A contribution to the debate on tinnitus definition

Did Kant suffer from misophonia?

Misophonia is a disorder of decreased tolerance to specific sounds, often produced by humans but not always, which can trigger intense emotional reactions (anger, disgust etc.). This relatively prevalent disorder can cause a reduction in the quality of life. The causes of misophonia are still unclear. In this article, we develop a hypothesis suggesting that misophonia can be caused by a failure in the organization of the perceived world. The perceived world is the result of both the structure of human thought and the many conditioning factors that punctuate human life, particularly social conditioning. It is made up of abstract symbols that map the world and help humans to orient himself in a potentially dangerous environment. In this context, the role of social rules acquired throughout life is considerable. Table manners, for example, are a set of deeply regulated and controlled behaviors (it's considered impolite to eat with the mouth open and to make noise while eating), which contribute to shape the way the perceived world is organized. So it's not surprising to find sounds from the mouth (chewing etc.) among the most common misophonic sound triggers. Politeness can be seen as an act of obedience to moral rules or courtesy, which is a prerequisite for peaceful social relations. Beyond this example, we also argue that any sound can become a misophonic trigger as long as it is not integrated into the perceived ordered and harmonious world, because it is considered an "anomaly," i.e., a disorder, an immorality or a vulgarity.

Consensus Statements on the Definition, Classification, and Diagnostic Tests for Tinnitus: A Delphi Study Conducted by the Korean Tinnitus Study Group

BACKGROUND

Tinnitus is a bothersome condition associated with various symptoms. However, the mechanisms of tinnitus are still uncertain, and a standardized assessment of the diagnostic criteria for tinnitus is required. We aimed to reach a consensus on diagnosing tinnitus with professional experts by conducting a Delphi study with systematic review of the literature.

METHODS

Twenty-six experts in managing tinnitus in Korea were recruited, and a two-round modified Delphi study was performed online. The experts evaluated the level of agreement of potential criteria for tinnitus using a scale of 1-9. After the survey, a consensus meeting was held to establish agreement on the results obtained from the Delphi process. Consensus was defined when over 70% of the participants scored 7-9 (agreement) and fewer than 15% scored 1-3 (disagreement). To analyze the responses of the Delphi survey, the content validity ratio and Kendall's coefficient of concordance were evaluated.

RESULTS

Consensus was reached for 22 of the 38 statements. For the definition of tinnitus, 10 out of 17 statements reached consensus, with three statements achieving complete agreement including; 1) Tinnitus is a conscious perception of an auditory sensation in the absence of a corresponding external stimulus, 2) Tinnitus can affect one's quality of life, and 3) Tinnitus can be associated with hearing disorders including sensorineural hearing loss, vestibular schwannoma, Meniere's disease, otosclerosis, and others. For the classification of tinnitus, 11 out of 18 statements reached consensus. The participants highly agreed with statements such as; 1) Vascular origin is expected in pulse-synchronous tinnitus, and 2) Tinnitus can be divided into acute or chronic tinnitus. Among three statements on the diagnostic tests for tinnitus only Statement 3, "There are no reliable biomarkers for sensory or emotional factors of tinnitus." reached consensus. All participants agreed to perform pure-tone audiometry and tinnitus questionnaires, including the Tinnitus Handicap Inventory and Tinnitus Questionnaire.

CONCLUSION

We used a modified Delphi method to establish a consensus-based definition, a classification, and diagnostic tests for tinnitus. The expert panel reached agreement for several statements, with a high level of consensus. This may provide practical information for clinicians in managing tinnitus.

The interface of paediatric ENT and autism spectrum disorder: a complex conundrum for otolaryngologists

OBJECTIVE

Autism spectrum disorder is a lifelong neurodevelopmental condition encompassing complex physical and neurological symptoms, including complex sensory symptoms. This review explores the interface between autism spectrum disorder and paediatric ENT.

METHODS

Using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses ('PRISMA') guideline, a robust literature search and review was conducted by two researchers. Thirty-four papers were filtered into the final review.

RESULTS

Published literature clearly demonstrates potential for autism spectrum disorder to present in the form of auditory and other sensory symptoms to ENT surgeons and audiologists who may not fully appreciate this complex condition. Despite this well-documented link, auditory symptoms, auditory processing disorders and hearing loss within autism spectrum disorder remain poorly understood.

