https://www.oto.theclinics.com/article/S0030-6665(02)00160-3/pdf

Classification and epidemiology of tinnitus

A systematic review of the reporting of tinnitus prevalence and severity.

Background Tinnitus affects up to 21% of the adult population with an estimated 1% to 3% experiencing severe problems. Cognitive behavioural therapy (CBT) is a collection of psychological treatments based on the cognitive and behavioural traditions in psychology and often used to treat people suffering from tinnitus. Objectives To assess the effects and safety of CBT for tinnitus in adults. Search methods The Cochrane ENT Information Specialist searched the ENT Trials Register; CENTRAL (2019, Issue 11); Ovid MEDLINE; Ovid Embase; CINAHL; Web of Science; ClinicalTrials.gov; ICTRP and additional sources for published and unpublished trials. The date of the search was 25 November 2019. Selection criteria Randomised controlled trials (RCTs) of CBT versus no intervention, audiological care, tinnitus retraining therapy or any other active treatment in adult participants with tinnitus. Data collection and analysis We used the standard methodological procedures expected by Cochrane. Our primary outcomes were the impact of tinnitus on disease-specific quality of life and serious adverse effects. Our secondary outcomes were: depression, anxiety, general health-related quality of life, negatively biased interpretations of tinnitus and other adverse effects. We used GRADE to assess the certainty of evidence for each outcome. Main results We included 28 studies (mostly from Europe) with a total of 2733 participants. All participants had had tinnitus for at least three months and their average age ranged from 43 to 70 years. The duration of the CBT ranged from 3 to 22 weeks and it was mostly conducted in hospitals or online. There were four comparisons and we were interested in outcomes at end of treatment, and 6 and 12 months follow-up. The results below only refer to outcomes at end of treatment due to an absence of evidence at the other follow-up time points. CBT versus no intervention/wait list control Fourteen studies compared CBT with no intervention/wait list control. For the primary outcome, CBT may reduce the impact of tinnitus on quality of life at treatment end (standardised mean difference (SMD) -0.56, 95% confidence interval (CI) -0.83 to -0.30; 10 studies; 537 participants; low certainty). Re-expressed as a score on the Tinnitus Handicap Inventory (THI; range 0 to 100) this is equivalent to a score 10.91 points tower in the CBT group, with an estimated minimal clinically important difference (MCID) for this scale being 7 points. Seven studies, rated as moderate certainty, either reported or informed us via personal commu nication about serious adverse effects. CBT probably results in little or no difference in adverse effects: six studies reported none and in one study one participant in the CBT condition worsened (risk ratio (RR) 3.00, 95% CI 0.13 to 69.87). For the secondary outcomes, CBT may result in a slight reduction in depression (SMD -0.34, 95% CI-0.60 to -0.08; 8 studies; 502 participants; low certainty). However, we are uncertain whether CBT reduces anxiety, improves health-related quality of life or reduces negatively biased interpretations of tinnitus (all very low certainty). From seven studies, no other adverse effects were reported (moderate certainty). CBT versus audiological care Three studies compared CBT with audiological care. CBT probably reduces the impact of tinnitus on quality of life when compared with audiological care as measured by the THI (range 0 to 100; mean difference (MD) -5.65, 95% CI -9.79 to -1.50; 3 studies; 444 participants) (moderate certainty; MCID = 7 points). No serious adverse effects occurred in the two included studies reporting these, thus risk ratios were not calculated (moderate certainty). The evidence suggests that CBT may slightly reduce depression but may result in little or no difference in anxiety or health-related quality of life (all low certainty) when compared with audiological care. CBT may reduce negatively biased interpretations of tinnitus when compared with audiological care (low certainty). No other adverse effects were reported for either group (moderate certainty). CBT versus tinnitus retraining therapy (TRT) One study compared CBT with TRT (including bilateral sound generators as per TRT protocol). CBT may reduce the impact of tinnitus on quality of life as measured by the THI when compared with TRT (range 0 to 100) (MD -15.79, 95% CI -27.91 to -3.67; 1 study; 42 participants; low certainty). For serious adverse effects three participants deteriorated during the study: one in the CBT (n = 22) and two in the TRT group (n = 20) (RR 0.45, 95% CI 0.04 to 4.64; low certainty). We are uncertain whether CBT reduces depression and anxiety or improves heal-threlated quality of life (low certainty). CBT may reduce negatively biased interpretations of tinnitus. No data were available for other adverse effects. CBT versus other active control Sixteen studies compared CBT with another active control (e.g. relaxation, information, Internet-based discussion forums). CBT may reduce the impact of tinnitus on quality of life when compared with other active treatments (SMD -0.30, 95% CI -0.55 to -0.05; 12 studies; 966 participants; low certainty). Re-expressed as a THI score this is equivalent to 5.84 points lower in the CBT group than the other active control group (MCID = 7 points). One study reported that three participants deteriorated: one in the CBT and two in the information only group (RR 1.70, 95% CI 0.16 to 18.36; low certainty). CBT may reduce depression and anxiety (both low certainty). We are uncertain whether CBT improves health-related quality of life compared with other control. CBT probably reduces negatively biased interpretations of tinnitus compared with other treatments. No data were available for other adverse effects. Authors' conclusions CBT may be effective in reducing the negative impact that tinnitus can have on quality of life. There is, however, an absence of evidence at 6 or 12 months follow-up. There is also some evidence that adverse effects may be rare in adults with tinnitus receiving CBT, but this could be further investigated. CBT fortinnitus may have small additional benefit in reducing symptoms of depression although uncertainty remains due to concerns about the quality of the evidence. Overall, there is limited evidence for CBT for tinnitus improving anxiety, heal-threlated quality of life or negatively biased interpretations of tinnitus.

