Repetitive transcranial magnetic stimulation for tinnitus

Management of vascular causes of pulsatile tinnitus

Pulsatile tinnitus is a debilitating symptom affecting millions of Americans and can be a harbinger of hemorrhagic or ischemic stroke. Careful diagnostic evaluation of pulsatile tinnitus is critical in providing optimal care and guiding the appropriate treatment strategy. When a vascular cause of pulsatile tinnitus has been established, attention must be focused on the patient's risk of hemorrhagic stroke, ischemic stroke, or blindness, as well as the risks of the available treatment options, in order to guide decision-making. Herein we review our approach to management of the vascular causes of pulsatile tinnitus and provide a literature review while highlighting gaps in our current knowledge and evidence basis.

Psychophysiological treatment of chronic tinnitus: A review

Subjective chronic tinnitus consists of a more or less continuous perception of sound in the absence of a corresponding acoustic source, which can lead to various psychological problems like depression, anxiety, attentional deficits and sleep disturbances. The prevalence is 10%-15% of the general population. Various therapy and management options have been proposed, but outcomes vary, and no generally accepted cure exists. In this review, the coherence of the most frequently used aetiological models shall be evaluated, and the efficacy of several treatment options will be discussed. With respect to tinnitus treatments, we focus on controlled studies and meta-analyses. Although there are some therapies that outweigh placebo effects such as cognitive behavioural therapy, neurofeedback or neuromodulation techniques, they mainly target secondary symptoms and not the tinnitus tone itself. Furthermore, positive treatment effects only seem to last for a limited period of time. We conclude that long-lasting combination therapies such as neurofeedback of auditory cortex inhibitory EEG signatures, cognitive therapy and sound-tactile stimulation may provide more efficient outcomes if they target the intensity of the tinnitus tone itself and not only secondary psychological symptoms.

Multidisciplinary Tinnitus Research: Challenges and Future Directions From the Perspective of Early Stage Researchers

Tinnitus can be a burdensome condition on both individual and societal levels. Many aspects of this condition remain elusive, including its underlying mechanisms, ultimately hindering the development of a cure. Interdisciplinary approaches are required to overcome long-established research challenges. This review summarizes current knowledge in various tinnitus-relevant research fields including tinnitus generating mechanisms, heterogeneity, epidemiology, assessment, and treatment development, in an effort to highlight the main challenges and provide suggestions for future research to overcome them. Four common themes across different areas were identified as future research direction: (1) Further establishment of multicenter and multidisciplinary collaborations; (2) Systematic reviews and syntheses of existing knowledge; (3) Standardization of research methods including tinnitus assessment, data acquisition, and data analysis protocols; (4) The design of studies with large sample sizes and the creation of large tinnitus-specific databases that would allow in-depth exploration of tinnitus heterogeneity.

Repetitive Transcranial Magnetic Stimulation for Tinnitus Treatment in Vestibular Schwannoma: A Pilot Study

Background: Vestibular schwannomas (VS) are brain tumors affecting the vestibulocochlear nerve. Thus, VS patients suffer from tinnitus (TN). While the pathophysiology is mainly unclear, there is an increasing interest in repetitive transcranial magnetic stimulation (rTMS) for TN treatment. However, the results have been divergent. In addition to the methodological aspects, the heterogeneity of the patients might affect the outcome. Yet, there is no study evaluating rTMS exclusively in VS-associated tinnitus. Thus, the present pilot study evaluates low-frequency rTMS to the right dorsolateral pre-frontal cortex (DLPFC) in a VS-associated tinnitus.

Methods: This prospective pilot study enrolled nine patients with a monoaural VS-associated tinnitus ipsilateral to the tumor. Patients were treated with a 10-day rTMS regime (1 Hz, 100% RMT, 1,200 pulses, right DLPFC). The primary endpoint of the study was the reduction of TN distress (according to the Tinnitus Handicap Inventory, THI). The secondary endpoint was a reduction of TN intensity (according to the Tinnitus Matching Test, TMT) and the evaluation of factors predicting tinnitus outcome (i.e., hearing impairment, TN duration, type of tinnitus).

Results: No complications or side effects occurred. There was one drop-out due to a non-responsiveness of the complaint. There was a significant acute effect of rTMS on the THI and TMT. However, there was no significant long-term effect after 4 weeks. While the THI failed to detect any clinically relevant acute effect of rTMS in 56% of the patients, TMT revealed a reduction of TN intensity for more than 20 in 89% and for more than 50 in 56% of the patients. Notably, the acute effect of rTMS was influenced by the TN type and duration. In general, patients with a tonal TN and shorter TN duration showed a better response to the rTMS therapy.

Conclusion: The present pilot study is the first one to exclusively evaluate the effect of low-frequency rTMS to the right DLPFC in a VS-associated tinnitus. Our results prove the feasibility and the efficacy of rTMS in this patient cohort. There is a significant acute but a limited long-term effect. In addition, there is evidence that patients with a tonal tinnitus and shorter tinnitus duration might have the strongest benefit. A larger, randomized controlled study is necessary to prove these initial findings.

An updated meta-analysis: repetitive transcranial magnetic stimulation for treating tinnitus

Objective

To undertake an updated meta-analysis to obtain more evidence from randomized controlled trials (RCTs) to assess the effect of repetitive transcranial magnetic stimulation (rTMS) for the treatment of tinnitus.

Methods

PubMed®, Embase®, Web of Science, Cochrane Database of Systematic Reviews, CBM, CNKI and Wanfang were searched for RCTs from inception up to March 2020. Studies meeting the eligibility criteria were included in the meta-analysis. The mean difference was calculated and the effect size was evaluated using a Z test.

