Does person-centred care improve outcomes for musicians fitted with hearing protectors?

Objective: To reduce the risk of hearing injury, musicians are often recommended custom-made musicians' hearing protectors (MHP). Studies report benefits of use however, many still report challenges leading to relatively low uptake and inconsistent usage. Person-centred approaches to health have been shown to improve patient outcomes, and these principles may be translatable to musicians' hearing care. The aim was to investigate if use of, and satisfaction with, MHP is influenced by the treatment delivered to musicians by audiologists.Design: Participants were randomly allocated to one of four conditions that varied in extent of person-centred care.Study sample: Forty-two musicians with an interest in purchasing MHP were recruited.Results: Satisfaction with MHP was high overall and users reported a reduction in incidence of tinnitus. Participants reported few issues related to sound quality, however insertion difficulty was the main problem reported. Only one musician self-identified the need for alterations to their MHP.Conclusions: Adoption of person-centred approaches to MHP was not found to increase likelihood of use, however, satisfaction was high across all conditions. Most often, the need for MHP alterations were clinician-identified during fitting appointments or follow-up contact, underscoring the importance of including these components when providing audiological services to musicians.

Avenue for Future Tinnitus Treatments

Tinnitus is a common symptom. Standard therapies aim at improving the quality of life and reducing the psychological stress associated with tinnitus. Most interventions have little or no effect on the main symptom. Those affected subjects, however, want such a change and prefer a specific solution, such as pharmacologic therapy to other modalities. Scientific efforts have not yet led to significant improvement in the range of therapies. This article outlines existing efforts and develops ideas on how research for improved tinnitus therapy might look in the future.

Cognitive behavioural therapy for tinnitus

BACKGROUND

Tinnitus affects up to 21% of the adult population with an estimated 1% to 3% experiencing severe problems. Cognitive behavioural therapy (CBT) is a collection of psychological treatments based on the cognitive and behavioural traditions in psychology and often used to treat people suffering from tinnitus.

OBJECTIVES

To assess the effects and safety of CBT for tinnitus in adults.

SEARCH METHODS

The Cochrane ENT Information Specialist searched the ENT Trials Register; CENTRAL (2019, Issue 11); Ovid MEDLINE; Ovid Embase; CINAHL; Web of Science; ClinicalTrials.gov; ICTRP and additional sources for published and unpublished trials. The date of the search was 25 November 2019.

SELECTION CRITERIA

Randomised controlled trials (RCTs) of CBT versus no intervention, audiological care, tinnitus retraining therapy or any other active treatment in adult participants with tinnitus.

DATA COLLECTION AND ANALYSIS

We used the standard methodological procedures expected by Cochrane. Our primary outcomes were the impact of tinnitus on disease-specific quality of life and serious adverse effects. Our secondary outcomes were: depression, anxiety, general health-related quality of life, negatively biased interpretations of tinnitus and other adverse effects. We used GRADE to assess the certainty of evidence for each outcome.

MAIN RESULTS

We included 28 studies (mostly from Europe) with a total of 2733 participants. All participants had had tinnitus for at least three months and their average age ranged from 43 to 70 years. The duration of the CBT ranged from 3 to 22 weeks and it was mostly conducted in hospitals or online. There were four comparisons and we were interested in outcomes at end of treatment, and 6 and 12 months follow-up. The results below only refer to outcomes at end of treatment due to an absence of evidence at the other follow-up time points. CBT versus no intervention/wait list control Fourteen studies compared CBT with no intervention/wait list control. For the primary outcome, CBT may reduce the impact of tinnitus on quality of life at treatment end (standardised mean difference (SMD) -0.56, 95% confidence interval (CI) -0.83 to -0.30; 10 studies; 537 participants; low certainty). Re-expressed as a score on the Tinnitus Handicap Inventory (THI; range 0 to 100) this is equivalent to a score 10.91 points lower in the CBT group, with an estimated minimal clinically important difference (MCID) for this scale being 7 points. Seven studies, rated as moderate certainty, either reported or informed us via personal communication about serious adverse effects. CBT probably results in little or no difference in adverse effects: six studies reported none and in one study one participant in the CBT condition worsened (risk ratio (RR) 3.00, 95% CI 0.13 to 69.87). For the secondary outcomes, CBT may result in a slight reduction in depression (SMD -0.34, 95% CI-0.60 to -0.08; 8 studies; 502 participants; low certainty). However, we are uncertain whether CBT reduces anxiety, improves health-related quality of life or reduces negatively biased interpretations of tinnitus (all very low certainty). From seven studies, no other adverse effects were reported (moderate certainty). CBT versus audiological care Three studies compared CBT with audiological care. CBT probably reduces the impact of tinnitus on quality of life when compared with audiological care as measured by the THI (range 0 to 100; mean difference (MD) -5.65, 95% CI -9.79 to -1.50; 3 studies; 444 participants) (moderate certainty; MCID = 7 points). No serious adverse effects occurred in the two included studies reporting these, thus risk ratios were not calculated (moderate certainty). The evidence suggests that CBT may slightly reduce depression but may result in little or no difference in anxiety or health-related quality of life (all low certainty) when compared with audiological care. CBT may reduce negatively biased interpretations of tinnitus when compared with audiological care (low certainty). No other adverse effects were reported for either group (moderate certainty). CBT versus tinnitus retraining therapy (TRT) One study compared CBT with TRT (including bilateral sound generators as per TRT protocol). CBT may reduce the impact of tinnitus on quality of life as measured by the THI when compared with TRT (range 0 to 100) (MD -15.79, 95% CI -27.91 to -3.67; 1 study; 42 participants; low certainty). For serious adverse effects three participants deteriorated during the study: one in the CBT (n = 22) and two in the TRT group (n = 20) (RR 0.45, 95% CI 0.04 to 4.64; low certainty). We are uncertain whether CBT reduces depression and anxiety or improves health-related quality of life (low certainty). CBT may reduce negatively biased interpretations of tinnitus. No data were available for other adverse effects. CBT versus other active control Sixteen studies compared CBT with another active control (e.g. relaxation, information, Internet-based discussion forums). CBT may reduce the impact of tinnitus on quality of life when compared with other active treatments (SMD -0.30, 95% CI -0.55 to -0.05; 12 studies; 966 participants; low certainty). Re-expressed as a THI score this is equivalent to 5.84 points lower in the CBT group than the other active control group (MCID = 7 points). One study reported that three participants deteriorated: one in the CBT and two in the information only group (RR 1.70, 95% CI 0.16 to 18.36; low certainty). CBT may reduce depression and anxiety (both low certainty). We are uncertain whether CBT improves health-related quality of life compared with other control. CBT probably reduces negatively biased interpretations of tinnitus compared with other treatments. No data were available for other adverse effects.

