Electrical stimulation of the ear, head, cranial nerve, or cortex for the treatment of tinnitus: a scoping review

Tinnitus is defined as the perception of sound in the absence of an external source. It is often associated with hearing loss and is thought to result from abnormal neural activity at some point or points in the auditory pathway, which is incorrectly interpreted by the brain as an actual sound. Neurostimulation therapies therefore, which interfere on some level with that abnormal activity, are a logical approach to treatment. For tinnitus, where the pathological neuronal activity might be associated with auditory and other areas of the brain, interventions using electromagnetic, electrical, or acoustic stimuli separately, or paired electrical and acoustic stimuli, have been proposed as treatments. Neurostimulation therapies should modulate neural activity to deliver a permanent reduction in tinnitus percept by driving the neuroplastic changes necessary to interrupt abnormal levels of oscillatory cortical activity and restore typical levels of activity. This change in activity should alter or interrupt the tinnitus percept (reduction or extinction) making it less bothersome. Here we review developments in therapies involving electrical stimulation of the ear, head, cranial nerve, or cortex in the treatment of tinnitus which demonstrably, or are hypothesised to, interrupt pathological neuronal activity in the cortex associated with tinnitus

Hyperacusis questionnaire as a tool for measuring hypersensitivity to sound in a tinnitus research population

Hypersensitivity to external sounds is often comorbid with tinnitus and may be significant for adherence to certain types of tinnitus management. Therefore, a clear measure of sensitivity to sound is important. The aim of this study was to evaluate the validity and reliability of the Hyperacusis Questionnaire (HQ) for use as a measurement tool using data from a sample of 264 adults who took part in tinnitus research. We evaluated the HQ factor structure, internal consistency, convergent and discriminant validity, and floor and ceiling effects. Internal consistency was high (Cronbach’s alpha = 0.88) and moderate correlations were observed between the HQ, uncomfortable loudness levels, and other health questionnaires. Confirmatory factor analysis revealed that the original HQ three-factor solution and a one-factor solution were both a poor fit to the data. Four problematic items were removed and exploratory factor analysis identified a two-factor (attentional and social) solution. The original three-factor structure of the HQ was not confirmed. All fourteen items do not accurately assess hypersensitivity to sound in a tinnitus population. We propose a 10-item (2-factor) version of the HQ, which will need to be confirmed using a new tinnitus and perhaps nontinnitus population

Understanding user reactions and interactions with an internet-based intervention for tinnitus self-management: mixed-methods process evaluation protocol

Background: Tinnitus is a common medical symptom that can affect an individual’s emotional and functional quality of life. Psychological therapies are acknowledged as beneficial to people with tinnitus; however, such therapies are not always readily accessible. With their global reach, automated Internet-based interventions have the potential to reduce the disparity in access to psychological support that people with tinnitus currently experience. However, the evidence on the acceptability and efficacy of these interventions is lacking. Process evaluations that develop an in-depth understanding of how users experience these interventions provide an essential first step when evaluating complex psychological interventions. Objective: To describe the protocol for a study that will explore past, current, and new users’ reactions to and interactions with the Tinnitus E-Programme, an Internet-based intervention for the self-management of tinnitus. Methods: Two parallel mixed-methods studies will be carried out with 2 different populations. Study 1 will use an online survey to gather past and current users’ views of the program. Study 2 will recruit new program users to take part in an interview and complete a relaxation log to explore how well they were able to implement the skills they learned during the program in their everyday lives. The findings from both studies will be triangulated to develop an in-depth understanding of the program’s mechanisms of impact and identify any implementation or contextual factors that strengthen or impede its delivery and functioning. Results: Study 1 is open for recruitment with a projected completion in June 2016 and Study 2 was completed November 2015. At the time of submission, 36 participants have been recruited to Study 1 and 12 participants have taken part in Study 2. Conclusions: Findings will inform the optimization of the Tinnitus E-Programme and guide future evaluation work to assess the program’s effectiveness as a therapy for people with tinnitus

