Repetitive transcranial magnetic stimulation improve tinnitus in normal hearing patients: a double-blind controlled, clinical and neuroimaging outcome study

BACKGROUND AND PURPOSE

Tinnitus is a frequent disorder which is very difficult to treat and there is compelling evidence that tinnitus is associated with functional alterations in the central nervous system. Targeted modulation of tinnitus-related cortical activity has been proposed as a promising new treatment approach. We aimed to investigate both immediate and long-term effects of low frequency (1 Hz) repetitive transcranial magnetic stimulation (rTMS) in patients with tinnitus and normal hearing.

METHODS

Using a parallel design, 20 patients were randomized to receive either active or placebo stimulation over the left temporoparietal cortex for five consecutive days. Treatment results were assessed by using the Tinnitus Handicap Inventory. Ethyl cysteinate dimmer-single photon emission computed tomography (SPECT) imaging was performed before and 14 days after rTMS.

RESULTS

After active rTMS there was significant improvement of the tinnitus score as compared to sham rTMS for up to 6 months after stimulation. SPECT measurements demonstrated a reduction of metabolic activity in the inferior left temporal lobe after active rTMS.

CONCLUSION

These results support the potential of rTMS as a new therapeutic tool for the treatment of chronic tinnitus, by demonstrating a significant reduction of tinnitus complaints over a period of at least 6 months and significant reduction of neural activity in the inferior temporal cortex, despite the stimulation applied on the superior temporal cortex.

Selective auditory attention and silence elicit auditory hallucination in a nonclinical sample

INTRODUCTION

Several investigations have shown that the occurrence of auditory hallucinations (AH) is not restricted to neuropsychiatric patients. The aim of this study is to analyse the effect of attention and sustained silence on the emergence of AH in a nonclinical sample.

METHODS

Sitting in a silent sound booth, 66 adults were studied under different attention demands and then where asked about their auditory perception.

RESULTS

While performing a Hanoi Tower in silence, 10.6% of the individuals had hallucination-like perceptions (music, voices, and others). This rate decreased to 6.0% during a visual attention task, but highly increased to 36.4% during auditory attention.

CONCLUSIONS

Auditory hallucinations may occur in a nonclinical population in a silent environment. Concomitant auditory attention increases both the quantity and the quality of those perceptions.

Influence of silence and attention on tinnitus perception

Objective

The purpose of this study was to study the effect of attention and sustained silence on the emergence of auditory phantom perception in normal-hearing adults.

Study Design

Cross-sectional survey.

Subjects and Methods

While sitting in a sound booth, 66 volunteers (age range, 18–65; mean age, 37.3) performed 3 experiments of 5 minutes each, consecutively and randomly presented. Two deviated attention from auditory system (Hanoi and visual attention experiments), and 1 drove attention to the auditory system (auditory attention). After each experiment, participants were asked about their auditory and visual perception. No sound or light change was given at any moment.

Results

Of the participants, 19.7% experienced tinnitus during Hanoi, 45.5% during visual attention, and 68.2% during auditory attention experiment, with no significant differences for studied variables.

Conclusion

Tinnitus-like perceptions may occur in a non-clinical population in a silent environment. Concomitant auditory attention plays an important role on the emergence of tinnitus.

Myofascial trigger point:a possible way of modulating tinnitus

In order to investigate whether myofascial trigger points can modulate tinnitus, as well as the association between tinnitus and myofascial trigger points, 94 individuals with and 94 without tinnitus, matched by age and gender, were analyzed by means of bilateral digital pressure of 9 muscles. Temporary modulation of tinnitus was frequently observed (55.9%) during digital pressure, mainly in the masseter. The rate of tinnitus modulation was significantly higher on the same side of the myofascial trigger point subject to examination in 6 out of 9 muscles. An association between tinnitus and the presence of myofascial trigger points was observed (p < 0.001), as well as a laterality association between the ear with the worst tinnitus and the side of the body with more myofascial trigger points (p < 0.001). Thus, this relationship could be explained not only by somatosensory-auditory system interactions but also by the influence of the sympathetic system.