AUTHORS' CONCLUSIONS

CBT may be effective in reducing the negative impact that tinnitus can have on quality of life. There is, however, an absence of evidence at 6 or 12 months follow-up. There is also some evidence that adverse effects may be rare in adults with tinnitus receiving CBT, but this could be further investigated. CBT for tinnitus may have small additional benefit in reducing symptoms of depression although uncertainty remains due to concerns about the quality of the evidence. Overall, there is limited evidence for CBT for tinnitus improving anxiety, health-related quality of life or negatively biased interpretations of tinnitus.

Prevalence of Persistent Tinnitus and Dizziness in an Elderly Population in Southern Taiwan

OBJECTIVES

Tinnitus and dizziness are common among the elderly. The conditions may increase depression, and patients may become susceptible to falls, thereby affecting the quality of life of the geriatric population. Investigating the prevalence of persistent tinnitus and chronic/recurrent dizziness in an elderly population and analyzing the association of certain comorbidities with tinnitus and dizziness in southern Taiwan were the main purposes of this study.

MATERIALS AND METHODS

This was a cross-sectional study performed in a metropolitan hospital. Hearing tests were conducted in a total of 597 volunteers aged ≥65 years involving 322 (53.9%) men and 275 (46.1%) women recruited in the study. The pure tone average (PTA) and hearing handicap (HH) score were calculated. Patients completed questionnaires regarding the history of hypertension and diabetes and symptoms of tinnitus and dizziness. The association of gender, age, PTA/HH, body mass index (BMI), hypertension, diabetes, and metabolic syndrome (MetS) with tinnitus and dizziness were analyzed.

RESULTS

The prevalence of persistent tinnitus and chronic/recurrent dizziness was 32.0% and 24.1%, respectively. Tinnitus or dizziness were not associated with age, BMI, hypertension, diabetes, and MetS but was associated with hearing impairment. Women and those with fasting glucose levels <100 mg/dL were more likely to experience dizziness.

CONCLUSION

Persistent tinnitus and dizziness were common in an elderly population in southern Taiwan. These findings may help develop strategies to promote the quality of life in the elderly population.

Prevalence, Incidence, and Risk Factors for Tinnitus

How many people are affected by tinnitus? Is the risk of developing tinnitus on the rise or has it been declining over time? What modifiable lifestyle factors could help to prevent tinnitus? These population-based questions can be addressed through epidemiological research. Epidemiology refers to the underlying and basic science of public health. It describes the study of the distribution and determinants of health-related states or events in specified populations and the application of this study to the control of health problems. There are two key concepts in epidemiology: (1) measures of frequency and (2) measures of effect. In this chapter, we introduce the two main measures of frequency, prevalence and incidence. We also introduce the notion of risk factors, critical for understanding measures of effect concerning the risk of developing a health condition. In both sections, we provide illustrative examples from the published literature on tinnitus. We end by offering a critical evaluation of the current status of epidemiological research on tinnitus and point to some promising future directions.

A study on the epidemiology of tinnitus in the United Kingdom

PURPOSE

Subjective tinnitus is a common symptom with potentially negative impact on quality of life. More research is required to gain a deeper understanding of the disease and its clinical presentation. To estimate the incidence of tinnitus and to describe patient-related characteristics such as lifestyle factors and comorbidities.

PATIENTS AND METHODS

Using the Clinical Practice Research Datalink, we calculated incidence rates of first-time diagnosed tinnitus in an adult population between 2000 and 2016. We stratified incidence rates by sex, age, and year of diagnosis. Additionally, we performed a 1:1 matched case-control study comparing body mass index, lifestyle factors and selected comorbidities between patients with incident tinnitus and tinnitus-free controls.

RESULTS

We identified 109 783 adults with a first-time diagnosis of tinnitus between 2000 and 2016, yielding an overall age-standardized incidence rate of 25.0 new tinnitus cases per 10,000 person-years (95% CI: 24.6-25.5). There was a steady increase in tinnitus incidence throughout the study period. Approximately 80% of tinnitus cases were diagnosed at age 40 years or older. We observed the highest incidence rate in individuals aged 60-69 years (41.2 per 10,000 person-years, 95% CI: 40.7-41.7). Smokers and alcohol drinkers were at lower risk of being diagnosed with tinnitus compared with non-smokers and non-drinkers, respectively. The occurrence of tinnitus was strongly associated with a recent diagnosis of several otological and vestibular disorders as well as head and neck disorders.

CONCLUSION

The present observational study found an increasing incidence of tinnitus over time, emphasizing the continuously growing health burden. The findings on patient characteristics, lifestyle factors, and selected comorbidities contribute to a better understanding of risk factors for tinnitus.

