The Tinnitus Research Initiative (TRI) database: a new approach for delineation of tinnitus subtypes and generation of predictors for treatment outcome

Screening for Circulating Inflammatory Proteins Does Not Reveal Plasma Biomarkers of Constant Tinnitus

BACKGROUND AND OBJECTIVE

Tinnitus would benefit from an objective biomarker. The goal of this study is to identify plasma biomarkers of constant and chronic tinnitus among selected circulating inflammatory proteins.

METHODS

A case-control retrospective study on 548 cases with constant tinnitus and 548 matched controls from the Swedish Tinnitus Outreach Project (STOP), whose plasma samples were examined using Olink's Inflammatory panel. Replication and meta-analysis were performed using the same method on samples from the TwinsUK cohort. Participants from LifeGene, whose blood was collected in Stockholm and Umeå, were recruited to STOP for a tinnitus subtyping study. An age and sex matching was performed at the individual level. TwinsUK participants (n = 928) were selected based on self-reported tinnitus status over 2 to 10 years. Primary outcomes include normalized levels for 96 circulating proteins, which were used as an index test. No reference standard was available in this study.

RESULTS

After adjustment for age, sex, BMI, smoking, hearing loss, and laboratory site, the top proteins identified were FGF-21, MCP4, GDNF, CXCL9, and MCP-1; however, these were no longer statistically significant after correction for multiple testing. Stratification by sex did not yield any significant associations. Similarly, associations with hearing loss or other tinnitus-related comorbidities such as stress, anxiety, depression, hyperacusis, temporomandibular joint disorders, and headache did not yield any significant associations. Analysis in the TwinsUK failed in replicating the top candidates. Meta-analysis of STOP and TwinsUK did not reveal any significant association. Using elastic net regularization, models exhibited poor predictive capacity tinnitus based on inflammatory markers [sensitivity = 0.52 (95% CI 0.47-0.57), specificity = 0.53 (0.48-0.58), positive predictive value = 0.52 (0.47-0.56), negative predictive values = 0.53 (0.49-0.58), and AUC = 0.53 (0.49-0.56)].

DISCUSSION

Our results did not identify significant associations of the selected inflammatory proteins with constant tinnitus. Future studies examining longitudinal relations among those with more severe tinnitus and using more recent expanded proteomics platforms and sampling of cerebrospinal fluid could increase the likelihood of identifying relevant molecular biomarkers.

COVID-19 and tinnitus: an initiative to improve tinnitus care

OBJECTIVE

To investigate the effects of COVID-19 on individuals with tinnitus and their views to guide future tinnitus care.

DESIGN

A mixed-methods cross-sectional research design.

STUDY SAMPLE

An online survey was completed by 365 individuals with tinnitus from Australia and other countries.

RESULTS

Tinnitus was reported to be more bothersome during the pandemic by 36% of respondents, whereas 59% reported no change and 5% reported less bothersome tinnitus. Nearly half of the respondents had received COVID-19 vaccination(s) and 12% of them reported more bothersome tinnitus while 2% developed tinnitus post-vaccination. Australian respondents spent less time in self-isolation or quarantine and saw fewer change in in-person social contact than respondents from other countries. More than 70% of respondents thought that tinnitus care services were insufficient both before and during the pandemic. Regarding their opinions on how to improve tinnitus care in the future, five themes including alleviation of condition, government policies, reduced barriers, self- and public-awareness, and hearing devices were identified.

CONCLUSIONS

A majority of respondents did not perceive any change in tinnitus perception and one-third of respondents had worsened tinnitus during the pandemic. To improve tinnitus care, better awareness and more accessible resources and management are crucial.

Validated French translation of the ESIT-SQ standardized tinnitus screening questionnaire

OBJECTIVES

The heterogeneity of tinnitus in terms of etiology, presentation and sometimes severe impact on quality of life hinders treatment and clinical research. The European School for Interdisciplinary Tinnitus Research Screening Questionnaire (ESIT-SQ) collects standardized tinnitus characteristics for patient subtyping. A validated French translation of the ESIT-SQ is presented here.

METHOD

On the initiative of the French Interdisciplinary Tinnitus Association (AFREPA), 3 translators (1 professional translator, 1 clinician and 1 researcher) were missioned to translate the English version of the ESIT-SQ into French, adhering to good practice guidelines. Nine patients were recruited with the help of the France-Acouphènes patient association, to test and validate the translation. Lastly, an exploratory survey of responses to the French questionnaire was conducted online via the Siopi mobile phone application.

RESULTS

The French translation of the ESIT-SQ was successfully validated. 105 patients responded to the exploratory survey, and their characteristics are presented here.

CONCLUSION

This new validated French translation of the ESIT-SQ will enable epidemiological and clinical data to be collected in French-speaking populations, and thus compiled and compared with data collected with other versions of this questionnaire already published in other languages.

The statistical analysis plan for the unification of treatments and interventions for tinnitus patients randomized clinical trial (UNITI-RCT)

BACKGROUND

Tinnitus is a leading cause of disease burden globally. Several therapeutic strategies are recommended in guidelines for the reduction of tinnitus distress; however, little is known about the potentially increased effectiveness of a combination of treatments and personalized treatments for each tinnitus patient.

METHODS

Within the Unification of Treatments and Interventions for Tinnitus Patients project, a multicenter, randomized clinical trial is conducted with the aim to compare the effectiveness of single treatments and combined treatments on tinnitus distress (UNITI-RCT). Five different tinnitus centers across Europe aim to treat chronic tinnitus patients with either cognitive behavioral therapy, sound therapy, structured counseling, or hearing aids alone, or with a combination of two of these treatments, resulting in four treatment arms with single treatment and six treatment arms with combinational treatment. This statistical analysis plan describes the statistical methods to be deployed in the UNITI-RCT.

DISCUSSION

The UNITI-RCT trial will provide important evidence about whether a combination of treatments is superior to a single treatment alone in the management of chronic tinnitus patients. This pre-specified statistical analysis plan details the methodology for the analysis of the UNITI trial results.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04663828 . The trial is ongoing. Date of registration: December 11, 2020. All patients that finished their treatment before 19 December 2022 are included in the main RCT analysis.

Tinnitus as a Potential Risk Factor for Uveitis: A 14-Year Nationwide Population-Based Cohort Study in Taiwan

BACKGROUND

Tinnitus and uveitis have shared commonality in pathophysiology in terms of autoimmunity. However, no studies that have linked any association between the conditions of tinnitus and uveitis.

METHODS

This is a retrospective study conducted from the Taiwan National Health Insurance database in order to investigate whether tinnitus patients are at increased risk of uveitis. Patients newly diagnosed with tinnitus between 2001 and 2014 were recruited and followed up until 2018. The endpoint of interest was a diagnosis of uveitis.

RESULTS

A total of 31,034 tinnitus patients and 124,136 matched comparisons were analyzed. Tinnitus patients were found to have a significantly higher cumulative incidence for uveitis than those without the diagnosis of tinnitus with incidence rate of 1.68 (95% CI 1.55-1.82) per 10 000 person-months for tinnitus group and 1.48 (95% CI 1.42-1.54) per 10 000 person-months for non-tinnitus group.

CONCLUSION

Tinnitus patients were found to have increased risk of developing uveitis.

Characterizing the most Popular Tinnitus Inquiries: Is Tinnitus Incidence on the Rise Since COVID-19?

