ITS 2011

Overview of the 10th International Tinnitus Seminar (ITS)

Florianopolis, Brazil, March 16-19, 2011

A report to the members and supporters of the American Tinnitus Association
Submitted by Scott C. Mitchell, J.D., ATA Board of Directors

Introduction
Destination: Brazil
Getting Started
Tinnitus Management
Can Drugs Help?
Sound Therapies
Understanding How Tinnitus Works in the Brain
A Call for Better Clinical Trials
Stimulating the Brain
A Multi-Disciplinary Approach to Treating Tinnitus
Deeper into the Brain
Special Aspects of Tinnitus
Conference Wrap-Up Begins
More on Drugs
Jack A. Vernon, Ph.D. Award
Getting a Better Picture of Tinnitus
Final Sessions
Closing Observations and Impressions from Scott

Introduction

The mission statement of the American Tinnitus Association (ATA) is to cure tinnitus through the development of resources that advance tinnitus research. Some research we fund directly, often in the form of seed grants that let investigators explore new ideas. Other research funding results from the ATA’s advocacy efforts to the National Institutes of Health and more recently the Department of Defense. Most tinnitus research is done in laboratories and clinics around the world, but another aspect of the research process is when these scientists meet together to share their findings. I had the privilege of being invited to attend the 10th International Tinnitus Seminar (ITS) held March 16 through 19, 2011, in a city off the south coast of Brazil called Florianopolis. This report to the members of the American Tinnitus Association is to inform them on the latest research, and show how the science is conducted that will lead to more treatments and eventually a cure for tinnitus.

A few disclaimers are in order. First, most of what follows is what could be called basic research. It is not intended to imply medical treatment. You should consult with your doctor before trying any particular medical treatment. Second, these conferences are conducted in the careful language of science, where words have precise meanings and complex ideas are shared in a kind of scientific shorthand. Some of this report’s effort to explain those concepts in everyday language certainly may not do justice to the precision and complexity–not to mention the work–behind the researchers’ presentations. This report is not intended to be any kind of full representation on the substantial body of work that these researchers have compiled in this field. Periodically, I have added parenthetical comments in brackets, [that will also be italicized] to make sure that my own musings are not confused with the comments of the researchers [or “investigators,” as they are sometimes called.] Any mistakes are mine, and will be corrected on the website if and when such mistakes are brought to our attention. This report is also provided to the ATA members in gratitude for their financial support of such research through ATA.
 

If there are still any terms that you do not completely understand ATA has provided a wonderful research terms glossary on their website. So please refer to it at any time if necessary ATA.org/glossary.

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Destination: Brazil

It says something about the expanding state of current tinnitus research that conferences have been held all over the world; it says something about Brazil that one of the crown jewel cities of this country hosted the 10th International Tinnitus Conference in March 2011.

The first thing you notice as you fly over this capital of Santa Catarina State that part of it is on a gorgeous island off the coast with over forty-two beaches, and a pulsing city life. Colonial architecture in part of the city provides an old-world counter-point to the dynamic business and cultural bustle of capital’s metro district. It was fitting that this brash, bustling and upbeat city played host to a conference that featured cutting-edge tinnitus research from around the world.

The President of the Executive Committee that brought the conference to Brazil was Tanit Ganz Sanchez, M.D., Ph.D., the founder of the Ganz Sanchez Institute - one of Brazil’s foremost tinnitus treatment clinics - and of the non-profit Associação de Pesquisa Interdisciplinar e Divulgação do Zumbido [in English: Association for Interdisciplinary Research and Tinnitus Divulgation.] Claudia Coelho, M.D., Ph.D., led the International Scientific Committee that gathered the world’s leading investigators to share their knowledge and most recent work; Marcia Kii, M.D., Ph.D., chaired the National Organizing Committee that drew together the resources and personnel to run the conference.
Getting Started

Dr. Sanchez welcomed the conference from the stage, with a dramatic backdrop design splashed with the national colors of Brazil – green, yellow and blue. She explained how the conference would work – with speakers both at the conference, and also with live online presentation on the big screens in front of the audience. Not only would there be questions from attendees after most presentations, questions would be sent via the internet and repeated live to the physical attendees. The proceedings were also accessible online. Ultimately, the conference would display 94 scientific contributions, with over 28 countries represented. The whole proceeding was a remarkable demonstration of how 21st century technology with its global reach can accelerate the spread of research ideas.

The conference contained a balanced mix of basic science research and practical clinical experience. The first session, began with ATA Scientific Advisory Committee member, Jinsheng Zhang, Ph.D., who presented his work on the “neural coherence of multiple brain structures as a neurophysiological signature of tinnitus,” via video presentation.
 
Tom Brozoski, Ph.D., continued on this area and updated the conference on the neuroplasticity, or brain-changes, of tinnitus. Edward Lobarinas, Ph.D., provided an online discussion of excitatory and inhibitory neurotransmitters in rats. This sort of work is crucial to understanding tinnitus, since many researchers suspect that tinnitus is more than just hyperactive neurons generating phantom “sound” in the auditory system; instead, tinnitus may happen when the brain is not exercising its subconscious capacity to filter out and block [or, as the scientists say, inhibit] that neuron activity. Dr. Lobarinas rounded out the first session with a report on the drug cyclobenzaprine used on animals with noise-induced tinnitus. Cyclobenzaprine is a muscle relaxant medication used to relieve skeletal muscle spasms and associated pain in acute musculoskeletal conditions. It is the most well-studied drug for this application, and it also has been used off-label for fibromyalgia treatment – a reason why it’s also being looked at for tinnitus. 

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Tinnitus Management

The next session focused on tinnitus management, with presentations by Dr. Tanit Ganz  Sanchez, Celene McNeil, Au.D., and Keila Knobel, MS.R., on how audiologists and ENTs [Ear, Nose and Throat doctors, also called otolaryngologists] can improve patient care. It was generally agreed that many ENTs don’t feel comfortable with tinnitus patients. ENTs are surgically trained, and at this stage there is no mainstream surgical solution. Also, knowledge of tinnitus can be limited in some ENT clinics, and nobody likes to deal with a problem they know little about. As a result, patients often get the wrong message from the encounter with an ENT, effectively being told you may not die from tinnitus, but you will almost certainly die with it. [More on this later from Laurence McKenna, Ph.D.]

