Transition from Acute to Chronic Tinnitus: Predictors for the Development of Chronic Distressing Tinnitus

Gray matter volumetric changes in tinnitus: The impact of hearing loss and severity

Tinnitus is a phantom auditory sensation that commonly co-occurs with hearing loss. Both tinnitus and hearing loss can impact the quality of life, emotional well-being, and cognitive functioning of the affected individuals. While previous studies have highlighted structural alterations in hearing loss and/or tinnitus, the fundamental neural mechanisms underpinning tinnitus severity remain poorly understood. In this study, we conducted a voxel-based morphometry to investigate gray matter (GM) volume differences among groups of participants with varying tinnitus severity and hearing status, and controls within a large sample. We observed reduced GM volume in the left anterior insula and right planum polare in participants with hearing loss, regardless of their tinnitus status, compared to normal hearing controls. We noted decreased GM volume in the bilateral anterior and posterior insula for those with tinnitus and normal hearing compared to a normal hearing control group. Further, the tinnitus with hearing loss group showed decreased GM volume in the left planum polare, left inferior temporal gyrus, bilateral anterior temporal gyri, and right superior frontal gyrus compared to the normal hearing control group, suggesting a combined effect of hearing loss and tinnitus. While tinnitus severity did not show a significant overall effect, there was a significant positive correlation between tinnitus distress and GM volume in bilateral planum polare. Our findings enhance the understanding of structural brain changes related to hearing loss and tinnitus, and advance the overall knowledge of tinnitus pathophysiology, which can contribute to the development of more effective treatments for tinnitus.

Associations between tinnitus and body composition: a cross-sectional study

The relationship between tinnitus and body composition in specific regions has not been extensively investigated. This study aimed to identify associations between tinnitus and body composition. Individuals with data on physical and otological examination findings, and bioelectrical impedance analysis were included from the ninth Korea National Health and Nutritional Examination Survey. They were divided into a tinnitus group and a non-tinnitus group. Participants with tinnitus were further classified into acute or chronic tinnitus group. The tinnitus group showed significantly higher body fat percentages in each region (arms: P = 0.014; legs: P = 0.029; trunk: P = 0.008; whole body: P = 0.010) and waist circumference (P = 0.007) than the non-tinnitus group, and exhibited lower leg muscle percentage (P = 0.038), total body fluid percentage (P = 0.010), and intracellular fluid percentage (P = 0.009) than the non-tinnitus group in men. Furthermore, men with chronic tinnitus showed a significantly higher trunk fat percentage (P = 0.015) and waist circumference (P = 0.043), and lower intracellular fluid percentage (P = 0.042) than their counterparts without tinnitus. No significant differences in body composition were observed among the groups in the female population. In men, body composition may be associated with tinnitus.

"I feel [so alone] nothing" - emotional vulnerability and detachment as transdiagnostic key characteristics of patients with chronic tinnitus: a schema mode model approach

Background

Gold-standard approaches for chronic tinnitus involve hearing amplification measures and psychological therapy, where applicable. Whilst schema therapy is accumulating evidence as a transdiagnostically useful treatment framework, its applicability for patients with chronic tinnitus has not yet been examined. The present study (a) explores latent dimensions of psychological distress in a sample of chronic tinnitus patients, and (b) examines whether the schema mode model might explain these dimensions - thus constituting a potentially helpful conceptualization and treatment framework.

Methods

N = 696 patients with chronic tinnitus completed the Tinnitus Questionnaire, Tinnitus Handicap Inventory, Hospital Anxiety and Depression Scale, Perceived Stress Questionnaire and ICD-10 Symptom Rating. As criterion, patients further completed the Schema Mode Inventory (SMI-r) - which assesses psychological constructs linked to negative self-beliefs ("parent modes"), primary emotions resulting from unmet psychological needs ("child modes"), and secondary emotional or behavioral attempts to reinstate or maintain psychological equilibrium ("coping modes"). A varimax-rotated principal axis factor analysis grouped the primary item pool. Factor scale scores were then correlated with the SMI-r.

Results

A three-factor solution explained 37.4% of variance and represented 78% of the included items. Following item content examination, the factors represented (1) General emotional distress, (2) Tinnitus-attributed emotional distress, and (3) Socio-audiological impairment. Factors 1|2 correlated highly (r = 0.70), Factors 2|3 moderately (r = 0.62). Linked to the schema mode model, Factor 1 correlated highly with the "vulnerable child" (r = 0.78), and moderately with the "parent", "angry child", and "detached protector" modes (0.53 < r < 0.65). Factor 2 correlated moderately with the "vulnerable child" (r = 0.53). Factor 3 was largely uncorrelated with SMI-r scores - although a low correlation with the "detached protector" warrants further examination.

Conclusion

"General" and "tinnitus-attributed" emotional distress correlate highly - warranting holistic (not symptom-specific) psychological case conceptualization and treatment planning. Viewed from a schema mode perspective, the "vulnerable child" explains substantial variance across both dimensions. Consequently, autobiographically anchored, unmet emotional needs and emotional detachment constitute key treatment targets. Social-audiological impairment should be multimodally conceptualised and treated with hearing aids and psychological support measures, as applicable.

Evaluation of factors predicting tinnitus outcomes following cochlear implantation: Protocol for a prospective quasi-experimental study

Cochlear implantation is an effective intervention to restore useful aspects of hearing function in adults with severe-to-profound hearing loss. Tinnitus, the perception of sound in the absence of an external source, is common in people with severe-to-profound hearing loss. Existing evidence suggests cochlear implantation may be effective in reducing the negative impact of tinnitus in this population. However, this is contradicted by data suggesting that up to half of cochlear implant recipients experience tinnitus, and that some of these patients who did not have tinnitus before cochlear implantation experience it after surgery or cochlear implant activation. Most evidence on the effects of cochlear implantation on tinnitus comes from secondary data in cochlear implant studies primarily concerned with hearing-related outcomes. Hence, the quality of the evidence for effects on tinnitus is low and not suitable to inform clinical recommendations or decision-making. This study will systematically collect data on tinnitus and tinnitus-related outcomes from patients at multiple points during the cochlear implant pathway to characterise changes in tinnitus. This will improve our understanding of the effects of cochlear implantation for tinnitus in adults with severe to profound hearing loss and inform the design of clinical trials of cochlear implantation for tinnitus.

Noise annoyance due to different sources is associated with tinnitus presence and distress in the general population

BACKGROUND

The pathophysiology of tinnitus is not yet fully understood. Although there is a large amount of evidence associating traffic noise exposure with non-auditory health outcomes, there is no evidence regarding the impact of noise annoyance on auditory disorders such as tinnitus.

OBJECTIVE

Thus, we aimed to investigate the association between noise annoyance due to different sources and tinnitus presence and distress in the general population.

METHODS

Data of 6813 participants from a large German population-based cohort were used (Gutenberg Health Study). Participants were asked about the presence of tinnitus and how much they were bothered by it. In addition, information on annoyance from road traffic, aircraft, railways, industrial, and neighborhood noise during the day and sleep was collected through validated questionnaires.

RESULTS

The prevalence of tinnitus was 27.3%, and the predominant sources of noise annoyance in these subjects were aircraft, neighborhood, and road traffic noise. Overall, logistic regression results demonstrated consistent positive associations between annoyance due to different noise sources and prevalent risk of tinnitus with increases in odds ratios ranging from 4 to 11% after adjustment for sex, age, and socioeconomic status. Likewise, consistent increases in odds ratios were observed for tinnitus distress in subjects with prevalent tinnitus. For instance, neighborhood noise annoyance during the sleep was associated with a 26% increase in tinnitus distress (OR 1.26, 95% CI 1.13; 1.39).

IMPACT

This is the first study investigating the association between noise annoyance and tinnitus presence and distress in a large cohort of the general population. Our results indicate consistent and positive associations between various sources of noise annoyance and tinnitus. These unprecedented findings are highly relevant as noise annoyance and tinnitus are widespread. The precise etiology and locus of tinnitus remain unknown, but excessive noise exposure is thought to be among the major causes. This study suggests that transportation and neighborhood noise levels thought merely to contribute to annoyance and non-auditory health effects may be sufficient to cause or exacerbate tinnitus.

The association of subjective and objective sleep measures with chronic tinnitus

STUDY OBJECTIVES

Poor sleep is a prevalent complaint in the population with chronic tinnitus, but the relationship between the two is not well-characterized. The objective of this study was to understand how subjective and objective measures of sleep compare in patients with or without chronic tinnitus.