Readability assessment of self-report hyperacusis questionnaires

Objective: To assess the overall readability of five currently available hyperacusis questionnaires and to assess the variability of single items within each questionnaire. Design: Comparative study of self-report hyperacusis questionnaires: (1) Geräuschüberempfindlichkeits-Fragebogen (GUF), (2) Noise Avoidance Questionnaire (NAQ), (3) Hyperacusis Questionnaire (HQ), (4) Sound Sensitive-Tinnitus Index (SSTI), and (5) Inventory of Hyperacusis Symptoms (IHS). Well-established readability formulas Flesh-Kincaid Grade Level (FKGL), Flesch Reading Ease (FRE), Simple Measure of Gobbledygook (SMOG) and FORCAST and a computerised readability calculation software were used. Study sample: Five questionnaires. Results: Reading levels calculated by each formula varied for every questionnaire. Readability scores ranged from 7.7th to 12.7th grade for overall readability depending on the questionnaire. This exceeded the grade reading levels of 5th to 6th grade (10-12 years old) as recommended by the American Medical Association or 7th to 8th grade (12-14 years old) as recommended by the US National Institutes of Health. Single item readability analysis based on FKGL revealed that 32% to 70% of single items are written above the recommended grade levels. Conclusion: All five questionnaires are written at close to or exceeding the recommended grade levels. This requires attention from developers but also when interpreting the questionnaire scores obtained in clinic

Cochrane corner: Sound therapy (using amplification devices and/or sound generators) for tinnitus

This Cochrane Corner features “Sound therapy (using amplification devices or sound generators) for tinnitus” published in 2018. Sereda et al. identified eight clinical trials including 590 participants receiving sound therapy for tinnitus. None of the included studies addressed three main comparisons of the review (comparing hearing aids, sound generators and combination devices with a waiting list control group, placebo or education/information only). One study compared patients fitted with sound generators versus those fitted with hearing aids and found no difference between them in their effects on tinnitus symptom severity. The use of both types of device was associated with a clinically significant reduction in tinnitus symptom severity. Three studies compared hearing aids with a sound generator to hearing aids alone and measured tinnitus symptom severity. The use of both types of device was again associated with a clinically significant reduction in tinnitus symptom severity. This Cochrane review shows that both hearing aids and sound generators may be beneficial for reducing tinnitus severity in some patients, but that there is insufficient evidence at this stage to recommend one device over another, or whether these devices offer any improvement over a placebo treatment

Neuromagnetic indicators of tinnitus and tinnitus masking in patients with and without hearing loss

Tinnitus is an auditory phenomenon characterised by the perception of a sound in the absence of an external auditory stimulus. Chronic subjective tinnitus is almost certainly maintained via central mechanisms, and this is consistent with observed measures of altered spontaneous brain activity. A number of putative central auditory mechanisms for tinnitus have been proposed. The influential thalamocortical dysrhythmia model suggests that tinnitus can be attributed to the disruption of coherent oscillatory activity between thalamus and cortex following hearing loss. However, the extent to which this disruption specifically contributes to tinnitus or is simply a consequence of the hearing loss is unclear because the necessary matched controls have not been tested. Here, we rigorously test several predictions made by this model in four groups of participants (tinnitus with hearing loss, tinnitus with clinically normal hearing, no tinnitus with hearing loss and no tinnitus with clinically normal hearing). Magnetoencephalography was used to measure oscillatory brain activity within different frequency bands in a ‘resting’ state and during presentation of a masking noise. Results revealed that low-frequency activity in the delta band (1–4 Hz) was significantly higher in the ‘tinnitus with hearing loss’ group compared to the ‘no tinnitus with normal hearing’ group. A planned comparison indicated that this effect was unlikely to be driven by the hearing loss alone, but could possibly be a consequence of tinnitus and hearing loss. A further interpretative linkage to tinnitus was given by the result that the delta activity tended to reduce when tinnitus was masked. High-frequency activity in the gamma band (25–80 Hz) was not correlated with tinnitus (or hearing loss). The findings partly support the thalamocortical dysrhythmia model and suggest that slow-wave (delta band) activity may be a more reliable correlate of tinnitus than high-frequency activity

