Small-Group Counseling in a Modified Tinnitus Retraining Therapy for Chronic Tinnitus

Objectives

The authors have treated chronic tinnitus patients using a combination of a simplified tinnitus retraining therapy (TRT) and medications, which we called modified TRT. In this clinical setting, we have attempted small-group counseling to find a time-effective equivalent of individual counseling. The aim of the present study was to evaluate the effectiveness of small-group counseling by comparing the treatment outcomes between individual and small-group counseling.

Methods

The patients who had distressing chronic tinnitus with normal hearing or mild hearing loss were included. The subjects were placed into the small-group (group 1:4) or the individual (group 1:1) counseling group, and underwent a modified TRT composed of a single session of directive counseling and ambient sound stimulation. In addition, alprazolam (0.25 mg) and ginkgo biloba extract (80 mg) were administered orally to the subjects for 3 months. The 3- and 6- month outcomes were assessed using the follow-up rates and tinnitus severity scores: awareness, tinnitus handicap inventory (THI), loudness, annoyance, and effect on life. The treatment responses were classified as improvement, no changes, and worsening.

Results

Of the total 149 patients (77 in group 1:1; 72 in group 1:4), 104 patients completed the protocol at 3 months, and 55 patients at 6 months. The follow-up rates were similar in both groups. Over the period of 6 months, all scores declined significantly except the loudness score at 3 months in both groups. Treatment responses showed no between-group differences. The success rate based on THI was 70% in group 1:1, and 64% in group 1:4 at 6 months.

Conclusion

The small-group counseling of our modified TRT was comparable to the individual counseling for tinnitus relief. We suggest that this protocol can be implemented effectively in any crowded otolaryngology clinics.     

Short Term Effects of Repetitive Transcranial Magnetic Stimulation in Patients with Catastrophic Intractable Tinnitus: Preliminary Report

Objectives

The short-term effects of low-frequency repetitive transcranial magnetic stimulation (rTMS) in the patients with catastrophic and intractable tinnitus were investigated.

Methods

Fifteen participants were recruited among patients with catastrophic intractable tinnitus to receive 1 Hz rTMS treatment. Tinnitus severity was assessed before rTMS and directly after sham or real rTMS using the tinnitus handicap inventory (THI) and visual analog scale (VAS).

Results

There was no statistical difference in the THI score before and after sham stimulation. However, after 5 replications of real rTMS there was statistically significant reduction in THI score. Eight patients showed a decrease of more than 10 in THI score. Patients who showed a vast change in THI score after rTMS also showed a large decrease in their VAS score (r=0.879, P<0.001). Duration of tinnitus and change of THI score showed statistically significant moderate negative correlation (r=-0.637, P=0.011). But in case of VAS, there was no significant difference between VAS and duration of tinnitus.

Conclusion

Among total 15 patients with catastrophic intractable chronic tinnitus, eight patients showed some improvement in symptoms after 1 Hz rTMS. rTMS can be considered management modality for intractable tinnitus even with distress as severe as catastrophic stage.     

Association between tinnitus retraining therapy and a tinnitus control instrument

Objective

Tinnitus retraining therapy (TRT), which is an adaptation therapy for tinnitus based on the neurophysiological model proposed by Jastreboff in 1990,consists of directive counseling and acoustic therapy with a tinnitus control instrument (TCI) or other devices. For the past 5 years, our hospital has administered TRT characterized by the use of a TCI.

Method

In this study, we reviewed the clinical course of patients with tinnitus who presented to our outpatient clinic for tinnitus and hearing loss during the 3-year period from April 2004 to March 2007 and underwent TRT with a TCI. Among 188 patients with tinnitus (105 males and 83 females), 88 patients (51 males and 37 females, excluding dropouts) who purchased a TCI and continued therapy were included in the study.

