Tinnitus

The following sections are included:

• Dedication
• Foreword
• Preface
• About the Editors
• Contents

Tinnitus, the perception of noise without external stimuli, is a prevalent and sometimes debilitating condition impacting sleep, attention, mood, and quality of life. Currently, the full pathophysiology of tinnitus remains unclear. What has been recently understood is that processes related to migraine play a significant role in the loudness of tinnitus. Given that these processes are influenced by diet and lifestyle factors (stress, sleep, overstimulation), modifying diet and lifestyle offers a promising strategy for the management of tinnitus. Establishing and maintaining regular meal schedules and adequate hydration play a pivotal role in managing tinnitus. Several food items identified as migraine triggers also exacerbate tinnitus symptoms through similar mechanisms in some patients. These include foods containing caffeine, tyramine, aspartame, phenylethylamine, monosodium glutamate, nitrates/nitrites, sulfites, and some forms of alcohol. Conversely, certain supplements have demonstrated the potential to support inner ear health. Magnesium, vitamin B₂ (riboflavin), and coenzyme Q10 are among the most notable. Adopting good sleep hygiene practices and stress management techniques are also crucial elements for general health and brain function. Poor sleep quality and lack of sleep have been linked to aggravation of tinnitus. Therefore, maintaining a regular sleep schedule, controlling sleep apnea, and using guided meditation before sleep can significantly improve sleep quality and help prevent or alleviate tinnitus. Additionally, stress management techniques, such as regular physical activity, mindfulness, and meditation, have shown promise in reducing both the frequency and intensity of loud tinnitus episodes. Integrating dietary adjustments, supplements, and lifestyle modifications represents a holistic approach to managing tinnitus without the need for invasive treatments. These strategies serve as a valuable initial step in tinnitus management, offering meaningful relief and fostering a sense of control over this challenging condition.

Tinnitus is a widespread condition affecting millions of people worldwide, with some experiencing a detrimental impact on their quality of life. Although the U.S. Food and Drug Administration (FDA) has not approved any pharmaceutical agent for tinnitus treatment, the American, European, and Japanese clinical guidelines strongly recommend cognitive behavioral therapy (CBT) as a preferred option for managing chronic and bothersome tinnitus over alternative modalities. CBT is a form of psychotherapy that was successful in changing how people think (cognitive) and how they react (behavior) to tinnitus. The “first” and “second” waves of Cognitive Behavioral Therapy (CBT) focused on behavioral principles and cognitive restructuring respectively, while the “third” wave represented a shift toward embracing mindfulness and contextual factors, incorporating approaches such as mindfulness-based CBT and acceptance and commitment therapy. Mindfulness-based CBT helped reduce tinnitus severity and associated distress when compared to relaxation techniques alone. Similarly, acceptance and commitment therapy demonstrated effectiveness in decreasing tinnitus severity when compared to tinnitus rehabilitation training or waitlist control. Another new advance is the CBT delivery method. Audiologist-delivered CBT is a new promising option to expand CBT accessibility for patients with tinnitus. In addition, social media and telehealth have become vital weapons in managing tinnitus. For instance, internet-based CBT and smartphone-based tinnitus intervention could offer a valuable alternative for providing care for patients who are reluctant to seek clinic-based care.

Tinnitus, characterized by the perception of sound in the absence of an external source, poses a significant challenge to millions worldwide due to its elusive etiology and impact on quality of life. Over the years, sound and music therapy have emerged as promising options for tinnitus management and rehabilitation. This chapter highlights current evidence on the efficacy of sound and music-based interventions in alleviating tinnitus-related distress and improving subjective well-being. The review begins by explaining the neurophysiological mechanisms underlying tinnitus perception and explores how sound therapy can help modulate these processes to reduce symptom severity. Various sound therapy approaches, including sound masking, sound enrichment, and sound therapy delivered through specialized devices, are examined in terms of their efficacy and feasibility in clinical settings. Moreover, the potential synergistic effects of combining sound therapy with cognitive-behavioral techniques are explored to optimize treatment outcomes. Furthermore, the therapeutic role of music in tinnitus rehabilitation is investigated, highlighting its unique ability to engage emotional, cognitive, and sensorimotor processes. Music-based interventions are evaluated for their capacity to promote habituation to tinnitus sensations and enhance coping mechanisms. Lastly, this chapter addresses practical considerations for implementing sound and music therapy protocols, including treatment duration, patient adherence, and individualized treatment planning. Indeed, sound and music therapy represent promising avenues for tinnitus rehabilitation, offering a holistic approach that addresses both the sensory and emotional components of tinnitus perception. By integrating insights from neuroscience, psychology, and sound therapy, these interventions hold the potential to transform the landscape of tinnitus management and improve the quality of life for individuals living with this prevalent condition.

