Clinical Research

Tinnitus in children attract more attention. Kentish et al. data show that tinnitus can have the same impact on children lives as in adults. Notably, children with hearing loss found tinnitus less troublesome that children with normal hearing.

As majority of epidemiological data were gathered in UK, Germany, and Sweden, there is still great need for epidemiological data from various countries. Vallianatou et al., report preliminary data from Greece. Results from Brazil (Pitcher et al.) describe prevalence of sensorineural hearing loss and tinnitus in patients with sickle cell, showing the presence of positive correlation.

The recurrent question of tinnitus treatment with low-intensity laser was addressed in randomized, prospective, double-blind, placebo-controlled trial (Mirz et al.). As in previous well controlled studies, there was no positive effect of laser, and the authors conclude that previous positive reports may be explained by the placebo effect.

There is no consensus on the method to evaluate tinnitus. Two studies were aimed at checking relative validity of various questionnaires. Baguley et al., evaluated correlation of findings from the tinnitus handicap inventory (THI) with tinnitus questionnaire (TQ), and concluded that both questionnaires provide convergent results. Meric et al., studied English and French version of Tinnitus Reaction Questionnaire and concluded that French version is equally valid as English original.

Children's experience of tinnitus: a preliminary survey of children presenting to a psychology department. Kentish RC, Crocker SR, McKenna L. Nuffield Hearing and Speech Centre, Royal National Throat, Nose and Ear Hospital, London, UK. Br J Audiol 2000 Dec;34(6):335_40

Tinnitus has been much researched within adult populations with consideration of prevalence as well as the impact of tinnitus on individual's lives. Although the literature highlights the prevalence of tinnitus in children, there is little information on its effects from a psychological perspective. This small_scale preliminary study looked at 24 children (50% with normal hearing and 50% with a hearing loss) who presented to the Psychology Department with troublesome tinnitus. In line with adult studies, preliminary results suggested that tinnitus can have as marked an effect on children's lives as it is reported to have on adults. Insomnia, emotional distress, listening and attention difficulties are the main psychological factors associated with tinnitus in children. These, in turn, may have an effect upon their school performance. Differences were found between children with normal hearing and those with some degree of hearing loss. Overall, children with normal hearing found tinnitus more troublesome and presented with higher levels of anxiety than those with some level of hearing impairment. The present study suggests that children who complain of tinnitus should be taken seriously. In terms of management, individual intervention packages were found to be useful in alleviating anxiety and other associated factors. Recommendations are made on areas for future research.

Audiologic and psychological profile of Greek patients with tinnitus_Preliminary findings. Vallianatou NG, Christodoulou P, Nestoros JN, Helidonis E. Department of Otorhinolaryngology, Laboratory of Audiology and Neurotology, University Hospital of Heraklion, Crete, Greece. Am J Otolaryngol 2001 Jan_Feb;22(1):33_7

Tinnitus is a common complaint among people who suffer from auditory disorders. Altering the patients' response to tinnitus and the development of coping techniques are the most important goals of the therapeutic or suppression methods. This is the first study in the Greek population to investigate the personality characteristics and coping techniques of tinnitus patients. We have studied the relation between the subjective assessment of tinnitus intensity with factors such as sex, age, duration of symptom, and degree of hearing loss. We have also studied the possible relation between the patients' personality characteristics on their attitude towards tinnitus. The participants were 80 tinnitus sufferers, men and women, between 18 and 65 years of age. The personality characteristics were assessed with the Minnesota Multiphasic Personality Inventory (MMPI). The mean MMPI scores in both men and women were within the normal range. The duration of symptoms did not prove to be an important factor for the patients' subjective assessment of the tinnitus intensity. Most patients showed "effective" coping style, were well adjusted to tinnitus, and had no significant interference in their everyday functioning. The above are discussed in the context of the influence of geographical, climatological, economic, social, and cultural factors that influence psychological functioning.

Sensorineural hearing loss among sickle cell disease patients from southern Brazil. Piltcher. O, Cigana L, Friedriech J, Ribeiro FA, da Costa SS. Hospital de Clinicas de Porto Alegre and the Faculdade de Ciencias Medicas da Santa Casa de Sao Paulo, Brazil. Am J Otolaryngol 2000 Mar_Apr;21(2):75_9

PURPOSE: A case_control study was done to confirm the higher prevalence of sensorineural hearing loss (SNHL) among sickle cell patients (HbSS) from southern Brazil. PATIENTS AND METHODS: Twenty_eight patients and 28 matched normal controls were studied. Besides complete anamneses and physical otolaryngological examination, all individuals had audiometric and tympanometric testings to determine the presence of SNHL or middle ear problems. The only significant difference between groups was the presence of a positive history of otologic symptoms (hearing loss, dizziness or tinnitus) and neurological sequelae in the HbSS patients. RESULTS: Six patients (21.4%) presented with SNHL compared with one control (3.6%) (Fisher's one_tailed P = .05; OR, 7.36 (95% CI, 0.82, 65.83). The average age of HbSS diagnosis was higher among the patients with SNHL (10 years +/_ 8.3) than those without SNHL (5.43 years +/_ 5.65), but this was not significant (analysis of variance P > .05). More patients 25 years and older on the examination date had SNHL than younger patients (Fisher's 2_tailed P < .05). Sixty_seven percent of the patients with SNHL had alterations in the acoustic reflex, and a surprising 27% of the patients without NSHL also presented with some elevation or an absence of acoustic reflex. CONCLUSIONS: These data indicate that patients with HbSS from southern Brazil are more predisposed to the development of sensorineural hearing problems than the general population.

[Treatment of tinnitus with low_intensity laser]. [Article in Danish] Mirz F, Zachariae B, Andersen SE, Nielsen AG, Johansen LV, Bjerring P, Pedersen CB. Arhus Universitetshospital, Arhus Kommunehospital, ore_naese_halsafdeling H. mirz@dadlnet.dk Ugeskr Laeger 2000 Jun 19;162(25):3607_10

This study evaluated the effect of low_power laser in the treatment of tinnitus in a randomized, prospective, double_blind, placebo_controlled trial. The active laser applied 50 mW (cw, 830 nm) over a period of 10 minutes per session. Forty_nine patients were included. The main outcome was measured using psychoacoustical match of tinnitus loudness, Visual Analog Scale (VAS) ratings of subjective loudness, annoyance and attention involved, scores on tinnitus_specific questionnaires, and a number of psychosocial questionnaires. Only few subjects (18%) experienced subjective improvement. There were no statistically significant differences between the effects of the active laser and placebo treatments. CONCLUSION: Low_power laser treatment is not indicated in the treatment of tinnitus. Reports of significant benefits of this treatment in previous studies may be explained by the placebo effect.

