Tinnitus: causes and clinical management
TL;DR: Assessment of patients includes a detailed case history, measurement of hearing function, quantification of tinnitus severity, and identification of causal factors, associated symptoms, and comorbidities.
Abstract: Summary Tinnitus is the perception of sound in the absence of a corresponding external acoustic stimulus. With prevalence ranging from 10% to 15%, tinnitus is a common disorder. Many people habituate to the phantom sound, but tinnitus severely impairs quality of life of about 1–2% of all people. Tinnitus has traditionally been regarded as an otological disorder, but advances in neuroimaging methods and development of animal models have increasingly shifted the perspective towards its neuronal correlates. Increased neuronal firing rate, enhanced neuronal synchrony, and changes in the tonotopic organisation are recorded in central auditory pathways in reaction to deprived auditory input and represent—together with changes in non-auditory brain areas—the neuronal correlate of tinnitus. Assessment of patients includes a detailed case history, measurement of hearing function, quantification of tinnitus severity, and identification of causal factors, associated symptoms, and comorbidities. Most widely used treatments for tinnitus involve counselling, and best evidence is available for cognitive behavioural therapy. New pathophysiological insights have prompted the development of innovative brain-based treatment approaches to directly target the neuronal correlates of tinnitus.
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Paris 12 Val de Marne University1, University of Göttingen2, University Hospital of Lausanne3, French Institute of Health and Medical Research4, University of Milan5, University of Otago6, University of Regensburg7, University of Marburg8, Ruhr University Bochum9, Ludwig Maximilian University of Munich10, University of Siena11, University of Texas at Dallas12, University of Tübingen13
TL;DR: It remains to be clarified whether the probable or possible therapeutic effects of tDCS are clinically meaningful and how to optimally perform tDCS in a therapeutic setting.
1,062 citations
Cites background from "Tinnitus: causes and clinical manag..."
...Although numerous treatments have been introduced, evidence for an uniformly successful treatment is lacking (Langguth et al., 2013)....
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...FU: follow-up; VAS: visual analogue scale. and has also been investigated as a novel therapeutic approach for tinnitus patients (Langguth et al., 2013)....
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...and has also been investigated as a novel therapeutic approach for tinnitus patients (Langguth et al., 2013)....
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TL;DR: This article critically assess the recent neuroimaging studies in individuals with tinnitus that suggest that the disorder is accompanied by functional and structural brain abnormalities in distributed auditory and non-auditory brain regions.
Abstract: Tinnitus is the perception of phantom sound in the absence of a corresponding external source. It is a highly prevalent disorder, and most cases are caused by cochlear injury that leads to peripheral deafferentation, which results in adaptive changes in the CNS. In this article we critically assess the recent neuroimaging studies in individuals with tinnitus that suggest that the disorder is accompanied by functional and structural brain abnormalities in distributed auditory and non-auditory brain regions. Moreover, we consider how the identification of the neuronal mechanisms underlying the different forms of tinnitus would benefit from larger studies, replication and comprehensive clinical assessment of patients.
223 citations
TL;DR: Understanding of the genetic pathways that regulate auditory function has revealed new targets for pharmacological treatment of the disease and approaches that are based on stem cells and gene therapy are beginning to emerge.
Abstract: Hearing loss, which is caused by both genetic and environmental factors, is the most common form of sensory impairment in humans. Current treatment relies on medical devices and there are no drug-based therapies available. Here, Muller and Barr-Gillespie review the various forms of hearing loss, highlight emerging pharmacological targets and discuss the potential of regenerative medicine and gene therapy to restore auditory function. Hearing loss is the most common form of sensory impairment in humans and affects more than 40 million people in the United States alone. No drug-based therapy has been approved by the Food and Drug Administration, and treatment mostly relies on devices such as hearing aids and cochlear implants. Over recent years, more than 100 genetic loci have been linked to hearing loss and many of the affected genes have been identified. This understanding of the genetic pathways that regulate auditory function has revealed new targets for pharmacological treatment of the disease. Moreover, approaches that are based on stem cells and gene therapy, which may have the potential to restore or maintain auditory function, are beginning to emerge.
143 citations
TL;DR: Findings indicate poor appreciation of the basic principles of good trial design, particularly the importance of specifying what aspect of therapeutic benefit is the main outcome.
Abstract: Background: There is no evidence-based guidance to facilitate design decisions for confirmatory trials or systematic reviews investigating treatment efficacy for adults with tinnitus. This systematic review therefore seeks to ascertain the current status of trial designs by identifying and evaluating the reporting of outcome domains and instruments in the treatment of adults with tinnitus.
Methods: Records were identified by searching PubMed, EMBASE CINAHL, EBSCO, and CENTRAL clinical trial registries (ClinicalTrials.gov, ISRCTN, ICTRP) and the Cochrane Database of Systematic Reviews. Eligible records were those published from 1 July 2006 to 12 March 2015. Included studies were those reporting adults aged 18 years or older who reported tinnitus as a primary complaint, and who were enrolled into a randomised controlled trial, a before and after study, a non-randomised controlled trial, a case-controlled study or a cohort study, and written in
English. Studies with fewer than 20 participants were excluded.