Source space estimation of oscillatory power and brain connectivity in tinnitus

Tinnitus is the perception of an internally generated sound that is postulated to emerge as a result of structural and functional changes in the brain. However, the precise pathophysiology of tinnitus remains unknown. Llinas’ thalamocortical dysrhythmia model suggests that neural deafferentation due to hearing loss causes a dysregulation of coherent activity between thalamus and auditory cortex. This leads to a pathological coupling of theta and gamma oscillatory activity in the resting state, localised to the auditory cortex where normally alpha oscillations should occur. Numerous studies also suggest that tinnitus perception relies on the interplay between auditory and non-auditory brain areas. According to the Global Brain Model, a network of global fronto—parietal—cingulate areas is important in the generation and maintenance of the conscious perception of tinnitus. Thus, the distress experienced by many individuals with tinnitus is related to the top—down influence of this global network on auditory areas. In this magnetoencephalographic study, we compare resting-state oscillatory activity of tinnitus participants and normal-hearing controls to examine effects on spectral power as well as functional and effective connectivity. The analysis is based on beamformer source projection and an atlas-based region-of-interest approach. We find increased functional connectivity within the auditory cortices in the alpha band. A significant increase is also found for the effective connectivity from a global brain network to the auditory cortices in the alpha and beta bands. We do not find evidence of effects on spectral power. Overall, our results provide only limited support for the thalamocortical dysrhythmia and Global Brain models of tinnitus

Mobile applications for management of tinnitus: users' survey, quality assessment and content analysis

Background: Tinnitus is the perception of a sound without any outside source. It affects 6 million people in the UK. Sound therapy is a core component of many tinnitus management programmes. Potential mechanisms of benefit include making tinnitus less noticeable, habituation, distracting attention from tinnitus, relaxation, and promoting neuroplastic changes within the brain. In recent years there has been a substantial increase in the use of mobile technology. This provided an additional medium via which people with tinnitus can access different tinnitus management options including sound therapy. Objective: The purpose of this study was to: 1) generate the list of apps that people use for management of their tinnitus; 2) explore reasons for apps use and non-use; 3) perform quality assessment of the most cited apps; 4) perform content analysis to explore and describe options and management techniques available in the most cited apps.Methods: An online survey consisting of 33 open and closed questions captured: i) demographic information about respondents, information about tinnitus, hearing loss; ii) mobile apps specific questions asked about the motivation to use an app to manage tinnitus, the apps which respondents used for managing tinnitus, important factors when choosing an app, devices used to access apps, reasons for not using apps. The quality of the most cited apps listed by respondents was assessed using the Mobile Apps Rating Scale (MARS) Content and features of the most cited apps were analysed. Results: Data from 643 respondents were analysed. The majority of respondents (75%) had never used an app for management of tinnitus mainly due to lack of awareness (79%). The list of the 55 apps that people use for the management of their tinnitus was generated. These included apps which were developed specifically for the management of tinnitus, however the majority of cited apps were developed for other problems (e.g. sleep, depression/anxiety, relaxation). Quality assessment of the 18 most popular apps, using MARS resulted in a range of mean scores from 1.6 to 4.2 (out of 5). In line with the current model of tinnitus management, sound was the main focus of the majority of the apps. Other components included relaxation exercises, elements of cognitive behaviour therapy, information and education and hypnosis. Conclusions: People use apps for the management of their tinnitus, however this was done mostly as a self-help option without conjunction with management provided by hearing healthcare professionals. Further research should consider the place for apps in the tinnitus management (standalone self-management intervention vs part of the management by a hearing professional). As the content of the apps varies in respect to sound options, information and management strategies it seems that the choice of the best management app should be guided by individual patient needs and preferences

