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Idiopathic Subjective Tinnitus Treated by Amitriptyline Hydrochloride/Biofeedback L

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Idiopathic Subjective Tinnitus Treated by Amitriptyline Hydrochloride/Biofeedback L 54 International Tinnitus Journal Vol. I, No. 1,1995 IDIOPATHIC SUBJECTIVE TINNITUS TREATED BY AMITRIPTYLINE HYDROCHLORIDE/BIOFEEDBACK L. Podoshin, M.D., Y. Ben-David, M.D., M. Fradis, M.D., S. Malatskey, M.D., and H. Hafner, M.D. ABSTRACT consequences, if any at all.S In this study we examined the effect of two treatment modalities: amitriptyline hydro-chloride and biofeedback. The efficiency of two treatment modal­ ities for subjective/idiopathic tinnitus (SIT): AMITRIPTYLINE HYDROCHLORIDE biofeedback (BF) and amitriptyline hydro­ (AT) chloride (AT) was investigated in 225 randomly selected subjects. Findings show that after 10 AT is a tricyclic antidepressant drug.9 weeks of treatment in the BF group, 43.5% of The precise mechanism of its antidepressant the patients reported an improvement of activity is unclear, but the drug has been shown tinnitus during activity. In the AT group, 27.5% to block the uptake of various neurotransmitters of patients reported subjective improvement of at the neural membrane. The effect is both anti­ tinnitus at rest although only 15.8% of the AT cholinergic and antihistaminic. The anti­ patients reported improvement during activity. cholinergic action leads to decreased pro­ Biofeedback during rest had a significantly duction of endolymph and a release of inhi­ better effect on tinnitus disturbance than AT. No bition in the afferent fibers at the organ of Corti objective diminishment of tinnitus loudness and the olivocochlear bundle. The antihis­ was found as a result of any of the treatment taminic effect products a vasoconstriction of the modalities. We believe that BF can help tinnitus cochlear artery, which decreases the cochlear patients especially during periods of rest and potential. Therefore, its effect on tinnitus could we also suggest trying tricyclic antidepressant be either peripheral or central.IO drugs such as AT for treatment of tinnitus patients, in small doses, however, to minimize the side effects of this drug. BIOFEEDBACK (BF) Subjective tinnitus (ST) is one of the most common and yet most unclear of otologic It is widely accepted that tinnitus is a symptoms.1-4 ST can accompany any type of disturbance that is connected to a tension hearing loss including both sensorineural as reaction.ll With the use of BF, the patient learns well as conductive hearing loss, and may to gain control of certain physiologic functions originate from any part of the auditory path­ of his body with the help of a device that way.I,S displays the results of this physiologic function Treatment of ST must be primarily electronically.12 Biofeedback has been used directed to the basic illness diagnosed after a successfully to gain control of migraine, pain, thorough general ear-nose-throat and neuro­ hypertension, and other tension-related dis­ logic evaluation.6 Severity of ST is evaluated eases.13 Control of tinnitus through biofeedback both objectively, by determining the pitch and was first reported by House and colleagues.14 intensity of the tinnitus? and subjectively as In a study of treatment of severe tinnitus by BF, described by the patient. Because of the 50% of patients reported an improvement in relatively high incidence of ST and in some their condition, and in a different study by the patients, the severe personal reaction to it, many same author,lS improvement was reported in different treatments have been suggested, but 77% of patients. generally only small to moderate success has The effectiveness of the different forms been achieved in reducing tinnitus and its of treatment is controversial and no ideal Idiopathic Subjective Tinnitus Treated by Amytriptyline 55 system has yet been found.I6 The purpose of Tinnitus was also evaluated objectively, the study was to compare the effectiveness of two by comparing its pitch and intensity to tonal methods of treatment for SIT: BF and AT, with stimuli of audiometers through a matching matched control groups. Another aim was to technique.6 determine the effectiveness of these treatments Subjects were randomly divided into during activity and rest. The third aim was to four treatment groups: Group A-treated with make a comparison between the subjective results BF, which included 62 subjects, 34 men and 28 of the treatment with the objective results. women. Age range was 23 to 64 years with a mean of 42.5 years. Group B-treated with AT, MATERIALS AND METHODS included 76 subjects, 39 men and 37 women, whose ages ranged from 26 to 70 with a mean of 44 years. Group C was a control to the BF Two hundred and twenty-five subjects group, treated by placebo BF and included 40 suffering from SIT were investigated. Of these, 7 subjects: 22 men and 18 women, whose ages subjects discontinued treatment, and 218 completed