Download The Many Faces of Research: From Leading Investigations in the RESEARCH

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
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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
•
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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 of​rTMS? (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
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Research From around the World
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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
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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
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A T A - F u n d e d R e s e ar c h
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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
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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
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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.
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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.
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