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Vol. 38, Number 2 Summer 2013 A publication of the American Tinnitus Association OUR AN NUA L R E S E A R C H I S S U E The Many Faces of Research: From Leading Investigations in the Lab & Clinic to Donating and Advocating 2013 RESEARCH IS 2013 Tinnitus Research Initiative Conference Participants Page 28 Donna Brown: She Does it Again! Susan E. Shore, Ph.D. Testifies for ATA Page 7 Page 26 SU E Advertisement — ATA does not endorse or recommend any tinnitus products or treatments. // ExpEriEncE a nEw, MOre PersOnaLiZeD TinniTus TreaTMenT sOLuTiOn Few ailments are as subjective as tinnitus. From what it sounds like to when it’s most annoying to how debilitating it can be, tinnitus affects every person differently. Our new Tinnitus Treatment Solution features new Multiflex Tinnitus Technology, which tackles the personal nature of tinnitus head-on. This patent-pending technology enables you and your tinnitus hearing professional to customize a sound stimulus designed to counterbalance the precise sounds you hear. Fine-tuned to your unique needs, it’s engineered to deliver consistent tinnitus relief. Call 1.877.210.0384 today to see if you’re a candidate for tinnitus relief. For more information, visit tinnitushearing.com. // Nearly invisible in the ear Proud Corporate Champion The American Tinnitus Association exists to cure tinnitus through the development of resources that advance tinnitus research. Vol. 38, Number 2 Jennifer Born, Editor Tinnitus Today is published three times a year, in Spring (April), Summer (August) and Winter (December), and mailed to American Tinnitus Association members and donors. Circulation is rotated to 75,000 annually. The American Tinnitus Association is a nonprofit human health and welfare agency under 26 USC 501(c)(3). ©2013 American Tinnitus Association. No part of this publication may be reproduced, stored in a retrieval system or transmitted in any form, or by any means, without the prior written permission of the Publisher. ISSN: 0897-6368 (print). ISSN: 1530-6569 (online). Board of Directors Thomas J. Lobl, Ph.D., Chair, Valencia, Calif. Melanie F. West, Vice-Chair, Cave Creek, Ariz. Marsha Johnson, Au.D., Treasurer, Portland, Ore. Norma Mraz, Au.D., Secretary, Alpharetta, Ga. James Chinnis, Jr., Ph.D., Warrenton, Va. Jeff De Cagna, FRSA FASAE, Reston, Va. Cathy Henderson Jones, M.S, Warrenville, Ill. Mark K. Johnson, J.D., Anchorage, Alaska Gary P. Reul, Ed.D., Issaquah, Wash. Scott C. Mitchell, J.D., Houston, Texas Susan E. Shore, Ph.D., Ann Arbor, Mich. Joseph Trevisani, M.I.A., New York, N.Y Bradley S. Vite, Elkhart, Ind. Honorary Director William Shatner, Los Angeles, Calif. Summer 2013 REGULAR FEATURES 4 A Call to Action from the New Chair of ATA Thomas J. Lobl, Ph.D. 5 Letters to the Editor Jennifer Born 6 Members Corner Katie Fuller 21 Questions and Answers Guest Professional, Harriet Jacobster, Au.D. 31 Special Donors and Tributes ATA-FUNDED RESEARCH 11 20 New ATA-Funded Research rTMS Bimodal Treatment For Patients with Subjective Idiopathic Tinnitus: A Pilot Study of High-Dose Stimulation Jay Piccirillo, M.D. 25 Open Enrollment Design, Randomized Clinical Trial of Acamprosate for Tinnitus William Hal Martin, Ph.D., and Yong-Bing Shi, M.D. 27 ATA-Funded Research Report: Brain Activity and Tinnitus Scientific Advisory Committee Susan E. Shore, Ph.D., Chair, Ann Arbor, Mich. Robert F. Burkard, Ph.D., Buffalo, N.Y. Donald Caspary, Ph.D., Springfield, Ill. Kejian Chen, Ph.D., San Diego, Calif. Dirk De Ridder, M.D., Ph.D., Otago, New Zealand James (Jay) W. Hall, Ph.D., FAAA, Gainesville, Fla. James Henry, Ph.D., Portland, Ore. Fatima T. Husain, Ph.D., Urbana-Champaign, Ill. Marlies Knipper-Breer, Ph.D., Tübingen, Germany Jennifer Melcher, Ph.D., Boston, Mass. Mark S. Mennemeier, Ph.D., Little Rock, Ark. Jay Piccirillo, M.D., FACS, St. Louis, Mo. Larry E. Roberts, Ph.D., Hamilton, Ontario Hinrich Staecker, M.D., Ph.D., Kansas City, Kan. Athanasios Tzounopoulos, Ph.D., Pittsburgh, Pa. Pim Van Dijk, Ph.D., Groningen, The Netherlands Fan-Gang Zeng, Ph.D., Irvine, Calif. Jinsheng Zhang, Ph.D., Detroit, Mich. Pim Van Dijk, Ph.D. Cover: Group photo credit: Javier Tomás 7 8 9 Ain’t No Mountain High Enough for Donna Brown Ian Punnett 26 Congressional Leaders Continue Their Support of Tinnitus Research and Treatment Jennifer Born 30 Successful Tinnitus Treatment Relies on Management and Habituation Jeff Carroll, Ph.D. The opinions expressed by contributors to Tinnitus Today are not necessarily those of its publishers or the American Tinnitus Association (ATA). The publishers of Tinnitus Today reserve the right to edit or reject any materials received for publication in Tinnitus Today. This publication provides, for information purposes only, a variety of topics related to tinnitus. The publishers of Tinnitus Today reserve the right to reject any advertising deemed unsuitable for this publication. Acceptance of advertising does not constitute endorsement of the advertiser or its products or services. This publication and ATA make no claims or guarantees as to the accuracy or validity of advertisers’ offers. ATA does not endorse or recommend any tinnitus treatment strategies. RESEARCH FROM AROUND THE WORLD 13 Tinnitus Caused by Dental Crowns: A Scientific Perspective Susan Shore, Ph.D., Roxana Stefanescu, Ph.D., and David Martel, MS, EE BME 14 Orchestrating Silence for Those with Pulsatile Tinnitus Michael J. A. Robb, M.D., Mia Pozzanghera, B.S., Cameron G. McDougall, M.D., Luis F. Gonzalez, M.D., Webster Crowley, M.D., Shirley S. Smith, M.D., and Angela Dagirmanjian, M.D. 16 19 28 Research Round Up 2013: Focus on Humans and Clinical Trials Glossary of Research Terms Tinnitus: A Treatable Disease Berthold Langguth, M.D., Ph.D. SPECIAL FEATURES Cara James The Changing of the Guard: New ATA Board Officers and Members The Buzz: Talking with Your Tinnitus Editorial and advertising office: American Tinnitus Association, P.O. Box 5, Portland, OR 97207 (503) 248-9985, (800) 634-8978 [email protected] ATA.org • • Summer 2013 | Tinnitus Today 3 A Call to Action from the New Chair of ATA On July 1, 2013, to coincide with the beginning of ATA’s new fiscal year, I began my term as Chair of the ATA Board of Directors. I am honored to take on this position and look forward to working with our dedicated staff and volunteers to grow ATA in the coming years. As you know ATA is the premier organization on tinnitus, from providing the latest information to patients that help them today, to funding cutting-edge research that will help us all tomorrow (I too have tinnitus). We have also recently redesigned our Health Professional Listing of tinnitus professionals who understand you and your needs. ATA’s mission is to develop resources that advance tinnitus research and that includes raising money to support innovative new research ideas that will bring us closer to the day when we can say that a cure is on the horizon. Our seed grants have provided the stimulus for progress in understanding the etiology of tinnitus and in some cases have developed new treatments. From our vantage point it is exciting to see so many promising research ideas being tested and progress made in the laboratory and clinic. ATA 4 Tinnitus Today | Summer 2013 is also your advocate in Washington, D.C. Our advocacy activities have been successful catalysts for educating governmental agencies to understand the need for more grant money to find a cure and to promote legislation to help veterans with tinnitus get better care. However, these activities alone are not enough. more aware of it. Tell them about our website, publications, support groups and our network of healthcare professionals who understand tinnitus patients and their unique needs. Ask them to donate to our cause so we can sponsor more research. The sooner we plant the seeds of creative research, the sooner we will harvest a cure. To accelerate progress we need to raise more money to support ATA’s mission. Donations come from many sources like our direct mail campaigns, walks and the Tour de Tinnitus for example. These events have been successful and are fun ways to raise money as well as awareness of ATA and we need your help in organizing more of them. If you or your local tinnitus support group would like to join or sponsor a walk or other fundraising activity please contact us. Your contributions here will have a big impact. Finally, we are committed not just to curing tinnitus but to helping you and others. So we look forward to hearing from you about how we can become an even better and more effective organization. Write me with your ideas and comments at [email protected] With your help we will make progress this year and next that we will all be proud of. Despite these accomplishments, we are frustrated that we cannot do more. For this reason I would like to ask for your help. Tinnitus is “silent” to others and most of the general public is unaware of how common tinnitus is. Talk about tinnitus with your friends and colleagues so they will become Thomas J. Lobl, Ph.D. Chair, ATA Board of Directors Thank you for your letters and ideas. Here, members share their thoughts about ATA and their opinions on tinnitus and treatments they have tried. We publish them with the hope that the information might be of help to others. Please read these anecdotal reports carefully. If you are interested in a treatment mentioned, consult with your health care professional and together decide if a given treatment might be right for you. The opinions expressed here are strictly those of the letter writers and do not reflect an opinion or endorsement by ATA. Tinnitus Today readers want to hear from other readers! So please write to me at [email protected] or Editor, Tinnitus Today, American Tinnitus Association, P.O. Box 5, Portland, OR, 97207. Letters to the Editor Dental Work and Tinnitus – A Response The article on dental work and tinnitus that appeared in the Spring 2013 issue of Tinnitus Today was very interesting. For years, I have had electric current sensations that would seem to pass from one ear to the other when I was talking on the telephone (whether land line, portable or cell). I later experienced sudden, severe sensorineural hearing loss followed by roaring tinnitus that has never left me. I also learned that I had Lyme disease within a year of the hearing loss that had likely gone undetected for quite some time. We don’t know for sure that the hearing loss is a result of Lyme disease, but my neurologist thinks it is very likely. I have been reading that mercury and various dental materials can cause all kinds of neurological problems for some. There is a well known conductor of the Boston Philharmonic, Benjamin Zander, whose symptoms of Meniere’s disease went away after he had his mercury fillings removed. I am considering having my mercury fillings removed as well as a silver crown. If I go through with this, I would be happy to update you on my tinnitus and “electrical current” sensations. Thank you for this wonderful article. Deborah Magnus ATA Member since 2011 Editors note: Please see Page 13 for an alternate explanation to why dental work may cause or exacerbate tinnitus. I’ve had tinnitus for 10 years (hissing in both ears) and I am quite accustomed to it. But recently another tinnitus sound – like an intermittent chirping noise – started plaguing my life. This came after suffering a cold and occurs only in my right ear. Even now that the cold is gone and my sinuses are doing well, the new tinnitus sound is lingering. My ENT ran some tests and told me that it could be many things with in the inner ear or brain. I asked him about innovative drugs that have been experimented within the last few years. He told me there are none approved, nothing in the pipeline for approval and he does not think that there will be one any time soon. The hopeless, disappointing comments of this ENT certainly does not help the tinnitus sufferer. Sometimes even a simple hopeful statement or promise of treatment from a professional gives you enough energy to deal with your tinnitus and even to some extent help cure it on its own. Are there certain ENTs that are more interested, knowledgeable, courageous and hopeful about tinnitus than others? If there are, can ATA help identifying one near me? Thanks Paul Ghossi ATA Member since 2003 Editors note: Please see ATA’s efforts to expand our multidisciplinary tinnitus health professional listing and all the new things you can search for by specialty in the Members Corner article on Page 6. Cochlear Implant Provides Relief! Why Don’t ENTs Understand? Frequently ATA recommends consulting an otolaryngologist (ENT) for diagnosis and treatment for tinnitus. While this is the right thing to do, it is mostly very disappointing that ENTs in general don’t offer suggestions for treatment. It seems that most ENTs are totally unaware of new research studies related to tinnitus, or simply don’t want to bother with tinnitus patients. I would like to share with my fellow ATA members my amazing treatment experience. I suffered from very severe tinnitus for 13 years, which came on suddenly one day and caused me a lot of suffering. I recently had cochlear implant surgery, and from the moment my implant was turned on my tinnitus went completely away. I had put off surgery for many years because I was afraid it would make the tinnitus worse, and Continued on Page 29 Summer 2013 | Tinnitus Today 5 Members Corner Katie Fuller, ATA Director of Support Tinnitus patients need more than a diagnosis and evaluation. They need tools to learn how to cope with and manage their tinnitus, the knowledge that their health professional is committed to understanding the condition, and help in determining which treatment strategy is suited for them. Because each tinnitus patient is unique, only a qualified hearing health professional can determine which form of treatment is ideal for each person. One such treatment, PATIENTS: New professionals sound therapy, is the most widely and updates to existing listings available and most effective form continue to roll in, so ATA of therapy for tinnitus. Typically members please check the an audiologist is best equipped listing often for the most and trained to help determine current information! Visit which form will work best for the Members Section at an individual. ATA.org/Members today Sound therapy has been shown or email [email protected] to help many with their tinnitus. Various treatment strategies utiPROFESSIONALS: If you are lize sound to decrease the louda healthcare professional with ness or prominence of tinnitus a developed understanding by introducing sound into the of tinnitus, tinnitus patients auditory parts of the brain for the and effective tinnitus evaluapurpose of refocusing the brain’s tions and treatments, please attention away from the tinnitus. sign-up to be a part of this Sound therapies can include great resource if you have not both wearable (hearing aid-like already, or please update your or MP3 player-like devices) and information at: ATA.org/profesnon-wearable devices (such as sionals/health-professionaltable-top sound machines or even listing-sign-up. a whirring fan). Often sound, like white noise, is used to completely or partially cover the tinnitus. Some people refer to this covering of sound as masking. Sound therapies, in general, are most effective when combined with a form of counseling. You can read about one particular sound therapy treatment and a patient’s experience with it on Page 30. An Update on ATA’s Health Professional Listing In the last issue of Tinnitus Today, we announced the overhaul of ATA’s Health Professional Listing – a valuable resource for tinnitus patients seeking health professionals who know and understand the condition. We have been working to enhance the listing to include more of the information that patients look 6 Tinnitus Today | Summer 2013 for when seeking a dependable tinnitus professional: current license information, professional affiliations, education, tinnitus coursework, number of years treating tinnitus patients, the type of facility they practice in, specialty/function, and what kind of insurance they accept. The list is searchable by state and/or by what types of evaluations, testing or treatment methods they offer. The selection of services has been expanded so you can search for even more detailed information. Here is a sample of what you can search for: Professional Evaluation(s): Audiological Evaluation Auditory Processing Disorders Evaluation ■■ Hearing Instrument Evaluation ■■ Hyperacusis Evaluation ■■ Medical Evaluation (Ear, Nose & Throat; Neurology, Psychology and Psychiatry) ■■ Misophonia/Phonophobia Evaluation ■■ Nutritional Evaluation ■■ Ototoxicity Monitoring Evaluation ■■ Stress Evaluation ■■ Tinnitus Evaluation ■■ Temporomandibular Joint Disorder (TMJ) Evaluation Treatment Method(s)*: Acupuncture Aural/Audiological Rehabilitation ■■ Biofeedback ■■ Cochlear