Recently, internet-based approaches for hearing-related services have presented considerable reliability and efficacy in comparison with traditional in-clinic methods. In this chapter, all aspects of internet-based self-help treatment for tinnitus patients are discussed. Internet-based therapies can cover different aspects of tinnitus management such as online counseling, internet Cognitive Behavioral Therapy, peer support, and sound therapy. However, these modules need guidance during treatment courses including supports regarding patients’ questions, outlining the content of modules, providing feedback, monitoring weekly scores, and monitoring progress. It is shown that internet-based methods can have comparable efficacy and outcomes to in-person methods, and they can also reduce the general costs per patient per year. It is worth mentioning that the characteristics or occurrence of side effects following internet-based treatment for tinnitus have not yet been known clearly. The need of internet-based methods for tinnitus patients was highlighted during the COVID-19 pandemic. Tinnitus patients often report a more noticeable tinnitus in the quiet, and the absence of masking sounds in daily life due to the quarantine may have made the tinnitus perception more noticeable. Additionally, the increased anxiety and stress levels are potential risk factors for worsening tinnitus. All of these factors during the pandemic have presented new insights about the priority of the internet-based self-help treatment for tinnitus patients. The next generation of internet-based self-help treatments will probably enroll Artificial Intelligence to combine multimodal sets. In recent years, the use of AI in various fields of medicine have surged and considering its function and mode of action, different aspects of tinnitus management may be covered by AI in future.

Tinnitus, the perception of sound without external stimuli, is a significant health burden globally. Effective treatment remains elusive due to an incomplete understanding of its mechanisms, heterogeneous manifestations, and limited treatment options.

Current pharmacological options for acute tinnitus treatment follow sudden hearing loss guidelines, recommending systemic or intratympanic steroids. Existing medications for chronic tinnitus mostly focus on alleviating the intensity of symptoms including tricyclic antidepressants, benzodiazepines, and lidocaine, showing varied efficacy and safety. However, various guidelines recommend against currently available pharmacological interventions due to insufficient efficacy and potential side effects.

Ongoing studies on emerging pharmacological treatments target various pathways to treat tinnitus effectively. Migraine treatments address the migraine-tinnitus link, offering relief by targeting underlying migraine pathology. Inflammatory pathways represent another promising target, with TNF-α inhibitors showing promise in animal models. Potassium channel modulators, such as Kv3 K+ channel activators and BK channel openers, are being investigated for their potential in modulating neuronal hyperexcitability and administrating agents targeting those demonstrated promising results in animal studies. GABAergic drugs, including extrasynaptic GABAA receptor modulators, offer a strategy to reduce abnormal hyperactivity which needs further investigations. Glutamate receptor antagonists, like mGluR agonists and AMPA receptor antagonists, hold promise in suppressing tinnitus in animal models. Also, potential treatment targets such as the limbic system, lipid metabolism, and synaptic genes have gained interest in recent studies. Moreover, ongoing clinical trials investigate novel treatment options like migraine medications, Etanercept, Brexanolone, and Curcumin for tinnitus management.

Challenges include methodological flaws in trials, lack of standardization across studies, tinnitus heterogeneity, and limited pharmacological options. Overcoming these requires standardized criteria, longer follow-ups, and diversified trial designs. Despite challenges, advancements in neuroinflammation and genetics and brain-targeted interventions offer promising drug targets. Lastly, establishing personalized treatment approaches will be crucial for improving tinnitus care and outcomes.

The lack of any definitive treatment for tinnitus is often unsatisfying for patients and can precipitate emotional distress in addition to increased healthcare expenditures. Many then look to natural remedies for treatments of their tinnitus. This chapter explores the use of complementary and alternative medicines for the management of tinnitus.

Less invasive treatments for tinnitus include herbs, trace elements, and antioxidant supplements. The mechanisms of alternative treatment often rely on vaso-regulatory and antioxidant properties for which tinnitus has known causes for. Herbs such as the Ginkgo Biloba, albeit controversy abounds, is accepted as evidence-based treatment with improved tinnitus handicap inventory (THI) and visual analogue scale (VAS) scores. Some antioxidant supplements such as B-vitamins and Coenzyme Q10 have also shown results that are promising. A separate evidence-based entity is behavioral therapy and its subsets, which are not discussed in this chapter.

More invasive methods could involve electrical stimulation and acupuncture. We specifically address acupuncture as it is deeply seeded in cultural roots but has been investigated to target specific tinnitus centers such as the cochlear nucleus, resulting in increased blood flow with improved THI and VAS scores.