A scoping review

Funding Information: LA is funded by King Abdul-Aziz University Hospital (KAU), Jeddah, Kingdom of Saudi Arabia. DH and MS are funded through the National Institute for Health and Care Research (NIHR) Biomedical Research Centre programme. The views expressed are those of the authors and not necessarily those of the NIHR, the NHS, the Department of Health, and Social Care. CC is funded by UNICAMP University of Campinas, Brazil, HH is funded by ENT Department, Hospital Cuf Tejo—Nova Medical School, Lisbon, Portugal and finally RD is funded by Sir Peter Mansfield Imaging Centre, School of Physics and Astronomy, University of Nottingham, United Kingdom. The funders had no role in preparation of the manuscript. Publisher Copyright: Copyright © 2022 Alzahrani, Sereda, Chamouton, Haider, Dewey and Hoare.Background: Tinnitus is defined as the subjective perception of sound in the absence of an external stimulus, and tinnitus disorder becomes relevant when it is associated with emotional distress, cognitive dysfunction, and/or autonomic arousal. Hearing loss is recognized as the main risk factor for the pathogenesis of tinnitus. However, clinical guidelines for tinnitus disorder provide little direction for those who have severe-to-profound hearing loss including those who are pre-lingually Deaf. The aim of this scoping review was to catalogue what is known from the existing literature regarding the experience and management of tinnitus in adults who have a severe-to-profound hearing loss. Summary: A scoping review was conducted following the Preferred Reporting Item for Systematic Reviews and Meta-analysis extension for Scoping Reviews. Records were included if they reported an evaluation of tinnitus in adults who had severe-to-profound hearing loss. The online databases Ovid (MEDLINE, EMBASE and PsycINFO), CINAHL, ProQuest, Scopus, and Google Scholar were searched using the search terms ‘tinnitus’ (as a MESH term) and ‘deaf’ OR ‘profound hearing loss. Thirty-five records met the inclusion criteria for this review and were cataloged according to three major themes: Impact of tinnitus in deaf adults; Primary treatment of tinnitus in deaf adults; and Cochlear implant studies where tinnitus was a secondary outcome. Tinnitus symptom severity was assessed before and after intervention using tinnitus validated questionnaires in 29 records, with six further records using other assessment tools to measure tinnitus severity. Participants using cochlear implants were included in 30 studies. Medication, repetitive transcranial magnetic stimulation (rTMS), electrical promontory stimulation, and behavioral self-control therapy were each reported in single records. Key messages: This scoping review cataloged the experience, assessment, and treatment of tinnitus in adults who have severe-to-profound hearing loss. It is shown that there is very limited research reported in this field. Although this review included many records, most focused on the provision of cochlear implants for severe-to-profound hearing loss, with assessment and measurement of tinnitus as a baseline or secondary outcome. Largely missing in the literature are empirical studies that seek firstly to understand the nature of the experience of tinnitus by people with no or little residual access to external sound.publishersversionpublishe

Relationship between tinnitus pitch and edge of hearing loss in individuals with a narrow tinnitus bandwidth

Objective: Psychoacoustic measures of tinnitus, in particular dominant tinnitus pitch and its relationship to the shape of the audiogram, are important in determining and verifying pathophysiological mechanisms of the condition. Our previous study postulated that this relationship might vary between different groups of people with tinnitus. For a small subset of participants with narrow tinnitus bandwidth, pitch was associated with the audiometric edge, consistent with the tonotopic reorganization theory. The current study objective was to establish this relationship in an independent sample. Design: This was a retrospective design using data from five studies conducted between 2008 and 2013. Study sample: From a cohort of 380 participants, a subgroup group of 129 with narrow tinnitus bandwidth were selected. Results: Tinnitus pitch generally fell within the area of hearing loss. There was a statistically significant correlation between dominant tinnitus pitch and edge frequency; higher edge frequency being associated with higher dominant tinnitus pitch. However, similar to our previous study, for the majority of participants pitch was more than an octave above the edge frequency. Conclusions: The findings did not support our prediction and are therefore not consistent with the reorganization theory postulating tinnitus pitch to correspond to the audiometric edge