Introduction
First described by Minor et al., in 1998, superior semicircular canal dehiscence is a bony defect in which a communicating dehiscence manifests between the middle cranial fossa and superior semicircular canal.Reference Minor, Solomon, Zinreich and Zee1–Reference Rajan, Leaper, Goggin, Atlas, Boeddinghaus and Eikelboom7 This ‘third window’ disrupts the barrier between the superior semicircular canal and the middle cranial fossa.Reference Ung, Pelargos, Chung, Voth, Barnette and Bhatt8 Clinical manifestations of superior semicircular canal dehiscence include vestibular and auditory symptoms, such as aural fullness, autophony, tinnitus, hearing loss, dizziness and vertigo.Reference Minor9–Reference Zhang, Hong, Dai, Chi and Sha12 As symptoms are often triggered by everyday tasks such as climbing stairs, bending over or turning over in bed, patients are often limited in their daily activities. For instance, patients avoid exposure to loud soundsReference Lagman, Ong, Chung, Elhajjmoussa, Fong and Wang4 or air pressure,Reference Ostrowski, Byskosh and Hain13 to prevent exacerbation of their symptoms. Such impairments may substantially affect patients’ abilities to navigate their environments, or function in social or occupational settings.
The severity and character of superior semicircular canal dehiscence symptoms are complex and vary across patients. Ultimately, the pernicious nature of these symptoms affects diverse aspects of patients’ lives. The symptomatology of superior semicircular canal dehiscence is thus not adequately encapsulated in terms of auditory or vestibular symptoms alone, but must also incorporate the concomitant functional impairments, limitations to daily living, psychosocial components and impact on general quality of life (QoL).Reference Newman, Jacobson and Spitzer14 Although literature on the aetiology, diagnosis and treatment of superior semicircular canal dehiscence has greatly expanded in recent years,Reference Beckett, Lagman, Chung, Bui, Lee and Voth3, Reference Gioacchini, Alicandri-Ciufelli, Kaleci, Scarpa, Cassandro and Re15, Reference Palma Diaz, Cisneros Lesser and Vega Alarcon16 thorough patient-centred assessment of superior semicircular canal dehiscence symptoms remains lacking.
Here, we present the Gopen–Yang Superior Semicircular Canal Dehiscence Questionnaire (‘GYSSCDQ’), which provides a holistic, patient-centred self-assessment of QoL, internally amplified sounds, tinnitus and dizziness in superior semicircular canal dehiscence patients. The present study aimed to characterise questionnaire responses in a consecutive series of patients prior to undergoing surgical repair of superior semicircular canal dehiscence at our institution, and to establish internal validity of the Gopen–Yang Superior Semicircular Canal Dehiscence Questionnaire in order to assess its potential as a patient-centred tool for understanding symptoms and general well-being before and after surgery.
Materials and methods
We administered the Gopen–Yang Superior Semicircular Canal Dehiscence Questionnaire to 27 patients during an out-patient consultation prior to surgical repair, between June 2011 and March 2016. Four patients were excluded from analysis because they received an incomplete version of the survey. This resulted in full survey response data for 23 patients, all of whom were included in our analysis. Patient demographic data, including age, sex and race, were obtained by voluntary self-report. Institutional review board approval was obtained for this study (approval number: 17-000622).
Questionnaire development
The Gopen–Yang Superior Semicircular Canal Dehiscence Questionnaire is designed to assess patients’ subjective perceptions of superior semicircular canal dehiscence related symptoms and general QoL before corrective surgery. The survey consists of four sections: general QoL, internally amplified sounds, dizziness and tinnitus. Modified and unmodified versions of several previously published surveys were included in the Gopen–Yang Superior Semicircular Canal Dehiscence Questionnaire, which is presented as a comprehensive pre-operative survey for superior semicircular canal dehiscence patients. Descriptions of each survey section are provided below. The full Gopen–Yang Superior Semicircular Canal Dehiscence Questionnaire is provided in Appendix 1.
The general QoL section was a modified version of the Rand 36-item Short-Form Health Survey (‘SF-36’), developed for the Medical Outcomes Study.Reference McHorney, Ware, Lu and Sherbourne17–Reference Ware and Sherbourne19 It consisted of 20 individual questions and evaluated patients’ perceived pain level, work and social limitations, and general psychological health. For each question, patients were given a variety of response options and asked to select the one best describing their subjective assessment of different aspects of QoL. Nine questions pertained to work and social limitations due to symptoms interfering with daily functioning. Six questions concerned psychological health and three questions pertained to general health. One question related to general QoL and one question referred to the subjective level of physical pain. Questions included sets of three, five or six possible responses, with higher scores indicating greater severity of symptoms or impact on QoL.
