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How to cite this article Nardo WD, Cianfrone F, Scorpecci A, Cantore I, Giannantonio S, Paludetti G. Tinnitus is a common symptom which often becomes disabling, affecting the emotional and psychosocial dimensions of life. Tinnitus is a quite common symptom, not infrequently reported by patients as a bothersome and upsetting experience severely affecting the emotional and psychosocial dimensions of life and sometimes impairing the patients' ability to perform daily life activities. As reported by basic and clinical research, lesions are more often localized within the auditory periphery and concern hairy cells. Our methods for patient enrollment, informed consent, psychoacoustic testing, placement of a transtympanic electrode, electrical stimulation, data analysis, and follow-up were reviewed and approved by our institutional review board and are in accordance with the Helsinki Declaration. In our clinic, we enrolled 11 patients (7 women and 4 men) affected by postlingual monaural or binaural profound hearing loss and with severe and disabling tinnitus in the worse ear. When the hearing loss was gradual in onset, patients underwent auditory brainstem response (ABR) recordings before their deafness became profound, and results were consistent with a peripheral origin of their disease.
The stimulation system we used is a Cochlear Promontory Stimulator Z10012 (Cochlear Ltd., Lane Cove, NSW, Australia), an active platinum-iridium needle electrode and a silver surface electrode located on the ipsilateral mastoid region. Characteristics of the study population, including age, cause of hearing loss, and duration of tinnitus, are shown in Table 1; tinnitus pitch, loudness, and MML as measured immediately before the electrical stimulation session are shown in Table 2. The most effective frequencies of electrical stimulation for tinnitus suppression or reduction were 50 Hz and 100 Hz. Conversely, factors such as tinnitus duration and patient's age appear to be associated with the THI outcome: Four of the six patients having had tinnitus for less than 5 years had a complete or partial benefit from the procedure, whereas only one of five patients with more than 5 years of tinnitus showed a THI score reduction after 1 month.
The effectiveness of electrical stimulation on tinnitus is well-known, thanks to studies on groups of patients affected by bilateral profound sensorineural hearing loss and undergoing cochlear implantation, the majority of whom report suppression or attenuation of tinnitus after device hookup [15-18].
Despite the remarkable amount of evidence pointing to a beneficial and lasting effect of EPS on tinnitus, studies generally describe the clinical effects of the procedure rather than focusing on the mechanisms underlying tinnitus suppression, so that at present there are many questions-and no certainty-as to how EPS should work. Whether EPS can restore some degree of normal firing in the cochlear nerve of humans affected by tinnitus is at present unknown.
Alternatively, suggested mechanisms through which a positive current delivered to the promontory or to the cochlea may work on nerve fibers include hyperpolarization of axons, with subsequent inhibition of spontaneous discharge rates [27], and even a reflex increase in microcirculation in the auditory pathway [21]. A temporary alteration of acoustic nerve firing cannot account for the long-term effect (at least 1 month) of a 60-second promontory stimulation such as the one we administered to our study patients. Finally, a possible effect of EPS on the cortical reorganization [31-34] underlying tinnitus must be assumed, as a positron emission tomography (PET) study has shown that electrical stimulation delivered to the promontory and round-window region causes activation of the primary auditory cortex and some of the surrounding association areas [35]. As for the tinnitus-associated psychosocial impairment, THI administration allowed us to appreciate a reduction of the THI score in five patients 1 month after transtympanic stimulation, which means most of the negative emotional, affective, and psychosocial impacts of tinnitus abated. Considering our preliminary results, we think more expansive series are necessary to precisely define the features that the electrical stimulation should possess to suppress tinnitus.
Aside from the optimal parameters of stimulation, clinical features that predict EPS success should be outlined more precisely for a correct selection of candidates who could derive the utmost benefit from the procedure.
In conclusion, we assume that EPS is to be considered per se a worthwhile attempt at tinnitus suppression, being quite easy to administer and successful in the majority of cases.
EPS results could help predict tinnitus response to the positioning of an implantable electrical stimulator: Patients for whom EPS proves to be effective could benefit from the implantation of an intratympanic stimulator that could be controlled by radiofrequencies from the outside.
The results from this clinical study strongly support the use of Widex Zen Therapy in tinnitus patient management. Previous reported investigations of hearing aids containing fractal tones1-6 have yielded favorable results in reducing the tinnitus annoyance or handicap for patients with significant tinnitus. Derived from these findings and subsequent research, Widex introduced a new tinnitus management approach called “Widex Zen Therapy” in 2012.7 The overall objective of Widex Zen Therapy (WZT) is to ensure that the tinnitus does not negatively impact the patient’s quality of life. 4) Relaxation strategy program, highlighted by relaxation exercises and sleep management strategies. The appropriate components constituting the therapeutic intervention are tailored for each individual in accordance with the audiologic evaluation and the patient’s reaction to the tinnitus.
2) to investigate how subjects employ the hearing aids and the acoustic (fractal tones or filtered noise) options. Two tinnitus clinics participated in the data collection (Hearing and Tinnitus Center Tinnitus Clinic in New York and Canadian Tinnitus and Hyperacusis Centre in Whitby, Ontario, Canada). Subjects were given a comprehensive audiologic and tinnitus evaluation by trained tinnitus clinicians at the two clinical sites. All subjects had significant tinnitus distress (THI >18) when they enrolled in the clinical study with a mean THI score of 51, ranging from 20 to 96. Instructional counseling was similar to that provided in Tinnitus Retraining Treatment (TRT)11 directive counseling.
The choice of the particular model (which varied from the high end 440 to the entry level 110) was based on the individual patient’s needs and economic considerations. There are five Zen fractal tone styles available that vary in their tempo, pitch, dynamic range, and chord. Zen Program A utilized the “Aqua” setting that has proven to be the most popular fractal tone style.
Subjects were instructed on hearing aid use, including how to access the various Zen programs and how to adjust the volume.
The mean TFI baseline score was 53 (range 20 to 82), while the final TFI mean score improved to 25 (range 0 to 62). Individual subject scores for the baseline and 6 months after WZT are shown in Figures 3 (THI) and 4 (TFI).
Symbols falling below these diagonal dashed lines reflect clinically significant relief from tinnitus on these two scales. A secondary objective of this study was to ascertain individual preferences and wearing habits for the hearing aids and programs.
The majority (80%) of subjects selected “Aqua style with microphone on” as their Zen A program. Figure 6 shows the mean percentage of time use for amplification versus the three Zen programs. Additionally, 74% and 75% of subjects achieved clinically significant changes in their THI and TFI scores, respectively. Although it is not possible to determine the relative contribution of each WZT component to the reduction of tinnitus handicap and quality of life improvement, it is interesting to note that the degree of improvement (in terms of THI and TFI reduction) was slightly greater (though not statistically significant) for the subjects receiving the more comprehensive cognitive behavioral intervention and relaxation exercises. Future clinical studies would be useful to lend support to these findings and to determine the longer-term efficacy of this treatment. How to cite this article Mahmoudian S, Shahmiri E, Rouzbahani M, Jafari Z, Keyhani MR, Rahimi F, Mahmoudian G, et al. Tinnitus is a debilitating condition that is widespread yet difficult to successfully diagnose and treat.
Regarding to McFadden (1982), Tinnitus is the "conscious experience of a sound that originates in an involuntary manner in the head of its owner or may appear to him to be so"1.
Some underlying causes were defined for tinnitus, including otological diseases, tumors, ototoxicity, acoustic trauma, noise-induced and psychological disturbances. Since almost the majority of tinnitus questionnaires for assessing individual's reaction to tinnitus are in English language and there is still no standardized and valid questionnaire in Persian, the provision of a Persian version of these questionnaires according to the culture of Iranian society is inevitable.
The first aim of the current study was to investigate the linguistic validity of the Persian Version of the THI as a measure of tinnitus-related reactions in three dimensions 95 International Tinnitus Journal, Vol.
The present study consists of translation and standardization of the original version of THI [25] into Persian version (Linguistic validation) then the reliability of the Persian version of THI has been identified. In the first step according to the IQOLA protocol26, THI questionnaire was translated by two native speakers of Persian, bilingual in English and Persian, separately translated the original instrument into Farsi (Persian) language (translator 1 and 2).
At the second step of linguistic validation, we used two other translators (5 and 6) with high level of proficiency in Persian and English languages. Before the THI-P can be administered to assess the effects of tinnitus, its test-retest stability must be determined. The degree of hearing loss is defined as the severity of the hearing loss measured by audiometry.
Patients were asked to complete the THI-P questionnaire as part of the initial assessment at the tinnitus center. All analyses were performed using statistical package for social science (SPSS) version 16. Student t-test was used to test for differences between THI scores and its subscales and gender, hearing impairments and tinnitus laterality. From the 25 items of THI-US version translated to Persian version of THI, thirteen items (52%) including 2, 3, 7, 8, 9, 10, 11, 15, 16, 20, 21 and 22 as an easy translation, six items (24%) including 6, 12, 14, 17, 18 and 19 as a relatively easy translation and finally other six items including 4, 5, 13, 23, 24 and 25 as a difficult translation were evaluated by translators. The tinnitus characteristics of the 112 subjects attending the tinnitus center to consult about tinnitus management have been summarized in Table 1.
The frequency distribution of tinnitus subjects who answered the various items in the THI-P questionnaire has been outlined in Table 3. The correlation of age and total THI-P score was calculated by Pearson's product and for calculating the effect of sex and total THI-P score we applied independent student t-test.
Pearson product-moment correlations were calculated between the first and second administrations of the THI-P among the tinnitus subjects to assess the strength of the relationship between tests and retest (Figure 2).
We assessed the percentages of "Yes", "Sometimes" and "No" answers and then we calculated the reproducibility (internal consistency reliability) of items in THI-P using the Cronbach's-alpha coefficient. In recent years, the need to assess and consider the consequences of diseases as well as distressing symptoms has been specifically considered in all special facilities of medical and rehabilitation. Hence, as a first step, standardization and validation of appropriate tools such as psychometric questionnaires are very important in order to evaluate disease or monitor treatment outcomes.
One of our ultimate goals for validating the Persian version of THI and for conducting current study was to develop a standard self-report tinnitus instrument, appropriate to the Persian's culture so that it could be administered as a criterion measure in clinical and research approaches available to clinicians and other researchers who are involved in different aspects of tinnitus subjects. It is widely agreed that in addition to desirable translation to validate an assessment tool, we should also use the terms adapted for socio-cultural setting of the population which will serve.
The translation quality was assessed by translator 3 and 4 using a VAS criterion (from desirable up to absolute undesirable score).
In order to determine the divergent or discriminate validity of THI-P, we used the effects of three factors including hearing impairment, gender and age of the tinnitus subjects on the questionnaire scores. Regarding to other studies, in order to identify validity of THI questionnaires (German, Brazilian, Danish versions), authors administered the correlation between items in translated THI with the other standardized questionnaires (convergent validity structure)33. The most important specifications of one assessing instrument are always including repeatability, consistency and validity of obtained scores.
