Elsevier

Auris Nasus Larynx

Volume 47, Issue 1, February 2020, Pages 1-6
Auris Nasus Larynx

Clinical practice guidelines for diagnosis and treatment of chronic tinnitus in Japan

https://doi.org/10.1016/j.anl.2019.09.007Get rights and content

Abstract

Clinical practice guidelines in Japan for tinnitus were published in May 2019. Effective treatment of tinnitus contributes to quality of life and may improve depression, anxiety, and cognitive function. The highest priority of treatment recommended by this guideline involves educational counseling, including an explanation of the mechanisms of tinnitus. Understanding tinnitus pathology has also been reported to be a therapeutically effective educational counseling strategy. Further, explaining how sound therapy such as tinnitus retraining therapy (TRT) works is effective. Psychological and cognitive behavioral therapies may be an option. Here, the hearing aid is coupled with a sound generator in order to administer sound therapy for patients with more-severe symptoms. In Japan, it can be difficult to perform psychotherapy alongside otorhinolaryngology, and exemplary sound therapy is more likely to be carried out. In any case, the purpose of treatment is not to eliminate tinnitus, but rather reduce distress that manifests in response to tinnitus by promoting sensory adaptation. Clinically, the most important subject is not the loudness of tinnitus, but the severity of tinnitus distress.

TRT consists of educational counseling and sound therapy. The tinnitus handicap inventory (THI) is used to measure the distress level for tinnitus and to determine treatment priorities. Rehabilitation of tinnitus is important because anxiety and depression are often observed in patients with severe tinnitus.

Additionally, drug administration should be avoided. As a surgical treatment, a cochlear implant can affect tinnitus symptoms. It is essential to establish a treatment policy according to the disease condition and degree of distress.

Introduction

Tinnitus is present in 10%–15% of the population. Clinically problematic tinnitus accounts for about 20%; that is, 2%–3% of the population. In Japan, approximately 3 million tinnitus patients experienced tinnitus onset accompanied by strong pain and were referred to otolaryngology. However, guidelines that systematically summarized the tinnitus practice in Japan have not been prepared. It is likely that medical treatments for patients with refractory tinnitus are unsatisfactory. As a result, quality of life (QOL) is decreased and patients may begin to “shop” for a different doctor; thus, this is an urgent issue.

With the following guidelines, we are seeking to (1) standardize methods for evidence-based diagnosis of tinnitus (diagnosis / treatment) and (2) to improve each patient's QOL. These guidelines are for patients who complain of chronic tinnitus. This tinnitus is non-pulsatile and lasts longer than 3 months.

Tinnitus practice was previously published by the United States, Germany, Denmark, the Netherlands, and Sweden, among other countries [1].

These guidelines also refer to previously reported guidelines, recent literature reports, and Japanese research reports.

The objectives of this study were as follows:

  • 1)

    Standardization of evidence-based tinnitus medical treatment (diagnosis and treatment)

  • 2)

    Improvement in the QOL of tinnitus patients

We also aimed to address two main clinical issues. Clinical issue 1: In Japan, “standardization of tinnitus evaluation” is necessary; however, “standard tinnitus test methods 1993” was published in 1993, more than 20 years previously. Pitch-match inspection and representation of the loudness balance test should be revised. Further, standardization of tinnitus distress and QOL evaluation in patients with tinnitus are urgent issues.

Clinical issue 2: We need to develop evidence-based treatment guidelines for chronic tinnitus. In recent years, cognitive behavioral and sound therapies have been found to be effective for reducing distress in tinnitus patients. Currently, different medical treatments are performed at the discretion of each doctor at each medical institution, and differences between the areas of facilities for treating tinnitus are also identified. Evidence-based standardization of tinnitus clinical practice guidelines is an important issue for improving the level of tinnitus medical examinations in Japan.

The guidelines were developed by subcommittee members, edited by the Japan Audiological Society, and authorized by the Oto-Rhino-Laryngological Society of Japan.

Section snippets

Methods

1. Users

The main enforcers of these guidelines are otolaryngologists who diagnose and treat patients.

2. Subjects

The subjects for whom these guidelines are created are patients with non-pulsatile tinnitus that has persisted for > 3 months after onset, excluding pulsatile tinnitus.

3. Systematic Review of the Diagnosis and Treatment of Tinnitus

We used the Cochrane Library, the medical journal Web, and PubMed for the literature search, and the search was performed in March 2017 under the following

Pre-release review

Before these guidelines were released for general use, they were reviewed with reference to the Conference on Guideline Standardization (COGS) proposals concerning their publication format [4] and the Appraisal of Guidelines for Research & Evaluation (AGREE) appraisal instrument for content assessment [5].

Before publication of the 2019 edition of the guidelines, opinions were solicited from the otolaryngologists and patients with tinnitus, and corrections were made as necessary.

Acknowledgement

This guideline was supported by AMED grant (2016−2019).

Disclosure Statement

All the authors are required to declare any financial support or relationship that may pose a conflict of interest. We have been granted by national goverment (AMED grant) as mentioned above.

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