Sequential Multilocus Repetitive Transcranial Magnetic Stimulation for Treatment of Tinnitus With and Without Comorbid Major Depressive Disorder

OBJECTIVE

Repetitive transcranial magnetic stimulation (rTMS) is a promising treatment for tinnitus, although outcomes are highly variable. We previously described a multilocus sequential rTMS treatment protocol for tinnitus involving stimulation of both prefrontal and auditory targets. In this study, we report results using this approach in an open-label treatment study of tinnitus with and without comorbid major depressive disorder (MDD).

MATERIALS AND METHODS

Forty patients with chronic tinnitus (mean age 56 years, ten female) and with (n = 17) or without (n = 23) MDD received multilocus rTMS administered sequentially to 1) left dorsolateral prefrontal cortex, followed by 2) auditory cortex (Heschel's gyrus). Patients completed weekly self-report ratings using the Tinnitus Functional Index (TFI) and Tinnitus Handicap Inventory, and patients with MDD completed the Inventory of Depressive Symptomatology Self-Report 30-item.

RESULTS

Patients showed significant mean improvement in tinnitus at sessions 5 (mean TFI improvement 6.8 points ± 12.2, p = 0.002) and 10 (mean improvement 9.2 points ± 14.1, p = 0.002), with 48% of patients responding within ten treatment sessions. Responders were significantly older than nonresponders (61.5 ± 15 years vs 51.3 ± 16 years), and there was a trend toward decreased likelihood of response in subjects with comorbid MDD compared with subjects without comorbidity (odds ratio = 0.28, p = 0.06). Patients with comorbid MDD reported significantly less improvement after ten sessions than did those with tinnitus alone (4.3 ± 10.3 vs 14.7 ± 15.0 points, p = 0.04). Post hoc analyses suggested that the comorbid group achieved improvement comparable to that of the tinnitus-only group after 30 treatments.

CONCLUSIONS

Patients showed significant improvement in tinnitus from multilocus sequential rTMS treatment, and those with tinnitus alone improved more quickly. Those with depression who continued rTMS through a full 30-session course further improved, indicating that tinnitus with comorbid MDD may respond with extended treatment.

History of Tinnitus Research at the VA National Center for Rehabilitative Auditory Research (NCRAR), 1997-2021: Studies and Key Findings

The Veterans Affairs (VA) Rehabilitation Research & Development (RR&D) National Center for Rehabilitative Auditory Research (NCRAR) was first funded by the RR&D Service in 1997 and has been funded continuously since that time. The overall purpose of the NCRAR is to "improve the quality of life of Veterans and others with hearing and balance problems through clinical research, technology development, and education that leads to better patient care" ( www.ncrar.research.va.gov ). An important component of the research conducted at the NCRAR has been a focus on clinical and rehabilitative aspects of tinnitus. Multiple investigators have received grants to conduct tinnitus research and the present article provides an overview of this research from the NCRAR's inception through 2021.

Sustainment of the TeleSleep program for rural veterans

Background

In fiscal year 2021, the Veterans Health Administration (VHA) provided care for sleep disorders to 599,966 Veterans, including 189,932 rural Veterans. To further improve rural access, the VA Office of Rural Health developed the TeleSleep Enterprise-Wide Initiative (EWI). TeleSleep's telemedicine strategies include tests for sleep apnea at the Veteran's home rather than in a sleep lab; Clinical Video Telehealth applications; and other forms of virtual care. In 2017 and 2020, VHA provided 3-year start-up funding to launch new TeleSleep programs at rural-serving VA medical facilities.

Methods

In early 2022, we surveyed leaders of 24 sites that received TeleSleep funding to identify successes, failures, facilitators, and barriers relevant to sustaining TeleSleep implementations upon expiration of startup funding. We tabulated frequencies on the multiple choice questions in the survey, and, using the survey's critical incident framework, summarized the responses to open-ended questions. TeleSleep program leaders discussed the responses and synthesized recommendations for improvement.

Results

18 sites reported sustainment, while six were "on track." Sustainment involved medical centers or regional entities incorporating TeleSleep into their budgets. Facilitators included: demonstrating value; aligning with local priorities; and collaborating with spoke sites serving rural Veterans. Barriers included: misalignment with local priorities; and hiring delays. COVID was a facilitator, as it stimulated adoption of telehealth practices; and also a barrier, as it consumed attention and resources. Recommendations included: longer startup funding; dedicated funding for human resources to accelerate hiring; funders communicating with local facility leaders regarding how TeleSleep aligns with organizational priorities; hiring into job classifications aligned with market pay; and obtaining, from finance departments, projections and outcomes for the return on investment in TeleSleep.

Unresolved Issues Associated with Transcranial Magnetic Stimulation (TMS) Treatment of Chronic Tinnitus

Transcranial magnetic stimulation (TMS) has been investigated as a potential treatment for chronic tinnitus for 20 years. Numerous studies have reported that repetitive TMS (rTMS) has demonstrated efficacy for reducing the severity of tinnitus and its associated co-conditions such as depression, anxiety, and insomnia. However, some researchers have reported that active rTMS is no more effective than sham (placebo) rTMS as a tinnitus treatment method. There are numerous unresolved issues in this field that need to be addressed before rTMS can become a viable treatment for tinnitus. These issues include the type or brand of TMS system and its configuration; coil type, orientation, and placement method; scalp or neural target; laterality of rTMS application; dual site vs. single site stimulation; stimulation frequency and intensity; number of sessions; number of pulses per session; determination of the resting motor threshold (rMT); characteristics of the study population and their tinnitus; and outcome measures and follow-up assessments. To address and resolve these issues, large-scale, multi-site clinical trials of rTMS for tinnitus need to be conducted to determine which rTMS protocols are the most effective. In the absence of such investigations, the issues that need to be studied and addressed remain unresolved and continue to impede the clinical application of this treatment method.