Implants ■■ Cognitive Behavioral Therapy ■■ Counseling ■■ Education ■■ Electrical Stimulation ■■ Hearing Aids ■■ Holistic Approaches ■■ Hyperacusis Treatments ■■ Hypnosis ■■ Massage/Musculoskeletal/ Neuromuscular Approaches ■■ Music Therapy ■■ Musician’s Custom Molds/ Earplugs/Monitors ■■ Neurofeedback ■■ Pharmacological Approaches ■■ Psychological Therapies ■■ Pulsatile Tinnitus Treatments ■■ Relaxation/Stress Management ■■ Sound Therapy ■■ Surgical Approaches ■■ Transcranial Magnetic Stimulation (TMS) Therapy ■■ Ultrasonic Tinnitus Treatment ■■ Vestibular/Balance Therapy ■■ ■■ ■■ ■■ Diagnostic Testing(s): Brainstem Auditory Evoked Response (BAER) Testing ■■ Diagnostic Hearing Services ■■ Electronystagmography (ENG) Testing ■■ Residual Inhibition Testing ■■ Tinnitus Pitch Matching ■■ Vestibular/Balance Testing ■■ Disclaimer: ATA’s Health Professional Listing helps tinnitus patients reach out to local health care resources. While the listing is not a formal referral service, it is provided to those seeking suggestions when making important health care choices. ATA Continued on Page 23 Above: Donna Brown successfully summits Mt. Hood. (photo: Jeff Ward) Left: Katy Thatch, Donna Brown and guide Jeff Ward wave the ATA banner. (photo: Cara James) Below: Donna and Gary Brown celebrate the victory with a post-climb embrace. (photo: Barb Garber) Ain’t No Mountain High Enough for Donna Brown! By Cara James, ATA Development Director When tinnitus patient and outdoor enthusiast, Donna Brown, flew from Colorado to Oregon for her “Summit for Silence” fundraising climb of Mt. Hood this July, ATA staff surprised her at the airport. Similarly, Donna surprised us! For someone so large in spirit, we were amazed she was so small in stature. But nothing, not even size, could stop 61-year-old Donna from tackling some of the highest peaks in the U.S. for the sake of tinnitus research! Donna’s personal mission is simple – she wants to see significant progress toward a tinnitus cure in her lifetime. She says, “This is my calling. It’s one of the gifts of tinnitus – to do something like this.” When Donna is in the mountains, she is fully present. “I’m focusing on where I’m going to put my hand hold, my foot. I’m thinking of getting up the mountain and down the mountain. That’s my kind of silence. You get so involved and taken with the wilderness. You’re focused on things around you. It helps me focus away from the tinnitus.” At 6 a.m., the day after Donna began her two-day trek up Mt. Hood, we received a text message with a photo of Donna at the summit (isn’t technology amazing?) There she was, aglow in the early morning light, edging along the ridge of the peak. She was still glowing many hours later, when we celebrated her successful return. It’s hard to capture the beautiful energy of that moment, seeing Donna embody the hope and promise of tinnitus patients everywhere. It was clear Donna felt the strength of the hundreds of people who supported her climb, whose names she carried to the summit on a banner in her pack. With everyone’s help, Donna raised nearly $52,000 for tinnitus research – enough to fund one ATA grant! “This cause chose me,” Donna told us. “I can’t do anything about hunger in the world, about poverty or homelessness. But I CAN do something about tinnitus. Why not climb a mountain?” So she did! “I can’t do anything about hunger in the world, about poverty, or homelessness. But I CAN do something about tinnitus. Why not climb a mountain?” Summer 2013 | Tinnitus Today 7 The Changing of the Guard: New ATA Board Officers and Members Each July 1 marks the beginning of ATA’s new fiscal year. This also usually coincides with ATA Board members’ terms beginning, ending, or being renewed as well as the election of new officers. ATA offers its thanks to these volunteers because without their vision, resources and dedication to ATA’s mission, we could not realize our goal of curing tinnitus. On June 30, Mark K. Johnson, J.D., completed his service as Chair of the ATA Board of Directors. Among many responsibilities, as Chair Mark planned and led quarterly meetings of the Board and specifically enhanced ATA’s advocacy program. Mark began his service on the Board in 2003 and has served for several terms. Prior to becoming Chair of the Board he led the efforts for beginning ATA’s focused advocacy efforts in Washington, D.C., as Chair of our Advocacy Committee. Mark will continue for one more year of service to help the newly elected Chair transition. We thank him for his leadership and look forward to another year of working with him toward fulfilling ATA’s mission. Thomas J. Lobl, Ph.D., has been elected to serve as the new Chair of ATA’s Board of Directors. In this twoyear period of service, Tom hopes to enhance ATA’s outreach to patients and professionals and to build new and strengthen existing partnerships for ATA within the tinnitus and hearing health community. Tom also just completed his term as Vice-Chair of ATA, so being elected as Chair was a natural progression and a great way for continuous leadership on the ATA Board. Tom has served since 2007 and brings business, scientific and personal patient expertise to this position. We welcome Melanie F. West as a brand new officer on the ATA Board. Melanie was elected as Vice-Chair to fill the vacancy left by Tom. Melanie has been on the ATA Board since 2011 and was the powerhouse behind the establishment of the AZ Walk to Silence Tinnitus held in Scottsdale, AZ in 2011 and 2012. Her fundraising, marketing and business experience bring a trifecta of talent to this position, and she will undoubtedly help to increase ATA’s visibility and outreach over the next two years. Marsha Johnson, Au.D., has been re-elected as Treasurer. Marsha served in this capacity for the past two years and has done an outstanding job providing oversight of ATA’s financial position and growth. As a practicing audiologist in Portland, Oregon, and 8 Tinnitus Today | Summer 2013 member of numerous professional organizations like the Tinnitus Practitioner’s Association, Marsha brings an important perspective to this position making sure the needs of the patient are first and foremost in all ATA conversations. Finally, Norma R. Mraz, Au.D., will serve as Secretary of the ATA Board. Norma began her service in 2011 and is a practicing audiologist in the Atlanta, Georgia area. Like Marsha, she brings her experience as a tinnitus health care provider and represents the needs of the patients. Norma also brings her strength in outreach and public education abilities to the Board and offers these important perspectives during Board decision-making. Norma is taking the place of James Chinnis Jr., Ph.D., who served as Secretary of the Board for the last two years. Jim will continue his service as an ATA Board member and Chair of the Nominating Committee through June of 2014. We welcome back Gary P. Reul, Ed.D., to the ATA Board. Gary has been intimately involved with ATA since 2004 and even stepped in to serve as its Chief Executive Officer from 2009-2010 when the Board asked him to do so. Gary has served as Chair and Vice-Chair of the Board and headed up countless committees during his service. We are thrilled to have him back and know he will continue to contribute whole-heartedly to advancing ATA’s programs aimed at curing tinnitus. Cathy Jones, M.S., has been re-elected to the ATA Board of Directors. She brings with her numerous years of experience with fundraising and volunteerism for many nonprofits around the world. Cathy was recently honored at the 2013 American Academy of Audiology convention in April with their Humanitarian award due to her work as Executive Director of the Hear the World Foundation, (the charitable arm of Phonak Hearing Systems) which has improved quality of life for hearing impaired people around the world. We bid a fond farewell to Carol A. Bauer, M.D., who served for the past three years as an ATA Board member. As an otolaryngologist (ENT) and tinnitus researcher, Carol brought an extremely unique perspective that aided our scientific discussions and helped to strengthen our focus on outreach to the ENT community. Prior to that, Carol served on our Scientific Advisory Committee and helped conduct continued on Page 23 The Buzz: Talking with Your Tinnitus By Ian Punnett I don’t know where this fits in the panoply of New Age beliefs, but a self-identified student of alternative medicine offered a treatment for my intrusive, disruptive tinnitus that, I confess, I had never considered before. Stopping me while walking my dog, she told me that a thought had come to her in meditation, something she really wanted me to think about. “Have you ever asked your tinnitus what it wants?” No, honestly, I had to admit I never had. “Well, you should. Ask your tinnitus what it wants and then listen for the answer. If you give your tinnitus what it wants, it just might go away.” I really wasn’t quite sure how to reply to that proposal. Pondering it for a moment, my first thought to myself was, I asked my tinnitus what it wants and it told me that it wanted people like you to leave me alone, but that wasn’t fair. The woman’s heart was in the right place – she just wanted to help – even if we disagree about whether tinnitus is a sentient force that can be reasoned with. I told her I would think about it. But frankly, even if my tinnitus could tell me what it wanted, I don’t know that I would meet its demands. In my experience, tinnitus is a spoiled child that whines and cries all day and all night and never seems satisfied by anything it ruins. For example, July 14, 2013, marked my last regularly scheduled radio show simply because while I am on the air, my tinnitus pitches a fit that takes too much to recover from the next day. I imagine, however, that there might have been a time when Tinnitus Retraining Therapy (TRT) might have been dismissed as so much New Age mumbo-jumbo yet it is provably efficacious with time and practice. Maybe if I spent hours every day asking my tinnitus what it wants, I might get similar, occasional results? Somehow I doubt that but, then again, others might question my own recent breakthrough in temporary tinnitus relief – a new, black 2013 Volkswagen Beetle convertible. Bear with me on this. It actually makes tons of stylish sense. Like many people, I always have been drawn to convertibles and made sure to rent one whenever I was on vacation or doing business in a sunny climate. More recently, however, I discovered that owning a convertible positively impacts my tinnitus and here’s how: At higher speeds, the air rushing past my ears replicates a really good white noise generator. “Wind” is one of my favorite white noise settings on either my bedside model or my iPhone® app so it shouldn’t be a surprise that the real thing might also distract my brain from my tinnitus. Someday, it would be a nice public service of the Sirius XM satellite radio people to offer a white noise channel for tinnitus sufferers, parents of fussy babies or just anybody who is stressed out in traffic. Until then, the best white noise generator I know is a black convertible Volkswagen. I put this theory to the ultimate test during a road trip to Davenport, Iowa to promote my new Random House® book, How to Pray When You’re Pissed at God (or anybody else for that matter). During the 10 hour roundtrip drive for media interviews and a book signing, I would lose awareness of my tinnitus unless I slowed down or became overwhelmed by the loud squeaking of passing tractor trailers. For the most part, though, there was a sweet spot of pleasant, almost masking, undulating wind that allowed me to forget the tinnitus for a hundred miles at a time. Could that be so effective that someday a doctor might prescribe drop-top cars for tinnitus sufferers? Even though a friend of mine with a tragically bad back once got a prescription for a hot tub, it seems unlikely. Still, if you have a free moment, try asking your tinnitus what it wants. Maybe if you listen closely enough, you’ll hear your tinnitus say, “I want a convertible.” I just never thought to ask. Ian Punnett is a scholar-in-residence at Walter Cronkite School of Journalism and Mass Communication at Arizona State University in Phoenix and the author of How to Pray When You’re Pissed at God available in bookstores nationwide and online (Howtopraybook.com). In addition, you can follow him on Twitter @deaconpunnett. Summer 2013 | Tinnitus Today 9 Walk teams enjoyed the props in this year’s photobooth (left). Muriel Mungia and ATA staffer, Sonja Jorgenson, know what the walk is all about (center)! Walk attendees set off on the 5k trail along the Portland waterfront (right). Fun in the Sun at the 2013 Jack Vernon Walk to Silence Tinnitus June 9, 2013 was an unusually sunny Sunday in Portland, Oregon, much to the delight of all who participated in this year’s Jack Vernon Walk to Silence Tinnitus. The event began with volunteer Annalisa Jorgenson leading the walkers in a lively round of calisthenic stretches as boats and paddle boarders cruised along the sparkling waters of the Willamette riverfront. After appreciative words from ATA staff, the three-mile park pathway was soon filled with family and friends who came out to support their loved ones. One walker in particular Jack A. Vernon, Ph.D. fondly remembered her experience as a patient of “Dr. Jack’s,” the pioneer tinnitus researcher who founded our organization four decades ago and whose namesake inspired this event. Portlanders weren’t the only ones honoring the work of Dr. Vernon and ATA. Walk teams sprung up in Denver, Colorado and Charlotte, North Carolina. A small team even walked across the Brooklyn Bridge in New York City! In all, these Walk teams (21 in total) raised about $47,000! These funds support ATA’s programs and efforts to advance tinnitus research. Please join us in giving a big round of applause to all the Walk participants and generous donors who, like us, are committed to a cure! Way to go, teams! Let’s Hear it For our 2013 Tour de Tinnitus Riders! Three cheers to our 2013 Tour de Tinnitus riders, Mark Church, Sal Gentile, Richard Johnston, Victor Kraus, and Ed Ruttledge (who did two separate rides this year). Between the four team captains a total of $15,490 was raised which represents approximately $5,000 more than the event raised last year. Between all riders, over 700 miles were logged through Florida, Missouri, Michigan, Washington and Oregon. Their efforts are directly helping to advance tinnitus research through ATA’s grant program and we owe a special thanks to all of our members who supported their efforts with a donation. If you or someone you know is interested in getting involved in the 2014 Tour de Tinnitus in the crusade to silence tinnitus, contact Cara James, ATA Development Director at [email protected] 10 Tinnitus Today | Summer 2013 Richard Johnston, Victor Kraus and Ed Ruttledge celebrate the completion of their 2013 Tour de Tinnitus ride. A T A - F u n d e d R e s e ar c h 2013 This year, the ATA Board of Directors approved $219,659 worth of funding to five deserving tinnitus ARCH investigators to start or continue their work toward advancing tinnitus research on ATA’s Roadmap RESE IS U E S to a Cure. Below is a snapshot of these grants. To read more detailed information about each of them please visit: ATA.org/research/ata-funded. New ATA-Funded Research Ola Alsalman Berthold Langguth, M.D., Ph.D. University of North Carolina at Greensboro University of Regensburg – Germany Student Project: A Psycho Neural Endocrine Model of Tinnitus Roadmap to a Cure Paths: A, B Funded: 1 Year, $10,000 Type: Human Stress can be caused by internal changes that result in homeostatic disturbance. Homeostatic reactions to stress caused by tinnitus involve the releasing of stress-related hormones such as cortisol. This study will investigate the systems involved in causing the condition including the brain, autonomic and endocrinal systems. Different treatment models have successfully been used including psychological counseling, hearing testing or offering sound therapy solutions. However, the use of a comprehensive neuro-endocrine-psychological model of tinnitus has not been investigated and could have significant impact on treatment options for tinnitus patients. Research Project: rTMS for the Treatment of Chronic Tinnitus: Optimization by Stimulation of the Cortical Tinnitus Network Roadmap to a Cure Paths: B, C, D Funded: Year 2, $50,000 Type: Human In the second year of this grant, the study aims to answer: 1) Is multisite rTMS protocol involving three stimulation sites more efficient for tinnitus reduction compared to over the auditory cortex? (Roadmap Path C). 2) Is multisite rTMS protocol more efficient for normalizing tinnitus-related alterations of oscillatory brain activity and connectivity as compared to over the auditory cortex? (Roadmap Paths B and D). 