The natural history of subjective tinnitus in adults: a systematic review and meta-analysis of ‘no-intervention’ periods in controlled trials

Objectives Tinnitus is a prevalent condition, but little has been published regarding the natural history of the condition. One technique for evaluating the long-term progression of the disease is to examine what happens to participants in the no-intervention control arm of a clinical trial. The aim of this study was to examine no-intervention or waiting-list data reported in trials, in which participants on the active arm received any form of tinnitus intervention. Data Sources CINAHL, PsychINFO, EMBASE, ASSIA, PubMed, Web of Science, Science Direct, EBSCO Host, and Cochrane. Methods Inclusion criteria followed the PICOS principles: Participants, adults with tinnitus; Intervention, none; Control, any intervention for alleviating tinnitus; Outcomes, a measure assessing tinnitus symptoms using a multi-item patient-reported tinnitus questionnaire. Secondary outcome measures included multi-item patient-reported questionnaires of mood and health-related quality of life and measures that quantified change in tinnitus loudness; Study design, randomized controlled trials or observational studies utilizing a no-intervention or waiting-list control group. Data were extracted and standardized mean difference was calculated for each study to enable meta-analysis. Results The evidence strongly favored a statistically significant decrease in the impact of tinnitus over time, though there was significant heterogeneity and clinical significance cannot be interpreted. Outcome data regarding secondary measures did not demonstrate any clinically significant change. Conclusions Participants allocated to the no-intervention or waiting-list control arm of clinical trials for a tinnitus intervention show a small but significant improvement in self-reported measures of tinnitus with time; the clinical significance of this finding is unknown. There is, however, considerable variation across individuals. These findings support previous work and can cautiously be used when counseling patients

Tinnitus

Tinnitus is a prevalent experience and, for those who are troubled by it, it can be debilitating.Risk factors include hearing loss, ototoxic medication, head injury and depression, and at presentationthe possibility of otologic disease and of anxiety/depression should be considered. Effective drugtreatments have proven elusive, though this is a vibrant theme in tinnitus research. Surgicalintervention for any otological pathology associated with tinnitus may be effective for that condition,but the tinnitus may persist. Presently available treatments include the provision of hearing aids whena hearing loss is identified (even when mild or unilateral), wide band sound therapy and counselling. Insome patients, cognitive behavioural therapy (CBT) is indicated though availability of tinnitus specificCBT is limited in the UK. Of these treatments the evidence base is strongest for a combination of soundtherapy and CBT based counselling, though clinical trials are constrained by the heterogeneity of thetinnitus patient population. Research into mechanisms of tinnitus and effective treatments nowabounds, and progress is keenly anticipated

Betahistine for tinnitus (Protocol)

Background: Tinnitus describes 'ringing', 'whooshing' or 'hissing' sounds that are heard in the absence of any corresponding external sound. Between 5% and 43% of people experience this symptom and for some it has a significant negative impact on their quality of life. Tinnitus can be managed through education and advice, prescription devices that improve hearing, over-the-counter devices that generate background sounds, psychological therapy and relaxation therapy. Drug therapies are used to manage complaints associated with tinnitus such as sleep difficulties, anxiety or depression. No drug therapies exist that manage the tinnitus itself. Nonetheless, betahistine is often prescribed for tinnitus. The purpose of this review is to evaluate the evidence from high-quality clinical trials to work out the effect of betahistine on people's tinnitus. We particularly wanted to look at the effect of betahistine on tinnitus loudness and the side effects of betahistine.Study characteristics: Our review identified five randomised controlled trials with a total of 303 to 305 participants who suffered from tinnitus. These studies compared participants receiving betahistine to those receiving a placebo. Four study designs allocated participants into parallel groups. In one study, participants consented to take all study medications in a pre-defined sequence. The outcomes that we evaluated included tinnitus loudness and intrusiveness, tinnitus symptoms and side effects.Key results: The included studies did not show differences in tinnitus loudness, severity of tinnitus symptoms or side effects between participants receiving betahistine and participants receiving a placebo. No significant side effects were reported. We had planned to evaluate changes in tinnitus intrusiveness, depression and anxiety and quality of life, but these were not measured. The evidence suggests that betahistine is generally well tolerated with a similar risk of side effects to placebo.Quality of the evidence: The quality of the evidence ranged from moderate to very low. The risk of bias in all of the included studies was unclear. The results were drawn from one or two studies only. In some studies, the participants that were included did not fully represent the entire population of people with tinnitus and so we cannot draw general conclusions

Uncomfortable loudness levels among children and adolescents seeking help for tinnitus and/or hyperacusis.

OBJECTIVE: To assess the prevalence of hyperacusis and severe hyperacusis among children and adolescents seen at an audiology outpatient tinnitus and hyperacusis service. DESIGN: This was a retrospective study. Hyperacusis was considered as present if the average uncomfortable loudness level (ULL) at 0.25, 0.5, 1, 2, 4 and 8 kHz for the ear with the lower average ULL, which is denoted as ULLmin, was ≤77 dB HL. Severe hyperacusis was considered as present if the ULL was 30 dB HL or less for at least one of the measured frequencies for at least one ear. STUDY SAMPLE: There were 62 young patients with an average age of 12 years (SD = 4.1 years, range 4-18 years). RESULTS: Eighty-five percent of patients had hyperacusis and 17% had severe hyperacusis. On average, ULLs at 8 kHz were 9.3 dB lower than ULLs at 0.25 kHz. For 33% of patients, ULLs were at least 20 dB lower at 8 than at 0.25 kHz. CONCLUSIONS: Among children and adolescents seen at an audiology outpatient clinic for tinnitus and hyperacusis, hyperacusis diagnosed on the basis of ULLs is very prevalent and it is often characterised by lower ULLs at 8 than at 0.25 kHz

Why Is There No Cure for Tinnitus?