Dr. Tanit Ganz Sanchez offered ENTs a different outlook on tinnitus: First, every patient is different; second, some cases of tinnitus can be treated, and third, a single treatment will never be enough to satisfy the full spectrum of patients. Patients with different symptoms in addition to tinnitus need to be treated differently. Hearing loss, dizziness, sound intolerance, somatosensory modulation; [like being able to change your tinnitus by moving your head or neck] these should all be noted and included in the patient profile. [This suggests that the tinnitus patient, if he/she is not asked about these other symptoms, should not hesitate to volunteer this information to his doctor!] Tinnitus definitely has subgroups with different treatments, and those should be noted so that ENTs become more interested in assuming their role in evaluating and treating tinnitus patients.
 
In her discussion on clinical practice, Dr. Celene McNeil provided a detailed checklist of audiological procedures designed to diagnose and treat each patient’s specific condition. She commented that hearing loss may account for large percentage of tinnitus cases: surveys have shown that just using hearing aids resulted in 43% of patients experiencing reduced tinnitus, and 35% reporting they could not hear their tinnitus, with 22% reporting no change [Note to tinnitus patients: perhaps the first thing you ought to do is have your hearing checked by an audiologist!] In those rare cases where hearing aids make tinnitus worse, the cause is often poor fittings or incorrect settings. Again, illustrating her clinical objective of matching specific treatments to unique patient conditions, she offered a variety of treatment combinations based on the factors of hearing capacity and how much a patient’s tinnitus is bothering them. This talk was an excellent illustration of a professional audiologist using the resources currently available to respond to each patient’s unique condition. [ATA maintains an updated list of healthcare practitioners who work with tinnitus patients, which is included in new member packets or can be requested by contacting us.]
 
Ms. Keila Knobel continued this series on clinical audiology by noting that a tinnitus trained audiologist should investigate a range of related symptoms, such as headaches, sound intolerance [also known as hyperacusis], dizziness, or loss of balance. Ask the patients to describe their condition in their own words. Use the variety of tinnitus questionnaires, as well as depression and anxiety checklists. She counseled to screen the patient for sleep disorders. This is a very sensible approach, because it breaks the “tinnitus experience” into better-defined problems, so that the whole patient can be treated. 
 
The final morning presentation of the first day featured Gerhard Andersson, Ph.D., and Laurence McKenna, Ph.D., who canvassed the psychological approaches for dealing with tinnitus. Dr. Gerhard Andersson, from the Karolinksa Institute in Stockholm Sweden, opened the topic of how Cognitive Behavior Therapy (CBT) can help tinnitus patients. The real suffering that can make tinnitus so miserable is often a product of their emotional response to tinnitus. CBT shows how you can challenge those moods.  
 
One of its simplest forms called the “ABC” model; “A” stands for an active experience–like, hearing the all-too-familiar hissing, ringing, or other sounds of tinnitus; leads to “B,” standing for beliefs the tinnitus sufferer has formed about tinnitus; then in turn produce “C,” standing for  that person’s internal concepts, feelings, emotions and behaviors. It’s all too easy, for example, to hear your tinnitus [experience], which summons up the thought that “I’ll never have peace and quiet again!" [false belief] which then produces chronic anxiety and depression. Working with a cognitive behavior therapist, the suffering tinnitus patient can learn to recognize bad feelings, and then examine the beliefs–often false beliefs–that underlie those feelings. The ancient philosophers Seneca and Epictetus spoke on fundamentally the same idea, when they said it is not life’s events that make us miserable, but how we think about those events. And every person has the option of controlling those thoughts. Dr. Gerhard Andresson explained to the conference how this basic idea has been honed by clinical psychologists into a successful therapy.  
 
Dr. Laurence McKenna expanded on this theme in his talk. “Patients come to psychotherapy because they are demoralized by the menacing meanings of their symptoms,” said Dr. McKenna. The psychotherapist collaborates with the patient in formulating a plausible story that makes the meanings of the symptoms more benign, and provides procedures for combating unfounded beliefs and toxic moods. This “middle of the night thinking,” as Dr. McKenna called it, about how miserable one’s tinnitus is, can lead to stress. Stress in turn just reinforces the same flawed beliefs. A patient’s thinking gets trapped in this vicious cycle. But that cycle can be broken through exercises that the patient learns to challenge those bad beliefs and just take tinnitus for the neutral stimuli it really is. This kind of therapy is surely an improvement over what tinnitus patients hear all the time: “You just have to learn to live with it.” Dr. McKenna observed this kind of talk can itself be an unintended negative belief foisted by the doctor onto the patient.

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Can Drugs Help?

The afternoon session of the first day offered a discussion of the placebo effect on tinnitus, by Fabrizio Benedetti, M.D., and Paolo Enrico, Ph.D. The “placebo effect” occurs when a patient is provided a treatment or drug and told to expect a positive effect; even though the treatment or drug is just some benign substance with no healing qualities whatsoever, patients will often experience claim they feel better. Dr. Paolo Enrico, from the University of Sassari, observed that no drug has been yet proven to provide replicable, long-term reduction of tinnitus, in excess of the placebo effect, in which patients tend to respond better to treatments that offer hope and expectancy of improvement.

And yet, some drugs do have an undeniable effect on tinnitus. “What about the drug lidocaine, for instance,” asked Dr. Paolo Enrico. This drug is related to the novacaine used by your dentist as a painkiller. Up to 70% of patients report reduced tinnitus following an injection of lidocaine. Even though the effect is not long-lasting [about thirty minutes for many patients], the fact is, for that brief interval, it can shut down tinnitus. This is “proof of principle,” as Dr. Enrico described it, that drugs can potentially become treatment options for tinnitus. Dr. Fabrizio Benedetti, of the Department of Neuroscience at the University of Turin Medical School, provided an interesting outline of the brain’s dopamine system, and how it interacts with GABA, the neurotransmitter that serves as an inhibitory factor that regulates neuronal activity. [This served as a good reminder how complex this phenomenon of tinnitus is. Most people with tinnitus keep hoping that some researcher will invent the “off switch” that will make the sound go away, when in fact the body may already have a built-in “off switch” in the form of these GABA inhibitors. The research objective then becomes to figure out why these inhibitory agents are not doing their job.] Dr. Benedetti then compared certain diseases and conditions, including pain, Parkinson’s disease, depression, and anxiety, and matched these up to their specific neurological mechanisms. This is another example how investigators are constantly probing to see if other conditions hold clues that could apply to tinnitus.
 
