Effects of cognitive behavioural therapy on insomnia in adults with tinnitus: Systematic review and meta-analysis of randomised controlled trials

Evaluation of factors predicting tinnitus outcomes following cochlear implantation: Protocol for a prospective quasi-experimental study

Cochlear implantation is an effective intervention to restore useful aspects of hearing function in adults with severe-to-profound hearing loss. Tinnitus, the perception of sound in the absence of an external source, is common in people with severe-to-profound hearing loss. Existing evidence suggests cochlear implantation may be effective in reducing the negative impact of tinnitus in this population. However, this is contradicted by data suggesting that up to half of cochlear implant recipients experience tinnitus, and that some of these patients who did not have tinnitus before cochlear implantation experience it after surgery or cochlear implant activation. Most evidence on the effects of cochlear implantation on tinnitus comes from secondary data in cochlear implant studies primarily concerned with hearing-related outcomes. Hence, the quality of the evidence for effects on tinnitus is low and not suitable to inform clinical recommendations or decision-making. This study will systematically collect data on tinnitus and tinnitus-related outcomes from patients at multiple points during the cochlear implant pathway to characterise changes in tinnitus. This will improve our understanding of the effects of cochlear implantation for tinnitus in adults with severe to profound hearing loss and inform the design of clinical trials of cochlear implantation for tinnitus.

Development of a Prognostic Nomogram for Modified Tinnitus Relieving Sound Therapy for Subjective Tinnitus

OBJECTIVE

We aimed to develop a modified tinnitus-relieving sound system and establish a model for predicting its treatment effects.

STUDY DESIGN

Retrospective study.

SETTING

Tinnitus Specialist Clinic of Eye & ENT Hospital, Fudan University.

METHODS

We recruited 107 patients undergoing modified tinnitus-relieving sounds between August 2020 and May 2021. Patients were divided into training (n = 75) and validation (n = 32) cohorts in a 7:3 ratio. The treatment outcome was Tinnitus Handicapped Inventory scores. Features were established using a least absolute shrinkage and selection operator-derived logistic regression model, where the selected clinical risk factors were included in the multivariate logistic regression, and a nomogram was established based on the model. The discrimination and calibration abilities of the nomogram were evaluated using the Hosmer-Lemeshow test and calibration curves. Decision curve analysis (DCA) was used to evaluate the net benefit of predictive efficacy.

RESULTS

Multivariate logistic analysis indicated that the initial Tinnitus Handicapped Inventory score (odds ratio [OR]: 1.13 [1.07-1.19], P < .001) and treatment duration (OR: 3.4 [1.34-8.62], P < .001) were positive factors for improved tinnitus. The nomogram model that included baseline Tinnitus Handicapped Inventory score and treatment duration achieved a better concordance index of 0.880. DCA revealed that the nomogram model could lead to net benefits and exhibited a wider range of threshold probabilities for the prediction of therapeutic effects.

CONCLUSION

Our study suggests that the nomogram model, including baseline Tinnitus Handicapped Inventory score and treatment duration, could achieve optimal performance in the preoperative prediction of the therapeutic effect of modified tinnitus-relieving sound.

The European Insomnia Guideline: An update on the diagnosis and treatment of insomnia 2023