3) Are there specific patterns of brain activity which can predict treatment response ofrTMS? (Roadmap Path D). This research will identify areas in the brain and the hypothalamic nuclei that exhibit abnormalities (Roadmap Path A) which will determine the role of the neural and endocrine systems that cause tinnitus and its psychological impact on patients by identifying the underlying mechanisms of neural and endocrinal abnormalities (Roadmap Path B). The pilot data obtained in the first year (read: “rTMS for the Treatment of Chronic Tinnitus: Optimization by Stimulation of the Cortical Tinnitus Network” from the Summer 2012 issue of Tinnitus Today) suggest that multisite stimulation shows better long-term effects than temporal rTMS. Furthermore, multisite stimulation turned out to be feasible in a clinical setting and it was well tolerated by all patients. Jake Richard Carpenter-Thompson Martin Schecklmann, Ph.D. University of Illinois at Urbana-Champaign Student Project: The Effect of Exercise on Tinnitus Severity Roadmap to a Cure Paths: A, C Funded: 1 Year, $10,000 Type: Human This project will identify treatment options that decrease tinnitus-related distress. The aims are: 1) To identify any existing relationship between tinnitus severity and physical activity and; 2) To characterize the differences between tinnitus subjects with varying physical fitness and tinnitus severity levels using both behavior and brain imaging tools. The hypothesis is that physical activity will be negatively correlated with tinnitus severity scores, and brain function and structure will be different between individuals with tinnitus based on fitness level. This research fits into Roadmap Paths A and C. For Path A, functional magnetic resonance imaging (fMRI) will be used to measure changes in brain areas associated with tinnitus abnormalities. Path C is satisfied by testing physical fitness as a therapeutic approach to treating tinnitus severity. University of Regensburg – Germany Research Project: Combination of TMS and EEG: The Role of Temporal and Frontal Cortical Excitability and Plasticity in Chronic Tinnitus Roadmap to a Cure Paths: A, B, C, D Funded: 1 year, $50,000 Type: Human Neuroscientific research indicates that temporal and frontal cortical areas are involved in tinnitus pathophysiology. This will introduce a new approach using the combination of two techniques (EEG and rTMS). The central aims are: 1) Are rTMS-induced neural changes in left and right temporal and prefrontal areas altered in chronic tinnitus? 2) Are there differences in rTMS-induced changes with respect to stimulation site? 3) Is chronic tinnitus a malfunction of cortical excitability or cortical plasticity? 4) Are there differences between responders and non-responders with respect to cortical excitability and plasticity? These findings will show if TMS-EEG combination measurements will be sufficient to serve as biological markers of tinnitus. The study will identify tinnitus generators and the underlying neural mechanisms mirroring Paths A and B of the Roadmap. Targeting frontal and temporal areas Continued on Page 24 Summer 2013 | Tinnitus Today 11 Office of Naval Research Highlights Auditory Injuries By Kurt Yankaskas, Office of Naval Research Imagine fighting in a war when a sudden blast leaves you unable to hear anything around you. You are under fire but can’t determine the location of the shots. Your radio crackles, but you can’t make out the instructions. You prepare to return fire without a clue as to the location of your comrades or the enemy. Try conducting a military mission and struggling to focus while hearing the phantom ringing of tinnitus in your ears. Unfortunately, these scenarios are more common than one might think. Two of the most common military service-related injuries are tinnitus and hearing loss. Veterans report these more than post-traumatic stress disorder. This is the chief concern of the Office of Naval Research’s (ONR) Noise-Induced Hearing Loss (NIHL) program that I manage. Every day, sailors and marines work on aircraft carriers or in cockpits, engine rooms and fighting vehicles where noise levels surpass the effectiveness of current hearing protection devices. Our program takes a multidisciplinary approach in the search for solutions. Researchers are investigating the mechanisms and etiology of both tinnitus and hearing loss. With better understanding of these causes, we hope to develop cures and treatments for the symptoms. We are also investigating ways to medically treat tinnitus and hearing loss with the hope of ultimately being able to regenerate hair cells in the cochlea. Amphibians and birds do this naturally, but humans need some help with it. We look at everything from making equipment quieter to developing more effective hearing protection devices. We want to tailor hearing protection devices to individual users and measure noise exposure in real time. Extensive modeling and simulation are providing our researchers with a better understanding of how to do both, as well as determine the susceptibility of individuals to hearing loss and tinnitus based on genetics. Naval Medical Center San Diego’s Captain Michael Hoffer, M.D., discussed the results of a study conducted in Iraq on those who had experienced signs of mild traumatic brain injury after blast incidents. Hoffer found that treating subjects with the antioxidant N-acetyl-cysteine (NAC) mitigated symptoms such as dizziness, headaches and memory loss. ONR previously had investigated NAC for its effectiveness in protecting against hearing loss. These results are made even more telling when one considers that in previous studies the majority of those with Traumatic Brain Injury (TBI) also reported experiencing tinnitus. John Casali, Ph.D., Director of the Auditory Systems Laboratory at Virginia Tech shared about the difficulty in selecting hearing protection devices that guard against noise damage but don’t hinder situational awareness. This is particularly important in trying to prevent NIHL and tinnitus in the military in the future. These are some of the developments that continue to lead us down promising new paths in our research. Because hearing loss and tinnitus are inextricably linked, discoveries in the prevention of one will most certainly lead to ways to mitigate the other. But we must push even harder toward these eventual breakthroughs, given the disturbing trends with hearing loss and tinnitus in the military. ONR recently hosted representatives from the Navy, Marine Corps, Army and Air Force for a candid discussion on developments that could help curb the problem of hearing loss in the military. At the end of 2012, the Department of Veterans Affairs estimated that more than 1.7 million veterans – about double the number from 2006 – were receiving compensation for hearing loss and tinnitus. This is not just about statistics. It’s about the folks deployed right now, be it on a ship, an aircraft or land. If they can’t hear what’s going on around them, it hinders their ability to execute their missions. That could be the difference between mission success or failure. It could be the difference between life and death. Therein lies our purpose and the reason we continue to take an aggressive and varied approach to our research. During this meeting, Rick Rogers, Ph.D., from the Harvard School of Public Health, discussed the potential For more information on ONR’s Noise-induced Hearing Loss program, visit: Tinyurl.com/on6npml. Focus on Auditory Injury 12 benefit of infrared light to hearing preservation. He relayed the results of an encouraging recent study, during which overnight exposure to infrared light kept noise-damaged hair cells from dying and even helped them to recover. Tinnitus Today | Summer 2013 R ESE A R CH F R O M A R O UND T HE W O R L D Tinnitus Caused by Dental Crowns: A Scientific Perspective 2013 RESEARCH IS by Susan Shore, Ph.D., Roxana Stefanescu, Ph.D., and David Martel, MS, EE, BME Kresge Hearing Research Institute, University of Michigan In the Spring 2013 issue of Tinnitus Today we shared Veronica Ducasse’s self-assessment of the possibility of tinnitus being caused by dental work. We received many responses from our members who related to this possible connection. Here, we offer another perspective based in science as to what might really be going on with tinnitus seemingly caused by dental work. Tinnitus is currently believed by researchers to be a pathological condition of brain activity in the auditory part of the brain. Tinnitus is usually associated with hearing loss but can also be associated with damage to the “touch” or somatosensory system, such as temporomandibular joint (TMJ) disorder, dental work or injury to the head or neck. Interestingly, about two thirds of the individuals with tinnitus are able to modulate the loudness (or pitch) of their tinnitus by manipulations of the jaw or by applying pressure on certain neck and head regions. This phenomenon is clinically known as somatic tinnitus. While a first intuition may suggest that tinnitus should be directly related to an abnormal function of the ear, the illusion of sound perception is in fact a form of abnormal neural activity arising in multiple brain areas which in normal conditions are involved in sound processing function. In one of these regions, the dorsal cochlear nucleus (DCN), there are cells that show hyperexcitability and enhanced sensitivity to somatosensory stimulation after a noise-damaging stimulus that would likely produce tinnitus. Located in the brain stem, this region is the first auditory processing station, receiving direct projections from cochlea via auditory nerve fibers. In addition, projections from the somatosensory system convey important “touch” information from oral, neck and head structures, establishing the region as an important structure mediating auditory-somatosensory integration. In the article presented in the last issue, the author shares that when the first abnormal perceptions of sound (tinnitus) began, is after a new dental crown had been mounted. She suggests that a possible explanation for this condition could be the generation of electrical currents in her dental crown, currents that are assumed to propagate into the ear and generate the sensation of tinnitus. Furthermore, it is suggested that electrical currents generated within the body or in the outside proximity of the person, perhaps by various appliances one may use daily (such as a hairdryer for instance) could induce additional currents in the dental frame which could intensify the tinnitus experience. Although the dental crown contains an alloy of conductive materials, the generation of such currents by internal physiological signals or induced by other exterior sources of current or magnetic fields commonly used in the household devices is not likely. Instead, it is likely that the insertion of the dental crown might have irritated the gums and the somatosensory nerves of the covered teeth to the point that the mechanical pressure associated with certain bites (or even gentle touches) may generate a signal in the nerve of one or several teeth covered by the crown. To be clear, this signal, while not an electrical current such as the one flowing throughout common wires, is electric in nature in the sense that activates the somatosensory nerve of the tooth that further propagates to reach the DCN. The research conducted in our laboratory on a tinnitus animal model (guinea pig) suggests that one possible mechanism for generation of tinnitus is the following: When the cochlear signals arriving to the DCN are diminished due to some form of prior insult (e.g., a loud noise), the somatosensory pathways reaching the same area are enhanced. In particular, the strength and number of the excitatory somatosensory synapses is enhanced while the strength of inhibitory connectivity is diminished. This results in hyperactivity of neurons in DCN. This hyperactivity is conveyed to more central auditory neural structures that produce the tinnitus perception. Unfortunately, there is currently no cure for this imbalance. However, our research group and several other research teams in the world are currently pursuing various avenues to better understand these mechanisms and to attempt to modify the synaptic connectivity of this brain region in order to reestablish its normal function. We hope that future advances in our understanding of tinnitus mechanisms will lead to better strategies to control the symptomatology and even cure this debilitating pathology. Summer 2013 | Tinnitus Today 13 SU E R ESE A R CH F R O M A R O UND T HE W O R L D 2013 RESEARCH IS S UE Orchestrating Silence for Patients with Pulsatile Tinnitus by Michael J. A. Robb, M.D., Mia Pozzanghera, B.S., Cameron G. McDougall, M.D., Luis F. Gonzalez, M.D., Webster Crowley, M.D., Shirley S. Smith, M.D., Melissa Rosenfeld, M.D. and Angela Dagirmanjian, M.D. Pulsatile tinnitus is the perception of a rhythmic noise in the ear or head that matches the heartbeat. This sound is worrisome when it results from abnormal, turbulent blood flow in the brain. If untreated, there is an increased risk of stroke. These vascular disorders escape detection on routine imaging tests like Computed Tomography & Angiography (CT/CTA) and Case 1 Figure 1a – Pre-treatment angiogram, lateral view of skull with injection of left common carotid artery showing early arteriovenous shunting due to a left transverse sinus dural arteriovenous fistula. The principal supply to the fistula is from the occipital artery. After passing through the fistula at the transverse sinus, drainage is to the jugular vein via the sigmoid sinus. Figure 1b – Same projection as 1a. Following percutaneous transcatheter placement of embolic coils at the site of the fistula and Onyx® injection to the fistula via the feeding arteries, there is no longer any filling of the fistula and no early arteriovenous shunting. Figure 1c – Later (venous) phase of same post treatment angiogram shown in “1b” demonstrating preservation of the normal venous drainage through the left transverse and sigmoid sinuses. Magnetic Resonance Imaging & Angiography (MRI/MRA). The patient’s pulsing tinnitus complaint can be validated on examination using the doctor’s ear and a stethoscope placed in the right positions. The patient may 14 Tinnitus Today | Summer 2013 give the doctor additional clues such as where the pulsing is located and what positions or maneuvers reduce the loudness of the pulsing. The best diagnostic tests are a special ultrasound and, most importantly, selective catheterization angiography under general anesthesia (cerebral angiogram). In our clinical experience, treating people with pulsatile tinnitus is very exciting and rewarding. Teamwork is vital. Although pulsatile tinnitus is rare, it can be life-threatening. A thorough medical and surgical workup is mandatory in order to reach a definitive diagnosis and a cure. Two patient stories are summarized here for the purposes of leading the reader down the path to a cure. The first patient is a woman, 69 years of age, who tripped on torn carpet outside a legal office striking the left side of her head on concrete with loss of consciousness. Two months after the fall, she started hearing a “loud washing machine sound” in her left ear which distressed her for three years. Clinical exam revealed objective pulsatile tinnitus detected with the stethoscope placed in precise locations around the head and neck. Light manual pressure on the back of the neck on the left side reduced the tinnitus loudness. Both of these techniques strongly suggested a vascular cause of the pulsatile tinnitus. Based on the history and the oto-neurological exam, the patient’s complaint was validated and it was only a matter of time before orchestrating the cure. The next step was to define and localize the lesion precisely. CT, CTA, MRI and MRA of the brain and neck were normal. Neck (carotid) Doppler ultrasound revealed increased speed of flow in the left external carotid artery. Custom ultrasound confirmed and recorded the presence of turbulent blood flow on the left side directly behind and superior to the patient’s ear. Since the radiological imaging was unhelpful, the final diagnostic step was absolutely necessary – the conventional dye cerebral angiogram. This test was performed in order to locate the vascular lesion as well as to serve as the conduit for endovascular neurosurgical techniques to repair the vascular defect. The cerebral angiogram revealed abnormal flow in the veins draining blood from the brain back to the heart. In particular, a group of veins were tangled amongst each other altering the normal course and increasing the turbulence of blood flow in the periphery of the left skull. CTA and MRA scans did not detect this disorder because those studies cannot see the smallest, most distant segments of veins of dural venous sinuses. However, the stethoscope and human ear, the ultrasound and the cerebral angiogram are all sensitive enough to localize the cause of the distressing pulsatile