The internally amplified sounds section consisted of 10 binary questions selected from the Rand Short-Form Health Survey.Reference McHorney, Ware, Lu and Sherbourne17–Reference Ware and Sherbourne19 Questions in this section pertained to the frequency, severity and functional impact of internal amplified sound symptoms experienced by patients (e.g. ‘Does hearing these sounds make it difficult to relax?’).
The dizziness and tinnitus sections were the previously published Dizziness Handicap InventoryReference Jacobson and Newman20 and Tinnitus Handicap Inventory,Reference Newman, Jacobson and Spitzer14 and consisted of 25 questions each. Questions in both surveys had response options of ‘No’, ‘Sometimes’ or ‘Yes’.
The dizziness section included three subsections: (1) physical, (2) functional and (3) emotional. The ‘physical’ subgroup included seven questions that assessed whether routine physical movements, such as sports activities, walking down an aisle or bending over, exacerbated patients’ dizziness. The ‘functional’ subgroup included nine questions assessing the extent to which dizziness symptoms limited patients’ lifestyles by impairing activities such as travelling, socialising or working. The ‘emotional’ subgroup included nine questions that evaluated the emotional impact of dizziness symptoms, including the extent to which dizziness caused patients to feel frustrated, embarrassed, depressed or unable to concentrate.
The tinnitus section included three subsections: (1) functional, (2) emotional and (3) catastrophic. Eleven questions were included in the ‘functional’ subgroup, and pertained to limitations in mental, social or occupational, and physical functioning (e.g. ‘Does the loudness of your tinnitus make it difficult to hear people?’). The ‘emotional’ subgroup consisted of nine questions that evaluated patients’ emotional responses to tinnitus (e.g. ‘Because of your tinnitus, do you feel irritable?’). Finally, the ‘catastrophic’ subgroup included five questions that pertained to possible severe psychological distress and inability to cope with symptoms (e.g. ‘Do you feel like you can no longer cope with your tinnitus?’).
Scoring of survey responses
Although the number of survey response options varied across questions, we normalised the magnitude of individual question scores to achieve equal weighting across questions in each section. For all questions across all survey sections, we normalised each question score by dividing the raw response scores (e.g. 0–4 on a question with five possible responses) by the maximum possible score for each corresponding question. This produced normalised question scores ranging from 0 (no symptoms) to 1 (most severe symptoms). In order to compute total scores for each survey section, normalised scores were summed across individual questions, and this sum was divided by the total number of questions and multiplied by 100. This produced section scores ranging from 0 (no symptoms) to 100 (most severe symptoms) that characterised the overall subjective impact of superior semicircular canal dehiscence in each domain. Finally, a composite score, ranging from 0 to 100, was computed by averaging patients’ total scores across the four survey sections (general QoL, internal amplified sounds, dizziness and tinnitus).
Statistical analysis
Statistical analysis was performed using SAS 9.3 software (SAS Institute, Cary, North Carolina, USA) and through manual calculations in Excel spreadsheet software (Microsoft, Redmond, Washington, USA). Total scores for individual survey sections (general QoL, internal amplified sounds, dizziness and tinnitus) were calculated for each survey respondent, in addition to composite scores. Next, means and standard deviations (SDs) were computed for the section scores and composite scores, across all 23 survey respondents.
Cross-respondent variability in survey responses was quantified via three complementary approaches. First, we computed Cronbach's α scores, characterising the internal consistency of question sets within each survey section and subsection, as well as Cronbach's α scores, characterising the internal consistency of the four section scores relative to the overall composite score of the entire survey. For a survey scored as the sum of responses to individual items, the Cronbach's α statistic (or tau-equivalent reliability) represents a ratio comparing the summed cross-respondent variances for individual survey items to the cross-respondent variance across the total (summed) survey scores:
$$\alpha = \displaystyle{K \over {K-1}}\left( {1-\displaystyle{{\mathop \sum \nolimits_{i = 1}^K Var\lpar {Y_i} \rpar } \over {Var\lpar X \rpar }}} \right),$$where K indicates the number of items contributing to the composite score, Y i indicates the individual item scores, and X indicates the summed composite score, such that X = Y 1 + Y 2 + … + Y K. Cronbach's α may range from 0 to 1. Higher values indicate smaller cross-respondent variance within individual item responses relative to cross-subject variance in composite scores, and thus greater so-called reliability or internal consistency among the survey items.Reference Cronbach21 For the purposes of computing Cronbach's α, total section or composite scores were not normalised to a scale of 0–100, but were instead taken as the raw sum of normalised question or subsection scores, as delineated in the equation above.
