Cochlear implant and tinnitus-a meta-analysis

Borges, Alda Linhares de Freitas; Duarte, Pauliana Lamounier e Silva; Almeida, Rodolfo Bonfim Siqueira de; Ledesma, Alleluia Lima Losno; Azevedo, Yaná Jinkings de; Pereira, Larissa Vilela; Bahmad Jr, Fayez

doi:10.1016/j.bjorl.2020.11.006

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Brazilian Journal of Otorhinolaryngology

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Review articles • Braz. j. otorhinolaryngol. 87 (3) • May-Jun 2021 • https://doi.org/10.1016/j.bjorl.2020.11.006 copy

Cochlear implant and tinnitus-a meta-analysis

Authorship SCIMAGO INSTITUTIONS RANKINGS

Abstract

Introduction

Tinnitus is a frequent symptom in cochlear implant patients, often reported as persistent and disabling in implant candidates. Tinnitus is rarely considered in the preoperative evaluation of patients who are eligible for cochlear implantation. Many studies have shown that a cochlear implant leads to a significant change in the perception of tinnitus.

Objective

To identify evidence in the scientific literature indicating that cochlear implant in eligible patients with tinnitus can improve tinnitus perception.

Methods

One hundred forty articles were found from nine databases, and 20 articles from the gray literature mentioned the relationship between cochlear implant and tinnitus perception in patients eligible for cochlear implant. The PICOS (population, intervention, comparison, and outcome) strategy, was used to define the eligibility criteria. The studies that met the inclusion criteria for this second step were included in a qualitative synthesis, and each type of study was analyzed using the Joanna Briggs Institute critical appraisal checklist for quasi-experimental studies and the Joanna Briggs Institute critical appraisal checklist for randomized clinical trials.

Results

The full texts of 11 articles were read, and 6 studies were selected for the meta-analysis. The total sample size in the evaluated articles was 136 patients with tinnitus who were eligible for cochlear implantation.

Conclusions

Taken together, these findings support the feasibility of cochlear implantation to reduce the perception of tinnitus, thus providing a new perspective in the treatment of tinnitus in patients with hearing loss who are candidates for cochlear implantation.