Convergent validity of the tinnitus handicap inventory and the tinnitus questionnaire. Baguley DM, Humphriss RL, Hodgson CA. Department of Audiology, Addenbrooke's Hospital, Cambridge, UK. dmb29@cam.ac.uk J Laryngol Otol 2000 Nov;114(11):840_3

For research into tinnitus to be robust and credible, the use of well_validated instruments of self_perceived tinnitus handicap as outcome measures is essential. The tinnitus handicap inventory (THI) and the tinnitus questionnaire (TQ) are two such instruments which are in widespread use. Both questionnaires were administered by mail to 100 consecutive new patients of the Cambridge Tinnitus Clinic, and completed in randomized order. These patients had been referred by the otolaryngology team and had not undergone any tinnitus therapy. The response rate was 78 per cent, neither questionnaire being more acceptable to patients than the other. The convergent validity of the instruments was high, with total and subscale scores all being significantly correlated at the five per cent level (Spearman correlation coefficients). A number of subscale scores were not significantly correlated at the one per cent level however. In particular, the sleep disturbance element of the TQ was demonstrated to have some discriminant validity from the THI and from other elements of the TQ at the one per cent significance level. The THI and TQ have been demonstrated to have high convergent validity and are both suitable for tinnitus outcome studies involving the quantification of self_perceived tinnitus handicap. For research that aims to determine the specific effect of an intervention on tinnitus_related sleep disturbance, the TQ sleep subscale has potential utility. The hypothetical constructs of tinnitus handicap underlying the psychologist_developed TQ and the audiologist_developed THI have been shown to be convergent.

Validation assessment of a French version of the tinnitus reaction questionnaire: a comparison between data from English and French versions. Meric C, Pham E, Chery_Croze S.

UMR CNRS, Lyon, France. J Speech Lang Hear Res 2000 Feb;43(1):184_90

The present study compares the results obtained on original and French versions of the TRQ (Tinnitus Reaction Questionnaire) initially published by Wilson, Henry, Bowen, and Haralambous (1991) in English to evaluate the psychological distress of tinnitus sufferers. Reliability and validity of the French translation were determined using data from 173 normal hearing or hearing_impaired patients with tinnitus lasting from 1 month to 41 years. They completed the translated questionnaire and a short version of the Minnesota Multiphasic Personality Inventory. The results indicated good internal consistency (Cronbach's alpha = .94), and the reliability of the French version of the TRQ was demonstrated, except for items 5 and 20. High statistically significant correlations were found between the TRQ and Depression, Psychaesthenia, and Anxiety Mini_Mult subscales. The validation demonstrates only minor effects of language. The French version of the TRQ thus is an equally valid tool as the original English version for evaluating tinnitus distress of a patient.

Audiology

The variability of repetitive evaluation of tinnitus loudness was proposed as one of method to validate the presence of tinnitus (particularly for legal cases). Jacobson et al. have shown that the underlying this approach assumption of larger variability in people who imagine tinnitus, versus those who actually experience it, is not correct, and consequently study of the variability has no value for proving existence of tinnitus. On the technical side Henry at al., proposed a computerized system for psychoacoustical tinnitus evaluation.

Another paper from Henry & Meikle confirmed one of postulates of the neurophysiological model of tinnitus that neither loudness nor other psychoacoustic measures of tinnitus have a consistent relation to the severity or perceived loudness of tinnitus. On the other hand, Holgers et al., reports that severity of tinnitus, measured by absence from work related to tinnitus, could be related to depression and physical immobility. Fowler et al., relate tinnitus severity to insomia, anxiety and depression, furthermore making analogy to chronic pain.

Effects of unilateral sudden hearing loss were investigated by Chiossoine-Kerdel et al. Tinnitus was found in 67% of cases with handicap present in 57% of subject with tinnitus. Hearing handicap was noted in 86% of patients. Notably, there was no correlation between the extent of audiometric loss and hearing or tinnitus handicap. The authors concluded that handicap in these patients results form both tinnitus and hearing loss.

Interesting occupational hearing loss was reported by Merchant at al., in rickshaw drivers. In addition to heairng loss they were twice as likely to develop tinnitus.

Attempt to detect some features related to tinnitus in DPOAE was reported by Linke et al. Unfortunately, the authors were not able to document any positive findings.

Katzenell & Segal review literature related to hyperacusis, list various medical problems and conditions accompanied by hyperacusis, and suggest dominance of central mechanism.

A re_evaluation of tinnitus reliability testing. Jacobson GP, Henderson JA, McCaslin DL. Division of Audiology, Henry Ford Hospital, Detroit, Michigan 48202, USA. J Am Acad Audiol 2000 Mar;11(3):156_61

The purposes of these investigations were to (1) evaluate tinnitus loudness measures of unskilled normal listeners asked to imagine that they are experiencing a constant monaural tonal tinnitus and (2) compare the performance of these listeners to that of a sample of patients with tinnitus. Subgroups of 24 patients participated in two investigations. Results suggest that (1) normal subjects asked to imagine a high_pitched, tonal tinnitus show significantly greater tinnitus loudness matching levels (a) when they do not have an external reference, (b) after a 1_week interval, and (c) for low_frequency matching tones; (2) patients with high_pitched tinnitus did not demonstrate statistically significant differences in tinnitus loudness judgments within or between sessions or frequencies; (3) tinnitus patients do not differ significantly from normals feigning tinnitus in the variability of tinnitus loudness matching levels within a single session (two measures) or after a 1_week interval (one measure); and (4) normals feigning tinnitus tended to choose significantly greater loudness matching levels than did tinnitus subjects.

Computer_automated clinical technique for tinnitus quantification. Henry JA, Fausti SA, Flick CL, Helt WJ, Ellingson RM. Veterans Affairs RR&D National Center for Rehabilitative Auditory Research, Portland VA Medical Center, OR, USA. henryj@ohsu.edu Am J Audiol 2000 Jun;9(1):36_49

This study addresses the need for uniformity in techniques for clinical quantification of tinnitus. Because automation can be an effective means to achieve standardization, this laboratory is developing techniques to perform computer_automated tinnitus testing. The present study was conducted to demonstrate the feasibility of obtaining reliable tinnitus measures using a fully automated system. A computer_controlled psychoacoustical system was developed to quantify tinnitus loudness and pitch using a tone_matching technique. Hearing thresholds were also obtained as part of the procedure. The system generated test stimuli and simultaneously controlled a notebook computer positioned in the sound chamber facing the patient. The notebook computer displayed instructions for responding and relayed response choices through on_screen "buttons" that the patient touched with a pen device. Twenty individuals with tinnitus were evaluated with the technique over two sessions, and responses were analyzed for test_retest reliability. Analyses revealed good reliability of thresholds, loudness matches, and pitch matches. These results demonstrate that use of a fully automated system to obtain reliable measurements of tinnitus loudness and pitch is feasible for clinical application.