Second, to supplement our primary analysis using Cronbach's α, the heterogeneity of responses to individual questions relative to total section scores was also assessed by computing item-total correlations for individual questions in each survey section. Item-total correlations were obtained by computing the Pearson's correlation between the vector of all patients’ responses to an individual survey question and the vector of patients’ section total scores. The range of item-total correlations observed across questions in each section was used to gauge the extent of heterogeneity in responses within the corresponding survey section. Item-total correlations for individual questions were also useful to identify the questions that were most or least correlated (i.e. redundant) with the section as a whole.
Third, to compare cross-patient variability at the level of section total scores, we also computed and tabulated Pearson's correlations between each pair of section total scores across patients.
Results
Demographics
A total of 23 patients completed the Gopen–Yang Superior Semicircular Canal Dehiscence Questionnaire in its entirety before undergoing surgery for repair of superior semicircular canal dehiscence. Basic demographics of the survey respondents included in our analysis are presented in Table 1. Twelve patients identified as female gender, and 11 patients identified as male gender. Average patient age (± SD) at completion of the pre-operative survey was 52.5 ± 12.7 years. Twelve patients identified as Caucasian, two patients identified as Asian and the remaining nine patients declined to identify with any racial background.
Table 1. Demographics of survey respondents
SD = standard deviation
Survey response scores
Individual subsection, section and overall composite scores for the Gopen–Yang Superior Semicircular Canal Dehiscence Questionnaire are summarised in Table 2, which provides the mean, SD and range (minimum and maximum) observed for the normalised scores among all survey respondents. Section scores were normalised to a scale of 0–100.
Table 2. Summary of Gopen–Yang Superior Semicircular Canal Dehiscence Questionnaire responses
SD = standard deviation; QoL = quality of life
The tinnitus section had the lowest normalised scores of any section in terms of symptom severity (33.3 ± 30.7), with the lowest scores contributed specifically from the ‘emotional’ subsection of the tinnitus inventory. The internal amplified sounds section had the highest scores of any section (52.5±23.9). All individual sections of the Gopen–Yang Superior Semicircular Canal Dehiscence Questionnaire had substantial variability across patients, with SDs for each section score ranging between 23.9 and 30.7 points. The dizziness and tinnitus sections had the greatest degree of heterogeneity overall, with scores ranging from 0 to 84 and from 0 to 94 points across subjects in our cohort, respectively. (Note that although each survey section was designed to characterise the severity and specific aspects of its corresponding domain, section scores were not designed to be compared against each other in terms of raw magnitude.)
Internal consistency of individual survey sections
We used two approaches to assess the internal consistency of each individual section of the Gopen–Yang Superior Semicircular Canal Dehiscence Questionnaire. As a primary analysis, we assessed the internal consistency of item responses in each section by computing Cronbach's α, a well-established metric for assessing the internal consistency of item responses in surveys.Reference Cronbach21 The greatest α values were observed for dizziness (0.957) and tinnitus (0.973) sections (Table 3), indicating that these sections tended to have the greatest response homogeneity in terms of patients’ response patterns across the individual questions.
Table 3. Internal consistency of responses within individual survey sections
QoL = quality of life
As a secondary analysis to supplement these findings, we also computed the range (minimum and maximum) of item-total correlations across all questions within each survey section (see Materials and methods). The range of item-total correlations provides another gauge of how heterogeneous the patients’ scores were on individual questions relative to their total scores on the entire section. In line with the Cronbach's α statistics, the widest range in item-total correlations was observed for the general QoL (−0.12 to 0.86) and internal amplified sounds (−0.04 to 0.83) sections, compared to the more homogeneous item responses (i.e. item-total correlations lying closer to 1) observed for the dizziness section (0.36 to 0.91), and the most homogeneous responses of all, observed for the tinnitus section (0.62 to 0.94) (Table 3).
Internal consistency across survey sections
Analogous to our analysis of internal consistency within individual survey sections, we also assessed the degree of correlation between the total scores of each survey section, as well as the internal consistency across section total scores relative to the composite score averaged across the four sections. Cronbach's α statistics evaluating the internal consistency of the subsection scores for dizziness and tinnitus were 0.89 and 0.94, respectively (Table 4). A Cronbach's α statistic of 0.83 was obtained when assessing the internal consistency of all four major section scores (general QoL, internal amplified sounds, dizziness and tinnitus) relative to the overall composite score (Table 4).
