Tinnitus and Ménière's disease: characteristics and prognosis in a tinnitus clinic sample

Cognitive Screening and Hearing Assessment in Patients With Chronic Tinnitus

OBJECTIVES

The study aimed to assess the relationship of tinnitus with hyperacusis with cognitive impairment as indicated by the Montreal Cognitive Assessment (MoCA) tool.

METHODS

This multicenter cross-sectional study included individuals with chronic tinnitus from the "Unification of Treatments and Interventions for Tinnitus Patients" (UNITI) database. Participants were recruited from four different tertiary clinical centers located in Athens and Granada (Mediterranean group), as well as Berlin and Regensburg (German group). In total, 380 individuals with a diagnosis of non-pulsatile chronic tinnitus (permanent and constant tinnitus lasting more than 6 months) and no evidence of severe cognitive impairment (MoCA score >22) were enrolled. The evaluation utilized the following tools: MoCA, Tinnitus Handicap Inventory (THI), Hyperacusis Questionnaire (GÜF), Patient Health Questionnaire (PHQ-9), and the European School for Interdisciplinary Tinnitus Research Screening Questionnaire.

RESULTS

MoCA scores differed between German and Mediterranean individuals (P<0.01), necessitating separate analyses for each group. In both cohorts, MoCA scores were significantly associated with education level, age, hearing threshold at 8 kHz, and THI. Furthermore, a significant correlation was observed between PHQ-9 scores and both THI and GÜF (P<0.01 for both Germans and those from the Mediterranean).

CONCLUSION

Our data suggest an association between tinnitus handicap, high-frequency hearing loss, and mild cognitive impairment. Additionally, PHQ-9 scores were associated with tinnitus and hyperacusis scores, independent of hearing loss thresholds.

Rare Deletions or Large Duplications Contribute to Genetic Variation in Patients with Severe Tinnitus and Meniere Disease

Meniere disease (MD) is a debilitating disorder of the inner ear defined by sensorineural hearing loss (SNHL) associated with episodes of vertigo and tinnitus. Severe tinnitus, which occurs in around 1% of patients, is a multiallelic disorder associated with a burden of rare missense single nucleotide variants in synaptic genes. Rare structural variants (SVs) may also contribute to MD and severe tinnitus. In this study, we analyzed exome sequencing data from 310 MD Spanish patients and selected 75 patients with severe tinnitus based on a Tinnitus Handicap Inventory (THI) score > 68. Three rare deletions were identified in two unrelated individuals overlapping the ERBB3 gene in the positions: NC_000012.12:g.56100028_56100172del, NC_000012.12:g.56100243_56101058del, and NC_000012.12:g.56101359_56101526del. Moreover, an ultra-rare large duplication was found covering the AP4M1, COPS6, MCM7, TAF6, MIR106B, MIR25, and MIR93 genes in another two patients in the NC_000007.14:g.100089053_100112257dup region. All the coding genes exhibited expression in brain and inner ear tissues. These results confirm the contribution of large SVs to severe tinnitus in MD and pinpoint new candidate genes to get a better molecular understanding of the disease.

Standardized Clinical Profiling in Spanish Patients with Chronic Tinnitus

Background: Tinnitus is a heterogeneous condition. The aim of this study as to compare the online and hospital responses to the Spanish version of European School for Interdisciplinary Tinnitus Research screening-questionnaire (ESIT-SQ) in tinnitus individuals by an unsupervised age clustering. Methods: A cross-sectional study was performed including 434 white Spanish patients with chronic tinnitus to assess the demographic and clinical profile through the ESIT-SQ, with 204 outpatients and 230 individuals from an online survey; a K-means clustering algorithm was used to classify both responses according to age. Results: Online survey showed a high proportion of Meniere’s disease (MD) patients compared to both the general population and the outpatient cohort. The responses showed statistically significant differences between groups regarding education level, tinnitus-related hearing disorders (MD, hyperacusis), sleep difficulties, dyslipidemia, and other tinnitus characteristics, including duration, type of onset, the report of mitigating factors and the use of treatments. However, these differences were partially confirmed after adjusting for age. Conclusions: Self-reported tinnitus surveys are a low confidence source for tinnitus phenotyping. Additional clinical evaluation is needed for tinnitus research to reach the diagnosis. Age-based cluster analysis might help to better define clinical profiles and to compare responses in ESIT-SQ among subgroups of patients with tinnitus.