Results: Two hundred and twenty-eight studies were included. Thirty-five different primary outcome domains were identified spanning seven categories (tinnitus percept, impact of tinnitus, co-occurring complaints, quality of life, body structures and function, treatment-related outcomes and unclear or not specified). Over half the studies (55 %) did not clearly define the complaint of interest. Tinnitus loudness was the domain most often reported (14 %), followed by tinnitus distress (7 %). Seventy-eight different primary outcome instruments were identified. Instruments assessing multiple attributes of the impact of tinnitus were most common (34 %). Overall, 24 different patient-reported tools were used, predominantly the Tinnitus Handicap Inventory (15 %). Loudness was measured in diverse ways including a numerical rating scale (8 %), loudness matching (4 %), minimum masking level (1 %) and loudness discomfort level (1 %). Ten percent of studies did not clearly report the instrument used.
Conclusions: Our findings indicate poor appreciation of the basic principles of good trial design, particularly the importance of specifying what aspect of therapeutic benefit is the main outcome. No single outcome was reported, in all studies and there was a broad diversity of outcome instruments.
123 citations
Cites background from "Tinnitus: causes and clinical manag..."
...As a symptom there is a no consensus on its aetiology [2, 3] and work is ongoing to profile tinnitus so that interventions can be more specifically targeted [4]....
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TL;DR: A multidisciplinary systematic analysis of the evidence for the different forms of treatment for chronic tinnitus and cognitive behavioural therapy is used to form the basis of an S3 guideline.
Abstract: The majority of tinnitus patients are affected by chronic idiopathic tinnitus, and almost 60 different treatment modalities have been reported. The present study is a multidisciplinary systematic analysis of the evidence for the different forms of treatment for chronic tinnitus. The results are used to form the basis of an S3 guideline. A systematic search was carried out in PubMed and the Cochrane Library. The basis for presenting the level of evidence was the evidence classification of the Oxford Centre of Evidence-based Medicine. Whenever available, randomised controlled trials were given preference for discussing therapeutic issues. All systematic reviews and meta-analyses were assessed for their methodological quality, and effect size was taken into account. As the need for patient counselling is self-evident, specific tinnitus counselling should be performed. Due to the high level of evidence, validated tinnitus-specific, cognitive behavioural therapy is strongly recommended. In addition, auditory therapeutic measures can be recommended for the treatment of concomitant hearing loss and comorbidities; those should also be treated with drugs whenever appropriate. In particular, depression should be treated, with pharmacological support if necessary. If needed, psychiatric treatment should also be given on a case-by-case basis. With simultaneous deafness or hearing loss bordering on deafness, a CI can also be indicated. For auditory therapeutic measures, transcranial magnetic or direct current stimulation and specific forms of acoustic stimulation (noiser/masker, retraining therapy, music, and coordinated reset) for the treatment of chronic tinnitus the currently available evidence is not yet sufficient for supporting their recommendation.
116 citations
References
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TL;DR: Existing theories and their extrapolation are presented, together with some new potential mechanisms of tinnitus generation, encompassing the involvement of calcium and calcium channels in cochlear function, with implications for malfunction and aging of the auditory and vestibular systems.
1,370 citations
TL;DR: The prevalence of frequent tinnitus is highest among older adults, non-Hispanic whites, former smokers, and adults with hypertension, hearing impairment, loud noise exposure, or generalized anxiety disorder.
767 citations
TL;DR: Three thousand six hundred randomly selected adults in the city of Gothenburg (425,000 inhabitants) stratified by age and gender, were questioned by mail concerning tinnitus, receiving 66% useful answers.
Abstract: Three thousand six hundred randomly selected adults in the city of Gothenburg (425,000 inhabitants) stratified by age and gender, were questioned by mail concerning tinnitus. We received 66% useful answers, 14.2% suffered from tinnitus 'often' or 'always'. Tinnitus was more common in males than in females. Tinnitus was much more common in the left than in the right ear. 2.4% of the whole population suffered from the worst severity degree, 'tinnitus plagues me all day'. Tinnitus was clearly more common with hearing loss than with subjectively normal hearing. Sleep disturbances were common and increased with tinnitus severity. A majority of the questioned subjects wanted further examination and treatment.
714 citations
TL;DR: It is demonstrated that tinnitus is related to plastic alterations in auditory cortex and similarities between these data and the previous demonstrations that phantom limb pain is highly correlated with cortical reorganization suggest that t Finnitus may be an auditory phantom phenomenon.
Abstract: Magnetic source imaging was used to determine whether tonotopy in auditory cortex of individuals with tinnitus diverges from normative functional organization. Ten tinnitus subjects and 15 healthy controls were exposed to four sets of tones while magnetoencephalographic recordings were obtained from the two cortical hemispheres in sequence. A marked shift of the cortical representation of the tinnitus frequency into an area adjacent to the expected tonotopic location was observed. The Euclidean distance of the tinnitus frequency from the trajectory of the tonotopic map was 5.3 mm (SD = 3.1) compared with a distance of 2.5 mm (SD = 1.3) of a corresponding frequency in the healthy controls (t = 3.13, P < 0.01). In addition, a strong positive correlation was found between the subjective strength of the tinnitus and the amount of cortical reorganization (r = 0.82, P < 0.01). These results demonstrate that tinnitus is related to plastic alterations in auditory cortex. Similarities between these data and the previous demonstrations that phantom limb pain is highly correlated with cortical reorganization suggest that tinnitus may be an auditory phantom phenomenon.
690 citations