Results

The analysis included 12 randomized sham-controlled clinical trials with a total of 717 participants. Active rTMS was superior to sham rTMS in terms of the short-term and long-term effects (6 months) on the tinnitus handicap inventory scores, but an immediate effect was not significant. There was no significant immediate effect on the tinnitus questionnaire (TQ) and Beck depression inventory (BDI) scores.

Conclusions

This meta-analysis demonstrated that rTMS improved tinnitus-related symptoms, but the TQ and BDI scores demonstrated little immediate benefit. Future research should be undertaken on large samples in multi-centre settings with longer follow-up durations.

Association of Central Noninvasive Brain Stimulation Interventions With Efficacy and Safety in Tinnitus Management: A Meta-analysis

Importance

Tinnitus has a prevalence of 10% to 25% and is frequently associated with numerous complications, such as neuropsychiatric disease. Traditional treatments have failed to meet the needs of patients with tinnitus. Noninvasive brain stimulation (NIBS) can focally modify cortical functioning and has been proposed as a strategy for reducing tinnitus severity. However, the results have been inconclusive.

Objective

To evaluate the association between different central NIBS therapies and efficacy and acceptability for treatment of tinnitus.

Data Sources

ClinicalKey, Cochrane CENTRAL, Embase, ProQuest, PubMed, ScienceDirect, and Web of Science databases were searched from inception to August 4, 2019. No language restriction was applied. Manual searches were performed for potentially eligible articles selected from the reference lists of review articles and pairwise meta-analyses.

Study Selection

Randomized clinical trials (RCTs) examining the central NIBS method used in patients with unilateral or bilateral tinnitus were included in the current network meta-analysis. The central NIBS method was compared with sham, waiting list, or active controls. Studies that were not clinical trials or RCTs and did not report the outcome of interest were excluded.

Data Extraction and Synthesis

Two authors independently screened the studies, extracted the relevant information, and evaluated the risk of bias in the included studies. In cases of discrepancy, a third author became involved. If manuscript data were not available, the corresponding authors or coauthors were approached to obtain the original data. This network meta-analysis was based on the frequentist model.

Main Outcomes and Measures

The primary outcome was change in the severity of tinnitus. Secondary outcomes were changes in quality of life and the response rate related to the NIBS method in patients with tinnitus.

Results

Overall, 32 unique RCTs were included with 1458 unique participants (mean female proportion, 34.4% [range, 0%-81.2%]; mean age, 49.6 [range, 40.0-62.8] years; median age, 49.8 [interquartile range, 48.1-52.4] years). The results of the network meta-analysis revealed that cathodal transcranial direct current stimulation over the left dorsolateral prefrontal cortex combined with transcranial random noise stimulation over the bilateral auditory cortex was associated with the greatest improvement in tinnitus severity (standardized mean difference [SMD], -1.89; 95% CI, -3.00 to -0.78) and quality of life (SMD, -1.24; 95% CI, -2.02 to -0.45) compared with the controls. Improvement in tinnitus severity ranked more favorably for continuous theta-burst stimulation (cTBS) over both auditory cortices (SMD, -0.79; 95% CI = -1.57 to -0.01) than cTBS over only the left auditory cortex (SMD, -0.30; 95% CI, -0.87 to 0.28), compared with controls. Repetitive transcranial magnetic stimulation with priming had a superior beneficial association with tinnitus severity compared with the strategies without priming. None of the investigated NIBS types had a significantly different dropout rate compared with that of the control group.

Conclusions and Relevance

This network meta-analysis suggests a potential role of NIBS interventions in tinnitus management. Future large-scale RCTs focusing on longer follow-up and different priming procedure NIBS are warranted to confirm these findings.

Tinnitus Update

This article provides an update on tinnitus for audiologists and other clinicians who provide tinnitus-specific services. Tinnitus can be attributable to hearing loss, somatosensory system dysfunction, or auditory cortex dysfunction, with hearing loss being the most common cause and serious underlying pathologies being rare. Hearing loss does not always lead to tinnitus, and patients with tinnitus do not always suffer from hearing loss. The first scenario is explained by a so-called inhibitory gating mechanism, whereas the second assumes that all tinnitus sufferers have some degree of hearing impairment, which might not be detected in standard audiological examinations. The treatments should aim at symptomatic relief and management of associated distress. Current treatment options include pharmacotherapy, education, counseling, cognitive behavioral therapy, and sound therapy.

Assessment of the Effectiveness of Transcranial Magnetic Stimulation in Subjective Tinnitus

Introduction  Increases in spontaneous activity in the neurons of the auditory cortex are presumed as the pathophysiology of tinnitus.

Objective  To investigate the effectiveness of transcranial magnetic stimulation (TMS) in the treatment of tinnitus.

Methods  A total of 62 patients between the ages of 22 and 74 with chronic subjective tinnitus were enrolled in the study. The inclusion criteria were normal findings on an otolaryngologic examination and normal ranges of complete blood count, routine biochemical parameter levels, thyroid function, air-bone gap on pure-tone audiometry, and middle-ear pressure and stapedial reflex on tympanometry. The patients were randomized into 2 groups: 40 patients were placed in the treatment for TMS (tTMS) group, and the rest (22 patients) were placed in the sham TMS group. The frequency and severity of the tinnitus, as well as the tinnitus handicap inventory (THI) score of each patient were measured before and one month after the treatment, and the values were statistically evaluated.