OBJECTIVE

Approximately 50 million US adults experience chronic tinnitus, yet search behaviors and topics of concern to these patients have not been investigated on a national level.

STUDY DESIGN

Observational.

SETTING

Online database and tertiary otology clinic.

PATIENTS

Nationwide and institutional samples.

INTERVENTIONS

None.

MAIN OUTCOME MEASURE

A search engine optimization tool was utilized to extract metadata on "People Also Ask" (PAA) questions pertaining to tinnitus. Website quality was assessed using JAMA benchmark criteria. Search volume trends were investigated along with institutional-level data on tinnitus incidence.

RESULTS

Of the 500 PAA questions assessed, the majority (54.0%) contained value-type content. The most popular question categories pertained to tinnitus treatment (29.3%), alternative treatment approaches (21.5%), technical details (16.9%), and timeline of symptoms (13.4%). Patients were most interested in treatment with wearable masking devices and most commonly searched for tinnitus as being attributable to a neurologic etiology. Online searches pertaining to unilateral tinnitus symptoms have increased >3-fold since the onset of the COVID-19 pandemic. Likewise, review of patient encounters at our tertiary otology clinic revealed a nearly 2-fold increase in tinnitus consultations since 2020.

CONCLUSIONS

Topics of interest and concern identified herein may inform the development of patient education materials and help guide clinical practice. Online search data suggest an increase in tinnitus searches since the onset of COVID-19, which did correlate clinically with an increase in tinnitus consultations at our institution.

Tinnitus Is Marginally Associated with Body Mass Index, Heart Rate and Arterial Blood Pressure: Results from a Large Clinical Sample

INTRODUCTION

This study aimed to explore whether body mass index (BMI), systolic blood pressure (RR syst), diastolic blood pressure (RR diast) or heart rate (HR) are associated with tinnitus status and/or severity.

METHODS

To that end, we evaluated the influence of tinnitus status and Tinnitus Handicap Inventory (THI) score on BMI, RR syst, RR diast and HR by comparing data from a large sample of patients presenting to a specialized tertiary referral clinic (N = 1066) with data from a population-based control group (N = 9885) by means of linear models.

RESULTS

Tinnitus patients had a significantly lower BMI and higher RR syst, RR diast and HR than non-tinnitus patients; however, the contribution of the case-control status to R² was very small (0.1%, 0.7%, 1.4% and 0.4%, respectively). BMI had little predictive power for the THI score (higher BMI scores were related to higher THI scores; R² = 0.5%) and neither RR syst, RR diast, nor HR showed a statistically significant association with THI.

DISCUSSION

Our findings suggest that HR, RR and BMI are at most marginally associated with tinnitus status and severity.

REM Sleep Impairment May Underlie Sleep-Driven Modulations of Tinnitus in Sleep Intermittent Tinnitus Subjects: A Controlled Study

(1) Background: Poor sleep and fragmented sleep are associated with several chronic conditions. Tinnitus is an auditory symptom that often negatively combines with poor sleep and has been associated with sleep impairment and sleep apnea. The relationship between tinnitus psychoacoustic characteristics and sleep is still poorly explored, notably for a particular subgroup of patients, for whom the perceived loudness of their tinnitus is highly modulated by sleep. (2) Methods: For this observational prospective study, 30 subjects with tinnitus were recruited, including 15 "sleep intermittent tinnitus" subjects, who had reported significant modulations of tinnitus loudness related to night sleep and naps, and a control group of 15 subjects displaying constant non-sleep-modulated tinnitus. The control group had matching age, gender, self-reported hearing loss grade and tinnitus impact on quality of life with the study group. All patients underwent a polysomnography (PSG) assessment for one complete night and then were asked to fill in a case report form, as well as a report of tinnitus loudness before and after the PSG. (3) Results: "Sleep Intermittent tinnitus" subjects had less Stage 3 sleep (p < 0.01), less Rapid-Eye Movement (REM) Sleep (p < 0.05) and more Stage 2 sleep (p < 0.05) in proportion and duration than subjects from the control group. In addition, in the "sleep Intermittent tinnitus" sample, a correlation was found between REM sleep duration and tinnitus overnight modulation (p < 0.05), as well as tinnitus impact on quality of life (p < 0.05). These correlations were not present in the control group. (4) Conclusions: This study suggests that among the tinnitus population, patients displaying sleep-modulated tinnitus have deteriorated sleep quality. Furthermore, REM sleep characteristics may play a role in overnight tinnitus modulation. Potential pathophysiological explanations accounting for this observation are hypothesized and discussed.

Study on tinnitus-related electroencephalogram microstates in patients with vestibular schwannomas

Tinnitus is closely associated with cognition functioning. In order to clarify the central reorganization of tinnitus in patients with vestibular schwannoma (VS), this study explored the aberrant dynamics of electroencephalogram (EEG) microstates and their correlations with tinnitus features in VS patients. Clinical and EEG data were collected from 98 VS patients, including 76 with tinnitus and 22 without tinnitus. Microstates were clustered into four categories. Our EEG microstate analysis revealed that VS patients with tinnitus exhibited an increased frequency of microstate C compared to those without tinnitus. Furthermore, correlation analysis demonstrated that the Tinnitus Handicap Inventory (THI) score was negatively associated with the duration of microstate A and positively associated with the frequency of microstate C. These findings suggest that the time series and syntax characteristics of EEG microstates differ significantly between VS patients with and without tinnitus, potentially reflecting abnormal allocation of neural resources and transition of functional brain activity. Our results provide a foundation for developing diverse treatments for tinnitus in VS patients.

Comparing Clustering Methods Applied to Tinnitus within a Bootstrapped and Diagnostic-Driven Semi-Supervised Framework

The understanding of tinnitus has always been elusive and is largely prevented by its intrinsic heterogeneity. To address this issue, scientific research has aimed at defining stable and easily identifiable subphenotypes of tinnitus. This would allow better disentangling the multiple underlying pathophysiological mechanisms of tinnitus. In this study, three-dimensionality reduction techniques and two clustering methods were benchmarked on a database of 2772 tinnitus patients in order to obtain a reliable segmentation of subphenotypes. In this database, tinnitus patients’ endotypes (i.e., parts of a population with a condition with distinct underlying mechanisms) are reported when diagnosed by an ENT expert in tinnitus management. This partial labeling of the dataset enabled the design of an original semi-supervised framework. The objective was to perform a benchmark of different clustering methods to get as close as possible to the initial ENT expert endotypes. To do so, two metrics were used: a primary one, the quality of the separation of the endotypes already identified in the database, as well as a secondary one, the stability of the obtained clusterings. The relevance of the results was finally reviewed by two ENT experts in tinnitus management. A 20-cluster clustering was selected as the best-performing, the most-clinically relevant, and the most-stable through bootstrapping. This clustering used a T-SNE method as the dimensionality reduction technique and a k-means algorithm as the clustering method. The characteristics of this clustering are presented in this article.

