Cost Effectiveness of Cognitive Behavioral Therapy for the Treatment of Subjective Tinnitus in Australia.

OBJECTIVES: The aim of this study was to conduct an economic evaluation for the treatment of subjective tinnitus using different modalities of cognitive behavioral therapy (CBT) in Australia. DESIGN: A decision tree model was used to conduct a cost-utility analysis for CBT to determine the cost effectiveness for tinnitus treatments, in terms of cost per responder and cost per quality-adjusted life-year (QALY), from a health system perspective using a 2-year time horizon. Meta-analysis was used to differentiate the levels of effectiveness between three delivery methods for CBT: individual face-to-face care (fCBT), group sessions (gCBT), and a supported internet program (iCBT). One-way sensitivity analysis and probabilistic sensitivity analysis (PSA) explored the uncertainty surrounding model inputs and outcomes. Results were presented as incremental cost-effectiveness ratios compared with no treatment, and as net monetary benefit at a $50,000 willingness-to-pay threshold. RESULTS: Compared with no treatment, the incremental cost per responder was $700 for gCBT, $871 for iCBT, and $1380 for fCBT. The base case incremental cost-effectiveness ratio was $35,363 per QALY for fCBT, $17,935 per QALY for gCBT, and $22,321 per QALY for iCBT compared with no treatment, although there was substantial uncertainty around the QALY gain for responders. Net monetary benefit was $356 (fCBT), $555 (gCBT), and $487 (iCBT), indicating the treatments were cost effective compared with no treatment. One-way sensitivity analysis revealed the results were most sensitive to the probability of a positive response to treatment and treatment length. The PSA found the probability of being cost effective compared with no treatment for gCBT was 99.8%, iCBT 98.4%, and fCBT 71.5% at a willingness-to-pay of $50,000 per QALY, although QALY gain remained at a fixed value in the PSA. CONCLUSIONS: CBT for tinnitus was likely to be cost effective compared with no treatment regardless of treatment modality, assuming they are not mutually exclusive. Of the interventions, gCBT was the lowest cost per responder and lowest cost per QALY. Internet CBT obtained comparable economic outcomes due to similar treatment effectiveness and cost. Group CBT and iCBT warrant greater adoption in clinical practice for the treatment of subjective tinnitus. Further research on preference-based utility measures for varying levels of tinnitus severity and the durability of treatment effect is required to enhance the quality of economic evaluation in this field.

Development of a Diagnostic Prediction Model for Conductive Conditions in Neonates Using Wideband Acoustic Immittance.

OBJECTIVES: Wideband acoustic immittance (WAI) is an emerging test of middle-ear function with potential applications for neonates in screening and diagnostic settings. Previous large-scale diagnostic accuracy studies have assessed the performance of WAI against evoked otoacoustic emissions, but further research is needed using a more stringent reference standard. Research into suitable quantitative techniques to analyze the large volume of data produced by WAI is still in its infancy. Prediction models are an attractive method for analysis of multivariate data because they provide individualized probabilities that a subject has the condition. A clinically useful prediction model must accurately discriminate between normal and abnormal cases and be well calibrated (i.e., give accurate predictions). The present study aimed to develop a diagnostic prediction model for detecting conductive conditions in neonates using WAI. A stringent reference standard was created by combining results of high-frequency tympanometry and distortion product otoacoustic emissions. DESIGN: High-frequency tympanometry and distortion product otoacoustic emissions were performed on both ears of 629 healthy neonates to assess outer- and middle-ear function. Wideband absorbance and complex admittance (magnitude and phase) were measured at frequencies ranging from 226 to 8000 Hz in each neonate at ambient pressure using a click stimulus. Results from one ear of each neonate were used to develop the prediction model. WAI results were used as logistic regression predictors to model the probability that an ear had outer/middle-ear dysfunction. WAI variables were modeled both linearly and nonlinearly, to test whether allowing nonlinearity improved model fit and thus calibration. The best-fitting model was validated using the opposite ears and with bootstrap resampling. RESULTS: The best-fitting model used absorbance at 1000 and 2000 Hz, admittance magnitude at 1000 and 2000 Hz, and admittance phase at 1000 and 4000 Hz modeled as nonlinear variables. The model accurately discriminated between normal and abnormal ears, with an area under the receiver-operating characteristic curve (AUC) of 0.88. It effectively generalized to the opposite ears (AUC = 0.90) and with bootstrap resampling (AUC = 0.85). The model was well calibrated, with predicted probabilities aligning closely to observed results. CONCLUSIONS: The developed prediction model accurately discriminated between normal and dysfunctional ears and was well calibrated. The model has potential applications in screening or diagnostic contexts. In a screening context, probabilities could be used to set a referral threshold that is intuitive, easy to apply, and sensitive to the costs associated with true- and false-positive referrals. In a clinical setting, using predicted probabilities in conjunction with graphical displays of WAI could be used for individualized diagnoses. Future research investigating the use of the model in diagnostic or screening settings is warranted.