Cognitive behavioural therapy for tinnitus

The generation of tinnitus is a topic of much scientific enquiry. This chapter reviews possible mechanisms of tinnitus, whilst noting that the heterogeneity observed within the human population with distressing tinnitus means that there may be many different mechanisms by which tinnitus can occur. Indeed, multiple mechanisms may be at work within one individual. The role of the cochlea in tinnitus is considered, and in particular the concept of discordant damage between inner and outer hair cells is described. Biochemical models of tinnitus pertaining to the cochlea and the central auditory pathway are considered. Potential mechanisms for tinnitus within the auditory brain are reviewed, including important work on synchronised spontaneous activity in the cochlear nerve. Whilst the number of possible mechanisms of tinnitus within the auditory system is considerable, the identification of the physiological substrates underlying tinnitus is a crucial element in the design of novel and effective therapies.

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Mechanisms of tinnitus.

Neuroanatomical Changes due to Hearing Loss and Chronic Tinnitus: A Combined VBM and DTI Study

Tinnitus is a common experience with up to one third of the adult population experiencing it at some time in their life. Less than 1% of the adult population have tinnitus of sufficient severity to affect their quality of life seriously (although up to 8% may seek medical advice about it). Much of the severity of tinnitus relates to the individuals' psychological response to the abnormal tinnitus signal. The prevalence of tinnitus increases in association with high frequency hearing loss. There is, unfortunately, no diagnostic test that either confirms the presence of tinnitus or its severity. Currently there is no satisfactory severity grading system. A five-point severity grading scheme is therefore proposed and the entry criteria detailed. The five severity points are: slight, mild, moderate, severe and catastrophic. Categorization as 'severe' or 'catastrophic' should be, by epidemiological definition, very rare. General guidance, theory and evidential support are contained within.

Guidelines for the grading of tinnitus severity: the results of a working group commissioned by the British Association of Otolaryngologists, Head and Neck Surgeons, 1999.

General versus specific sino-nasal outcome measures.

effect of these moves will be to reduce the power of consultants and must be seen in the same light as the threat of Medical and Surgical Care Practitioners. The desirablity of consultant power may well be questioned but the desirability of delivering a high standard of professional care to the public cannot. We feel that a strong independent consultant body is the best way to ensure that that care is provided. It is hard to predict just what the future holds but political sands are capable of shifting and hopefully the strongly vocalised voices of reason from the profession will eventually be heard.

Postoperative discharge advice given to ENT patients admitted under a non-ENT ward.

