Tinnitus Questionnaire Research Articles

Changes in motor cortex excitability associated with temporal repetitive transcranial magnetic stimulation in tinnitus: hints for cross-modal plasticity?

BackgroundMotor cortex excitability was found to be changed after repetitive transcranial magnetic stimulation (rTMS) of the temporal cortex highlighting the occurrence of cross-modal plasticity in non-invasive brain stimulation. Here, we investigated the effects of temporal low-frequency rTMS on motor cortex plasticity in a large sample of tinnitus patients. In 116 patients with chronic tinnitus different parameters of cortical excitability were assessed before and after ten rTMS treatment sessions. Patients received one of three different protocols all including 1 Hz rTMS over the left temporal cortex. Treatment response was defined as improvement by at least five points in the tinnitus questionnaire (TQ). Variables of interest were resting motor threshold (RMT), short-interval intra-cortical inhibition (SICI), intracortical facilitation (ICF), and cortical silent period (CSP).ResultsAfter rTMS treatment RMT was decreased by about 1% of stimulator output near-significantly in the whole group of patients. SICI was associated with significant changes with respect to treatment response. The group of treatment responders showed a decrease of SICI over the course of treatment, the group of non-responders the reverse pattern.ConclusionsMinor RMT changes during rTMS treatment do not necessarily suggest the need for systematic re-examination of the RMT for safety and efficacy issues. Treatment response to rTMS was shown to be related to changes in SICI that might reflect modulation of GABAergic mechanisms directly or indirectly related to rTMS treatment effects.

Tinnitus

Patients visiting the department of Otorhinolaryngology-Head and Neck Surgery often recite tinnitus as the primary complaint. Frequently, tinnitus is accompanied by other symptoms such as hyperacusis and hearing loss. The present study is a cross-sectional study analyzing the relationships between tinnitus, hearing loss, and hyperacusis by the use of the audiologic measurements performed in a clinical practice. All patients visiting the Otorhinolaryngology-Head and Neck Surgery department of the University Hospital Antwerp with complaints of tinnitus (sometimes accompanied by hyperacusis) during the year of 2012, were looked up (n = 588). All patients underwent audiometry and filled out the Tinnitus Questionnaire (TQ) and Hyperacusis Questionnaire (HQ), and tinnitus analysis was performed. The relationships between all measurements were examined by use of correlations, multinomial logistic regression analyses, and descriptive statistics. Scores on the TQ and HQ were significantly positively correlated (r = 0.5, p < 0.001). In general, patients with a combination of tinnitus and hyperacusis showed significantly higher TQ scores (p < 0.001) and higher ratings on the VAS for loudness and distress (p < 0.001) compared with tinnitus patients without hyperacusis. Furthermore, an age-dependent influence on the audiometric configuration and tinnitus type was found. Tinnitus and hyperacusis are two frequent symptoms recited at a consultation. The present study found that patients with a high TQ grade more often also perceive hyperacusis compared with patients with a low TQ grade. Tinnitus and hyperacusis are two frequent symptoms recited at a consultation. We have to point out that also other issues, such as additional health problems and stress, may influence tinnitus severity. In addition, tinnitus type seems to be age dependent as younger patients more often experience a pure tone tinnitus and older patients more often experience a noise-like tinnitus.

Combining Transcranial Direct Current Stimulation and Tailor-Made Notched Music Training to Decrease Tinnitus-Related Distress – A Pilot Study

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

Chronischer Stress als Einflussgröße bei Tinnituspatienten

Using the Trier Stress Inventory and based on a comparison between tinnitus and psoriasis patients, it is evaluated to what extent chronic stress is a definable influencing factor among tinnitus sufferers Psychological assessment of 114 tinnitus and 103 psoriasis inpatients was conducted using a test battery consisting of the tinnitus questionnaire (Tinnitus-Fragebogen, TF), the Trier Stress Inventory (Trierer Inventar zum chronischen Stress, TICS), a questionnaire about social support (Fragebogen zur sozialen Unterstützung, F-SozU) and the Patient Health Questionnaire (PHQ). On average, hospitalized tinnitus patients have significantly higher values than the normative group on the following scales: social tensions, excessive work demands, chronic anxiety, professional strain, professional discontent, lack of social acceptance and social isolation, as well as on the overall screening scale. The measured stress values of tinnitus patients did not significantly differ from those of the comparison group, i.e. the hospitalized psoriasis patients. Although both groups show increased stress levels as measured by TICS, the hospitalized tinnitus patients had significantly more psychological comorbidities. No relationship exists between the raised stress values and hearing status. Stress also has an influence on tinnitus suffering and is therefore certain to be of therapeutic relevance. In this respect, there is no significant difference between tinnitus and psoriasis patients; stress alone cannot explain the psychological comorbidity.

