Leif Lyttkens

A meta-analytic review of psychological treatments for tinnitus

Meta-analysis is a technique of combining results from different trials in order to obtain estimates of effects across studies. Meta-analysis has, as yet, rarely been used in audiological research. The aim of this paper was to conduct a meta-analysis on psychological treatment of tinnitus. The outcomes of 18 studies, including a total of 24 samples and up to 700 subjects, were included and coded. Included were studies on cognitive/cognitive-behavioural treatment, relaxation, hypnosis, biofeedback, educational sessions and problem-solving. Effect sizes for perceived tinnitus loudness, annoyance, negative affect (e.g. depression) and sleep problems were calculated for randomized controlled studies, pre-post-treatment design studies and follow-up results. Results showed strong to moderate effects on tinnitus annoyance for controlled studies (d = 0.86), pre-post designs (d = 0.5) and at follow-up (d = 0.48). Results on tinnitus loudness were weaker and disappeared at follow-up. Lower effect sizes were also obtained for measures of negative affect and sleep problems. Exploratory analyses revealed that cognitive-behavioural treatments were more effective on ratings of annoyance in the controlled studies. It is concluded that psychological treatment for tinnitus is effective, but that aspects such as depression and sleep problems may need to be targeted in future studies.

Regional cerebral blood flow during tinnitus: a PET case study with lidocaine and auditory stimulation.

Brain imaging of tinnitus has suggested central correlates of tinnitus perception. This study presents positron emission tomographic (PET) measurements of regional cerebral blood flow (rCBF) in a female tinnitus patient with bilateral left dominant tinnitus. Lidocaine infusion (75 mg during 5 min (0.2 mg/kg/min)) resulted in a 75% reduction of tinnitus and a temporary abolition of the dominant tinnitus in her left ear. Regional CBF was measured in four conditions: i) at rest while concentrating on tinnitus, ii) following maximum effect of lidocaine, iii) during sound stimulation, and iv) the following day at rest while concentrating on tinnitus. Subtraction analyses showed that tinnitus was associated with increased rCBF in the left parieto-temporal auditory cortex, including the primary and secondary auditory cortex with a focus in the parietal cortex (Brodmann areas 39, 41, 42, 21, 22). Activations were also found in right frontal paralimbic areas (Brodmann areas 47, 49 and 15). Sound stimulation resulted in bilateral activation of auditory areas. It is suggested that tinnitus is processed in primary, secondary and integrative auditory cortical areas. Tinnitus perception may involve areas related to auditory attention, while emotional processing relates to temporofrontal paralimbic areas.

Predictors of tinnitus discomfort, adaptation and subjective loudness

In a nation-wide investigation, covering all the hearing centres in Sweden, a study was made of adaptation processes, subjective discomfort from tinnitus, subjective loudness of tinnitus and psychological complaints in 3372 subjects by means of a questionnaire. The most important predictors of discomfort from and adaptation to tinnitus were found to be the controllability and the degree of maskability by external sounds, i.e. the subjects coping abilities or internal-external locus of control. Increased control and masking effects from the environment imply a decrease in discomfort and better adaptation. The most important predictor of worsened subjective loudness of tinnitus was the duration of the tinnitus. That is, subjects who had had tinnitus for a longer time perceived the loudness as more intense. The psychosomatic factors which most strongly predicted increased discomfort from and decreased tolerance to tinnitus were depression and insomnia. These findings have theoretical and practical implications for the management and treatment of tinnitus.

Psychological Treatment of Tinnitus An Experimental Group Study

Twenty-four patients with moderately severe (grade 2) to severe (grade 3) subjective tinnitus participated in an experimental group study. The patients were randomly assigned to a treatment group and a waiting-list control group. Treatment was given with a coping technique and comprised 10 one-hour sessions. Following a corresponding period without treatment, the control group was treated similarly. Daily self-recording of the subjective tinnitus loudness, the discomfort from the tinnitus, depression and irritation was performed before and after treatment. In addition, psychoacoustic measurement was undertaken on three occasions. The treatment group improved significantly more than the waiting-list control group. After treatment of the latter group, combined data of both groups showed statistically significant improvements in all variables. The results show that tinnitus annoyance can be treated by psychological methods.

The psychological treatment of tinnitus: An experimental evaluation

Disabling tinnitus in 27 patients was treated in an experimental setting with two different type of therapy aiming at the development of coping behaviour. One was focused on behavioural control procedures, while the other aimed at more cognitive control methods such as distraction. The results of the two forms of therapy were compared with each other and with observations of the untreated control subjects. Assessments of subjective loudness, discomfort from tinnitus and controllability were made on analogue scales and at a questionnaire follow-up. Psychoacoustic measures such as personal loudness units (PLU) were used in connection with these self-recordings and for evaluation of treatment effects. The results confirmed favourable reports on behavioural methods in tinnitus. However, no differences were found between therapies. The results are discussed in the light of the coping and adaptation theory.

