the differences

in the results of the investigations. Hyperacusis was present

in the patients of our study in 63% of the cases, so the

DPOAE amplitude in the NT group, especially in fine

structure, almost completely reflects the amplitude in

tinnitus patients with normal hearing and hyperacusis.

The range of statistically significant differences in these

groups is also similar to that of the control group. A similar

proportion of normally hearing tinnitus patients with

hyperacusis was reported by Herraiz et al. [31], who

stressed that 47% of the patients complained about worse

life quality. Otoacoustic emission values for low f2 values

were markedly lower in patients with misophonia and


Fig. 4. Average otoemission intensity in patients from the NT group in

subgroups with hyperacusis and with misophonia and without these ill-

nesses. The arrows indicate f2 ranges for which the differences are statis-

tically significant (p < 0.05).


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without hyperacusis than in the patients of the control group.

Shiomi et al. [5] reported similar results, but they included

tinnitus patients with proper hearing without distinguishing

those with hyperacusis. However, in our material, especially

in the fine structure, the average DPOAE intensities in the

subgroups with misophonia and without hyperacusis were

significantly higher than in the control group for an f2frequency in the range of 30004000 Hz. As it may be noted,

the DPOAE amplitude in tinnitus patients with normal

hearing and misophonia has a similar pattern to that in

patients without these disturbances. DPOAE reveals the

highest values in tinnitus patients with proper hearing and

hyperaucisis, and there was a high percentage of hyperacusis

in the control group (63%), so the otoacoustic emission

values of the hyperacusis patients probably influenced the

final results in the tinnitus patients with proper hearing

significantly. Linke et al. [32] and Wilson [33] did not find

any statistically significant differences in DPOAE intensity

in patients with proper hearing and tinnitus in comparison

with a control group.

According to the theory of Nelson and Chen [4] the

serotoninergic system may be impaired in tinnitus patients,

in our report with proper hearing. This may inhibit the

activity of efferent fibers of the medial olivocochlear fascicle

[22]. Castello [29] also observed dysfunction of the efferent

system in otologically healthy patients with normal hearing.

Efferent system disturbances alter outer hair cell activity,

which may provoke the appearance of tinnitus [11,29,34

36]. Alterations in the efferent system due to limbic

dysfunction may be the reason for so many statistically

significant differences in DPOAE amplitude between the

subgroups of tinnitus patients distinguished by theappearance of hyperacusis or misophonia and in comparing

them with the control group. The fine structure diagram

confirms the results obtained in the DP-gram of the two

points per octave recording, showing more precisely the

range of f2 frequencies for which statistical differences

exist. Thanks to the fine structure, some extra information

about statistically insignificant differences in the two points

per octave recording may be obtained. Certain differences in

the DPOAE results in the two points per octave and in the

fine structure patterns between the NT group with

misophonia and the NT group without hyperacusis

compared with the control group should be stressed. The

information refers to average f2 values for which the

DPOAE amplitude is significantly higher both in the NT

subgroups with misophonia and without hyperacusis in

comparison with the control group. This is why the fine

structure not only more precisely defines the f2 range that

shows differences in amplitude between the groups, but also

supplies some extra information on the DPOAE amplitude

not visible in the basic DP-gram. The fine structure reflects

the cochlea function more precisely. This was also

confirmed by Mauermann et al. [37] and Kapadia and

Lutman [38]. According to Mauermann et al. [37], the fine

structure reflects outer hair cell disturbances even when

nothing pathological is noted in the DP-gram of the two

points per octave distribution. It may predict hearing and

cochlea impairment. According to Liu et al. [30], DPOAE

amplitude disturbances occur only in an f2 frequency that is

consistent with the tinnitus range. In our results the DPOAE

amplitudes significantly differed from those of the control

group and referred to the high f2 frequencies, the onesusually heard by tinnitus patients with normal hearing. In

our investigations, the DPOAE values for higher f2

frequencies were significantly higher in the whole tinnitus

patient group with proper hearing in comparison with the

control group with regard to most of the hearing range of the

tinnitus patients.

Considering our results concerning application of the

growth rate function, it should be stressed that DPOAE

threshold values reflected DPOAE amplitude only partially in

the tinnitus patients compared with the control group. We

think that DPOAE amplitude analysis in tinnitus patients

cannot be replaced by otoacoustic emission threshold testing.

Other authors maintain that when considering otoemission

threshold variability, its usefulness is very restricted.

7. Conclusions

1. DPOAE amplitude recorded at two points per octave and

in the fine structure is a valuable parameter in cochlear

evaluation in tinnitus patients;

2. The fine structure provides extra information about

DPOAE amplitude expanding f2 frequency range for

which differences between the groups exist;

3. The growth rate function cannot be the only parameterused to evaluate DPOAE in tinnitus patients or patients

with misophonia and hyperacusis. It cannot replace

DPOAE amplitude analysis in tinnitus patients;

4. Hyperacusis influences DPOAE amplitude and increases

its value in tinnitus patients with normal hearing. This

may help to establish a new treatment method.

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