Clinical practice guidelines for diagnosis and treatment of chronic tinnitus in Japan

Clinical practice guidelines in Japan for tinnitus were published in May 2019. Effective treatment of tinnitus contributes to quality of life and may improve depression, anxiety, and cognitive function. The highest priority of treatment recommended by this guideline involves educational counseling, including an explanation of the mechanisms of tinnitus. Understanding tinnitus pathology has also been reported to be a therapeutically effective educational counseling strategy. Further, explaining how sound therapy such as tinnitus retraining therapy (TRT) works is effective. Psychological and cognitive behavioral therapies may be an option. Here, the hearing aid is coupled with a sound generator in order to administer sound therapy for patients with more-severe symptoms. In Japan, it can be difficult to perform psychotherapy alongside otorhinolaryngology, and exemplary sound therapy is more likely to be carried out. In any case, the purpose of treatment is not to eliminate tinnitus, but rather reduce distress that manifests in response to tinnitus by promoting sensory adaptation. Clinically, the most important subject is not the loudness of tinnitus, but the severity of tinnitus distress. TRT consists of educational counseling and sound therapy. The tinnitus handicap inventory (THI) is used to measure the distress level for tinnitus and to determine treatment priorities. Rehabilitation of tinnitus is important because anxiety and depression are often observed in patients with severe tinnitus. Additionally, drug administration should be avoided. As a surgical treatment, a cochlear implant can affect tinnitus symptoms. It is essential to establish a treatment policy according to the disease condition and degree of distress.

Voltage-gated Sodium Channels in Sensory Information Processing

Objective & Background:

Voltage-gated sodium channels (VGSCs) and potassium channels are critical in the generation of action potentials in the nervous system. VGSCs and potassium channels play important roles in the five fundamental senses of vision, audition, olfaction, taste and touch. Dysfunctional VGSCs are associated with clinical sensory symptoms, such as hyperpselaphesia, parosphresia, and so on.

Conclusion:

This short review highlights the recent advances in the study of VGSCs in sensory information processing and discusses the potential role of VGSCs to serve as pharmacological targets for the treatment of sensory system diseases.

A Systematic Review of Eligibility and Outcomes in Tinnitus Trials

Objective

To analyze existing tinnitus treatment trials with regard to eligibility criteria, outcome measures, study quality, and external validity and to recognize the effect of patient demographics, symptom duration, severity, and otologic comorbidity on research findings to help practitioners apply them to patient encounters.

Data Sources

Systematic literature search conducted by an information specialist for development of the American Academy of Otolaryngology—Head and Neck Surgery Foundation’s tinnitus clinical practice guideline.

Review Methods

Articles were assessed for eligibility with the PRISMA protocol (Preferred Reporting Items for Systematic Reviews and Meta-analyses) and data extracted by 2 independent investigators. Studies were assessed for methodological quality, inclusion and exclusion criteria, patient demographics, and outcome measures.

Results

A total of 147 randomized trials met inclusion criteria. Nearly all studies took place in a specialist setting. More than 50% did not explicitly define tinnitus, and 44% used a subjective severity threshold, such as “severely disturbing.” Fifty-four percent required symptom duration of at least 6 months for study eligibility, and up to 33% excluded patients with “organic” hearing loss or otologic conditions. Mean age was 52.2 years, and median follow-up was 3 months. Only 20% had a low risk of bias.

Conclusion

Randomized trials of tinnitus interventions are most applicable to older adults with tinnitus lasting ≥6 months who are evaluated in specialty settings. High risk of bias, short follow-up, and outcome reporting raise concerns about the validity of findings and may influence how clinicians apply trial results to individual patients and establish treatment expectations, thus demonstrating the need for further quality research in this field.

A prospective, randomized, blinded study of continuous ropivacaine infusion in the median sternotomy incision following cardiac surgery

OBJECTIVE

The aim of this prospective, randomized, double-blind, placebo controlled trial was to evaluate the safety and efficacy of continuous ropivacaine infusion of into the sternal wound.

METHODS

We planned to enroll 200 patients scheduled for various cardiac surgical procedures into the study. Patients, in a double-blind randomized fashion, were given either normal saline or 0.3% ropivacaine through 2 subcutaneous multiport catheters placed on either side of the sternal split at an infusion rate of 4 mL/h for 64 hours. The efficacy outcomes measured were time to extubation of the trachea, intensive care unit and hospital stay duration, pain scores, and narcotic usage. The safety outcomes measured were systemic local anesthetic toxicity, major cardiac complications, and wound infection.

