Pilot study on the role of somatic modulation in hyperacusis.

BACKGROUND: Hyperacusis is a reduced tolerance to sounds that often co-occurs with tinnitus. Both symptoms have convergent as well as divergent characteristics. Somatic modulation, changes in pitch or loudness during certain movements, is common in patients with a primary complaint of tinnitus. However, thus far, this is not documented in patients with hyperacusis. OBJECTIVES: This study aimed to examine the influence of somatic manoeuvres on the perception of external sounds in patients with a primary complaint of hyperacusis. METHODOLOGY: In this prospective cross-sectional pilot study, 18 patients with a primary complaint of hyperacusis were recruited at the Tinnitus Treatment and Research Center Antwerp (TINTRA). While patients listened to a 1 kHz broadband noise of 30 dB sensation level, six neck manoeuvres (flexion, extension, lateroflexion left/right, traction and compression), three jaw manoeuvres (protrusion, laterotrusion left/right) and one placebo manoeuvre (hand on head) were performed. The primary outcome measure was the change in the perception of the presented sound in terms of loudness and intrusiveness between baseline and each modulation measured by a visual analogue scale (VAS). RESULTS: No overall significant changes were found; however, individual results indicated that five patients presented a clinically relevant change of more than three points out of ten on VAS in terms of hyperacusis after at least one of the executed somatic manoeuvres. CONCLUSIONS: This pilot study did not demonstrate an overall significant change in hyperacusis after somatic manoeuvres but does not rule out the possibility of somatic modulation in some hyperacusis patients. TRIAL REGISTRATION: The protocol of this prospective cross-sectional pilot study was registered on clinicaltrials.gov with registration number NCT04693819.

The use of patient-report measures and intervention strategies for children and adolescents with chronic tinnitus: a scoping review.

BACKGROUND: Chronic tinnitus during childhood/adolescence can be associated with impaired quality of life. Guidelines for managing paediatric tinnitus recommend assessment and interventions are often based upon the experiences and opinions of guideline committee members. OBJECTIVE: To examine patient response tools used for the assessment and management of childhood tinnitus and how interventions had been evaluated. DESIGN: A structured scoping review (i) identifying and critically appraising patient response measures (PRMs) assessing tinnitus in children/adolescents, and (ii) critically appraising evidence supporting reported interventions. Original papers written in English, involving paediatric participants ≤19 years, reporting (i) application of established PRMs to assess the experience of chronic tinnitus or (ii) application and evaluation of tinnitus interventions were included. STUDY SAMPLE: Papers written in English, identifying, or assessing the experience of chronic tinnitus (>3 months) as a primary complaint during childhood/adolescence in participants ≤19 years of age using a PRM and studies evaluating the application of non-pharmaceutical interventions for tinnitus in children/adolescents. RESULTS: Six studies involving the assessment of tinnitus during childhood/adolescence using a PRM were identified and evaluated. Three established (previously named, described, and published) PRMs were applied of which none were developed specifically for children/adolescents. Three behavioural tinnitus interventions and three combination intervention strategies (coupling of psychological intervention with sound enrichment) had been applied to and evaluated within paediatric populations. CONCLUSIONS: Although clinicians are seeing children/adolescents with tinnitus, they are evaluating and managing children's distress without appropriate PRMs, and little evidence exists to support clinical interventions.

A Systematic Review and Meta-Analysis of Extended High-Frequency Hearing Thresholds in Tinnitus With a Normal Audiogram.

OBJECTIVES: Current evidence supports the growing application of extended high-frequency (EHF: 9 to 20 kHz) audiometry in hearing research, which likely results from the high vulnerability of this frequency region to damage induced by known auditory risk factors. The present systematic review and meta-analysis were performed to investigate whether adults with a normal audiogram and tinnitus show increased EHF hearing thresholds relative to control peers. DESIGN: A comprehensive search was undertaken on electronic databases consisting of PubMed, ScienceDirect, Wiley, and Google Scholar using combined keywords: "tinnitus," "extended high frequency," "normal audiogram," and "hidden hearing loss." RESULTS: From 261 articles found by searching databases, nine studies met the inclusion criteria for the meta-analysis. A significant difference was observed between tinnitus and control groups in the effect size analysis of hearing thresholds at 10, 12.5, 14, 16, and 18 kHz ( p ≤ 0.001), and the I-square heterogeneity analysis was below 50% in all studies ( p ≥ 0.131). Visual inspection by the Funnel plot and Egger's regression test ( p ≥ 0.211) also exhibited no publication bias in the meta-analyses. CONCLUSIONS: Our findings are in support of the idea that in most cases, tinnitus is associated with some degree of cochlear mechanical dysfunction, which may not be detected by conventional audiometry alone. This finding underscores the significance of EHF audiometry in clinical practice, which may help both early identification of individuals susceptible to developing tinnitus and reduce the number of new cases through preventive counseling programs.