Amplification with hearing aids for patients with tinnitus and co-existing hearing loss.

Tinnitus is described as the perception of sound or noise in the absence of real acoustic stimulation. In the current absence of a cure for tinnitus, clinical management typically focuses on reducing the effects of co-morbid symptoms such as distress or hearing loss. Hearing loss is commonly co-morbid with tinnitus and so logic implies that amplification of external sounds by hearing aids will reduce perception of the tinnitus sound and the distress associated with it. To assess the effects of hearing aids specifically in terms of tinnitus benefit in patients with tinnitus and co-existing hearing loss. We searched the Cochrane Ear, Nose and Throat Disorders Group Trials Register; the Cochrane Central Register of Controlled Trials (CENTRAL); PubMed; EMBASE; CINAHL; Web of Science; Cambridge Scientific Abstracts; ICTRP and additional sources for published and unpublished trials. The date of the search was 19 August 2013. Randomised controlled trials and non-randomised controlled trials recruiting adults with subjective tinnitus and some degree of hearing loss, where the intervention involves amplification with hearing aids and this is compared to interventions involving other medical devices, other forms of standard or complementary therapy, or combinations of therapies, no intervention or placebo interventions. Three authors independently screened all selected abstracts. Two authors independently extracted data and assessed those potentially suitable studies for risk of bias. For studies meeting the inclusion criteria, we used the mean difference (MD) to compare hearing aids with other interventions and controls. One randomised controlled trial (91 participants) was included in this review. We judged the trial to have a low risk of bias for method of randomisation and outcome reporting, and an unclear risk of bias for other criteria. No non-randomised controlled trials meeting our inclusion criteria were identified. The included study measured change in tinnitus severity (primary measure of interest) using a tinnitus questionnaire measure, and change in tinnitus loudness (secondary measure of interest) on a visual analogue scale. Other secondary outcome measures of interest, namely change in the psychoacoustic characteristics of tinnitus, change in self reported anxiety, depression and quality of life, and change in neurophysiological measures, were not investigated in this study. The included study compared hearing aid use to sound generator use. The estimated effect on change in tinnitus loudness or severity as measured by the Tinnitus Handicap Inventory score was compatible with benefits for both hearing aids or sound generators but no difference was found between the two alternative treatments (MD -0.90, 95% confidence interval (CI) -7.92 to 6.12) (100-point scale); moderate quality evidence. No negative or adverse events were reported. The current evidence base for hearing aid prescription for tinnitus is limited. To be useful, future studies should make appropriate use of blinding and be consistent in their use of outcome measures. Whilst hearing aids are sometimes prescribed as part of tinnitus management, there is currently no evidence to support or refute their use as a more routine intervention for tinnitus.

Erratum to: Onset-related differences in neural substrates of tinnitus-related distress: the anterior cingulate cortex in late-onset tinnitus, and the frontal cortex in early-onset tinnitus

Recent findings regarding differences in tinnitus-related neural activity according to onset age have raised a question on possible onset age-related differences in neural substrates of distress. Hence we collected quantitative electroencephalography (qEEG) findings of 28 late-onset tinnitus (LOT) and 29 early-onset tinnitus (EOT) (mean onset age 52.3 and 29.0 years, respectively) participants. According to the tinnitus questionnaire (TQ) score grade, LOTs were then subdivided into 13 high distress (HD; TQ grade 3 or 4) and 15 low distress (LD; TQ grade 1 or 2), while EOTs into 14 HD and 15 LD. Compared to the EOT group, the LOT group demonstrated increased qEEG source-localized activity and functional connectivity primarily in the anterior cingulate cortex (ACC) and parahippocampus. In subgroup comparisons, the ACC was activated more in HD-LOT participants than in LD-LOT participants for the beta 1, beta 2 and gamma frequency bands, while the left orbitofrontal cortex and left dorsolateral prefrontal cortex were activated more in HD-EOT than in LD-EOT for the delta/beta and gamma frequency bands, respectively. Even with the same amount of tinnitus-related distress level, responsible neural substrates are different according to the onset age. These differences may be important for exploring different target areas of treatment according to tinnitus onset age, as well as for conducting similar studies on other pathologies, such as depression or pain.