MEASUREMENTS AND MAIN RESULTS

The data safety monitoring board stopped the study after enrolling 85 patients because of excessive sternal wound infections (9%, n = 44) in the ropivacaine group. This rate of infection was not statistically different from the control group (0%, n = 41, P = 0.12), but it was statistically different from our historical incidence of sternal wound infection (1.9%, no = 6381, P = 0.002). There was also a lack of evidence of efficacy for time to extubation of the trachea, narcotic usage, and pain control.

CONCLUSIONS

The phase III trial did not show improvement in time to extubation of the trachea or pain control in the 0.3% ropivacaine group, but it was stopped early by the data safety monitoring board.

Safety and efficacy outcomes of long-term treatment up to 4 years with 5% lidocaine medicated plaster in patients with post-herpetic neuralgia

OBJECTIVE

Prospective evaluation of the long-term efficacy and safety of the 5% lidocaine medicated plaster in patients with post-herpetic neuralgia (PHN).

RESEARCH DESIGN AND METHODS

Patients with persisting pain for ≥3 months after acute herpes zoster and a baseline pain intensity of at least 4 on an 11-point numerical rating scale (NRS 0-10) were treated with 5% lidocaine medicated plasters for up to 5 years and monitored in regular intervals. Efficacy parameters are presented for the first 4 years and include patients' recall of pain relief (6-point verbal rating scale (VRS), clinical global impression of change (CGIC), patients' global impression of change PGIC), and the global evaluations of study medication. Safety parameters (clinical examination, skin evaluation, laboratory) and adverse events (AEs) were assessed at regular visits.

CLINICAL TRIAL REGISTRATION

KF10004/02.

RESULTS

A total of 102 patients continuing from a 1 year main study period were included in an extension phase of up to 3 years. Ten patients (9.8%) dropped out due to lack of efficacy and 9 patients (8.8%) due to treatment-related AEs; 56 patients (54.9%) left the study for non-treatment-related reasons. Twenty-seven patients (26.4%) were still under treatment after a total treatment period of 4 years. On average, a pain relief of at least 4.3 (between moderate and a lot) was achieved throughout the study. At all visits the CGIC and the PGIC were much or very much improved in about 80% of patients. At the final visit, study medication was rated at least to be good by 91% of physicians and 89% of patients. Drug-related adverse events (DRAEs) were reported in 19 of 102 patients, mainly mild to moderate localized skin reactions. There were no hints for a reduced analgesic effect or an increase of DRAEs with long-term treatment.

CONCLUSIONS

This study demonstrates that long-term treatment of ≥12 months with the 5% lidocaine medicated plaster is effective and well tolerated in PHN patients. These findings support the recommendations to use the 5% lidocaine medicated plaster as baseline therapy for localized neuropathic pain after herpes zoster infection (PHN).

PHARMACOLOGICAL TREATMENTS FOR TINNITUS: NEW AND OLD

Subjective tinnitus, the phantom ringing or buzzing sensation that occurs in the absence of sound, affects 12-14% of adults; in some cases the tinnitus is so severe or disabling that patients seek medical treatment. However, although the economic and emotional impact of tinnitus is large, there are currently no FDA-approved drugs to treat this condition. Clinical trials are now underway to evaluate the efficacy of N-methyl-d-aspartate (NMDA) and dopamine D(2) antagonists, selective serotonin reuptake inhibitors (SSRIs), γ-aminobutyric acid (GABA) agonists and zinc dietary supplements. Previous off-label clinical studies, while not definitive, suggest that patients with severe depression may experience improvement in their tinnitus after treatment with antidepressants such as nortriptyline or sertraline. A small subpopulation of patients with what has been described as "typewriter tinnitus" have been shown to gain significant relief from the anticonvulsant carbamazepine. Preliminary studies with misoprostol, a synthetic prostaglandin E1 analogue, and sulpiride, a dopamine D(2) antagonist, have shown promise. Animal behavioral studies suggest that GABA transaminase inhibitors and potassium channel modulators can suppress tinnitus. Additionally, improvements in tinnitus have also been noted in patients taking melatonin for significant sleep disturbances. Like other complex neurological disorders, one drug is unlikely to resolve tinnitus in all patients; therapies targeting specific subgroups are likely to yield the greatest success.

Recent Publications on Medications and Pharmacy

Hospital Pharmacy presents this feature to keep pharmacists abreast of new publications in the medical/pharmacy literature. Articles of interest regarding a broad scope of topics are abstracted monthly.