Results  We observed a statistically significant improvement in the tTMS group ( p  < 0.05 and p  < 0.05 respectively) regarding the THI and tinnitus severity scores. The sham TMS group showed no significant improvement in terms of the THI ( p  > 0.05). However, the tinnitus severity showed a significant increase in this group ( p  < 0.05). The comparison of differences in the changes in the THI and the tinnitus severity scores showed a significant statistical improvement in the tTMS group compared with the sham TMS group ( p  < 0.05 and p  < 0.05 respectively).

Conclusion  Transcranial magnetic stimulation was found to be effective in the treatment of tinnitus, and may be adopted as a treatment for tinnitus after further comprehensive studies.

Chronic Primary Tinnitus: A Management Dilemma

Tinnitus often described as sound in the ear in absence of any external stimulus. It poses a challenge to the psychological and mental wellbeing of the patient and professional unsatisfaction to the clinician. The patient often an old aged individual usually approaches the outpatient department with various sounds in the ear, making him feel ill or unable to have a sound sleep. The middle-aged patient often complains of professional incapability and lack of concentration due to tinnitus. Despite vast academic research and advances, the efficiency of available treatment is debatable, often compelling the clinician to convey the message that “you may have to learn to live with it”. In the present overview of reviews, we tend to look into the management of tinnitus and present a comprehensive outlook of various evidence-based reviews from Cochrane and augmented with various studies from PubMed.

Repetitive transcranial magnetic stimulation on chronic tinnitus: a systematic review and meta-analysis

BACKGROUND

Although the clinical efficacy and safety of repetitive transcranial magnetic stimulation (rTMS) in the treatment of chronic tinnitus have been frequently examined, the results remain contradictory. Therefore, we performed a systematic review and meta-analysed clinical trials examining the effects of rTMS to evaluate its clinical efficacy and safety.

METHODS

Studies of rTMS for chronic tinnitus were retrieved from PubMed, Embase, and Cochrane Library through April 2020. Review Manager 5.3 software was employed for data synthesis, and Stata 13.0 software was used for analyses of publication bias and sensitivity.

RESULTS

Twenty-nine randomized studies involving 1228 chronic tinnitus patients were included. Compared with sham-rTMS, rTMS exhibited significant improvements in the tinnitus handicap inventory (THI) scores at 1 week (mean difference [MD]: - 7.92, 95% confidence interval [CI]: - 14.18, - 1.66), 1 month (MD: -8.52, 95% CI: - 12.49, - 4.55), and 6 months (MD: -6.53, 95% CI: - 11.406, - 1.66) post intervention; there were significant mean changes in THI scores at 1 month (MD: -14.86, 95% CI: - 21.42, - 8.29) and 6 months (MD: -16.37, 95% CI: - 20.64, - 12.11) post intervention, and the tinnitus questionnaire (TQ) score at 1 week post intervention (MD: -8.54, 95% CI: - 15.56, - 1.52). Nonsignificant efficacy of rTMS was found regarding the THI score 2 weeks post intervention (MD: -1.51, 95% CI: - 13.42, - 10.40); the mean change in TQ scores 1 month post intervention (MD: -3.67, 95% CI: - 8.56, 1.22); TQ scores 1 (MD: -8.97, 95% CI: - 20.41, 2.48) and 6 months (MD: -7.02, 95% CI: - 18.18, 4.13) post intervention; and adverse events (odds ratios [OR]: 1.11, 95% CI: 0.51, 2.42). Egger's and Begg's tests indicated no publication bias (P = 0.925).

CONCLUSION

This meta-analysis demonstrated that rTMS is effective for chronic tinnitus; however, its safety needs more validation. Restrained by the insufficient number of included studies and the small sample size, more large randomized double-blind multi-centre trials are needed for further verification.

Auditory Neural Plasticity in Tinnitus Mechanisms and Management

Tinnitus, which is the perception of sound in the absence of a corresponding external acoustic stimulus, including change of hearing and neural plasticity, has become an increasingly important ailment affecting the daily life of a considerable proportion of the population and causing significant burdens for both the affected individuals and society as a whole. Here, we briefly review the epidemiology and classification of tinnitus, and the currently available treatments are discussed in terms of the available evidence for their mechanisms and efficacy. The conclusion drawn from the available evidence is that there is no specific medication for tinnitus treatment at present, and tinnitus management might provide better solutions. Therapeutic interventions for tinnitus should be based on a comprehensive understanding of the etiology and features of individual cases of tinnitus, and more high quality and large-scale research studies are urgently needed to develop more efficacious medications.

What is the efficacy of gentamicin on the incidence of vertigo attacks and hearing in patients with Meniere's disease compared with steroids? A meta-analysis

OBJECTIVE

To compare the efficacy of gentamicin and steroids in patients with Meniere's disease (MD).

METHODS

The study protocol was structured in accordance with the Population, Intervention, Comparison and Outcome (PICO) framework. We used "Endnote" (Thomson ResearchSoft; Stanford, Connecticut, the United States) to retrieve database documents. A systematic literature search of Web of Science and PubMed Database through May 2020 was conducted using specific search terms. Inclusion criteria, exclusion criteria, vertigo improvement, and exact hearing changes were defined. Review Manager 5.3 (Cochrane) was used for data analysis.

