The Magnitude and Determinants of Tinnitus among Health Science Students at King Khalid University

Background Tinnitus is a symptom that is defined as a subjective perception of noise in an absence of external sound. It is an indicator of auditory system abnormalities. It can also be present in individuals without any hearing abnormalities. Difficulty to consternate, insomnia, and decreased speech discrimination are the most common symptoms related to tinnitus. Aim To assess the magnitude and pattern with determinants of tinnitus among health science students at King Khalid University. Methodology. A descriptive cross-sectional survey was conducted targeting all accessible students in health science colleges in King Khalid University which is the main university in the Aseer region, south of Saudi Arabia. Students were included consecutively from different faculties and different grades. Data were collected through a self-administered prestructured questionnaire, which was distributed and recollected the next day. Tinnitus was screened using an adapted form of the National Health and Nutrition Examination Survey (NHANES). Results A total sample of 400 students have been included with their ages ranging from 18 to 30 years with a mean age of 22 ± 1.8 years), and 28.5% of the students recorded positive findings. Tinnitus was bilateral among 51.8% of students, and 44.7% of tinnitus students hear buzzing sound while 21.1% have hissing sound and 10.5% had pulsating sound. Among 46.5% of students with tinnitus, the heard sound was of moderate loudness and intermittent among 64.9% of them. Conclusions and Recommendations. In conclusion, the study revealed that just more than a quarter of students complained of tinnitus which was bilateral among half of them. Tinnitus frequency was mainly moderate in intensity and intermittent. Having ear problems, loud sounds, and allergy were the most important predictors of having Tinnitus.


Background
Tinnitus is a symptom that is defined as a subjective perception of noise in an absence of external sound. It is an indicator of auditory system abnormalities. It results from several health conditions such as noise-induced hearing loss, acoustic trauma, history of head injury, presbycusis, metabolic disorders, use of medications (NSAID), ear infections, arthritis, somatosensory impairment, and/or other chronic comorbidities. It can also be present in individuals without any hearing abnormalities [1,2]. Difficulty to consternate, insomnia, and decreased speech discrimination are the most common symptoms related to tinnitus [3]. It affects 10%-25% of the adult population with a different degree in associated life difficulties [4,5]. Our targeted population in this study is the college students as they have shown a high prevalence of tinnitus about 66% and unhealthy behavior toward their auditory health regarding a study conducted in the United States at 2008 [6].
Audiologists recently concluded that the prevalence of tinnitus will increase as considerably due to many factors such as environmental factors which include exposure to loud noise. Arguably, exposure to high noisy sounds may aggravate the likelihood of physiological damage to the auditory organ which, in turn, can end with tinnitus. Although tinnitus can be a symptom of an illness that can be managed and treated, for example, acoustic neuroma or otosclerosis, the most common underlying cause of tinnitus is associated with relatively small changes in the cochlea [7,8]. Studies on hearing loss and tinnitus have often been based on occupational noise exposure. With increasing media exposure by young people like undergraduates, more time is spent on listening to devices for entertainment: radios, televisions, iPods, laptops, and others [9].
Currently and up to our literature search, there is a lack of studies that estimate the prevalence of tinnitus among health sciences students in the Aseer region. erefore, this study could help to cover this gap in knowledge and it will be conducted in the Aseer region among health science students to mainly estimate the prevalence and determinants of tinnitus.

Methodology
A descriptive cross-sectional survey was conducted targeting all accessible students in health science colleges in King Khalid University, which is the main university in the Aseer region, south of Saudi Arabia. Students were included consecutively from different faculties and different grades after explaining the research objectives and importance and after having oral consent for participation. After giving the consent, data were collected through a self-administered prestructured questionnaire, which was distributed and recollected the next day.
e self-administered questionnaire used in this study has been taken from previous research after approval from its authors. Tinnitus was screened using an adopted form of the National Health and Nutrition Examination Survey (NHANES), and noise exposure background was estimated by using a questionnaire developed by Megerson (2010) which is a valid questionnaire [7].

