A meta-analytic review of psychological treatments for tinnitus

Evaluation of the effectiveness of cognitive behavioral therapy on tinnitus

OBJECTIVE

This research aims to examine the effects of Cognitive Behavioral Therapy (CBT) on tinnitus in individuals aged 18-60 years.

METHODS

Thirty participants with subjective tinnitus for at least six months were included a randomized controlled trial was conducted with 15 participants in the experimental group and 15 in the control group, with pre-test and post-test measurements. The experimental group received eight CBT sessions for eight weeks. Data were collected using Tinnitus Handicap Inventory (THI) and Visual Analog Scale (VAS). The Mann-Whitney and Wilcoxon Signed Rank Test were used to compare scores between experimental and control groups before and after the intervention.

RESULTS

A within-group difference was found between total scores on THI and VAS before and after CBT in the experimental (z = -3.241, P = 0.001), but not in the control group (z = -1.764, P = 0.078). Following the intervention, there was a significant between-group difference on the THI Emotional, Catastrophic, and Functional tinnitus subscale scores, favoring the experimental group.

CONCLUSIONS

CBT significantly reduced tinnitus level, severity, duration, frequency, discomfort, tinnitus-related attention deficit, and sleep problems. Further studies are needed to replicate these results in other populations.

Conceptual framework for tinnitus: a cognitive model in practice

Tinnitus is a conscious attended awareness perception of sourceless sound. Widespread theoretical and evidence-based neurofunctional and psychological models have tried to explain tinnitus-related distress considering the influence of psychological and cognitive factors. However, tinnitus models seem to be less focused on causality, thereby easily misleading interpretations. Also, they may be incapable of individualization. This study proposes a Conceptual Cognitive Framework (CCF) providing insight into cognitive mechanisms involved in the predisposition, precipitation, and perpetuation of tinnitus and consequent cognitive-emotional disturbances. The current CCF for tinnitus relies on evaluative conditional learning and appraisal, generating negative valence (emotional value) and arousal (cognitive value) to annoyance, distress, and distorted perception. The suggested methodology is well-defined, reproducible, and accessible, which can help foster future high-quality clinical databases. Perceived tinnitus through the perpetual-learning process can always lead to annoyance, but only in the clinical stage directly cause annoyance. In the clinical stage, tinnitus perception can lead indirectly to distress only with experiencing annoyance either with ("I n d - 1 C " = 1.87; 95% CI 1.18-2.72)["1st indirect path in the Clinical stage model": Tinnitus Loudness → Attention Bias → Cognitive-Emotional Value → Annoyance → Clinical Distress]or without ("I n d - 2 C "= 2.03; 95% CI 1.02-3.32)[ "2nd indirect path in the Clinical stage model": Tinnitus Loudness → Annoyance → Clinical Distress] the perpetual-learning process. Further real-life testing of the CCF is expected to express a meticulous, decision-supporting platform for cognitive rehabilitation and clinical interventions. Furthermore, the suggested methodology offers a reliable platform for CCF development in other cognitive impairments and supports the causal clinical data models. It may also enhance our knowledge of psychological disorders and complicated comorbidities by supporting the design of different rehabilitation interventions and comprehensive frameworks in line with the "preventive medicine" policy.

[Chronic tinnitus: An interplay between somatic and psychological factors]

Chronic tinnitus is a common, sometimes highly distressing phenomenon that can be triggered and maintained by an interplay of physical and psychological factors. Partnering with clinical psychology and psychosomatic medicine, modern otolaryngology integrates both medical (e.g., hearing loss) and psychological influences (e.g., interactions between biographical experiences, personality traits, subjective evaluation of intrapsychic and interpersonal stimuli, emotional states, and intrapsychic or interpersonal emotion regulation strategies). Both groups of variables can influence the intensity and course of chronic tinnitus symptomatology both directly and indirectly, whereby the quality and relative degrees of psychological and physical components in a person's self-experience can fluctuate. With this in mind, the present article distinguishes between chronic tinnitus symptomatology with or without hearing loss-and strongly advocates for an integrated understanding of the symptomatology within a holistic psychological frame of reference. After a brief introduction to the principles of psychosomatic medicine and psychotherapy, the article discusses psychological case conceptualization using a vulnerability-stress-coping (VSC) model as an example, outlines clinical aspects and diagnostics of chronic tinnitus symptomatology, and concludes with a conceptualization of chronic tinnitus-related distress as a function of person-centered VSC interactions.

Patient-Reported Functional Impairment Due to Hearing Loss and Tinnitus After Cisplatin-Based Chemotherapy

PURPOSE

Cisplatin is widely used and highly ototoxic, but patient-reported functional impairment because of cisplatin-related hearing loss (HL) and tinnitus has not been comprehensively evaluated.

PATIENTS AND METHODS

Testicular cancer survivors (TCS) given first-line cisplatin-based chemotherapy completed validated questionnaires, including the Hearing Handicap Inventory for Adults (HHIA) and Tinnitus Primary Function Questionnaire (TPFQ), each of which quantifies toxicity-specific functional impairment. Spearman correlations evaluated associations between HL and tinnitus severity and level of functional handicap quantified with the HHIA and TPFQ, respectively. Associations between HL or tinnitus and five prespecified adverse health outcomes (cognitive dysfunction, fatigue, depression, anxiety, and overall health) were evaluated.

RESULTS

HL and tinnitus affected 137 (56.4%) and 147 (60.5%) of 243 TCS, respectively. Hearing aids were used by 10% TCS (14/137). Of TCS with HL, 35.8% reported clinically significant functional impairment. Severe HHIA-assessed functional impairment was associated with cognitive dysfunction (odds ratio [OR], 10.62; P < .001), fatigue (OR, 5.48; P = .003), and worse overall health (OR, 0.19; P = .012). Significant relationships existed between HL severity and HHIA score, and tinnitus severity and TPFQ score (P < .0001 each). TCS with either greater hearing difficulty or more severe tinnitus were more likely to report cognitive dysfunction (OR, 5.52; P = .002; and OR, 2.56; P = .05), fatigue (OR, 6.18; P < .001; and OR, 4.04; P < .001), depression (OR, 3.93; P < .01; and OR, 3.83; P < .01), and lower overall health (OR, 0.39; P = .03; and OR, 0.46; P = .02, respectively).

CONCLUSION

One in three TCS with HL report clinically significant functional impairment. Follow-up of cisplatin-treated survivors should include routine assessment for HL and tinnitus. Use of the HHIA and TPFQ permit risk stratification and referral to audiologists as needed, since HL adversely affects functional status and is the single largest modifiable risk factor for cognitive decline and dementia in the general population.

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.

Sound Tolerance Conditions (Hyperacusis, Misophonia, Noise Sensitivity, and Phonophobia): Definitions and Clinical Management

Purpose: For some people, exposure to everyday sounds presents a significant problem. The purpose of this tutorial was to define and differentiate between the various sound tolerance conditions and to review some options for their clinical management.

METHOD

We informally reviewed the literature regarding sound tolerance conditions. The terminology and definitions provided are mostly consistent with how these terms are defined. However, many inconsistencies are noted. Methods of assessment and treatment also differ, and different methodologies are briefly described.

RESULTS

Hyperacusis describes physical discomfort or pain when any sound reaches a certain level of loudness that would be tolerable for most people. Misophonia refers to intense emotional reactions to certain sounds (often body sounds such as chewing and sniffing) that are not influenced by the perceived loudness of those sounds. Noise sensitivity refers to increased reactivity to sounds that may include general discomfort (annoyance or feeling overwhelmed) due to a perceived noisy environment, regardless of its loudness. Phonophobia, as addressed in the audiology profession, describes anticipatory fear of sound. Phonophobia is an emotional response such as anxiety and avoidance of sound due to the "fear" that sound(s) may occur that will cause a comorbid condition to get worse (e.g., tinnitus) or the sound itself will result in discomfort or pain. (Note that phonophobia is a term used by neurologists to describe "migraineur phonophobia"-a different condition not addressed herein.) Conclusions: The literature addresses sound tolerance conditions but reveals many inconsistencies, indicating lack of consensus in the field. When doing an assessment for decreased sound tolerance, it is important to define any terms used so that the patient and all health care professionals involved in the care of the patient are aligned with the goals of the treatment plan. Treatment generally involves gradual and systematic sound desensitization and counseling.

