Short and intense tailor-made notched music training against tinnitus: the tinnitus frequency matters

SoundMind Trial: a study protocol for a randomised controlled trial for online acceptance and commitment therapy and sound therapy for tinnitus

INTRODUCTION

Tinnitus is a common ailment that affects 10%-15% of adults worldwide. Comorbidities associated with tinnitus often include hearing loss, emotional distress and sleep disorders, with insomnia being a common issue among patients with tinnitus. Audiological and psychological approaches are typically used to treat chronic subjective tinnitus, with the combination of sound therapy and cognitive-behavioural therapy-based counselling having the strongest evidence for effectiveness. Acceptance and commitment therapy (ACT) has also shown promising effects in reducing the impact of tinnitus when delivered in groups or online. However, there is a lack of evidence on the effects of combining ACT with sound therapy for patients with tinnitus-related insomnia. Therefore, this study aims to compare the efficacy of internet-delivered ACT combined with sound therapy versus sound therapy alone for tinnitus in a superiority, two-arm randomised controlled trial.

METHODS AND ANALYSIS

A total of 164 patients with chronic subjective tinnitus and insomnia will be randomised to receive internet-delivered guided self-help tinnitus treatment based on ACT combined with tailored sound therapy or tailored sound therapy alone. The primary outcome is the variation in Tinnitus Handicap Inventory scores observed 2 months after randomisation between the two study groups. Secondary outcomes will include insomnia severity, sleep parameters, tinnitus loudness, tinnitus acceptance, depression and anxiety. The outcomes will be assessed at 2, 3 and 6 months post randomisation.

ETHICS AND DISSEMINATION

The study is approved by the review board and ethics committee of the Eye and ENT Hospital of Fudan University (approval number: 2023066-1). The findings will be disseminated through presentations at relevant conferences and peer-reviewed publications.

TRIAL REGISTRATION NUMBER

NCT05963542.

The Current State of Tinnitus Diagnosis and Treatment: a Multidisciplinary Expert Perspective

Tinnitus, the perception of sound without an external source, affects 15% of the population, with 2.4% experiencing significant distress. In this review, we summarize the current state of knowledge about tinnitus management with a particular focus on the translation into clinical practice. In the first section, we analyze shortcomings, knowledge gaps, and challenges in the field of tinnitus research. Then, we highlight the relevance of the diagnostic process to account for tinnitus heterogeneity and to identify all relevant aspects of the tinnitus in an individual patient, such as etiological aspects, pathophysiological mechanisms, factors that contribute most to suffering, and comorbidities. In the next section, we review available treatment options, including counselling, cognitive-behavioral therapy (CBT), hearing aids and cochlear implants for patients with a relevant hearing loss, sound generators, novel auditory stimulation approaches, tinnitus retraining therapy (TRT), pharmacological treatment, neurofeedback, brain stimulation, bimodal stimulation, Internet- and app-based digital approaches, and alternative treatment approaches. The evidence for the effectiveness of the various treatment interventions varies considerably. We also discuss differences in current respective guideline recommendations and close with a discussion of how current pathophysiological knowledge, latest scientific evidence, and patient perspectives can be translated in patient-centered care.

Efficacy of tailor-made notched music training for primary tinnitus: A systematic review and meta-analysis

OBJECTIVE

We systematically reviewed and meta-analyzed the efficacy of Tailor-Made Notched Music Training (TMNMT) for primary subjective tinnitus in adults. The main goal was to evaluate TMNMT's impact on tinnitus symptoms.

METHODS

Following PRISMA guidelines, we included randomized and non-randomized trials. Studies considered involved adults with primary subjective tinnitus treated with TMNMT alone or combined with other therapies. Bias risk was assessed using the Cochrane RoB 2 and ROBINS-I tools. Comprehensive database searches were conducted, and relevant data were extracted and analyzed.

RESULTS

Three studies (total: 99 TMNMT patients, 109 sound therapy) were meta-analyzed. Using THI scores, the Forest plot showed no significant difference in tinnitus distress between TMNMT and listening to music groups (p > 0.05), with low study heterogeneity (I2 = 0 %).

CONCLUSION

While TMNMT offers a non-invasive approach with a potential to reduce tinnitus distress, it did not significantly outperform the only listening to music. More research is needed to optimize TMNMT for tinnitus management and to better document its safety profile.

Customized Music Therapy Combined With the Counseling and Follow-Up System: Stratified Results for Tinnitus Efficacy

Objective

Chronic subjective tinnitus is a worldwide intractable problem. In our previous studies, customized music therapy combined with a follow-up system can reduce tinnitus perception and improve anxiety/depression. This study aims to explore which characteristics of tinnitus patients are more likely to benefit from our therapy.

Study Design

This study included 1031 patients with chronic subjective tinnitus, all of whom completed customized music therapy with the follow-up system. Population demographics, tinnitus characteristics, and tinnitus-related scales at pretherapy and posttherapy were collected.

Setting

Huadong Hospital affiliated Fudan University, Department of Otorhinolaryngology-Head & Neck Surgery from 2018 to 2022.

Methods

A paired t test and the one-way analysis of variance were utilized to the overall efficacy and stratified difference based on tinnitus duration/age/tinnitus frequency.

Results

There were significant statistical differences in the Tinnitus Handicap Inventory (THI), Tinnitus Loudness Visual Analog Scale (VAS), and Hospital Anxiety and Depression Scale (HADS)-A/D scores between pretherapy and 3 months posttherapy. THI and HADS (A/D) scores decreased the most in the 1-year duration tinnitus group. The most significant decrease in THI and VAS scores was observed in the 31- to 50-year-old tinnitus group. Patients with high-frequency tinnitus and extended high-frequency tinnitus had greater decreases generally than those with low-frequency tinnitus though no significance.

Conclusion

Group with severe and prolonged tinnitus, shorter duration of tinnitus onset, and 31 to 50 years old benefit more from our therapy. Therefore, standardized personalized music and consulting and follow-up systems while promoting early treatment can reduce tinnitus and its comorbidities.

A Pilot Study to Evaluate a Residual Inhibition Technique in Hearing Aids for Suppression of Tinnitus

Tinnitus acoustic therapy is defined as any use of sound where the intent is to alter the tinnitus perception and/or the reactions to tinnitus in a clinically beneficial way. The parameters of sound that may cause beneficial effects, however, are currently only theorized with limited data supporting their effectiveness. Residual inhibition is the temporary suppression or elimination of tinnitus that is usually observed following appropriate auditory stimulation. Our pilot study investigated the effects of a therapeutic acoustic stimulus that was individually customized to maximize residual inhibition of tinnitus and extend its duration to determine if there could be a sustained suppression of the tinnitus signal (i.e., reduced tinnitus loudness) and a reduction in the psychological and emotional reactions to tinnitus. This pilot study had two objectives: (1) to evaluate the feasibility of residual inhibition technique therapy through daily use of hearing aids and (2) to determine its effects by measuring reactionary changes in tinnitus with the Tinnitus Functional Index (TFI) and perceptual changes in tinnitus loudness. A total of 20 adults (14 males, 6 females; mean age: 58 years, SD = 12.88) with chronic tinnitus were enrolled in a four-visit study that consisted of the following: (1) baseline visit and initiation of the intervention period, (2) a 1-month postintervention visit, (3) 2-month postintervention visit and initiation of a wash-out period, and (4) a 3-month visit to assess the wash-out period and any lasting effects of the intervention. The intervention consisted of fitting bilateral hearing aids and creating an individualized residual inhibition stimulus that was streamed via Bluetooth from a smartphone application to the hearing aids. The participants were instructed to wear the hearing aids and stream the residual inhibition stimulus all waking hours for the 2-month intervention period. During the wash-out period, the participants were instructed to use the hearing aids for amplification, but the residual inhibition stimulus was discontinued. At all visits, the participants completed the TFI, study-specific self-report measures to document perceptions of tinnitus, a psychoacoustic test battery consisting of tinnitus loudness and pitch matching, and a residual inhibition test battery consisting of minimum masking and minimum residual inhibition levels. At the end of the trial, participants were interviewed about the study experience and acceptability of the residual inhibition treatment technique. Repeated measures analyses of variance (ANOVA) were conducted on the two main outcomes (TFI total score and tinnitus loudness) across all four visits. The results showed a significant main effect of visit on the TFI total score ( p  < 0.0001). Specifically, the results indicated a significant reduction in TFI total scores from baseline to the 1-month post-intervention period, which remained stable across the 2-month post-intervention period and the wash-out period. The ANOVA results did not show a significant change in tinnitus loudness as a function of visit ( p  = 0.480). The majority of the participants reported a positive experience with the study intervention at their exit interview. This pilot study demonstrated that residual inhibition as a sound therapy for tinnitus, specifically through the daily use of hearing aids, was feasible and acceptable to individuals suffering from chronic tinnitus. In addition, participants showed improvement in reactions to tinnitus as demonstrated by sustained reduction in TFI scores on average over the course of the treatment period. Achieving residual inhibition may also provide patients a feeling of control over their tinnitus, and this may have a synergistic effect in reducing the psychological and emotional distress associated with tinnitus. There was no significant reduction in long-term tinnitus loudness resulting from the residual inhibition treatment; however, the current pilot study may not have had sufficient power to detect such a change. The combination of tinnitus suppression and improved psychosocial/emotional reactions to tinnitus may result in a better quality of life in both the short and long term. A larger-scale study is needed to determine the validity of using residual inhibition as a clinical therapy option and to ascertain any effects on both perception and reactions to tinnitus.