Cognitive Behavioral Group Therapy for Chronic Tinnitus in a German Tertiary Clinical Real-World Setting

Cognitive behavioral therapy (CBT) was shown to be effective in reducing tinnitus-related distress in numerous controlled trials. Real-world data from tinnitus treatment centers are an important addition to controlled trials for demonstrating the ecological validity of the results from the randomized controlled trials. Thus, we provided the real-world data of 52 patients participating in CBT group therapies during the time period from 2010 to 2019. The groups consisted of five to eight patients with typical CBT content such as counseling, relaxation, cognitive restructuring, attention training, etc. applied through 10-12 weekly sessions. The mini tinnitus questionnaire, different tinnitus numeric rating scales and the clinical global impression were assessed in a standardized way and were analyzed retrospectively. All outcome variables showed clinically relevant changes from before to after the group therapy, which were still evident in the follow-up visit after three months. Amelioration of distress was correlated to all numeric rating scales, including tinnitus loudness but not annoyance. The observed positive effects were in a similar range as effects of controlled and uncontrolled studies. Somewhat unexpected was the observed reduction in loudness, which was associated with distress and the missing association of changes in distress with annoyance as it is generally assumed that standard CBT concepts reduce annoyance and distress, but not tinnitus loudness. Apart from confirming the therapeutic effectiveness of CBT in real-world settings, our results highlight the need for a clear definition/operationalization of outcome measures when investigating psychological interventions of tinnitus.

One way or another: Treatment effects of 1 Hz rTMS using different current directions in a small sample of tinnitus patients

INTRODUCTION

So far studies on the efficacy of repetitive transcranial magnetic stimulation (rTMS) as a treatment for tinnitus are inconclusive. Two large scale placebo-controlled randomized clinical trials (RCT) examined the efficacy of low frequency temporal cortex rTMS and report different findings. As the used TMS devices differ in their used primary current direction by default, this technical parameter was speculated as a potential reason for the observed incongruences in tinnitus-related outcomes. The aim of the present pilot study was to investigate the treatment effect of 1 Hz rTMS using two different current flows.

MATERIALS AND METHODS

Nine tinnitus patients were treated in two different groups each comprised of 10 treatment sessions á 3000 biphasic pulses of 1 Hz rTMS applied over the left temporo-parietal cortex using either an anterior-posterior to posterior-anterior (AP-PA) or posterior-anterior to anterior-posterior (PA-AP) induced current flow.

RESULTS

1 Hz rTMS with a primary posterior-anterior to anterior-posterior (PA-AP) current flow caused a superior reduction in tinnitus-related symptoms, particularly tinnitus unpleasantness, loudness and tinnitus-related distress.

CONCLUSIONS

The present pilot study demonstrated that the technical TMS parameter current direction might be essential for the efficacy of rTMS as a treatment for tinnitus. Systematic investigations of technical TMS parameters like current direction in larger samples of tinnitus patients are highly needed.

Activate & fire: a feasibility study in combining acoustic stimulation and continuous theta burst stimulation in chronic tinnitus

BACKGROUND

Low frequency repetitive transcranial magnetic stimulation (rTMS) is commonly used to inhibit pathological hyperactivity of the auditory cortex in tinnitus. Novel and supposedly superior and faster inhibitory protocols such as continuous theta burst stimulation (cTBS) were examined as well, but so far there is not sufficient evidence for a treatment application in chronic tinnitus. rTMS effects in general are dependent on the brain state immediate before stimulation. This feasibility study was designed based on the concept to shift the pathological intrinsic brain state of tinnitus patients via acoustic stimulation ("activate") and induce inhibitory effects via cTBS ("fire").

METHODS

Seven tinnitus patients with response in residual inhibition received 10 consecutive daily sessions of a combinatory treatment comprised of 3-minute acoustic stimulation with white noise followed by 600 pulses of cTBS over the left temporo-parietal cortex (activate & fire). A control group of 5 patients was treated parallel to the activate & fire data collection with 10 sessions á 3000 pulses of 1 Hz rTMS over the left temporo-parietal cortex.

RESULTS

The activate & fire protocol was well tolerated except in one patient with tinnitus loudness increase. This patient was excluded from analyses. No statistical superiority of the activate & fire treatment approach in alleviating tinnitus-related symptoms was evident. Power calculations showed an effect size of 0.706 and a needed sample size of 66 for statistical significant group differences. On a descriptive level the activate & fire group demonstrated a stronger decrease in tinnitus-related symptoms.

CONCLUSION

The present feasibility study showed that combining acoustic stimulation with magnetic brain stimulation may be well-tolerable in the majority of patients and represents a promising treatment approach for tinnitus by hypothetically alter the intrinsic state prior to brain stimulation.

Linking Affective and Hearing Sciences-Affective Audiology

A growing number of health-related sciences, including audiology, have increasingly recognized the importance of affective phenomena. However, in audiology, affective phenomena are mostly studied as a consequence of hearing status. This review first addresses anatomical and functional bidirectional connections between auditory and affective systems that support a reciprocal affect-hearing relationship. We then postulate, by focusing on four practical examples (hearing public campaigns, hearing intervention uptake, thorough hearing evaluation, and tinnitus), that some important challenges in audiology are likely affect-related and that potential solutions could be developed by inspiration from affective science advances. We continue by introducing useful resources from affective science that could help audiology professionals learn about the wide range of affective constructs and integrate them into hearing research and clinical practice in structured and applicable ways. Six important considerations for good quality affective audiology research are summarized. We conclude that it is worthwhile and feasible to explore the explanatory power of emotions, feelings, motivations, attitudes, moods, and other affective processes in depth when trying to understand and predict how people with hearing difficulties perceive, react, and adapt to their environment.

A data-driven approach to clinical decision support in tinnitus retraining therapy

Background

Tinnitus, known as “ringing in the ears”, is a widespread and frequently disabling hearing disorder. No pharmacological treatment exists, but clinical management techniques, such as tinnitus retraining therapy (TRT), prove effective in helping patients. Although effective, TRT is not widely offered, due to scarcity of expertise and complexity because of a high level of personalization. Within this study, a data-driven clinical decision support tool is proposed to guide clinicians in the delivery of TRT.

Methods

This research proposes the formulation of data analytics models, based on supervised machine learning (ML) techniques, such as classification models and decision rules for diagnosis, and action rules for treatment to support the delivery of TRT. A knowledge-based framework for clinical decision support system (CDSS) is proposed as a UI-based Java application with embedded WEKA predictive models and Java Expert System Shell (JESS) rule engine with a pattern-matching algorithm for inference (Rete). The knowledge base is evaluated by the accuracy, coverage, and explainability of diagnostics predictions and treatment recommendations.

Results

The ML methods were applied to a clinical dataset of tinnitus patients from the Tinnitus and Hyperacusis Center at Emory University School of Medicine, which describes 555 patients and 3,000 visits. The validated ML classification models for diagnosis and rules: association and actionable treatment patterns were embedded into the knowledge base of CDSS. The CDSS prototype was tested for accuracy and explainability of the decision support, with preliminary testing resulting in an average of 80% accuracy, satisfactory coverage, and explainability.

Conclusions

The outcome is a validated prototype CDS system that is expected to facilitate the TRT practice.

Low Sleep Satisfaction Is Related to High Disease Burden in Tinnitus

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

Smartphone-Guided Educational Counseling and Self-Help for Chronic Tinnitus

Tinnitus is an auditory phantom perception in the ears or head in the absence of a corresponding external stimulus. There is currently no effective treatment available that reliably reduces tinnitus. Educational counseling is a treatment approach that aims to educate patients and inform them about possible coping strategies. For this feasibility study, we implemented educational material and self-help advice in a smartphone app. Participants used the educational smartphone app unsupervised during their daily routine over a period of four months. Comparing the tinnitus outcome measures before and after smartphone-guided treatment, we measured changes in tinnitus-related distress, but not in tinnitus loudness. Improvements on the Tinnitus Severity numeric rating scale reached an effect size of 0.408, while the improvements on the Tinnitus Handicap Inventory (THI) were much smaller with an effect size of 0.168. An analysis of user behavior showed that frequent and intensive use of the app is a crucial factor for treatment success: participants that used the app more often and interacted with the app intensively reported a stronger improvement in the tinnitus. Between study allocation and final assessment, 26 of 52 participants dropped out of the study. Reasons for the dropouts and lessons for future studies are discussed in this paper.