Burden of rare variants in synaptic genes in patients with severe tinnitus: An exome based extreme phenotype study

BACKGROUND

tinnitus is a heterogeneous condition associated with audiological and/or mental disorders. Chronic, severe tinnitus is reported in 1% of the population and it shows a relevant heritability, according to twins, adoptees and familial aggregation studies. The genetic contribution to severe tinnitus is unknown since large genomic studies include individuals with self-reported tinnitus and large heterogeneity in the phenotype. The aim of this study was to identify genes for severe tinnitus in patients with extreme phenotype.

METHODS

for this extreme phenotype study, we used three different cohorts with European ancestry (Spanish with Meniere disease (MD), Swedes tinnitus and European generalized epilepsy). In addition, four independent control datasets were also used for comparisons. Whole-exome sequencing was performed for the MD and epilepsy cohorts and whole-genome sequencing was carried out in Swedes with tinnitus.

FINDINGS

we found an enrichment of rare missense variants in 24 synaptic genes in a Spanish cohort, the most significant being PRUNE2, AKAP9, SORBS1, ITGAX, ANK2, KIF20B and TSC2 (p < 2E-04), when they were compared with reference datasets. This burden was replicated for ANK2 gene in a Swedish cohort with 97 tinnitus individuals, and in a subset of 34 Swedish patients with severe tinnitus for ANK2, AKAP9 and TSC2 genes (p < 2E-02). However, these associations were not significant in a third cohort of 701 generalized epilepsy individuals without tinnitus. Gene ontology (GO) and gene-set enrichment analyses revealed several pathways and biological processes involved in severe tinnitus, including membrane trafficking and cytoskeletal protein binding in neurons.

INTERPRETATION

a burden of rare variants in ANK2, AKAP9 and TSC2 is associated with severe tinnitus. ANK2, encodes a cytoskeleton scaffolding protein that coordinates the assembly of several proteins, drives axonal branching and influences connectivity in neurons.

Smartphone Apps in the Context of Tinnitus: Systematic Review

Smartphones containing sophisticated high-end hardware and offering high computational capabilities at extremely manageable costs have become mainstream and an integral part of users' lives. Widespread adoption of smartphone devices has encouraged the development of many smartphone applications, resulting in a well-established ecosystem, which is easily discoverable and accessible via respective marketplaces of differing mobile platforms. These smartphone applications are no longer exclusively limited to entertainment purposes but are increasingly established in the scientific and medical field. In the context of tinnitus, the ringing in the ear, these smartphone apps range from relief, management, self-help, all the way to interfacing external sensors to better understand the phenomenon. In this paper, we aim to bring forth the smartphone applications in and around tinnitus. Based on the PRISMA guidelines, we systematically analyze and investigate the current state of smartphone apps, that are directly applied in the context of tinnitus. In particular, we explore Google Scholar, CiteSeerX, Microsoft Academics, Semantic Scholar for the identification of scientific contributions. Additionally, we search and explore Google's Play and Apple's App Stores to identify relevant smartphone apps and their respective properties. This review work gives (1) an up-to-date overview of existing apps, and (2) lists and discusses scientific literature pertaining to the smartphone apps used within the context of tinnitus.

Epidemiology of Clinically Significant Tinnitus: A 10-Year Trend From Nationwide Health Claims Data in South Korea

OBJECTIVES

Prevalence of tinnitus has been reported to vary according to the target population and definition of tinnitus. To improve the understanding of tinnitus, authors used the nation-wide health claim data to study the tinnitus in the entire population of South Korea.

STUDY DESIGN

Retrospective big data review.

SETTING

Analysis of big data from the National Health Information Database.

PATIENTS

Patients diagnosed with tinnitus according to International Classification of Diseases code 10th edition (ICD-10) and requested to receive National Health Insurance claim at least once from January 2006 to December 2015.

INTERVENTION

None.

MAIN OUTCOME MEASURE

Epidemiologic data, association of tinnitus with the otologic and systemic diseases.

