The influence of sound generator associated with conventional amplification for tinnitus control: randomized blind clinical trial

Recent Updates on Tinnitus Management

In this comprehensive review, we discuss recent updates on tinnitus evaluation and treatment. Tinnitus evaluation commences with comprehensive medical history taking and audiological evaluation, which can provide valuable insight into the nature and extent of auditory disturbances. Additionally, tinnitus evaluation includes investigation of psychosomatic comorbidities to determine the intricate interplay between psychological factors and tinnitus perception. Various therapeutic approaches are available to minimize the burden of tinnitus. Cognitive behavioral therapy reshapes negative thought patterns and behaviors that are closely associated with tinnitus-induced distress. Acceptance and commitment therapy fosters mindfulness and value-aligned actions to address emotional effects. Tinnitus retraining therapy combines counseling and sound therapy for habituation. Tailor-made notched music therapy offers customized auditory experiences for symptom relief. Hearing aids and cochlear implants compensate for hearing loss and associated stress. Both neuromodulation and neurofeedback may be potentially useful. The role of pharmacotherapy and dietary supplements remains uncertain. Physiotherapy and head-neck manipulation relieve tinnitus associated with orofacial factors. Virtual reality, smartphone applications, and photobiomodulation may serve as novel therapeutic avenues. Although promising interventions are available, further research is warranted to confirm their effectiveness and long-term effects.

Hearing Aids Combined With Educational Counseling Versus Educational Counseling Alone for Tinnitus Treatment in Patients With Hearing Loss: A Longitudinal Follow-Up Study

PURPOSE

The effect of hearing aids (HAs) and educational counseling (EC) or their combination on tinnitus is ambiguous. This study aimed to investigate whether the combined use of HAs and EC is more effective than EC alone on tinnitus relief.

METHOD

A total of 72 adults with chronic, bothersome tinnitus and coexisting sensorineural hearing loss completed at least 1-month and 3-month follow-up. After receiving EC and HA prescriptions, 21 participants selected to purchase HAs (i.e., the HA + EC group), whereas the remaining 51 refused to use HAs despite recommendations (i.e., the EC group). Tinnitus severity was measured by Tinnitus Handicap Inventory (THI), Tinnitus Evaluation Questionnaire (TEQ), and Visual Analog Scale (VAS) for loudness. The primary outcome measure was THI, and tinnitus relief was defined as a 20-point or more reduction in THI. A generalized linear mixed model was used to confirm that the heterogeneity in baseline characteristics between groups did not interfere with the results.

RESULTS

The THI, TEQ, and VAS scores decreased significantly after treatments, and both groups yielded a similar trend of reduction. There were no significant differences in the incidence of tinnitus relief and time-to-event curves between the two groups. In addition, the length of follow-up did not affect treatment effectiveness.

CONCLUSION

There was insufficient evidence to support the superiority of the combined use of HA and EC for tinnitus over EC with no device.

The Impact of Daily Hours of Sound Therapy on Tinnitus Relief for People With Chronic Tinnitus: A Randomized Controlled Study

PURPOSE

Tinnitus is defined as the perception of sounds in the absence of extrinsic sound stimuli. Sound therapy is an option for tinnitus rehabilitation, which aims to mitigate the functional and emotional effects of tinnitus. Several studies have reported that a longer duration of sound therapy may result in a greater tinnitus relief effect. However, the relationship between the daily hours of sound therapy and the tinnitus relief effect remains unclear. Thus, we aimed to evaluate the tinnitus relief effect according to the time spent in daily performing sound therapy.

METHOD

Fifty-eight chronic tinnitus participants were randomly assigned to three groups according to their daily hours of sound therapy (1-hr, 3-hr, and 5-hr groups), and mixing point-based sound therapy, which adjusts the volume of the external stimulus to blend with the participant's tinnitus sound, was administered for 3 months. The effectiveness of sound therapy was determined based on changes in the tinnitus loudness level, visual analog scale for loudness score, and the Korean version of the Tinnitus Primary Function Questionnaire (K-TPFQ) score between the baseline and 3-month time points.

RESULTS

Longer daily sound therapy hours were associated to a greater effect of sound therapy in the tinnitus loudness level and the total K-TPFQ scores, including the emotion and hearing subcategories. Particularly, the 3-hr and 5-hr groups showed a greater tinnitus relief than the 1-hr group.