METHODS

This prospective cohort study included consecutive adult patients who presented to a sleep laboratory between January 19, 2017, and January 10, 2020. All patients underwent an in-laboratory nocturnal polysomnogram and filled out questionnaires including the Pittsburgh Sleep Quality Index (PSQI), Tinnitus Screener, and Tinnitus Handicap Inventory, among others.

RESULTS

The study included 1,968 participants, out of which 284 (14.4%) reported chronic tinnitus. Patients with chronic tinnitus were younger (51.6 years vs 54.1 years; P < .05) and more likely female (16.4% vs 11.7%; P < .005). They demonstrated worse subjective sleep quality (PSQI: 11.3 vs 9.5; P < .0005) and increased sleepiness (Epworth Sleepiness Scale: 9.8 vs 8.6; P < .005). In the objective sleep parameters only the total sleep time was increased in chronic tinnitus (311.5 vs 294.5 minutes; P < .05) and total arousals were decreased (41.7 vs 47; P < .005). Sleep stage N3 was higher in those with chronic tinnitus (14.9% vs 13.0%; P < .05). In multivariable analyses, as PSQI increases the odds of chronic tinnitus increases. This effect was modified by age: In those younger than 55 years of age, the odds of the presence of chronic tinnitus was 1.10 (95% confidence interval, 1.03, 1.17) times higher as PSQI increased.

CONCLUSIONS

Chronic tinnitus is associated with significant changes in qualitative sleep (higher PSQI) but no major differences in quantitative sleep measures were observed.

CITATION

Weingarten JA, Islam A, Dubrovsky B, Gharanei M, Coelho DH. The association of subjective and objective sleep measures with chronic tinnitus. J Clin Sleep Med. 2024;20(3):399-405.

What is the role of the hippocampus and parahippocampal gyrus in the persistence of tinnitus?

The hippocampus and parahippocampal gyrus have been implicated as part of a tinnitus network by a number of studies. These structures are usually considered in the context of a "limbic system," a concept typically invoked to explain the emotional response to tinnitus. Despite this common framing, it is not apparent from current literature that this is necessarily the main functional role of these structures in persistent tinnitus. Here, we highlight a different role that encompasses their most commonly implicated functional position within the brain-that is, as a memory system. We consider tinnitus as an auditory object that is held in memory, which may be made persistent by associated activity from the hippocampus and parahippocampal gyrus. Evidence from animal and human studies implicating these structures in tinnitus is reviewed and used as an anchor for this hypothesis. We highlight the potential for the hippocampus/parahippocampal gyrus to facilitate maintenance of the memory of the tinnitus percept via communication with auditory cortex, rather than (or in addition to) mediating emotional responses to this percept.

Heterogeneity in response to treatment across tinnitus phenotypes

The clinical heterogeneity of chronic tinnitus poses major challenges to patient management and prompts the identification of distinct patient subgroups (or phenotypes) that respond more predictable to a particular treatment. We model heterogeneity in treatment response among phenotypes of tinnitus patients concerning their change in self-reported health burden, psychological characteristics, and tinnitus characteristics. Before and after a 7-day multimodal treatment, 989 tinnitus patients completed 14 assessment questionnaires, from which 64 variables measured general tinnitus characteristics, quality of life, pain experiences, somatic expressions, affective symptoms, tinnitus-related distress, internal resources, and perceived stress. Our approach encompasses mechanisms for patient phenotyping, visualizations of the phenotypes and their change with treatment in a projected space, and the extraction of patient subgroups based on their change with treatment. On average, all four distinct phenotypes identified at the pre-intervention baseline showed improved values for nearly all the considered variables following the intervention. However, a considerable intra-phenotype heterogeneity was noted. Five clusters of change reflected variations in the observed improvements among individuals. These patterns of treatment effects were identified to be associated with baseline phenotypes. Our exploratory approach establishes a groundwork for future studies incorporating control groups to pinpoint patient subgroups that are more likely to benefit from specific treatments. This strategy not only has the potential to advance personalized medicine but can also be extended to a broader spectrum of patients with various chronic conditions.

Development, Insults and Predisposing Factors of the Brain's Predictive Coding System to Chronic Perceptual Disorders-A Life-Course Examination

The predictive coding theory is currently widely accepted as the theoretical basis of perception and chronic perceptual disorders are explained as the maladaptive compensation of the brain to a prediction error. Although this gives us a general framework to work with, it is still not clear who may be more susceptible and/or vulnerable to aberrations in this system. In this paper, we study changes in predictive coding through the lens of tinnitus and pain. We take a step back to understand how the predictive coding system develops from infancy, what are the different neural and bio markers that characterise this system in the acute, transition and chronic phases and what may be the factors that pose a risk to the aberration of this system. Through this paper, we aim to identify people who may be at a higher risk of developing chronic perceptual disorders as a reflection of aberrant predictive coding, thereby giving future studies more facets to incorporate in their investigation of early markers of tinnitus, pain and other disorders of predictive coding. We therefore view this paper to encourage the thinking behind the development of preclinical biomarkers to maladaptive predictive coding.

Cognitive functioning and psychosomatic syndromes in a subjective tinnitus sample

Introduction

Tinnitus is the perception of a sound in the absence of any corresponding external sound source. Current research suggests a relationship among emotional, cognitive, and psychosomatic symptoms and the occurrence or maintenance of chronic tinnitus. This study aimed to detect the prevalence and role of psychosomatic conditions, as defined by the Diagnostic Criteria for Psychosomatic Research (DCPR), and cognitive functioning in a group of patients with tinnitus.

Methods

Sixty-two patients with subjective tinnitus and 62 non-tinnitus controls were recruited from the Otorhinolaryngology Unit of the University of Bari. Pure-tone audiometry was performed in all tinnitus subjects, and sound level tolerance was evaluated. Additionally, tinnitus handicap (Tinnitus Handicap Inventory [THI]), psychopathological symptoms (Symptom Checklist-90, Revised [SCL-90-R]), anxiety (State-Trait Anxiety Inventory [STAI-Y1/2]), depression (Beck Depression Inventory [BDI]), cognitive impairment (Mini-Mental State Examination [MMSE]), executive functions (Frontal Assessment Battery [FAB]), and psychosomatic syndromes (DCPR) were evaluated. Parametric and non-parametric tests were used to detect cognitive and symptomatological differences between patients and controls. The predictivity of these factors for tinnitus severity was studied using multiple regression (Backward Elimination). All tests were considered significant at p < 0.05 (family wise error corrected for each comparison).

Results

69.4% tinnitus patients met multiple DCPR criteria, compared to 32.3% of controls. Tinnitus patients exhibited elevated rates of illness denial (ꭓ2 = 9.02; p < 0.009), demoralization (ꭓ2 = 8.05; p < 0.018), somatization (ꭓ2 = 4.92; p < 0.063) and functional symptoms (ꭓ2 = 5.21; p < 0.06) scoring significantly higher on the BDI, STAI-Y1, and STAI-Y2, and SCL-90-R compared to controls. Patients with tinnitus showed lower MMSE scores, compared to controls (t = -2.282; p < 0.001). No association between tinnitus severity and global cognitive impairment emerged. Conversely, executive function deficits were associated to tinnitus severity. Among the cognitive and psychological factors, only trait anxiety, one or more psychosomatic syndromes, and somatization clusters were strongly correlated with tinnitus severity.

Discussion

Our findings suggest a relationship between tinnitus severity, psychological, psychosomatic symptoms, and frontal impairment. Additionally, the influence of tinnitus on cognitive functions paves the way for integrated, multidisciplinary diagnostic and treatment options for patients. Although preliminary, our findings highlight the importance of early cognitive and psychological screening to improve patients' quality of life.

Eavesdropping on Tinnitus Using MEG: Lessons Learned and Future Perspectives

Tinnitus has been widely investigated in order to draw conclusions about the underlying causes and altered neural activity in various brain regions. Existing studies have based their work on different tinnitus frameworks, ranging from a more local perspective on the auditory cortex to the inclusion of broader networks and various approaches towards tinnitus perception and distress. Magnetoencephalography (MEG) provides a powerful tool for efficiently investigating tinnitus and aberrant neural activity both spatially and temporally. However, results are inconclusive, and studies are rarely mapped to theoretical frameworks. The purpose of this review was to firstly introduce MEG to interested researchers and secondly provide a synopsis of the current state. We divided recent tinnitus research in MEG into study designs using resting state measurements and studies implementing tone stimulation paradigms. The studies were categorized based on their theoretical foundation, and we outlined shortcomings as well as inconsistencies within the different approaches. Finally, we provided future perspectives on how to benefit more efficiently from the enormous potential of MEG. We suggested novel approaches from a theoretical, conceptual, and methodological point of view to allow future research to obtain a more comprehensive understanding of tinnitus and its underlying processes.

