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INTRODUCTION: The general consensus on the roles of hearing loss in triggering tinnitus seems not applicable in patients with normal hearing thresholds. OBJECTIVE: To scrutinize auditory functioning in a sample of tinnitus subjects with normal hearing thresholds and non-tinnitus normally hearing control participants using transient evoked and distortion product otoacoustic emission (TEOAE and DPOAE) and Threshold Equalising Noise (TEN) test. METHODS: Twenty-seven tinnitus adult patients with normal hearing thresholds and 27 normally hearing volunteers were tested with TEOAE, DPOAE and TEN test. CONCLUSION: These results suggest the possible existence of subtle auditory deficit in normally hearing tinnitus patients, which may be an early sign of diseases that are only diagnosed after the onset of hearing loss. Keywords: coustic neuroma, otoacoustic emissions, tinnitus, threshold equalising noise test. Tinnitus is defined as the perception of sound that results completely from activity within the nervous system without any corresponding mechanical, vibratory activity within the cochlea, and not related to external stimulation of any kind1. An increasing amount of epidemiology studies provide both self-reported data on tinnitus and hearing status which allows closer examination on the relationship between tinnitus and hearing status. Although some studies have different theoretical assumptions and approaches, the significance of hearing loss in tinnitus generation is not questioned. Thus, several attempts have been made to explain pathophysiology mechanisms of tinnitus in patients with normal hearing ability particularly using otoacoustic emissions (OAEs). Several studies have revealed that TEOAEs and DPOAEs can be used as a tool to detect early hearing loss before it can be diagnosed by PTA13-15. The contradict findings from previous research motivates researchers to find alternative theories to explain tinnitus mechanisms in tinnitus patients with normal hearing thresholds.
This study investigated 27 tinnitus subjects (42 tinnitus ears and 12 contralateral non-tinnitus ear) with normal hearing thresholds who were recruited from Welsh Hearing Institute, University Hospital of Wales.
Full history taking and otoscopy examination were carried out at the beginning of the session. TEOAEs test was performed using unfiltered clicks of 80 µs duration presented in non-linear modes. The stimulus comprised of a pair of primary pure tones (f1 and f2) at a frequency ratio equal to 1.22.
The basic principle of this test is to control for "off-frequency listening" from occurring by using a broad band noise (the threshold equalising noise).
This research has received the ethical approvals from the School of Applied Community and Health Studies (SACHS), University of Bristol Human Participants Ethics Committee and the South East Wales Research Ethics Committee.
Initially, the left and right of DPOAE results were compared within the tinnitus and control groups. Then, the differences of overall mean DPOAE amplitude between tinnitus and control ear were compared. Various hypotheses have been put forward to explain tinnitus generation in normal hearing patients. Decreased TEOAE amplitudes were observed in 35.7% of the tinnitus subjects with normal hearing sensitivity. A statistically significant increase in DPOAE amplitude was observed in tinnitus ears at f2 frequency of 1414 Hz. The fact that tinnitus patients with normal hearing have a significantly higher percentage of abnormal TEOAEs and a limited frequency of DPOAE than the controls may suggest that OHC dysfunction may be pivotal in tinnitus generation.
In the current study, the percentage between abnormal TEOAE and DPOAE in both groups had no statistically significant difference. In the field of tinnitus, however, only two studies reported the application of TEN(HL) test in tinnitus patients with normal hearing24,25. Based on systematic review, no research on the application of TEN test in detecting acoustic neuroma has been published. No published data was found on the application of a TEN test in detecting acoustic neuroma. This study showed that subtle cochlear problem may exist in tinnitus patients before it is significantly appeared in the audiogram.
Thanks to University Hospital of Wales, UK for providing the facilities to conduct this research.
This study was supported by the University of Bristol, UK and Ministry of Higher Education (MOHE) Malaysia and Universiti Kebangsaan Malaysia (UKM) as parts of the first author's PhD research.
Paper submitted to the ITJ-SGP (Publishing Management System) on February 17, 2014; and accepted on February 20, 2014. To date, no known curative medical or surgical treatment is available for addressing chronic tinnitus. However, habituation to tinnitus is a central auditory process; accordingly, persistent suffering of tinnitus patients is connected to deficits within this process. The functions of sound transfer in the middle ear and the treatment of diseases in that area are well-known.