CONCLUSION

An increase in the daily sound therapy hours may increase the possibility of improving tinnitus relief effects.

Reevaluating the Use of Sound Therapy for Tinnitus Management: Perspectives on Relevant Systematic Reviews

PURPOSE

Tinnitus is a highly prevalent condition that can severely reduce health functioning. In spite of extant clinical practice guidelines (CPGs), implementation of these CPGs is relatively uncommon. As a result, patients seeking professional services for tinnitus often have no assurance of receiving evidence-based care. The purpose of this tutorial was to clarify the evidence for sound therapy so that it may be included in future CPGs for tinnitus.

METHOD

"Best clinical evidence" is obtained from high-quality systematic reviews, which are generally considered the highest level of evidence. Our review of recent, comprehensive, high-quality systematic reviews of interventions for tinnitus concludes that cognitive behavioral therapy is the only effective intervention, though the strength of evidence was generally rated as low in these reviews. Although trials of sound therapy for tinnitus have been included in these reviews, they have been rated as having high risk of bias (RoB) and not included in syntheses or rated as insufficient strength of evidence.

RESULTS

Conclusions from these and other reviews have influenced recommendations made in CPGs for tinnitus. These conclusions, however, can make it appear that an intervention for tinnitus is not effective, even if the opposite is true. We contend that the strict inclusion criteria for these reviews are counterproductive and have the effect of obscuring decades of evidence demonstrating the clinical effectiveness of sound therapies for tinnitus. Ultimately, this process has resulted in many patients not receiving sound therapy, despite what should be sufficient evidence that this is an effective form of intervention.

CONCLUSION

If we rely on systematic reviews using contemporary RoB assessment criteria for studies published prior to these reporting guidelines, then we risk excluding important conclusions regarding interventions that could help patients in need.

Broadband Amplification as Tinnitus Treatment

This study investigated the effect of broadband amplification (125 Hz to 10 kHz) as tinnitus treatment for participants with high-frequency hearing loss and compared these effects with an active placebo condition using band-limited amplification (125 Hz to 3–4 kHz). A double-blinded crossover study. Twenty-three participants with high-frequency (≥3 kHz) hearing loss and chronic tinnitus were included in the study, and 17 completed the full treatment protocol. Two different hearing aid treatments were provided for 3 months each: Broadband amplification provided gain in the frequency range from 125 Hz to 10 kHz and band-limited amplification only provided gain in the low-frequency range (≤3–4 kHz). The effect of the two treatments on tinnitus distress was evaluated with the Tinnitus Handicap Inventory (THI) and the Tinnitus Functional Index (TFI) questionnaires. The effect of the treatment on tinnitus loudness was evaluated with a visual analog scale (VAS) for loudness and a psychoacoustic loudness measure. Furthermore, the tinnitus annoyance was evaluated with a VAS for annoyance. The tinnitus pitch was evaluated based on the tinnitus likeness spectrum. A statistically significant difference was found between the two treatment groups (broadband vs. band-limited amplification) for the treatment-related change in THI and TFI with respect to the baseline. Furthermore, a statistically significant difference was found between the two treatment conditions for the annoyance measure. Regarding the loudness measure, no statistically significant differences were found between the treatments, although there was a trend towards a lower VAS-based loudness measure resulting from the broadband amplification. No changes were observed in the tinnitus pitch between the different conditions. Overall, the results from the present study suggest that tinnitus patients with high-frequency hearing loss can experience a decrease in tinnitus-related distress and annoyance from high-frequency amplification.

Hearing Aid Fitting in Tinnitus: A Scoping Review of Methodological Aspects and Effect on Tinnitus Distress and Perception

Current evidence on efficacy of hearing aids (HAs) on tinnitus perception and annoyance is considered insufficient due to the heterogeneity of tinnitus characteristics and of methods used in the relevant clinical studies. This is a scoping review focused on the methodological aspects of clinical studies evaluating the value of HA fitting as part of tinnitus management over the past 10 years. Thirty-four studies were included in the review, showing important heterogeneity in almost all aspects of inclusion criteria, comparators, outcome measures, follow-up time and HA fitting procedures. Although all studies show that HA fitting has a positive impact on tinnitus perception in patients with hearing loss, the methodological heterogeneity does not allow robust conclusions. Future studies taking into account the different nature and goals of each tinnitus therapeutic modality and adapting their methods, endpoints and timelines according to them could lay the groundwork for obtaining high-quality evidence on whether and how HA fitting shall be implemented in tinnitus management strategies.

