Ginkgo biloba for tinnitus

Pharmacologic treatments in preclinical tinnitus models with special focus on Ginkgo biloba leaf extract EGb 761®

Tinnitus is defined as the perception of sound in the absence of external acoustic stimuli. Frequent comorbidities or associated factors are depression, anxiety, concentration problems, insomnia, resignation, helplessness, headache, bruxism, or social isolation, just to name a few. Although many therapeutic approaches have already been tested with varying success, there still is no cure available for tinnitus. The search for an effective treatment has been hampered by the fact that the mechanisms of tinnitus development are still not fully understood, although several models are available and discussed in this review. Our review will give a brief overview about preclinical models, presenting the heterogeneity of tinnitus sub-types depending on the different inner ear and brain structures involved in tinnitus etiology and pathogenesis. Based on these models we introduce the different target structures and transmitter systems implicated in tinnitus development and provide an extensive overview on preclinical drug-based therapeutic approaches that have been explored in various animal models. As the special extract from Ginkgo biloba leaves EGb 761® has been the most widely tested drug in both non-clinical tinnitus models as well as in clinical trials, a special focus will be given to EGb 761®. The efficacy of terpene lactones, flavone glycosides and proanthocyanidines with their distinct contribution to the overall efficacy profile of the multi-constituent drug EGb 761® will be discussed.

Small-group counseling in a modified tinnitus retraining therapy for chronic tinnitus

Objectives

The authors have treated chronic tinnitus patients using a combination of a simplified tinnitus retraining therapy (TRT) and medications, which we called modified TRT. In this clinical setting, we have attempted small-group counseling to find a time-effective equivalent of individual counseling. The aim of the present study was to evaluate the effectiveness of small-group counseling by comparing the treatment outcomes between individual and small-group counseling.

Methods

The patients who had distressing chronic tinnitus with normal hearing or mild hearing loss were included. The subjects were placed into the small-group (group 1:4) or the individual (group 1:1) counseling group, and underwent a modified TRT composed of a single session of directive counseling and ambient sound stimulation. In addition, alprazolam (0.25 mg) and ginkgo biloba extract (80 mg) were administered orally to the subjects for 3 months. The 3- and 6- month outcomes were assessed using the follow-up rates and tinnitus severity scores: awareness, tinnitus handicap inventory (THI), loudness, annoyance, and effect on life. The treatment responses were classified as improvement, no changes, and worsening.

Results

Of the total 149 patients (77 in group 1:1; 72 in group 1:4), 104 patients completed the protocol at 3 months, and 55 patients at 6 months. The follow-up rates were similar in both groups. Over the period of 6 months, all scores declined significantly except the loudness score at 3 months in both groups. Treatment responses showed no between-group differences. The success rate based on THI was 70% in group 1:1, and 64% in group 1:4 at 6 months.

Conclusion

The small-group counseling of our modified TRT was comparable to the individual counseling for tinnitus relief. We suggest that this protocol can be implemented effectively in any crowded otolaryngology clinics.

Chronic tinnitus: an interdisciplinary challenge

BACKGROUND

Tinnitus is defined as the perception of sound in the absence of a corresponding external acoustic stimulus. It is a common problem that markedly impairs the quality of life of about 1% of the general population.

METHODS

We selectively reviewed the pertinent literature to provide an overview of the current treatment options for chronic tinnitus.

RESULTS

Cognitive behavioral therapy is effective and is the best studied of all currently available treatments. All patients should have a therapeutic interview for counseling. Auditory stimulation can also lessen tinnitus: It is used in tinnitus maskers and hearing aids, as well as in tinnitus retraining therapy. An improved understanding of the neural mechanisms of tinnitus has led to the development of innovative techniques of neuromodulation and neurostimulation, but these are still experimental. Drugs are indicated only for the treatment of tinnitus-associated symptoms such as depression, sleep disturbances, and anxiety.

CONCLUSION

There are many ways to treat chronic tinnitus, and new treatments are now being developed. As tinnitus has many causes and can be associated with many different comorbid disturbances, multidisciplinary diagnostic evaluation and treatment are important. For many tinnitus patients, long-term therapeutic success depends on the maintenance of a therapeutic relationship with the treating physician, so that the physician and the patient can work together to give careful consideration to each newly proposed diagnostic test or treatment step.

Ginkgo biloba for tinnitus

BACKGROUND

This is an update of a Cochrane review first published in The Cochrane Library in Issue 2, 2004 and previously updated in 2007 and 2009.Tinnitus can be described as the perception of sound in the absence of external acoustic stimulation. At present no specific therapy for tinnitus is acknowledged to be satisfactory in all patients. There are a number of reports in the literature suggesting that Ginkgo biloba may be effective in the management of tinnitus. However, there also appears to be a strong placebo effect in tinnitus management.

OBJECTIVES

To assess the effect of Ginkgo biloba in patients who are troubled by tinnitus.

SEARCH METHODS

We searched the Cochrane Ear, Nose and Throat Disorders Group Trials Register; the Cochrane Central Register of Controlled Trials (CENTRAL); PubMed; EMBASE; AMED; Web of Science; BIOSIS Previews; Cambridge Scientific Abstracts; ICTRP and additional sources for published and unpublished trials. The date of the most recent search was 12 March 2012.

SELECTION CRITERIA

Adults (18 years and over) complaining of tinnitus or adults with a primary complaint of cerebral insufficiency, where tinnitus forms part of the syndrome.

DATA COLLECTION AND ANALYSIS

Both original authors independently extracted data and assessed trials for quality. For the 2012 update two authors determined trial eligibility, extracted data, analysed data and updated the contents of the review.

MAIN RESULTS

Four trials with a total of 1543 participants were included in the review; we assessed all the included studies as having a low risk of bias. Three trials (1143 participants) included patients with a primary complaint of tinnitus and one (400 participants) included patients with mild to moderate dementia, some of whom had tinnitus.There was no evidence that Gingko biloba was effective in patients with a primary complaint of tinnitus. In the study of patients with dementia, mean baseline levels of tinnitus were low (1.7 to 2.5 on a 10-point subjective symptom rating scale). A small but statistically significant reduction of 1.5 and 0.7 points was seen in patients taking Gingko biloba with vascular dementia and Alzheimer's disease respectively. The practical clinical significance of this is unclear. The incidence of side effects was low.