This type of specialization of cells and the anatomy of the entire afferent sound path is well-known. The efferent path descends from the auditory cortex down to the corpus geniculatum mediale. One main target is to develop diagnostic tools to prove these functions or deficits by audiological examinations. Objective diagnosis of cochlear function, mainly OHC activity, is based on recordings of otoacoustic emissions. Research work on the functions and major characteristics of the psychoacoustical hearing process is based mainly on research by Zwicker [13] but, as mentioned, these elements are not very commonly known within general practices. Certain objective controlling methods with humans were tested according to the idea of brain-mapping; here, especially the group working with Hoke and Hoke [15] and Pantev [16] have achieved high merits mainly because of functional nuclear magnetographic measurements.
DP data from 20 normally hearing ears, obtained in the same manner, were used as reference data [20]. To quantify the DP growth, the slope was calculated between L2 = 40 and L2 = 60 dB SPL, where a flat course occurred in the normal hearing state and a steep course in the pathological state.
Between 1 and 3 kHz, where the hearing threshold Lt was within normal limits, the DP levels were unusually low. Similar findings led us to examine these functions with hyperacusis patients with normal subjective hearing on pure-tone audiogram.
Between the years 2001 and 2002, we examined 127 patients with tinnitus and an almost normal hearing threshold. All these findings give evidence that in a great number of tinnitus and hyperacusis patients, the efferent regulation of the OHCs fails or is even turned off completely. Our audiological data show specific findings in many tinnitus and hyperacusis patients, although they are not similar in all such patients.
Similar to these findings with tinnitus patients [26,27], our data show the same effect with 6 8% of normally hearing hyperacusis patients. These results suggest that in many hyperacusis patients and in tinnitus patients, some alteration of auditory processing already occurs on the cochlear level. Until today, tinnitus perception could not be influenced by any medicine without completely destroying the sense of hearing or incurring the risk of severe side effects.
Some approaches involve implanting special catheters, placing them at the area close to the round window and trying to apply medicine with a special dosage pump as a local therapy for the inner ear. Surgical approaches (except, of course, surgery that treats such middle-ear diseases as otosclerosis and thus preserves or restores hearing as the main goal) are restricted to cutting the acoustic nerve, with its known complications. Therefore, as curative treatments are far from being applicable, the focus of tinnitus therapy is trained on habituation processes [33]. With our clinical data, we could prove that in a large number of tinnitus patients, these deficits of central auditory processing and efferent inhibition can be recorded. This research was presented at the Thirty-First Congress of the Neurootological and Equilibriometric Society, Bad Kissingen, Germany, March 25-27, 2004. INTRODUCTION: Tinnitus is considered as one of the major symptom associated with many pathologies along with its presence in individuals with normal hearing. OBJECTIVE: Study was undertaken to find the efficacy of Residual Inhibition Therapy as treatment procedure for unilateral tinnitus in individuals with normal hearing by comparing pre and post Residual Inhibition Therapy, Contra-lateral Acoustic Reflexes and Tinnitus Handicap Inventory. MATERIALS AND METHODS: Ten subjects between the age range of 20-45 years were included for the study. RESULTS AND CONCLUSION: Statistical analysis revealed no significant difference, however, elevated contra-lateral acoustics reflexes post Residual Inhibition Therapy were seen. Tinnitus is referred to, a sound generated by brain in the absence of acoustic stimulation due to increased neural activity1. Today, with advancing field of Audiology, treatment strategies are aimed to reduce or eliminate symptoms and distress caused by tinnitus which includes Residual Inhibition Therapy (RIT), Masking Tinnitus Retraining Therapy and Cognitive Behavioral Therapy.
In support of the literature, audiological practice encounters an increasing number of tinnitus and thus, one needs to evaluate the efficacy of the treatment. Reflexometry at 500 Hz, 1000 Hz, 2000 Hz and 4000 Hz was repeated to elicit the baseline contra-lateral acoustic reflexes pre Residual Inhibition Therapy. Statistical analysis using paired sample t test is carried out with Bonferroni's correction applied for multiple comparison between pre and post comparison of four frequency thresholds in contra-lateral reflexometry. The present study investigated the effectiveness of RIT using a questionnaire aiming to betterment of tinnitus and contra-lateral acoustic reflexes in adult individuals.
From Table 2, the Tinnitus Handicap Inventory did not show any significant changes in the scores obtained pre and post RIT. Similarly, obtained contra-lateral reflexes pre and post RIT were compared using sample t-test. From Figure 1 we can conclude that, post RIT contra-lateral acoustic reflexes required higher intensity in comparison to pre RIT contra-lateral acoustic reflexes to elicit a reflex.
