An X-ray picture of tinnitus treatment in Europe


Tinnet 2017

Researchers from TINNET, the International Tinnitus Network, shared the results of their complementary work on this disorder at a conference held on march 31 at Madrid's Complutense University.

Among fields explored in different countries by the group's members were measurement techniques for evaluating tinnitus, genotype studies, cerebral factors, and chiropractic treatment. Results included several studies involving patients, a database, and a survey amongst professionals of tinnitus in 24 European countries with special factors distinguishing three zones - North, South, and East - which revealed frequent use of TRI (Tinnitus Retraining Therapy) and other sound-based therapies, as well as general lack of treatment for what has been a long-endured pathology in many countries.

The latest European TINNET Conference 2017 was held in Madrid, coordinated by Spaniards Isabel Diges, director of the Acure Clinic (Madrid) for tinnitus and hyperacusis, and José Antonio López-Escámez, head of the Otology and Otoneurology Research Group at the ENT unit, San Cecilio Hospital, Granada. These periodic meetings bring together scientific teams from different countries so they can update each other on advances in their different investigations, thus contributing to coordinated progress without overlapping or repeating work, and to a complementary approach, explained Isabel Diges, the Spanish representative at this European-funded programme.

This multiple focus, which began some years ago, provides an x-ray picture of the current treatment situation in tinnitus across the continent. Among the results presented were those of a voluntary survey that received 625 answers from professionals in 24 countries from January to October, 2015. It shows, among other things, that of the first two treatment options for patients with this complaint, the most frequent are sound therapies and TRT, these appearing as the first choice in studies of all three zones, along with drug treatments in the east. As a second option, professionals choose the same treatments in reverse order, i.e. the more frequent treatment being the one not used as a first option, with the use of assessment being incorporated in the north of Europe. This internet survey was presented by Dimitris Kikidis from Athens, Greece, and it required a second round of consultations after the scarce response obtained initially in Spain, Italy, France, and Israel. In total, 264 answers were registered which ticked treatment with drugs, 56%; 244 ticked assessment, 52% of the total; another 233 indicated sound therapies with hearing aids and sound generators, 49%; 162 ticked relaxation techniques, 34%; 134 psychotherapy, 26.6%; 128 TRT, 27%; 77 cognitive behavioural therapy, 16%; and finally other techniques, amounting to less than 10% of answers, such as alternative therapies or TMS (transcranial magnetic stimulation).

Lack of knowledge and cover

Another relevant datum concerning the treatment cover for tinnitus sufferers reveals that there is still a long way to go; 58% of all answers to the question of whether tinnitus clinics exist in the respondent’s country were affirmative, therefore 42% answered in the negative. This is nuanced by the great variability between countries and different answers within each state. In this respect, while 100% answered ‘yes’ in Belgium and Germany, in the Czech Republic the percentage was half that (50%), and 60% of respondents in Greece claimed there were no professional clinics. Also evident from the surveys were the shortage of organised networks, medical approaches and protocols, as well as communication errors. And even in countries where there is awareness of tinnitus, more than 10% of respondents answered that no such service exists, as in Holland and Poland, for example, thus giving an idea of the lack of awareness that exists amongst professionals. The study also reflects “deviations from recommendations”: guidelines do not exist or are not followed; standardised procedures are lacking; there is a shortage of tinnitus clinics and multidisciplinary teams; treatments proven to be inefficacious are still being used, while those that are effective are not used; results from validated measurements are not adapted globally. With regard to time devoted to each visit, professionals in the north of Europe mostly declared between 30 minutes and one hour (41%), while less time is given in the south and east, respectively 43% with 56% admitting to winding up visits in 15 to 30 minutes.

Genetics and brain activity

One of the organisers of the Spanish gathering, José Antonio López-Escamez, explained strategies applied to patient selection and genomic studies, with the conclusion that a selection of individuals based on a specific phenotype will provide the identification of genes involved in resilience (adaptation) to tinnitus and susceptibility to it. Another conclusion is that a fresh taxonomy (classification) of tinnitus disturbances needs to include clinical and genetic information, and also that better understanding of the pathways involved will benefit the development of new treatments, among other things.

Meanwhile, Dutch specialist Emile de Kleine (Groningen) focused on the relation between tinnitus and activity in the auditory cortex, which does not only involve the central auditory system but also the limbic system and, possibly, the frontal lobe and cerebellum. He pointed out stronger fluctuations in the brain as a whole, and highlighted reduced functional connections within the central auditory system. Following in this field of research, Peyman Adjamian (Nottingham, UK), referred to the cerebral networks of tinnitus, underlining that—as published by Vanneste and De Ridder in 2012—magnetoencephalography (MEG) used as a source of localisation allows for study of how its oscillations relate to changes produced in some areas of the auditory cortex, the dorsal anterior cingulate and posterior cingulate cortices, the dorsolateral prefrontal cortex, regions of the frontal cortex, and the parahippocampus. Brain function (perception and cognition) depends on integrated activity between different areas and it is reasonable to assume that a large network of cerebral areas is involved in tinnitus interactions. For example, the interaction between auditory and non-auditory areas processing emotion and attention. How does the brain integrate information in order to form a coherent perception? The neurons that oscillate together work together and connect in this way. To sum up, Adjamian explained how MEG and electroencephalography (EEG) reveal aspects of tinnitus, measuring different features of the same neural phenomena and, among other conclusions, he pointed out that: variable effects result in the individual’s attention—sometimes uncontrollable—and that “comorbid” conditions can be present or absent, essentially hyperacusis; age is an influence, as well as the degree of hearing loss; and that connectivity methods are used to carry out statistical assessments of the functional relations between the temporal dynamics of signals. Furthermore, given the apparent heterogeneity of tinnitus sounds, care must be taken with subtypes of conditions that have important and necessary results. In fact, there are discrepancies in the literature published on these tests for tinnitus.