AUTHORS' CONCLUSIONS

The limited evidence does not demonstrate that Ginkgo biloba is effective for tinnitus when this is the primary complaint.

Rationale for the tinnitus retraining therapy trial

The Tinnitus Retraining Therapy Trial (TRTT) is a National Institutes of Health-sponsored, multi-centered, placebo-controlled, randomized trial evaluating the efficacy of tinnitus retraining therapy (TRT) and its component parts, directive counseling and sound therapy, as treatments for subjective debilitating tinnitus in the military. The TRTT will enroll 228 individuals at an allocation ratio of 1:1:1 to: (1) directive counseling and sound therapy using conventional sound generators; (2) directive counseling and placebo sound generators; or (3) standard of care as administered in the military. Study centers include a Study Chair's Office, a Data Coordinating Center, and six Military Clinical Centers with treatment and data collection standardized across all clinics. The primary outcome is change in Tinnitus Questionnaire (TQ) score assessed longitudinally at 3, 6, 12, and 18-month follow-up visits. Secondary outcomes include: Change in TQ sub-scales, Tinnitus Handicap Inventory, Tinnitus Functional Index, and TRT interview visual analog scale; audiometric and psychoacoustic measures; and change in quality of life. The TRTT will evaluate TRT efficacy by comparing TRT (directive counseling and conventional sound generators) with standard of care; directive counseling by comparing directive counseling plus placebo sound generators versus standard of care; and sound therapy by comparing conventional versus placebo sound generators. We hypothesize that full TRT will be more efficacious than standard of care, directive counseling and placebo sound generators more efficacious than standard of care, and conventional more efficacious than placebo sound generators in habituating the tinnitus awareness, annoyance, and impact on the study participant's life.

Ginkgo biloba extract for age-related macular degeneration

BACKGROUND

Ginkgo is used in the treatment of peripheral vascular disease and 'cerebral insufficiency'. It is thought to have several potential mechanisms of action including increased blood flow, platelet activating factor antagonism, and prevention of membrane damage caused by free radicals. Vascular factors and oxidative damage are thought to be two potential mechanisms in the pathology of age-related macular degeneration (AMD).

OBJECTIVES

The objective of this review was to determine the effect of Ginkgo biloba extract on the progression of AMD.

SEARCH METHODS

We searched CENTRAL (which contains the Cochrane Eyes and Vision Group Trials Register) (The Cochrane Library 2012, Issue 10), Ovid MEDLINE, Ovid MEDLINE In-Process and Other Non-Indexed Citations, Ovid MEDLINE Daily, Ovid OLDMEDLINE (January 1946 to October 2012), EMBASE (January 1980 to October 2012), Allied and Complementary Medicine Database (AMED) (January 1985 to October 2012), OpenGrey (System for Information on Grey Literature in Europe) (www.opengrey.eu/), the metaRegister of Controlled Trials (mRCT) (www.controlled-trials.com), ClinicalTrials.gov (www.clinicaltrials.gov) and the WHO International Clinical Trials Registry Platform (ICTRP) (www.who.int/ictrp/search/en). We did not use any date or language restrictions in the electronic searches for trials. We last searched the electronic databases on 5 October 2012. We searched the reference lists of identified reports and the Science Citation Index. We also contacted investigators of included studies for additional information.

SELECTION CRITERIA

All randomised trials in people with AMD where Ginkgo biloba extract had been compared to control were included.

DATA COLLECTION AND ANALYSIS

The review author extracted data using a standardised form. The data were verified with the trial investigators. Trial quality was assessed.

MAIN RESULTS

Two published trials were identified that randomised a total of 119 people. In one study conducted in France, 20 people were randomly allocated to Gingko biloba extract EGb 761 80 mg twice daily or placebo. In the other study conducted in Germany, 99 people were randomly allocated to two different doses of Ginkgo biloba extract EGb 761 (240 mg per day and 60 mg per day). Treatment duration in both studies was six months. Both trials reported some positive effects of Ginkgo biloba on vision however their results could not be pooled. Adverse effects and quality of life for people with AMD were not reported.

AUTHORS' CONCLUSIONS

The question as to whether people with AMD should take Ginkgo biloba extract to prevent progression of the disease has not been answered by research to date. Two small trials have suggested possible benefit of Gingko biloba on vision and further trials are warranted. Ginkgo biloba is widely used in China, Germany, and France. Future trials should be larger, and last longer, in order to provide a more robust measure of the effect of Gingko biloba extract on AMD.

Sound therapy (masking) in the management of tinnitus in adults

BACKGROUND

This is an update of a Cochrane Review first published in The Cochrane Library in Issue 12, 2010.Tinnitus is described as the perception of sound or noise in the absence of real acoustic stimulation. Numerous management strategies have been tried for this potentially debilitating, heterogeneous symptom. External noise has been used as a management tool for tinnitus, in different capacities and with different philosophical intent, for over a century.

OBJECTIVES

To assess the effectiveness of sound-creating devices (including hearing aids) in the management of tinnitus in adults. Primary outcome measures were changes in the loudness or severity of tinnitus and/or impact on quality of life. Secondary outcome measures were change in pure-tone auditory thresholds and adverse effects of treatment. 

SEARCH METHODS

We searched the Cochrane ENT Group Trials Register; CENTRAL; PubMed; EMBASE; CINAHL; Web of Science; BIOSIS Previews; Cambridge Scientific Abstracts; ICTRP and additional sources for published and unpublished trials. The date of the most recent search was 8 February 2012.

SELECTION CRITERIA

Prospective randomised controlled trials recruiting adults with persistent, distressing, subjective tinnitus of any aetiology in which the management strategy included maskers, noise-generating device and/or hearing aids, used either as the sole management tool or in combination with other strategies, including counselling.

DATA COLLECTION AND ANALYSIS

Two authors independently examined the 387 search results to identify studies for inclusion in the review, of which 33 were potentially relevant. The update searches in 2012 retrieved no further potentially relevant studies. Both authors extracted data independently.