CONCLUSION

Improved recognition and understanding of autism spectrum disorder by otolaryngologists could enable more effective diagnostic and management strategies for autistic children who present with auditory and other sensory symptoms. In light of the current 'autism epidemic,' there is an urgent need for further research on this theme.

The Analogy between Tinnitus and Chronic Pain: A Phenomenological Approach

Tinnitus is an auditory sensation without external acoustic stimulation or significance, which may be lived as an unpleasant experience and impact the subject's quality of life. Tinnitus loudness, which is generally low, bears no relation to distress. Factors other than psychoacoustic (such as psychological factors) are therefore implicated in the way tinnitus is experienced. The aim of this article is to attempt to understand how tinnitus can, like chronic pain, generate a 'crisis' in the process of existence, which may go as far as the collapse of the subject. The main idea put forward in the present article is that tinnitus may be compared to the phenomenon of pain from the point of view of the way it is experienced. Although the analogy between tinnitus and pain has often been made in the literature, it has been limited to a parallel concerning putative physiopathological mechanisms and has never really been explored in depth from the phenomenological point of view. Tinnitus is comparable to pain inasmuch as it is felt, not perceived: it springs up (without intention or exploration), abolishes the distance between the subject and the sensation (there is only a subject and no object), and has nothing to say about the world. Like pain, tinnitus is formless and abnormal and can alter the normal order of the world with maximum intensity. Finally, tinnitus and pain enclose the subject within the limits of the body, which then becomes in excess. Tinnitus may be a source of suffering, which affects not only the body but a person's very existence and, in particular, its deployment in time. Plans are thus abolished, so time is no longer 'secreted', it is enclosed in an eternal present. If the crisis triggered by tinnitus is not resolved, the subject may buckle and collapse (depression) when their resources for resisting are depleted. The path may be long and winding from the moment when tinnitus emerges to when it assaults existence and its eventual integration into a new existential norm where tinnitus is no longer a source of disturbance.

Listening Effort in Tinnitus: A Pilot Study Employing a Light EEG Headset and Skin Conductance Assessment during the Listening to a Continuous Speech Stimulus under Different SNR Conditions

Background noise elicits listening effort. What else is tinnitus if not an endogenous background noise? From such reasoning, we hypothesized the occurrence of increased listening effort in tinnitus patients during listening tasks. Such a hypothesis was tested by investigating some indices of listening effort through electroencephalographic and skin conductance, particularly parietal and frontal alpha and electrodermal activity (EDA). Furthermore, tinnitus distress questionnaires (THI and TQ12-I) were employed. Parietal alpha values were positively correlated to TQ12-I scores, and both were negatively correlated to EDA; Pre-stimulus frontal alpha correlated with the THI score in our pilot study; finally, results showed a general trend of increased frontal alpha activity in the tinnitus group in comparison to the control group. Parietal alpha during the listening to stimuli, positively correlated to the TQ12-I, appears to reflect a higher listening effort in tinnitus patients and the perception of tinnitus symptoms. The negative correlation between both listening effort (parietal alpha) and tinnitus symptoms perception (TQ12-I scores) with EDA levels could be explained by a less responsive sympathetic nervous system to prepare the body to expend increased energy during the "fight or flight" response, due to pauperization of energy from tinnitus perception.

Amplification of the poorer ear by StereoBiCROS in case of asymmetric sensorineural hearing loss: effect on tinnitus

Tinnitus is prevalent among patients suffering from Single-Sided Deafness (SSD) and Asymmetrical Hearing Loss (AHL). In addition to bothersome tinnitus in the poorer ear, these patients also report issues with understanding speech in noise and sound localization. The conventional treatment options offered to these patients to improve auditory abilities are cochlear implantation, bone conduction devices or Contralateral Routing Of Signal (CROS) hearing aids. It was recently found that the benefit of cochlear implantation for tinnitus associated with AHL/SSD was greater than the other two approaches. It is conceivable that the lack of stimulation provided to the poorer ear in these last approaches explains their modest impact on tinnitus perception. A new technology that combines the ability to reroute the sound from the poorer ear to the good ear (CROS system) while still stimulating the poorer ear with conventional sound amplification has recently been developed: the StereoBiCROS system. The aim of this study was to investigate the effects of this new device on tinnitus. Twelve AHL and two SSD patients aged 70.7 ± 7.9 years with tinnitus were fitted with bilateral hearing aids that included 3 programs: Stereophonic, BiCROS and StereoBiCROS (CROS + bilateral amplification). The short-and long-term effect of the approach on tinnitus was assessed using a tinnitus Loudness Visual Analog Scale (VAS) and the Tinnitus Handicap Inventory (THI), respectively. Both the VAS and the THI were used before and one month after the hearing aid fitting. Of the 14 patients who used their hearing aids daily (12.6 ± 1.6 h per day) the StereoBiCROS program was the most used program (81.8 ± 20.5% of the time). The average THI total score decreased from 47 (± 22) to 15 (± 16) (p = 0.002) and the VAS-Loudness score decreased from 7 (± 1) to 2 (± 2) (p < 0.001) after the one-month trial period. In conclusion, StereoBiCROS stimulation strategy seems to offer an effective alternative to reduce tinnitus handicap and loudness for patients with AHL/SSD and tinnitus. This effect may be driven by sound amplification of the poorer ear.