An Exploratory Investigation of Pupillometry As a Measure of Tinnitus Intrusiveness on a Test of Auditory Short-Term Memory.

OBJECTIVES: The purpose of the current study was to investigate the potential of pupillometry to provide an objective measure of competition between tinnitus and external sounds during a test of auditory short-term memory. DESIGN: Twelve participants with chronic tinnitus and twelve control participants without tinnitus took part in the study. Pretest sessions used an adaptive method to estimate listeners' frequency discrimination threshold on a test of delayed pitch discrimination for pure tones. Target and probe tones were presented at 72 dB SPL and centered on 750 Hz±2 semitones with an additional jitter of 5 to 20 Hz. Test sessions recorded baseline pupil diameter and task-related pupillary responses (TEPRs) during three blocks of delayed pitch discrimination trials. The difference between target and probe tones was set to the individual's frequency detection threshold for 80% response-accuracy. Listeners with tinnitus also completed the Tinnitus Handicap Inventory (THI). Linear mixed effects procedures were applied to examine changes in baseline pupil diameter and TEPRs associated with group (tinnitus versus control), block (1 to 3) and their interaction. The association between THI scores and maximum TEPRs was assessed using simple linear regression. RESULTS: Patterns of baseline pupil dilation across trials diverged in listeners with tinnitus and controls. For controls, baseline pupil dilation remained constant across blocks. For listeners with tinnitus, baseline pupil dilation increased on blocks 2 and 3 compared with block 1. TEPR amplitudes were also larger in listeners with tinnitus than controls. Linear mixed effects models yielded a significant group by block interaction for baseline pupil diameter and a significant main effect of group on maximum TEPR amplitudes. Regression analyses yielded a significant association between THI scores and TEPR amplitude in listeners with tinnitus. CONCLUSIONS: Our data indicate measures of baseline pupil diameter, and TEPRs are sensitive to competition between tinnitus and external sounds during a test of auditory short-term memory. This result suggests pupillometry can provide an objective measure of intrusion in tinnitus. Future research will be required to establish whether our findings generalize to listeners across a full range of tinnitus severity.

The Neural Bases of Tinnitus: Lessons from Deafness and Cochlear Implants.

Subjective tinnitus is the conscious perception of sound in the absence of any acoustic source. The literature suggests various tinnitus mechanisms, most of which invoke changes in spontaneous firing rates of central auditory neurons resulting from modification of neural gain. Here, we present an alternative model based on evidence that tinnitus is: (1) rare in people who are congenitally deaf, (2) common in people with acquired deafness, and (3) potentially suppressed by active cochlear implants used for hearing restoration. We propose that tinnitus can only develop after fast auditory fiber activity has stimulated the synapse formation between fast-spiking parvalbumin positive (PV+) interneurons and projecting neurons in the ascending auditory path and coactivated frontostriatal networks after hearing onset. Thereafter, fast auditory fiber activity promotes feedforward and feedback inhibition mediated by PV+ interneuron activity in auditory-specific circuits. This inhibitory network enables enhanced stimulus resolution, attention-driven contrast improvement, and augmentation of auditory responses in central auditory pathways (neural gain) after damage of slow auditory fibers. When fast auditory fiber activity is lost, tonic PV+ interneuron activity is diminished, resulting in the prolonged response latencies, sudden hyperexcitability, enhanced cortical synchrony, elevated spontaneous γ oscillations, and impaired attention/stress-control that have been described in previous tinnitus models. Moreover, because fast processing is gained through sensory experience, tinnitus would not exist in congenital deafness. Electrical cochlear stimulation may have the potential to reestablish tonic inhibitory networks and thus suppress tinnitus. The proposed framework unites many ideas of tinnitus pathophysiology and may catalyze cooperative efforts to develop tinnitus therapies.

Investigating tinnitus subgroups based on hearing-related difficulties.