The other part of consistency was related to the correlation between test-retest which was evaluated by Pearson correlation coefficient. In this study, with omitting any of the THI-P items, the acquired score of Cronbach's alpha coefficient as calculated by the total score of Cronbach's alpha coefficient was very close (r = 0.943). In conclusion, this study demonstrated that the Persian version of THI (THI-P) is a valid and reproducible tool to assess the psychological complaints of tinnitus sufferers. We find that THI-P in structural and practical point of view is compatible with the original English version of THI. In this era, the determination of both objective and subjective effects of clinical intervention is critical, because clinicians using outcome measures could make decision about patient's status and the effective treatment. People with tinnitus often characterize their tinnitus as “ringing in the ears” or a “buzzing sound.” The American Tinnitus Association (ATA) describes it as a subjective noise that only the patient can hear. About 50 million people in the United States experience tinnitus to some degree and, in severe cases, seek medical attention. HR: Why should hearing care professionals who traditionally focus on hearing impairment get involved in tinnitus? Clint Keifer, AuD: As audiologists, we possess an in-depth understanding of the anatomical, physiological, and psychoacoustical aspects of the auditory system.
Wendy Switalski, AuD: In conversations I’ve had as an audiologist and as a consultant to audiologists, it is clear that these conditions coexist for so many of our patients.
Clement Sanchez, AuD: Tinnitus can be a problem for those who are hearing impaired and have a hearing loss. Sanchez: Hearing aids can be very effective if they can reduce the symptoms related to the tinnitus. A clinician can play a vital role in helping the patient deal with the sounds of everyday living, instead of avoiding sounds all together. Switalski: Professionals interested in expanding their services have so many resources available. Practices may begin by simply offering tinnitus assessment, patient questionnaires, or surveys. Keifer: Ideally, practices would be “full-service,” but in practical terms, it is difficult for any one practice to offer every possible solution. Sanchez: Assessing tinnitus can be challenging, so clinicians who decide to add a full-service tinnitus treatment plan have a few details to consider. Aside from my traditional practice, I used to schedule consultation with tinnitus patients 1 day a week and this worked well. HR: I’ve heard that tinnitus patients can consume huge amounts of practice time and many dispensing professionals are not adequately staffed for that. Sanchez: Yes, tinnitus patients will need time to express their fears, frustrations, and the discomfort they are experiencing because the sounds they hear are unclear and can be difficult to describe. I would describe the tinnitus consultation as “a mix of charisma and empathy,” where clinicians can focus on gathering the information that can benefit the treatment.
The MADSEN Astera2 features a dedicated tinnitus assessment module designed to help clinicians address increased claims for tinnitus and hearing loss disability.
The new tinnitus test module we have developed as part of fundamental audiometry in MADSEN Astera2 supports the professional through a series of integrated questionnaires. Keifer: Tinnitus treatment protocols should not be rigid, but rather they should adapt to the individual.
The treatment may also involve retraining strategies, amplification, masking, sound therapy device application, support group attendance, and so forth. Sanchez: In addition, it will entail an in-depth hearing assessment, such as audiometry with UCL, immittance, otoacoustic emissions (OAE), and auditory brainstem response (ABR).
The full tinnitus psychoacoustic test battery is designed to improve patient counseling and test precision. Visualization of the tinnitus on the audiogram is a great experience for a patient who has looked for help for years and may have felt misunderstood at times. The electronic questionnaires—Tinnitus Functional Index (TFI), Tinnitus Handicap Inventory (THI) and Tinnitus and Hearing Survey (THS)—can be saved in NOAH and are designed to eliminate the need for paper records. The next step is explaining that, for example, a 7 dB tinnitus is quite a small issue that can be managed. Once again, dialogue with other professionals is important and should be considered from the very beginning. HR: What types of equipment should you consider for your practice when starting up a tinnitus treatment program? Switalski: Having access to the proper audiometer features is important for performing a tinnitus assessment. Otometrics has developed a dedicated tinnitus management tool for audiologists, which is integrated with our clinical audiometer, the MADSEN Astera2.
Key words: assessment, counseling, education, hearing disorders, quality of healthcare, rehabilitation, screening, tinnitus, treatment, triage.
In spite of the growing magnitude of the problem of tinnitus in veterans, most VA medical centers (VAMCs) do not provide clinical management for the condition [14].
Presently, no accepted standard of practice exists for the clinical management of tinnitus, either within or outside of the VHA. This article proposes a basic model for efficiently managing tinnitus patients at all levels of clinical need.
The proposed model is designed for application at any audiology clinic that desires to optimize resourcefulness, cost efficiency, and expedience in its practice of tinnitus management. Dobie reviewed 69 randomized clinical trials that had been conducted to assess the efficacy of various treatments for tinnitus [17]. The reports by Dobie reveal that the literature does not provide definitive evidence to support any particular form of tinnitus intervention.
Numerous causes of tinnitus have been identified, many of which involve head and neck injuries or diseases or systemic diseases. Patients should also receive a general physical examination consistent with an ideal standard of tinnitus clinical management.
The mechanism(s) of tinnitus is still unknown; thus, no rational basis exists upon which to select a drug to control tinnitus [25].
Many forms of tinnitus therapy recommend the use of sound in some manner to reduce the effects of tinnitus. Hearing aids have been long recognized to reduce the bothersome effects of tinnitus [28-30]. The primary treatment modality with Tinnitus Masking is the use of wearable ear-level devices-tinnitus maskers, hearing aids, or combination instruments [33-34].
TRT patients are advised to wear hearing aids or combination instruments rather than sound generators if their hearing loss is considered a significant problem. Psychological forms of treatment for tinnitus have included progressive muscular relaxation training, biofeedback, hypnosis, and cognitive-behavioral intervention [45,53].
Tinnitus research has been conducted at the Portland VAMC (PVAMC) since 1995 (under the auspices of the NCRAR since 1997). Our randomized clinical trials, described in the following paragraphs, are a systematic effort to develop and document structured forms of tinnitus management for veterans. Before attending the intake evaluation, each of the 172 study candidates completed written tinnitus questionnaires, including the Tinnitus Handicap Inventory (THI) [70], Tinnitus Handicap Questionnaire (THQ) [71], and Tinnitus Severity Index (TSI) [72]. 1.Study patients completed the written questionnaires (THI, THQ, and TSI) before each visit. Of the 123 patients, 111 (53 in masking; 58 in TRT) completed the 18-month treatment protocol. Mean ± standard deviation (SD) scores from Tinnitus Handicap Inventory (THI) for patients at baseline and ongoing treatment appointments. Mean ± standard deviation (SD) scores from Tinnitus Handicap Questionnaire (THQ) for patients at baseline and ongoing treatment intervals.
Mean ± standard deviation (SD) scores from Tinnitus Severity Index (TSI) for patients at baseline and follow-up treatment intervals.
Numbers and percentages of patients in each treatment group (Tinnitus Masking and Tinnitus Retraining Therapy [TRT]) who made statistically significant improvement (0.05 level of significance) based on a 20-point reduction in total index score of Tinnitus Handicap Inventory (THI). Results of these preliminary analyses reveal that both groups experienced comparable improvement through 6 months of treatment. Further analyses have been conducted on these data (which are too extensive to include in this brief summary) on an intent-to-treat basis, using multilevel modeling (MLM) [78]. Although this study was well controlled, one should note that a number of variables could have influenced the outcomes. The investigators hypothesized that the majority of veterans with clinically significant tinnitus would be treated effectively using group counseling that was adapted from the structured TRT counseling protocol. Study patients were recruited via local (Seattle area) newspaper and radio advertisements and via flyers posted at the Seattle and American Lake (Tacoma) VAMCs. Qualifying veterans who completed and returned baseline questionnaires were randomized into one of the three study arms: educational counseling, traditional support group, and usual care (no treatment). Mean ± standard deviation scores from Tinnitus Severity Index (TSI) for patients in three treatment groups at baseline and 1, 6, and 12 months posttreatment (usual care received no treatment). We need to emphasize that the outcome data from this study have received only a very cursory analysis. We can begin to address the question of relative benefit for group versus individualized therapy by comparing outcome data between our two studies.
A further possibility for tinnitus group therapy is to provide the educational program as a videotaped presentation.
We have developed videotape modules for this purpose, and they are being evaluated as a pilot project to assess their potential for clinical application in this manner.
We are accumulating research evidence that supports the efficacy and efficiency of providing clinical tinnitus services with a progressive intervention approach.
We need to emphasize that proper implementation of this model depends critically on the audiologist making appropriate referrals to other disciplines. Level 1 of tinnitus progressive intervention would involve screening for clinically significant tinnitus-separating persons who do require clinical services from those who do not. How to cite this article Cevette MJ, Barrs DM, Patel A, Conroy KP, Sydlowski S, Nelson BNNGA, Stepanek J, et al.
Background: Recent studies in noise-induced and idiopathic sensorineural hearing loss have suggested that magnesium supplementation may lessen both hearing loss and the severity of tinnitus in patients. Descriptions of tinnitus date back to the time of ancient Egypt, yet science has failed to unravel the mysterious underlying mechanisms that produce these subjective auditory perceptions of sound.
Despite these encouraging findings, no controlled study has examined the effect of magnesium supplementation for patients with moderate to severe tinnitus. Between March 6 and December 10, 2008, patients aged 18 years or older who were seen for an audiological evaluation at Mayo Clinic in Scottsdale, Arizona, and who had a Tinnitus Distress Rating (TDR) scale score from 3 through 8 (Figure 1) were eligible for the study. Participants were given a daily magnesium supplement, 532 mg (Mg Plus Protein, 133-mg tablets; Miller Pharmacal Group, Carol Stream, Illinois). The primary outcome measures were comparisons of TDR scale scores and THI scores as converted to TSS grades at baseline and the end of the study. The present study indicated that subjects showed significant improvement in their self-rating of tinnitus with a magnesium supplement of 532 mg daily for 3 months.
Recent interest has surfaced in symptom-specific handicap outcome measures for many audiological and otological diseases. There is no valid and reliable tinnitus handicap inventory for Turkish people in their native language. We assessed test-retest reliability with a second investigation in 21 randomly chosen patients. The three groups of patients were divided according to their ages: 19-39 years, 40-59 years, and 60 years and older. We tested internal validity by multi-item analysis, to assess item convergent and discriminant validity. This study was designed to obtain the THI as a standard measuring instrument for patients and clinicians all over Turkey.
Sequential sound therapy, which uses wide-band white noise distinguished by some unique characteristics, is applied in the treatment of tinnitus. Currently, tinnitus treatment involving the application of sounds is being performed according to a protocol defined as tinnitus retraining therapy (TRT) [1-6], which consists basically of the application of white noise of an intensity inferior to that of tinnitus to permit a patient's habituation to and decreased perception of tinnitus. TRT, which is being performed worldwide, is considered a conceptual methodology that has helped to standardize the treatment of tinnitus. The neurophysiological model is structured as a net composed of five aspects: the generation, detection, emotional aspects, and perception of, and the aversive reaction to tinnitus. Therapeutic counseling for tinnitus should primarily address a patient's understanding of the condition.
Sound therapy is created using noises from three sources, such as natural sounds from a patient's environment, sound amplification of earphones, and generators of white noise of a lower intensity than the patient's tinnitus.
Sequential sound therapy applies the two tinnitus treatments that use sounds as if they are total masking and partial masking, incorporates an intermediate step - limit masking - for interconnection, and is adapted to each individual patient and so that it can be administered in either a public health system or in private medical practice. The application of sequential sound therapy comprises three steps: It begins with total masking (white noise more intense than tinnitus), proceeds to limit masking (white noise of an intensity similar to that of tinnitus), and culminates in partial masking (white noise less intense than tinnitus). Twenty-six patients, 21 of whom were women (median age, 69 years) and 5 of whom were men (median age, 63 years), gave their informed consent to be entered into the study. Aside from anamnesis focused on discerning information about tinnitus [10], complementary tests that were carried out in all patients were otoscopy, tympanometry, tonal audiometry (bony and air auditory thresholds, discomfort thresholds, and pain thresholds), logo-audiometry (thresholds of voice detection, word detection, perception, understanding, and discomfort), and tinnitometry (tinnitus measurement). In patients treated by means of either sequential sound therapy or TRT, the sound generators used were Siemens (Germany) model TCI and TCI COMBI, the latter incorporating earphones. During the first month of adaptation, in patients with tinnitus but without hearing loss, the sound generator was adapted for total masking (level 3 or 4) for 6 hours per day - 2 hours in the morning, 2 hours at noon, and 2 hours in the afternoon. During month 2 of adaptation, in patients with tinnitus but without hearing loss, the sound generator was graduated to level 2 for a 6-hour daily span selected by the patient. In the third month of adaptation, control patients received treatment personalized according to time and masking type.
