[Somatosensory tinnitus]. / Somatosensorischer Tinnitus.

BACKGROUND: Somatosensory tinnitus represents a clinically significant subgroup of chronic tinnitus. Although not completely understood, increasing evidence suggests interactivity between the somatosensory and auditory systems is responsible for both the development and maintenance of tinnitus. OBJECTIVES: The aim of this study is to provide an overview of the evaluation of somatosensory tinnitus and to propose an examination protocol to support the diagnosis and treatment of this patient group. MATERIALS AND METHODS: In addition to patient history, various clinical examination maneuvers are presented to establish the diagnosis of somatosensory tinnitus. RESULTS: The maneuvers can be divided into examinations of the cervical spine, temporomandibular joint, and soft tissue near the jaw. The maneuvers should be performed in a quiet environment and usually in comparison between sides. CONCLUSION: Accurate and efficient diagnosis of somatosensory tinnitus is essential to initiate appropriate treatment. The clinical maneuvers presented here are well suited for this purpose.

Effects of text supplementation on speech intelligibility for listeners with normal and impaired hearing: a systematic review with implications for telecommunication.

OBJECTIVE: Telecommunication can be difficult in the presence of noise or hearing loss. The purpose of this study was to systematically review evidence regarding the effects of text supplementation (e.g. captions, subtitles) of auditory or auditory-visual signals on speech intelligibility for listeners with normal or impaired hearing. DESIGN: Three databases were searched. Articles were evaluated for inclusion based on the Population Intervention Comparison Outcome framework. The Effective Public Health Practice Project instrument was used to evaluate the quality of the identified articles. STUDY SAMPLE: After duplicates were removed, the titles and abstracts of 2019 articles were screened. Forty-six full texts were reviewed; ten met inclusion criteria. RESULTS: The quality of all ten articles was moderate or strong. The articles demonstrated that text added to auditory (or auditory-visual) signals improved speech intelligibility and that the benefits were largest when auditory signal integrity was low, accuracy of the text was high, and the auditory signal and text were synchronous. Age and hearing loss did not affect benefits from the addition of text. CONCLUSIONS: Although only based on ten studies, these data support the use of text as a supplement during telecommunication, such as while watching television or during telehealth appointments.

[Measuring the cochlea using a tablet-based software package: influence of imaging modality and rater background]. / Vermessung der Cochlea mittels eines Tablet-basierten Softwarepakets: Einfluss der Bildgebungsmodalität und des Untersucherhintergrunds.

BACKGROUND: Cochlear duct length (CDL) is subject to significant individual variation. In the context of cochlear implantation, adapting the electrode array length to the CDL is of potential interest, as it has been associated with improvements in both speech recognition and sound quality. Using a tablet-based software package, it is possible to measure CDL at the level of the organ of Corti (CDLOC) to select appropriate electrode array lengths based on individual cochlear anatomy. OBJECTIVE: To identify effects of imaging modality and rater background on CDL estimates. METHODS: Magnetic resonance imaging (MRI) and flat-panel volume CT (fpVCT) scans of 10 patients (20 cochleae) were analyzed using the OTOPLAN software package (MED-EL, Innsbruck, Austria). Raters were an otorhinolaryngology (ORL) specialist, an ORL resident, and an audiologist. To analyze effects of rater background and imaging modality on CDL measurements, linear mixed models were constructed. RESULTS: Measurements showed mean CDLOC(fpVCT) = 36.69 ± 1.78 mm and CDLOC(MRI) = 36.81 ± 1.87 mm. Analyses indicated no significant effect of rater background (F(2, 105) = 0.84; p = 0.437) on CDL estimates. Imaging modality, on the other hand, significantly affected CDL (F (1, 105) = 20.70; p < 0.001), whereby estimates obtained using MRI were 0.89 mm larger than those obtained using fpVCT. CONCLUSION: No effect of rater background on CDL estimates could be identified, suggesting that comparable measurements could be obtained by personnel other than specially trained neurootologists. While imaging modality (fpVCT vs. MRI) did impact CDL results, the difference was small and of questionable clinical significance.