PURPOSE: Meaningfully grouping individuals with tinnitus who share a common characteristics (ie, subgrouping, phenotyping) may help tailor interventions to certain tinnitus subgroups and hence reduce outcome variability. The purpose of this study was to test if the presence of tinnitus subgroups are discernible based on hearing-related comorbidities, and to identify predictors of tinnitus severity for each subgroup identified. METHODS: An exploratory cross-sectional study was used. The study was nested within an online survey distributed worldwide to investigate tinnitus experiences during the COVID-19 pandemic. The main outcome measure was the tinnitus Handicap Inventory- Screening Version. RESULTS: From the 3400 respondents, 2980 were eligible adults with tinnitus with an average age of 58 years (SD = 14.7) and 49% (n = 1457) being female. A three-cluster solution identified distinct subgroups, namely, those with tinnitus-only (n = 1306; 44%), those presenting with tinnitus, hyperacusis, hearing loss and/or misophonia (n = 795; 27%), and those with tinnitus and hearing loss (n = 879; 29%). Those with tinnitus and hyperacusis reported the highest tinnitus severity (M = 20.3; SD = 10.5) and those with tinnitus and no hearing loss had the lowest tinnitus severity (M = 15.7; SD = 10.4). Younger age and the presence of mental health problems predicted greater tinnitus severity for all groups (ß ≤ -0.1, P ≤ .016). CONCLUSION: Further exploration of these potential subtypes are needed in both further research and clinical practice by initially triaging tinnitus patients prior to their clinical appointments based on the presence of hearing-related comorbidities. Unique management pathways and interventions could be tailored for each tinnitus subgroup.

Auditory dysfunction in type 2 Stickler Syndrome.

PURPOSE: To present the extent and site of lesion of auditory dysfunction in a large cohort of individuals with type 2 Stickler Syndrome. Type 2 Stickler Syndrome results from a mutation in the gene coding for α-1 type XI pro-collagen, which has been identified in the human vitreous, cartilage and the cochlea of the mouse. The condition is characterised by classic ocular abnormalities, auditory dysfunction, osteoarthropathy and oro-facial dysplasia. METHODS: This is a population study which used a combination of audiometric, tympanometric, and self-report measures on a series of 65 individuals (mean age 29.2 years, range 3-70, female 63.1%) with genetically confirmed type 2 Stickler Syndrome. RESULTS: Hearing impairment was identified in at least one ear for 69% of individuals. Analysis against age-matched normative data showed that reduced hearing sensitivity was present across all test frequencies. Sensorineural hearing loss was most common (77% of ears), with conductive (3%), mixed (7%) and no hearing loss (13%), respectively. The proportion of hypermobile tympanic membranes (24%) was less than previously documented in type 1 Stickler Syndrome. When present, this appears to arise as a direct result of collagen abnormalities in the middle ear. Self-report measures of speech and spatial hearing in sound were comparable to a non-syndromic cohort with similar audiometric thresholds. CONCLUSIONS: Auditory impairment in type 2 Stickler Syndrome is predominantly associated with cochlear hearing loss of varying severities across affected individuals. The impact on hearing thresholds can be seen across the frequency range, suggesting a contribution of defective collagen throughout the cochlea. Self-report questionnaires showed that difficulties understanding speech, and spatial information in sound (such as that used for localisation), were worse than a young, normal-hearing population but comparable to a non-syndromic cohort with similar audiometric thresholds. Therefore, it is likely that hearing loss in type 2 Stickler Syndrome arises in the auditory periphery, without significant central processing deficits.

Tinnitus and stress in adults: a scoping review.

OBJECTIVE: Tinnitus and stress are recurrently reported together. The strength and direction of this relationship is not clear. The aim of this review is to catalogue the evidence of this relationship, how it has been described in adults and which instruments were used. DESIGN: Five-stage framework was followed. An online search of databases and published journals were conducted. The main inclusion criteria were original studies published in English and conducted in an adult human population, in which both tinnitus and stress were measured using different instruments. STUDY SAMPLES: 5699 records were identified in the searching stage and 50 studies were eligible for data extraction. RESULTS: Measurements of perceived stress were most frequently used. Tinnitus patients tend to report louder and more bothersome tinnitus when they are stressed, but not all tinnitus patients associated stress with the onset or the severity of their tinnitus. Any positive correlation reported between stress and tinnitus levels varied in strength according to the used instrument. Post-intervention changes in stress and tinnitus levels showed inconsistency. CONCLUSION: There is considerable room for further research to study the relationship between stress and tinnitus. We highlight principal issues that should be considered in future studies.