From Table 3 it is evident that there is no significant difference (p > 0.05) between contra-lateral acoustic reflexes pre and post RIT (Boneferroni's correction applied for multiple comparisons). Primary aim of the study was to establish the effectiveness of RIT on subjects experiencing tinnitus. The depth and duration of residual inhibition was found to be varied from individual to individual and the peak measurement of duration of residual inhibition was 70 sec.
The current study results are in support with the previous literature where the 57% of tinnitus experiencing subjects relapse in 2 minutes, 23% subjects in 2 to 4 minutes, 11% subjects in 4 to 6 minutes, 4% subjects in 6 to 8 minutes, 2% subjects in 8 to 10 minutes and 3% subjects with more than 10 minutes19. The current study used duration of 60 seconds for the presentation of target stimulus and the RIT success rate is obtained with increase in number of the target stimulus experienced to suppress tinnitus however, due to the fatigue of masking in subjects some might require longer duration of target stimulus to maintain residual inhibition12. The poor agreement with the earlier literature could be due to differences in noise bandwidths used for the study, tinnitus pitch tuning methods, sound levels used and the various differences in the experimental details.
The present study aimed at testing the effectiveness of RIT using pre and post tinnitus questionnaire response and contra-lateral acoustic reflexes. Paper submitted to the ITJ-SGP (Publishing Management System) on May 21, 2015; and accepted on June 23, 2015. Key words:aural rehabilitation, chemotherapy, cisplatin, COMP-VA, distortion-product otoacoustic emissions, DPOAE, hearing, OtoID, ototoxicity monitoring, sensitive range for ototoxicity. Prevention and rehabilitation of hearing loss and tinnitus are high priority initiatives in the Department of Veterans Affairs (VA). Within the inner ear, cisplatin primarily damages the cochlea, resulting in permanent, usually bilateral, high-frequency sensorineural hearing loss in approximately 60 percent of adults treated with the drug [9].
Currently, only a small fraction of Veterans undergoing chemotherapy with cisplatin are systematically monitored for signs of ototoxicity. Nearly 30 yr of prospective ototoxicity monitoring and research by the VA Rehabilitation Research and Development (RR&D) National Center for Rehabilitative Auditory Research (NCRAR) have shown that education and frequent communication with the monitoring audiologist improve the likelihood that oncologists will seek out and use information about ototoxic hearing changes for purposes of fine-tuning chemotherapy, when medically appropriate, to avoid disabling hearing loss.
The purpose of this article is to report on a complete program of evidence-based ototoxicity monitoring protocols, the comprehensive ototoxicity monitoring program for VA (COMP-VA), developed at the NCRAR.
COMP-VA is designed to be administered on the chemotherapy treatment unit just prior to treatment (chairside).
The OtoID portable audiometer is comprised of a touch screen computer module, Sennheiser HDA200 circumaural headphones (Sennheiser Electronic Corp; Old Lyme, Connecticut) modified with ambient noise monitoring microphones and custom audiometric testing software. The device has both manual (audiologist-directed testing) and automated (patient self-testing) modes.
Ongoing development of the OtoID includes the secure exchange of information between the device and the VA’s computerized patient records system and telehealth capabilities. Currently, most ototoxicity programs monitor in the conventional frequency range only, even though numerous studies show greater sensitivity is achieved by testing frequencies above 8,000 Hz [22].
We have recently confirmed that the risk for hearing shift from cisplatin is primarily related to the cumulative drug dose and, established in three separate data sets, that patients with better preexposure hearing have a greater risk of hearing change within the SRO at a given dose compared with patients with worse preexposure hearing [1–2,23]. In their respective clinical guidelines for ototoxicity monitoring, ASHA and the American Academy of Audiology (AAA) have proposed that both behavioral and nonbehavioral (objective) measures of auditory function be routinely used at the baseline evaluation because it is not clear which patients will become unable to provide reliable behavioral thresholds during treatment [20,26].
DPOAEs are objective measures able to identify cochlear changes associated with ototoxicity [29–30]. Another proposed DPOAE protocol involves the use of test-retest reference limits based on normal variability in serial DPOAE level plotted as a function of f2 frequency levels obtained in a nonexposed (to cisplatin) group of Veteran research participants. Even though many Veterans have preexisting hearing loss, most have DPOAEs that can be monitored for changes.