Axonal sprouting in the dorsal cochlear nucleus affects gap‑prepulse inhibition following noise exposure

One of the primary theories of the pathogenesis of tinnitus involves maladaptive auditory-somatosensory plasticity in the dorsal cochlear nucleus (DCN), which is assumed to be due to axonal sprouting. Although a disrupted balance between auditory and somatosensory inputs may occur following hearing damage and may induce tinnitus, examination of this phenomenon employed a model of hearing damage that does not account for the causal relationship between these changes and tinnitus. The present study aimed to investigate changes in auditory-somatosensory innervation and the role that axonal sprouting serves in this process by comparing results between animals with and without tinnitus. Rats were exposed to a noise-inducing temporary threshold shift and were subsequently divided into tinnitus and non-tinnitus groups based on the results of gap prepulse inhibition of the acoustic startle reflex. DCNs were collected from rats divided into three sub-groups according to the number of weeks (1, 2 or 3) following noise exposure, and the protein levels of vesicular glutamate transporter 1 (VGLUT1), which is associated with auditory input to the DCN, and VGLUT2, which is in turn primarily associated with somatosensory inputs, were assessed. In addition, factors related to axonal sprouting, including growth-associated protein 43 (GAP43), postsynaptic density protein 95, synaptophysin, α-thalassemia/mental retardation syndrome X-linked homolog (ATRX), growth differentiation factor 10 (GDF10), and leucine-rich repeat and immunoglobulin domain-containing 1, were measured by western blot analyses. Compared to the non-tinnitus group, the tinnitus group exhibited a significant decrease in VGLUT1 at 1 week and a significant increase in VGLUT2 at 3 weeks post-exposure. In addition, rats in the tinnitus group exhibited significant increases in GAP43 and GDF10 protein expression levels in their DCN at 3 weeks following noise exposure. Results from the present study provided further evidence that changes in the neural input distribution to the DCN may cause tinnitus and that axonal sprouting underlies these alterations.

Bothersome tinnitus : Cognitive behavioral perspectives

Tinnitus is not traceable to a single disease or pathology, but merely a symptom, which is distressing to some but not all individuals able to perceive it. The experience of tinnitus does not equate to tinnitus distress. Tinnitus suffering might be understood as a function of tinnitus-related distress in that bothersome tinnitus is an illness rather than a disease. In bothersome (distressing) tinnitus, the perception of the characteristic sound is a very disturbing and bothersome experience because of maladaptive psychological responses. Several cognitive and behavioral theoretical frameworks attempting to explain the nature and cause of tinnitus suffering have been introduced in and will be summarized here. Current treatment approaches are generally based on models that aim to: alleviate the perceptional experience by focusing on the tinnitus perception for habituation or even soothing purposes; decrease awareness of the sound by attentional training and cognitive interventions; decrease the maladaptive responses and the resulting distress by behavioral methods (i. e., exposure). The cognitive behavioral fear-avoidance model may offer an integrative cognitive behavioral approach that can lead to a new set of paradigms for studying the underlying mechanisms explaining chronic tinnitus suffering as well for developing innovative strategies to treat bothersome tinnitus.

Tinnitus Severity Is Related to the Sound Exposure of Symphony Orchestra Musicians Independently of Hearing Impairment

Objectives:

Tinnitus can be debilitating and with great impact of musicians professional and private life. The objectives of the study were therefore to: (1) describe the epidemiology of tinnitus including its severity in classical orchestra musicians, (2) investigate the association between tinnitus severity in classical musicians and their cumulative lifetime sound exposure, and (3) the association between tinnitus and hearing thresholds.

Design:

The study population included all musicians from five Danish symphony orchestras. Answers regarding their perception of tinnitus were received from 325 musicians, and 212 musicians were also tested with audiometry. Any tinnitus and severe tinnitus were two definitions of tinnitus used as outcomes and analyzed in relation to an estimation of the cumulative lifetime sound exposure from sound measurements and previously validated questionnaires and the average hearing threshold of 3, 4, and 6 kHz.

Results:

Thirty-five percentage of all musicians (31% female and 38% of male musicians) reported having experienced at least one episode of tinnitus lasting for more than 5 minutes during their life. Severe tinnitus with a severe impact on daily life was reported by 19% of the musicians (18% of female and 21% of male musicians). The severity of tinnitus was associated with increased lifetime sound exposure but not to poorer high frequency hearing thresholds when the lifetime sound exposure was considered. The odds ratio for an increase in one unit of tinnitus severity was 1.25 (95% CI, 1.12–1.40) for every 1 dB increase in lifetime sound exposure.

Conclusion:

Musicians frequently report tinnitus. Any tinnitus and severe tinnitus are significantly associated with the cumulative lifetime sound exposure, which was shown to be the most important factor not only for the prevalence but also for the severity of tinnitus—even in musicians without hearing loss. High-frequency hearing thresholds and tinnitus severity were correlated only if the cumulative lifetime sound exposure was excluded from the analyses.

Standardized questions in English for estimating tinnitus prevalence and severity, hearing difficulty and usage of healthcare resources, and their translation into 11 European languages

INTRODUCTION

Prevalence estimates depend largely on the nature of the question asked to define the presence of the health condition, and the literature on the population burden of tinnitus and hearing difficulties is no different in this respect. The lack of standardized questions for data collection limits comparison across studies and across countries. The purpose of this short Technical Note is to report the first attempt to establish a set of standard questions developed for use in population-based surveys, and their adaptation and translation from English into 11 European languages.

METHODS

Four questions and their corresponding response options were adapted from existing population-based surveys to assess tinnitus prevalence, tinnitus symptom severity, use of healthcare resources for tinnitus and hearing difficulty. The translated versions (Bulgarian, French, German, Greek, Italian, Latvian, Polish, Portuguese, Romanian, Russian, and Spanish) were generated using recognized methods to achieve a "world-for-world" translation.

RESULTS

Translated versions were produced with acceptable functional equivalence to the original English-language version, as judged by a small panel of bilingual speakers who participated in the online field testing.

CONCLUSION

This work is the first of its kind to promote multi-national standardization by creating a set of tools that can readily be used across countries. These are currently being used in a European-wide study of tinnitus prevalence, and have wider application across English- and Spanish speaking countries including the Americas and Oceania.

Therapeutic Approaches to the Treatment of Tinnitus

Tinnitus is a highly prevalent condition that is associated with hearing loss in most cases. In the absence of external stimuli, phantom perceptions of sounds emerge from alterations in neuronal activity within central auditory and nonauditory structures. Pioneering studies using lidocaine revealed that tinnitus is susceptible to pharmacological interventions. However, lidocaine is not effective in all patients, and no other drug has been identified with clear efficacy for the long-term treatment of tinnitus. In this review, we present recent advances in tinnitus research, including more detailed knowledge of its pathophysiology and involved neurotransmitter systems. Moreover, we summarize results from animal and clinical treatment studies as well as from studies that identified tinnitus as a side effect of pharmacological treatments. Finally, we focus on challenges in the development of pharmacological compounds for the treatment of tinnitus, namely the limitations of available animal models and of standardized clinical research methodologies.