SUPPLEMENTAL MATERIAL

https://doi.org/10.23641/asha.20164130.

Prediction of treatment outcome in patients suffering from chronic tinnitus - from individual characteristics to early and long-term change

BACKGROUND AND OBJECTIVE

Despite the availability of successful treatment approaches for chronic tinnitus, it has proven difficult to predict who profits from treatment and it is still an open question if it is possible at all. We tried to overcome methodological shortcomings and to predict treatment outcome indicated by questionnaires measuring tinnitus distress.

METHODS

This is an observational, prospective cohort study. Lasso and post-selection inference methods were used to predict treatment outcome in patients suffering from chronic tinnitus (N = 747). Patients were treated for five consecutive days in an interdisciplinary setting according to guidelines.

RESULTS

Early change, i.e. a positive response after the screening day, as well as change due to treatment was predicted by several psychopathological variables, but also tinnitus-related factors. Female gender as an example was a predictor for change due to treatment. In general, therapy success both for early change and change due to treatment cannot be predicted satisfactorily as indicated by a high mean cross-validation error (for early change: 9.83, for change due to treatment: 14.40). Analyzing sub-groups separated by tinnitus severity to reduce heterogeneity did not improve the situation and for patients with high tinnitus severity no predictors at all could be reported (cross-validated error: 11.62 for the low quartile, 13.38 for the low-medium quartile, and 15.61 for the medium-high quartile).

CONCLUSION

Several psychopathological and tinnitus-related variables predicted early and long-term change. Nevertheless, also overcoming methodological shortcomings to predict treatment success did not lead to satisfactory results, but rather emphasizes the high heterogeneity of chronic tinnitus.

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.

Cognitive Behavioral Therapy for Tinnitus: Addressing the Controversy of Its Clinical Delivery by Audiologists

Audiologists' role in providing care for tinnitus typically includes conducting an audiologic evaluation, fitting hearing aids when appropriate, assessing the impact of tinnitus, and facilitating use of sound to improve quality of life with tinnitus when appropriate. Cognitive behavioral therapy (CBT) is consistently judged by systematic reviews as having the strongest evidence relative to other therapies for improving quality of life with tinnitus. Because audiologists are already playing an active role in providing care for tinnitus, and the relative paucity of behavioral health providers who are experienced in implementing CBT for tinnitus, a logical question is whether audiologists can provide CBT and whether it is within their scope of practice. In this article, we present both sides of the argument as to whether audiologists can provide CBT and we make recommendations for appropriate administration of CBT for tinnitus management.

Development and Preliminary Evaluation of the Tinnitus Severity Short Form

Purpose Tinnitus, or the perception of sounds that occur without an external sound source, is a prevalent condition worldwide. For a subset of adults, tinnitus causes significant distress and impairment. Several patient-reported outcome measures have been developed to assess severity of tinnitus distress. However, at present, the field lacks a brief measure that is sensitive to treatment change. The purpose of the current study was to develop and preliminarily validate a brief questionnaire for tinnitus severity from two existing measures of tinnitus-related distress, the Tinnitus Handicap Inventory (THI) and Tinnitus Functional Index (TFI). Method Using data from nine study samples in the United States and United Kingdom, we conducted exploratory and confirmatory factor analyses to identify a short measure with good psychometric properties. We also assessed sensitivity to treatment-related change by examining associations with change in the TFI and THI. Finally, we conducted a confirmatory factor analysis of the final short questionnaire in a new sample of adults seeking treatment for tinnitus-related distress. Results We identified 10 items from the THI and TFI that exhibited limited loadings on secondary factors. The resulting Tinnitus Severity Short Form achieved good to excellent fit, including in a unique sample of individuals seeking online treatment for tinnitus, and appeared sensitive to treatment-related change. Conclusions The Tinnitus Severity Short Form developed in the current study may be a useful tool for the assessment of subjective severity and distress associated with tinnitus, especially when patient burden is a concern. Further research is necessary to fully validate the questionnaire for the assessment of treatment-related change.

Evaluation of Spin in the Abstracts of Systematic Reviews and Meta-Analyses Focused on Tinnitus

HYPOTHESIS

The objective was to investigate the prevalence of spin in abstracts of systematic reviews and meta-analyses covering the treatment of tinnitus. We hypothesized that spin would be present in these articles and a significant relationship would exist between spin usage and extracted study characteristics.

BACKGROUND

Spin, the misrepresentation of study findings, can alter a clinician's interpretation of a study's results, potentially affecting patient care. Previous work demonstrates that spin is present in abstracts of randomized clinical trials.

METHODS

Using a cross-sectional analysis, we conducted a systematic search using MEDLINE and Embase databases on June 2, 2020, for systematic reviews focused on tinnitus treatment. Investigators performed screening and data extraction in a masked, duplicate fashion.

RESULTS

Forty systematic reviews met inclusion criteria, and spin was identified in four of them. Spin in abstracts most frequently occurred when conclusions claimed the beneficial effect of the experimental treatment despite high risk of bias in primary studies (n = 3). The other form of spin found was the conclusion claims safety based on nonstatistically significant results with a wide confidence interval (n = 1). There was no significant association between spin and any of our extracted study characteristics.

CONCLUSION

Spin was observed in 10% of abstracts of systematic reviews and meta-analyses covering the treatment of tinnitus. Although this percentage may be small, we recommend that medical journals provide a more detailed framework for abstract structure and require the inclusion of risk of bias assessment results in abstracts to prevent the incorporation of spin.

Two birds with one stone.-Addressing depressive symptoms, emotional tension and worry improves tinnitus-related distress and affective pain perceptions in patients with chronic tinnitus

BACKGROUND

Psychological factors link the co-occurrence of tinnitus-related distress and pain perceptions in patients with chronic tinnitus.

OBJECTIVE

This study examines, if treatment-related changes in these factors ameliorate both tinnitus-related distress and pain perceptions in a sample of patients with chronic tinnitus.

METHODS

N = 1238 patients with chronic tinnitus provided pre- and post-treatment ratings of tinnitus-related distress and affective or sensory pain perceptions alongside measures of depressive symptoms and perceived stress. Treatment comprised an intensive tinnitus-specific multimodal treatment program. Using serial indirect-effects analyses, we examined association patterns between baseline values and change rates of those variables that were found to respond to treatment.

RESULTS

Small effect sizes emerged for changes in tinnitus-related distress, affective (but not sensory) pain perceptions, depressive symptoms, emotional tension and worry. At pre- or post-treatment respectively, baseline values and change rates intercorrelated. Across timepoints, (1) baseline tinnitus-related distress and affective pain perceptions were positively associated with improvements in tinnitus-related distress, affective pain perceptions and depressive symptoms. (2) Baseline depressive symptoms or emotional tension mediated positive associations between baseline tinnitus-related distress and improvement in affective pain perceptions. (3) Change in depressive symptoms mediated the effect of baseline tinnitus-related distress on change in affective pain perceptions-partly through associated change in emotional tension or worry. Mood-independent aspects of emotional tension were negatively associated with improvement in affective pain perceptions.

CONCLUSIONS

Depressive symptoms, emotional tension and worry emerge as key predictors of treatment response and transdiagnostic treatment targets for alleviating tinnitus-related distress and functionally associated affective pain perceptions.