Below, we describe ototoxicity in two patients seen as part of our research on ototoxicity monitoring at the Portland VAMC. This patient is a 63 yr-old male treated for squamous cell carcinoma of the right base of tongue (stage IVa) with lymph node involvement. This patient is a 58 yr-old male treated for squamous cell carcinoma of the right tonsil (stage IVa).
Pretreatment ototoxicity risk assessment to demonstrate the anticipated hearing loss in the conventional frequency range as a result of the prescribed cisplatin dosing schedule. Screening for early hearing changes to identify any ASHA-significant hearing shift within each patient’s individualized SRO, as measured directly using pure-tone threshold testing or estimated using DPOAE testing.
Screening for outer hair cell dysfunction DPOAEs to identify early, potentially preclinical damage.
Screen failure follow-up testing to determine the extent that hearing changes include frequencies in the conventional audiometric frequency range as measured directly using pure-tone threshold testing or estimated using DPOAE testing. Screening for tinnitus to determine whether the drug treatment is instigating or exacerbating tinnitus and the need for a tinnitus management referral.
Patient and provider education about ototoxic-induced hearing and tinnitus, synergistic effects of ototoxins and noise overexposure, and rehabilitative solutions to hearing loss and tinnitus. The Table summarizes the COMP-VA clinical objectives pertinent to identifying and monitoring changes in hearing and outer hair cell function (objectives 1–4, listed above).
Description of proposed comprehensive ototoxicity monitoring program for Department of Veterans Affairs (COMP-VA) clinical objectives 1–4. How to cite this article Nicolas-puel C, Akbaraly T, Lloyd R, Berr C, Uziel A, Rebillard G, Puel J, et al. We undertook this prospective study with 555 patients attending a specialist tinnitus clinic at University Hospital, Montpellier, France, between 1998 and 2003. The semiological analysis of tinnitus covered several parameters, and each patient completed a questionnaire. For spatial localization, patients were asked to describe their symptoms as being either left- or rightsided or as nonlateralized.
Intensity was measured on a visual analog scale graded from 0 to 100, where 0 corresponded to an absence of tinnitus and 100 indicated the loudest tinnitus imaginable. We considered the length of history, age at presentation, intensity of the tinnitus, and any associated hearing loss as continuous variables. Table 1 details the population that was seen within a specialist tinnitus clinic (N = 555). Generally, patients were able to describe the circumstances in which they noticed the appearance of their tinnitus (Table 2). Analysis of the audiograms of the tinnitus patients showed a predominantly left-sided hearing loss, particularly in the higher frequencies (data not shown). In this study, we focused on those patients who said that the onset of their tinnitus began after noise trauma. Whereas in the overall population patients showed a mainly left-sided high-frequency hearing loss ( > 4,000 Hz), patients in the noise trauma population had similar hearing loss in each ear (Fig. Our study, undertaken in the context of a specialist tinnitus clinic at the University Hospital, Montpellier, shows that tinnitus affects both genders equally. In contrast to other tinnitus patients, those with a history of noise trauma demonstrated similar hearing losses in each ear and showed no difference in side of lateralization or nonlateralization of their tinnitus.
In this study, almost all the patients who had a history of noise exposure said that their tinnitus was of a highpitched whistling frequency.
In this study, we evaluated the intensity of tinnitus after noise trauma by using a visual analog scale.
The vast majority of patients with noise trauma described their tinnitus as high-pitched and stable over time. This study shows that noise trauma appears to provoke a high-pitched whistling tinnitus that is stable over time, occurs in either ear, and usually appears in men who are, on average, younger than the general tinnitus population.
The authors thank the Fond d'Aide a la Qualite des Soins de Ville Languedoc-Roussillon for his support in statistical analysis of the data. Is It Necessary to Do Temporal Bone Computed Tomography of the Internal Auditory Canal in Tinnitus with Normal Hearing?
Measurement of subtle auditory deficit in tinnitus patients with normal audiometric thresholds using evoked otoacoustic emissions and threshold equalizing noise tests.
The absence of hearing loss on the audiogram in this group of patients poses a serious challenge to the cochlear theories in explaining tinnitus generation in this group of patients. For many years, progress towards finding the effective treatments for tinnitus was hindered by vague understanding of its underlying pathologic mechanisms. The association between hearing loss and tinnitus has been well documented in the previous literature2-4.
Some studies found a correlation between severity of tinnitus and degree of hearing loss3,8 while others found no such correlation9.