The various types of tinnitus identified in the 26 patients studied are detailed in Table 1. A total of 38 sound generators, of which 34 incorporated earphones, were adapted initially to the 26 patients treated by means of sequential sound therapy. In the 15 control group patients treated by means of TRT, 30 sound generators with incorporated earphones were adapted binaurally. Tympanometry was normal in 19 patients (73%) of patients, being smooth or plane in the remaining patients for medial ear problems. In every one of the 26 patients treated by means of sequential sound therapy, a subjective, quantitative improvement was obtained according to the THI answered by both a patient and his or her cohabitant. The perception of tinnitus diminished in all patients treated with sequential sound therapy: in six patients from the moment of adaptation, in one patient after 15 days of treatment, in two patients at 1 month of adaptation, in three patients at 2 months, in one patient at 3 months, in four patients at 4 months, and in three patient at 6 months.
Three patients, once their perception of tinnitus had decreased, experienced periods of increased tinnitus perception again that were related to stressful situations. Sequential sound therapy is an original methodology being described here for the first time. In our 26 patients, tinnitus was prevalent in the left ear, coinciding with other published results in which the left ear is the most frequently affected [12-14].
The most common complaint in patients treated by TRT - that is, the presence of two noises instead of one - contributed to these patients' abandonment of therapy.
The evolution of masking in sequential sound therapy is described as a chain of three links: the first link being total masking, the second being partial masking, and the third being sequential sound therapy.
The therapeutic masking of tinnitus began in 1969 in Germany, where Feldmann [17] began to mask tinnitus in a total way, as much homolaterally as contralaterally and using different spectra of noises: wide-band, narrow-band, and pure-tone.
Many patients whom we subjected to TRT with the application of sounds less intense than their tinnitus did not experience improvement. There are many reports describing tinnitus suppression or attenuation through electrical stimulation of the ear, provided either by cochlear implants or by transtympanic stimulation. The subsequent change in the acoustic nerve fiber excitation pattern triggers an immediately successive elaboration by neural centers and then, after some time, the priming of neural plasticity phenomena. Many studies have described attempts at suppressing tinnitus by means of electrical stimulation, delivered both transcutaneously [3-9] and transtympanically [10-12]. The anesthetic procedures consisted in careful cleansing of the external auditory canal and local administration of lidocaine to anesthetize the tympanic membrane for 5 minutes. Table 3 lists data concerning the modalities and the effects of EPS, such as pulse rate of the delivered stimulus, threshold, discomfort level, and best tinnitus-suppressing frequencies for each patient. For lower frequencies of stimulation, electrical intensity for tinnitus suppression or attenuation was just above auditory threshold, whereas for high frequencies of stimulation, it was quite near maximum acceptable level in the majority of patients.
THI scores obtained immediately before and 1 month after EPS are shown in Table 4, which also provides information about pre- and poststimulation partial scores relative to the three categories (emotional, functional, and catastrophic) comprising the THI. As for patients' age, four of the five subjects reporting longer-lasting benefit from the procedure were younger than 50 years.
Our short-term and long-term results are consistent both with the evidence provided by such studies on cochlear implants and with recent works on transtympanic electrical stimulation [20-22]. The "masking" hypothesis, which was among the earliest proposed [23], has long been considered too simplistic and insufficient, because in some cases tinnitus reduction can be obtained by means of subliminal electrical pulse rates. Very few reports are currently available about a real-time monitoring of nerve fiber activity during and immediately after peripheral electrical stimulation. In fact, the lasting residual inhibition we observed in some of them implies that central stations along the auditory pathway are likely to be involved as well.
Other PET studies report that the electrical stimulation produced by a cochlear implant can reduce the signs of abnormal activity supposed to be associated with tinnitus in the primary auditory and associated cortices and in brain areas of the limbic system [36]. This outcome seems to suggest that electrical stimulation also affects the activity of association areas (limbic system) that are notoriously closely intertwined with the neural pathways involved in tinnitus pathogenesis and play a very important role in producing negative emotional correlates of tinnitus, such as anxiety and annoyance.
However, even the results on our small series seem to indicate that tinnitus suppression occurs mostly at lower pulse rates (50 and 100 Hz) and at an intensity of stimulation between threshold and minimum discomfort level, although in two of our patients, tinnitus suppression was achieved through subthreshold stimuli. Our results suggest that recent onset of tinnitus and a patient's age can be predictive of tinnitus suppression, although selection criteria deserve deeper investigations in larger series. Considering the recent achievements of cochlear implant "soft surgery," which allows preservation of residual hearing, cochlear implants could definitely be used to suppress intractable tinnitus in patients with unilateral profound hearing loss [38].
The data revealed substantial positive adjustment to tinnitus, as measured by the TFI and THI, evident within the first 2 months of treatment, with further (albeit not statistically significant) changes occurring through 6 months.
It appears that a combination of fractal tones (generated by hearing aids), amplification, and counseling have great potential for tinnitus patient management. The more severe and negative the tinnitus reaction, the more components listed above will be added in the individualized program.
The mean tinnitus loudness was 6 (on a 10-point scale) and the tinnitus pitch was 7 (on a 10-point scale).
Subjects participating in the study were patients who visited the clinics to seek tinnitus management. In addition, adjustment-based cognitive behavioral intervention (explained below) and relaxation exercises were applied for those individuals demonstrating more severe negative reactions to their tinnitus. All subjects received detailed instructional counseling related to the hearing loss and tinnitus. The objectives were to provide the patient with an understanding of the habituation process and to help the patient reclassify the tinnitus. Because many clinicians feel instructional counseling alone is not adequate to address the emotional consequences of tinnitus, including fear, anxiety, and depression,12 WZT recommends adjustment-based counseling or Cognitive Behavioral Intervention (CBI) to help the patient identify barriers to achieving natural habituation.
All subjects were fit bilaterally with Widex Dream hearing aids with True Input Technology that remain undistorted at the input stage with inputs as high as 113 dB SPL. All of the hearing aids were programmed to have four memories; a “master” (amplification only) program, and three “Zen” programs, as explained below. The Zen programs use fractal (Zen) tones that are generated by a semi-random recursive algorithm.
In addition, fine-tuning adjustments of each style can be made to its pitch, tempo, and volume by the clinicians. They were told that the fractal tones should be audible, but soft enough to not interfere with conversational speech. The use of relaxation exercises was given to patients to break the vicious cycle of tinnitus and stress. Mean Tinnitus Handicap Inventory (THI) and Tinnitus Functional Index (TFI) scores at baseline, 2 and 6 months. Individual subject Tinnitus Handicap Inventory (THI) baseline and 6 months post Widex Zen Therapy scores for 23 subjects (one subject was missing the THI at baseline). Individual subject Tinnitus Functional Index (TFI) baseline and 6 months post Widex Zen Therapy scores for the 24 subjects.
Inspection of individual subject data revealed that 74% of subjects obtained a clinically significant change in THI scores, and 75% of the subjects had clinically significant changes in TFI scores.
In addition, the degree of improvement (in terms of THI and TFI reduction) was slightly greater (though not statistically significant) for the subjects receiving the more comprehensive cognitive behavioral intervention and relaxation exercises. Choice of styles and microphone settings for Zen A, Zen B, and Zen C programs at the initial fitting. About two-thirds (65%) of the subjects selected “Aqua + microphone off” as their Zen B program. Percentage (time) of use of amplification only (Master program), Zen A, Zen B, and Zen C at the 2 and 6 month visits. The average use of amplification only (the Master program) was 50%, and the average use of the three Zen programs combined was 50% also. The data revealed substantial positive adjustment to tinnitus (as measured by the TFI and THI) evident within the first 2 months of treatment, with further (albeit not statistically significant) changes occurring through 6 months. While other tinnitus treatments have reported similar success,16 the speed in which the WZT treatment achieved these changes is particularly impressive and vital, considering the importance of early success in maintaining motivation for tinnitus patients. It is also relevant to note that WZT is one of the few current tinnitus treatments utilizing amplification in addition to other sound therapy options.
In addition, investigations focusing on and delineating the individual components of WZT would help understand how each component contributes to the process. Meikle MB, Henry JA, Griest SE, Stewart BJ, Abrams HB, McArdle R, Myers PJ, Newman CW, Sandridge S, Turk DC, Folmer RL, Frederick EJ, House JW, Jacobson GP, Kinney SE, Martin WH, Nagler SM, Reich GE, Searchfield G, Sweetow R, Vernon JA.
Persian language version of the "Tinnitus Handicap Inventory": translation, standardization, validity and reliability.
This symptom is a debilitating condition that is widespread yet difficult to successfully diagnose and treat. For some patients with tinnitus this sensation does not interfere with their daily activities and for others it is disabling and restricts their work, sleep, and social activities10,11.
Numerous studies using various open-ended or self-report structured questionnaires have been conducted. For this reason we perform according to the International Quality of Life Assessment protocol (IQOLA) approved by WHO in 1991. Craig Newman, author of the original questionnaire of THI, has permitted us to develop and use the Tinnitus Handicap Inventory in Persian Language Version.
They were asked, if needed, to mention a list of possible translations for some words, sentences and phrases. On the other hand, the words and items on the level of reading ability of 14 years old or less were noticed for linguistic validation of THI-P.
All subjects gave written informed consent in accord with the declaration of Helsinki before examinations. So, in retest after one week from filling the first THI-P, the questionnaire was filled again by the same patients.
Descriptive statistics, including frequency distributions, means and standard deviation were computed for each item of THI-P.
Multiple linear regression analysis was used to study the effect of gender, hearing loss and the tinnitus laterality on the overall THI score as well as the functional, emotional and catastrophic subscales. In this study, the research method and the role of subjects were explained clearly and completely.
The translation clarity exception in one item (item 17) which was evaluated as relatively desirable, in the other 24 items (96%) of THI-P was evaluated as desirable. Most of tinnitus subjects (72.7%) perceived one type of tinnitus sound, while others complained of sensation of more than one type of sound on different occasions.
Scatter plots illustration the relationship between the THI-P score and the age in all subscales.
As shown in Figure 2, the scatter plot indicates the correlation between the first (test) and second (retest) administration of the THI-P and their subscales on tinnitus subjects. Scatter plots illustration the correlation between the first (test) and second (retest) administration of the THI-P and their subscales.
Researches in many different countries around the world in this area indicate the global emphasis on the importance of these assessments.


This symptom is as a common problem which can affect several aspects of patients' life including: going to sleep, understanding speech, depression, irritation, concentration and worse on awakening.
To acquire this expressed goal, it was necessary to translate and standardize the original version of THI and then to evaluate the test-retest reliability of the THI-P. The measure of difficulty of Persian translation of THI was evaluated by translator 1 and 2 using a visual analogue scale from easy up to difficult (VAS; 100 mm total length).