Psychoacoustic measures of tinnitus. Henry JA, Meikle MB. VA RR&D National Center for Rehabilitative Auditory Research, Portland VA Medical Center, Oregon 97207, USA. J Am Acad Audiol 2000 Mar;11(3):138_55

This report reviews research from the 1930s to the present that has extended our understanding by investigating the characteristics of tinnitus that can be studied using psychoacoustic techniques. Studies of tinnitus masking and residual inhibition began in the 1970s, leading to the therapeutic use of tinnitus masking and a consequent increase in research devoted to tinnitus measurement. In 1981, the CIBA Foundation symposium on tinnitus advocated general adoption of four tinnitus measures: (1) pitch, (2) loudness, (3) maskability, and (4) residual inhibition. Since then, psychoacoustic research into all four topics has proliferated, yielding many valuable insights and controversies concerning the details of measurement techniques. A consensus has emerged that neither the loudness nor other psychoacoustic measures of tinnitus bear a consistent relation to the severity or perceived loudness of tinnitus. Nevertheless, quantification is needed in clinical trials of proposed treatments and in a variety of other types of tinnitus research. Standardization of techniques for specifying the acoustic parameters of tinnitus thus continues to be an important research goal.

Predictive factors for the severity of tinnitus Holgers KM, Erlandsson SI, Barrenas ML.

Department of Audiology, Sahlgrenska University Hospital, Goteborg University, Sweden. Audiology 2000 Sep;39(5):284_91

The majority of patients with tinnitus experience a lessening of their symptoms during an 18_month period after their first consultation. The exception to this rule is severe incapacitating tinnitus, the sometimes very troublesome symptoms of which show no sign of diminishing with time. The aim of the present study was to investigate risk factors for incapacitating tinnitus, as measured by absence from work related to tinnitus (AWT) of more than 1 month during an 18_month period after the first visit to the tinnitus clinic. Audiometric data and the scores from the Tinnitus Severity Questionnaire and the Nottingham Health Profile at the first visit to the clinic were correlated to AWT by a logistic regression model. By using this risk model, an individual risk score for AWT could be estimated. Depression and physical immobility were strong predictors of AWT, and hearing loss was moderate. Based on these results, we suggest that the aetiology of tinnitus severity could be described as depression_/anxiety_related, somatic, and auditory tinnitus.

Chronic tinnitus as phantom auditory pain. Folmer RL, Griest SE, Martin WH. Tinnitus Clinic, Oregon Hearing Research Center, Department of Otolaryngology, Oregon Health Sciences University. Otolaryngol Head Neck Surg 2001 Apr;124(4):394_400

OBJECTIVES: To investigate similarities between patients who experience chronic tinnitus or pain and to formulate treatment strategies that are likely to be effective for patients who experience phantom auditory pain. Study design: A total of 160 patients rated the severity and loudness of their tinnitus and completed the State_Trait Anxiety Inventory (STAI) and an abbreviated version of the Beck Depression Inventory (aBDI). Patients received counseling, audiometric testing, and matched the loudness of their tinnitus to sounds played through headphones. SETTING: A specialized tinnitus clinic within an urban medical center. RESULTS: Tinnitus severity was highly correlated with patients' degree of sleep disturbance, STAI, and aBDI scores. The self_rated (on a 1_to_10 scale)_but not the matched_loudness of tinnitus was correlated with tinnitus severity, sleep disturbance, STAI, and aBDI scores. CONCLUSIONS: The severity of chronic tinnitus is correlated with the severity of insomnia, anxiety, and depression. These relationships are the same for many patients with chronic pain. Treatment recommendations are discussed in reference to these results.

An investigation of the audiologic handicap associated with unilateral sudden sensorineural hearing loss. Chiossoine_Kerdel JA, Baguley DM, Stoddart RL, Moffat DA. Department of Otolaryngology, Addenbrooke's Hospital, Cambridge, UK. Am J Otol 2000 Sep;21(5):645_51

OBJECTIVE: To determine the incidence of tinnitus and associated handicap after unilateral sudden sensorineural hearing loss (SSNHL); in addition, to determine the hearing handicap experienced as a consequence of such a loss. STUDY DESIGN: Identification of patients and determination of demographic and audiologic data by retrospective case review; determination of handicap and distress by postal questionnaire. SETTING: Teaching hospital department of otolaryngology. PATIENTS: Thirty_eight patients were identified as having been treated for a unilateral sudden sensorineural hearing loss in the period 1988 through 1997. Of those, 21 (55.3%) replied to the questionnaire. MAIN OUTCOME MEASURES: Audiometric data at admission and at 4_week follow_up, Tinnitus Handicap Inventory (THI), visual analogue scales of tinnitus loudness and distress, Hearing Handicap Inventory in Adults (HHIA). RESULTS: The questionnaire responder group did not significantly differ from the questionnaire nonresponder group on demographic nor audiometric variables, and hence were considered to be a representative sample. Tinnitus was present in 14 patients (67%). Hearing handicap was found in 86% of patients (of the 21 questionnaire responders) and tinnitus handicap in 57% (of the 14 with tinnitus). Correlations were found between tinnitus loudness, distress, and handicap. There was no correlation between time elapsed since SSNHL and tinnitus or hearing handicap, nor was there a correlation between the extent of audiometric loss and hearing or tinnitus handicap. A strong negative correlation was, however, found between recovery in audiometry in the first 4 weeks after onset and tinnitus and hearing handicap. The audiometric status of the contralateral ear correlated with hearing handicap. CONCLUSIONS: A majority of patients after unilateral SSNHL have a perceived handicap associated with tinnitus and hearing. Although this condition is an otologic emergency, careful thought should be given to the audiologic rehabilitation of this patient group.