The Prevalence and Severity of Misophonia in a UK Undergraduate Medical Student Population and Validation of the Amsterdam Misophonia Scale.

Misophonia is a condition of abnormal emotional responses to specific auditory stimuli. There is limited information available on the prevalence of this condition. This study aimed to estimate the prevalence of misophonia in an undergraduate medical student population at the University of Nottingham. A secondary aim of this study was to assess the psychometric validity of the Amsterdam Misophonia Scale (A-Miso-S) questionnaire tool in this population. The A-Miso-S was administered online to medical students at the University of Nottingham. To assess the validity of the A-Miso-S, a factor analysis was conducted. To determine prevalence and severity the results of the questionnaire were quantitatively analysed using SPSS. Actor analysis was conducted. Free text responses to one questionnaire item were analysed using a thematic approach. Responses were obtained from 336 individuals. Clinically significant misophonic symptoms appear to be common, effecting 49.1% of the sample population. This is statistically significantly higher prevalence than previous studies have found (p < 0.00001). Using the classification of the A-Miso-S, mild symptoms were seen in 37%, moderate in 12%, severe in 0.3% of participants. No extreme cases were seen. The A-Miso-S was found to be a uni-factorial tool, with good internal consistency. This study has provided new information on misophonia and validity of the A-Miso-S questionnaire in a sample population of UK undergraduate medical students. The results indicate that misophonia is a phenomenon that a significant proportion of medical students experience though only a small subset experience it severely.

A Cross-Sectional Study of the Prevalence and Factors Associated With Tinnitus and/or Hyperacusis in Children.

OBJECTIVES: The aim of this study was to determine the prevalence of tinnitus and/or hyperacusis in Danish children aged 10 to 16 years, and to assess associations between tinnitus or hyperacusis and other relevant factors. DESIGN: A cross-sectional study based on a previously established child cohort. A total of 501 children were enrolled in the project. The study was performed in eight mainstream schools and data were collected during an 8-week period from October 27, 2014 to December 16, 2014. RESULTS: Using broad tinnitus research questions, the prevalence of any tinnitus was 66.9%; of noise-induced tinnitus (NIT) was 35.7%; and of spontaneous tinnitus (ST) was 53.7%. Bothersome tinnitus was reported by 34.6% of the children with any tinnitus, 23.2% of the whole population. Few children were severely bothered (2.4%, 1.6%, respectively). It was significantly more common for children with NIT to report tinnitus episodes lasting for minutes or longer than for children with ST (p = 0.01). Girls were more likely than boys to be bothered by tinnitus [Odds ratio (OR) = 2.96; 95% confidence interval (CI) 1.34 to 6.51; p = 0.01]. 14.6% of the children reported hyperacusis, and 72.6% of those reporting hyperacusis were bothered by it, 10.6% of the whole population. The odds of having hyperacusis were 4.73 (1.57, 14.21) times higher among those with ST compared with those without ST. Furthermore, hyperacusis was associated with sound avoidance behaviors such as experience of sound-induced pain in the ear (OR = 2.95, 95% CI 1.65 to 5.27; p < 0.001), withdrawal from places or activities (OR = 3.33; 95% CI 1.44 to 7.69; p = 0.01), or concerns about sound could damage the hearing (OR = 1.85, 95% CI 1.06 to 3.31; p = 0.03). CONCLUSIONS: Tinnitus and hyperacusis are common in children but prevalence is dependent on tinnitus definitions. Only a few children are severely bothered by tinnitus. In the case of hyperacusis, children may exhibit sound avoidance behavior.

Audiovestibular clinician experiences and opinions about cisplatin vestibulotoxicity.

PURPOSE: Vestibulotoxicity associated with cisplatin chemotherapy is known to exist, but the extent, severity, and impact is unclear from the literature. This study explored knowledge, experiences, and opinions of audiovestibular professionals about cisplatin vestibulotoxicity. METHODS: An online survey was disseminated to clinicians working in the audiovestibular field. RESULTS: Ninety-three respondents participated in the survey. Most professionals were aware of potential vestibulotoxicity associated with cisplatin chemotherapy. Thirty-three percent of the respondents reported that they had seen patients with cisplatin vestibulotoxicity. Forty percent of them were confident in making the diagnosis and in managing the patient in this situation. The prevalence and impact of vestibulotoxicity including practicality of the assessment should be considered when designing an effective vestibulotoxicity screening protocol. CONCLUSION: This study provides a better understanding of cisplatin vestibulotoxicity from the perspectives of audiovestibular clinicians, which will underpin appropriate detection and management of the condition.