Data Analysis
After data were collected, they were revised, coded, and fed to statistical software IBM SPSS version 20. e given graphs were constructed using Microsoft Excel software. All statistical analysis was done using two-tailed tests and an alpha error of 0.05. A P value less than or equal to 0.05 was considered to be statistically significant. Frequency and percent were used to describe the frequency distribution of students' tinnitus-related data. Chi-square/Monte Carlo exact test and Fisher's exact test were used to test for the association between students' biodemographic data tinnitus. Exact tests were used if there are small frequencies where chi-square is invalid. Chi-square test for linear trend was used to test the association between tinnitus status and different risk factors due to the ordinal nature of risk factor responses.

Results
A total sample of 400 students have been included with their ages ranging from 18 to 30 years with a mean age of 22 ± 1.8 years. Exact 83.3% of the students were males and 7.8% were smokers. About 23% of the students recorded a positive history of allergy and 13.5% of them were on drugs due to health-related problems. Also, 8% of the students had a hearing problem which was bilateral in 43.8% of them.
On screening for tinnitus (Figure 1), 28.5% of the students recorded positive findings. Exact 19.5% of the students were bothered by loud sounds during the past period for less than 3 months among 32.5% of the students and for 10 or more years among 3.9% of them. Also, 28.5% of the students experienced ringing, roaring, or buzzing in their ears/head and 50% of them were bothered by ringing, roaring, or buzzing in their ears or head only after listening to loud sounds or loud music. e ringing exposure was not problematic among 40.4% of the students and constituted a big problem for only 1.8% of the students. Tinnitus was bilateral among 51.8% of students, and 44.7% of tinnitus students hear buzzing sound while 21.1% have hissing sound and 10.5% had pulsating sound. Among 46.5% of students with tinnitus, the heard sound was of moderate loudness and intermittent among 64.9% of them. About 18% of students reported noise as the main triggering factor for sound followed by music exposure (12.3%), and after sleep (6.1%) ( Table 1). Table 2 shows the relation between students' biodemographic data and tinnitus status. Exact 51.7% of students aged 25 years or more recorded positive tinnitus findings compared to 22.5% of those aged less than 20 years with recorded statistical significance (P � 0.003). Also, 33.8% of female students had tinnitus compared to 22.5% of females who did not (P � 0.012). Also, 42.6% of students with a positive history of allergy had positive tinnitus findings compared to 24.2% of those who did not (P � 0.001). As for health problems, 90.9% of students with a history of head trauma had tinnitus compared to 50% of diabetic students and 25.8% of free students (P � 0.001). Also, 50% of students with hearing problems recorded 71.5% 28.5% Negative Positive  e Scientific World Journal positive tinnitus findings compared to 26.6% of others (P � 0.005). About 50% of students with recurrent ear infections had tinnitus compared to 26.6% of those who did not (P � 0.007). All other factors were insignificantly related to tinnitus findings among the students. On relating tinnitus findings with the different risk factors of tinnitus among the sampled students (Table 3), it was clear that 50% of students who were exposed to loud sounds that made their ears "ring" or "buzz" weekly had positive finding compared to 14.9% of those who never exposed (P � 0.001). Also, 66.7% of students who were monthly exposed to loud sounds that made their hearing seem muffled had positive findings compared to 22.4% of those who never exposed (P � 0.001). Regarding patients who suffered from tinnitus, we found that 50% had a history of monthly exposure to loud sounds, compared to 21% of being never exposed (P � 0.001). Table 4 shows the continuation of the relation between tinnitus and different risk factors. As for riding/operating motorized vehicles such as motorcycles, jet skis, and speed boats, tinnitus was recorded among 50% of monthly or even weekly riders compared to 25.8% of those who did not (P � 0.048). About 33% of those who played music daily recorded positive tinnitus findings compared to 26.7% of others who did not (P � 0.001). Also, 39.8% of those who wear earphones for 8 hours or more experienced tinnitus attacks compared to 15.8% of those who use it for less than one hour (P � 0.035). All other studied risk factors including listening to the radio, reading motorized vehicles, and attending sporting events were insignificantly related to tinnitus among students.

