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

Using Participatory Action Research to Redirect Tinnitus Treatment and Research-An Interview Study

Background: Chronic bothersome tinnitus is a prevalent tinnitus subtype placing a high burden on affected individuals, economies, and healthcare systems. Patient and professional perspectives seem to be partly misaligned on how to improve tinnitus research and treatments in the future. This qualitative interview study was aimed at exploring, comparing, and stipulating the perspectives of different tinnitus stakeholder groups on ways of redirecting research and treatments to reduce patients' suffering while accounting for challenges within these practices. Methods: This study used the participatory action research approach to facilitate the stakeholder involvement. Semi-structured online interviews including five participants (two tinnitus patients, two tinnitus researchers and medical specialists, one general practitioner) were conducted. Inductive grounded theory and the constant comparative method were used for data analysis. Results: Four categories for suggested research adaptations ((I) ethical patient involvement; (II) prioritising cure versus coping research; (III) funding; (IV) ethical publication) and six categories for suggested treatment adaptations ((I) ethical professional support; (II) patient involvement; (III) interdisciplinarity; (IV) professional tinnitus education; (V) clinical treatment guidelines; (VI) psychological treatment) were identified. Participants held partly similar priorities such as increasing pathophysiological and cure research. Differences between participants included, for instance, patients aiming for increasing patient involvement in tinnitus research and treatments compared to professionals arguing that the excessive focus on patients' conditions might reduce the patients' chances of habituating to their symptoms. Conclusions: Four action redirections for improving tinnitus research and treatment practices were defined: (I) facilitating communication between and within stakeholder groups, (II) increasing the reflective use of patient involvement, (III) increasing interdisciplinarity, and (IV) reducing barriers to receiving psychological treatment.

Personalized Neuromodulation: A Novel Strategy for Improving Tinnitus Treatment

This study evaluated the efficacy of personalized neuromodulation, where treatment modalities are chosen based on the patient's responses in a pilot trial. A total of 71 patients with tinnitus were divided into two groups: a personalized group and a randomized neuromodulation group. In the personalized group (n = 35), repetitive transcranial magnetic stimulation (rTMS) and transcranial direct-current stimulation (tDCS) were assessed in a pilot trial, and responsive modalities were administered to 16 patients, while the non-responders (n = 19) were randomly assigned to rTMS, tDCS, or combined modalities. Patients in the randomized group (n = 36) were randomly allocated to rTMS, tDCS, or combined modalities. The Tinnitus Handicap Inventory (THI) score improvement after 10 sessions of each neuromodulation was significantly greater in the personalized group than in the randomized group (p = 0.043), with no significant differences in tinnitus loudness, distress, or awareness. The treatment success rate was highest in the personalized responder subgroup (92.3%), and significantly greater than that in the non-responder subgroup (53.0%; p = 0.042) and the randomized group (56.7%; p = 0.033). Personalized neuromodulation, where the treatment modality is chosen based on the patient's responses in a pilot trial, is an advantageous strategy for treating tinnitus.

Current and Emerging Therapies for Chronic Subjective Tinnitus

IMPORTANCE

Chronic subjective tinnitus, the perception of sound without an external source for longer than six months, may be a greatly debilitating condition for some people, and is associated with psychiatric comorbidities and high healthcare costs. Current treatments are not beneficial for all patients and there is a large need for new therapies for tinnitus.

OBSERVATIONS

Unlike rarer cases of objective tinnitus, chronic subjective tinnitus often has no obvious etiology and a diverse pathophysiology. In the absence of objective testing, diagnosis is heavily based on clinical assessment. Management strategies include hearing aids, sound masking, tinnitus retraining therapy, cognitive behavioral therapy, and emerging therapies including transcranial magnetic stimulation and electrical stimulation.

CONCLUSIONS AND RELEVANCE

Although current treatments are limited, emerging diagnostics and treatments provide promising avenues for the management of tinnitus symptoms.

Linking Affective and Hearing Sciences-Affective Audiology

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

Vulnerability to chronic stress and the phenotypic heterogeneity of presbycusis with subjective tinnitus

Age-related functional reserve decline and vulnerability of multiple physiological systems and organs, as well as at the cellular and molecular levels, result in different frailty phenotypes, such as physical, cognitive, and psychosocial frailty, and multiple comorbidities, including age-related hearing loss (ARHL) and/or tinnitus due to the decline in auditory reserve. However, the contributions of chronic non-audiogenic cumulative exposure, and chronic audiogenic stress to phenotypic heterogeneity of presbycusis and/or tinnitus remain elusive. Because of the cumulative environmental stressors throughout life, allostasis systems, the hypothalamus-pituitary-adrenal (HPA) and the sympathetic adrenal-medullary (SAM) axes become dysregulated and less able to maintain homeostasis, which leads to allostatic load and maladaptation. Brain-body communication via the neuroendocrine system promotes systemic chronic inflammation, overmobilization of energetic substances (glucose and lipids), and neuroplastic changes via the non-genomic and genomic actions of glucocorticoids, catecholamines, and their receptors. These systemic maladaptive alterations might lead to different frailty phenotypes and physical, cognitive, and psychological comorbidities, which, in turn, cause and exacerbate ARHL and/or tinnitus with phenotypic heterogeneity. Chronic audiogenic stressors, including aging accompanying ontological diseases, cumulative noise exposure, and ototoxic drugs as well as tinnitus, activate the HPA axis and SAM directly and indirectly by the amygdala, promoting allostatic load and maladaptive neuroplasticity in the auditory system and other vulnerable brain regions, such as the hippocampus, amygdala, and medial prefrontal cortex (mPFC). In the auditory system, peripheral deafferentation, central disinhibition, and tonotopic map reorganization may trigger tinnitus. Cross-modal maladaptive neuroplasticity between the auditory and other sensory systems is involved in tinnitus modulation. Persistent dendritic growth and formation, reduction in GABAergic inhibitory synaptic inputs induced by chronic audiogenic stresses in the amygdala, and increased dendritic atrophy in the hippocampus and mPFC, might involve the enhancement of attentional processing and long-term memory storage of chronic subjective tinnitus, accompanied by cognitive impairments and emotional comorbidities. Therefore, presbycusis and tinnitus are multisystem disorders with phenotypic heterogeneity. Stressors play a critical role in the phenotypic heterogeneity of presbycusis. Differential diagnosis based on biomarkers of metabonomics study, and interventions tailored to different ARHL phenotypes and/or tinnitus will contribute to healthy aging and improvement in the quality of life.