RESULTS

A total of 80 articles were searched from Web of Science and 23 articles were searched from PubMed database. After further reviewing the specific points of the inclusion criteria and exclusion criteria, 9 papers were finally selected. Intratympanic gentamicin (ITG) was superior to intratympanic steroid (ITS) in reducing the number of vertigo attacks (odds ratio (OR) 3.08, 95% confidence intervals (CI) [2.05-3.65]), probability (P) < 0.01). As for hearing improvement, we did the analysis twice. With all the studies included, the odds of hearing improvement (by "x") was 0.31 among patients receiving gentamicin compared to those treated by steroids (OR 0.31, 95% CI [0.16-0.61]). But after removing one study with outlying results from the analysis, this effect disappeared. Hearing loss of ITG and ITS was not statistically significant (P = 0.29).

CONCLUSIONS

ITG is superior to ITS in reducing the number of vertigo attacks in the treatment of MD (P < 0.01); the impact on hearing is more heterogeneous in the studies. Overall, there was no clear difference between ITG and ITS on hearing improvement and on hearing loss.

Low-Frequency Repetitive Transcranial Magnetic Stimulation for the Treatment of Chronic Tinnitus: A Systematic Review and Meta-Analysis of Randomized Controlled Trials

Background

Chronic tinnitus affects approximately 10-15% of the population. Low-frequency repetitive transcranial magnetic stimulation (rTMS) has been considered as a promising and well-tolerated therapeutic strategy for chronic tinnitus. However, a recent large-scale multicenter clinical trial showed a negative result.

Objective

This systematic review is aimed at assessing the efficacy and safety of low-frequency rTMS in chronic tinnitus.

Methods

We searched PubMed, Embase, and Cochrane Library for randomized controlled studies of rTMS treatment of chronic tinnitus. A pooled analysis of standardized mean difference (SMD) was performed with 95% confidence intervals (CI).

Results

Ten RCTs involving 567 participants were included in this review. Compared with sham stimulation, rTMS showed no significant efficacy in tinnitus severity and disability measured by Tinnitus Handicap Inventory (THI) in short-term (SMD = −0.04, 95% CI -0.23 to 0.16, P = 0.72), medium-term (SMD = −0.13, 95% CI -0.43 to 0.17, P = 0.41), and long-term (SMD = −0.16, 95% CI -0.38 to 0.05, P = 0.14) follow-up. Tinnitus severity and disability measured by Tinnitus Questionnaire (TQ) also showed no significant improvement in short-term (SMD = −0.11, 95% CI -0.31 to 0.10, P = 0.30), medium-term (SMD = −0.10, 95% CI -0.37 to 0.16, P = 0.44), and long-term (SMD = −0.20, 95% CI -0.40 to 0.01, P = 0.06) follow-up. Additionally, no statistically significant difference was shown in the changes of tinnitus loudness assessed by a visual analogue scale (VAS) between rTMS and sham groups in the short-term (SMD = −0.28, 95% CI -0.59 to 0.02, P = 0.07), medium-term (SMD = −0.26, 95% CI -0.59 to 0.07, P = 0.13), and long-term (SMD = −0.20, 95% CI -0.53 to 0.13, P = 0.24) follow-up. Few mild or moderate adverse events were observed in both the rTMS and sham groups.

Conclusion

Low-frequency rTMS is well tolerated but not effective in treating chronic tinnitus based on the current analysis of pooled data. Further studies with modified and uniform protocols are required to investigate the potential benefit of rTMS in chronic tinnitus.

A process for prioritising systematic reviews in tinnitus

Objective: To develop an innovative prioritisation process to identify topics for new or updated systematic reviews of tinnitus research.Design: A two-stage prioritisation process was devised. First, a scoping review assessed the amount of randomized controlled trial-level evidence available. This enabled development of selection criteria for future reviews, aided the design of template protocol and suggested the scale of work that would be required to conduct these reviews. Second, using the pre-defined primary and secondary criteria, interventions were prioritised for systematic review.Study sample: Searches identified 1080 records. After removal of duplicates and out of scope works, 437 records remained for full data charting.Results: The process was tested, using subjective tinnitus as the clinical condition and using Cochrane as the systematic review platform. The criteria produced by this process identified three high priority reviews: (1) Sound therapy using amplification devices and/or sound generators; (2) Betahistine and (3) Cognitive behaviour therapy. Further secondary priorities were: (4) Gingko biloba, (5) Anxiolytics, (6) Hypnotics, (7) Antiepileptics and (8) Neuromodulation.Conclusions: A process was developed which successfully identified priority areas for Cochrane systematic reviews of interventions for subjective tinnitus. This technique could easily be transferred to other conditions and other types of systematic reviews.

Effect of Nitrous Oxide as a Treatment for Subjective, Idiopathic, Nonpulsatile Bothersome Tinnitus: A Randomized Clinical Trial

Importance

The tinnitus research literature suggests that N-methyl-d-aspartate (NMDA) receptor antagonists may be useful in reducing tinnitus. Nitrous oxide, a member of the NMDA receptor antagonist class, is a widely used general anesthetic and sedative with a proven safety record.

Objective

To investigate whether nitrous oxide can reduce bothersome tinnitus.

Design, Setting, and Participants

Randomized, placebo-controlled crossover trial conducted between October 15, 2016, and June 22, 2017. Participants attended 2 interventional sessions separated by at least 14 days and were randomized to receive either placebo first or nitrous oxide first. Participants were followed up through completion of the second arm of the study. The setting was a clinical research unit at an academic medical center. Adults aged 18 to 65 years with subjective, idiopathic, nonpulsatile bothersome tinnitus of 6 months' duration or longer were recruited from 2 clinical research databases. Seventy-one individuals were screened, of whom 40 were enrolled. Of those enrolled, 37 participants completed all components of the study.