Veterans Health Administration TeleSleep Enterprise-Wide Initiative 2017-2020: bringing sleep care to our nation's veterans

STUDY OBJECTIVES

The Veterans Health Administration cares for many veterans with sleep disorders who live in rural areas. The Veterans Health Administration's Office of Rural Health funded the TeleSleep Enterprise-Wide Initiative (EWI) to improve access to sleep care for rural veterans through creation of national telehealth networks.

METHODS

The TeleSleep EWI consists of (1) virtual synchronous care, (2) home sleep apnea testing, and (3) REVAMP (Remote Veterans Apnea Management Platform), a patient- and provider-facing web application that enabled veterans to actively engage with their sleep care and sleep care team. The TeleSleep EWI was designed as a hub-and-spoke model, where larger sites with established sleep centers care for smaller, rural sites with a shortage of providers. Structured formative evaluation for the TeleSleep EWI is supported by the Veterans Health Administration's Quality Enhancement Research Initiative and was critical in assessing outcomes and effectiveness of the program.

RESULTS

The TeleSleep EWI launched with 7 hubs and 34 spokes (2017) and rapidly expanded to 13 hubs and 63 spokes (2020). The TeleSleep EWI resulted in a significant increase in rural veterans accessing sleep care by utilizing home sleep apnea testing to establish a diagnosis of obstructive sleep apnea and virtual care for follow-up. Rates of virtual care utilization were greater in hubs and spokes participating in the TeleSleep EWI compared with non-EWI sleep programs. Additionally, veterans expressed satisfaction with their virtual care TeleSleep experiences.

CONCLUSIONS

The TeleSleep EWI successfully increased sleep care access for rural veterans, promoted adoption of virtual care services, and resulted in high patient satisfaction.

CITATION

Chun VS, Whooley MA, Williams K, et al. Veterans Health Administration TeleSleep Enterprise-Wide Initiative 2017-2020: bringing sleep care to our nation's veterans. J Clin Sleep Med. 2023;19(5):913-923.

Reevaluating the Use of Sound Therapy for Tinnitus Management: Perspectives on Relevant Systematic Reviews

PURPOSE

Tinnitus is a highly prevalent condition that can severely reduce health functioning. In spite of extant clinical practice guidelines (CPGs), implementation of these CPGs is relatively uncommon. As a result, patients seeking professional services for tinnitus often have no assurance of receiving evidence-based care. The purpose of this tutorial was to clarify the evidence for sound therapy so that it may be included in future CPGs for tinnitus.

METHOD

"Best clinical evidence" is obtained from high-quality systematic reviews, which are generally considered the highest level of evidence. Our review of recent, comprehensive, high-quality systematic reviews of interventions for tinnitus concludes that cognitive behavioral therapy is the only effective intervention, though the strength of evidence was generally rated as low in these reviews. Although trials of sound therapy for tinnitus have been included in these reviews, they have been rated as having high risk of bias (RoB) and not included in syntheses or rated as insufficient strength of evidence.

RESULTS

Conclusions from these and other reviews have influenced recommendations made in CPGs for tinnitus. These conclusions, however, can make it appear that an intervention for tinnitus is not effective, even if the opposite is true. We contend that the strict inclusion criteria for these reviews are counterproductive and have the effect of obscuring decades of evidence demonstrating the clinical effectiveness of sound therapies for tinnitus. Ultimately, this process has resulted in many patients not receiving sound therapy, despite what should be sufficient evidence that this is an effective form of intervention.

CONCLUSION

If we rely on systematic reviews using contemporary RoB assessment criteria for studies published prior to these reporting guidelines, then we risk excluding important conclusions regarding interventions that could help patients in need.

Study protocol to assess de-implementation of the initial provider encounter for diagnosis and treatment of obstructive sleep apnea: the DREAM (Direct Referral for Apnea Monitoring) Project

Background

Obstructive sleep apnea (OSA) is a very common and serious health condition which is highly prevalent among U.S. military Veterans. Because the demand for sleep medicine services often overwhelms the availability of such services, it is necessary to streamline diagnosis and treatment protocols. The goals of this study are to, (1) assess the efficacy of de-implementing the initial provider encounter for diagnosis and treatment of OSA; (2) determine the negative predictive value (NPV) of home sleep apnea testing (HSAT); (3) develop HSAT usage recommendations for various at-risk patient populations.

Methods

This is a large, pragmatic study that will take place in 3 VA sleep medicine programs: San Francisco, CA; Portland, OR; and Pittsburgh, PA. All Veterans referred for new sleep apnea evaluations at these sites will be included in this four-year study. Outcomes will include time from referral for OSA to sleep testing and treatment; positive airway pressure (PAP) treatment adherence measures; patient-reported clinical outcomes and measures of satisfaction; determination of the NPV of HSAT; HSAT usage recommendations for at-risk patient populations.

Discussion

The DREAM (Direct Referral for Apnea Monitoring) Project will inform sleep medicine providers and clinical organizations regarding strategies to streamline diagnosis and treatment protocols for OSA. Results of this study should have significant impact on clinical practices and professional guidelines.

Trial registration The majority of this project is an observational study of clinical procedures. Therefore, clinical trial registration is not required.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12890-022-01899-y.

Hearing Health Care Utilization Following Automated Hearing Screening

BACKGROUND

 The study examined follow-up rates for pursuing hearing health care (HHC) 6 to 8 months after participants self-administered one of three hearing screening methods: an automated method for testing of auditory sensitivity (AMTAS), a four-frequency pure-tone screener (FFS), or a digits-in-noise test (DIN), with and without the presentation of a 2-minute educational video about hearing.

PURPOSE

 The study aims to determine if the type of self-administered hearing screening method (with or without an educational video) affects HHC follow-up rates.

RESEARCH DESIGN

 The study is a randomized controlled trial of three automated hearing screening methods, plus control group, with and without an educational video. The control group completed questionnaires and provided follow-up data but did not undergo a hearing screening test.

