Ginkgo biloba for tinnitus.

BACKGROUND: Tinnitus is a symptom defined as the perception of sound in the absence of an external source. In England alone there are an estimated ¾ million general practice consultations every year where the primary complaint is tinnitus, equating to a major burden on healthcare services. Clinical management strategies include education and advice, relaxation therapy, tinnitus retraining therapy (TRT), cognitive behavioural therapy (CBT), sound enrichment using ear-level sound generators or hearing aids, and drug therapies to manage co-morbid symptoms such as insomnia, anxiety or depression.  OBJECTIVES: To assess the effects of Ginkgo biloba for tinnitus in adults and children. SEARCH METHODS: The Cochrane ENT Information Specialist searched the Cochrane ENT Register; CENTRAL (2022, Issue 6); Ovid MEDLINE; Ovid Embase; CINAHL; Web of Science; ClinicalTrials.gov; ICTRP and additional sources for published and unpublished trials. The date of the search was 7 June 2022. SELECTION CRITERIA: Randomised controlled trials (RCTs) recruiting adults and children with acute or chronic subjective tinnitus. We included studies where the intervention involved Ginkgo biloba and this was compared to placebo, no intervention, or education and information. Concurrent use of other medication or other treatment was acceptable if used equally in each group. Where an additional intervention was used equally in both groups, we analysed this as a separate comparison. The review included all courses of Ginkgo biloba, regardless of dose regimens or formulations, and for any duration of treatment. DATA COLLECTION AND ANALYSIS: We used standard Cochrane methods. Our primary outcomes were tinnitus symptom severity measured as a global score on a multi-item tinnitus questionnaire and serious adverse effects (bleeding, seizures). Our secondary outcomes were tinnitus loudness (change in subjective perception), tinnitus intrusiveness, generalised depression, generalised anxiety, health-related quality of life and other adverse effects (gastrointestinal upset, headache, allergic reaction). We used GRADE to assess the certainty of the evidence for each outcome. MAIN RESULTS: This review included 12 studies (with a total of  1915 participants). Eleven studies compared the effects of Ginkgo biloba with placebo and one study compared the effects of Ginkgo biloba with hearing aids to hearing aids alone. All included studies were parallel-group RCTs. In general, risk of bias was high or unclear due to selection bias and poor reporting of allocation concealment and blinding of participants, personnel and outcome assessments. Due to heterogeneity in the outcomes measured and measurement methods used, only limited data pooling was possible.  Ginkgo biloba versus placebo When we pooled data from two studies for the primary outcome tinnitus symptom severity, we found that Ginkgo biloba may have little to no effect (Tinnitus Handicap Inventory scores) at three to six months compared to placebo, but the evidence is very uncertain (mean difference (MD) -1.35 (scale 0 to 100), 95% confidence interval (CI) -8.26 to 5.55; 2 studies; 85 participants) (very low-certainty). Ginkgo biloba may result in little to no difference in the risk of bleeding or seizures, with no serious adverse effects reported in either group (4 studies; 1154 participants; low-certainty). For the secondary outcomes, one study found that there may be little to no difference between the effects of Ginkgo biloba and placebo on tinnitus loudness measured with audiometric loudness matching at 12 weeks, but the evidence is very uncertain (MD -4.00 (scale -10 to 140 dB), 95% CI -13.33 to 5.33; 1 study; 73 participants) (very low-certainty). One study found that there may be little to no difference between the effects of Ginkgo biloba and placebo on health-related quality of life measured with the Glasgow Health Status Inventory at three months (MD -0.58 (scale 0 to 100), 95% CI -4.67 to 3.51; 1 study; 60 participants) (low-certainty). Ginkgo biloba may not increase the frequency of other adverse effects (gastrointestinal upset, headache, allergic reaction) at three months compared to placebo (risk ratio 0.91, 95% CI 0.52 to 1.60; 4 studies; 1175 participants) (low-certainty). None of the studies reported the other secondary outcomes of tinnitus intrusiveness or changes in depressive symptoms or depression, anxiety symptoms or generalised anxiety. Gingko biloba with concurrent intervention versus concurrent intervention only One study compared Ginkgo biloba with hearing aids to hearing aids only. It assessed the mean difference in the change in Tinnitus Handicap Inventory scores and tinnitus loudness using a 10-point visual analogue scale (VAS) at three months. The study did not report adverse effects, tinnitus intrusiveness, changes in depressive symptoms or depression, anxiety symptoms or generalised anxiety, or health-related quality of life. This was a single, very small study (22 participants) and for all outcomes the certainty of the evidence was very low. We were unable to draw meaningful conclusions from the numerical results. AUTHORS' CONCLUSIONS: There is uncertainty about the benefits and harms of Ginkgo biloba for the treatment of tinnitus when compared to placebo. We were unable to draw meaningful conclusions regarding the benefits and harms of Ginkgo biloba when used with concurrent intervention (hearing aids). The certainty of the evidence for the reported outcomes, assessed using GRADE, ranged from low to very low. Future research into the effectiveness of Ginkgo biloba in patients with tinnitus should use rigorous methodology. Randomisation and blinding should be of the highest quality, given the subjective nature of tinnitus and the strong likelihood of a placebo response. The CONSORT statement should be used in the design and reporting of future studies. We also recommend the use of validated, patient-centred outcome measures for research in the field of tinnitus.