No evidence for enhanced processing of speech that is low-pass filtered near the edge frequency of cochlear dead regions in children.

OBJECTIVES: Cochlear dead regions (DRs) are regions in the cochlea where the inner hair cells and/or neurons are not functioning. Adults with extensive high-frequency DRs have enhanced abilities in processing sounds with frequencies just below the edge frequency, fedge, of the DR. It was assessed whether the same is true for children. DESIGN: Performance was compared for children aged 8 to 13 years with: DRs (group DR), hearing impairment but without DRs (group NODR), and normal hearing (group NH). Seven ears in each group were tested. Each ear in the DR group was matched in age and low-frequency hearing with an ear in the NODR group, and in age with an ear in the NH group, giving seven "triplets". Within each triplet, the percent correct identification of vowel-consonant-vowel stimuli was measured using stimuli that were low-pass filtered at fedge and 0.67fedge, based on the ear with a DR. For the hearing-impaired ears, stimuli were given frequency-selective amplification as prescribed by DSL 4.1. RESULTS: No significant differences in performance were found between groups for either low-pass cut-off frequency. CONCLUSION: Unlike adults, the children with DRs did not show enhanced discrimination of speech stimuli with frequencies below fedge.

Clinical feasibility of fast psychophysical tuning curves evaluated using normally hearing adults: success rate, range of tip shift, repeatability, and comparison of methods used for estimation of frequency at the tip.

OBJECTIVE: Psychophysical tuning curves (PTCs) have been used predominantly in laboratory settings to assess frequency selectivity in the auditory system. Recently, a fast-PTC procedure has been developed for diagnosis of cochlear dead regions. In this study the clinical feasibility of using fast PTCs in adults was investigated. Success rate (the number of successes per number of attempts) and repeatability were assessed. The range of the tip frequency (ftip) shift was established and different methods of ftip estimation compared. DESIGN: Fast PTCs were measured for signal frequencies (fs) of 500, 1000, 2000, 3000, and 4000 Hz on two occasions using an upward-sweeping masker. Five methods were used to estimate ftip for each PTC. STUDY SAMPLE: Thirty-two adults with normal hearing were tested. RESULTS: All participants were able to successfully complete the task, the majority of them with minimal training. The moving average, quadratic function, and double lowpass filtering methods had the highest success rate in ftip estimation. The quadratic function method had the smallest 95% range of - 3.4% fs to 10.2% fs and the best test-retest reliability of 5.1% fs. CONCLUSIONS: Fast PTCs show potential for clinical use due to a high success rate with minimal training required. We suggest the quadratic function method for routine clinical use as it had the smallest 95% range, a high success rate in ftip estimation and the best test-retest reliability. For fast PTCs measured for signal frequencies from 500 to 4000 Hz using an upward-sweeping masker, we suggest the normative range of ftip to be - 3% fs to 10% fs with a test-retest reliability of 5% fs.

The effect of low-pass filtering on identification of nonsense syllables in quiet by school-age children with and without cochlear dead regions.