Gender-Specific Differences in Patients With Chronic Tinnitus-Baseline Characteristics and Treatment Effects

Whilst some studies have identified gender-specific differences, there is no consensus about gender-specific determinants for prevalence rates or concomitant symptoms of chronic tinnitus such as depression or anxiety. However, gender-associated differences in psychological response profiles and coping strategies may differentially affect tinnitus chronification and treatment success rates. Thus, understanding gender-associated differences may facilitate a more detailed identification of symptom profiles, heighten treatment response rates, and help to create access for vulnerable populations that are potentially less visible in clinical settings. Our research questions are: RQ1: how do male and female tinnitus patients differ regarding tinnitus-related distress, depression severity, and treatment response, RQ2: to what extent are answers to questionnaires administered at baseline associated with gender, and RQ3: which baseline questionnaire items are associated with tinnitus distress, depression, and treatment response, while relating to one gender only? In this work, we present a data analysis workflow to investigate gender-specific differences in N = 1,628 patients with chronic tinnitus (828 female, 800 male) who completed a 7-day multimodal treatment encompassing cognitive behavioral therapy (CBT), physiotherapy, auditory attention training, and information counseling components. For this purpose, we extracted 181 variables from 7 self-report questionnaires on socio-demographics, tinnitus-related distress, tinnitus frequency, loudness, localization, and quality as well as physical and mental health status. Our workflow comprises (i) training machine learning models, (ii) a comprehensive evaluation including hyperparameter optimization, and (iii) post-learning steps to identify predictive variables. We found that female patients reported higher levels of tinnitus-related distress, depression and response to treatment (RQ1). Female patients indicated higher levels of tension, stress, and psychological coping strategies rates. By contrast, male patients reported higher levels of bodily pain associated with chronic tinnitus whilst judging their overall health as better (RQ2). Variables measuring depression, sleep problems, tinnitus frequency, and loudness were associated with tinnitus-related distress in both genders and indicators of mental health and subjective stress were found to be associated with depression in both genders (RQ3). Our results suggest that gender-associated differences in symptomatology and treatment response profiles suggest clinical and conceptual needs for differential diagnostics, case conceptualization and treatment pathways.

Low-Frequency Repetitive Transcranial Magnetic Stimulation for the Treatment of Chronic Tinnitus: A Systematic Review and Meta-Analysis of Randomized Controlled Trials

Background

Chronic tinnitus affects approximately 10-15% of the population. Low-frequency repetitive transcranial magnetic stimulation (rTMS) has been considered as a promising and well-tolerated therapeutic strategy for chronic tinnitus. However, a recent large-scale multicenter clinical trial showed a negative result.

Objective

This systematic review is aimed at assessing the efficacy and safety of low-frequency rTMS in chronic tinnitus.

Methods

We searched PubMed, Embase, and Cochrane Library for randomized controlled studies of rTMS treatment of chronic tinnitus. A pooled analysis of standardized mean difference (SMD) was performed with 95% confidence intervals (CI).

Results

Ten RCTs involving 567 participants were included in this review. Compared with sham stimulation, rTMS showed no significant efficacy in tinnitus severity and disability measured by Tinnitus Handicap Inventory (THI) in short-term (SMD = −0.04, 95% CI -0.23 to 0.16, P = 0.72), medium-term (SMD = −0.13, 95% CI -0.43 to 0.17, P = 0.41), and long-term (SMD = −0.16, 95% CI -0.38 to 0.05, P = 0.14) follow-up. Tinnitus severity and disability measured by Tinnitus Questionnaire (TQ) also showed no significant improvement in short-term (SMD = −0.11, 95% CI -0.31 to 0.10, P = 0.30), medium-term (SMD = −0.10, 95% CI -0.37 to 0.16, P = 0.44), and long-term (SMD = −0.20, 95% CI -0.40 to 0.01, P = 0.06) follow-up. Additionally, no statistically significant difference was shown in the changes of tinnitus loudness assessed by a visual analogue scale (VAS) between rTMS and sham groups in the short-term (SMD = −0.28, 95% CI -0.59 to 0.02, P = 0.07), medium-term (SMD = −0.26, 95% CI -0.59 to 0.07, P = 0.13), and long-term (SMD = −0.20, 95% CI -0.53 to 0.13, P = 0.24) follow-up. Few mild or moderate adverse events were observed in both the rTMS and sham groups.

Conclusion

Low-frequency rTMS is well tolerated but not effective in treating chronic tinnitus based on the current analysis of pooled data. Further studies with modified and uniform protocols are required to investigate the potential benefit of rTMS in chronic tinnitus.

Current Validated Medical Treatments for Tinnitus: Cognitive Behavioral Therapy

Tinnitus distress results from a weave of physical and psychological processes. Reducing the power of the psychological processes will therefore reduce the degree of suffering. The main psychological therapy in this context is cognitive behavioral therapy (CBT). This seeks to understand and change the influence of thinking processes, including information processing biases, and the behaviors that these motivate, on the experience of tinnitus. The results of systematic reviews and meta-analyses indicate that CBT is the tinnitus management approach for which there is the most robust evidence. In spite of this, it remains difficult to access for people with tinnitus.

Efficacy of an Integrative Treatment for Tinnitus Combining Music and Cognitive-Behavioral Therapy-Assessed With Behavioral and EEG Data

Chronic tinnitus is a prevalent condition that could cause severe negative impact on an individual's life. However, there has not been an established treatment due to a limited understanding of the pathophysiology of this multifarious disorder. In this study, we tested the efficacy of an integrative treatment, combining music therapy with cognitive-behavioral therapy (CBT). We collected three groups of patients receiving three different treatments: Music-CBT, music therapy and CBT. We used both subjective (i.e., questionnaires) and objective (i.e., resting-state EEG data) measurements to assess the behavioral and neural changes brought upon by the treatments. Analyses of the subjective measurements found a significant improvement of scale scores in Music-CBT and CBT, but not in the Music group. Analysis of the EEG data further showed increased powers in alpha and theta band after the Music-CBT treatment, and increased gamma power after CBT, whereas no significant difference was found for the music therapy. Further source localization analysis of alpha and theta changes in the Music-CBT group found that primary sources of the changes were located at auditory processing regions such as superior temporal gyrus, and higher emotional and cognitive processing regions such as ventromedial prefrontal cortex (vMPFC), lateral prefrontal cortex and parahippocampus. These results indicated that Music-CBT was effective in improving tinnitus symptoms on both a behavioral and neural level, which is more robust than the music therapy or CBT alone.

Tinnitus-related distress after multimodal treatment can be characterized using a key subset of baseline variables

BACKGROUND

Chronic tinnitus is a complex condition that can be associated with considerable distress. Whilst cognitive-behavioral treatment (CBT) approaches have been shown to be effective, not all patients benefit from psychological or psychologically anchored multimodal therapies. Determinants of tinnitus-related distress thus provide valuable information about tinnitus characterization and therapy planning.

OBJECTIVE

The study aimed to develop machine learning models that use variables (or "features") obtained before treatment to characterize patients' tinnitus-related distress status after treatment. Whilst initially all available variables were considered for model training, the final model was required to achieve highest predictive performance using only a small number of features.

METHODS

1,416 tinnitus patients (decompensated tinnitus: 32%) who completed a 7-day multimodal treatment encompassing tinnitus-specific components, CBT, physiotherapy and informational counseling were included in the analysis. At baseline, patients were assessed using 205 features from 10 questionnaires comprising sociodemographic and clinical information. A data-driven workflow was developed consisting of (a) an initial exploratory correlation analysis, (b) supervised machine learning to predict tinnitus-related distress after treatment (T1) using baseline data only (T0), and (c) post-hoc analysis of the best model to facilitate model inspection and understanding. Classification methods were embedded in a feature elimination wrapper that iteratively learned on features found to be important for the model in the preceding iteration, in order to keep the performance stable while successively reducing the model complexity. 10-fold cross-validation with area under the curve (AUC) as performance measure was implemented for model generalization error estimation.

RESULTS

The best machine learning classifier (gradient boosted trees) can predict tinnitus-related distress in T1 with AUC = 0.890 using 26 features. Subjectively perceived tinnitus-related impairment, depressivity, sleep problems, physical health-related impairments in quality of life, time spent to complete questionnaires and educational level exhibited a high attribution towards model prediction.

CONCLUSIONS

Machine learning can reliably identify baseline features recorded prior to treatment commencement that characterize tinnitus-related distress after treatment. The identification of key features can contribute to an improved understanding of multifactorial contributors to tinnitus-related distress and thereon based multimodal treatment strategies.

