Depression and tinnitus

Results of two cross-sectional database analyses regarding nap-induced modulations of tinnitus

The influence of naps on tinnitus was systematically assessed by exploring the frequency, clinical and demographic characteristics of this phenomenon. 9,724 data from two different tinnitus databases (Tinnitus Hub: n = 6115; Tinnitus Research Initiative (TRI): n = 3627) were included. After separate analysis of the databases, these results were then compared with each other. In the Tinnitus Hub survey database, a total of 31.1% reported an influence on tinnitus by taking a nap (26.9% in the TRI database), with much more frequent worsening after a nap than improvement (23.0% a little or a lot worse; TRI: 17.7% worse; 8.1% a little or a lot better; TRI: 9.2% better). The influence of napping on tinnitus was associated in both databases with other clinical features, such as the dependence of tinnitus on night quality, stress and somatosensory maneuvers. The present study confirms the clinical observation that more tinnitus sufferers report worsening after a nap than tinnitus sufferers reporting an improvement. It was consistently shown that tinnitus sufferers reporting nap-induced modulation of tinnitus also report more frequently an influence of night sleep on their tinnitus. Further clinical and polysomnographic research is warranted to better understand the interaction between sleep and tinnitus.

Evaluation of the effectiveness of cognitive behavioral therapy on tinnitus

OBJECTIVE

This research aims to examine the effects of Cognitive Behavioral Therapy (CBT) on tinnitus in individuals aged 18-60 years.

METHODS

Thirty participants with subjective tinnitus for at least six months were included a randomized controlled trial was conducted with 15 participants in the experimental group and 15 in the control group, with pre-test and post-test measurements. The experimental group received eight CBT sessions for eight weeks. Data were collected using Tinnitus Handicap Inventory (THI) and Visual Analog Scale (VAS). The Mann-Whitney and Wilcoxon Signed Rank Test were used to compare scores between experimental and control groups before and after the intervention.

RESULTS

A within-group difference was found between total scores on THI and VAS before and after CBT in the experimental (z = -3.241, P = 0.001), but not in the control group (z = -1.764, P = 0.078). Following the intervention, there was a significant between-group difference on the THI Emotional, Catastrophic, and Functional tinnitus subscale scores, favoring the experimental group.

CONCLUSIONS

CBT significantly reduced tinnitus level, severity, duration, frequency, discomfort, tinnitus-related attention deficit, and sleep problems. Further studies are needed to replicate these results in other populations.

Associations between somatic symptoms and remission of major depressive disorder: A longitudinal study in China

Previous studies have documented negative associations between somatic symptoms and remission of major depressive disorder (MDD). However, the correlations of specific somatic symptoms with remission remain uncertain. We aimed to explore the associations between specific somatic symptoms and remission focusing on sex differences among patients with MDD. We used data from patients with MDD in the Depression Cohort in China. At baseline, total somatic symptoms were evaluated using the 28-item Somatic Symptoms Inventory and were categorized into pain, autonomic, energy, and central nervous system (CNS) symptoms. To measure remission of MDD, depressive symptoms were evaluated using the Patient Health Questionnaire-9 after 3 months of treatment. We ultimately included 634 patients. Compared with quartile 1 of total somatic symptom scores, the full-adjusted ORs (95% CIs) for remission from quartile 2 to quartile 4 were 0.52 (0.30, 0.90), 0.44 (0.23, 0.83), and 0.36 (0.17, 0.75), respectively (P-value for trend = 0.005). The restricted cubic spline showed no non-linear associations between total somatic symptoms with remission (P-value for non-linear = 0.238). Pain, autonomic, and CNS symptoms showed similar results. Sex-stratified analysis showed that total somatic symptoms, pain symptoms, and autonomic symptoms were negatively correlated with remission in females, whereas CNS symptoms were negatively associated with remission in males. Our findings indicate that specific somatic symptoms exert differential effects on remission of MDD. Therapeutic interventions that target pain, autonomic, and CNS symptoms may increase the probability of remission. Furthermore, interventions for somatic symptoms should be tailored by sex, and females deserve more attention.

The Placebo Effect on Tinnitus: A Systematic Review and Meta-Analysis of Randomized Controlled Trials

OBJECTIVE

To quantify the placebo effect in randomized clinical trials treating tinnitus with oral or intratympanic placebo treatment.

DATA SOURCES

CINAHL, PubMed, and Scopus were searched for articles from conception to October 2022. MESH and key terms such as "tinnitus," "placebo," and "medication" were used to find randomized, placebo-controlled trials. The search was limited to articles in English.

METHODS

Randomized controlled trials with adult subjects evaluating tinnitus pretreatment and posttreatment with an oral or intratympanic medication versus a placebo arm were included. Crossover studies, studies involving middle/inner ear operations or devices, and studies that exclusively included nonidiopathic etiologies of tinnitus were excluded. Mean tinnitus symptom survey scores for the Tinnitus Handicap Inventory (THI), Tinnitus Severity Index, Tinnitus Functional Index, Tinnitus Handicap Questionnaire, and Visual Analog Scales for tinnitus Intensity/Loudness (VAS-L), Annoyance (VAS-An), and Awareness (VAS-Aw) were extracted for both placebo and experimental groups.

RESULTS

953 studies were screened with 23 studies being included in the final analysis. Meta-analysis of mean difference (MD) was calculated using RevMan 5.4. MD between pretreatment and posttreatment THI scores of the placebo arms was 5.6 (95% confidence interval, 3.3-8.0; p < 0.001). MD between pretreatment and posttreatment VAS scores of the placebo groups for Loudness, Annoyance, and Awareness were 0.8 (0.0 to 1.6, p = 0.05), 0.2 (-0.2 to 0.5, p = 0.34), and 0.3 (-0.0 to 0.7, p = 0.08), respectively.

CONCLUSIONS

Placebo treatment has shown effectiveness in improving patient-reported evaluations of tinnitus when using some standardized metrics such as THI and VAS-L; however, the improvement is not as substantial as nonplacebo treatment.

Eavesdropping on Tinnitus Using MEG: Lessons Learned and Future Perspectives

Tinnitus has been widely investigated in order to draw conclusions about the underlying causes and altered neural activity in various brain regions. Existing studies have based their work on different tinnitus frameworks, ranging from a more local perspective on the auditory cortex to the inclusion of broader networks and various approaches towards tinnitus perception and distress. Magnetoencephalography (MEG) provides a powerful tool for efficiently investigating tinnitus and aberrant neural activity both spatially and temporally. However, results are inconclusive, and studies are rarely mapped to theoretical frameworks. The purpose of this review was to firstly introduce MEG to interested researchers and secondly provide a synopsis of the current state. We divided recent tinnitus research in MEG into study designs using resting state measurements and studies implementing tone stimulation paradigms. The studies were categorized based on their theoretical foundation, and we outlined shortcomings as well as inconsistencies within the different approaches. Finally, we provided future perspectives on how to benefit more efficiently from the enormous potential of MEG. We suggested novel approaches from a theoretical, conceptual, and methodological point of view to allow future research to obtain a more comprehensive understanding of tinnitus and its underlying processes.

Evidence of cochlear neural degeneration in normal-hearing subjects with tinnitus

Tinnitus, reduced sound-level tolerance, and difficulties hearing in noisy environments are the most common complaints associated with sensorineural hearing loss in adult populations. This study aims to clarify if cochlear neural degeneration estimated in a large pool of participants with normal audiograms is associated with self-report of tinnitus using a test battery probing the different stages of the auditory processing from hair cell responses to the auditory reflexes of the brainstem. Self-report of chronic tinnitus was significantly associated with (1) reduced cochlear nerve responses, (2) weaker middle-ear muscle reflexes, (3) stronger medial olivocochlear efferent reflexes and (4) hyperactivity in the central auditory pathways. These results support the model of tinnitus generation whereby decreased neural activity from a damaged cochlea can elicit hyperactivity from decreased inhibition in the central nervous system.

Desensitizing nicotinic agents normalize tinnitus-related inhibitory dysfunction in the auditory cortex and ameliorate behavioral evidence of tinnitus

Tinnitus impacts between 10-20% of the population. Individuals most troubled by their tinnitus have their attention bound to and are distracted by, their tinnitus percept. While numerous treatments to ameliorate tinnitus have been tried, no therapeutic approach has been clinically accepted. The present study used an established condition-suppression noise-exposure rat model of tinnitus to: (1) examine tinnitus-related changes in nAChR function of layer 5 pyramidal (PNs) and of vasoactive intestinal peptide (VIP) neurons in primary auditory cortex (A1) and (2) examine how the partial desensitizing nAChR agonists, sazetidine-A and varenicline, can act as potential therapeutic agents in the treatment of tinnitus. We posited that tinnitus-related changes in layer 5 nAChR responses may underpin the decline in attentional resources previously observed in this animal model (Brozoski et al., 2019). In vitro whole-cell patch-clamp studies previously revealed a significant tinnitus-related loss in nAChR-evoked excitatory postsynaptic currents from A1 layer 5 PNs. In contrast, VIP neurons from animals with behavioral evidence of tinnitus showed significantly increased nAChR-evoked excitability. Here we hypothesize that sazetidine-A and varenicline have therapeutic benefits for subjects who cannot divert their attention away from the phantom sound in their heads. We found that sazetidine-A or varenicline normalized tinnitus-related reductions in GABAergic input currents onto A1 layer 5 PNs. We then tested sazetidine-A and varenicline for the management of tinnitus using our tinnitus animal model. Subcutaneous injection of sazetidine-A or varenicline, 1 h prior to tinnitus testing, significantly decreased the rat's behavioral evidence of tinnitus in a dose-dependent manner. Collectively, these results support the need for additional clinical investigations of partial desensitizing nAChR agonists sazetidine-A and varenicline for the treatment of tinnitus.