Changes over time of psychoacoustic outcome measurements are not a substitute for subjective outcome measurements in acute tinnitus

The aim of this study was to assess correlations between the changes over time of various tinnitus measurements. A longitudinal prospective study comparing two test moments was performed: before treatment and after 90 days. Tinnitus assessment consisted of psychoacoustic outcome measurements (minimal masking level and loudness matching at 1 kHz) and subjective outcome measurements (Tinnitus Impairment Questionnaire, Tinnitus Questionnaire and Numeric Rating Scale of loudness and annoyance). Additionally, the effect size was measured. 35 subjects were included in this study. The subjects had a permanent, non-pulsatile tinnitus acquired <3 months previously. Weak or no significant correlations were found between ∆psychoacoustic outcome measurements and ∆subjective outcome measurements. The effect size showed that subjective outcome measurements were the most responsive to measure change in tinnitus complaints. We can conclude that psychoacoustic outcome measurements of tinnitus cannot substitute subjective outcome measurements in patients with acute tinnitus. The authors recommend subjective outcome measurements as primary outcome measurements in a clinical setting. In research, however, it is meaningful to quantify tinnitus in both ways.

Assessing Outcomes of Tinnitus Intervention

It has been estimated that as many as 50 million Americans do experience or have experienced tinnitus. For approximately 12 million of these individuals, tinnitus makes it impossible for them to carry out normal everyday activities without limitation. These are the patients that present to audiology clinics for assessment and management. The tinnitus evaluation includes the measurement of acoustical characteristics of tinnitus and the impact that this impairment has on health-related quality of life (HRQoL). Tinnitus is a disorder that often occurs as a result of auditory system impairment. The impairment for some can impart an activity limitation and a participation restriction (i.e., tinnitus-related disability or handicap, respectively). The goal of tinnitus management is to reduce, or eliminate, activity limitations and participation restrictions by reducing or eliminating a patient's perception of tinnitus or their reaction to tinnitus. Implicit in this statement is the assumption that there exist standardized measures for quantifying the patient's tinnitus perception and their reaction to it. If there existed stable and responsive standardized tinnitus measures, then it would be possible to compare a patient's tinnitus experience at different time points (e.g., before and after treatment) to assess, for example, treatment efficacy. The purposes of the current review are to (1) describe psychometric standards used to select outcome measurement tools; (2) discuss available measurement techniques and their application to tinnitus evaluation and treatment-related assessment within the domains established by the World Health Organization's International Classification of Functioning, Disability and Health; (3) list and briefly describe self-report tinnitus questionnaires; (4) describe how valuation of tinnitus treatment can be assessed using economic models of treatment effectiveness; and (5) provide future directions including the development of a tinnitus outcomes test battery and treatment-related study designs. Retrospective literature review Although psychometrically robust measures of tinnitus HRQoL do exist, there is no unanimity in, for example, what tests should be included in the tinnitus assessment, and how studies of HRQoL should be conducted. The current authors suggest that future studies employ more rigorous designs and contain (minimally) the following characteristics: (1) utilization of randomized control groups and blinding; (2) appropriate statistical testing including "dropouts" that should be used in an "intention to treat" analysis rather than elimination from the final data set; (3) long-term follow-up assessment to evaluate responsiveness; (4) appropriate inclusion criteria to avoid "ceiling" and "floor" effects; and (5) suitable sample sizes based on the application of power analyses.

Is there a link between tinnitus and temporomandibular disorders?

