Don McFerran

Tinnitus in childhood

Tinnitus is a common symptom in adults and there is a wealth of published information on the pathogenesis and management of the condition. Tinnitus in childhood is likewise quite common when children are directly asked about the symptom. However, children rarely spontaneously complain of tinnitus. Little is known about effective management strategies for paediatric tinnitus. We review the literature regarding the prevalence and nature of paediatric tinnitus and suggest a logical and practical approach to managing this symptom.

Insights from the first international conference on hyperacusis: Causes, evaluation, diagnosis and treatment

The First International Conference on Hyperacusis gathered over 100 scientists and health care professionals in London, UK. Key conclusions from the conference included: (1) Hyperacusis is characterized by reduced tolerance of sound that has perceptual, psychological and social dimensions; (2) there is a growing awareness that children as well as adults experience symptoms of hyperacusis or misophonia; (3) the exact mechanisms that give rise to hyperacusis are not clear, but the available evidence suggests that functional changes within the central nervous system are important and in particular, hyperacusis may be related to increased gain in the central auditory pathways and to increased anxiety or emotional response to sound; (4) various counseling and sound therapy approaches seem beneficial in the management of hyperacusis, but the evidence base for these remains poor.

Tinnitus and Patterns of Hearing Loss

Tinnitus is strongly linked with the presence of damaged hearing. However, it is not known why tinnitus afflicts only some, and not all, hearing-impaired listeners. One possibility is that tinnitus patients have specific inner ear damage that triggers tinnitus. In this study, differences in cochlear function inferred from psychophysical measures were measured between hearing-impaired listeners with tinnitus and hearing-impaired listeners without tinnitus. Despite having similar average hearing loss, tinnitus patients were observed to have better frequency selectivity and compression than those without tinnitus. The results suggest that the presence of subjective tinnitus may not be strongly associated to outer hair cell impairment, at least where hearing impairment is evident. The results also show a different average pattern of hearing impairment amongst the tinnitus patients, consistent with the suggestion that inner hair cell dysfunction with subsequent reduced auditory innervation is a possible trigger of tinnitus.

Incidence Rates of Clinically Significant Tinnitus: 10-Year Trend From a Cohort Study in England

Objective: To investigate the incidence of tinnitus that burdens the health service in England. Design: This was an observational study of 4.7 million residents of England under 85 years of age who were at risk for developing clinically significant tinnitus (sigT). SigT was defined by a discharge from hospital with a primary diagnosis of tinnitus, or a primary care recording of tinnitus with subsequent related medical follow-up within 28 days. The database used was the Clinical Practice Research Datalink and individual records were linked to additional data from the Hospital Episode Statistics. The observational period was from January 1, 2002 to December 31, 2011. Age-, gender-, and calendar year-specific incidence rates for and cumulative incidences of sigT were estimated and a projection of new cases of sigT between 2012 and 2021 was performed. Results: There were 14,303 incident cases of sigT identified among 26.5 million person-years of observation. The incidence rate was 5.4 new cases of sigT per 10,000 person-years (95% confidence interval: 5.3 to 5.5). The incidence rate did not depend on gender but increased with age, peaking at 11.4 per 10,000 in the age group 60 to 69 years. The annual incidence rate of sigT increased from 4.5 per 10,000 person-years in 2002 to 6.6 per 10,000 person-years in 2011. The 10-year cumulative incidence of sigT was 58.4 cases (95% confidence interval: 57.4 to 59.4) per 10,000 residents. Nearly 324,000 new cases of sigT are expected to occur in England between 2012 and 2021. Conclusions: Tinnitus presents a burden to the health care system that has been rising in recent years. Population-based studies provide crucial underpinning evidence; highlighting the need for further research to address issues around effective diagnosis and clinical management of this heterogeneous condition.

Is psychology really the best treatment for tinnitus

Despite many recent advances in our understanding of the pathogenesis of tinnitus, the optimal management of this condition remains a contentious issue. Some recent developments have been used to suggest that health-care resources for tinnitus should be directed towards psychological treatments, rather than the current otological ⁄ audiological model of care delivery. While there is evidence that psychological treatment modalities may help some people with tinnitus, the argument that such techniques should become the benchmark treatment for tinnitus seems far from convincing. Evidence increasingly suggests that some degree of malfunction of the peripheral auditory system is involved in the majority of patients with troublesome tinnitus. However, tinnitus cannot be explained without consideration of the central auditory system and other central nervous system pathways, including systems of reaction to aversive stimuli and systems of emotion. These observations have been used to produce a model of tinnitus pathogenesis that is divided into two stages: first, there is a trigger event at an ignition site which may be at any point within the auditory system or at a point outside the classical auditory system. Secondly, there is a process of promotion of the tinnitus signal: this occurs in the central auditory system. Because of this increased knowledge regarding pathogenesis, the pharmaceutical industry is showing renewed interest in drug treatment for tinnitus, using drugs that are likely to have effect upon receptors in the central auditory system. To date, however, results have not borne fruit and the mainstay of clinical treatment for tinnitus remains modalities that encourage habituation to the symptom. There are several techniques used to this end and historically there has been a dichotomy between mainstream psychological treatments, particularly cognitive behavioural therapy (CBT), and other techniques, derived from the neurophysiological model of tinnitus. Cognitive behavioural therapy has a well-defined structure. The same cannot be said of the neurophysiological treatments. The best defined of the neurophysiological treatments is tinnitus retraining therapy, which combines directive counselling and sound therapy. However, relatively few health-care professionals are trained to use this technique and there is only one extant training course, in North America. The principles of the neurophysiological model can be applied in a looser fashion using an ad hoc mixture of patient education, relaxation therapy, various counselling techniques and sound therapies. Such strategies have formed the backbone of tinnitus treatments in the United Kingdom over the last two decades with the bulk of such therapy being delivered by audiologists and hearing therapists. A small number of studies have examined the comorbidity of tinnitus and psychological illness and have reported a high prevalence of psychological distress among tinnitus patients. However, the studies that have been undertaken all have methodological flaws and have examined highly selected groups of patient. The true prevalence of psychological distress among all the people who experience tinnitus remains unknown. A recently published Cochrane review has produced evidence supporting the use of CBT in the management of tinnitus and this has been used to suggest that CBT is now the de facto treatment of choice for tinnitus patients. This has gained further credence in a UK Department of Health document regarding the commissioning of services for tinnitus care. There are, however, serious shortcomings to this argument. The Cochrane review has some significant weaknesses. First, it is likely that the studies used for the review examined treatment outcomes on highly selected patient populations: patients undergoing psychological treatments for tinnitus by definition are receptive to using psychological treatment modalities and are sufficiently emotionally distressed to justify referral. Many other tinnitus patients are less willing to contemplate such treatments arguing that they do not have a mental-health issue: they simply required relief from the noise in their ears or head. Secondly, the primary Correspondence: David M. Baguley, PhD, MBA, Department of Audiology, Cambridge University Hospitals Trust, Cambridge, UK. Tel.: +44 1223 217594; fax: +44 1223 596101; e-mail: dmb29@cam.ac.uk E D I T O R I A L E S S A Y