Hypothyroidism and related comorbidities on the risks of developing tinnitus

This is a retrospective longitudinal study that uses data from the National Health Insurance Research Database (NHIRD) of Taiwan of which hypothyroid patients who received a diagnosis between 2000 and 2010 were selected and followed up until 2011. The primary outcome of this study was the occurrence of tinnitus (ICD-9-CM code 388.3). The relevant comorbidities were selected as potential confounders according to the literature, which included vertigo (ICD-9-CM code 386), insomnia (ICD-9-CM code 780), anxiety (ICD-9-CM code 300.00), and hearing loss (ICD-9-CM code 388–389). The overall incidence of tinnitus was significantly higher in the hypothyroidism cohort than in the non-hypothyroidism cohort (9.49 vs. 6.03 per 1000 person-years), with an adjusted HR of 1.35 (95% CI 1.18–1.54) after adjusting potential confounders. The incidences of tinnitus, as stratified by gender, age, comorbidity, and follow-up time, were all significantly higher in the hypothyroidism cohort than those in the non-hypothyroidism cohort. The incidence of tinnitus significantly increased with age (aHR = 1.01, 95% CI 1.01–1.02). In conclusion, we report the relationship between hypothyroidism and the increased risk for tinnitus. We also found that hypothyroidism patients are at increased risk of developing tinnitus when associated with comorbidities including vertigo, hearing loss, and insomnia.

Alterations in auditory brainstem response distinguish occasional and constant tinnitus

BACKGROUND

The heterogeneity of tinnitus is thought to underlie the lack of objective diagnostic measures.

METHODS

Longitudinal data from 20,349 participants of the Swedish Longitudinal Occupational Survey of Health (SLOSH) cohort from 2008 to 2018 were used to understand the dynamics of transition between occasional and constant tinnitus. The second part of the study included electrophysiological data from 405 participants of the Swedish Tinnitus Outreach Project (STOP) cohort.

RESULTS

We determined that with increasing frequency of the occasional perception of self-reported tinnitus, the odds of reporting constant tinnitus after 2 years increases from 5.62 (95% CI, 4.83–6.55) for previous tinnitus (sometimes) to 29.74 (4.82–6.55) for previous tinnitus (often). When previous tinnitus was reported to be constant, the odds of reporting it as constant after 2 years rose to 603.02 (524.74–692.98), suggesting that once transitioned to constant tinnitus, the likelihood of tinnitus to persist was much greater. Auditory brain stem responses (ABRs) from subjects reporting nontinnitus (controls), occasional tinnitus, and constant tinnitus show that wave V latency increased in constant tinnitus when compared with occasional tinnitus or nontinnitus. The ABR from occasional tinnitus was indistinguishable from that of the nontinnitus controls.

CONCLUSIONS

Our results support the hypothesis that the transition from occasional to constant tinnitus is accompanied by neuronal changes in the midbrain leading to a persisting tinnitus, which is then less likely to remit.

FUNDING

This study was supported by the GENDER-Net Co-Plus Fund (GNP-182), the European Union’s Horizon 2020 grants no. 848261 (Unification of Treatments and Interventions for Tinnitus [UNITI]) and no. 722046 (European School for Interdisciplinary Tinnitus Research [ESIT]).

Tinnitus: Characteristics, Need for Therapy, and Therapeutic Outcomes; Results of an International Patient Initiated Platform

Introduction

So far, there is a gap of knowledge about factors influencing the impact of tinnitus, the need for treatment, as well as the experienced effect of regular and alternative tinnitus therapies. In this study, we analyzed the need for treatment and the outcomes of these treatments in an international patient initiated in tinnitus platform.

Materials and Methods

Two surveys were undertaken at an online tinnitus patient support community (www.tinnitustalk.com). The surveys were aimed at (1) using tinnitus treatment and outcomes and (2) the factors that influence tinnitus. Univariable logistic and linear regression were used to calculate the relation between the factors and the tinnitus impact as well as the relation with the used tinnitus treatments and the outcomes.

Results

Of the participants to the first survey (n = 5,017), 2,914 (58.1%) used one or more tinnitus therapies, whereas others most commonly self-administered sound therapy [n = 1,562 (31.1%)] and supplements/herbal medicines [n = 1,157 (23.1 %)]. Being female [odds ratio (OR) 0.83 (95% CI 0.74–0.93, p < 0.01)], tinnitus impact, and some degrees of hearing loss and hyperacusis were all statistically significantly associated with higher odds of having tinnitus treatment. Out of the second survey (n = 6,115), it was found that patient physical and psychological factors were statistically significantly related to tinnitus impact.

Conclusion

In this study, we demonstrated the usage and experience of (multiple) tinnitus therapy in patients. Several patient physical and psychological characteristics were found to be related to tinnitus impact and therapy usage. These outcomes might function as the next step to find a personalized treatment and to improve the tinnitus health care.

Unification of Treatments and Interventions for Tinnitus Patients (UNITI): a study protocol for a multi-center randomized clinical trial

BACKGROUND

Tinnitus represents a relatively common condition in the global population accompanied by various comorbidities and severe burden in many cases. Nevertheless, there is currently no general treatment or cure, presumable due to the heterogeneity of tinnitus with its wide variety of etiologies and tinnitus phenotypes. Hence, most treatment studies merely demonstrated improvement in a subgroup of tinnitus patients. The majority of studies are characterized by small sample sizes, unstandardized treatments and assessments, or applications of interventions targeting only a single organ level. Combinatory treatment approaches, potentially targeting multiple systems as well as treatment personalization, might provide remedy and enhance treatment responses. The aim of the present study is to systematically examine established tinnitus therapies both alone and in combination in a large sample of tinnitus patients. Further, it wants to provide the basis for personalized treatment approaches by evaluating a specific decision support system developed as part of an EU-funded collaborative project (Unification of treatments and interventions for tinnitus patients; UNITI project).

METHODS/STUDY DESIGN

This is a multi-center parallel-arm randomized clinical trial conducted at five different clinical sites over the EU. The effect of four different tinnitus therapy approaches (sound therapy, structured counseling, hearing aids, cognitive behavioral therapy) applied over a time period of 12 weeks as a single or rather a combinatory treatment in a total number of 500 chronic tinnitus patients will be investigated. Assessments and interventions are harmonized over the involved clinical sites. The primary outcome measure focuses on the domain tinnitus distress assessed via the Tinnitus Handicap Inventory.

DISCUSSION

Results and conclusions from the current study might not only provide an essential contribution to combinatory and personalized treatment approaches in tinnitus but could also provide more profound insights in the heterogeneity of tinnitus, representing an important step towards a cure for tinnitus.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04663828 . Registered on 11 December 2020.