Betahistine for tinnitus

BACKGROUND

Tinnitus is a symptom defined as the perception of sound in the absence of an external source. In England alone there are an estimated ¾ million general practice consultations every year where the primary complaint is tinnitus, equating to a major burden on healthcare services. Clinical management strategies include education and advice, relaxation therapy, tinnitus retraining therapy, cognitive behavioural therapy, sound enrichment using ear-level sound generators or hearing aids, and drug therapies to manage co-morbid symptoms such as sleep difficulties, anxiety or depression. As yet, no drug has been approved for tinnitus by a regulatory body. Nonetheless, over 100,000 prescriptions for betahistine are being filled every month in England, and nearly 10% of general practitioners prescribe betahistine for tinnitus.

OBJECTIVES

To assess the effects of betahistine in patients with subjective idiopathic tinnitus.

SEARCH METHODS

The Cochrane ENT Information Specialist searched the Cochrane ENT Register; Central Register of Controlled Trials (CENTRAL, via the Cochrane Register of Studies); Ovid MEDLINE; Ovid Embase; Web of Science; ClinicalTrials.gov; ICTRP and additional sources for published and unpublished trials. The date of the search was 23 July 2018.

SELECTION CRITERIA

Randomised controlled trials (RCTs) recruiting patients of any age with acute or chronic subjective idiopathic tinnitus were included. We included studies where the intervention involved betahistine and this was compared to placebo, no intervention or education and information. We included all courses of betahistine, regardless of dose regimens or formulations and for any duration of treatment.

DATA COLLECTION AND ANALYSIS

We used the standard methodological procedures expected by Cochrane. Our primary outcomes included tinnitus loudness and significant adverse effects (upper gastrointestinal discomfort). Our secondary outcomes included tinnitus symptom severity as measured by the global score on a multi-item tinnitus questionnaire, depressive symptoms, symptoms of generalised anxiety, health-related quality of life, other adverse effects (e.g. headache, drowsiness, allergic skin reactions (pruritis, rashes) and exacerbation of tinnitus) and tinnitus intrusiveness. We used GRADE to assess the quality of evidence for each outcome; this is indicated in italics.

MAIN RESULTS

This review included five studies (with a total of 303 to 305 participants) comparing the effects of betahistine with placebo in adults with subjective idiopathic tinnitus. Four studies were parallel-group RCTs and one had a cross-over design. The risk of bias was unclear in all of the included studies.Due to heterogeneity in the outcomes measured and measurement methods used, very limited data pooling was possible. When we pooled the data from two studies for the primary outcome tinnitus loudness, the mean difference on a 0- to 10-point visual analogue scale at one-month follow-up was not significant between betahistine and placebo (-0.16, 95% confidence interval (CI) -1.01 to 0.70; 81 participants) (very low-quality evidence). There were no reports of upper gastrointestinal discomfort (significant adverse effect) in any study.As a secondary outcome, one study found no difference in the change in the Tinnitus Severity Index between betahistine and placebo (mean difference at 12 weeks 0.02, 95% CI -1.05 to 1.09; 50 participants) (moderate-quality evidence). None of the studies reported the other secondary outcomes of changes in depressive symptoms or depression, anxiety symptoms or generalised anxiety, or health-related quality of life as measured by a validated instrument, nor tinnitus intrusiveness.Other adverse effects that were reported were not treatment-related.

AUTHORS' CONCLUSIONS

There is an absence of evidence to suggest that betahistine has an effect on subjective idiopathic tinnitus when compared to placebo. The evidence suggests that betahistine is generally well tolerated with a similar risk of adverse effects to placebo treatments. The quality of evidence for the reported outcomes, using GRADE, ranged from moderate to very low.If future research into the effectiveness of betahistine in patients with tinnitus is felt to be warranted, it should use rigorous methodology. Randomisation and blinding should be of the highest quality, given the subjective nature of tinnitus and the strong likelihood of a placebo response. The CONSORT statement should be used in the design and reporting of future studies. We also recommend the development of validated, patient-centred outcome measures for research in the field of tinnitus.

Sound therapy (using amplification devices and/or sound generators) for tinnitus

BACKGROUND

Tinnitus affects 10% to 15% of the adult population, with about 20% of these experiencing symptoms that negatively affect quality of life. In England alone there are an estimated ¾ million general practice consultations every year where the primary complaint is tinnitus, equating to a major burden on healthcare services. Clinical management strategies include education and advice, relaxation therapy, tinnitus retraining therapy (TRT), cognitive behavioural therapy (CBT), sound enrichment using ear-level sound generators or hearing aids, and drug therapies to manage co-morbid symptoms such as insomnia, anxiety or depression. Hearing aids, sound generators and combination devices (amplification and sound generation within one device) are a component of many tinnitus management programmes and together with information and advice are a first line of management in audiology departments for someone who has tinnitus.

OBJECTIVES

To assess the effects of sound therapy (using amplification devices and/or sound generators) for tinnitus in adults.

SEARCH METHODS

The Cochrane ENT Information Specialist searched the Cochrane ENT Register; Central Register of Controlled Trials (CENTRAL, via the Cochrane Register of Studies); Ovid MEDLINE; Ovid Embase; CINAHL; Web of Science; ClinicalTrials.gov; ICTRP and additional sources for published and unpublished trials. The date of the search was 23 July 2018.

SELECTION CRITERIA

Randomised controlled trials (RCTs) recruiting adults with acute or chronic subjective idiopathic tinnitus. We included studies where the intervention involved hearing aids, sound generators or combination hearing aids and compared them to waiting list control, placebo or education/information only with no device. We also included studies comparing hearing aids to sound generators, combination hearing aids to hearing aids, and combination hearing aids to sound generators.

DATA COLLECTION AND ANALYSIS

We used the standard methodological procedures expected by Cochrane. Our primary outcomes were tinnitus symptom severity as measured as a global score on multi-item tinnitus questionnaire and significant adverse effects as indicated by an increase in self-reported tinnitus loudness. Our secondary outcomes were depressive symptoms, symptoms of generalised anxiety, health-related quality of life and adverse effects associated with wearing the device such as pain, discomfort, tenderness or skin irritation, or ear infections. We used GRADE to assess the quality of evidence for each outcome; this is indicated in italics.