Efeito da timpanoplastia no zumbido de pacientes com hipoacusia condutiva: seguimento de seis meses

O timpanoplastia tem como objetivos erradicar a doença da orelha média e restaurar os mecanismos de condução sonora. Contudo, alguns pacientes apresentam incômodo com o zumbido e muitas vezes questionam o médico sobre os resultados da cirurgia em relação ao zumbido. OBJETIVO: Avaliar a evolução do zumbido em pacientes com hipoacusia condutiva após timpanoplastia. Forma de Estudo: Coorte prospectiva. CASUÍSTICA E MÉTODO: Foram avaliados 23 pacientes com queixa de zumbido e diagnóstico de otite média crônica simples com indicação cirúrgica. Os pacientes foram submetidos a um protocolo de investigação médica e audiológica do zumbido antes, 30 e 180 dias após a timpanoplastia. RESULTADOS: 82,6% dos pacientes apresentaram melhora ou abolição do zumbido. Melhora significante do incômodo do zumbido no pré-operatório (5,26) em relação ao pós-operatório (1,91 com 30 e 180 dias), assim como entre o incômodo da perda auditiva pré-operatória (6,56) e pós-operatória (3,65 e 2,91). A audiometria revelou melhora do limiar tonal em todas as freqüências, com exceção de 8KHz, havendo fechamento ou gap máximo de 10dB NA em 61% dos casos. Pega total do enxerto em 78% dos casos. CONCLUSÃO: Além da melhora da perda auditiva, a timpanoplastia também proporciona bons resultados sobre o controle do zumbido.

The efficacy of open molds in controlling tinnitus

Hearing aids may be a option to improve tinnitus and hearing loss. Aim: to evaluate tinnitus after one month use of BTE hearing aids with open molds and pressure vent molds in patients with symmetric sensorineural hearing loss. Methods: 50 patients seen at our Tinnitus Clinic who presented bilateral tinnitus and hearing loss underwent a randomized blind crossover clinical trial: 26 first used BTE hearing aids with open molds, and the remaining 24 first used pressure vent molds. After 30 days using the first mold and a wash-out period, the type of earmold was changed and was applied for another 30-day-period. Tinnitus evaluation was done qualitatively (improved, unchanged and worsened) and quantitatively (variation on a numeric scale from 0 to 10). Results: 82% of the cases reported improvement of tinnitus with at least one type of earmold; there was no significant difference in the reduction of discomfort due to tinnitus in the quantitative and qualitative evaluations. Although similar tinnitus control was obtained with both methods, 66% of the patients preferred the open mold. Conclusion: In a short-term evaluation improvement of tinnitus by the use of hearing aids does not depend on earmold ventilation.

The effect of timpanoplasty on tinnitus in patients with conductive hearing loss: a six month follow-up

Tympanoplasty is done to eradicate ear pathology and to restore the conductive hearing mechanism (eardrum and ossicles). Some patients, however, do not tolerate tinnitus and question physicians about the results of surgery when tinnitus persists.

AIM

to evaluate the progression of tinnitus in patients with conductive hearing loss after tympanoplasty.

STUDY DESIGN

a prospective cohort study.

MATERIAL AND METHODS

23 consecutive patients with tinnitus due to chronic otitis media underwent tympanoplasty. The patients underwent a medical and audiological protocol for tinnitus before and after tympanoplasty.

RESULTS

82.6% of patients had improvement or elimination of tinnitus after tympanoplasty The mean score of postoperative intolerance to tinnitus (1.91 for 30 and 180 days) was significantly different from preoperative scores (5.26). As to hearing loss, patients improved medically 30 and 180 days after surgery (3.65 and 2.91) compared to the preoperative condition (6.56). Audiometry revealed improvement at all frequencies from 0.25 to 6KHz, except at 8KHz. The air-bone gap was closed or was within 10dB in 14 cases (61%). An intact tympanic membrane was achieved in 78% of the cases.