Efficacy and factors influencing outcomes of customized music therapy combined with a follow-up system in chronic tinnitus patients

BACKGROUNDS

Tinnitus is a meaningless sound signal perceived by the patients in the absence of auditory stimuli. Due to the complex etiology and unclear mechanism, specific therapies for tinnitus are still in the exploratory stage. In recent years, personalized and customized music therapy has been proposed as an effective method for tinnitus treatment. The aim of this study was to explore the efficacy of customized therapy with a well-designed follow-up system in the treatment of tinnitus through a large sample one arm study and to identify the relevant factors affecting the treatment outcome.

METHODS

The study investigated a total of 615 patients with unilateral or bilateral chronic tinnitus who received personalized and customized music therapy for 3 months. A complete follow-up system was designed by the professionals. Questionnaires of Tinnitus Handicap Inventory (THI), Hospital Anxiety and Depression Scale (HADS) and Visual Analogue Scale (VAS) were used to evaluate the therapeutic effects and relevant factors affecting the efficacy of therapy.

RESULTS

The results showed a decreasing trend in THI and VAS scores after 3 months of therapy, with statistically significant differences between pre- and post-therapy time points (P < 0.001). All patients were divided into 5 groups according to THI scores, and the mean reduction score in catastrophic, severe, moderate, mild and slight group was 28, 19, 11, 5, 0 respectively. The proportion of tinnitus patients with anxiety was higher than that with depression (70.57% and 40.65%, respectively), and there were statistically significant differences between HADS-A/D scores pre- and post-therapy. Binary logistic regression showed that the baseline of THI, VAS scores, the duration of tinnitus and the state of anxiety prior to therapy were significant influencing factors of therapeutic efficacy.

CONCLUSIONS

The magnitude of reduction in THI scores after music therapy depended on the severity of the patients' tinnitus, the higher the initial THI scores, the greater the potential for improvement in tinnitus disorders. Music therapy also reduced the anxiety and depression levels of tinnitus patients. Therefore, personalized and customized music therapy with a comprehensive follow-up system may be an effective treatment option for chronic tinnitus patients.

Tinnitus-frequency specific activity and connectivity: A MEG study

Tinnitus pathophysiology has been associated with an atypical cortical network that involves functional changes in auditory and non-auditory areas. Numerous resting-state studies have replicated a tinnitus brain network to be significantly different from healthy-controls. Yet it is still unknown whether the cortical reorganization is attributed to the tinnitus frequency specifically or if it is frequency-irrelevant. Employing magnetoencephalography (MEG), the current study aimed to identify frequency-specific activity patterns by using an individual tinnitus tone (TT) and a 500 Hz-control tone (CT) as auditory stimuli, across 54 tinnitus patients. MEG data were analyzed in a data-driven approach employing a whole-head model in source space and in sources' functional connectivity. Compared to the CT, the event related source space analysis revealed a statistically significant response to TT involving fronto-parietal regions. The CT mainly involved typical auditory activation-related regions. A comparison of the cortical responses to a healthy control group that underwent the same paradigm rejected the alternative interpretation that the frequency-specific activation differences were due to the higher frequency of the TT. Overall, the results suggest frequency-specificity of tinnitus-related cortical patterns. In line with previous studies, we demonstrated a tinnitus-frequency specific network comprising left fronto-temporal, fronto-parietal and tempo-parietal junctions.

The association between stress, emotional states, and tinnitus: a mini-review

Extensive literature supporting the view of tinnitus induced stress in patients is available. However, limited evidence has been produced studying the opposite, that is, does stress cause tinnitus? The hypothalamus pituitary adrenal axis, one of the main neuroendocrine systems involved in stress response, is commonly disturbed in tinnitus patients. Patients with chronic tinnitus have been shown to develop abnormal responses to psycho-social stress, where the hypothalamus pituitary adrenal axis response is weaker and delayed, suggesting chronic stress contributes to the development of chronic tinnitus. The sympathetic branch of the autonomic nervous system also plays a major role in stress response and its chronic hyperactivity seems to be involved in developing tinnitus. Psycho-social stress has been shown to share the same probability of developing tinnitus as occupational noise and contributes to worsening tinnitus. Additionally, exposure to high stress levels and occupational noise doubles the likelihood of developing tinnitus. Interestingly, short-term stress has been shown to protect the cochlea in animals, but chronic stress exposure has negative consequences. Emotional stress also worsens pre-existing tinnitus and is identified as an important indicator of tinnitus severity. Although there is limited body of literature, stress does seem to play a vital role in the development of tinnitus. This review aims to highlight the association between stress, emotional states, and the development of tinnitus while also addressing the neural and hormonal pathways involved.

Changes in late-latency auditory evoked potentials after tinnitus suppression using auditory stimulation

OBJECTIVE

Tinnitus can result from auditory system reorganization due to neural activity dysfunctions. Auditory stimulation can cause temporary or persistent tinnitus alleviation by altering the neural generators. The present study investigated the changes in Late-Latency Auditory Evoked Potentials (LLAEPs) after tinnitus suppression using auditory stimulation with short-term Residual Inhibition (RI) and long-term Tinnitus Masker (TM).

METHODS

The study included 40 participates with equal numbers in the Tinnitus Group (TG), including the chronic tinnitus subjects, and the Control Group (CG), including matched volunteers. The participants had normal hearing in conventional audiometry. All the participants underwent LLAEP recording pre-intervention and after a one-minute auditory stimulation (RI), as well as a pre-intervention Dichotic Digit Test (DDT) as a behavioral assessment of the selective attention. Moreover, TG underwent a 3-month course of TM, a third LLAEP recording post-TM, a second DDT post-TM, and the Tinnitus Handicap Inventory (THI) before and after the TM.

RESULTS

In the baseline LLAEP recording, the TG had significantly later N1, P3a, and P3b latencies, as well as significantly lower P3a and P3b amplitudes. The second LLAEP recording showed a significant intragroup increase in P3a amplitude and a significant decrease in P3a latency in the TG, while no significant intragroup difference was observed in the CG. In the third LLAEP recording performed on TG, the P3a amplitude and latency had significant changes compared to the second recording, while the N1 latency was significantly decreased. Moreover, the DDT and THI scores had significant improvement after the TM in TG.

CONCLUSIONS

The present study showed the neurophysiological changes after short-term (RI) and long-term (TM) auditory stimulations in tinnitus subjects. The LLAEP changes suggest that these interventions lead to tinnitus suppression through common mechanisms. The electrophysiological observation was also confirmed using behavioral assessments.

LEVEL OF EVIDENCE

This study type is a "comparative study" with the level of evidence "3".

Utilizing Co-Creative Principles to Develop an E-Learning Platform for Interprofessional Training on Tinnitus: The Erasmus+ Project Tin-TRAC

Tinnitus treatment, diagnosis and management across Europe varies significantly. The lack of national clinical guidelines for tinnitus management in most European countries and the absence of a common language across all disciplines involved is reflected in the diversification of healthcare practices. Interprofessional Training for Tinnitus Researchers and Clinicians (Tin-TRAC) is an Erasmus+ project that aims to develop common educational ground in the form of an e-Learning platform, co-created by patients, researchers and clinicians, which is able to unify tinnitus diagnosis and treatment strategies across Europe. A pan-European thematic educational platform integrating the best practices and latest research achievements with regard to tinnitus diagnosis and management has the potential to act as a facilitator of the reduction of interdisciplinary and interregional practice diversification. A detailed analysis of the educational needs of clinicians and researchers across disciplines will be followed by the co-creative development of the curriculum. Reusable learning objects will incorporate the training contents and will be integrated in an open e-Learning platform. Tin-TRAC envisions that its output will answer the need to create a common language across the clinicians and researchers of different disciplines that are involved in tinnitus management, and reduce patients' prolonged suffering, non-adherence and endless referral trajectories.

Correlation Between Chronic Tinnitus Distress and Symptoms of Depression: A Systematic Review

Objectives

In this systematic review, we aim to evaluate the evidence regarding the correlation between tinnitus distress and the severity of depressive symptoms in patients with chronic tinnitus. Also, the prevalence of clinically relevant depressive symptoms scores in patients with chronic tinnitus was evaluated.

Methods

We performed a systematic review in PubMed, EMBASE, and the Cochrane library in June 2021 using the terms “depression” and “tinnitus,” and their synonyms, following PRISMA guidelines. Studies were selected on relevance and critically appraised regarding risk of bias using the Newcastle–Ottowa Quality Assessment Scale.

Results

A total of 1,912 articles were screened on title and abstract after the removal of the duplicates. Eventually, 33 (1.5%) articles were included for the final analysis. Only cross-sectional cohort studies and case–control studies with a low level of evidence and a high risk of bias due to the study design and patient selection were found. Statistically significant correlations between the experienced tinnitus distress and depressive symptoms were reported in 31 out of 33 studies. Clinically relevant depression scores had a prevalence of 4.6–41.7%.