[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.

Development and Validation of a Nomogram to Predict the Risk of Tinnitus Severity in Patients With Unilateral Subjective Tinnitus

Purpose: To develop and validate a nomogram for predicting the risk of tinnitus severity in patients with unilateral subjective tinnitus. Methods: The objective of this study was to establish and validate a nomogram specifically designed for patients with unilateral subjective tinnitus. We collected data on unilateral subjective tinnitus from the Air Force Medical Center, including 146 participants between January 2021 and June 2022. Risk factors for unilateral subjective tinnitus severity were evaluated by least absolute shrinkage and selection operator (LASSO) and binary logistic regression analysis. Internal verification was used to evaluate the performance of the nomogram. The discriminative ability was measured by the consistency index (C-indices) and the area under the curve (AUC) of the receiver operating characteristic (ROC) curves. Results: All included patients were randomized according to a 7:3 ratio into the training cohort (104 patients) and the validation cohort (42 patients). The LASSO regression model identified sex, tinnitus loudness, and hearing loss as candidate variables. Binary logistic regression analysis showed that gender (OR: 0.76; 95% CI: 0.6-0.95; P = 0.021) and tinnitus loudness (OR: 1.37; 95% CI: 1.09-1.72; P = 0.009) were significant predictors of unilateral subjective tinnitus severity, while age, tinnitus matching frequency, and tinnitus duration were not. The significant predictors were included in the nomogram. Hearing loss was included in the nomogram based on prior clinical experience and previous studies. The training and validation cohorts C-indexes were 0.707 (95% CI: 0.607-0.806) and 0.706 (95% CI: 0.548-0.863), respectively. The training and validation cohort's AUC of the ROC curves were 0.692 and 0.705, respectively. Conclusion: We have developed and validated a nomogram based on gender, hearing loss, and tinnitus loudness, which can effectively predict the risk of tinnitus severity in patients with unilateral subjective tinnitus. The nomogram provides personalized prediction results for patients with unilateral subjective tinnitus, which is beneficial for clinical decision-making and treatment plan development.

Ageing as risk factor for tinnitus and its complex interplay with hearing loss-evidence from online and NHANES data

BACKGROUND

Tinnitus affects 10 to 15% of the population, but its underlying causes are not yet fully understood. Hearing loss has been established as the most important risk factor. Ageing is also known to accompany increased prevalence; however, the risk is normally seen in context with (age-related) hearing loss. Whether ageing per se is a risk factor has not yet been established. We specifically focused on the effect of ageing and the relationship between age, hearing loss, and tinnitus.

METHODS

We used two samples for our analyses. The first, exploratory analyses comprised 2249 Austrian individuals. The second included data from 16,008 people, drawn from a publicly available dataset (NHANES). We used logistic regressions to investigate the effect of age on tinnitus.

RESULTS

In both samples, ageing per se was found to be a significant predictor of tinnitus. In the more decisive NHANES sample, there was an additional interaction effect between age and hearing loss. Odds ratio analyses show that per unit increase of hearing loss, the odds of reporting tinnitus is higher in older people (1.06 vs 1.03).

CONCLUSIONS

Expanding previous findings of hearing loss as the main risk factor for tinnitus, we established ageing as a risk factor in its own right. Underlying mechanisms remain unclear, and this work calls for urgent research efforts to link biological ageing processes, hearing loss, and tinnitus. We therefore suggest a novel working hypothesis that integrates these aspects from an ageing brain viewpoint.

The Analogy between Tinnitus and Chronic Pain: A Phenomenological Approach

Tinnitus is an auditory sensation without external acoustic stimulation or significance, which may be lived as an unpleasant experience and impact the subject's quality of life. Tinnitus loudness, which is generally low, bears no relation to distress. Factors other than psychoacoustic (such as psychological factors) are therefore implicated in the way tinnitus is experienced. The aim of this article is to attempt to understand how tinnitus can, like chronic pain, generate a 'crisis' in the process of existence, which may go as far as the collapse of the subject. The main idea put forward in the present article is that tinnitus may be compared to the phenomenon of pain from the point of view of the way it is experienced. Although the analogy between tinnitus and pain has often been made in the literature, it has been limited to a parallel concerning putative physiopathological mechanisms and has never really been explored in depth from the phenomenological point of view. Tinnitus is comparable to pain inasmuch as it is felt, not perceived: it springs up (without intention or exploration), abolishes the distance between the subject and the sensation (there is only a subject and no object), and has nothing to say about the world. Like pain, tinnitus is formless and abnormal and can alter the normal order of the world with maximum intensity. Finally, tinnitus and pain enclose the subject within the limits of the body, which then becomes in excess. Tinnitus may be a source of suffering, which affects not only the body but a person's very existence and, in particular, its deployment in time. Plans are thus abolished, so time is no longer 'secreted', it is enclosed in an eternal present. If the crisis triggered by tinnitus is not resolved, the subject may buckle and collapse (depression) when their resources for resisting are depleted. The path may be long and winding from the moment when tinnitus emerges to when it assaults existence and its eventual integration into a new existential norm where tinnitus is no longer a source of disturbance.

Correlation between the Degree of Hearing Loss and the Levels of Anxiety and Depression in Patients with Tinnitus

Objectives

This study aimed to explore the correlation between the degree of hearing loss (HL) and the degrees of anxiety and depression in patients with tinnitus.

Materials and Methods

This retrospective study involved the use of basic clinical data from 600 enrolled patients with tinnitus who visited the otolaryngology clinic in Affiliated Jinhua Hospital, Zhejiang University School of Medicine from April 2020 to June 2022. The tinnitus handicap inventory (THI) scale was used to assess the tinnitus status among the participants. The pure tone audiometry (PTA) test was used to conduct audiological assessments for all patients to determine their hearing condition. The self-rating anxiety scale (SAS) and self-rating depression scale (SDS) were used to assess the levels of anxiety and depression among the participants, respectively. The correlation between the HL and anxiety/depression scores from the questionnaires was tested through Pearson correlation analysis.

Results

Among the 600 enrolled patients with tinnitus, most patients had mild-to-moderate degree of tinnitus, accounting for 248 cases (41.3%) and 179 cases (29.8%), respectively. PTA results showed that a large proportion of patients with tinnitus were accompanied with HL (467 cases, 77.8%). Among them, patients with mild HL accounted for the largest proportion with a total of 241 cases (40.2%). Based on the results of SAS and SDS test, almost half of the patients had symptoms of anxiety and depression, accounting for 52.3% (314 cases) and 48.8% (293 cases), respectively. Similarly, patients with mild anxiety and depression occupy the largest proportion, accounting for 35.8% (215 cases) and 23% (138 cases), respectively. Pearson correlation analysis showed that the degree of HL was closely related to THI/SAS/SDS scores (P < 0.001).

Conclusion

These findings indicate a strong positive correlation between the degree of HL and anxiety/depression scores in patients with tinnitus.

The neuroanatomical hallmarks of chronic tinnitus in comorbidity with pure-tone hearing loss

Tinnitus is one of the main hearing impairments often associated with pure-tone hearing loss, and typically manifested in the perception of phantom sounds. Nevertheless, tinnitus has traditionally been studied in isolation without necessarily considering auditory ghosting and hearing loss as part of the same syndrome. Hence, in the present neuroanatomical study, we attempted to pave the way toward a better understanding of the tinnitus syndrome, and compared two groups of almost perfectly matched individuals with (TIHL) and without (NTHL) pure-tone tinnitus, but both characterized by pure-tone hearing loss. The two groups were homogenized in terms of sample size, age, gender, handedness, education, and hearing loss. Furthermore, since the assessment of pure-tone hearing thresholds alone is not sufficient to describe the full spectrum of hearing abilities, the two groups were also harmonized for supra-threshold hearing estimates which were collected using temporal compression, frequency selectivity und speech-in-noise tasks. Regions-of-interest (ROI) analyses based on key brain structures identified in previous neuroimaging studies showed that the TIHL group exhibited increased cortical volume (CV) and surface area (CSA) of the right supramarginal gyrus and posterior planum temporale (PT) as well as CSA of the left middle-anterior part of the superior temporal sulcus (STS). The TIHL group also demonstrated larger volumes of the left amygdala and of the left head and body of the hippocampus. Notably, vertex-wise multiple linear regression analyses additionally brought to light that CSA of a specific cluster, which was located in the left middle-anterior part of the STS and overlapped with the one found to be significant in the between-group analyses, was positively associated with tinnitus distress level. Furthermore, distress also positively correlated with CSA of gray matter vertices in the right dorsal prefrontal cortex and the right posterior STS, whereas tinnitus duration was positively associated with CSA and CV of the right angular gyrus (AG) and posterior part of the STS. These results provide new insights into the critical gray matter architecture of the tinnitus syndrome matrix responsible for the emergence, maintenance and distress of auditory phantom sensations.

