EDITORIAL



Noise and health special issue: Advances in the neuroscience of tinnitus p. 81

Edward Lobarinas, Richard Salvi, Joan Baizer, Carol Altman, Brian Allman

DOI:10.4103/1463-1741.110283 PMID:23571296

ARTICLES



Intratympanic treatment for tinnitus: A review p. 83

Thomas Meyer

DOI:10.4103/1463-1741.110285 PMID:23571297 Since the 1940s, various attempts have been made to treat peripheral tinnitus by way of intratympanic injection. This administration procedure requires only low concentrations of medication, thanks to the highly targeted delivery to the site of action and comes with minimal systemic exposure. While different compounds have been tested for their effects on tinnitus by intratympanic injection, there has been no breakthrough so far. Accordingly, the clinical use of intratympanic tinnitus treatments has remained limited to date. A more widespread adoption of this approach will require the development of specific medications for peripheral tinnitus, as well as proof of safety and efficacy, which would be determined from randomized controlled clinical trials.



Association between sleep disorders, hyperacusis and tinnitus: Evaluation with tinnitus questionnaires p. 91

Alessandra B Fioretti, Marco Fusetti, Alberto Eibenstein

DOI:10.4103/1463-1741.110287 PMID:23571298 Patients with tinnitus are heterogeneous and several factors influence the impact of this symptom on the quality of life. The aim of the study is to evaluate the relationship between age, gender, sleep disorders, hyperacusis and tinnitus annoyance and to demonstrate the utility of tinnitus questionnaires as screening tools for sleep disorders and hyperacusis in patients with tinnitus. 37 consecutive patients (18 males and 19 females) with subjective tinnitus lasting over 3 months were evaluated with a complete interview, otological examination, pure tone audiometry, Italian version of tinnitus sample case history (TSCH) and tinnitus handicap inventory (THI). Statistical analysis was performed with the Wilcoxon's rank sum test, the Spearman's rho non-parametric correlation and the logistic regression analysis. THI grades were slight (16%), mild (32%), moderate (30%), severe (19%) and catastrophic (3%). Based on the answers to TSCH 20 patients reported sleep disorders (54%) and 20 patients reported hyperacusis (54%). 11 patients (30%) reported sleep disorders and hyperacusis. No significant correlation was found between the severity of tinnitus and patients' age and gender. Significant correlation was found between sleep disorders (P = 0.0009) and tinnitus annoyance and between hyperacusis (P = 0.03) and tinnitus annoyance. TSCH and THI may be considered as screening tools in the clinical practice to evidence sleep disorders and hyperacusis in patients with tinnitus.



The use of fractal tones in tinnitus patient management p. 96

Robert W Sweetow

DOI:10.4103/1463-1741.110289 PMID:23571299 A variety of noises have been employed for decades in an effort to facilitate habituation, mask, or suppress tinnitus. Many of these sounds have reportedly provided benefit, but success has not been universal. More recently, musical stimuli have been added as a sound therapy component. The potential advantages of using such stimuli, in particular fractal tones, in combination with amplification are discussed in this paper.



Can the tinnitus spectrum identify tinnitus subgroups? p. 101

Karin M Heijneman, Emile de Kleine, Esther Wiersinga-Post, Pim van Dijk

DOI:10.4103/1463-1741.110290 PMID:23571300 The tinnitus spectrum is a psycho-acoustic metric of tinnitus. Previous work found a tight relation between the spectrum and the tone audiogram. This suggests that the spectrum and the audiogram provide essentially the same information, and the added value of the spectrum is limited. In order to test whether the spectrum shows tinnitus characteristics that cannot be inferred from the audiogram, we re-examined the relation between the tinnitus spectrum and the tone audiogram, in a group of 80 tinnitus patients. We defined three subgroups of patients, using the shape of their tinnitus spectrum: (1) patients with a spectrum, monotonously increasing with frequency (2) patients with a distinct peak in their spectrum, (3) all other patients. Patients in group 3 typically showed low frequency tinnitus spectra. In all three groups, the largest hearing loss was at high frequencies (>2 kHz). The mean audiograms of group 1 and 2 were remarkably similar; group 3 had an additional hearing loss for the lower frequencies (<2 kHz). The three groups did not differ with respect to age, sex, or tinnitus questionnaire outcomes. In subgroups 2 and 3, the shape of the spectrum clearly differed from that of the tone audiogram. In other words, the spectrum technique provided information that could not have been obtained by tone audiometry alone. Therefore, the spectrum measurement may develop into a technique that can differentiate between classes of tinnitus. This may eventually contribute to the effective management of tinnitus, as various classes of tinnitus may require different therapeutic interventions.