Conclusions

In this systematic review, in which mostly cross-sectional studies were included, a statistically significant correlation was found between the experienced tinnitus distress and the reported severity of symptoms of depression in patients with chronic tinnitus. A wide range of clinically relevant depression scores were reported in included studies. Due to the high risk of bias of included studies it is not possible to provide a definite answer on the existence of this relationship. Future population-based studies are necessary to provide more clarity.

Tinnitus suppression with electrical stimulation in adults: long-term follow-up

Objectives

To investigate the long-term effects of cochlear implants as a treatment for patients with severe to profound neurosensory loss associated with severe tinnitus.

Methods

Prospective study in 17 adult patients with severe to profound sensorineural hearing loss associated with severe tinnitus, indicated with a Tinnitus Handicap Inventory (THI) score ≥ 58%, and hyperacusis. Measures were made on hearing, tinnitus, hyperacusis and quality of life up to 5 years after activation of the sound processor of the cochlear implant. It was evaluated by using the disyllabic test, THI, visual analogue scale and Glasgow Benefit Inventory questionnaire.

Results

60 months after cochlear implantation, improvements in loudness and discomfort of tinnitus, speech discrimination and hyperacusis were observed. Subjects perceive an important subjective benefit upon receiving the cochlear implant.

Conclusions

Cochlear implants can be used as treatment for patients with severe to profound sensorineural hearing loss associated with severe tinnitus and hyperacusis with long-term benefits on quality of life and lasting relief of tinnitus.

Sex-Specific Prevalence, Demographic Characteristics, and Risk Factors of Tinnitus in the Hispanic Community Health Study/Study of Latinos

PURPOSE

The aim of this study was to determine the prevalence of any and chronic tinnitus among female and male individuals from varied Hispanic/Latino backgrounds and to estimate associations between risk factors for chronic tinnitus.

METHOD

Our analysis used cross-sectional baseline data collected from 2008 to 2011 from the Hispanic Community Health Study/Study of Latinos (HCHS/SOL). Prevalence estimates and multivariable logistic regression were conducted using survey methodology. Participants included 15,768 adults (8,229 women and 7,539 men) aged 18-76 years. The primary outcome of interest was chronic tinnitus, defined as self-reported tinnitus lasting ≥ 5 min at a time and at least once per week. We hypothesized that after adjusting for covariates, the risk factors of depressed and anxious symptoms, smoking history, hypertension, and noise exposure history would be associated with higher odds of chronic tinnitus.

RESULTS

Unstratified prevalence for any tinnitus was 32.9%, and for chronic tinnitus, it was 12.1%. Sex-stratified results demonstrated that 2,995 female individuals (36.4%) and 2,187 male individuals (29.0%) reported any tinnitus, and of these, 1,043 female individuals (12.7%) and 870 male individuals (11.5%) reported chronic tinnitus. In the fully adjusted model, depressed and anxious symptoms as well as recreational noise exposure were associated with higher odds of chronic tinnitus in female individuals (odds ratios [ORs] = 1.06, confidence interval [CI; 1.04, 1.07]; 1.02, CI [1.01, 1.04]; and 1.40, CI [1.20, 1.62]) and in male individuals (ORs = 1.06, CI [1.03, 1.08]; 1.05, CI [1.02, 1.08]; and 1.30, CI [1.05, 1.65]). Current smoking was a risk factor for chronic tinnitus in male individuals (OR = 1.53, CI [1.16, 2.02]).

CONCLUSIONS

Prevalence of any and chronic tinnitus in the HCHS/SOL baseline cohort is higher than that reported in previous studies, particularly among female individuals. Understanding risk factors associated with tinnitus is important for the development of culturally and linguistically appropriate public health programs that consider sex differences and promote lifestyle modifications known to lower the odds of experiencing tinnitus.

Reduction of Somatic Tinnitus Severity is Mediated by Improvement of Temporomandibular Disorders

BACKGROUND

Successful orofacial treatment can reduce tinnitus severity in patients with somatic tinnitus (ST). However, it is still unclear to what extent the degree of reduction in temporomandibular disorders (TMD) actually contributes to the decrease in tinnitus severity after orofacial treatment. Therefore, the aim of this study was to analyze the mediating effect of reduction in TMD pain on the improvement of tinnitus severity after multidisciplinary orofacial treatment.

METHODS

A total of 80 patients with moderate to severe ST attributed to the temporomandibular region, were recruited from a tertiary tinnitus clinic. At baseline, patients were randomly assigned to the orofacial treatment group or to the control group. Both groups received a minimum of information and advice regarding their tinnitus complaints. The orofacial treatment group received orofacial physical therapy complemented with occlusal splints when needed, while the control group received no other treatment. A mediation analysis was performed according to the steps described by Baron and Kenny and the proportion of the mediating effect was calculated for the potential mediator: "change in TMD pain," measured by a one-point decrease in TMD pain screener score.

RESULTS

Our analysis showed that 35% of the observed decrease in tinnitus severity can be attributed to a reduction in TMD pain. A significant total effect of orofacial treatment compared with control on the change in tinnitus functional index (TFI) score was found (B = 0.253 p = 0.025 Cl for B = 1.265-18.576). Orofacial treatment was also significantly related to the change in TMD pain (Exp (B) = 2.800, p = 0.034 Cl for Exp B 1.081-7.251). Additionally, the change in TMD pain screener score was significantly related to the change in TFI score (B = -0.273 p = 0.016 Cl for B = -19.875 to -2.119).

CONCLUSION

Reduction of TMD pain is a mediating factor in the decrease of tinnitus severity after multidisciplinary orofacial treatment.

PRACTICAL IMPLICATIONS

Orofacial treatment can be used to decrease tinnitus severity in patients with TMD related somatic tinnitus.

The Road Traveled and Journey Ahead for the Genetics and Genomics of Tinnitus

The feasibility to unravel genetic and genomic signatures for disorders affecting the auditory system has accelerated since arriving in the post-genomics era roughly 20 years ago. Newly emerging studies have provided initial landmarks signaling heritability and thus, a genetic link, to severe tinnitus. Tinnitus, the phantom perception of ringing in the ears, is experienced by at least 15% of the adult population and can be extremely disabling. Despite its ubiquity, there is no cure for tinnitus and modalities offering relief are often of limited success. Because tinnitus is frequently reported in patients with acquired conductive or sensorineural hearing impairment, it has been widely accepted that tinnitus is secondary to and a symptom arising from hearing impairment. However, tinnitus has also been identified in the absence of auditory dysfunction and in young individuals, resulting in a debate about its origins. Genetics studies have identified severe tinnitus as a complex disorder arising from gene and environment interactions, refining its classification as a neurological disorder and, in at least a subset of patients, it appears not as a symptom of another health issue. This current opinion summarizes several recent studies that have challenged a long-accepted dogma and postulates how this information could eventually be used in the future to help patients. It is with great hope that this knowledge opens translational paths to provide relief for the many who suffer from the burden of tinnitus on a daily basis.

The effectiveness of the combined transcranial direct current stimulation (tDCS) and tailor-made notched music training (TMNMT) on psychoacoustic, psychometric, and cognitive indices of tinnitus patients

PURPOSE

Tinnitus network(s) consists of pathways in the auditory cortex, frontal cortex, and the limbic system. The cortical hyperactivity caused by tinnitus may be suppressed by neuromodulation techniques. Due to the lack of definitive treatment for tinnitus and limited usefulness of the individual methods, in this study, a combination of transcranial direct current stimulation (tDCS) over the dorsolateral prefrontal cortex (DLPFC) and tailor-made notched music training (TMNMT) was used.

MATERIAL AND METHODS

In this descriptive-analytic study, 26 patients with chronic unilateral tinnitus of the right ear were randomly divided into the clinical trial group (CTG) and the control group (CG). In both groups, six sessions of tDCS with 2 mA intensity for 20 min, with anode on F4 and cathode on F3, were conducted. Simultaneous with tDCS sessions, and based on TMNMT, the participant was asked to listen passively for 120 min/day, to a CD containing her/his favorite music with a proper notch applied in its spectrum according to the individual's tinnitus The treatment outcome was measured by, psychoacoustic (loudness-matching), psychometric (awareness, loudness and annoyance Visual Analogue Scale (VAS) scores, and Tinnitus Handicap Inventory (THI)) scores, and cognitive assessments (randomized dichotic digits test (RDDT) and dichotic auditory-verbal memory test (DAVMT)). Repeated measurement test was used for statistical analyses.

RESULTS

In the CTG, the tinnitus loudness and annoyance VAS scores, and THI were reduced significantly (p = 0.001). In addition, the DAVMT and RDDT scores were enhanced (p = 0.001). Such changes were not observed in the CG (p > 0.05).

CONCLUSION

The combination of tDCS and TMNMT led to a reduction in the loudness, awareness, annoyance, and also disability induced by tinnitus in CTG. Furthermore, this method showed an improvement of cognitive functions (auditory divided attention, selective attention and working memory) in the CTG.

Surrounded by Sound: The Impact of Tinnitus on Musicians

AIM

To investigate the impact of tinnitus on professional musicians in the UK.