History of Tinnitus Research at the VA National Center for Rehabilitative Auditory Research (NCRAR), 1997-2021: Studies and Key Findings

The Veterans Affairs (VA) Rehabilitation Research & Development (RR&D) National Center for Rehabilitative Auditory Research (NCRAR) was first funded by the RR&D Service in 1997 and has been funded continuously since that time. The overall purpose of the NCRAR is to "improve the quality of life of Veterans and others with hearing and balance problems through clinical research, technology development, and education that leads to better patient care" ( www.ncrar.research.va.gov ). An important component of the research conducted at the NCRAR has been a focus on clinical and rehabilitative aspects of tinnitus. Multiple investigators have received grants to conduct tinnitus research and the present article provides an overview of this research from the NCRAR's inception through 2021.

The effect of music therapy on tinnitus: A systematic review

OBJECTIVES

Tinnitus is a common otological symptom affecting almost all aspects of life, especially the quality of daily life. The present study aims to analyze music therapy effect on tinnitus patients. This paper mainly analyzes 3 kinds of music therapy: Heidelberg model of music therapy (HMOMT), standard music therapy (SMT), and tailor-made notched music training (TMNMT). To provide a reference for the follow-up treatment of tinnitus, whether to take and what kind of music therapy.

METHOD

A systematic literature search was performed in PubMed, Cochrane Library, EMBASE, Web of Science, and MEDLINE to obtain potential studies from their inception to May 2023 in all languages. Two researchers independently screened the studies, extracted data, and assessed the quality of the included studies. We included all randomized and non-randomized controlled trials that used music therapy to treat patients with tinnitus. We used fixed-effects and random-effect models to analyze data based on the heterogeneity results. The data analysis was performed by using Stata 12.0.

RESULTS

A total of 19 studies with 904 cases were included. Compared with before treatment, music therapy significantly reduces the tinnitus questionnaire score and tinnitus handicap inventory score. HMOMT, SMT, and TMNMT all significantly decrease tinnitus scores. Although the order of effectiveness of the 3 drugs is TMNMT > SMT > HMOMT, there is no statistical significance (P > .5).

CONCLUSION

This meta-analysis of accumulated clinical trial data suggests that music therapy can relieve tinnitus symptoms and loudness. Among music therapies, SMT is recommended first for tinnitus based on cost, efficacy, and convenience. At the same time, TMNMT and HMOMT can be used as alternative therapies for specific cases.

EEG spectral and microstate analysis originating residual inhibition of tinnitus induced by tailor-made notched music training

Tailor-made notched music training (TMNMT) is a promising therapy for tinnitus. Residual inhibition (RI) is one of the few interventions that can temporarily inhibit tinnitus, which is a useful technique that can be applied to tinnitus research and explore tinnitus mechanisms. In this study, RI effect of TMNMT in tinnitus was investigated mainly using behavioral tests, EEG spectral and microstate analysis. To our knowledge, this study is the first to investigate RI effect of TMNMT. A total of 44 participants with tinnitus were divided into TMNMT group (22 participants; ECnm, NMnm, RInm represent that EEG recordings with eyes closed stimuli-pre, stimuli-ing, stimuli-post by TMNMT music, respectively) and Placebo control group (22 participants; ECpb, PBpb, RIpb represent that EEG recordings with eyes closed stimuli-pre, stimuli-ing, stimuli-post by Placebo music, respectively) in a single-blind manner. Behavioral tests, EEG spectral analysis (covering delta, theta, alpha, beta, gamma frequency bands) and microstate analysis (involving four microstate classes, A to D) were employed to evaluate RI effect of TMNMT. The results of the study showed that TMNMT had a stronger inhibition ability and longer inhibition time according to the behavioral tests compared to Placebo. Spectral analysis showed that RI effect of TMNMT increased significantly the power spectral density (PSD) of delta, theta bands and decreased significantly the PSD of alpha2 band, and microstate analysis showed that RI effect of TMNMT had shorter duration (microstate B, microstate C), higher Occurrence (microstate A, microstate C, microstate D), Coverage (microstate A) and transition probabilities (microstate A to microstate B, microstate A to microstate D and microstate D to microstate A). Meanwhile, RI effect of Placebo decreased significantly the PSD of alpha2 band, and microstate analysis showed that RI effect of Placebo had shorter duration (microstate C, microstate D), higher occurrence (microstate B, microstate C), lower coverage (microstate C, microstate D), higher transition probabilities (microstate A to microstate B, microstate B to microstate A). It was also found that the intensity of tinnitus symptoms was significant positively correlated with the duration of microstate B in five subgroups (ECnm, NMnm, RInm, ECpb, PBpb). Our study provided valuable experimental evidence and practical applications for the effectiveness of TMNMT as a novel music therapy for tinnitus. The observed stronger residual inhibition (RI) ability of TMNMT supported its potential applications in tinnitus treatment. Furthermore, the temporal dynamics of EEG microstates serve as novel functional and trait markers of synchronous brain activity that contribute to a deep understanding of the neural mechanism underlying TMNMT treatment for tinnitus.

Tinnitus Guidelines and Their Evidence Base

Evidence-based medicine (EBM) is generally accepted as the gold standard for high-quality medicine and, thus, for managing patients with tinnitus. EBM integrates the best available scientific information with clinical experience and patient values to guide decision-making about clinical management. To help health care providers and clinicians, the available evidence is commonly translated into medical or clinical guidelines based on a consensus. These involve a systematic review of the literature and meta-analytic aggregation of research findings followed by the formulation of clinical recommendations. However, this approach also has limitations, which include a lack of consideration of individual patient characteristics, the susceptibility of guideline recommendations to material and immaterial conflicts of interest of guideline authors and long latencies till new knowledge is implemented in guidelines. A further important aspect in interpreting the existing literature is that the absence of evidence is not evidence of absence. These circumstances could result in the decoupling of recommendations and their supporting evidence, which becomes evident when guidelines from different countries differ in their recommendations. This opinion paper will discuss how these weaknesses can be addressed in tinnitus.

Does Compliance or Cost Regulate Effectiveness of Notched Sound Therapy Phone Applications for Tinnitus Relief? Preliminary Data of a Prospective Randomized Control Trial

OBJECTIVE

The objective of this study is to evaluate compliance with and effectiveness of notched sound therapy (NST) administered through a mobile application in improving symptoms of patients experiencing chronic tinnitus.

STUDY DESIGN

A prospective randomized control trial was done.

SETTING

The study was done at a tertiary referral center.

PATIENTS

Adult patients with tinnitus were monitored.