Recent technological advances in sound-based approaches to tinnitus treatment: A review of efficacy considered against putative physiological mechanisms p. 107

Derek J Hoare, Peyman Adjamian, Magdalena Sereda, Deborah A Hall

DOI:10.4103/1463-1741.110292 PMID:23571301 The past decade has seen an escalating enthusiasm to comprehend chronic tinnitus from the perspective of both scientific understanding and clinical management. At the same time, there is a significant interest and commercial investment in providing targeted and individualized approaches to care, which incorporate novel sound-based technologies, with standard audiological and psychological strategies. Commercially produced sound-based devices for the tinnitus market include Co-ordinated Reset Neuromodulation ® , Neuromonics © , Serenade ® , and Widex ® Zen. Additionally, experimental interventions such as those based on frequency-discrimination training are of current interest. Many of these interventions overtly claim to target the underlying neurological causes of tinnitus. Here, we briefly summarize current perspectives on the pathophysiology of tinnitus and evaluate claims made by the device supporters from a critical point of view. We provide an opinion on how future research in the field of individualized sound-based interventions might best provide a reliable evidence-base in this growing area of translational medicine.



Tonic tensor tympani syndrome in tinnitus and hyperacusis patients: A multi-clinic prevalence study p. 117

Myriam Westcott, Tanit Ganz Sanchez, Isabel Diges, Clarice Saba, Ross Dineen, Celene McNeill, Alison Chiam, Mary O'Keefe, Tricia Sharples

DOI:10.4103/1463-1741.110295 PMID:23571302 Tonic tensor tympani syndrome (TTTS) is an involuntary, anxiety-based condition where the reflex threshold for tensor tympani muscle activity is reduced, causing a frequent spasm. This can trigger aural symptoms from tympanic membrane tension, middle ear ventilation alterations and trigeminal nerve irritability. TTTS is considered to cause the distinctive symptoms of acoustic shock (AS), which can develop after exposure to an unexpected loud sound perceived as highly threatening. Hyperacusis is a dominant AS symptom. Aural pain/blockage without underlying pathology has been noted in tinnitus and hyperacusis patients, without wide acknowledgment. This multiclinic study investigated the prevalence of TTTS symptoms and AS in tinnitus and hyperacusis patients. This study included consecutive patients with tinnitus and/or hyperacusis seen in multiple clinics. Data collected: Symptoms consistent with TTTS (pain/numbness/burning in and around the ear; aural "blockage"; mild vertigo/nausea; "muffled" hearing; tympanic flutter; headache); onset or exacerbation from exposure to loud/intolerable sounds; tinnitus/hyperacusis severity. All patients were medically cleared of underlying pathology, which could cause these symptoms. 60.0% of the total sample (345 patients), 40.6% of tinnitus only patients, 81.1% of hyperacusis patients had ≥1 symptoms (P < 0.001). 68% of severe tinnitus patients, 91.3% of severe hyperacusis patients had ≥1 symptoms (P < 0.001). 19.7% (68/345) of patients in the total sample had AS. 83.8% of AS patients had hyperacusis, 41.2% of non-AS patients had hyperacusis (P < 0.001). The high prevalence of TTTS symptoms suggests they readily develop in tinnitus patients, more particularly with hyperacusis. Along with AS, they should be routinely investigated in history-taking.