When tinnitus patients dream of a “cure” for tinnitus, they often think the answer will someday be a pill. Pharmacology plays such a large role in many health conditions, why not tinnitus? Dr. Marcia Kii, Dr. Claudia Coelho, and Carol Bauer, M.D., FACS, ATA Board member, provided an excellent overview of what medications are available today to treat various forms of tinnitus. Drugs can be helpful in two ways – modulate [diminish] the tinnitus, and helping control the reaction to tinnitus [like anti-anxiety medications.]
 
In the same way that pain can be treated differently depending on the cause, [headache pain being different from, say, pain from a burn] one strategy for medicating tinnitus is to find ways to subgroup the condition by some distinguishing aspect – like how it was acquired, what it sounds like, or any other symptoms - as a way of matching up specific drugs to specific varieties of tinnitus. All of this is headed for the “Holy Grail” of tinnitus treatment, in which each patient would be given customized tinnitus treatment.
 
Here are some possible drug/symptom match-ups for tinnitus under certain circumstances:
[Please note that these are therapies administered under the careful watch of a trained tinnitus health professional for research purposes and you should not attempt to administer these on your own.]
 
Eustachian tube dysfunction - Nasal saline and antihistamine
Tinnitus with migraine - Topiramate 
So called “Typewriter Tinnitus” - Carbamazepin
Noise-induced tinnitus - Gabapentin
Head Injury - Ginkgo biloba extract
 
That’s a start.  However, we don’t yet have a good grasp of the different kinds of tinnitus. “In the absence of effective tools for identifying subgroups,” said Dr. Coelho, “investigators should consider open-trial designs before large placebo controlled trials.” What this means is that one way to begin drug testing is try a broad testing program, just to see if certain existing drugs have any positive effects. Once some good responses are noted, then the researcher can construct clinical trials that have the usual protocols to safeguard the integrity of the test – procedures like double-blind placebo controlled studies, where patients [and even the pill-dispensing investigators] don’t know whether the patient is getting a placebo or the real drug, to make sure any positive responses are genuine.
 
Dr. Coelho described how this “shotgun” [my word, not hers] approach has led to some very interesting results with her clinical trials of the drug cyclobenzaprine, and the related drugs of orphenadrine and tizanidine. Cyclobenzaprine is already an Food and Drug Administration (FDA) approved medication to decrease muscle spasms, manage fibromyalgia and temporomandibular (TMJ) disorders to reduce pain. All this suggested to Dr. Coelho that it might have some application to tinnitus [an idea also generated and backed up by the Pharmacology workgroup of Tinnitus Research Initiative Foundation.]  The other two drugs also had promising aspects for tinnitus relief. In a study ranging over 16 weeks with various dosages, Dr. Coelho reported very favorable reactions among her clinical subjects, to make these drugs good candidates for further exploration.
 
Why do they work? Dr. Coelho says at this stage her research, nobody knows for sure. Maybe cyclobenzaprine has a special effect on the brain’s neurotransmitters. The drug was used at one time as tri-cyclic anti-depressant medication, as well as an “off-label” use to treat insomnia, so perhaps it has a calming effect on the brain. Then again, the drug has been used as a muscle-relaxant, so maybe it releases compression on nerves that might be a marker for subgroup of tinnitus called “somatosensory.”  There is much here to investigate.

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Sound Therapies
Sound therapies were the topic for the final talks that day. Grant Searchfield, Ph.D., from the University of Auckland, New Zealand, provided an update on sound therapies for tinnitus controls. Dr. Searchfield said sound therapy can address the three critical components of tinnitus: 1) The psychological response to tinnitus, 2) the perception of tinnitus, and 3) the quality of hearing. Sound therapy should therefore provide corresponding remedies: 1) Counseling, 2) Avoiding silence, and 3) Communications training, hearing aids, and cochlear implants. Dr. Searchfield emphasized it was important to “customize the cure,” as he put it. Hearing aids, for example, can reduce tinnitus audibility, enrich the sound environment, improve hearing, and also lead to long-term plastic changes in the brain. Paul Davis, Ph.D., founder of the “Neuromonics,” program, discussed acoustic therapy, with individually programmed systems compensated for hearing loss, combined with a six-month program of counseling. Luca Del Bo, M.Sc., of the Italian Fondazione Ascolta Vivi compared “traditional” with “new” sound therapies, emphasizing once again it would be ideal to base such therapies on subgroups.
 
Still in the realm of sound therapies, Robert Sweetow, Ph.D., from the University of California San Francisco, described his exploration of music as an acoustical treatment, used in connection with hearing aids. He agreed with many of the investigators who believe that tinnitus is somehow connected to some kind of dysfunction in the “gateway system,” of the brain, that normally filters out the tinnitus sound. Once again, the limbic system may be the source of this dysfunction, especially the sympathetic part of the autonomic nervous system. [Need to define some terms here: The nervous system – brain, nerves, neurons, etc.–can be broken down into a number of subsystems. One of the subsystems is the autonomic nervous system, which handles all the things your body needs to do without conscious thought, such as pump blood and breathe. But this autonomic function is divided again, into two parts: the “sympathetic” and the “para-sympathetic.” These two parts are reversed mirror images of each other. The “sympathetic” subsystem is best remembered as your “fight or flight responses.” In stressful situations, it shuts some discretionary functions off, like digestion, and revs up other survival functions – your heart rate increases, breathing deepens, the eyes actually let in more light – all the things your body needs to do to confront the danger it faces (or thinks it faces). The parasympathetic works the other way – the “rest and digest”. Breathing slow, the gut goes back to digesting your lunch, blood flows out of your muscles and returns to your skin. So when we are talking about the reaction of your nervous system to stress, it is likely the sympathetic part of your autonomic nervous system that is being activated.]
 
Meanwhile, back to the music, Dr. Sweetow pointed out how music is known for its emotional impact. Music also activates a wide range of brain areas, even though he concentrated on the auditory system and the limbic system. So, he reasoned, if we want to construct some kind of acoustical treatment, music might be the fast lane into the limbic system, where emotions are expressed. What is needed, is music that continually engages the brain. The goal of using music is to activate the neural plasticity of the brain. If you have some kind of injury in the periphery (like a damaged cochlea), the brain will reorganize itself to try to adapt to the new input; often, this reorganization does not go well, and the result is tinnitus. But a rich sound environment, with the right kind of sounds, may be able to minimize some of the unwanted reorganization. Dr. Sweetow was especially interested in “fractal” music, music of pure tones produced in mathematical patterns that are not predictable, but still engaging. With such music, your brain cannot just tune it out, but is obliged to process it, and thus start reforming the jumbled part of the brains auditory processing. The delivery vehicle for the music would likely be hearing-aid like devices; the estimated therapy time would be six months.