OBJECTIVES: The presence of cochlear dead regions (DRs) can have a significant effect on speech perception. Some studies have reported that adults do not benefit from amplification of frequencies well inside an extensive DR. However, the importance of high-frequency amplification for hearing-impaired children has been emphasized by many researchers. This study investigates the benefit of high-frequency amplification for children with various degrees of high-frequency hearing impairment, with and without DRs. DESIGN: The children, aged 8 to 13 years, were divided into two groups according to the severity of their hearing impairment. Group MS had moderate to severe impairment (9 ears without DRs and 3 ears with restricted DRs). Group SP had severe to profound hearing impairment (7 ears with DRs and 1 ear without a DR). The vowel-consonant-vowel stimuli were subjected to the frequency-gain characteristics prescribed by the desired sensation level fitting method and presented via headphones broadband and under various low-pass filtering conditions. RESULTS: Group MS benefited from high-frequency amplification whether or not a restricted DR was present. In contrast, ears in group SP with continuous extensive DRs showed limited benefit from high-frequency amplification. For the latter, performance improved with increasing cutoff frequency up to approximately 1 octave above the edge frequency of the DR and generally stayed the same, or deteriorated, with further increases in bandwidth. In one case of severe to profound hearing impairment without evidence of DRs, performance increased with increasing cutoff frequency up to 2 kHz and remained almost constant with further increases in bandwidth. CONCLUSIONS: For children with severe to profound hearing impairment and continuous high-frequency DRs commencing from approximately 1 kHz, applying amplification only for frequencies up to approximately 1 octave above the edge frequency of the DR may be of benefit. Tests with more participants are needed to confirm this finding.

Hallucinations in Hearing Impairment: How Informed Are Clinicians?

BACKGROUND AND HYPOTHESIS: Patients with hearing impairment (HI) may experience hearing sounds without external sources, ranging from random meaningless noises (tinnitus) to music and other auditory hallucinations (AHs) with meaningful qualities. To ensure appropriate assessment and management, clinicians need to be aware of these phenomena. However, sensory impairment studies have shown that such clinical awareness is low. STUDY DESIGN: An online survey was conducted investigating awareness of AHs among clinicians and their opinions about these hallucinations. STUDY RESULTS: In total, 125 clinicians (68.8% audiologists; 18.4% Ear-Nose-Throat [ENT] specialists) across 10 countries participated in the survey. The majority (96.8%) was at least slightly aware of AHs in HI. About 69.6% of participants reported encountering patients with AHs less than once every 6 months in their clinic. Awareness was significantly associated with clinicians' belief that patients feel anxious about their hallucinations (ß = .018, t(118) = 2.47, P < .01), their belief that clinicians should be more aware of these hallucinations (ß =.018, t(118) = 2.60, P < .01), and with confidence of clinicians in their skills to assess them (ß = .017, t(118) = 2.63, P < .01). Clinicians felt underequipped to treat AHs (Median = 31; U = 1838; PFDRadj < .01). CONCLUSIONS: Awareness of AHs among the surveyed clinicians was high. Yet, the low frequency of encounters with hallucinating patients and their belief in music as the most commonly perceived sound suggest unreported cases. Clinicians in this study expressed a lack of confidence regarding the assessment and treatment of AHs and welcome more information.

Diagnosing cochlear dead regions in children.