CONCLUSION

Aside from the classical improvement of hearing loss, tympanoplasty also offers good control of tinnitus.

Transient tinnitus suppression induced by repetitive transcranial magnetic stimulation and transcranial direct current stimulation

Modulation of activity in the left temporoparietal area (LTA) by 10 Hz repetitive transcranial magnetic stimulation (rTMS) results in a transient reduction of tinnitus. We aimed to replicate these results and test whether transcranial direct current stimulation (tDCS) of LTA could yield similar effect. Patients with tinnitus underwent six different types of stimulation in a random order: 10-Hz rTMS of LTA, 10-Hz rTMS of mesial parietal cortex, sham rTMS, anodal tDCS of LTA, cathodal tDCS of LTA and sham tDCS. A non-parametric analysis of variance showed a significant main effect of type of stimulation (P = 0.002) and post hoc tests showed that 10-Hz rTMS and anodal tDCS of LTA resulted in a significant reduction of tinnitus. These effects were short lasting. These results replicate the findings of the previous study and, in addition, show preliminary evidence that anodal tDCS of LTA induces a similar transient tinnitus reduction as high-frequency rTMS.

Endonasal approach of salpingopharyngeus muscle for the treatment of ear click related to palatal tremor

Palatal tremor (PT) is a rare disease associated with rhythmic movements of the soft palate. It can be separated into two distinct clinical entities: symptomatic and essential. Most patients with essential PT complain of the rhythmic ear clicks and in some cases tinnitus, but usually have an uneventful medical history. Symptomatic PT patients are often unaware of the palatal movements and have symptoms and signs of brainstem or cerebellar dysfunction. We describe the case of a 25-year-old patient who developed severe essential PT, with very distressing bilateral objective tinnitus, constantly perceived as ear clicks. Several oral medications were prescribed with poor results. No significant improvement was obtained with repetitive injections of botulinum toxin type A (BTX A) distributed in soft palate muscles. Because of the continuous tinnitus and its impact on the patient's quality of life, chemical denervation of the salpingopharyngeus muscles, which is involved in the production of tinnitus, with BTX A was performed endonasally under endoscopic guidance. The result was very satisfactory. Tinnitus due to essential PT may be satisfactorily treated by endonasal injection of BTX into the salpingopharyngeus and palatopharyngeus muscles.

Contralateral suppression of otoacoustic emission in patients with tinnitus

Introduction: The medial olivocochlear bundle effect is studied through the suppression of otoacoustic emissions and seems to be influenced by the laterality of the central nervous system, presenting no symmetry between right and left ear. A dysfunction of this bundle may be involved in the generation of tinnitus, although this fact was not confirmed. Objectives: Study the suppression of distortion product otoacoustic emissions in tinnitus patients. Material and Method: A case-controlled study involving 44 tinnitus patients from the Tinnitus Group of the ENT Department of the University of São Paulo Medical School and 44 controls who underwent distortion product otoacoustic emissions testing with and without contralateral noise. Only the results from the right ears from both groups were compared. Results: There was a relationship between the presence of tinnitus and the absence of suppression at all frequencies studied (OR>2.1). Conclusion: There was a correlation between diminished effectiveness of the medial olivocochlear bundle and the presence of tinnitus.

Transient evoked otoacoustic emissions after vestibular nerve section in chinchillas

Transient evoked otoacoustic emissions are believed to be sensitive to the effects of the cochlear efferent system. The most well-known function of this system is inhibitory on cochlear response. It has been demonstrated that crossed medial efferent system section produces inhibitory control of the outer hair cells mechanisms responsible for non-linear transient evoked otoacoustic emissions generation. However, we suppose that the uncrossed medial efferent system plays a role in outer hair cell function too. We recorded the non-linear part of transient evoked otoacoustic emissions in 17 chinchillas before and after section of the vestibular nerve (crossed and uncrossed fibers). Responses at frequencies bands centered on 0.8, 1.6, 2.4, 3.2 and 4.0 kHz, as well as total emission responses, were analyzed. After vestibular nerve section, there were significant increases in the amplitudes of the 2.4- and 4.0 kHz responses and of the total response. These results indicate that the medial efferent system is important to maintain normal cochlear mechanics. Uncrossed medial efferent system and lateral efferent system seem to be not important in maintaining normal cochlear mechanics.