INTERVENTIONS

Patients were randomized at enrollment to either the NST or a standard of care (SOC) group. NST arm included, in addition to SOC, a free subscription to NST mobile application, whereas the SOC arm included NST at subscription cost.

MAIN OUTCOME MEASURES

The main outcome measures were continued enrollment in study, compliance with the therapy, frequency and duration of therapy use, and change from the baseline in the Tinnitus Handicap Inventory (THI).

RESULTS

Patients in the NST group were 2.25 times more likely to use the NST application for 3 months postenrollment. Only 33% of users in the NST group listened for the prescribed 2 h/d compared with 0% of users in the SOC group. There was a clinically relevant mean decrease in THI from a baseline of 13.5 in the NST group (p = 0.09) and of 14.8 in the SOC group (p = 0.02). There was a positive correlation between initial THI and decrease in THI after 3 months (p = 0.001).

CONCLUSIONS

Monitoring tinnitus for 3 months leads to a decrease in subjective symptoms regardless of NST use. Patients who received a free subscription to the application were more likely to continue with therapy, but very few patients were able to comply with 2 hours of listening time per day.

Efficacy of Tailor-Made Notched Music Training Versus Tinnitus Retraining Therapy in Adults With Chronic Subjective Tinnitus: A Randomized Controlled Clinical Trial

OBJECTIVES

Chronic subjective tinnitus can have a serious effect on daily life, even causing serious psychological disorders. Currently there are no specific effective solutions or cures. Tailor-made notched music training (TMNMT) is a recently proposed sound therapy that has simpler processes and a higher compliance rate than tinnitus retraining therapy (TRT), a widely used treatment for chronic subjective tinnitus. This study explores the therapeutic effect of TMNMT in comparison to TRT to highlight its clinical value.

DESIGN

The study was a randomized controlled, single-blinded clinical trial. One hundred twenty eligible participants were randomly assigned to receive TMNMT (n = 60) or TRT (n = 60) for 3 mo with concurrent follow-up. It should be noted that the duration of sound treatment in TRT was modified to 2 hr per day for better feasibility in practice. The primary outcome was mean change in tinnitus handicap inventory (THI) measured at baseline ( T0 ), 1 mo ( T1 ) and 3 mo ( T2 ) after intervention. Change in visual analog scale (VAS) was measured as a secondary outcome. A comparison of therapeutic effectiveness between TMNMT and TRT was evaluated by repeated measure analysis of variance.

RESULTS

One hundred and twelve (93%) of participants took part in the study, of which 64 were men and 48 women. Mean (SD) age was 42.80 (12.91) years. Fifty-eight were allocated to receive TMNMT and 54 to receive TRT. The between-group difference in primary outcome was -6.90 points (95% confidence interval [CI], -13.53 to -0.27) at T1 and -6.17 points (95% CI, -13.04 to 0.71) at T2 . These results closely reached to clinical significance of tinnitus-related effective relief. For the secondary outcome, the mean value in the TMNMT group was 0.83 points (95% CI, 0.12 to 1.54), significantly lower than the mean value of the TRT group. The differences in THI and VAS between the two groups were statistically significant after intervention. Further analysis showed that age and baseline THI and VAS scores were associated with change in THI and VAS scores after interventions.

CONCLUSIONS

Both TMNMT and TRT were able to alleviate chronic subjective tinnitus effectively after a 3 month intervention. When the two forms of therapy were compared TMNMT appeared to be more effective and consequently potentially superior to TRT for reducing tinnitus loudness and functional and emotional disturbance associated with chronic subjective tinnitus.

Prognostic Factors Influencing the Tinnitus Improvement After Idiopathic Sudden Sensorineural Hearing Loss Treatment

PURPOSE

Logistic regression analysis was used to explore the factors that influence tinnitus improvement after idiopathic sudden sensorineural hearing loss (ISSNHL) treatment.

MATERIALS AND METHODS

In this retrospective study, 137 ISSNHL patients with tinnitus were recruited at the Sun Yatsen Memorial Hospital of Sun Yat-sen University, China. They underwent audiological examinations, vestibular assessments, tinnitus examinations, a Tinnitus Handicap Inventory (THI) assessment and ISSNHL treatments. Logistic regression analysis was performed to investigate factors that affected tinnitus improvement.

RESULTS

Participants were divided into an effective group (73 patients) and noneffective group (64 patients) according to THI scores before and after treatment. The effective group had better averaged hearing threshold than the noneffective group (effective group vs. noneffective group: 74.47 vs. 87.66 dB HL; t = 3.03, p < 0.05). Additionally, before intervention there were significant difference in profound audiogram configuration (effective group vs. noneffective group: 17.81% vs. 46.88%, x2 = 23.63; p < 0.001), mid tinnitus pitch (effective group vs. noneffective group: 19.18% vs. 35.94%, x2 = 6.58; p = 0.037) and mean THI scores (effective group vs. noneffective group: 57.07 ± 22.27 vs. 36.78 ± 24.41, t = -5.09, p < 0.001) between the effective and noneffective tinnitus groups. Logistic regression analysis showed that audiogram configurations (profound audiogram: OR = 0.10, 95% CI 0.01-0.72, p = 0.022), tinnitus pitch (mid tinnitus pitch: OR = 0.16, 95% CI 0.05-0.57, p = 0.004) and THI scores (OR = 1.05, 95% CI 1.03-1.07, p < 0.001) were independent factors associated with tinnitus improvement.

CONCLUSION

Audiogram configuration, tinnitus pitch, and THI scores before intervention appear to be predictive of the effectiveness of acute tinnitus improvement following ISSNHL treatment.

Does Listening to Tinnitus Frequency-Filtered Music Relieve Tinnitus?

Background and Objectives

Tinnitus frequency-filtered music therapy aims to restore lateral inhibition to reverse tonotopic reorganization in the auditory cortex. Although the tinnitus-relieving effect of this therapy has been investigated, the results remain controversial. We performed a prospective, randomized, controlled double-blind study to determine the tinnitus-suppressing effect of tinnitus frequency-filtered music therapy.

Subjects and Methods

The study included 90 participants who were randomly categorized into an experimental group that listened to tinnitus frequency-filtered music and a control group that listened to music from which a random frequency was removed. The Tinnitus Handicap Inventory (THI) score and measures of tinnitus loudness, daily awareness, and tinnitus-induced annoyance were evaluated at the initial visit and at 3 and 6 months (final follow-up). The rates of improvement in THI scores in the two groups were also recorded.

Results

All measured variables showed significant improvement in both groups, except the matched tinnitus loudness and minimal masking level. However, no significant intergroup differences were observed in the amount of improvement in THI scores and any other variable. The rates of improvement in THI scores were higher in the control group at 3 and 6 months.

Conclusions

Listening to tinnitus frequency-filtered music reduced tinnitus-induced handicaps; however, this approach was not significantly better than listening to music from which a random frequency was removed.

Specific brain network predictors of interventions with different mechanisms for tinnitus patients

BACKGROUND

The aberrant brain network that gives rise to the phantom sound of tinnitus is believed to determine the effectiveness of tinnitus therapies involving neuromodulation with repetitive transcranial magnetic stimulation (rTMS) and sound therapy utilizing tailor-made notch music training (TMNMT). To test this hypothesis, we determined how effective rTMS or TMNMT were in ameliorating tinnitus in patients with different functional brain networks.

METHODS

Resting-state functional MRI was used to construct brain functional networks in patients with tinnitus (41 males/45 females, mean age 49.53±11.19 years) and gender-matched healthy controls (22 males/35 females, mean age 46.23±10.23 years) with independent component analysis (ICA). A 2 × 2 analysis of variance with treatment outcomes (Effective group, EG/Ineffective group, IG) and treatment types (rTMS/TMNMT) was used to test the interaction between outcomes and treatment types associated with functional network connections (FNCs).

FINDINGS

The optimal neuroimaging indicator for responding to rTMS (AUC 0.804, sensitivity 0.700, specificity 0.913) was FNCs in the salience network-right frontoparietal network (SN-RFPN) while for responding to TMNMT (AUC 0.764, sensitivity 0.864, specificity 0.667) was the combination of FNCs in the auditory network- salience network (AUN-SN) and auditory network-cerebellar network (AUN-CN).