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Understanding How Tinnitus Works in the Brain
If tinnitus is nothing more than an amorphous phantom sound floating around in your head, perhaps the quest for treatment could end right here. But it seems every time you try to define tinnitus, you end up expanding the borders of the possible. Richard Salvi, Ph.D., hosted a panel which asked this question: Granted, tinnitus can be found in the auditory nerve pathways; but does it also activate non-auditory nerve pathways? The answer seems to be yes. ATA Scientific Advisory Committee member, Susan Shore, Ph.D., from the Department of Otolaryngology, Molecular and Integrative Physiology, at the University of Michigan, presented her findings that there may be some interaction between the auditory system and the somatosensory system. The system is a neural network that responds to such stimuli as touch, temperature, pressure, pain. Why does Dr. Shore think there may be a significant connection between this system and tinnitus? Because, as she reported, patients who have TMJ disorders [like pain in the hinge of the jaw] have a 50% higher incidence of tinnitus. Two-thirds of tinnitus patients can make their tinnitus change by moving their jaw, or neck, or even eyes. [I wonder how many patients have described this weird connection to their doctor, hoping this reveals some clue for an immediate treatment, only to see the doctor shrug!]  On top of that, this whole jaw/ear area is the nexus of a lot of traffic–the trigeminal cranial nerve, muscles, joints, middle ear and inner ear, all flexing cheek-to-jowl. So if anything in that little bundle gets irritated or buzzed or compressed, your whole head knows about it. Among many fascinating findings, Dr. Shore described how her monitoring of these tiny neurons in that area seems to suggest a pairing of somatosensory nerve cells with auditory nerve cell: if one fires off, the other fires off too. Not only may this explain why some people can modulate their tinnitus by physical movement; it may someday offer a treatment option that takes advantage of this system connection.
 
Another system that is almost certainly interacting with the auditory system, which has a direct impact on the tinnitus experience is the limbic system. Josef Rauschecker, Ph.D., advanced the thesis that tinnitus is normally suppressed or “gated” by the limbic system, that peculiar cluster of small brain organs, huddled underneath the big covering lobes of the brain, that influences our emotional state. In a normal brain, different parts of the brain maintain different frequencies. But if something comes along and disturbs all those ephemeral harmonies, like an injury on the outside the brain such as the cochlea, that damage can ripple along the neural pathways. This in turn can lead to a “cortical remapping,” with the leftover clashing bits being perceived as tinnitus. This analysis highlights one of the most distinct aspects of the tinnitus experience – the suffering that goes with it. Why should a background noise drive tinnitus patients into despair? It’s a classic chicken-and-egg question: does the tinnitus make us anxious and depressed? Or does the depression and anxiety in our limbic system present itself as tinnitus? Or, as Dr. Rauschecker’s work suggests, maybe something intervenes from the periphery, or outside the nervous system, that starts a ripple effect down certain neural pathways that lead to the limbic system, making the inter-brain frequencies “out of phase” and that in turn triggers the auditory system to create the perceived “sound” of tinnitus. Or do the two systems – auditory and limbic–start entwining and reinforcing one another like a vicious feedback loop? And of course that begs the question–can this process be tamped down or reset? We don’t know the answers until we formulate the right questions.

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A Call for Better Clinical Trials
The evening presentation was a challenge by William Martin, Ph.D., of the Oregon Health and Science University in Portland, Oregon, for more rigorous clinical trials. How can we accelerate the progress of tinnitus research, he asked? For clinical trials, he said, we need tougher standards of experimental design. And more care in choosing outcome parameters - how do you define a “cure.” Patients who participate in clinical trials often have major differences in age, ethnicity, hearing loss, diseases, and other medications. The side conditions may not always be taken into account and may affect the outcome of the clinical trial. Dr. Martin then focused on the aspect of suffering with the tinnitus experience. Through ingenious animal model design, we can be pretty sure whether or not, say, lab rats have tinnitus. That allows us to experiment with drugs to see if we can diminish that tinnitus in rats. But even if we can detect tinnitus perception in animals, that is a far cry from measuring the emotional impact that tinnitus is having. That same uncertainty applies to human patients: Statistical variances in test results can be tabulated, but how do you reliably measure if a treatment affects the emotional experience of tinnitus? How can you begin to put it into words, much less into numbers? It was a thoughtful keynote address, and it demonstrates how close these researcher-clinicians are to their tinnitus patients, to understand the subtext of suffering underlying the scientific notation. 

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Stimulating the Brain

The ability to organize tinnitus by subgroups may be critical to treatments, especially if tinnitus has multiple causes and just as many ways of showing itself. If you accept the notion of tinnitus as a symptom, and not a separate disease by itself, then it should be treated by understanding and then treating the underlying cause. Subgroups might be defined by any number of variables – the pitch of the sound, whether it is heard in either ear or centrally in the head, its signature appearance with any number of ways to scan the brain, the presence of any other symptoms, or by distinguishing characteristics we have yet to fathom. And the exciting thought is that if we can identify different varieties of tinnitus, we might – just might – be able to devise specifically targeted treatments. We may find out there is no single “cure” for tinnitus, in the same way there is no “cure” for pain [and neurologically speaking, tinnitus and pain are alike in many ways.]  

To explore this area of subgroups, ATA Scientific Advisory Committee member, Dirk de Ridder, M.D., Ph.D., described his work on cortical tinnitus [tinnitus found in the outer layer of the brain that deal with higher brain function, like sensation and thought], with EEG. EEG stands for “electroencephalogram," a procedure which records multiple frequency bands of brain waves, and is one of the techniques of neural imaging that can be used to “see” tinnitus. Clinical trials still leave much unanswered; it is sometimes hard to interpret the data. For example, attention has focused recently on the hippocampus; data suggests that whatever is going on there is being transmitted to the auditory cortex–or the other way round! But investigators are beginning to understand how specific interventions (like drugs or electromagnetic stimulation) influence tinnitus, and the neural mechanisms at work. ATA-funded researcher, Berthold Langguth, M.D., from the University of Regensburg in Germany, continued this quest for tinnitus subgroups by employing PET (short for “positron emission topography”) scans, which create a three-dimensional computer-generated map of metabolic functions in brain tissues–a moving picture of how the brain is functioning. 