Activating a Noise-Gating Algorithm and Personalizing Electrode Threshold Levels Improve Recognition of Soft Speech for Adults With CIs.

OBJECTIVE: In contrast to the moderate presentation levels most commonly used in clinical practice, speech encountered in everyday life often occurs at low levels, such as when a conversational partner whispers or speaks from another room. In addition, even when the overall signal level is moderate, levels for particular words or speech sounds, such as voiceless consonants, can be considerably lower. Existing techniques for improving recognition of low-level speech for cochlear implant users include using a wider input dynamic range and elevating electrode threshold levels (T-levels). While these techniques tend to positively impact recognition of soft speech, each has also been associated with drawbacks. Recently, a noise-gating (NG) algorithm was reported, which works by eliminating input to an electrode when signal level in the associated frequency channel is at or below a predetermined threshold. Available evidence suggests that activation of this algorithm can improve recognition of sentences presented at low levels (35 to 50 dB SPL), though it remains unclear whether the benefits will be equally evident with both manufacturer default and individually optimized T-levels. The primary aim of this study was therefore to evaluate the independent and combined effects of NG activation and T-level personalization. METHODS: Twenty adults between the ages of 25 and 77 years (M = 54.9 years, SD = 17.56) with postlingually acquired profound hearing loss completed testing for this study. Participants were fit with an Advanced Bionics Naida CI Q90 speech processor, which contained four programs based on each participant's existing everyday program. The programs varied by the NG algorithm setting (on, off) and T-level method (default 10% of M-level, personalized based on subjective ratings of "very quiet"). All participants completed speech sound detection threshold testing (/m/, /u/, /a/, /i/, /s/, and /∫/), as well as tests of monosyllabic word recognition in quiet (45 and 60 dB SPL), sentence recognition in quiet (45 and 60 dB SPL), and sentence recognition in noise (45-dB SPL speech, +10 dB SNR). RESULTS: Findings demonstrated that both activating NG and personalizing T-levels in isolation significantly improved detection (speech sounds) and recognition (monosyllables, sentences in quiet, and sentences in noise) of soft speech, with their respective individual effects being comparable. However, the lowest speech sound detection thresholds and the highest speech recognition performance were identified when NG was activated in conjunction with personalized T-levels. Importantly, neither T-level personalization nor NG activation affected recognition of speech presented at 60 dB SPL, which suggests the strategies should not be expected to interfere with recognition of average conversational speech. CONCLUSIONS: Taken together, these data support the clinical recommendation of personalizing T-levels and activating NG to improve the detection and recognition of soft speech. However, future work is needed to evaluate potential limitations of these techniques. Specifically, speech recognition testing should be performed in the presence of diverse noise backgrounds and home-trials should be conducted to determine processing effects on sound quality in realistic environments.

Are annoyance scores based on sound pressure levels suitable for snoring assessment in the home environment?

PURPOSE: An objective statement about the annoyance of snoring can be made with the Psychoacoustic Snore Score (PSS). The PSS was developed based on subjective assessments and is strongly influenced by observed sound pressure levels. Robustness against day-to-day interfering noises is a fundamental requirement for use at home. This study investigated whether or not the PSS is suitable for use in the home environment. METHODS: Thirty-six interfering noises, which commonly occur at night, were played in the acoustic laboratory in parallel with 5 snoring sounds. The interfering noises were each presented at sound pressure levels ranging from 25 to 55 dB(A), resulting in 3255 distinct recordings. Annoyance was then assessed using the PSS. RESULTS: In the case of minimally annoying snoring sounds, interfering noises with a sound pressure level of 25 dB(A) caused significant PSS changes from 40 to 55 dB(A) for annoying snoring sounds. If the interfering noise was another snoring sound, the PSS was more robust depending on the sound pressure level of the interfering noise up to 10 dB(A). Steady (no-peak) interfering noises influenced the PSS more strongly than peak noises. CONCLUSIONS: The PSS is significantly distorted by quiet interfering noises. Its meaningfulness therefore depends strongly on the acoustic environment. It may therefore be assumed that scores dependent on sound pressure level are suitable for measurements when there is minimal ambient noise, as in the sleep laboratory. However, for measurements where noise is incalculable, as in the home environment, interfering noises may distort the results.

