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Tinnitus Management: Interview with Amr El Refaie, MD, PhD

Tinnitus Management: Interview with Amr El Refaie, MD, PhD

February 22, 2011 Interviews

Douglas L. Beck, AuD, speaks with Dr. El Refaie about tinnitus, tinnitus management, transcranial magnetic stimulation, outcomes- and evidence-based research, and more.

Academy:

Good Morning, Amr. Very nice to speak with you again.

El Refaie:

Hi, Doug. Good to be with you, too.

Academy: Amr, I really enjoyed your presentation at the British Academy of Audiology with regard to transcranial magnetic stimulation (TMS) to help control or eliminate tinnitus. If you don't mind, can you briefly review that information here?
El Refaie:

Absolutely. It would be my pleasure. First, let's start with the definition of tinnitus.

Academy:

"The perception of sound or noise in the absence of acoustic stimulation."

El Refaie:

Exactly. And as you know, tinnitus is a huge problem worldwide, ranging from slight or mild, to severe, and in some cases, tinnitus significantly decreases quality of life, such that the individual suffering from tinnitus cannot work or enjoy their social life, and in some cases, they cannot sleep. So, in brief, a very significant problem and it may be as common, or more common than hearing loss.

Academy:

Yes, some sources quote up to 40 or 50 million people with tinnitus in the United States and the most recent data on hearing loss indicates up to 34.25 million people with hearing loss in the United States.

El Refaie:

And of course treatments have ranged from Volta sticking electrodes in the ears hundreds of years ago (not a good idea!), to medicine, vitamins, and alternative pharmacological and holistical initiatives, to counseling and tinnitus rehabilitation therapy, to introducing alternative sounds via maskers, noise generators and of course, hearing aids, which some consider as the front line in management of tinnitus accompanied with hearing loss, and then there have been many surgical protocols to tinnitus.

Academy:

Right. And I should be clear that there are no "universal tinnitus solutions." That is, some of these therapies have worked in some patients, but clearly none have worked in all patients, and some therapies are just silly and some can be very dangerous.

El Refaie:

Exactly. Tinnitus is a very individual symptom. How it is generated and how it affects sufferers are so different; an individual protocol for everyone is probably not possible. For potential patients suffering from tinnitus who might read this interview, I want to be clear, prior to engaging in a tinnitus therapy program or protocol, an audiologist or physician must be consulted and only after the diagnosis has been made, can appropriate and safe therapy be selected.

Academy: Of course, diagnosis first, treatment second!
El Refaie:

Yes, and as you know, Doug, many times tinnitus can be a sign or symptom of a medical problem that can be managed effectively. So it is very important to see the right professionals first, get a diagnosis and then work with the professional to determine the best treatment for the individual.

Academy:

I totally agree. And so, I know you and your colleagues recently reviewed the world's literature on the use of sound therapy in tinnitus management as it related to mitigating, reducing, or eliminating tinnitus. What did you learn?

El Refaie:

Well, I should start by telling you the Cochrane Database of Systematic Reviews 2010 just published our findings, and the link will be posted at the end of this interview.

Academy:

Excellent and congratulations!

El Refaie:

Thank you. In essence, we reviewed more than 350 articles to find outcomes-based and evidence-based articles for review and analysis. Of those, we used 33 articles in our analysis. The bottom line was that only limited data has been published and the standards were variable with regard to sound-based and counseling therapies, and so conclusions cannot be easily drawn. Nonetheless, it appears combined therapies are often indicated and they appear to offer potentially improved results. Another newish therapy for tinnitus management is repetitive transcranial magnetic stimulation (rTMS) and it is the subject of several double blinded control studies worldwide and a Cochrane review of evidence under preparation at the moment.

Academy:

And I should add the idea of magnetically or electrically stimulating the brain is not new. Of course, there was Volta hundreds of years ago, as you mentioned, electro-convulsive therapies for psychiatric patients has been going on for more than 100 years, cochlear implants have been around for more than 50 years, and of course there are brain stem implants, retinal implants and deep brain stimulation for Parkinson's—which has been remarkably successful for thousands of patients. So the idea of using magnetic energy is not very different from using electrical stimulation in that the thought is to enhance or suppress neuronal activity in the brain.

El Refaie:

Right. In that respect, the researchers anticipate magnetic stimulation would do exactly that, but so far, we're not sure. I should note we're not actually doing this work in the United Kingdom; the exploratory work has been done in Germany and other locations in the EU. As you suggest, the idea is the alternation of cortical hyperactivity to reduce or eliminate tinnitus. Researchers have delivered magnetic pulses through an external "wand" also called "coil" over a specific area on the scalp to create a secondary current. The current only penetrates an inch or so and only reaches the cortical layer of brain tissue usually in the area of the temporal and frontal lobes. As you can imagine, some researchers have used low frequency magnetic pulses, others have used high frequencies, some use one anatomic area, some use multiple areas, some use one treatment session, others use multiple sessions and so again, it is difficult to gather all the data and make sense of the results. Although some published results appear quite promising.

Academy:

And, in addition to standardization of the treatment protocol, other issues will need careful attention, too, such as deciding which tinnitus evaluation tool to use to characterize tinnitus pre-treatment, and then how and when to re-evaluate post-treatment, which I presume will be as difficult as standardizing the TMS protocol!

El Refaie:

Yes, this will be a major issue because everyone has tried to get as accurate as possible in characterizing and quantifying the tinnitus. There are many outcome measures being used in tinnitus evaluation, some better than others, but there are no universally accepted tool to be used by everyone, making comparing results of different protocols originating from different studies very hard, if impossible—the bottom line is, tinnitus is a subjective perception and difficult to capture objectively.

Academy:

Of course, the same issues arise in dizziness, pain, and headaches, too.

El Refaie:

Yes, these are difficult areas of study, but over time as we learn more and apply more knowledge, we get closer to solutions.

Academy:

Yes, I agree. Amr, thanks so much for your time and insight. It's been a pleasure speaking with you and I wish you good luck in your research.

El Refaie:

Thanks, Doug!

Amr El Refaie, MD, PhD, is a lecturer in audiology and a program director at the Center for Hearing and Balance Studies, University of Bristol, England.

Douglas L. Beck, AuD, Board Certified in Audiology, is the Web content editor for the American Academy of Audiology.

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