MAIN RESULTS

Six trials (553 participants) are included in this review. Studies were varied in design, with significant heterogeneity in the evaluation of subjective tinnitus perception, with different scores, scales, tests and questionnaires as well as variance in the outcome measures used to assess the improvement in tinnitus sensation/quality of life. This precluded meta-analysis of the data. There was no long-term follow-up. We assessed the risk of bias as medium in three and high in three studies. Following analysis of the data, no significant change was seen in the loudness of tinnitus or the overall severity of tinnitus following the use of sound therapy compared to other interventions such as patient education, 'relaxation techniques', 'tinnitus coping strategies', counselling, 'tinnitus retraining' and exposure to environmental sounds. No side effects or significant morbidity were reported from the use of sound-creating devices.

AUTHORS' CONCLUSIONS

The limited data from the included studies failed to show strong evidence of the efficacy of sound therapy in tinnitus management. The absence of conclusive evidence should not be interpreted as evidence of lack of effectiveness. The lack of quality research in this area, in addition to the common use of combined approaches (hearing therapy plus counselling) in the management of tinnitus are, in part, responsible for the lack of conclusive evidence. Other combined forms of management, such as tinnitus retraining therapy, have been subject to a Cochrane Review. Optimal management may involve multiple strategies.

Antidepressants for patients with tinnitus

BACKGROUND

This is an update of a Cochrane review first published in The Cochrane Library in Issue 4, 2006 and previously updated in 2009.Tinnitus is described as the perception of sound or noise in the absence of real acoustic stimulation. It has been compared with chronic pain, and may be associated with depression or depressive symptoms which can affect quality of life and the ability to work. Antidepressant drugs have been used to treat tinnitus in patients with and without depressive symptoms.

OBJECTIVES

To assess the effectiveness of antidepressants in the treatment of tinnitus and to ascertain whether any benefit is due to a direct tinnitus effect or a secondary effect due to treatment of concomitant depressive states.

SEARCH METHODS

We searched the Cochrane Ear, Nose and Throat Disorders Group Trials Register; the Cochrane Central Register of Controlled Trials (CENTRAL); PubMed; EMBASE; PsycINFO; CINAHL; Web of Science; BIOSIS; ICTRP and additional sources for published and unpublished trials. The date of the most recent search was 5 January 2012.

SELECTION CRITERIA

Randomised controlled clinical studies of antidepressant drugs versus placebo in patients with tinnitus.

DATA COLLECTION AND ANALYSIS

Two authors critically appraised the retrieved studies and extracted data independently. Where necessary we contacted study authors for further information.

MAIN RESULTS

Six trials involving 610 patients were included. Trial quality was generally low. Four of the trials looked at the effect of tricyclic antidepressants on tinnitus, investigating 405 patients. One trial investigated the effect of a selective serotonin reuptake inhibitor (SSRI) in a group of 120 patients. One study investigated trazodone, an atypical antidepressant, versus placebo. Only the trial using the SSRI drug reached the highest quality standard. None of the other included trials met the highest quality standard, due to use of inadequate outcome measures, large drop-out rates or failure to separate the effects on tinnitus from the effects on symptoms of anxiety and depression. All the trials assessing tricyclic antidepressants suggested that there was a slight improvement in tinnitus but these effects may have been attributable to methodological bias. The trial that investigated the SSRI drug found no overall improvement in any of the validated outcome measures that were used in the study although there was possible benefit for a subgroup that received higher doses of the drug. This observation merits further investigation. In the trial investigating trazodone, the results showed an improvement in tinnitus intensity and in quality of life after treatment, but in neither case reached statistical significance. Reports of side effects including sedation, sexual dysfunction and dry mouth were common.

AUTHORS' CONCLUSIONS

There is as yet insufficient evidence to say that antidepressant drug therapy improves tinnitus.

Methodological aspects of clinical trials in tinnitus: a proposal for an international standard

Chronic tinnitus is a common condition with a high burden of disease. While many different treatments are used in clinical practice, the evidence for the efficacy of these treatments is low and the variance of treatment response between individuals is high. This is most likely due to the great heterogeneity of tinnitus with respect to clinical features as well as underlying pathophysiological mechanisms. There is a clear need to find effective treatment options in tinnitus, however, clinical trials differ substantially with respect to methodological quality and design. Consequently, the conclusions that can be derived from these studies are limited and jeopardize comparison between studies. Here, we discuss our view of the most important aspects of trial design in clinical studies in tinnitus and make suggestions for an international methodological standard in tinnitus trials. We hope that the proposed methodological standard will stimulate scientific discussion and will help to improve the quality of trials in tinnitus.

Repetitive transcranial magnetic stimulation for tinnitus

BACKGROUND

Tinnitus is the perception of sound, in the ear or in the head, in the absence of any external acoustic stimulation. Repetitive transcranial magnetic stimulation (rTMS) is a non-invasive means of inducing electrical currents in the brain, and has received increasing attention in recent years for the treatment of many neuropsychiatric disorders, including tinnitus.

OBJECTIVES

To assess the effectiveness and safety of rTMS versus placebo in patients with tinnitus.

SEARCH STRATEGY

We searched the Cochrane Ear, Nose and Throat Disorders Group Trials Register; the Cochrane Central Register of Controlled Trials (CENTRAL); PubMed; EMBASE; CINAHL; Web of Science; BIOSIS Previews; Cambridge Scientific Abstracts; ICTRP and additional sources for published and unpublished trials. The date of the most recent search was 24 May 2011.

SELECTION CRITERIA

Randomised controlled trials of rTMS versus sham rTMS.

DATA COLLECTION AND ANALYSIS

Two review authors reviewed the titles, abstracts and keywords of all records retrieved. Three review authors independently collected and extracted data, and assessed the risk of bias of the trials.