Tinnitus is unusual for such a common symptom in that there are few treatment options and those that are available are aimed at reducing the impact rather than specifically addressing the tinnitus percept. In particular, there is no drug recommended specifically for the management of tinnitus. Whilst some of the currently available interventions are effective at improving quality of life and reducing tinnitus-associated psychological distress, most show little if any effect on the primary symptom of subjective tinnitus loudness. Studies of the delivery of tinnitus services have demonstrated considerable end-user dissatisfaction and a marked disconnect between the aims of healthcare providers and those of tinnitus patients: patients want their tinnitus loudness reduced and would prefer a pharmacological solution over other modalities. Several studies have shown that tinnitus confers a significant financial burden on healthcare systems and an even greater economic impact on society as a whole. Market research has demonstrated a strong commercial opportunity for an effective pharmacological treatment for tinnitus, but the amount of tinnitus research and financial investment is small compared to other chronic health conditions. There is no single reason for this situation, but rather a series of impediments: tinnitus prevalence is unclear with published figures varying from 5.1 to 42.7%; there is a lack of a clear tinnitus definition and there are multiple subtypes of tinnitus, potentially requiring different treatments; there is a dearth of biomarkers and objective measures for tinnitus; treatment research is associated with a very large placebo effect; the pathophysiology of tinnitus is unclear; animal models are available but research in animals frequently fails to correlate with human studies; there is no clear definition of what constitutes meaningful change or “cure”; the pharmaceutical industry cannot see a clear pathway to distribute their products as many tinnitus clinicians are non-prescribing audiologists. To try and clarify this situation, highlight important areas for research and prevent wasteful duplication of effort, the British Tinnitus Association (BTA) has developed a Map of Tinnitus. This is a repository of evidence-based tinnitus knowledge, designed to be free to access, intuitive, easy to use, adaptable and expandable

An economic evaluation of the healthcare cost of tinnitus management in the UK

Background: There is no standard treatment pathway for tinnitus patients in the UK. Possible therapies include education and reassurance, cognitive behavioural therapies, modified tinnitus retraining therapy (education and sound enrichment), or amplification of external sound using hearing aids. However, the effectiveness of most therapies is somewhat controversial. As health services come under economic pressure to deploy resources more effectively there is an increasing need to demonstrate the value of tinnitus therapies, and how value may be continuously enhanced. The objective of this project was to map out existing clinical practice, estimate the NHS costs associated with the management approaches used, and obtain initial indicative estimates of cost-effectiveness.Methods: Current treatment pathways, costs and health outcomes were determined from the tinnitus literature, national statistics, a patient survey, and expert opinion. These were used to create an Excel-based economic model of therapy options for tinnitus patients. The probabilities associated with the likelihood of an individual patient receiving a particular combination of therapies was used to calculate the average cost of treatment per patient, average health outcome per patient measured in QALYs gained, and cost-effectiveness, measured by the average cost per QALY gained.Results: The average cost of tinnitus treatment per patient per year is GB£717, equating to an NHS healthcare bill of GB£750 million per year. Across all pathways, tinnitus therapy costs £10,600 per QALY gained. Results were relatively insensitive to restrictions on access to cognitive behaviour therapy, and a subsequent reliance on other therapies.Conclusions: NHS provisions for tinnitus are cost-effective against the National Institute for Health and Care Excellence cost-effective threshold. Most interventions help, but education alone offers very small QALY gains. The most cost-effective therapies in the model were delivered within audiology

Tinnitus

Tinnitus is a prevalent experience and, for those who are troubled by it, it can be debilitating. Risk factors include hearing loss, ototoxic medication, head injury and depression, and at presentation the possibility of otologic disease and of anxiety/depression should be considered. Effective drug treatments have proven elusive, though this is a vibrant theme in tinnitus research. Surgical intervention for any otological pathology associated with tinnitus may be effective for that condition, but the tinnitus may persist. Presently available treatments include the provision of hearing aids when a hearing loss is identified (even when mild or unilateral), wide band sound therapy and counselling. In some patients, cognitive behavioural therapy (CBT) is indicated though availability of tinnitus specific CBT is limited in the UK. Of these treatments the evidence base is strongest for a combination of sound therapy and CBT based counselling, though clinical trials are constrained by the heterogeneity of the tinnitus patient population. Research into mechanisms of tinnitus and effective treatments now abounds, and progress is keenly anticipated

In Memoriam: David Mark Baguley

Reverend Professor David (Dave) Mark Baguley, audiologist, hearing scientist, tinnitus clinician, educator, and Church of England priest, died suddenly and unexpectedly in Nottingham, UK on 11 June 2022, at the age of 61 (Figure 1) [...