Effect of Fractal Tones on the Improvement of Tinnitus Handicap Inventory Functional Scores among Chronic Tinnitus Patients: An Open-label Pilot Study

THIEME Original Research Effect of Fractal Tones on the Improvement of Tinnitus Handicap Inventory Functional Scores among Chronic Tinnitus Patients: An Open-label Pilot Study Patricia Simonetti1 Laura Garcia Vasconcelos1 Jeanne Oiticica1 1 Department of Otorhinolaryngology, Faculdade de Medicina da Universidade de São Paulo, São Paulo, SP, Brazil Int Arch Otorhinolaryngol 2018;22:387–394. Abstract Keywords ► tinnitus ► fractal ► music therapy ► THI Introduction Music-based sound therapies become recently a trend in the treatment of tinnitus. Few publications have studied the therapeutic use of fractal tones to treat chronic tinnitus. Objective The aim of this study was to determine the benefits of using fractal tones as a unique sound therapy for chronic tinnitus sufferers. Methods Twelve participants were recruited; however, six could not be assigned. At baseline and at 1, 3 and 6 months, the participants were provided with the Tinnitus Handicap Inventory (THI) and Hearing Handicap Inventory for Adults (HHIA) questionnaires, and their visual analog scale score was recorded. Tinnitus pitch and loudness matching was performed before fitting and after 6 months of use. Results The visual analog scale (VAS) score, pitch and loudness matching and minimal masking levels did not result in significant improvement at the end of the treatment. The mean THI measured at baseline was 45, and the final one was 25. A paired sample t-test showed that this 20-point difference was statistically significant. Conclusions We measured the benefits of using fractal tone therapy for the treatment of chronic tinnitus and found that most of the benefits were in the THI functional domain, which includes concentration, reading, attention, consciousness, sleep, social activities, and household tasks. For all patients with bothersome chronic tinnitus and high scores on the THI functional scale, fractal tones should be considered a promising initial sound therapy strategy. The findings from this open-label pilot study are preliminary, and further trials are needed before these results can be generalized to a larger tinnitus population. Introduction Tinnitus is a common, persistent symptom characterized by a sound sensation in the “ears” or “head” that is not produced by mechanical-acoustic signals from the external environment.1 A recent epidemiological study based on 1,960 interviews conducted in the city of São Paulo, Brazil, showed that 22% of the inhabitants had tinnitus,2 a higher prevalence than the 10–17% value commonly reported in the literature.3,4 We also observed received June 13, 2017 accepted February 19, 2018 published online March 29, 2018 Address for correspondence Jeanne Oiticica, MD, PhD, Departmento de Otorrinolaringologia, Universidade de São Paulo, Alameda dos Jurupis 657, CJ 72, Indianópolis, São Paulo, SP, 04088-002, Brazil (e-mail: ). DOI https://doi.org/ 10.1055/s-0038-1635575. ISSN 1809-9777. that the prevalence of the symptoms increases progressively with age and can be three times higher in the elderly (36% over 65 years of age) than that in young adults (12%).2 Many of the tinnitus sufferers also exhibited hearing loss and hypersensitivity to sound.5,6 Various pathophysiological causes underlie tinnitus, and all of the associated symptoms interfere with evaluations of affected patients. For most patients, medical management and appropriate counselling suffice; however, for other patients, the symptoms are persistent and bothersome, Copyright © 2018 by Thieme Revinter Publicações Ltda, Rio de Janeiro, Brazil 387 388 Fractal Tones Effect for Tinnitus Simonetti et al. and they interfere with daily activities and with the quality of life. A recent U.S. study found that nearly a quarter of those who reported tinnitus symptoms described it as disabling,7 and according to Brazilian data,
34% of cases are severely annoying.2 The habituation theory8 and the neurophysiological model of tinnitus proposed by Jastreboff in 1990 provided new approaches for the clinical treatment of patients with tinnitus. Several therapeutic approaches have been proposed based on these models, including TRT (tinnitus retraining therapy), TAT (tinnitus therapy activities) and many other protocols that combine counselling, sound therapy and relaxation.9,10 These approaches combine sound therapy (as a facilitator) with procedures to habituate the reactions caused by tinnitus and its perception, thereby resulting in a decreased conscious perception of the signal. Sound therapy, such as sound amplification or the use of sound generators, aims to decrease the contrast in quiet environments and promote sound enrichment to facilitate habituation and provide partial or total masking of tinnitus. Currently, different forms of sound therapy are available, and several forms of stimuli can be delivered from sound devices, which can be combined with amplification. Tinnitus primarily occurs because of sensory deprivation and increased central neural activity. A hearing aid can restore this system and is an effective treatment that has been confirmed by several studies. Other studies have revealed that music has great therapeutic potential for tinnitus relief.11,12 Listening to music leads to relaxation and stress relief, both of which can contribute to tinnitus control. In patients suffering from tinnitus, the presence of an annoying, persistent, and uncontrolled out-of-context sound signal can increase stress levels and cause an emotional disturbance that can exacerbate the perception of tinnitus. Neuroimaging has revealed the brain structures involved in tinnitus perception, which include the hippocampus, limbic area, frontal lobe, and cerebellum. These areas are also highly activated when listening to music.13–15 Music can be customized16 and filtered in accordance with the individual’s hearing loss and tinnitus pitch and listening to pre-recorded music provides the patients with a structured listening protocol. Fractal tones are harmonic and melodic tones that sound like “wind chimes”; however, because they are not predictable, these tones cannot be associated with any other conventional music to which the patient may have been previously exposed. This unpredictability is a unique and desirable feature of fractal tone music sound therapy because it induces passive listening, which is required for habituation. Habituation represents a natural brain function designed to reduce neutral stimulus perception under repeated exposure. Recent studies have shown that the use of fractal sounds may represent a viable alternative for minimizing the annoyance caused by tinnitus.17 Fractal tones appear to lead the listener to a pleasant and relaxing auditory experience and induce greater relaxation and stress relief compared with conventional music. In an open-label clinical trial, 14 hearing-impaired adults with a primary complaint of tinnitus were provided with one of several programs, including amplification onl (...truncated)