BACKGROUND

Tinnitus is the experience of sound when an external source is absent, primarily associated with the ageing process, hearing loss, and noise exposure. Amongst populations exposed to industrial noise, noise exposure and noise-induced hearing loss (NIHL) have been found to be the factors most associated with tinnitus. The risk of NIHL amongst professional musicians is greater than that amongst the general population, meaning they may be at increased risk of tinnitus.

METHODS

Seventy-four professional musicians completed an online survey involving closed and open-ended questions, and completed the Tinnitus fuctional Index (TFI) questionnaire. Descriptive statistics and thematic analysis of open-ended qualitative responses were used to analyse the data.

RESULTS

Three themes were generated from the analysis of the responses to the open-ended questions. These themes were: (1) the impact of tinnitus on the lives of professional musicians, (2) professional musician experience of tinnitus services, support, and hearing health and safety, and (3) the support professional musicians want. The mean global TFI score for professional musicians was 39.05, interpreted as tinnitus being a moderate problem. Comparisons with general population data revealed lower TFI scores for the TFI subscales of 'sense of control' and 'intrusiveness' for professional musicians and higher for auditory difficulties associated with tinnitus amongst professional musicians.

CONCLUSION

Tinnitus can negatively impact on professional musicians' lives. There is a need for bespoke self-help groups, awareness raising, and education to prevent tinnitus and promote hearing health among musicians.

Quality of Life and Psychological Distress in Portuguese Older Individuals with Tinnitus

Tinnitus is the perception of a sound without an external source, often associated with adverse psychological and emotional effects leading to impaired quality of life (QoL). The present study investigated QoL and psychological distress in tinnitus patients and analysed the effects of associated comorbidities. Tonal and speech audiometry, tinnitus assessment, and clinical interviews were obtained from 122 Portuguese individuals (aged from 55 to 75). Portuguese versions of the Brief Symptoms Inventory (BSI), the Medical Outcomes Study Short Form Health Survey (MOS SF-36) and Tinnitus Handicap Inventory (THI) were used to evaluate psychological distress, health-related QoL, social difficulties and tinnitus severity. The presence of tinnitus was significantly associated with hearing loss. The increases in tinnitus severity were associated with decreases in QoL, particularly regarding MOS SF-36 subscales “perception of health”, “social functioning”, and “mental health”. Regarding BSI, patients with greater tinnitus severity had more severe psychopathology symptoms, measured with scales “Obsessive–compulsive”, “Depression”, “Anxiety”, “Hostility” and “Phobic Anxiety”. Our study supports the notion of the negative impact of increased tinnitus severity on QoL and psychological distress in older adults. Presented data strengthen the importance of a multidisciplinary approach to tinnitus assessment and treatment.

What's the buzz? The neuroscience and the treatment of tinnitus

Tinnitus is a pervasive public health issue that affects ∼15% of the United States population. Similar estimates have also been shown on a global scale, with similar prevalence found in Europe, Asia, and Africa. The severity of tinnitus is heterogeneous, ranging from mildly bothersome to extremely disruptive. In the United States, ∼10-20% of individuals who experience tinnitus report symptoms that severely reduce their quality of life. Due to the huge personal and societal burden, in the last 20 yr a concerted effort on basic and clinical research has significantly advanced our understanding and treatment of this disorder. Yet, neither full understanding, nor cure exists. We know that tinnitus is the persistent involuntary phantom percept of internally generated nonverbal indistinct noises and tones, which in most cases is initiated by acquired hearing loss and maintained only when this loss is coupled with distinct neuronal changes in auditory and extra-auditory brain networks. Yet, the exact mechanisms and patterns of neural activity that are necessary and sufficient for the perceptual generation and maintenance of tinnitus remain incompletely understood. Combinations of animal model and human research will be essential in filling these gaps. Nevertheless, the existing progress in investigating the neurophysiological mechanisms has improved current treatment and highlighted novel targets for drug development and clinical trials. The aim of this review is to thoroughly discuss the current state of human and animal tinnitus research, outline current challenges, and highlight new and exciting research opportunities.

Two birds with one stone.-Addressing depressive symptoms, emotional tension and worry improves tinnitus-related distress and affective pain perceptions in patients with chronic tinnitus

BACKGROUND

Psychological factors link the co-occurrence of tinnitus-related distress and pain perceptions in patients with chronic tinnitus.

OBJECTIVE

This study examines, if treatment-related changes in these factors ameliorate both tinnitus-related distress and pain perceptions in a sample of patients with chronic tinnitus.

METHODS

N = 1238 patients with chronic tinnitus provided pre- and post-treatment ratings of tinnitus-related distress and affective or sensory pain perceptions alongside measures of depressive symptoms and perceived stress. Treatment comprised an intensive tinnitus-specific multimodal treatment program. Using serial indirect-effects analyses, we examined association patterns between baseline values and change rates of those variables that were found to respond to treatment.

RESULTS

Small effect sizes emerged for changes in tinnitus-related distress, affective (but not sensory) pain perceptions, depressive symptoms, emotional tension and worry. At pre- or post-treatment respectively, baseline values and change rates intercorrelated. Across timepoints, (1) baseline tinnitus-related distress and affective pain perceptions were positively associated with improvements in tinnitus-related distress, affective pain perceptions and depressive symptoms. (2) Baseline depressive symptoms or emotional tension mediated positive associations between baseline tinnitus-related distress and improvement in affective pain perceptions. (3) Change in depressive symptoms mediated the effect of baseline tinnitus-related distress on change in affective pain perceptions-partly through associated change in emotional tension or worry. Mood-independent aspects of emotional tension were negatively associated with improvement in affective pain perceptions.

CONCLUSIONS

Depressive symptoms, emotional tension and worry emerge as key predictors of treatment response and transdiagnostic treatment targets for alleviating tinnitus-related distress and functionally associated affective pain perceptions.

The Mediating Effect of Psychological Distress on the Association between BDNF, 5-HTTLPR, and Tinnitus Severity

OBJECTIVE

To investigate the association between genetic polymorphisms of brain-derived neurotrophic factor (BDNF) or serotonin transporter gene-linked polymorphic region (5-HTTLPR) and tinnitus, and the mediating effects of psychological distress on this association.

METHODS

Eighty-six patients experiencing tinnitus and 252 controls were recruited. The Tinnitus Handicap Inventory was used to assess the severity of tinnitus and the Beck Depression Inventory-II (BDI-II), Beck Anxiety Inventory-II (BAI-II), and the Korean version of the Brief Encounter Psychosocial Instrument (BEPSI-K) were used to assess psychological distress. We compared the association of BDNF rs6265 (Val66Met) and 5-HTTLPR variants in the two groups. The mediating effects of BDI-II, BAI-II, and BEPSI-K were examined using multiple regression analysis and validated by the Sobel test and bootstrapping.

RESULTS

No significant differences were found between the groups regarding BDNF Val66Met and 5-HTTLPR, but the 5-HTTLPR variants trended toward association. Depressive symptoms appeared to act as a mediator on the relationship within the 5-HTTLPR s/s genotype and the severity of tinnitus.

CONCLUSION

Our findings provide a speculative idea on the association between the serotonergic system and tinnitus and suggest that depressive symptoms act as a mediator in tinnitus. Therefore, screening for depressive symptoms in patients with tinnitus is essential and intervention for depressive symptoms may help alleviate the severity of tinnitus.

Neuroanatomical Alterations in Patients With Tinnitus Before and After Sound Therapy: A Combined VBM and SCN Study

Many neuroanatomical alterations have been detected in patients with tinnitus in previous studies. However, little is known about the morphological and structural covariance network (SCN) changes before and after long-term sound therapy. This study aimed to explore alterations in brain anatomical and SCN changes in patients with idiopathic tinnitus using voxel-based morphometry (VBM) analysis 24 weeks before and after sound therapy. Thirty-three tinnitus patients underwent magnetic resonance imaging scans at baseline and after 24 weeks of sound therapy. Twenty-six age- and sex-matched healthy control (HC) individuals also underwent two scans over a 24-week interval; 3.0T MRI and high-resolution 3D structural images were acquired with a 3D-BRAVO pulse sequence. Structural image data preprocessing was performed using the VBM8 toolbox. The Tinnitus Handicap Inventory (THI) score was assessed for the severity of tinnitus before and after treatment. Two-way mixed model analysis of variance (ANOVA) and post hoc analyses were performed to determine differences between the two groups (patients and HCs) and between the two scans (at baseline and on the 24th week). Student-Newman-Keuls (SNK) tests were used in the post hoc analysis. Interaction effects between the two groups and the two scans demonstrated significantly different gray matter (GM) volume in the right parahippocampus gyrus, right caudate, left superior temporal gyrus, left cuneus gyrus, and right calcarine gyrus; we found significantly decreased GM volume in the above five brain regions among the tinnitus patients before sound therapy (baseline) compared to that in the HC group. The 24-week sound therapy group demonstrated significantly greater brain volume compared with the baseline group among these brain regions. We did not find significant differences in brain regions between the 24-week sound therapy and HC groups. The SCN results showed that the left superior temporal gyrus and left rolandic operculum were significantly different in nodal efficiency, nodal degree centrality, and nodal betweenness centrality after FDR correction. This study characterized the effect of sound therapy on brain GM volume, especially in the left superior temporal lobe. Notably, sound therapy had a normalizing effect on tinnitus patients.

