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For sham stimulation a specific sham-coil system was used. Treatment outcome was assessed over a 3 months period with a tinnitus questionnaire (Goebel and Hiller). Results: Up to now 60 patients have been included in the trial. In a majority of patients we could localize an increased metabolic activation in the upper dorsal part of the left superior temporal gyrus correspon- ding to areas of the auditory cortex. Preliminary results indicate that active rTMS results in a significant improvement of tinnitus perception compared to sham rTMS. Treatment effects lasted up to 3 months in some patients. Conclusion: Neuronavigated low-frequency rTMS seems to represent a promising strategy for the treat- ment of chronic tinnitus.

IV Behavioral therapy

Cognitive behavioural therapy for tinnitus. Cochrane Database Syst Rev. 2007 Jan 24;(1):CD005233. Martinez Devesa P, Waddell A, Perera R, Theodoulou M

Background: Tinnitus is an auditory perception that can be described as the experience of sound, in the ear or in the head, in the absence of external acoustic stimulation (not usually audible to anyone else). At present no specific therapy for tinnitus is acknowledged to be satisfactory in all patients.Cognitive beha- vioural therapy (CBT) uses relaxation, cognitive restructuring of the thoughts and exposure to exacerba- ting situations in order to promote habituation and may benefit tinnitus patients, as may the treatment of associated psychological conditions. Objectives: To assess whether cognitive behavioural therapy is effective in the management of patients suffering from tinnitus. Search strategy: Our search included the Cochrane ENT Group Trials Register, the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library Issue 2, 2006), MEDLINE and EMBA- SE. The last search date was June 2006. Selection criteria: Randomised controlled trials in which patients with unilateral or bilateral tinnitus as main symptom received cognitive behavioural treatment. Data collection and analysis: One review author (PMD) assessed every report identified by the search strategy. The four review authors assessed the methodological quality, applied inclusion/exclusion crite- ria and extracted data. Main results: Six trials comprising 285 participants were included.1. Primary outcome: subjective tin- nitus loudnessCBT compared to a waiting list control group: we found no significant difference (Stan- dardised Mean Difference (SMD) 0.06 (95% CI -0.25 to 0.37)).CBT compared to another intervention (Yoga, Education, Minimal Contact - Education and Education): we found no significant difference (SMD 0.1 (95% CI -0.22 to 0.42)).2. Secondary outcomesa) DepressionCBT compared to a waiting list control group: we found no significant difference in either group (SMD 0.29 (95%CI -0.04 to 0.63)).CBT compa- red to another intervention (Yoga, Education and Minimal Contact - Education): we found no significant difference (SMD 0.01 (95% CI -0.43 to 0.45)).b) Quality of lifeCBT compared to a waiting list control group: we found a significant difference in favour of CBT versus the waiting list group (SMD 0.7 (95% CI 0.33 to 1.08)).CBT compared to another intervention (Education, Minimal Contact - Education and Education): we also found a significant difference between CBT and the other intervention control group (SMD 0.64 (95% CI 0.29 to 1.00)).There were no adverse/side effects reported in any trial. Authors conclusions: We did not find a significant difference in the subjective loudness of tinnitus, or in the associated depression. However we found a significant improvement in the quality of life (decrea- se of global tinnitus severity) of the participants, thus suggesting that cognitive behavioural therapy has an effect on the qualitative aspects of tinnitus and contributes positively to the management of tinnitus.

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