He said he began to conceive of using PET imaging to investigate tinnitus when he realized that it was not sufficient to focus only on the auditory system, where most imaging studies were looking. New imaging could help identify subgroups of tinnitus, and perhaps target specific brain areas for drug treatment. It could also help assess treatment outcomes. We have a pretty good idea that activation of the auditory pathways is present during tinnitus; but is that all? Looking outside tinnitus research - say, in studies of disorder of consciousness, we can tell that more than just auditory pathways are involved. In fact, at least two other areas of the brain are activated: the prefrontal cortex, which is front part of the big lobe of the brain, and the frontal parietal, which is a lobule that the Gray’s Anatomy text shows as being a few layers down in the brain, beneath the crown of the head. [This is interesting, these are not among the “usual suspects” of brain parts associated with tinnitus, at least in my reading. The frontal parietal is usually associated with the “executive function” of the brain – making decisions and engaging social behaviors. You may have heard about that case where a railroad worker unfortunately had a steel rod driven through his brain; even though he survived, his frontal cortex was shredded. His behavior after that accident showed a changed personality. The inferior parietal has been shown to be connected to interpreting sensory information, which makes sense in the tinnitus context.] Dr. Langguth discussed the ventral medial [or center-middle] prefrontal cortex is important; activity in this area makes it possible to habituate tinnitus. This has a direct influence on the thalamic function; as soon as this area becomes active, the patient can start compensating their tinnitus with habituation. Severity of tinnitus can also be imaged. Significantly, in tinnitus patients there appears to be a structural deficiency in the hippocampus.
 
 [This neurobiology can really make your head spin. The old 19th century model of the brain was easier to understand–distinct parts of the brain controlled very specific functions – the vision part, the digestion part, etc. In the minds of Victorian criminologists, it was logical to look for the part of the brain that inspired evil deeds. Everything was neatly labeled and color-coded. But whenever researchers like Dr. DeRidder and Dr. Langguth start discussing brain functions in connection with tinnitus, you realize there is probably no single “tinnitus switch” in the brain. Instead, multiple parts of the brain are being activated throughout the entire process–more like summer lightening flashing across a cloud bank in the sky. And all of these investigators make it clear that just because some parts of the brain seem to be involved together in the perception of tinnitus, that does not come close to saying that tinnitus is “caused” by one or the other. The complexity of the brain itself defies easy answers.]
 
Michael Landgrebe, M.D., also of University of Regensburg, discussed Transcranial Magnetic Stimulation (TMS), to reduce tinnitus in patients. Using both high and low frequencies, his research team have looked for differences in results as they apply this stimulation to the cortex. High-frequency pulses (10-20 Hz) have effects that are short-lived–but for a few minutes, at least, some patients report lowered tinnitus perception. Low-frequency pulses (1.0 - 1.5 Hz) also can reduce tinnitus perception, for several hours, so the effect is more prolonged than high-frequency. Newer techniques are having better results. Much still needs to be learned about using this treatment: where to place the magnetic coil? Is the primary auditory cortex the best target? Would the results be any different using other frequencies? These questions can only be answered by patient - and rigorous  - experimentation.

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The Need for a Multi-Disciplinary Approach to Treating Tinnitus

After a break, Ron Goodey, M.D., and Dr. Tanit Ganz Sanchez, hosted a spirited round table discussion of the interdisciplinary approach to treat tinnitus, with audiologist Luca Del Bo, M.Sc., dentist Wagner De Oliveira, D.D.S., and the online participation of psychologist Nicholas Dauman, Ph.D., neurologist, Jose Miguel Lainez, M.D., and physiotherapist, Carina Rocha, M.D. Dr. Goody drew from the conference a general nod that the generation of subjective tinnitus– at least certain aspects of tinnitus–are a “central phenomenon” involving the brain and nervous system, not just an auditory problem. He then posed an important question: can we realistically expect to reverse or change for the better these unwanted plastic changes that cause tinnitus? [A word, here: the term “plastic” has special meaning in neuroscience. The brain is understood to operate along certain established neural pathways, with synapses crackling along well-grooved networks. However, if something happens to disrupt this circuit–an injury, say–then the brain has the capacity to rewire itself and establish new pathways. That’s why some people with strokes are able to regain much of their former capacity. Tinnitus itself is sometimes thought to be the result of this brain plasticity at work.] 

So assuming that brain plasticity allowed tinnitus to happen in the first place, can the brain be drugged/ jolted/ conditioned/ habituated/stimulated to go back to the way it was? Here and there were scattered voices of cautious, and qualified, assent, pointing out that electromagnetic stimulation seems to be leading to that effect, and cochlear implants have been known to eradicate tinnitus. [Dr. Goody was presumably referring to the goal of silencing tinnitus, actually turning the sound off. As this conference demonstrated, there are several treatments, such as habituation and a multitude of sound therapies, or the right kind of medication, which have been successful in making the sound far less impactful to the quality of life.]
 
This was followed by a topic that every new tinnitus patient ought to understand: the need for some coordination in treating a patient across several disciplines. In the United States healthcare system, this role is usually assigned to the family doctor, who refers cases to the appropriate specialist. In the case of tinnitus, however, that role might better be fulfilled by an audiologist or ENT. Often a patient will roam among specialists without guidance, which is a frustrating and inefficient process. It was gratifying to hear a systemized approach is available. Steven Benton, Au.D., representing the U.S. Veterans Affairs (VA) health system discussed the different levels patients are directed to at the VA, based on the progress of their treatment. This progressive tinnitus management is a way of treating a population of tinnitus patients so that the harder cases get the more specialized care.
 
Psychiatry and counseling got special mention in this multi-disciplinary treatment approach. As Dr. Berthold Langguth said, “Tinnitus is not a psychiatric disorder, but is frequently accompanied by psychiatric co-morbidities [accompanying conditions.]  Diagnosis of psychiatric co-morbidity and psycho-pharmacological treatment should be performed by psychiatrists and psychotherapy by psychotherapists.”
 
Dentistry’s relation to tinnitus does not get that many clinical trials, said Dr. Wagner de Oliveira of Brazil. But it could definitely be a factor, particularly in cases where there seems to be facial pain, TMJ pain, temporal headaches, enervation of the trigeminal nerve near the ear, and any of the other somatosensory clues that something is amiss in the head, neck and jaw area, such as numbness or pain. Dr. Carina Rocha, commented on treatments by applying pressure to certain areas of the head and neck, and other myofascial trigger points.

