About our work Tinnitus research Research reviews Quarter 3 2016 review Surgery Could some types of tinnitus be cured by surgery? Two recent studies are of interest. In the first , ear specialists in South Korea set out to help eight patients with pulsatile tinnitus. Less than 10% of people with tinnitus have this form of the condition,which can be caused by ‘turbulence’ in blood flow as a result of abnormalities in blood vessels. Using a technique called ‘transmastoid SS-reshaping surgery’ and asking patients to rate their tinnitus loudness and distress levels on scales of 1–10, they found reductions in tinnitus in seven cases. The benefits were noted immediately after surgery and were still present when patients were followed up a few months later. The authors draw attention to several limitations in their small study but this approach to pulsatile tinnitus certainly seems to deserve further investigation. A Spanish team  worked with people suffering from a type of brain tumour (acoustic neuroma) which often leads to tinnitus; 28 of the 39 patients they saw in a four-year period had tinnitus. Surgical removal of the tumour tended, particularly in younger patients, to reduce the level of tinnitus, as measured with the tinnitus handicap inventory (THI). Of course, only a very small minority of people with tinnitus have developed their condition as a result of a brain tumour but the study demonstrates that issues arising within the brain can be responsible for tinnitus, and that they may sometimes be successfully treated. Psychological methods Psychological approaches to tinnitus treatment may offer hope for many people with the condition. A recent review , intended to compile a list of all the research has been published to date, found there have been over 5000 studies. While many different approaches have been investigated, the most studied have been cognitive behavioural therapy (particularly when delivered over the internet) and education/training about tinnitus. Very little of this research, however, has involved randomised controlled trials (RCTs) so the quality of the evidence available is not high. One psychological issue is motivating people to persist with the treatment they have been prescribed. This is particularly the case with hearing aids. In Sweden  a ‘motivational interview’ has been developed during which health workers provide additional encouragement to tinnitus patients who have been given hearing aids. It is based on a technique which has been used successfully to help smokers and drug addicts. The researchers conducted an RCT in which 23 people with tinnitus were given hearing aids in the usual way and a further 23 received hearing aids plus motivational interviews. Both groups showed improvements, in terms of scores on the THI, but the motivational interview group fared significantly better. The researchers call for further studies using this technique. The study supports the notion that, for many health conditions, it isn’t enough to hand over a treatment to a patient; people need continuing support. Sound In Ireland  41 patients were provided with an ‘auditory and somatosensory stimulation’ device and 45% of them showed an improvement in their THI scores. Only 30 patients used their devices properly and amongst them the improvement rate was higher (57%). Once again what we have here is a small, uncontrolled pilot study but it shows it is feasible to use this new device and further research could prove worthwhile. Comparing and combining A US team  compared a sound generator with a psychological approach (both given by trained audiologists) in an RCT involving 148 ex-military personnel over an 18-month period. A tinnitus RCT following patients for such a long time is quite unusual. A quarter of the patients were fitted with a ‘masking’ device – a sound generator in their ears. The other treatment group were given ‘tinnitus retraining therapy’. There were two control groups: patients in one received no treatment (though they were ‘wait-listed’ to get treatment later on) and the other received standard treatment – educational counselling on tinnitus plus hearing aids for those who needed them. The group that received no treatment had not improved by the end of the study. Significant improvements occurred in all the other groups (about half the patients in each showed ‘strong or modest improvement’ in THI scores) but no group was better than the others. It is encouraging that many of the patients who got treatment did improve but disappointing that the newer techniques (the masking and the retraining) were no better than standard treatment from an audiologist. Interestingly the researchers report that there was a huge demand from ex-military personnel to join the study; many US veterans are troubled by tinnitus. Researchers sometimes combine treatments of different types. A Belgian team  focused on people with somatic tinnitus, defined as tinnitus that is changes in intensity and pitch when there are head and neck movements or whose tinnitus is accompanied by abnormal sensations in the face. They took 21 such people and provided them with both sound therapy (white-noise generators) and retraining therapy. They report that average THI scores were reduced by half. Unfortunately this was not a controlled study and the published report provides little information on how the two therapies were delivered. A German team  did not set up a new experimental study but instead reviewed data on 5536 patients who had, during a seven-year period, attended an out-patient tinnitus centre in Düsseldorf. This clinic combines many different treatments, given over the course of nine days. These include muscle relaxation and ‘cognitive methods of restructuring and mindfulness-based techniques including aspects of counselling and emotional accompaniment, positive imagination techniques, attentional engagement and mental refocussing on inner resources.’ The aim is to ‘manage the unpleasantness of tinnitus through active self-control’ while focussing the patient’s attention away from the tinnitus. But in addition patients are also given ‘auditive stimulation therapy which includes receptive psychoacoustic training, musical perception training and music therapeutic exercises originally employed in the treatment of chronic pain.’ The researchers used the Tinnitus Questionnaire scoring system (which goes up to a maximum score of 84) and using complex statistical analysis they have calculated that patients succeed in significantly lowering their scores (by an average of 18). An ‘observational’ study like this one, with no control group, which evaluates several different techniques at the same time does not give us high-quality evidence. However, it is clear that many patients have had some benefit from attending this clinic and the methods used there certainly deserve further investigation. Pills The use of dietary supplements for tinnitus has usually proved disappointing but some patients have reported benefits from taking manganese supplements. US researchers have now conducted an RCT , in which 20 people with tinnitus were given manganese plus another supplement (‘Lipoflavonoid Plus’) and compared with 20 control patients given Lipoflavonoid Plus only. There was a high dropout rate in this study, mainly due to side-effects in the manganese group, so only 28 patients were part of the final analysis. No patients reported clear benefits following treatment. One patient (out of 12) in the manganese group showed some improvement based on tinnitus handicap and function questionnaire scores, compared with none (out of 16) in the control group. Loudness and annoyance questionnaire scores showed an improvement for one treatment patient and for three control patients. No benefits from manganese (or Lipobase Plus) can be claimed on the basis of evidence from this trial. The trial was small, the authors do not say whether the patients were ‘blinded’ to treatment and the high dropout rate also reduces the strength of any evidence. Trimetazidine dihydrochloride is a drug much used for ear, nose and throat conditions including sometimes for tinnitus. Turkish researchers  have conducted a double-blinded RCT involving 82 patients with tinnitus, 42 of whom were given capsules containing the drug while 40 received identical looking capsules containing only powdered sugar. Using two standard tinnitus questionnaires, there were no significant differences between the treatment and control groups after treatment. The authors, who in their paper also provide a good summary of evidence on other drugs currently used for tinnitus, conclude that trimetazidine dihydrochloride offers no benefits for people with tinnitus. Physiotherapy Finally, could physiotherapy help some people with tinnitus? It is thought that some cases result from problems in the cervical area of the spine, so researchers in Belgium carried out an RCT involving people with tinnitus who also had neck complaints. Physiotherapy was given to 19 patients for six weeks; a control group of 19 were listed to get the same treatment later. The main ‘tool’ used to assess the results was the Tinnitus Functional Index (TFI). At the end of the six weeks 53% of those who were treated showed ‘substantial improvements’ but this had declined to only 24% after a further six weeks had gone by. References 1. 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Henry JA, Stewart BJ, Griest S et al. Multisite Randomized Controlled Trial to Compare Two Methods of Tinnitus Intervention to Two Control Conditions. Ear Hear 201; 37:e346-e359.7. Ostermann K, Lurquin P, Horoi M et al. Somatic tinnitus prevalence and treatment with tinnitus retraining therapy. B-ENT 2016; 12:59-65.8. Ostermann T, Boehm K, Kusatz M. Evaluation of 5536 patients treated in an integrative outpatient tinnitus treatment center–immediate effects and a modeling approach for sustainability. BMC Health Services Research 2016; 16:377.9. Rojas-Roncancio E, Tyler R, Jun HJ et al. Manganese and Lipoflavonoid Plus(®) to Treat Tinnitus: A Randomized Controlled Trial. J Am Acad Audiol 2016; 27:661-668.10. Kumral TL, Yıldırım G, Berkiten G et al. Efficacy of Trimetazidine Dihydrochloride for Relieving Chronic Tinnitus: A Randomized Double-Blind Study. Clin Exp Otorhinolaryngol 2016; 192-197. 11. Michiels S, Van de Heyning P, Truijen S et al. Does multi-modal cervical physical therapy improve tinnitus in patients with cervicogenic somatic tinnitus? Man Ther 2016; 26:125-131.