A clinical comparison of DPOAE fine structure reduction methods.

OBJECTIVE: To evaluate two real-time methods for reducing distortion product otoacoustic emission (DPOAE) fine structure in terms of DPOAE amplitude and fine structure depth. DESIGN: A prospective, repeated-measures design was used to assess DPOAE characteristics in response to a conventional stimulation method (Conv.), as well as for methods implementing either a generic suppressor tone (Supp.) or frequency modulation of the f2 primary tone (FM). STUDY SAMPLE: Eighty-three young adults (58 females) between the ages of 20 and 34 years with normal hearing completed testing for this study. RESULTS: Use of the Conv. and FM methods resulted in consistently higher DPOAE levels relative to the Supp. method, with average advantages of 6 and 5 dB, respectively. For all methods, increased fine structure depth was observed for stimulation with lower level (25-45 dB SPL) and lower frequency (1000-3000 Hz) primary tones. Finally, use of the Supp. and FM methods resulted in significantly decreased fine structure depth relative to the Conv. method. CONCLUSION: Through frequency modulation of the f2 primary tone, it was possible to reduce the depth of fine structure across a clinically meaningful range of stimulation levels and frequencies without concomitant reduction in DPOAE amplitude.

Feedback reduction system influence on additional gain before feedback and maximum stable gain in open-fitted hearing aids.

OBJECTIVE: The primary purpose of this study was to update existing data on additional gain before feedback and maximum stable gain in commercially available, open-fit hearing instruments. A secondary purpose was to evaluate ratings of sound quality with feedback reduction systems active. DESIGN: Additional gain before feedback, maximum stable gain and subjective sound quality ratings were obtained for six commercially available hearing instruments utilising modern feedback reduction systems. STUDY SAMPLE: Twenty adults (22-46 years) with normal hearing participated in gain measurement testing. Thirty adults (22-39 years) with normal hearing provided ratings of sound quality. RESULTS: Mean additional gain before feedback for 2000-4000 Hz ranged from 5 to 16 dB across manufacturers. Mean maximum stable gain in the same frequency region ranged from 25 to 35 dB across manufacturers. However, meaningful performance differences between participants within each given manufacturer were also identified. Sound quality ratings were not related to the type of feedback reduction algorithm. CONCLUSIONS: AGBF and MSG continue to vary significantly both across manufacturers as well as individual ears within a given manufacturer. User satisfaction and performance with hearing aids might be improved by identifying the feedback reduction system optimal for the individual patient.

Estimation of Minor Conductive Hearing Loss in Humans Using Distortion Product Otoacoustic Emissions.