tinnitus! During the angiogram, catheters were placed through the vessels in the groin to analyze blood flow in the head and neck. The left occipital artery (arises from the external neck artery opposite the facial artery) was found to be feeding a transverse-sigmoid dural arteriovenous fistula (DAVF). Case 2 Figure 2a – Lateral view of skull for orientation, prior to treatment. Figure 2b – Same orientation as shown in “2a”, with skull now subtracted, showing injection of contrast into the left common carotid artery. The site of fistula is at the wall of the marginal sinus, which is a dural venous sinus adjacent to the foramen magnum. The main arteries supplying this fistula are the ascending pharyngeal and occipital arteries, and from the fistula the drainage is to the jugular vein. Figure 2c – Same orientation as “a” and “b.” Following transvenous catheterization of the fistula site, metallic coils were placed at the site of the fistula occluding the arteriovenous fistula. Figure 2d – Same orientation as shown in “c” with the skull image subtracted showing injection of contrast into left common carotid artery. This image was acquired two months after the initial treatment and documents continued occlusion of the fistula with regression of the previously pathologically enlarged ascending pharyngeal and occipital arteries. The endovascular neurosurgeon and his fellow neurosurgeon in training, implemented a strategy to slow the flow down and then stop it eventually without causing the patient to have a stroke in the process. First, they used a combination of detachable Guglielmi platinum matrix coils deployed via microcatheters to slow down the flow. Next they stopped the abnormal flow completely. To accomplish this task, the neurosurgeons injected a special type of medical glue called Onyx®, a non-adhesive liquid embolic material, which was successful. If the coils had not been used first, then the glue substance may have leaked out and traveled into normal vessels thus running the risk of blocking normal blood flow and causing a stroke. After the procedure, the patient reported complete resolution of the washing machine noise! No more pulsatile tinnitus! Her only side effect was a moderate headache which resolved after a few weeks. The two most serious side effects associated with endovascular repair of DAVF, occurring in 1-2% of cases, are stroke and cranial nerve injury. Alopecia (hair loss), associated with prolonged contrast dye exposure, is more common but usually temporary. Our second case is a woman, 68 years of age, who fell over a hose in her garden striking the left side of her head on gravel without loss of consciousness or scalp laceration. She developed left pulsatile tinnitus shortly thereafter and struggled with the noise for over two years. The “whooshing sound” was so loud that her husband could hear it when he snuggled up to her at night. The sound could be detected via the stethoscope, but also could be heard when the naked ear was up close to her head! We knew it was only a matter of time before we would resolve this patient’s tinnitus as well. In similar fashion, the CT, CTA, MRI and MRA of the brain and neck were normal. The carotid doppler ultrasound was normal. The custom ultrasound of the head and face was abnormal and confirmed bruits over the left face and around the front of the ear. Cerebral angiogram revealed a very rare DAVF of the marginal sinus with contributions from the left ascending pharyngeal (part of the throat situated just below the nasal cavity) and the left occipital artery. The DAVF was “closed” without difficulty and she was discharged from the hospital in a few days with total resolution of the pulsatile tinnitus. An examination two months later revealed no recurrence of the tinnitus, absence of side effects and regression of the feeding arteries. Both of these patients self-referred to the oto-neurology clinic and were very distressed pre-operatively and elated post-operatively. They were cured of their pulsatile tinnitus without need for traditional neurosurgery – where the skull is partially removed to expose brain – but rather via the modern technique called endovascular coiling as described in the first patient’s case. These inspiring cases are examples of the modern day miracles extended through the hands of the physicians and surgeons involved in caring for those with pulsatile tinnitus. References Sismanis A. Pulsatile tinnitus: contemporary assessment and management. Curr Opin Otolaryngol Head Neck Surg 2011;19(5):348-357. Malek AM, Halbach VV, Higashida RT, Phatouros CC, Meyers PM, Dowd CF. Treatment of dural arteriovenous malformations and fistulas. Neurosurg Clin N Am 2000;11(1):147-166. McDougall CG, Halbach VV, Dowd CF, Higashida RT, Larsen DW, Hieshima GB. Dural arteriovenous fistulas of the marginal sinus. AJNR Am J Neuroradiol 1997;18(8):1565-1572. Dr. Robb is an oto-neurologist at the Robb OtoNeurology Clinic in Phoenix, AZ and former ATA Board & Scientific Advisory Committee member. Mia Pozzanghera, B.S., is a doctoral candidate in audiology (Au.D.) at A.T. Still University/Arizona School of Health Sciences. Dr. McDougall is a neurosurgeon and chief of endovascular neurosurgery at the Barrow Neurological Institute (BNI) in Phoenix. Drs. Gonzalez and Crowley are fellows in endovascular neurosurgery at the BNI. Dr. Smith & Dr. Rosenfeld are anesthesiologists at St. Joseph’s Hospital & Medical Center in Phoenix. Dr. Dagirmanjian is a neuroradiologist at Insight Imaging - Biltmore in Phoenix. Special thanks to Melanie West, Reina Cordova, Maressa Houle, R.V.T., Nitin Patel, M.D., George W. Engisch, D.O., Dean Gain, M.D., Cindy McElfresh, Terry D. Fife, M.D., Edward J. Donahue, M.D., and Ross L. Levine, M.D. Summer 2013 | Tinnitus Today 15 Research From around the World 2013 RESEARCH IS SU E Research Round Up 2013: Focus on Humans and Clinical Trials In the Winter 2012 issue of Tinnitus Today, we told you about some exciting clinical trials that will take place in 2013 which will have direct impact in treating tinnitus. In this annual “Research Round Up,” we focus on human studies of tinnitus, including some clinical trial results, that will influence tinnitus patients worldwide. Tinnitus and Co-Morbidities Mental Health in Adults with Sudden Sensorineural Hearing Loss: An Assessment of Depressive Symptoms and its Correlates1 Objective: Sudden sensorineural hearing loss (SSNHL) is defined as >30dB of hearing loss in at least three contiguous test frequencies occurring within three days or less and may be accompanied by tinnitus and vertigo. Despite the well-documented association between hearing loss and depressive symptoms, research on the emotional distress after SSNHL receives little attention. Methods: The study sought to investigate the degree of self-reported mental distress in patients with SSNHL after a median follow-up period of one year and the association between mental distress, hearing recovery and tinnitus. One hundred and forty seven patients admitted for sudden hearing loss and diagnosed with SSNHL were examined. Results: Patients who recovered from SSNHL reported significantly less depressive symptoms. Patients with tinnitus, compared to those without tinnitus, reported more depressive thoughts and feelings, more disruptive activities and personal relationships, and more physical symptoms. This study showed that SSNHL patients who developed continuous tinnitus had a higher rate of greater emotional distress than those without tinnitus. Why it’s Important: Because tinnitus is a subjective condition arising from many causes, examining all the characteristics of subgroups of patients is important in the successful treatment and eventual cure of 16 Tinnitus Today | Summer 2013 this condition. Patients who experience SSNHL do not get tinnitus in traditional ways and by looking at the co-morbidities like depression, which can be more severe in this patient population, will help doctors in treating subgroups of tinnitus patients. Otologic Assessment of Blast and Nonblast Injury in Returning Middle East-Deployed Service Members2 Objective: To determine if tympanic membrane (eardrum) perforation offers any protection from inner ear damage and determine the incidence and pattern of otologic blast injury in military personnel returning from deployment. Methods: One-hundred ten blast-injured U.S. Service members injured in Operation Iraqi Freedom and Operation Enduring freedom were compared to 54 nonblast-injured patients returning from deployment. Data captured included audiogram results, presence of tympanic membrane perforation, demographic data, location and nature of injury, loss of consciousness, sleep disturbance, confusion, and symptoms of headache, dizziness, memory loss and tinnitus. Results: Of 110 blast-injured patients, 16% suffered tympanic membrane perforation, of which 8% suffered bilateral tympanic membrane perforation. Blast patients suffered more hearing loss than controls as measured by pure-tone averages of varying speech reception frequencies at 6,000 hertz (Hz). Of the blast patients who recorded an audiogram, nearly 24% suffered moderate to profound hearing loss. There was no statistically significant difference in hearing outcomes between blast-injured patients with tympanic membrane perforations and those without; however, when comparing patients with unilateral perforations with their contralateral ear, there was a difference in hearing thresholds at 6,000 Hz. There was a significantly increased risk of tinnitus, memory loss, headache and dizziness between blast-injured patients compared to controls. Why it’s Important: Blast exposure causes greater neuro-otological injuries and deserves prompt evaluation. For many decades, injuries such as tinnitus and hearing loss have been overlooked and not thought of as important first interventions – particularly on the battlefield. However, research has demonstrated that prompt and early intervention can help lessen and in some cases reverse auditory trauma and damage if done soon after exposure, to mitigate the potential long-term impacts they can have on a person’s quality of life. Tinnitus and Drugs/Supplements The Role of Plasma Melatonin and Vitamins C and B12 in the Development of Idiopathic Tinnitus in the Elderly3 Objective: To determine the correlation between plasma levels of melatonin, vitamin C and vitamin B12 and the presence of tinnitus among elderly subjects with unexplained subjective tinnitus. Methods: Plasma levels of melatonin, vitamin C and vitamin B12 were determined using high performance liquid chromatography and correlation determined by comparing subjects with and without tinnitus. Results: There were 139 elderly subjects (78 females and 61 males), with an average age of 66.9 years. Of these, 58.3% had tinnitus. Plasma levels of melatonin and vitamin B12 were significantly lower among those with tinnitus compared to those without, while the difference in the plasma level of vitamin C was not. Low plasma melatonin and vitamin B12 have significant correlation with the development of subjective idiopathic tinnitus among the elderly. Why it’s Important: By determining biological factors in subgroups of tinnitus patients, particularly those without prior exposure to noise or head, neck or nerve damage, it may be possible in some cases to manage or lessen tinnitus by restoring the body’s natural balance – accounting for deficiencies in melatonin and B12 for instance as this study indicates. Tinnitus Prevalence The Prevalence and Characteristics of Tinnitus in the Youth Population of the United States4 Objective: To evaluate the prevalence, characteristics and associated risk factors of tinnitus in U.S. adolescents. Methods: A cross-sectional analysis of demographic and audiometric data from the National Health and Nutrition Examination Survey (NHANES) from 2005 to 2008 was examined. The study population consisted of 3,520 individuals aged 12 to 19 years with complete tinnitus-related data. Tinnitus was defined as the presence of ringing or buzzing in the ears lasting for at least five minutes during the preceding 12 months. In addition, we defined a chronic tinnitus subgroup as being bothered by tinnitus for more than three months. Results: Tinnitus lasting five minutes or more in the preceding 12 months was reported by 7.5% of the population. This represents about 2.5 million adolescents in the U.S. The prevalence of chronic tinnitus was 4.7%, corresponding to about 1.6 million adolescents in the United States. Why it’s Important: For many years tinnitus was thought of as an older person’s condition. However this data analysis indicates that tinnitus afflicts a substantial portion of the youth population and warrants further investigation of the association between tinnitus and the risk factors for youth. Tinnitus Diagnostics Can the Tinnitus Spectrum Identify Tinnitus Subgroups?5 Objective: The tinnitus spectrum is a psychoacoustic metric of tinnitus. Previous work found a tight relation between the spectrum and audiogram. This suggests that the spectrum and the audiogram provide the same information and the added value of the spectrum is limited. Methods: The relation between the tinnitus spectrum and the tone audiogram was examined in a group of 80 tinnitus patients. Three subgroups of patients were defined using the shape of their tinnitus spectrum: 1) patients with a spectrum, monotonously increasing with frequency; 2) patients with a distinct peak in their spectrum; 3) all other patients. Patients in group three typically showed low frequency tinnitus spectra. In all three groups, the largest hearing loss was at high frequencies (>2 kilohertz (kHz)). The mean audiograms of groups one and two were remarkably similar; group three had an additional hearing loss for the lower frequencies (< 2 kHz). The three groups did not differ with respect to age, sex or tinnitus questionnaire outcomes. In groups two and three, the shape of the spectrum clearly differed from that of the tone audiogram. Results: The spectrum technique provided information that could not have been obtained by tone audiometry alone. This measurement may help differentiate between classes of tinnitus. Why it’s Important: By developing new and improved diagnostic tools, clinicians will better understand each patient’s unique tinnitus. This may eventually contribSummer 2013 | Tinnitus Today 17 Research From around the World 2013 RESEARCH IS SU E continued from Page 17 Research Round Up 2013: Focus on Humans and Clinical Trials ute to the more effective management of tinnitus as different groups of tinnitus patients require different management interventions. Tinnitus Treatments The Cochlear Implant as a Tinnitus Treatment6 Objective: To determine if patients with cochlear pathology who received unilateral cochlear implantation to treat profound hearing loss also benefited from it being a tinnitus treatment. Methods: This was a longitudinal, retrospective study of patients that underwent unilateral cochlear implantation and who had bilateral tinnitus. Tinnitus was assessed quantitatively and qualitatively before surgery and at six and 12 months after surgery. Twenty patients that underwent unilateral cochlear implantation with a Nucleus® CI24RE Contour Advance™ electrode device were examined. Results: During the periods in which the device was in operation, improvement or disappearance of tinnitus was evidenced in the ipsilateral ear in 65% of patients, and in the contralateral ear, in 50%. When the device was disconnected, improvement or disappearance of tinnitus was found in the ipsilateral ear in 50% of patients, and in the contralateral ear to the implant in 45% of the patients. In 10% of the patients, a new tinnitus appeared in the ipsilateral ear. The patients with profound hearing loss and bilateral tinnitus treated with unilateral cochlear implantation improved in a high percentage of cases, in the ipsilateral ear and in the contralateral ear. Why it’s Important: Cochlear implants provide both electrical and auditory stimulation, which literature has demonstrated can be effective forms of tinnitus management. By examining those who benefitted from a cochlear implant that had positive effects on their tinnitus (even in the case of unilateral hearing loss and bilateral tinnitus,) it shows that cochlear implantation may also provide benefit to tinnitus patients, even in the absence of profound hearing loss. Transcranial Direct Current Stimulation Intensity and Duration Effects on Tinnitus Suppression7 Objective: Various forms of electrical stimulation therapies are being explored for tinnitus alleviation. This pilot study examined transcranial direct current 18 Tinnitus Today | Summer 2013 stimulation (tDCS) dose (current intensity and duration) and response effects for tinnitus suppression. Methods: Anodal tDCS of the left temporoparietal area (LTA) was explored for tinnitus relief. Twentyfive participants with chronic tinnitus and a mean age of 54 years took part. Anodal tDCS of LTA was carried out. Current intensity (one milliamperes (mA) and two mA) and duration (10 minutes, 15 minutes, and 20 minutes) were varied and their impact on tinnitus measured. Results: tDCS was well tolerated. Fifty-six percent of participants experienced transient suppression of tinnitus, and 44% of participants experienced long-term improvement of symptoms including less annoyance, more relaxed, and better sleep. There was an interaction between duration and intensity of the stimulus on the change in rated loudness of tinnitus as well. Current intensity of two mA for 20 minutes was the more effective stimulus parameter for anodal tDCS of LTA. tDCS can be a potential clinical tool for reduction of tinnitus, although longer term trials are needed. Why it’s Important: Electrical stimulation of the brain for tinnitus treatment is rapidly growing area of research. Previous studies have indicated less than expected or desired effects on tinnitus with stimulation location, intensity and duration. By continuing to refine these therapies, we are getting closer to brand new viable and clinically sound tinnitus therapies that may offer the hope of long-term relief from tinnitus. References Chen J, Liang J, Ou J, Cai W. J Psychosom Res. Mental Health in Adults with Sudden Sensorineural Hearing Loss: An Assessment of Depressive Symptoms and its Correlates. 