Association of tinnitus and self-reported systemic arterial hypertension: a retrospective study

PURPOSE

To describe data on hearing loss, systemic arterial hypertension and tinnitus of individuals, and to verify the association between self-reported systemic arterial hypertension and tinnitus, as well as to correlate other variables present in the sample: hearing loss and tinnitus, age and tinnitus and age and systemic arterial hypertension.

METHODS

Quantitative, descriptive and inferential, retrospective research with data collection from 473 medical records of adults and elderly people treated between 2008 and 2018. Selected were information on age, gender, result of pure tone audiometry, tinnitus, tinnitus type and frequency, presence of SAH and use of medication to control the disease.

RESULTS

No association was found between systemic arterial hypertension and tinnitus or between hearing loss and tinnitus and between age and tinnitus, however, an association was observed between age and systemic arterial hypertension using the Chi - Square test. The most common type of tinnitus was wheezing and most individuals who reported feeling more than one type of tinnitus were hypertensive.

CONCLUSION

The results found and the literature suggest that systemic arterial hypertension may be an additional factor or an aggravating factor of preexisting factors in the generation of tinnitus, but not the primary cause.

Translation and validation of the Tinnitus Primary Function Questionnaire into Brazilian Portuguese

OBJECTIVE

In this study, the Tinnitus Primary Function Questionnaire was translated, culturally adapted and validated for Brazilian Portuguese.

METHODS

This study was carried out in two stages. First, a prospective study of translation and cultural adaptation was carried out with a group of 20 patients. The questionnaire was translated, revised and back-translated from Portuguese into English. Subsequently, a retrospective study was carried out with 1,095 patients, 18 months after the first stage. The validation and reliability of the Tinnitus Primary Function Questionnaire was verified by comparing its results with the results of the Tinnitus Handicap Inventory.

RESULTS

The interclass correlation coefficient of the behavioral aspects ranged from 0.82 to 0.90 and the total score was 0.93, while Cronbach's alpha was >0.94 for the total score during the test-retest application. To validate the questionnaire, a database was used, which consisted of 1,095 patients submitted to tinnitus assessment using the Tinnitus Primary Function Questionnaire and Tinnitus Handicap Inventory simultaneously. Patients were enrolled from 14 Brazilian states (46% female), with a mean age of 58 years. The reliability of the Tinnitus Primary Function Questionnaire was tested during validation for the four different evaluated behavioral aspects, and the results were significantly high for all aspects and the total score. To validate the Tinnitus Primary Function Questionnaire, the results of the total Tinnitus Primary Function Questionnaire and Tinnitus Handicap Inventory scores were compared using Pearson's product-moment correlation test. The results indicate a high correlation between the two questionnaires (r=0.84; p<0.001; 95% CI 0.82-0.85).

CONCLUSION

The data from the Tinnitus Primary Function Questionnaire showed a high correlation with those of the Tinnitus Handicap Inventory. This indicates that the Portuguese version of the Tinnitus Primary Function Questionnaire can be adopted as a valuable tool in the clinical evaluation of patients with tinnitus.

LEVEL OF EVIDENCE

2C.