Progress in the field of insomnia since 2017 necessitated this update of the European Insomnia Guideline. Recommendations for the diagnostic procedure for insomnia and its comorbidities are: clinical interview (encompassing sleep and medical history); the use of sleep questionnaires and diaries (and physical examination and additional measures where indicated) (A). Actigraphy is not recommended for the routine evaluation of insomnia (C), but may be useful for differential-diagnostic purposes (A). Polysomnography should be used to evaluate other sleep disorders if suspected (i.e. periodic limb movement disorder, sleep-related breathing disorders, etc.), treatment-resistant insomnia (A) and for other indications (B). Cognitive-behavioural therapy for insomnia is recommended as the first-line treatment for chronic insomnia in adults of any age (including patients with comorbidities), either applied in-person or digitally (A). When cognitive-behavioural therapy for insomnia is not sufficiently effective, a pharmacological intervention can be offered (A). Benzodiazepines (A), benzodiazepine receptor agonists (A), daridorexant (A) and low-dose sedating antidepressants (B) can be used for the short-term treatment of insomnia (≤ 4 weeks). Longer-term treatment with these substances may be initiated in some cases, considering advantages and disadvantages (B). Orexin receptor antagonists can be used for periods of up to 3 months or longer in some cases (A). Prolonged-release melatonin can be used for up to 3 months in patients ≥ 55 years (B). Antihistaminergic drugs, antipsychotics, fast-release melatonin, ramelteon and phytotherapeutics are not recommended for insomnia treatment (A). Light therapy and exercise interventions may be useful as adjunct therapies to cognitive-behavioural therapy for insomnia (B).

Suffering from chronic tinnitus, chronic neck pain, or both: Does it impact the presence of signs and symptoms of central sensitization?

Chronic subjective tinnitus is a prevalent symptom, which has many similarities with chronic pain. Central sensitization is considered as a possible underlying mechanism of both symptoms. Central sensitization has already been investigated in chronic pain populations but not in patients with chronic subjective tinnitus. Therefore, the main objective of this cross-sectional study was to compare signs and symptoms, indicative for central sensitization, in tinnitus patients with and without chronic idiopathic neck pain, patients with chronic idiopathic neck pain only, and healthy controls. Also, differences in psychological and lifestyle factors, possibly influencing the association between central sensitization and tinnitus, were examined as well as correlations between signs and symptoms of central sensitization, and tinnitus, pain, psychological and lifestyle factors. Differences in signs and symptoms of central sensitization were examined using the self-report Central Sensitization Inventory and QST protocol (local and distant mechanical and heat hyperalgesia, conditioned pain modulation). Tinnitus, pain, psychological and lifestyle factors were evaluated using self-report questionnaires. Symptoms of central sensitization and local mechanical hyperalgesia were significantly more present in both tinnitus groups, compared to healthy controls, but were most extensive in the group with chronic tinnitus+chronic idiopathic neck pain. Distant mechanical hyperalgesia, indicative for central sensitization, was only observed in the group with both chronic tinnitus+chronic idiopathic neck pain. This group also displayed a significantly higher psychological burden and poorer sleep than patients with chronic tinnitus only and healthy controls. Signs and symptoms of central sensitization were also shown to be associated with tinnitus impact, pain-related disability, psychological burden and sleep disturbances. This study shows preliminary evidence for the presence of central sensitization in patients with chronic tinnitus+chronic idiopathic neck pain. This could be explained by the higher perceived tinnitus impact, psychological burden and sleep problems in this group. Trial registration: This study is registered as NCT05186259 (www.clinicaltrials.gov).

Cognitive behavioural therapy for insomnia (CBTi) as a treatment for tinnitus-related insomnia: a randomised controlled trial

Insomnia is a significant difficulty and is reported by large proportion of people with tinnitus. Although cognitive behavioural therapy for insomnia (CBTi) might be an effective treatment, no controlled studies had been conducted to date. This randomised controlled trial evaluated the benefits of CBTi on a sample of 102 people with tinnitus-related insomnia. Participants were randomised to 1) CBTi, 2) Audiology-Based Care (ABC) or 3) Sleep Support Group (SSG). Primary outcomes included insomnia, sleep efficiency and total sleep time. Secondary outcomes measured sleep onset latency, sleep quality, tinnitus distress, psychological distress, functioning and quality of life. CBTi was superior at reducing insomnia and increasing sleep efficiency compared to ABC post-intervention and at 6-month follow-up. ABC was superior at reducing insomnia and increasing sleep efficiency compared to SSG. Both CBTi and ABC reported increased total sleep time compared to SSG at 6-month follow. More than 80% of participants in the CBTi group reported clinically meaningful improvements compared to 47% in ABC and 20% for those receiving social support. CBTi was more effective in reducing tinnitus distress and improving sleep quality, functioning and some aspects of mental health. CBTi and ABC offer effective treatments for tinnitus-related sleep disorder but CBTi offers a sizeable benefit.