The frequent concurrence of tinnitus and temporomandibular joint and masticatory muscle disorders (TMD) has led to the assumption that a possible relationship exists between these 2 conditions. The present prospective clinical study was conducted to assess the possible association between tinnitus and TMD and to investigate the effect of stomatognathic therapy on tinnitus distress. The prevalence of TMD and tinnitus was investigated in a consecutive series of 951 patients at the Department of Prosthetic Dentistry at the University Medical Center Regensburg, Germany. Patients with TMD and simultaneous tinnitus were included in the prospective clinical trial (n=25). Baseline examination comprised a detailed functional analysis, diagnosis of temporomandibular joint and masticatory muscle disorder, and a tinnitus questionnaire. All the participants received individual dental functional therapy (oral splints, physiotherapy). The effects of functional therapy on TMD and tinnitus symptoms were examined 3 to 5 months after the initiation of dental functional therapy. Means (standard deviations) were calculated, and 1-way ANOVA was used to investigate statistical differences (α=.05). The differences of the 2 binary outcomes were compared with the Pearson χ(2) test, and the relative risk was calculated. Prevalence of tinnitus was found to be 8 times higher in participants with TMD (30 of 82 [36.6%]) than in participants without TMD (38 of 869 [4.4%]). All the participants with unilateral TMD and unilateral tinnitus showed theseconditions on the same side. Stomatognathic therapy improved tinnitus symptoms in 11 of 25 participants (44%). The results of this study and the prospective clinical trial showed a significant correlation between tinnitus and TMD. The observed treatment outcome suggests that dental functional therapy may have a positive effect on TMD-related tinnitus.

Bilateral Low-Frequency Repetitive Transcranial Magnetic Stimulation of the Auditory Cortex in Tinnitus Patients Is Not Effective: A Randomised Controlled Trial

Background: Although some therapies may be beneficial for some patients in reducing tinnitus, there is no curative therapy. Repetitive transcranial magnetic stimulation (rTMS) has been applied as a treatment for chronic tinnitus, but the effect remains controversial. Material and Methods: Fifty patients were treated with rTMS or placebo. Treatment consisted of 2,000 TMS pulses on each auditory cortex, at a rate of 1 Hz and an intensity of 110% of the individual motor threshold, on 5 consecutive days. rTMS and placebo effects were evaluated directly after treatment, after 1 week, and after 1, 3 and 6 months. Primary outcome was the Tinnitus Questionnaire (TQ). Secondary outcomes were the Tinnitus Handicap Inventory (THI) and a visual analogue scale. Results: At none of the follow-up evaluation moments a significant difference between rTMS and placebo was observed with respect to changes in TQ or THI scores relative to pretreatment scores. Multilevel modelling (MLM) analyses did not show a global treatment effect either. Patients with a higher degree of burden showed slightly greater improvement after rTMS (only significant on the THI with MLM analyses). Conclusion: Bilateral low-frequency rTMS of the auditory cortex was not effective in treating tinnitus.

Onset-related differences in neural substrates of tinnitus-related distress: the anterior cingulate cortex in late-onset tinnitus, and the frontal cortex in early-onset tinnitus

Recent findings regarding differences in tinnitus-related neural activity according to onset age have raised a question on possible onset age-related differences in neural substrates of distress. Hence we collected quantitative electroencephalography (qEEG) findings of 28 late-onset tinnitus (LOT) and 29 early-onset tinnitus (EOT) (mean onset age 52.3 and 29.0 years, respectively) participants. According to the tinnitus questionnaire (TQ) score grade, LOTs were then subdivided into 13 high distress (HD; TQ grade 3 or 4) and 15 low distress (LD; TQ grade 1 or 2), while EOTs into 14 HD and 15 LD. Compared to the EOT group, the LOT group demonstrated increased qEEG source-localized activity and functional connectivity primarily in the anterior cingulate cortex (ACC) and parahippocampus. In subgroup comparisons, the ACC was activated more in HD-LOT participants than in LD-LOT participants for the beta 1, beta 2 and gamma frequency bands, while the left orbitofrontal cortex and left dorsolateral prefrontal cortex were activated more in HD-EOT than in LD-EOT for the delta/beta and gamma frequency bands, respectively. Even with the same amount of tinnitus-related distress level, responsible neural substrates are different according to the onset age. These differences may be important for exploring different target areas of treatment according to tinnitus onset age, as well as for conducting similar studies on other pathologies, such as depression or pain.