MAIN RESULTS

This review included eight studies (with a total of 590 participants). Seven studies investigated the effects of hearing aids, four combination hearing aids and three sound generators. Seven studies were parallel-group RCTs and one had a cross-over design. In general, risk of bias was unclear due to lack of detail about sequence generation and allocation concealment. There was also little or no use of blinding.No data for our outcomes were available for any of our three main comparisons (comparing hearing aids, sound generators and combination devices with a waiting list control group, placebo or education/information only). Data for our additional comparisons (comparing these devices with each other) were also few, with limited potential for data pooling.Hearing aid only versus sound generator device onlyOne study compared patients fitted with sound generators versus those fitted with hearing aids and found no difference between them in their effects on our primary outcome, tinnitus symptom severity measured with the Tinnitus Handicap Inventory (THI) at 3, 6 or 12 months (low-quality evidence). The use of both types of device was associated with a clinically significant reduction in tinnitus symptom severity.Combination hearing aid versus hearing aid onlyThree studies compared combination hearing aids with hearing aids and measured tinnitus symptom severity using the THI or Tinnitus Functional Index. When we pooled the data we found no difference between them (standardised mean difference -0.15, 95% confidence interval -0.52 to 0.22; three studies; 114 participants) (low-quality evidence). The use of both types of device was again associated with a clinically significant reduction in tinnitus symptom severity.Adverse effects were not assessed in any of the included studies.None of the studies measured the secondary outcomes of depressive symptoms or depression, anxiety symptoms or generalised anxiety, or health-related quality of life as measured by a validated instrument, nor the newly developed core outcomes tinnitus intrusiveness, ability to ignore, concentration, quality of sleep and sense of control.

AUTHORS' CONCLUSIONS

There is no evidence to support the superiority of sound therapy for tinnitus over waiting list control, placebo or education/information with no device. There is insufficient evidence to support the superiority or inferiority of any of the sound therapy options (hearing aid, sound generator or combination hearing aid) over each other. The quality of evidence for the reported outcomes, assessed using GRADE, was low. Using a combination device, hearing aid or sound generator might result in little or no difference in tinnitus symptom severity.Future research into the effectiveness of sound therapy in patients with tinnitus should use rigorous methodology. Randomisation and blinding should be of the highest quality, given the subjective nature of tinnitus and the strong likelihood of a placebo response. The CONSORT statement should be used in the design and reporting of future studies. We also recommend the use of validated, patient-centred outcome measures for research in the field of tinnitus.

Internet-based interventions for adults with hearing loss, tinnitus and vestibular disorders: a protocol for a systematic review

BACKGROUND

Internet-based interventions are emerging as an alternative way of delivering accessible healthcare for various conditions including hearing and balance disorders. A comprehensive review regarding the evidence-base of Internet-based interventions for auditory-related conditions is required to determine the existing evidence of their efficacy and effectiveness. The objective of the current protocol is to provide the methodology for a systematic review regarding the effects of Internet-based interventions for adults with hearing loss, tinnitus and vestibular disorders.

METHOD

This protocol was developed according to the Preferred Reporting Items for Systematic reviews and Meta-analyses for Protocols (PRISMA-P) 2015 guidelines. Electronic database searches will include EBSCOhost, PubMed and Cochrane Central Register performed by two researchers. This will be complemented by searching other resources such as the reference lists for included studies to identify studies meeting the eligibility for inclusion with regard to study designs, participants, interventions, comparators and outcomes. The Cochrane risk of bias tool (RoB 2) for randomised trials will be used for the bias assessments in the included studies. Criteria for conducting meta-analyses were defined.

DISCUSSION

The result of this systematic review will be of value to establish the effects of Internet-based interventions for hearing loss, tinnitus and vestibular disorders. This will be of importance to guide future planning of auditory intervention research and clinical services by healthcare providers, researchers, consumers and stakeholders.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42018094801.

Nationwide analysis of the relationships between mental health, body mass index and tinnitus in premenopausal female adults in Korea: 2010-2012 KNHANES

Tinnitus is related to serious comorbidities such as suicidal ideation and attempts. Body mass index (BMI) is associated with auditory symptoms including hearing loss. The aim of this nationwide, population-based, cross-sectional study was to evaluate the relationship between mental health, body mass index and tinnitus in a Korean premenopausal female population. This study analyzed data from the Korea National Health and Nutrition Examination Surveys in 2010–2012. Data were collected from 4628 19 years or older, premenopausal women. After adjustments, underweight premenopausal women exhibited a higher odds ratio for tinnitus (odd ratio = 1.54; 95% confidence interval = 1.14–2.08) compared with women of normal weight. Moderate and severe tinnitus was highly prevalent in underweight as well as extremely obese women. The prevalence of perceived stress, melancholy, and suicide ideation was significantly higher in women with tinnitus. The prevalence of perceived stress and suicide ideation was significantly higher in underweight women with tinnitus, but that of melancholy was significantly lower. This study demonstrated that underweight premenopausal Korean women had a higher risk of tinnitus, which has grown in importance as a public health issue. Women with tinnitus experience perceived stress and suicide ideation more frequently, but melancholy less frequently than women without.

Urine Cotinine Should Be Involved in Initial Evaluation of Tinnitus in Adolescents

Objectives

Smoking is associated with hearing loss, while the correlation between tinnitus and smoking is not fully elucidated. This study aimed to evaluate risk factors of tinnitus in adolescents in terms of smoking, and we identified a rectifiable parameter that can be serially monitored.

Methods

A cross-sectional study was conducted using data from the Korea National Health and Nutrition Examination Survey, with 2,782 participants aged 12 to 18 years, from 2008 through 2011. Participants with history of ear disease, hearing loss, and inadequate responses to questionnaires were excluded. We investigated the prevalence of tinnitus and tinnitus-related annoyance by questionnaire and sought potential risk factors in blood and urine tests and smoking history.