Nível de desconforto para sensação de intensidade em indivíduos com audição normal

TEMA: o Loudness Discomfort Level (LDL), teste muito utilizado na adaptação de próteses auditivas, teve sua indicação ampliada e passou a ser recomendado para complementar a avaliação de pacientes com zumbido e/ou com suspeita de hiperacusia. OBJETIVO: determinar valores de referência do LDL para normo-ouvintes e sua correlação com o Limiar do Reflexo Acústico (LRA). MÉTODO: o LDL foi aplicado em 64 sujeitos normo-ouvintes de 18 a 25 anos (53,1% do sexo feminino) nas freqüências de 0,5 a 8KHz e para sons da fala encadeada espontânea a viva-voz. Os tons puros pulsáteis foram apresentados por dois segundos, com intervalo de um segundo entre cada apresentação, a partir de 50dB de modo ascendente em passos de 5dB até que o sujeito referisse desconforto inicial com a sensação de intensidade. O procedimento foi realizado nas duas orelhas separadamente e repetido imediatamente (situações de teste e reteste), com alternância da orelha inicial a cada sujeito. O reflexo contralateral foi obtido em seguida. Foi considerado LRA a menor intensidade sonora capaz de provocar uma deflexão visível na agulha do imitanciômetro (maior que 0,05ml). RESULTADOS: a mediana do LDL variou de 86 a 98dBNA, sem diferenças estatisticamente significativas entre homens e mulheres (p > 0,11), entre orelhas (p > 0,36) ou entre as situações de teste e reteste (p > 0,34). Os coeficientes de determinação (r²) do modelo de regressão linear mostraram ausência de correlação entre log(LDL) e log(LRA). CONCLUSÃO: normo-ouvintes apresentam LDL de 86 a 98dBNA para todos os estímulos apresentados. Diferenças inter-sujeitos e boa reprodutibilidade sugerem que a interpretação do teste deve ser cuidadosa e aliada à anamnese e que o teste pode ser útil no acompanhamento de pacientes. Não houve correlação entre LDL e LRA.

Zumbido em pacientes com audiometria normal: caracterização clínica e repercussões

Pacientes com zumbido e audiometria normal constituem um grupo importante, pois seus achados não sofrem influência da perda auditiva. Apesar disso, este grupo é pouco estudado e não sabemos se suas características clínicas e repercussões são semelhantes às dos indivíduos com perda auditiva. OBJETIVOS: Comparar as características clínicas do zumbido e sua interferência nas atividades diárias em pacientes com e sem perda auditiva. FORMA DE ESTUDO: coorte histórica. MATERIAL E MÉTODO: Entre 744 pacientes atendidos no Grupo de Pesquisa em Zumbido do HCFMUSP, avaliou-se retrospectivamente com um corte transversal os 55 indivíduos com audiometria tonal normal. O grupo controle correspondeu a 198 pacientes com zumbido e perda auditiva atendidos sob o mesmo protocolo. Analisou-se os dados dos pacientes, as características clínicas do zumbido e sua repercussão na vida do paciente. RESULTADOS: A idade média no grupo de estudo (43,1 ± 13,4 anos) foi significantemente menor do que a do grupo controle (49,9 ± 14,5 anos). Em ambos os grupos houve predomínio do sexo feminino e o zumbido foi predominantemente bilateral, único e constante, porém sem diferença entre os grupos. A interferência na concentração e no equilíbrio emocional foi significantemente menor no grupo de estudo (25,5% e 36,4%) do que no controle (46% e 61,6%), porém sem diferença quanto à interferência no sono e na atividade social. CONCLUSÕES: O grupo de pacientes com zumbido e audição normal apresentou características clínicas semelhantes em relação ao grupo com perda auditiva. Entretanto, a faixa etária acometida e a interferência sobre a concentração e o equilíbrio emocional foram significantemente menores nestes.