The Therapeutic Objective: Reducing the Stress Caused by Tinnitus

The article laudably provided an overview of the topic from an interdisciplinary perspective (1). One cannot but agree with the authors in objecting to the still prevalent therapeutic nihilism. At the same time it should be emphasized that management of tinnitus is the rule, rather than its actual cure. Especially in severely affected patients, the realistic therapeutic objective is a significant reduction in the stress caused by tinnitus. Cognitive behavioral therapy (CBT) is the only genuinely evidence based therapy, but this goes almost unnoticed in the article owing to the very short explanation and cautious wording (“the best-evaluated treatment for tinnitus”). In order to assess the indication for treatment (and therapeutic success) it is vital to determine the extent of the stress caused by tinnitus. Relevant validated questionnaires are not only available, as was mentioned almost as an aside, but they should be an integral component of the diagnostic evaluation. The first one to mention in this context is the tinnitus questionnaire ([2] or the mini-tinnitus questionnaire-12 [3]). Psychologically oriented tinnitus therapy, which ranges from one-off counseling to multimodal tinnitus management therapy including CBT, should be used in a differentiated manner, depending on the stress caused by the tinnitus and the psychological comorbidity (4). Psychological comorbidity, which often also includes somatoform disorders, correlates with the severity of the tinnitus. Especially highly stressed tinnitus patients should undergo targeted screening for psychological disorders (3, 4). Psychological comorbidities are not only a consequence of tinnitus; rather, pre-existing mental disorders are often a form of adaptive processing of the tinnitus and as such constitute a crucial risk factor for its chronification and decompensation (4). Treating psychological comorbidities should not, as shown in Figure 2, precede (behavioral therapeutic) tinnitus therapy but be treated alongside the tinnitus.

Remember Self-Help

The article (1) unfortunately omits any mention of self-help. The charitable self-help organization Deutsche Tinnitus Liga (DTL, the German tinnitus association) makes a valuable contribution to support affected persons in this context (2). However, the authors deserve credit for explaining the topic of tinnitus so comprehensively. At the same time it should be clear that we are mostly talking about management, not cure. For patients with severe tinnitus, even just reducing the burden is a realistic therapeutic objective. Scientific evaluations have shown that of the 14 000 DTL members, 16% have grade 4 tinnitus (mini tinnitus questionnaire–12, Mini-TF12) (3). In order to confirm the effectiveness of self-help in qualified self-help groups, the DTL has started a large, prospective 3-year study in collaboration with the University Medical Center Hamburg-Eppendorf (2, 4). In our experience there are better grading scales for the severity of tinnitus than the external assessment that the authors list in the Box. The DTL on its home page provides a tinnitus test for interested parties that is based on the scientifically evaluated mini-tinnitus questionnaire 12 and is being undertaken by some 20 000 affected persons every year. 16% of these are most severely affected (3). The article mentions “tinnitus patients” in several places, sometimes for all those affected, but elsewhere for those who are actually suffering, which may well be termed “patients.” If suffering caused by tinnitus is the main symptom then tinnitus should not be subsumed under the symptom category H 93.1 in the ICD-10 but should be integrated as a disease under a new category that is yet to be established. The DTL—supported by the Association of the Scientific Medical Societies in Germany (AWMF)—has taken this up with the German Institute of Medical Documentation and Information (Deutsches Institut fur Medizinische Dokumentation und Information, DIMDI) for the purposes of the ICD-10-GM 2014.

Role of Hearing Aids in Tinnitus Intervention: A Scoping Review

Tinnitus can have a devastating impact on the quality of life of the sufferer. Although the mechanisms underpinning tinnitus remain uncertain, hearing loss is often associated with its onset, and hearing aids are among the most commonly used tools for its management. To conduct a scoping review to explore the role of hearing aids in tinnitus management. Scoping review based on the six-stage framework of Arksey and O'Malley (2005). Relevant studies were identified using various databases (Scopus, Google Scholar, SpringerLink, and PubMed) and hand searching of journals and a reference list of articles. Out of 277 shortlisted articles, 29 studies (18 research studies and 11 reviews) were chosen for charting of data based on their abstracts. Tinnitus assessment measures used in studies were recorded along with changes in their scores. Measures used in studies included the Tinnitus Handicap Inventory (THI), Tinnitus Handicap Questionnaire (THQ), Tinnitus Severity Index (TSI), Tinnitus Reaction Questionnaire (TRQ), German version of Tinnitus Questionnaire (TQ), Beck Depression Inventory (BDI), and visual analogue scale (VAS) of tinnitus intensity. Where possible Cohen's d effect size statistic was calculated. Although the quality of evidence for hearing aids' effect on tinnitus is not strong, the weight of evidence (17 research studies for, 1 against) suggests merit in using hearing aids for tinnitus management. The majority of studies reviewed support the use of hearing aids for tinnitus management. Clinicians should feel reassured that some evidence shows support for the use of hearing aids for treating tinnitus, but there is still a need for stronger methodology and randomized control trials.