A randomized, controlled study comparing the effects of vestipitant or vestipitant and paroxetine combination in subjects with tinnitus.

Objective: Tinnitus is a common symptom that demonstrates a significant comorbidity with anxiety and depression. The novel neurokinin-1 receptor antagonist, vestipitant, has anxiolytic properties and a good safety profile. Vestipitant was investigated for potential effect against chronic tinnitus as a stand-alone treatment and in conjunction with a selective serotonin reuptake inhibitor, paroxetine. Study Design: Randomized, double-blind, crossover study. Setting: Tertiary neurotologic and audiologic center with additional referrals from a secondary university hospital center. Patients: Twenty-four adult patients with tinnitus were randomized into the study. Main Outcome Measures: Visual analogue scale (VAS) measurements of tinnitus loudness (intensity), pitch and distress, VAS measurements of arousal/anxiety, Tinnitus Handicap Inventory, Quick Inventory of Depressive Symptomatology, and plasma concentrations of trial drugs. Results: No statistically significant treatment benefit effect was detected for tinnitus (intensity, pitch, and distress) VAS scores, arousal-anxiety VAS scores, Tinnitus Handicap Inventory, or tinnitus aggravation scores assessed on Days 1 and 14. However, a statistically significant worsening of tinnitus intensity and distress scores was observed after vestipitant compared with placebo for the mean data collected over the treatment period. No relevant differences in vestipitant plasma concentrations were observed between the subjects given the combination with paroxetine and those receiving vestipitant alone. No specific relationships were observed between tinnitus intensity and vestipitant plasma concentrations. Conclusion: Although well-tolerated vestipitant, alone or in combination with paroxetine, was not effective in ameliorating tinnitus in this patient group.

Hyperacusis and Disorders of Loudness Perception

1. There are several forms of loudness perception disorder. 2. The terminology of such disorders is often confused. 3. The most commonly used terms in an audiological context are hyperacusis, denoting a generalized reduced tolerance for sound, as well as phonophobia, denoting a fear of sounds. 4. The majority of people with a loudness perception disorder also have tinnitus. Just under one half of individuals with tinnitus also describe some degree of loudness perception disorder. 5. There are few rigorous studies regarding the epidemiology of loudness perception disorders; the true prevalence of hyperacuis and phonophobia remains a matter of conjecture. 6. Some loudness perception disorders are associated with disorders of facial nerve function with consequent loss of the acoustic reflex. Most cases have no such association and the underlying pathological mechanism is unclear. 7. Various management strategies have been suggested, including the use of tinnitus therapies, with or without the use of sound therapy, and psychological therapies.

Acquisition of auditory profiles for good and impaired hearing.

Abstract Objective: The aim of this study was to develop a user-friendly way of measuring patients’ threshold and supra-threshold hearing, with potential for application in clinical research. The end-product of these tests is a graphical profile summarizing absolute threshold, frequency selectivity, and compression characteristics across a spectrum of frequencies (0.25–6 kHz). Design: A battery of three psychophysical hearing tests consisted of measures of absolute threshold, frequency selectivity, and compression. An automated, cued, single-interval, adaptive tracking procedure was employed. The tests results were collated and used to generate a readily visualized ‘profile’ for each listener. Study sample: Participants were 83 adults (57 impaired-hearing and 26 good-hearing, age 20–75 years). Results: Listeners tolerated the tests well. Single-ear profiles were obtained in an average of 74 minutes testing time (range 46–120 minutes). The variability of individual measurements was low. Substantial differences between normal and impaired listeners and also among the impaired listeners were observed. Qualitative differences in compression and frequency-selectivity were seen that could not be predicted by threshold measurements alone. Conclusions: The hearing profiles are informative with respect to supra-threshold hearing performance and the information is easily accessible through the graphical display. Further development is required for routine use in a clinical context.

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

BackgroundThere 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.MethodsCurrent 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.ResultsThe 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.ConclusionsNHS 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.

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

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.