Discussion
Tinnitus is an abnormal perception of sound without an external mechanical or electrical stimulant [10]. Tinnitus is one of the frequent otological complaints reflecting an abnormality in perception which may be subjective or objective. ere are local and systemic factors causing tinnitus [11]. Among three-quarters of persons with tinnitus, the main cause is unknown (idiopathic) [12]. For some people, tinnitus may be caused by a sequence of noise exposure [12]. e majority of cases of tinnitus with known causes involving the cochlea include hearing loss due to aging, noiseinduced hearing loss, head/ear trauma, lymphatic disorders, cochlear vascular deficiency, and viral infection [11]. e current study revealed that 28.5% of the students had tinnitus or hearing a loud sound. ese results were larger than that recorded by other studies as a study was carried out in Northern Arizona University, USA, which showed that 8.4% of college students have chronic tinnitus, 13.0% have acute tinnitus, and 37.9% have subacute tinnitus [13]. Another study was carried out in Nigeria, which showed that 20.6% of college students have tinnitus and 95.6% are regular users of the earphone on a daily basis [14]. Regarding college students' behaviors and tinnitus, a study carried out in Serbia showed that 82.1% of them had a habit of listening to loud music, with 65.8% having tinnitus and 10.1% had a subjective hearing loss [15]. Another study carried out among medical students by using a personal sound system  [16]. e higher rate recorded among the current research may be due to overestimation by the used survey tool which could be adjusted if it was followed with a clinical confirmation. e research findings recorded significantly higher tinnitus among older age students, males who had a history of chronic health problems, allergy or hearing problems especially recurrent ear infections and also on exposure to loud sounds, noise, and wearing earphones. ese findings were concordant with that recorded by Widén et al. [17] and Brunnberg et al. [18]. Sunny et al. [19] conducted a study in Nigeria to test the association with the use of earphones and tinnitus among students of the College of Medicine. e study concluded that the prevalence of earphone use among the students and subjective tinnitus was 95.6% and 20.6%, respectively. More than 90% of the earphone users had a duration of earphone use for a duration of 3 to 6 years. ese findings are concordant with the current research conclusion regarding using earphones especially for long duration (more than 8 hours per day). Also, the effect of noise and earphone use was tested by Tung et al. [20] to investigate teenage students' hearing impairment, their experience with recreational noise exposure, and their self-reported hearing, and they concluded that approximately 90.9% of the participants had the habit of using earphones during the past year. Pure tone audiometry showed 11.9% of subjects had one or both ears with hearing threshold over 25 dB. It was found that 13.5% of the subjects reported that they suffered from tinnitus. e noise exposure group had more selfreported hearing problems than the control group.
Generally, tinnitus is not an uncommon problem among the studied students which was mainly related to their habits (earphone wearing for a long time) and lifestyles like driving high-speed motors and exposure to noise or loud sounds.

Study Limitations
Irrespective of the large sample size but sampling technique based on nonprobability procedure (consecutive sample) may affect the representatives of the sample and generalizability of results. Also, tinnitus screening based on a survey but not on clinical diagnosis (no audiological evaluation) introduces some bias in estimation. But, due to the nature of the sample and large sample size, the clinical assessment was difficult to confirm. How often were you exposed to loud sounds that made your ears "ring" or "buzz"? How often were you exposed to loud sounds that made your hearing seem muffled for a while?

Conclusions and Recommendations
In conclusion, the study revealed that just more than a quarter of students complained of tinnitus, which was bilateral among half of them. Tinnitus frequency was mainly moderate in intensity and intermittent. Researchers recommended that large-scale study covering nearly all university students with more specific tools and clinical assessment is required to detect the magnitude of this noisy problem. is can be a university-funded project for early detection and management.

Data Availability
Our data used to support the findings of this study are available from the corresponding author upon request.

Conflicts of Interest
e authors declare that they have no conflicts of interest.