2013 Jul;75(1):72-4. doi: 10.1016/j.jpsychores.2013.03.006. Epub 2013 Apr 28. 1 2 Shah A, Ayala M, Capra G, Fox D, Hoffer M. Otologic Assessment of Blast and Nonblast Injury in Returning Middle East-Deployed Service Members. Laryngoscope. 2013 May 17. doi: 10.1002/lary.24169. Lasisi AO, Fehintola FA, Lasisi TJ. The Role of Plasma Melatonin and Vitamins C and B12 in the Development of Idiopathic Tinnitus in the Elderly. Ghana Med J. 2012 Sep;46(3):152-7. 3 Mahboubi H, Oliaei S, Kiumehr S, Dwabe S, Djalilian HR. The Prevalence and Characteristics of Tinnitus in the Youth Population of the United States. Laryngoscope. 2013 Apr 18. doi: 10.1002/lary.24015. 4 Heijneman KM, de Kleine E, Wiersinga-Post E, van Dijk P. Can the Tinnitus Spectrum Identify Tinnitus Subgroups?. Noise Health 2013;15:101-6. 5 6 Vallés-Varela H, Royo-López J, Carmen-Sampériz L, Sebastián-Cortés JM, Alfonso-Collado I. The Cochlear Implant as a Tinnitus Treatment. Acta Otorrinolaringol Esp. 2013 Mar 15. pii: S0001-6519(13)00030-7. doi: 10.1016/j.otorri.2012.11.008. Shekhawat GS, Stinear CM, Searchfield GD. Transcranial Direct Current Stimulation Intensity and Duration Effects on Tinnitus Suppression. Neurorehabil Neural Repair. 2013 Feb;27(2):164-72. doi: 10.1177/1545968312459908. Epub 2012 Oct 2. 7 Glossary of Research Terms The following scientific definitions will help you in reading the tinnitus research-focused articles throughout this issue of Tinnitus Today. Each word in the glossary, appears italicized the first time it appears on the page. If you come across a word that‚ is not listed that you still don’t understand, visit ATA.org/glossary for a more complete list of research terms and definitions. Amygdala: a limbic system structure involved in many of our emotions and motivations, particularly those that are related to survival. Amplitude: an acoustic or electromagnetic signal, usually measured in decibels. Angiogram: an X-ray photograph of blood or lymph vessels. Anodal: a positively charged electrode. Audiogram: a graphic representation of the relation of vibration frequency that shows the softest sounds a person can hear at different pitches or frequencies. Auditory: of or relating to hearing, the organs of hearing or the sense of hearing. Auditory cortex (AC): sensory area of the brain’s temporal lobe. Bimodal: involving or having two different modes or means of delivery. Beam F3 location system: a newer and more efficient but accurate method of finding the F3 position during repetitive transcranial magnetic stimulation using only three skull measurements. Benzene ring: the hexagonal unsaturated ring of six carbon atoms present in benzene and many other aromatic molecules. Brainstem: the stem-like part of the brain connected to the spinal cord managing messages between the brain and rest of the body. Bruits: unusual sound that blood makes when it rushes past an obstruction (called turbulent flow) in an artery when the sound is listened to with the bell portion of a stethoscope. Dural venous sinus: venous channels that receive blood from internal and external veins of the brain, receive cerebrospinal fluid from the subarachnoid space and empty into the internal jugular vein. Epidemiology/epidemiological: dealing with incidence, distribution and control of diseases. Electroencephalography (EEG): a test that measures and records electrical brain activity. Functional magnetic resonance imaging (fMRI): unlike a standard MRI, which can only record the physical appearance of the brain, an fMRI records brain activity. An fMRI scan can show the region of the brain where there is a change in neural activity associated with an external event (e.g., sound) or internal process (e.g., tinnitus). Gamma-aminobutyric acid (GABA): an amino acid that is found in the central nervous system. Gaze-evoked tinnitus: a rare form of tinnitus that may arise after vestibular schwannoma removal that typically arises in the deaf ear on the side of surgery and can be modulated by peripheral eye movement. Glutamic acid: one of the 20-22 proteinogenic amino acids. Hippocampus: an area deep in the forebrain that helps regulate emotion and memory. Hertz (Hz): a measurement of the number of cycles per second. Homeostatic: the ability of a system to regulate its internal environment and remain stable. Cochlea: the spiral-shaped organ in the inner ear that contains hair cells. Hypothalamic: referring to the hypothalamus, a portion of the brain that contains a number of small nuclei with a variety of functions; one of the most important is linking the nervous system to the endocrine system via the pituitary gland. Cochlear implant: medical device that bypasses damaged structures in the inner ear and directly stimulates the auditory nerve, allowing some deaf individuals to learn to hear and interpret sounds and speech. International 10-20 system: a method for standardized placement of electroencephalogram (EEG) electrodes which correlates external skull locations with underlying cortical areas. Cochlear nucleus: a collection of neurons in the brainstem divided, into the dorsal and ventral cochlear nucleus, that receive input from the cochlear nerve that carries sound information from the cochlea. Ipsilateral: located on the same side of the body. Contralateral: located on the opposite side of the body. Cortical: of or relating to a cortex in the brain. Dorsal cochlear nucleus (DCN): one of the first relay stations between the cochlea and the brain, the DCN receives and processes nerve impulses from the ear and sends those signals to higher relay centers in the brain. Dorsolateral prefrontal cortex (DLPFC): area of the brain that serves as the highest cortical area responsible for motor planning, organization, and regulation. It plays an important role in the integration of sensory and mnemonic information and the regulation of intellectual function and action. Also involved in working memory. Dural arteriovenous fistula (dAVF): an abnormal connection between vessels associated with disturbance of blood flow. Lesion: a region in an organ or tissue that has suffered damage. Limbic system: a system of nerves and networks in the brain that controls basic emotions and drives. Milliamperes (mA): one thousandth of an ampere, a measure for small electric currents. Melatonin: a hormone secreted by the pineal gland that inhibits melanin (dark brown hair/skin pigment) formation and may regulate the reproductive cycle. Neural: of or relating to a nerve or the nervous system. Neuronal: of or relating to neurons; excitable cells in the nervous system that process and transmit information by electrochemical signaling. Neuroplastic/neuroplasticity: changes in neural pathways and synapses which are due to changes in behavior, environment and neural processes, as well as changes resulting from bodily injury. Neurotransmitters: chemicals in the brain which allow the transmission of signals from one neuron to the next across synapses. Pathogenesis: the manner of a development of a disease or condition. Pathophysiology: the study of the changes of normal mechanical, physical, and biochemical functions, either caused by a disease, or resulting from an abnormal syndrome. Placebo: a treatment used in a scientific study as a control, usually omitting some or all key therapeutic elements of the treatment being studied; also called “sham”. Plasticity: the ability of the synapse (connection) between two neurons to change in strength. Prefrontal cortex: the anterior part of the frontal lobes of the brain, lying in front of the motor and premotor areas. Psychoacoustic test: measures the subjective human perception of sound (tinnitus). Psychophysical: relating to the relationships between physical stimuli and sensory response. Pure-tone thresholds: the measurement of an individual’s hearing sensitivity for calibrated pure tones. Repetitive transcranial magnetic stimulation (rTMS): noninvasive method of treatment that sends focused magnetic pulses to stimulate targeted neurons in the brain. Somatosensory: neural activity caused by activation of sensory receptors on the body (e.g., through touch, vibrations, movements of muscles). For some people, somatosensory activity (e.g. movements or touch to the arm, neck or face) can cause the perception of tinnitus to change. Temporoparietal cortex: a region of the brain known to be involved in speech perception. Thalamus: a symmetrical structure within the brain, situated between the cerebral cortex and midbrain that relays sensory and motor signals to the cerebral cortex, along with the regulation of consciousness, sleep, and alertness. Tonotopic map: the orderly projection of inputs originating from the cochlea to sensory areas in the brain, such that neighboring neurons in the target regions respond to progressively higher frequencies. Transcranial direct current stimulation (tDCS): a form of neurostimulation which uses constant, low current delivered directly to the brain area of interest via small electrodes. Transverse-sigmoid: a type of uncommon vascular lesion. Vascular: relating to or consisting of vessels, especially those that carry blood. Vestibular schwannoma: a noncancerous (benign), often slow-growing tumor of the acoustic nerve that connects the ear to the brain. It is located behind the ear, under the brain. Also called acoustic neruoma/schwannoma. Summer 2013 | Tinnitus Today 19 A T A - F u n d e d R e s e ar c h 2013 RESEARCH IS SU E rTMS Bimodal Treatment For Patients with Subjective Idiopathic Tinnitus: A Pilot Study of High-Dose Stimulation By Jay Piccirillo, M.D. We describe an open-label pilot study investigating the safety and tolerability of combination high-frequency repetitive Transcranial Magnetic Stimulation (rTMS) to the left dorsolateral prefrontal cortex (DLPFC), lateral prefrontal cortex and low-frequency rTMS to the left temporoparietal Jay Piccirillo, M.D. cortex (TPC) in patients with severe, bothersome tinnitus. In the hopes of achieving greater response, we elected to use a higher number of stimulations than previously reported in tinnitus patients. Because the rTMS magnet is associated with a loud noise close to the subject’s ear, we wanted to ensure that tinnitus patients could tolerate higher stimulation without worsening of their tinnitus or other adverse events. During treatments patients were comfortably seated in a recliner, wearing foam ear plugs, while the magnet was held by a boom-arm system that allows for adjustment between the two treatment areas. The motor threshold was determined by stimulating the motor cortex with a dedicated motor threshold magnet to elicit a reproducible response (half of the time or more) in the right thumb muscle. The magnet was placed over the left DLPFC first, and sequentially placed over the left TPC for all subjects, regardless of side of tinnitus laterality. The site of stimulation for DLPFC was localized by using the Beam F3 location system. Localization of the TPC was done by means of the International 10–20 System of electroencephalographic electrode placement. Every TMS session consisted of initial 4,000 pulses of high frequency rTMS applied over the DLPFC at 10 Hz, five seconds on and 15 seconds off at 110% of the motor threshold (26.6 minutes duration). Subsequently, subjects received 1,800 pulses of lowfrequency rTMS applied over the TPC at 1 Hz, 900 seconds (15 minutes) on and 60 seconds off at 110% motor threshold (31 minutes duration). All participants were aware that they were receiving active treatment. Each participant received five rTMS treatments per week, Monday through Friday, for two weeks. There were five subjects in the study (four males), the median age was 55, and all were caucasians. Sleep disturbance was reported by three subjects and two 20 Tinnitus Today | Summer 2013 subjects reported considerable effort to ignore tinnitus. The mean baseline Tinnitus Handicap Index (THI) score was 51.2, the mean post-treatment THI score was 39.6, and the mean of the change post-treatment baseline in THI score was 11.6. A clinically significant decrease of six points or greater on the THI was experienced by three subjects. Upon completion, one subject reported that, “Overall the ringing in [his] ears has become lower in tone, less frequent, shorter lived, and lower in volume than at the start of the study. It’s still there, but [he is] aware of it less often, and it doesn’t seem to last as long.” In addition to the decrease in the THI scores, we found that subjects with severe bothersome tinnitus were able to tolerate an intense TMS protocol with 4,000 pulses of high-frequency DLPFC stimulation and 1,800 pulses for an approximately one hour total duration. These stimulation intensities are significantly higher than those reported in the only other report in the literature of bimodal stimulation in tinnitus. No patient experienced a serious side effect and all subjects were able to complete all sessions. Previous studies of rTMS in the treatment of tinnitus have focused primarily on stimulating auditory pathways thought to be involved in the pathogenesis of tinnitus; however the perception of tinnitus is thought to be modulated by brain circuitry responsible for attention and mood. Thus, rTMS of the DLPFC might strengthen deficient inhibitory top-down mechanisms in tinnitus patients. Furthermore, the DLPFC is part of the temporal-prefrontal network, which is considered critical for transient storage of auditory stimuli. rTMS of the DLPFC given in conjunction with rTMS of the TPC was shown to increase the durability of rTMS response to tinnitus and while the results are quite exciting, they do not speak to the independent effect of DLPFC stimulus. Further studies to explore the independent effect of DLPFC stimulation alone are necessary. Dr. Piccirillo and his colleagues at Washington University in St. Louis School of Medicine recently submitted a grant application to National Institute on Deafness and Other Communication Disorders seeking funds to conduct a randomized clinical trial of rTMS to the DLPFC in severely bothered tinnitus patients. The results from this pilot study, supported by the ATA, were used in that grant application. From 1975, until his passing in 2010, Jack A. Vernon, Ph.D., generously shared excellent and reassuring tinnitus information with our readers. We will continue our Q&A column in Jack’s memory. The advice and opinions of outside health professionals do not necessarily reflect the opinions of the American Tinnitus Association. Their advice is for informational purposes only and should not take the place of a full medical evaluation by your own tinnitus health professional. If you have a question that you would like to be considered for this column, please write to the Tinnitus Today team at [email protected], or Editor, Tinnitus Today, American Tinnitus Association, PO Box 5, Portland, OR 97207. Questions and Answers Guest Health Professional Dr. Harriet Jacobster, Au.D. Q I’ve read that recent research has demonstrated that tinnitus comes from the brain and not the ear. Is this true in all cases? and use ear protection as noise can add to the effects of the medication. One word of caution: never stop or change any medication without first discussing it with your doctor. Good luck! A Q It is true that in most cases, tinnitus originates from the brain – it is the brain’s way of “filling in” the missing sounds from a damaged auditory system. But is it true in all cases? Let’s examine the types of tinnitus first. Subjective tinnitus – where the sound is only perceived by the individual – usually comes from damage along the auditory system; the brain reacts to the absence of sound input and creates tinnitus. In the case of objective tinnitus – tinnitus heard by others – it is created by another physical mean, such as a pulsing blood vessel, or muscle contraction. Here the sound is heard by the ear, sent to the brain where it is perceived as annoying tinnitus. So, since all sound is ultimately perceived by the brain and the brain reacts, whether to the absence of sound or the presence or an unwanted sound, then I guess one can say, yes, this is true in most cases. Q I have read about ototoxic medications and how they can cause or worsen existing tinnitus. I have anxiety and I take medication for it. Now I am scared to take it because I am afraid it is making my tinnitus worse. What should I do? A This is such a major concern for so many people. There are many medications that are ototoxic – causing damage to the hearing and/or balance system. Many doctors may not be aware of this side effect when choosing a particular medication. What to do? First, make a list of all your medications, including over-the-counter supplements, and bring them to your doctor. Discuss your concerns and ask the following questions: 1) Is there another medication as effective that is not or less ototoxic? 