Cognitive behavioural therapy for tinnitus

BACKGROUND

Tinnitus affects up to 21% of the adult population with an estimated 1% to 3% experiencing severe problems. Cognitive behavioural therapy (CBT) is a collection of psychological treatments based on the cognitive and behavioural traditions in psychology and often used to treat people suffering from tinnitus.

OBJECTIVES

To assess the effects and safety of CBT for tinnitus in adults.

SEARCH METHODS

The Cochrane ENT Information Specialist searched the ENT Trials Register; CENTRAL (2019, Issue 11); Ovid MEDLINE; Ovid Embase; CINAHL; Web of Science; ClinicalTrials.gov; ICTRP and additional sources for published and unpublished trials. The date of the search was 25 November 2019.

SELECTION CRITERIA

Randomised controlled trials (RCTs) of CBT versus no intervention, audiological care, tinnitus retraining therapy or any other active treatment in adult participants with tinnitus.

DATA COLLECTION AND ANALYSIS

We used the standard methodological procedures expected by Cochrane. Our primary outcomes were the impact of tinnitus on disease-specific quality of life and serious adverse effects. Our secondary outcomes were: depression, anxiety, general health-related quality of life, negatively biased interpretations of tinnitus and other adverse effects. We used GRADE to assess the certainty of evidence for each outcome.

MAIN RESULTS

We included 28 studies (mostly from Europe) with a total of 2733 participants. All participants had had tinnitus for at least three months and their average age ranged from 43 to 70 years. The duration of the CBT ranged from 3 to 22 weeks and it was mostly conducted in hospitals or online. There were four comparisons and we were interested in outcomes at end of treatment, and 6 and 12 months follow-up. The results below only refer to outcomes at end of treatment due to an absence of evidence at the other follow-up time points. CBT versus no intervention/wait list control Fourteen studies compared CBT with no intervention/wait list control. For the primary outcome, CBT may reduce the impact of tinnitus on quality of life at treatment end (standardised mean difference (SMD) -0.56, 95% confidence interval (CI) -0.83 to -0.30; 10 studies; 537 participants; low certainty). Re-expressed as a score on the Tinnitus Handicap Inventory (THI; range 0 to 100) this is equivalent to a score 10.91 points lower in the CBT group, with an estimated minimal clinically important difference (MCID) for this scale being 7 points. Seven studies, rated as moderate certainty, either reported or informed us via personal communication about serious adverse effects. CBT probably results in little or no difference in adverse effects: six studies reported none and in one study one participant in the CBT condition worsened (risk ratio (RR) 3.00, 95% CI 0.13 to 69.87). For the secondary outcomes, CBT may result in a slight reduction in depression (SMD -0.34, 95% CI-0.60 to -0.08; 8 studies; 502 participants; low certainty). However, we are uncertain whether CBT reduces anxiety, improves health-related quality of life or reduces negatively biased interpretations of tinnitus (all very low certainty). From seven studies, no other adverse effects were reported (moderate certainty). CBT versus audiological care Three studies compared CBT with audiological care. CBT probably reduces the impact of tinnitus on quality of life when compared with audiological care as measured by the THI (range 0 to 100; mean difference (MD) -5.65, 95% CI -9.79 to -1.50; 3 studies; 444 participants) (moderate certainty; MCID = 7 points). No serious adverse effects occurred in the two included studies reporting these, thus risk ratios were not calculated (moderate certainty). The evidence suggests that CBT may slightly reduce depression but may result in little or no difference in anxiety or health-related quality of life (all low certainty) when compared with audiological care. CBT may reduce negatively biased interpretations of tinnitus when compared with audiological care (low certainty). No other adverse effects were reported for either group (moderate certainty). CBT versus tinnitus retraining therapy (TRT) One study compared CBT with TRT (including bilateral sound generators as per TRT protocol). CBT may reduce the impact of tinnitus on quality of life as measured by the THI when compared with TRT (range 0 to 100) (MD -15.79, 95% CI -27.91 to -3.67; 1 study; 42 participants; low certainty). For serious adverse effects three participants deteriorated during the study: one in the CBT (n = 22) and two in the TRT group (n = 20) (RR 0.45, 95% CI 0.04 to 4.64; low certainty). We are uncertain whether CBT reduces depression and anxiety or improves health-related quality of life (low certainty). CBT may reduce negatively biased interpretations of tinnitus. No data were available for other adverse effects. CBT versus other active control Sixteen studies compared CBT with another active control (e.g. relaxation, information, Internet-based discussion forums). CBT may reduce the impact of tinnitus on quality of life when compared with other active treatments (SMD -0.30, 95% CI -0.55 to -0.05; 12 studies; 966 participants; low certainty). Re-expressed as a THI score this is equivalent to 5.84 points lower in the CBT group than the other active control group (MCID = 7 points). One study reported that three participants deteriorated: one in the CBT and two in the information only group (RR 1.70, 95% CI 0.16 to 18.36; low certainty). CBT may reduce depression and anxiety (both low certainty). We are uncertain whether CBT improves health-related quality of life compared with other control. CBT probably reduces negatively biased interpretations of tinnitus compared with other treatments. No data were available for other adverse effects.

AUTHORS' CONCLUSIONS

CBT may be effective in reducing the negative impact that tinnitus can have on quality of life. There is, however, an absence of evidence at 6 or 12 months follow-up. There is also some evidence that adverse effects may be rare in adults with tinnitus receiving CBT, but this could be further investigated. CBT for tinnitus may have small additional benefit in reducing symptoms of depression although uncertainty remains due to concerns about the quality of the evidence. Overall, there is limited evidence for CBT for tinnitus improving anxiety, health-related quality of life or negatively biased interpretations of tinnitus.

Effectiveness of Guided Internet-Based Cognitive Behavioral Therapy vs Face-to-Face Clinical Care for Treatment of Tinnitus: A Randomized Clinical Trial

Importance

Accessible clinical care is not always available to individuals with distressing tinnitus. Internet-based cognitive behavioral therapy has the potential to increase access to evidence-based services that manage tinnitus. Research comparing the effectiveness of this internet-based intervention with face-to-face care is required.

Objective

To evaluate whether an internet-based cognitive behavioral therapy intervention is at least as effective as established individualized face-to-face clinical care in reducing tinnitus distress and tinnitus-related difficulties.

Design, Setting, and Participants

A randomized, multicenter, 2-arm parallel group, noninferiority trial with 2-month follow-up was performed between October 4, 2016, and July 14, 2017. Invited to participate were 374 adults based in the United Kingdom who had been referred to their local tinnitus clinics because of bothersome tinnitus. The experimental group received the internet-based intervention online, and the active control group underwent the usual face-to-face tinnitus care at 1 of 3 UK-based National Health Service hospitals. Participants were randomly assigned (1:1) to either intervention using variable permuted block sizes of 4 and 6. Of 92 participants who were randomized (46 each in the experimental and control groups), 88 participants completed the assessment immediately after intervention and 74 participants completed the follow-up assessment.

Interventions

Participants were randomized to receive either 8 weeks of guided internet-based cognitive behavioral therapy or a mean of 2 to 3 individualized face-to-face appointments in a tinnitus clinic.

Main Outcomes and Measures

The primary outcome was a change in tinnitus distress (assessed by the Tinnitus Functional Index). Secondary assessment measures were included for insomnia, anxiety, depression, hearing disability, hyperacusis, cognitive failures, and satisfaction with life.

Results

Of 92 patients overall, 55 (60%) were men with a mean (SD) age of 52.96 (12.07) years and mean (SD) tinnitus duration of 6.54 (9.25) years. The between-group difference in the Tinnitus Functional Index scores after intervention were 5.18 (95% CI, -4.17 to 14.53) at the initial assessment and 5.52 (95% CI, -4.60 to 15.61) at follow-up; both differences were within the noninferiority margin of 13 points for the lower 95% CI. For the secondary outcomes, only outcomes for insomnia fell outside the noninferiority margin, both after intervention and at follow-up, favoring internet-based cognitive behavioral therapy.