Methodological Aspects of Randomized Controlled Trials for Tinnitus: A Systematic Review and How a Decision Support System Could Overcome Barriers

Although a wide range of tinnitus management interventions is currently under research and a variety of therapeutic interventions have already been applied in clinical practice, no optimal and universal tinnitus treatment has been reached yet. This fact is to some extent a consequence of the high heterogeneity of the methodologies used in tinnitus related clinical studies. In this manuscript, we have identified, summarized, and critically appraised tinnitus-related randomized clinical trials since 2010, aiming at systematically mapping the research conducted in this area. The results of our analysis of the 73 included randomized clinical trials provide important insight on the identification of limitations of previous works, methodological pitfalls or gaps in current knowledge, a prerequisite for the adequate interpretation of current literature and execution of future studies.

Development and Evaluation of Portal do Zumbido : A Novel Telehealth Approach to Tinnitus

Introduction  Tinnitus is a prevalent symptom in audiological clinics, and the speech therapist participates in the assessment, diagnosis, and intervention of tinnitus. A range of studies have been developed with the aim to promote auditory health, and telehealth is an option for this purpose. Objective  The aim of the present study was to develop and assess a virtual platform for tinnitus management for speech therapists. Methods  The present study provided a distance-learning-course, with the aid of Portal do Zumbido , available in the following electronic address: zumbido.fob.usp.br. Infographics were available for download, and modules were made to comprise the introduction to the symptoms, assessment, and intervention for tinnitus. Results  Speech therapists of different regions of Brazil received an e-mail invitation to participate and to assess the platform, 46 of whom registered. From the 46 speech therapists registered, 38 assessed the virtual platform with the aid of a questionnaire about the theoretical content and then answered a motivational research sheet (MRS). The speech therapists correctly answered 90% and 100% of the questions in the questionnaire and in the MRS, respectively, which may indicate that the professionals positively absorbed the content; thus, the content was considered to be impressive when the MRS was analyzed. Conclusion   Portal do Zumbido was developed and is available for access in the following electronic address: zumbido.fob.usp.br. Furthermore, the platform received a positive assessment by the speech therapists who participated in the present study.

The state of the art of sound therapy for subjective tinnitus in adults

Background:

Sound therapy is a clinically common method of tinnitus management. Various forms of sound therapy have been developed, but there are controversies regarding the selection criteria and the efficacy of different forms of sound therapy in the clinic. Our goal was to review the types and forms of sound therapy and our understanding of how the different characteristics of tinnitus patients influence their curative effects so as to provide a reference for personalized choice of tinnitus sound therapy.

Method:

Using an established methodological framework, a search of six databases including PubMed identified 43 records that met our inclusion criteria. The search strategy used the following key words: tinnitus AND (acoustic OR sound OR music) AND (treatment OR therapy OR management OR intervention OR measure).

Results:

There are various forms of sound therapy, and most of them show positive therapeutic effects. The effect of customized sound therapy is generally better than that of non-customized sound therapy, and patients with more severe initial tinnitus respond better to sound therapy.

Conclusion:

Sound therapy can effectively suppress tinnitus, at least in some patients. However, there is a lack of randomized controlled trials to identify effective management strategies. Further studies are needed to identify the most effective form of sound therapy for individualized therapy, and large, multicenter, long-term follow-up studies are still needed in order to develop more effective and targeted sound-therapy protocols. In addition, it is necessary to analyze the characteristics of individual tinnitus patients and to unify the assessment criteria of tinnitus.

Sound Therapy for Tinnitus: Options for Audiologists

Purpose

Sound therapy to reduce the emotional and functional effects of tinnitus has been used by audiologists since the 1970s when Jack Vernon introduced the masking method to provide a sense of relief from tinnitus distress. Our group renamed masking sound as “soothing” sound and distinguished it from “interesting” and “background” sound, each of which has a different purpose for tinnitus sound therapy. Other methods of sound therapy have the potential to reduce the “sensation” of tinnitus, including notched noise, matched noise, desynchronization, and residual inhibition. The purpose of this article is to provide an overview of the different sound therapy approaches to serve as a resource for audiologists who often provide sound therapy to their patients with tinnitus.