The measure of this criterion administers three measures including clarity scores, common language and identifies conceptual equivalence. Both convergent and discriminate validity methods were used for identifying validity of original English version of THI19.
In current research the reliability of THI-P was evaluated from two 102 International Tinnitus Journal, Vol. We obtained 0.96 in Persian THI version, consistent with significant correlation in retest. The findings showed that none of the items of the Persian version of the questionnaire need to be removed. Also, THI-P could be administered as a standard measuring instrument for patients and clinicians all over Iran.
Henceforth, THI-P could be used for both clinical and research purposes by different professionals like audiologists, otolaryngologists, psychiatrists and could be also used for monitoring, treatment and rehabilitative effects on the life's quality of tinnitus sufferers. ENT and Head & Neck Research Center, Hazrat Rasoul Akram Hospital, Tehran University of Medical Sciences (TUMS), Tehran, Iran.
Department of Audiology, School of Rehabilitation Sciences, Tehran University of Medical Sciences (TUMS). Department of Biometry, School of Rehabilitation Sciences, Tehran University of Medical Sciences (TUMS). In some cases of objective tinnitus, physicians can identify the symptom with the use of a stethoscope placed on the neck or directly in the ear canal. There is currently no known cure for tinnitus; however, there are advanced devices and treatments today that can help alleviate tinnitus symptoms. Drs Sanchez, Switalski, and Keifer share their thoughts on the benefits of tinnitus assessment, and provide advice to audiologists and hearing care professionals who are interested in adding tinnitus assessment to their practice. As hearing care professionals, we are skilled in diagnostic, counseling, and rehabilitative approaches to managing auditory disorders. And for some of them, treating the tinnitus is necessary to address the concerns that led them to seek hearing care in the first place.
They may have difficulty sleeping, be unable to concentrate, and experience irritability and high stress levels. A hearing aid can amplify soft sounds, which can have a “masking” effect and helps to decrease the contrast between the environmental sounds and the tinnitus. This is an important step to address the patient’s fears and provide supportive tools when the tinnitus is too intense. Today, tinnitus management tools also include sound enrichment devices, sound generation pillows, as well as sound generators like MP3 and relaxing music.
Are there different levels at which practices can participate, or should every hearing care practice seek to have a full-service tinnitus treatment plan? They can also provide informational counseling and supplement their fittings with hearing instruments that include features and options for tinnitus relief. My recommendation would be to offer as many options as possible within the means of the practice and the practitioner.
Collaboration with other professionals like ENTs, psychologists, and general practitioners is helpful.
Prior to the consultation, patients can fill out questionnaires in the waiting room to avoid external influences during the test. While proper diagnostic testing and quantification measures should be performed for hearing and tinnitus aspects, the treatment options will vary greatly based on the individual and should focus on addressing identifiable needs. Tinnitus can be viewed as a spectrum disorder where trying a combination of approaches may be necessary.
Highlighted in magnifying glass on lower left is the electronic questionnaires for the TFI, THI, and Tinnitus and Hearing Survey (THS), which saves in NOAH and eliminates the need for paper records. Clinicians should ensure they are working with a subjective tinnitus and characterization via the existing questionnaires, like the Tinnitus Handicap Inventory (THI), Tinnitus Functional Index (TFI), and Tinnitus Handicap Questionnaire (THQ).
Testing efficiency and immediate availability of measurement results allow more time for consultation. Test results will provide the professional with information concerning the effect of an external sound on the tinnitus.
A high-resolution audiometer in frequency (1 Hz) and intensity (1 dB) is required to perform a characterization of the tinnitus. Today’s clinicians and audiologists can now more effectively evaluate the tinnitus and its impact on the lives of their patients.
People requiring intervention have different levels of need, ranging from the provision of basic information to long-term, individualized treatment.
The VHA is committed to implementing only efficient, evidence-based practices to improve healthcare outcomes in veteran patients [15-16]. Our clinical trials and screening methodology support the commonly reported observation that most individuals who experience tinnitus do not require intervention.
Use of these recommendations should lead to more widespread and consistent tinnitus assessment and treatment by audiologists.
He concluded that none of these studies demonstrated replicable, long-term reduction in tinnitus impact on lifestyle.
With that caveat in mind, we will now review various methods of treatment for tinnitus that are most commonly reported in the literature and have been used in clinical practice. An otologic evaluation is essential when symptoms are consistent with an acoustic neuroma or when the tinnitus is pulsatile or objective in nature [21].
Because so many drugs have been taken for so many different conditions, anecdotal evidence of correlative tinnitus relief has accumulated.
Patients with hearing loss and tinnitus often receive the secondary benefit of tinnitus relief when using hearing aids [31]. Some methods use counseling only, while others combine counseling with a different modality of treatment.
These types of therapy are not intended to remove or reduce the perceived tinnitus in any way but rather to help one cope with the effects of tinnitus on quality of life. Studies have shown that direct current is generally effective but results in tissue damage [54-57]. Because of the anecdotal reports of tinnitus relief with the use of these various methods, numerous studies have been conducted to attempt to verify the reports.
Our long-term objective is to develop a tinnitus management program for veterans that is documented for treatment efficacy.
The methods studied are based on existing techniques that are appropriate for audiologists to implement and that should offer the greatest potential to benefit veterans.
Figures 1 to 3 show line graphs of the mean ± standard deviation (SD) index scores from the THI, THQ, and TSI, respectively (graphs correspond with means ± SDs shown in Tables 1-3). At the 12- and 18-month visits, however, the TRT group showed significantly greater improvement relative to the masking group. That is, if any degree of clinical intervention was required, the veteran was considered a study candidate.
These participants completed questionnaires as for the main study: at baseline and at 1, 6, and 12 months following the sessions.
We can directly compare TSI data for the 6- and 12-month outcome time points from both studies.
Of course, the concern exists that some patients have tinnitus that requires medical attention. Such use of electronic media could decrease further the costs of administering this basic level of treatment. We can now propose a basic outline of this approach, with the caveat that much more research is needed to more specifically define the approach and to document its efficacy. A section follows that outlines the most common referral concerns for tinnitus patients and describes how referrals should be handled at each of the five levels of progressive intervention. Most likely, the majority of individuals who inquire about tinnitus services could have their needs met through an effective screening process. Further epidemiological evidence indicates that all age groups of Americans fall short of the recommended daily allowance for magnesium by 100 mg daily. These perceptions may be manifestations of damage resulting from noise exposure, ototoxicity, or other abnormal conditions of the auditory system. Additionally, no study to date has examined self-reported tinnitus severity before and after magnesium supplementation. The TDR was adapted from an existing pain scale, with the subject rating him- or herself between 0 (no tinnitus) to 10 (worst possible tinnitus). The Tinnitus Handicap Inventory is a 25-item self-report questionnaire that the patient can complete in about 10 minutes. A review by the Division of Cardiovascular Diseases indicated that daily magnesium supplementation at the level of 532 mg was benign for heart patients whose kidney function was normal. After beginning magnesium supplementation, the participants rated themselves daily for 3 months using the TDR. The data collected for each participant included informed consent, sex, date of birth, hearing threshold at 8 frequencies (250, 500, 1,000, 2,000, 3,000, 4,000, 6,000, and 8,000 Hz), weekly diaries of daily TDR ratings of tinnitus, THI questionnaires at baseline and the end of the study, dates of first and last dose of magnesium, number of tablets used, reason for discontinuation, and adverse events. Of these, 2 patients (8%) discontinued the study because of adverse events and subsequently had no follow-up data.
Change in tinnitus rating in 26 patients from baseline to 3 months after treatment with magnesium. In fact, significant improvement in the TDR occurred as early as 1 month into the study, suggesting that benefit of magnesium supplementation occurred early in treatment and was sustained throughout the 3 months of the study.
Standing Committee on the Scientific Evaluation of Dietary Reference Intakes, Food and Nutrition Board, Institute of Medicine. PhD, Department of Otolaryngology, Section of Audiology - Mayo Clinic - Scottsdale - AC - United States. MD, Department of Otolaryngology, Head and Neck Surgery - Mayo Clinic - Scottsdale - United States. AuD, Department of Otolaryngology, Section of Audiology - Mayo Clinic - Scottsdale - United States.
AuD, Section of Audiology - Cleveland Clinic Head and Neck Institute - Cleveland - United States. BS, Department of Otolaryngology, Section of Audiology - Mayo Clinic - Scottsdale - United States.
MD, Division of Preventive, Occupational and Aerospace Medicine - Mayo Clinic - Scottsdale - United States.
Each of two individuals independently translated and retranslated the English version of the THI, and it was adapted by an expert team. That is, clinicians plan to quantify their patients' symptoms, administer their treatment, and get objective results about the patient's satisfaction. Therefore, most clinicians use their own questionnaires, which lack reliability or validity (or both).
This study sought to analyze the validity and reliability of the Turkish version of the THI.
Internal consistency reliability of the Turkish version of the THI was assessed using Cronbach's alpha.
This was assessed by categorizing the patients into three groups according to their age and according to tinnitus duration. We investigated the differences in the mean values for scale and subscales, though the F test results did not provide significant results. The 25-item inventory can be used in neurootology clinics to evaluate the tinnitus symptom and its impact on knowledge and attitudes toward tinnitus.
After minor alterations in translation and retranslation, scaling assumptions were met satisfactorily for the three multi-item subscales, and the first Turkish-language scale for evaluating tinnitus was developed. The methodology is described, as are the differences from and similarities to tinnitus retraining therapy. Other types of tinnitus treatment using sounds have been described that involve the total masking of tinnitus by the application of white noise of an intensity greater than that of tinnitus [7-9]. The fundamentals of TRT are (1) the neurophysiological model, (2) therapeutic counseling, and (3) sound therapy. To assist a patient in understanding tinnitus, counseling must attempt to demystify by explaining (1) the physiology (thereby making the patient aware of all the implied mechanisms of this condition), (2) the necessity to control aversive reactions to eliminate suffering, and (3) the details of each step of treatment. Passage from one type of masking to another depends on the obtained result and on the treated patient's opinion about the success of adapting white noise to the individual's tinnitus experience. The predominant pathological findings were arterial hypertension in five patients, diabetes in three, obesity in two, a cerebrovascular accident in one, and acoustic traumatism in another. All these thresholds are useful during adaptation of the sound generators and the earphones. Adaptation of the sound generators and the earphones were undertaken with attention paid to each patient's intrinsic tinnitus characteristics and to whether a patient experienced any hearing loss or deafness.
In patients with tinnitus and hearing loss, sound generators with earphones were used for 6 hours per day - 2 hours in the morning, 2 hours at midday, and 2 hours in the afternoon.
In general, treatment was applied monthly except for necessities expressed by each patient. Light or moderate hearing loss occurred in 25 patients (96%), a single patient retaining audition within the normal range. One such patient experienced increased tinnitus perception in connection with a cerebrovascular accident suffered by his wife. This therapeutic approach consists of a three-step sequential application of the white noise of tinnitus, first for a total masking effect, next as a limited masking effect and, finally, for partial masking.
Monaural adaptation is carried out in sequential sound therapy for psychological and economic reasons. The flow diagram in Figure 1 depicts a guide to clinical practice that reflects the medical procedures and audio-prosthetics that are integral to our treatment of tinnitus. Flow diagram depicting a guide to clinical practice that reflects the medical procedures and audio-prosthetics integral to our (total) treatment of tinnitus. In both groups of patients, therapy involved similarly generated sounds and was administered by the same personnel (otorhinolaryngologist and audio-prosthetist).