Tinnitus and Influencing Comorbidities

Numerous studies show that impairments in chronic tinnitus are closely connected with psychosomatic and other concomitant symptoms. This overview summarizes some of these studies. Beyond hearing loss, individual interactions of medical and psychosocial stress factors as well as resources are of central importance. Tinnitus related distress reflects a large number of intercorrelated, psychosomatic influences - such as personality traits, stress reactivity and depression or anxiety - which can be accompanied by cognitive difficulties and should be conceptualized and assessed within a vulnerability-stress-reaction model. Superordinate factors such as age, gender or education level can increase vulnerability to stress. Therefore, diagnosis and therapy of chronic tinnitus be individualised, multidimensional and interdisciplinary. Multimodal psychosomatic therapy approaches aim to address individually constellated medical, audiological and psychological influences in order to sustainably increase the quality of life of those affected. Counselling in the first contact is also indispensable for diagnosis and therapy.

A Heterogeneous Sample of a Spanish Tinnitus Cohort

Taking into account heterogeneity has been highly recommended in tinnitus studies both to disentangle all diverse factors that can contribute to their complexity and to design personalized treatments. To this aim, a heterogeneous sample of 270 tinnitus subjects is analyzed considering the gender (male/female), hearing condition (hearing-impaired/normal-hearing), and tinnitus severity (compensated/decompensated) subgroups. Two categorical variables (tinnitus laterality and tinnitus sound type) and four quantitative variables (average auditory threshold, age of tinnitus onset, tinnitus frequency, and tinnitus severity) are used. The percentages (for categorical variables) and mean values (for quantitative variables) of the whole sample are compared with these of each subgroup. Furthermore, correlational and hypothesis testing is applied to calculate the correlation coefficients and statistical significance, respectively. The results show that the male and female subgroups contrast in the sound type and frequency of their tinnitus, hearing-impaired and normal-hearing individuals differ, in addition, in their average auditory threshold, and the compensated/decompensated tinnitus subgroup provides significantly distinct values in tinnitus laterality and tinnitus sound.

Tinnitus and Its Relation to Depression, Anxiety, and Stress-A Population-Based Cohort Study

Tinnitus is a common symptom reported in otolaryngologic practice. Although the pathophysiology of tinnitus has not been fully understood, clinical studies suggest that psychological symptoms of depression, anxiety, and somatization are increased in tinnitus patients. However, patients seeking medical treatment for tinnitus may be especially vulnerable. Population-based studies reporting on the association between tinnitus and psychological distress are still lacking. The aim of this study was to investigate the correlation of tinnitus with depression, anxiety, or somatization in a large population-based cohort. The Gutenberg Health Study is a population-based cohort study. Participants were asked about the occurrence of tinnitus (yes/no) and how much they were bothered by it. In addition, they completed the PHQ-9, GAD-7, and SSS-8 questionnaires to assess depressive symptoms, anxiety, and somatic symptom disorders. A total of 8539 participants were included in the study cohort. Tinnitus prevalence was 28.0% (2387). The prevalence of depression/anxiety/somatic symptom disorders was significantly higher among participants with tinnitus than among participants without tinnitus (7.9%/5.4%/40.4% participants with tinnitus vs. 4.6%/3.3%/26.9% participants without tinnitus, p-value < 0.0001). Logistic regression results showed that participants with tinnitus were more likely to suffer from depression (OR = 2.033, 95% CI [1.584; 2.601], p-value < 0.0001), anxiety (OR = 1.841, 95% CI [1.228; 2.728], p-value = 0.0027), or somatic symptom disorders (OR = 2.057, 95% CI [1.799; 2.352], p-value < 0.0001). Symptoms of depression, anxiety, and somatic symptom disorders were increased in participants with tinnitus. This must be taken into account when treating these patients.

Correlation Between Tinnitus Handicap and Depression and Anxiety Scores

OBJECTIVES

This study aimed to analyse the correlation between depression, anxiety, and tinnitus handicap in patients with primary tinnitus.

METHODS

A total of 102 patients (41 men, 61 women; mean age ± SD: 56.8 ± 11.6 years) were examined. They completed the Tinnitus Handicap Inventory (THI), Beck Depression Inventory (BDI), and Symptom-Checklist-90-Revised (SCL-90-R). Correlations were analysed using Pearson's and Spearman's tests. Logistic regression analysis was performed.

RESULTS

The demographic data suggested a slight female predominance. The THI questionnaires indicated a worsening handicap in 73.5% of the patients, of which the 'mild' category was the most frequent, followed by severe handicaps. According to BDI, 69.6% of individuals fell in the normal category, with mild cases being the most frequent. Of the two psychiatric symptoms, depression (BDI) and tinnitus were strongly correlated (rho= 0.579, P < .0001*). The correlation was also significant according to the SCL-90-R depression questions (rho= 0.523, P < .0001*). Upon comparing the depressive scores and the THI subscores (i.e., functional, emotional, and catastrophic), each showed a significant correlation, with the strongest correlation with functional and emotional scores. The correlation with anxiety was slightly weaker (rho= 0.480, P < .0001*) but also significant. According to the Kaplan-Meier curves and logistic regression, the appearance of depressive symptoms did not significantly influence the appearance of a worsening handicap [P = .428; OR: 1.124 (95% CI: 0.842-1.501)]. However, a worsening handicap significantly influenced the appearance of depressive symptoms [P < .0001*; OR: 1.35 (95% CI: 1.34-4.86)], indicating that tinnitus has a more expressed effect on the appearance of depressive symptoms than reversed.

CONCLUSIONS

The correlation between tinnitus handicap and psychiatric comorbidities indicates the importance of psychological factors in tinnitus management. Tinnitus handicap has a more profound effect on depression scores. To avoid the occurrence of comorbidities, tinnitus handicaps must be reduced.

Hearing Aid Use Time Is Causally Influenced by Psychological Parameters in Mildly Distressed Patients with Chronic Tinnitus and Mild-to-Moderate Hearing Loss

Background: Hearing aids (HAs) can improve tinnitus-related distress (TRD) and speech-comprehension (SC) in silence or at 55 dB level of noise-interference (SC_55 dB) in patients with chronic tinnitus and mild-to-moderate hearing loss. However, the role of HA use time in relation to psychological, audiological, or self-reported tinnitus characteristics is an under-investigated area. Methods: We examine 177 gender-stratified patients before (t1) and after an intervention comprising binaural DSLchild algorithm-based HA fitting and auditory training (t2) and at a 70-day follow up [t3]. HA use time was retrospectively retrieved (at t2) for the pre-post- and (at t3) post-follow up periods. General linear models investigated HA use time in relation to (1) general audiological, (2) tinnitus-related audiological, (3) tinnitus-related self-report, and (4) distress-related self-report indices before and after treatment, where applicable. Receiver operator characteristic analyses identified optimal HA use time for hereby-mediated treatment changes. Results: At t1 and t2, psychological, but not audiological indices causally influenced prospective HA use time—except for SC_55 dB at t1, which, however, correlated with patients’ anxiety, depressivity, and psychological distress levels. Correlations did not differ between patient subgroups defined by categorical tinnitus-related audiological or self-report indices. HA use time partly mediated treatment-related improvement in TRD, but not SC. Optimal use amounted to 9.5–10.5 h/day. Conclusions: An awareness of psychological influences may help clinicians facilitate HA use and, thereby, TRD improvement with hearing amplification.

Disrupted intra- and inter-network connectivity in unilateral acute tinnitus with hearing loss

Purpose

Currently, the underlying neurophysiological mechanism of acute tinnitus is still poorly understood. This study aimed to explore differences in brain functional connectivity (FC) within and between resting-state networks (RSNs) in acute tinnitus patients with hearing loss (ATHL). Furthermore, it also evaluated the correlations between FC alterations and clinical characteristics.

Methods

Two matched groups of 40 patients and 40 healthy controls (HCs) were included. Independent component analysis (ICA) was employed to obtain RSNs and FC differences were calculated within RSNs. In addition, the relationships between networks were conducted using functional network connectivity (FNC) analysis. Finally, an analysis of correlation was used to evaluate the relationship between FNC abnormalities and clinical data.