[Distortion products of otoacoustic emissions (DPOAE) in acute tinnitus aurium]. [Article in German] Linke R, Mazurek B, Matschke RG. Hals_Nasen_Ohren_Klinik, Klinikum Schwerin. Laryngorhinootologie 2000 Sep;79(9):517_22

BACKGROUND: The origin of subjective tinnitus is not really known yet. It is possible to investigate the function of outer hair cells by means of the distortion products of otoacoustic emissions (DPOAE). METHODS: DPOAE of 56 patients were analysed in a prospective study (tinnitus without any loss of hearing n = 34; hearing loss with a maximum of 35 dB and tinnitus n = 22). There was always a normal tympanogram and in no case a conductive hearing loss. The relation of the primary tones f2/f1 was 1.22, the levels of the primary tones were 70 dB. RESULTS: DPOAE_amplitudes were reduced distinctly in both groups of patients. But there was no general difference and no difference at the frequency of tinnitus between the ear with tinnitus and the contralateral ear (no hearing loss) or there was a small reduction related to the normal ear (distinct hearing loss). DPOAE_amplitudes did not change in patients without hearing loss after a treatment with Pentoxifylline i.v., also not at the frequency of tinnitus, although there was a subjective reduction of tinnitus. In patients with hearing loss DPOAE_amplitudes enhanced like the improvement of hearing threshold at the frequency of tinnitus. CONCLUSIONS: The low DPOAE_amplitudes are a sign of damaged outer hair cells of the patients. But there is a symmetry of the DPOAE_amplitudes and there is no change of DPOAE after a therapy with Pentoxifylline i.v. in patients without hearing loss.

Hyperacusis: review and clinical guidelines. Katzenell U, Segal S. Department of Otolaryngology, Wolfson Medical Center, Holon, Israel. katzudi@zahav.net.il Otol Neurotol 2001 May;22(3):321_6; discussion 326_7

OBJECTIVE: To review the current known causes of hyperacusis and the different hypotheses concerning its etiology, and to suggest clinical guidelines. DATA SOURCE: A review of the literature with the aid of the MEDLINE database, using the following key words: hyperacusis, intolerance to sound, loudness discomfort level, and phonophobia. DATA EXTRACTION: The data collected included clinical studies, case reports and laboratory studies. CONCLUSION: Hyperacusis was shown to be caused by pathologic conditions of the peripheral auditory system, diseases of the central nervous system diseases, and hormonal and infectious diseases. In some cases there was no known cause. The pathophysiology of hyperacusis probably involves a central mechanism rather than a peripheral one. Suggested clinical guidelines and treatment are discussed.

Habituation based therapies

Two contrasting papers were published recently; one representing group of German psychologist strongly criticizing TRT, and the other by PJ & MM Jastreboff providing outline of the present status of the method. Future will show if “German concept” or TRT survive the test of time.

[An assessment of tinnitus retraining therapy]. [Article in German] von Wedel H, von Wedel UC. Abteilung fur Audiologie und Padaudiologie, Klinik und Poliklinik fur Hals_, Nasen_ und Ohrenheilkunde der Universitat zu Koln, Joseph Stelzmann_Strasse 9, 50924 Koln. hasso.von.wedel@uni_koeln.de HNO 2000 Dec;48(12):887_901

Based on the neurophysiological model of tinnitus developed by Jastreboff and Hazell [39] there have been some important developments in understanding and therapy of tinnitus over the last decade. The clinical applications of this model are known as "tinnitus retraining therapy", which has the objective of reducing both the distress associated with tinnitus and the tinnitus perception itself. As a form of systematic, repeated and skilled counselling over a long period of up to 2 years supported by sound therapy (hearing aid or noise generator) the evidence for their high degree of effectiveness is overwhelming. On the basis of a "German concept" of tinnitus retraining therapy developed and proposed by the ADANO (Arbeitsgemeinschaft deutschsprachiger Audiologen und Neurootologen) the current status of this treatment will be briefly reviewed including some actual studies of Goebel et al. [14] that confirm the world wide critical comments on the recent developments in the management of tinnitus especially with regard to tinnitus retraining therapy [79].

Tinnitus Retraining Therapy (TRT) as a method for treatment of tinnitus and hyperacusis patients. Jastreboff PJ, Jastreboff MM. Tinnitus and Hyperacusis Center, Department of Otolaryngology, Emory University School of Medicine, Atlanta, Georgia 30322, USA. J Am Acad Audiol 2000 Mar;11(3):162_77

The aim of this paper is to provide information about the neurophysiologic model of tinnitus and Tinnitus Retraining Therapy (TRT). With this overview of the model and therapy, professionals may discern with this basic foundation of knowledge whether they wish to pursue learning and subsequently implement TRT in their practice. This paper provides an overview only and is insufficient for the implementation of TRT.

Pharmacology

Treating tinnitus with medications attract would be very welcome, however so far none of the drugs pass the test of offering clear help without profound side effects. A case report presents potential beneficial effect of gabapentin (Zapp) while detailed, well controlled study dispose with hope of effectiveness of Ginkgo biloba (Drew & Davies).

The list of drug reported to have tinnitus as a side effect is long. Valproate is reported to induce tinnitus which disappear after discontinuation of the drug which indicates potential causal relation (Reeves et al.). This finding is of interest as the drug is used for treatment of bipolar disorder, which would make tinnitus treatment more complex.

So far no medications were reported to be effective for hyperacusis. A case study (Gopat et al.) suggest potential for use of selective serotonin reuptake inhibitors, which are cominly used as antidepressant. While typical hyperacusis is relatively easy treated and cured with TRT, it is more difficult when hyperacusis is accompanied by hypersensitivity in other sensory modalities. Therefore, if this finding is confirmed by double blind study, this would be of clear interest.

Gabapentin for the treatment of tinnitus: a case report. Zapp JJ. Pain Institute of Northeast Florida, 2021 Kingsley Ave., Suite 102, Orange Park, FL 32073, USA. Ear Nose Throat J 2001 Feb;80(2):114_6

The objective of this article is to discuss the clinically effective use of gabapentin in patients with tinnitus. The author describes the case of a man who came to the office complaining of tinnitus of 10 months' duration. The patient was started on gabapentin and maintained on a regimen of 500 mg/day in divided doses. Subsequently, he reported that he was free of tinnitus approximately 23 days a month and that he experienced a 75% decrease in symptoms during the remaining days. At 2 years' follow_up, he remains noise_ and pain_free on 500 mg/day of gabapentin.

