Noninvasive Bimodal Neuromodulation for the Treatment of Tinnitus: Protocol for a Second Large-Scale Double-Blind Randomized Clinical Trial to Optimize Stimulation Parameters

Combining sound with tongue stimulation for the treatment of tinnitus: a multi-site single-arm controlled pivotal trial

Bimodal neuromodulation is emerging as a nonsurgical treatment for tinnitus. Bimodal treatment combining sound therapy with electrical tongue stimulation using the Lenire device is evaluated in a controlled pivotal trial (TENT-A3, NCT05227365) consisting of 6-weeks of sound-only stimulation (Stage 1) followed by 6-weeks of bimodal treatment (Stage 2) with 112 participants serving as their own control. The primary endpoint compares the responder rate observed in Stage 2 versus Stage 1, where a responder exceeds 7 points in the Tinnitus Handicap Inventory. In participants with moderate or more severe tinnitus, there is a clinically superior performance of bimodal treatment (58.6%; 95% CI: 43.5%, 73.6%; p = 0.022) compared to sound therapy alone (43.2%; 95% CI: 29.7%, 57.8%), which is not observed in the full cohort across all severity groups. Consistent results are observed for the secondary endpoint based on the Tinnitus Functional Index (bimodal treatment: 45.5%; 95% CI: 31.7%, 59.9%; sound-only stimulation: 29.6%; 95% CI: 18.2%, 44.2%; p = 0.010), where a responder exceeds 13 points. There are no device related serious adverse events. These positive outcomes led to FDA De Novo approval of the Lenire device for tinnitus treatment.

Tinnitus: A Dimensionally Segregated, yet Perceptually Integrated Heterogeneous Disorder

OBJECTIVES

Tinnitus subtypes are proposed to lie on a continuum of different symptom dimensions rather than be categorical. However, there is no comprehensive empirical data showing this complex relationship between different tinnitus symptoms. The objective of this study is to provide empirical evidence for the dimensional nature of tinnitus and how different auditory and non-auditory symptoms interact with each other through complex interactions. We do this using graph theory, a mathematical tool that empirically maps this complex interaction. This way, graph theory can be utilised to highlight a new and possibly important outlook on how we can understand the heterogeneous nature of tinnitus.

DESIGN

In the current study, we use the screening databases of the Treatment Evaluation of Neuromodulation for Tinnitus-Stage A1 (TENT-A1) and A2 (TENT-A2) randomised trials to delineate the dimensional relationship between different clinical measures of tinnitus as a secondary data analysis. We first calculate the empirical relationship by computing the partial correlation. Following this, we use different measures of centrality to describe the contribution of different clinical measures to the overall network. We also calculate the stability of the network and compare the similarity and differences between TENT-A1 and TENT-A2.

RESULTS

Components of the auditory subnetwork (loudness discomfort level, sound sensitivity, average hearing loss and high frequency hearing loss) are highly inter-connected in both networks with sound sensitivity and loudness discomfort level being highly influential with high measures of centrality. Furthermore, the relationship between the densely connected auditory subnetwork with tinnitus-related distress seems to vary at different levels of distress, hearing loss, duration and age of the participants.

CONCLUSION

Our findings provide first-time evidence for tinnitus varying in a dimensional fashion illustrating the heterogeneity of this phantom percept and its ability to be perceptually integrated, yet behaviourally segregated on different symptomatic dimensions.

Cognitive Functions following Trigeminal Neuromodulation

Vast scientific effort in recent years have been focused on the search for effective and safe treatments for cognitive decline. In this regard, non-invasive neuromodulation has gained increasing attention for its reported effectiveness in promoting the recovery of multiple cognitive domains after central nervous system damage. In this short review, we discuss the available evidence supporting a possible cognitive effect of trigeminal nerve stimulation (TNS). In particular, we ask that, while TNS has been widely and successfully used in the treatment of various neuropsychiatric conditions, as far as research in the cognitive field is concerned, where does TNS stand? The trigeminal nerve is the largest cranial nerve, conveying the sensory information from the face to the trigeminal sensory nuclei, and from there to the thalamus and up to the somatosensory cortex. On these bases, a bottom-up mechanism has been proposed, positing that TNS-induced modulation of the brainstem noradrenergic system may affect the function of the brain networks involved in cognition. Nevertheless, despite the promising theories, to date, the use of TNS for cognitive empowering and/or cognitive decline treatment has several challenges ahead of it, mainly due to little uniformity of the stimulation protocols. However, as the field continues to grow, standardization of practice will allow for data comparisons across studies, leading to optimized protocols targeting specific brain circuitries, which may, in turn, influence cognition in a designed manner.