2) Can the dosage be adjusted to lessen the potential side effects? and 3) Can I change the scheduling of the dosage to lessen the potential side effects? Remember, just because it “may” make your tinnitus worse, doesn’t mean it will. Being anxious also can contribute to your tinnitus. So, by lessening your anxiety, the medication may actually help your tinnitus. It is also important to avoid noise The worst part of having tinnitus for me is the fact that I cannot concentrate or focus on simple tasks anymore like reading the newspaper. What can I do to regain my concentration? A This is a very big problem for many people. Tinnitus can interfere with concentration because it is distracting. One method that helps is to have some background sound. The sound should be monotonous and not distracting. Any soft to moderate level of constant sound is acceptable; it does not have to mask the tinnitus. Find a sound – whether it be music, a fish tank pump or a desktop waterfall that will make the tinnitus seem inconspicuous and will allow you to concentrate on more pleasant tasks. Q I’ve read about stem cell research to help people with hearing loss. Can this possibly help those of us with tinnitus as well? A This is a very interesting topic. Stem cell research is constantly expanding and leading to treatments in so many areas. It is known that hearing loss and loss of sound to the brain is a major cause of tinnitus. Thus, if stem cells are shown to help in restoring hearing, it may also help the tinnitus caused by hearing loss by restoring sound to the ear and brain. Because tinnitus itself is a symptom and not a disease, by treating the underlying cause – whether by stem cells or other methods – the tinnitus should be treated as well. Dr. Jacobster has a private practice in Monroe, NY. She provides full audiological, tinnitus and hearing aid assessments and treatments for children and adults. Among her many professional affiliations, she has been on the faculty of several colleges, a guest lecturer and author of several articles and board member of several organizations dealing with hearing and hearing loss. She is also the leader of the Monroe Tinnitus Support Group which meets the third Saturday of every month. For more information on this group, please email [email protected] Summer 2013 | Tinnitus Today 21 2013 RESEARCH IS SU E Spotlight On ATA Scientific Advisory Committee Members By Jennifer Born, ATA Director of Public Affairs At ATA we work with the best and the brightest tinnitus investigators in the world to ensure that we are on the cutting-edge of advancing science when we fund our research grants. Our Scientific Advisory Committee (SAC) is a multidisciplinary body of researchers representing a cross-section of tinnitus expertise. This is extremely important because we Dr. Tzounopoulos in his lab (left); Dr. Shore and her team (right). receive proposals covering many areas of research and because tinnitus is such a subjective condition, it requires this diverse group of experts to accurately review and score these grants. However this expertise goes beyond just scoring proposals, as the majority of SAC members are also 22 leaders in conducting research in their given specialty. We’d like to highlight two members in particular, Susan E. Shore, Ph.D., Chair of ATA’s SAC and Thanos Tzounopoulos, Ph.D., who have recently made headlines with breakthroughs that could soon translate directly to the tinnitus patient, offering hope of prospective new treatments. Dr. Shore and her team at the University of Michigan Health System have shown that that noise exposure can cause long-term changes to sensory pathways in the brain including the auditory and touch systems. They found that after hearing damage, touch-sensing somatosensory nerves in the face and neck that end in the cochlear nucleus can become overactive, likely compensating for the loss of auditory input and contributing to phantom perceptions or tinnitus. They also found that these somatosensory neurons maintain this overactivity even when hearing returns to normal. Research has demonstrated that over two-thirds of people with tinnitus can modulate it (make it louder, softer, or change its pitch) by clenching their jaw or pushing on parts of their face. These observations, together with the research Dr. Shore and her team have conducted, has initiated the development of a non-invasive device that will combine acoustic and Advertisement — ATA does not endorse or recommend any tinnitus products or treatments. Tinnitus Today | Summer 2013 electrical stimulation of the face or the neck. They have shown that by combining these types of stimuli with particular intervals and in specific sequences they can cause a long-lasting reduction in hyperactivity in neural centers believed to generate tinnitus. Using these principles they hope to reduce or reverse the hyperactivity of the sensory system and possibly offer a new treatment for tinnitus. Dr. Tzounopoulos was funded by ATA in 2008 to study the cellular mechanisms of tinnitus. This study aimed to find out why tinnitus originating in the brain shifts from a transient condition to become a lifelong disorder and to figure out ways of preventing tinnitus from becoming chronic, particularly immediately following acoustic trauma. By better understanding the pathophysiology of tinnitus and the mechanisms that initially trigger tinnitus, they proposed that they could develop or use existing drugs and therapies to prevent tinnitus from becoming permanent. The grants that ATA typically funds are “seed” grants, which allow investigators to gather pilot data and then potentially go on to receive multi-year grants from larger funding sources like the National Institute on Deafness and Other Communication Disorders and the Department of Defense (DoD). And Dr. Tzounopoulos did just that. With the pilot data obtained from his 2008 ATA grant, he and his colleagues at the University of Pittsburgh were granted funding from the DoD’s Peer Review Medical Research Program in 2010, a program that ATA has advocated for tinnitus’ inclusion (and succeeded) for the past six years. With the DoD grant they hoped to develop therapies that would prevent tinnitus from becoming permanent after acoustic trauma. They recently reported that they found that an existing epilepsy drug called retigabine could do this, when administered shortly after exposure to loud noise in an animal model. This is particularly relevant because it could have application for soldiers on the battlefield or people who work in high noise environments who are susceptible to developing tinnitus. And with tinnitus being the leading service-connected disability for veterans, it is important in helping to address that population due to the nature of how they sustain their injuries. We will continue to follow and report upon important discoveries like these. Both Dr. Shore and Dr. Tzounopoulos have discovered important mechanisms of tinnitus generation in targeted areas of the brain that could have direct translational impact on treatment in humans in the near future. We will keep you posted on clinical trial opportunities for therapies such as these as well as any other potential new therapies in future issues of Tinnitus Today and at ATA.org/research/ clinical-trials. To watch a short video about Dr. Shore and her team’s work at the University of Michigan visit: Engin.umich. edu/college/about/news/stories/2013/june/ringing-inyour-ears. To read more about Dr. Tzounopoulos and his research visit: Audres.pitt.edu/people/ tzounopoulos.php. Members Corner Continued from Page 6 makes no recommendations or representations as to the individuals on the listing. ATA urges prospective patients to first call and speak with the health practitioner of your choice. Ask those questions you deem appropriate, and then decide for yourself if there is a match of needs and services between the two of you. *These are current ways of treating and managing tinnitus, but it is important to know that the research community is coming even closer to a cure every day. Treatments are being refined and advanced as we speak. A big thank you to our members for all of your support. You are helping us reach the ultimate goal of silencing tinnitus by supporting ATA’s research and other programs! The Changing of the Guard: New ATA Board Officers and Members Continued from Page 8 the peer review of the grant proposals received at ATA. Carol’s contributions to ATA and the tinnitus community will continue through her important research studies and peer outreach. We also say goodbye William (“Van”) Vanbrooks Harrison who began his service to ATA in 2010. Van assisted with corporate outreach during the 2012 AZ Walk to Silence Tinnitus and offered his expertise to ATA as the co-founder and chief technology officer for Silere Medical, Inc., a company aimed at developing an implantable tinnitus solution. ATA is thankful for the volunteerism of all our Board officers and members past and present. We look forward to working with all of them in the coming years to grow ATA’s visibility and outreach toward fulfilling our mission of curing tinnitus. Summer 2013 | Tinnitus Today 23 A T A - F u n d e d R e s e ar c h 2013 RESEARCH IS SU E New ATA-Funded Research continued from Page 11 induced hippocampal plasticity; and verified that D-cycloserine, a drug that crosses the blood brain barrier, reduces hippocampal activity. will show which area is involved in chronic tinnitus. These measurements will also shed light into the functionality of rTMS as treatment option in chronic tinnitus mirroring Paths C and D of the Roadmap. In year two the aim is to fully test this drug’s dose and schedule-dependent efficacy to reduce or eliminate neurophysiological and psychophysical signs of tinnitus in our rat model (Roadmap Path C). Lucien Thompson, Ph.D. Pim Van Dijk, Ph.D. University of Texas at Dallas University Medical Center Groningen, The Netherlands Research Project: Developing and Treating Tinnitus by Modulating Neuroplasticity in Hippocampus and Amygdala Roadmap to a Cure Paths: A, B, C Funded: Year 2, $49,659 Type: Animal Tinnitus induces brain plasticity, but most research has focused upon auditory brain regions. It also occurs in limbic regions, supporting memory functions and contributing significantly to pathologies like epilepsy and tinnitus. Project: Tinnitus and Tonotopic Remapping of the Auditory Cortex Roadmap to a Cure Paths: A, B, C Funded: Year 1, $50,000 Type: Human Several experimental tinnitus therapies aim to restore a normal tonotopic organization of the auditory cortex. Since tinnitus and tonotopic reorganization are both consequences of hearing loss, it suggests that tonotopic reorganization may cause tinnitus. This project will test that hypothesis. Tonotopic measurements in subjects with and without tinnitus, using state-of-the-art neuroimaging methods will be taken. If tinnitus is found to be related to tonotopic reorganization in the human brain, it will strongly stimulate the development of therapies (such as new sound therapies) that aim at restoring normal tonotopic representation and thereby cure tinnitus. The first year of this project accomplished the following: identified a form of rapid onset and persistent abnormal hippocampal plasticity induced after prolonged loud noise exposure and quantified the changes in hippocampal activity; used a behavioral pre-pulse startle paradigm to demonstrate initial absence of, and later development of, signs of tinnitus in an animal model; demonstrated that stress alone induces similar aberrant hippocampal plasticity, but that tinnitus-inducing noise exposure has a larger magnitude effect on the hippocampus; showed that cortisol release post-noise exposure is enhanced; established that transient inactivation of a major stress regulating center prevents auditory- 8th International TRI Tinnitus Conference 10-13 March 2014 Auckland, New Zealand TRI2014.org.nz 24 Tinnitus Today | Summer 2013 This project aims at identifying areas in the brain that are abnormal in tinnitus (Roadmap Path A). It also relates to Path B, where cellular populations are identified that give rise to tinnitus. If tonotopic reorganization is verified to be directly related to tinnitus, it will directly affect Path C, the development of therapies for tinnitus. A T A - F u n d e d R e s e ar c h 2013 We know that tinnitus is a complex condition that often starts with injury to the inner ear but is sustained by processes in the brain that are not clearly understood. One of the proposed mechanisms of sustaining tinnitus is that there are changes in the balance between excitatory and inhibitory chemicals (neurotransmitters) that control brain activity and that may result in abnormal activity that is perceived by the individual as sound. RESEARCH IS Open Enrollment Design, Randomized Clinical Trial of Acamprosate for Tinnitus Co-PIs: William Hal Martin, Ph.D., and Yong-bing Shi, M.D. It would be reasonable to expect that modifying the excitatory/inhibitory balance in the hearing centers of the brain could restore normalcy to the brain’s activity patterns and reduce or eliminate the abnormal activity that is perceived as tinnitus. There are a host of medications that modify the chemistry of the human brain that are used to treat pain, movement disorders, insomnia and a wide range of psychiatric disorders. Acamprosate is a medication that has been used to treat those recovering from alcoholism. Its suspected mechanism of action is to stabilize the chemical balance in the brain disrupted by extended alcohol use by reducing the effects of the excitatory glutamic acid and increasing the effects of the inhibitory gamma-aminobutryc acid (GABA) type A systems. There is evidence that suggests that low GABA levels in the auditory pathway structures causes abnormal firing patterns in those nerves that could be responsible for the sounds perceived as tinnitus. Acamprosate might be one of the medications that could help tinnitus and this was supported by studies published in Brazil1 and India2. The purpose of this study was to perform an extremely well-controlled, randomized, placebo comparison clinical trial of acamprosate using an open enrollment design. An open enrollment design is well suited for complex conditions like tinnitus because it incorporates an initial open-label phase that identifies and eliminates non-responders prior to the double-blind, crossover, placebo/treatment phase of study. This increases the statistical power of the study and the likelihood of identifying subgroups who may respond to the specific intervention being evaluated. Neither the study in Brazil or India used an open enrollment study design. One thousand four individuals were initially screened using strict inclusion/exclusion criteria that included duration and stability of the tinnitus, current medical conditions, baseline tinnitus severity and other factors critical to a valid clinical trial for tinnitus. Of those screened, only 38% met the inclusion criteria and began the open label trial phase I of the study. Phase I of the study was a six week long, open label trial, during which patients took 666 mg of acamprosate daily. Phase I was followed by a washout period of at least four weeks. At the end of the open-label trial 99 participants qualified as responders but only 58 elected to enroll in the extended double blind cross-over phase II. Phase II was a 16 week period of either placebo or treatment, followed by a four week washout, then a second 16 week period using the other intervention (treatment or placebo). Measurements included the Tinnitus Functional Index, psychoacoustic measures of tinnitus and subject loudness ratings. No significant differences in outcome measures were identified between when participants were taking the placebo or the acamprosate at the end of phase II. The results in this study differ from the results reported by the groups from Brazil and India. The difference in results may be due to differences in experimental designs, subject selection parameters, medication dosage, choice of outcome measures and/or criteria for what was considered a significant change. This study was supported by grants from the American Tinnitus Association, the Flexion Corporation and the Oregon Health & Science University Tinnitus Clinic. Azevedo AA, Figueiredo RR (2005). Tinnitus treatment with acamprosate: double-blind study. Braz J Otorhinolaryngol, 71(5):618–23. 