Repetitive Transcranial Magnetic Stimulation for the Treatment of Chronic Tinnitus After Traumatic Brain Injury

Tinnitus is a frequent symptom of traumatic brain injury, which is difficult to treat. Repetitive transcranial magnetic stimulation has shown beneficial effects in some forms of tinnitus. However, traumatic brain injury in the past has been considered as a relative contraindication for repetitive transcranial magnetic stimulation because of the increased risk of seizures. Here we present the case of a 53-year-old male patient suffering from severe tinnitus after traumatic brain injury with comorbid depression and alcohol abuse, who received 5 treatment series of repetitive transcranial magnetic stimulation (1 Hz stimulation protocol over left primary auditory cortex, 10 sessions of 2000 stimuli each, stimulation intensity 110% resting motor threshold). Repetitive transcranial magnetic stimulation was tolerated without any side effects and tinnitus complaints (measured by a validated tinnitus questionnaire and numeric rating scales) were improved in a replicable way throughout 5 courses of transcranial magnetic stimulation up to now.

P 187. Tinnitus-related neuroplastic alterations in the motor cortex

Introduction Chronic tinnitus is a brain network disorder with involvement of auditory and non-auditory areas motivating the clinical use of repetitive transcranial magnetic stimulation (rTMS). Several small studies indicated that motor cortex excitability is altered in tinnitus. Furthermore, motor cortex excitability was changed according to treatment response of rTMS of auditory cortex. Objectives Here, we aimed to investigate motor cortex excitability before and after rTMS of auditory cortex. Materials and methods We investigated 231 patients with chronic tinnitus and 120 healthy controls in a retrospective manner pooling data from different studies. Variables of interest were resting motor threshold (RMT), short-interval intra-cortical inhibition (SICI), intracortical facilitation (ICF), and cortical silent period (CSP). 118 patients were tested twice-at the first and last day of treatment with temporal oriented rTMS. Treatment response was defined as five-point change in tinnitus questionnaire. Results Tinnitus was associated with increased motor inhibition (SICI, CSP) and facilitation (ICF). Successful treatment response was associated with normalisation of increased SICI. Conclusion Our data suggest that altered SICI may reflect a state parameter, whereas CSP and ICF may rather mirror a trait-like predisposing factor of tinnitus.

P 111. Repetitive transcranial magnetstimulation (rTMS) for the treatment of chronic tinnitus: Results of the german multicenter study

Chronic tinnitus is a frequent disease accompanied in many cases by high morbidity and reduction in quality of life. Despite its high incidence, treatment remains elusive. Aggregated research over the last years has contributed to a deeper understanding of the neurobiological basis of chronic tinnitus and point to the involvement of auditory and non-auditory brain areas. Repetitive transcranial magnetic stimulation (rTMS) is able to non-invasively modulate brain activity. Pilot studies indicate a potential therapeutic effect of rTMS in tinnitus patients, however, sample sizes were small so far. The aim of this study was to evaluate the efficacy and safety of rTMS in tinnitus in a large patient sample. 7 study centers participated in this randomized, placebo-controlled trial. From February 2008 until May 2011 a total of 154 patients were enrolled and received 10 sessions of either verum or sham 1 Hz-rTMS over the left primary auditory cortex. Effects on tinnitus and accompanying psychiatric symptoms were evaluated using a variety of standardized rating scales (tinnitus questionnaire (TQ), tinnitus handicap inventory (THI), beck depression inventory, etc.). rTMS treatment was well tolerated in all patients. In the primary outcome (change of the TQ-score baseline vs. day 12) no significant difference between both study arms was observed. During the follow-up period, a trend to superiority of verum rTMS could be observed, which did not reach statistical significance. This study shows, that 1 Hz-rTMS over the left primary auditory cortex is not superior to placebo treatment. Therefore, more effective treatment protocols are needed and combined treatment regimes focusing on auditory and non-auditory brain regions may be better as recent studies have demonstrated.

How Much Additional Information Is Provided by High‐Frequency‐Audiometry in Tinnitus Patients with Normal Standard Audiogram?