INTERPRETATION

Tinnitus patients with higher FNCs in the SN-RFPN is associated with a recommendation for rTMS whereas patients with lower FNCs in the AUN-SN and AUN-CN would suggest TMNMT as the better choice. These results indicate that brain network-based measures aid in the selection of the optimal form of treatment for a patient contributing to advances in precision medicine.

FUNDING

Yuexin Cai is supported by Key R&D Program of Guangdong Province, China (Grant No. 2018B030339001), National Natural Science Foundation of China (82071062), Natural Science Foundation of Guangdong province (2021A1515012038), the Fundamental Research Funds for the Central Universities (20ykpy91), and Sun Yat-Sen Clinical Research Cultivating Program (SYS-Q-201903). Yu-Chen Chen is supported by Medical Science and Technology Development Foundation of Nanjing Department of Health (No. ZKX20037), and Natural Science Foundation of Jiangsu Province (No. BK20211008).

Psychophysiological treatment of chronic tinnitus: A review

Subjective chronic tinnitus consists of a more or less continuous perception of sound in the absence of a corresponding acoustic source, which can lead to various psychological problems like depression, anxiety, attentional deficits and sleep disturbances. The prevalence is 10%-15% of the general population. Various therapy and management options have been proposed, but outcomes vary, and no generally accepted cure exists. In this review, the coherence of the most frequently used aetiological models shall be evaluated, and the efficacy of several treatment options will be discussed. With respect to tinnitus treatments, we focus on controlled studies and meta-analyses. Although there are some therapies that outweigh placebo effects such as cognitive behavioural therapy, neurofeedback or neuromodulation techniques, they mainly target secondary symptoms and not the tinnitus tone itself. Furthermore, positive treatment effects only seem to last for a limited period of time. We conclude that long-lasting combination therapies such as neurofeedback of auditory cortex inhibitory EEG signatures, cognitive therapy and sound-tactile stimulation may provide more efficient outcomes if they target the intensity of the tinnitus tone itself and not only secondary psychological symptoms.

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

PURPOSE

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

MATERIAL AND METHODS

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

RESULTS

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

CONCLUSION

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

The Pathological Mechanisms and Treatments of Tinnitus

Tinnitus is defined as the ringing, hissing, clicking or roaring sounds an individual consciously perceives in the absence of an external auditory stimulus. Currently, the literature on the mechanism of tinnitus pathology is multifaceted, ranging from tinnitus generation at the cellular level to its perception at the system level. Cellular level mechanisms include increased neuronal synchrony, neurotransmission changes and maladaptive plasticity. At the system level, the role of auditory structures, non-auditory structures, changes in the functional connectivities in higher regions and tinnitus networks have been investigated. The exploration of all these mechanisms creates a holistic view on understanding the changes the pathophysiology of tinnitus undertakes. Although tinnitus percept may start at the level of cochlear nerve deafferentation, the neuronal changes in the central auditory system to the neuronal and connectivity changes in non-auditory regions, such as the limbic system, become cardinal in chronic tinnitus generation. At the present moment, some tinnitus generation mechanisms are well established (e.g., increased neuronal synchrony) whereas other mechanisms have gained more traction recently (e.g., tinnitus networks, tinnitus-distress networks) and therefore, require additional investigation to solidify their role in tinnitus pathology. The treatments and therapeutics designed for tinnitus are numerous, with varied levels of success. They are generally two-fold: some treatments focus on tinnitus cessation (including cochlear implants, deep brain stimulation, transcranial direct current stimulation and transcranial magnetic stimulation) whereas the other set focuses on tinnitus reduction or masking (including hearing aids, sound therapy, cognitive behavioral therapy, tinnitus retraining therapy, and tailor made notched musical training).  Tinnitus management has focused on implementing tinnitus masking/reducing therapies more than tinnitus cessation, since cessation treatments are still lacking in streamlined treatment protocols and long-term sustainability and efficacy of the treatment. This review will focus on concisely exploring the current and most relevant tinnitus pathophysiology mechanisms, treatments and therapeutics.

Notched and Nonnotched Stimuli Are Equally Effective at the Mixing Point Level in Sound Therapy for Tinnitus Relief

BACKGROUND

 Broadband noise (nonnotched) and notched noise are common sound sources in sound therapy for tinnitus relief. Studies on sound therapy using nonnotched or notched stimuli have reported large and small tinnitus improvements depending on the participant. However, the more effective sound source remains unclear given the among-study methodology differences.

PURPOSE

 This study aimed to evaluate the tinnitus relief effects of sound therapy using stimuli with different spectral characteristics.

RESEARCH DESIGN

 This was a prospective study involving within-subject (baseline vs. 12-month follow-up) measurements for two groups (notched noise group vs. broadband noise group).

STUDY SAMPLE

 We enrolled 30 adults with subjective and tonal tinnitus (notched noise group: 16, broadband noise group: 14).

INTERVENTION

 The participants underwent 3-hour daily sound therapy using either notched noise or broadband noise for 12 months. The stimulus level for sound therapy was set to each participant's mixing point.

DATA COLLECTION AND ANALYSIS

 Tinnitus loudness and the Korean version of the Tinnitus Primary Function Questionnaire score were measured at baseline and at the 12-month follow-up time point.

RESULTS

 Both groups showed a significant improvement in tinnitus loudness and the Korean version of the Tinnitus Primary Function Questionnaire score.

CONCLUSIONS

 Notched and nonnotched stimuli are equally effective at the mixing point in sound therapy for tinnitus relief. Individuals with difficulties in tinnitus frequency measurement could easily undergo sound therapy using nonnotched stimuli.

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.

Auditory Neural Plasticity in Tinnitus Mechanisms and Management

Tinnitus, which is the perception of sound in the absence of a corresponding external acoustic stimulus, including change of hearing and neural plasticity, has become an increasingly important ailment affecting the daily life of a considerable proportion of the population and causing significant burdens for both the affected individuals and society as a whole. Here, we briefly review the epidemiology and classification of tinnitus, and the currently available treatments are discussed in terms of the available evidence for their mechanisms and efficacy. The conclusion drawn from the available evidence is that there is no specific medication for tinnitus treatment at present, and tinnitus management might provide better solutions. Therapeutic interventions for tinnitus should be based on a comprehensive understanding of the etiology and features of individual cases of tinnitus, and more high quality and large-scale research studies are urgently needed to develop more efficacious medications.

Aberrant Functional and Causal Connectivity in Acute Tinnitus With Sensorineural Hearing Loss

Purpose

The neural bases in acute tinnitus remains largely undetected. The objective of this study was to identify the alteration of the brain network involved in patients with acute tinnitus and hearing loss.

Methods

Acute tinnitus patients (n = 24) with hearing loss and age-, sex-, education-matched healthy controls (n = 21) participated in the current study and underwent resting-state functional magnetic resonance imaging (fMRI) scanning. Regional homogeneity and amplitude of low-frequency fluctuation were used to investigate the local spontaneous neural activity and functional connectivity (FC), and Granger causality analysis (GCA) was used to analyze the undirected and directed connectivity of brain regions.

Results

Compared with healthy subjects, acute tinnitus patients had a general reduction in FC between auditory and non-auditory brain regions. Based on FC analysis, the superior temporal gyrus (STG) revealed reduced undirected connectivity with non-auditory brain regions including the amygdala (AMYG), nucleus accumbens (NAc), the cerebellum, and postcentral gyrus (PoCG). Using the GCA algorithm, increased effective connectivity from the right AMYG to the right STG, and reduced connectivity from the right PoCG to the left NAc was observed in acute tinnitus patients with hearing loss. The pure-tone threshold was positively correlated with FC between the AMYG and STG, and negatively correlated with FC between the left NAc and the right PoCG. In addition, a negative association between the GCA value from the right PoCG to the left NAc and the THI scores was observed.

Conclusion

Acute tinnitus patients have aberrant FC strength and causal connectivity in both the auditory and non-auditory cortex, especially in the STG, AMYG, and NAc. The current findings will provide a new perspective for understanding the neuropathophysiological mechanism in acute 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.