1 Sharma DK, Kaur S, Sing J, Kaur I (2012). Role of acamprosate in sensorineural tinnitus. Indian J Pharmacology, 44(1):93-96. 2 Summer 2013 | Tinnitus Today 25 SU E Congressional Leaders Continue Their Support of Tinnitus Research and Treatment By Jennifer Born, ATA Director of Public Affairs In April, Representative Michael Michaud (D-ME) the current ranking Member on the House Veterans Affairs (VA) Committee, reintroduced a bill to help spur research into tinnitus by the VA and to encourage tinnitus research cooperation and support by the Department of Defense (DoD) and the DoD Hearing Center of Excellence. H.R. 1443, the Tinnitus Research and Treatment Act of 2013 would require the VA to: (1) ensure the allocation of appropriate resources directed at tinnitus research and treatment by VA Auditory Centers of Excellence, (2) ensure that research is conducted at VA facilities on the prevention and treatment of tinnitus, and (3) encourage VA cooperation with the DoD Hearing Center of Excellence. At the time of writing, the bill had four co-sponsors and was part of a VA Health Subcommittee legislative hearing on July 9, 2013 where ATA was invited to testify. Susan E. Susan E. Shore, Ph.D. Shore, Ph.D., ATA Scientific Advisory Committee Chair traveled to Washington, D.C. to give scientific testimony on the progress of tinnitus research and what new treatments are on the horizon. We thank Dr. Shore for representing ATA and hope that it inspires these Congressional leaders to include the provisions of this bill as part of a larger VA Health initiative soon. In addition to the exciting discoveries in tinnitus research, sadly the incidence of tinnitus continues to escalate – particularly in veterans. The VA recently released its 2012 annual benefits report that showed that at the end of 2012 almost 972,000 veterans were service-connected for tinnitus, representing an increase of more than 100,000 in one year and making it the leading disability for veterans from all periods of service for the fifth year in a row. The cost to compensate veterans for tinnitus at the end of 2012 was $1.5 billion. At the current rate of increase, the cost will grow to $3 billion annually by 2017. 26 Tinnitus Today | Summer 2013 We especially thank Rep. Michaud for his continued support of tinnitus research and treatment by the VA. Because of his leadership over the past two years, during National Tinnitus Awareness Week in May, Melanie West, Vice-Chair, ATA Board of Directors, presented Rep. Michaud with ATA’s 2012 House Legislative Champion award for his demonstrated leadership in advancing tinnitus research toward a cure. We look forward to continuing to work with Mr. Michaud and his staff as well as the many other Congressional leaders who have supported tinnitus research over the years. We especially thank Melanie for taking the time to make this special presentation on behalf of ATA. To read more about Dr. Shore’s testimony and the VA legislative hearing visit ATA.org/HR1443. There you will also find information on how to contact your own House Member of Congress to ask them to support this bill. If you have any questions, please contact [email protected] Advertisement — ATA does not endorse or recommend any tinnitus products or treatments. …with a new, FDA approved sound cancellation procedure pioneered by Columbia scientist Dr. Dan Choy and Bell Labs’ Dr. Ivan Kaminow with a nearly 100% success rate. For complete information and to download your app, visit the Apple or Google App Store or www.phaseoutapp.com A T A - F u n d e d R e s e ar c h ATA-Funded Research Report: Brain Activity and Tinnitus 2013 RESEARCH IS Pim van Dijk, Ph.D., University of Groningen, University Medical Center Groningen, The Netherlands Many researchers think that the brain is involved in tinnitus. The brain is involved in everything we perceive, including everything we hear. Therefore it must also be involved in tinnitus. However, this idea is a bit more specific than just saying that everything we hear involves the brain. Tinnitus is often associated with hearing loss. The hearing loss may be anything between barely noticeable and severe. We know from observations in animals that hearing loss causes changes in the brain. In other words, the brain appears to adapt to the hearing loss. In animal studies, it has been found that spontaneous or resting-state activity of auditory brain centers increases after a hearing loss has been induced. It is very well possible, that similar changes occurred in humans who developed tinnitus. Our research group aims at finding the unusual patterns of neural activity in tinnitus patients that may explain why a person hears tinnitus. Thanks to a research grant from ATA, we were able to conduct two studies, which gave remarkable results about brain mechanisms in tinnitus. intense sounds cause more brain activity. However, the decrease in the thalamus is remarkable and counterintuitive: it suggests a special role for the thalamus in tinnitus. Cortex Thalamus The second study involved subjects with tinnitus and moderate hearing Auditory nerve loss, a common combination of Cortex symptoms. We compared the brain’s response to sound in these subjects to that in subjects with similar hearing aiin Brainloss, but no tinnitus. The amplitude stem Thalamus of the brain response was very similar between these two subject groups. However, there was a subtle difference. Normally, the ear drives the (Upper): a schematic picture of the human brain. Sound brainstem, which drives the thalamus, which in turn drives the AC. We hear that reaches the ear causes neural activity in the auditory nerve. This activity drives activity in the brainstem because the AC becomes active. In (CN, SO, and IC), which in turn drives the thalamus (MG), the tinnitus subjects, activity in the which finally controls activity in the cortex (AC). The con- AC was less correlated to activity in scious perception of a sound corresponds to activity in the brainstem in comparison to subthe cortex. (Lower): activity of auditory brain centers can jects without tinnitus. Apparently, the be measured by functional Magnetic Resonance Imaging brainstem was slightly less efficient in (fMRI). The gray images show regular MRI scans, from driving the AC, via the thalamus. This which the anatomy of the brain can be recognized. In suggests that the brainstem lost some addition, the colored blobs correspond to neural activity of its control over the activity in the in response to sound. In the cortex, the blobs are easy AC. We imagine that this lack of to identify, but in the thalamus and brainstem, they are control prompts uncontrolled neural tiny. The lower panel shows four brain slices (A, B, C, activity in the AC, which could result D). These slices can also be recognized as the straight white lines in the scan on the right. The research group in tinnitus. This sounds quite dramatic, in Groningen studies brain activity in subjects with tinbut was actually a very subtle effect. nitus by functional MRI. These studies suggest that tinIt may however correspond to an nitus may arise due to reduced control by the thalamus observation that is made by clinicians over activity in the cortex. (Upper panel: adapted from and some patients. Some tinnitus Langers, 2006; lower panel: adapted from Boyen, 2013) patients report that wearing hearing The first project involved aids reduces their tinnitus. Possibly, the amplified sound subjects with gaze-evoked tinnitus. This sounds very at the ear restores some of the control over cortical exotic, but gaze-evoked tinnitus is relatively common activity and thereby silences tinnitus. in patients who underwent vestibular schwannoma Brainstem surgery. This is an interesting group to study because the fact that these subjects can control the loudness of their tinnitus, allowed us to measure the changes in brain activity due to an increase of tinnitus loudness. We found that with increasing tinnitus loudness, activity increases in the brainstem and auditory cortex (AC), but decreases in the thalamus (see graphic). The increase of activity in the brainstem and cortex corresponds closely to what happens in normal external sound that reaches the ear: more The ear Both these studies suggest that the thalamus functions abnormally in tinnitus. From a scientific point of view, it is important that these results were obtained in very different groups of tinnitus subjects. After all, tinnitus patients differ substantially in the sounds they describe to hear, in their hearing loss and in the factors that influence their tinnitus. Finding the common trait in the auditory system of two groups of tinnitus subjects may be the start of a road that leads to a common treatment. Summer 2013 | Tinnitus Today 27 SU E SE V EN T H I n t e r n atio n al T i n n it u s R e s e ar c h I n itiativ e Co n f e r e n c e 2013 “Tinnitus: A Treatable Disease” RESEARCH IS SU E By Berthold Langguth, M.D., Ph.D. This year’s Tinnitus Research Initiative (TRI) meeting was hosted in Valencia, Spain by Professor Jose Miguel Lainez, Ph.D., one of the founders of TRI. The special atmosphere of this Mediterranean city with its combination of a long historic tradition and a futuristic character represented a unique venue. The dream-like progressive architecture of Santiago Calatrava’s city of arts and science represented an inspiring environment for the opening talk, “The Dream to Cure Tinnitus“ by Dirk De Ridder, M.D., Ph.D., who gave those words a manifold meaning. Just like Dr. Martin Luther-King Jr. had a dream – what was once a dream – became reality later. But it is not only that dreams may help to overcome obstacles, which seem to be insurmountable. It is also that many scientific breakthroughs have appeared in dreams. The discovery of the benzene ring by August Kekule, Ph.D., is just one of many examples. Finally the dream-state itself is proof of principle that a tinnitus cure is achievable. The vast majority of tinnitus patients have no tinnitus when they dream. Thus a better understanding of the dream state itself may provide a hint in the search for efficient targets to cure tinnitus. Following the title, “Tinnitus: A Treatable Disease,” this year’s meeting was clinically oriented, starting with a session in which the need for multidisciplinary work was stressed. Collaboration of audiologists, otologists, neuro-otologists, neurologists, neurosurgeons, psychiatrists and psychotherapists is required for efficient diagnostic and therapeutic tinnitus management. Other talks focused on psychotherapy and sound therapy. While important progress has been made in these “traditional” treatments and they can be extremely useful in some patients, we also must acknowledge their limitations. In order to overcome these limitations, a deeper understanding of the involved mechanisms is needed. Advances in animal research, electrophysiology and neuroimaging enable an increasingly deeper understanding of the neuronal mechanisms underlying tinnitus. Recent basic scientific research has demonstrated the complexity of dynamic changes of brain structure and function after hearing loss. Most important is the differentiation between changes related to hearing loss and those related to tinnitus. Other concepts like spike timing dependent plasticity are increasingly recognized as relevant for tinnitus and its treatment. Of importance is that the advances in the understanding of the neuronal mechanisms are translated into innovative treatment approaches. Examples are the development of new pharmacologic compounds targeting potassium channels or combined electrical and auditory stimulation for inducing therapeutic neuroplastic changes in the auditory system. Also highlighted was that in addition to basic science, other approaches may prove beneficial to overcome current limitations. Variability may be such an approach. We must continue to develop and test new ideas – aware that the vast majority of them might fail. By continuing to try and learn from failures, progress will be made analogous to what evolution does in nature. As Thomas Kuhn, Ph.D., stated in The Structure of Scientific Revolutions, “...also in science the fittest idea, the fittest concept, the fittest treatment will survive.” Progress is based on failure, if we draw the right conclusions. As an example, large scale analysis of drug target and side effect databases enables the identification of neuronal targets involved in the development of tinnitus as a side effect of drug treatment. Inversing this approach may provide guidance for identification of potential targets for treatment. As important as the creativity and open-mindedness are, application of proper methodology and research structure is needed. This will prevent rejection of efficient approaches because of false negative results and not lead us down the wrong path because of false Calatrava’s City of Arts and Sciences, Valencia, Spain. (Photo credit Bela Benedek / Belabenedek.com) 28 Tinnitus Today | Summer 2013 positive results. The relevance of epidemiological studies has been made clear, identifying the need for activities to prevent tinnitus and hearing loss, but also to demonstrate how emotional factors and tinnitus interact. For example there is evidence that depression is not only a potential consequence of tinnitus, but also represents a risk factor for its development. Additional sessions discussed progress in animal research, the interaction between the auditory and the non-auditory system in tinnitus. Neuroimaging becomes increasingly successful in order to disentangle neuronal effects related to the various aspects and comorbidities of tinnitus. This knowledge can be directly implemented in brain stimulation approaches for modulating tinnitus-related brain activity. Similarly, advances in animal models offer more possibilities to develop and test new treatment approaches, whether pharmacological or specific stimulation approaches. Let’s use the momentum built up in Valencia to foster our inspiration and motivation and to drive our efforts. These efforts will decide whether the meeting was a success, and whether the dream of a cure for tinnitus will come true. Next year’s meeting, will be held in Auckland, New Zealand from March 10-13, 2014 and the title will be “Beyond the Horizon”. Letters to the Editor Continued from Page 5 the doctors could not say what the outcome would be. I think the electrical stimulation of the auditory nerve by the implant may be the reason. When I take the implant off, I still do hear sounds but they are much quieter and do not bother me. I am able to fall asleep for the first time without listening to my ocean surf CD. I encourage anyone with severe hearing loss and tinnitus to explore this option. Faith Sokol ATA Member since 1999 Editors note: Electrical stimulation of the brain and auditory nerve are very promising areas of research that are being explored worldwide for tinnitus alleviation. You can read more on all the latest tinnitus research from around the globe in our annual Research Round-Up on Page 16. Advertisement — ATA does not endorse or recommend any tinnitus products or treatments. Summer 2013 | Tinnitus Today 29 Successful Tinnitus Treatment Relies on Management and Habituation by Jeff Carroll, Ph.D. In 2008, Gig Harbor, Washington resident Joyce Greenfield suffered from vertigo and sought the help of a physical therapist. While her vertigo symptoms subsided, Greenfield developed a case of tinnitus that wouldn’t go away. Her tinnitus was the loudest when she engaged in Jeff Carroll, Ph.D. her favorite quiet activities like reading, sewing and quilting. She had to use the TV to fall asleep and drown out the ringing sound. Tinnitus disrupted her life. “I had to put music on all the time to drown out the ringing but then I couldn’t concentrate on my favorite hobbies,” Greenfield said. “Even outside if I wanted to sit quietly on my patio I couldn’t get away from the sound. Bedtime was the absolute worst. The tinnitus would keep me awake. I was always turning on the news, trying to sleep with the TV on in the background, which was like putting on music during the day.” Not All Sound Therapies “Sound” Alike While research continues there is still no “magic bullet” to treat tinnitus. Patients must learn to manage their condition and sound therapy remains the most effective approach. It can provide immediate relief as well as long term benefit through habituation where patients gradually put their tinnitus in the background where it belongs. However certain sound therapy tools if used incorrectly won’t be effective. A combination of patient education, counseling and ongoing management are critical. Sound generators come in different varieties. There are highly dynamic sounds that are intended to produce relaxation or distraction. Devices with highly fluctuating sounds, such as music, can be effective in distracting patients, in much the same way a conversation does. However, these sounds remain in the foreground which makes many tasks like reading, conversing or sleeping even more challenging for tinnitus patients. 