This problem was not encountered among patients treated with sequential sound therapy; rather, patients felt a sense of well-being when they did not hear their tinnitus and had normal audition from the beginning of the treatment. Later, in 1977, Vernon [18] of the United States made important contributions to the development of this technique known currently as TRT. Since 1998, we have undertaken to develop a different methodology in which sounds are applied in a sequential way. Otorhinolaryngology Service, Specialties Center Doctor Fleming, Virgin of the Rocio University Hospital.
Our study project aims to assess the effects of electrical promontory stimulation (EPS) on persistent disabling tinnitus.We enrolled 11 patients affected by postlingual monoaural or binaural profound hearing loss and disabling tinnitus in the worse ear. Therefore, tinnitus could be due to central nervous system reorganization as a long-term consequence of a peripheral alteration [1,2].
Recently, attempts have been made at relieving chronic intractable tinnitus by delivering electrical stimuli directly to the auditory cortex [13,14]. Furthermore, to exclude the most common central causes of tinnitus (acoustic neuroma, vascular lesion, neurovascular conflict), all patients underwent brain magnetic resonance imaging with gadolinium.
The questionnaire was introduced into the tinnitus assessment battery in order to give the clinician a quick and effective tool for evaluating tinnitus and for classifying patients clinically [19].
We performed transtympanic electrical stimulation with direct continuous positive current at levels ranging from 0 to 500 µA. No association was found among tinnitus pitch and loudness, MML, and effect of electrical stimulation. Finally, there seemed to be no association between the cause of hearing loss and the benefits derived from EPS. The dorsal cochlear nucleus (DCN) and the inferior colliculus (IC) could be plausible candidates, given the amount of evidence pointing to them as tinnitus generators [28,29], although there is currently a paucity of direct evidence of their role in humans [30]. To confirm this, functional brain imaging should be improved so as to reliably identify central areas of tinnitus-related activity. In particular, the issue of using subthreshold or suprathreshold electrical stimulation should be addressed with special attention in future studies: Subthreshold stimulation would be better, avoiding replacement of tinnitus with an unpleasant and intrusive sound, just as often happens with maskers. Specific features, such as recent onset of tinnitus and patients' young age, appear to be associated with a better outcome and should therefore be considered as major factors for patient selection. Expanding the biological basis of tinnitus: Cross-modal origins and the role of neuroplasticity. Treatment of tinnitus with transcutaneous electrical nerve stimulation improves patients' quality of life. Tinnitus suppression by electrical promontory stimulation (EPS) in patients with sensorineural hearing loss. Response of the auditory nerve to sinusoidal electrical stimulation: Effects of high-rate pulse trains. Improved temporal coding of sinusoids in electric stimulation of the auditory nerve using desynchronizing pulse trains. Electrocochleographic analysis of the suppression of tinnitus by electrical promontory stimulation.
Summary of evidence pointing to a role of the dorsal cochlear nucleus in the etiology of tinnitus.
Lateralized tinnitus studied with functional magnetic resonance imaging: Abnormal inferior colliculus activation.
Functional MR imaging of the auditory cortex with electrical stimulation of the promontory in 35 deaf patients before cochlea implantation. Quantitative electroencephalography power analysis in subjective idiopathic tinnitus patients: A clinical paradigm shift in the understanding of tinnitus, an electrophysiological correlate.
The average (mean) reduction in THI scores was 30 points (23 points after only 2 months) and was 28 points in TFI scores (25.5 points after only 2 months). A total of 32 subjects were initially enrolled, but only 24 subjects completed the data collection.
Only 6 of the subjects indicated having received previous tinnitus management such as counseling, chiropractic adjustment, medication, dental treatment, Neuromonics,10 and hearing aids. The initial Widex Intake Questionnaire, THI, TFI measures, and the clinician’s observation of the subjects were used to determine which components of Widex Zen Therapy were utilized during the treatment.
Table 2 shows the number of subjects receiving the various WZT components in the clinical trial. In addition, the relationship between impaired hearing and tinnitus perception, as well as the reasons why there is commonly an emotional connection established in the brain between the limbic system, autonomic nervous system, and the auditory cortex, was explained.
This intervention utilizes segments of the programs and tools used by psychologists and clinicians who provide comprehensive Cognitive Behavioral Therapy. These instruments have wide dynamic range compression (WDRC) with compression thresholds as low as 0 dB HL, adaptive multichannel directional microphones, noise reduction, active feedback cancellation, inter-ear communication, and data logging. The four normal-hearing subjects had their hearing aids programmed as if they had a 15 dB hearing loss in order to ensure audibility of the Zen programs. The fractal tones are harmonically related but vary in tonality, intensity, or tempo over time. Each Zen setting was programmed in accordance with the hearing loss (based on the Sensogram) to assure audibility of the tones. They were further advised to avoid frequent volume changes and to use the Zen programs as much as needed for tinnitus and relaxation management and to avoid silence when possible. Tinnitus measures and hearing aid data logging information were collected at baseline, 2 and 6 months. The solid line represents equivalent baseline vs final (post treatment) scores while the dashed line represents the 20-point benefit score considered clinically significant. The solid line represents equivalent baseline vs final (post treatment) scores while the dashed line represents the 13-point benefit score required for clinical efforts to be considered clinically significant.
Given the high prevalence of hearing loss (often too mild to clearly warrant the necessity for hearing aids), the benefit of using amplification is an added value. The Tinnitus Functional Index: Development of a new clinical measure for chronic, intrusive tinnitus. Treatment of tinnitus with a customized acoustic neural stimulus: a controlled clinical study.
A critical analysis of the directive counseling as a component of tinnitus retraining therapy.
Objectives: The aim of current study was to compose and validate a Persian version of the Tinnitus Handicap Inventory (THI-P). The prevalence of chronic tinnitus in the general population is estimated between 5-15% and causes to develop serious psychosocial complications in 1% to 3%1. It is reported that tinnitus can be severe enough to cause significant discomfort in one's daily life12.
Finding the effects of tinnitus on the quality of life and assessing the individual's reaction to tinnitus are very important. The aim of IQOLA is to translate and provide health questionnaires with high validity and reliability for using in different countries by their formal language26.
This version is both simple to administer and interpret and also a powerful psychometric tool. After that, each of the expert translators were asked about the difficulties of the translations and they were attributed a score according to the 100 point visual analogue scale (VAS). Afterward, the pooled back translation was compared and formed by translators and then an agreement was obtained for one English version of THI questionnaire for finding the coherency with original version. Therefore the formulated initial Persian version of the instrument was attended by 24 (10 female and 14 male) high school students in Tehran. The Cronbach's Coefficient Alpha test (where values>0.70 indicate a satisfactory internal consistency) was used to test for the evaluating internal stability of the THI-P29, and Pearson correlation coefficient was calculated between the total score of the THI-P and the scores of its subscales, age and pure tone average (PTA).
The common language score of THI-P was assessed as desirable in all 25 items (100%) and also the conceptual equivalence for three items (4, 10, 16) undesirable response (12%), for two items (23 and 14) in a relatively desirable level (8%), and the other items were desirable response (80%). The type of sound reported by most tinnitus subjects was subjectively described as high-pitch tone, matched by external stimuli (described by 52.3% of subjects).
Table 2 summarized the mean air conduction thresholds across frequencies of 500-4000 Hz for left and right ears. As shown in Figure 1, the total score of THI-P and its subscales were not correlated with the age of tinnitus subjects. Total score of the THI-P and its associated subscales are very close to corresponding values in the original THI-US (Table 6). In Iran, in order to converge and coordinate with the ongoing research at the international level concerning the evaluation of consequences of diseases, impairments, handicaps, treatments and rehabilitation, we should create a new movement. Sense of the various problems among the subject sufferer from tinnitus and understanding the impact of tinnitus on their quality of life are of the uttermost importance. Translation of the original questionnaire of THI in Persian language in overall was easy due to its simple sentences, whereas, the translators in six items acknowledged difficult translation (items of 4, 5, 13, 23, 24 and 25). The translation clarity in 24 items of THI-P was evaluated desirable and only one item (item 17) evaluated as relatively desirable. Majority of epidemiological tinnitus studies have reported a positive relationship between tinnitus and hearing loss4,34-35.
This valid tool allows us to quantify how much tinnitus impacts the life's quality of these individuals. Functional brain abnormalities localized in 55 chronic tinnitus patients: fusion of SPECT coincidence imaging and MRI. Prevalence of tinnitus and hearing thresholds of a non-noise-exposed population with and without tinnitus. Assessment of psychopathological aspects and psychiatric comorbidities in patients affected by tinnitus. Psychologic profile of tinnitus patients using the SCL-90-R and tinnitus handicap inventory. Psychological profile and somatic complaints between help-seeking and non-help-seeking tinnitus subjects. Tinnitus reaction questionnaire: psychometric properties of a measure of distress associated with tinnitus. Developmental and Psychometric Adequacy of the Screening Version of the Tinnitus Handicap Inventory. Psychometric Adequacy of the Tinnitus Handicap Inventory (THI) for Evaluating Treatment Outcome. Tinnitus with normal hearing sensitivity: extended high-frequency audiometry and auditory nerve brain-stem-evoked responses. Validity of the Italian adaptation of the Tinnitus Handicap Inventory; focus on quality of life and psychological distress in tinnitus-sufferers.
Brazilian Portuguese Language version of the "Tinnitus Handicap Inventory": Validity and Reproducibility. Impact of tinnitus as measured by the Tinnitus Handicap Inventory among tinnitus sufferers in Singapore. With this clinical foundation, few other health professionals are as well suited to help those with tinnitus. For example, the US Center for Health Statistics estimates that tinnitus was reported by 25% of those who are hearing impaired and have hearing loss.
The hearing care professional needs to consider these issues if they want to succeed in managing the hearing loss on top of the tinnitus. However, it’s important to check the effect of the external sound on the tinnitus before introducing the benefits of wearing a hearing aid to the patient. Additionally, training from hearing instrument manufacturers and collaborating with colleagues can be valuable.
Then be sure to include information that the patient may benefit from—like additional options or resources not offered at your practice.
It is important to consider that treating patients with tinnitus requires the ability to listen and a high degree of patience.
When testing patients with tinnitus, clinicians should consider scheduling a dedicated time just for consultation because it will take longer than usual and the patient is expecting a solution. For this, I would recommend using an analog visual scale of relief to set the objective from the very beginning.
When the patient becomes more comfortable describing their situation, the clinician should then begin to drive the conversation. Then the follow-up treatment can be done online, where the answers provided previously can help clinicians evaluate the impact of this strategy. This may include education, information, or recommendations for further medical evaluation or treatment by other professionals. Psychoacoustical tests are also important and can include pitch and loudness matching and minimum masking level (MML). If there is a positive impact, like an attenuation of the perception, a strategy like the TRT (Tinnitus Retraining Therapy) can be considered. The lack of VA tinnitus services reflects the fact that research evidence for all forms of tinnitus treatment remains equivocal and that no one method is as yet proven to be any more effective than another [17-19]. That is, many patients will improve regardless of the type of treatment, provided they perceive that expert treatment is being received [20]. A structured method of screening is needed that can rapidly and accurately determine who requires intervention. Before describing the model, we will first review various methodologies that are used for tinnitus management. He updated his review in 2002 and again in 2004, with essentially the same conclusions [18-19]. Even when these symptoms are not present, the ideal standard for tinnitus management would be for every tinnitus patient to receive a complete examination by an otolaryngologist or otologist [22]. Such evidence has been the impetus to conduct controlled clinical studies to determine if these effects could be generalized.