Transcranial electric and acoustic stimulation for tinnitus: study protocol for a randomized double-blind controlled trial assessing the influence of combined transcranial random noise and acoustic stimulation on tinnitus loudness and distress

Background

Tinnitus is the result of aberrant neuronal activity. As a novel treatment form, neuromodulation is used to modify neuronal activity of brain areas involved in tinnitus generation. Among the different forms of electric stimulation, transcranial random noise stimulation (tRNS) has been shown to be a promising treatment option for tinnitus. In addition, recent studies indicate that the reduction in tinnitus can be more pronounced when different modalities of stimulation techniques are combined (“bimodal stimulation”). TRNS can be used in combination with acoustic stimulation (AS), a further treatment option recognized in the literature. The aim of the proposed study is to investigate whether simultaneous tRNS and AS improve levels of tinnitus loudness and distress.

Methods

The intervention consists of bilateral high-definition tRNS (HD-tRNS) over the auditory cortex combined with the application of AS which is studied in a crossover design. The visits will be performed in 26 sessions. There will be 20 treatment sessions, divided into two blocks: active and sham HD-tRNS. Within the blocks, the interventions are divided into group A: HD-tRNS and AS, and group B: HD-tRNS alone. Furthermore, in addition to the assessments directly following the intervention sessions, there will be six extra sessions performed subsequently at the end of each block, after a period of some days (follow-ups 1 and 2) and a month after the last intervention (C). Primary outcome measures are analog scales for evaluation of subjective tinnitus loudness and distress, and the audiological measurement of minimum masking level (MML). Secondary outcome measures are brain activity as measured by electroencephalography and standardized questionnaires for evaluating tinnitus distress and severity.

Discussion

To the best of our knowledge, this is the first study which uses HD-tRNS combined with AS for tinnitus treatment. The crossover design permits the comparison between HD-tRNS active vs. sham and with vs. without AS. Thus, it will be possible to evaluate the efficacy of the combined approach to HD-tRNS alone. In addition, the use of different objective and subjective evaluations for tinnitus enable more reliable and valid results.

Trial registration

Swiss Ethics Committee (BASEC-Nr. 2020-02027); Swiss Federal Complementary Database (kofam.ch: SNCTP000004051); and ClinicalTrials.gov (clinicaltrials.gov: NCT04551404).

Toward a Multidimensional Understanding of Misophonia Using Cluster-Based Phenotyping

Misophonia is a condition characterized by hypersensitivity and strong emotional reactivity to specific auditory stimuli. Misophonia clinical presentations are relatively complex and reflect individualized experiences across clinical populations. Like some overlapping neurodevelopmental and neuropsychiatric disorders, misophonia is potentially syndromic where symptom patterns rather than any one symptom contribute to diagnosis. The current study conducted an exploratory k-means cluster analysis to evaluate symptom presentation in a non-clinical sample of young adult undergraduate students (N = 343). Individuals participated in a self-report spectrum characteristics survey indexing misophonia, tinnitus severity, sensory hypersensitivity, and social and psychiatric symptoms. Results supported a three-cluster solution that split participants on symptom presentation: cluster 1 presented with more severe misophonia symptoms but few overlapping formally diagnosed psychiatric co-occurring conditions; cluster 3 was characterized by a more nuanced clinical presentation of misophonia with broad-band sensory hypersensitivities, tinnitus, and increased incidence of social processing and psychiatric symptoms, and cluster 2 was relatively unaffected by misophonia or other sensitivities. Clustering results illustrate the spectrum characteristics of misophonia where symptom patterns range from more “pure” form misophonia to presentations that involve more broad-range sensory-related and psychiatric symptoms. Subgroups of individuals with misophonia may characterize differential neuropsychiatric risk patterns and stem from potentially different causative factors, highlighting the importance of exploring misophonia as a multidimensional condition of complex etiology.

Effect of transcranial Direct Current Stimulation for tinnitus treatment: A systematic review and meta-analysis

OBJECTIVES

To evaluate the effect of tDCS on tinnitus distress, loudness and psychiatric symptoms.

METHODS

A systematic literature search of PubMed, Web of Science, Cochrane Library, VHL, EMBASE, PsycINFO, OVID, and CINAHL databases was carried out on articles published until July 2021. Inclusion criteria were published controlled trials using tDCS intervention with tinnitus patients, using a sham/control group, and measuring tinnitus loudness, distress and/or psychiatric symptoms. A meta-analysis was performed for the overall effect as well as to compare subgroups according to tDCS target (left temporoparietal area (LTA) and dorsolateral prefrontal cortex (DLPFC)).