MAIN RESULTS

Five trials comprising of 233 participants met our inclusion criteria. Each study described the use of a different rTMS device that delivered different waveforms at different frequencies. All five trials were relatively small studies but generally they demonstrated a low risk of bias.When considering the impact of tinnitus on patients' quality of life, the results of only one study demonstrated a statistically significant improvement in Tinnitus Handicap Inventory (THI) scores at four months follow-up (defined as a 'partial improvement' by the study authors (THI reduction of 21% to 80%)) when low-frequency rTMS was compared with a sham control treatment. However, no statistically significant improvement was demonstrated by another two studies that considered rTMS at the same frequency. Furthermore, this single positive finding should be taken in the context of the many different variables which were recorded at many different points in time by the study authors.In accordance with our pre-specified subgroup analysis we extracted the data from one study to consider the differential effectiveness between 'lower' low-frequency rTMS (1 Hz) and 'higher' low-frequency rTMS (10 Hz, 25 Hz). In doing this we were able to demonstrate a statistically significant difference between rTMS employing a frequency of 1 Hz and the sham group when considering tinnitus severity and disability after four months follow-up ('partial' improvement). However, no statistically significant difference was demonstrated between 10 Hz and 25 Hz rTMS, and the sham control group, when considering the severity and disability of tinnitus at four months follow-up.When considering tinnitus loudness in patients undergoing rTMS we were able to demonstrate a statistically significant reduction in tinnitus loudness when the results of two studies were pooled (risk ratio 4.17, 95% confidence interval 1.30 to 13.40). However, this finding was based on two small trials and consequently the confidence interval was particularly wide.No serious adverse effects were reported in any of the trials.

AUTHORS' CONCLUSIONS

There is very limited support for the use of low-frequency rTMS for the treatment of patients with tinnitus. When considering the impact of tinnitus on patients' quality of life, support is from a single study with a low risk of bias based on a single outcome measure at a single point in time. When considering the impact on tinnitus loudness, this is based on the analysis of pooled data with a large confidence interval.Studies suggest that rTMS is a safe treatment for tinnitus in the short-term, however there were insufficient data to provide any support for the safety of this treatment in the long-term.More prospective, randomised, placebo-controlled, double-blind studies with large sample sizes are needed to confirm the effectiveness of rTMS for tinnitus patients. Uniform, validated, tinnitus-specific questionnaires and measurement scales should be used in future studies.

Anticonvulsants for tinnitus

BACKGROUND

Tinnitus is the perception of sound or noise in the absence of an external or internal acoustic stimulation. It is a common and potentially distressing symptom for which no adequate therapy exists.

OBJECTIVES

To assess the effectiveness of anticonvulsants in patients with chronic tinnitus.

SEARCH STRATEGY

We searched the Cochrane Ear, Nose and Throat Disorders Group Specialised Register, CENTRAL (2010, Issue 2), MEDLINE, EMBASE, bibliographies and additional sources for published and unpublished trials. The date of the most recent search was 26 May 2010.

SELECTION CRITERIA

We selected randomised controlled trials in patients with chronic tinnitus comparing orally administered anticonvulsants with placebo. The primary outcome was improvement in tinnitus measured with validated questionnaires. Secondary outcomes were improvement in tinnitus measured with self-assessment scores, improvement in global well-being or accompanying symptoms, and adverse drug effects.

DATA COLLECTION AND ANALYSIS

Three authors assessed risk of bias and extracted data independently.

MAIN RESULTS

Seven trials (453 patients) were included in this review. These studies investigated four different anticonvulsants: gabapentin, carbamazepine, lamotrigine and flunarizine. The risk of bias of most studies was 'high' or 'unclear'. Three studies included a validated questionnaire (primary outcome). None of them showed a significant positive effect of anticonvulsants. One study showed a significant negative effect of gabapentin compared to placebo with an increase in Tinnitus Questionnaire (TQ) score of 18.4 points (standardised mean difference (SMD) 0.82, 95% confidence interval (CI) 0.07 to 1.58). A second study showed a positive, non-significant effect of gabapentin with a difference compared to placebo of 2.4 points on the Tinnitus Handicap Inventory (THI) (SMD -0.11, 95% CI -0.48 to 0.25). When the data from these two studies are pooled no effect of gabapentin is found (SMD 0.07, 95% CI -0.26 to 0.40). A third study reported no differences on the THI after treatment with gabapentin compared to placebo (exact numbers could not be extracted from the article).A meta-analysis of 'any positive effect' (yes versus no) based on a self-assessment score (secondary outcome) showed a small favourable effect of anticonvulsants (RD 14%, 95% CI 6% to 22%). A meta-analysis of 'near or total eradication of tinnitus annoyance' showed no effect of anticonvulsants (risk difference (RD) 4%, 95% CI -2% to 11%). Side effects of the anticonvulsants used were experienced by 18% of patients.

AUTHORS' CONCLUSIONS

Current evidence regarding the effectiveness of anticonvulsants in patients with tinnitus has significant risk of bias. There is no evidence from studies performed so far to show that anticonvulsants have a large positive effect in the treatment of tinnitus but a small effect (of doubtful clinical significance) has been demonstrated.

‘‘Ringing in the Ears’’: Narrative Review of Tinnitus and Its Impact

About 10% of the population experiences tinnitus, a common and distressing symptom characterized by the perception of sound in the absence of external stimuli. There is, however, marked heterogeneity in etiology, perception, and extent of distress among those who experience tinnitus. Reactions to tinnitus vary from simple awareness to severe irritation; some people have difficulty in hearing because of the loudness of the noise. Severe tinnitus causes many, often psychological, symptoms (e.g., tension, frustration, impaired concentration, disrupted sleep). For some, tinnitus is temporary, for others it is longstanding. Although many people adjust successfully, others are disabled by tinnitus; approximately 5% experience persistent and severe symptoms affecting their lifestyle and significantly reducing their quality of life. Because tinnitus is poorly understood and no single therapeutic approach is effective for all patients, many patients are told that ‘‘nothing can be done’’ and they must ‘‘learn to live with it.’’ In spite of these challenges, there is remarkably little relevant nursing literature on tinnitus. This literature review was conducted to explore current knowledge of tinnitus, including prevalence, causes and diagnosis, and assessment. Its psychosocial effects and impact on individuals are considered. Implications for practice are discussed—demonstrating that understanding the full impact of the condition and identifying patients’ needs are essential to effective care.