RESULTS

The number of patients who received medical care because of tinnitus was 1.44% (0.78 million per 51 million) in 2015. There was a higher prevalence of tinnitus in women, and the overall prevalence increased with increasing age of patients and peaked at patients in their 70s (4.43%). The prevalence of tinnitus among patients aged 10 to 30 years, showed a tendency to increase during study period. In the regional analysis, highest prevalence was observed in Gwangju (2.02%). In comparison with the control group, the patients with tinnitus showed a higher frequency in otologic and systemic disease. Especially, noise induced hearing loss (adjusted odds ratio [AOR] = 82.1, 95% confidence interval [95% CI] = 74.8-90.2) and sudden sensorineueal hearing loss (AOR = 49.7, 95% CI = 48.4-51.0) showed high frequency in tinnitus patient group.

CONCLUSIONS

The prevalence and incidence of tinnitus in this study for entire nation were lower than previously reported studies. These results have limitation because the study only covered patient using the medical service for tinnitus and missed tinnitus sufferers not seeking medical service. However, this study is meaningful in that it was targeting entire nation, reflected the characteristics of clinically significant tinnitus patient enough to visit medical service.

Fluctuating Sensorineural Hearing Loss

BACKGROUND

Several otologic conditions can present with fluctuating sensorineural hearing loss, including Ménière's disease, autoimmune inner ear disease, and enlarged vestibular aqueduct. Although these 3 etiologies vary greatly, distinguishing between these conditions at initial presentation can be challenging. Furthermore, initial treatment of these conditions is often similar. In this review, we discuss historical and current perspectives on diagnosis and treatment of these conditions.

SUMMARY

A literature search was performed regarding fluctuating hearing loss, and current treatment of these etiologies of fluctuating hearing loss was summarized. Immediate measures at the onset of acute hearing loss include corticosteroid therapy, while preventative and chronic therapies, which can limit disease severity and frequency, vary based on the specific condition treated. Key Messages: Fluctuating hearing loss can represent a range of pathologies, but the precise etiology may not be clear at initial presentation. Timely treatment and long-term follow-up, along with appropriate diagnostics, are necessary to optimize long-term hearing.

Tinnitus in the side with better hearing

OBJECTIVES

We aimed to confirm the characteristics of patients with tinnitus in the better-hearing side.

MATERIALS AND METHODS

Among the 778 patients who visited the tinnitus clinic complaining of unilateral tinnitus at a local university hospital between March 2014 and December 2017, we recruited 62 patients who showed tinnitus in the better-hearing side on pure-tone audiometry. The mean hearing threshold was calculated using the arithmetic mean of the pure tone thresholds at 1, 2, 3, and 4 kHz. In addition, patients' medical history, tinnitus questionnaires, and other audiologic test results were thoroughly analyzed together for diagnosis.

RESULTS

Fluctuating hearing loss without vertigo or Ménière's disease were the most common etiologies (n = 16, 25.8%), followed by high-frequency hearing loss (n = 13, 21.0%), sudden idiopathic hearing loss (n = 6, 9.7%), and presbycusis (n = 6, 9.7%). Somatosensory tinnitus was also observed in seven patients. Neck pain was associated with tinnitus in five patients (8.1%), and two other patients (3.2%) experienced temporomandibular disorder in the same side as the tinnitus.

CONCLUSION

Tinnitus was associated with deterioration of hearing even when it occurred in the better-hearing side. Among the possible etiologies, fluctuating hearing loss in the tinnitus side was the most common audiologic finding. Assessment of hearing level at each frequency was more effective in detecting high-frequency hearing loss rather than the use of the mean hearing level. In addition, somatosensory tinnitus should not be ignored.

Gender Differences Affecting Psychiatric Distress and Tinnitus Severity

Objective

This study evaluated gender differences in the relationship between psychiatric distress and subjective tinnitus severity.

Methods

This cross-sectional study included 134 female and 114 male patients who visited the otology outpatient clinic at Seoul St. Mary's Hospital for tinnitus from February to July 2015. Patients completed a series of instruments, including the Tinnitus Handicap Inventory, Beck Depression Inventory, Korean version of Brief Encounter Psychosocial Instrument (BEPSI-K), and visual analogue scales assessing various tinnitus characteristics (loudness, awareness, annoyance, and effect on life).