Results

Results of this study found that seven major RSNs including the auditory network (AN), cerebellum network (CN), default mode network (DMN), executive control network (ECN), sensorimotor network (SMN), ventral attention network (VAN), and visual network (VN) were extracted using the group ICA in both groups. Furthermore, it was noted that the ATHL group showed aberrant FC within the CN, ECN, and VN as compared with HCs. Moreover, different patterns of network interactions were observed between groups, including the SMN-ECN, SMN-CN, ECN-AN, DMN-VAN, and DMN-CN connections. The correlations between functional disconnection and clinical characteristics in ATHL were also found in this study.

Conclusion

In conclusion, this study indicated widespread alterations of intra- and inter-network connectivity in ATHL, suggesting that multiple large-scale network dysfunctions and interactions are involved in the early stage. Furthermore, our findings may provide new perspectives to understand the neuropathophysiological mechanism of acute tinnitus.

Tinnitus and the triple network model: a perspective

Tinnitus is defined as the conscious awareness of a sound without an identifiable external sound source, and tinnitus disorder as tinnitus with associated suffering. Chronic tinnitus has been anatomically and phenomenologically separated into three pathways: a lateral “sound” pathway, a medial “suffering” pathway, and a descending noise-canceling pathway. Here, the triple network model is proposed as a unifying framework common to neuropsychiatric disorders. It proposes that abnormal interactions among three cardinal networks—the self-representational default mode network, the behavioral relevance-encoding salience network and the goal-oriented central executive network—underlie brain disorders. Tinnitus commonly leads to negative cognitive, emotional, and autonomic responses, phenomenologically expressed as tinnitus-related suffering, processed by the medial pathway. This anatomically overlaps with the salience network, encoding the behavioral relevance of the sound stimulus. Chronic tinnitus can also become associated with the self-representing default mode network and becomes an intrinsic part of the self-percept. This is likely an energy-saving evolutionary adaptation, by detaching tinnitus from sympathetic energy-consuming activity. Eventually, this can lead to functional disability by interfering with the central executive network. In conclusion, these three pathways can be extended to a triple network model explaining all tinnitus-associated comorbidities. This model paves the way for the development of individualized treatment modalities.

Vascular-Metabolic Risk Factors and Psychological Stress in Patients with Chronic Tinnitus

Little is known about molecular correlates of chronic tinnitus. We examined interrelationships between vascular−metabolic risk factors, perceived stress, and other routine blood values in patients with chronic tinnitus. Two-hundred patients (51% female) were screened for 49 blood parameters pertaining to vascular−metabolic risk, immune function, and redox processes. They further completed perceived stress- and tinnitus-related distress questionnaires. Following descriptive analyses, gender-specific sets of age- and tinnitus-severity-adjusted regression models investigated associations between perceived stress and blood parameters. Patients reported mildly elevated levels of perceived stress. Elevated levels of total cholesterol (65% and 61% of female and male patients, respectively), non-HDL-c (43/50%), LDL-c (56/59%), and lipoprotein_a (28/14%) were accompanied by high rates of overweight (99/100%) and smoking (28/31%). A low-level inflammatory state was accompanied by reduced reactive oxygen species (ROS)-neutralizing capacity (reduced co-enzyme Q10 and SOD1 levels). Most vascular risk factors were not correlated with perceived stress, except for fibrinogen (ß = −0.34) as well as C-reactive protein (ß = −0.31, p < 0.05) in men, and MCV (ß = −0.26, p < 0.05) in women. Interrelations between blood parameters and stress levels need to be investigated within psychobehavioural frameworks across varying distress levels. Alongside psychological interventions, a low-level inflammatory state may be a route for pharmacological therapeutics.

Higher Peripheral Inflammation Is Associated With Lower Orbitofrontal Gamma Power in Chronic Tinnitus

Chronic tinnitus, the continuous perception of a phantom sound, is a highly prevalent audiological symptom, for which the underlying pathology has not yet been fully understood. It is associated with neurophysiological alterations in the central nervous system and chronic stress, which can be related with a disinhibition of the inflammatory system. We here investigated the association between resting-state oscillatory activity assessed with Magnetoencephalography (MEG), and peripheral inflammation assessed by C-reactive protein (CRP) in a group of patients with chronic tinnitus (N = 21, nine males, mean age: 40.6 ± 14.6 years). Additionally, CRP was assessed in an age- and sex-matched healthy control group (N = 21, nine males, mean age: 40.9 ± 15.2 years). No MEG data was available for the control group. We found a significant negative correlation between CRP and gamma power in the orbitofrontal cortex in tinnitus patients (p < 0.001), pointing to a deactivation of the orbitofrontal cortex when CRP was high. No significant clusters were found for other frequency bands. Moreover, CRP levels were significantly higher in the tinnitus group than in the healthy controls (p = 0.045). Our results can be interpreted based on findings from previous studies having disclosed the orbitofrontal cortex as part of the tinnitus distress network. We suggest that higher CRP levels and the associated deactivation of the orbitofrontal cortex in chronic tinnitus patients is maintaining the tinnitus percept through disinhibition of the auditory cortex and attentional or emotional top-down processes. Although the direction of the association (i.e., causation) between CRP levels and orbitofrontal gamma power in chronic tinnitus is not yet known, inflammation reducing interventions are promising candidates when developing treatments for tinnitus patients. Overall, our study highlights the importance of considering immune-brain communication in tinnitus research.

The Road Traveled and Journey Ahead for the Genetics and Genomics of Tinnitus

The feasibility to unravel genetic and genomic signatures for disorders affecting the auditory system has accelerated since arriving in the post-genomics era roughly 20 years ago. Newly emerging studies have provided initial landmarks signaling heritability and thus, a genetic link, to severe tinnitus. Tinnitus, the phantom perception of ringing in the ears, is experienced by at least 15% of the adult population and can be extremely disabling. Despite its ubiquity, there is no cure for tinnitus and modalities offering relief are often of limited success. Because tinnitus is frequently reported in patients with acquired conductive or sensorineural hearing impairment, it has been widely accepted that tinnitus is secondary to and a symptom arising from hearing impairment. However, tinnitus has also been identified in the absence of auditory dysfunction and in young individuals, resulting in a debate about its origins. Genetics studies have identified severe tinnitus as a complex disorder arising from gene and environment interactions, refining its classification as a neurological disorder and, in at least a subset of patients, it appears not as a symptom of another health issue. This current opinion summarizes several recent studies that have challenged a long-accepted dogma and postulates how this information could eventually be used in the future to help patients. It is with great hope that this knowledge opens translational paths to provide relief for the many who suffer from the burden of tinnitus on a daily basis.

Audiometric Characteristics and Tinnitus Features in a Cohort of 170 Spanish Patients

BACKGROUND

Tinnitus is a rather prevalent, quite heterogeneous, and difficult to treat auditory disorder. The aim of this article is to provide the design and results of a cross-sectional study related to audiological and tinnitus features in a group of 170 Spanish patients.

METHODS

Audiometric characteristics were assessed on the basis of the pure-tone audiometry of both ears in 170 tinnitus patients and 85 control subjects. The audiometric status of each tinnitus participant was assessed on the basis of the average auditory threshold (AAT) in the whole frequency range (from 125 Hz to 8 kHz), and low (from 125 Hz to 2 kHz) and high (from 3 kHz to 8 kHz)-frequency intervals. Tinnitus features were evaluated through personal interview with patients and included tinnitus duration, laterality, pitch, sound, and distress (Tinnitus Handicap Inventory, THI). Correlational analysis was carried out between audiological (AAT) and tinnitus (THI) variables.

RESULTS

A very weak Spearman rank correlation factor is found between both variables.

CONCLUSIONS

The subjective outcome of tinnitus distress (THI) was not correlated with the objective measure of hearing loss (AAT) in our cohort.

Cerebral Blood Flow Difference Between Acute and Chronic Tinnitus Perception: A Perfusion Functional Magnetic Resonance Imaging Study

Purpose: The central nervous mechanism of acute tinnitus is different from that of chronic tinnitus, which may be related to the difference of cerebral blood flow (CBF) perfusion in certain regions. To verify this conjecture, we used arterial spin labeling (ASL) perfusion magnetic resonance imaging (MRI) in this study to compare the CBF alterations of patients with acute and chronic tinnitus. Methods: The current study included patients with chronic tinnitus (n = 35), acute tinnitus (n = 30), and healthy controls (n = 40) who were age-, sex-, and education-matched. All participants underwent MRI scanning and then ASL images were obtained to measure CBF of the entire brain and analyze the differences between groups as well as the correlations with tinnitus characteristics. Results: The chronic tinnitus group showed increased z-CBF in the right superior temporal gyrus (STG) and superior frontal gyrus (SFG) when compared with the acute tinnitus patients. Further connectivity analysis found enhanced CBF connectivity between the right STG and fusiform gyrus (FG), the right SFG and left middle occipital gyrus (MOG), as well as the right parahippocampal gyrus (PHG). Moreover, in the chronic tinnitus group, the tinnitus handicap questionnaire (THQ) score was positively correlated with the normalized z-CBF of right STG (r = 0.440, p = 0.013). Conclusion: Our results confirmed that the CBF changes in some brain regions were different between acute and chronic tinnitus patients, which was correlated with certain tinnitus characteristics. This is of great value to further research on chronicity of tinnitus, and ASL has a promising application in the measurement of CBF.