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Deeper into the Brain
After a break for lunch, it was time to once again to crack open the skull and look inside the brain – the place where many investigators believe the deepest secrets of tinnitus can be found. Dr. Richard Salvi reported on the effects of hearing loss and tinnitus on the hippocampus, a paw-shaped structure that forms part of the emotion-driving limbic system. Dr. Salvi observed a pleasing confirmation of theory with results when brain imaging showed tinnitus activating the limbic system, just as predicted by Dr. Pawel Jastreboff’s “Neurophysiological Model” of tinnitus, of how the mechanisms of tinnitus were thought to work. This is a very interesting part of the brain to study, said Dr. Salvi, since many tinnitus patients suffer from impaired concentration, depression, and memory impairment – all activities associated with the hippocampus. It has been shown that stress and depression can have an impact on this part of the brain, but – and this is the exciting discovery–the hippocampus can also produce new brain cells, a process called “neurogenesis.” People used to think that the brain could only make a finite number of brain cells and then that was it. Well, now we know that, yes it can, and this is one of the places where that takes place. Early tests show that noise-induced hearing loss can diminish this process of neurogenesis. A question from the audience: does this mean that tinnitus is connected to this diminished capacity to generate new brain cells? Or, to put it differently, can tinnitus be treated by restoring some of this brain-cell-producing capacity of the hippocampus? Way too early to tell, reported Dr. Salvi. At this stage, the test results related only to noise-induced hearing loss. Dr. Paolo Enrico delved into the complex biochemistry of the brain, and the voltage-gated sodium channels may have a profound impact on tinnitus. Craig Markovitz, (Ph.D. candidate) posed the question of whether direct cortical stimulation to suppress tinnitus may need to target specific regions in the auditory system, and here we get into the issue of what kind of electromagnetic stimulation is used. Contrast a narrow-target approach of direct cortical stimulation with transcranial magnetic stimulation (TMS). TMS affects a broad swath of the brain, but with only shallow penetration into the brain tissue. Direct cortical stimulation can penetrate deeper. If it is deep enough, and aimed right on target, perhaps it can be used to “reset” the nervous system.
 
And that led to the session on stimulation of the brain as a possible treatment. [It all seems so logical: if tinnitus is created by out-of-control neurons crackling through auditory system or the central nervous system, a kind of home-brewed electricity, then couldn’t electro-magnetic stimulation provide a path to a cure? Fighting fire with fire. . .  But the question remains: where precisely do you target the treatment? On the periphery of the nervous system, like the auditory nerves? Or deeper inside the brain, the very core? Ever since electricity and magnetism were discovered, scientists have tried countless experiments to see if there are medical benefits from that kind of stimulation. Electromagnetic stimulation was considered a way to tap into “animal magnetism” and “vital force” to treat everything from palsy to toothaches. An analog in pain management in modern times is “TENS” (transcutaneous electrical nerve stimulation), whose electrical charges can suppress neurological activity the brain interprets as “pain.”]
 
Dr. Berthold Langguth updated the conference on his work with Repetitive Transcranial Magnetic Stimulation (rTMS). It’s not enough to just zap patients with a blast of such stimulation; Dr.Langguth has been attempting to establish specific protocols of wavelengths and treatment time. Dr. Dirk de Ridder then discussed paired associative stimuli of the auditory system in particular. Peter Kreuzer, M.D. related a comparison of combined temporal and prefrontal stimulation, with standard temporal stimulation–does location of treatment make a difference, singly or in combination?
 
In the same vein, ATA Scientific Advisory Committee member Dr. Jinsheng Zhang, Associate Professor in the Department of Otolaryngology at Wayne State University, related his “Scientific Experience with Brain Stimulation.” He traced the neural track of “sound” as it enters the auditory nerve, then passes through several brain centers like train stations along the way, finally being decoded and processed in the auditory cortex. What’s interesting, he observed, is that you can apply electro-magnetic stimulation from either direction: From the “top down”, starting with stimulation deep in the brain in the auditory cortex, or from the “bottom up,” such as with a cochlear implant device that is hooked up to the auditory nerve. [In cases of profound deafness, a device called a cochlear implant be surgically implanted into the ear, with its tiny microphone, transmitters and electrodes actually connected to the auditory nerve. Not only does this restore hearing to some degree, but the patients who happened to have tinnitus reported to their astonished doctors that their tinnitus was reduced or eliminated!]

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Special Aspects of Tinnitus

Ana Carolina Binetti, M.D., and Piotr Skarzynski, M.D., shared with the conference their work on tinnitus with children, who may exhibit other symptoms like dizziness or hearing loss. Christine Tan, M.D., related her studies on measuring hearing frequency selectivity between groups of hearing-impaired individuals with and without tinnitus. 

Many patients report stressful episodes marking the onset of their tinnitus. Grazyna Bartnik, M.D., Ph.D., from the Institute of Physiology and Pathology of Hearing in Warsaw, Poland, described a connection between tinnitus and stress. Stress affects the function of the inner ear and auditory pathways in normal-hearing patients with tinnitus. This can lead to another feedback loop, where anguish of tinnitus can lead to a condition of chronic stress, which further affects the tinnitus. [Breaking these feedback loops and others like them in the nervous system may be one of the necessary challenges to confront in any tinnitus treatment program.] In fact, said Dr. Bartnik, animal studies have shown that stress can damage the hippocampus in the brain. [Interesting -  it echoes what Dr. Salvi said earlier in the day, about noise-induced hearing loss also impairing the ability of the hippocampus to grow new brain cells.]  Perhaps stress it what triggers the initial detection of the tinnitus through the influence of the inner ear. Anna Fabinjanska, M.D., also from Warsaw, maintained that peripheral damage is necessary for tinnitus generation, such as outer hair cell damage in the inner ear. She concluded that unilateral tinnitus can be caused by a combination of impairment of the cochlea, and a hearing sensitivity at extended high frequencies can provoke a serious alteration in the central processing system.  
 
Ms. Keila Knobel,  moderated a series of presentations that highlighted the auditory system’s role in tinnitus. Since distorted sound is the distinguishing characteristic of tinnitus, these auditory studies are a logical place to start to unravel the mystery of tinnitus. Wolfgang Delb, M.D., drew attention to the curious finding that dominant frequencies in the tinnitus spectrum–whether it is high-pitched, low, or in between–correspond to dead regions in the cochlea. This may imply a future therapy of resuscitating those dead regions [such as my finding ways to regrow inner hair cells] that could be the first step in restoring tinnitus. 
 