Low Sleep Satisfaction Is Related to High Disease Burden in Tinnitus

Previous studies have shown a high prevalence of sleep disturbances in tinnitus patients. However, no study has yet evaluated subjective sleep satisfaction. The present study aimed to investigate associations of self-reported sleep satisfaction with sociodemographic factors, tinnitus-related distress, depression, and self-reported quality of life. This is a retrospective analysis of 2344 outpatients with tinnitus presenting at a tertiary German tinnitus clinic from 2010 to 2020. Patients who filled in five questionnaires (Tinnitus Handicap Inventory (THI), Tinnitus Questionnaire (TQ), Major Depression Inventory (MDI), Tinnitus Sample Case History Questionnaire (TSCHQ), and the World Health Organization Quality of Life Brief Version (WHOQOL-Bref)) were included. Based on the question about sleep satisfaction in the WHOQOL-Bref, group classification into (I) sleep-satisfied, (II) neither satisfied or dissatisfied, and (III) sleep-dissatisfied patients was performed. Associations between sleep satisfaction and quality of life, depression, tinnitus distress, and tinnitus characteristics were analyzed by group differences and a multinomial regression model with elastic net penalization. A total of 42.38% of patients were satisfied or very satisfied with sleep, whereas 40.91% of patients were dissatisfied or very dissatisfied with sleep. The remaining patients reported being neither satisfied nor dissatisfied with sleep. Sleep-dissatisfied patients were significantly more burdened in questionnaires on depressive symptoms (MDI), tinnitus distress (TQ, THI), and quality of life (WHOQOL-Bref). In addition, they suffered significantly more often from comorbidities such as headache, neck pain, or temporomandibular joint disorder (TMJ). The elastic net regression based on sum scores of THI, TQ, MDI, the four domains of WHOQOL-Bref, as well as all individual questions from the TSCHQ was able to classify patients satisfied with their sleep with an accuracy of 79%, 87.8% sensitivity, and 70.4% specificity. The model could not identify patients indifferent with the quality of their sleep (neither satisfied nor dissatisfied) (sensitivity: 0%; specificity: 100%). The accuracy of the model to predict patients dissatisfied with their sleep was 80.7%, with 83% sensitivity and 78.4% specificity. Poor physical and mental health (Domain I/II WHOQOL-Bref) as well as tinnitus distress were the strongest predictors of sleep dissatisfaction. Conversely, for sleep satisfaction, good physical and mental health as well as low tinnitus distress were the strongest predictors. The division into sleep-satisfied and sleep-dissatisfied tinnitus patients allows a very good discrimination regarding disease burden as indicated by depression, tinnitus distress, quality of life, and pain-related comorbidities. Physical and mental health as well as tinnitus distress seem to be strongly related to sleep satisfaction underscoring the concept of "tinnitus" versus "tinnitus disorder", but also the importance of sleep satisfaction as a global health indicator. Moreover, these data indicate the relevance of addressing sleep disorders in the therapeutic management of chronic tinnitus patients.

Predicting the optimal therapeutic intervention for tinnitus patients using random forest regression: A preliminary study of UNITI's decision support system model

Tinnitus is the conscious perception of a phantom sound in absence of an external or internal stimulus. More than 1 in 7 adults in the EU experience tinnitus and for a large proportion of them tinnitus is an intrusive, persistent, and disabling condition, which impairs their life quality. Therefore, tinnitus is posed as a major global burden, which requires a precision-medicine approach in terms of treatments that are tailored to individual patients, due to its high heterogeneity. UNITI is a research and innovation project which aims towards this goal, unifying treatments and interventions for tinnitus. In the context UNITI, a randomized controlled trial (RCT) is being conducted and all the participants' data will be utilized for the development of a clinical decision support system (CDSS). This CDSS will predict the optimal therapeutic intervention for a tinnitus patient based on their profile. In this paper, we present a preliminary study of the CDSS model development process. We describe the available input data, the pre-processing steps conducted, the algorithms tested to model the CDSS' prediction, the models' results, and the future work in the context of this project. The R2 score of the selected model is currently 0.65, indicating that its development process is in the right direction but further tuning and hyperparameter optimization is needed. Clinical Relevance- The proposed model will be integrated in a CDSS aiming at indicating the optimal treatment strategy for a tinnitus patient based their personal profile.