Ginkgo biloba extract in the treatment of tinnitus: a systematic review

Tinnitus is a symptom frequently encountered by ear, nose, and throat practitioners. A causal treatment is rarely possible, and drug and nondrug treatment options are limited. One of the frequently prescribed treatments is Ginkgo biloba extract. Therefore, randomized, placebo-controlled clinical trials of Ginkgo biloba extract preparations were searched for and reviewed systematically. There is evidence of efficacy for the standardized extract, EGb 761(®) (Dr Willmar Schwabe GmbH & Co KG Pharmaceuticals, Karlsruhe, Germany), in the treatment of tinnitus from three trials in patients in whom tinnitus was the primary complaint. Supportive evidence comes from a further five trials in patients with age-associated cognitive impairment or dementia in whom tinnitus was present as a concomitant symptom. As yet, the efficacy of other ginkgo preparations has not been proven, which does not necessarily indicate ineffectiveness, but may be due to flawed clinical trials. In conclusion, EGb 761(®), a standardized Ginkgo biloba extract, is an evidence-based treatment option in tinnitus.

Sound therapy (masking) in the management of tinnitus in adults

BACKGROUND

Tinnitus is described as the perception of sound or noise in the absence of real acoustic stimulation. Numerous management strategies have been tried for this potentially debilitating, heterogeneous symptom. External noise has been used as a management tool for tinnitus, in different capacities and with different philosophical intent, for over a century.

OBJECTIVES

To assess the effectiveness of sound-creating devices (including hearing aids) in the management of tinnitus in adults. Primary outcome measures were changes in the loudness or severity of tinnitus and/or impact on quality of life. Secondary outcome measures were change in pure-tone auditory thresholds and adverse effects of treatment. 

SEARCH STRATEGY

We searched the Cochrane ENT Group Trials Register; CENTRAL (2009, Issue 3); PubMed; EMBASE; CINAHL; Web of Science; BIOSIS Previews; Cambridge Scientific Abstracts; mRCT and additional sources for published and unpublished trials. The date of the most recent search was 11 September 2009.

SELECTION CRITERIA

Prospective randomised controlled trials recruiting adults with persistent, distressing, subjective tinnitus of any aetiology in which the management strategy included maskers, noise-generating device and/or hearing aids, used either as the sole management tool or in combination with other strategies, including counselling.

DATA COLLECTION AND ANALYSIS

Two authors independently examined the 362 search results to identify studies for inclusion in the review, of which 33 were potentially relevant. Both authors extracted data independently.

MAIN RESULTS

Six trials (553 participants) are included in this review. Studies were varied in design, with significant heterogeneity in the evaluation of subjective tinnitus perception, with different scores, scales, tests and questionnaires as well as variance in the outcome measures used to assess the improvement in tinnitus sensation/quality of life. This precluded meta-analysis of the data. There was no long-term follow up. We assessed the risk of bias as medium in three and high in three studies. No side effects or significant morbidity were reported from the use of sound-creating devices.

AUTHORS' CONCLUSIONS

The limited data from the included studies failed to show strong evidence of the efficacy of sound therapy in tinnitus management. The absence of conclusive evidence should not be interpreted as evidence of lack of effectiveness. The lack of quality research in this area, in addition to the common use of combined approaches (hearing therapy plus counselling) in the management of tinnitus are, in part, responsible for the lack of conclusive evidence. Other combined forms of management, such as Tinnitus Retraining Therapy, have been subject to a Cochrane Review. Optimal management may involve multiple strategies.

Cognitive behavioural therapy for tinnitus

BACKGROUND

This is an update of a Cochrane Review originally published in Issue 1, 2007 of The Cochrane Library.Tinnitus is an auditory perception that can be described as the experience of sound, in the ear or in the head, in the absence of external acoustic stimulation. Cognitive behavioural therapy (CBT) uses relaxation, cognitive restructuring of the thoughts and exposure to exacerbating situations in order to promote habituation and may benefit tinnitus patients, as may the treatment of associated psychological conditions.

OBJECTIVES

To assess whether CBT is effective in the management of patients suffering from tinnitus.

SEARCH STRATEGY

We searched the Cochrane Ear, Nose and Throat Disorders Group Trials Register; the Cochrane Central Register of Controlled Trials (CENTRAL); PubMed; EMBASE; CINAHL; Web of Science; BIOSIS Previews; Cambridge Scientific Abstracts; PsycINFO; ISRCTN and additional sources for published and unpublished trials. The date of the most recent search was 6 May 2010.

SELECTION CRITERIA

Randomised controlled trials in which patients with unilateral or bilateral tinnitus as their main symptom received cognitive behavioural treatment.

DATA COLLECTION AND ANALYSIS

One review author (PMD) assessed every report identified by the search strategy. Three authors (PMD, AW and MT) assessed the methodological quality and applied inclusion/exclusion criteria. Two authors (PMD and RP) extracted data and conducted the meta-analysis. The four authors contributed to the final text of the review.

MAIN RESULTS

Eight trials comprising 468 participants were included.For the primary outcome of subjective tinnitus loudness we found no evidence of a difference between CBT and no treatment or another intervention (yoga, education and 'minimal contact - education').In the secondary outcomes we found evidence that quality of life scores were improved in participants who had tinnitus when comparing CBT to no treatment or another intervention (education and 'minimal contact education'). We also found evidence that depression scores improved when comparing CBT to no treatment. We found no evidence of benefit in depression scores when comparing CBT to other treatments (yoga, education and 'minimal contact - education').There were no adverse/side effects reported in any trial.

AUTHORS' CONCLUSIONS

In six studies we found no evidence of a significant difference in the subjective loudness of tinnitus.However, we found a significant improvement in depression score (in six studies) and quality of life (decrease of global tinnitus severity) in another five studies, suggesting that CBT has a positive effect on the management of tinnitus.

Tinnitus Retraining Therapy (TRT) for tinnitus

BACKGROUND

Tinnitus is described as the perception of sound or noise in the absence of real acoustic stimulation. Although an outright cure for tinnitus remains elusive, various management strategies have been developed to help to lessen the impact of the symptom. Following the publication of a neurophysiological model of tinnitus, Tinnitus Retraining Therapy (TRT) was developed. Using a combination of directive counselling and sound therapy in a strict framework, this is one of the most commonly used treatment modalities for tinnitus. Many studies refer to the use of TRT where in fact a modified version of this therapy is actually being implemented. It is therefore important to confirm the use of authentic TRT when reviewing any study that reports its use.

OBJECTIVES

To assess the efficacy of TRT in the treatment of tinnitus.

SEARCH STRATEGY

The search included the Cochrane ENT Group Trials Register, the Cochrane Central Register of Controlled Trials (CENTRAL), PubMed, EMBASE and reference lists of identified publications. The date of the most recent search was 26 August 2009.