While evidenced-based research continues for alternative treatments, including the techniques outlined in everyday practice will take significant efforts from both the patient and the provider. Complementary and integrative medicine should be considered in addition to traditional medical and behavioral management for tinnitus.

The pathophysiological mechanisms that underlie the generation and maintenance of tinnitus are being unraveled progressively. Based on this knowledge, a large variety of different neuromodulatory interventions have been developed, and has still been designed, adapting to the progressive mechanistic insights in the pathophysiology of tinnitus. Non-surgical or non-invasive brain stimulation involves the transcranial delivery of magnetic or electrical stimuli. Repeated transcranial magnetic stimulation (rTMS) targeting the temporal, temporoparietal and the frontal cortex has been the mainstay of non-invasive neuromodulation. Yet, the evidence is still unclear, and therefore systematic meta-analyses have been performed demonstrating that rTMS can slightly improve suffering but not loudness perception. Different forms of transcranial electrical stimulation (tDCS, tACS, tRNS), applied over the frontal and temporal cortex, have been investigated with meta-analyses in tinnitus patients as well. Most meta-analyses demonstrate that tDCS can slightly improve suffering, and some suggest that tDCS can also improve loudness, but only when applied to the left temporal area. Recently, the initial studies reporting on bimodal non-invasive stimulation have revealed promising results and it appears that targeting different sensory modalities in temporally combined manners may be more promising than single target approaches. While most neuromodulatory approaches seem promising, only rTMS and tDCS seem ready for clinical use, but further research is required to help translating the scientific outcomes of surgical and bimodal stimulation into routine clinical practice.

Given the chronicity, prevalence, and morbidity of tinnitus, major efforts have been applied to intervene with symptoms. Studies indicating central nervous system involvement with tinnitus have led to more invasive therapies over time, including electrical modalities such as vagus nerve, transtympanic, auditory cortex, and deep brain stimulation. Dozens of studies have explored the optimal parameters, target regions, and conditions from which a greater understanding of efficacy can be discussed here. For each intervention, we describe the route of administration, history of use, and significant studies that articulate and inform modern understandings and clinical applications. Literature on auditory cortex stimulation included various reports and case studies, the most thorough of which found no significant benefits of the treatment. Understanding of transtympanic and tinnitus distress network stimulation remains ongoing, though preliminary studies show a variety of responses that require further exploration. In a cohort of 30, vagus nerve stimulation has shown positive results on symptoms. As of today, deep brain stimulation for tinnitus in a cohort of 122 affected and matched controls showed a strong reduction in symptoms, leading to phase 1 studies and beyond. The wide berth of available invasive electrical techniques for tinnitus serves as an insight into the exciting frontier of available therapies, bound to alleviate the daily burden of this disease in millions.

Bimodal neurostimulation, an innovative neuromodulatory approach combining auditory and somatosensory stimuli, has emerged as a promising intervention for tinnitus management. Devices such as Lenire™, Neosensory Duo™, and the device developed at the University of Michigan (a.k.a., “Dr. Susan Shore Device”) utilize this approach by delivering synchronized auditory and electrical stimulation to the tongue, wrist, or neck, respectively. These techniques attempt to modulate imbalances in neuronal activity thought to underly the etiology of tinnitus symptoms. Clinical trials have demonstrated significant reductions in tinnitus severity, with sustained benefits observed in many patients. This chapter explores the neurophysiological mechanisms, clinical efficacy, and therapeutic applications of bimodal neurostimulation in tinnitus management. It delves into the underlying neuroplastic changes, including the modulation of neural plasticity and the reorganization of auditory pathways. Additionally, it discusses the design and outcomes of key clinical trials, highlighting the safety profile and tolerability of bimodal neurostimulation. The potential for integrating this therapy into standard clinical practice and its implications for future research are also considered. By providing a comprehensive overview of bimodal neurostimulation, this chapter aims to elucidate its role in advancing tinnitus treatment and improving patient outcomes.