Conclusions and Relevance

This is the first trial, to our knowledge, to compare an internet-based intervention with standard individualized face-to-face care for tinnitus. It revealed that both interventions are equally effective for reducing tinnitus distress and most tinnitus-related difficulties.

Trial Registration

ClinicalTrials.gov identifier: NCT02665975.

Bothersome tinnitus : Cognitive behavioral perspectives

Tinnitus is not traceable to a single disease or pathology, but merely a symptom, which is distressing to some but not all individuals able to perceive it. The experience of tinnitus does not equate to tinnitus distress. Tinnitus suffering might be understood as a function of tinnitus-related distress in that bothersome tinnitus is an illness rather than a disease. In bothersome (distressing) tinnitus, the perception of the characteristic sound is a very disturbing and bothersome experience because of maladaptive psychological responses. Several cognitive and behavioral theoretical frameworks attempting to explain the nature and cause of tinnitus suffering have been introduced in and will be summarized here. Current treatment approaches are generally based on models that aim to: alleviate the perceptional experience by focusing on the tinnitus perception for habituation or even soothing purposes; decrease awareness of the sound by attentional training and cognitive interventions; decrease the maladaptive responses and the resulting distress by behavioral methods (i. e., exposure). The cognitive behavioral fear-avoidance model may offer an integrative cognitive behavioral approach that can lead to a new set of paradigms for studying the underlying mechanisms explaining chronic tinnitus suffering as well for developing innovative strategies to treat bothersome tinnitus.

Mindfulness-Based Cognitive Therapy for Chronic Tinnitus: Evaluation of Benefits in a Large Sample of Patients Attending a Tinnitus Clinic

OBJECTIVES

Mindfulness-based approaches may benefit patients with chronic tinnitus, but most evidence is from small studies of nonstandardized interventions, and there is little exploration of the processes of change. This study describes the impact of mindfulness-based cognitive therapy (MBCT) in a "real world" tinnitus clinic, using standardized MBCT on the largest sample of patients with chronic tinnitus to date while exploring predictors of change.

DESIGN

Participants were 182 adults with chronic and distressing tinnitus who completed an 8-week MBCT group. Measures of tinnitus-related distress, psychological distress, tinnitus acceptance, and mindfulness were taken preintervention, postintervention, and at 6-week follow-up.

RESULTS

MBCT was associated with significant improvements on all outcome measures. Postintervention, reliable improvements were detected in tinnitus-related distress in 50% and in psychological distress in 41.2% of patients. Changes in mindfulness and tinnitus acceptance explained unique variance in tinnitus-related and psychological distress postintervention.

CONCLUSIONS

MBCT was associated with significant and reliable improvements in patients with chronic, distressing tinnitus. Changes were associated with increases in tinnitus acceptance and dispositional mindfulness. This study doubles the combined sample size of all previously published studies. Randomized controlled trials of standardized MBCT protocols are now required to test whether MBCT might offer a new and effective treatment for chronic tinnitus.

Is there any effect of anxiety and depression scores on the improvement of tinnitus after surgery in chronic otitis patients with tinnitus

BACKGROUND

Tinnitus is a common disease in public. It is not only associated with neuronal, muscular, vascular pathologies, but also with related psychological parameters. In this study, we aimed to investigate the relationship between tinnitus, anxiety and depression in patients undergoing tympanoplasty.

METHODS

Patients with tinnitus and operated for chronic otitis media were included in our study. Before and after the operation, tinnitus handicap inventory, beck anxiety and depression scales were filled and pre- and postoperative values were compared. In addition, our patients were divided into two groups as tinnitus improve and did not improve and differences between them were investigated.

RESULTS

148 patients were included in our study. Of 148 patients, 60 were male and 88 were female. There was no significant difference between the patients with and without tinnitus when the dermografic features, hearing levels and physical examination findings were compared. After the operation, the patients who did not improve tinnitus had higher levels of depression and depression than others (<0.001).

CONCLUSION

As a result of our study, anxiety and depression scales of the patients whose tinnitus did not improve were found to be higher than the patients whose tinnitus improved.

Tinnitus

Objective and subjective tinnitus can often be differentiated based on comprehensive history, physical examination, and audiogram. Examples of objective tinnitus include vascular abnormalities, palatal myoclonus, patulous eustachian tube, and stapedial/tensor tympani muscle spasm. Subjective tinnitus is usually associated with hearing loss. Rarely, tinnitus is the result of an underlying condition. In these cases, imaging and additional testing may be indicated. Classification of the type, quality, and intensity of tinnitus is helpful in the work-up and treatment of tinnitus. Treatment modalities include cognitive behavioral therapy, tinnitus retraining therapy, sound therapy, hearing aids, cochlear implants, pharmacotherapy, and brain stimulation.

Tinnitus: The Sound of Stress?

Background:

Emotional stress is frequently associated with otologic symptoms as tinnitus and dizziness. Stress can contribute to the beginning or worsening of tinnitus.

Objective:

The objective of the study is to evaluate the presence of stress symptoms in patients with chronic, subjective tinnitus, and correlate its presence to annoyance associated with tinnitus.

Methods:

This is a cross-sectional study. One hundred and eighty patients with chronic, subjective tinnitus were included. Patients answered the Tinnitus Handicap Inventory (THI) to evaluate the impact of tinnitus in the quality of life and answered the Lipp's inventory symptoms of stress for adults (ISSL). The data obtained was organized using Excel® 2010, mean values, linear regression and p-value were calculated.

Results:

Of the 180 patients included in the study, 117 (65%) had stress symptoms, 52 of the 117 (44%) were in the resistance phase and 23 of the 117 (20%) in the exhaustion phase, the remaining was in the alert phase. There was a clear progressive increase in stress as THI raised, with more impact of tinnitus in quality of life.

Conclusion:

The presence of stress symptoms, measured by ISSL was observed in most of our patients with chronic subjective tinnitus, specially in the resistance and exhaustion phases and it is directly associated with tinnitus annoyance.

Coping with tinnitus

This narrative article on coping with tinnitus has four primary objectives. First, theoretical perspectives about defining and categorizing coping are discussed. Second, an overview of the empirical research on coping with tinnitus is provided, focusing on how coping with tinnitus has been measured and on the trends that were found in research on coping with tinnitus. Third, the problems related to the current state of research on coping with tinnitus are highlighted. Fourth, suggestions are provided on ways that researchers can improve research on coping with tinnitus.

Results of an Interdisciplinary Day Care Approach for Chronic Tinnitus Treatment: A Prospective Study Introducing the Jena Interdisciplinary Treatment for Tinnitus

Objective: Considering the heterogeneity of the symptoms shown by patients suffering from chronic tinnitus, there are surprisingly few interdisciplinary treatments available, and mostly available only for inpatients. In order to provide an interdisciplinary treatment, we developed a day care concept in which each patient was treated by an ENT doctor, a cognitive behavioral therapist, a specialist for medical rehabilitation and an audiologist (Jena Interdisciplinary Treatment for Tinnitus, JITT). The aim of this study was to observe the changes of tinnitus related distress due to interdisciplinary day care treatment and to determine which factors mediate this change.

Subjects and Methods: Tinnitus annoyance was measured using the Tinnitus Questionnaire on 308 patients with chronic tinnitus. They were treated in the day care unit over five consecutive days between July 2013 and December 2014. Data were collected before treatment when screened (T0), at the beginning (T1) and at the end of the 5 day treatment (T2), as well as 20 days (T3) and 6 months after treatment (T4).

Results: Overall, tinnitus annoyance improved significantly from the screening day to the beginning of treatment, and to a much larger degree from the beginning to the end of treatment. The treatment outcome remained stable 6 months after treatment. Patients with the following symptoms displayed higher tinnitus annoyance at T0: dizziness at tinnitus onset, tinnitus sound could not be masked with background noise, tinnitus worsening during physical stress, comorbid psychiatric diagnosis, higher age and higher hearing loss. Loudness of tinnitus perceived in the right ear correlated with tinnitus annoyance significantly. Demographic, tinnitus and strain variables could only explain 12.8% of the variance of the change in tinnitus annoyance from T0 to T4. Out of 39 predictors, the only significant ones were “sick leave 6 months before treatment” and “tinnitus annoyance at T0.”