Readability assessment of self-report hyperacusis questionnaires.

Objective: To assess the overall readability of five currently available hyperacusis questionnaires and to assess the variability of single items within each questionnaire.Design: Comparative study of self-report hyperacusis questionnaires: (1) Geräuschüberempfindlichkeits-Fragebogen (GUF), (2) Noise Avoidance Questionnaire (NAQ), (3) Hyperacusis Questionnaire (HQ), (4) Sound Sensitive-Tinnitus Index (SSTI), and (5) Inventory of Hyperacusis Symptoms (IHS). Well-established readability formulas Flesh-Kincaid Grade Level (FKGL), Flesch Reading Ease (FRE), Simple Measure of Gobbledygook (SMOG) and FORCAST and a computerised readability calculation software were used.Study sample: Five questionnaires.Results: Reading levels calculated by each formula varied for every questionnaire. Readability scores ranged from 7.7th to 12.7th grade for overall readability depending on the questionnaire. This exceeded the grade reading levels of 5th-6th grade (10-12 years old) as recommended by the American Medical Association or 7th-8th grade (12-14 years old) as recommended by the US National Institutes of Health. Single item readability analysis based on FKGL revealed that 32%-70% of single items are written above the recommended grade levels.Conclusion: All five questionnaires are written at close to or exceeding the recommended grade levels. This requires attention from developers but also when interpreting the questionnaire scores obtained in clinic.

A process for prioritising systematic reviews in tinnitus.

Objective: To develop an innovative prioritisation process to identify topics for new or updated systematic reviews of tinnitus research.Design: A two-stage prioritisation process was devised. First, a scoping review assessed the amount of randomized controlled trial-level evidence available. This enabled development of selection criteria for future reviews, aided the design of template protocol and suggested the scale of work that would be required to conduct these reviews. Second, using the pre-defined primary and secondary criteria, interventions were prioritised for systematic review.Study sample: Searches identified 1080 records. After removal of duplicates and out of scope works, 437 records remained for full data charting.Results: The process was tested, using subjective tinnitus as the clinical condition and using Cochrane as the systematic review platform. The criteria produced by this process identified three high priority reviews: (1) Sound therapy using amplification devices and/or sound generators; (2) Betahistine and (3) Cognitive behaviour therapy. Further secondary priorities were: (4) Gingko biloba, (5) Anxiolytics, (6) Hypnotics, (7) Antiepileptics and (8) Neuromodulation.Conclusions: A process was developed which successfully identified priority areas for Cochrane systematic reviews of interventions for subjective tinnitus. This technique could easily be transferred to other conditions and other types of systematic reviews.

The efficacy of statins as otoprotective agents: A systematic review.

OBJECTIVE: This systematic review examined current literature, summarised research findings and identified research gaps regarding the efficacy of statins on audiological outcomes. METHODS: Systematic search of electronic databases and grey literature was performed. Eligibility criteria were the study of a statin drug with report of audiological outcomes such as hearing, tinnitus or balance in either human or animal studies. Data extraction and quality assessment were performed by two independently researchers. The characteristics of the study and research findings were collated and summarised. A narrative synthesis was conducted. Meta-analysis was not possible due to heterogeneity of the included studies. RESULTS: Analysis of searches yielded 17 studies meeting the criteria. Included studies had variable drug type and dosage, outcome measures and associated inner ear conditions. Most animal experiments showed promising audiological outcomes after statin treatment, demonstrated by the results of auditory brainstem response, distortion product otoacoustic emissions and inner ear histology. However, no clear effect can be discerned in human trials due to the mixed results, and heterogeneity in research methodology and quality. Audiological outcomes were not always correlated with cholesterol levels. CONCLUSIONS: Statins remain a potential candidate as otoprotective agents which warrant further investigation.

A Cross-Sectional Questionnaire Study of Tinnitus Awareness and Impact in a Population of Adult Cochlear Implant Users.