OBJECTIVES: Conductive hearing loss (CHL) systematically alters distortion product otoacoustic emission (DPOAE) levels through attenuation of both the primary tones and the evoked response by the middle ear, as well as through modification of the effective L1-L2 relationship within the cochlea. It has been postulated that, if optimal primary tone level relationships for an ear without CHL are known or can be estimated accurately and a CHL can be presumed to attenuate both primary tones to a similar extent, the adjustment to L1 required to restore an optimal L1-L2 separation following CHL induction can be utilized to estimate CHL magnitude objectively. The primary aim of this study was to assess the feasibility of objectively estimating experimentally produced CHL in humans by comparing CHL estimates resulting from DPOAE- and pure-tone audiometry-based methods. A secondary aim was to compare the accuracy of DPOAE-based CHL estimates when obtained using generic, as opposed to ear-specific, optimal primary tone level formula parameters. DESIGN: For a single ear of 30 adults with normal hearing, auditory threshold for a 1 kHz tone was obtained using automated Békésy audiometry at an ear-canal pressure of 0 daPa, as well as at a negative pressure sufficient for increasing threshold by 3 to 10 dB. The difference in threshold for the ear-canal pressure conditions was defined as the pure-tone audiometry-based estimate of CHL (CHLPT). For the same two ear-canal pressures, optimal DPOAE primary tone level relationships were identified for f2 = 1 kHz. Specifically, for 20 ≤ L2 ≤ 70 dB SPL, L1 was varied 15 dB above and below the recommendation of L1 = 0.49 L2 + 41 (dB SPL). The difference between the optimal L1-L2 relationships for the two pressure conditions was defined as ΔL1OPT. A DPOAE-based estimate of CHL (CHLDP) was obtained using the formula CHLDP = ΔL1OPT/(1 - a), where a represents the slope of the optimal L1-L2 relationship observed in the absence of CHL. RESULTS: A highly significant linear dependence was identified between pure-tone audiometry- and DPOAE-based estimates of CHL, r(19) = 0.71, p < 0.001. However, the correlation was only significant when ear-specific optimization formula parameters were known. Use of generic, frequency-nonspecific parameters resulted in significantly less accurate estimates than did either ear-specific (p < 0.001) or generic, frequency-specific parameters (p = 0.007). CONCLUSIONS: This study provides empirical support for a theory of how CHL, through a combination of middle ear filtering and alteration of effective primary tone level relationships within the cochlea, systematically affects DPOAE amplitude. Although CHLDP was shown to be significantly predictive of CHLPT when optimization formula parameters for a given ear, both with and without mild CHL, were known, the lack of a meaningful relationship when using generic primary tone level formula parameters significantly limits the method's potential for clinical utility.

Avoiding disconnection: An evaluation of telephone options for cochlear implant users.

OBJECTIVE: The primary aim of this study was to evaluate the effect of coupling method on telephone-based speech recognition and perceived listening difficulty in noise for cochlear implant (CI) users. A secondary aim was to evaluate potential impacts of additional processing modifications within coupling conditions, such as activating noise reducing algorithms or muting environmental microphones. DESIGN: Hochmair-Schulz-Moser sentences were bandpass-filtered (300-3400 Hz) and presented unilaterally either via telephone handset or advanced wireless streaming device in a background of cafeteria babble (signal-to-noise ratio =15 dB). Sentence recognition was scored at the word level and perceived listening difficulty was assessed via visual-analogue scale for each of five test conditions. STUDY SAMPLE: Twenty native German-speaking CI users participated. RESULTS: Repeated measures analysis of variance revealed coupling via advanced streaming significantly improved sentence recognition and reduced listening difficulty, when compared to either telecoil or acoustic coupling configurations. In addition, program modifications further increased benefit within a coupling condition. CI users who exhibited the most difficulty during basic acoustic coupling were most likely to benefit from advanced wireless streaming. CONCLUSION: CI users have several options for improving speech recognition and decreasing listening difficulty over the telephone when listening in noisy environments.

Average optimal DPOAE primary tone levels in normal-hearing adults.