Conclusion: The newly developed JITT represents a valuable treatment for chronic tinnitus patients with improvement remaining stable for at least 6 months after treatment. Using a large number of variables did not allow predicting treatment outcome which underlines the heterogeneity of tinnitus.

Treatment of tinnitus

PURPOSE OF REVIEW

Tinnitus, the perception of sound in the absence of a corresponding external acoustic stimulus, is a highly prevalent and frequently severely impairing disorder with worldwide impact. In this article after a short overview about epidemiology and pathophysiology the currently available treatment options will be discussed with specific consideration of the available evidence, their mechanisms of action and their limitations.

RECENT FINDINGS

During the last decades, advances in neuroimaging methods and the development of animal models have contributed to an increasing understanding of the neuronal correlates of tinnitus and have motivated the development of innovative brain-based treatment approaches for directly targeting the neuronal correlates of tinnitus. A further important development has been the insight that there exist different forms of tinnitus that differ in their pathophysiology and their response to specific treatments.

SUMMARY

Treatment of tinnitus should be based on a comprehensive diagnosis of etiologic and concomitant aspects of an individual's tinnitus. Already today a large variety of therapeutic interventions are available, which can efficiently reduce tinnitus severity. Several innovative treatment approaches are currently under development.

The changeability and predictive value of dysfunctional cognitions in cognitive behavior therapy for chronic tinnitus

BACKGROUND

Multidimensional tinnitus models describe dysfunctional cognitions as a complicating factor in the process of tinnitus habituation. However, this concept has rarely been investigated in previous research.

PURPOSE

The present study investigated the effects of two cognitive-behavioral treatments on dysfunctional tinnitus-related cognitions in patients with chronic tinnitus. Furthermore, dysfunctional cognitions were examined as possible predictors of the therapeutic effect on tinnitus distress.

METHOD

A total of 128 patients with chronic tinnitus were randomly assigned to either an Internet-delivered guided self-help treatment (Internet-based cognitive-behavioral therapy, ICBT), a conventional face-to-face group therapy (cognitive-behavioral group therapy, GCBT), or an active control group in the form of a web-based discussion forum (DF). To assess tinnitus-related dysfunctional thoughts, the Tinnitus Cognitions Scale (T-Cog) was used at pre- and post-assessment, as well as at the 6- and 12-month follow-up.

RESULTS

Multivariate ANOVAs with post hoc tests revealed significant and comparable reductions of dysfunctional tinnitus-related cognitions for both treatments (GCBT and ICBT), which remained stable over a 6- and 12-month period. Negative correlations were found between the catastrophic subscale of the T-Cog and therapy outcome for ICBT, but not for GCBT. This means a higher degree of catastrophic thinking at baseline was associated with lower benefit from ICBT directly after the treatment. Hierarchical regression analysis confirmed catastrophizing as a predictor of poorer therapy outcome regarding emotional tinnitus distress in ICBT. No associations were detected in the follow-up assessments.

CONCLUSION

Both forms of CBT are successful in reducing dysfunctional tinnitus-related cognitions. Catastrophizing significantly predicted a less favorable outcome regarding emotional tinnitus distress in ICBT. Clinical implications of these results are described. Dysfunctional cognitions could be targeted more intensively in therapy and in future research on tinnitus.

Tinnitus and anxiety disorders: A review

BACKGROUND

The most common form of tinnitus is a subjective, auditory, and distressing phantom phenomenon. Comorbidity with depression is high but other important psychiatric disorders such as anxiety disorders have received less attention. The current paper reviews the literature on the associations between tinnitus and anxiety disorders and the underlying pathophysiology, and discusses the clinical implications.

METHODOLOGY

PubMed and Web of Science were searched for all articles published up until October 2014 using combinations of the following search strings "Tinnitus", "Anxiety disorder", "Panic Disorder", "Generalized Anxiety Disorder", "Post traumatic stress disorder", "PTSD" "Social Phobia", "Phobia Disorder", "Obsessive Compulsive Disorder", "Agoraphobia".

RESULTS

A total of 117 relevant papers were included. A 45% lifetime prevalence of anxiety disorders is reported in tinnitus populations, while an important overlap in associated (sub)cortical brain areas and cortico-subcortical networks involved in attention, distress, and memory functions is suggested. A disturbed hypothalamic-pituitary-adrenal axis function can be found in tinnitus and in anxiety disorders but, in comorbidity, the direction of the dysfunction is unclear.

CONCLUSION

Comorbidity is high and screening for and treatment of anxiety disorders is recommended in moderate to severe tinnitus, as, given the overlap in the structural and functional brain circuitries involved, theoretically, their management could improve (subjective) levels of tinnitus although further empirical research on this topic is required.

[On the interdisciplinary S3 guidelines for the treatment of chronic idiopathic tinnitus]

INTRODUCTION

Tinnitus is a frequent symptom, which, particularly in combination with comorbidities, can result in a severe disease-related burden. Chronic idiopathic tinnitus (CIT) is the most frequent type of tinnitus. A considerable number of treatment strategies are used to treat CIT-for many of which there is no evidence of efficacy. In order to enable scientific evidence-based treatment of CIT, German interdisciplinary S3 guidelines have recently been constructed for the first time. Here we present a short form of these S3 guidelines.

MATERIALS AND METHODS

The guidelines were constructed based on a meta-analysis of the treatment of chronic tinnitus performed by the authors. Additionally, a systematic literature search was performed in the PubMed and Cochrane Library databases. Furthermore, a systematic search for international guidelines was performed in Google, as well as in the Guidelines International Network and National Guideline Clearinghouse (USA) database. Evidence was classified according to the Oxford Centre for Evidence-Based Medicine system.

RESULTS

According to the guidelines, alongside counselling, manualized structured tinnitus-specific cognitive behavioral therapy (tCBT) with a validated treatment manual is available as evidence-based therapy. In addition, the guidelines recommend concurrent treatment of comorbidities, including drug-based treatment, where appropriate. Particularly important is treatment of anxiety and depression. Where a psychic or psychiatric comorbidity is suspected, further diagnosis and treatment should be performed by an appropriately qualified specialist (psychiatrist, neurologist, psychosomatic medicine consultant) or psychological psychotherapist. In cases accompanied by deafness or hearing loss bordering on deafness, cochlear implants may be indicated.

CONCLUSION

No recommendations can be made for drug-based treatment of CIT, audiotherapy, transcranial magnetic or electrical stimulation, specific forms of acoustic stimulation or music therapy; or such recommendations must remain open due to the lack of available evidence. Polypragmatic tinnitus treatment with therapeutic strategies for which there is no evidence of efficacy from controlled studies is to be refused.

A novel treatment for tinnitus and tinnitus-related cognitive difficulties using computer-based cognitive training and D-cycloserine

IMPORTANCE

Tinnitus affects more than 40 million people in the Unites States, and cognitive difficulties are among the most commonly associated symptoms.

OBJECTIVE

To test the feasibility and preliminarily the effectiveness of using a putative neuroplasticity-enhancing drug, D-cycloserine, to facilitate a computer-assisted CT program for improving tinnitus bother and related cognitive difficulties.

DESIGN, SETTING, AND PARTICIPANTS

Double-blind, randomized clinical trial at an outpatient academic medical center of 34 participants aged 35 to 65 years with subjective, unilateral or bilateral, nonpulsatile tinnitus of at least 6 months' duration.

INTERVENTIONS

Five weeks of twice-weekly computer-based CT with either 250 mg D-cycloserine or placebo orally prior to computer CT sessions.

MAIN OUTCOMES AND MEASURES

Difference in the change in Tinnitus Functional Index (TFI) score between the 2 groups.