RESULTS

Fourteen articles with 1031 participants were included. Six studies applied tDCS over the DLPFC, six over the LTA and two over both areas. Although the overall meta-analysis showed that tDCS significantly decreased tinnitus loudness (SMD=-0.35; 95%CI=-0.62 to -0.08, p = 0.01) and distress (SMD=-0.50, 95%CI=-0.91 to -0.10, p = 0.02).The subgroup analysis showed a significant effect only for tDCS over LTA for loudness (SMD=-0.46, 95%CI=-0.80 to -0.12, p = 0.009), and no other area resulted in significant change. There was no significant effect of treatment on psychiatric symptoms.

CONCLUSION

tDCS may improve tinnitus loudness and distress with a small to moderate effect size. Despite the overall positive effect, only LTA tDCS yielded a significant effect. Further well-controlled studies with larger sample sizes and broader exploration of tDCS montages and doses are warranted.

Characterization of patients with tinnitus seen by the Hearing Health service

ABSTRACT Purpose: to establish the profile of individuals with tinnitus treated at a Hearing Health service and to associate the symptom with gender, audiological profile, and presence of vertigo. Methods: a descriptive, retrospective study with an analysis of 6,000 medical records of individuals treated at a hearing health service was carried out. The data collected from the medical records were: sociodemographic data, characteristics of hearing impairment, characteristics of tinnitus and vertigo, speech therapy interview, and otorhinolaryngological, audiological, otoneurological assessments, characteristics of life style and risk factors. An descriptive analysis was performed using the Chi-square test of association, adopting a statistical significance level of 5% (p<0.05) for the inferential analysis. Results: there was a statistically significant association between the presence of tinnitus and gender, normal hearing, and vertigo, and a significant association was also found between tinnitus and unilateral and bilateral conductive hearing loss, and unilateral and bilateral sensorineural hearing loss. Conclusion: there was a significant association, in the population evaluated, for the presence of tinnitus and female gender, normal hearing, unilateral and bilateral conductive hearing loss, unilateral and bilateral sensorineural hearing loss, and the presence of vertigo.

Influência de diferentes aspectos nas medidas psicoacústicas de pacientes com zumbido crônico

RESUMO Objetivo: verificar o gênero, a idade, a localização do zumbido, a presença ou ausência de perda auditiva e seu grau, assim como as medidas psicoacústicas (pitch, loudness, nível mínimo de mascaramento e inibição residual) de pacientes com zumbido crônico e as suas relações. Métodos: o estudo incluiu sujeitos de ambos os gêneros, com idades entre 25 e 85 anos, com queixa de zumbido crônico e que realizassem acompanhamento em ambulatório especializado do Hospital de Clínicas de Porto Alegre. Foram submetidos a anamnese, avaliação audiológica básica, pesquisa de pitch, loudness, inibição residual (IR) e nível mínimo de mascaramento (NMM). Foram utilizados os seguintes testes estatísticos: Teste Qui-Quadrado, Teste Exato de Fisher, Teste U de Wilcoxon - Mann-Whitney, Teste Kruskal Wallis e Coeficiente de Correlação de Spearman. O nível de significância utilizado foi de 5% (p≤0,05). Resultados: houve associação entre a variável tipo de zumbido e presença ou ausência de perda auditiva (PA), grau de PA, NMM e loudness, assim como, entre idade e presença ou ausência de PA e seu grau. A loudness e o NMM apresentaram fraca correlação diretamente proporcional, ao passo que as correlações entre pitch e loudness, pitch e NMM e IR versus NMM apresentaram-se fracas e inversamente proporcionais. Conclusão: houve heterogeneidade entre as características do zumbido e dos indivíduos acometidos. Conclui-se, de acordo com os resultados expostos, que existe influência de algumas variáveis entre si, da mesma maneira que ocorre entre as medidas psicoacústicas.

Influence of different aspects on psychoacoustic measurements of patients with chronic tinnitus

ABSTRACT Purpose: to verify the sex, age, tinnitus location, presence or absence of hearing loss, its degree, and the psychoacoustic measurements (pitch, loudness, minimum masking level [MML], and residual inhibition [RI]) of patients with chronic tinnitus and their relationships. Methods: the study included subjects of both sexes, aged 25 to 85 years, with complaints of chronic tinnitus, followed up at the health service where the research was conducted. They were submitted to medical history survey, basic audiological assessment, and pitch, loudness, RI, and MML research. The following statistical tests were used: chi-square test, Fisher’s exact test, Wilcoxon-Mann-Whitney U test, Kruskal-Wallis test, and Spearman’s correlation coefficient. The significance level was set at 5% (p≤0.05). Results: the type of tinnitus was associated with the presence or absence of hearing loss (HL), degree of HL, MML, and loudness; age was associated with the presence or absence of HL and its degree. There was a directly weak proportional correlation between loudness and MML, whereas the correlations between pitch and loudness, pitch and MML, and RI and MML were weak and inversely proportional. Conclusion: both the affected subjects and their tinnitus characteristics were heterogeneous. The results indicate that some variables influence one another, which also happens between psychoacoustic measurements.