Keywords
Cochlear implant; Hearing loss; Tinnitus; Tinnitus perception

Study	Author	Type of study	Year	Location	Sample	Subjective outcomes for tinnitus	Study group	Age at cochlear implantation (mean)	Device	Type of procedure	Length of follow-up (mo)	Outcomes
Cochlear implantation as a long-term treatment for ipsilateral incapacitating tinnitus in subjects with unilateral hearing loss up to 10 years	Mertens G. et al.	Quasi-experimental-studies	2015	Belgium	23	TQ + VAS	SSD (profound) and AHL	55 yr.	No information	Unilateral	1 to 36	Reduction in TQ scores (55 to 31 points) and on VAS (8 to 3 points)
Effect of cochlear implantation on quality of life in adults with unilateral hearing loss^b b Articles eligible for meta-analysis.	Dillon M.T. et al.	Quasi-experimental studies	2017	USA	20	THI	SSD (moderate/profound)	50 yr. (SD = 11.5)	MED-EL, concerto, standard electrode array	Unilateral	12 to 48	Reduction in THI scores (23.3 to 2.8 points), 90% reduction in THI scores
Effect of unilateral and simultaneous bilateral cochlear implantation on tinnitus: a prospective study^b b Articles eligible for meta-analysis.	van Zon A. et al.	Quasi-experimental studies	2016	Multicentric	38	THI + TQ + VAS	NSHL (severe/profound)	50.3 yr. (SD = 14.4)	Advanced Bionics HiRes90 K	Unilateral and Bilateral (simulta neous)	48	Reduction in THI scores (13 to 3 points) and TQ (17 to 7 points) and VAS (5 to 2), 80% reduction in THI scores
On the necessity of full length electrical cochlear stimulation to suppress severe tinnitus in single-sided deafness	Punte A.K. et al.	Quasi-experimental studies	2013	Belgium	14	TQ + VAS	SSD (profound)	No information	MED-EL Sonata TI 100	Unilateral	6	Reduction in TQ scores (60 to 39 points) and VAS (8.2 to 4.1 points), 85.7% reduction in TQ scores and 100% on VAS scores
Self-reported benefits from successive bilateral cochlear implantation in postlingually deafened adults: randomized controlled trial	Quentin Summerfield A. et al.	Randomized controlled trial	2006	Multicentric	24	VAS own questionnaire	NSHL (profound)	No information	Cochlear Nucleus CI-24	Unilateral and bilateral (simultaneous and sequential)	3 to 22	Reduction in tinnitus perception and annoyance
Suppression of tinnitus in chinese patients receiving regular cochlear implant programming	Liu Y. et al.	Randomized controlled trial	2015	China	234	THI	NSHL (profound)	28.6 yr.	Cochlear Nucleus 24	Unilateral	1 to 30	Reduction in THI scores in all patients
the impact of cochlear implantation on speech understanding, subjective hearing performance, and tinnitus perception in patients with unilateral severe to profound hearing loss	Távora-Vieira D. et al.	Quasi-experimental studies	2015	Australia	28	TRQ	SSD (severe/ profound)	53.75 yr.	MED-EL GmbH	Unilateral	3 to 24	Reduction in TRQ scores (48.8 to 1.75 points)
Tinnitus after simultaneous and sequential bilateral cochlear implantation^b b Articles eligible for meta-analysis.	Ramakers G.G.J. et al.	Quasi-experimental studies	2017	Netherlands	38	THI + TQ	NSHL (moderate/profound)	No information	Advanced Bionics HiRes90 K	Bilateral (simultaneous/sequential)	12 to 144	Reduction THI scores (13 to 5) and TQ (17 to 7 points), 62% reduction in THI scores
Tinnitus modifications after cochlear implantation^b b Articles eligible for meta-analysis.	Di Nardo W. et al.	Quasi-experimental studies	2007	Italy	30	THI	NSHL (severe/ profound)	39.17 yr. (SD = 16.49)	Cochlear, Digisonic MSM, Clarion, MED-EL, COMBI-40 + MED-EL	No Information	24	Reduction in THI scores (44,5 to 25 points), 65% reduction in THI scores
Tinnitus suppression by intracochlear electrical stimulation in single-sided deafness: a prospective clinical trial - part I^b b Articles eligible for meta-analysis.	Arts R.A. et al.	Quasi-experimental-studies	2014	Multicentric	10	THI + TQ + VAS	SSD (moderate/severe)	48.2 yr. (SD = 12.6)	MED-EL, Concerto, OPUS2, Maestro version 4.1.2	Unilateral	1 to 8	Reduction in THI scores (45 to 31 points), TQ (41 to 26 points) and VAS (7.1 to 4.3 points), 70% reduction in THI scores
Tinnitus suppression by intracochlear electrical stimulation in single-sided deafness - a prospective clinical trial: follow-up^b b Articles eligible for meta-analysis.	Arts R.A. et al	Quasi-experimental studies	2015	Multicentric	10^a a The 10 patients analyzed in Part I of the Remo Arts study were the same as those analyzed in the follow-up but at different times after CI activation.	THI + TQ + VAS	SSD (moderate/severe)	48.2 yr.	MED-EL, Concerto, OPUS2, Maestro version 4.1.2	Unilateral	1 to 12	Reduction in THI scores (45 to 31 points), TQ (40 to 30 points) and VAS (7.1 to 2.8 points), 80% reduction in THI scores