Results

The prevalence of tinnitus in the 12- to 18-year-old population was 17.5%, with 3.3% reporting tinnitus-related annoyance. On univariate analysis, the prevalence of tinnitus increased with age (P<0.001) and was higher among girls (P=0.012). Blood tests and urinalysis showed significant correlation between tinnitus and red blood cell count, alkaline phosphatase levels, and urine cotinine (P=0.002, P<0.001, P=0.018, respectively). In multivariate analysis, the urine cotinine level was the only parameter associated with tinnitus (odds ratio, 1.000; 95% confidence interval, 0.999 to 1.000; P=0.038). Smoking was also significantly correlated with tinnitus (P=0.043), and amount of smoking with tinnitus-related annoyance (P=0.045). However, current smoking and past smoking were not correlated with tinnitus.

Conclusion

Urine cotinine may be a rectifiable marker for management of tinnitus in adolescents. This suggests that smoking cessation should be incorporated in the management of tinnitus in adolescents.

Prevalence, Incidence Proportion, and Heritability for Tinnitus: A Longitudinal Twin Study

OBJECTIVES

The purpose of this longitudinal twin study was to explore the effect of tinnitus on hearing thresholds and threshold shifts over two decades and to investigate the genetic contribution to tinnitus in a male twin cohort (n = 1114 at baseline and 583 at follow-up). The hypothesis was that participants with faster hearing deterioration had a higher risk for developing tinnitus and there is an underlying role of genetic influences on tinnitus.

DESIGN

Male mono- and dizygotic twin pairs, born between 1914 and 1958 were included. Mixed models were used for comparison of hearing threshold shifts, adjusted for age. A co-twin comparison was made within pairs discordant for tinnitus. The relative influence of genetic and environmental factors was estimated by genetic modeling.

RESULTS

The overall prevalence of tinnitus was 13.5% at baseline ((Equation is included in full-text article.)age 50) and 34.4% at follow-up ((Equation is included in full-text article.)age 67). The overall incidence proportion was 27.8%. Participants who reported tinnitus at baseline or at both time points were older. At baseline, the hearing thresholds differed between tinnitus cases and controls at all frequencies. New tinnitus cases at follow-up had the greatest hearing threshold shift at the high-frequency area compared with the control group. Within pairs, the tinnitus twin had poorer hearing than his unaffected co-twin, more so for dizygotic than monozygotic twin pairs. The relative proportion of additive genetic factors was approximately 0.40 at both time points, and the influence of individual-specific environment was 0.56 to 0.61. The influence of genetic factors on tinnitus was largely independent of genetic factors for hearing thresholds.

CONCLUSIONS

Our hypotheses were confirmed: The fastest hearing deterioration occurred for new tinnitus cases. A moderate genetic influence for tinnitus was confirmed.

Is smoking a risk factor for tinnitus? A systematic review, meta-analysis and estimation of the population attributable risk in Germany

OBJECTIVE

To assess the epidemiological association of smoking status and tinnitus with a systematic review and meta-analysis and to estimate the population attributable risk in Germany.

DATA SOURCES

A systematic literature search in PubMed and ISI-Web of Science Core Collection resulted in 1026 articles that were indexed until 15 September 2015. Additionally, proceedings of the international tinnitus seminars and reference lists of relevant articles were screened.

STUDY SELECTION

Two reviewers searched independently for epidemiological studies. Tinnitus as a manifestation of tumours, vascular malformations, specific syndromes or as a consequence of surgical and medical treatment was not considered. Moreover, studies conducted among patients of ear, nose and throat clinics were excluded.

DATA EXTRACTION

If only raw data were provided, effect sizes were calculated. Further unpublished data were received by corresponding authors.

DATA SYNTHESIS

Data of 20 studies were pooled. Current smoking (OR 1.21, 95% CI 1.09 to 1.35), former smoking (OR 1.13, 95% CI 1.01 to 1.26) and ever smoking (OR 1.20, 95% CI 1.11 to 1.30) were significantly associated with tinnitus. Moreover, sensitivity analyses for severe tinnitus (OR 1.32, 95% CI 1.10 to 1.58) and for studies of superior quality (OR 1.15, 95% CI 1.03 to 1.29) showed increased risks. According to this, the population attributable risk estimate in Germany is 3.5%.

CONCLUSION

There is sufficient evidence that smoking is associated with tinnitus. As the review mainly consists of cross-sectional studies, the observed correlation does not give evidence of a causal relationship. Due to the impact of various confounders, further research is needed to provide more evidence on the strength of association and causal relationships.

Clinical characteristics of patients with tinnitus evaluated with the Tinnitus Sample Case History Questionnaire in Japan: A case series

Background

The Tinnitus Sample Case History Questionnaire was determined as a standardized questionnaire for obtaining patient case histories and for characterizing patients into subgroups at the Tinnitus Research Initiative in 2006. In this study, we developed a Japanese version of this questionnaire for evaluating the clinical characteristics of patients with tinnitus. The Japanese version of the questionnaire will be available for evaluating treatments for tinnitus and for comparing data on tinnitus in research centers.

Aims/Objectives

To evaluate the clinical characteristics of patients with tinnitus in Japan using a newly developed Japanese version of Tinnitus Sample Case History Questionnaire.

Study design

This was a prospective study based on patient records.

Setting

University hospitals, general hospitals, and clinics.

Subjects and methods

We collected patient data using a Japanese translated version of the Tinnitus Sample Case History Questionnaire. In total, 584 patients who visited our institutions in Japan between August 2012 and March 2014 were included (280 males and 304 females; age 13–92 years; mean age, 60.8). We examined patients after dividing them into two groups according to the presence or absence of hyperacusis. The collected results were compared with those from the Tinnitus Research Initiative database.

Results

Compared with the TRI database, there were significantly more elderly female patients and fewer patients with trauma-associated tinnitus. There was a statistically lower ratio of patients with hyperacusis. We found that patients with tinnitus in addition to hyperacusis had greater tinnitus severity and exhibited higher rates of various complications.

Conclusion

The Japanese version of the Tinnitus Sample Case History Questionnaire developed in this study can be a useful tool for evaluating patients with tinnitus in Japan. The results of this multicenter study reflect the characteristics of patients with tinnitus who require medical care in Japan. Our data provides a preliminary basis for an international comparison of tinnitus epidemiology.