In some cases, tinnitus relief is the primary goal of hearing aids, especially if the patient is a marginal hearing aid candidate. However, patients with more troublesome tinnitus are advised to wear ear-level devices (sound generators, hearing aids, or combination instruments) to optimize the habituation process. Regardless of the form of treatment, certain counseling topics would be considered universal for tinnitus patients. Successful coping may involve the use of several different techniques, including cognitive restructuring, attention diversion, imagery training, and relaxation training [26,53]. Alternating current does not cause these damaging effects, but its effectiveness is restricted to very few patients. Second, no form of tinnitus treatment can claim unequivocal research evidence demonstrating consistent success.
Our efforts run in two parallel tracks to address the needs of veterans with (1) severe tinnitus and (2) mild-to-moderate tinnitus.
Study participants were veterans who required long-term, individualized treatment for their tinnitus. It was therefore critical to select only veterans with tinnitus of enough severity to warrant the long-term treatment that would be provided. Each questionnaire provides an index score, with higher scores reflecting greater perceived tinnitus handicap. In addition, candidates were interviewed by the study audiologist using the TRT Initial Interview form [75] that we modified for use in this study [76].
When patients began treatment with lower index scores (reflecting a less severe tinnitus problem), the benefits of TRT compared with masking were more modest. Therefore, the participants in this study did not have as severe a tinnitus condition (on average) as did those in the trial just described. The group, which focuses on providing useful information for reducing tinnitus impact on lifestyle, has consistently benefited the attendees.
Of the 310 patients in the main study, 269 met the strict randomization criteria and are included in the data analysis, including 94 in education, 84 in support, and 91 in usual care. In contrast, the clinical contact time for each veteran who was given individualized treatment with TRT in our controlled trial (C2887R) averaged 15.5 hours.
The educational program should therefore inform all patients of symptoms that suggest acoustic neuroma, Meniere's disease, or tinnitus that may be correctable through medical or surgical means. Figure 4 shows a clinical flowchart that depicts the routing of patients through the different levels of intervention. Effective screening would also identify individuals requiring immediate care versus those for whom group educational-counseling should be adequate to meet their treatment needs. Purpose: The purpose of this study was to examine any potential benefit in lessening the severity of tinnitus in patients taking supplemental magnesium.
However, many individuals have idiopathic tinnitus for which no specific cause can be determined.
For example, the putative magnesium mechanism within the auditory system involves a metabolic cellular cascade of events. The purpose of this study was to examine any potential lessening of the severity of tinnitus in patients receiving magnesium supplementation.
The Tinnitus Handicap Inventory (THI) and Tinnitus Severity Scale (TSS) (Table 1), developed by McCombe et al.
A review by the Mayo Pharmacy indicated that there were no major drug interactions with magnesium at the levels of the current protocol. Differences in TDR scores before and after supplementation were compared to determine any effect of supplementation on a participant's self-rated tinnitus. The adverse event data included the date of onset and whether the adverse event led to premature discontinuation of the intervention. The THI was measured at the time of discontinuation if a patient discontinued the study before 3 months.
The Tinnitus Handicap-Support Questionnaire [1,7], the Tinnitus Effect Questionnaire [8], and the Tinnitus Severity Questionnaire [9] are measurement tools in the English literature, but they have no (or low) internal consistency reliability and low test-retest reliability. One translator was aware of the purpose of the study and the concepts involved in the instrument: to obtain a better idiomatic and conceptual-rather than literal-equivalence between the two versions of the inventory and to render the intended measurement more reliable. We made an inspection of the percentage of subjects responding "yes," "sometimes," or "no" to individual questions. Total scale scores, Pearson's correlation coefficients (r), and ICCs for three subscales are shown in Table 7.
Patients with tinnitus generally live with their problem for long periods of time; thus, they want to know their symptom's quality or intensity.
On the basis of our study results, we found the first Turkish version of the THI to be a measure that is acceptable, reliable, and valid for evaluating tinnitus in patients. The Hearing Handicap Inventory for Adults: Psychometric adequacy and audiometric correlates. Functional status and well-being of patients with chronic conditions: Results from the Medical Outcomes Study. Brazilian- Portuguese validation of the University of Washington Quality of Life Questionnaire for patients with head and neck cancer. In JM Aran, R Dauman (eds), Tinnitus 91: Proceedings of the Fourth International Tinnitus Seminar. All patients began the treatment regimen by means of sound generators, according to the sequential sound therapy protocol, during the year 2002 and part of 2003.
In patients with tinnitus and without hearing loss, sound generators were adapted, whereas in patients with tinnitus and hearing loss, sound generators with incorporated earphones were adapted. The function of the sound generator in this group graduated to level 3 or 4 during 2 hours of each day that proved to be most tranquil. In patients with tinnitus and hearing loss, the sound generator incorporating earphones was applied in the earphone function for as much time daily as desired by each patient, except for a 2-hour daily span during which a patient could choose the masking level of the sound generator without earphones. Thereafter, patients in the control group received treatment at 3 months, biannually, and annually according to the results obtained in each case. In patients with unilateral tinnitus, monaural adaptation was performed in the ear in which the patient suffered the tinnitus. The intensity of tinnitus varied between 1 and 15 dB above the air threshold of audition, even in the same patient. Six patients no longer perceived their tinnitus - one patient after 15 days of adaptation, three patients after the first month, and two patients after the 3-month adaptation using only the earphone function, thereafter not needing the function of a sound generator. Passage from one masking type to another in a given patient depends on the result obtained in that patient and on the patient's assessment of the regulation of his or her tinnitus by this method. A decreased perception of tinnitus is said to have occurred when the tinnitus ceases to bother a patient; this decreased perception is known objectively because the patient passes from level 3 or 4 to level 2 or 1 in the sound generator.


We define tinnitus as a noise that the patient hears that it is causing him or her to suffer. The otorhinolaryngologist provides medical counsel in relation to the sound therapy, and the audio-prosthetist provides audio-prosthetic counsel relative to adaptation and its control.
Treatment can be provided as an aspect of a national health system or as a service covered by health insurance companies or extended through private clinics.
Evaluation of the outcomes of therapy is carried out by means of the tinnitus handicap inventory as answered by both the patient and his or her cohabitant.
However, all 26 tinnitus patients treated with sequential sound therapy experienced improvement, and none left the treatment group, whereas among the 15 control patients treated with TRT, only 33% registered improvement, and 53% abandoned sound therapy. Hazell [19], together with Wood, contributed to the benefits of total masking in this therapeutic modality. In developing this approach, we relied on prior knowledge of masking, both total and partial, and added to this limit masking. Neuropsychological model of tinnitus: Dependence of the minimal masking level on treatment outcome.
Tinnitus retraining therapy (TRT) as a method for treatment of tinnitus and hyperacusis patients.
Chronic complex tinnitus: Therapeutic results of in-patient treatment in a tinnitus clinic.
Homolateral and contralateral masking of subjective tinnitus by broad spectrum noise, narrow spectrum noise and pure tones. Neurophysiological model of tinnitus: Dependence of the minimal masking level on treatment outcome. EPS was performed with direct continuous positive current delivered by an active platinum-iridium needle electrode connected to a promontory stimulator device.
Nonetheless, given the invasiveness of cortical stimulation and the uncertainty of its beneficial effect on tinnitus, and also considering the as-yet-undefined criteria of patient selection for such a treatment option, we believe that electrical promontory stimulation (EPS) still deserves attention on account of its good rate of success and of its low invasiveness. We obtained from each patient a complete history and ear, nose, and throat physical examination.
On the whole, 9 of the 11 patients (81.8%) had immediate benefit from EPS relative to their tinnitus. In vivo monitoring of electrical activity in these centers during and after electrical stimulation delivered to the promontory or to the cochlea would be an optimal method to ascertain whether changes occur in the DCN and IC in response to EPS. No other reports address the central effects of electrical stimulation on tinnitus in humans , though other noninvasive, promising techniques, such as quantitative electroencephalography, could well serve the purpose of a precise monitoring of EPS brain effects as long as they become more reliable in defining central correlates of tinnitus [37]. The other 8 subjects kept the hearing aids but were excluded from the final data analysis because they did not return for the 6-month follow-up. Twenty of the 24 subjects reported having had tinnitus for more than 1 year, and 18 reported having bilateral tinnitus. However, CBI does not require the same intensive therapeutic approach, which would be beyond the expertise of many hearing care professionals and would require a greater time commitment than can be reasonably expected. Subjects with hearing loss were instructed to use the devices during waking hours where hearing and communication were essential.
The tones (which sound somewhat like wind chimes) are generated while incorporating the properties of music that are proven to be most relaxing.1,2,7 Thus, they are meant to be pleasant and are not associated with music that the listener may hold in memory. Zen Programs B and C were only recommended if the subjects experienced periods where the tinnitus was very bothersome. In addition, data logging revealed that the Zen A and Zen C programs were used more frequently than the Zen B program. Materials and Methods: The linguistic validation of the original version of THI into Persian version (THI-P) included translation, back translation and data gathering. Epidemiological studies indicated that in developed countries such as Germany about 1.5 million people, in the United States about 10 million out of 40 million tinnitus sufferers and a similar ratio in the United Kingdom have been reported that were seriously affected by tinnitus2-4. Tinnitus symptoms have been linked to various psychological and psychosomatic disorders13-15. One of the most important methods in the assessment of the severity of tinnitus and its effects on the lifestyle of a patient is the use of psychometrical evaluations.
Finally, we formulated the initial Persian version of the instrument with proper and satisfactory translation. The final version of THI-P was administered in all tinnitus subjects who were managed in our center between September 2009 and May 2010. The score of "Yes", "No" and "Occasionally" were 4, 0 and 2, respectively in three subscales: emotional, functional and catastrophic.
All personal information in the questionnaire were confidential and only used in this research. The other descriptions of tinnitus included cricket, sizzling, hissing, humming and other sounds. Tinnitus is a subjective idiopathic symptom in which it is not detected by blood examination and CT scan or like this. In this regard, translator 1 and 2 were asked to provide a list of possible alternative translations for the replacement in relatively difficult and difficult items of THI-P. The prevalence of tinnitus among normal hearing subjects has been reported between 7%-10%36-37. Good tinnitus resources are needed in every community to bring new exposure and business to your office. The Tinnitus Clinic at Oregon Health and Science University found that 90% of their patients who have tinnitus also have some degree of hearing loss. If the patient can accept a sound generating strategy, many hearing instrument manufacturers deliver interesting solutions today—with or without an amplifier for the hearing loss. These prevalence estimates may be somewhat low for veterans because of their higher average age and greater general noise exposure in relation to the civilian population [4].
This is not to say that patients cannot receive quality care from competent professionals, even if the effects are nonspecific. For those who do, different levels of service should range from brief counseling to individualized, long-term treatment. We will then describe results of our prospective trials that are building research support for the progressive intervention approach.
Regardless of the form of treatment, sound is used in one way or another to distract attention from the tinnitus and to reduce the brain's perceived need for stimulation [27].
Most importantly, all patients should be advised to avoid exposure to loud noise, which is well known to cause damage to the auditory system and to potentially cause or exacerbate tinnitus [47]. The premise of TRT is that these negative associations must be removed for habituation to occur, which is the primary objective of treatment. Electrical stimulation is not a method that is presently useful in clinical practice to treat tinnitus but is considered a promising area of investigation.
Herbal remedies also have been used in the attempt to reduce tinnitus symptoms-extract of ginkgo biloba has received the greatest attention. Tinnitus sufferers therefore do not have the benefit of referring to any standardized guidelines when seeking help for their condition.