Targeting the Limbic System: Insights into Its Involvement in Tinnitus

Tinnitus is originally derived from the Latin verb tinnire, which means "to ring". Tinnitus, a complex disorder, is a result of sentient cognizance of a sound in the absence of an external auditory stimulus. It is reported in children, adults, and older populations. Patients suffering from tinnitus often present with hearing loss, anxiety, depression, and sleep disruption in addition to a hissing and ringing in the ear. Surgical interventions and many other forms of treatment have been only partially effective due to heterogeneity in tinnitus patients and a lack of understanding of the mechanisms of tinnitus. Although researchers across the globe have made significant progress in understanding the underlying mechanisms of tinnitus over the past few decades, tinnitus is still deemed to be a scientific enigma. This review summarises the role of the limbic system in tinnitus development and provides insight into the development of potential target-specific tinnitus therapies.

Evaluation and Management of Tinnitus: Are There Opportunities for Improvement?

OBJECTIVE

To review current information about diagnosis and management of tinnitus aiming to identify opportunities for achieving a cost-effective, efficient, evidence-based approach that meets the needs of tinnitus sufferers.

DATA SOURCES

PubMed/MEDLINE.

REVIEW METHODS

In total, 249 relevant published reports were reviewed. Pertinent keywords and MeSH terms identified reports via PubMed and EMBASE. Acknowledged experts were consulted on ways to improve tinnitus management.

CONCLUSIONS

There may be opportunities to improve evaluation and management of patients with tinnitus using modern modes of communication and a multidisciplinary therapeutic approach.

IMPLICATIONS FOR PRACTICE

Tinnitus can adversely affect quality of life while being time-consuming and costly to evaluate and manage. Based on both personal experience and the reports of others, patients with tinnitus who choose to see a physician primarily want to know two things: (1) that the tinnitus that is so distressing will not remain at the same level of severity forever and (2) that something can be done to help cope with the tinnitus that is so annoying. Recent advancements in internet communications, social media, information technology, artificial intelligence, machine learning, holistic medical care, mind-body integrative health care, and multidisciplinary approaches in medical therapeutics may be possibly making new ways of meeting the needs of patients with tinnitus.

Different bimodal neuromodulation settings reduce tinnitus symptoms in a large randomized trial

More than 10% of the population suffers from tinnitus, which is a phantom auditory condition that is coded within the brain. A new neuromodulation approach to treat tinnitus has emerged that combines sound with electrical stimulation of somatosensory pathways, supported by multiple animal studies demonstrating that bimodal stimulation can elicit extensive neural plasticity within the auditory brain. More recently, in a large-scale clinical trial, bimodal neuromodulation combining sound and tongue stimulation drove significant reductions in tinnitus symptom severity during the first 6 weeks of treatment, followed by diminishing improvements during the second 6 weeks of treatment. The primary objective of the large-scale randomized and double-blinded study presented in this paper was to determine if background wideband noise as used in the previous clinical trial was necessary for bimodal treatment efficacy. An additional objective was to determine if adjusting the parameter settings after 6 weeks of treatment could overcome treatment habituation effects observed in the previous study. The primary endpoint at 6-weeks involved within-arm and between-arm comparisons for two treatment arms with different bimodal neuromodulation settings based on two widely used and validated outcome instruments, Tinnitus Handicap Inventory and Tinnitus Functional Index. Both treatment arms exhibited a statistically significant reduction in tinnitus symptoms during the first 6-weeks, which was further reduced significantly during the second 6-weeks by changing the parameter settings (Cohen’s d effect size for full treatment period per arm and outcome measure ranged from − 0.7 to − 1.4). There were no significant differences between arms, in which tongue stimulation combined with only pure tones and without background wideband noise was sufficient to reduce tinnitus symptoms. These therapeutic effects were sustained up to 12 months after the treatment ended. The study included two additional exploratory arms, including one arm that presented only sound stimuli during the first 6 weeks of treatment and bimodal stimulation in the second 6 weeks of treatment. This arm revealed the criticality of combining tongue stimulation with sound for treatment efficacy. Overall, there were no treatment-related serious adverse events and a high compliance rate (83.8%) with 70.3% of participants indicating benefit. The discovery that adjusting stimulation parameters overcomes previously observed treatment habituation can be used to drive greater therapeutic effects and opens up new opportunities for optimizing stimuli and enhancing clinical outcomes for tinnitus patients with bimodal neuromodulation.

