About our work Tinnitus research Research reviews Quarter 2 2016 review A recent Australian survey  has found that most patients are unhappy with the healthcare they get after seeking treatment for their tinnitus. Patients elsewhere have similar views and experiences. More effective treatments are desperately needed. Research continues although not on the scale that is required. Psychology Psychological treatments, particularly cognitive behavioural therapy (CBT), are increasingly recommended for tinnitus and often take place over the internet. Do such treatments work for everyone? Swedish researchers  asked whether a patient’s response to treatment depends on his or her level of ‘cognitive flexibility’, which they define as ‘the ability to simultaneously consider several concepts and tasks, and switch effortlessly between them.’ The study team worked with 53 people receiving internet-based psychological treatments for their tinnitus. Their tinnitus was measured (before and after treatment) using the tinnitus handicap inventory (THI) questionnaire. Before treatment all patients were tested using the Wisconsin Card Sorting Test, which produces a score for cognitive flexibility. Most patients found their tinnitus improved but – contrary to the researchers’ expectations – no statistical association was found between the amount of improvement and the level of cognitive flexibility. This is good news; it suggests psychological treatments should suit a wide variety of people. Nevertheless, people with tinnitus must be motivated to seek help and to complete psychological treatments. A German team  tried to find out what factors are involved in seeking and completing internet-based CBT (ICBT). They recruited 112 patients for a 10-week course of ICBT. At both the start and end of the course and one year later, they were asked to complete questionnaires with ‘open-ended’ questions (ie not just yes/no) about their reasons for starting and persisting with the course, but only 72 completed all the questionnaires. Most decided to try ICBT because they had not been able to find other effective alternatives. Patients with several objectives (eg they specified they wanted not just to reduce the level of the tinnitus noise, but to learn how to cope with or control it) were more likely to start and to persist. Those who said they were willing to take a proactive role in their treatment (making statements such as '“I think that a long-lasting improvement can only happen at the hands of myself”’) were also more inclined to persist. Unsurprisingly, patients who found the treatment was helping were more likely to complete the full course. Sound Some people with tinnitus use devices that generate sound to help them cope. Bedside sound generators, intended to aid sleep, have been evaluated in a US study . Researchers contacted over 500 people already using commercially available bedside devices and asked them to complete a questionnaire which included rating the degree of sleep improvement on a scale of one to ten. Over 200 returned their questionnaires, but only 184 (all from men) were considered ‘useable’ by the researchers. A study like this is not a proper trial and cannot produce high-quality evidence, but the results are of some interest; 79% said their sleep had improved substantially since starting to use sound generators. The level of improvement seemed to be no different between hearing aid users and non-users, and was no different for people with sleep disorders. People with mental health diagnoses did, however, report higher levels of sleep improvement. Most sound generators allow the user to choose from a range of different sounds. Two types of sound were compared in a small Italian trial  in which 17 patients heard conventional ‘technical’ sounds through their hearing aids and 20 were chosen from a selection of ‘sounds of nature’. They all completed THI questionnaires before treatment began and after three and six months. THI scores improved after treatment in both groups, but there was no significant difference between groups. There was no ‘control’ group.Both those with hearing impairment and those without experienced benefits. The findings are perhaps surprising – personally selected natural sounds might be expected to be more popular. The authors make the case for further study. Music is of particular interest as a sound that could mask tinnitus. We have previously mentioned small studies on ‘notched music’, in which the pitch of each patient’s tinnitus is identified and they choose music or other pleasant sounds, from which a ‘notch’ of frequency range is then removed. The first rigorously conducted trial  of this treatment has now been published. Disappointingly, after three months of listening to notched music for two hours per day, 40 patients showed no significant improvement in tinnitus levels measured by questionnaire. A control group of 43 patients who listened to music from which random notches of frequency (not related to the pitch of their tinnitus) had been removed did show a very small measure of improvement. However, on the basis of further complex statistical analysis, the researchers argue that there is still a case for further studies. People who receive a cochlear implant for hearing problems often report that their implant has reduced their tinnitus. A Dutch research team  wondered whether an implant that also provided environmental sounds would have more benefit than a standard implant. Ten patients were given first one type of implant, then the other. Both types seemed to have a similar level of effect. The researchers hope that further research will lead to the development of implants specifically intended for tinnitus patients. Other approaches Using electricity or magnetism to stimulate activity in the brain remains a popular area for researchers. A small German trial  investigated a new form of transcranial magnetic stimulation (rTMS), known as continuous theta burst stimulation; patients receiving this therapy did no better than those given a sham