Objectives: The majority of tinnitus patients suffer from hearing loss. However, a significant proportion of tinnitus patients show normal hearing thresholds in the standard pure tone audiogram (PTA, 125Hz – 8kHz). It has been argued that PTA is not sensitive for all forms of hearing impairment and the additional measurement of high frequencies (9 – 16 kHz) should complete the diagnostic set-up. Here we aimed to investigate whether the results of high frequency audiometry (HFA) provide relevant additional information in tinnitus patients with normal standard PTA. Methods: From the database of the Tinnitus Clinic of the University of Regensburg we identified 75 patients with normal hearing thresholds in the standard PTA. We then contrasted patients with normal and pathological HFA and compared these two groups with respect to tinnitus severity, laterality, duration, tinnitus pitch, the presentation of selected somatic symptoms, and triggers of tinnitus onset. Results: Patients with pathological HFA were significantly older and had higher scores on the Tinnitus Questionnaire and the Tinnitus Handicap Inventory in comparison to patients with normal HFA. Furthermore, there was an association of high frequency audiograms and the laterality of tinnitus: patients with left and bilateral tinnitus had more pronounced high frequency hearing loss in the left ear. Conclusions: In summary, our data indicate that in patients with normal hearing in standard PTA, some additional information is provided by HFA. The association between tinnitus laterality and asymmetry of HFA suggests a potential causal role for the high frequency hearing loss in tinnitus etiopathogenesis.

The Prognostic Factors of Intratympanic Steroid Treatment for Acute Tinnitus

Objectives: We report the better therapeutic efficacy of intratympanic dexamethasone injection (ITD) in patients with acute subjective tinnitus (AST) compared to alprazolam medication only. The present study aimed to determine the prognostic factors of ITD injection for AST. Methods: A total of 139 subjects who underwent treatment of ITD injection for AST from 2009 to 2012 were enrolled. The relationships between treatment outcomes and various clinical features or audiometric findings were analyzed retrospectively. Three months post-treatment tinnitus questionnaires were completed in 90 patients. Audiologic response was defined as hearing threshold recovery greater than 15 dB in any frequency of the pure-tone audiogram. Results: Tinnitus completely disappeared in 43 patients (cure rate = 30.9%). The mean duration of symptoms and initial tinnitus loudness score were significantly lower in the cure group than in other groups ( P &lt;.05). In the cure group, the number of patients with asymmetric hearing were larger than the number with symmetric hearing ( P &lt;.05).The mean improvement index of tinnitus was significantly higher in the unilateral tinnitus group than in the bilateral tinnitus group ( P &lt;.05). The audiologic response following ITD is more frequent in the patients with asymmetric hearing than in those with symmetric hearing ( P &lt;.05). Conclusions: Duration of symptoms and initial tinnitus loudness score might affect the cure rate of AST by ITD injection. Audiometric asymmetry and unilaterality of tinnitus are preferable factors of ITD treatment for AST.

Tinnitus in a Single-Sided Deaf Ear Reduces Speech Reception in the Nontinnitus Ear

The influence of tinnitus on speech reception is under debate. A few previous studies addressed this issue and compared speech reception in groups with and without tinnitus, with tinnitus arising in both ears or in the same test ear. Recently, we demonstrated that loudness of tinnitus in single-sided deafness (SSD) could be reduced dramatically by implanting and activating a cochlear implant (CI). The aim of the study was to evaluate whether changing the level of tinnitus in the SSD ear by disenabling or enabling the CI changes the speech reception in noise in the non-tinnitus ear. Fifteen CI users (MED-EL multichannel) with SSD and incapacitating tinnitus participated. They had an initial score of 6 or greater out of 10 on the Visual Analogue Scale (VAS) and an average total score of 58.05 (standard deviation [SD], 13.68) on the Tinnitus Questionnaire. The outcome measure, speech reception threshold (SRT) in noise using an adaptive procedure was measured in the nontinnitus ear using insert earphones. The measurements were performed with a high tinnitus level and a low tinnitus level in the SSD ear, realized by switching the CI off or on. Tinnitus loudness was assessed on a VAS, and tinnitus loudness was also matched using an audiometer. Speech reception in noise is significantly worse in case of high tinnitus loudness. The mean difference in SRT in the nontinnitus ear between the 2 conditions (SRTCI off-SRTCI on) of the 15 subjects was 1.98 dB SNR (SD, 3.01 dB SNR). The mean tinnitus loudness on the VAS was 7.2 (SD, 2.6) in the CI-off condition. In the CI-on condition, the mean VAS score significantly declined to 3.4 (SD, 2.5). Also, the tinnitus loudness match improved from 22 dB SL (SD, 14.4 dB SL) to 10 dB SL (SD, 10.1 dB SL) in the CI-on condition. Unilateral tinnitus can significantly decrease speech reception in noise in the nontinnitus ear.