Tinnitus, the perception of sound originating internally, poses a significant challenge for millions worldwide. Despite its complexity, emerging therapies offer hope for relief. One such approach, neural therapy with botulinum toxin (BTX), targets the neuroplastic changes within the central auditory system involved in tinnitus perception. This chapter provides a comprehensive overview of the rationale, efficacy, and clinical evidence of BTX therapy in tinnitus management. By disrupting maladaptive neuroplastic processes, BTX injections hold promise in restoring the balance of excitatory and inhibitory neurotransmissions within auditory circuits. Clinical trials, along with multiple case reports, demonstrate encouraging outcomes, particularly in cases of middle ear myoclonic tinnitus (MEMT) and palatal myoclonus (PM), where BTX therapy provides sustained symptom relief and improved quality of life with minimal adverse effects. Furthermore, existing evidence supports the use of BTX in managing the symptoms of migraine, a common comorbidity and often a contributing factor to tinnitus. Intramuscular injections of Onabotulinumtoxin A (OnaA) into craniocervical muscles have also shown promise in alleviating tinnitus associated with chronic migraine (CM), suggesting broader therapeutic applications for neurological comorbidities. Overall, neural therapy with BTX offers a novel, individualized approach to tinnitus management, addressing specific subtypes and underlying pathophysiological mechanisms. With ongoing research and clinical trials, BTX emerges as a safe and effective treatment option for tinnitus, including refractory cases, improving patient outcomes and quality of life.

Tinnitus, often linked with hearing loss, arises from decreased auditory stimulation to the brain, leading to hyperactive neural firing in the auditory cortex. This chapter explores how hearing aids can mitigate tinnitus by reintroducing sound stimulation, thereby reducing the perception of tinnitus and the stress associated with it. Hearing aids amplify ambient sounds, providing the auditory stimulation needed to counteract neural hyperactivity, and reduce listening effort that can exacerbate tinnitus symptoms. Many users report significant tinnitus reduction with hearing aid use, though evidence of permanent resolution remains insufficient.

Understanding tinnitus involves recognizing its origins in cochlear damage and subsequent neural plasticity in the auditory cortex and other areas of the brain. The distress linked to tinnitus is primarily mediated by the limbic system, particularly the amygdala, which amplifies the perceived threat of tinnitus, creating a cycle of stress and heightened perception. Effective tinnitus management aims to interrupt this cycle, fostering neural pathways that allow the brain to habituate to tinnitus.

Hearing aids support this process by amplifying ambient sounds, which reduces the brain’s focus on tinnitus, and by utilizing built-in noise generators that can provide continuous sound therapy. Modern hearing aids offer a range of sound options, including broad- and narrowband noises, proprietary sounds like fractal tones, and notched acoustic stimuli. Hearing aids with Bluetooth capability offer additional sound therapy options, further enhancing their utility.

The role of listening effort is also instrumental in tinnitus management. Hearing aids reduce the cognitive effort required for central processing of acoustic stimuli, preserving cognitive resources and reducing fatigue that can further exacerbate tinnitus symptoms.

By integrating amplification with sophisticated sound therapy features, hearing aids provide a multi-faceted approach to tinnitus management. Properly programmed and supported by counseling, hearing aids can help tinnitus sufferers achieve reduced perception and distress, ultimately improving their quality of life.

Both hyperacusis and misophonia are common disorders of sound tolerance. Hyperacusis is a reduced tolerance to sound level. Misophonia is a reduced tolerance to specific sounds or stimuli associated with specific sounds. People with hyperacusis typically respond to intolerable loudness levels with pain or discomfort. The response in people with misophonia to trigger sounds is often emotional such as rage or disgust. While there are no current established diagnostic criteria, multiple questionnaires are used to diagnose and monitor the severity of hyperacusis and misophonia. Hyperacusis may be experienced by 0.2–17.2% of the general population and misophonia has been found in 19.9–49% of students. Hyperacusis is often associated with tinnitus, Williams syndrome, and autism spectrum disorder. Misophonia is frequently comorbid with psychiatric disorders. Cognitive behavioral therapy (CBT) is an appropriate first-line and evidence-supported method for treatment. Programs of CBT specific to misophonia have been developed. Auditory therapy consists of passive sound attenuators, sound maskers or generators, and tinnitus retraining therapy (TRT). For patients with tinnitus, TRT may successfully alleviate disease burden of hyperacusis. There are no routine medical or surgical procedures provided for misophonia or hyperacusis at this time. Surgical intervention for intractable hyperacusis includes round and oval window reinforcement. Medical management for misophonia has been included in case reports with drugs commonly used for ADHD, OCD, psychosis, and panic disorder. Multi-modal migraine prophylaxis has successfully alleviated symptoms of hyperacusis. This consists of both lifestyle modifications, supplementation, and escalating treatment with nortriptyline, verapamil, and/or topiramate. As more people suffering from misophonia and hyperacusis seek diagnoses and treatments, there are opportunities for social support and future research.