Differences in characteristics between people with tinnitus that seek help and that do not

Knowledge on characteristics of people that seek help for tinnitus is scarce. The primary objective of this study was to describe differences in characteristics between people with tinnitus that seek help compared to those who do not seek help. Next, we described differences in characteristics between those with and without tinnitus. In this cross-sectional study, we sent a questionnaire on characteristics in different domains; demographic, tinnitus-specific, general- and psychological health, auditory and noise- and substance behaviour. We assessed if participants had sought help or planned to seek help for tinnitus. Tinnitus distress was defined with the Tinnitus Functional Index. Differences between groups (help seeking: yes/no, tinnitus: yes/no) were described. 932 people took part in our survey. Two hundred and sixteen participants were defined as having tinnitus (23.2%). Seventy-three of those sought or planned to seek help. A constant tinnitus pattern, a varying tinnitus loudness, and hearing loss, were described more frequently in help seekers. Help seekers reported higher TFI scores. Differences between help seekers and people not seeking help were mainly identified in tinnitus- and audiological characteristics. These outcomes might function as a foundation to explore the heterogeneity in tinnitus patients.

Patients with tinnitus use more primary healthcare compared to people without tinnitus

Tinnitus is a heterogeneous condition not only in terms of nature of the sound, but also in co-morbidities such as mental health issues. Prevalence number range widely between 5 and 43%. Even though the etiologic pathway between tinnitus and its comorbidities remains unclear, in this study we aim to assess whether people with tinnitus use more primary health care than people without tinnitus. To compare primary healthcare consumption between patients with tinnitus and people without tinnitus. In this cross-sectional study, data on number of consultations with the general practitioner or nurse practitioner mental health services were obtained from Nivel (Netherlands Institute for Health Service Research) Primary Care Database in 2018 (n = 963,880 people). People with an open tinnitus episode (n = 8050) were defined as a patient with tinnitus and compared to all other people. Percentages, means, ranges and mean differences were calculated for the total number of consultations and for organ specific diagnoses registered as ICPC-1 code on the day of consultation. Secondary, the total number of referrals to medical specialists and number of drug prescriptions was collected. Logistic regressions were performed to predict having one or more contacts, referrals, and prescriptions,with having tinnitus, this was corrected for age and gender. Patients with tinnitus had a mean of 9.8 (SD 10.9) primary care consultations in 2018, compared to 5.7 (SD 7.9) for people without tinnitus. More patients with tinnitus had more than one referral to medical specialists (47%) compared to people without tinnitus (25%). Patients with tinnitus have 1.2 (mean difference) more drug prescriptions than people without tinnitus. Compared to people without tinnitus, patients with tinnitus were more likely to have one or more of primary healthcare contact, independent of age group and gender. Patients with tinnitus had more consultations in primary health care than people without tinnitus. They are more often referred to medical specialists and receive more drug prescriptions. The causal relationship between tinnitus and the higher healthcare consumption remains to be researched.

Multidisciplinary Tinnitus Research: Challenges and Future Directions From the Perspective of Early Stage Researchers

Tinnitus can be a burdensome condition on both individual and societal levels. Many aspects of this condition remain elusive, including its underlying mechanisms, ultimately hindering the development of a cure. Interdisciplinary approaches are required to overcome long-established research challenges. This review summarizes current knowledge in various tinnitus-relevant research fields including tinnitus generating mechanisms, heterogeneity, epidemiology, assessment, and treatment development, in an effort to highlight the main challenges and provide suggestions for future research to overcome them. Four common themes across different areas were identified as future research direction: (1) Further establishment of multicenter and multidisciplinary collaborations; (2) Systematic reviews and syntheses of existing knowledge; (3) Standardization of research methods including tinnitus assessment, data acquisition, and data analysis protocols; (4) The design of studies with large sample sizes and the creation of large tinnitus-specific databases that would allow in-depth exploration of tinnitus heterogeneity.

Investigating the relation between minimum masking levels and hearing thresholds for tinnitus subtyping

Heterogeneity of tinnitus imposes a challenge for its treatment. Identifying tinnitus subtypes might help to establish individualized diagnosis and therapies. The minimum masking level (MML) is a clinical tool defined as the minimum intensity of a masking sound required to cover tinnitus. Understanding the differences among masking patterns in patients could facilitate the task of subtyping tinnitus. Here, we studied the variability of hearing thresholds and MMLs among patients with tinnitus to identify tinnitus subgroups. A population of 366 consecutive patients from a specialized tinnitus clinic were included in the analysis. Hearing thresholds and MMLs were determined for octave frequencies from 0.25 to 8kHz, as well as for 3 and 6kHz. Subjects were divided into two groups according to whether their tinnitus was maskable (M, 329 subjects) or non-maskable (NM, 37 subjects). Hearing thresholds and tinnitus loudness did not differ significantly between both groups. The dimensionality of the data was reduced by means of principal component analysis (PCA), and the largest resulting components were used for clustering the data. The cluster analysis resulted in five clusters with differences in tinnitus pitch, lateralization, hearing thresholds and MML, as well as on age and gender. Clusters differed in contours of hearing thresholds and MML, describing patterns of low or high thresholds in combination with low or high MML. The clustering solution presented a low silhouette value (0.45), implying that the clustering is weak and could be artificial. The analysis pointed out the diversity across tinnitus patients. Our results suggest that there might be a continuum of patients' characteristics rather than discrete subgroups.

Application of Latent Growth Curve modeling to predict individual trajectories during neurofeedback treatment for tinnitus

Tinnitus is a heterogeneous phenomenon indexed by various EEG oscillatory profiles. Applying neurofeedback (NFB) with the aim of changing these oscillatory patterns not only provides help for those who suffer from the phantom percept, but a promising foundation from which to probe influential factors. The reliable attribution of influential factors that potentially predict oscillatory changes during the course of NFB training may lead to the identification of subgroups of individuals that are more or less responsive to NFB training. The present study investigated oscillatory trajectories of delta (3-4Hz) and individual alpha (8.5-12Hz) during 15 NFB training sessions, based on a Latent Growth Curve framework. First, we found the desired enhancement of alpha, while delta was stable throughout the NFB training. Individual differences in tinnitus-specific variables and general-, as well as health-related quality of life predictors were largely unrelated to oscillatory change prior to and across the training. Only the predictors age and sex at baseline were clearly related to slow-wave delta, particularly so for older female individuals who showed higher delta power values from the start. Second, we confirmed a hierarchical cross-frequency association between the two frequency bands; however, in opposing directions to those anticipated in tinnitus. The establishment of individually tailored NFB protocols would boost this therapy's effectiveness in the treatment of tinnitus. In our analysis, we propose a conceptual groundwork toward this goal of developing more targeted treatment.

Insomnia Associated with Tinnitus and Gender Differences

Chronic tinnitus causes a decrease in well-being and can negatively affect sleep quality. It has further been indicated that there are clinically relevant gender differences, which may also have an impact on sleep quality. By conducting a retrospective and explorative data analysis for differences in patients with tinnitus and patients diagnosed with tinnitus and insomnia, hypothesized differences were explored in the summed test scores and on item-level of the validated psychometric instruments. A cross-sectional study was conducted collecting data from a sample of tinnitus patients (n = 76). Insomnia was diagnosed in 49 patients. Gender differences were found on aggregated test scores of the MADRS and BDI with men scoring higher than women, indicating higher depressive symptoms in men. Women stated to suffer more from headaches (p < 0.003), neck pain (p < 0.006) and nervousness as well as restlessness (p < 0.02). Women also reported an increase in tinnitus loudness in response to stress compared to men (p < 0.03). Male individuals with tinnitus and insomnia have higher depression scores and more clinically relevant depressive symptoms than women, who suffer more from psychosomatic symptoms. The results indicate a need for a targeted therapy of depressive symptoms in male patients and targeted treatment of psychosomatic symptoms, stress-related worsening of insomnia and tinnitus in women.