Sense and Sensibility: A Review of the Behavioral Neuroscience of Tinnitus Sound Therapy and a New Typology

Tinnitus Sound Therapy is not a single strategy. It consists of many different sound types, targeting many different mechanisms. Therapies that use sound to cover, reduce attention to, or facilitate habituation of tinnitus are among the most common tinnitus treatment paradigms. Recent history has seen a proliferation of sound therapies, but they have each been criticized for having limited empirical support. In this review, Sound Therapy's modern history will be described, and a typology will be introduced and discussed in light of current behavioral neuroscience research. It will be argued that contributing factors to the limited evidence for the efficacy of Sound Therapy are its diversity, plural modes of action, and absence of a clear typology. Despite gaps in understanding the efficacy of sound's effects on tinnitus, there is compelling evidence for its multiple, but related, neurophysiological mechanisms. Evidence suggests that sound may reduce tinnitus through its presence, context, reaction, and potentially adaptation. This review provides insights into the neurocognitive basis of these tinnitus Sound Therapy modes. It concludes that a unifying classification is needed to secure and advance arguments in favor of Sound Therapy.

Individual Reliability of the Standard Clinical Method vs Patient-Centered Tinnitus Likeness Rating for Assessment of Tinnitus Pitch and Loudness Matching

Importance

Current individualized sound therapies for tinnitus rely on tinnitus pitch assessment, which is commonly derived from the standard clinical 2-alternative forced-choice (2-AFC) approach driven by the examiner. However, this method is limited by lack of individual test-retest reliability and focuses on a single rather than multiple tinnitus frequencies.

Objective

To assess individual test-retest reliability of the 2-AFC, with a single final frequency (and corresponding loudness), and the tinnitus likeness rating (TLR), with the participant exposed to the entire audible frequency spectrum, from which 3 dominant frequencies and corresponding loudness were extracted.

Design, Setting, and Participants

In this case series, participants with tinnitus underwent testing twice with both methods at a 1-month interval by experienced clinicians from January 6 through March 17, 2017. Each clinician tested each patient only once at visit 1 or 2 in a university audiology training setting with standardized equipment and was blind to previous assessment. Participants with bilateral or unilateral chronic tinnitus for longer than 6 months, in good health, without total deafness in either ear, and without cerumen in the ear canal were recruited through advertisements (community and clinics) and word of mouth (volunteer sample). The audiologists were likewise participants in the planned comparison between TLR and 2-AFC in the test-retest measures.

Main Outcomes and Measures

Test-retest concordance with 95% CIs for each method, calculated as the proportion of participants with the same final frequency between the 2 visits (2-AFC) or with at least 1 concordant dominant frequency (TLR) as well as loudness differences of no greater than 10 dB.

Results

The study sample included 31 participants (55% men; mean [SD] age, 50.7 [13.7] years). For TLR, 26 of 31 participants had at least 1 concordant dominant frequency between the 2 visits (proportion, 0.84; 95% CI, 0.66-0.95), whereas for 2-AFC, 7 of 31 participants had a concordant final tinnitus pitch in either ear (proportion, 0.23; 95% CI, 0.10-0.41). Loudness reliability followed the same pattern, with more concordant loudness levels in the TLR (proportion, 0.73; 95% CI, 0.52-0.88) than in the 2-AFC (proportion, 0.40; 95% CI, 0.05-0.85). Mean time taken to complete the tests was less than 15 minutes, and general appreciation by participants with tinnitus and audiologists were overall similar for both.

Conclusions and Relevance

Superior test-retest concordance can be demonstrated at the individual level using the several dominant frequencies extracted from the patient-centered TLR.

Inhibition of Brain Area and Functional Connectivity in Idiopathic Sudden Sensorineural Hearing Loss With Tinnitus, Based on Resting-State EEG

This study aimed to identify the mechanism behind idiopathic sudden sensorineural hearing loss (ISSNHL) in patients with tinnitus by investigating aberrant activity in areas of the brain and functional connectivity. High-density electroencephalography (EEG) was used to investigate central nervous changes in 25 ISSNHL subjects and 27 healthy controls. ISSNHL subjects had significantly reduced activity in the left frontal lobe at the alpha 2 frequency band compared with controls. Linear lagged connectivity and lagged coherence analysis showed significantly reduced functional connectivity between the temporal gyrus and supramarginal gyrus at the gamma 2 frequency band in the ISSNHL group. Additionally, a significantly reduced functional connectivity was found between the central cingulate gyrus and frontal lobe under lagged phase synchronization analysis. These results strongly indicate inhibition of brain area activity and change in functional connectivity in ISSNHL with tinnitus patients.

[Smartphone app-supported approaches to tinnitus therapy]

In recent years, applications (apps) for medical purposes have been developed and introduced, including apps that perform diagnostics and documentation for hearing loss and tinnitus in combination with smartphones. Even therapeutic apps, particularly for chronic tinnitus, have been launched. This review discusses the existing scientific literature for these smartphone applications. For tinnitus, Internet-based cognitive behavioral therapy has been developed and evaluated. For tinnitus therapy, introduced apps combine acoustic stimulation and music, or serve acoustic stimulation of cortical regions around the tinnitus frequency. Although these apps appear very innovative, their effectiveness has not yet been scientifically proven. A general problem associated with using smartphone apps lies in their safety in terms of possible side effects and personal data protection. However, Internet programs and apps can be a useful supplement to multimodal tinnitus therapies.

Altered Resting-State EEG Microstate in Idiopathic Sudden Sensorineural Hearing Loss Patients With Tinnitus

In order to clarify the central reorganization in acute period of hearing loss, this study explored the aberrant dynamics of electroencephalogram (EEG) microstates and the correlations with the features of idiopathic sudden sensorineural hearing loss (ISSNHL) and tinnitus. We used high-density EEG with 128 channels to investigate alterations in microstate parameters between 25 ISSNHL patients with tinnitus and 27 healthy subjects. This study also explored the associations between microstate characteristics and tinnitus features. Microstates were clustered into four categories. There was a reduced presence of microstate A in amplitude, coverage, lifespan, frequency and an increased presence of microstate B in frequency in ISSNHL patients with tinnitus. According to the syntax analysis, a reduced transition from microstate C to microstate A and an increased transition from microstate C to microstate B were found in ISSNHL subjects. In addition, the significant negative correlations were found between Tinnitus Handicap Inventory (THI) scores and frequency of microstate A as well as between THI scores and the probability of transition from microstate D to microstate A. While THI was positively correlated with the transition probability from microstate D to microstate B. To sum up, the significant differences in the characteristics of resting-state EEG microstates were found between ISSNHL subjects with tinnitus and healthy controls. This study suggests that the alterations of central neural networks occur in acute stage of hearing loss and tinnitus. And EEG microstate may be considered as a useful tool to study the whole brain network in ISSNHL patients.

Manipulation of Auditory Inputs as Rehabilitation Therapy for Maladaptive Auditory Cortical Reorganization

Neurophysiological and neuroimaging data suggest that the brains of not only children but also adults are reorganized based on sensory inputs and behaviors. Plastic changes in the brain are generally beneficial; however, maladaptive cortical reorganization in the auditory cortex may lead to hearing disorders such as tinnitus and hyperacusis. Recent studies attempted to noninvasively visualize pathological neural activity in the living human brain and reverse maladaptive cortical reorganization by the suitable manipulation of auditory inputs in order to alleviate detrimental auditory symptoms. The effects of the manipulation of auditory inputs on maladaptively reorganized brain were reviewed herein. The findings obtained indicate that rehabilitation therapy based on the manipulation of auditory inputs is an effective and safe approach for hearing disorders. The appropriate manipulation of sensory inputs guided by the visualization of pathological brain activities using recent neuroimaging techniques may contribute to the establishment of new clinical applications for affected individuals.

Logistic regression analysis of factors influencing the effectiveness of intensive sound masking therapy in patients with tinnitus

OBJECTIVES

To investigate factors influencing the effectiveness of intensive sound masking therapy on tinnitus using logistic regression analysis.