Genetic predisposition to tinnitus in the UK Biobank population

Tinnitus, the phantom perception of noise originating from the inner ear, has been reported by 15% of the world's population, with many patients reporting major deficits to cognition and mood. However, both objective diagnostic tools and targeted therapeutic strategies have yet to be established. To better understand the underlying genes that may preclude tinnitus, we performed a genome-wide association study of the UK Biobank's 49,960 whole exome sequencing participants to identify any loci strongly associated with tinnitus. We identified 17 suggestive single nucleotide polymorphisms (p < 1e-5) spanning 13 genes in two sex-separated cohorts reporting chronic, bothersome tinnitus (control males n = 7,315, tinnitus males n = 226, control females n = 11,732, tinnitus females n = 300). We also found a significant missense mutation in WDPCP (p = 3.959e-10) in the female cohort, a mutation which has been previously implicated in typical neuronal functioning through axonal migration and structural reinforcement, as well as in Bardet-Biedl syndrome-15, a ciliopathy. Additionally, in situ hybridization in the embryonic and P56 mouse brain demonstrated that the majority of these genes are expressed within the dorsal cochlear nucleus, the region of the brain theorized to initially induce tinnitus. Further RT-qPCR and RNAScope data also reveals this expression pattern. The results of this study indicate that predisposition to tinnitus may span across multiple genomic loci and be established by weakened neuronal circuitry and maladaptive cytoskeletal modifications within the dorsal cochlear nucleus.

Health-Related Quality of Life, Depressive Symptoms, Anxiety, and Somatization Symptoms in Male and Female Patients with Chronic Tinnitus

Objective: To investigate the joint impact of tinnitus-related distress (TRD), anxiety, depressive symptoms, and other somatization symptoms on health-related quality of life (HRQoL) in female vs. male patients with chronic tinnitus. Method: Three-hundred-and-fifty-two patients with chronic tinnitus completed audiological testing and a psychological assessment battery that comprised—among other measures—German versions of the Tinnitus Questionnaire, Hospital Anxiety and Depression Scale, Somatic Symptom Scale-8, and Health-Related Quality of Life scale. Descriptive analyses examined associations as well as within- and between-gender differences of the measured variables. Gender-specific serial indirect effects analyses aimed to explain the impact of TRD on HRQoL through psychological processes, notably anxiety, depressive symptoms, and somatization symptoms. Results: Both female and male patients yielded lower mental than physical HRQoL and negative associations between the measured psychological variables and HRQoL. Compared to male patients, female patients reported higher levels of tinnitus-related- and wider psychological distress, other somatization symptoms (e.g., headaches), and impairments in mental and physical HRQoL. For each gender, depressive symptoms, anxiety, and somatization symptoms fully mediated the effect of TRD on mental and physical HRQoL. A double-dissociation revealed an interaction of somatization symptoms and depression on the TRD-HRQoL association in women, and of somatization symptoms and anxiety in men. Conclusions: In patients with chronic tinnitus, psychological constructs account for reported impairments in both mental and physical HRQoL. To improve patients’ HRQoL, treatment conceptualizations should consider gender-specific psychological expressions of low mood or anxiety.

Analysis of Auditory Brainstem Response Change, according to Tinnitus Duration, in Patients with Tinnitus with Normal Hearing

OBJECTIVES

The purpose of this study was to analyze auditory brainstem response (ABR) waveforms of patients with tinnitus with normal hearing, according to tinnitus duration, and demonstrate the possible pathophysiological mechanisms of tinnitus.

MATERIALS AND METHODS

From January 2016 to December 2017, patients who presented to our hospital with tinnitus as their chief complaint were enrolled and reviewed retrospectively. Pure tone audiometry and ABR tests were performed. The patients were classified into three groups according to tinnitus duration: acute (<1 month), subacute (1-6 months), and chronic (>6 months). The amplitudes of waves I and V and the latencies of waves I, III, and V were evaluated. In this study, 177 ears of 128 patients with tinnitus with normal hearing were evaluated.

RESULTS

Wave V amplitude was significantly lower during the subacute phase than during the acute phase. The absolute latency value of wave V was greater during the subacute phase than during the acute phase. The interpeak latency I-V was significantly prolonged during the subacute phase compared with the acute and chronic phases. Wave V amplitude, wave V absolute latency, and interpeak latency I-V varied significantly between cases with a 1-month and 6-month tinnitus history.

CONCLUSION

The compensatory response to tinnitus decreased sharply after 1 month of symptoms. Early tinnitus identification and treatment initiation are recommended.

Co-occurrence of Hyperacusis Accelerates With Tinnitus Burden Over Time and Requires Medical Care

Although tinnitus represents a major global burden, no causal therapy has yet been established. Ongoing controversies about the neuronal pathophysiology of tinnitus hamper efforts in developing advanced therapies. Hypothesizing that the unnoticed co-occurrence of hyperacusis and differences in the duration of tinnitus may possibly differentially influence the neural correlate of tinnitus, we analyzed 33 tinnitus patients without (T-group) and 20 tinnitus patients with hyperacusis (TH-group). We found crucial differences between the T-group and the TH-group in the increase of annoyance, complaints, tinnitus loudness, and central neural gain as a function of tinnitus duration. Hearing thresholds did not differ between T-group and TH-group. In the TH-group, the tinnitus complaints (total tinnitus score) were significantly greater from early on and the tinnitus intensity distinctly increased over time from ca. 12 to 17 dB when tinnitus persisted more than 5 years, while annoyance responses to normal sound remained nearly constant. In contrast, in the T-group tinnitus complaints remained constant, although the tinnitus intensity declined over time from ca. 27 down to 15 dB beyond 5 years of tinnitus persistence. This was explained through a gradually increased annoyance to normal sound over time, shown by a hyperacusis questionnaire. Parallel a shift from a mainly unilateral (only 17% bilateral) to a completely bilateral (100%) tinnitus percept occurred in the T-group, while bilateral tinnitus dominated in the TH-group from the start (75%). Over time in the T-group, ABR wave V amplitudes (and V/I ratios) remained reduced and delayed. By contrast, in the TH-group especially the ABR wave III and V (and III/I ratio) continued to be enhanced and shortened in response to high-level sound stimuli. Interestingly, in line with signs of an increased co-occurrence of hyperacusis in the T-group over time, ABR wave III also slightly increased in the T-group. The findings disclose an undiagnosed co-occurrence of hyperacusis in tinnitus patients as a main cause of distress and the cause of complaints about tinnitus over time. To achieve urgently needed and personalized therapies, possibly using the objective tools offered here, a systematic sub-classification of tinnitus and the co-occurrence of hyperacusis is recommended.

All for One and One for All? - Examining Convergent Validity and Responsiveness of the German Versions of the Tinnitus Questionnaire (TQ), Tinnitus Handicap Inventory (THI), and Tinnitus Functional Index (TFI)

BACKGROUND

Measurement of tinnitus-related distress and treatment responsiveness is key in understanding, conceptualizing and addressing this often-disabling symptom. Whilst several self-report measures exist, the heterogeneity of patient populations, available translations, and treatment contexts requires ongoing psychometric replication and validation efforts.

OBJECTIVE

To investigate the convergent validity and responsiveness of the German versions of the Tinnitus Questionnaire [TQ], Tinnitus Handicap Inventory [THI], and Tinnitus Functional Index [TFI] in a large German-speaking sample of patients with chronic tinnitus who completed a psychologically anchored 7-day Intensive Multimodal Treatment Programme.

METHODS

Two-hundred-and-ten patients with chronic tinnitus completed all three questionnaires at baseline and post-treatment. Intraclass correlation coefficients determined the convergent validity of each questionnaire's total and subscale scores. Treatment responsiveness was investigated by [a] comparing treatment-related change in responders vs. non-responders as classified by each questionnaire's minimal clinically important difference-threshold, and [b] comparing agreement between the questionnaires' responder classifications.