The more the merrier? Preliminary results regarding treatment duration and stimulation frequency of multisite repetitive transcranial magnetic stimulation in chronic tinnitus

The current study examines two different protocols of repetitive transcranial magnetic stimulation (rTMS) targeting three key hubs of cortical tinnitus networks. Patients chose whether they preferred to undergo rTMS treatment for 10 or 20 sessions and were randomized to the different rTMS protocols thereafter. Ninety patients were enrolled in the study with a total dropout rate of 10%. Both rTMS protocols were well tolerated by the patients without any serious adverse events. Overall treatment effects were small both for 2 weeks and 4 weeks of treatment. There was no significant interaction effect between measurement time point and treatment group for neither of the outcome measures nor any differences regarding the applied treatment regimens. The effects of this study contradict former observations suggesting multisite rTMS protocols as promising neuromodulatory strategies. This lack of effect could not be enhanced by increasing the number of treatment sessions in our study.

Psychosocial Variables That Predict Chronic and Disabling Tinnitus: A Systematic Review

To improve tinnitus management we have to gain more knowledge of factors that explain how a persistent distressing tinnitus develops. The central aim of this systematic review was to identify longitudinal studies that investigated psychosocial variables predicting the transition from an acute to a chronic, disabling tinnitus (i.e. tinnitus decompensation) or tinnitus outcomes in chronic tinnitus sufferers. We conducted a systematic literature search of electronic databases and searched manually reference lists. We identified 16 eligible studies: Four longitudinal studies targeted predictors of the transition from acute to chronic tinnitus and 12 longitudinal studies investigated predictors of tinnitus distress (k = 9 observational, longitudinal studies; k = 3 ecological momentary assessment [EMA] and diary studies). The results of this systematic review showed that tinnitus distress, general psychological distress, tendencies to somatize, tinnitus-related delay of sleep onset, certain health behaviors, general illness coping, and certain personality traits (e.g. neuroticism) predicted the transition from acute to chronic, disabling tinnitus. General psychological, mental disorders, tinnitus distress, tinnitus disability (e.g. in different domains of physical, emotional, and social functioning; sleep disturbances), certain health behaviors (e.g. physical exercise), the level of physical and social functioning, and the report of other somatic problems such as pain were predictors of tinnitus outcomes in chronic tinnitus patients at a later follow-up. Studies that examined psychosocial variables as predictors of tinnitus distress are rare and had substantial methodological shortcomings. Future research should focus on core outcome domains and use standardized outcome measures to improve the comparability of results from different studies. Numerous psychosocial variables that have already been investigated as correlates of tinnitus sufferers' functioning in cross-sectional studies are worth investigating with longitudinal designs in future research. Identified predictors of the transition from acute to chronic, disabling tinnitus have to be addressed by health care practitioners who commonly function as the first contact person of individuals with acute tinnitus in the healthcare system.

Emerging Topics in the Behavioral Neuroscience of Tinnitus

This volume has highlighted the many recent advances in tinnitus theory, models, diagnostics, therapies, and therapeutics. But tinnitus knowledge is far from complete. In this chapter, contributors to the Behavioral Neuroscience of Tinnitus consider emerging topics and areas of research needed in light of recent findings. New research avenues and methods to explore are discussed. Issues pertaining to current assessment, treatment, and research methods are outlined, along with recommendations on new avenues to explore with research.

A portable neurofeedback device for treating chronic subjective tinnitus: Feasibility and results of a pilot study

BACKGROUND

Several clinical studies have shown that neurofeedback (NFB) has the potential to significantly improve the quality of life of patients complaining of chronic subjective tinnitus. Yet the clinical applicability of such a therapeutic approach in the everyday practice has not been tested so far.

OBJECTIVE

This study aims at investigating the feasibility and efficacy of a semi-automated NFB intervention by means of a portable device that eventually could be used by the patients at home on an everyday basis. The duration of setup procedures is minimized through the use of a dry electrodes electroencephalography (EEG) headset and an automated user-interface.

METHODS

We conducted a pilot clinical study (non-controlled, single arm, NCT03773926). According to a predetermined power calculation, a homogeneous population of 33 subjects with strict inclusion criteria was enrolled. After inclusion, all patients underwent 10 NFB sessions lasting 50min each, over a period of 5 weeks and a 3-month follow-up period. According to previous studies, the NFB training aimed at increasing the alpha-band power (8-12Hz) in the EEG power spectrum on the averaged signal of leads FC1, FC2, F3 and F4. Tinnitus handicap inventory (THI) was used as a primary outcome measure. Secondary outcome measures were the visual analog scales (VAS) and the change of the alpha-band power within sessions and across training. Time points of assessment were before intervention (T1), after intervention (T2) and at the 3-month follow-up (T3).

RESULTS

Patient exhibited a clinically significant decrease of the THI score, with a 23% decrease (N=28) on average between T1 and T2 and a 31% decrease (N=25) between T1 and T3. A significant increase of the alpha-band power within sessions was observed. No significant increase of the alpha-band power across sessions was observed. For the 19 subjects where sufficient data were exploitable, a significant correlation was found between the evolution of the alpha-band training across sessions and the evolution of the THI between T1 and T2. The sessions were well tolerated and no adverse effect was reported.

CONCLUSION

This study suggests that neurofeedback has potential to suit everyday clinical practice with the goal to significantly reduce tinnitus intrusiveness. The merits and limitations of this NFB procedure are discussed, especially with respect to the choice of EEG electrodes to ensure a good signal quality.

Noise Induced Hearing Loss and Tinnitus-New Research Developments and Remaining Gaps in Disease Assessment, Treatment, and Prevention

Long-term noise exposure often results in noise induced hearing loss (NIHL). Tinnitus, the generation of phantom sounds, can also result from noise exposure, although understanding of its underlying mechanisms are limited. Recent studies, however, are shedding light on the neural processes involved in NIHL and tinnitus, leading to potential new and innovative treatments. This review focuses on the assessment of NIHL, available treatments, and development of new pharmacologic and non-pharmacologic treatments based on recent studies of central auditory plasticity and adaptive changes in hearing. We discuss the mechanisms and maladaptive plasticity of NIHL, neuronal aspects of tinnitus triggers, and mechanisms such as tinnitus-associated neural changes at the cochlear nucleus underlying the generation of tinnitus after noise-induced deafferentation. We include observations from recent studies, including our own studies on associated risks and emerging treatments for tinnitus. Increasing knowledge of neural plasticity and adaptive changes in the central auditory system suggest that NIHL is preventable and transient abnormalities may be reversable, although ongoing research in assessment and early detection of hearing difficulties is still urgently needed. Since no treatment can yet reverse noise-related damage completely, preventative strategies and increased awareness of hearing health are essential.