OBJECTIVE: Despite great progress towards optimizing DPOAE primary tone characteristics, factors such as stimulus and intra-subject emission variability have not been addressed. The purpose of this study was to identify optimal primary tone level relationships when these sources of variability were acknowledged, and to identify any influences of test frequency. DESIGN: Following coupler-based measurements assessing primary tone level stability, two experiments were conducted. In experiment 1, DPOAE test-retest reliability without probe replacement was measured for f2 = 1-6 kHz with L1 = L2 = 65 dB SPL. In experiment 2, optimal L1-L2 relationships were identified for f2 = 1-6 kHz. For 20 ≤ L2 ≤ 75 dB SPL, L1 was varied 15 dB SPL above and below the recommendation of L1 = 0.4 L2 + 39 [dB SPL]. STUDY SAMPLE: Eleven normal-hearing adults participated in experiment 1. Thirty normal-hearing adults participated in experiment 2. RESULTS: Stimulus variability did not exceed 0.1 dB SPL. DPOAE reliability testing revealed an across-frequency mean standard error of measurement of 0.52 dB SPL. The average optimal L1-L2 relationship was described by L1 = 0.49 L2 + 41 [dB SPL]. A significant effect of frequency was identified for 6 kHz. CONCLUSION: Including relevant sources of variability improves internal validity of a primary tone level optimization formula.

Early indication of noise-induced hearing loss from PMP use in adolescents: A cross-sectional analysis.

CONTEXT: Distortion product otoacoustic emissions (DPOAEs) may indicate preclinical noise-induced hearing loss (NIHL) in adolescents from unsafe personal music player (PMP) use. AIMS: The objective, therefore, was to observe preclinical signs of NIHL in 9th grade adolescents with clinically normal hearing by comparing DPOAE signals between different levels of A-weighted equivalent PMP exposure. SETTINGS AND DESIGN: Subjects were recruited from all secondary-level schools located in the city of Regensburg, Germany during two academic years 2009/2010 and 2010/2011. SUBJECTS AND METHODS: A-weighted equivalent sound pressure levels (SPLs) for a 40-hour work week (LAeq,40h) were estimated from questionnaire responses on output and duration of PMP use of the previous week. Subjects were then categorized into four levels of exposure: <80, 80-85, >85 to <90, and ≥90 A-weighted Decibel [dB(A)]. DPOAE signals were collected by trained audiological staff, applying a standard optimized protocol, at the Department of Otorhinolaryngology of the University Hospital Regensburg. STATISTICAL ANALYSIS USED: Mean DPOAE signals were compared between levels by unpaired t test. Novel linear regression models adjusting for other leisure noise exposures and with outcome variables DPoutcome and 4 kilo Hertz (kHz) DPOAEs estimated effects between levels. RESULTS: A total of 1468 subjects (56% female, mostly aged 15 or 16 years) were available for analysis. Comparison of DPOAE means by PMP exposure typically showed no greater than 1 dB difference between groups. In fact, comparisons between ≥90 dB(A) and <80 dB(A) presented the least differences in magnitude. Both DPoutcome and 4 kHz linear regression models presented a weak association with the 4-level PMP exposure variable. An expected dose-response to PMP exposure was not observed in any analyses. CONCLUSIONS: DPOAE signal strength alone cannot indicate preclinical NIHL in adolescents.

Evaluation of the effects of nonlinear frequency compression on speech recognition and sound quality for adults with mild to moderate hearing loss.

OBJECTIVE: While potentially improving audibility for listeners with considerable high frequency hearing loss, the effects of implementing nonlinear frequency compression (NFC) for listeners with moderate high frequency hearing loss are unclear. The purpose of this study was to investigate the effects of activating NFC for listeners who are not traditionally considered candidates for this technology. DESIGN: Participants wore study hearing aids with NFC activated for a 3-4 week trial period. After the trial period, they were tested with NFC and with conventional processing on measures of consonant discrimination threshold in quiet, consonant recognition in quiet, sentence recognition in noise, and acceptableness of sound quality of speech and music. STUDY SAMPLE: Seventeen adult listeners with symmetrical, mild to moderate sensorineural hearing loss participated. Better ear, high frequency pure-tone averages (4, 6, and 8 kHz) were 60 dB HL or better. RESULTS: Activating NFC resulted in lower (better) thresholds for discrimination of /s/, whose spectral center was 9 kHz. There were no other significant effects of NFC compared to conventional processing. CONCLUSION: These data suggest that the benefits, and detriments, of activating NFC may be limited for this population.