Tinnet 2017
Isabel Diges and José Antonio López-Escámez ©J.L.F.

International database

German specialists Berthold Langguth and Michael Landgrebe, from Regensburg, talked about the international database they are building, as well as its legal fundaments, while Deborah Hall, from Nottingham, UK, described a study carried out on a sample of 1,344 patients aged from 16 to 88, in which multiple variables were evaluated. In close relation, she delved deep into the question of the need to measure and into how to measure, drawing on her experience in 228 clinical tests on adult tinnitus sufferers. Delegates showed interest in 35 domains of primary results and 60 among secondary results, while seven categories of aspects were put forward for analysis: perception of tinnitus, impact, associated complaints, quality of life, structures and functions of the organism, results related to treatment, and “unclear or miscellaneous”.

Professionals were asked for their thoughts on each one of the 66 different tinnitus domains: “Is it of critical importance to decide whether a treatment has had effects? Was anything missing?

Meanwhile, Lisbon’s Alain Londero and Haula Haider advocated the establishment of “minimum” and standard measurement protocols for the community of professionals dealing with this health problem.

The gathering also saw discussion of quiropractic therapies carried out in Milan, Italy, through manual stimulation of the vertebral column, specifically between the first and second cervical vertebrae, as a means of relaxation and to correctly modify posture and tone-up neck muscles. This was repeated over three months, and Luca del Bo’s team observed a “strong reduction” in the disabling effects of tinnitus, with reductions in four out of five patients. These “preliminary” results suggest a causal relationship between quiropractic treatment and tinnitus, which this group hypothetically attributes to better blood flow to the cochlea, as well as effects on neural activity and the efferent system.

Tinnitus hub on Internet

The UK’s Steve Harrison presented the so-called internet site Tinnitus Hub, a non-profit initiative started in 2015 with the idea of linking up patients to researchers. It now boasts 200,000 unique visitors per month and 2.3m in the last 12 months, with half this traffic registered in the US, followed a long way behind by the UK (15%) and, with percentages under 10%, in this order, Canada, Australia, India, Holland, Germany, Ireland, France, and Sweden. The scheme’s commitment to “impartiality” is patent, since it seeks no advertising.

A survey run by this channel last year obtained 5,017 answers, and had the cooperation of the Tinnitus Research Initiative (TRI) and participation from the University of Magdeburg (Germany) in processing its data. It is set up to predict what patients will want to discuss about their tinnitus (the condition itself, treatment, evolution, recommendations). Goals in sight for the next 12 months include, among others, a small selection of “high-value”projects, collaboration with researchers so that they can have greater impact, involving patients in tests, and an internet audio site so that a sound profile can be established, one that is wider than the traditional four-octave profile, differentiating between right and left ear, with notice of a regular test and with tone and sound lined up to enable comprehension of tinnitus.

Another front emerging from “Tinnitus Hub” is the study of physical factors linked to the complaint which Sarah Michiels, from the University of Antwerp, Belgium, estimates as between 38% and 60% of cases, due to lesions, stiffening, ear blockage or jaw tension, among other things. Efforts are also being made to integrate research tools (such as TCHQ, TFI, and THS), and a support forum has been created as a self-help “don’t panic guide” for patients. On the benefits of “Tinnitus Hub” as a stream of collective information, Harrison highlighted its rapid accessibility for a very extensive group of people and to different populations, the volume of individual cases, and understanding of patients online. Among its disadvantages, he pointed to the fact that it only reaches patients with access to communications technology, so over- 65s are not currently well-represented. There is also the predominance of those who are suffering from tinnitus effects, as opposed to those who have managed to diminish effects, while there is “relative difficulty” in providing longitudinal data, i.e. from a long-term and continuous angle.

According to Harrison, the greatest foreseeable impact is noticeable in patients’ sense of involvement, and the improvement in speed and quality of information contributed by researchers worldwide.

The event also enjoyed the participation of Spanish experts Francisco Carricondo and Bárbara Romero, who offered a vision based on the research of Ramón y Cajal from the Neurobiology perspective, and Christopher Cederroth, from Stockholm, Sweden, who highlighted the genetic susceptibility of suffering bilateral tinnitusChristopher Cederroth, from Stockholm, Sweden, who highlighted the genetic susceptibility of suffering bilateral tinnitus in a sample of patients from his country.

European survey fact sheet

Number of persons surveyed by country: Lithuania (85), Portugal (82), Czech Republic (67), Spain (58), Belgium (53), Italy (48), Holland (40), France (37), Greece (28), Germany (26), Sweden (23), Denmark (14), UK (12), Israel (11), Malta (8), and Serbia (7).

By professional specialty: ENT (56%), audiologists (21%), neurologists (5%), psychiatrists (5%), psychologists (2.5%), and researchers (1.5%). The authors stress that despite the survey considering tinnitus as a problem of the central system, the majority of respondents were ENT.

By medical centre or establishment where respondent works: Surgery or private hospital (26%), state hospital (29%), state or private (18%), university (14%), and hearing care centre (4.5%). This is nuanced by universities being over-represented, the audiologist/hearing care professional category being unclear since there is no common framework, and by those working in the private sector who are paid by the state system.

José Luis Fernández, editor in chief of Audio Infos Spain