Many patients associate stressful episodes with the onset of their tinnitus; Dr. Grazyna Bartnik described how stress affects the function of the inner ear and auditory pathways. Dr. Anna Fabinjanska contrasted acoustic emission distortion of patients with normal hearing and patients with tinnitus.
 
So ended the second day of sessions. The President of the conference, Dr. Tanit Ganz Sanchez, hosted a lovely dinner by the seashore. The measured timbre of waves rolling into shore, with all its multitude of soothing frequencies, could be nature’s best sound therapy for tinnitus.

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Conference Wrap-Up Begins

The last day started with a panel on the science of studying tinnitus. As Dr. William Martin said in an earlier talk, what tinnitus research needs most is not necessarily more scientific studies, but scientific studies that use rigorous research standards and techniques, particularly in terms of clinical trials.  

Dr. Fabrizio Benedetti revisited the placebo effect, which if left uncontrolled, can make a hash of any study. Richard Tyler, Ph.D., Professor in both the Department of Otolaryngology and the Department of Speech Pathology and Audiology at the University of Iowa, offered insight on how and why to measure tinnitus. [Note: Although Dr. Tyler was scheduled for the conference, he was unable to attend, and he graciously provided his comments for this report.]  “In order to study anything,” he observed, “it is necessary to be able to measure it.” For tinnitus, clinicians and researchers should distinguish by measuring tinnitus magnitude and the reactions to tinnitus. The tinnitus magnitude can be measured by having the patient adjust the loudness of a tone so it has the same loudness of the tinnitus. A validated, sensitive and widely used method is the Tinnitus Handicap Questionnaire (Kuk, Tyler, Russell and Jordan, 1990). One advantage of this is that it uses a 100 point percentage scale.  
 
New measuring tools include developments like attempting to use brain-imaging studies to map the severity of the tinnitus and the regions that are active in tinnitus patients. A new questionnaire is being developed that is focused on 1) thoughts and emotions, 2) hearing, 3) sleep, and 4) concentration; the focus of Tinnitus Activities Treatment. [From a patient’s perspective, sometimes just being able to take the measure of your tinnitus lets you get a handle on it; most patients are astonished at how quiet their tinnitus really is on an objective scale, even though it sounds quite louder subjectively.]

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More on Drugs
Dr. Carol Bauer from Southern Illinois University, an ATA Board member, gave a splendid overview of drugs that have shown some effectiveness [unlike the tinnitus snake oil remedies that are occasionally peddled on late-night television infomercials and on the back pages of disreputable magazines.] What is needed, said Dr. Bauer, is “evidence-based pharmacy.” That evidence is ideally a controlled clinical test, but can also include descriptive case studies and even personal experience. But then you have to ask, how strong is the evidence? Can the results be replicated? Are they consistent? She mentioned some of the drugs that have shown some promise, in certain cases including: Lidocaine, Alprazolam, Clonazepam, Gabapentin, Acamprosate, Tegretol, anti-depressants that are classified as selective serotonin reuptake inhibitors (SSRI’s), Gingko and Sulpiride. But none of these so far have proved to be a universal cure for tinnitus.  
 
Dr. Bauer then spoke with exasperation about a strange phenomenon seen by tinnitus drug researchers: A patient will report a trial drug appears to work well, followed by additional good results in case studies of several patients. . . then positive treatment outcomes will be reported on questionnaires with larger studies, so far so good. . . but when the drug is finally tested against a placebo [a benign substance in the same type of capsule, for example, so the patient doesn’t know if he’s not taking the real drug], then nobody can tell the difference between the real drug and the placebo. A bust, in other words.
 
How can that happen? Well, several reasons, said Dr. Bauer. Different doses. Different patient groups, as with age, other symptoms, hearing loss, etc. In other words, evidence-based pharmacy has to be done rigorously, according to strict scientific protocols.
 
Eberhard Biesinger, M.D., led a panel which confronted the thorny issue of how do you treat tinnitus patients who also can’t stand noise, have dizziness, or can change their tinnitus by physical movement, such as by turning their heads or moving their jaws. This panel was a good reminder that tinnitus treatments cannot be “one-size-fits-all.”

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Jack A. Vernon, Ph.D. Award
At this time, the leaders of the conference announced a new award. Named after tinnitus research pioneer and ATA-co founder, the late Jack A. Vernon Ph.D., the ITS 2011 announced the winner of the award for the best conference poster. These posters play a critical part in sharing ideas. They summarize the work that an investigator or team has being doing, present evidence, and form conclusions. These ideas are the bricks that form the structure, which leads to a better understanding of tinnitus and how to treat it. If and when the first cures for tinnitus are found, they will likely be based on this patient, rigorous accumulation of steady scientific work. 
 
Dr. Vernon was, of course, researching tinnitus when practically nobody was willing to touch it with a ten-foot long wooden tongue depressor, since everyone knew that tinnitus could never be treated and patients just had to learn to live with it. Dr. Vernon’s legacy includes the legion of tinnitus researchers over the years who were educated and inspired by him. You can read more about Jack’s lasting impact on the tinnitus community through special tributes penned by his colleagues and those he mentored.
 
In presenting the award, Dr. Claudia Coelho commented on the need to combine basic research with treating patients. “Science without clinical perspective is empty,” she said.  “Clinical treatment without science is blind. There can’t be advances without a dialogue between the two.”
 
Of the 95 submitted posters [it is rather stirring to think of it: 95 new ideas on how to tackle tinnitus], five finalists were chosen by a petit-committee formed by Drs. Ron Goodey, Jaqueline Sheldrake and Laurence McKenna. Of those five, one was awarded the Jack Vernon prize for originality, innovation, study design, analysis and ultimate impact on the field of tinnitus.  That award went to [...drum roll please. . .] the co-authors Myriam Westcott, Tanit Ganz Sanchez, Isabel Diges, Margaret Jastreboff, Ross Dineen, Celene McNeill, and Alison Chiam for their multicenter combined studies, in different countries, of a curious condition called Tonic Tensor Tympani Syndrome (TTTS). This is an involuntary anxiety-based condition where a tiny muscle in the ear called the tensor tympani goes into a frequent or continual spasm. This can trigger a whole chain of reactions in and around the ear and irritate the trigeminal nerve. All this can lead to a sense of fullness in the ear, pain around the ear, and a weird feeling called “tympanic flutter” which makes you feel like there’s a moth trapped in your ear. This condition can readily develop with tinnitus patients in a surprising prevalence, since exposure to sound can apparently trigger it. So, TTTS seems to be a complimentary mechanism to explain further sensations in many patients who are exposed to loud sounds, in addition to the outer hair cells damage.