Tinnitus Is Marginally Associated with Body Mass Index, Heart Rate and Arterial Blood Pressure: Results from a Large Clinical Sample.

INTRODUCTION: This study aimed to explore whether body mass index (BMI), systolic blood pressure (RR syst), diastolic blood pressure (RR diast) or heart rate (HR) are associated with tinnitus status and/or severity. METHODS: To that end, we evaluated the influence of tinnitus status and Tinnitus Handicap Inventory (THI) score on BMI, RR syst, RR diast and HR by comparing data from a large sample of patients presenting to a specialized tertiary referral clinic (N = 1066) with data from a population-based control group (N = 9885) by means of linear models. RESULTS: Tinnitus patients had a significantly lower BMI and higher RR syst, RR diast and HR than non-tinnitus patients; however, the contribution of the case-control status to R2 was very small (0.1%, 0.7%, 1.4% and 0.4%, respectively). BMI had little predictive power for the THI score (higher BMI scores were related to higher THI scores; R2 = 0.5%) and neither RR syst, RR diast, nor HR showed a statistically significant association with THI. DISCUSSION: Our findings suggest that HR, RR and BMI are at most marginally associated with tinnitus status and severity.

The statistical analysis plan for the unification of treatments and interventions for tinnitus patients randomized clinical trial (UNITI-RCT).

BACKGROUND: Tinnitus is a leading cause of disease burden globally. Several therapeutic strategies are recommended in guidelines for the reduction of tinnitus distress; however, little is known about the potentially increased effectiveness of a combination of treatments and personalized treatments for each tinnitus patient. METHODS: Within the Unification of Treatments and Interventions for Tinnitus Patients project, a multicenter, randomized clinical trial is conducted with the aim to compare the effectiveness of single treatments and combined treatments on tinnitus distress (UNITI-RCT). Five different tinnitus centers across Europe aim to treat chronic tinnitus patients with either cognitive behavioral therapy, sound therapy, structured counseling, or hearing aids alone, or with a combination of two of these treatments, resulting in four treatment arms with single treatment and six treatment arms with combinational treatment. This statistical analysis plan describes the statistical methods to be deployed in the UNITI-RCT. DISCUSSION: The UNITI-RCT trial will provide important evidence about whether a combination of treatments is superior to a single treatment alone in the management of chronic tinnitus patients. This pre-specified statistical analysis plan details the methodology for the analysis of the UNITI trial results. TRIAL REGISTRATION: ClinicalTrials.gov NCT04663828 . The trial is ongoing. Date of registration: December 11, 2020. All patients that finished their treatment before 19 December 2022 are included in the main RCT analysis.

Daily Contributors of Tinnitus Loudness and Distress: An Ecological Momentary Assessment Study.

Background: Tinnitus is a heterogeneous condition which may be associated with moderate to severe disability, but the reasons why only a subset of individuals is burdened by the condition are not fully clear. Ecological momentary assessment (EMA) allows a better understanding of tinnitus by capturing the fluctuations of tinnitus symptoms, such as distress and loudness, and psychological processes, such as emotional arousal, overall stress, mood, and concentration and how these variables interact over time. Whether any of those variables have an influence over the next day, that is, whether any of these variables are auto- or cross-correlated, is still unanswered. Objectives: Assess whether behavioral and symptom-related data from tinnitus users from the TrackYourTinnitus (TYT) mobile app have an impact on tinnitus loudness and distress on subsequent days. Methods: Anonymized data was collected from 278 users of the iOS or Android TYT apps between 2014 and 2020. Tinnitus-related distress, tinnitus loudness, concentration level, mood, emotional arousal, and overall stress level were assessed using either a slider or the Wong-Baker Pain FACES scale via a daily survey. Three modeling strategies were used to investigate whether tinnitus loudness and distress are affected by previous days symptoms or psychological processes: auto- and cross correlations, regressions with elastic net regularization, and subgrouping within group iterative multiple model estimation (S-GIMME). Results: No autocorrelation or cross-correlation was observed at the group level between the variables assessed. However, application of the regression models with elastic net regularization identified individualized predictors of tinnitus loudness and distress for most participants, with the models including contemporaneous and lagged information from the previous day. S-GIMME corroborated these findings by identifying individualized predictors of tinnitus loudness and distress from the previous day. Discussion: We showed that tinnitus loudness and tinnitus distress are affected by the contemporaneous and lagged dynamics of behavioral and emotional processes measured through EMA. These effects were seen at the group, and individual levels. The relevance EMA and the implications of the insights derived from it for tinnitus care are discussed, especially considering current trends toward the individualization of tinnitus care.