Results

Tinnitus severity did not significantly differ between the gender groups (p=0.632), and it correlated significantly with tinnitus characteristics and psychiatric distress. Partial correlations between tinnitus severity and depressive symptoms were stronger in males (r=0.411, p＜0.01) than in females (r=0.304, p＜0.01) while controlling for duration of tinnitus and tinnitus characteristics. However, stress (BEPSI-K) was positively correlated with tinnitus severity in only males (r=0.463, p＜0.01). A multiple regression analysis revealed that effect of tinnitus on life, depressive symptoms, and stress were significantly associated with tinnitus severity in males, whereas only tinnitus annoyance and depressive symptoms were associated with tinnitus severity in females.

Conclusion

Tinnitus severity was significantly correlated with depressive symptoms and stress, and there were gender differences in the relationship between tinnitus severity and psychiatric components. It is necessary to be vigilant of psychiatric symptoms among patients with tinnitus who visit the otology outpatient clinic, especially for male patients.

Tinnitus in Normal-Hearing Participants after Exposure to Intense Low-Frequency Sound and in Ménière's Disease Patients

Tinnitus is one of the three classical symptoms of Ménière’s disease (MD), an inner ear disease that is often accompanied by endolymphatic hydrops. Previous studies indicate that tinnitus in MD patients is dominated by low frequencies, whereas tinnitus in non-hydropic pathologies is typically higher in frequency. Tinnitus of rather low-frequency (LF) quality was also reported to occur for about 90 s in normal-hearing participants after presentation of intense, LF sound (120 dB SPL, 30 Hz, 90 s). LF sound has been demonstrated to also cause temporary endolymphatic hydrops in animal models. Here, we quantify tinnitus in two study groups with chronic (MD patients) and presumably transient endolymphatic hydrops (normal-hearing participants after LF exposure) with a psychophysical procedure. Participants matched their tinnitus either with a pure tone of adjustable frequency and level or with a noise of adjustable spectral shape and level. Sensation levels of matching stimuli were lower for MD patients (mean: 8 dB SL) than for normal-hearing participants (mean: 15 dB SL). Transient tinnitus after LF-exposure occurred in all normal-hearing participants (N = 28). About half of the normal-hearing participants matched noise to their tinnitus, the other half chose a pure tone with frequencies below 2 kHz. MD patients matched their tinnitus with either high-frequency pure tones, mainly above 3 kHz, or with a noise. Despite a significant proportion of MD patients matching low-pass (roaring) noises to their tinnitus, the range of matched stimuli was more heterogeneous than previous data suggested. We propose that in those participants with noise-like tinnitus, the percept is probably generated by increased spontaneous activity of auditory nerve fibers with a broad range of characteristic frequencies, due to an impaired ion balance in the cochlea. For tonal tinnitus, additional mechanisms are conceivable: focal hair cell loss can result in decreased auditory nerve firing and a central auditory overcompensation. Also, normal-hearing participants after LF-exposure experience alterations in spontaneous otoacoustic emissions, which may contribute to a transient tonal tinnitus.

Hearing function after betahistine therapy in patients with Ménière's disease

Introduction

Objective

Methods

Results

Conclusion

The correlation between symptoms of definite Meniere's disease and endolymphatic hydrops visualized by magnetic resonance imaging

OBJECTIVE/HYPOTHESIS

This study aimed at investigating the correlation between a battery of diagnostic symptoms of definite Meniere's disease (MD) and the degree of endolymphatic hydrops (EH) in the inner ear.

STUDY DESIGN

Prospective study.

METHODS

Fifty-four patients diagnosed with unilateral definite MD were enrolled in the study. The hearing levels of all patients at the low, middle, and high frequencies were evaluated. Three-dimensional fluid-attenuated inversion recovery (3D-FLAIR) and three-dimensional real inversion recovery (3D-real IR) magnetic resonance imaging (MRI) were performed 24 hours after bilateral intratympanic injection of gadolinium to assess the presence and grading of EH.