Study	Type of study	Sample	Patients (with SHL, uni or bilateral)	Therapy (IC uni or bilateral)	Outcome (evaluation of tinnitus perception after implantation)	Follow-up (≥ 6 months)	DoE^a a Level of directness of evidence: A high directness of evidence was defined as a positive score on all criteria, moderate as a positive score on three out of the four criteria, and a low directness of evidence if they complied with less than three criteria.
Mertens G. et al. ¹⁹19 Mertens G, De Bodt M, Van de Heyning P. Cochlear implantation as a long-term treatment for ipsilateral incapacitating tinnitus in subjects with unilateral hearing loss up to 10 years. Hear Res. 2016;331:1-6.	PCS	23	(+)	(+)	(+)	(+)	H
Dillon M.T. et al. ¹⁴14 Ramakers GGJ, Kraaijenga VJC, Smulders YE, van Zon A, Stegeman I, Stokroos RJ, et al. Tinnitus after simultaneous and sequential bilateral cochlear implantation. Front Surg. 2017;4:65.	PCS	20	(+)	(+)	(+)	(+)	H
van Zon A. et al. ⁶6 van Zon A, Smulders YE, Ramakers GGJ, Stegeman I, Smit AL, Van Zanten GA, et al. Effect of Unilateral and Simultaneous Bilateral Cochlear Implantation on Tinnitus: A Prospective Study. Laryngoscope. 2016;126:956-61.	RCT	38	(+)	(+)	(+)	(+)	H
Punte A.K. et al. ²⁰20 Távora-Vieira D, Marino R, Acharya A, Rajan GP. The Impact of Cochlear Implantation on Speech Understanding, Subjective Hearing Performance, and Tinnitus Perception in Patients with Unilateral Severe to Profound Hearing Loss. Otol Neurootol. 2015;36:430-6.	PCS	14	(+)	(+)	(+)	(-)	M
Quentin Summerfield A. et al. ²¹21 Punte AK, De Ridder D, Van de Heyning P. On the necessity of full length electrical cochlear stimulation to suppress severe tinnitus in single-sided deafness. Hear Res. 2013;295:24-9.	RCT	24	(+)	(+)	(+)	(-)	M
Liu Y. et al. ¹⁸18 Liu Y, Wang H, Han DX, Li MH, Xiao YL. Suppression of Tinnitus in Chinese Patients Receiving Regular Cochlear Implant Programming. Ann Otol Rhinol Laryngol. 2016;125:303-10.	RCT	234	(+)	(+)	(+)	(+)	H
Távora-Vieira D. et al. ²²22 Summerfield AQ, Barton GR, Toner J, McAnallen C, Proops D, Harries C, et al. Self-reported benefits from successive bilateral cochlear implantation in postlingually deafened adults: randomised controlled trial. Int J Audiol. 2006;45:S99-107.	PCS	28	(+)	(+)	(+)	(+)	H
Ramakers G.G.J. et al. ¹⁵15 Arts RAGJ, George ELJ, Griessner A, Zierhofer C, Stokroos RJ. Tinnitus Suppression by Intracochlear Electrical Stimulation in Single-Sided Deafness: A Prospective Clinical Trial-Part I. Audiol Neurootol. 2015;20:294-313.	RCT	38	(+)	(+)	(+)	(+)	H
Di Nardo W. et al. ³3 Di Nardo W, Cantore I, Cianfrone F, Melillo P, Scorpecci A, Paludetti G. Tinnitus modifications after cochlear implantation. Eur Arch Otorhinolaryngol. 2007;264:1145-9.	PCS	30	(+)	(-)	(+)	(+)	M
Arts R.A. et al. ¹⁶16 Arts RAGJ, George ELJ, Janssen M, Griessner A, Zierhofer C, Stokroos RJ. Tinnitus Suppression by Intracochlear Electrical Stimulation in Single Sided Deafness-A Prospective Clinical Trial: Follow-Up. PloS One. 2016;11:e0153131.	PCS	10	(+)	(+)	(+)	(-)	M
Arts R.A. et al. ¹⁷17 Higgins JP, Green S. Cochrane handbook for systematic reviews of interventions. http://handbook-5-1.cochrane.org/. Accessed September 16, 2020. http://handbook-5-1.cochrane.org/...	RCS	10	(+)	(+)	(+)	(-)	M