RESULTS

The total scores of all three questionnaires showed high agreement before and after therapy (TQ | THI: 0.80 [Pre], 0.83 [Post], TQ | TFI: 0.72 [Pre], 0.78 [Post], THI | TFI: 0.76 [Pre] 0.80 [Post]). All total scores changed significantly with treatment yielding small effect sizes. The TQ and TFI yielded comparable (19.65 and 18.64%) and the THI higher responder rates (38.15%). The TQ | THI and TQ | TFI showed fair, and the THI | TFI moderate agreement of responder classifications. Independent of classification, responders showed significantly higher change rates than non-responders across most scores. Each questionnaire's total change score distinguished between responders and non-responders as classified by the remaining two questionnaires.

CONCLUSION

The total scores of all three questionnaires show high convergent validity and thus, comparability across clinical and research contexts. By contrast, subscale scores show high inconsistency. Whilst the TFI appears well suited for research purposes, the THI may be better suited to measure psychological aspects of tinnitus-related distress and their changes with accordingly focused treatment approaches.

Psychological Comorbidities of Tinnitus

In this chapter, I address the topic of tinnitus in the context of the patient's trajectory of care, with special attention to psychological comorbidities. Although most patients will cope with tinnitus and need no more than information and reassurance from professionals, a proportion of patients will need more supportive management. Assessment of psychological comorbidities is important to determine how urgent they should be seen in the clinic and their specific needs. The most frequent complaints are stress, depression, and anxiety. Although the direction of this relationship is still unclear (are comorbidities at the origin of tinnitus or are they a consequence of it), it is evident that the more serious comorbidities are at the onset of tinnitus, the worse the prognosis. Therefore, an assessment at the initial visit in the clinic is of utmost importance. There are valid and reliable psychometric tools to quickly draw a portrait of the psychological state of patients that can be used by audiologists, psychologists, or doctors. Therapeutic avenues can then be discussed with the patients to ensure them the best support possible.

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

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

What Makes Tinnitus Loud?

INTRODUCTION

Tinnitus loudness is a subjective measure, and it does not directly reflect either tinnitus severity or the impact on daily life. Nevertheless, loud tinnitus may be the most frequent clinical complaint of tinnitus patients. Factors contributing to the loudness of the phantom sound have rarely been studied. We evaluated both matched and self-rated loudness in a large sample of patients with tinnitus and analyzed the influencing factors among demographic, hearing, and tinnitus characteristics.

METHODS

Two hundred ninety-nine patients with chronic tinnitus were enrolled. We evaluated the matched loudness, minimal masking level (MML), and visual analog scale (VAS) loudness. Stepwise multiple regression analyses were performed for each loudness measure using independent variables of age, sex, time since tinnitus onset, tinnitus laterality, pure-tone average, tinnitus pitch, tinnitus handicap inventory (THI) score, VAS annoyance, disturbance and daily tinnitus duration, and depression score. We calculated bivariate correlations between each loudness measure and all independent variables.

RESULTS

The psychoacoustic loudness measures (matched loudness and MML) were highly correlated and were affected by the hearing deficit and tinnitus pitch (Pearson r > 0.5 for pure tone averages, and r > 0.3 for tinnitus pitch for both variables, p < 0.05), whereas the subjective measurement (VAS loudness) exhibited little to no correlation with the other two measures and was related to psycho-emotional factors such as the THI score, VAS variables, and depression (Pearson r > 0.6 for VAS annoyance, r > 0.4 for VAS daily duration and disturbance and THI score, r > 0.3 for the depression score, p < 0.05).

CONCLUSION

The matched tinnitus loudness and MML values were influenced principally by the extent of hearing loss and related factors, suggesting that rehabilitation using hearing aids could help reduce perception of tinnitus loudness. A psycho-emotional approach might more effectively lessen self-perceived loudness.

Tinnitus and tinnitus disorder: Theoretical and operational definitions (an international multidisciplinary proposal)

As for hypertension, chronic pain, epilepsy and other disorders with particular symptoms, a commonly accepted and unambiguous definition provides a common ground for researchers and clinicians to study and treat the problem. The WHO's ICD11 definition only mentions tinnitus as a nonspecific symptom of a hearing disorder, but not as a clinical entity in its own right, and the American Psychiatric Association's DSM-V doesn't mention tinnitus at all. Here we propose that the tinnitus without and with associated suffering should be differentiated by distinct terms: "Tinnitus" for the former and "Tinnitus Disorder" for the latter. The proposed definition then becomes "Tinnitus is the conscious awareness of a tonal or composite noise for which there is no identifiable corresponding external acoustic source, which becomes Tinnitus Disorder "when associated with emotional distress, cognitive dysfunction, and/or autonomic arousal, leading to behavioural changes and functional disability.". In other words "Tinnitus" describes the auditory or sensory component, whereas "Tinnitus Disorder" reflects the auditory component and the associated suffering. Whereas acute tinnitus may be a symptom secondary to a trauma or disease, chronic tinnitus may be considered a primary disorder in its own right. If adopted, this will advance the recognition of tinnitus disorder as a primary health condition in its own right. The capacity to measure the incidence, prevalence, and impact will help in identification of human, financial, and educational needs required to address acute tinnitus as a symptom but chronic tinnitus as a disorder.

Tinnitus Update

This article provides an update on tinnitus for audiologists and other clinicians who provide tinnitus-specific services. Tinnitus can be attributable to hearing loss, somatosensory system dysfunction, or auditory cortex dysfunction, with hearing loss being the most common cause and serious underlying pathologies being rare. Hearing loss does not always lead to tinnitus, and patients with tinnitus do not always suffer from hearing loss. The first scenario is explained by a so-called inhibitory gating mechanism, whereas the second assumes that all tinnitus sufferers have some degree of hearing impairment, which might not be detected in standard audiological examinations. The treatments should aim at symptomatic relief and management of associated distress. Current treatment options include pharmacotherapy, education, counseling, cognitive behavioral therapy, and sound therapy.

Cannabinoids, Inner Ear, Hearing, and Tinnitus: A Neuroimmunological Perspective

Cannabis has been used for centuries for recreational and therapeutic purposes. Whereas, the recreative uses are based on the psychotropic effect of some of its compounds, its therapeutic effects range over a wide spectrum of actions, most of which target the brain or the immune system. Several studies have found cannabinoid receptors in the auditory system, both at peripheral and central levels, thus raising the interest in cannabinoid signaling in hearing, and especially in tinnitus, which is affected also by anxiety, memory, and attention circuits where cannabinoid effects are well described. Available studies on animal models of tinnitus suggest that cannabinoids are not likely to be helpful in tinnitus treatment and could even be harmful. However, the pharmacology of cannabinoids is very complex, and most studies focused on neural CB1R-based responses. Cannabinoid effects on the immune system (where CB2Rs predominate) are increasingly recognized as essential in understanding nervous system pathological responses, and data on immune cannabinoid targets have emerged in the auditory system as well. In addition, nonclassical cannabinoid targets (such as TRP channels) appear to play an important role in the auditory system as well. This review will focus on neuroimmunological mechanisms for cannabinoid effects and their possible use as protective and therapeutic agents in the ear and auditory system, especially in tinnitus.

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

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

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

Purpose

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

Methods

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

Results

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

Conclusion

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

Tinnitus-related distress and pain perceptions in patients with chronic tinnitus - Do psychological factors constitute a link?

OBJECTIVE

To investigate the co-occurrence of tinnitus-related distress and pain experiences alongside psychological factors that may underlie their association.

METHOD

Patients with chronic tinnitus (N = 1238) completed a questionnaire battery examining tinnitus-related distress and affective and sensory pain perceptions. A series of simple, parallel- and serial multiple mediator models examined indirect effects of psychological comorbidities as well as -process variables including depressivity, perceived stress and coping attitudes. Moderator and moderated mediation analyses examined differential relational patterns in patients with decompensated vs. compensated tinnitus.

RESULTS

There were significant associations between tinnitus-related distress and pain perceptions. These were partially mediated by most specified variables. Psychological comorbidities appeared to influence tinnitus-pain associations through their impact on depressivity, perceived stress, and coping attitudes. Some specific differences in affective vs. sensory pain perception pathways emerged. Patients with decompensated tinnitus yielded significantly higher symptom burden across all measured indices. Tinnitus decompensation was associated with heightened associations between [1] tinnitus-related distress and pain perceptions, depressivity and negative coping attitudes; and [2] most psychological comorbidities and sensory, but not affective pain perception. Moderated mediation analyses revealed stronger indirect effects of depressivity and anxiety in mediating affective-, and anxiety in mediating sensory pain perception in patients with decompensated tinnitus.

CONCLUSION

Psychological constructs mediate the co-occurrence of tinnitus- and pain-related symptoms across different levels of tinnitus-related distress. Psychological treatment approaches should conceptualize and address individualised interactions of common cognitive-emotional processes in addressing psychosomatic symptom clusters across syndromatic patients with varying distress levels.