OBJECTIVES: The primary aim was to identify the proportion of individuals within the adult cochlear implant population who are aware of tinnitus and those who report a negative impact from this perception, using a bespoke questionnaire designed to limit bias. A secondary aim was to use qualitative analysis of open-text responses to identify themes linked to tinnitus perception in this population. DESIGN: A cross-sectional questionnaire study of a large clinical population who received an implant from Cambridge University Hospitals, United Kingdom. RESULTS: Seventy-five percent of respondents reported tinnitus awareness. When impact scores for six areas of difficulty were ranked, 13% of individuals ranked tinnitus their primary concern and nearly a third ranked tinnitus in the top two positions. Tinnitus impact was not found to reduce with duration since implantation. The most common open-text responses were linked to a general improvement postimplantation and acute tinnitus alleviation specific to times when the device was in use. CONCLUSIONS: Tinnitus is a problem for a significant proportion of individuals with a cochlear implant. Clinicians, scientists, and cochlear implant manufacturers should be aware that management of tinnitus may be a greater priority for an implantee than difficulties linked to speech perception. Where a positive effect of implantation was reported, there was greater evidence for masking of tinnitus via the implant rather than reversal of maladaptive plasticity.

Cancer survivors treated with platinum-based chemotherapy affected by ototoxicity and the impact on quality of life: a narrative synthesis systematic review.

Objective: To identify any change in quality of life (QoL) caused by chemotherapy-induced toxicities, such as hearing loss and tinnitus, to provide information in order to improve services and aid clinicians in their decision-making. Design: This systematic review followed the preferred reporting items for systematic reviews and meta-analysis (PRISMA) checklist. The search terms were cancer, platinum-based chemotherapy, ototoxicity and "quality of life". Titles and abstracts, followed by full texts, were screened by two independent researchers. The relevant data were extracted and quality analysis was performed using the NIH Quality Assessment Tool. Study sample: About 308 titles and abstracts were screened, and 27 full-text articles were screened. Ten articles representing 11 studies were included in the review. Study design included cross-sectional studies, randomised control trials and longitudinal studies. Results: Diagnostic criteria consisted of audiograms, questionnaires and patient complaints. The study quality ranged from 21.43% to 85.71%. Overall results found that those treated with cisplatin had more hearing loss and tinnitus than those treated with other therapies. Furthermore, those with hearing loss and tinnitus were more likely to have a lower QoL. Conclusions: There is an urgent need to standardise diagnostics when investigating ototoxicity and its effect on QoL, particularly for research into risk factors, prevention and management.

Audiologist-Guided Internet-Based Cognitive Behavior Therapy for Adults With Tinnitus in the United Kingdom: A Randomized Controlled Trial.

OBJECTIVES: Specialist tinnitus services are in high demand as a result of the negative effect tinnitus may have on quality of life. Additional clinically and cost-effective tinnitus management routes are needed. One potential route is providing Cognitive Behavioural Therapy for tinnitus via the Internet (iCBT). This study aimed to determine the efficacy of guided iCBT, using audiological support, on tinnitus distress and tinnitus-related comorbidities, in the United Kingdom. A further aim was to establish the stability of intervention effects 2-months postintervention. The hypothesis was that iCBT for tinnitus would be more effective at reducing tinnitus distress than weekly monitoring. DESIGN: A randomized, delayed intervention efficacy trial, with a 2-month follow-up was implemented to evaluate the efficacy of iCBT in the United Kingdom. Participants were randomly assigned to the experimental (n = 73) or weekly monitoring control group (n = 73) after being stratified for tinnitus severity and age. After the experimental group completed the 8-week long iCBT intervention, the control group undertook the same intervention. Intervention effects were, therefore, evaluated in two independent groups at two time points. The primary outcome was a change in tinnitus distress between the groups as assessed by the Tinnitus Functional Index. Secondary assessment measures were included for insomnia, anxiety, depression, hearing disability, hyperacusis, cognitive failures, and satisfaction with life. These were completed at baseline, postintervention, and at a 2-month postintervention follow-up. RESULTS: After undertaking the iCBT intervention, the experimental group had a greater reduction in tinnitus distress when compared with the control group. This reduction was statistically significant (Cohen's d = 0.7) and was clinically significant for 51% of the experimental group and 5% of the control group. This reduction was evident 4 weeks after commencing the iCBT intervention. Furthermore, the experimental group had a greater reduction in insomnia, depression, hyperacusis, cognitive failures, and a greater improvement in quality of life, as evidenced by the significant differences in these assessment measures postintervention. Results were maintained 2 months postintervention. CONCLUSIONS: Guided (using audiological support) iCBT for tinnitus resulted in statistically significant reductions in tinnitus distress and comorbidities (insomnia, depression, hyperacusis, cognitive failures) and a significant increase in quality of life. These effects remained stable at 2-months postintervention. Further trials to determine the longer term efficacy of iCBT to investigate predictors of outcome and to compare iCBT with standard clinical care in the United Kingdom are required.Registered at clinicaltrials.gov: NCT02370810 on 5/03/2015.