Understanding Factors That Cause Tinnitus: A Mendelian Randomization Study in the UK Biobank.

OBJECTIVES: To investigate the causal role of established risk factors and associated conditions to tinnitus and tinnitus severity in the UK Biobank. DESIGN: The prospective cohort study with large dataset of >500,000 individuals. The analytical sample of 129,731 individuals in the UK Biobank of European descent. Participants were recruited from National Health Service registries, baseline age range between 37 and 73 years, response rate to baseline survey 6%. Participants were asked subjective questions about tinnitus and its severity. Previously observed associations (n = 23) were confirmed in the UK Biobank using logistic and ordinal regression models. Two-sample Mendelian randomization approaches were then used to test causal relationships between the 23 predictors and tinnitus and tinnitus severity. The main outcome measures were observational and genetic association between key demographics and determinants and two tinnitus outcomes (current tinnitus and tinnitus severity). RESULTS: Prevalence of tinnitus was 20% and severe tinnitus 3.8%. The observational results are consistent with the previous literature, with hearing loss, older age, male gender, high BMI, higher deprivation, higher blood pressure, smoking history, as well as numerous comorbidities being associated with higher odds of current tinnitus. Mendelian randomization results showed causal correlations with tinnitus. Current tinnitus was predicted by genetically instrumented hearing loss (odds ratio [OR]: 8.65 [95% confidence interval (CI): 6.12 to 12.23]), major depression (OR: 1.26 [95% CI: 1.06 to 1.50]), neuroticism (OR: 1.48 [95% CI: 1.28 to 1.71]), and higher systolic blood pressure (OR: 1.01 [95% CI:1.00 to 1.02]). Lower odds of tinnitus were associated with longer duration in education (OR: 0.74 [95% CI: 0.63 to 0.88]), higher caffeine intake (OR: 0.89 [95% CI: 0.83 to 0.95]) and being a morning person (OR: 0.94 [95% CI: 0.90 to 0.98]). Tinnitus severity was predicted by a higher genetic liability to neuroticism (OR: 1.15 [95% CI: 1.06 to 1.26]) and schizophrenia (OR: 1.02 [95% CI: 1.00 to 1.04]). CONCLUSIONS: Tinnitus data from the UK Biobank confirm established associated factors in the literature. Genetic analysis determined causal relationships with several factors that expand the understanding of the etiology of tinnitus and can direct future pathways of clinical care and research.