Conclusion

Although, according to systematic reviews, sound therapy does not have strong evidence for treatment of tinnitus, it is nonetheless well evidenced both through abundant research and clinical utilization mostly by audiologists. It is unknown if any one form of sound therapy is superior to any other.

Audiologists and Tinnitus

Purpose Although tinnitus is highly prevalent among patients receiving audiology services, audiologists are generally untrained in tinnitus management. Audiology graduate programs, as a rule, do not provide comprehensive instruction in tinnitus clinical care. Training programs that do exist are inconsistent in their recommendations. Furthermore, no standards exist to prevent the delivery of unvetted audiologic services, which can be expensive for patients. Patients seeking professional services by an audiologist, therefore, have no basis upon which to be assured they will receive research-based care. The purpose of this article is to describe the current status of tinnitus management services that exist within the general field of audiology and to suggest specific approaches for improving those services. Conclusion Audiologists may be in the best position to serve as the primary health care providers for patients experiencing tinnitus. Tinnitus care services by audiologists, however, must achieve a level of evidence-based standardization.

Clinical Protocol to Promote Standardization of Basic Tinnitus Services by Audiologists

Purpose Clinical services for tinnitus are needed by millions of people annually. These services have not been standardized, and patients are vulnerable to receiving services that may appear legitimate but are not based on research evidence. The purpose of this clinical focus article is to promote standardization of tinnitus services by proposing an efficient clinical protocol for audiologists. Method The suggested clinical protocol is based primarily on research conducted at the National Center for Rehabilitative Auditory Research for the past 2 decades, with the focus on 2 randomized controlled trials completed recently that showed efficacy of an audiologic protocol involving hearing aids and brief tinnitus counseling. The protocol is mostly consistent with clinical practice guidelines that have been published. Results The two National Center for Rehabilitative Auditory Research randomized controlled trials revealed significant reduction of tinnitus functional effects for both hearing aids and "combination instruments" (hearing aids with a built-in sound generator), although there were no significant differences between devices. Existing clinical practice guidelines for tinnitus are summarized with respect to their common recommendations for assessment and intervention. Conclusions A defined clinical protocol is suggested for audiologists, which includes a case history, appropriate referral, audiologic assessment, use of the Tinnitus and Hearing Survey ( Henry, Griest, et al., 2015 ), brief tinnitus counseling, hearing aids or combination instruments as warranted, follow-up assessment, and criteria for determining if further tinnitus-specific services are needed. Use of this protocol can help to promote standardization of tinnitus practice by audiologists.

Sound therapy (using amplification devices and/or sound generators) for tinnitus

BACKGROUND

Tinnitus affects 10% to 15% of the adult population, with about 20% of these experiencing symptoms that negatively affect quality of life. In England alone there are an estimated ¾ million general practice consultations every year where the primary complaint is tinnitus, equating to a major burden on healthcare services. Clinical management strategies include education and advice, relaxation therapy, tinnitus retraining therapy (TRT), cognitive behavioural therapy (CBT), sound enrichment using ear-level sound generators or hearing aids, and drug therapies to manage co-morbid symptoms such as insomnia, anxiety or depression. Hearing aids, sound generators and combination devices (amplification and sound generation within one device) are a component of many tinnitus management programmes and together with information and advice are a first line of management in audiology departments for someone who has tinnitus.

OBJECTIVES

To assess the effects of sound therapy (using amplification devices and/or sound generators) for tinnitus in adults.

SEARCH METHODS

The Cochrane ENT Information Specialist searched the Cochrane ENT Register; Central Register of Controlled Trials (CENTRAL, via the Cochrane Register of Studies); Ovid MEDLINE; Ovid Embase; CINAHL; Web of Science; ClinicalTrials.gov; ICTRP and additional sources for published and unpublished trials. The date of the search was 23 July 2018.

SELECTION CRITERIA

Randomised controlled trials (RCTs) recruiting adults with acute or chronic subjective idiopathic tinnitus. We included studies where the intervention involved hearing aids, sound generators or combination hearing aids and compared them to waiting list control, placebo or education/information only with no device. We also included studies comparing hearing aids to sound generators, combination hearing aids to hearing aids, and combination hearing aids to sound generators.