STUDY SAMPLE

 The study sample includes 1,665 participants (mean age 50.8 years; 935 males) at two VA Medical Centers and at university and community centers in Portland, OR; Bay Pines, FL; Minneapolis, MN; Mauston, WI; and Columbus, OH.

DATA COLLECTION AND ANALYSIS

 HHC follow-up data at 6 to 8 months were obtained by contacting participants by phone or mail. Screening methods and participant characteristics were compared in relation to the probability of participants pursuing HHC during the follow-up period.

RESULTS

 The 2-minute educational video did not have a significant effect on HHC follow-up rates. When all participants who provided follow-up data are considered (n = 1012), the FFS was the only test that resulted in a significantly greater percentage of HHC follow-up (24.6%) compared with the control group (16.8%); p = 0.03. However, for participants who failed a hearing screening (n = 467), follow-up results for all screening methods were significantly greater than for controls. The FFS resulted in a greater probability for HHC follow-up overall than the other two screening methods. Moreover, veterans had higher follow-up rates for all screening methods than non-veterans.

CONCLUSION

 The FFS resulted in a greater HHC follow-up rate compared with the other screening methods. This self-administered test may be more motivational for HHC follow-up because participants who fail the screening are aware of sounds they could not hear which does not occur with adaptive assessments like AMTAS or the DIN test. It is likely that access to and reduced personal cost of audiological services for veterans contributed to higher HHC follow-up rates in this group compared with non-veteran participants.

Barriers and facilitators to the implementation of a novel web-based sleep apnea management platform

STUDY OBJECTIVE

Obstructive sleep apnea (OSA) is a highly prevalent yet underdiagnosed disorder affecting US military Veterans. The Remote Veterans Apnea Management Platform (REVAMP) is a web-based OSA management program created to improve access to care. REVAMP was launched within the Veterans Health Administration (VHA) in July 2017, with variable patient recruitment rates (from 0 to 573 patients per site) at the first 10 Veterans Affairs (VA) medical centers (Wave-1 sites). This study aimed to examine the contextual circumstances surrounding the implementation of REVAMP from the provider perspective to inform strategies to increase its uptake at future rollout sites.

METHODS

A purposive sample of REVAMP site leaders from the Wave-1 sites was recruited with additional staff members being solicited as well. Semi-structured interviews were conducted. Two independent coders reviewed individual transcripts using content analysis to identify emerging themes.

RESULTS

Fifteen individuals from Wave-1 sites were interviewed. Implementation of REVAMP was facilitated by the presence of leadership support, staff, and time dedicated to REVAMP, and perceived usefulness of REVAMP by staff as well as positive feedback from the Veterans using REVAMP. The difficulty of supporting Veteran creation of login credentials to the program and integrating REVAMP into the existing workflow were major barriers to its implementation.

CONCLUSION

Improving leadership engagement, simplifying the enrollment process, and enhancing the medical staff experience through shared best practice alerts were identified as actions needed to improve the penetration of REVAMP at future rollout sites.

Effects of Computer-Based Documentation Procedures on Health Care Workload Assessment and Resource Allocation: An Example From VA Sleep Medicine Programs

Background

Computer-based documentation (CBD) is used commonly throughout the world to track patient care and clinical workloads. However, if capture of clinical services within the electronic health record (EHR) is not implemented properly, patient care services and workload credit will be inaccurate, which impacts business decisions related to demand for care and resources allocated to meet the demand. Understaffing of medical personnel can contribute to delays in treatment, missed treatments, and workforce turnover.

Objective

To illustrate the impact of CBD procedures on health care workload assessment and resource allocation, this article uses data from the US Department of Veterans Affairs Corporate Data Warehouse to provide examples from the Veterans Health Administration (VHA) sleep medicine programs.

Discussion

Inaccurate CBD led to underreporting of sleep medicine services provided at VHA facilities nationwide and contributed to insufficient allocation of resources and personnel. Recent modifications in CBD protocols (Stop Codes) improved the accuracy of data capture and reporting while providing VHA sleep programs with data they can use to advocate for workforce expansion to meet patient care needs.

Conclusions

Inaccurate CBD of clinical workloads can result in inadequate allocation of health care personnel and resources to meet the needs of patients. Untreated sleep disorders are associated with increased risk of depression, anxiety, impaired neurocognitive functions, cardiovascular disease, motor vehicle accidents, and premature death. Educating health care providers and administrators on the importance of accurate designation of clinical services within the EHR is necessary to facilitate improvements in health care availability and delivery.

Experimental, Controversial, and Futuristic Treatments for Chronic Tinnitus

Background: Because chronic tinnitus is a condition that negatively impacts the quality of life of millions of people worldwide, a safe and effective treatment for tinnitus has been sought for millennia. However, effective treatments for tinnitus are greatly outnumbered by ineffective strategies, medications, devices, and surgeries that continue to be developed and promoted for the condition.

Purpose: This article describes and critiques experimental, controversial, and potential treatments for chronic tinnitus. The purpose of this review is to provide information that should help patients and clinicians to select tinnitus treatment and management strategies most likely to be effective for each set of symptoms and circumstances.

Research Design: PubMed and MEDLINE databases (National Center for Biotechnology Information, U.S. National Library of Medicine) were searched for the term tinnitus in articles published from 1940 to 2012. Other historical documents and publications were also reviewed as needed for particular topics.

Study Sample: Studies included in this review were selected to represent a sampling of treatment methodologies that have been used for tinnitus.

Data Collection and Analysis: Due to the heterogeneity of the studies reviewed, it was not appropriate to perform a meta-analysis. A selective review of the literature was conducted to summarize and critique published research results.

Results: Most invasive treatments for tinnitus should be avoided because (1) at best, there is scant evidence that any of these treatments is effective, and (2) the risk to patients for most invasive procedures is much greater than the risk posed by the tinnitus perception. Effective and noninvasive treatments for tinnitus include acoustic therapy (which includes hearing aids and other types of environmental sound enrichment); cognitive-behavioral therapy; psychological counseling; hypnosis; biofeedback; and relaxation training. Over-the-counter or prescription medications may be used as needed to facilitate sleep and to reduce anxiety, depression, or obsessive-compulsiveness.