Outpatient Tinnitus Clinic, Self-Help Web Platform, or Mobile Application to Recruit Tinnitus Study Samples?

For understanding the heterogeneity of tinnitus, large samples are required. However, investigations on how samples recruited by different methods differ from each other are lacking. In the present study, three large samples each recruited by different means were compared: N = 5017 individuals registered at a self-help web platform for tinnitus (crowdsourcing platform Tinnitus Talk), N = 867 users of a smart mobile application for tinnitus (crowdsensing platform TrackYourTinnitus), and N = 3786 patients contacting an outpatient tinnitus clinic (Tinnitus Center of the University Hospital Regensburg). The three samples were compared regarding age, gender, and duration of tinnitus (month or years perceiving tinnitus; subjective report) using chi-squared tests. The three samples significantly differed from each other in age, gender and tinnitus duration (p < 0.05). Users of the TrackYourTinnitus crowdsensing platform were younger, users of the Tinnitus Talk crowdsourcing platform had more often female gender, and users of both newer technologies (crowdsourcing and crowdsensing) had more frequently acute/subacute tinnitus (<3 months and 4–6 months) as well as a very long tinnitus duration (>20 years). The implications of these findings for clinical research are that newer technologies such as crowdsourcing and crowdsensing platforms offer the possibility to reach individuals hard to get in contact with at an outpatient tinnitus clinic. Depending on the aims and the inclusion/exclusion criteria of a given study, different recruiting strategies (clinic and/or newer technologies) offer different advantages and disadvantages. In general, the representativeness of study results might be increased when tinnitus study samples are recruited in the clinic as well as via crowdsourcing and crowdsensing.

A Pilot Genome-Wide Association Study Identifies Potential Metabolic Pathways Involved in Tinnitus

Tinnitus, the perception of an auditory phantom sound in the form of ringing, buzzing, roaring, or hissing in the absence of an external sound source, is perceived by ~15% of the population and 2.5% experiences a severely bothersome tinnitus. The contribution of genes on the development of tinnitus is still under debate. The current manuscript reports a pilot Genome Wide Association Study (GWAS) into tinnitus, in a small cohort of 167 independent tinnitus subjects, and 749 non-tinnitus controls, who were collected as part of a cross-sectional study. After genotyping, imputation, and quality checking, the association between the tinnitus phenotype and 4,000,000 single-nucleotide polymorphisms (SNPs) was tested followed by gene set enrichment analysis. None of the SNPs reached the threshold for genome-wide significance (p < 5.0e–8), with the most significant SNPs, situated outside coding genes, reaching a p-value of 3.4e–7. By using the Genetic Analysis of Complex Traits (GACT) software, the percentage of the variance explained by all SNPs in the GWAS was estimated to be 3.2%, indicating that additive genetic effects explain only a small fraction of the tinnitus phenotype. Despite the lack of genome-wide significant SNPs, which is, at least in part, due to the limited sample size of the current study, evidence was found for a genetic involvement in tinnitus. Gene set enrichment analysis showed several metabolic pathways to be significantly enriched with SNPs having a low p-value in the GWAS. These pathways are involved in oxidative stress, endoplasmatic reticulum (ER) stress, and serotonin reception mediated signaling. These results are a promising basis for further research into the genetic basis of tinnitus, including GWAS with larger sample sizes and considering tinnitus subtypes for which a greater genetic contribution is more likely.

Different Patterns of Hearing Loss among Tinnitus Patients: A Latent Class Analysis of a Large Sample

BACKGROUND

The heterogeneity of tinnitus is a major challenge for tinnitus research. Even if a complex interaction of many factors is involved in the etiology of tinnitus, hearing loss (HL) has been identified as the most relevant etiologic factor. Here, we used a data-driven approach to identify patterns of hearing function in a large sample of tinnitus patients presenting in a tinnitus clinic.

METHODS

Data from 2,838 patients presenting at the Tinnitus Center of the University Regensburg between 2007 and 2014 have been analyzed. Standard audiometric data were frequency-wise categorized in four categories [a: normal hearing (0-20 dB HL); b: moderate HL (25-50 dB HL; representing outer hair cell loss); c: severe HL (>50 dB HL; representing outer and inner hair cell loss); d: no data available] and entered in a latent class analysis, a statistical method to find subtypes of cases in multivariate categorical data. To validate the clinical relevance of the identified latent classes, they were compared with respect to clinical and demographic characteristics of their members.

RESULTS

The classification algorithm identified eight distinct latent classes with an excellent separation. Patient classes differed with respect to demographic (e.g., age, gender) and clinical characteristics (e.g., tinnitus location, tinnitus severity, gradual, or abrupt onset, etc.).

DISCUSSION

Our results demonstrate that data-driven categorization of hearing function seems to be a promising approach for profiling tinnitus patients, as it revealed distinct subtypes that reflect prototypic forms of HL and that differ in several relevant clinical characteristics.

Measuring the Moment-to-Moment Variability of Tinnitus: The TrackYourTinnitus Smart Phone App

Tinnitus, the phantom perception of sound without a corresponding external sound, is a frequent disorder which causes significant morbidity. So far there is no treatment available that reliably reduces the tinnitus perception. The research is hampered by the large heterogeneity of tinnitus and the fact that the tinnitus perception fluctuates over time. It is therefore necessary to develop tools for measuring fluctuations of tinnitus perception over time and for analyzing data on single subject basis. However, this type of longitudinal measurement is difficult to perform using the traditional research methods such as paper-and-pencil questionnaires or clinical interviews. Ecological momentary assessment (EMA) represents a research concept that allows the assessment of subjective measurements under real-life conditions using portable electronic devices and thereby enables the researcher to collect longitudinal data under real-life conditions and high cost efficiency. Here we present a new method for recording the longitudinal development of tinnitus perception using a modern smartphone application available for iOS and Android devices with no costs for the users. The TrackYourTinnitus (TYT) app is available and maintained since April 2014. A number of 857 volunteers with an average age of 44.1 years participated in the data collection between April 2014 and February 2016. The mean tinnitus distress at the initial measurement was rated on average 13.9 points on the Mini-Tinnitus Questionnaire (Mini-TQ; max. 24 points). Importantly, we could demonstrate that the regular use of the TYT app has no significant negative influence on the perception of the tinnitus loudness nor on the tinnitus distress. The TYT app can therefore be proposed as a safe instrument for the longitudinal assessment of tinnitus perception in the everyday life of the patient.