Association of tinnitus and self-reported systemic arterial hypertension: a retrospective study

ABSTRACT Purpose To describe data on hearing loss, systemic arterial hypertension and tinnitus of individuals, and to verify the association between self-reported systemic arterial hypertension and tinnitus, as well as to correlate other variables present in the sample: hearing loss and tinnitus, age and tinnitus and age and systemic arterial hypertension. Methods Quantitative, descriptive and inferential, retrospective research with data collection from 473 medical records of adults and elderly people treated between 2008 and 2018. Selected were information on age, gender, result of pure tone audiometry, tinnitus, tinnitus type and frequency, presence of SAH and use of medication to control the disease. Results No association was found between systemic arterial hypertension and tinnitus or between hearing loss and tinnitus and between age and tinnitus, however, an association was observed between age and systemic arterial hypertension using the Chi - Square test. The most common type of tinnitus was wheezing and most individuals who reported feeling more than one type of tinnitus were hypertensive. Conclusion The results found and the literature suggest that systemic arterial hypertension may be an additional factor or an aggravating factor of preexisting factors in the generation of tinnitus, but not the primary cause.

Caracterização dos pacientes com zumbido atendidos por serviço de Saúde Auditiva

RESUMO Objetivo: estabelecer o perfil dos indivíduos com zumbido, atendidos em um serviço de Saúde Auditiva e associar o sintoma com gênero, perfil audiológico e presença de vertigem. Métodos: estudo descritivo, retrospectivo. Foi realizada a análise de 6.000 prontuários de indivíduos atendidos em um serviço de saúde auditiva, os dados coletados do prontuário foram: dados sociodemográficos, características da deficiência auditiva, caraterísticas do zumbido e da vertigem, entrevista fonoaudiológica, avaliações otorrinolaringológicas, audiológicas, otoneurológicas, estilo de vida e dos fatores de risco. A análise descritiva, foi realizada por meio do teste de associação Qui-quadrado, sendo adotado o nível de significância estatística de 5% (p<0,05) para a análise inferencial. Resultados: houve associação estatisticamente significante entre presença de zumbido e gênero, audição normal e vertigem e foi constatada também associação significante entre zumbido e perda auditiva condutiva unilateral e bilateral, perda auditiva sensorioneural unilateral e bilateral. Conclusão: houve associação significante, na população avaliada, para presença de zumbido e gênero feminino, audição normal, perda auditiva condutiva unilateral e bilateral, perda auditiva sensorioneural unilateral e bilateral e presença de vertigem.

Too Blind to See the Elephant? Why Neuroscientists Ought to Be Interested in Tinnitus

A curative therapy for tinnitus currently does not exist. One may actually exist but cannot currently be causally linked to tinnitus due to the lack of consistency of concepts about the neural correlate of tinnitus. Depending on predictions, these concepts would require either a suppression or enhancement of brain activity or an increase in inhibition or disinhibition. Although procedures with a potential to silence tinnitus may exist, the lack of rationale for their curative success hampers an optimization of therapeutic protocols. We discuss here six candidate contributors to tinnitus that have been suggested by a variety of scientific experts in the field and that were addressed in a virtual panel discussion at the ARO round table in February 2021. In this discussion, several potential tinnitus contributors were considered: (i) inhibitory circuits, (ii) attention, (iii) stress, (iv) unidentified sub-entities, (v) maladaptive information transmission, and (vi) minor cochlear deafferentation. Finally, (vii) some potential therapeutic approaches were discussed. The results of this discussion is reflected here in view of potential blind spots that may still remain and that have been ignored in most tinnitus literature. We strongly suggest to consider the high impact of connecting the controversial findings to unravel the whole complexity of the tinnitus phenomenon; an essential prerequisite for establishing suitable therapeutic approaches.