Results

Significant improvement in Tinnitus Handicap Inventory (THI) and Visual Analogue Scale (VAS) scores was found as early as 1 month of treatment and later compared with those on initial examination, suggesting that TRT with a TCI may be an effective treatment for tinnitus. Among the noises generated by the TCI, the sound pressure output from the TCI was set at just below tinnitus loudness level both of the first adjustment and the second adjustment. Speech noise and white noise were frequently selected, whereas high-frequency noise and pink noise were infrequently selected. Speech noise was most frequently selected at the first adjustment, and the number of patients selecting white noise increased at the second adjustment. The results that we compared the two also revealed that the mean hearing level and tinnitus loudness levels were higher in the white noise group than in the speech noise group, which suggested that the inner ear disorder was more harder in the white noise group. Both the THI score and VAS grade improved after 1 month of treatment in the speech noise group, whereas improvement in these parameters was observed in the white noise group after 6 months of treatment. These results suggest that it took much longer the patients in the white noise group to improve.

Conclusion

: Significant improvement in THI and VAS scores was found as early as 1 month of treatment and later compared with those on initial examination, suggesting that TRT with a TCI may be an effective treatment for tinnitus. It resulted that many patients chose the speech noise or the white noise. And also it was indicated that noise generators set at just below mixing point with tinnitus are more effective. In this study, however, speech noise was often selected probably because of the reduced output at high frequencies and the level of comfort. As white noise produces greater sound volume, patients tended to switch from other therapeutic sound to white noise at the second adjustment. These findings may help administer acoustic therapy in the future.     

Validation of a Korean Version of the Tinnitus Handicap Questionnaire

Objectives

The goal of the present study was to evaluate the reliability and validity of the Korean version of the tinnitus handicap questionnaire (THQ-K).

Methods

A total of 60 patients were included in this study. Patients responded to the THQ-K, the tinnitus handicap inventory (THI), Beck''s depression index (BDI), and the visual analogue scale (VAS) for loudness and pitch, loudness match, and minimum masking level (MML) test were performed.

Results

Internal consistency of the THQ-K was examined using Cronbach coefficient alpha. Cronbach alpha was 0.96. The THQ-K showed a significant correlation with THI, BDI, VAS for distress, and VAS for loudness, but no significant correlation with psychoacoustic measurement of tinnitus, such as loudness match, pitch match, and MML.

Conclusion

The THQ-K is a reliable and valid test for evaluating the degree of handicap due to tinnitus for both research and clinical use.     

Evaluation of tinnitus retraining therapy for patients with normal audiograms versus patients with hearing loss

Objective

A few chronic tinnitus patients show normal hearing thresholds in the pure tone audiometry from 125 Hz to 8000 Hz (≤20 dB). We report the characteristics of the course of those patients underwent tinnitus retraining therapy (TRT) compared with other patients suffering from chronic and severe tinnitus.

Tinnitus retraining therapy using portable music players

Objective

We aimed to perform acoustic analysis of environmental sounds used in sound therapy for tinnitus retraining therapy (TRT) and to evaluate the efficacy of TRT performed by using a portable music player (PMP) with recorded environmental sounds as the sound generator.

Methods

Acoustic analysis of environmental sounds was performed using a sound analyzer. The subjects were 23 patients with chronic tinnitus. Patients who had bilateral hearing loss and required hearing assistance were fitted with hearing aids (HAs). Patients with normal hearing or unilateral hearing loss were fitted with a tinnitus control instrument (TCI) or a PMP. The patients were divided into the PMP group, TCI group, and HA group. All subjects underwent audiometric evaluations prior to TRT and completed the tinnitus handicap inventory (THI). The THI scores were evaluated before treatment and 1 month, 3 months, 6 months, and 12 months after treatment.

Results

The sound spectrogram of the murmur of a stream showed a wide-frequency band with a constant strength, whereas that of a wave sound showed a wide-frequency band with variable strength. The THI score clearly decreased after 1 month, and this decrease tended to continue over 12 months. The TRT efficacy ratios in the PMP group, TCI group, and HA group at 12 months after treatment were 71%, 67%, and 70%, respectively.