Integrative Treatment for Tinnitus Combining Repeated Facial and Auriculotemporal Nerve Blocks With Stimulation of Auditory and Non-auditory Nerves

Background

Tinnitus is a prevalent condition (>10% of the population) affecting the quality of life of 0.5–3% of the population. Although several treatments have been proposed, most of these lack evidence of efficacy in the treatment of chronic tinnitus. Thus, we aimed to evaluate an integrative treatment strategy for subacute and chronic tinnitus.

Methods

This retrospective chart review study included 55 patients with tinnitus (subacute, n = 15; chronic, n = 40) who underwent repeated nerve blocks after stimulation of the trigeminal (V) and facial (VII) nerves to modulate the auditory and non-auditory nervous systems via the vestibulocochlear (VIII) cranial nerve pathways. We used a simplified smiley tinnitus-visual analog scale (T-VAS) with scores ranging from 0 to 10 combining the effect of tinnitus loudness, distress, and quality of life as the outcome measure to evaluate the efficacy of our treatment method. Statistical analyses were performed using SPSS (version 18.0, SPSS Inc., Chicago, IL, United States), one-way and two-way analysis of variance.

Results

In more than 87.5% of patients (14/15 subacute, 35/40 chronic), tinnitus disappeared or had significantly reduced by the end of the treatment. The mean T-VAS score reduced significantly from 7.13 to 0.60 in the subacute group and from 7.73 to 1.53 in the chronic group by the end of treatment (p < 0.05). The benefits were maintained after treatment cessation and at the 1-year follow-up. The average number of treatment procedures was 9.8 ± 3.589 (range, 5–15) in the subacute group and 9.775 ± 3.717 (range, 5–18) in the chronic group.

Conclusion

Our results show that the proposed integrative approach is highly effective in treating subacute and chronic tinnitus and represents a promising therapeutic approach.

A contribution to the debate on tinnitus definition

Tinnitus is generally defined as an auditory perception in the absence of environmental sound stimulation. However, this definition is quite incomplete as it omits an essential aspect, the patient's point of view. This point of view constitutes, first and foremost, a global and unified lived experience, which is not only sensory (localization, loudness, pitch and tone), but also cognitive (thoughts, attentiveness, behaviors) and emotional (discomfort, suffering). This experience can be lived in a very unpleasant way and consequently have a very negative impact on quality of life. This article proposes and justifies a new definition for tinnitus elaborated by a group of French clinicians and researchers, which is more in line with its phenomenology. It also provides a minimum knowledge base, including possibilities for clinical care, hoping to eradicate all misinformation, misconceptions and inappropriate attitudes or practices toward this condition. Here is the short version of our definition: Tinnitus is an auditory sensation without an external sound stimulation or meaning, which can be lived as an unpleasant experience, possibly impacting quality of life.