The Epley (canalith repositioning) manoeuvre for benign paroxysmal positional vertigo.

BACKGROUND: This is an update of a Cochrane Review first published in The Cochrane Library in Issue 1, 2002 and previously updated in 2004 and 2007.Benign paroxysmal positional vertigo (BPPV) is a syndrome characterised by short-lived episodes of vertigo in association with rapid changes in head position. It is a common cause of vertigo presenting to primary care and specialist otolaryngology clinics. Current treatment approaches include rehabilitative exercises and physical manoeuvres, including the Epley manoeuvre. OBJECTIVES: To assess the effectiveness of the Epley manoeuvre for posterior canal BPPV. SEARCH METHODS: We searched the Cochrane Ear, Nose and Throat Disorders Group Trials Register; CENTRAL; PubMed; EMBASE; CINAHL; Web of Science; Cambridge Scientific Abstracts; ICTRP and additional sources for published and unpublished trials. The date of the most recent search was 23 January 2014. SELECTION CRITERIA: Randomised controlled trials of the Epley manoeuvre versus placebo, no treatment or other active treatment for adults diagnosed with posterior canal BPPV (including a positive Dix-Hallpike test). The primary outcome of interest was complete resolution of vertigo symptoms. Secondary outcomes were conversion of a 'positive' Dix-Hallpike test to a 'negative' Dix-Hallpike test and adverse effects of treatment. DATA COLLECTION AND ANALYSIS: We used the standard methodological procedures expected by The Cochrane Collaboration. MAIN RESULTS: We included 11 trials in the review with a total of 745 patients.Five studies compared the efficacy of the Epley manoeuvre against a sham manoeuvre, three against other particle repositioning manoeuvres (Semont, Brandt-Daroff and Gans) and three against a control (no treatment, medication only, postural restriction). Patients were treated in hospital otolaryngology departments in eight studies and family practices in two studies. All patients were adults aged 18 to 90 years old, with a sex ratio of 1:1.5 male to female.There was a low risk of overall bias in the studies included. All studies were randomised with six applying sealed envelope or external allocation techniques. Eight of the trials blinded the assessors to the participants' treatment group and data on all outcomes for all participants were reported in eight of the 11 studies. Complete resolution of vertigo Complete resolution of vertigo occurred significantly more often in the Epley treatment group when compared to a sham manoeuvre or control (odds ratio (OR) 4.42, 95% confidence interval (CI) 2.62 to 7.44; five studies, 273 participants); the proportion of patients resolving increased from 21% to 56%. None of the trials comparing Epley versus other particle repositioning manoeuvres reported vertigo resolution as an outcome. Conversion of Dix-Hallpike positional test result from positive to negative Conversion from a positive to a negative Dix-Hallpike test significantly favoured the Epley treatment group when compared to a sham manoeuvre or control (OR 9.62, 95% CI 6.0 to 15.42; eight studies, 507 participants). There was no difference when comparing the Epley with the Semont manoeuvre (two studies, 117 participants) or the Epley with the Gans manoeuvre (one study, 58 participants). In one study a single Epley treatment was more effective than a week of three times daily Brandt-Daroff exercises (OR 12.38, 95% CI 4.32 to 35.47; 81 participants). Adverse effects Adverse effects were infrequently reported. There were no serious adverse effects of treatment. Rates of nausea during the repositioning manoeuvre varied from 16.7% to 32%. Some patients were unable to tolerate the manoeuvres because of cervical spine problems. AUTHORS' CONCLUSIONS: There is evidence that the Epley manoeuvre is a safe, effective treatment for posterior canal BPPV, based on the results of 11, mostly small, randomised controlled trials with relatively short follow-up. There is a high recurrence rate of BPPV after treatment (36%). Outcomes for Epley manoeuvre treatment are comparable to treatment with Semont and Gans manoeuvres, but superior to Brandt-Daroff exercises.

Ginkgo biloba for tinnitus.