On the other hand, clinical observations have shown that 8 to 10 per cent of tinnitus patients had normal audiometric thresholds12. It is hypothesised that outer hair cells damage results in stereocilia decoupling from the tectorial membrane, thus causing them to depolarise and subsequently resulting in tinnitus perception1. An association of tinnitus with the changes in amplitude of TEOAEs and DPOAEs has been reported. One study by Weisz et al.24 proposed that subtle auditory abnormality may also arise from the inner hair cells (IHCs) dysfunction. The subjects who were attending the Institute from January to December 2010, were identified by an audiology physician and audiologists based in this hospital.
Then, all subjects underwent basic audiological tests which include pure tone audiometry and tympanometry.
Off-frequency listening occurs when the presented stimulus is being picked up by other parts of the cochlea instead of the targeted frequency area of the cochlea.
From the analysis, the parameters of the TEOAEs for tinnitus ears are not significantly different from the control ears.
Since no statistically significant difference was observed between both ears, further statistical analyses were performed using combined data from both sides together. Distribution of the number of test frequencies with abnormal DPOAE in tinnitus and control ears. Based on the chi-square analysis, tinnitus ears have a statistically significant higher percentage of abnormal DPOAEs at some frequencies, mainly at 2000 and 4000 Hz regions (Table 4). For example, it has been postulated that the different level of functionality between OHCs and IHCs (the Jastreboff's discordant dysfunction theory) can generate an unbalanced stimulation of dorsal cochlear nucleus's cells which produces abnormal neural activity.
Abnormal DPOAE amplitudes were also found in this group, particularly at high frequency regions, but in a slightly lower percentage than the TEOAE.
For example, in Shiomi et al.19, the mean amplitudes of the DPOAE were significantly decreased in tinnitus patients with normal hearing than in normally hearing controls. One possible explanation for this finding is that it may be due to OHCs hypersensitivity, as reported in some previous research. Abnormal TEOAEs and DPOAE in the tinnitus patients also imply that they may have subtle cochlear damage that is not yet appearing on the audiogram. This finding might suggest that both tests were sensitive to detect minor OHCs dysfunction. Unexpectedly, the use of a TEN test in the current study has led us to find an acoustic neuroma in a patient.
Sincere thanks to Ministry of Higher Education (MOHE), Malaysia, Universiti Kebangsaan Malaysia (UKM) and University of Bristol for providing sponsorship to pursue this PhD study.
Program Audiologi, Pusat Pengajian Sains Rehabilitasi, Fakulti Sains Kesihatan - Universiti Kebangsaan Malaysia - Kuala Lumpur - AC - Malaysia. Specific Findings in Distortion Product Otoacoustic Emissions and Growth Functions with Chronic Tinnitus.
Latest studies found chronic tinnitus in 4% of the German population, with almost 2% suffering severely in their daily life. The latest data from Germany showed that 25% of the population experienced tinnitus for a short period at one time of their life, 13.8% did so for a longer period, and approximately 4% suffer from tinnitus to an extent requiring special intervention.
We know from our own clinical data that 90% of tinnitus sounds are generated in the internal ear, mainly caused by damage of the outer hair cells (OHCs) [3]. The theoretical background of this auditory sensory habituation is based on understanding the complete process of hearing.
Today, even the mechanisms of the inner ear are better known because of new findings of the function and structure of the OHCs [5] and the effective motor protein prestin [6]. The first binaural interaction takes place in the first neuron that ends in the dorsal and ventral nucleus cochlearis in the brainstem. The inferior colliculus seems to have a major function in the control of the efferent sound path and, thereby, of the function of enhancement and inhibition. Function controls for the different sectors of the sound paths are not commonly used in clinical practice; specific microscopical and electrophysiological research is based mainly on findings with cats and rats [11,12]. In particular, the frequency-specific measurement of distortion product otoacoustic emissions (DPOAE) can characterize the cochlear amplification process of the OHC, originating as a consequence of nonlinear sound amplification.
Recently, the binaural masking level difference test, a psychoacoustic test differentiating sound detection in unilateral and bilateral broadband noise, has been evaluated for clinical use [14]. DPs could be recorded well in the frequency range that corresponded to the appearance of tinnitus. Pure-tone audiometry showed normal thresholds (hearing loss not exceeding 10-15 dB HL) in all frequencies from 250 to 2,000 Hz. We performed pitch and loudness matching of the tinnitus by means of a clinical audiometer [19].
Normal hearing controls and normal, compressive, nonlinear DP-grams, growth function, slope (s), and pure-tone audiogram. Calculation of the slope between 40 and 60 dB SPL was chosen because, in that range, normal and pathological DP growth did differ most. Patient with sudden hearing loss and tinnitus measured at 6 kHz: DP-gram, growth function, slope (s), and pure-tone audiogram.