SELECTION CRITERIA

Randomised controlled trials of TRT versus no treatment, or other forms of treatment, in adult patients with tinnitus.

DATA COLLECTION AND ANALYSIS

Both authors critically appraised the retrieved studies for risk of bias and extracted data independently. Where necessary, we contacted the original study authors for further information.

MAIN RESULTS

Only one trial (123 participants) was included in the review. Several excluded trials did not follow the strict protocol for TRT, evaluating instead a modified form of TRT. The included trial showed TRT to be more effective than a tinnitus masking (TM) approach. In this study outcome data for tinnitus severity were presented using three instruments (Tinnitus Handicap Inventory (THI), Tinnitus Handicap Questionnaire (THQ), Tinnitus Severity Index (TSI)) for patients in three groups (participants' tinnitus being a 'moderate problem', big problem' or 'very big problem').At 18 months, improvements for the three groups in the three scores (TRT versus TM) were respectively: 'moderate problem' - THI: 18.2 versus 4.6, THQ: 489 versus 178, TSI 7.5 versus 1.6; 'big problem' - THI: 29.2 versus 16.7, THQ: 799 versus 256, TSI: 12.1 versus 6.7; and 'very big problem' - THI: 50.4 versus 10.3, THQ; 1118 versus 300, TSI: 19.7 versus 4.8.

AUTHORS' CONCLUSIONS

A single, low-quality randomised controlled trial suggests that TRT is much more effective as a treatment for patients with tinnitus than tinnitus masking.

Emerging pharmacotherapy of tinnitus

Tinnitus, the perception of sound in the absence of an auditory stimulus, is perceived by about 1 in 10 adults, and for at least 1 in 100, tinnitus severely affects their quality of life. Because tinnitus is frequently associated with irritability, agitation, stress, insomnia, anxiety and depression, the social and economic burdens of tinnitus can be enormous. No curative treatments are available. However, tinnitus symptoms can be alleviated to some extent. The most widespread management therapies consist of auditory stimulation and cognitive behavioral treatment, aiming at improving habituation and coping strategies. Available clinical trials vary in methodological rigor and have been performed for a considerable number of different drugs. None of the investigated drugs have demonstrated providing replicable long-term reduction of tinnitus impact in the majority of patients in excess of placebo effects. Accordingly, there are no FDA or European Medicines Agency approved drugs for the treatment of tinnitus. However, in spite of the lack of evidence, a large variety of different compounds are prescribed off-label. Therefore, more effective pharmacotherapies for this huge and still growing market are desperately needed and even a drug that produces only a small but significant effect would have an enormous therapeutic impact. This review describes current and emerging pharmacotherapies with current difficulties and limitations. In addition, it provides an estimate of the tinnitus market. Finally, it describes recent advances in the tinnitus field which may help overcome obstacles faced in the pharmacological treatment of tinnitus. These include incomplete knowledge of tinnitus pathophysiology, lack of well-established animal models, heterogeneity of different forms of tinnitus, difficulties in tinnitus assessment and outcome measurement and variability in clinical trial methodology.

Complementary and alternative medicine use by otolaryngology patients: a paradigm for practitioners in all surgical specialties

There is growing interest in complementary and alternative medicine (CAM) amongst the general population. Little information is available on CAM use in otolaryngology patients in the UK. Despite concerns over safety, efficacy and cost-effectiveness, CAM use is common amongst ENT patients. Patients perceive these medications as possible boosters to their immune system. It is becoming increasingly important that health care providers in all specialties ask their patients about CAM use and are aware of the implications it carries. The objective is to study the prevalence and pattern of CAM use among adult and paediatric ENT patients in a UK teaching hospital. A cross-sectional study was done by sending anonymous questionnaire to all outpatient and elective inpatients over a 3-month period. Response rate was 73% (1,789/2,440). Prominent demographics: female, married, over-50 s. Sixty percent had used CAM, 35% in last year. Most common herbs: cod liver oil (n = 481), garlic (n = 255), cranberry (n = 224); non-herbal: massage (n = 287), acupuncture (n = 233), aromatherapy (n = 170). Most commonly cited reasons for using CAM: general health, enhanced immunity and prevention/treatment of common illnesses like the common cold, asthma and bodily aches and pains.

Evidence from the Cochrane Collaboration for Traditional Chinese Medicine therapies

BACKGROUND

The Cochrane Collaboration, an international not-for-profit organization that prepares and maintains systematic reviews of randomized trials of health care therapies, has produced reviews summarizing much of the evidence on Traditional Chinese Medicine (TCM). Our objective was to review the evidence base according to Cochrane systematic reviews.

METHODS

In order to detect reviews focusing on TCM, we searched the titles and abstracts of all reviews in Issue 4, 2008 of the Cochrane Database of Systematic Reviews. For each review, we extracted data on the number of trials included and the total number of participants. We provided an indication of the strength of the review findings by assessing the reviewers' abstract conclusions statement. We supplemented our assessment of the abstract conclusions statements with a listing of the comparisons and outcomes showing statistically significant meta-analyses results.

RESULTS

We identified 70 Cochrane systematic reviews of TCM, primarily acupuncture (n = 26) and Chinese herbal medicine (n = 42), and 1 each of moxibustion and t'ai chi. Nineteen (19) of 26 acupuncture reviews and 22/42 herbal medicine reviews concluded that there was not enough good quality trial evidence to make any conclusion about the efficacy of the evaluated treatment, while the remaining 7 acupuncture and 20 herbal medicine reviews and each of the moxibustion and t'ai chi reviews indicated a suggestion of benefit, which was qualified by a caveat about the poor quality and quantity of studies. Most reviews included many distinct interventions, controls, outcomes, and populations, and a large number of different comparisons were made, each with a distinct forest plot.

CONCLUSIONS

Most Cochrane systematic reviews of TCM are inconclusive, due specifically to the poor methodology and heterogeneity of the studies reviewed. Some systematic reviews provide preliminary evidence of Chinese medicine's benefits to certain patient populations, underscoring the importance and appropriateness of further research. These preliminary findings should be considered tentative and need to be confirmed with rigorous randomized controlled trials.

