Tinnitus treatment guidelines

A European study [1] has examined the national guidelines for assessment and treatment of tinnitus that have been published in different countries. The researchers found that such guidelines exist in five countries: Denmark, Germany, Sweden, the Netherlands, and the United States. In recent years, Cognitive behavioural therapy (CBT) has become the most widely recommended treatment for tinnitus. They found a high level of consistency across these guidelines with regard to how patients should be assessed and on their recognition of the likely benefits of CBT.

In addition, the guidelines recommend the provision of information and education to all patients, and the use of hearing aids for those who also have hearing loss. Prescribed medicines and herbal supplements should not be used for the treatment of tinnitus, according to all the guidelines. There were some differences between the guidelines with regard to whether various sound therapies should be considered as treatment options.

Further support for CBT comes from a major systematic review [2] of studies of all types of tinnitus treatment, which has been conducted by a German team. 
Pharmaceutical approaches

Drugs are still often prescribed to people with tinnitus. Some new studies of the use of particular medicines have been published. Korean researchers [3] found that, of 52 patients they were treating for tinnitus, 15 met the criteria for depression. They gave the depressed patients an antidepressant called tianeptine. They report improvements in both depression and tinnitus (measured on one of the standard scales). But this is a small study with no control group and, like similar antidepressants, tianeptine is known to have side-effects and is a drug that can be misused. 
Also in Korea, researchers injected a steroid (dexamethasone) into the eardrums of 27 people with tinnitus [4], while 27 other patients were injected with saline as a control group. There was some improvement in both groups but there was no significant difference between them, suggesting that steroid treatment administered this way is unlikely to be of benefit.

Gabapentin – a drug used for epilepsy and other conditions – has often been studied with tinnitus patients. Results have been varied but it is generally considered not to be effective. A new study from Iran [5], however, found that at the end of six months treatment 55 patients given gabapentin showed greater reductions in their tinnitus levels (again using a standard scale) than did 48 control patients.

Physiotherapy

Could physiotherapy help people with tinnitus? A Belgian team used the systematic review approach to search the medical journals for any randomised controlled trials that had addressed this question [6]. They found four studies in which physiotherapy had been done focusing on the cervical spine, and two where the focus was on the temporomandibular joint (i.e. where the jaw and the skull meet). The reviewers say that, ‘… it is noteworthy that all included studies show positive treatment effects’. However, they note that the methods used in the trials (and therefore the evidence from them) were not of high quality. They say that more research, and of higher quality, will be needed before physiotherapy can be recommended.

Acupuncture

Acupuncture has attracted much interest and a Korean study [7) now compares three different types of this procedure. Forty-two patients were chosen to receive either ‘systemic manual’ acupuncture (i.e. standard acupuncture with points across the whole body), or electroacupuncture in the region of the ear, or electroacupuncture with points in other parts of the body. The treatments were given twice a week for four months. Tinnitus was measured using recognised scales before, during and four weeks after treatment. All three groups showed roughly the same improvement in their tinnitus but there was no control group. This and other problems with the methods used mean that the evidence in favour of acupuncture in this study is very weak.

Focus on sound

‘Auditory training’ is technique that is being researched for people with hearing loss; it involves actively listening to sounds such as tones, parts of words, or whole words, over a period of time. A Brazilian paper [8] reports the use of this procedure with six tinnitus patients. As a control, six other patients were given ‘visual training’ (word games on paper). In both cases the training was given once a week for two months. One of the auditory training patients had a small improvement in their tinnitus but overall there was no significant difference between the treatment and control groups. This of course is a tiny study with no long-term follow-up. Further research might still be worth conducting.

Cochlear implants, conducted to combat hearing loss, have often been reported to help tinnitus. A new US study [9] has confirmed this. Twelve patients who had been given implants for their hearing loss were asked to complete the Tinnitus Handicap Inventory (THI) questionnaire before and after their treatment, and six months later. There were significant reductions in their tinnitus. Of course the implants were not given as a treatment for the tinnitus – the hearing loss was the target. And the study was small and uncontrolled. However, the consistent finding of tinnitus improvement with cochlear implants is worth noting.

A type of sound therapy is the subject of a new systematic review [10] that has tried to determine whether there is any evidence in favour of the technique known as ‘acoustic coordinated reset neuromodulation …. a patterned stimulation with tones adjusted to the patient’s dominant tinnitus frequency’. The reviewers found that eight studies (total 329 patients) have been conducted. Most patients reported a reduction of tinnitus symptoms and no safety issues emerged. But the quality of the evidence was considered to be poor and more research is needed.