No cochlear dead regions detected in non-pulsatile tinnitus patients: An assessment with the threshold equalizing noise (sound pressure level) test p. 129

Annick Gilles, Dirk De Ridder, Paul Van de Heyning

DOI:10.4103/1463-1741.110297 PMID:23571303 One of the hypotheses on the etiology of non-pulsatile tinnitus in normal or hearing impaired patients is the existence of sharp edged cochlear dead regions (DR) flanking normal functioning hair cells. The lack of inhibition of DR on the neighboring neurons may lead to hyperactivity. Currently the Threshold Equalizing Noise test (TEN test) is the reference test to clinically assess cochlear DR. To identify cochlear DR in patients with non-pulsatile tinnitus with and without hearing loss using the TEN (sound pressure level)-test. Data were obtained from adult patients with non-pulsatile tinnitus visiting the Tinnitus Clinic of the University Hospital Antwerp. The TEN (SPL)-test was performed to assess the presence of cochlear DR for test frequencies ranging from 0.5 to 8 kHz. A total of 55 ears of 33 subjects (15 male; 18 female) with non-pulsatile tinnitus were included in the study. Subjects were divided into subgroups based on the audiometric configuration of hearing loss: Flat configuration (N = 23), high-frequency gently sloping (N = 10) and high-frequency steeply sloping (N = 22). In forty-eight ears there was no evidence of cochlear DR. In seven ears the results were inconclusive. This occurred in patients with high-frequency steeply sloping audiogram configurations. The present study does not support the TEN (SPL) test as a reliable tool for the detection of cochlear DR in a tinnitus population.



Rationale for the tinnitus retraining therapy trial p. 134

Craig Formby, Roberta Scherer

DOI:10.4103/1463-1741.110299 PMID:23571304 The Tinnitus Retraining Therapy Trial (TRTT) is a National Institutes of Health-sponsored, multi-centered, placebo-controlled, randomized trial evaluating the efficacy of tinnitus retraining therapy (TRT) and its component parts, directive counseling and sound therapy, as treatments for subjective debilitating tinnitus in the military. The TRTT will enroll 228 individuals at an allocation ratio of 1:1:1 to: (1) directive counseling and sound therapy using conventional sound generators; (2) directive counseling and placebo sound generators; or (3) standard of care as administered in the military. Study centers include a Study Chair's Office, a Data Coordinating Center, and six Military Clinical Centers with treatment and data collection standardized across all clinics. The primary outcome is change in Tinnitus Questionnaire (TQ) score assessed longitudinally at 3, 6, 12, and 18-month follow-up visits. Secondary outcomes include: Change in TQ sub-scales, Tinnitus Handicap Inventory, Tinnitus Functional Index, and TRT interview visual analog scale; audiometric and psychoacoustic measures; and change in quality of life. The TRTT will evaluate TRT efficacy by comparing TRT (directive counseling and conventional sound generators) with standard of care; directive counseling by comparing directive counseling plus placebo sound generators versus standard of care; and sound therapy by comparing conventional versus placebo sound generators. We hypothesize that full TRT will be more efficacious than standard of care, directive counseling and placebo sound generators more efficacious than standard of care, and conventional more efficacious than placebo sound generators in habituating the tinnitus awareness, annoyance, and impact on the study participant's life.



Illustrative cases of unorthodox tinnitus management p. 143

Kenneth H Brookler

DOI:10.4103/1463-1741.110300 PMID:23571305 Bone remodeling disorders have been identified as potential candidates for the etiology underlying some forms of otologic disease. Here, four clinical cases are presented to demonstrate a novel approach to tinnitus management that focuses on two fundamental etiologic bases. First, is the effect of bone remodeling abnormalities of the otic capsule and second, the effect of blood sugar and insulin abnormalities upon the function of the inner ear and self-reports of tinnitus. This report presents the effect of treatment directed at bone remodeling abnormalities of the otic capsule and abnormalities of blood sugar and insulin. The treatment effects led to a substantial reduction in subjective tinnitus. These findings suggest a potential convergence between bone pathophysiology and some forms of tinnitus.



Letter to Editor: Are the findings of "Effects of industrial wind turbine noise on sleep and health" supported? p. 148

Christopher A Ollson, Loren D Knopper, Lindsay C McCallum, Melissa L Whitfield-Aslund

DOI:10.4103/1463-1741.110302 PMID:23571306



Letter to Editor: Issues of wind turbine noise p. 150