Conclusions

TRT using a PMP had efficacy similar to those of TCI and HA. The murmur of a stream was one of the most effective sounds in TRT. TRT using a PMP as the sound generator can provide the most cost-effective treatment option for tinnitus patients.     

Reliability and validity of the chinese (mandarin) tinnitus handicap inventory

Objectives

The Tinnitus Handicap Inventory (THI) is a commonly used self-reporting tinnitus questionnaire. We undertook this study to determine the reliability and validity of the Chinese-Mandarin version of the Tinnitus Handicap Inventory (THI-CM) for measuring tinnitus-related handicaps.

Methods

We tested the test-retest reliability, internal reliability, and construct validity of the THI-CM. Two-hundred patients seeking treatment for primary or secondary tinnitus in Southwest China were asked to complete THI-CM prior to clinical evaluation. Patients were evaluated by a clinician using standard methods, and 40 patients were asked to complete THI-CM a second time 14±3 days after the initial interview.

Results

The test-retest reliability of THI-CM was high (Pearson correlation, 0.98), as was the internal reliability (Cronbach''s α, 0.93). Factor analysis indicated that THI-CM has a unifactorial structure.

Conclusion

The THI-CM version is reliable. The total score in THI-CM can be used to measure tinnitus-related handicaps in Mandarin-speaking populations.     

Untersuchungen von Rauschsignalen für die akustische Tinnitustherapie

Background

In terms of sound acceptance and tinnitus-masking efficacy, tinnitus sound therapy appears to be more effective using dynamic natural sounds than static noise signals. The aim of this study was to systematically determine the effects of physical dynamics parameters on tinnitus masking and sound acceptance.

Materials and Methods

Based on a dynamic model, noise signals with different dynamic properties were synthesized and used to investigate minimal masking levels (MMLs) and spontaneous sound acceptance in six tinnitus patients.

Results

High signal dynamics resulted in high MMLs and low sound acceptance. In some instances, low signal dynamics gave rise to slightly lower MMLs than white noise. Despite unfavourable MMLs, natural dynamic sounds were better accepted than synthesized sounds with comparable dynamics.

Conclusions

The higher spontaneous acceptance of natural sounds as compared to white noise appears not to be due solely to physical sound properties, but rather to result primarily from psychological factors. It may be possible to improve sound acceptance in tinnitus sound therapy by using signals with low amounts of dynamics and implementing the use of natural sounds.     

Intratympanic dexamethasone plus melatonin versus melatonin only in the treatment of unilateral acute idiopathic tinnitus

Purpose

The aim of our study was to determine whether the combination of intratympanic (IT) corticosteroid with melatonin could be associated with decreased tinnitus in patients with unilateral acute idiopathic tinnitus developed within 3 months.

Materials and methods

We evaluated this hypothesis through a prospective, randomized, controlled, double-blinded trial. Patients included in the study were randomly allocated into two groups: Group A – comprising 30 patients, received melatonin and IT dexamethazone, and Group B – including 30 patients receiving melatonin alone. After 3 months, improvement in tinnitus was assessed using different outcome measures: tinnitus loudness score, tinnitus awareness score, Tinnitus Handicap Inventory (THI), Pittsburgh Sleep Quality Index (PSQI) and Beck Depression Inventory (BDI).

Results

We have demonstrated significant improvements in each of the above mentioned outcomes subsequent to treatment in both groups. However, patients in the IT dexamathazone and melatonin group attained statistically significant better outcomes. Besides, the differences in improvement rate and cure rate were highly significant between the two groups, favoring the IT dexamethazone and melatonin group.

Conclusions

Our preliminary study demonstrated that IT dexamethazone plus melatonin is efficient in improvement of idiopathic unilateral tinnitus developed within 3 months.     

Is Hypozincemia Related to Tinnitus?: A Population Study Using Data From the Korea National Health and Nutrition Examination Survey

Objectives

The aim of present study was to determine the relationship between serum zinc level and tinnitus using data from the Korea National Health and Nutrition Examination Survey (KNHANES).