Effectiveness of Ginkgo biloba in treating tinnitus: double blind, placebo controlled trial. Drew S, Davies E. Pharmacology Department, Division of Neuroscience, University of Birmingham, Birmingham B15 2TT, UK. s.j.drew@bham.ac.uk BMJ 2001 Jan 13;322(7278):73

OBJECTIVE: To determine whether Ginkgo biloba is effective in treating tinnitus. DESIGN: Double blind, placebo controlled trial using postal questionnaires. PARTICIPANTS: 1121 healthy people aged between 18 and 70 years with tinnitus that was comparatively stable; 978 participants were matched (489 pairs). Intervention: 12 weeks' treatment with either 50 mg Ginkgo biloba extract LI 1370 three times daily or placebo. MAIN OUTCOME MEASURES: Participants' assessment of tinnitus before, during, and after treatment. Questionnaires included items assessing perception of how loud and how troublesome tinnitus was. Changes in loudness were rated on a six point scale. Changes in how troublesome were rated on a five point scale. RESULTS: There were no significant differences in primary or secondary outcome measures between the groups. 34 of 360 participants receiving active treatment reported that their tinnitus was less troublesome after 12 weeks of treatment compared with 35 of 360 participants who took placebo. CONCLUSIONS: 50 mg Ginkgo biloba extract LI 1370 given 3 times daily for 12 weeks is no more effective than placebo in treating tinnitus.

Valproate_induced tinnitus misinterpreted as psychotic symptoms. Reeves RR, Mustain DW, Pendarvis JE. Department of Psychiatry, Montgomery VA Medical Center, USA. South Med J 2000 Oct;93(10):1030_1

Valproate sodium is an anticonvulsant medication, which has also been shown to be effective in the treatment of bipolar disorder. We report a case of valproate_induced tinnitus that was initially misinterpreted as increasing psychotic symptoms, which began approximately 2 days after initiation of valproate therapy. Tinnitus worsened during the next 6 days of treatment until it was recognized that this symptom was related to valproate. After discontinuance of the medication, the tinnitus gradually resolved over a period of 10 days with no residual effects. Although it is a rare adverse effect, valproate_induced tinnitus should be included in the differential diagnosis for tinnitus in patients receiving this medication. Tinnitus may be difficult to recognize in patients with active psychosis or mania.

Effects of selective serotonin reuptake inhibitors on auditory processing: case study. Gopal KV, Daly DM, Daniloff RG, Pennartz L. Department of Speech and Hearing Sciences, University of North Texas, Denton 76203, USA. J Am Acad Audiol 2000 Sep;11(8):454_63

Auditory sensitivity and processing ability were evaluated in a patient who suffered from hyperacusis, difficulty understanding speech, withdrawn depression, lethargy, and hypersensitivity to touch, pressure, and light. Treatment with fluvoxamine and fluoxetine (selective serotonin reuptake inhibitors) reversibly alleviated complaints. Testing while medicated and unmedicated (after voluntary withdrawal from medication for several weeks) revealed no difference in pure_tone thresholds, speech thresholds, word recognition scores, tympanograms, or acoustic reflex thresholds. Medicated SCAN_A (a screening test for central auditory processing disorders) results were normal, and unmedicated results were abnormal. Unmedicated transient otoacoustic emissions and auditory brainstem response waves I, III, and V were significantly larger bilaterally. Uncomfortable loudness levels indicated greater tolerance during the medicated condition. Central processing and vigilance were evaluated with analog_synthesized three_formant consonant_vowel syllables. While medicated, responses to stimuli at each ear revealed well_defined, labeling crossovers of about 90 msec. Vowel identification matched normal subject responses; labeling of /gE/jE/ and /bE/wE/ continua was well defined but all crossover points differed from normals (p < .0001). During unmedicated testing, responses to /gE/jE/ began at medicated levels but approached chance levels for the entire continuum within 10 min; labeling of /bE/wE/ was consistent with medicated responses throughout with earlier than normal crossover points.

Medical approaches

Large variety of papers addressed medical issues related to tinnitus. Another modification for treating Ménière’s disease is presented. Several issues related to vestibular neuroma such as its prevalence, confirming other reports that tinnitus occurs less often with increasing tumor size (Heerma et al.), and recommendation of a conservative management of unilateral vestibular schwannomas which coming from the group of Dr. Ugo Fisch has a special meaning (Tschudi et al.). Potential causes of tinnitus, from perilymphatic fistula to lighting and car air bags explosion are presented. Various source of somatosounds are reported as well. These papers mainly confirm and expand previous findings.

Effects of exposing the opened endolymphatic sac to large doses of steroids to treat intractable Meniere's disease. Kitahara T, Takeda N, Mishiro Y, Saika T, Fukushima M, Okumura S, Kubo T. Department of Otolaryngology, Osaka Rosai Hospital, Sakai, Japan. Ann Otol Rhinol Laryngol 2001 Feb;110(2):109_12

To enhance the effect of treatment for intractable Meniere's disease, we exposed the opened endolymphatic sac to high concentrations of steroids. This technique__endolymphatic sac drainage and steroid instillation surgery__involves the application of a mass of prednisolone followed by absorbable gelatin sponges soaked in a high concentration of dexamethasone into a sac lumen opened and expanded with a bundle of absorbable gelatin film. These sponges are also placed around the sac and coated with biochemical adhesive so that the medicine is slowly delivered into the sac over a prolonged period of time by means of a natural sustained_release vehicle. The short_term results (6 to 14 months) in 12 patients with Meniere's disease, including those in stage IV, treated by the above techniques showed that definitive spells were completely controlled in all cases. Hearing was improved, and annoyance due to tinnitus was decreased in all cases except one.

Clinical picture of vestibular schwannoma. Kentala E, Pyykko I I. Department of Otolaryngology, Helsinki University Central Hospital, PO Box 220, 00029 HYKS, Helsinki, Finland. Auris Nasus Larynx 2001 Jan;28(1):15_22

Purpose: To characterize the clinical picture with vestibular schwannoma, we retrieved 122 patients with vestibular schwannoma from the vestibular unit of the Helsinki University Central Hospital. Procedures: The patients filled out a questionnaire concerning their symptoms, earlier diseases, accidents, and the use of tobacco and alcohol. This information was then completed with results of audiometric, neurotologic and imaging studies. The data were prospectively stored to the database of neurotologic expert system called ONE. Results: The average tumor size was 21 mm. Most of the patients had hearing loss (94%) and tinnitus (83%) but only half of them (49%) had vertigo attacks. The most common initial symptom was hearing loss combined with tinnitus (34%, n=44). Vertigo only was the initial symptom for 12 patients. The mean duration of a vertigo attack was from 5 min to 4 h and the intensity of the attack was regularly mild (37%) or moderate (32%). The vertigo of the vestibular schwannoma patients differed from vertigo in other diseases by the absence (63%) or low intensity (18%) of nausea. Spontaneous nystagmus was present in 56 patients (46%), and caloric asymmetry (>25%) was observed in 66% (n=69). Caloric asymmetry increased with tumor size. The prevalence of headache was 18% (n=21). Sudden slips seldom (7%) occurred. Conclusion: Hearing loss and tinnitus are the main symptoms of vestibular schwannoma. Only half of patients have vertigo. Screening to detect vestibular schwannoma is more yielding in sudden deafness patients rather than in patients with Meniere's disease.

