Neural Substrates of Tinnitus in an Auditory Brainstem Implant Patient: A Preliminary Molecular Imaging Study Using H2 15 O-PET Including a 5-year Follow-up of Auditory Performance and Tinnitus Perception
Authors: Gilles Annick , Song Jae-Jin , Hofkens-Van den Brandt Anouk , Mertens Griet , Matthies Cordula , Staelens Steven , Stroobants Sigrid , Vanderveken Olivier , Topsakal Vedat , Van de Heyning Paul , Van Rompaey Vincent 
Published: December 2019

Introduction:
It was previously demonstrated that tinnitus due to profound unilateral hearing loss can be treated by the use of electrical stimulation via a cochlear implant (CI) with long-lasting positive effects. In cases where patients are not suitable for cochlear implantation due to aplasia/hypoplasia, cochlear malformations etc., an auditory brainstem implant (ABI) may be a solution. While auditory performance with ABI is well investigated, it is currently unknown whether stimulation through ABI also renders tinnitus reduction in patients with incapacitating tinnitus. The current case study reports on the subjective tinnitus perception during a 5-year follow-up period. In addition, a first H2
15O PET imaging study in an ABI patient is carried out revealing underlying neural substrates of tinnitus.

Methods:
A 56-year-old male single-sided deaf patient with incapacitating tinnitus received an ABI after insufficient auditory performances and only minor tinnitus reduction with CI. Audiological follow-up was carried out during a 5-year follow-up period comprising pure-tone audiometry, speech-in-quiet testing, speech-in-noise testing, tinnitus questionnaires (tinnitus questionnaire and numeric rating scale) and the HISQUI19 questionnaire. To investigate the neural substrates of tinnitus in this subject, H2
15O PET tomography scans were acquired in three different conditions: 1) ABI switched off which was considered as the resting-state measurement rendering the loudest possible tinnitus for the patient (ABI OFF); 2) ABI switched on causing a small suppression of tinnitus due to electrical stimulation (ABI ON); 3) ABI switched on and 70 dB SPL white noise presented directly to the external audio processor through a direct audio cable providing the maximum tinnitus suppression for the patient (NOISE).

Results:
Subjectively the patient reported a significant tinnitus reduction after implantation which remained stable over time with a decrease in tinnitus questionnaire from grade 4 to grade 2 and a 50% reduction in the numeric rating scale (from 8 to 4) during the 5-year period. Comparing the ABI OFF and ABI ON conditions, significant increase in regional cerebral blood flow (rCBF) was observed in brain areas involved in the salience network showing already suppression of tinnitus only by electrical stimulation in the absence of auditory stimuli. The NOISE condition showed relatively decreased rCBF in the insula (as well as in the orbitofrontal cortex) as compared with the ABI OFF condition. Abnormally activated areas comprising the salience network may have been significantly suppressed by the NOISE condition both by acoustic and electrical stimulations of the auditory pathway. Moreover, the NOISE condition showed significantly decreased rCBF in the parahippocampus as compared with the ABI OFF condition. This finding supports the idea of distinct tinnitus generators depending on the amount of hearing loss.

Conclusion:
The reduction of tinnitus in the current ABI subject may be attributable to partial peripheral reafferentation-induced deactivation of the parahippocampus-based tinnitus generator as well as the salience network. Further validation is required by the use of a follow-up study with a larger number of subjects.