Interventions

The placebo session consisted of 50% nitrogen and 50% oxygen inhaled for 40 minutes, and the treatment session consisted of 50% nitrous oxide and 50% oxygen inhaled for 40 minutes.

Main Outcomes and Measures

Tinnitus was assessed before and after intervention, with the change in the Tinnitus Functional Index (TFI) as the primary outcome measure. Secondary outcome measures included the Patients' Global Impression of Change score and the change in the Global Bothersome Scale score.

Results

Among 40 participants in this intent-to-treat randomized clinical trial with 20 participants randomly assigned to each group, the mean (SD) age of participants was 52.9 (11.1) years, with equal numbers of male and female participants. The TFI after intervention was a mean (SD) of 1.8 (8.8) points lower than before intervention in the placebo arm and a mean (SD) of 2.5 (11.0) points lower than before intervention in the nitrous oxide arm. The within-participant mean difference in the change in the TFI of the placebo arm compared with the nitrous oxide arm was -1.1 points (95% CI, -5.6 to 3.4 points). The difference between the placebo and nitrous oxide arms was neither clinically meaningful nor statistically significant.

Conclusions and Relevance

Nitrous oxide was no more effective than placebo for the treatment of subjective, idiopathic tinnitus.

Trial Registration

ClinicalTrials.gov identifier: NCT03365011.

Homeostatic activity regulation as a mechanism underlying the effect of brain stimulation

Hyperexcitability of the neural network often occurs after brain injuries or degeneration and is a key pathophysiological feature in certain neurological diseases such as epilepsy, neuropathic pain, and tinnitus. Although the standard approach of pharmacological treatments is to directly suppress the hyperexcitability through reducing excitation or enhancing inhibition, different techniques for stimulating brain activity are often used to treat refractory neurological conditions. However, it is unclear why stimulating brain activity would be effective for controlling hyperexcitability. Recent studies suggest that the pathogenesis in these disorders exhibits a transition from an initial activity loss after acute injury or progressive neurodegeneration to subsequent development of hyperexcitability. This process mimics homeostatic activity regulation and may contribute to developing network hyperexcitability that underlies neurological symptoms. This hypothesis also predicts that stimulating brain activity should be effective in reducing hyperexcitability due to homeostatic activity regulation and in relieving symptoms. Here we review current evidence of homeostatic plasticity in the development of hyperexcitability in some neurological diseases and the effects of brain stimulation. The homeostatic plasticity hypothesis may provide new insights into the pathophysiology of neurological diseases and may guide the use of brain stimulation techniques for treating them.

RTMS parameters in tinnitus trials: a systematic review

Over the past few years extensive body of research was produced investigating the effects of repetitive transcranial magnetic stimulation (rTMS) for the treatment of chronic tinnitus with heterogeneous results. This heterogeneity is exemplified by two recently published large-scale clinical trials reporting different outcomes. Technical aspects of rTMS were suspected as a potential source for this incongruency. The aim of this systematic review is to examine the overall efficacy as well as to identify possible technical factors relevant for the effectiveness of rTMS tinnitus trials. Via a literature search appropriate original research papers were identified and rTMS parameters were extracted from each study arm for subsequent statistical analysis with respect to observed effects (significant vs. not significant pre-post rTMS effects). Our findings indicate that verum rTMS is superior to sham rTMS as demonstrated by the proportion of significant pre-post contrasts. Some relevant rTMS parameters (e.g., pulse waveform) are not reported. Lower rTMS stimulation intensity was associated with significant effects in verum rTMS arms. An additional stimulation of the DLPFC to the temporal cortex was not found to promote efficacy. Future research should consider differential effects of rTMS induced by technical parameters and strive for an exhaustive reporting of relevant rTMS parameters.

Tinnitus Management in Lateral Skull Base Lesions

Tinnitus, the phantom perception of sound in the absence of a physical sound source, is a complex problem with multiple etiologies. While most commonly presenting in a subjective fashion caused by measurable hearing loss, other etiologies including lateral skull base tumors that encroach on middle and inner ear structures can lead to phantom sound perception as well. In addition to discussing the basic background of tinnitus, here we also review current theories of etiology that include central auditory and nonauditory neural mechanisms and potential treatments that range from sound therapy to medications to cognitive and behavioral therapies and cranial nerve and brain stimulation. One main purpose of this article is to relate tinnitus causes to skull base tumors, surgical removal, and resultant sequelae, including damage to cranial nerves resulting in audiovestibular dysfunction. We also discuss the utility of microvascular decompression for both tumor and nontumor-associated tinnitus and the current literature regarding hearing preservation rates and tinnitus perception, where documented, with the three common treatment modalities employed for most lateral skull base tumors that includes watchful waiting with serial imaging, stereotactic radiosurgery and primary surgical resection using hearing preservation and hearing ablative approaches. The management of skull base tumors is a complex process that depending upon the approach and sequelae, may lead to manageable or worsening phantom sound perception that must be considered when discussing the multiple treatment options with patients.