BACKGROUND: This is an update of a Cochrane review first published in The Cochrane Library in Issue 2, 2004 and previously updated in 2007 and 2009.Tinnitus can be described as the perception of sound in the absence of external acoustic stimulation. At present no specific therapy for tinnitus is acknowledged to be satisfactory in all patients. There are a number of reports in the literature suggesting that Ginkgo biloba may be effective in the management of tinnitus. However, there also appears to be a strong placebo effect in tinnitus management. OBJECTIVES: To assess the effect of Ginkgo biloba in patients who are troubled by tinnitus. SEARCH METHODS: We searched the Cochrane Ear, Nose and Throat Disorders Group Trials Register; the Cochrane Central Register of Controlled Trials (CENTRAL); PubMed; EMBASE; AMED; Web of Science; BIOSIS Previews; Cambridge Scientific Abstracts; ICTRP and additional sources for published and unpublished trials. The date of the most recent search was 12 March 2012. SELECTION CRITERIA: Adults (18 years and over) complaining of tinnitus or adults with a primary complaint of cerebral insufficiency, where tinnitus forms part of the syndrome. DATA COLLECTION AND ANALYSIS: Both original authors independently extracted data and assessed trials for quality. For the 2012 update two authors determined trial eligibility, extracted data, analysed data and updated the contents of the review. MAIN RESULTS: Four trials with a total of 1543 participants were included in the review; we assessed all the included studies as having a low risk of bias. Three trials (1143 participants) included patients with a primary complaint of tinnitus and one (400 participants) included patients with mild to moderate dementia, some of whom had tinnitus.There was no evidence that Gingko biloba was effective in patients with a primary complaint of tinnitus. In the study of patients with dementia, mean baseline levels of tinnitus were low (1.7 to 2.5 on a 10-point subjective symptom rating scale). A small but statistically significant reduction of 1.5 and 0.7 points was seen in patients taking Gingko biloba with vascular dementia and Alzheimer's disease respectively. The practical clinical significance of this is unclear. The incidence of side effects was low. AUTHORS' CONCLUSIONS: The limited evidence does not demonstrate that Ginkgo biloba is effective for tinnitus when this is the primary complaint.

Modifications of the Epley (canalith repositioning) manoeuvre for posterior canal benign paroxysmal positional vertigo (BPPV).

