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Tinnitus and Meniere's update

Randomised trials in tinnitus
Psychological treatments for tinnitus
Medical treatments of Meniere's disease
Comment

Bandolier is frequently asked about treatments for tinnitus and Meniere's disease, and occasionally trawls the literature to see if there is anything new. Depressingly there isn't. Three reviews published in recent years at least give an insight into the extent of research.

Randomised trials in tinnitus


One review [1] had a good search strategy using MEDLINE and found 69 randomised studies of drug and non drug treatments, 51 of which included a placebo arm. Positive studies were closely scrutinised for trial quality and validity. Common problems were inadequate controls, failure to measure the impact of tinnitus and treatment on patients, and small size. Positive studies were often small and their results were not always replicated by later, larger, studies.

There is no easy way of describing the results. Table 1 shows the treatments, the number of trials, and comments on the results. Those treatments demonstrating some benefit included alprazolam, tricyclics, and electrical stimulation over the mastoid. The caution is that we do not have solid evidence of effect, nor can we be sure of the size of the effect. But the rest we can probably dismiss.

Table 1: Evidence of efficacy from randomised trials for tinnitus

Treatment Number of trials Comments
Tocainide and related drugs 9 No evidence for any effect, and significant adverse effects
Lidocaine iontophoresis   No benefit
Carbamazepine 4 No benefit
Benzodiazepines 4 Alprazolam was effective in one trial said to be of good quality. Some benzodiazepines made tinnitus worse in some patients.
Tricyclics 4 Some evidence of minor benefit with nortriptyline and amitriptyline
Ginkgo 2 No benefit
Miscellaneous drugs 14 No evidence for any effect from a wide variety of other drugs
Psychotherapy 11 Mixed evidence of efficacy, with short-lived, small effects, probably clinically insignificant
Electrical/magnetic 6 Some evidence of electrical stimulation over the mastoid
Acupuncture 6 No benefit in any study
Masking 6 No evidence for any significant effect
Biofeedback 5 Mixed evidence of efficacy
Hypnosis 3 No evidence for any significant effect
Ultrasound 2 No evidence for any significant effect
Miscellaneous non drug 4 No evidence for any significant effect

Psychological treatments for tinnitus


It is always interesting to pick up two reviews which come to different conclusions. The first review [1] concluded that psychological interventions were ineffective. A review concentrating on psychological treatments [2] for tinnitus concluded that they were effective.

The difficulty is to know where the truth lies. The review of psychological interventions had a good search strategy, including specialist journals, and eventually used 18 for analysis, covering cognitive behavioural therapy, relaxation, hypnosis, biofeedback, educational sessions and problem solving. But it included non-randomised studies, and used effect size to describe the results, which makes it impossible to know what they were. Bandolier is suspicious.

The biggest problem is the size of the studies. Sixteen of 24 comparisons in the analysis were based on fewer than 30 patients. Three were based on more than 50 patients. This paper was full of statistics, and though there were some interesting comments on different outcomes, it is impossible to use the information other than a list of studies.

Medical treatments of Meniere's disease


A review of MEDLINE between 1978 and 1995 was conducted to find papers relating to Meniere's disease [3]. Trials of all architecture were included and discussed, including animal experiments. The main clinical outcomes of treatments where the words double-blind are mentioned are shown in Table 2.

Table 2: Evidence of efficacy from double-blind trials for Meniere's disease

Treatment Number of trials Comments
Betahistine 5 Betahistine effective in controlling vertigo, dizziness or imbalance. Does not improve hearing levels
Diuretics 1 Effective in controlling vertigo, but no effect on hearing
Vaso-active drugs 1? Less effective than betahistine
Aminoglycosides 0  
Salt restriction 0  
Steroids 0  
Other treatments 0  

The only clear evidence is for betahistine, as reviewed in Bandolier 13 . Our own searches found no new randomised trials in Meniere's disease since 1995.

Comment


Tinnitus is common, with between 1% and 2% having a tinnitus that plagues them all day and affects quality of life to a severe degree. Aside from betahistine in Meniere's disease there seems little good evidence for effective treatments. Trials are often small, and with poor design, and there are many questions about appropriateness of outcomes. It is about time someone got this by the scruff of the neck, laid out appropriate conditions for valid trials, and found a medical research organisation to fund trials to give us spoke sensible evidence to be getting on with.

Reference:

  1. RA Dobie. A review of randomized clinical trials in tinnitus. Laryngoscope 1999 109: 1202-1211.
  2. G Andersson, L Lyttkens. A meta-analytic review of psychological treatments for tinnitus. British Journal of Audiology 1999 33: 201-210.
  3. J Claes, PH van de Heyning. Medical treatment of Meniere's disease: a review of the literature. Acta Otolaryngologica 1997 Suppl 526:37-42.
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