OBJECTIVE: A dead region (DR) is defined as a region in the cochlea where inner hair cells and/or neurons are functioning so poorly that a tone producing peak vibration in this region is detected by off-frequency listening, i.e., via a place on the basilar membrane with a characteristic frequency different from that of the tone. The presence of a DR can have a significant effect on the perception of speech. People with and without DRs may differ in the benefit obtained from amplification and require different hearing aid settings. The Threshold Equalizing Noise (TEN) test and psychophysical tuning curves (PTCs) are two procedures used to identify a DR in adults. Because diagnosing a DR involves measuring masked thresholds, and there are reports in the literature that young children perform poorly compared with adults in background noise, it may be possible that the criteria used with adults may not be appropriate when testing children. Therefore, the aim of this study was to evaluate the consistency of the fast-PTC and TEN tests in diagnosing a DR in hearing-impaired children. In addition, the masked thresholds for normal-hearing children were measured with different TEN levels to assess whether any age-related effect in children compared with adults may occur. DESIGN: Participants were divided into two groups: eight normal-hearing children (16 ears) and 12 hearing-impaired children (21 ears), aged 7 to 13 yr. TEN is based on measuring masked threshold in TEN. For normal-hearing participants, the masked thresholds were measured for five levels of noise (30, 40, 50, 60, and 70 dB per averaged equivalent rectangular bandwidth). For hearing-impaired participants, the level of the TEN was selected separately for each ear based on the highest acceptable level minus 5 dB. The TEN test results in hearing-impaired children were further validated by measuring fast-PTCs. The fast-PTC technique involves measuring the level of the narrowband noise masker needed to mask the signal. The center frequency of the masker sweeps across the required frequency range. RESULTS: The masked thresholds in TEN measured for normal-hearing children were usually below and never higher than 5 dB above TEN level per averaged equivalent rectangular bandwidth. This suggests that no age-related effect on masked threshold in children compared with adults was observed. All hearing-impaired children were able to perform the TEN test and fast-PTCs. The results of the two tests were consistent in 17 of 21 ears (81%): eight ears did not show evidence of a DR and nine ears did. In three ears, the criteria for a DR were met on the TEN test, but there was no evidence of a DR on the fast-PTC test. In one ear, the TEN test did not show evidence of DRs at two frequencies, whereas fast-PTCs did. CONCLUSIONS: The results of this study suggest that DRs can be detected in children using the fast-PTC technique and the TEN test interpreted with the adult criteria, which are the most appropriate in terms of specificity and sensitivity. However, in cases in which the masked threshold is 10 to 15 dB above the TEN level, it is recommended to confirm DR diagnosis with fast-PTC measurement.

Fast method for psychophysical tuning curve measurement in school-age children.

The 'fast' method for measuring psychophysical tuning curves (PTC) uses a masker that sweeps across frequency and a Békésy threshold tracking procedure. The fast-PTC procedure has been recommended as a technique for diagnosing cochlear dead regions in adults. The aim of this study was to evaluate the fast-PTC procedure in children. Twelve normal-hearing children (7-10 years old) and five adults were tested. The fast-PTCs were measured for 1000 and 4000 Hz signals using ascending and descending masker sweeps. Measurements were repeated on a separate day to assess test-retest variability. All children were able to perform the task; however it was possible to define the tip in only 87% of the fast-PTCs. Although the variability in tip frequency was higher for children, the mean difference between children and adults was not statistically significant. As expected, the difference on retest was higher for children. Studies investigating the use of the fast-PTC procedure with hearing-impaired children are warranted.

Diagnosing Conductive Dysfunction in Infants Using Wideband Acoustic Immittance: Validation and Development of Predictive Models.

Purpose The aims of this study were (a) to validate the wideband acoustic immittance (WAI) model developed by Myers et al. (2018a) in a new sample of neonates and (b) to develop a prediction model for diagnosing middle ear dysfunction in infants aged 6-18 months using wideband absorbance, controlling for the effect of age. Method Tympanometry, distortion product otoacoustic emissions, and WAI were measured in 124 neonates and longitudinally in 357 infants at 6, 12, and 18 months of age. Results of tympanometry and distortion product otoacoustic emissions were used to assess middle ear function of each infant. For the first study, results from the neonates were applied to the diagnostic WAI model developed by Myers et al. (2018a). For the second study, a prediction model was developed using results from the 6- to 18-month-old infants. Results from 1 ear of infants in each age group (6, 12, and 18 months) were used to develop the model. The amount of bias (overfitting) was estimated with bootstrap resampling and by applying the model to the opposite ears (the test sample). Performance was assessed using measures of discrimination (c-index) and calibration (calibration curves). Results For the validation study, the Myers et al. (2018a) model was well calibrated and had a c-index of 0.837 when applied to a new sample of neonates. Although this was lower than the apparent performance c-index of 0.876 reported by Myers et al., it was close to the bias-corrected estimate of 0.845. The model developed for 6- to 18-month-old infants had satisfactory calibration and apparent, bias-corrected, and test sample c-index of 0.884, 0.867, and 0.887, respectively. Conclusions The validated and developed models may be clinically useful, and further research validating, updating, and assessing the clinical impact of the models is warranted.