First, veterans who require clinical management for their tinnitus have widely varying levels of need, thus requiring a program that addresses these different levels. Results of these studies are promising, but further studies are needed to validate the results, to improve efficiency of treatment, and to develop methods to most appropriately triage tinnitus patients into a management program.
Qualifying veterans were quasi-randomly assigned (alternating assignment) to one of the treatment methods. After the initial treatment session, ongoing treatment was provided at 3, 6, 12, and 18 months. Independent-samples t-tests compared mean index scores between groups at each of the outcome visits. These findings suggest that TRT may be most effective for patients who have the most serious difficulty with their tinnitus, and that treatment of 1 to 2 years may be necessary to achieve maximum benefit of therapy. This group, along with the availability of a structured tinnitus counseling protocol, provided the impetus for conducting this randomized clinical trial. The usual care group received no study intervention, and they were not restricted from pursuing outside treatment. Mean TSI scores were calculated for each of the three groups at each completed outcome point (0, 1, 6, and 12 months). The contact time per patient was thus about 50 times greater for individualized treatment compared with group treatment. Research Design: The study was a single-arm, open-label, before-and-after study of oral magnesium (532 mg per day) in 26 patients for 3 months. Although often presenting in conjunction with hearing loss, the magnitude of hearing loss does not necessarily correspond with the severity of tinnitus. Specifically, magnesium deficiency leads to increased permeability of the calcium channel in the hair cells with a consequent over-influx of calcium, an increased release of glutamate via exocytosis, and overstimulation of N-methyl-D-aspartate receptors on the auditory nerve fibers. In addition, all participants completed another THI after 3 months of magnesium supplementation. The mean hearing thresholds and mean TDR scores before and after treatment were assessed using a paired t test. For the subjects lost to follow-up, we assumed for the purposes of this analysis that there was no benefit from treatment. Effect of various serotoninergically induced manipulations on audiogenic seizures in magnesium-deficient mice. Influence of dietary magnesium on the amplitude of wave V of the auditory brainstem response.
Guidelines for the grading of tinnitus severity: the results of a working group commissioned by the British Association of Otolaryngologists, Head and Neck Surgeons, 1999. We assessed the internal consistency and reliability of the Turkish version by Cronbach's alpha.
Additionally, these evaluations quantify the effects of tinnitus on functional, emotional, and social life. The original Tinnitus Handicap Inventory (THI), developed by a working group commissioned by the British Association of Otolaryngologists, Head and Neck Surgeons, consists of 50 questions [10].
The other translator was unaware of the translation objective, and this was useful in eliciting unexpected meanings from the original tool.
We assessed internal consistency coefficients (ICCs) for all three subscales: emotional, catastrophic, and functional.
Item 21 had the greatest contribution-the emotional subscale-because of its highest item-total correlation score. This preliminary version of the THI is able to detect the quality of the tinnitus symptom and its impact on patients' daily lives and psychosocial functioning, in addition to registering satisfaction with treatment. Thirty-eight generators of sounds were adapted for use in this therapy and, of these, 34 incorporated an earphone. The control group was composed of 15 patients, 11 women (median age, 66 years) and 4 men (median age, 63 years). In both groups of patients, if a patient was unable to sleep owing to tinnitus, the sound generator was used at level 3 or 4 throughout the night as well. If a patient could not sleep at night, he or she was permitted the use of the sound generator during the entire night. Adaptation was carried out monaurally in unilateral tinnitus and binaurally in bilateral tinnitus. After the adaptation, either immediately or after some delay, the tinnitus generally appeared in the opposite ear from that in which tinnitus originally was present (Table 3). Similarly, but to a lesser degree, the tinnitus frequency varied for a given patient, being distributed throughout 8 9% of the area of acute frequencies. In the 15 control patients treated by means of TRT, subjective, quantitative improvement was obtained in 33% (n = 5), and 53% left the study (n = 8). In a third patient, increased tinnitus perception occurred on several occasions in connection with personality dysfunctions. Other authors who used TRT in their patients found improvement rates varied widely, ranging between 23% and 88% [10]. Once the benefits of total tinnitus masking were well-known, the technique continued to be perfected. The short-term effect on tinnitus was assessed during and immediately after the stimulation.
Furthermore, the assumption that peripheral stimulation can effectively achieve tinnitus suppression is strengthened by the common observation that sensorineurally deaf patients undergoing cochlear implantation often experience reduction or even utter suppression of their tinnitus [15-18].
We started by delivering current at the lowest pulse rate (50 Hz) and proceeded to increase the pulse rate. During this phase, the clinicians help the patient identify the unwanted thoughts and behaviors hindering natural habituation, challenge their validity, and help the patient replace them with alternative and logical thoughts and behaviors.13 Basically, the intervention’s objective is to help the patient recognize that it is not the tinnitus itself that produces these beliefs, it is the patient’s reaction to tinnitus. It is shown that 48% to 60% of patients with chronic or disabling tinnitus have major depressive disorder (MDD)16.
Such self-report questionnaires include the Tinnitus Questionnaire (TQ)18, Tinnitus Handicap Inventory (THI)19, Tinnitus Severity Scale (TSS)20, Tinnitus Handicap Questionnaire (THQ)21, Subjective Tinnitus Severity Scale22 and Tinnitus Reaction Questionnaire (TRQ)23. The THI is a 25-item self-report instrument which is divided into three subscales including functional, emotional and catastrophic reactions to tinnitus. On the basis of these two translations and their VAS scores to each THI items, we formed the pooled version that was then reviewed by presence of translators for considering suggested replacing words and difficulty in translation. This questionnaire was used as an initial instrument for gathering data from tinnitus subjects at next steps. Each single item was read loudly and the participants were asked to follow the items on the given sheet.
Age, gender, medical history and tinnitus characteristics were recorded as baseline information. In total, more than 92% of tinnitus subjects who attended the current study revealed high pitch tinnitus, matched by external stimuli (>3000 Hz).
Independent Student t-tests did not demonstrate statistically difference between total THI-P score and those with or without hearing impairment, neither did those with unilateral or bilateral tinnitus (Table 4). The main problem with tinnitus is its subjective nature so that evaluation of this complaint always depends upon patient's words. These alternative items were reviewed again by translator 3 and 4 in order to optimize quality of translation and finally revised for appropriate items. In conceptual equivalence of the translation, three items had undesirable response (4, 10 and 16) and two items had relatively desirable response.
For example, a clinician may have to wait for the patient to fall asleep using a sound generator pillow. Level 1 is an interview method of screening for determining if the person requires clinical intervention (and addressing basic questions). Veterans can claim tinnitus as a service-connected disability, which is occurring with increasing frequency. Certain forms of therapy are well defined and are used routinely in clinics that offer tinnitus management.
Although test results may reveal that otologic surgery is an appropriate option, such surgery would be indicated only for a very small proportion of tinnitus patients and results are often unpredictable [23]. Patients should also maintain a background of constant low-level sound that can make the tinnitus less noticeable. Initial reports indicated that ginkgo provided significant improvement for many patients [63]. Their plight will not change until research produces an evidence basis for prescribing and implementing treatment. Second, the limited resources at VAMCs necessitate the development of highly efficient methods of treatment. Both methods were conducted according to published descriptions, with modifications made as necessary to optimize consistency within and between protocols. Of the 800 veterans who telephoned to inquire, use of the TISI reduced this number to 172 (20%). Treatment with masking is traditionally provided during a single visit with minimal, if any, subsequent appointments [35-37]. Patients in the two treatment groups completed outcome questionnaires at baseline and at 1, 6, and 12 months postintervention. These results suggest the possibility that group therapy can be as effective as individual therapy over a 6-month period. Tinnitus severity was evaluated and recorded daily by the patient using the Tinnitus Distress Rating (TDR) scale of 0 (no tinnitus) to 10 (worst possible tinnitus). Recent studies of both noise-induced hearing loss and idiopathic sensorineural hearing loss have suggested that magnesium supplementation may lessen the severity of tinnitus in patients. The THI scores were converted to the grades of the TSS for the purpose of categorizing the numeric values of the THI into a reliable 5-item grading scheme. These participants were included because if noncompleters doing poorly enough to drop out were not analyzed, then selection bias would be likely.
Because the items having high item-total correlation were considered more representative of the scale's content, all itemtotal statistics were reported and are shown in Table 4. The results of sequential sound therapy in our 26 patients were compared with the results of tinnitus retraining therapy in 15 patients treated during the years 2000 and 2001.
The perception and evaluation of tinnitus occur in cortical areas, and the aversive reaction to tinnitus emanates from the autonomic nervous system.
The predominant pathological findings in this group were arterial hypertension in four patients, diabetes in two, and obesity in one. Control patients generally were treated biweekly during the second month, although such treatment was personalized to the needs of the individual patient. When the tinnitus appeared in the opposite ear, adaptation of another sound generator was made for this ear. On the basis of work published by Hazell and colleagues in 1985 [20], various authors built on the foundation of the application of noises less intense than a patient's tinnitus to obtain positive results [21,22].
Outcomes using this methodology have improved substantially over those obtained with only total masking or partial masking.
Longterm effects were estimated after one month by comparing pre- and post-EPS Tinnitus Handicap Inventory (THI) scores. Our study project aims to assess the effectiveness of EPS as a treatment of persistent tinnitus induced by cochlear lesions and to try to define the most effective electrostimulation type. Eventually, each patient was asked about tinnitus or hearing loss (or both) in his or her family.
For each presented frequency of stimulation, current intensity was slowly increased to find threshold first and then the discomfort level, and we asked patients about the effect of stimulation on tinnitus. Patient 3 reported suppression of both tinnitus components, whereas patients 4 and 8 said that only one of the components had been reduced or suppressed, the other one remaining unchanged (see Table 3). So, even if a role for masking cannot be completely ruled out, it appears that other mechanisms play a role. The duration of tinnitus, location, and quality reported by the subjects are shown in Table 1. In addition, tinnitus is a common symptom of the auditory system disorders that is usually associated with sensoryneural hearing loss6,7. Asplund reported that among subjects with tinnitus poor sleep and frequent waking were more common in men and women17.
In this regard the client was questioned in order to find out which activity or performance of the patient is affected by tinnitus.
Analysis of the THI items suggested that this self-report instrument had excellent internal consistency reliability and adequate convergent and constructive validity28.
It is worth to mention that in this step, for differentiation of the level of difficulty in translation, average scores less than 25 were considered as easy, more than 30 as difficult and between 25 and 30 as relatively easy. Thus, items with undesirable translation were revised by translator 5 and 6 and revised by suggested replacing proper words, sentences and phrases. As reported in several studies for the original version (US), Italian, Turkish, Danish, Portuguese and Singapore translations of THI19,28,38-41, the Persian version of THI was not significantly different in the handicap scores between those with normal hearing and those with hearing impairment with regard to the degree of handicap severity.
Eventually it became clear that internal consistency was high and the response of every item to the response of total items was matched. As of September 2005, 339,573 veterans had been awarded a service-connected tinnitus disability (Department of Veterans Affairs [VA] Office of Policy and Planning).
The need is for randomized clinical trials to document the efficacy of the various techniques [19]. Cerumen impaction or significant cerumen on the tympanic membrane can cause temporary tinnitus [24], and its removal may require specialized equipment and medicine expertise. The use of drugs should be considered for tinnitus patients only when sleep disorder, depression, or anxiety are reported as significant coexisting conditions [17]. Recognition of the importance of the contributory effects of the limbic and autonomic nervous systems is a major aspect of this treatment model.
Serendipitously, cochlear implants were found to be effective for reducing the sensation of tinnitus [59-61].