DESIGN

The study used a retrospective cross-section analysis.

PARTICIPANTS

102 patients with tinnitus were recruited at the Sun Yat-sen Memorial Hospital of Sun Yat-sen University, China.

INTERVENTION

Intensive sound masking therapy was used as an intervention approach for patients with tinnitus.

PRIMARY AND SECONDARY OUTCOME MEASURES

Participants underwent audiological investigations and tinnitus pitch and loudness matching measurements, followed by intensive sound masking therapy. The Tinnitus Handicap Inventory (THI) was used as the outcome measure pre and post treatment. Multivariate logistic regression was performed to investigate the association of demographic and audiological factors with effective therapy.

RESULTS

According to the THI score changes pre and post sound masking intervention, 51 participants were categorised into an effective group, the remaining 51 participants were placed in a non-effective group. Those in the effective group were significantly younger than those in the non-effective group (P=0.012). Significantly more participants had flat audiogram configurations in the effective group (P=0.04). Multivariable logistic regression analysis showed that age (OR=0.96, 95% CI 0.93 to 0.99, P=0.007), audiometric configuration (P=0.027) and THI score pre treatment (OR=1.04, 95% CI 1.02 to 1.07, P<0.001) were significantly associated with therapeutic effectiveness. Further analysis showed that patients with flat audiometric configurations were 5.45 times more likely to respond to intervention than those with high-frequency steeply sloping audiograms (OR=5.45, 95% CI 1.67 to 17.86, P=0.005).

CONCLUSION

Audiometric configuration, age and THI scores appear to be predictive of the effectiveness of sound masking treatment. Gender, tinnitus characteristics and hearing threshold measures do not seem to be related to treatment effectiveness. A further randomised control study is needed to provide evidence of the effectiveness of prognostic factors in tinnitus interventions.

A State-of-the-Art Review: Personalization of Tinnitus Sound Therapy

Background: There are several established, and an increasing number of putative, therapies using sound to treat tinnitus. There appear to be few guidelines for sound therapy selection and application. Aim: To review current approaches to personalizing sound therapy for tinnitus. Methods: A "state-of-the-art" review (Grant and Booth, 2009) was undertaken to answer the question: how do current sound-based therapies for tinnitus adjust for tinnitus heterogeneity? Scopus, Google Scholar, Embase and PubMed were searched for the 10-year period 2006-2016. The search strategy used the following key words: "tinnitus" AND "sound" AND "therapy" AND "guidelines" OR "personalized" OR "customized" OR "individual" OR "questionnaire" OR "selection." The results of the review were cataloged and organized into themes. Results: In total 165 articles were reviewed in full, 83 contained sufficient details to contribute to answering the study question. The key themes identified were hearing compensation, pitched-match therapy, maskability, reaction to sound and psychosocial factors. Although many therapies mentioned customization, few could be classified as being personalized. Several psychoacoustic and questionnaire-based methods for assisting treatment selection were identified. Conclusions: Assessment methods are available to assist clinicians to personalize sound-therapy and empower patients to be active in therapy decision-making. Most current therapies are modified using only one characteristic of the individual and/or their tinnitus.

Self-Administered Tinnitus Pitch Matching versus a Conventional Audiometric Procedure

Objective: Obtaining an accurate tinnitus pitch match is an initial and critical requirement for tinnitus evaluation and treatment, particularly for applying tailor-made notched music training. We investigated whether computer-based self-administered tinnitus pitch matching (CSTPM) is comparable with a conventional audiometric procedure (CAP). Methods: In total, 82 patients (mean age 45.52 years; 42 females) with tonal tinnitus participated. The CAP was performed by the same audiologist using a 2-alternative forced choice method with a frequency range of 0.25-16 kHz. In the CSTPM, the subjects used personal computer software with a scrolling slider to select the sound closest to their tinnitus pitch. After each matching procedure, an octave challenge test was applied. A multivariate logistic regression was performed to determine factors associated with the difference between the CSTPM and CAP. Results: The subjects' mean hearing threshold was 21.25 ± 17.61 dB HL; the mean tinnitus handicap inventory score was 35.56 ± 24.09. The mean pitches measured with the CSTPM and CAP were 6.29 ± 4.30 and 6.98 ± 5.33 kHz, respectively. In total, 57 (69.5%) subjects matched their tinnitus with less than half an octave difference between the procedures. The results of the 2 methods correlated significantly with each other (Pearson r = 0.793, p < 0.001). Octave confusion was a significant factor affecting the difference between the procedures (odds ratio 8.92, p < 0.05). Conclusions: The CSTPM appears to be as accurate as the standard audiological procedure, and may be used instead of the CAP when octave confusion is minimized.

Evidence and evidence gaps in tinnitus therapy

A nearly endless number of procedures has been tried and in particular sold for the treatment of tinnitus, unfortunately they have not been evaluated appropriately in an evidence-based way. A causal therapy, omitting the tinnitus still does not exist, actually it cannot exist because of the various mechanisms of its origin. However or perhaps because of that, medical interventions appear and reappear like fashion trends that can never be proven by stable and reliable treatment success. This contribution will discuss and acknowledge all current therapeutic procedures and the existing or non-existing evidence will be assessed. Beside external evidence, the term of evidence also encompasses the internal evidence, i.e. the experience of the treating physician and the patient's needs shall be included. While there is no evidence for nearly all direct procedures that intend modulating or stimulating either the cochlea or specific cervical regions such as the auditory cortex, there are therapeutic procedures that are acknowledged in clinical practice and have achieved at least a certain degree of evidence and generate measurable effect sizes. Those are in particular habituation therapy and psychotherapeutic measures, especially if they are combined with concrete measures for improved audio perception (hearing aids, CI, hearing therapies).

Clinical trial on tonal tinnitus with tailor-made notched music training

Background

Tinnitus is a result of hyper-activity/hyper-synchrony of auditory neurons coding the tinnitus frequency, which has developed due to synchronous mass activity owing to the lack of inhibition. We assume that removal of exactly these frequencies from a complex auditory stimulus will cause the brain to reorganize around tonotopic regions coding the tinnitus frequency through inhibition-induced plasticity. Based on this assumption, a novel treatment for tonal tinnitus - tailor-made notched music training (TMNMT) - has been introduced and was tested in this clinical trial.

Methods

A randomized controlled trial in parallel group design was performed in a double-blinded manner. We included 100 participants with chronic, tonal tinnitus who listened to tailor-made notched music for two hours a day for three consecutive months. Our primary outcome measures were the Tinnitus Handicap Questionnaire and Visual Analog Scales measuring perceived tinnitus loudness, awareness, distress and handicap. Participants rated their tinnitus before and after the training as well as one month after cessation of the training.

Results

While no effect was found for the primary outcome measures, tinnitus distress, as measured by the Tinnitus Questionnaire, a secondary outcome measure, developed differently in the two groups. The treatment group showed higher distress scores while the placebo group revealed lower distress scores after the training. However, this effect did not reach significance in post-hoc analysis and disappeared at follow-up measurements. At follow-up, tinnitus loudness in the treatment group was significantly reduced as compared to the control group. Post hoc analysis, accounting for low reliability scores in the Visual Analog Scales, showed a significant reduction of the overall Visual Analog Scale mean score in the treatment group even at the post measurement.

Conclusion

This is the first study on TMNMT that was planned and conducted following the CONSORT statement standards for clinical trials. The current work is one more step towards a final evaluation of TMNMT. Already after three months the effect of training with tailor-made notched music is observable in the most direct rating of tinnitus perception – the tinnitus loudness, while more global measures of tinnitus distress do not show relevant changes.