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Getting a Better Picture of Tinnitus

After the awards, the next collection of afternoon presentations covered the issue of imaging. Tinnitus has often been described as a phantom noise; can you photograph a ghost? Maybe not the ghost itself, but sometimes you can catch a reflection in a window or the swaying of curtains to hint at a ghost passing by, in old mystery stories. Likewise, tinnitus investigators have proved that you can at least capture telltale images of where the tinnitus is flitting through the brain. Dr. Jinsheng Zhang, moderated the discussion. Fatima Husain, M.D., contrasted neuroanatomical differences in hearing loss and tinnitus. Dr. Wolfgang Delb used fMRI (functional magnetic resonance imaging) technology to stimulate the brain with reconstructed tinnitus sounds. Functional MRI is one of the most widely used neuroimaging techniques, since it can “see” blood flow in the brain, caused by neurological activity; this tells you what part of the brain is “working.” Audrey Maudoux, M.D., in exactly the kind of sideways thinking that may offer key clues to treatment, asked and answered the question, what does the brain of a tinnitus patient look like when it is at rest, not experiencing tinnitus?

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Final Sessions

The conference talks switched back and forth between basic science theory and practical clinical experience. A series of clinicians, on the front lines of tinnitus treatment, offered their perspectives, as moderated by Dr. Ron Goodey. Dr. Iem Bakker presented his experience with tinnitus treatment by manual therapy, to correct imbalance of the spinal column and the skull and to restore spinal range of motion, with a combination of manipulation and mobilization. Since many patients do not have access to qualified cognitive behavior therapists (CBT), Maria Kleinstauber Ph.D., developed an internet-based self-training program for CBT for chronic tinnitus patients. Marisa Pedemonte, M.D., Ph.D., reported on her clinical trials using sound stimulation during sleep. [Do people experience tinnitus while they sleep?  Yes, they do.]

Paul Davis, Ph.D., continued these talks on clinical experiences by relating his use of the “Neuromonics” treatment for war veterans who came back from battle with raging tinnitus. The treatment utilizes a customized neural stimulus combined with specific music, delivered according to a coordinated program. Shekhawat Giriraj Singh, Ph.D.,  provided a quality of life study for people with hearing aids, since similar devices are used from some types of tinnitus sound therapy. Dr. Celene McNeil, rounded out the discussion by identifying pitch-matches of tinnitus [in other words, measuring how high or low pitch the tinnitus sound is perceived] with the masking effects of wearing sound-generating devices.
 
It was time to talk about surgery. In a few cases, a surgical procedure may treat tinnitus. Dr. Dirk deRidder identified one such opportunity with vascular decompression, in which a blood vessel presses against the auditory nerve; with that kind of compression, you get tinnitus. However, it is possible to surgically correct that condition. Luiz Lavinsky, M.D., Ph.D., described the application of intratympanic drugs–injecting drugs into the middle ear, past the eardrum. Ricardo Bento, M.D., Ph.D., described the process and results of implanting hearing aids.
 
The last session of the conference involved three new treatment strategies. Thomas Meyer, M.D., presented a new middle ear treatment; Dr. Peter Kreuzer discussed a pilot study of the use of transcutaneous stimulation of the vagus nerve. A similar procedure has already been successful in treating some varieties of epilepsy.
 
This conference made you aware that frontline clinical treatment, like basic research, is actively exploring any and all options in confronting tinnitus.

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Closing Observations and Impressions from Scott
1. If you suffer from tinnitus, and you have wished that some researcher, somewhere, anywhere, might come up with a cure–then take heart by the fact that there are hundreds of brilliant and dedicated people who are working on every conceivable angle to do just that. Never lose your hope! These few words do not do justice to the verbal explanations, computer simulations, the graphs of data, and brain-scan imagery that were so effectively used by these scientists to share their complex ideas. These researchers bring more to the table than just their intellect; they do their work with a passion and empathy for the millions of people who suffer from this condition. To see them share ideas as they did at ITS 2011 in Brazil, is a reminder of the growing networks of communication that accelerate tinnitus research.
 
2. Several times during the conference, the need for “multi-disciplinary and interdisciplinary” approaches to tinnitus research and treatment were highlighted. It seems to me that this must mean more than just getting experts from different fields involved, because then you just have neurologists talking about neurology and audiologists talking about audiology. There must be a synthesis of these diverse fields. You see such synthesis, especially during question-and-answer sessions when investigators from different specialties struggle to understand new concepts being presented. To me it is nothing short of heroic that researchers who have spent a lifetime in mastering one field are willing to retool themselves in another field, to better understand tinnitus.
 
3.  Let’s talk about a “cure” for tinnitus. As you listen to the painstaking research of these investigators who participated in this conference, either in person or online, you begin to glimpse how some of this might fit together in a variety of treatments. Not some mad scientist stirring a witch’s brew of off-the-elemental-chart chemicals to concoct a magic pill, but instead putting together some of these amazing scientific advances into something resembling an effective combined therapy. If tinnitus is a result of discordant and ungated brainwaves, maybe that can be reset by the advances in electromagnetic stimulation. And since the limbic system plays such a key role in the suffering aspect of tinnitus, we already have effective psychological approaches to deal with that part of it. And there is no question that certain drugs and surgery techniques can have direct application for tinnitus. There are a lot of exciting pieces to the puzzle that might be combined in different ways for patients with different kinds of tinnitus.
 
3. Keep your eye on Brazil. A team led by Drs. Tanit Ganz Sanchez, Claudia Coelho, and Marcia Kii mobilized the resources of their universities and clinics to put on a world-class conference. Online presentations from researchers around the world, electronic posters, taking questions from the internet, the Jack Vernon Award, and recorded sessions to allow a 3-month follow-up–these innovations and more made this a benchmark conference for the tradition of the International Tinnitus Seminar.
 
The next International Tinnitus Seminar will be held in Berlin, in 2014. And there are other conferences coming up: The Tinnitus Research Initiative Foundation (TRI) is hosting a meeting in Buffalo, New York on August 19-21, on the neuroscience of tinnitus, with another TRI meeting in Belgium on June 13-16 on auditory neuroscience.

If you have any questions about ATA-funded research or tinnitus research in general, please contact ATA Director of Research, Daniel Born at daniel@ata.org.

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