Perception of, and Reaction to, Tinnitus: The Depression Factor

Tinnitus is the perception of a self-generated sound and an individual's psychological reaction to it. This article discusses one element of the reaction: depression. Epidemiologic studies have noted high comorbidity of tinnitus and depression. Findings from recent brain imaging studies have noted shared neural networks in depression and severe tinnitus. As further evidence of this overlaps, antidepressants, counseling, and psychology-based approaches have been used to treat tinnitus. Multifaceted treatment strategies, using both sound-based therapies (not discussed in this paper) and psychology-based approaches, are a necessary part of the treatment options, with the aim of enhancing self-efficacy in patients with tinnitus.

The Experience of Tinnitus and Its Interaction With Unique Life Histories-Life Events, Trauma and Inner Resources Narrated by Patients With Tinnitus

Background: The challenges facing people with chronic tinnitus include finding relief and rebuilding quality of life. However, previous traumatic episodes may influence adjustment and prolong suffering. Recovery implies reducing aggravating reactions and improving social roles, relationships and interests. Self-narratives about living with tinnitus have not yet received the attention they deserve in the research literature. Thus, the main goal of the present study was to illustrate how tinnitus suffering interacts with the participants' unique life histories. Method: Four women and one man (ages 52-58) took part in the study after consulting a special hearing clinic for annoying tinnitus. Criteria for inclusion were that tinnitus was regarded as a problem with negative consequences for quality of life. The participants should be willing to share how the experience of tinnitus suffering interacts with their previous life story. Narrative methodology was employed in order to achieve the goals of the study. We used unstructured interviews with free conversation, which allowed for rich narratives with full contextual meaning. Results: The findings, based on the narrative analysis, revealed that three out of five participants presented a regressive form of narrative indicating ongoing struggles beyond tinnitus itself, which they were unable to bring to closure. For them, valued goals were continuously thwarted by frustrating circumstances in their lives, either past events or current unresolved issues. Progressive and stable narratives, as identified in the other two participants, demonstrated values that rely on others' attitude and understanding toward their suffering, in sharp contrast to the regressive narratives. We suggest that a central issue in tinnitus rehabilitation should be to help suffering patients to overcome unresolved conflicts and thereby extend their ability for a fuller commitment in life. Conclusion: Considering enduring tinnitus as a chronic condition, whose course is likely to vary depending on the patient's general health status, an alteration of progressive and stable narratives is likely to occur during the lifespan. A progressive narrative shows similarities to the core construct of the salutogenesis model of health promotion (1). In conclusion, a narrative approach in tinnitus rehabilitation can be health promoting by offering the patient the opportunity to engage in storytelling, which in turn can increase comprehensibility and a sense of coherence.

Analysis of the audiological characteristics and comorbidity in patients with chronic tinnitus

Tinnitus is defined as perception of a sound without sound stimulation. This study aims to investigate the correlation between chronic tinnitus and the most significant clinical comorbidities and pharmacological treatments. We recruited 130 consecutive outpatients with a tinnitus for least from three months and 100 subjects without tinnitus. All patients had a full medical and audiological evaluation and all filled in Tinnitus Handicap Inventory questionnaire and Khalfa’s Hyperacusis questionnaire. We also analyzed the qualitative variables: audiometry exam, tinnitus characteristics and psychometric questionnaires. Univariate logistic regression was performed to evaluate the associations between the presence of tinnitus and the presence of comorbidities and drug intake. The statistical analysis provided the following results in the group of patients with tinnitus. We obtained an Odds Ratio statistically significant for the following categories taken into consideration: the presence of anxiety and depression, neurological diseases, headache, temporomandibular joint (TMJ) disorders, intake of levothyroxine and proton-pump inhibitor. In this study, we tried to evaluate the audiological characteristics in the subjects affected by chronic tinnitus in order to find a possible correlation with the comorbidities and any drugs intake. We found a statistically significant correlation between tinnitus and comorbidities like anxiety, depression, TMJ disorders, dysthyroidism, headache and levothyroxine and PPI intake.

Tinnitus in the side with better hearing

OBJECTIVES

We aimed to confirm the characteristics of patients with tinnitus in the better-hearing side.

MATERIALS AND METHODS

Among the 778 patients who visited the tinnitus clinic complaining of unilateral tinnitus at a local university hospital between March 2014 and December 2017, we recruited 62 patients who showed tinnitus in the better-hearing side on pure-tone audiometry. The mean hearing threshold was calculated using the arithmetic mean of the pure tone thresholds at 1, 2, 3, and 4 kHz. In addition, patients' medical history, tinnitus questionnaires, and other audiologic test results were thoroughly analyzed together for diagnosis.

RESULTS

Fluctuating hearing loss without vertigo or Ménière's disease were the most common etiologies (n = 16, 25.8%), followed by high-frequency hearing loss (n = 13, 21.0%), sudden idiopathic hearing loss (n = 6, 9.7%), and presbycusis (n = 6, 9.7%). Somatosensory tinnitus was also observed in seven patients. Neck pain was associated with tinnitus in five patients (8.1%), and two other patients (3.2%) experienced temporomandibular disorder in the same side as the tinnitus.

CONCLUSION

Tinnitus was associated with deterioration of hearing even when it occurred in the better-hearing side. Among the possible etiologies, fluctuating hearing loss in the tinnitus side was the most common audiologic finding. Assessment of hearing level at each frequency was more effective in detecting high-frequency hearing loss rather than the use of the mean hearing level. In addition, somatosensory tinnitus should not be ignored.

Prediction and perception: Insights for (and from) tinnitus

More than 150 years have passed since Helmholtz first described perception as a process of unconscious inference about the causes of sensations. His ideas have since inspired a wealth of literature investigating the mechanisms underlying these inferences. In recent years, much of this work has converged on the notion that the brain is a hierarchical generative model of its environment that predicts sensations and updates itself based on prediction errors. Here, we build a case for modeling tinnitus from this perspective, i.e. predictive coding. We emphasize two key claims: (1) acute tinnitus reflects an increase in sensory precision in related frequency channels and (2) chronic tinnitus reflects a change in the brain's default prediction. We further discuss specific neural biomarkers that would constitute evidence for or against these claims. Finally, we explore the implications of our model for clinical intervention strategies. We conclude that predictive coding offers the basis for a unifying theory of cognitive neuroscience, which we demonstrate with several examples linking tinnitus to other lines of brain research.

Aberrant thalamocortical coherence in an animal model of tinnitus

Electrophysiological and imaging studies from humans suggest that the phantom sound of tinnitus is associated with abnormal thalamocortical neural oscillations (dysrhythmia) and enhanced gamma band activity in the auditory cortex. However, these models have seldom been tested in animal models where it is possible to simultaneously assess the neural oscillatory activity within and between the thalamus and auditory cortex. To explore this issue, we used multichannel electrodes to examine the oscillatory behavior of local field potentials recorded in the rat medial geniculate body (MBG) and primary auditory cortex (A1) before and after administering a dose of sodium salicylate (SS) that reliably induces tinnitus. In the MGB, SS reduced theta, alpha, and beta oscillations and decreased coherence (synchrony) between electrode pairs in theta, alpha, and beta bands but increased coherence in the gamma band. Within A1, SS significantly increased gamma oscillations, decreased theta power, and decreased coherence between electrode pairs in theta and alpha bands but increased coherence in the gamma band. When coherence was measured between one electrode in the MGB and another in A1, SS decreased coherence in beta, alpha, and theta bands but increased coherence in the gamma band. SS also increased cross-frequency coupling between the phase of theta oscillations in the MGB and amplitude of gamma oscillations in A1. Altogether, our results suggest that SS treatment fundamentally alters the manner in which thalamocortical circuits communicate, leading to excessive cortical gamma power and synchronization, neurophysiological changes implicated in tinnitus. Our data provide support for elements of both the thalamocortical dysrhythmia (TD) and synchronization by loss of inhibition (SLIM) models of tinnitus, demonstrating that increased cortical gamma band activity is associated with both enhanced theta-gamma coupling as well as decreases alpha power/coherence between the MGB and A1. NEW & NOTEWORTHY There are no effective drugs to alleviate the phantom sound of tinnitus because the physiological mechanisms leading to its generation are poorly understood. Neural models of tinnitus suggest that it arises from abnormal thalamocortical oscillations, but these models have not been extensively tested. This article identifies abnormal thalamocortical oscillations in a drug-induced tinnitus model. Our findings open up new avenues of research to investigate whether cellular mechanisms underlying thalamocortical oscillations are causally linked to tinnitus.