Cortical stimulation for treatment of neurological disorders of hyperexcitability: a role of homeostatic plasticity

Hyperexcitability of neural network is a key neurophysiological mechanism in several neurological disorders including epilepsy, neuropathic pain, and tinnitus. Although standard paradigm of pharmacological management of them is to suppress this hyperexcitability, such as having been exemplified by the use of certain antiepileptic drugs, their frequent refractoriness to drug treatment suggests likely different pathophysiological mechanism. Because the pathogenesis in these disorders exhibits a transition from an initial activity loss after injury or sensory deprivation to subsequent hyperexcitability and paroxysmal discharges, this process can be regarded as a process of functional compensation similar to homeostatic plasticity regulation, in which a set level of activity in neural network is maintained after injury-induced activity loss through enhanced network excitability. Enhancing brain activity, such as cortical stimulation that is found to be effective in relieving symptoms of these disorders, may reduce such hyperexcitability through homeostatic plasticity mechanism. Here we review current evidence of homeostatic plasticity in the mechanism of acquired epilepsy, neuropathic pain, and tinnitus and the effects and mechanism of cortical stimulation. Establishing a role of homeostatic plasticity in these disorders may provide a theoretical basis on their pathogenesis as well as guide the development and application of therapeutic approaches through electrically or pharmacologically stimulating brain activity for treating these disorders.

Management of Functional Somatic Syndromes and Bodily Distress

Functional somatic syndromes (FSS), like irritable bowel syndrome or fibromyalgia and other symptoms reflecting bodily distress, are common in practically all areas of medicine worldwide. Diagnostic and therapeutic approaches to these symptoms and syndromes vary substantially across and within medical specialties from biomedicine to psychiatry. Patients may become frustrated with the lack of effective treatment, doctors may experience these disorders as difficult to treat, and this type of health problem forms an important component of the global burden of disease. This review intends to develop a unifying perspective on the understanding and management of FSS and bodily distress. Firstly, we present the clinical problem and review current concepts for classification. Secondly, we propose an integrated etiological model which encompasses a wide range of biopsychosocial vulnerability and triggering factors and considers consecutive aggravating and maintaining factors. Thirdly, we systematically scrutinize the current evidence base in terms of an umbrella review of systematic reviews from 2007 to 2017 and give recommendations for treatment for all levels of care, concentrating on developments over the last 10 years. We conclude that activating, patient-involving, and centrally acting therapies appear to be more effective than passive ones that primarily act on peripheral physiology, and we recommend stepped care approaches that translate a truly biopsychosocial approach into actual management of the patient.

Innovations in Doctoral Training and Research on Tinnitus: The European School on Interdisciplinary Tinnitus Research (ESIT) Perspective

Tinnitus is a common medical condition which interfaces many different disciplines, yet it is not a priority for any individual discipline. A change in its scientific understanding and clinical management requires a shift toward multidisciplinary cooperation, not only in research but also in training. The European School for Interdisciplinary Tinnitus research (ESIT) brings together a unique multidisciplinary consortium of clinical practitioners, academic researchers, commercial partners, patient organizations, and public health experts to conduct innovative research and train the next generation of tinnitus researchers. ESIT supports fundamental science and clinical research projects in order to: (1) advancing new treatment solutions for tinnitus, (2) improving existing treatment paradigms, (3) developing innovative research methods, (4) performing genetic studies on, (5) collecting epidemiological data to create new knowledge about prevalence and risk factors, (6) establishing a pan-European data resource. All research projects involve inter-sectoral partnerships through practical training, quite unlike anything that can be offered by any single university alone. Likewise, the postgraduate training curriculum fosters a deep knowledge about tinnitus whilst nurturing transferable competencies in personal qualities and approaches needed to be an effective researcher, knowledge of the standards, requirements and professionalism to do research, and skills to work with others and to ensure the wider impact of research. ESIT is the seed for future generations of creative, entrepreneurial, and innovative researchers, trained to master the upcoming challenges in the tinnitus field, to implement sustained changes in prevention and clinical management of tinnitus, and to shape doctoral education in tinnitus for the future.

Tinnitus: still 'A Ghost in the Machine' or a Darwinian survival phenomenon?

INTRODUCTION

The causation of tinnitus continues to intrigue. Despite the plethora of publications there is no definitive path available to concentrate our efforts, in alleviating the symptom. Several mechanical theories are available in standard tinnitus literature with varying empiricism. Purpose/aim of the study: To investigate a possible way forward.

MATERIALS AND METHODS

Employing a forensic methodology ("crime scene analysis" technique) and utilizing available evidence from the related sciences, inductive and abstract reasoning, a pragmatic model incorporating the known features of tinnitus is available.

RESULTS

A plausible evolutionary explanation of the origins and functions for the causation of tinnitus is offered with a possible link to its evasive nature, in our search for a cause.

CONCLUSION

The functional value of tinnitus may be provided by our evolutionary history. It is possible that tinnitus was a protective adaptive phenomenon in earlier forms but in our current environment merely contributes to nuisance value.

The effects of repetitive transcranial magnetic stimulation in an animal model of tinnitus

Tinnitus (phantom auditory perception associated with hearing loss) can seriously affect wellbeing. Its neural substrate is unknown however it has been linked with abnormal activity in auditory pathways. Though no cure currently exists, repetitive transcranial magnetic stimulation (rTMS) has been shown to reduce tinnitus in some patients, possibly via induction of cortical plasticity involving brain derived neurotrophic factor (BDNF). We examined whether low intensity rTMS (LI-rTMS) alleviates signs of tinnitus in a guinea pig model and whether this involves changes in BDNF expression and hyperactivity in inferior colliculus. Acoustic trauma was used to evoke hearing loss, central hyperactivity and tinnitus. When animals developed tinnitus, treatment commenced (10 sessions of 10 minutes 1 Hz LI-rTMS or sham over auditory cortex over 14 days). After treatment ceased animals were tested for tinnitus, underwent single-neuron recordings in inferior colliculus to assess hyperactivity and samples from cortex and inferior colliculus were taken for BDNF ELISA. Analysis revealed a significant reduction of tinnitus after LI-rTMS compared to sham, without a statistical significant effect on BDNF levels or hyperactivity. This suggests that LI-rTMS alleviates behavioural signs of tinnitus by a mechanism independent of inferior colliculus hyperactivity and BDNF levels and opens novel therapeutic avenues for tinnitus treatment.