RESULTS

Various degrees of EH were observed in the vestibule and/or each turn of the cochlea in the affected ears of all patients. The duration of MD disease and low-tone and middle-tone hearing thresholds were proportional to the extent of EH in the vestibule and cochlear. However, no significant correlation was demonstrated between EH and other aspects of symptoms such as high-tone hearing loss, tinnitus, and aural fullness. Of all subjects, 16.7% exhibited bilateral EH on MRI exam who were diagnosed with unilateral MD based on diagnostic criteria.

CONCLUSIONS

EH in the inner ear of MD patients exhibits a progressive deteriorative trend over time. Low-tone and middle-tone hearing thresholds can indirectly reflect the severity of EH in the cochlea. EH may not be the primary cause of tinnitus and aural fullness in patients with MD. Patients diagnosed with unilateral MD should maintain long-term regular follow-ups for the possibility of developing bilateral EH.

LEVEL OF EVIDENCE

4.

A review of hyperacusis and future directions: part I. Definitions and manifestations

PURPOSE

Hyperacusis can be extremely debilitating, and at present, there is no cure. We provide an overview of the field, and possible related areas, in the hope of facilitating future research.

METHOD

We review and reference literature on hyperacusis and related areas. We have divided the review into 2 articles. In Part I, we discuss definitions, epidemiology, different etiologies and subgroups, and how hyperacusis affects people. In Part II, we review measurements, models, mechanisms, and treatments, and we finish with some suggestions for further research.

RESULTS

Hyperacusis encompasses a wide range of reactions to sound, which can be grouped into the categories of excessive loudness, annoyance, fear, and pain. Many different causes have been proposed, and it will be important to appreciate and quantify different subgroups. Reasonable approaches to assessing the different forms of hyperacusis are emerging, including psychoacoustical measures, questionnaires, and brain imaging.

CONCLUSIONS

Hyperacusis can make life difficult for many, forcing sufferers to dramatically alter their work and social habits. We believe this is an opportune time to explore approaches to better understand and treat hyperacusis.

Tinnitus pitch and minimum masking levels in different etiologies

OBJECTIVE

We sought to determine whether the results of audiological tests and tinnitus characteristics, particularly tinnitus pitch and minimum masking level (MML), depend on tinnitus etiology, and what other etiology-specific tinnitus characteristics there are.

DESIGN

The patients answered questions concerning tinnitus laterality, duration, character, aggravation, alleviation, previous treatment, and circumstances of onset. The results of tympanometry, pure-tone audiometry, distortion-product otoacoustic emissions, tinnitus likeness spectrum, MML, and uncomfortable loudness level were evaluated.

STUDY SAMPLE

Patients with several tinnitus etiological factors were excluded. The remaining participants were divided into groups according to medical history: acute acoustic trauma: 67 ears; chronic acoustic trauma: 82; prolonged use of oral estrogen and progesterone contraceptives: 46; Ménière's disease: 25; congenital hearing loss: 19; sensorineural sudden deafness: 40; dull head trauma: 19; viral labyrinthitis: 53; stroke: 6; presbycusis: 152. Data of 509 ears were analysed.

RESULTS

Tinnitus pitch was highest in patients with acute acoustic trauma and lowest in patients receiving estrogen and progesterone. MML was lowest after acute acoustic trauma and in congenital hearing loss, and highest after a stroke and in the case of presbytinnitus.

CONCLUSIONS

Tinnitus pitch and MML are etiology dependent.

New Treatment of Vertigo Caused by Jugular Bulb Abnormalities

Objective. Jugular bulb abnormalities can induce tinnitus, hearing loss, or vertigo. Vertigo can be very disabling and may need surgical treatments with risk of hearing loss, major bleeding or facial palsy. Hence, we have developed a new treatment for vertigo caused by jugular bulb anomalies, using an endovascular technique. Patients. Three patients presented with severe vertigos mostly induced by high venous pressure. One patient showed downbeat vertical nystagmus during the Valsalva maneuver. The temporal-bone computed tomography scan showed a high rising jugular bulb or a jugular bulb diverticulum with dehiscence and compression of the vestibular aqueduct in all cases. Intervention. We plugged the upper part of the bulb with coils, and we used a stent to maintain the coils and preserving the venous permeability. Results. After 12- to 24-month follow-up, those patients experienced no more vertigo, allowing return to work. The 3-month arteriographs showed good permeability of the sigmoid sinus and jugular bulb through the stent, with complete obstruction of the upper part of the bulb in all cases. Conclusion. Disabling vertigo induced by jugular bulb abnormalities can be effectively treated by an endovascular technique. This technique is minimally invasive with a probable greater benefit/risk ratio compare with surgery.