treatment. In a joint US-New Zealand study , researchers varied the level, duration and location of transcranial direct current stimulation (tDCS). All 27 patients in the study received the same varieties of tDCS given in increasing doses. There was no control group. Tinnitus loudness was reduced slightly in 21 of the patients. The highest dose and longest duration of stimulation appeared to be the most effective. Indian researchers  report a pilot randomised control trial (RCT) with intramuscular injections of vitamin B12. Forty patients were tested for vitamin B12 deficiency; 43% of them were found to be deficient. All the patients were then randomly chosen to receive either vitamin B12 or a placebo. Those of the treatment group who had been vitamin B12 deficient showed an improvement in tinnitus levels (assessed by questionnaires). In those who were not deficient, and in all the placebo group, there was no improvement. In most parts of the world, only a small minority of patients will be vitamin B12 deficient. This is also another study that is not fully reported. However, it is worth looking at this further; possibly doctors should check the vitamin B12 status of their patients. A systematic review  looked for evidence in favour of the use of electroacupuncture, in which electrical stimulation is administered through acupuncture needles. The reviewers confined themselves to evidence from RCTs. They were only able to find five such studies, in all of which quality was low and risk of bias high. They concluded there is no evidence as to whether or not electroacupuncture works. Meanwhile, ‘Chinese scalp acupuncture’ has been used in an RCT in Brazil . Twenty-five patients received treatment twice a week for five weeks; the same number of patients were in a control group, where no treatment was given. Significant improvements were seen in tinnitus levels in the treatment group, whilst there was none in the controls. This is an interesting study; the authors tried hard to reduce the possibility of bias, which is not always the case in studies of ‘alternative’ medicine. However, it is surprising that the control received simply no treatment, rather than a sham procedure. This means that the placebo effect could have been a factor. The authors say follow-up measurements of tinnitus levels is needed to find out whether the benefits last after the period of treatment is over. Objective tinnitus is a rare form of the condition (less than 5% of cases); In contrast to ‘subjective’ tinnitus, objective tinnitus can be heard by the examiner as well as by the patient. It can be caused by muscular tremors, so Botulinum toxin (BT or Botox™), which paralyses muscles, has been used in treatment. A systematic review  of the evidence has been published. Most of the data in the review comes from individual case studies, and is not regarded as high-quality evidence. Nevertheless, the authors conclude that, when correctly injected, BT would seem to be an effective treatment of objective tinnitus due to EPT, with few adverse effects and complications. But what do patients themselves think of the treatment they have been given for their tinnitus? A UK survey  asked 200 patients to rate the effectiveness of any treatment they had been given on a score of 1–5. Only 97 responded. The mean score was greatest for counselling (4.7), followed by education (4.5), CBT (4.4), and hearing tests (4.4). Only 6% of responders rated counselling as 3 or below. In contrast, bedside sound generators, hearing aids, and wideband noise generators were rated as 3 or below by 25%, 36%, and 47% of participants, respectively. References 1. Carmodie N. Help-Seeking in Tinnitus: Low Patient Satisfaction Calls for Improvements. Hearing Journal 2016; 69:41-44.2. Lindner P, Carlbring P, Flodman E et al. Does cognitive flexibility predict treatment gains in internet-delivered psychological treatment of social anxiety disorder, depression, or tinnitus? Peer J 2016; 4:e1934.3. Heinrich S, Rozental A, Carlbring P et al. Treating tinnitus distress via the Internet: A mixed methods approach of what makes patients seek help and stay motivated during Internet-based cognitive behavior therapy. Internet Interventions 2016; 4:120-1304. Benton S. Bedside Sound Generators as a Tool for Tinnitus Management. Hearing Journal 2016; 5:31-34.5. Barozzi S, Del Bo L, Crocetti A et al. A Comparison of Nature and Technical Sounds for Tinnitus Therapy: Acta Acustica 2016; 102: 540-546.6. Stein A, Wunderlich R, Lau P. Clinical trial on tonal tinnitus with tailor-made notched music training. BMC Neurology 2016; 16:38.7. Arts R George E, Janssen M, et al. Tinnitus Suppression by Intracochlear Electrical Stimulation in Single Sided Deafness – A Prospective Clinical Trial:Follow-Up. PLoS ONE 2016; 11: e015313.8. Schecklmann M, Giani A, Tupak S. Neuronavigated left temporal continuous theta burst stimulation in chronic tinnitus Restorative Neurology and Neuroscience 2016; 34: 165-175.9. Shekhawat GS, Sundram F, Bikson M. Intensity, duration, and location of high-definition transcranial direct current stimulation for tinnitus relief Neurorehabilitation and Neural Repair 2015; 30:349-359.10. Singh C, Kawatra R, Gupta J, et al Therapeutic role of Vitamin B12 in patients of chronic tinnitus: A pilot study. Noise Health 2016;18: 93-97.11. He M, Li X, Liu Y, et al. Electroacupuncture for Tinnitus: A Systematic Review. PLoS ONE 2016; 11(3): e0150600.12. Doi M, Tano S, Schultz A et al. Effectiveness of acupuncture therapy as treatment for tinnitus: a randomized controlled trial. Brazilian Journal of Otorhinolaryngology 2016; 82:458-465.13. Slengerik-Hansen J , Ovesen T. Botulinum Toxin Treatment of Objective Tinnitus because of Essential Palatal Tremor: A Systematic Review. Otology and Neurotology 2016; 37: 820-828.14. Aazh H, Moore BC, Lammaing K, Cropley M. Tinnitus and hyperacusis therapy in a UK National Health Service audiology department: Patients’ evaluations of the effectiveness of treatments. International Journal of Audiology 2016; 55: 514-522.