Combined rTMS treatment targeting the Anterior Cingulate and the Temporal Cortex for the Treatment of Chronic Tinnitus

Repetitive transcranial magnetic stimulation (rTMS) has been proposed as a tinnitus treatment option. Promising results have been obtained by consecutive stimulation of lateral frontal and auditory brain regions. We investigated a combined stimulation paradigm targeting the anterior cingulate cortex (ACC) with double cone coil rTMS, followed by stimulation of the temporo-parietal junction area with a figure-of-eight coil. The study was conducted as a randomized, double-blind pilot trial in 40 patients suffering from chronic tinnitus. We compared mediofrontal stimulation with double-cone-coil, (2000 stimuli, 10 Hz) followed by left temporo-parietal stimulation with figure-of-eight-coil (2000 stimuli, 1 Hz) to left dorsolateral-prefrontal-cortex stimulation with figure-of-eight-coil (2000 stimuli, 10 Hz) followed by temporo-parietal stimulation with figure-of-eight-coil (2000 stimuli, 1 Hz). The stimulation was feasible with comparable dropout rates in both study arms; no severe adverse events were registered. Responder rates did not differ in both study arms. There was a significant main effect of time for the change in the TQ score, but no significant time x group interaction. This pilot study demonstrated the feasibility of combined mediofrontal/temporoparietal-rTMS-stimulation with double cone coil in tinnitus patients but failed to show better outcome compared to an actively rTMS treated control group.

The efficacy of individual treatment of subjective tinnitus with cognitive behavioural therapy

INTRODUCTION

It has been a long time since subjective tinnitus cases were described for the first time but they still lack a treatment with proven effectiveness. The main goal of this study was to evaluate the effectiveness of cognitive behavioural therapy in these patients.

PATIENTS AND METHOD

Between 2012 and 2013, 310 patients that suffered from subjective tinnitus were studied. Of these, 267 were included in treatment based on cognitive behavioural therapy. The monitoring period lasted 18 months for most cases, while it lasted 21 months for 11 patients.

RESULTS

Considering patients that interrupted their treatment as failures, the percentage of recovery was 95.7%.

CONCLUSION

Cognitive behavioural therapy should always be included in the treatment of people suffering from tinnitus.

Current-reported outcome domains in studies of adults with a focus on the treatment of tinnitus: protocol for a systematic review

INTRODUCTION

In Europe alone, over 70 million people experience tinnitus. Despite its considerable socioeconomic relevance, progress in developing successful treatments has been limited. Clinical effectiveness is judged according to change in primary outcome measures, but because tinnitus is a subjective condition, the definition of outcomes is challenging and it remains unclear which distinct aspects of tinnitus (ie, 'domains') are most relevant for assessment. The development of a minimum outcome reporting standard would go a long way towards addressing these problems. In 2006, a consensus meeting recommended using 1 of 4 questionnaires for tinnitus severity as an outcome in clinical trials, in part because of availability in different language translations. Our initiative takes an approach motivated by clinimetrics, first by determining what to measure before seeking to determine how to measure it. Agreeing on the domains that contribute to tinnitus severity (ie, 'what') is the first step towards achieving a minimum outcome reporting standard for tinnitus that has been reached via a methodologically rigorous and transparent process.

METHODS AND ANALYSIS

Deciding what should be the core set of outcomes requires a great deal of discussion and so lends itself well to international effort. This protocol lays out the first-step methodology in defining a Core Domain Set for clinical trials of tinnitus by establishing existing knowledge and practice with respect to which outcome domains have been measured and which instruments used in recent registered and published clinical trials.

ETHICS AND DISSEMINATION

No ethical issues are foreseen. Findings will be reported at national and international ear, nose and throat (ENT) and audiology conferences and in a peer-reviewed journal, using PRISMA (Preferred Reporting Items for Systematic reviews and Meta-analysis) guidelines.

TRIAL REGISTRATION NUMBER

The systematic review protocol is registered on PROSPERO (International Prospective Register of Systematic Reviews): CRD42015017525.

Use of cortical stimulation in neuropathic pain, tinnitus, depression, and movement disorders

Medical treatment must strike a balance between benefit and risk. As the field of neuromodulation develops, decreased invasiveness, in combination with maintenance of efficacy, has become a goal. We provide a review of the history of cortical stimulation from its origins to the current state. The first part discusses neuropathic pain and the nonpharmacological treatment options used. The second part covers transitions to tinnitus, believed by many to be another deafferentation disorder, its classification, and treatment. The third part focuses on major depression. The fourth section concludes with the discussion of the use of cortical stimulation in movement disorders. Each part discusses the development of the field, describes the current care protocols, and suggests future avenues for research needed to advance neuromodulation.

Tinnitus

Tinnitus is a common medical symptom that can be debilitating. Risk factors include hearing loss, ototoxic medication, head injury, and depression. At presentation, the possibilities of otological disease, anxiety, and depression should be considered. No effective drug treatments are available, although much research is underway into mechanisms and possible treatments. Surgical intervention for any otological pathology associated with tinnitus might be effective for that condition, but the tinnitus can persist. Available treatments include hearing aids when hearing loss is identified (even mild or unilateral), wide-band sound therapy, and counselling. Cognitive behavioural therapy (CBT) is indicated for some patients, but availability of tinnitus-specific CBT in the UK is poor. The evidence base is strongest for a combination of sound therapy and CBT-based counselling, although clinical trials are constrained by the heterogeneity of patients with tinnitus.