Clinical and Audio Vestibular Profile of Meniere's Disease in a Tertiary Care Centre in India

The aims of this study are to determine the frequency of patients presenting with Meniere's Disease(MD) in an Indian setting, using the American Academy of Otolaryngology-Head and Neck Surgery (AAO) diagnostic criteria, and to describe the clinical and audio vestibular profiles of these patients. The study was based on prospective case series design in the settings of a tertiary referral hospital. The study included all consecutive patients aged between 5 and 75 years presenting with the history of hearing loss, vertigo, tinnitus and or aural fullness as participants, satisfying inclusion and exclusion criteria for MD (AAO 1995) recruited over a 12 month period. Main outcome measures comprised the evaluation of epidemiological profile, clinical features, and results of audio vestibular investigations like Pure Tone Audiometry with and without glycerol, Impedance Audiometry, Electrocochleography (ECohG), Distortion Product Otoacoustic Emission and Electronystagmography (ENG). The results of the study are as follows: The frequency of MD was 15.6%, being commoner in males than females (2.6:1) and occurring more in the age group 40-49  years among males and 30-39 years among females. High frequency tinnitus was commoner than low frequency tinnitus. Extra tympanic ECohG had a positive predictive value of 76% for endolymphatic hydrops. ENG was useful for demonstrating canal paresis pattern of nystagmus in 61%. Indian patients with MD commonly present to tertiary care at the functional level scale of 3. The results of this study revealed that the frequency of MD is not as low in the Indian ENT setting as earlier believed. There is a high chance of missing cases in the routine ENT outpatient clinic setting unless a structured proforma incorporating the AAO 1995 diagnostic criteria is used.

A compartment-based approach for the imaging evaluation of tinnitus

Tinnitus affects 10% of the US general population and is a common indication for imaging studies. We describe a sequential compartment-based diagnostic approach, which simplifies the interpretation of imaging studies in patients with tinnitus. The choice of the initial imaging technique depends on the type of tinnitus, associated symptoms, and examination findings. Familiarity with the pathophysiologic mechanisms of tinnitus and the imaging findings is a prerequisite for a tailored diagnostic approach by the radiologist.

[Tinnitus treatment: neurosurgical management]

Tinnitus is a very frequent symptom affecting 10% of the general population. It corresponds to the perception of an internal noise that can severely impair the quality of life. Tinnitus management requires a multidisciplinary approach in which neuromodulation and neurosurgery tend to play major roles. Classification of tinnitus separates objective tinnitus (i.e., tinnitus that can be heard or recorded) from the more frequent subjective tinnitus (i.e., tinnitus only perceived by the patient). Objective tinnitus is either pulsatile synchronous with heartbeat or asynchronous. In the former, appropriate radiological testing should search for a vascular abnormality as well as other neurological diseases (intracranial hypertension, Arnold-Chiari malformation, vascular loops, etc.). Asynchronous objective tinnitus generally corresponds to muscular contractions that require specific management. The pathophysiology of subjective tinnitus is more complex, showing strong analogies with postamputation pain syndromes. After peripheral middle ear or inner ear damage, auditory deafferentation could result in hyperactivity and/or functional reorganization within central auditory and nonauditory structures. This could explain the persistence of tinnitus after total hearing amputation (e.g., translabyrinthine approach for vestibular schwannoma) and associated symptoms such as hyperacusis or anxiety and depression. This central model finds strong support in animal experiments and in functional neuroimagery (PET, fMRI, MEG). Since no etiologically based therapies are currently available, severe subjective tinnitus management only targets tinnitus tolerance with sound enrichment or cognitive behavior therapy. However, in the near future better knowledge of tinnitus pathophysiology and innovative therapeutic tools could emerge from neuromodulation techniques such as repeated transcranial magnetic or epidural electric stimulation.