Cognitive behavioural therapy for tinnitus

BACKGROUND

Tinnitus is an auditory perception that can be described as the experience of sound, in the ear or in the head, in the absence of external acoustic stimulation (not usually audible to anyone else). At present no specific therapy for tinnitus is acknowledged to be satisfactory in all patients. Cognitive behavioural therapy (CBT) uses relaxation, cognitive restructuring of the thoughts and exposure to exacerbating situations in order to promote habituation and may benefit tinnitus patients, as may the treatment of associated psychological conditions.

OBJECTIVES

To assess whether cognitive behavioural therapy is effective in the management of patients suffering from tinnitus.

SEARCH STRATEGY

Our search included the Cochrane ENT Group Trials Register, the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library Issue 2, 2006), MEDLINE and EMBASE. The last search date was June 2006.

SELECTION CRITERIA

Randomised controlled trials in which patients with unilateral or bilateral tinnitus as main symptom received cognitive behavioural treatment.

DATA COLLECTION AND ANALYSIS

One review author (PMD) assessed every report identified by the search strategy. The four review authors assessed the methodological quality, applied inclusion/exclusion criteria and extracted data.

MAIN RESULTS

Six trials comprising 285 participants were included. 1.

PRIMARY OUTCOME

subjective tinnitus loudness. CBT compared to a waiting list control group: we found no significant difference (Standardised Mean Difference (SMD) 0.06 (95% CI -0.25 to 0.37)). CBT compared to another intervention (Yoga, Education, Minimal Contact - Education and Education): we found no significant difference (SMD 0.1 (95% CI -0.22 to 0.42)).2.

SECONDARY OUTCOMES

a) Depression. CBT compared to a waiting list control group: we found no significant difference in either group (SMD 0.29 (95%CI -0.04 to 0.63)). CBT compared to another intervention (Yoga, Education and Minimal Contact - Education): we found no significant difference (SMD 0.01 (95% CI -0.43 to 0.45)). b) Quality of life: CBT compared to a waiting list control group: we found a significant difference in favour of CBT versus the waiting list group (SMD 0.7 (95% CI 0.33 to 1.08)). CBT compared to another intervention (Education, Minimal Contact - Education and Education): we also found a significant difference between CBT and the other intervention control group (SMD 0.64 (95% CI 0.29 to 1.00)). There were no adverse/side effects reported in any trial.

AUTHORS' CONCLUSIONS

We did not find a significant difference in the subjective loudness of tinnitus, or in the associated depression. However we found a significant improvement in the quality of life (decrease of global tinnitus severity) of the participants, thus suggesting that cognitive behavioural therapy has an effect on the qualitative aspects of tinnitus and contributes positively to the management of tinnitus.

Antidepressants for patients with tinnitus

BACKGROUND

Tinnitus is described as the perception of sound or noise in the absence of real acoustic stimulation. It has been compared with chronic pain, and may be associated with depression or depressive symptoms which can affect quality of life and the ability to work. Antidepressant drugs have been used to treat tinnitus in patients with and without depressive symptoms.

OBJECTIVES

To assess the effectiveness of antidepressants in the treatment of tinnitus and to ascertain whether any benefit was due to a direct tinnitus effect or a secondary effect due to treatment of concomitant depressive states.

SEARCH STRATEGY

We searched the Cochrane Ear, Nose and Throat Disorders Group Trials Register, the Cochrane Central Register of Controlled Trials (CENTRAL) The Cochrane Library Issue 1, 2006); MEDLINE (January 1951 to 2006); EMBASE (1974 to 2006), CINAHL (to 2006), PSYCINFO (to 2006), LILACS (to 2006), and Cambridge Scientific Abstracts. The date of the most recent search was March 2006.

SELECTION CRITERIA

Randomised controlled clinical studies of antidepressant drugs versus placebo in patients with tinnitus.

DATA COLLECTION AND ANALYSIS

The studies retrieved were critically appraised and data extracted independently by two authors. Where necessary study authors were contacted for further information.

MAIN RESULTS

Five trials involving 525 patients were included. Four of these trials looked at the effect of tricyclic antidepressants on tinnitus, investigating 405 patients. One trial investigated the effect of a selective serotonin reuptake inhibitor (SSRI) in a group of 120 patients. No trials involving other antidepressant agents met the inclusion criteria. Only the trial using the SSRI drug met the highest quality standard. None of the other included trials met the highest quality standard, due to use of inadequate outcome measures, large drop out rates or failure to separate the effects on tinnitus from the effects on symptoms of anxiety and depression. All the trials assessing tricyclic antidepressants suggested that there was a slight improvement in tinnitus but these effects may have been attributable to methodological bias. The trial that investigated the SSRI drug found no overall improvement in any of the validated outcome measures that were used in the study although there was possible benefit for a subgroup that received higher doses of the drug. This observation merits further investigation. Reports of side effects including sedation, sexual dysfunction and dry mouth were common.

AUTHORS' CONCLUSIONS

There is insufficient evidence to say that antidepressant drug therapy improves tinnitus.

Ginkgo biloba for acute ischaemic stroke

BACKGROUND

Ginkgo biloba extract is widely used in the treatment of acute ischaemic stroke in China. We aimed to assess the evidence from randomised controlled trials and quasi-randomised controlled trials on the use of Ginkgo biloba extract in acute ischaemic stroke.

OBJECTIVES

The primary objective was to determine whether Ginkgo biloba extract improves functional outcome without causing undue harm in patients with acute ischaemic stroke. Secondary objectives were to assess the effect of Ginkgo biloba extract on neurological impairment and quality of life.

SEARCH STRATEGY

We searched the Cochrane Stroke Group Trials Register (last searched October 2004), the Trials Register of the Cochrane Complementary Medicine Field (last searched October 2004) and the Chinese Stroke Trials Register (last searched June 2004). In addition, we searched the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library Issue 3, 2004), MEDLINE (1966 to August 2004), EMBASE (1980 to June 2004), AMED (1985 to May 2002) and the China Biological Medicine Database (CBM-disc, 1979 to August 2004). We searched relevant clinical trials and research registers and contacted pharmaceutical companies and researchers in an effort to identify further published and unpublished studies.

SELECTION CRITERIA

Randomised controlled trials or quasi-randomised controlled clinical trials comparing Ginkgo biloba extract with placebo or open control (no placebo) in patients with acute ischaemic stroke.