Low-frequency repetitive transcranial magnetic stimulation to the temporoparietal junction for tinnitus: four-week stimulation trial

IMPORTANCE

This research examines the impact of 4 weeks of repetitive transcranial magnetic stimulation (rTMS) stimulation to the temporoparietal junction and compares the results of this longer duration of treatment with a similar stimulus protocol of only 2 weeks' duration.

OBJECTIVE

To examine the effectiveness and safety of 4 weeks of low-frequency rTMS to the left temporoparietal junction in a cohort of patients with bothersome tinnitus.

DESIGN

Crossover, double-blind, randomized controlled trial.

SETTING

Outpatient academic medical center.

PARTICIPANTS

The study population comprised 14 adults aged between 22 and 59 years with subjective, unilateral or bilateral, nonpulsatile tinnitus of 6 months' duration or greater and a score of 34 or greater on the Tinnitus Handicap Inventory (THI).

INTERVENTIONS

Low-frequency (1 Hz) 110% motor threshold rTMS or sham to the left temporoparietal junction for 4 weeks.

MAIN OUTCOME AND MEASURE

The difference of the change in the THI score between active rTMS and sham rTMS.

RESULTS

Active treatment was associated with a median reduction in THI score of 10 (range, -20 to +4) points, and sham treatment was associated with a median reduction of 6 (range, -24 to +12) points. The median difference in THI score between the change associated with active and sham rTMS was 4 (95% CI, -9 to 10; and range, -32 to +14) points.

CONCLUSIONS AND RELEVANCE

Daily low-frequency active rTMS to the left temporoparietal junction area for 4 weeks was no more effective than sham for patients with chronic bothersome tinnitus. Possible explanations for this negative study include the failure of rTMS to stimulate deeper parts of auditory cortex within the sylvian fissure and more widespread cortical network changes not amenable to localized rTMS effects.

TRIAL REGISTRATION

clinicaltrials.gov Identifier: NCT00567892.

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.

Tinnitus: therapeutic use of superficial brain stimulation

Tinnitus is a common disorder and traditional treatment approaches such as medication, active or passive sound enhancement, and cognitive behavioral therapy have limited efficacy. Thus, there is an urgent need for more effective treatment approaches. Functional imaging studies in patients with tinnitus have revealed alterations in neuronal activity of central auditory pathways, probably resulting as a consequence of sensory deafferentation. However, nonauditory brain areas are also involved. These nonauditory brain areas might represent both an "awareness" network involved in the conscious perception of the tinnitus signal as well as areas related to a nontinnitus-specific distress network consisting of the anterior cingulate cortex, anterior insula, and amygdala. Moreover, memory mechanisms involving the hippocampus and the parahippocampal region may play a role in the persistence of the awareness of the phantom percept, as well as in the reinforcement of the associated distress. All of these networks represent potential targets for treatment via pharmacological treatment or noninvasive and invasive brain stimulation. Repetitive transcranial magnetic stimulation (rTMS) is a noninvasive method of applying electromagnetic fields to the brain that can induce alterations of neuronal activity that outlast the stimulation period. Single sessions of rTMS over the temporal or temporoparietal cortex have been successful in transiently reducing tinnitus perception. Repeated sessions of rTMS have resulted in tinnitus relief in a subgroup of patients, lasting from several days to several months. However, effect sizes of rTMS in the treatment of tinnitus are only moderate, and interindividual variability is high. Larger and longer lasting effects have been observed with direct electrical stimulation of the auditory cortex via implanted epidural electrodes. Transcranial direct current stimulation (tDCS) has also shown potential for the treatment of tinnitus. Both auditory and frontal tDCS have shown tinnitus reduction in a subgroup of patients. In spite of the promising results of the different brain stimulation approaches, further research is needed before these techniques can be recommended for routine clinical use.

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.

The treatment of hallucinations in schizophrenia spectrum disorders

This article reviews the treatment of hallucinations in schizophrenia. The first treatment option for hallucinations in schizophrenia is antipsychotic medication, which can induce a rapid decrease in severity. Only 8% of first-episode patients still experience mild to moderate hallucinations after continuing medication for 1 year. Olanzapine, amisulpride, ziprasidone, and quetiapine are equally effective against hallucinations, but haloperidol may be slightly inferior. If the drug of first choice provides inadequate improvement, it is probably best to switch medication after 2-4 weeks of treatment. Clozapine is the drug of choice for patients who are resistant to 2 antipsychotic agents. Blood levels should be above 350-450 μg/ml for maximal effect. For relapse prevention, medication should be continued in the same dose. Depot medication should be considered for all patients because nonadherence is high. Cognitive-behavioral therapy (CBT) can be applied as an augmentation to antipsychotic medication. The success of CBT depends on the reduction of catastrophic appraisals, thereby reducing the concurrent anxiety and distress. CBT aims at reducing the emotional distress associated with auditory hallucinations and develops new coping strategies. Transcranial magnetic stimulation (TMS) is capable of reducing the frequency and severity of auditory hallucinations. Several meta-analyses found significantly better symptom reduction for low-frequency repetitive TMS as compared with placebo. Consequently, TMS currently has the status of a potentially useful treatment method for auditory hallucinations, but only in combination with state of the art antipsychotic treatment. Electroconvulsive therapy (ECT) is considered a last resort for treatment-resistant psychosis. Although several studies showed clinical improvement, a specific reduction in hallucination severity has never been demonstrated.