Conclusions: Patients and clinicians should be especially cautious when considering invasive (and potentially harmful) treatments for tinnitus, which is a non-life-threatening symptom. Unless well-designed clinical trials verify that a tinnitus therapy demonstrates effectiveness above and beyond the placebo effect, consumers should be wary of medications, devices, or procedures promoted as a “cure.” Although a true cure for tinnitus has not yet been found, effective and noninvasive tinnitus management strategies are available now. If progress is made to medically (or genetically) treat sensorineural hearing loss in humans, this breakthrough should also help to simultaneously reduce the perception of tinnitus for many patients.

Prevalence and management of sleep disorders in the Veterans Health Administration

The prevalence of diagnosed sleep disorders among Veterans treated at Veterans Affairs (VA) medical facilities increased significantly during fiscal years (FY) 2012 through 2018. Specifically, the prevalence of sleep-related breathing disorders (SRBD) increased from 5.5% in FY2012 to 22.2% in FY2018, and the prevalence of insomnia diagnoses increased from 7.4% in FY2012 to 11.8% in FY2018. Consequently, Veterans' demand for sleep medicine services also increased significantly between FY2012-2018, with steady increases in the annual number of VA sleep clinic appointments during this period (<250,000 in FY 2012; >720,000 in FY2018). Common co-morbid conditions among Veterans diagnosed with sleep disorders include obesity, diabetes, congestive heart failure, depression, post-traumatic stress disorder (PTSD) and traumatic brain injury (TBI). To address this healthcare crisis, the Veterans Health Administration (VHA) developed and/or implemented numerous innovations to improve the quality and accessibility of sleep care services for Veterans. These innovations include a TeleSleep Enterprise-Wide Initiative to improve rural Veterans' access to sleep care; telehealth applications such as the Remote Veteran Apnea Management Platform (REVAMP), Clinical Video Telehealth, and CBT-i Coach; increased use of home sleep apnea testing (HSAT); and programs for Veterans who experience sleep disorders associated with obesity, PTSD, TBI and other conditions.

A Prospective, Multicenter Study to Assess the Safety and Efficacy of Translingual Neurostimulation Plus Physical Therapy for the Treatment of a Chronic Balance Deficit Due to Mild‐to‐Moderate Traumatic Brain Injury

Objectives

Materials and Methods

Results

Conclusions

National Expansion of Sleep Telemedicine for Veterans: The TeleSleep Program

STUDY OBJECTIVES

(1) Review the prevalence and comorbidity of sleep disorders among United States military personnel and veterans. (2) Describe the status of sleep care services at Veterans Health Administration (VHA) facilities. (3) Characterize the demand for sleep care among veterans and the availability of sleep care across the VHA. (4) Describe the VA TeleSleep Program that was developed to address this demand.

METHODS

PubMed and Medline databases (National Center for Biotechnology Information, United States National Library of Medicine) were searched for terms related to sleep disorders and sleep care in United States military and veteran populations. Information related to the status of sleep care services at VHA facilities was provided by clinical staff members at each location. Additional data were obtained from the VA Corporate Data Warehouse.

RESULTS

Among United States military personnel, medical encounters for insomnia increased 372% between 2005-2014; encounters for obstructive sleep apnea (OSA) increased 517% during the same period. The age-adjusted prevalence of sleep disorder diagnoses among veterans increased nearly 6-fold between 2000-2010; the prevalence of OSA more than doubled in this population from 2005-2014.

CONCLUSIONS

Most VA sleep programs are understaffed for their workload and have lengthy wait times for appointments. The VA Office of Rural Health determined that the dilemma of limited VHA sleep health care availability and accessibility might be solved, at least in part, by implementing a comprehensive telehealth program in VA medical facilities. The VA TeleSleep Program is an expansion of telemedicine services to address this need, especially for veterans in rural or remote regions.

CITATION

Sarmiento KF, Folmer RL, Stepnowsky CJ, Whooley MA, Boudreau EA, Kuna ST, Atwood CW, Smith CJ, Yarbrough WC. National expansion of sleep telemedicine for veterans: the telesleep program. J Clin Sleep Med. 2019;15(9):1355-1364.

Enhancing Screening Systems to Facilitate Hearing-Healthcare Access: A Qualitative Study

BACKGROUND

Although hearing loss is a common health issue, hearing healthcare (HHC) is poorly accessed. Screening to identify hearing loss is an important part of HHC access, specifically for those who screen positive for hearing loss and would benefit from seeing a HHC provider. New technologies can be automated to provide information and recommendations that are tailored to the needs of individual users, potentially enhancing rates of HHC access after positive screens. A greater understanding of the facilitators of postscreening HHC access that could be leveraged in such systems is needed.

PURPOSE

The purpose of this project was to identify facilitators of postscreening HHC access that can be used in automated screening systems.

RESEARCH DESIGN

This qualitative study used focus groups (FGs) to understand perceived barriers, perceived benefits, and potential cues to action, as informed by the Health Belief Model, for accessing HHC after use of automated hearing screening systems.

STUDY SAMPLE

Fifty individuals participated in one of seven FGs. FGs were conducted separately with three types of stakeholders: four FGs included adults who reported some degree of perceived hearing loss and had recently completed a hearing screening; two FGs included adults who had recently sought HHC for the first time because of hearing loss; and one FG involved significant others/family members of individuals with hearing loss.

DATA COLLECTION AND ANALYSIS

FGs were 60-90 minutes in length and were led by a trained facilitator following a discussion guide. A research audiologist was present at each FG and served as a notetaker. FGs were recorded and transcribed by research team members, and transcripts were then coded in an iterative process by multiple team members. Qualitative content analysis was used to reduce data and to identify salient themes and subthemes, following an inductive approach. We focused on identifying themes that were related to facilitators of HHC access after positive screens for hearing loss and, separately, potential enhancements to automated hearing screening systems that would leverage these facilitators to improve HHC access.