Pulsatile tinnitus (PT) is defined as the self-perception of one’s blood flow, accounting for about 4% of all patients with a chief complaint of tinnitus. PT etiologies can be classified into different categories, including abnormal sound production such as sigmoid sinus wall and transverse sinus anomalies, abnormal sound perception like third mobile window syndromes and Eustachian tube dysfunction, a combination of both, or causes of unknown mechanisms such as migraine and Meniere’s disease. It is crucial to explain to patients that PT is a symptom of an underlying disease. Based on the findings of a comprehensive review of the patient’s medical history, focusing on PT and its associated otologic and non-otologic symptoms, physical examination, and hearing evaluation, appropriate imaging can be ordered to aid in the diagnosis. Parasympathetic paragangliomas, specifically jugulotympanic paraganglia, are associated with PT due to their location within the middle ear and/or jugular foramen. In addition, PT is one of the most common presenting symptoms in patients with idiopathic intracranial hypertension (IIH). Furthermore, sigmoid sinus wall abnormalities and transverse sinus stenosis, frequently associated with IIH, can also cause PT. Dural vascular lesions, specifically type I lesions of the transverse sigmoid sinus, are an important cause of arterial PT. A dehiscence in the superior semicircular canal is another cause of PT by increasing inner ear compliance and sensitivity to bone-conducted sounds as well as potentially having the third window transmitting dural pulsations to the cochlea. Finally, in patients with a normal imaging workup and normal neuroophthalmologic exam, otologic migraine should be considered as a potential etiology for PT. For each of these conditions, several treatment options are available. However, when a specific cause cannot be found, non-specific treatments, such as tinnitus habituation therapies, masking, and cognitive therapies, like cognitive behavioral therapy, can be employed.

Childhood tinnitus is characterized by ‘phantom auditory perceptions’ in the absence of external stimuli, which poses significant challenges for pediatric healthcare providers. This chapter offers an overview of the underlying factors and treatment modalities available for children with tinnitus. Despite the broad estimates for its prevalence, childhood tinnitus often goes underreported due to communication barriers by children. Various factors such as hearing loss, noise exposure, and psychological stressors contribute to its onset, underscoring the importance of comprehensive assessment and tailored interventions. Treatment options for childhood tinnitus include counseling, psychological therapies, sound therapy, and amplification devices. Counseling serves as a cornerstone, educating children and parents about tinnitus while addressing associated psychological distress. Cognitive Behavioral Therapy (CBT) aims to modify unhelpful thoughts and behaviors, although its efficacy in children necessitates further investigation. Additionally, biofeedback training, relaxation techniques, and mindfulness-based interventions offer alternative avenues for managing tinnitus-related stress. Sound therapy, including masking and Tinnitus Retraining Therapy (TRT), aims to alleviate tinnitus perception and distress. However, evidence supporting their effectiveness in children remains limited, highlighting the need for future research. Amplification devices like hearing aids and cochlear implants may provide relief for children with concurrent hearing loss, though their efficacy specifically for tinnitus management requires further exploration. Pharmacotherapy and migraine management strategies are emerging as potential avenues for tinnitus relief, emphasizing the multifaceted approach needed to address childhood tinnitus. Moreover, managing tinnitus-related challenges in the classroom is essential for supporting children’s educational progress. In conclusion, childhood tinnitus presents a complex clinical scenario requiring tailored interventions addressing both auditory and psychological aspects. Further research is warranted to elucidate optimal treatment strategies and improve outcomes for affected children.

Hearing loss is frequently linked to tinnitus. It is believed that damage to the auditory system, such as hair cell loss in the inner ear, can lead to hearing loss and tinnitus. Despite advances in noninvasive and invasive neuromodulation techniques for tinnitus management, a permanent solution remains elusive. During the early stages of life and growth, stem cells possess an exceptional ability to differentiate into a wide spectrum of cell types within the body. They can also divide and differentiate to replenish other cells, serving as the body’s built-in repair system. One of the key advantages of stem cell treatment is its capability to provide long-lasting and possibly permanent cures for diseases and injuries that were formerly considered untreatable. Stem cell therapy has become a promising strategy for managing tinnitus, providing the potential to recover impaired hair cells and auditory neurons. with promising results in preclinical studies showing the ability of stem cells to repair damaged auditory pathways and reduce tinnitus. Ongoing research in stem cell biology, coupled with precise delivery techniques and thorough clinical trials, continues to advance the potential role of stem cell therapy as a groundbreaking approach for alleviating tinnitus. To further improve their therapeutic potential, stem cells may be used in conjunction with growth factors and gene editing methods. This emerging therapeutic approach offers hope for those who suffer from chronic and debilitating tinnitus, potentially enhancing the quality of life for countless patients. Nevertheless, many challenges and ethical concerns associated with stem cell therapy still need to be addressed, such as the risk of immune rejection, tumor formation, and the ethical implications of using embryonic stem cells.

The following section is included:

• Index