The effect of stapedotomy on tinnitus in patients with otospongiosis

Stapedotomy is primarily performed to treat hearing loss secondary to otospongiosis, although some patients find that the accompanying tinnitus is more bothersome than the hearing loss. We prospectively studied 23 consecutive patients with tinnitus secondary to otospongiosis who had undergone stapedotomy, and we compared their pre- and postoperative medical and audiologic findings. Patients' annoyance with their tinnitus was quantified by means of a visual analog scale, and their air-conduction thresholds were determined by measurements of a 4-frequency pure-tone average (0.5, 1, 2, and 4 kHz). Statistical analysis was performed using the paired Student's t test and Fisher's exact test. In the group as a whole, the mean tinnitus annoyance visual analog scores were 8.34 preoperatively and 1.56 postoperatively, a highly significant difference. Clinically, 22 of the 23 patients (95.7%) achieved satisfactory control of their tinnitus (improvement or complete resolution) following stapedotomy. With respect to hearing loss, all patients clinically improved postoperatively, and audiometry confirmed improvement at all 4 frequencies between 0.5 and 4 kHz. An air-bone gap of less than 10 dB was noted in 17 patients (73.9%). We conclude that in addition to improving hearing, stapedotomy also provides good control of tinnitus.

Tinnitus in normally hearing patients: clinical aspects and repercussions

Patients with tinnitus and normal hearing constitute an important group, given that findings do not suffer influence of the hearing loss. However, this group is rarely studied, so we do not know whether its clinical characteristics and interference in daily life are the same of those of the patients with tinnitus and hearing loss. Aim: To compare tinnitus characteristics and interference in daily life among patients with and without hearing loss. Study design: historic cohort. Material and Method: Among 744 tinnitus patients seen at a Tinnitus Clinic, 55 with normal audiometry were retrospectively evaluated. The control group consisted of 198 patients with tinnitus and hearing loss, following the same protocol. We analyzed the patients’ data as well as the tinnitus characteristics and interference in daily life. Results: The mean age of the studied group (43.1 ± 13.4 years) was significantly lower than that of the control group (49.9 ± 14.5 years). In both groups, tinnitus was predominant in women, bilateral, single tone and constant, but there were no differences between both groups. The interference in concentration and emotional status (25.5% and 36.4%) was significantly lower in the studied group than that of the control group (46% and 61.6%), but it did not happen in regard to interference over sleep and social life. Conclusions: Patients with tinnitus and normal hearing showed similar characteristics when compared to those with hearing loss. However, the age of the patients and the interference over concentration and emotional status were significantly lower in this group.

The Effect of Stapedotomy on Tinnitus in Patients with Otospongiosis

Stapedotomy is primarily performed to treat hearing loss secondary to otospongiosis, although some patients find that the accompanying tinnitus is more bothersome than the hearing loss. We prospectively studied 23 consecutive patients with tinnitus secondary to otospongiosis who had undergone stapedotomy, and we compared their pre- and postoperative medical and audiologic findings. Patients annoyance with their tinnitus was quantified by means of a visual analog scale, and their air-conduction thresholds were determined by measurements of a 4-frequency pure-tone average (0.5, 1, 2, and 4 kHz). Statistical analysis was performed using the paired Student's t test and Fisher's exact test. In the group as a whole, the mean tinnitus annoyance visual analog scores were 8.34 preoperatively and 1.56 postoperatively, a highly significant difference. Clinically, 22 of the 23 patients (95.7%) achieved satisfactory control of their tinnitus (improvement or complete resolution) following stapedotomy. With respect to hearing loss, all patients clinically improved postoperatively, and audiometry confirmed improvement at all 4 frequencies between 0.5 and 4 kHz. An air-bone gap of less than 10 dB was noted in 17 patients (73.9%). We conclude that in addition to improving hearing, stapedotomy also provides good control of tinnitus.