RESULTS

We identified five key themes related to HHC access after a positive screen for hearing loss, along with ideas for enhancing automated hearing screening systems based on these themes. The themes included knowledge, trust, access, quality of life, and interpersonal influence.

CONCLUSIONS

The results of our work help inform the development of innovative hearing screening systems that can be automated to leverage individual facilitators of HHC access.

Validation of a Computer-Administered Version of the Digits-in-Noise Test for Hearing Screening in the United States

BACKGROUND

The sooner people receive treatment for hearing loss (HL), the quicker they are able to recognize speech and to master hearing aid technology. Unfortunately, a majority of people with HL wait until their impairments have progressed from moderate to severe levels before seeking auditory rehabilitation. To increase the number of individuals with HL who pursue and receive auditory rehabilitation, it is necessary to improve methods for identifying and informing these people via widely accessible hearing screening procedures. Screening for HL is the first in a chain of events that must take place to increase the number of patients who enter the hearing health-care system. New methods for hearing screening should be readily accessible through a common medium (e.g., telephone or computer) and should be relatively easy and quick for people to self-administer.

PURPOSE

The purpose of this study was to assess a digits-in-noise (DIN) hearing screening test that was delivered via personal computer.

RESEARCH DESIGN

Participants completed the Hearing Handicap Inventory for Adults (HHIA) questionnaire, audiometric testing in a sound booth, and computerized DIN testing. During the DIN test, sequences of three spoken digits were presented in noise via headphones at varying signal-to-noise ratios (SNRs). Participants entered each three-digit sequence they heard using an on-screen keypad.

STUDY SAMPLE

Forty adults (16 females, 24 males) participated in the study, of whom 20 had normal hearing and 20 had HL (pure-tone average [PTA] thresholds for 0.5, 1, 2, and 4 kHz >25 dB HL).

DATA COLLECTION AND ANALYSIS

DIN SNR and PTA data were analyzed and compared for each ear tested. Receiver operating characteristic curves based on these data were plotted. A measure of overall accuracy of a screening test is the area under the receiver operating characteristic curve (AUC). This measures the average true positive rate across false positives at varying DIN SNR cutoffs. Larger values of the AUC indicate, on average, more accurate screening tests. HHIA responses were analyzed and compared to PTA and DIN SNR results using Pearson correlation statistics.

RESULTS

HHIA scores were positively correlated with audiometric PTA and DIN SNR results (p < 0.001 for all correlations). For an HL criterion of one or more frequencies from 0.25 to 8 kHz >25 dB HL, the AUC for the DIN test was 0.95. When a criterion of hearling level was set at one or more frequencies from 0.25 to 8 kHz >20 dB HL, the AUC for the DIN test was 0.96.

CONCLUSIONS

The computer version of the DIN test demonstrated excellent sensitivity and specificity for our sample of 40 participants. AUC results (≥0.95) suggest that this DIN test administered via computer should be very useful for adult hearing screening.

Cortical Measures of Binaural Processing Predict Spatial Release from Masking Performance

Binaural sensitivity is an important contributor to the ability to understand speech in adverse acoustical environments such as restaurants and other social gatherings. The ability to accurately report on binaural percepts is not commonly measured, however, as extensive training is required before reliable measures can be obtained. Here, we investigated the use of auditory evoked potentials (AEPs) as a rapid physiological indicator of detection of interaural phase differences (IPDs) by assessing cortical responses to 180° IPDs embedded in amplitude-modulated carrier tones. We predicted that decrements in encoding of IPDs would be evident in middle age, with further declines found with advancing age and hearing loss. Thus, participants in experiment #1 were young to middle-aged adults with relatively good hearing thresholds while participants in experiment #2 were older individuals with typical age-related hearing loss. Results revealed that while many of the participants in experiment #1 could encode IPDs in stimuli up to 1,000 Hz, few of the participants in experiment #2 had discernable responses to stimuli above 750 Hz. These results are consistent with previous studies that have found that aging and hearing loss impose frequency limits on the ability to encode interaural phase information present in the fine structure of auditory stimuli. We further hypothesized that AEP measures of binaural sensitivity would be predictive of participants' ability to benefit from spatial separation between sound sources, a phenomenon known as spatial release from masking (SRM) which depends upon binaural cues. Results indicate that not only were objective IPD measures well correlated with and predictive of behavioral SRM measures in both experiments, but that they provided much stronger predictive value than age or hearing loss. Overall, the present work shows that objective measures of the encoding of interaural phase information can be readily obtained using commonly available AEP equipment, allowing accurate determination of the degree to which binaural sensitivity has been reduced in individual listeners due to aging and/or hearing loss. In fact, objective AEP measures of interaural phase encoding are actually better predictors of SRM in speech-in-speech conditions than are age, hearing loss, or the combination of age and hearing loss.

Transcranial magnetic stimulation for tinnitus: using the Tinnitus Functional Index to predict benefit in a randomized controlled trial

Background

Identifying characteristics associated with transcranial magnetic stimulation (TMS) benefit would offer insight as to why some individuals experience tinnitus relief following TMS treatment, whereas others do not. The purpose of this study was to use the Tinnitus Functional Index (TFI) and its subscales to identify specific factors associated with TMS treatment responsiveness.

Methods

Individuals with bothersome tinnitus underwent 2000 pulses of 1-Hz TMS for 10 consecutive business days. The primary outcome measure was the TFI which yields a total score and eight individual subscale scores. Analyses were performed on baseline data from the active arm (n = 35) of a prospective, double-blind, randomized placebo-controlled clinical trial of TMS for tinnitus.