DATA COLLECTION AND ANALYSIS

We used the standard methodological procedures expected by Cochrane. Our primary outcomes were tinnitus symptom severity as measured as a global score on multi-item tinnitus questionnaire and significant adverse effects as indicated by an increase in self-reported tinnitus loudness. Our secondary outcomes were depressive symptoms, symptoms of generalised anxiety, health-related quality of life and adverse effects associated with wearing the device such as pain, discomfort, tenderness or skin irritation, or ear infections. We used GRADE to assess the quality of evidence for each outcome; this is indicated in italics.

MAIN RESULTS

This review included eight studies (with a total of 590 participants). Seven studies investigated the effects of hearing aids, four combination hearing aids and three sound generators. Seven studies were parallel-group RCTs and one had a cross-over design. In general, risk of bias was unclear due to lack of detail about sequence generation and allocation concealment. There was also little or no use of blinding.No data for our outcomes were available for any of our three main comparisons (comparing hearing aids, sound generators and combination devices with a waiting list control group, placebo or education/information only). Data for our additional comparisons (comparing these devices with each other) were also few, with limited potential for data pooling.Hearing aid only versus sound generator device onlyOne study compared patients fitted with sound generators versus those fitted with hearing aids and found no difference between them in their effects on our primary outcome, tinnitus symptom severity measured with the Tinnitus Handicap Inventory (THI) at 3, 6 or 12 months (low-quality evidence). The use of both types of device was associated with a clinically significant reduction in tinnitus symptom severity.Combination hearing aid versus hearing aid onlyThree studies compared combination hearing aids with hearing aids and measured tinnitus symptom severity using the THI or Tinnitus Functional Index. When we pooled the data we found no difference between them (standardised mean difference -0.15, 95% confidence interval -0.52 to 0.22; three studies; 114 participants) (low-quality evidence). The use of both types of device was again associated with a clinically significant reduction in tinnitus symptom severity.Adverse effects were not assessed in any of the included studies.None of the studies measured the secondary outcomes of depressive symptoms or depression, anxiety symptoms or generalised anxiety, or health-related quality of life as measured by a validated instrument, nor the newly developed core outcomes tinnitus intrusiveness, ability to ignore, concentration, quality of sleep and sense of control.

AUTHORS' CONCLUSIONS

There is no evidence to support the superiority of sound therapy for tinnitus over waiting list control, placebo or education/information with no device. There is insufficient evidence to support the superiority or inferiority of any of the sound therapy options (hearing aid, sound generator or combination hearing aid) over each other. The quality of evidence for the reported outcomes, assessed using GRADE, was low. Using a combination device, hearing aid or sound generator might result in little or no difference in tinnitus symptom severity.Future research into the effectiveness of sound therapy in patients with tinnitus should use rigorous methodology. Randomisation and blinding should be of the highest quality, given the subjective nature of tinnitus and the strong likelihood of a placebo response. The CONSORT statement should be used in the design and reporting of future studies. We also recommend the use of validated, patient-centred outcome measures for research in the field of tinnitus.

Technical Feasibility of Acoustic Coordinated Reset Therapy for Tinnitus Delivered via Hearing Aids: A Case Study

Primary tinnitus has a severe negative influence on the quality of life of a substantial portion of the general population. When acoustic coordinated reset (CR) neuromodulation stimuli are delivered for several hours per day over several weeks a clinically significant symptom reduction in patients with primary tonal tinnitus has been reported by several clinical sites. Here, we reported the first case where CR neuromodulation was delivered through a hearing aid. A 52-year-old man with chronic primary tonal tinnitus was previously considered untreatable with sound therapy. He initially received the classic CR treatment protocol with signals delivered with the separate proprietary device with his hearing aids removed during treatment. He was subsequently treated with the therapy being deployed through a set of contemporary hearing aids. After 5 months of classic CR treatment with the separate custom device, the THI and VAS_L/A scores worsened by 57% and 13%/14%, respectively. Using the hearing aid without CR treatment for 5 months no change in tinnitus symptoms was observed. However, after three months of CR treatment delivered through the hearing aids, the THI and VAS_L/A scores were reduced by 70% and 32%/32%, respectively.