ranged from 30 to 72 years, with a mean of 46 it. All subjects underwent a general ear-nose-throat years. Group 0 was a control to the AT group, examination and neurologic investigation including treated by placebo tablets and included 40 a detailed anamnestic questionnaire, physical subjects: 20 men and 20 women, whose ages examination, tonal audiometry, test for speech ranged from 35 to 69 years with a mean of 52 discrimination, recruitment test, brainstem auditory years. evoked potentials, and in selected cases, a computed Each patient received a preliminary tomographic (CT) brain scan was performed. explanation as to the types of treatment and a Patients who suffered from pathologic entities such as Meniere's disease, acoustic neurinoma, or questionnaire on which to mark the degree of tinnitus every week for periods of both activity cochlear otosclerosis, were excluded from the study. and rest. Table 1. The matching technique was performed Severity Rating for Tinnitus Disturbance before the first treatment and immediately after the last. The subjects treated with BF underwent During Activity 10 weekly sessions of 30 minutes each. The BF Grade 0 No tinnitus subjects were treated by electromyogram Grade 1 Mild tinnitus without disturbance (EMG) BF using the frontal muscle as described Grade 2 Moderate, disturbs but does by House.IS not affect activity The base-level muscular tension of every Grade 3 Severe, which affects activity patient was evaluated before treatment. Each Grade 4 Very severe, making activity subject was constantly reminded of the degree impossible of tension through visual and auditory stimu­ During Rest lation of the BF device. Grade 0 No tinnitus The AT group received 10 mg tablets of Grade 1 Mild tinnitus without disturbance AT three times daily for a 10-week period. Grade 2 Moderate, which disturbs but The BF control group was connected to does not affect sleep the BF device, but the sounds and the visual Grade 3 Severe, which affects sleep scale were not connected to their muscle tension Grade 4 Very severe tinnitus, which causes but to a tape recorder instead. All other details severe insomnia and spontaneous were the same as in the actual BF group. The arousals AT control group received one placebo tablet three times daily for 10 weeks. Each patient completed a questionnaire Statistical evaluation was calculated in which the patient was required to give a using the Chi-square test to compare the activity detailed description of the tinnitus. The tinnitus and rest periods within the same group, and was rated on a scale of 5 degrees of disturbance then compared with each other. The results of (0 to 4) during activity and rest, and is shown the test were considered as significant when the in Table II. p value was less than 0.05. 56 International Tinnitus Journal Vol. I, No.1, 1995 RESULTS of tinnitus disturbance after treatment is noticed in the BF group during the rest No significant difference was found in period. pitch or intensity of tinnitus comparing those Table II shows a statistical comparison before to those after treatment in either among the different groups regarding the group. The comparison of the four patient degree of improvement of tinnitus disturbance groups regarding improvement of the degree at rest versus activity period. of tinnitus at rest and activity during 1st, 5th Table III presents a statistical comparison and 10th weekly sessions is illustrated in between the BF and AT treatment groups Figure l. regarding improvement in degree of tinnitus. After 10 weeks of treatment in the BF Although a significant difference was group, 43.5% of the patients reported an found in the tinnitus improvement of the BF improvement in the degree of tinnitus at rest, and AT groups at rest, but no significant whereas only 24% reported improvement of difference was found regarding the same tinnitus during activity. In the AT group, comparison during activity (see Table III). 27.5% of patients reported improvement of When the BF and AT treatment groups tinnitus at rest, whereas only 15.8% reported were compared with their control (placebo) improvement during activity. In the control groups regarding improvement of degree of groups only a 2.5% to 5% improvement was tinnitus, only the comparison between placebo reported. and the AT group during activity was found to Figures 2 to 5 show the curves of be insignificant. The other groups when degree of tinnitus disturbance during rest compared with their placebo were found compared with those during activity in the statistically significant, as follows: (1) BF at rest, different groups before and after treatment. p < 0.0001, (2) BF at activity, p < 0.011, and (3) The most prominent decrease in the degree AT at rest, p < 0.011. Improved Cases (%) 45 40 35 30 25 20 15 10 5 o JL~~~~ __~~ __L-~~~~~~.--L __.--L-. __ ~ BF.R BF.A Am.R Am.A BF.R.C BF.A.C Am.R.C Am.A.C BF - Biofeedback R- Rest C-Control Am - Amitriptyline A - Activity W - Week Fig.
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