Translational Research in Audiology: Presence in the Literature

Translational research is a process that focuses on advancing basic research-based clinical solutions and is characterized by a structured process accelerating the implementation of scientific discoveries in healthcare. Translational research originated in oncology but has spread to other disciplines in recent decades. A translational project may refer to pharmacological research, the development of non-pharmacological therapies, or to disease monitoring processes. Its stages are divided into basic research focused on the clinical problem (T0), testing the developed means in humans (T1), conducting trials with patients (T2), implementation and dissemination of successful approaches (T3), and improving community health (T4). Many audiological studies are translational in nature. Accordingly, this scoping review aimed to evaluate the use of the terms "translational audiology" and "translational research in audiology" in the literature and examine the goals of the identified studies. PubMed and Web of Science search identified only two publications meeting the search criteria. We conclude that identifying translational audiological studies in the literature may be hampered by the lack of use of the terms "translational audiology" or "translational research". We suggest using these terms when describing translational work in audiology, with a view to facilitating the identification of this type of research and credit it appropriately.

A Combined Image- and Coordinate-Based Meta-Analysis of Whole-Brain Voxel-Based Morphometry Studies Investigating Subjective Tinnitus

Previous voxel-based morphometry (VBM) studies investigating tinnitus have reported structural differences in a variety of spatially distinct gray matter regions. However, the results have been highly inconsistent and sometimes contradictory. In the current study, we conducted a combined image- and coordinate-based meta-analysis of VBM studies investigating tinnitus to identify robust gray matter differences associated with tinnitus, as well as examine the possible effects of hearing loss on the outcome of the meta-analysis. The PubMed and Web of Science databases were searched for studies published up to August 2021. Additional manual searches were conducted for studies published up to December 2021. A whole-brain meta-analysis was performed using Seed-Based d Mapping with Permutation of Subject Images (SDM-PSI). Fifteen studies comprising 423 individuals with tinnitus and either normal hearing or hearing loss (mean age 50.94 years; 173 females) and 508 individuals without tinnitus and either normal hearing or hearing loss (mean age 51.59 years; 234 females) met the inclusion criteria. We found a small but significant reduction in gray matter in the left inferior temporal gyrus for groups of normal hearing individuals with tinnitus compared to groups of hearing-matched individuals without tinnitus. In sharp contrast, in groups with hearing loss, tinnitus was associated with increased gray matter levels in the bilateral lingual gyrus and the bilateral precuneus. Those results were dependent upon matching the hearing levels between the groups with or without tinnitus. The current investigation suggests that hearing loss is the driving force of changes in cortical gray matter across individuals with and without tinnitus. Future studies should carefully account for confounders, including hearing loss, hyperacusis, anxiety, and depression, to identify gray matter changes specifically related to tinnitus. Ultimately, the aggregation of standardized individual datasets with both anatomical and useful phenotypical information will permit a better understanding of tinnitus-related gray matter differences, the effects of potential comorbidities, and their interactions with tinnitus.

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

BACKGROUND

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

METHODS/STUDY DESIGN

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

DISCUSSION

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

TRIAL REGISTRATION

ClinicalTrials.gov NCT04663828 . Registered on 11 December 2020.

Doctoral Studies as part of an Innovative Training Network (ITN): Early Stage Researcher (ESR) experiences

Background: The Marie-Skłodowska-Curie Actions' (MSCA) Innovative Training Network (ITN) is a doctoral training programme jointly implemented by academic institutions and industries from countries across Europe and beyond. To our knowledge no study has examined the experience of students participating in MSCA-ITNs. This study aims to evaluate and report MSCA-ITN Early Stage Researcher (ESR) experiences. Methods: The Innovative Training Network - Evaluation Questionnaire (ITN-EQ) was developed to assess supervision, training, collaborations and experiences of ESRs and forwarded to two tinnitus-related ITNs and seven ITNs of other disciplines. Results: Key advantages identified included better career prospects, multidisciplinary research opportunities/collaborations, international exposure, personal/professional development, plus generous salaries and research budgets. However, lack of a common EU framework resulted in the experience being largely dependent on the host institution, country and supervisor. Moreover, managing the dual requirements of ITNs and host institutions while completing a three-year PhD seemed challenging for most ESRs. ESR involvement in workshop and training school planning was desirable. More than 80% of ESRs rated the overall ITN experience favourably and 98.3% would recommend the same to prospective PhD students. Conclusions: This report could provide valuable insights in planning and management of future ITNs and could assist prospective students in their decision of joining an ITN for their PhD.