Lidocaine injections to the otic ganglion for the treatment of tinnitus-A pilot study

Tinnitus is defined as the perception of noise without an external acoustic stimulus. Due to the heterogeneity of tinnitus, no treatment has proven equally beneficial to every single of these patients. Previous studies have shown that trigeminal input can interfere with the perception of tinnitus. Therefore, we aimed to explore the therapeutic potential of lidocaine injections in trigeminal structures. We conducted a pilot study with 19 participants to explore feasibility and tolerability of this approach. The intervention consisted of three injections of lidocaine in the anatomical area of the trigeminal ganglion and the ganglion oticum via an oral approach corresponding to the affected side of tinnitus. We performed an assessment that included the Mini-TQ, CGII, and numeric rating scales of tinnitus loudness and severity at different time points over a follow-up period of 12 weeks. In addition to changes of subjective tinnitus complaints, potential adverse events were documented. Patients were treated at the Centre of Otorhinolaryngology in Traunstein, Germany, and data were analyzed at the University of Regensburg, Germany. We did not observe any relevant side effects. There was a significant reduction of tinnitus distress (Mini-TQ, Tinnitus severity) and loudness (measured subjectively) over time. Our pilot data suggests that lidocaine injections targeting trigeminal structures may be able to reduce tinnitus complaints. Future studies should investigate the effects of lidocaine injections in placebo-controlled trials in an extended sample size to further explore the potential benefits of this therapeutic approach on tinnitus.

Phenotyping chronic tinnitus patients using self-report questionnaire data: cluster analysis and visual comparison

Chronic tinnitus is a complex, multi-factorial symptom that requires careful assessment and management. Evidence-based therapeutic approaches involve audiological and psychological treatment components. However, not everyone benefits from treatment. The identification and characterisation of patient subgroups (or “phenotypes”) may provide clinically relevant information. Due to the large number of assessment tools, data-driven methods appear to be promising. The acceptance of these empirical results can be further strengthened by a comprehensive visualisation. In this study, we used cluster analysis to identify distinct tinnitus phenotypes based on self-report questionnaire data and implemented a visualisation tool to explore phenotype idiosyncrasies. 1228 patients with chronic tinnitus from the Charité Tinnitus Center in Berlin were included. At baseline, each participant completed 14 questionnaires measuring tinnitus distress, -loudness, frequency and location, depressivity, perceived stress, quality of life, physical and mental health, pain perception, somatic symptom expression and coping attitudes. Four distinct patient phenotypes emerged from clustering: avoidant group (56.8%), psychosomatic group (14.1%), somatic group (15.2%), and distress group (13.9%). Radial bar- and line charts allowed for visual inspection and juxtaposition of major phenotype characteristics. The phenotypes differed in terms of clinical information including psychological symptoms, quality of life, coping attitudes, stress, tinnitus-related distress and pain, as well as socio-demographics. Our findings suggest that identifiable patient subgroups and their visualisation may allow for stratified treatment strategies and research designs.

The difference in poststimulus suppression between residual inhibition and forward masking

The phenomenon of tinnitus masking (TM) and residual inhibition (RI) of tinnitus are two ways to investigate how external sounds interact with tinnitus: TM provides insight on the fusion between external sound activity and tinnitus related activity while RI provides insight on how the external sound might suppress the tinnitus related activity for a period of time. Differences in masking level between the tinnitus and an external tone with tinnitus characteristics (frequency, loudness) have previously shown a high level of heterogeneity. The difference in poststimulus suppression between the two, that is, residual inhibition for the former, and forward masking for the latter, has never been explored. This study aims to investigate minimum masking levels (MMLs) and minimum residual inhibition levels (MRILs) of tinnitus and of an external tone mimicking tinnitus while using diotic and dichotic noises. Pulsed narrowband noises (1 octave width and centered at 1kHz, frequency of the hearing loss slope, tinnitus frequency) and white noise were randomly presented to 20 tinnitus participants and 20 controls with an external tone mimicking tinnitus (4kHz, intensity level corresponding to tinnitus loudness). The MML values obtained for the masking of tinnitus and for the mimicking external sounds were very similar. On the other hand, the MRILs were significantly different between the tinnitus and the mimicking external sounds within tinnitus participants. They were also different between the tinnitus participants and the controls. Overall, for both within and between comparisons, the MRIL values were much higher to produce a poststimulus suppression for the mimicking sound than for the tinnitus. The results showed no significant differences between the diotic and dichotic conditions. These results corroborate other findings suggesting that the tinnitus-related neural activity is very different from the stimulus-related neural activity. The consequences of this last finding are discussed.

From Acute to Chronic Tinnitus: Pilot Data on Predictors and Progression

Little is known about the transition from acute tinnitus to chronic tinnitus. By means of this study, we are attempting to close this gap by presenting prospective pilot data of patients with acute tinnitus, followed by tracking their condition's trajectory over a period of 6 months. Forty-nine patients presenting with acute tinnitus (duration < 28 days) were recruited in two clinics. We recorded demographic and clinical tinnitus-related data as well as data on personality, health, treatments, and life-style, during patients' first appearance in the clinic and again three and 6 months thereafter. Standard audiograms were performed at the first and the second visit. Nine (18.4%) patients showed full remission of their tinnitus. These patients differed from patients with a chronic course of tinnitus by shorter tinnitus duration, lower fear-related hyperacusis, higher proportion of female gender, increased ear pressure, and lower levels of alcohol consumption. Among the patients with a chronification of tinnitus, there was no change in tinnitus characteristics. However, their tinnitus distress improved moderately over time. These preliminary data are in line with earlier studies that have shown that only a small proportion of those patients presenting in the clinic with acute tinnitus experience a full remission. The results of this study can be of service in deducing hypotheses for the transition from acute to chronic tinnitus and in developing designs for interventional studies.

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.

Gender Comparison of Psychological Comorbidities in Tinnitus Patients - Results of a Cross-Sectional Study

Background

In the last decades, research focused on gender-related features in patients with tinnitus has often led to controversial results. The complex clinical picture of tinnitus patients often consists of an interdependent relationship between audiological symptoms and co-occurrent psychological disorders, which can complicate the diagnostic evaluation.

Methods

Therefore, we studied 107 patients with tinnitus, investigating their psychological comorbidities in the light of gender differences. All patients were evaluated with ENT/audiological and psychological examination to consider presence/absence, type and gender distribution of psychopathological comorbidities. Patients completed questionnaires on tinnitus distress (Tinnitus Handicap Inventory, THI), anxiety (Beck Anxiety Inventory, BAI), depression (Beck Depression Inventory, BDI), metacognition (Metacognition Questionnaire-30, MCQ-30) and worry (Penn State Worry Questionnaire). The influence of gender on the relationship between tinnitus distress and psychological comorbidities was investigated with simple moderation analyses using the SPSS PROCESS macro.

Results

The total sample included 65 male and 42 female patients (60.7 vs. 39.3%), matched for age and duration of tinnitus. We found no significant differences for tinnitus distress (THI total score, THI subscales) and MCQ-30 subscales, except for the control over thoughts, where men showed significantly higher scores than women (p = 0.045). Also, in our sample women showed significantly higher values for depression (BDI total score, p = 0.019), anxiety (BAI total score, p = 0.010) and worries (PSQW total score, p = 0.015). Moderation analyses revealed a significant influence of gender on the relationship of tinnitus distress with depression: higher scores of tinnitus distress were associated with significantly elevated levels of depression amongst men. No further gender influences could be observed in our sample.