The Influence of Diet on Tinnitus Severity: Results of a Large-Scale, Online Survey.

Optimization of dietary intake is an essential component in the multidimensional effort to prevent and manage chronic disease. Recently, demand has increased for nutrition-focused management strategies for chronic tinnitus. The primary aim of this study was to evaluate 10 dietary items for their association with changes in subjective tinnitus severity. A secondary aim was to develop an algorithm to better identify those individuals who might benefit from dietary modification strategies. A total of 5017 anonymous users of the TinnitusTalk forum completed an online survey regarding how various dietary items affected the severity of their tinnitus. Results suggest that, while intake of caffeine [positive effect (PE): 0.4%; negative effect (NE): 16.2%], alcohol (PE: 2.7%; NE: 13.3%, and salt (PE: 0.1%; NE: 9.9%) was most likely to influence tinnitus severity, it did so only for a small proportion of participants and reported effects were most commonly mild. Further, though a classification algorithm was able to leverage participant demographic, comorbidity, and tinnitus characteristics to identify those individuals most likely to benefit from dietary modification above chance levels, further efforts are required to achieve significant clinical utility. Taken together, these results do not support dietary modification as a primary treatment strategy for chronic tinnitus in the general population, though clinically meaningful effects might be observable in certain individuals.

HHT-Related Epistaxis and Pregnancy-A Retrospective Survey and Recommendations for Management from an Otorhinolaryngology Perspective.

Appropriate management of hereditary hemorrhagic telangiectasia (HHT) is of particular importance in females, as HHT-mediated modifications of the vascular bed and circulation are known to increase the risk of complications during pregnancy and delivery. This study was undertaken to evaluate female HHT patients' awareness of and experience with HHT during pregnancy and delivery, with a focus on epistaxis. In this retrospective study, 46 females (median age: 60 years) with confirmed HHT completed a 17-item questionnaire assessing knowledge of HHT and its pregnancy-associated complications, the severity of epistaxis during past pregnancies and deliveries, and the desire for better education and counselling regarding HHT and pregnancy. Results revealed that 85% of participants were unaware of their disease status prior to the completion of all pregnancies. Further, 91% reported no knowledge of increased pregnancy-related risk due to HHT. In regard to epistaxis, 61% of respondents reported experiencing nosebleeds during pregnancy. Finally, approximately a third of respondents suggested that receiving counseling on the risks of HHT in pregnancy could have been helpful. Findings suggest that awareness of HHT and its potential for increasing pregnancy-related risk is poor. Best practices in HHT management should be followed to minimize negative effects of the disorder.

Conventional versus notch filter amplification for the treatment of tinnitus in adults with mild-to-moderate hearing loss.