Coping in Chronic Tinnitus Patients

Background: Tinnitus is the perception of sound without an external stimulus. A large part of the adult population experiences this symptom but never seeks professional help, where others have devastating complaints in daily life. This suggests that the impact of tinnitus varies among patients and may be influenced by coping strategies and multiple psychological factors.

Method: Cross- sectional study of patients visiting the tertiary tinnitus referral center of the University Medical Center Utrecht, the Netherlands. Three hundred and twenty-one consecutive chronic tinnitus patients were evaluated by the tinnitus care group Utrecht from 6–2007 till 11–2012 of which 308 patients were included. Patients completed two tinnitus distress questionnaires (THI, TQ), a coping questionnaire (CISS) as well as a psychopathological questionnaire (SCL-90-R).

Results: Emotional-orientated coping and distraction-orientated coping strategies were significantly correlated with the experienced tinnitus burden. Also a significant negative correlation with task orientated coping was found. The effect size was small. Tinnitus distress also had a significant positive correlation with anxiety, agoraphobia, depression, insufficiency of handling, distrust & personal sensitivity, hostility and sleeping problems.

Conclusion: Patients with higher tinnitus handicap scores demonstrated the use different coping strategies than the patients with lower distress scores. This insight in coping strategies in a group of patients with high tinnitus burden is useful for counseling patients. As tinnitus coping strategy might be related to the extent and success of habituation, this outcome could be of interest to optimize tinnitus treatments in the near future.

Maintaining the legacy and moving forward: The new tinnitus questionnaire short form version 2

OBJECTIVE

The original 52-item version of the Tinnitus Questionnaire (TQ) is a widely applied self-report instrument to measure tinnitus-related distress. One objective of the current study was the validation of the reported five-factor structure of the German TQ in a new, large sample of patients with chronic tinnitus. Since former studies have yielded conflicting results for the factor structure of the 12-item short version (Mini-TQ), analysis of its factor structure and the generation of a new short version were further study aims.

METHODS

Data of 7112 subsequent patients with chronic tinnitus that filled out the German 52-item version of the TQ at the Tinnitus Center at Charité University Hospital Berlin, Germany, were included in the study. Statistical analyses included exploratory factor analysis (EFA) and confirmatory factor analysis (CFA).

RESULTS

CFA showed reasonably acceptable fit indices for a five-factor model for the 52-item version of the TQ, at least for RMSEA, one of the three fit indices (RMSEA = 0.059; CFI = 0.871; TLI = 0.861). Factors were called emotional distress, auditory perceptual difficulties, intrusiveness, sleep disturbances, and coping. Another CFA supports a three-factor model of the newly generated 15-item short version (RMSEA = 0.060; CFI = 0.942; TLI = 0.931) with the factors emotional distress, auditory perceptual difficulties, and intrusiveness.

CONCLUSION

Validation of the German 52-item version of the TQ in a large, new sample of patients with chronic tinnitus supports the previously reported five-factor structure with slight differences concerning the identified factors. The new three-factorial 15-item short version allows a more rapid and economical assessment of tinnitus-related distress.

Vagus nerve stimulation for tinnitus: A review and perspective

Vagus nerve stimulation is a promising new tool in the treatment of chronic tinnitus. Current protocols involve pairing sounds, which exclude the tinnitus frequency, with simultaneous vagus nerve stimulation (VNS). This is based on extensive preclinical animal studies that demonstrate that pairing non-tinnitus sounds with VNS results in a tonotopic map plasticity. It is thought that by expanding the non-tinnitus sound representation, it is possible to overturn the expanded tonotopic map associated with the tinnitus frequency in these animal models. These findings have been translated into a clinical approach, where a clinically significant, but moderate improvement, in tinnitus distress and a modest benefit in tinnitus loudness perception has been shown. Yet, pairing tinnitus matched sound to VNS may produce tinnitus improvement by Pavlovian conditioning, in which the distressful tinnitus sound becomes associated with a relaxing "rest and digest" response from activation of the vagus nerve. If this hypothesis is correct, beneficial effects should be achieved with paired sounds that resemble the tinnitus sounds as much as possible. In conclusion, although the potential to use VNS to drive neural plasticity to reduce or eliminate the neural drivers of ongoing tinnitus is exciting, much work is needed to more completely understand the neural basis of tinnitus and to develop tailored therapies to address the suffering caused by this heterogeneous condition. Whether pairing of the vagus stimulation with non-tinnitus or tinnitus-matched sounds is essential is still to be determined.

Stress and Tinnitus; Transcutaneous Auricular Vagal Nerve Stimulation Attenuates Tinnitus-Triggered Stress Reaction

Introduction

Tinnitus can become a strong stressor for some individuals, leading to imbalance of the autonomous nervous system with reduction of parasympathetic activity. It can manifest itself as sleep disturbances, anxiety and even depression. This condition can be reversed by bioelectrical vagal nerve stimulation (VNS). Conventional invasive VNS is an approved treatment for epilepsy and depression. Transcutaneous VNS (taVNS) stimulating the auricular branch of the vagus nerve has been shown to activate the vagal pathways similarly as an implanted VNS. Therefore, taVNS might also be a therapeutic alternative in health conditions such as tinnitus-related mental stress (TRMS). This retrospective study in 171 TRMS patients reports the clinical features, psychophysiological characteristics, and results of the heart rate variability (HRV) tests before and after test-taVNS. This study also reports the therapy outcomes of 113 TRMS patients treated with taVNS, in combination with standard tinnitus therapy.

Methods

Diagnostic tinnitus and hearing profiles were defined. To detect possible cardiac adverse effects, test-taVNS with heart rate monitoring as well as pre- and post-stimulation HRV tests were performed. Daily taVNS home therapy was prescribed thereafter. To assess therapeutic usefulness of taVNS, 1-year follow-up outcome was studied. Results of HRV tests were retrospectively analyzed and correlated to diagnostic data.

Results

The large majority of patients with TRMS suffer from associated symptoms such as sleep disturbances and anxiety. Baseline HRV data showed that more than three quarters of the 171 patients had increased sympathetic activity before test-taVNS. Test-taVNS shifted mean values of different HRV parameters toward increased parasympathetic activity in about 80% of patients. Test-taVNS did not cause any cardiac or other side effects. No significant adverse effects were reported in follow-up questionnaires.

Conclusion

TRMS is an example of a stress condition in which patients may benefit from taVNS. As revealed by HRV, test-taVNS improved parasympathetic function, most efficiently in patients with a low starting HRV level. Our tinnitus treatment program, including taVNS, effectively alleviated tinnitus stress and handicap. For wider clinical use, there is a great need for more knowledge about the optimal methodology and parameters of taVNS.

Neuroanatomical Alterations in Patients With Tinnitus Before and After Sound Therapy: A Voxel-Based Morphometry Study

According to previous studies, many neuroanatomical alterations have been detected in patients with tinnitus. However, few studies have reported on the morphological changes observed following sound therapy. To explore the brain anatomical alterations in patients with idiopathic tinnitus using voxel-based morphometry (VBM) analysis before and after effective 12 weeks sound therapy. The protocol was registered on ClinicalTrials.gov, ID: NCT02774122. In this study, we collected data from 27 matched healthy control (HC) individuals and 27 idiopathic tinnitus patients before and after 12 weeks of sound therapy by using adjusted narrow band sound. 3.0T MRI system and high-resolution 3D structural images were acquired with a 3D-BRAVO pulse sequence. Structural image data preprocessing was performed using the VBM8 toolbox. The Tinnitus Handicap Inventory (THI) score was acquired in the tinnitus group to assess the severity of tinnitus and tinnitus-related distress. Mann-Whitney U Test, Wilcoxon Signed-Ranks test, and Pearson's correlation analysis were used in the statistical analysis. We found significantly decreased gray matter (GM) volume in the left thalami, right thalami, and cochlear nucleus among the tinnitus patients before sound therapy (baseline) compared to the HC group. However, we did not find significant differences in brain regions between the 12-week treatment and HC groups. According to the results of Wilcoxon Signed-Ranks test, the 12-week sound therapy group demonstrated significant greater brain volume compared with the baseline group among these brain regions. Decreased THI score and changed GM volume were not correlated. This is a useful study for observing the characteristics of neuroanatomical changes in patients with idiopathic tinnitus before and after sound treatment. The study characterized the effect of sound therapy on brain volume. It found that sound therapy had a normalizing effect on the bilateral thalami and cochlear nucleus. Clinical Trial Registration: www.ClinicalTrials.gov, NCT02774122.

Prevalence of Self-Reported Depression Symptoms and Perceived Anxiety Among Community-Dwelling U.S. Adults Reporting Tinnitus

Purpose

The aim of this study was to examine the relationship between tinnitus and self-reported mental health distress, namely, depression symptoms and perceived anxiety, in adults who participated in the National Health and Nutrition Examinations Survey between 2009 and 2012. A secondary aim was to determine if a history of serving in the military modified the associations between tinnitus and mental health distress.