Results

Baseline total TFI score and three of the eight TFI subscales were useful in differentiating between responders and nonresponders to TMS intervention for tinnitus. These findings are not definitive, but suggest potential factors that contribute to perceived benefit following TMS.

Conclusions

Overall, the main factor associated with TMS benefit was a higher tinnitus severity score for responders at baseline. The TFI subscales helped to clarify the factors that contributed to a higher severity score at baseline. Large-scale prospective research using systematic approaches is needed to identify and describe additional factors associated with tinnitus benefit following TMS.

Trial registration

ClinicalTrials.gov, ID: NCT01104207. Registered on 13 April 2010.

Hearing loss associated with long-term exposure to high-speed dental handpieces

The purpose of this study was to record and compare audiometric pure tone thresholds of dental clinicians (DCs), dental professionals (DPs), and dental students (DSs); determine the percentage of these groups who use hearing protection devices while at work in the clinic; and measure the sound intensities generated by a few representative high-speed handpieces while they are being used on patients. Participants included DCs who regularly used these handpieces (n = 16), DPs who did not use these handpieces (n = 13), and DSs (n = 8). A questionnaire was used to collect demographic information, assess occupational and recreational noise exposure, and note the level of hearing protection used. A sound level meter was used to measure the sound intensity generated by dental instruments near a clinician's ear. Results showed that DCs who regularly used high-speed handpieces had worse hearing than did members of the other study groups. These results indicate that the implementation of protective strategies should help to reduce the prevalence of occupational hearing loss among DCs.

Implications of blast exposure for central auditory function: a review

Auditory system functions, from peripheral sensitivity to central processing capacities, are all at risk from a blast event. Accurate encoding of auditory patterns in time, frequency, and space are required for a clear understanding of speech and accurate localization of sound sources in environments with background noise, multiple sound sources, and/or reverberation. Further work is needed to refine the battery of clinical tests sensitive to the sorts of central auditory dysfunction observed in individuals with blast exposure. Treatment options include low-gain hearing aids, remote-microphone technology, and auditory-training regimens, but clinical evidence does not yet exist for recommending one or more of these options. As this population ages, the natural aging process and other potential brain injuries (such as stroke and blunt trauma) may combine with blast-related brain changes to produce a population for which the current clinical diagnostic and treatment tools may prove inadequate. It is important to maintain an updated understanding of the scope of the issues present in this population and to continue to identify those solutions that can provide measurable improvements in the lives of Veterans who have been exposed to high-intensity blasts during the course of their military service.

Electrophysiological assessments of cognition and sensory processing in TBI: applications for diagnosis, prognosis and rehabilitation

Traumatic brain injuries are often associated with damage to sensory and cognitive processing pathways. Because evoked potentials (EPs) and event-related potentials (ERPs) are generated by neuronal activity, they are useful for assessing the integrity of neural processing capabilities in patients with traumatic brain injury (TBI). This review of somatosensory, auditory and visual ERPs in assessments of TBI patients is provided with the hope that it will be of interest to clinicians and researchers who conduct or interpret electrophysiological evaluations of this population. Because this article reviews ERP studies conducted in three different sensory modalities, involving patients with a wide range of TBI severity ratings and circumstances, it is difficult to provide a coherent summary of findings. However, some general trends emerge that give rise to the following observations and recommendations: 1) bilateral absence of somatosensory evoked potentials (SEPs) is often associated with poor clinical prognosis and outcome; 2) the presence of normal ERPs does not guarantee favorable outcome; 3) ERPs evoked by a variety of sensory stimuli should be used to evaluate TBI patients, especially those with severe injuries; 4) time since onset of injury should be taken into account when conducting ERP evaluations of TBI patients or interpreting results; 5) because sensory deficits (e.g., vision impairment or hearing loss) affect ERP results, tests of peripheral sensory integrity should be conducted in conjunction with ERP recordings; and 6) patients' state of consciousness, physical and cognitive abilities to respond and follow directions should be considered when conducting or interpreting ERP evaluations.

Controversy: Does repetitive transcranial magnetic stimulation/ transcranial direct current stimulation show efficacy in treating tinnitus patients?

BACKGROUND

Tinnitus affects 10% of the population, its pathophysiology remains incompletely understood, and treatment is elusive. Functional imaging has demonstrated a relationship between the intensity of tinnitus and the degree of reorganization in the auditory cortex. Experimental studies have further shown that tinnitus is associated with synchronized hyperactivity in the auditory cortex. Therefore, targeted modulation of auditory cortex has been proposed as a new therapeutic approach for chronic tinnitus.

METHODS

Repetitive transcranial magnetic stimulation (rTMS) and transcranial direct current stimulation (tDCS) are noninvasive methods that can modulate cortical activity. These techniques have been applied in different ways in patients with chronic tinnitus. Single sessions of high-frequency rTMS over the temporal cortex have been successful in reducing the intensity of tinnitus during the time of stimulation and could be predictive for treatment outcome of chronic epidural stimulation using implanted electrodes.

RESULTS

Another approach that uses rTMS as a treatment for tinnitus is application of low-frequency rTMS in repeated sessions, to induce a lasting change of neuronal activity in the auditory cortex beyond the duration of stimulation. Beneficial effects of this treatment have been consistently demonstrated in several small controlled studies. However, results are characterized by high interindividual variability and only a moderate decrease of the tinnitus. The role of patient-related (for example, hearing loss, tinnitus duration, age) and stimulation-related (for example, stimulation site, stimulation protocols) factors still remains to be elucidated.

CONCLUSIONS

Even in this early stage of investigation, there is a convincing body of evidence that rTMS represents a promising tool for pathophysiological assessment and therapeutic management of tinnitus. Further development of this technique will depend on a more detailed understanding of the neurobiological effects mediating the benefit of TMS on tinnitus perception. Moreover clinical studies with larger sample sizes and longer follow-up periods are needed.