Tinnitus—Incidence and Handicap

A questionnaire investigation, comprising 1091 patients, was conducted at a hearing centre. A majority of patients, 59%, claimed that they were troubled by tinnitus. A strong correlation was found between the laterality of tinnitus and that of subjective hearing loss. Neither a greater degree of hearing loss nor a longer duration of tinnitus was shown to be associated with more severe tinnitus. Among patients with both subjective hearing loss and tinnitus, 23% stated that tinnitus was the greater problem and 38% that their tinnitus and hearing loss were equally troublesome. The corresponding figures for patients with hearing impairment of such a degree that a hearing aid had been fitted were 9% and 41% respectively. Stress symptoms such as headache, tension of facial muscles and sleep disturbances were correlated to tinnitus. Psychosomatic complaints should therefore be taken into account in the treatment of tinnitus. Of patients with tinnitus, 83% were interested in obtaining treatment for their tinnitus. It is postulated that the previously reported predominance of left-sided tinnitus is due to a higher frequency of left-sided hearing impairment. A majority of patients with tinnitus and hearing impairment regarded their tinnitus as the major problem. Efforts towards investigation and treatment of tinnitus might therefore considerably improve the prospects for hearing rehabilitation.

Melanin Capacity to Accumulate Drugs in the Internal Ear: A Study on Lidocaine, Bupivacaine and Chlorpromazine

The distribution and retention of labelled lidocaine, bupivacaine, and chlorpromazine to melanin in the internal ear after intravenous and intraperitoneal injection were examined by whole-body autoradiography. Both young pigmented hooded rats and albino rats were studied. In the pigmented rats chlorpromazine showed the greatest accumulation, which was more pronounced in the cochlea than in the vestibular portion. The other two substances were evenly distributed in the internal ear. After a single injection of chlorpromazine and of bupivacaine these substances were still bound to the melanin of the internal ear after 14 days, which was the longest survival time. Lidocaine, on the other hand, had disappeared after only 4 days. Strong uptake and retention of the three substances were observed in the eyes of pigmented animals. In albino animals there was very weak, transient uptake in the internal ear of chlorpromazine and bupivacaine, but not of lidocaine. In studies in vitro on isolated bovine eye melanin there was considerably greater adsorption of chlorpromazine than of lidocaine and bupivacaine. An uptake was noted in the human eye in experiments in vitro. Clinical tests revealed no acute or late damage to hearing or sight after large doses of lidocaine. The participation of melanin in different basal labyrinthine functions such as the energy transfer mechanism and the sound protective mechanism is discussed in the light of the results obtained. Further, the theory is put forward that the melanin affinity of certain substances can be of both therapeutic and ototoxic importance.

The Influence of Vertigo, Hearing Impairment and Tinnitus on the Daily Life of Meniere Patients

The aim of this questionnaire study was to investigate the impact of the symptoms in Menieres disease on the daily life of patients and to analyse the relationships between the cardinal symptoms and environmental, emotional and activity factors. The study comprised 514 patients, recruited from two different sources. The results showed that vertigo, hearing impairment and tinnitus had a strong negative influence on the daily life of patients. Seventy-five percent of the subjects avoided certain everyday activities or situations because of the disease. However, the correlation between discomfort and reported satisfaction with life was moderate. Most of the subjects experienced premonitory symptoms of the attacks and 80% reported relations between external factors and vertigo attacks.

Accumulation of 14C-Lidocaine in the Inner Ear Preliminary Clinical Experience utilizing Intravenous Lidocaine in the Treatment of Severe Tinnitus

Clinical experience has demonstrated that intravenously administered local anaesthetics have a mitigating effect on severe tinnitus. In an attempt to gain some insight into the mechanism of this effect, autoradiography of the inner ear of young pigmented rats was performed after intravenous injection of 14C-lidocaine. Some accumulation of lidocaine was found in the modiolus, but almost none in the stria vascularis. A large accumulation was observed in other melanincontaining tissues, such as the hair follicles and uvea. The in vitro accumulation of 14C-labelled lidocaine adsorbed on melanin granules was low (12%) as compared with that of other drugs, such as kanamycin (89%) and chloroquine (85%). These autoradiographic results indicate that lidocaine has an effect upon the inner ear, in addition to its previously demonstrated effect on the CNS.

Hearing aids and tinnitus -an experimental group study

From a waiting list consisting of hearing-impaired patients waiting for hearing aids to be fitted, 39 subjects who at interview also stated that they had tinnitus took part in an experimental group study with the aim of investigating the effect of a hearing aid on tinnitus. No subject had any previous experience of hearing aids. The subjects were randomly allocated to a treatment and a waiting list control group. After an initial interview, the routine programme for the fitting of hearing aids started in the treatment group, while the waiting list control group had to wait for 6 weeks before starting the same hearing aid rehabilitation programme. The hearing aids were fitted exclusively for hearing purposes. As expected, the hearing aids improved the hearing capacity, but they did not reduce tinnitus as recorded on a visual analogue scale. According to information obtained at the final interview, there were significant differences in tinnitus between subjects who used their aid for more than 2 hours daily and those who used it for less than 2 hours. However, the results of scaling (pre- and post-fitting) did not support this finding. The discrepancy between the scaling and interview data is probably due to demand characteristics.