Factors associated with Self Rated Health in persons with tinnitus from the general population

OBJECTIVES

Tinnitus, the perception of a sound without a corresponding external source, may be associated with decreased Self-Rated Health (SRH). Most research on tinnitus has been done in clinical populations. We aimed to study factors associated with SRH in individuals reporting tinnitus from the general population.

METHODS

In this cross-sectional study, we used data of participants of the Lifelines population-based cohort who answered the question: "Do you hear soughing or whistling in your ear or ears?" (N=124,490). SRH was assessed using the RAND-36 item on SRH. Linear regression was used to study associations between SRH and impairment of hearing, physical and mental health, lifestyle, personality, and demographic features, in the group reporting always tinnitus (N=8,011). Models were also run in the entire study cohort, to test whether tinnitus was associated with SRH after adjustment for these variables.

RESULTS

Of all participants, 6.4% reported always hearing tinnitus, with 83.7% of these reporting good to excellent SRH. The strongest positive associations with SRH in the group reporting always tinnitus were found for younger age, higher education levels, good sleep quality, more social contacts, absence of irritable bowel syndrome and fibromyalgia, high competence, and low impulsivity. In the total population, tinnitus was negatively associated with SRH, while adjusting for demographic features, physical and mental health history, lifestyle, and personality.

CONCLUSION

Our findings contribute to increased understanding of resilience towards the negative consequences of tinnitus. In their early encounters with tinnitus patients, clinicians could focus on self-help regarding sleep hygiene and stimulate social activities.

Audiologist-Supported Internet-Based Cognitive Behavioral Therapy for Tinnitus in the United States: A Pilot Trial

Background Patients often report that living with a condition such as tinnitus can be debilitating, worrying, and frustrating. Efficient ways to foster management strategies for individuals with tinnitus and promoting tinnitus self-efficacy are needed. Internet-based cognitive behavioral therapy (ICBT) for tinnitus shows promise as an evidence-based intervention in Europe, but is not available in the United States. The aim of this pilot study was to evaluate the feasibility of an ICBT intervention for tinnitus in the United States. Method This study reports the Phase 1 trial intended to support implementation of a larger randomized clinical trial (RCT) comparing ICBT to a weekly monitoring group. As a pilot study, a single-group pretest-posttest design was used to determine outcome potential, recruitment strategy, retention, and adherence rates of ICBT for tinnitus. The primary outcome was a change in tinnitus distress. Secondary outcome measures included measures of anxiety, depression, insomnia, tinnitus cognitions, hearing-related difficulties, and quality of life. Results Of the 42 screened participants, nine did not meet the inclusion criteria and six withdrew. There were 27 participants who completed the intervention, with a mean age of 55.48 (± 9.9) years. Feasibility was established, as a large pretest-posttest effect size of d = 1.6 was found for tinnitus severity. Large pretest-posttest effect sizes were also found for tinnitus cognitions and hearing-related effects, and a medium effect was found for insomnia and quality of life. Treatment adherence varied with a retention rate of 85% (n = 23) at post-intervention assessment and 67% (n = 18) for the follow-up assessment. Conclusions This pilot study supported the feasibility of ICBT for tinnitus in the United States. Ways of improving intervention retention and recruitment rates need to be explored in future ICBT studies. Protocol refinements that were identified will be implemented prior to further RCTs to investigate the efficacy of ICBT for tinnitus in the United States. Supplemental Material https://doi.org/10.23641/asha.15501135.