Table 4. Internal consistency of subsection total scores
Finally, for reference, we computed a correlation matrix tabulating all pairwise correlations between each section score for our cohort (Table 5).
Table 5. Correlations between Gopen–Yang Superior Semicircular Canal Dehiscence Questionnaire sections
Numbers indicate pairwise Pearson's correlations between the total scores of each survey section. QoL = quality of life
Discussion
There has been increasing interest within healthcare to develop questionnaires that evaluate patients’ subjective symptoms and self-reported experiences of how their medical conditions affect: their physical, emotional and psychological health; their ability to engage in their normal activities; and their general sense of well-being and QoL.Reference Kulseng-Hanssen and Borstad22, Reference Castle, Brown, Hepner and Hays23 Such surveys offer an account of symptoms and the functional impact of disease from the perspective of those best able to define their illness, and fulfil an essential role in clinicians’ abilities to deliver patient-centred care. Surveys are also an effective way to strengthen communication between patients and physicians. It is well-known that strong communication is a critical factor contributing to a positive patient–clinician relationship, helping to establish patient trust.Reference Anhang Price, Elliott, Zaslavsky, Hays, Lehrman and Rybowski24
Additionally, there have been attempts to use questionnaires to help quantify symptoms for which the character and severity are otherwise difficult for the clinician to determine.Reference Newman, Jacobson and Spitzer14, Reference Jacobson and Newman20 This is especially true in the context of superior semicircular canal dehiscence, as the core clinical manifestations involve symptoms that are subjectively assessed and quantified (e.g. dizziness, tinnitus and internally amplified sounds). Manifestations of superior semicircular canal dehiscence that may be objectively assessed are generally limited to functional impairments. Functional limitations are, in turn, substantially shaped by subjective symptoms that affect patients on physical, emotional and psychological levels. Through patient-centred questionnaires, physicians gain added insights into how patients react to and cope with their symptoms and disabilities.Reference Newman, Jacobson and Spitzer14, Reference Jacobson and Newman20
We developed the Gopen–Yang Superior Semicircular Canal Dehiscence Questionnaire in light of the paucity of validated, standardised assessments for superior semicircular canal dehiscence patients that provide a holistic view of patients’ overall health, well-being and QoL. Excellent, validated inventories for dizziness and tinnitus have been described.Reference Newman, Jacobson and Spitzer14, Reference Jacobson and Newman20 Thus, we incorporated these previously published inventories into our questionnaire, and expanded upon them with further sections to assess internally amplified sounds and the impact of symptoms on QoL.
As reported, our survey includes 90 questions in total, and provides a thorough assessment of the range of subjective symptoms, associated functional limitations and effects on QoL reported by patients. However, our statistical analysis of the variability and internal consistency of responses to the Gopen–Yang Superior Semicircular Canal Dehiscence Questionnaire across 23 patients provides a quantitative basis for streamlining our survey in future iterations so it may be more efficiently administered in busy clinical settings.
Internal consistency of questionnaire
Our analyses of internal consistency demonstrated that all sections and subsections of the Gopen–Yang Superior Semicircular Canal Dehiscence Questionnaire had Cronbach's α statistics above 0.82. The α metric has historically been used to assess the ‘reliability’ or internal consistency of responses across multiple items or questions on surveys.Reference Revelle and Zinbarg25 Conceptually, it represents the estimated average pairwise correlation between all individual questions in a survey section.Reference Nunnally and Bernstein26 The metric ranges from 0 to 1; higher values indicate increasingly correlated responses between the individual items of the survey section, and are thus interpreted as reflecting high ‘reliability’ or internal consistency of item responses. This is particularly true for α values exceeding 0.80. Conversely, however, α metrics approaching 1 also indicate that the individual items do not provide substantially unique information, hence reflecting redundancy among the survey questions.
We found that the dizziness and tinnitus sections of the Gopen–Yang Superior Semicircular Canal Dehiscence Questionnaire had excellent cross-question reliability, with Cronbach's α over 0.95 obtained for both sections. The redundancy in patient responses within these sections is perhaps unsurprising; it seems intuitive that as the severity of tinnitus or dizziness increases, the impact of these symptoms on the various emotional, physical and functional aspects of patients’ lives might scale consistently. In contrast, internally amplified sounds are the result of a wide range of physiological processes that vary across individuals. The impact of superior semicircular canal dehiscence symptoms on perceived QoL has complex interactions with factors such as lifestyle, other co-morbidities, socioeconomic background and social environment. While speculative, these observations may explain why the internal amplified sounds and general QoL sections had lower α metrics and thus less internal consistency than observed for the dizziness and tinnitus sections.