Methods

The present study examined the relationship between serum zinc level and tinnitus using data from the KNHANES. A total of 2,225 KNHANES participants responded to the tinnitus questionnaire and provided blood samples to measure serum zinc concentration. Based on questionnaire responses, participants were categorized into control, mild tinnitus, moderate tinnitus, and severe tinnitus subgroups.

Results

There were no significant differences between groups in serum zinc level after adjustment for sex, age, and hearing loss.

Conclusion

It was concluded that hypozincemia is not related to tinnitus in a large population.     

Tinnitus and sound intolerance: evidence and experience of a Brazilian group

Introduction

Tinnitus and sound intolerance are frequent and subjective complaints that may have an impact on a patient's quality of life.

Hearing Abilities at Ultra-High Frequency in Patients with Tinnitus

Objectives

To compare tinnitus patients who have normal hearing between 250 Hz and 8 kHz with normal controls with regard to the ability of each group to hear extended high-frequency pure tone thresholds.

Methods

We enrolled 18 tinnitus patients, each of whom had a threshold of HL <25 dB and threshold differences of <10 dB between ears at frequencies of 250 and 500 Hz and 1, 2, 4, and 8 kHz. We also enrolled age- and gender-matched normal volunteers (10 ears), for each patient. Extended high frequency pure tone audiometry was performed, and the mean hearing thresholds at 10, 12, 14, and 16 kHz of each tinnitus ear were compared with those of the 10 age- and sex-matched normal ears.

Results

Of the 18 patients with tinnitus, 12 had significantly increased hearing thresholds at more than one of the four high frequencies, compared with the normal group. When we assessed results according to frequency, we found that 8 patients had decreased hearing ability at 10 kHz, 10 at 12 kHz, 8 at 14 kHz, and 4 at 16 kHz.

Conclusion

Some patients with tinnitus who have normal hearing below 8 kHz have decreased hearing ability at extended high-frequencies. Thus, the proportion of patients with tinnitus who have normal hearing over the entire audible range is smaller than in previous reports.     

Degree of Sigmoid Sinus Compression and the Symptom Relief Using Magnetic Resonance Angiography in Venous Pulsating Tinnitus

Objectives

To show that mechanical compression of sigmoid sinus is effective for treatment of pulsatile tinnitus caused by sigmoid sinus enlargement, and to evaluate the relationship between the compression degree of sigmoid sinus and the tinnitus symptom relief using magnetic resonance angiography.

Methods

Medical records of twenty-four patients who were diagnosed with venous tinnitus caused by sigmoid sinus enlargement and underwent mechanical compression of sigmoid sinus were reviewed between April 2009 and May 2013. All these patients received computed tomography and magnetic resonance venography study before undergoing surgery and were followed for at least 4 months.

Results

Twenty-three patients felt relief from tinnitus three months after the surgery, and the cross-sectional area of the sigmoid sinus on the tinnitus side was compressed approximately by half (46%-69%) after the surgery. There were 4 patients whose tinnitus suddenly disappeared while lying on the operating table before operation, which may be a result of the patient''s emotional tension or postural changes from standing. One of the four patients felt no relief from tinnitus after the surgery, with the cross-sectional area of the sigmoid sinus only compressed by 30%. And two patients of them had a recurrence of tinnitus about 6 months after the surgery. Seven patients had sigmoid sinus diverticula, and tinnitus would not disappear merely by eliminating the diverticulum until by compressing the sigmoid sinus to certain degree. There were 3 minor complications, including aural fullness, head fullness and hyperacusis. The preoperative low frequency conductive and sensorineural hearing loss of 7 subjects subsided.

Conclusion

Mechanical compression of sigmoid sinus is an effective treatment for pulsatile tinnitus caused by sigmoid sinus enlargement, even if it might be accompanied by sigmoid sinus diverticulum. A compression degree of sigmoid sinus about 54% is adequate for the relief of tinnitus symptom. Cases in which patients'' tinnitus suddenly disappeared before the surgery might be excluded to improve the efficacy of surgery.     