Conservative management of unilateral acoustic neuromas. Tschudi DC, Linder TE, Fisch U. Department of Otolaryngology, University Hospital of Zurich, Switzerland. Am J Otol 2000 Sep;21(5):722_8

OBJECTIVE: The aim of this study was to analyze the natural course of unilateral acoustic neuromas and to evaluate the advantages and disadvantages of an initial conservative approach. METHODS: Between 1989 and 1994, 74 consecutive patients with the diagnosis of unilateral acoustic neuroma were evaluated at the Department of Otorhinolaryngology, University of Zurich. Their charts and magnetic resonance imaging scans were retrospectively analyzed regarding duration and type of symptoms, initial tumor size, tumor growth pattern, and audiometric data. RESULTS: Of the 74 tumors, 68.9% (51/74) did not grow during a mean follow_up of 35 months. Eight (16%) of these tumors had radiologically documented tumor regression. Twenty_three tumors did grow, 16 of them (70%) with a growth rate of <2 mm/year. There was a statistically significant correlation between the first_year and the total growth rate, indicating that the tumor's behavior in the first year is highly predictive of its subsequent growth pattern. Patients with progressive hearing loss as a first symptom had a significantly lower tumor growth than those presenting with tinnitus, sudden hearing loss, or dizziness. Patients with tumor growth showed a greater tendency for hearing loss, although this trend was significant only for isolated frequencies. In 12% of the cases (9/74), the initial conservative approach had to be abandoned in favor of surgery. CONCLUSION: Watchful expectation can be regarded as a safe approach for selected cases of acoustic neuromas. Surgery or irradiation is indicated in patients with proven growth of their tumors.

[Effect of microneurosurgical operation in acoustic neurinoma on symptoms of vertigo and tinnitus]. [Article in German] Heerma H, Braun V, Richter HP. Neurochirurgische Klinik, Universitat Ulm. HNO 2000 May;48(5):372_7

After exstirpation of an acoustic neuroma one trends to concentrated on the preservation of hearing and facial function. But how does the surgical removal for an acoustic neuroma, influence the symptoms of tinnitus and vertigo? Our report follows a retrospective evaluation of 78 patients. Based on these results we will also discuss aspects of the origin of these symptoms. Our patients suffered from tinnitus at a rate of 73% preoperatively and 59% postoperatively. With increasing tumor size tinnitus occurred less often, therefore we considered the size of the tumor exclusively. Also, an intraoperative dissection of the cochlear nerve often did not result in an improvement of the symptoms. Vertigo was stated prooperatively in 44% of the cases, postoperatively in 22%. Again as with tinnitus, there was an inverse relationship between the size of the tumor and the severity of the symptoms. In conclusion a deafferention_like syndrome has to be considered as the major causative factor for the tinnitus in patients with acoustic neuromas. However, in the vertigo cases, the symptoms seem to be caused vestibularily due to the increasing tumor and then after a temporary compensation a cerebellar ataxia occurred which the patients often perceive as vertigo.

Perilymph fistula _ 45 case analysis. Goto F, Ogawa K, Kunihiro T, Kurashima K, Kobayashi H, Kanzaki J. Department of Otolaryngology, School of Medicine, Keio University, Tokyo, Japan. Auris Nasus Larynx 2001 Jan;28(1):29_33

Purpose of the study: Though perilymph fistula (PLF) is not a rare disease, preoperative diagnosis still remains to be established. Some new diagnostic methods are challenging, but there is still no established diagnostic method except exploratory tympanotomy that verifies the occurrence of leakage. Early diagnosis of PLF is fully depending on history taking and some clinical examinations. To know the clinical features of PLF is one of the greatest helps to make both earlier and accurate diagnosis. In spite of some innovations in clinical examinations classic diagnostic procedure is thought to be still reliable. Procedures: We investigated the clinical symptoms, basic tests results and therapeutic results in patients with PLF. Results: From 1983 to 1998 PLF was identified in 44 patients (45 ears) with exploratory tympanotomies in our hospital. With respect to clinical history the predisposing factors such as blowing the nose, lifting heavy goods, and landing in an airplane were found in almost half of the patients, while the rest of them had no clear inducing factors. Their major symptoms included hearing loss (93%), vertigo and dizziness (91%), tinnitus (76%), and aural fullness (31%). The patients who have a clear predisposing factor tended to make diagnosis easily; on the other hand the rest of the patients who do not have clear etiology had some diagnostic difficulty. Subjective positive fistula signs were observed in 71% of patients. Vestibular symptoms improved in 80% of patients after closure of PLF. Conclusions: These results suggest that the variety of clinical manifestation make diagnosis more difficult. At the moment meticulous clinical history taking and close follow_up applying repeating fistula tests are the most important for not only earlier but also accurate diagnosis.

[Ear dysfunction due to air bag detonation]? [Article in German] Brehmer D, Geidel O, Hesse G, Laubert A. Universitats_HNO_Klinik Witten/Herdecke, St. Marien_Hospital, Katholisches Krankenhaus Hagen gGmbH. HNO 2000 Oct;48(10):768_72

Air bags are among the latest developments in extensive automobile safety systems. They successfully have saved the lives of car occupants in road accidents. Many additional injuries caused by air bags from minor to severe have been reported. With the help of two acceleration sensors, the electronic tuner amplifier records the vehicle's deceleration. This is the adequate trigger for air bag deployment, which creates an intense noise of up to 170 dB sound pressure level. This noise level can cause cochlear damage. We present two patients with otologic symptoms after spontaneous air bag deployment.

[Bilateral acoustic trauma after air bag inflation]. [Article in German] Fahimi_Weber S, Kessler A, Bakkal E, Siegert R. Klinik fur Hals_Nasen_Ohren_Heilkunde, Kopf_ und Hals_Chirurgie, Prosper Hospital Recklinghausen. s.fahmi_weber@ruhr_uni_bochum.de HNO 2000 Oct;48(10):765_7

Airbag inflation is associated with a loud noise. This very short noise has a peak amplitude of 170 dB sound pressure level and can make otologic injuries. We report a case of acoustic trauma after airbag inflation. The 24_year_old man has hearing loss both side in the 3000_ to 6000_Hz range and in the deep_frequency. The possibility of acoustic trauma from airbag noise are probably much more common and need more attention in the clinic.