Two hundred and twelve cervical lymph node biopsies were performed. The median age of presentation was 44 years (range 2–88). Haematological malignancy, predominantly lymphoma, was diagnosed in 95 patients (41.5%). ‘Benign’ pathology was found in 90 patients (39.3%), which included 39 cases of granulomatous lymphadenitis (17%), 50 simple reactive nodes (21.8%) and 1 case of amyloid infiltration (0.4%). Metastatic carcinoma was diagnosed in 27 patients (11.8%). Primary source data were unavailable for two cases. Eighteen were of non-head and neck origin. The top three primarysources inourseries indescendingorderof frequency were lung (n = 5), unknown primary source (n = 5) and genitourinary (prostate, testicular and renal) (n = 3). Data regarding referral sourceswere retrieved for 193 cases (90.6%): 49 were referred by haematology (23%), 94 from primary care (45%) and 15 each from paediatricians and respiratory physicians (7%). The remaining 20 cases (9%) were referred from various other allied specialties.

The diagnostic yield of cervical lymph node excision biopsy presenting via the head and neck ‘lump-and-bump’ clinic

Sir, I read the interesting audit conducted by Khan et al. which highlighted discrepancies in postoperative advice given to patients on non-ENT wards. Their efforts to improve care and the steps taken are noteworthy and commendable. Whilst I agree that patients should all receive similar high standard of care, the results seem to demonstrate that nursing staff have failed to properly manage and advice patients. In my opinion, this is an unjustified indictment of our colleagues, who are frequently over-stretched and poorly supported. In addition, the suggested solution that patients remain in their respective surgical speciality ward due to untrained staff elsewhere is simply missing the point. The problems besetting hospitals in the current climate of the NHS are manifold. Budgetary constraints, bed shortages, lack of trained staff and high patient turnover are some of the ever increasing number of challenges faced by both clinicians and hospital managers. These are here to stay for the foreseeable future. Consequently, there is an increasing move towards a mixed-skill level workforce, working closely with other relevant professionals, to provide an integrated approach to patient care. It would be imprudent to assume that even staff on the ENT ward has all the necessary ENT-specific training to discharge their duties to the expected norm. The audit does not mention postoperative ward round, and give the impression that there is no further medical input post-surgery. I am sure this does not happen anywhere, however, ludicrous it sounds. In my experience, patients are reviewed by the surgeon at days’ end, and are normally reviewed again the next morning prior to discharge. Although there are exceptions to this in the form of nurse-led discharge, proper judgement to which patients can be discharged without seeing a doctor must be made on a case-to-case basis. This is undoubtedly good clinical practice, but is also an opportunity to impart advice and trouble shoot. Should the team discover an inexperienced member of staff (ENT or non-ENT), it is a great opportunity to teach and share knowledge. The example given of the inexperienced nurse at removing nasal pack is a clear example. Teaching is, after all, a duty enshrined in GMCs Good Medical Practice. The suggestion that patients should attend the ENT ward for postoperative advice is good, but there remained a high non-compliance rate. The audit has simply delegated to nursing staff the task of giving advice. It has overlooked the fact that there may not be time or a designated staff to do this. As it is, the ward is a busy and stressful environment. Would this task be better served by the SHO? One wonders what reasons were given by the 25% who did not attend the ENT ward. Perhaps the thought of further waiting for a member of staff to attend to them was not appealing. Empowering nurses to give post-surgical advice can easily be a veil for delegating medical duty and creating more work for our colleagues. Rather than pointing out deficiencies, it is time to take the mantle of training and supporting our nursing colleagues. There are certainly no easy solutions as any suggestion will have both proponents and opponents. As an interim measure, however, nurse-led discharge should not be applicable to patients on out-lying wards. Patients having undergone more complicated operations can be transferred back to the ENT ward, in exchange for simpler cases which can be safely ‘parcelled’ out. Simple suggestions perhaps, but who would now campaign for our porters who have to transport these patients around the hospital at night?

A. McCombe

Papers

Guidelines for the grading of tinnitus severity: the results of a working group commissioned by the British Association of Otolaryngologists, Head and Neck Surgeons, 1999.

General versus specific sino-nasal outcome measures.

Postoperative discharge advice given to ENT patients admitted under a non-ENT ward.

The diagnostic yield of cervical lymph node excision biopsy presenting via the head and neck ‘lump-and-bump’ clinic

Response to Leong