Obsessive-compulsiveness in a population of tinnitus patients

The purpose of this study was to use the Maudsley Obsessional-Compulsive Inventory (MOCI) to assess obsessive-compulsiveness in a population of 196 tinnitus patients and to correlate MOCI scores with measures of anxiety, depression, and tinnitus severity. Tinnitus severity was positively correlated with measures of anxiety and depression. Depression was positively correlated with MOCI and anxiety scores. MOCI scores exhibited weaker positive correlations with tinnitus severity and anxiety. Effective management of tinnitus requires identification of psychological disorders or symptoms when they are present so that patients can receive appropriate treatment as soon as possible. The MOCI can be used to assess obsessive-compulsiveness in tinnitus patients.

Effectiveness of “Dangerous Decibels,” a School-Based Hearing Loss Prevention Program

Purpose

To evaluate the effectiveness of the “Dangerous Decibels” educational program in increasing students' knowledge and positively changing their attitudes and intended behaviors related to hearing and hearing loss prevention.

Method

Baseline questionnaires were completed by 478 4th-grade students and 550 7th-grade students. Approximately half of the students in each grade received a 35-min interactive classroom presentation on hearing and hearing loss prevention. The remaining students served as comparison groups. Students who received the curriculum filled out questionnaires immediately after the presentation. All students filled out follow-up questionnaires 3 months after baseline.

Results

Fourth-grade students who participated in the Dangerous Decibels presentation exhibited significant improvements in knowledge and attitudes related to hearing and hearing loss prevention. These improvements were maintained 3 months after the presentation. Seventh-grade students also experienced long-term improvements in their knowledge base. However, attitudes and intended behaviors in 7th graders returned to baseline levels 3 months postpresentation.

Conclusion

The Dangerous Decibels hearing loss prevention program was effective at producing long-term improvements in the knowledge base of 4th- and 7th-grade students. Future studies should include components on peer pressure and should incorporate repeated, multimodality interventions to increase the likelihood of long-term improvement in adolescents.

Effects of repetitive transcranial magnetic stimulation (rTMS) on chronic tinnitus

CONCLUSIONS

Preliminary results indicate that repetitive transcranial magnetic stimulation (rTMS) can suppress tinnitus for some people. However, several procedural questions need to be addressed before the results of TMS studies can be interpreted or applied. For example, the placebo effect might be a significant factor because it is easy for patients to distinguish between real and sham stimulation.

OBJECTIVES

This study was undertaken to determine the following: Can rTMS reduce patients' perception of chronic tinnitus? Is ipsilateral or contralateral stimulation most effective at reducing patients' perception of tinnitus? What is the extent and duration of the change in tinnitus following rTMS?

PATIENTS AND METHODS

Fifteen subjects rated the loudness of their tinnitus on a 1-10 scale (1 = very quiet, 10 = very loud) before and after sham or real TMS. Participants wore foam ear plugs during the following procedures. After the patient's motor threshold was established, a figure-of-eight stimulating coil was positioned over the temporal region of the head at a location that corresponds to International 10-20 electrode position T3 (left) or T4 (right). 'Sham' rTMS was then delivered to this region of the head, first on the ipsilateral side, then on the contralateral side from where participants perceived tinnitus. Sham TMS consisted of an audio recording of actual TMS stimulus sounds. Actual rTMS was next delivered to each side of the head, starting with the side ipsilateral to tinnitus perception. Stimulation intensity was 100% of the resting motor threshold. A train of 30 pulses at 10 Hz was delivered every minute for 5 min.

RESULTS

Two subjects reported reductions in tinnitus loudness following sham stimulation. Actual TMS resulted in partial suppression of tinnitus for six subjects. The amount of suppression ranged from 19% to 86% (average 50%). The durations of tinnitus suppression for each of the six subjects were: 20 min, 30 min, 45 min, 60 min, and 1 and 4 days, respectively.

Long-term effectiveness of ear-level devices for tinnitus

OBJECTIVE

This study was undertaken to assess long-term changes in tinnitus severity exhibited by patients who purchased and used ear-level devices (hearing aids or sound generators).

STUDY DESIGN AND SETTING

Patients were evaluated and treated within a comprehensive tinnitus management program. Follow-up questionnaires were mailed to patients 6 to 48 months after their initial appointment.

RESULTS

Follow-up questionnaires from 150 patients were reviewed. Fifty patients purchased and used hearing aids, 50 patients purchased and used in-the-ear sound generators for an average of 18 months after their initial appointment; 50 patients did not use ear-level devices. At follow-up, all 3 groups of patients exhibited significant reductions in Tinnitus Severity Index scores and self-rated tinnitus loudness. Patients who used ear-level devices reported greater improvement than patients who did not use hearing aids or sound generators.

CONCLUSIONS

Ear-level devices such as hearing aids or sound generators can help a significant number of patients who experience chronic tinnitus. Both types of devices reduce patients' perception of tinnitus and can facilitate habituation to the symptom. Amplification provides additional benefits of improved hearing and communication.

SSRI use by Tinnitus Patients: Interactions between Depression and Tinnitus Severity

Depression is often coincident with chronic tinnitus, and several studies have suggested that antidepressant medications may play a role in relieving tinnitus as well as depression. We conducted a retrospective study of the use of selective serotonin reuptake inhibitors (SSRIs) by patients at a large tinnitus clinic to assess the effects of these antidepressants on tinnitus severity. We focused on a subgroup of 30 patients with depression who had begun taking SSRI medication after the onset of their tinnitus; these patients had also been treated with psychotherapy by a mental health clinician. At a mean follow-up of 20.6 months, only 10 of the 30 patients reported that they were still experiencing major depression. Moreover, this group as a whole demonstrated a statistically significant improvement in tinnitus symptoms as reflected by a reduction in their Tinnitus Severity Index scores. We conclude that SSRIs represent one category of tools that can be used to help patients with severe tinnitus and depression. Like all antidepressant medications, SSRIs should be used in conjunction with psychotherapy to facilitate patient improvement.