INTRODUCTION: Conventional hearing aids are commonly recommended for the treatment of tinnitus, though results of studies investigating the efficacy of hearing aid-based tinnitus treatments have been mixed. Recently, it has been suggested that the addition of a notch filter around the tinnitus frequency might enhance lateral inhibitory mechanisms and thereby improve tinnitus severity relative to traditional processing. The primary aim of this study was to compare the effects of conventional versus notch filter amplification strategies on subjective tinnitus severity in adults with mild-to-moderate hearing loss and no previous hearing aid experience. METHODS: Thirty-nine adults (mean age=53.6 years; SD=9.7 years) with bilateral, mild to moderate sensorineural hearing loss and an established clinical history of stable, tonal tinnitus participated in this double-blinded study. Each participant was randomly assigned to complete a 12-week hearing aid trial using either a conventional amplification strategy or a strategy which applied a notch filter at the given participant's tinnitus pitch match frequency. Tinnitus-related handicap and distress were assessed before and after the hearing aid trial via the Tinnitus Handicap Inventory (Newman et al., 1996) and the Tinnitus Questionnaire (Hallam et al., 1988). RESULTS: Average tinnitus severity did not differ significantly between the conventional and notch filter amplification groups following treatment. Moreover, average pre- to post-intervention change scores were relatively low for both groups, indicating minimal effect of either treatment on tinnitus symptoms. Participant age, high-frequency pure-tone average hearing threshold, average daily hearing aid usage, and pre-intervention tinnitus severity ratings were not predictive of treatment success or failure. DISCUSSION: Results of the present study suggest no significant effect of either conventional or notch filter amplification on average ratings of tinnitus severity following a 12-week hearing aid trial. However, as clinically meaningful changes in tinnitus severity were identified for some participants, future work is needed to better identify those individuals most likely to benefit, as well as optimal amplification characteristics.

Towards a unification of treatments and interventions for tinnitus patients: The EU research and innovation action UNITI.

Tinnitus is the perception of a phantom sound and the patient's reaction to it. Although much progress has been made, tinnitus remains a scientific and clinical enigma of high prevalence and high economic burden, with an estimated prevalence of 10%-20% among the adult population. The EU is funding a new collaborative project entitled "Unification of Treatments and Interventions for Tinnitus Patients" (UNITI, grant no. 848261) under its Horizon 2020 framework. The main goal of the UNITI project is to set the ground for a predictive computational model based on existing and longitudinal data attempting to address the question of which treatment or combination of treatments is optimal for a specific patient group based on certain parameters. Clinical, epidemiological, genetic and audiological data, including signals reflecting ear-brain communication, as well as patients' medical history, will be analyzed making use of existing databases. Predictive factors for different patient groups will be extracted and their prognostic relevance validated through a Randomized Clinical Trial (RCT) in which different patient groups will undergo a combination of tinnitus therapies targeting both auditory and central nervous systems. From a scientific point of view, the UNITI project can be summarized into the following research goals: (1) Analysis of existing data: Results of existing clinical studies will be analyzed to identify subgroups of patients with specific treatment responses and to identify systematic differences between the patient groups at the participating clinical centers. (2) Genetic and blood biomarker analysis: High throughput Whole Exome Sequencing (WES) will be performed in well-characterized chronic tinnitus cases, together with Proximity Extension Assays (PEA) for the identification of blood biomarkers for tinnitus. (3) RCT: A total of 500 patients will be recruited at five clinical centers across Europe comparing single treatments against combinational treatments. The four main treatments are Cognitive Behavioral Therapy (CBT), hearing aids, sound stimulation, and structured counseling. The consortium will also make use of e/m-health applications for the treatment and assessment of tinnitus. (4) Decision Support System: An innovative Decision Support System will be implemented, integrating all available parameters (epidemiological, clinical, audiometry, genetics, socioeconomic and medical history) to suggest specific examinations and the optimal intervention strategy based on the collected data. (5) Financial estimation analysis: A cost-effectiveness analysis for the respective interventions will be calculated to investigate the economic effects of the interventions based on quality-adjusted life years. In this paper, we will present the UNITI project, the scientific questions that it aims to address, the research consortium, and the organizational structure.