Process evaluation of Internet-based cognitive behavioural therapy for adults with tinnitus in the context of a randomised control trial.

OBJECTIVE: The research objective was to identify processes that could either facilitate or hinder clinical implementation of an Internet-based cognitive behavioural therapy intervention for tinnitus in the UK. This was done by exploring the research context, the intervention components and the factors that contributed to the outcomes obtained. DESIGN: This study investigated eight processes including the recruitment strategies, reach, research context, treatment dose delivered and received, implementation fidelity, barriers to implementation and effectiveness of the intervention. STUDY SAMPLE: Of the 169 registered participants, 146 were randomly assigned to the experimental or control groups (23 were excluded). The mean age was 55.57 years with an average tinnitus duration of 11.63 years. RESULTS: The intended sample of people with distressing tinnitus who were underserved with evidence-based tinnitus interventions was reached. The full guided intervention was delivered. The recommended modules were read more than the optional modules. Intervention components such as the easily readable format and the benefits of the applied relaxation programme facilitated significant positive post-intervention outcomes. Barriers hampering the intervention application included time pressures and low self-motivation. CONCLUSIONS: Results of this process evaluation together with the outcome data can be used to facilitate translating this research into clinical practice.

Participants' experiences of an Internet-based cognitive behavioural therapy intervention for tinnitus.

OBJECTIVE: This study aimed to explore participants' experiences after undertaking an Internet-based cognitive behavioural therapy intervention (ICBT) for tinnitus. DESIGN: Semi-structured telephone interviews were conducted 6-8 months after participants undertook the ICBT intervention. Qualitative thematic analysis was used to interpret the interview data. STUDY SAMPLE: A purposeful sampling strategy was used to identify a diverse range of participants. Semi-structured interviews were carried out with 15 participants. The mean age was 58.5 years, 7 men and 8 women participated. RESULTS: The analysis generated the following main themes: (1) expectations and motivation for doing the intervention, (2) experiences of the intervention, (3) intervention engagement and (4) intervention effects. Most participants' expectations were hopeful that the intervention would lessen the impact of their tinnitus. Aspects of the intervention that were beneficial, as well as difficult, were identified together with the impact they had on engagement. Intervention effects were evident on both tinnitus and activities of daily life. CONCLUSIONS: The benefits described by participants indicate the potential of ICBT as an alternate form of intervention delivery. The difficulties that hampered engagement need to be addressed to enhance the application and to optimise the clinical acceptability of ICBT for tinnitus.

Ototoxicity (cochleotoxicity) classifications: A review.

OBJECTIVE: Drug-mediated ototoxicity, specifically cochleotoxicity, is a concern for patients receiving medications for the treatment of serious illness. A number of classification schemes exist, most of which are based on pure-tone audiometry, in order to assist non-audiological/non-otological specialists in the identification and monitoring of iatrogenic hearing loss. This review identifies the primary classification systems used in cochleototoxicity monitoring. By bringing together classifications published in discipline-specific literature, the paper aims to increase awareness of their relative strengths and limitations in the assessment and monitoring of ototoxic hearing loss and to indicate how future classification systems may improve upon the status-quo. DESIGN: Literature review. STUDY SAMPLE: PubMed identified 4878 articles containing the search term ototox*. RESULTS: A systematic search identified 13 key classification systems. Cochleotoxicity classification systems can be divided into those which focus on hearing change from a baseline audiogram and those that focus on the functional impact of the hearing loss. CONCLUSIONS: Common weaknesses of these grading scales included a lack of sensitivity to small adverse changes in hearing thresholds, a lack of high-frequency audiometry (>8 kHz), and lack of indication of which changes are likely to be clinically significant for communication and quality of life.