Role of angiography in the evaluation of patients with pulsatile tinnitus. Shin EJ, Lalwani AK, Dowd CF. Department of Otolaryngology__Head and Neck Surgery, University of California, San Francisco, USA. Laryngoscope 2000 Nov;110(11):1916_20

OBJECTIVES/HYPOTHESIS: Pulsatile tinnitus in the face of normal findings on otoscopy is a common otological diagnostic dilemma and can be due to serious vascular malformations such as transverse or sigmoid sinus dural arteriovenous fistula (transverse or sigmoid sinus [TS] DAVF). Left untreated, TS DAVF may result in significant morbidity and mortality. TS DAVF can be suspected or diagnosed with computed tomography (CT), magnetic resonance imaging (MRI), and magnetic resonance angiography (MRA), with the gold standard being angiography. Our objective was to assess the utility of these various diagnostic modalities in the diagnosis of dural arteriovenous fistula. STUDY DESIGN: Retrospective clinical review. METHODS: Between 1986 and 1996, 54 patients were evaluated and treated for TS DAVF. Between 1996 and 1999, an additional 33 patients underwent MRI combined with MRA for the evaluation of pulsatile tinnitus. A retrospective review of the medical records for both groups, with special attention to clinical presentation, diagnostic evaluation, therapy, and outcome, was performed. RESULTS: All patients had pulsatile tinnitus with normal findings on otoscopy. CT scan was relatively insensitive in the detection of TS DAVF. MRI and MR/MRA were significantly more sensitive than CT. In the evaluation of patients with subjective pulsatile tinnitus, MRI/MRA defined anatomical abnormalities that may contribute to pulsatile tinnitus in 63% of patients. CONCLUSIONS: In the absence of objective pulsatile tinnitus, MRI/MRA is an appropriate initial diagnostic step. When a patient has an objective bruit, the clinician may choose to proceed directly to angiography to make certain that a TS DAVF is not missed.

Pulsatile tinnitus in patients with morbid obesity: the effectiveness of weight reduction surgery. Michaelides EM, Sismanis A, Sugerman HJ, Felton WL 3^rd. Department of Otolaryngology/Head Neck Surgery, Medical College of Virginia of Virginia Commonwealth University, Richmond 23298, USA. Am J Otol 2000 Sep;21(5):682_5

BACKGROUND: Morbid obesity is increasing in the United States population. Morbidly obese patients may have disabling pulsatile tinnitus (PT) secondary to pseudotumor cerebri syndrome and often seek treatment from otolaryngologists because of this symptom. OBJECTIVE: To determine the effectiveness of weight reduction surgery (WRS) for relief of PT in patients with morbid obesity. STUDY DESIGN: Retrospective study of morbidly obese patients with associated PT. SETTING: Academic tertiary referral center. PATIENTS: Sixteen women with morbid obesity and associated PT who underwent WRS. RESULTS: Median age was 34 years (range 24_45 years). Average preoperative body mass index was 45 kg/m2 (range 33_70 kg/m2). Average weight loss was 45+/_17 kg (range 25_99 kg). Average postoperative weight was 75+/_14 kg (range 57_105 kg). The average preoperative cerebrospinal fluid pressure was 344+/_103 mm H2O (range 220_520 mm H2O). Postoperative measurements of cerebrospinal fluid, obtained on 4 patients, revealed an average decrease in pressure of 198 mm H2O (range 120_400 mm H2O). Thirteen patients experienced complete resolution of their PT (81%). Three patients continued to have PT despite significant weight reduction. CONCLUSIONS: Weight reduction surgery was effective in relieving PT in morbidly obese patients with associated pseudotumor cerebri syndrome and should be considered when conservative management has failed.

Middle_ear myoclonus. Zipfel TE, Kaza SR, Greene JS. Department of Otolaryngology_Head and Neck Surgery, Penn State Geisinger Medical Center, USA. J Laryngol Otol 2000 Mar;114(3):207_9

Tinnitus produced by repetitive contraction of the middle_ear muscles is a rare condition. We present an interesting case of bilateral middle_ear myoclonus causing incapacitating tinnitus in a patient with multiple sclerosis. Otological examination demonstrated rhythmic involuntary movement of the tympanic membrane. These movements correlated with a rhythmic 'rushing wind' noise perceived by the patient. Oropharyngeal examination showed no evidence of palatal myoclonus. Impedance audiometry confirmed rhythmic change in the middle_ear volume. Medical management was unsuccessful. The patient's tinnitus was subsequently cured with bilateral sectioning of the tensor tympani and stapedial tendons.

Intratympanic and systemic dexamethasone for Meniere's disease. Hirvonen TP, Peltomaa M, Ylikoski J. Department of Otorhinolaryngology, Helsinki University Central Hospital, Helsinki, Finland. timo.hirvonen@huch.fi ORL J Otorhinolaryngol Relat Spec 2000 May_Jun;62(3):117_20

Intratympanic and systemic dexamethasone treatment of Meniere's disease (MD) was evaluated in a prospective study. Seventeen patients (6 men and 11 women) with MD (5 right_sided, 11 left_sided and 1 bilateral) were treated with three 0.2_ to 0.4_ml injections of intratympanic dexamethasone hyaluronate (16 mg/ml) during a week and with an initial intramuscular dexamethasone injection of 15 mg. Most of patients were in stage 3, and the mean duration of MD was 5. 3 years. Pure_tone and speech audiometry and the symptom scale of the patients were followed up for 1 year after the treatment. Symptoms of aural fullness, hearing loss, tinnitus and vertigo did not improve significantly. However, sufficient control of vertigo was achieved in 76% of the patients. In conclusion, no definite treatment effect has yet been shown for intratympanic and systemic dexamethasone treatment. Therefore, the clinical use of dexamethasone in MD needs further investigation. Copyright 2000 S. Karger AG, Basel

Ear injuries caused by lightning: report of 18 cases. Gluncic I, Roje Z, Gluncic V, Poljak K. Department of Otorhinolaryngology, University Hospital Split, Croatia. J Laryngol Otol 2001 Jan;115(1):4_8

The clinical management and long_term outcome in lightning survivors with substantial ear damage treated at the Department of Otorhinolaryngology, University Hospital Split during the 1984_1999 period are reviewed. Results of clinical management and outcomes of lightning ear damage in 18 patients (mean age 35.3 +/_ 5 years) were retrospectively analyzed. On admission, all patients complained of severe pain, tinnitus and hearing impairment. Otomicroscopy revealed tympanic membrane rupture in 12 patients. The active therapeutic approach included immediate otomicroscopy, aseptic aspiration toilet, and eversion of perforation edges. In all patients, the ruptures healed well, and restitution of the hearing function was achieved. Follow_up examination performed in 1999 (13.2 +/_ 2.9 years later) in 11 patients (mean age 52.3 +/_ 6.1 years) revealed an almost identical audiogram as on discharge from the hospital, however, neuropsychological testing revealed numerous sequelae. Tympanic injury caused by lightning should be actively treated. Lightning survivors require additional psychotherapeutic treatment.