Method

This was a cross-sectional study design of a national data set that included 5,550 U.S. community-dwelling adults ages 20 years and older, 12.7% of whom were military Veterans. Bivariable and multivariable logistic regression was used to estimate the association between tinnitus and mental health distress. All measures were based on self-report. Tinnitus and perceived anxiety were each assessed using a single question. Depression symptoms were assessed using the Patient Health Questionnaire, a validated questionnaire. Multivariable regression models were adjusted for key demographic and health factors, including self-reported hearing ability.

Results

Prevalence of tinnitus was 15%. Compared to adults without tinnitus, adults with tinnitus had a 1.8-fold increase in depression symptoms and a 1.5-fold increase in perceived anxiety after adjusting for potential confounders. Military Veteran status did not modify these observed associations.

Conclusions

Findings revealed an association between tinnitus and both depression symptoms and perceived anxiety, independent of potential confounders, among both Veterans and non-Veterans. These results suggest, on a population level, that individuals with tinnitus have a greater burden of perceived mental health distress and may benefit from interdisciplinary health care, self-help, and community-based interventions.

Supplemental Material

https://doi.org/10.23641/asha.12568475

Association between Hyperacusis and Tinnitus

Many individuals with tinnitus report experiencing hyperacusis (enhanced sensitivity to sounds). However, estimates of the association between hyperacusis and tinnitus is lacking. Here, we investigate this relationship in a Swedish study. A total of 3645 participants (1984 with tinnitus and 1661 without tinnitus) were enrolled via LifeGene, a study from the general Swedish population, aged 18-90 years, and provided information on socio-demographic characteristics, as well as presence of hyperacusis and its severity. Tinnitus presence and severity were self-reported or assessed using the Tinnitus Handicap Inventory (THI). Phenotypes of tinnitus with (n = 1388) or without (n = 1044) hyperacusis were also compared. Of 1661 participants without tinnitus, 1098 (66.1%) were women and 563 were men (33.9%), and the mean (SD) age was 45.1 (12.9). Of 1984 participants with tinnitus, 1034 (52.1%) were women and 950 (47.9%) were men, and the mean (SD) age was 47.7 (14.0) years. Hyperacusis was associated with any tinnitus [Odds ratio (OR) 3.51, 95% confidence interval (CI) 2.99-4.13], self-reported severe tinnitus (OR 7.43, 95% CI 5.06-10.9), and THI ≥ 58 (OR 12.1, 95% CI 7.06-20.6). The association with THI ≥ 58 was greater with increasing severity of hyperacusis, the ORs being 8.15 (95% CI 4.68-14.2) for moderate and 77.4 (95% CI 35.0-171.3) for severe hyperacusis. No difference between sexes was observed in the association between hyperacusis and tinnitus. The occurrence of hyperacusis in severe tinnitus is as high as 80%, showing a very tight relationship. Discriminating the pathophysiological mechanisms between the two conditions in cases of severe tinnitus will be challenging, and optimized study designs are necessary to better understand the mechanisms behind the strong relationship between hyperacusis and tinnitus.

Combining neurofeedback with source estimation: Evaluation of an sLORETA neurofeedback protocol for chronic tinnitus treatment

Background:

Alpha/delta neurofeedback has been shown to be a potential treatment option for chronic subjective tinnitus. Traditional neurofeedback approaches working with a handful of surface electrodes have been criticized, however, due to their low spatial specificity.

Objective:

The purpose of this study was to evaluate an innovative tomographic neurofeedback protocol that combines neural activity measured across the whole scalp with sLORETA source estimation.

Methods:

Forty-eight tinnitus patients participated in 15 neurofeedback training sessions as well as extensive pre, post, and follow-up testing. Patients were randomly assigned to either a tomographic (TONF) or a traditional electrode-based neurofeedback (NTNF) group. Main outcome measures of this study were defined as tinnitus-related distress measured with the Tinnitus Handicap Inventory (THI) and Tinnitus Questionnaire (TQ), tinnitus loudness, and resting-state EEG activity in trained frequency bands.

Results:

For both groups a significant reduction of tinnitus-related distress and tinnitus loudness was found. While distress changes remained persistent irrespective of group, loudness levels returned to baseline in the follow-up period. No significant between-group differences between the 2 neurofeedback applications (TONF vs. NTNF) were found, which suggests a similar contribution to symptom improvement. The trained alpha/delta ratio increased significantly over the course of the training and remained stable in the follow-up period. This effect was found irrespective of group on both surface and source levels with no meaningful differences between the 2 groups.

Conclusions:

Our study shows that a tomographic alpha/delta protocol should be considered a promising addition to tinnitus treatment but that more individually specific neurofeedback protocols should be developed.

Altered Topological Patterns of Gray Matter Networks in Tinnitus: A Graph-Theoretical-Based Study

Objective

Tinnitus is a prevalent hearing disorder, which could have a devastating impact on a patient’s life. Functional studies have revealed connectivity pattern changes in the tinnitus brains that suggested a change of network dynamics as well as topological organization. However, no studies have yet provided evidence for the topological network changes in the gray matter. In this research, we aim to use the graph-theoretical approach to investigate the changes of topology in the tinnitus brain using structural MRI data, which could provide insights into the underlying anatomical basis for the neural mechanism in generating phantom sounds.

Methods

We collected 3D MRI images on 46 bilateral tinnitus patients and 46 age and gender-matched healthy controls. Brain networks were constructed with correlation matrices of the cortical thickness and subcortical volumes of 80 cortical/subcortical regions of interests. Global network properties were analyzed using local and global efficiency, clustering coefficient, and small-world coefficient, and regional network properties were evaluated using the betweenness coefficient for hub connectivity, and interregional correlations for edge properties. Between-group differences in cortical thickness and subcortical volumes were assessed using independent sample t-tests, and local efficiency, global efficiency, clustering coefficient, sigma, and interregional correlation were compared using non-parametric permutation tests.

Results

Tinnitus was found to have increased global efficiency, local efficiency, and cluster coefficient, indicating generally heightened connectivity of the network. The small-world coefficient remained normal for tinnitus, indicating intact small-worldness. Betweenness centrality analysis showed that hubs in the amygdala and parahippocampus were only found for tinnitus but not controls. In contrast, hubs in the auditory cortex, insula, and thalamus were only found for controls but not tinnitus. Interregional correlation analysis further found in tinnitus enhanced connectivity between the auditory cortex and prefrontal lobe, and decreased connectivity of the insula with anterior cingulate gyrus and parahippocampus.

Conclusion

These findings provided the first morphological evidence of altered topological organization of the brain networks in tinnitus. These alterations suggest that heightened efficiency of the brain network and altered auditory-limbic connection for tinnitus, which could be developed in compensation for the auditory deafferentation, leading to overcompensation and, ultimately, an emotional and cognitive burden.

Relationship between headaches and tinnitus in a Swedish study

The heterogeneity of tinnitus is likely accounting for the lack of effective treatment approaches. Headaches have been related to tinnitus, yet little is known on how headaches impact tinnitus. We use cross-sectional data from the Swedish Tinnitus Outreach Project to i) evaluate the association between headaches and tinnitus (n = 1,984 cases and 1,661 controls) and ii) investigate the phenotypic characteristics of tinnitus subjects with tinnitus (n = 660) or without (n = 1,879) headaches. In a multivariable logistic regression model, headache was significantly associated with any tinnitus (odds ratio, OR = 2.61) and more so with tinnitus as a big problem (as measured by the tinnitus functional index, TFI ≥ 48; OR = 5.63) or severe tinnitus (using the tinnitus handicap inventory, THI ≥ 58; OR = 4.99). When focusing on subjects with tinnitus, the prevalence of headaches was 26% and reached 40% in subjects with severe tinnitus. A large number of socioeconomic, phenotypic and psychological characteristics differed between headache and non-headache subjects with any tinnitus. With increasing tinnitus severity, fewer differences were found, the major ones being vertigo, neck pain and other pain syndromes, as well as stress and anxiety. Our study suggests that headaches could contribute to tinnitus distress and potentially its severity.

A proof-of-concept study comparing tinnitus and neural connectivity changes following multisensory perceptual training with and without a low-dose of fluoxetine

Background. This proof-of-concept study investigated a method of multisensory perceptual training for tinnitus, and whether a short, low-dose administration of fluoxetine enhanced training effects and changed neural connectivity.Methods. A double-blind, randomized placebo controlled design with 20 participants (17 male, 3 female, mean age = 57.1 years) involved 30 min daily computer-based, multisensory training (matching visual, auditory and tactile stimuli to perception of tinnitus) for 20 days, and random allocation to take 20 mg fluoxetine or placebo daily. Behavioral measures of tinnitus and correlations between pairs of a priori regions of interest (ROIs), obtained using resting-state functional magnetic resonance imaging (rs-fMRI), were performed before and after the training.Results. Significant changes in ratings of tinnitus loudness, annoyance, and problem were observed with training. No statistically significant changes in Tinnitus Functional Index, Tinnitus Handicap Inventory or Depression Anxiety Stress Scales were found with training. Fluoxetine did not alter any of the behavioural outcomes of training compared to placebo. Significant changes in connectivity between ROIs were identified with training; sensory and attention neural network ROI changes correlated with significant tinnitus rating changes. Rs-fMRI results suggested that the direction of functional connectivity changes between auditory and non-auditory networks, with training and fluoxetine, were opposite to the direction of those changes with multisensory training and placebo.Conclusions. Improvements in tinnitus measures were correlated with changes in sensory and attention networks. The results provide preliminary evidence for changes in rs-fMRI accompanying a multisensory training method in persons with tinnitus.