Diagnosing Middle Ear Dysfunction in 10- to 16-Month-Old Infants Using Wideband Absorbance: An Ordinal Prediction Model.

Purpose The aim of this study was to develop an ordinal prediction model for diagnosing middle ear dysfunction in 10- to 16-month-old infants using wideband absorbance. Method Wideband absorbance, tympanometry, and distortion product otoacoustic emissions were measured in 358 ears of 186 infants aged 10-16 months (M age = 12 months). An ordinal reference standard (normal, mild, and severe middle ear dysfunction) was created from the tympanometry and distortion product otoacoustic emission results. Absorbance from 1000 to 5657 Hz was used to model the probability of middle ear dysfunction with ordinal logistic regression. Model performance was evaluated using measures of discrimination (c-index) and calibration (calibration curves). Performance measures were adjusted for overfitting (bias) using bootstrap resampling. Probabilistic and simplified methods for interpreting the model are presented. The probabilistic method displays the probability of ≥ mild and ≥ severe middle ear dysfunction, and the simplified method presents the condition with the highest probability as the most likely diagnosis (normal, mild, or severe middle ear dysfunction). Results The c-index of the fitted model was 0.919 (0.914 after correction for bias), and calibration was satisfactory for both the mild and severe middle ear conditions. The model performed well for the probabilistic method of interpretation, and the simplified (most likely diagnosis) method was accurate for normal and severe cases but diagnosed some cases with mild middle ear dysfunction as normal. Conclusions The model may be clinically useful, and either the probabilistic or simplified paradigm of interpretation could be applied, depending on the context. In situations where the main goal is to identify severe middle ear dysfunction and ease of interpretation is highly valued, the simplified interpretation may be preferable (e.g., in a screening clinic that may not be concerned about missing some mild cases). In a diagnostic clinical environment, however, it may be beneficial to use the probabilistic method of interpretation.

Longitudinal Development of Wideband Absorbance and Admittance Through Infancy.

Purpose The aim of this article was to study the normal longitudinal development of wideband absorbance and admittance measures through infancy. Method Two hundred one infants who passed the newborn hearing screen (automated auditory brainstem response) were tested at birth and then followed up at approximately 6, 12, and 18 months of age. Most infants were of either White (86%) or Asian (11%) descent. At each test session, infants passed tympanometry and distortion product otoacoustic emission tests. High-frequency (1000-Hz) tympanometry was used at birth and 6 months of age, and low-frequency (226-Hz) tympanometry was used at 12 and 18 months of age. Wideband pressure reflectance was also measured at each session and analyzed in terms of absorbance, admittance at the probe tip, and admittance normalized for differences in ear canal area. Multilevel hierarchical models were fitted to the absorbance and admittance data to investigate for effects of age, ear side, gender, ethnicity, and frequency. Results There were considerable age effects on wideband absorbance and admittance measurements over the first 18 months of life. The most dramatic changes occurred between birth and 6 months of age, and there were significant differences between all age groups in the 3000- to 4000-Hz region. There were significant ethnicity effects that were substantial for certain combinations of ethnicity, age, and frequency (e.g., absorbance at 6000 Hz at 12 months of age). Conclusion There are large developmental effects on wideband absorbance and admittance measures through infancy. For absorbance, we recommend separate reference data be used at birth, 6 months of age, and 12-18 months of age. For admittance (both normalized and at the probe tip), we advise using separate normative regions for each age group (neonates and 6, 12, and 18 months).