Discussion

In conclusion, our results indicate general gender differences for psychological comorbidities in tinnitus patients, with women reporting more depression, anxiety and worries. Men, on the other hand, showed a higher need to control their thoughts. Additionally, our results indicate that men might have more coping problems with increasing levels of tinnitus distress, leading to increased depressive symptoms. Nevertheless, several gender related aspects in tinnitus patients remain unclear, thus warranting the need future studies in this field.

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.

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.

Avenue for Future Tinnitus Treatments

Tinnitus is a common symptom. Standard therapies aim at improving the quality of life and reducing the psychological stress associated with tinnitus. Most interventions have little or no effect on the main symptom. Those affected subjects, however, want such a change and prefer a specific solution, such as pharmacologic therapy to other modalities. Scientific efforts have not yet led to significant improvement in the range of therapies. This article outlines existing efforts and develops ideas on how research for improved tinnitus therapy might look in the future.

Pharmacotherapy of Tinnitus

Tinnitus is a common symptom for which there is in most cases no causal therapy. The search for an improvement of tinnitus through pharmacological interventions has a long tradition. The observation that tinnitus can be transiently suppressed by the use of lidocaine has shown that the symptom is susceptible to pharmacotherapy. So far, however, no medication has been found for either acute or chronic subjective tinnitus that reliably leads to a long-term reduction or even complete disappearance of the symptom for the majority of tinnitus sufferers. Nevertheless, in everyday clinical life, drugs are frequently used, usually off-label, to relieve tinnitus or tinnitus-associated symptoms (e.g. sleep disturbance, depression, anxiety disorder or hearing loss). This chapter shows the different approaches to acute and chronic subjective tinnitus by means of pharmacotherapeutic interventions. Furthermore, this review reports on the scientific studies carried out in this area in recent years and explains the difficulties in finding a suitable medication for most forms of tinnitus. In addition, it reports on the pharmacotherapeutic options for objective tinnitus and describes the development of tinnitus as a side effect of certain drugs. Finally, possible target structures are mentioned, which should possibly be addressed in pharmacological studies in the near future.

Validation of the Chronic Tinnitus Acceptance Questionnaire (CTAQ-I): the Italian version

Tinnitus is a widespread symptom that is chronically experienced by approximately 10% of the adult population. While the vast majority of individuals do not feel impaired by their ear noise, about 0.5-3% of the adult population develops severe distress and feels impaired in everyday life. The severity of the distress experienced can only partially be explained by the characteristics of the ear noise itself (e.g. objective tinnitus loudness or duration). Psychological variables such as tinnitus acceptance are being increasingly investigated by tinnitus research. The aim of this study was to analyse the psychometric quality of the Italian version of the “Chronic Tinnitus Acceptance Questionnaire” (CTAQ-I). The CTAQ-I is an adaption of the Italian “Chronic Pain Acceptance Questionnaire (CPAQ)” and altered for the study of tinnitus acceptance. This cross-sectional multicentre questionnaire study included 141 outpatients with chronic tinnitus. Sociodemographic and clinical data were assessed with the Tinnitus Sample Case History (TSCH), tinnitus acceptance with the Italian “Chronic Tinnitus Acceptance Questionnaire” (CTAQ-I), tinnitus distress with the Tinnitus Handicap Inventory (THI) and the Tinnitus Questionnaire Short Form (TQ 12-I). Furthermore, we assessed the patient’s general psychological distress (Brief Symptom Inventory - BSI) and Health Related Quality of Life (SF-36). Psychometric and factorial evaluation of the CTAQ-I were carried out. To investigate the influence of sociodemographic and numerous clinical variables on tinnitus acceptance we calculated correlation coefficients, analysis of variance and independent sample-t-tests. The factor analysis revealed a two-factor solution (“activity engagement” and “tinnitus willingness”), accounting for 41.1% of the variance. Good internal consistency for the total score (α = 0.84) and both factors (α = 0.80-0.88) was found. Moderate negative correlations with tinnitus distress indicated good validity. Tinnitus acceptance was further correlated with lower psychological distress and subjective tinnitus loudness, as well as increased emotional well-being. Tinnitus acceptance is considered to be an important source of therapeutic change in behavioural-based treatments as well as in professional counselling for tinnitus. Our study shows that the CTAQ-I is a reliable and valid instrument to measure the acceptance of patients suffering from chronic tinnitus.

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.

Daily high-frequency transcranial random noise stimulation of bilateral temporal cortex in chronic tinnitus - a pilot study

Several studies emphasized the potential of single and multiple transcranial random noise stimulation (tRNS) sessions to interfere with auditory cortical activity and to reduce tinnitus loudness. It was the objective of the present study to evaluate the use of high-frequency (hf) tRNS in a one-arm pilot study in patients with chronic tinnitus. Therefore, 30 patients received 10 sessions of high frequency tRNS (100-640 Hz; 2 mA; 20 minutes) over the bilateral temporal cortex. All patients had received rTMS treatment for their tinnitus at least 3 months before tRNS. Primary outcome was treatment response (tinnitus questionnaire reduction of ≥5 points). The trial was registered at clinicaltrials.gov (NCT01965028). Eight patients (27%) responded to tRNS. Exactly the same number of patients had responded before to rTMS, but there were only two “double responders” for both treatments. None of the secondary outcomes (tinnitus numeric rating scales, depressivity, and quality of life) was significant when results were corrected for multiple comparisons. tRNS treatment was accompanied by tolerable side effects but resulted in temporal increases in tinnitus loudness in 20% of the cases (2 drop-outs). Our trial showed that hf-tRNS is feasible for daily treatment in chronic tinnitus. However, summarizing low treatment response, increase of tinnitus loudness in 20% of patients and missing of any significant secondary outcome, the use of hf-tRNS as a general treatment for chronic tinnitus cannot be recommended at this stage. Differences in treatment responders between tRNS and rTMS highlight the need for individualized treatment procedures.

The sound-sensitive tinnitus index: Psychometric properties of a scale to assess the impact of tinnitus exacerbated by sound

CONTEXT

Although studies of tinnitus exacerbated by sound exposure have indicated increased treatment challenges and intensified mental health and quality of life concerns, there is a lack of valid screening measures to differentiate or assess diagnostic factors and areas of impact unique to this specific symptom manifestation.

AIMS

The purpose of this study was to design a self-rated measurement tool that can accurately assess the subjective impact of tinnitus negatively modulated by external sound.

SETTINGS AND DESIGN

Based on review of established models of tinnitus and hyperacusis measurement and a two-part pilot study, the 20-item Sound-Sensitive Tinnitus Index (SSTI) was developed and administered in online survey format to 277 individuals worldwide.

METHODS AND MATERIAL

Cronbach's alpha was used to estimate reliability properties, and dimensional factor analysis was performed. To establish validity, statistical correlations of the SSTI were estimated with valid measures of related constructs including tinnitus, hyperacusis, depression, anxiety, and quality of life.

RESULTS

Statistical analysis yielded high levels of internal consistency reliability, and convergent validity was demonstrated through significant correlations with all established measures of related constructs. Initial factor analysis indicated two components split between overall functional impact and coping factors, while rotated factor analyses revealed four distinct scale dimensions, labeled: functional challenges, relational and communication challenges, coping factors, and prevention and hearing protection.

CONCLUSIONS

As a valid and reliable measure, the SSTI fills an important gap as a clinical and research tool that can differentiate and assess severity and treatment progress in manifestations of combined tinnitus and auditory sensitivity symptoms.