In the context of our current work, the large Cronbach's α values obtained from our cohort's responses to the Gopen–Yang Superior Semicircular Canal Dehiscence Questionnaire establish the internal validity of our survey, indicating that it provides a reliable assessment of the core features of superior semicircular canal dehiscence. The values also suggest that a more streamlined questionnaire consisting of fewer total questions might be achievable, by targeting sections or questions with the highest levels of internal consistency for potential exclusion. As discussed above, we found excellent internal consistency (α values above 0.95) within the tinnitus and dizziness sections. Given the constraint of limited time in which to administer the survey, it would seem reasonable to abbreviate these sections, to achieve a more streamlined questionnaire that could be more rapidly administered with minimal loss of information. In this regard, the item-total correlations we computed for each individual question provide a robust statistical means by which to identify the most redundant questions (i.e. those with the highest item-total correlations) to be considered for exclusion, as they provide item-level granularity indicating the level of redundancy of specific questions compared to the survey section as a whole.
Finally, it is important to note that although the individual sections of the Gopen–Yang Superior Semicircular Canal Dehiscence Questionnaire generally had excellent internal consistency, with most α values above 0.9, the Cronbach's α statistic of the composite scores as a whole was somewhat lower, at 0.83. While an α metric over 0.8 still indicates strong correlations among questionnaire sections, it also suggests there is more heterogeneity in patients’ subjective characterisation of their symptoms and impact on general QoL than observed when only characterising the more straightforward symptoms of superior semicircular canal dehiscence (i.e. dizziness and tinnitus). This observation underscores the need for patient-centred approaches like ours to provide robust, holistic characterisation of subjective symptomatology, particularly in the context of a condition such as superior semicircular canal dehiscence, which has only been defined and treated fairly recently.Reference Minor, Solomon, Zinreich and Zee1, Reference Gioacchini, Alicandri-Ciufelli, Kaleci, Scarpa, Cassandro and Re15, Reference Palma Diaz, Cisneros Lesser and Vega Alarcon16
Future directions
As patient satisfaction is a major concern for improving the quality of care,Reference Prakash27 surveys are increasingly utilised to obtain direct patient input regarding their health conditions and treatment.Reference Hickey, Kleefield, Pearson, Hassan, Harding and Haughie28 Studies have weighed the advantages and disadvantages of applying standardised surveys, and generally conclude that such surveys are an effective means through which to assess patients’ perspectives of their illnesses and care.Reference Castle, Brown, Hepner and Hays23, Reference Dull, Lansky and Davis29 The ideal length of clinical questionnaires, however, is an important issue, as patients may find them exhausting and produce incomplete or unreliable responses.Reference Younger, McCue and Mackey30 Furthermore, care is needed in the development of questionnaires to phrase questions in clear and unambiguous ways for laypersons lacking clinical backgrounds. Although we drew upon previously validated inventories,Reference Newman, Jacobson and Spitzer14, Reference Jacobson and Newman20 and were cautious to develop clear and intuitive questions, the clarity of survey questions should be continuously evaluated by eliciting feedback from patients, clinicians and experts in survey design.
Other directions for future work include administering the Gopen–Yang Superior Semicircular Canal Dehiscence Questionnaire both pre- and post-operatively. Our study is limited in that we only validated the questionnaire using pre-operative data. The present study sought to validate a patient-centred clinical questionnaire to assess pre-operative symptoms in patients undergoing superior semicircular canal dehiscence surgery. However, a longer-term goal is to use the Gopen–Yang Superior Semicircular Canal Dehiscence Questionnaire to assess subjective symptom resolution after surgery. This requires further validation of the questionnaire in post-operative patients after recovery from superior semicircular canal dehiscence repair. In future work, we intend to assess subjective symptom resolution in a prospective longitudinal cohort, wherein patients are administered identical questionnaires prior to surgery and post-operatively at clinical follow up.