	Arts R.A. et al.	Arts R.A. et al.	Dillon M.T. et al.	Geerte G.J. et al.	Di Nardo W. et al.	Mertens G. et al.	Punte A.K. et al.	Távora-Vieira D. et al.
Is it clear in the study what is the "cause" and what is the "effect"?	Y	Y	Y	Y	Y	Y	Y	Y
Were the participants included in any comparisons similar?	Y	Y	Y	Y	Y	Y	Y	Y
Were the participants included in any comparisons receiving similar treatment/care, other than the exposure or intervention of interest?	Y	Y	Y	Y	Y	Y	Y	Y
Was there a control group?	N	N	N	N	Y	N	Y	N
Were there multiple measurements of the outcome both pre and post the intervention/exposure?	Y	Y	Y	Y	Y	Y	Y	Y
Was follow up complete and if not, were differences between groups in terms of their follow up adequately described and analyzed?	Y	Y	Y	Y	Y	Y	Y	Y
Were the outcomes of participants included in any comparisons measured in the same way?	Y	Y	Y	N	Y	Y	Y	Y
Were outcomes measured in a reliable way?	Y	Y	Y	Y	Y	Y	Y	Y
Was appropriate statistical analysis used?	Y	Y	Y	Y	Y	Y	Y	Y
Bias risk (%)	88,88%	88,88%	88,88%	77,77%	100%	88,88%	100%	88,88%

	van Zon A. et al.	Quentin Summerfield A. et al.	Liu Y. et al.
Was true randomization used for assigning participants to treatment groups?	Y	Y	Y
Was allocation to treatment groups concealed?	Y	Y	Y
Were treatment groups similar at the baseline?	Y	Y	Y
Were participants blind to treatment assignment?	NA	NA	NA
Were those delivering treatment blind to treatment assignment?	NA	NA	NA
Were outcomes assessors blind to treatment assignment?	NA	NA	NA
Were treatment groups treated identically other than the intervention of interest?	Y	Y	Y
Was follow up complete and if not, were differences between groups in terms of their follow up adequately described and analyzed?	Y	Y	Y
Were participants analyzed in the groups to which they were randomized?	Y	Y	Y
Were outcomes measured in the same way for treatment groups?	Y	Y	Y
Were outcomes measured in a reliable way?	Y	Y	Y
Was appropriate statistical analysis used?	Y	Y	Y
Was the trial design appropriate, and any deviations from the standard RCT design (individual randomization, parallel groups) accounted for in the conduct and analysis of the trial?	Y	Y	Y
Bias risk (%)	90%	90%	90%

Study	Mean differences	95% CI	Weight (%)
1. Arts R.A. et al.	12.50	8.16; 16.84	13.87
2. Arts R.A. et al.	17.10	13.17; 21.03	14.06
3. Dillon M.T. et al.	18.15	16.11; 20.19	14.71
4. Ramakers G.G.J. et al. ¹1 Bhatt JM, Lin HW, Bhattacharyya N. Tinnitus epidemiology: Prevalence, severity, exposures, and treatment pattern in the United States. JAMA. 2016;142:959-65.	-3.07	-6.07; -0.06	14.42
5. Ramakers G.G.J. et al. ²2 Quaranta N, Wagstaff S, Baguley DM. Tinnitus, and cochlear implantation. Int J Audiol. 2004;43:245-51.	6.44	4.07; 8.82	14.62
6. Di Nardo W. et al.	19.50	14.99; 24.01	13.79
7. van Zon A. et al.	11.46	8.77; 14.15	14.53
Global	11.66	5.67; 17.65	100.00

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[1] * Corresponding author. E-mail: fayezbjr@gmail.com (F. Bahmad Jr).