Trial registration

Current Controlled Trials ISRCTN04840953; Trial registration date: 17.07.2013

Impact of Spectral Notch Width on Neurophysiological Plasticity and Clinical Effectiveness of the Tailor-Made Notched Music Training

Tinnitus, the ringing in the ears that is unrelated to any external source, causes a significant loss in quality of life, involving sleep disturbance and depression for 1 to 3% of the general population. While in the first place tinnitus may be triggered by damage to the inner ear cells, the neural generators of subjective tinnitus are located in central regions of the nervous system. A loss of lateral inhibition, tonotopical reorganization and a gain-increase in response to the sensory deprivation result in hypersensitivity and hyperactivity in certain regions of the auditory cortex. In the tailor-made notched music training (TMNMT) patients listen to music from which the frequency spectrum of the tinnitus has been removed. This evokes strong lateral inhibition from neurons tuned to adjacent frequencies onto the neurons involved in the tinnitus percept. A reduction of tinnitus loudness and tinnitus-related neural activity was achieved with TMNMT in previous studies. As the effect of lateral inhibition depends on the bandwidth of the notch, in the current study we altered the notch width to find the most effective notch width for TMNMT. We compared 1-octave notch width with ½-octave and ¼-octave. Participants chose their favorite music for the training that included three month of two hours daily listening. The outcome was measured by means of standardized questionnaires and magnetoencephalography. We found a general reduction of tinnitus distress in all administered tinnitus questionnaires after the training. Additionally, tinnitus-related neural activity was reduced after the training. Nevertheless, notch width did not have an influence on the behavioral or neural effects of TMNMT. This could be due to a non-linear resolution of lateral inhibition in high frequencies.

Enhancing Inhibition-Induced Plasticity in Tinnitus – Spectral Energy Contrasts in Tailor-Made Notched Music Matter

Chronic tinnitus seems to be caused by reduced inhibition among frequency selective neurons in the auditory cortex. One possibility to reduce tinnitus perception is to induce inhibition onto over-activated neurons representing the tinnitus frequency via tailor-made notched music (TMNM). Since lateral inhibition is modifiable by spectral energy contrasts, the question arises if the effects of inhibition-induced plasticity can be enhanced by introducing increased spectral energy contrasts (ISEC) in TMNM. Eighteen participants suffering from chronic tonal tinnitus, pseudo randomly assigned to either a classical TMNM or an ISEC-TMNM group, listened to notched music for three hours on three consecutive days. The music was filtered for both groups by introducing a notch filter centered at the individual tinnitus frequency. For the ISEC-TMNM group a frequency bandwidth of 3/8 octaves on each side of the notch was amplified, additionally, by about 20 dB. Before and after each music exposure, participants rated their subjectively perceived tinnitus loudness on a visual analog scale. During the magnetoencephalographic recordings, participants were stimulated with either a reference tone of 500 Hz or a test tone with a carrier frequency representing the individual tinnitus pitch. Perceived tinnitus loudness was significantly reduced after TMNM exposure, though TMNM type did not influence the loudness ratings. Tinnitus related neural activity in the N1m time window and in the so called tinnitus network comprising temporal, parietal and frontal regions was reduced after TMNM exposure. The ISEC-TMNM group revealed even enhanced inhibition-induced plasticity in a temporal and a frontal cortical area. Overall, inhibition of tinnitus related neural activity could be strengthened in people affected with tinnitus by increasing spectral energy contrast in TMNM, confirming the concepts of inhibition-induced plasticity via TMNM and spectral energy contrasts.

The effectiveness of neuro-music therapy according to the Heidelberg model compared to a single session of educational counseling as treatment for tinnitus: a controlled trial

OBJECTIVES

Tinnitus is a very common symptom, yet the quest for an effective treatment is challenging. Results from several clinical trials support the notion that neuro-music therapy is an effective means to reduce tinnitus distress with short duration and long lasting effect. However, until now, the effectiveness has not been tested in a controlled trial against an active comparator.

METHODS

The trial was designed as two-center, parallel intervention group controlled study with two intervention groups: Counseling (50minute individualized personal instruction) or neuro-music therapy (counseling plus eight 50-minute sessions of individualized music therapy). Data of n=290 patients suffering from chronic tinnitus were analyzed. Outcome measure was the change in Tinnitus Questionnaire Total Scores (TQ) from baseline (admission) to end of treatment.

RESULTS

Both treatment groups achieved a statistically relevant reduction in TQ scores, though 66% of patients in the music therapy group attained a clinically meaningful improvement compared to 33% in the counseling group. A binary logistic regression revealed two variables significantly influencing therapy outcome: initial tinnitus score and type of therapy with an OR for the music therapy compared to the counseling of 4.34 (CI 2.33-8.09).

CONCLUSIONS

Counseling is an appropriate treatment option with well above chance of improvement. The neuro-music therapy outperformed the counseling. This treatment targets the tinnitus sound itself, is short in duration, intrinsically motivating and easy to operate and thus presents a possible complement to the therapeutic spectrum in chronic tinnitus. The trial was registered at the ClinicalTrials.gov registry (ID: NCT01845155).

Playing and listening to tailor-made notched music: cortical plasticity induced by unimodal and multimodal training in tinnitus patients

Background. The generation and maintenance of tinnitus are assumed to be based on maladaptive functional cortical reorganization. Listening to modified music, which contains no energy in the range of the individual tinnitus frequency, can inhibit the corresponding neuronal activity in the auditory cortex. Music making has been shown to be a powerful stimulator for brain plasticity, inducing changes in multiple sensory systems. Using magnetoencephalographic (MEG) and behavioral measurements we evaluated the cortical plasticity effects of two months of (a) active listening to (unisensory) versus (b) learning to play (multisensory) tailor-made notched music in nonmusician tinnitus patients. Taking into account the fact that uni- and multisensory trainings induce different patterns of cortical plasticity we hypothesized that these two protocols will have different affects. Results. Only the active listening (unisensory) group showed significant reduction of tinnitus related activity of the middle temporal cortex and an increase in the activity of a tinnitus-coping related posterior parietal area. Conclusions. These findings indicate that active listening to tailor-made notched music induces greater neuroplastic changes in the maladaptively reorganized cortical network of tinnitus patients while additional integration of other sensory modalities during training reduces these neuroplastic effects.

Study protocol: Münster tinnitus randomized controlled clinical trial-2013 based on tailor-made notched music training (TMNMT)

Background

Tinnitus is a result of hyper-activity/hyper-synchrony of auditory neurons coding the tinnitus frequency, which has developed to synchronous mass activity owing the lack of inhibition. We assume that removal of exactly these frequency components from an auditory stimulus will cause the brain to reorganize around tonotopic regions coding the tinnitus frequency. Based on this assumption a novel treatment for tonal tinnitus - tailor-made notched music training (TMNMT) (Proc Natl Acad Sci USA 107:1207–1210, 2010; Ann N Y Acad Sci 1252:253–258, 2012; Frontiers Syst Neurosci 6:50, 2012) has been introduced and will be tested in this clinical trial on a large number of tinnitus patients.

Methods and design

A randomized controlled trial (RCT) in parallel group design will be performed in a double-blinded manner. The choice of the intervention we are going to apply is based on two “proof of concept” studies in humans (Proc Natl Acad Sci USA 107:1207–1210, 2010; Ann N Y Acad Sci 1252:253–258, 2012; Frontiers Syst Neurosci 6:50, 2012; PloS One 6(9):e24685, 2011) and on a recent animal study (Front Syst Neurosci 7:21, 2013).

The RCT includes 100 participants with chronic, tonal tinnitus who listened to tailor-made notched music (TMNM) for two hours a day for three months. The effect of TMNMT is assessed by the tinnitus handicap questionnaire and visual analogue scales (VAS) measuring perceived tinnitus loudness, distress and handicap.

Discussion

This is the first randomized controlled trial applying TMNMT on a larger number of patients with tonal tinnitus. Our data will verify more securely and reliably the effectiveness of this kind of completely non-invasive and low-cost treatment approach on tonal tinnitus.