• A pre-operative survey was developed to characterise subjective symptomatology in patients undergoing surgical intervention for superior semicircular canal dehiscence
• The Gopen–Yang Superior Semicircular Canal Dehiscence Questionnaire included sections addressing general quality of life, internal amplification of sound, tinnitus and dizziness
• The questionnaire provides physicians with a better understanding of patient-centred superior semicircular canal dehiscence symptomology and its impact on general health
Applying the Gopen–Yang Superior Semicircular Canal Dehiscence Questionnaire in a post-operative context should improve understanding of which aspects of patients’ symptoms and lifestyle are improved or persistent after surgery. Additionally, analysing pre-operative questionnaire responses in relationship to patients’ post-surgical outcomes will be worthwhile for determining the prognostic power of various aspects of patients’ initial symptomatology on their post-operative course. This could help to identify patients who may be ideal surgical candidates for superior semicircular canal dehiscence repair, and conversely may help elucidate which patients may derive more benefit from alternative treatments.
Finally, as patients with superior semicircular canal dehiscence often present with a spectrum of symptom severity, it would also be beneficial to administer the questionnaire to patients presenting with mild symptoms that do not require surgical intervention, as well as asymptomatic superior semicircular canal dehiscence patients with incidental diagnoses on imaging. Together, these investigations could more fully characterise the symptomology of superior semicircular canal dehiscence and its effects on QoL and the overall health of the patient.
Conclusion
Although previous surveys have been developed and administered to superior semicircular canal dehiscence patients, their focus has been limited to specific symptoms, general health and treatment.Reference Powell, Khalil and Saeed31 Our development of the Gopen–Yang Superior Semicircular Canal Dehiscence Questionnaire emphasises a shift in focus towards patients’ perspectives regarding their superior semicircular canal dehiscence symptoms, but is equally critical for informing physicians’ understanding of superior semicircular canal dehiscence symptomatology. Harnessing the strength of patient-centred surveys allows clinicians to best leverage the perspectives of our patients, and helps to continually refine our understanding of the symptoms, clinical presentation and concerns encountered by patients suffering from superior semicircular canal dehiscence or other ailments.
Competing interests
None declared
Appendix 1. Gopen–Yang Superior Semicircular Canal Dehiscence Questionnaire
Semicircular canal dehiscence pre-surgery survey
Name: ______________________ Date: ____________________ MRN: ______________________
General quality of life
The general quality of life questions were selected from the Rand 36-item Short-Form Health Survey (‘SF-36’), developed for the Medical Outcomes Study.17–19
Circle or mark the single best response for each question below.
1. In general, would you say your health is:
Excellent Very good Good Fair Poor
2. How much physical pain have you had during the past month?
None Very mild Mild Moderate Severe
3. How has your health limited you in any of the following activities?
4. Does your health keep you from working at a job, doing work around the house or going to school?
Yes, more than 3 months Yes, less than 3 months No
5. Have you been unable to do certain types of work?
Yes, more than 3 months Yes, less than 3 months No
6. How much has your health limited your social activity during the past month?
All Most A lot Some A little None
7. How much of the time have you been very nervous in the past month?
All Most A lot Some A little None
8. During the last month, how much of the time have you felt calm and peaceful?
All Most A lot Some A little None
9. During the past month, how much of the time have you felt downhearted and blue?
All Most A lot Some A little None
10. During the past month, how much of the time have you been a happy person?
All Most A lot Some A little None
11. During the past month, how often have you felt so down that nothing could cheer you up?
All Most A lot Some A little None
12. I am somewhat ill:
Definitely true Mostly true Not sure Mostly false Definitely false
13. I am as healthy as anybody I know:
Definitely true Mostly true Not sure Mostly false Definitely false
14. My health is excellent:
Definitely true Mostly true Not sure Mostly false Definitely false
15. I have been feeling bad lately:
Definitely true Mostly true Not sure Mostly false Definitely false
Internally amplified sounds (If none, skip this section)
The internally amplified sounds questions were selected from the Rand 36-item Short-Form Health Survey (‘SF-36’), developed for the Medical Outcomes Study.17–19
1. Please circle any of the following you hear amplified (circle all that apply):
Voice Eyes moving Footsteps
Digestive sounds Breathing Other: _______________
2. Which side(s) are your amplified sounds (circle one):
Left Right Both
3. Please answer the following questions related to any of the above amplified sounds (mark the appropriate columns):
Tinnitus symptoms (If none, skip this section)
The tinnitus questions were previously published as the Tinnitus Handicap Inventory.Reference Newman, Jacobson and Spitzer14
Dizziness symptoms (If none, skip this section)
The dizziness questions were previously published as the Dizziness Handicap Inventory.Reference Jacobson and Newman20
