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Tinnitus Research Advancing Treatment

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Jeffrey D. Lewine, PhD, said that by understanding the neurobiology of tinnitus, it is possible to develop therapeutic interventions that actually alter the tinnitus precept and alter the brain dysfunction, during yesterday’s Minseminar “Tinnitus Lessons Learned from Combat and Service.”

Tinnitus is a persistent problem for which there is no cure, but new neurobiology research shows the promise of developing effective treatments. In addition, an AAO-HNSF guideline and the research of Veterans Administration (VA) institutions help to direct effective management of the condition.

A series of speakers discussed these advances as well as the effects of military service on hearing issues for veterans Tuesday during the Miniseminar “Tinnitus: Lessons Learned from Combat and Service.”

“We have very little that actually changes the tinnitus percept. Most of our therapies are focusing on the distress and the psychological consequences of tinnitus rather than trying to actually alter the perception of tinnitus,” said Jeffrey D. Lewine, PhD. “But there is at least a group of us who believe that if we truly understand the neurobiology of tinnitus, we might be able to develop therapeutic interventions that go after that neurobiology and actually alter the tinnitus percept and alter the brain dysfunction that has given rise to the distress we see in tinnitus.”

Dr. Lewine, a Professor of Translational Neuroscience and Director of Business Development, Mind Research Network, Albuquerque, NM, discussed research that shows that tinnitus distress involves different networks of the brain regions, such as the attention network and the memory network.

“The good news is that we potentially have target areas to think about in terms of intervention,” he said. “What this has led to over the last 10 years is a movement to look at neuromodulatory strategies that target different nodes of these networks to try to do therapeutic interventions.”

Two such interventions are transcranial direct current stimulation and transcranial magnetic stimulation, both of which send pulses into targeted brain regions. Other promising areas are vagus nerve stimulation that could reorganize the auditory cortex and tinnitus reorganization training to reduce tinnitus distress.

“Ultimately, we want to be doing all of these within the global picture of associating them with cognitive behavioral therapy,” Dr. Lewine said. “This is going after the percept. We still need to go after the distress, and it is going to be a combination of the two that is going to be most effective.”

Abraham Shulman, MD, Professor Emeritus of Clinical Otolaryngology at SUNY/Downstate, New York, NY, discussed advances in the study of tinnitus. In particular, he emphasized that there are different types of tinnitus, with medical trauma tinnitus (MTT) identified as a new type.

MTT is a mental health condition that is clinically manifested predominantly with a recurring and increasing anxiety. MTT is the emotional traumatic event clinically considered a mental health disorder, he said.

Tinnitus Treatment Paradigm PTSD (TTPP) is a combined therapy for attempting relief of MTT with a focus predominantly on behavioral therapy, and EEG-based neurofeedback—not medication—in combination with instrumentation, Dr. Shulman said.

He concluded by adding that electroencephalography (EEG) functional brain imaging is recommended for MTT. Functional brain imaging technologies provide a visual display of brain wave oscillations, reflecting multiple brain functions in the presence of the tinnitus signal.

James A. Henry, PhD, and Lynn W. Henselman, PhD, discussed the development of evidence-based management of tinnitus as developed at VA institutions. That management is based on the AAO-HNSF tinnitus guideline and guidelines based on Cochrane Reviews. Dr. Henry is Research Career Scientist at VA Portland Health Care System, Portland, OR, and Dr. Henselman is Deputy Director, Defense Hearing Center of Excellence, Department of Veterans Affairs, Washington, DC.

“The AAO-HNSF guideline for tinnitus should be the standard for management,” Dr. Henry said, walking through several recommendations from the guideline, which was published in October 2014. It is the first multidisciplinary, evidence-based clinical practice guideline to improve the diagnosis and management of tinnitus. To read the guideline and access related resources, visit www.entnet.org/TinnitusCPG.

Dr. Henry also reviewed the VA’s principles of tinnitus management, based on research over the last 20 years:

  • Clinical services for tinnitus should be progressive
  • Use an interdisciplinary approach
  • Clinicians need training in tinnitus management
  • All patients reporting tinnitus need audiologic evaluation
  • Determine if the tinnitus problem is clinically significant
  • Questionnaires are the best way to determine tinnitus severity
  • Make sure the tinnitus problem is not a hearing problem
  • Intervention should start with patient education
  • Address the problem of low health literacy

Dr. Henselman discussed the five hierarchy levels the VA follows in determining the level of treatment needed. It starts at level one with a referral, then moves on to audiologic evaluation, skills education for self-management, interdisciplinary treatment, and individualized support.

Also speaking at the session was U.S. Air Force Col. Mark Packer, MD, Director, Hearing Center of Excellence, San Antonio Military Health System, Lackland AFB, TX. He reviewed information the military has gathered about the effects of “work that involves weapons with a lot of noise.”

In addition, research into hearing-related injuries, including tinnitus, has expanded to the cellular level, he said, adding, “We want to look at what is going on under the surface.”

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