Bimodal Auditory Electrical Stimulation for the Treatment of Tinnitus: Preclinical and Clinical Studies

Tinnitus, or the phantom perception of sound, arises from pathological neural activity. Neurophysiological research has shown increased spontaneous firing rates and synchronization along the auditory pathway correlate strongly with behavioral measures of tinnitus. Auditory neurons are plastic, enabling external stimuli to be utilized to elicit long-term changes to spontaneous firing and synchrony. Pathological plasticity can thus be reversed using bimodal auditory plus nonauditory stimulation to reduce tinnitus. This chapter discusses preclinical and clinical evidence for efficacy of bimodal stimulation treatments of tinnitus, with highlights on sham-controlled, double-blinded clinical trials. The results from these studies have shown some efficacy in reducing the severity of tinnitus, based on subjective and objective outcome measures including tinnitus questionnaires and psychophysical tinnitus measurements. While results of some studies have been positive, the degree of benefit and the populations that respond to treatment vary across the studies. Directions and implications of future studies are discussed.

Tinnitus and Brain Stimulation

The pathophysiological mechanisms that underlie the generation and maintenance of tinnitus are being unraveled progressively. Based on this knowledge, a large variety of different neuromodulatory interventions have been developed and are still being designed, adapting to the progressive mechanistic insights in the pathophysiology of tinnitus. rTMS targeting the temporal, temporoparietal, and the frontal cortex has been the mainstay of non-invasive neuromodulation. Yet, the evidence is still unclear, and therefore systematic meta-analyses are needed for drawing conclusions on the effectiveness of rTMS in chronic tinnitus. Different forms of transcranial electrical stimulation (tDCS, tACS, tRNS), applied over the frontal and temporal cortex, have been investigated in tinnitus patients, also without robust evidence for universal efficacy. Cortex and deep brain stimulation with implanted electrodes have shown benefit, yet there is insufficient data to support their routine clinical use. Recently, bimodal stimulation approaches have revealed promising results and it appears that targeting different sensory modalities in temporally combined manners may be more promising than single target approaches.While most neuromodulatory approaches seem promising, further research is required to help translating the scientific outcomes into routine clinical practice.

Bimodal neuromodulation combining sound and tongue stimulation reduces tinnitus symptoms in a large randomized clinical study

Tinnitus is a phantom auditory perception coded in the brain that can be bothersome or debilitating, affecting 10 to 15% of the population. Currently, there is no clinically recommended drug or device treatment for this major health condition. Animal research has revealed that sound paired with electrical somatosensory stimulation can drive extensive plasticity within the brain for tinnitus treatment. To investigate this bimodal neuromodulation approach in humans, we evaluated a noninvasive device that delivers sound to the ears and electrical stimulation to the tongue in a randomized, double-blinded, exploratory study that enrolled 326 adults with chronic subjective tinnitus. Participants were randomized into three parallel arms with different stimulation settings. Clinical outcomes were evaluated over a 12-week treatment period and a 12-month posttreatment phase. For the primary endpoints, participants achieved a statistically significant reduction in tinnitus symptom severity at the end of treatment based on two commonly used outcome measures, Tinnitus Handicap Inventory (Cohen’s d effect size: −0.87 to −0.92 across arms; P < 0.001) and Tinnitus Functional Index (−0.77 to −0.87; P < 0.001). Therapeutic improvements continued for 12 months after treatment for specific bimodal stimulation settings, which had not previously been demonstrated in a large cohort for a tinnitus intervention. The treatment also achieved high compliance and satisfaction rates with no treatment-related serious adverse events. These positive therapeutic and long-term results motivate further clinical trials toward establishing bimodal neuromodulation as a clinically recommended device treatment for tinnitus.

Non-Invasive Neuromodulation for Tinnitus

Tinnitus is a prevalent disorder that has no cure currently. Within the last two decades, neuroscientific research has facilitated a better understanding of the pathophysiological mechanisms that underlie the generation and maintenance of tinnitus, and the brain and nerves have been identified as potential targets for its treatment using non-invasive brain stimulation methods. This article reviews studies on tinnitus patients using transcranial magnetic stimulation, transcranial electrical stimulation, such as transcranial direct current stimulation, alternating current stimulation, transcranial random noise stimulation as well as transcutaneous vagus nerve stimulation and bimodal combined auditory and somatosensory stimulation. Although none of these approaches has demonstrated effects that would justify its use in routine treatment, the studies have provided important insights into tinnitus pathophysiology. Moreover bimodal stimulation, which has only been developed recently, has shown promising results in pilot trials and is a candidate for further development into a valuable treatment procedure.

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.