Diagnosing Middle Ear Pathology in 6- to 9-Month-Old Infants Using Wideband Absorbance: A Risk Prediction Model.

Purpose: The aim of this study was to develop a risk prediction model for detecting middle ear pathology in 6- to 9-month-old infants using wideband absorbance measures. Method: Two hundred forty-nine infants aged 23-39 weeks (Mdn = 28 weeks) participated in the study. Distortion product otoacoustic emissions and high-frequency tympanometry were tested in both ears of each infant to assess middle ear function. Wideband absorbance was measured at ambient pressure in each participant from 226 to 8000 Hz. Absorbance results from 1 ear of each infant were used to predict middle ear dysfunction, using logistic regression. To develop a model likely to generalize to new infants, the number of variables was reduced using principal component analysis, and a penalty was applied when fitting the model. The model was validated using the opposite ears and with bootstrap resampling. Model performance was evaluated through measures of discrimination and calibration. Discrimination was assessed with the area under the receiver operating characteristic curve (AUC); and calibration, with calibration curves, which plotted actual against predicted probabilities. Results: AUC of the fitted model was 0.887. The model validated adequately when applied to the opposite ears (AUC = 0.852) and with bootstrap resampling (AUC = 0.874). Calibration was satisfactory, with high agreement between predictions and observed results. Conclusions: The risk prediction model had accurate discrimination and satisfactory calibration. Validation results indicate that it may generalize well to new infants. The model could potentially be used in diagnostic and screening settings. In the context of screening, probabilities provide an intuitive and flexible mechanism for setting the referral threshold that is sensitive to the costs associated with true and false-positive outcomes. In a diagnostic setting, predictions could be used to supplement visual inspection of absorbance for individualized diagnoses. Further research assessing the performance and impact of the model in these contexts is warranted.

The effect of rTMS on auditory processing in adults with chronic, bilateral tinnitus: a placebo-controlled pilot study.

BACKGROUND: On the basis that tinnitus may result from neural hyperactivity in the auditory cortex, researchers have investigated the use of low frequency (1 Hz) repetitive transcranial magnetic stimulation (rTMS) as a potential modulator of this hyperactivity. While these investigations show promise, investigations to date have neglected to consider the possible effect of 1 Hz rTMS on other functions of the auditory cortex of these individuals, such as auditory processing. OBJECTIVE/HYPOTHESIS: This placebo-controlled pilot study aimed to determine whether 1 Hz rTMS applied to the primary auditory cortex (PAC), specifically Brodmann Area 41 (BA41), of adults with chronic, bilateral tinnitus would influence their auditory processing abilities. METHODS: Eight participants with bilateral, chronic tinnitus were randomized to receive a 10-day course of neuronavigationally guided active rTMS (n = 4) or placebo rTMS (n = 4) treatment applied to a focal region of the left PAC (BA41). Participants' auditory processing was measured using Time Compressed Reverberant Speech and three-pair Dichotic Digits (DD). Their tinnitus was measured using the Tinnitus Handicap Inventory (THI) and a psychoacoustic measure of tinnitus perception. All outcome measures were administered at baseline (1 week prior to rTMS), 1 week, 1, 2 and 3 months post-rTMS. RESULTS: All four participants in the active rTMS (A) group, and none of the participants in the sham (placebo) rTMS (S) group, showed improved auditory processing scores at multiple assessment points post-stimulation, with the group differences in median normalized gain scores reaching significance at the 5% level from 1 week or 1 month post-stimulation onwards. Three of the four participants in the active rTMS (A) group, and none of the participants in the sham rTMS (S) group, showed improved tinnitus scores at multiple assessment points post-stimulation, with some of the group differences in median normalized gain scores reaching significance at the 5% level. CONCLUSIONS: The results of this preliminary study suggest that 1 Hz rTMS applied to the PAC (BA41) has the capacity to improve both auditory processing and tinnitus perception in some adults with chronic, bilateral tinnitus.