Evidence-based guidelines on the therapeutic use of transcranial direct current stimulation (tDCS)

A group of European experts was commissioned by the European Chapter of the International Federation of Clinical Neurophysiology to gather knowledge about the state of the art of the therapeutic use of transcranial direct current stimulation (tDCS) from studies published up until September 2016, regarding pain, Parkinson's disease, other movement disorders, motor stroke, poststroke aphasia, multiple sclerosis, epilepsy, consciousness disorders, Alzheimer's disease, tinnitus, depression, schizophrenia, and craving/addiction. The evidence-based analysis included only studies based on repeated tDCS sessions with sham tDCS control procedure; 25 patients or more having received active treatment was required for Class I, while a lower number of 10-24 patients was accepted for Class II studies. Current evidence does not allow making any recommendation of Level A (definite efficacy) for any indication. Level B recommendation (probable efficacy) is proposed for: (i) anodal tDCS of the left primary motor cortex (M1) (with right orbitofrontal cathode) in fibromyalgia; (ii) anodal tDCS of the left dorsolateral prefrontal cortex (DLPFC) (with right orbitofrontal cathode) in major depressive episode without drug resistance; (iii) anodal tDCS of the right DLPFC (with left DLPFC cathode) in addiction/craving. Level C recommendation (possible efficacy) is proposed for anodal tDCS of the left M1 (or contralateral to pain side, with right orbitofrontal cathode) in chronic lower limb neuropathic pain secondary to spinal cord lesion. Conversely, Level B recommendation (probable inefficacy) is conferred on the absence of clinical effects of: (i) anodal tDCS of the left temporal cortex (with right orbitofrontal cathode) in tinnitus; (ii) anodal tDCS of the left DLPFC (with right orbitofrontal cathode) in drug-resistant major depressive episode. It remains to be clarified whether the probable or possible therapeutic effects of tDCS are clinically meaningful and how to optimally perform tDCS in a therapeutic setting. In addition, the easy management and low cost of tDCS devices allow at home use by the patient, but this might raise ethical and legal concerns with regard to potential misuse or overuse. We must be careful to avoid inappropriate applications of this technique by ensuring rigorous training of the professionals and education of the patients.

Genetics of Tinnitus: An Emerging Area for Molecular Diagnosis and Drug Development

Subjective tinnitus is the perception of sound in the absence of external or bodily-generated sounds. Chronic tinnitus is a highly prevalent condition affecting over 70 million people in Europe. A wide variety of comorbidities, including hearing loss, psychiatric disorders, neurodegenerative disorders, and temporomandibular joint (TMJ) dysfunction, have been suggested to contribute to the onset or progression of tinnitus; however, the precise molecular mechanisms of tinnitus are not well understood and the contribution of genetic and epigenetic factors remains unknown. Human genetic studies could enable the identification of novel molecular therapeutic targets, possibly leading to the development of novel pharmaceutical therapeutics. In this article, we briefly discuss the available evidence for a role of genetics in tinnitus and consider potential hurdles in designing genetic studies for tinnitus. Since multiple diseases have tinnitus as a symptom and the supporting genetic evidence is sparse, we propose various strategies to investigate the genetic underpinnings of tinnitus, first by showing evidence of heritability using concordance studies in twins, and second by improving patient selection according to phenotype and/or etiology in order to control potential biases and optimize genetic data output. The increased knowledge resulting from this endeavor could ultimately improve the drug development process and lead to the preventive or curative treatment of tinnitus.

Emotion dynamics and tinnitus: Daily life data from the "TrackYourTinnitus" application

It is well established that emotions influence tinnitus, but the role of emotion dynamics remains unclear. The present study investigated emotion dynamics in N = 306 users of the “TrackYourTinnitus” application who completed the Mini-Tinnitus Questionnaire (Mini-TQ) at one assessment point and provided complete data on at least five assessment points for the following state variables: tinnitus loudness, tinnitus distress, arousal, valence. The repeated arousal and valence ratings were used for two operationalizations of emotion dynamics: intra-individual variability of affect intensity (pulse) as well as intra-individual variability of affect quality (spin). Pearson correlation coefficients showed that the Mini-TQ was positively correlated with pulse (r = 0.19; p < 0.05) as well as with spin (r = 0.12; p < 0.05). Multilevel models revealed the following results: increases in tinnitus loudness were more strongly associated with increases in tinnitus distress at higher levels of pulse as well as at higher levels of spin (both p < 0.05), whereby increases in tinnitus loudness correlated even stronger with increases in tinnitus distress when both pulse as well as spin were high (p < 0.05). Moreover, increases in spin were associated with a less favorable time course of tinnitus loudness (p < 0.05). To conclude, equilibrating emotion dynamics might be a potential target in the prevention and treatment of tinnitus.

Maladaptive plasticity in tinnitus--triggers, mechanisms and treatment

Tinnitus is a phantom auditory sensation that reduces quality of life for millions of people worldwide, and for which there is no medical cure. Most cases of tinnitus are associated with hearing loss caused by ageing or noise exposure. Exposure to loud recreational sound is common among the young, and this group are at increasing risk of developing tinnitus. Head or neck injuries can also trigger the development of tinnitus, as altered somatosensory input can affect auditory pathways and lead to tinnitus or modulate its intensity. Emotional and attentional state could be involved in the development and maintenance of tinnitus via top-down mechanisms. Thus, military personnel in combat are particularly at risk owing to combined risk factors (hearing loss, somatosensory system disturbances and emotional stress). Animal model studies have identified tinnitus-associated neural changes that commence at the cochlear nucleus and extend to the auditory cortex and other brain regions. Maladaptive neural plasticity seems to underlie these changes: it results in increased spontaneous firing rates and synchrony among neurons in central auditory structures, possibly generating the phantom percept. This Review highlights the links between animal and human studies, and discusses several therapeutic approaches that have been developed to target the neuroplastic changes underlying tinnitus.