Evaluation of Internal Auditory Canal Structures in Tinnitus of Unknown Origin

Objectives

The aim of the present study was to evaluate the internal auditory canal (IAC) and the nerves inside it to define possible structural differences in cases with subjective tinnitus of unknown origin.

Methods

Cases applying to the ear, nose and throat department with the complaint of tinnitus with unknown origin and having normal physical examination and test results were included in the study (n=78). Patients admitted to the radiology clinic for routine cranial magnetic resonance imaging (MRI) and whose MRI findings revealed no pathologies were enrolled as the control group (n=79). Data for the control group were obtained from the radiology department and informed consent was obtained from all the patients. Diameters of the IAC and the nerves inside it were measured through enhanced images obtained by routine temporal bone MRIs in all cases. Statistical evaluations were performed using Student t-test and statistical significance was defined as P<0.05.

Results

Measurements of IAC diameters revealed statistically significant differences between the controls and the tinnitus group (P<0.05). Regarding the diameters of the cochlear nerve, facial nerve, inferior vestibular nerve, superior vestibular nerve, and total vestibular nerve, no statistically significant difference was found between the controls and the tinnitus group.

Conclusion

Narrowed IAC has to be assessed as an etiological factor in cases with subjective tinnitus of unknown origin.     

The Cochleural Alternating Acoustic Beam Therapy (CAABT): A pre-clinical trial

Purpose

We intend to assess the effectiveness of a novel tinnitus treatment therapy, the Cochleural Alternating Acoustic Beam Therapy (CAABT) using the psychoacoustic measures, the questionnaires and rs-fMRI.

Clinical Presentation and Management of Jugular Foramen Paraganglioma

Objectives

Jugular foramen paraganglioma is a locally invasive, benign tumor, which grow slowly and causes various symptoms such as pulsatile tinnitus and low cranial nerve palsy. Complete surgical resection is regarded as the ideal management of these tumors. The goal of this study is to identify the clinical characteristics and most effective surgical approach for jugular foramen paraganglioma.

Methods

Retrospective analysis of 9 jugular foramen paraganglioma patients who underwent surgical resection between 1986 and 2005 was performed. Clinical records were reviewed for analysis of initial clinical symptoms and signs, audiological examinations, neurological deficits, radiological features, surgical approaches, extent of resection, treatment outcomes and complications.

Results

Most common initial symptom was hoarseness, followed by pulsatile tinnitus. Seven out of 9 patients had at least one low cranial nerve palsy. Seven patients were classified as Fisch Type C tumor and remaining 2 as Fisch Type D tumor on radiologic examination. Total of 11 operations took place in 9 patients. Total resection was achieved in 6 cases, when partial resection was done in 3 cases. Two patients with partial resection received gamma knife radiosurgery (GKS), when remaining 1 case received both GKS and two times of revision operation. No mortality was encountered and there were few postoperative complications.

Conclusion

Neurologic examination of low cranial nerve palsy is crucial since most patients had at least one low cranial nerve palsy. All tumors were detected in advanced stage due to slow growing nature and lack of symptom. Angiography with embolization is crucial for successful tumor removal without massive bleeding. Infratemporal fossa approach can be considered as a safe, satisfactory approach for removal of jugular foramen paragangliomas. In tumors with intracranial extension, combined approach is recommended in that it provides better surgical view and can maintain the compliance of the patients.     

Psychoacoustic classification of persistent tinnitus

Introduction

Tinnitus is a difficult to treat symptom, with different responses in patients. It is classified in different ways, according to its origin and associated diseases.

The Singer's Formant and Speaker's Ring Resonance: A Long-Term Average Spectrum Analysis

Objectives

We previously showed that a trained tenor''s voice has the conventional singer''s formant at the region of 3 kHz and another energy peak at 8-9 kHz. Singers in other operatic voice ranges are assumed to have the same peak in their singing and speaking voice. However, to date, no specific measurement of this has been made.