These early results generated considerable interest, but subsequent placebo-controlled investigations did not substantiate these reports [64-66]. The tinnitus research program at the National Center for Rehabilitative Auditory Research (NCRAR) aims to provide evidence to support effective methods of treatment. Most VA audiology clinics operate at capacity just to meet the hearing aid needs of veterans in a timely fashion.
Many of the callers expressed the common misconception that their tinnitus caused their hearing difficulties [6,67-69].
Usual care patients completed their questionnaires at baseline and at 1, 6, and 12 months postbaseline. Regardless of time and cost savings, however, sufficient benefit must be received from the more efficient program. The Tinnitus Handicap Inventory (THI) was administered before and at the end of the study, and scores were converted to the grades of the 5-item Tinnitus Severity Scale (TSS).
This relationship suggests these processes may be linked by underlying imbalances at the level of the hair cell.
Magnesium improved hearing recovery and lessened tinnitus in patients with idiopathic sudden hearing loss (Gordin et al., 2002). Therefore, subjects with no follow-up were treated as though they had no improvement and were included in the analysis. We assessed construct validity by analyzing the patients according to their age and to tinnitus duration. These findings indicate that the Turkish version of the THI has good stability in the test-retest trial to assess the clinical change. Satisfactory results obtained with sequential sound therapy totaled 100%, whereas only 33% of subjects treated with tinnitus retraining therapy obtained satisfactory results. The control group began the treatment regimen with white noise by means of sound generators, according to the TRT protocol, during the years 2000 and 2001. In fact, any matter that causes hypersensitivity in a patient can fix his or her attention on the noise and cause that patient to begin suffering. We conclude that the effectiveness of sequential sound therapy has surpassed that of TRT in the treatment of tinnitus, by modifying the application of white noise to the patient and integrating medication, surgery, adaptation, and human behavior during the entire treatment process until improvement of tinnitus is achieved. We performed a complete audiological assessment (pure-tone audiometry, speech audiometry, and transitory evoked otoacoustic emissions) and a study of tinnitus pitch, loudness, and minimum masking level (MML) on the day of the EPS session. Having learned from the patients the frequency causing the best tinnitus suppression, we delivered continuous stimulation at that frequency for at least 60 seconds. After 1 month, among the eight patients who had benefited from EPS, five (45.4%) said their tinnitus was still present but that its intensity was much lower than before. One of the theories about peripheral tinnitus suggests that its origin lies in an alteration of spontaneous firing by acoustic nerve fibers.
All participants complained of chronic unilateral or bilateral subjective idiopathic tinnitus lasting for at least 6 months before consulting about their tinnitus.
An epidemiological study in Italy based on a tinnitus questionnaire demonstrated that the prevalence of tinnitus was 8% in normal hearing subjects while this amount rose up to 30.5% in the presence of auditory dysfunctions8. This agreed version of Persian THI translation was given to the two other translators who were expert to Persian philology (translator 3 and 4). Finally, the results of the present investigation suggest that the THI-P was simple and clear, without losing its equivalence towards cultural issues. All values of item-total correlation coefficient are greater than 0.3 which also indicated high internal consistency in THI-P except item 19. If the screening determines that care is urgently required or if further help is needed following the group session(s), a tinnitus intake assessment (Level 3) should be performed. For their tinnitus disability, these veterans received a combined 1-year compensation of approximately $418,000,000. Physicians also are qualified to evaluate for drug interactions or circulatory abnormalities that could be associated with tinnitus. To date, controlled studies have not identified any effective herbal remedies for tinnitus.
Efficiency and economy are crucial for VA acceptance and implementation of tinnitus programs.
These veterans required education about this issue and about their other tinnitus concerns. This immediate-relief strategy may work best for patients with a more moderate tinnitus problem.
The individualized, ongoing treatment thus made a considerable difference in outcomes over the long term. The purpose of this phase 2 study was to investigate whether the treatment was effective at all, and, as such, a placebo control was not performed.
The possible influence of magnesium and its antagonist, calcium, has been discussed in the literature as a contributing factor in the mitigation of noise-induced hearing loss, ototoxicity, and the hyperexcitability of the auditory system (Cevette et al., 2003).
Internal validity was tested by multi-item analysis, to assess item convergence and discriminant validity. The THI, beta version, is the most standardized tinnitus handicap- measuring tool in the literature (Table 1). One of them was a medical doctor, and the other was a chiropractor; however, both were unaware of the content and original wording of the THI. Three days after the first investigation, the inventory was answered again by randomly selected patients. At the end of the procedure, we asked patients whether tinnitus was still present or had abated or disappeared. The remaining six patients (54.6%) reported that tinnitus was unchanged or had progressively returned to its former loudness. In a number of animal studies, this abnormal activity was brought back to a spontaneous-type nerve firing by application of an electrical stimulus [24,25].
Results: There was no significant difference between gender, age, hearing impairment and total score and subscales of THI-P. Therefore, the valid psychometrical evaluations such as THI can be administered as a robust instrument to objectify tinnitus distress, but additional measures might be needed in order to catch the dimensions of tinnitus-related problems.
Inoverall the translation quality of THI-P was evaluated as desirable from both aspects of a careful translation and adapted to the socio-cultural setting. The intake assessment, which includes educational counseling, can often meet a patient's needs. Patients should be counseled to obtain treatment from a physician, mental health professional, or sleep disorders clinic if this is a concern. Anecdotally, these 25 veterans generally responded favorably to the group-treatment format. Of these 373, 335 (90%) were enrolled, including 25 in the pilot study and 310 in the main study.
The key issue in evaluating the efficiency of group therapy will be the ability to predict which patients will benefit sufficiently from group therapy and which require more intensive treatment.
All data were collected at Mayo Clinic in Scottsdale, Arizona, between March 6 and December 10, 2008.
Permanent and temporary changes in auditory function have been linked to nutritional deficiencies of magnesium. Based on the results of the present study, the authors have initiated a Phase 3 study using a placebo and double-blinding to control for factors unrelated to the magnesium supplementation. An expert team composed of one of the investigators and a bilingually experienced translator reviewed the preliminary version of the THI. We calculated Pearson correlation coefficients for total item score and score for three subscales and ICCs.
In addition, no patient receiving sequential sound therapy has left the treatment protocol, whereas 53% of patients receiving tinnitus retraining therapy abandoned the treatment protocol. Pearson product-moment correlations revealed adequate test-retest reliability for the THI-P (r = 0.96). Also the valid questionnaires are valuable in the evaluation of results from before to after special treatment and its effect on the individual's quality of life. Our current studies, and factor analyses of existing data, will help to develop a means to triage patients into different levels of intervention. It demonstrates adequate reliability-validity and has good internal consistency, reliability, and convergent and construct validity.
Construct validity was assessed by separating the patients into three groups according to their age and to tinnitus duration.
It is also useful to calculate the efficient of multiple determination (R2) by using multiple linear regression to understand the importance of an item. The beneficial effects of EPS on tinnitus might be explained by interference with tinnitus generating circuits such as the dorsal cochlear nucleus and the inferior colliculus and by modification of cortical activity. Therefore, the symptom of tinnitus has forced clinicians to attempt to establish protocols for accuracy of tinnitus diagnosis and treatment9. The Tinnitus Handicap Inventory (THI)25 has gained widespread acceptance as a self-report measure of tinnitus around the world. Therefore, these translators (3 and 4) for each question determined 3 scores on the basis of 100 point criteria. Therefore, the Persian translation of THI was not affected by hearing impairment, gender and age factors. If significant benefit were not achieved through consistent treatment over 1-2 years, longer-term treatment (Level 5) would be indicated, which could include alternate or multiple treatment modalities. Untreated depression, anxiety, or sleep disorder can negate tinnitus rehabilitation efforts.
There was no significant change in hearing thresholds from 250 Hz through 8,000 Hz for either ear during the duration of the study (Table 2). The Turkish version of the THI is a highly consistent and reliable measure that can be used in evaluating symptoms in tinnitus patients.
Internal validity was tested by multi-item analysis to assess item convergence and discriminant validity.
In this approach, one of the items is taken to be a dependent variable whereas others are taken to be independent variables. EPS is to be considered a worthwhile attempt at tinnitus suppression, and could help select candidates for the positioning of an implantable electrical stimulator that might provide longer-term beneficial effect on tinnitus. In this VAS, zero point means absolutely improper quality and 100 means absolutely proper and satisfactory quality. After that, the subsequent processing was attended by audiologists from department and research center of otolaryngology of Tehran University of Medical Sciences (TUMS). At all levels, the goal is to minimize the impact of tinnitus on the patient's life as efficiently as possible. Data Collection and Analysis: The main outcome measures were mean TDR scale scores and THI scores as converted to TSS grades. There was a significant decrease in the severity of tinnitus for subjects on the basis of their THI responses (P=.03). We asked them whether they had any difficulties in understanding the questions or had any comments regarding the content or layout of the inventory.
Criteria for decision making in improper quality of each translation items was the average score less than 90 (determined by translators 3 and 4). Those patients whose THI scores translated to "slight" or greater grade on the TSS before the intervention showed a significant decrease in the severity of their tinnitus (P=.008) (Table 3). According to the answers obtained from the interview and face validity test, we performed minor alterations, and our Turkish version of the THI was finalized. When an item was deleted, Cronbach's alpha for that item did not change, except for items 2, 15, and 19. Accordingly, in this step, Persian version of the THI was obtained, which regarding to all translators 1 to 4, had satisfactory quality.
Therefore, it can be concluded that all items indicated high internal consistency (Cronbach's alpha scale, 0.886). En el presente articulo se propone una homologacion linguistica nacional de dicho test que permita obtener respuestas confiables y veraces. Figure 3 graphically represents the change in TDR in 26 patients from baseline to 3 months after treatment with magnesium. Conclusion: The results suggest that magnesium may have a beneficial effect on perception of tinnitus-related handicap when scored with the THI. After supplementation, by intention-to-treat analysis, 14 of 26 patients (54%) continued to have more than slight impairment; by analysis of patients who completed the study, only 7 of 19 patients (37%) had more than slight impairment.
The best known and valued test for this purpose is the Tinnitus Handicap Inventory (THI).
Homolateral and contralateral masking of tinnitus by noise bands and by pure tones.
In this article, a national linguistic homologation of this test is proposed, that allows for reliable and truthful answers. La segunda subescala es la llamada Emocional compuesta por 9 items que abarcan un amplio rango de respuestas afectivas provocadas por el acufenos, a saber, rabia, frustracion, irritabilidad y depresion.
La tercera escala es la llamada Catastrofica, compuesta por 5 items y que reflejan la desesperacion del paciente, su incapacidad de poder escapar del problema, su percepcion de tener una enfermedad gravisima, la perdida del control y su incapacidad de enfrentar el problema. Este grupo encabezado por Me Combe11 clasifico en 5 niveles la incapacidad provocada por el acufenos: muy leve, leve, moderado, severo y catastrofico.
Psychometric adecuacy of the Tinnitus Handicap Inventory (THI) for evaluating treatment outcome. Por tal motivo parece necesario una homologacion linguistica nacional del THI que sea facilmente comprensible a todos los estratos socioculturales del pais y que nos permita obtener respuestas confiables, veraces y fidedignas de nuestros pacientes (Tabla 1). Guidelines for the grading of tinnitus severty: the results of a working group commisioned by the British Association of Otolaryngologists.




Meaning of hearing aid mode
Ear wax build up pregnancy traduccion
Sudden hearing loss in old age
Tinnitus af stress test




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