BACKGROUND: Benign paroxsymal positional vertigo (BPPV) is a syndrome characterised by short-lived episodes of vertigo associated with rapid changes in head position. It is a common cause of vertigo presenting to primary care and specialist otolaryngology (ENT) clinics. BPPV of the posterior canal is a specific type of BPPV for which the Epley (canalith repositioning) manoeuvre is a verified treatment. A range of modifications of the Epley manoeuvre are used in clinical practice, including post-Epley vestibular exercises and post-Epley postural restrictions. OBJECTIVES: To assess whether the various modifications of the Epley manoeuvre for posterior canal BPPV enhance its efficacy in clinical practice. SEARCH METHODS: We searched the Cochrane ENT Group Trials Register; the Cochrane Central Register of Controlled Trials (CENTRAL); PubMed; EMBASE; CINAHL; Web of Science; BIOSIS Previews; Cambridge Scientific Abstracts; ICTRP and additional sources for published and unpublished trials. The date of the search was 15 December 2011. SELECTION CRITERIA: Randomised controlled trials of modifications of the Epley manoeuvre versus a standard Epley manoeuvre as a control in adults with posterior canal BPPV diagnosed with a positive Dix-Hallpike test. Specific modifications sought were: application of vibration/oscillation to the mastoid region, vestibular rehabilitation exercises, additional steps in the Epley manoeuvre and post-treatment instructions relating to movement restriction. DATA COLLECTION AND ANALYSIS: Two authors independently selected studies from the search results and the third author reviewed and resolved any disagreement. Two authors independently extracted data from the studies using standardised data forms. All authors independently assessed the trials for risk of bias. MAIN RESULTS: The review includes 11 trials involving 855 participants. A total of nine studies used post-Epley postural restrictions as their modification of the Epley manoeuvre. There was no evidence of a difference in the results for post-treatment vertigo intensity or subjective assessment of improvement in individual or pooled data. All nine trials included the conversion of a positive to a negative Dix-Hallpike test as an outcome measure. Pooled data identified a significant difference from the addition of postural restrictions in the frequency of Dix-Hallpike conversion when compared to the Epley manoeuvre alone. In the experimental group 88.7% (220 out of 248) patients versus 78.2% (219 out of 280) in the control group converted from a positive to negative Dix-Hallpike test (risk ratio (RR) 1.13, 95% confidence interval (CI) 1.05 to 1.22, P = 0.002). No serious adverse effects were reported, however three studies reported minor complications such as neck stiffness, horizontal BPPV, dizziness and disequilibrium in some patients.There was no evidence of benefit of mastoid oscillation applied during the Epley manoeuvre, or of additional steps in the Epley manoeuvre. No adverse effects were reported. AUTHORS' CONCLUSIONS: There is evidence supporting a statistically significant effect of post-Epley postural restrictions in comparison to the Epley manoeuvre alone. However, it important to note that this statistically significant effect only highlights a small improvement in treatment efficacy. An Epley manoeuvre alone is effective in just under 80% of patients with typical BPPV. The additional intervention of postural restrictions has a number needed to treat (NNT) of 10. The addition of postural restrictions does not expose the majority of patients to risk of harm, does not pose a major inconvenience, and can be routinely discussed and advised. Specific patients who experience discomfort due to wearing a cervical collar and inconvenience in sleeping upright may be treated with the Epley manoeuvre alone and still expect to be cured in most instances.There is insufficient evidence to support the routine application of mastoid oscillation during the Epley manoeuvre, or additional steps in an 'augmented' Epley manoeuvre. Neither treatment is associated with adverse outcomes. Further studies should employ a rigorous randomisation technique, blinded outcome assessment, a post-treatment Dix-Hallpike test as an outcome measure and longer-term follow-up of patients.

Dissection versus diathermy for tonsillectomy.

BACKGROUND: This is an update of a Cochrane Review first published in The Cochrane Library in Issue 4, 2001 and previously updated in 2003.Tonsillectomy is a commonly performed surgical procedure. There are several operative methods currently in use, but the superiority of one over another has not been clearly demonstrated. OBJECTIVES: To compare the morbidity associated with tonsillectomy by two different techniques - dissection and diathermy. SEARCH STRATEGY: We searched the Cochrane Ear, Nose and Throat Disorders Group Trials Register, the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2010, Issue 3), PubMed, EMBASE, CINAHL, Web of Science, BIOSIS Previews, ISRCTN and additional sources for published and unpublished trials. The date of the most recent search was 1 October 2010, following a previous update search in 2003. SELECTION CRITERIA: Randomised controlled trials of children and adults undergoing tonsillectomy or adenotonsillectomy by dissection or diathermy techniques. DATA COLLECTION AND ANALYSIS: Two review authors selected studies, extracted data and assessed risk of bias independently. MAIN RESULTS: Two studies (254 participants) are included in the review. The overall risk of bias in the included studies was low, although we excluded pain data from one study due to unclear risk of bias. One study compared monopolar dissection diathermy with conventional cold dissection in children and the other compared microscopic bipolar dissection with cold dissection in children and adults. These studies demonstrate reduced intraoperative bleeding, but increased pain in the diathermy group. There was no difference in the rate of secondary bleeding overall, although the power of both studies to detect a small difference was insufficient. AUTHORS' CONCLUSIONS: There are insufficient data to show that one method of tonsillectomy is superior. There is evidence that pain may be greater after monopolar dissection. Large, well designed randomised controlled trials are necessary to determine the optimum method for tonsillectomy.