Department of Neurology, E-Da Cancer Hospital, Kaohsiung, Taiwan.
Prospect Clinic for Otorhinolaryngology and Neurology, Kaohsiung City, Taiwan.
JAMA Otolaryngol Head Neck Surg. 2020 Sep 1;146(9):801-809. doi: 10.1001/jamaoto.2020.1497.
IMPORTANCE: Tinnitus has a prevalence of 10% to 25% and is frequently associated with numerous complications, such as neuropsychiatric disease. Traditional treatments have failed to meet the needs of patients with tinnitus. Noninvasive brain stimulation (NIBS) can focally modify cortical functioning and has been proposed as a strategy for reducing tinnitus severity. However, the results have been inconclusive. OBJECTIVE: To evaluate the association between different central NIBS therapies and efficacy and acceptability for treatment of tinnitus. DATA SOURCES: ClinicalKey, Cochrane CENTRAL, Embase, ProQuest, PubMed, ScienceDirect, and Web of Science databases were searched from inception to August 4, 2019. No language restriction was applied. Manual searches were performed for potentially eligible articles selected from the reference lists of review articles and pairwise meta-analyses. STUDY SELECTION: Randomized clinical trials (RCTs) examining the central NIBS method used in patients with unilateral or bilateral tinnitus were included in the current network meta-analysis. The central NIBS method was compared with sham, waiting list, or active controls. Studies that were not clinical trials or RCTs and did not report the outcome of interest were excluded. DATA EXTRACTION AND SYNTHESIS: Two authors independently screened the studies, extracted the relevant information, and evaluated the risk of bias in the included studies. In cases of discrepancy, a third author became involved. If manuscript data were not available, the corresponding authors or coauthors were approached to obtain the original data. This network meta-analysis was based on the frequentist model. MAIN OUTCOMES AND MEASURES: The primary outcome was change in the severity of tinnitus. Secondary outcomes were changes in quality of life and the response rate related to the NIBS method in patients with tinnitus. RESULTS: Overall, 32 unique RCTs were included with 1458 unique participants (mean female proportion, 34.4% [range, 0%-81.2%]; mean age, 49.6 [range, 40.0-62.8] years; median age, 49.8 [interquartile range, 48.1-52.4] years). The results of the network meta-analysis revealed that cathodal transcranial direct current stimulation over the left dorsolateral prefrontal cortex combined with transcranial random noise stimulation over the bilateral auditory cortex was associated with the greatest improvement in tinnitus severity (standardized mean difference [SMD], -1.89; 95% CI, -3.00 to -0.78) and quality of life (SMD, -1.24; 95% CI, -2.02 to -0.45) compared with the controls. Improvement in tinnitus severity ranked more favorably for continuous theta-burst stimulation (cTBS) over both auditory cortices (SMD, -0.79; 95% CI = -1.57 to -0.01) than cTBS over only the left auditory cortex (SMD, -0.30; 95% CI, -0.87 to 0.28), compared with controls. Repetitive transcranial magnetic stimulation with priming had a superior beneficial association with tinnitus severity compared with the strategies without priming. None of the investigated NIBS types had a significantly different dropout rate compared with that of the control group. CONCLUSIONS AND RELEVANCE: This network meta-analysis suggests a potential role of NIBS interventions in tinnitus management. Future large-scale RCTs focusing on longer follow-up and different priming procedure NIBS are warranted to confirm these findings.
重要性:耳鸣的患病率为 10%至 25%,常伴有许多并发症,如神经精神疾病。传统的治疗方法未能满足耳鸣患者的需求。非侵入性脑刺激(NIBS)可以局部改变皮质功能,并被提议作为减轻耳鸣严重程度的一种策略。然而,结果并不一致。
目的:评估不同的中枢 NIBS 治疗方法与疗效和可接受性之间的关系,以治疗耳鸣。
数据来源:从成立到 2019 年 8 月 4 日,在 ClinicalKey、Cochrane 中央、Embase、ProQuest、PubMed、ScienceDirect 和 Web of Science 数据库中进行了检索,没有语言限制。从综述文章和成对荟萃分析的参考文献中手动搜索可能符合条件的文章。
研究选择:纳入了单侧或双侧耳鸣患者使用中枢 NIBS 方法的随机临床试验(RCT)进行本次网络荟萃分析。中枢 NIBS 方法与假刺激、等待名单或阳性对照进行比较。未进行临床试验或 RCT 且未报告感兴趣结局的研究被排除在外。
数据提取和综合:两名作者独立筛选研究、提取相关信息,并评估纳入研究的偏倚风险。如有分歧,第三名作者参与其中。如果手稿数据不可用,则联系相应的作者或合著者以获取原始数据。本网络荟萃分析基于经典似然法。
主要结局和测量:主要结局是耳鸣严重程度的变化。次要结局是耳鸣患者生活质量的变化和与 NIBS 方法相关的反应率。
结果:共有 32 项独特的 RCT 纳入了 1458 名独特的参与者(女性比例平均为 34.4%[范围,0%-81.2%];平均年龄为 49.6[范围,40.0-62.8]岁;中位数年龄为 49.8[四分位间距,48.1-52.4]岁)。网络荟萃分析的结果表明,左侧背外侧前额叶皮质的阴极经颅直流电刺激联合双侧听觉皮层的经颅随机噪声刺激与对照组相比,耳鸣严重程度(标准化均数差[SMD],-1.89;95%置信区间,-3.00 至-0.78)和生活质量(SMD,-1.24;95%置信区间,-2.02 至-0.45)的改善最大。双侧听觉皮层的连续 theta 爆发刺激(cTBS)(SMD,-0.79;95%置信区间 = -1.57 至-0.01)优于左侧听觉皮层的 cTBS(SMD,-0.30;95%置信区间,-0.87 至 0.28),与对照组相比,耳鸣严重程度的改善更为有利。与无预激的策略相比,带预激的重复经颅磁刺激在与耳鸣严重程度相关方面具有更好的有益关联。与对照组相比,未发现任何一种被调查的 NIBS 类型的辍学率有显著差异。
结论和相关性:本网络荟萃分析表明,NIBS 干预措施在耳鸣管理中可能具有潜在作用。未来需要进行大规模的 RCT,重点关注更长时间的随访和不同的预激程序 NIBS,以证实这些发现。
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