Efficacy of an Integrative Treatment for Tinnitus Combining Music and Cognitive-Behavioral Therapy-Assessed With Behavioral and EEG Data

Chronic tinnitus is a prevalent condition that could cause severe negative impact on an individual's life. However, there has not been an established treatment due to a limited understanding of the pathophysiology of this multifarious disorder. In this study, we tested the efficacy of an integrative treatment, combining music therapy with cognitive-behavioral therapy (CBT). We collected three groups of patients receiving three different treatments: Music-CBT, music therapy and CBT. We used both subjective (i.e., questionnaires) and objective (i.e., resting-state EEG data) measurements to assess the behavioral and neural changes brought upon by the treatments. Analyses of the subjective measurements found a significant improvement of scale scores in Music-CBT and CBT, but not in the Music group. Analysis of the EEG data further showed increased powers in alpha and theta band after the Music-CBT treatment, and increased gamma power after CBT, whereas no significant difference was found for the music therapy. Further source localization analysis of alpha and theta changes in the Music-CBT group found that primary sources of the changes were located at auditory processing regions such as superior temporal gyrus, and higher emotional and cognitive processing regions such as ventromedial prefrontal cortex (vMPFC), lateral prefrontal cortex and parahippocampus. These results indicated that Music-CBT was effective in improving tinnitus symptoms on both a behavioral and neural level, which is more robust than the music therapy or CBT alone.

One Step Closer towards a Reliable Tinnitus Pitch-Match Frequency Determination Using Repetitive Recursive Matching

Introduction: The determination of the tinnitus pitch-match (PM) frequency is not straightforward but an important audiological assessment recommended for clinical and research purposes. We evaluated repetitive recursive matching using an iPod-based matching procedure as a method to estimate a patient’s PM frequency without audiometric equipment. Methods: One hundred and seventeen patients with chronic tonal tinnitus (uni- and bilateral tinnitus) measured their tinnitus in 10 sessions using a self-administered automated iPod-based procedure comprising a recursive 2 interval forced-choice test. Results: Mean SD of the PM frequency of all participants across sessions was 0.41 octaves. The internal consistency measured by Cronbach’s α was very high (0.8–>0.95). As an example, 7 PMs obtained excellent internal consistency (α = 0.93). The exclusion of the first and/or second session led to more definite PMs with a decreased SD. Outliers were identified by PMs departing 2 SDs (i.e., 0.94 octaves) from the mean variability (n = 5). Conclusion: Repetitive recursive matching together with recommendations for the exclusion of initial and redundant sessions as well as outlier identification and treatment can enable a reliable estimation of the PM frequency.

Tinnitus-related distress after multimodal treatment can be characterized using a key subset of baseline variables

BACKGROUND

Chronic tinnitus is a complex condition that can be associated with considerable distress. Whilst cognitive-behavioral treatment (CBT) approaches have been shown to be effective, not all patients benefit from psychological or psychologically anchored multimodal therapies. Determinants of tinnitus-related distress thus provide valuable information about tinnitus characterization and therapy planning.

OBJECTIVE

The study aimed to develop machine learning models that use variables (or "features") obtained before treatment to characterize patients' tinnitus-related distress status after treatment. Whilst initially all available variables were considered for model training, the final model was required to achieve highest predictive performance using only a small number of features.

METHODS

1,416 tinnitus patients (decompensated tinnitus: 32%) who completed a 7-day multimodal treatment encompassing tinnitus-specific components, CBT, physiotherapy and informational counseling were included in the analysis. At baseline, patients were assessed using 205 features from 10 questionnaires comprising sociodemographic and clinical information. A data-driven workflow was developed consisting of (a) an initial exploratory correlation analysis, (b) supervised machine learning to predict tinnitus-related distress after treatment (T1) using baseline data only (T0), and (c) post-hoc analysis of the best model to facilitate model inspection and understanding. Classification methods were embedded in a feature elimination wrapper that iteratively learned on features found to be important for the model in the preceding iteration, in order to keep the performance stable while successively reducing the model complexity. 10-fold cross-validation with area under the curve (AUC) as performance measure was implemented for model generalization error estimation.

RESULTS

The best machine learning classifier (gradient boosted trees) can predict tinnitus-related distress in T1 with AUC = 0.890 using 26 features. Subjectively perceived tinnitus-related impairment, depressivity, sleep problems, physical health-related impairments in quality of life, time spent to complete questionnaires and educational level exhibited a high attribution towards model prediction.

CONCLUSIONS

Machine learning can reliably identify baseline features recorded prior to treatment commencement that characterize tinnitus-related distress after treatment. The identification of key features can contribute to an improved understanding of multifactorial contributors to tinnitus-related distress and thereon based multimodal treatment strategies.

Tinnitus groups: A model of social support and social connectedness from peer interaction

Tinnitus is a chronic condition for which there is no medical treatment. Tinnitus groups are a widely available resource for people with tinnitus.

OBJECTIVES

Our objectives were to explore the active ingredients of tinnitus support groups in terms of their mechanisms for providing support, the contextual factors that elicit such mechanisms, and the outcomes in terms of coping enhancement.

DESIGN

We adopted a pluralist and iterative approach informed by the realist evaluation method.

METHODS

We conducted ethnographic data generation at tinnitus support groups involving observations (n = 160), focus groups (n = 130), and individual interviews (n = 20). Inductive analyses were conducted following the constant comparison method of grounded theory. We then interrogated the inductive themes to identify evidence of Contexts, Mechanisms, and Outcomes. We then produced a model which was tested in a survey of tinnitus group members (n = 65) in effect providing large-scale respondent validation of the data-driven model created through our inductive analysis.

RESULTS

We identified that tinnitus groups can facilitate social connectedness between group members. This experience appeared to build resilience among those experiencing tinnitus-related distress. Groups also played a role in building a sense of control related to knowledge and information sharing. Additionally, we identified risks associated with not accessing social support in a group environment.

CONCLUSIONS

Our findings contribute to the growing understanding of the power of social connectedness as building shared social identity when living with tinnitus. Statement of contribution What is already known on this subject? Tinnitus is a prevalent condition with approximately 10-15% of the population experiencing a spontaneous sound without obvious source. Tinnitus is an invisible health and chronic condition. People with tinnitus experience high levels of distress, anxiety, and depression. Group support is beneficial to people with many health problems. What does this study add? This study describes the mechanisms by which tinnitus support groups can support coping in tinnitus. This is the first study to comprehensively explore the views of those who attend tinnitus groups. The study identifies the key features of support groups that facilitate social connectedness among group members. The most valued features of groups are the knowledge and information provided, the sense of belonging communicated to group members, and the creation and maintenance of a sense of hope towards the tinnitus. This study contributes new insights to both the tinnitus field and adds to the literature on support groups in health.

Maladaptive alterations of resting state cortical network in Tinnitus: A directed functional connectivity analysis of a larger MEG data set

The present study used resting state MEG whole-head recordings to identify how chronic tonal tinnitus relates to altered functional connectivity of brain's intrinsic cortical networks. Resting state MEG activity of 40 chronic tinnitus patients and 40 matched human controls was compared identifying significant alterations in intrinsic networks of the tinnitus population. Directed functional connectivity of the resting brain, at a whole cortex level, was estimated by means of a statistical comparison of the estimated phase Transfer Entropy (pTE) between the time-series of cortical activations, as reconstructed by LORETA. As pTE identifies the direction of the information flow, a detailed analysis of the connectivity differences between tinnitus patients and controls was possible. Results indicate that the group of tinnitus patients show increased connectivity from right dorsal prefrontal to right medial temporal areas. Our results go beyond previous findings by indicating that the role of the left para-hippocampal area is dictated by a modulation from dmPFC; a region that is part of the dorsal attention network (DAN), as well as implicated in the regulation of emotional processing. Additionally, this whole cortex analysis showed a crucial role of the left inferior parietal cortex, which modulated the activity of the right superior temporal gyrus, providing new hypotheses for the role of this area within the context of current tinnitus models. Overall, these maladaptive alterations of the structure of intrinsic cortical networks show a decrease in efficiency and small worldness of the resting state network of tinnitus patients, which is correlated to tinnitus distress.

Impact of Temporomandibular Joint Complaints on Tinnitus-Related Distress

There is increasing evidence of associations between the presence of temporomandibular joint (TMJ) disorders and tinnitus. It has been recently proposed that tinnitus patients with TMJ complaints could constitute a subtype, meaning a subgroup of tinnitus patients responsive to specific treatments. Tinnitus patients with TMJ complaints are often young women with somatosensory features of their tinnitus. Here, we investigate the socio-economic factors, phenotypic characteristics and psychological variables of tinnitus subjects from the Swedish Tinnitus Outreach Project, with (n = 486) or without (n = 1,996) TMJ complaints. The prevalence of TMJ complaints was greater in tinnitus subjects with severe tinnitus (36%) when compared to those with any tinnitus (19%), strongly indicating the contribution of TMJ problems to the severity of tinnitus. Comparing subgroups with or without TMJ complaints in the whole sample, differences were found regarding a large number of socioeconomic, phenotypic, and psychological characteristics. Subjects with TMJ complaints were more often women, more often reported stress as the cause of tinnitus, were more severely affected by tinnitus, scored worse in measures of psychological well-being and life quality, and were more often affected by problems tolerating sounds, headache, vertigo/dizziness, and neck pain. In addition, they more often reported pulsating and tonal tinnitus, somatic modulation of tinnitus, and aggravation of tinnitus by loud sounds and stress. When focusing the analysis in subjects with tinnitus as a big problem using the Tinnitus Functional Index cut-off ≥ 48, or with severe tinnitus according to the Tinnitus Handicap Inventory cut-off ≥ 58, the impact of somatosensory modulations and stress on tinnitus were greater in subjects with TMJ complaints in comparison to those without. In light of these results, we hypothesize that stress could contribute to the co-occurrence of TMJ problems and tinnitus and also to the development of severe tinnitus. Our study supports the need of involving dental care and stress management in the holistic treatment of patients with severe tinnitus.