RESULTS

After excluding 1 participant lost to follow-up, 1 who withdrew, 1 who did not complete 90% of sessions, and 1 outlier, 30 participants were included in the analysis. The D-cycloserine plus CT group showed a significant improvement in median TFI score (-5.8 [95% CI, -9.4 to -1.1]) and self-reported cognitive deficits (-4.5 [95% CI, -11.5 to -1.0]), but the placebo group did not (-1.0 [95% CI, -11.7 to 4.9] and -2.0 [95% CI, -5.1 to 2.0], respectively). After controlling for age and duration of tinnitus, there was no significant difference in TFI score change between the 2 groups (P = .41). After confounders were controlled for, the D-cycloserine group demonstrated a significantly greater improvement in self-reported cognitive deficits as compared with the placebo group (P = .03). No serious adverse events were reported.

CONCLUSIONS AND RELEVANCE

Use of a computer-based CT program with a putative neuroplasticity-sensitizing drug, D-cycloserine, was feasible and well tolerated. With the limited sample size, the adjuvant use of D-cycloserine was no more effective than placebo at improving tinnitus bother. The finding that D-cycloserine use was more effective than placebo at improving self-reported cognitive difficulties could be important given the high rate of concern for cognitive deficits in patients with tinnitus. D-cycloserine and other putative neuroplasticity-facilitating agents could be investigated in the future as a strategy to enhance neuroplasticity-based tinnitus treatments.

TRIAL REGISTRATION

clinicaltrials.gov Identifier: NCT01550796.

A review of hyperacusis and future directions: part II. Measurement, mechanisms, and treatment

PURPOSE

Hyperacusis can be extremely debilitating, and at present, there is no cure. In this detailed review of the field, we consolidate present knowledge in the hope of facilitating future research.

METHOD

We review and reference the literature on hyperacusis and related areas. This is the 2nd of a 2-part review.

RESULTS

Hyperacusis encompasses a wide range of reactions to sounds, which can be grouped into the categories of excessive loudness, annoyance, fear, and pain. Reasonable approaches to assessing the different forms of hyperacusis are emerging, including brain-imaging studies. Researchers are only beginning to understand the many mechanisms at play, and valid animal models are still evolving. There are many counseling and sound-therapy approaches that some patients find helpful, but well-controlled studies are needed to measure their long-term efficacy and to test new approaches.

CONCLUSIONS

Hyperacusis can make life difficult in this increasingly noisy world, forcing sufferers to dramatically alter their work and social habits. We believe this is an opportune time to explore approaches to better understand and treat hyperacusis.

Clinical efficacy of tinnitus retraining therapy and cognitive behavioural therapy in the treatment of subjective tinnitus: a systematic review

OBJECTIVE

This study aimed to compare the outcomes of two frequently employed interventions for the management of tinnitus: tinnitus retraining therapy and cognitive behavioural therapy.

METHOD

A systematic review of literature published up to and including February 2013 was performed. Only randomised control trials and studies involving only human participants were included.

RESULTS

Nine high-quality studies evaluating the efficacy of tinnitus retraining therapy and cognitive behavioural therapy were identified. Of these, eight assessed cognitive behavioural therapy relative to a no-treatment control and one compared tinnitus retraining therapy to tinnitus masking therapy. Each study used a variety of standardised and validated questionnaires. Outcome measures were heterogeneous, but both therapies resulted in significant improvements in quality of life scores. Depression scores improved with cognitive behavioural therapy.

CONCLUSION

Both cognitive behavioural therapy and tinnitus retraining therapy are effective for tinnitus, with neither therapy being demonstrably superior. Further research using standardised, validated questionnaires is needed so that objective comparisons can be made.

A scientific cognitive-behavioral model of tinnitus: novel conceptualizations of tinnitus distress

The importance of psychological factors in tinnitus distress has been formally recognized for almost three decades. The psychological understanding of why tinnitus can be a distressing condition posits that it becomes problematic when it acquires an emotive significance through cognitive processes. Principle therapeutic efforts are directed at reducing or removing the cognitive (and behavioral) obstacles to habituation. Here, the evidence relevant to a new psychological model of tinnitus is critically reviewed. The model posits that patients' interpretations of tinnitus and the changes in behavior that result are given a central role in creating and maintaining distress. The importance of selective attention and the possibility that this leads to distorted perception of tinnitus is highlighted. From this body of evidence, we propose a coherent cognitive-behavioral model of tinnitus distress that is more in keeping with contemporary psychological theories of clinical problems (particularly that of insomnia) and which postulates a number of behavioral processes that are seen as cognitively mediated. This new model provides testable hypotheses to guide future research to unravel the complex mechanisms underpinning tinnitus distress. It is also well suited to define individual symptomatology and to provide a framework for the delivery of cognitive-behavioral therapy.

Clinical Practice Guideline

Objective

Tinnitus is the perception of sound without an external source. More than 50 million people in the United States have reported experiencing tinnitus, resulting in an estimated prevalence of 10% to 15% in adults. Despite the high prevalence of tinnitus and its potential significant effect on quality of life, there are no evidence-based, multidisciplinary clinical practice guidelines to assist clinicians with management. The focus of this guideline is on tinnitus that is both bothersome and persistent (lasting 6 months or longer), which often negatively affects the patient’s quality of life. The target audience for the guideline is any clinician, including nonphysicians, involved in managing patients with tinnitus. The target patient population is limited to adults (18 years and older) with primary tinnitus that is persistent and bothersome.

Purpose

The purpose of this guideline is to provide evidence-based recommendations for clinicians managing patients with tinnitus. This guideline provides clinicians with a logical framework to improve patient care and mitigate the personal and social effects of persistent, bothersome tinnitus. It will discuss the evaluation of patients with tinnitus, including selection and timing of diagnostic testing and specialty referral to identify potential underlying treatable pathology. It will then focus on the evaluation and treatment of patients with persistent primary tinnitus, with recommendations to guide the evaluation and measurement of the effect of tinnitus and to determine the most appropriate interventions to improve symptoms and quality of life for tinnitus sufferers.

Action Statements

The development group made a strong recommendation that clinicians distinguish patients with bothersome tinnitus from patients with nonbothersome tinnitus. The development group made a strong recommendation against obtaining imaging studies of the head and neck in patients with tinnitus, specifically to evaluate tinnitus that does not localize to 1 ear, is nonpulsatile, and is not associated with focal neurologic abnormalities or an asymmetric hearing loss. The panel made the following recommendations: Clinicians should (a) perform a targeted history and physical examination at the initial evaluation of a patient with presumed primary tinnitus to identify conditions that if promptly identified and managed may relieve tinnitus; (b) obtain a prompt, comprehensive audiologic examination in patients with tinnitus that is unilateral, persistent (≥ 6 months), or associated with hearing difficulties; (c) distinguish patients with bothersome tinnitus of recent onset from those with persistent symptoms (≥ 6 months) to prioritize intervention and facilitate discussions about natural history and follow-up care; (d) educate patients with persistent, bothersome tinnitus about management strategies; (e) recommend a hearing aid evaluation for patients who have persistent, bothersome tinnitus associated with documented hearing loss; and (f) recommend cognitive behavioral therapy to patients with persistent, bothersome tinnitus. The panel recommended against (a) antidepressants, anticonvulsants, anxiolytics, or intratympanic medications for the routine treatment of patients with persistent, bothersome tinnitus; (b) Ginkgo biloba, melatonin, zinc, or other dietary supplements for treating patients with persistent, bothersome tinnitus; and (c) transcranial magnetic stimulation for the routine treatment of patients with persistent, bothersome tinnitus. The development group provided the following options: Clinicians may (a) obtain an initial comprehensive audiologic examination in patients who present with tinnitus (regardless of laterality, duration, or perceived hearing status); and (b) recommend sound therapy to patients with persistent, bothersome tinnitus. The development group provided no recommendation regarding the effect of acupuncture in patients with persistent, bothersome tinnitus.

Amplitude modulated S-tones can be superior to noise for tinnitus reduction

PURPOSE

Recent evidence has suggested that amplitude modulated tones might have some advantages over broadband noise.

METHOD

Fifty-six subjects listened to S-Tones at a carrier frequency matched at the tinnitus pitch (amplitude modulation rate of 40 Hz) and to broadband noise. Subjects rated their tinnitus loudness before, during, and after a 120-s duration masker.