Methods

Tenors, baritones, sopranos and mezzo sopranos were chosen to participate in this study of the singer''s formant and the speaker''s ring resonance. Untrained males (n=15) and females (n=15) were included in the control group. Each subject was asked to produce successive /a/ vowel sounds in their singing and speaking voice. For singing, the low pitch was produced in the chest register and the high notes in the head register. We collected the data on the long-term average spectra of the speaking and singing voices of the trained singers and the control groups.

Results

For the sounds produced from the head register, a significant energy concentration was seen in both 2.2-3.4 kHz and 7.5-8.4 kHz regions (except for the voices of the mezzo sopranos) in the trained singer group when compared to the control groups. Also, the chest register had a significant energy concentration in the 4 trained singer groups at the 2.2-3.1 kHz and 7.8-8.4 kHz. For speaking sound, all trained singers had a significant energy concentration at 2.2-5.3 kHz and sopranos had another energy concentration at 9-10 kHz.

Conclusion

The results of this study suggest that opera singers have more energy concentration in the singer''s formant/speaker''s ring region, in both singing and speaking voices. Furthermore, another region of energy concentration was identified in opera singer''s singing sound and in sopranos'' speaking sound at 8-9 kHz. The authors believe that these energy concentrations may contribute to the rich voice of trained singers.     

Invasive Fungal Sinusitis of the Sphenoid Sinus

Objective

This study was conducted to present the clinical outcome of invasive fungal sinusitis of the sphenoid sinus and to analyze clinical factors influencing patient survival.

Methods

A retrospective review of 12 cases of invasive fungal sphenoiditis was conducted.

Results

Cases were divided into acute fulminant invasive fungal spheonoidits (n=4) and chronic invasive fungal sphenoiditis (n=8). The most common underlying disease was diabetes mellitus (n=9). The most common presenting symptoms and signs included visual disturbance (100%). Intracranial extension was observed in 8 patients. Endoscopic debridement and intravenous antifungals were given to all patients. Fatal aneurysmal rupture of the internal carotid artery occurred suddenly in two patients. The mortality rate was 100% for patients with acute fulminant invasive fungal sphenoiditis and 25% for patients with chronic invasive fungal sphenoiditis. In survival analysis, intracranial extension was evaluated as a statistically significant factor (P=0.027).

Conclusion

The survival rate of chronic invasive fungal sphenoiditis was 75%. However, the prognosis of acute fulminant invasive fungal sphenoiditis was extremely poor despite the application of aggressive treatment, thus, a high index of suspicion should be required and new diagnostic markers need to be developed for early diagnosis of invasive fungal sinusitis of the sphenoid sinus.     

Is BPPV a Prognostic Factor in Idiopathic Sudden Sensory Hearing Loss?

Objectives

The prognostic significance of vertigo in patients with idiopathic sudden sensorineural hearing loss (SSNHL) remains a matter of debate because vertigo is associated with many different vestibular disorders. The purpose of this study is to determine the role of benign paroxysmal positional vertigo (BPPV) as a prognostic factor in patients with SSNHL.

Methods

We conducted a retrospective study of 298 patients with SSNHL. Hearing outcomes were evaluated by assessments of pre-treatment hearing and hearing gain. Comparative multivariate analyses between prognostic factors and hearing outcome were conducted.

Results

Thirty-eight (12.7%) SSNHL patients were found to also have BPPV. BPPV showed significant negative prognostic factors in hearing outcome on multivariate analysis (odds ratio, 0.15). In comparison to average pure tone audiometry (PTA), patients diagnosed with SSNHL with BPPV exhibited poorer hearing in pre- and post-treatment PTA compared to SSNHL without BPPV. Old age (>60 years), pre-treatment hearing, and canal paresis were significant outcome predictors.

Conclusion

BPPV in SSNHL patients, representing definitive vestibular damage, was closely related to poor prognosis.