The Role of the Brainstem in Generating and Modulating Tinnitus

Purpose The purpose of this work is to present a perspective article summarizing ideas pertaining to the brainstem's role in generating and modulating tinnitus. It is organized in 4 sections: Part 1, the role of the brainstem as a tinnitus generator; Part 2, the role of the brainstem in modulating tinnitus; Part 3, the role of the brainstem in nonauditory comorbid conditions associated with tinnitus; and Part 4, clinical implications. In Part 1, well-established neurophysiological models are discussed providing the framework of evidence that auditory brainstem nuclei play a role in generating tinnitus. In Part 2, ideas are presented explaining modulatory effects on tinnitus related to underlying pathways originating from or projecting to brainstem auditory and nonauditory nuclei. This section addresses multiple phenomena including somatic-related, attention-mediated, and emotion-mediated changes in the tinnitus percept. In Part 3, the role of the brainstem in common nonauditory comorbidities that occur in patients with tinnitus is discussed. Part 4 presents clinical implications of these new ideas related to the brainstem's involvement in generating and modulating tinnitus. Impact Knowledge of the brainstem's involvement in generating and modulating tinnitus provides a context for health care professionals to understand the temporal relationship between tinnitus and common nonauditory comorbid conditions.

Investigating the Efficacy of an Individualized Alpha/Delta Neurofeedback Protocol in the Treatment of Chronic Tinnitus

First attempts have demonstrated that the application of alpha/delta neurofeedback in the treatment of chronic tinnitus leads to a reduction of symptoms at the group level. However, recent research also suggests that chronic tinnitus is a decidedly heterogeneous phenomenon, one that requires treatment of distinct subgroups or even on an individual level. Thus, the purpose of this study was to evaluate an individually adjusted alpha/delta neurofeedback protocol. Following previous studies, the delta band fixed between 3 and 4 Hz was chosen as the frequency for inhibition. However, unlike the previous studies, the frequency range for the rewarded alpha band was not fixed between 8 and 12 Hz but rather individually determined according to each patient's specific alpha peak frequency (IAF). Twenty-six chronic tinnitus patients participated in 15 weekly neurofeedback training sessions and extensive pre- and post-tests, as well as follow-up testing 3 and 6 months after training. The main outcome measures were tinnitus-related distress measured with the Tinnitus Handicap Inventory (THI) and Tinnitus Questionnaire (TQ), tinnitus loudness, and pre- and post-training resting-state EEG activity in trained frequency bands. In Results, the neurofeedback protocol led to a significant reduction of tinnitus-related distress and tinnitus loudness. While distress remained on a low level even 6 months after the completion of training, loudness returned to baseline levels in the follow-up period. In addition, resting-state EEG activity showed an increase in the trained alpha/delta ratio over the course of the training. This ratio increase was related to training-induced changes of tinnitus-related distress as measured with TQ, mainly due to increases in the alpha frequency range. In sum, this study confirms the alpha/delta neurofeedback as a suitable option for the treatment of chronic tinnitus and represents a first step towards the development of individual neurofeedback protocols. This clinical trial was registered online at ClinicalTrials.gov (NCT02383147) and kofam.ch (SNCTP000001313).

A Comprehensive Study of Oxidative Stress in Tinnitus Patients

Oxidative stress is considered to be one of the molecular changes that are the underlying causes of tinnitus. The aim of this study was to investigate the dynamic thiol/disulphide homeostasis as a new oxidative stress parameter in tinnitus patients as well as to investigate the lipid hydroperoxide (LOOH), total antioxidant status (TAS), total oxidant status (TOS) and oxidative stress index (OSI) parameters and compare the results with the results of the healthy control group. A prospective controlled trial was performed on tinnitus patients in Harran University hospital. A total of 70 subjects, including 35 tinnitus patients and 35 healthy individuals participated in this study. Their total thiol, native thiol levels and LOOH, TAS, TOS levels were measured in plasma of all tinnitus patients and healthy volunteers participants. TOS and OSI levels were significantly increased, and TAS levels were significantly lower in the patient groups compared with the control group (p < 0.01). Native thiol levels and Native thiol/total thiol ratios were significantly lower in the tinnitus group compared to the control group (p < 0.01). Disulphide level and disulphide/native thiol and disulphide/total thiol ratios were significantly higher in the patients (p < 0.01). Also, LOOH ratios were significantly higher in the tinnitus group (p < 0.01). The results of this study reveal that in tinnitus cases, the oxidative stress and antioxidant enzyme imbalance were more significant than in healthy control group. The nature of the relationship between oxidative stress and tinnitus should be clarified with larger studies.

Sulodexide Monotherapy in Chronic Idiopathic Subjective Tinnitus: A Randomized Controlled Trial

Objective To report the therapeutic value of sulodexide monotherapy in the management of patients with chronic subjective idiopathic tinnitus. Study Design Randomized double-blinded controlled trial. Setting Single tertiary care institution. Subjects and Methods Observations from 124 patients who received either sulodexide or placebo were collected from the patients' medical records. Computer-generated tables were used to allocate treatments. Patients took 1 tablet of the drug or placebo each morning and evening for 40 consecutive days. The response was assessed by the Tinnitus Handicap Inventory and the Mini-Tinnitus Questionnaire. Results Between 2014 and 2017, 124 patients were divided into 2 treatment arms. The sulodexide group encompassed 63 patients, whereas the placebo arm contained 61 patients. Tinnitus Handicap Inventory and Mini-Tinnitus Questionnaire scores were more decreased in the sulodexide arm compared to the placebo group ( P = .03 and P < .01, respectively). Conclusions Sulodexide monotherapy decreases chronic subjective idiopathic tinnitus.

Neuromodulation for tinnitus treatment: an overview of invasive and non-invasive techniques

Tinnitus is defined as a perception of sound without any external sound source. Chronic tinnitus is a frequent condition that can affect the quality of life. So far, no causal cure for tinnitus has been documented, and most pharmacologic and psychosomatic treatment modalities aim to diminish tinnitus' impact on the quality of life. Neuromodulation, a novel therapeutic modality, which aims at alternating nerve activity through a targeted delivery of a stimulus, has emerged as a potential option in tinnitus treatment. This review provides a brief overview of the current neuromodulation techniques as tinnitus treatment options. The main intention is to provide updated knowledge especially for medical professionals counselling tinnitus patients in this emerging field of medicine. Non-invasive methods such as repetitive transcranial magnetic stimulation, transcranial electrical stimulation, neurofeedback, and transcutaneous vagus nerve stimulation were included, as well as invasive methods such as implanted vagus nerve stimulation and invasive brain stimulation. Some of these neuromodulation techniques revealed promising results; nevertheless, further research is needed, especially regarding the pathophysiological principle as to how these neuromodulation techniques work and what neuronal change they induce. Various studies suggest that individually different brain states and networks are involved in the generation and perception of tinnitus. Therefore, in the future, individually tailored neuromodulation strategies could be a promising approach in tinnitus treatment for achieving a more substantial and longer lasting improvement of complaints.

Targeting Heterogeneous Findings in Neuronal Oscillations in Tinnitus: Analyzing MEG Novices and Mental Health Comorbidities

Tinnitus is a prevalent phenomenon and bothersome for people affected by it. Its occurrence and maintenance have a clear neuroscientific tie and one aspect are differences in the neuronal oscillatory pattern, especially in auditory cortical areas. As studies in this field come to different results, the aim of this study was to analyze a large number of participants to achieve more stable results. Furthermore, we expanded our analysis to two variables of potential influence, namely being a novice to neuroscientific measurements and the exclusion of psychological comorbidities. Oscillatory brain activity of 88 subjects (46 with a chronic tinnitus percept, 42 without) measured in resting state by MEG was investigated. In the analysis based on the whole group, in sensor space increased activity in the delta frequency band was found in tinnitus patients. Analyzing the subgroup of novices, a significant difference in the theta band emerged additionally to the delta band difference (sensor space). Localizing the origin of the activity, we found a difference in theta and gamma band for the auditory regions for the whole group and the same significant difference in the subgroup of novices. However, no differences in oscillatory activity were observed between tinnitus and control groups once subjects with mental health comorbidity were excluded. Against the background of previous studies, the study at hand underlines the fragility of the results in the field of neuronal cortical oscillations in tinnitus. It supports the body of research arguing for low frequency oscillations and gamma band activity as markers associated with tinnitus.