DATA COLLECTION AND ANALYSIS

Two reviewers independently selected trials for inclusion, assessed trial quality and extracted the data.

MAIN RESULTS

Fourteen trials were identified, of which 10 trials (792 patients) were included. Four trials are awaiting assessment. In the 10 included trials follow up was performed at 14 to 35 days after stroke. In all studies neurological outcome was assessed but none of them reported on disability (activities of daily living function) or quality of life. Only three trials reported adverse events. In nine trials, all of them assessed to be of inferior quality, significant improvement in neurological deficit at the end of the treatment was used as the outcome measure. When analysing these trials together, Ginkgo biloba extract was associated with a significant increase in the number of improved patients (Peto odds ratio (OR) 2.66; 95% confidence interval (CI) 1.79 to 3.94). One placebo-controlled trial, assessed to be of good quality, reported neurological outcome as a continuous variable. It failed to show an improvement of neurological deficit at the end of treatment (weighted mean difference (fixed) 0.81; 95% CI -8.9 to 10.52). No deaths or major adverse events were reported during the follow-up period.

AUTHORS' CONCLUSIONS

There was no convincing evidence from trials of sufficient methodological quality to support the routine use of Ginkgo biloba extract to promote recovery after stroke. High-quality and large-scale randomised controlled trials are needed to test its efficacy.

General review of tinnitus: prevalence, mechanisms, effects, and management

Tinnitus is an increasing health concern across all strata of the general population. Although an abundant amount of literature has addressed the many facets of tinnitus, wide-ranging differences in professional beliefs and attitudes persist concerning its clinical management. These differences are detrimental to tinnitus patients because the management they receive is based primarily on individual opinion (which can be biased) rather than on medical consensus. It is thus vitally important for the tinnitus professional community to work together to achieve consensus. To that end, this article provides a broad-based review of what is presently known about tinnitus, including prevalence, associated factors, theories of pathophysiology, psychological effects, effects on disability and handicap, workers' compensation issues, clinical assessment, and various forms of treatment. This summary of fundamental information has relevance to both clinical and research arenas.

Ginkgo biloba extracts for tinnitus: More hype than hope?

The investigation into the effects of Ginkgo biloba extracts on tinnitus has suffered from a dearth of effective animal models as well as systematic clinical trials employing double-blind and placebo-controlled designs. Some clinical trials have yielded positive results, however, these studies are few and have been limited either by design flaws, the small size of the significant effects, or else the results have not been published in peer-reviewed journals and therefore the quality of the research is not assured. By contrast, the two most systematic clinical trials, both double-blind and placebo controlled, and published in respected peer-reviewed journals, have yielded negative results and suggest that Ginkgo biloba extracts are of little more use in the treatment of tinnitus than a placebo. Treatments for tinnitus that do not have therapeutic efficacy not only waste money but can potentially prevent patients from seeking therapy that is efficacious. Furthermore, the unsupervised use of Ginkgo biloba extracts with other medications could lead to adverse side effects which are unnecessary and not justified in terms of therapeutic benefit.

Ginkgo biloba for tinnitus

BACKGROUND

Tinnitus can be described as the perception of sound in the absence of external acoustic stimulation. At present no specific therapy for tinnitus is acknowledged to be satisfactory in all patients. There are a number of reports in the literature suggesting that Ginkgo biloba may be effective in the management of tinnitus. However, there also appears to be a strong placebo effect in tinnitus management.

OBJECTIVES

To assess the effect of Ginkgo biloba in patients who are troubled by tinnitus.

SEARCH STRATEGY

The Cochrane Central Register of Controlled Trials (CENTRAL) (Cochrane Library Issue 4 2003), MEDLINE (1966 - 2003), EMBASE (1974 - 2003), and reference lists of identified publications. Date of the most recent search was December 2003.

SELECTION CRITERIA

Adults (18 years and over) complaining of tinnitus. Adults with a primary complaint of cerebral insufficiency where tinnitus forms part of the syndrome.

DATA COLLECTION AND ANALYSIS

Both reviewers independently extracted data and assessed trials for quality.

MAIN RESULTS

Twelve trials were identified from the search as being relevant to the review. Ten trials were excluded on methodological grounds. No trials of tinnitus in cerebral insufficiency reached a satisfactory standard for inclusion in the review. There was no evidence that Ginkgo biloba was effective for the primary complaint of tinnitus. The incidence of side effects was small.

REVIEWERS' CONCLUSIONS

The limited evidence did not demonstrate that Ginkgo biloba was effective for tinnitus which is a primary complaint. There was no reliable evidence to address the question of Ginkgo biloba for tinnitus associated with cerebral insufficiency.

Ginkgo biloba extract for age-related macular degeneration

BACKGROUND

Ginkgo is used in the treatment of peripheral vascular disease and 'cerebral insufficiency'. It is thought to have several potential mechanisms of action including increased blood flow, platelet activating factor antagonism and prevention of membrane damage caused by free radicals. Vascular factors and oxidative damage are thought to be two potential mechanisms in the pathology of age-related macular degeneration.

OBJECTIVES

The objective of this review is to determine the effect of Ginkgo biloba extract on the progression of age-related macular degeneration.

SEARCH STRATEGY

The Cochrane Eyes and Vision Group specialised register, the Cochrane Controlled Trials Register - Central, MEDLINE, reference lists of identified trial reports, and the Science Citation Index were searched. The reviewer contacted Investigators of included studies for additional information. The most recent searches were performed in February 2000.

SELECTION CRITERIA

All randomised trials where Ginkgo biloba extract had been compared to control in people with age-related macular degeneration were included.

DATA COLLECTION AND ANALYSIS

The reviewer extracted data using a standardised form. The data were verified with the trial investigator.

MAIN RESULTS

One published trial was identified. Although a beneficial effect was observed, as only 20 people were enrolled in the trial, and assessment of outcome was not masked, its results must be considered equivocal. Adverse effects and quality of life for people with age-related macular degeneration have not been addressed. One unpublished trial is awaiting translation and assessment.

REVIEWER'S CONCLUSIONS

The question as to whether people with age-related macular degeneration should take Ginkgo biloba extract to prevent progression of the disease has not been answered by research to date.