Psychology

Erlandson & Hallberg published interesting study correlating quolity of life with number of variables. While several of them were predictable on the base of common sense (feeling depressed, negative attitudes, etc.) unrespectably, fluctuation in tinnitus, vertigo and headache did not contributed significantly to decrease of life quality. Note, that even listed 6 variables explain only 65% of the variance. While this is statistically significant the possibility that other important factors were omitted need to be considered.

Possibility that tinnitus patients have impaired cognitive performance was explored by Andersson et al. The results indicate that this indeed might be a case, however, due to methodology of the study, there is a possibility that hearing loss, and not tinnitus, is responsible for the results.

Another study by Andersson et al. assess long term follow-up of tinnitus complaints in patients seen by a psychologist. The interesting findings was that tinnitus maskability could be used as a prognostic factor of future annoyance. As maskability is not a factor in case of TRT treatment, this difference might be helpful in better understanding differences of mechanisms involved in psychological treatments versus TRT.

Prediction of quality of life in patients with tinnitus. Erlandsson SI, Hallberg LR. Department of Psychology, University of Goteborg, Sweden. Soly.Erlandsson@htu.se Br J Audiol 2000 Feb;34(1):11_20

According to epidemiological studies of tinnitus prevalence, 0.5_1% of respondents report that tinnitus severely affects their ability to lead a normal life. In the present investigation quality of life and its association with tinnitus_related factors: psychological, psychosomatic and audiological, was studied based on a sample of 122 patients, who attended the hearing clinic for distress due to tinnitus. A stepwise regression analysis was performed with quality of life as a dependent variable. Six of 13 variables included in the model proved to be significant regressors and to explain 65% of the variance. The six predictor variables were: impaired concentration, feeling depressed, perceived negative attitudes, hypersensitivity to sounds, average hearing level (best ear) and tinnitus duration (the shorter the duration of tinnitus the more negative impact on quality of life). The three most significant predictors were directly related to perceived psychological distress and explained most of the variance in quality of life in tinnitus patients included in this study. An unexpected finding was that fluctuations in tinnitus, vertigo, headache or perceived social support did not prove to belong to the significant regressors. The results are discussed in view of the construct of quality of life, depressive cognitions and social support in general, as well as in tinnitus_specific life circumstances.

Tinnitus and cognitive interference: a stroop paradigm study. Andersson G, Eriksson J, Lundh LG, Lyttkens L. Department of Psychology, Uppsala University, Sweden. gerhard.andersson@psyk.uu.se J Speech Lang Hear Res 2000 Oct;43(5):1168_73

The aim of this study was to investigate cognitive interference caused by tinnitus by means of a modified version of the Stroop color_word test. In a mixed_design study, the performances of tinnitus patients (n = 23) and healthy controls with normal hearing (n = 23) were compared on three versions of the Stroop test: the original version, a modified version including physical_threat words, and a tinnitus version for which tinnitus words (descriptors of tinnitus; e.g., peep) were derived empirically. Matched control conditions (words) were included for all three versions, yielding a total of six screens that were presented on a computer. Participants in the control group were matched with the patients for age and gender. Main dependent measures were performance on the Stroop tests in terms of total time for completing each test. Also included were the Tinnitus Questionnaire (TQ), the Beck Depression Inventory (BDI), the state version of the Spielberger Trait State Anxiety Inventory (STAI_S), and a subtest from the Wechsler Adult Intelligence Scale measuring verbal ability. Results showed that tinnitus patients performed significantly slower on all six test conditions. The classical Stroop color_word interference was replicated in both groups. Also, an effect for physical_threat words was found for both groups. Our expected tinnitus word interference could not be established. Patients scored significantly higher than controls on the BDI and the STAI, but these measures did not correlate with the Stroop results. In conclusion, the results indicate that tinnitus patients have impaired cognitive performance overall, as measured by these variations of the Stroop paradigm, but hearing impairment cannot be excluded as a possible confounder.

Longitudinal Follow_up of Tinnitus Complaints. Andersson G, Vretblad P, Larsen HC, Lyttkens L

Department of Psychology, Uppsala University, Box 1225, SE_751 42 Uppsala, Sweden. Gerhard.Andersson@ psyk.uu.se Arch Otolaryngol Head Neck Surg 2001 Feb;127(2):175_179

OBJECTIVE: To investigate the long_term outcome of patients with tinnitus, the long_term effects of cognitive behavioral therapy, and what properties of tinnitus predict distress at follow_up. DESIGN: A longitudinal follow_up of a consecutive sample of patients with tinnitus initially seen by a clinical psychologist. SETTING: Department of Audiology, University Hospital, Uppsala, Sweden. PARTICIPANTS: A consecutive series of 189 patients with tinnitus treated between January 1988 and March 1995 were sent a postal questionnaire booklet. One hundred forty_six (77 women and 69 men) provided usable responses, in all yielding a 77% response rate. MAIN OUTCOME MEASURES: A questionnaire was derived from a structured interview "Questions About Your Tinnitus." Also included were the Tinnitus Reaction Questionnaire and tinnitus_matching data. RESULTS: Questionnaire data showed that many patients with tinnitus still experienced distress an average of 4.9 years after admission. Tolerance of tinnitus increased over time overall. For patients who had received cognitive behavioral therapy (59%), there was a reduction in tinnitus_related distress. Further, an open_ended question showed that the benefits from treatment outnumbered the deficits. Multiple regression analysis showed that tinnitus maskability at admission was a significant predictor of distress at follow_up. CONCLUSIONS: Severe tinnitus shows some signs of improvement over time, especially when psychological treatment has been given. Tinnitus maskability is an important prognostic factor of future tinnitus annoyance.