SSRI use by tinnitus patients: interactions between depression and tinnitus severity

Depression is often coincident with chronic tinnitus, and several studies have suggested that antidepressant medications may play a role in relieving tinnitus as well as depression. We conducted a retrospective study of the use of selective serotonin reuptake inhibitors (SSRIs) by patients at a large tinnitus clinic to assess the effects of these antidepressants on tinnitus severity. We focused on a subgroup of 30 patients with depression who had begun taking SSRI medication after the onset of their tinnitus; these patients had also been treated with psychotherapy by a mental health clinician. At a mean follow-up of 20.6 months, only 10 of the 30 patients reported that they were still experiencing major depression. Moreover, this group as a whole demonstrated a statistically significant improvement in tinnitus symptoms as reflected by a reduction in their Tinnitus Severity Index scores. We conclude that SSRIs represent one category of tools that can be used to help patients with severe tinnitus and depression. Like all antidepressant medications, SSRIs should be used in conjunction with psychotherapy to facilitate patient improvement.

Chronic tinnitus resulting from cerumen removal procedures

This study was undertaken to determine how many cases of chronic tinnitus in a clinic population resulted from cerumen removal procedures and to summarize cerumen management methodologies and recommendations that will reduce the likelihood of such serious complications. Detailed questionnaires were mailed to 2400 consecutive patients (1704 male, 696 female; mean age, 53.3 +/- 11.8 years; age range, 7-87 years) prior to their initial appointment at the Oregon Health & Science University Tinnitus Clinic between 1986 and 2000. These questionnaires requested information about patients' medical, hearing, and tinnitus histories. Records were analyzed to determine how many patients reported that their chronic tinnitus began as a result of cerumen removal procedures. Of 2400 patients, 11 (0.46%) reported that their tinnitus began as a result of cerumen removal procedures performed by clinicians. Three additional patients reported that chronic tinnitus began as a result of their own attempts to clean their ear canals. Chronic and debilitating conditions, such as hearing loss and tinnitus, can occur as results of attempts to remove cerumen. By following the recommendations of experts in cerumen management techniques, clinicians can reduce the likelihood of catastrophic complications and subsequent litigation.

The importance of hearing conservation instruction

According to Denehy (1999), "school nurses can play a powerful role in promoting health in their schools and community." She encouraged school nurses to "Take and make opportunities to promote health in the classroom" (p. 4). Classroom presentation of hearing conservation information is one way for school nurses to promote health and to reduce the prevalence of noise-induced hearing loss (NIHL), an irreversible yet preventable condition. Because of excessive sound exposure, the prevalence of NIHL among children is increasing. Numerous experts have recommended the implementation of hearing conservation education programs in schools. Despite these recommendations made over the last 3 decades, basic hearing conservation information that could prevent countless cases of NIHL remains conspicuously absent from most school curricula. School nurses should seize this "golden opportunity" to promote health in the classroom and help to reduce the prevalence of NIHL.

Chronic tinnitus resulting from head or neck injuries

OBJECTIVES

The main objectives were 1) to determine the percentage of cases of chronic tinnitus in a specialized clinic that resulted from head or neck injuries; 2) to describe the characteristics of this population; and 3) to compare patients with head or neck trauma with patients whose tinnitus onset was not associated with head or neck injuries.

STUDY DESIGN

Retrospective analysis of tinnitus clinic patient data.

METHODS

Detailed questionnaires were mailed to 2400 patients before their initial appointment at the Oregon Health and Science University Tinnitus Clinic (Portland, OR). All of the patients experienced and received treatment for chronic tinnitus. Patient data were entered into a database and later analyzed.

RESULTS

Two hundred ninety-seven patients (214 male and 83 female patients) reported that their chronic tinnitus started as a result of head or neck injuries. Compared with patients whose tinnitus onset was not associated with trauma, patients with tinnitus associated with head or neck trauma were younger; had better hearing thresholds; experienced headaches more frequently; reported greater difficulties with concentration, memory, and thinking clearly; were more likely to experience current depression, but not lifetime depression; rated their tinnitus as louder on a 1-to-10 scale; matched their tinnitus to louder sounds on the right side; and had higher Tinnitus Severity Index scores.

CONCLUSIONS

Tinnitus is a significant symptom that commonly occurs as a result of head or neck trauma. The fact that tinnitus resulting from head or neck injuries tends to be more severe (and is often accompanied by a greater number of co-symptoms) than tinnitus resulting from other causes should be taken into account by clinicians treating these patients.

Long-term reductions in tinnitus severity

BACKGROUND: This study was undertaken to assess long-term changes in tinnitus severity exhibited by patients who completed a comprehensive tinnitus management program; to identify factors that contributed to changes in tinnitus severity within this population; to contribute to the development and refinement of effective assessment and management procedures for tinnitus. METHODS: Detailed questionnaires were mailed to 300 consecutive patients prior to their initial appointment at the Oregon Health & Science University Tinnitus Clinic. All patients were then evaluated and treated within a comprehensive tinnitus management program. Follow-up questionnaires were mailed to the same 300 patients 6 to 36 months after their initial tinnitus clinic appointment. RESULTS: One hundred ninety patients (133 males, 57 females; mean age 57 years) returned follow-up questionnaires 6 to 36 months (mean = 22 months) after their initial tinnitus clinic appointment. This group of patients exhibited significant long-term reductions in self-rated tinnitus loudness, Tinnitus Severity Index scores, tinnitus-related anxiety and prevalence of current depression. Patients who improved their sleep patterns or Beck Depression Inventory scores exhibited greater reductions of tinnitus severity scores than patients who continued to experience insomnia and depression at follow-up. CONCLUSIONS: Individualized tinnitus management programs that were designed for each patient contributed to overall reductions in tinnitus severity exhibited on follow-up questionnaires. Identification and treatment of patients experiencing anxiety, insomnia or depression are vital components of an effective tinnitus management program. Utilization of acoustic therapy also contributed to improvements exhibited by these patients.