Other approaches

Neurofeedback, a fascinating concept, is the subject of a small study [11] by an international group. The idea is to show people videos of their own brain activity in the hope that they can learn to regulate that activity at will. There have been many studies suggesting that this can help people with a range of other problems including addiction, depression, pain and aggressive behaviour. In nine sessions over the course of three days, 14 people with tinnitus were shown ‘real-time’ videos of magnetic resonance (MRI) images of the auditory areas of their brains. Some were given feedback continuously and others intermittently. Before and after scores using the Tinnitus Functional Index (TFI) showed no change. However, the researchers argue that their MRI data shows patients were able to modify their own brain activity in response to the images they were shown and, on these grounds, they call for further research.

The potential treatment that probably attracts the most attention from researchers is the various forms of electrical stimulation for the brain, although interestingly, the Netherlands guidelines specifically recommend against such treatments. It has been noted that while some patients may show benefit others do not. The researchers in a US study [12] looked at the characteristics of 35 people participating in a trial of transcranial magnetic stimulation (TMS) and concluded that those most likely to benefit were the patients whose tinnitus was most severe (as measured by TFI scores).

A South Korean team [13] argue that it may be necessary to stimulate more than one region of the brain. They gave eight patients TMS focused on just one site (the brain’s dorsolateral prefrontal cortex) while nine received TMS both to this region and to the auditory cortex. After 12 weeks both groups showed improvements in their THI scores (and on other measures) but this was to a greater level in the two-site group. There was no control group.

Dutch researchers have tried a different approach [14] – they used an implant to provide electrical stimulation to one of the nerves in the head (but not within the brain itself) – the cochleovestibular nerve. They had 10 patients all of whom had tinnitus in one ear that was described as being ‘severe and intractable’. Overall there were significant improvements in THI score and this was still the case four years later – an unusually long follow-up period for tinnitus studies. In six cases the tinnitus was reduced to a much more bearable level. However, there were side-effects for four patients, so there would be risks in having this procedure and the researchers say they would only consider it for serious cases.

References

1. Fuller TE, Haider HF, Kikidus D et al. Front. Different teams, same conclusions? A systematic review of existing clinical guidelines for the assessment and treatment of tinnitus in adults Front. Psycho 2017; 22 Feb.
2. Zenner HP, Delb W, Kröner-Herwig B et al. A multidisciplinary systematic review of the treatment for chronic idiopathic tinnitus. Eur Arch Otorhinolaryngol 2017;274:2079.
3. Hwant SM, Lim SH, Dong JO. Effect of tianeptine on depressed tinnitus patients. J Audiol Otol. 2016;20:90.
4. Lee H.-J, Kim MB, Yoo, S-Y et al. Clinical effect of intratympanic dexamethasone injection in acute unilateral tinnitus: A prospective, placebo-controlled, multicenter study. Laryngoscope 2017; 22 Feb.
5. Tabrizi AG, Naine A, Baradaran N. Short-term effect of gabapentin on subjective tinnitus in acoustic trauma patients.Iran J Otorhinolaryng 2017; 29: Serial No.91.
6. Michiels S, Naessens S, Van de Heynin P et al. The effect of physical therapy treatment in patients with subjective tinnitus: a systematic review Front. Neurosci. 2016; 29 Nov. 
7. Kim BH, Kim KK, Nam HJ. A comparative study on the effects of systemic manual acupuncture, periauricular electroacupuncture, and digital electroacupuncture to treat tinnitus: A randomized, paralleled, open-labeled exploratory trial. BMC Complementary and Alternative Medicine 2017; 17:85.
8. Tugumia D, Samelli AG, Matas CG. Auditory training program in subjects with tinnitus. CoDAS 2017; 28(1).
9. Holder JT, O’Connell B, Hedley-Williams A, Wanna G. Cochlear implantation for single-sided deafness and tinnitus suppression. Am. J Oto 2017; 38:226.
10. Weger M, Ovesen T, Larsen DG. Acoustic coordinated reset neuromodulation: a systematic review of a novel therapy for tinnitus. Front. Neurol. 2017; 13 Feb.
11. Emmert K, Kopel R, Koush Y et al. Continuous vs. intermittent neurofeedback to regulate auditory cortex activity of tinnitus patients using real-time fMRI; a pilot study. Neuroimaging 2017; 14:97.
12. Theodoroff SM, Griest SE, Folmer RL. Transcranial magnetic stimulation for tinnitus: Using the Tinnitus Functional Index to predict benefit in a randomized controlled trial. Trials 2017; 18:Article 64.
13. Noh T-S, Kyong JS, Chang MY. Comparison of treatment outcomes following either prefrontal cortical-only or dual-site repetitive transcranial magnetic stimulation in chronic tinnitus patients: a double-blind randomized study. Otol. Neurotol. 2017; 38:296.
14. van den Berge MJC, van Dijk JMC, Free RH. Effect of Direct Stimulation of the Cochleovestibular Nerve on Tinnitus: A Long-Term Follow-Up Study World Neurosurg. 2017; 1 Feb:571.