Trial registration

Current Controlled Trials ISRCTN04840953

Combining transcranial direct current stimulation and tailor-made notched music training to decrease tinnitus-related distress--a pilot study

The central auditory system has a crucial role in tinnitus generation and maintenance. Curative treatments for tinnitus do not yet exist. However, recent attempts in the therapeutic application of both acoustic stimulation/training procedures and electric/magnetic brain stimulation techniques have yielded promising results. Here, for the first time we combined tailor-made notched music training (TMNMT) with transcranial direct current stimulation (tDCS) in an effort to modulate TMNMT efficacy in the treatment of 32 patients with tonal tinnitus and without severe hearing loss. TMNMT is characterized by regular listening to so-called notched music, which is generated by digitally removing the frequency band of one octave width centered at the individual tinnitus frequency. TMNMT was applied for 10 subsequent days (2.5 hours of daily treatment). During the initial 5 days of treatment and the initial 30 minutes of TMNMT sessions, tDCS (current strength: 2 mA; anodal (N = 10) vs. cathodal (N = 11) vs. sham (N = 11) groups) was applied simultaneously. The active electrode was placed on the head surface over left auditory cortex; the reference electrode was put over right supra-orbital cortex. To evaluate treatment outcome, tinnitus-related distress and perceived tinnitus loudness were assessed using standardized tinnitus questionnaires and a visual analogue scale. The results showed a significant treatment effect reflected in the Tinnitus Handicap Questionnaire that was largest after 5 days of treatment. This effect remained significant at the end of follow-up 31 days after treatment cessation. Crucially, tDCS did not significantly modulate treatment efficacy - it did not make a difference whether anodal, cathodal, or sham tDCS was applied. Possible explanations for the findings and functional modifications of the experimental design for future studies (e.g. the selection of control conditions) are discussed.

Modulatory effects of spectral energy contrasts on lateral inhibition in the human auditory cortex: an MEG study

We investigated the modulation of lateral inhibition in the human auditory cortex by means of magnetoencephalography (MEG). In the first experiment, five acoustic masking stimuli (MS), consisting of noise passing through a digital notch filter which was centered at 1 kHz, were presented. The spectral energy contrasts of four MS were modified systematically by either amplifying or attenuating the edge-frequency bands around the notch (EFB) by 30 dB. Additionally, the width of EFB amplification/attenuation was varied (3/8 or 7/8 octave on each side of the notch). N1m and auditory steady state responses (ASSR), evoked by a test stimulus with a carrier frequency of 1 kHz, were evaluated. A consistent dependence of N1m responses upon the preceding MS was observed. The minimal N1m source strength was found in the narrowest amplified EFB condition, representing pronounced lateral inhibition of neurons with characteristic frequencies corresponding to the center frequency of the notch (NOTCH CF) in secondary auditory cortical areas. We tested in a second experiment whether an even narrower bandwidth of EFB amplification would result in further enhanced lateral inhibition of the NOTCH CF. Here three MS were presented, two of which were modified by amplifying 1/8 or 1/24 octave EFB width around the notch. We found that N1m responses were again significantly smaller in both amplified EFB conditions as compared to the NFN condition. To our knowledge, this is the first study demonstrating that the energy and width of the EFB around the notch modulate lateral inhibition in human secondary auditory cortical areas. Because it is assumed that chronic tinnitus is caused by a lack of lateral inhibition, these new insights could be used as a tool for further improvement of tinnitus treatments focusing on the lateral inhibition of neurons corresponding to the tinnitus frequency, such as the tailor-made notched music training.

Directing neural plasticity to understand and treat tinnitus

The functional organization of cortical and subcortical networks can be altered by sensory experience. Sensory deprivation destabilizes neural networks resulting in increased excitability, greater neural synchronization and increased spontaneous firing in cortical and subcortical neurons. This pathological activity is thought to generate the phantom percept of chronic tinnitus. While sound masking, pharmacotherapy and cortical stimulation can temporarily suppress tinnitus for some patients, these interventions do not eliminate the pathological activity that is responsible for tinnitus. A treatment that could reverse the underlying pathology would be expected to be effective in alleviating the symptoms, if not curative. Targeted neural plasticity can provide the specificity required to restore normal neural activity in dysfunctional neural circuits that are assumed to underlie many forms of tinnitus. The forebrain cholinergic system and the noradrenergic system play a significant role in modulating cortical plasticity. Stimulation of the vagus nerve is known to activate these neuromodulatory pathways. Our earlier studies have demonstrated that pairing sounds with either nucleus basalis of Meynert (NB) stimulation or vagus nerve stimulation (VNS) generates highly specific and long-lasting plasticity in auditory cortex neurons. Repeatedly pairing tones with brief pulses of VNS reversed the physiological and behavioral correlates of tinnitus in noise exposed rats. We also recently demonstrated that VNS modulates synchrony and excitability in the auditory cortex at least in part by activation of muscarinic acetylcholine receptors, suggesting that acetylcholine is involved in the mechanism of action of VNS. These results suggest that pairing sounds with VNS provides a new avenue of treatment for some forms of tinnitus. This paper discusses neuromodulation as treatment for tinnitus with a focus on the potential value of pairing VNS with sound stimulation as a treatment of chronic tinnitus.

Music-induced cortical plasticity and lateral inhibition in the human auditory cortex as foundations for tonal tinnitus treatment

Over the past 15 years, we have studied plasticity in the human auditory cortex by means of magnetoencephalography (MEG). Two main topics nurtured our curiosity: the effects of musical training on plasticity in the auditory system, and the effects of lateral inhibition. One of our plasticity studies found that listening to notched music for 3 h inhibited the neuronal activity in the auditory cortex that corresponded to the center-frequency of the notch, suggesting suppression of neural activity by lateral inhibition. Subsequent research on this topic found that suppression was notably dependent upon the notch width employed, that the lower notch-edge induced stronger attenuation of neural activity than the higher notch-edge, and that auditory focused attention strengthened the inhibitory networks. Crucially, the overall effects of lateral inhibition on human auditory cortical activity were stronger than the habituation effects. Based on these results we developed a novel treatment strategy for tonal tinnitus-tailor-made notched music training (TMNMT). By notching the music energy spectrum around the individual tinnitus frequency, we intended to attract lateral inhibition to auditory neurons involved in tinnitus perception. So far, the training strategy has been evaluated in two studies. The results of the initial long-term controlled study (12 months) supported the validity of the treatment concept: subjective tinnitus loudness and annoyance were significantly reduced after TMNMT but not when notching spared the tinnitus frequencies. Correspondingly, tinnitus-related auditory evoked fields (AEFs) were significantly reduced after training. The subsequent short-term (5 days) training study indicated that training was more effective in the case of tinnitus frequencies ≤ 8 kHz compared to tinnitus frequencies >8 kHz, and that training should be employed over a long-term in order to induce more persistent effects. Further development and evaluation of TMNMT therapy are planned. A goal is to transfer this novel, completely non-invasive and low-cost treatment approach for tonal tinnitus into routine clinical practice.

Neural plasticity expressed in central auditory structures with and without tinnitus

Sensory training therapies for tinnitus are based on the assumption that, notwithstanding neural changes related to tinnitus, auditory training can alter the response properties of neurons in auditory pathways. To assess this assumption, we investigated whether brain changes induced by sensory training in tinnitus sufferers and measured by electroencephalography (EEG) are similar to those induced in age and hearing loss matched individuals without tinnitus trained on the same auditory task. Auditory training was given using a 5 kHz 40-Hz amplitude-modulated (AM) sound that was in the tinnitus frequency region of the tinnitus subjects and enabled extraction of the 40-Hz auditory steady-state response (ASSR) and P2 transient response known to localize to primary and non-primary auditory cortex, respectively. P2 amplitude increased over training sessions equally in participants with tinnitus and in control subjects, suggesting normal remodeling of non-primary auditory regions in tinnitus. However, training-induced changes in the ASSR differed between the tinnitus and control groups. In controls the phase delay between the 40-Hz response and stimulus waveforms reduced by about 10° over training, in agreement with previous results obtained in young normal hearing individuals. However, ASSR phase did not change significantly with training in the tinnitus group, although some participants showed phase shifts resembling controls. On the other hand, ASSR amplitude increased with training in the tinnitus group, whereas in controls this response (which is difficult to remodel in young normal hearing subjects) did not change with training. These results suggest that neural changes related to tinnitus altered how neural plasticity was expressed in the region of primary but not non-primary auditory cortex. Auditory training did not reduce tinnitus loudness although a small effect on the tinnitus spectrum was detected.