RESULTS

The results suggested that S-Tones were generally more effective at reducing tinnitus loudness than noise. In about one third (21/56) of the subjects, there was no significant effect from any masker. In other subjects, 54.3% (19/35) showed a greater reduction for the S-Tones, 20% (7/35) showed a greater reduction with the noise, and 25.7% (9/35) showed similar performance between the 2 stimuli. The S-Tones showed a statistically significant benefit ( p < .01) versus noise at reducing the patient's tinnitus perception. Using low-level stimuli that were rated much softer than the subjects' baseline tinnitus, the S-Tones reduced the tinnitus loudness by 1.9 times the amount that noise did (about 28% on average, whereas the noise reduced the tinnitus by about 15%).

CONCLUSION

S-Tones at the tinnitus pitch-match frequency are more likely to be effective than broadband noise at reducing tinnitus loudness.

Cognitive behavioral therapy for tinnitus: evidence and efficacy

Tinnitus is defined as auditory perception without external sound. There is currently no cure for tinnitus. Cognitive behavioral therapy (CBT) is a tinnitus treatment that addresses the affected individual's reaction to tinnitus. It aims not to eliminate auditory perception as sound but to reduce or correct one's negative response to tinnitus. CBT identifies negative automatic thought and then evaluates its validity with the patient. It also aims to change negative automatic thought to more positive and realistic thought. In this way, tinnitus sufferers can function well despite the presence of tinnitus. Many studies have supported the efficacy of CBT for treating tinnitus. A meta-analysis of CBT for tinnitus also concluded that CBT is effective in treating tinnitus. Thus, CBT is considered a good option for treating tinnitus. We herein discuss the use of CBT for tinnitus with a literature review.

Short term effects of repetitive transcranial magnetic stimulation in patients with catastrophic intractable tinnitus: preliminary report

OBJECTIVES

The short-term effects of low-frequency repetitive transcranial magnetic stimulation (rTMS) in the patients with catastrophic and intractable tinnitus were investigated.

METHODS

Fifteen participants were recruited among patients with catastrophic intractable tinnitus to receive 1 Hz rTMS treatment. Tinnitus severity was assessed before rTMS and directly after sham or real rTMS using the tinnitus handicap inventory (THI) and visual analog scale (VAS).

RESULTS

There was no statistical difference in the THI score before and after sham stimulation. However, after 5 replications of real rTMS there was statistically significant reduction in THI score. Eight patients showed a decrease of more than 10 in THI score. Patients who showed a vast change in THI score after rTMS also showed a large decrease in their VAS score (r=0.879, P<0.001). Duration of tinnitus and change of THI score showed statistically significant moderate negative correlation (r=-0.637, P=0.011). But in case of VAS, there was no significant difference between VAS and duration of tinnitus.

CONCLUSION

Among total 15 patients with catastrophic intractable chronic tinnitus, eight patients showed some improvement in symptoms after 1 Hz rTMS. rTMS can be considered management modality for intractable tinnitus even with distress as severe as catastrophic stage.

Ginkgo biloba for tinnitus

BACKGROUND

This is an update of a Cochrane review first published in The Cochrane Library in Issue 2, 2004 and previously updated in 2007 and 2009.Tinnitus can be described as the perception of sound in the absence of external acoustic stimulation. At present no specific therapy for tinnitus is acknowledged to be satisfactory in all patients. There are a number of reports in the literature suggesting that Ginkgo biloba may be effective in the management of tinnitus. However, there also appears to be a strong placebo effect in tinnitus management.

OBJECTIVES

To assess the effect of Ginkgo biloba in patients who are troubled by tinnitus.

SEARCH METHODS

We searched the Cochrane Ear, Nose and Throat Disorders Group Trials Register; the Cochrane Central Register of Controlled Trials (CENTRAL); PubMed; EMBASE; AMED; Web of Science; BIOSIS Previews; Cambridge Scientific Abstracts; ICTRP and additional sources for published and unpublished trials. The date of the most recent search was 12 March 2012.

SELECTION CRITERIA

Adults (18 years and over) complaining of tinnitus or adults with a primary complaint of cerebral insufficiency, where tinnitus forms part of the syndrome.

DATA COLLECTION AND ANALYSIS

Both original authors independently extracted data and assessed trials for quality. For the 2012 update two authors determined trial eligibility, extracted data, analysed data and updated the contents of the review.

MAIN RESULTS

Four trials with a total of 1543 participants were included in the review; we assessed all the included studies as having a low risk of bias. Three trials (1143 participants) included patients with a primary complaint of tinnitus and one (400 participants) included patients with mild to moderate dementia, some of whom had tinnitus.There was no evidence that Gingko biloba was effective in patients with a primary complaint of tinnitus. In the study of patients with dementia, mean baseline levels of tinnitus were low (1.7 to 2.5 on a 10-point subjective symptom rating scale). A small but statistically significant reduction of 1.5 and 0.7 points was seen in patients taking Gingko biloba with vascular dementia and Alzheimer's disease respectively. The practical clinical significance of this is unclear. The incidence of side effects was low.

AUTHORS' CONCLUSIONS

The limited evidence does not demonstrate that Ginkgo biloba is effective for tinnitus when this is the primary complaint.

Sound therapy (masking) in the management of tinnitus in adults

BACKGROUND

This is an update of a Cochrane Review first published in The Cochrane Library in Issue 12, 2010.Tinnitus is described as the perception of sound or noise in the absence of real acoustic stimulation. Numerous management strategies have been tried for this potentially debilitating, heterogeneous symptom. External noise has been used as a management tool for tinnitus, in different capacities and with different philosophical intent, for over a century.

OBJECTIVES

To assess the effectiveness of sound-creating devices (including hearing aids) in the management of tinnitus in adults. Primary outcome measures were changes in the loudness or severity of tinnitus and/or impact on quality of life. Secondary outcome measures were change in pure-tone auditory thresholds and adverse effects of treatment. 

SEARCH METHODS

We searched the Cochrane ENT Group Trials Register; CENTRAL; PubMed; EMBASE; CINAHL; Web of Science; BIOSIS Previews; Cambridge Scientific Abstracts; ICTRP and additional sources for published and unpublished trials. The date of the most recent search was 8 February 2012.

SELECTION CRITERIA

Prospective randomised controlled trials recruiting adults with persistent, distressing, subjective tinnitus of any aetiology in which the management strategy included maskers, noise-generating device and/or hearing aids, used either as the sole management tool or in combination with other strategies, including counselling.

DATA COLLECTION AND ANALYSIS

Two authors independently examined the 387 search results to identify studies for inclusion in the review, of which 33 were potentially relevant. The update searches in 2012 retrieved no further potentially relevant studies. Both authors extracted data independently.

MAIN RESULTS

Six trials (553 participants) are included in this review. Studies were varied in design, with significant heterogeneity in the evaluation of subjective tinnitus perception, with different scores, scales, tests and questionnaires as well as variance in the outcome measures used to assess the improvement in tinnitus sensation/quality of life. This precluded meta-analysis of the data. There was no long-term follow-up. We assessed the risk of bias as medium in three and high in three studies. Following analysis of the data, no significant change was seen in the loudness of tinnitus or the overall severity of tinnitus following the use of sound therapy compared to other interventions such as patient education, 'relaxation techniques', 'tinnitus coping strategies', counselling, 'tinnitus retraining' and exposure to environmental sounds. No side effects or significant morbidity were reported from the use of sound-creating devices.

AUTHORS' CONCLUSIONS

The limited data from the included studies failed to show strong evidence of the efficacy of sound therapy in tinnitus management. The absence of conclusive evidence should not be interpreted as evidence of lack of effectiveness. The lack of quality research in this area, in addition to the common use of combined approaches (hearing therapy plus counselling) in the management of tinnitus are, in part, responsible for the lack of conclusive evidence. Other combined forms of management, such as tinnitus retraining therapy, have been subject to a Cochrane Review. Optimal management may involve multiple strategies.