30 Tinnitus Today | Summer 2013 Louder Maskers vs. Soft Sounds Steady sounds, also called maskers, are easier to put in the background and can simultaneously interfere with tinnitus. The most common masker is white noise which due to its broadband nature can be quite soothing for patients. But often the treatment sound must be loud to cover up the tinnitus. Furthermore, maskers, when not combined with a habituation program, offer relief only during use – once turned off, the tinnitus continues. New developments in sound therapy have led to the creation of a device called Serenade®, which uses soft, low volume tones called S-Tones to offer relief. These treatment tones are meant to be played softer than the perceived tinnitus sound, and listened to passively, in the same way someone might hear a refrigerator humming. The tones are pitch-matched to the person’s tinnitus sound and rapidly modulated. Research suggests this modulation raises neural activity, which helps refocus the brain, “giving it something different” to pay attention to.1 Through a Tacoma audiologist, Greenfield was fitted with Serenade, which includes a programmable handheld device and ear buds. “I use Serenade daily, mostly at night. I listen to four different tones. If I want to go to sleep I’ll put the ear phones in and I can go to sleep within five-10 minutes. It really has worked. It’s like I’ve turned the volume down on my tinnitus.” Sound therapy is not appropriate for all patients and Serenade may not benefit everyone. Only your hearing healthcare provider can determine if you are a candidate for Serenade or if another treatment option is best. Jeff Carroll, Ph.D., is Director of Clinical Services and Engineering for SoundCure, Inc. He was the founding Director of the Tinnitus Treatment Center at the University of California, Irvine and has worked with hundreds of tinnitus patients over the past decade. Dr. Carroll holds a doctoral degree in Biomedical Engineering from UC Irvine and is one of the inventors of the S-Tone technology in the SoundCure sound therapy system. Reavis et al, “Temporary Suppression of Tinnitus by Modulated Sounds.” Journal of the Association for Research in Otolaryngology. Published online, April 2012. 1 Special Donors and Tributes Thank you to all of our donors. Your generosity and commitment make possible ATA’s continuing effort to support innovative tinnitus research – investigations that are searching for improved tinnitus treatments, and eventually a cure. We greatly appreciate each and every ATA member. Without you, there would not be an American Tinnitus Association. All contributions to the American Tinnitus Association are tax-deductible to the extent provided by law. For more information about giving to ATA, please contact us at (800) 634-8978 or [email protected] In order to provide you with plenty of information in Tinnitus Today, we display Supporting Donors ($100-499) yearround on ATA’s website at ATA.org/about-ata/donor-recognition. We recognize all $100+ donors in the Spring issue of Tinnitus Today for the previous calendar year. Christen Speer Barbara F. Sturtevant Daniel R. Talbot Paul Texter Charles A. Turack Widex USA The gifts listed below are from January 1, 2013 through June 30, 2013. TRIBUTES *Indicates deceased/bequest. Bold indicates monthly donor. Research Patron Donors $50,000+ Benefactor Donors $1,000 to 4,999 Walter and Lucille Rubin Bryan Richard Aubie Anonymous (1 donor) Research Advocate Donors $10,000 to 49,999 AXA Advisors, LLC John R. and Linda Bates Kenneth R. Cherry Anonymous (1 donor) John and Margaret Chickering Family Gift Fund Principal Investigator Donors $5,000 to 9,999 Clay S. Coleman Willis and Jane Fletcher Family Fund II at the San Diego Foundation Jim L. Schiller Starkey Hearing Technologies Otoharmonics Corporation SoundCure Inc. Wolf Creek Charitable Foundation Dan Hamelberg Mark K. Johnson, J.D. John W. and Marina Little John Malcolm Norma M. Masella Don G. and Mary Beth McMahon Gary P. Reul, Ed.D. and Barbara T. Reul William L. Ritchie Jr. Jerry Shannon William Stubbeman, M.D., TMS Psychiatry F. Helmut and Caroline Weymar, Twin Chimney, Inc. John L. Zabriskie and Adelaide W. Zabriskie Fund Sponsor Donors $500 to 999 Joseph F. and Frances A. Bachman Charitable Fund Norbert W. and Inger A. Bischofberger Gary A. Bleiberg Bouchard Insurance Frank P. Cheng Steve Collins Mark Davis Frederick R. Entwistle, M.D. IN MEMORY Elmar R. Altwicker Anonymous Dwight W. and Anne L. Fawcett Janet and Kee Lim John W. Finger Ruth Arndt Martha K. Chestem Alison Kay French Gary Bass Arthur Gelb, Ph.D. David Michael Keeter John Gresko, Direct Sound Extreme Isolation Headphones Edwin R. Czajka Nancy L. Czajka Laurence E. Hallas, Ph.D. Patricia Ehms James R. and Colleen A. Hartel Robert G. Diener, Ph.D. Alex K. Khoo Nancy L. Diener Kiwanis Club of the Top of the Judith “Judy” Glass Bay Foundation Inc. Barry and Lois Altman Altman Lou N. Marincovich, Jr. Arthur Caion Stanley Goldberg William D. Miller Julie Goldstein Scott C. Mitchell, J.D., C.P.A. Howard Gordon Fernando Otoya Susie Grapel Bonnie Hausman Warren Palmer Tommy Hung, HK Hung Corp. Vincent E. Piccione Mary Kolkhorst Lorrie Ratchford Judith Lewis SoundCure, Inc. William Heath Lewis Distinctive Groups of Individuals and Organizations ATA is proud to have the following individuals and organizations support our research efforts and our crucial involvement in the tinnitus community. They include members of the Jack Vernon Legacy Society (those who have generously included ATA in their planned giving), our Corporate Membership Program and our Professional Membership Program as of July 2013. Corporate Members Corporate Visionary $1,000 to 4,999 Corporate Leaders $500 to 999 Corporate Champion $5,000 + SoundCure’s Serenade® device is a novel sound therapy platform used by audiologists to treat tinnitus. Serenade consists of a handheld acoustic stimuli generator, earphones, and pleasant treatment sounds that are intended to address the underlying cause of tinnitus. A suite of three different types of sounds is included, enabling the audiologist to determine the specific clinical approach that is most likely to be effective for each patient. Unlike most treatment methodologies, Serenade is customizable, and can be programmed to meet the unique needs of each patient, day or night. Established in 2009 to commercialize the technology developed for years at the University of California, Irvine (partially funded by an ATA grant.) SoundCure, Inc. is a privately held medical device company whose mission is to revolutionize the treatment of tinnitus and provide relief to the millions of people suffering its effects Starkey Hearing Technologies, the global leader in hearing health technology, has engineered a new Tinnitus Treatment Solution that will change the way people deal with ringing in the ears. Using patent-pending Multiflex Tinnitus Technology, this comfortable, nearly invisible device generates a customizable sound stimulus that a tinnitus hearing professional can fine-tune to soothe the irritating sounds you hear. Personalized for your unique tinnitus, it is designed to deliver all-day relief. Click here to learn more. Since 1967, American-ownedand-operated Starkey Hearing Technologies has consistently advanced better hearing by creating solutions that push auditory research and microelectronic technology to the leading edge, and by giving hearing healthcare professionals around the world the tools they need to transform lives one person at a time . . Jack Vernon Legacy Society ANONYMOUS (3) Paul A. Bauml Monte Beilharz Virginia Blackman Gerald L. Bray, LCSW John U. Buchman, M.D. G. Cheston Carey, III Carl L. Cochrane, Jr. Simon Couvier Jules H. Drucker AXA Advisors has financial professionals in communities throughout the United States. AXA Advisors’ local presence allows clients to develop special relationships with talented, capable financial professionals in their local communities. Many of these financial professionals have attained one or more coveted professional designations, such as Certified Financial Planner® or Chartered Financial Consultant. Some even have a background or training in the fields of law or accounting. AXA Advisors is a subsidiary of AXA Financial, Inc., a member of the global AXA Group. Financial services and products available to individuals and small businesses through AXA Advisors and its affiliates include: Financial planning; Business, retirement, and estate planning; College planning; Life insurance; Annuities; Mutual funds. IBM is an American multinational technology and consulting corporation, which manufactures and markets computer hardware and software, and offers infrastructure, hosting and consulting services in areas ranging from mainframe computers to nanotechnology. Joy A. Fogarty Drs. Norman and Gilda Greenberg D. G. Gumpertz Marcene M. Herron Richard and Estella Hoag Charitable Fund Ginger L. Hoiland Richard Iannacone Ben L. Jones Harold M. Kahn, Jr. Clifford L. Kohler Bouchard Insurance Direct Sound Extreme Isolation Headphones EarPeace Swanson Print & Design Widex Corporate Members $250 to 499 HushTinnitus Tampa Bay ENT Tri-City Audiology Marita Maxey Ruth E. Ochs Gary P. Reul, Ed.D., and Barbara T. Reul Edward P. Rosenberg James W. Soudriette Neil D. Valentino Delmer D. and Wanda Weisz Michael Scarimbolo Irene Wolfson Simon Golding LaVerne Fox Robert M. Johnson Wayne O. Olsen Bernie Keeter David Michael Keeter Margie Robertson Keeter David Michael Keeter Leonore Mary Petito Rosemary C. Petito Bert Smith David Michael Keeter Anita Steiner Teresa Fryman Jack A. Vernon, Ph.D. Jerome Ott Anthony Williamson David Michael Keeter Mark Zonfrelli Chris Bourbeau IN HONOR Linda Beach Mary-Ann Halladay John DeAtley Chris H. Hansen, CFP and John M. Britton of Personal Choice Financial Advisors Richard Harold Keeter David Michael Keeter Judy Lynn Keeter Cannon David Michael Keeter Sharon Lemke Arnold W. and Shirley F. Christensen Richard Lewis Martin and Caral Snyder Donald E. Salom James W. Beshears Matching Corporations Agilent Technologies Foundation American Express Foundation Ericsson Matching Gifts Program GE Foundation Global Impact Kaiser Permanente Matching Gift Program Lorton Data, Inc. Markel Corporation Microsoft Pepsico Foundation Pitney Bowes Employees and Employee Investment Fund Thomson Reuters Verizon Foundation Professional Members ATA offers a special thanks to our Founding Members (names bolded below) who joined by June 30, 2008 and helped ATA successfully launch this great program. As of July 2013 our Professional Membership Program includes: ATA Gold Level Professional Members ($300+) Jennifer Auer, Au.D., F-AAA,CCC-A, Audiology by the Sound Gail B. Brenner, Au.D., Tinnitus & Sound Sensitivity Treatment Center of Philadelphia, PC Francis S. Cardarelli, M.A., Frank Cardarelli, LLC Paulo Coelho, Instituto de Odontologia Dr Paulo Coelho Theresa Cullen, Au.D., Cape Cod Hearing Center Leslie W. Dalton, Jr., Ph.D., West Texas A&M University - Speech and Hearing Clinicity Speech and Hearing Clinic Nikki DeGeorge, Au.D., Fayette Hearing Clinic and Coweta Hearing Clinic Stelios G. Dokianakis, Au.D., Holland Doctors of Audiology James L. Everette, Jr., M.D., Bayhealth Kent General - Milford Memorial Hospital Melanie Herzfeld, Au.D., Hearing and Tinnitus Center Maria Holl, LSW, CBT, Institut Maria Holl GmbH Lata Jain, Au.D., Sonus Hearing Care Professionals Pamela Keenan, Au.D., McDonald Audiology & Hearing Health Care Dennis Kisiel, Ph.D., A & B Hearing Aid Centre Audiology Affiliates Maryanne Knaub, ReNewed Hearing Solutions Albert Langely, BC- HIS, Hearing Enhancement Centers, Inc. Ha-Sheng Li-Korotky, Au.D., Ph.D., M.D., F-AAA, Pacific Northwest Audiology, LLC Thomas Lobl, Ph.D. Michael MacDonald, Hearing Center of Excellence Maura Marks, Ph.D., Au.D., Speech-Language & Hearing Associates of Greater Boston, PC Jill B. Meltzer, Au.D., North Shore AudioVestibular Lab Norma R. Mraz, Au.D., Mraz Audiology Consulting, Inc. Stephen M. Nagler, M.D., FACS, General Hearing Instruments Nebraska Hearing Instruments Richard S. Reikowski, Au.D., CCC/A, F/A, Family Hearing and Balance Center Ann Rhoten, Au.D., Kentucky Audiology & Tinnitus Services Vanessa Rothholtz, M.D., M.S.c., Otosurgical Group Medical Clinic, Inc. Richard J. Salvi, Ph.D., SUNY Buffalo/Center for Hearing and Deafness Susan Shore, Ph.D., University of Michigan Med. School, Dept. of Otolaryngology Murray Steinfeld, BC-HIS, ACA, Hearing Solutions of the Palm Beaches, LLC William Stubbeman, M.D., TMS Psychiatry Edward Szumowski, Au.D., Western Michigan Hearing Services ATA Silver Level Professional Members ($150 - 299) Scott Austin, Willoughby Hearing Aid Centers Tonya Barlow M.S., CCC-A., Avada Audiology & Balance Center Kathleen Bartels, Ph.D., CCC-A/SLP Jennifer Battaglino, LCSW Anita Carroll, Au.D., Hearing Solutions in the Triangle, PLLC Jeffrey Clark, B.S., M.S., Au.D., Physician’s Choice Hearing & Dizziness Center Lois N. Cohen, LCSW, ACSW, BCD Jim Cole, Hearing Specialists of Kalamazoo Julie Eschenbrenner, Flatirons Audiology Inc. Laura Feldhake, Au.D., Northland ENT Dana Fiske, Au.D., Professional Audiology Center Rebecca Fogel, ENT Consultants of North Texas Anne Curtis Galloway, M.S., CCC-A, Anchorage Audiology Clinic Elizabeth Galster, Au.D., CCC-A, Starkey Laboratories, Inc. Shonie Hannah, M.A., CCC-A, Cascade Audiology & Hearing Susan Hansel, Au.D., FAAA, Barrington Hearing Center Hearing Speech & Deafness Center Donna Hill, Au.D., Audiology Professionals Barbara H. Jenkins, Au.D., Advanced Audiology & Tinnitus Treatment Center Jennifer Jennings, Au.D., CCC-A, Dean Clinic Marsha Johnson, Au.D., Oregon Tinnitus & Hyperacusis Clinic Ruth Kaspar, Au.D., Santa Cruz ENT Medical Group Deborah Lain, M.S., Hope for Tinnitus Sharon Macner, Au.D., Champlain Valley Audiology, PLLC Michael Mallahan, Au.D., Hearing and Balance Lab, PC Carol Ann Manning, The Tinnitus Treatment Center Sol Marghzar, Au.D., M.S., CCC-A, The Hearing Doctor Peter J. Marincovich, Ph.D.,CCC-A Mary Miller, Ph.D., Premier Hearing and Balance Richard Mowry, M.S., M.P.H., FAAA, Professional Hearing Services, Inc. Ram Nileshwar, Au.D., The Hearing Center of Lake Charles Tracy Peck, Au.D. Hearing and Speech Center of Northern California Aaron J. Prussin, M.D., Lewis Gale Physicians - SW Virginia ENT Associates Leslie Purcell, Mount Nittany Physician Group Michael J. A. Robb, M.D., Robb Oto-Neurology Clinic Rachel Roberts, Au.D., CCC-A, FAAA, Accent on Hearing J. Lewis Romett, M.D., Colorado ENT and Allergy Deanna Ross, Au.D., Albany ENT & Allergy Services, PC Scott A. Sims, Au.D., Physician’s Choice Hearing & Dizziness Center Martin J. Smith, Psy.D. Judith Sonner, LICSW, Newton Biofeedback Ronald Leif Steenerson, M.D., Atlanta Ear Clinic Bradley S. Thedinger, M.D., Otologic Center, Inc. Cori Walker, Au.D., M.A., B.S. Lixin Zhang, M.D., Ph.D., DENT Dizziness and Balance Center Summer 2013 | Tinnitus Today 31 P.O. Box 5 Portland, OR 97207-0005 Advertisement — ATA does not endorse or recommend any tinnitus products or treatments. TAKE CONTROL OF YOUR TINNITUS TODAY WIDEX ZEN THERAPY A Sound Approach for Tinnitus Management If you have tinnitus, you’re not alone. It’s estimated that 50 million people in the United States are affected by tinnitus. Widex, one of the world’s most respected manufacturers of high-quality hearing aids, is now a leader in tinnitus management. Widex ZEN Therapy is a unique sound therapy tool for tinnitus management. The patented ZEN Program uses chime-like fractal tones for tinnitus relief and relaxation and has shown promise in the treatment of tinnitus in a published clinical study. Contact your Hearing Healthcare Provider today to learn more about Widex ZEN Therapy. www.widexusa.com Indications for Use: The ZEN Program is intended to provide a relaxing sound background for adults (21 years and older) who desire to listen to such a background in quiet. It may be used as a sound therapy tool in a tinnitus treatment program that is prescribed by a licensed hearing healthcare professional (audiologists, hearing aid specialists, otolaryngologists) who is trained in tinnitus management.