The DP-grams at high primary tone levels, however, lay close together, indicating normal compressive growth behavior.
Patient with progressive cochlear hearing loss and tinnitus at 8 kHz: DP-gram, growth function, slope (s), and pure-tone audiogram. In normal-hearing individual,distortion product otoacoustic emission amplitudes decreased after contralateral stimulation with a 60-dB broadband noise.
Distortion product otoacoustic emission amplitude reduction in certain frequencies in tinnitus patients. Distortion product otoacoustic emission amplitude reduction in certam frequencies (controls). However, in tinnitus patients without hyperacusis, this inverse reaction or hypermotility of OHCs is restricted to the tinnitus frequency; in hyperacusis patients, it seems to reflect a wider range of frequencies. Most probably, hyperacusis as an oversensitivity to all sounds is due to an inefficient input control of sounds or even overamplification of incoming sound [28]. Thus, audiological analysis, especially recording of DPOAEs, provides objective signs of different auditory processing in at least 40-50% of tinnitus patients. Instruments and specific tests for central auditory function also must be developed to give evidence to these deficits of efferent control: They must be easily applicable so as to be used on a wider clinical scale. Optimization of cochlear blood flow and oxygen supply may be efficient in acute types of OHC damage, especially after acoustic trauma or sudden sensorineural hearing loss.
However, even in these cases, more than 50% retain their tinnitus owing to central excitation of a primarily peripherally generated sound [32]. This process works the innate ability of the auditory system to alter the perception of random noise if its meaning is not connected to such emotions as fear or anger. Our results further indicate that in many tinnitus and hyperacusis patients, abnormal hypermotility of OHCs may occur even if hearing is completely normal. With varied cause and mechanism of its generation and increase in number of individuals with complaint of tinnitus, rehabilitation becomes crucial for Audiologists. Even though small sample size made it hard to conclude on the effectiveness of Residual Inhibition Therapy as treatment of tinnitus, elevated contralateral acoustic reflexes post Residual Inhibition Therapy pay way for further advanced studies on the same. It is considered to be an auditory phantom sensation experienced by 10-15 persons out of general population2.
RIT is referred to the auditory stimulation that results in temporary suppression of tinnitus6. Thus, the study was designed to know the effectiveness of RIT by comparing pre RIT contra-lateral acoustic reflexes to post RIT contra-lateral acoustic reflexes in normal hearing subjects experiencing continuous tinnitus unilaterally. The study protocol was approved by the Institutional Ethical Committee Board at Nitte Institute of Speech and Hearing, Mangalore. Subjects answered a questionnaire developed by five experienced Audiologists to rule out nature of complaint. For this, obtained questionnaire score and contra-lateral acoustic reflexes were measured at octave frequencies between 500 Hz and 4000 Hz were compared. Bonferroni's correction was applied for multiple comparison between pre and post comparison of four frequency thresholds. However there is no significant difference between the pre and post RIT contra- lateral acoustic reflexes.
For this, pre and post RIT questionnaire response and contra-lateral acoustic reflexes were compared.
This variation may be due to quieter level of stimulus intensity and lesser duration of narrow band noise played to the subjects which were required to influence the tinnitus triggering system. Explanation on subject's response to RIT after the target sound ends is with the start of silent phase of 20 to 35 seconds, followed by 30 to 35 seconds in which the tinnitus sound gradually recovers back. RIT has approved good effectiveness when the pitch of the tinnitus is matched with the target sound presented to suppress tinnitus15 however; in the present study we used narrowband noise of the nearing experienced tinnitus frequency.
Also, sample size used is small which can significantly influence the effectiveness of RIT.
Contra-lateral acoustics reflex thresholds obtained post therapy state is relatively higher than the pre therapy state, however, Tinnitus Handicap Inventory scores showed not much improvement.
Lectutrer, Nitte Institute of Speech and Hearing, Mangalore University, Approved by Rehabilitation Council of India.
Intern (BASLP), Nitte Institute of Speech and Hearing, Mangalore University, Approved by Rehabilitation Council of India.
At least 4,000 Veterans, most with significant hearing loss, will receive cisplatin this year, with more than half sustaining permanent hearing shift and nearly 40% developing new tinnitus. In the last decade, more than 33,000 Veterans nationally were treated with cisplatin chemotherapy at VA medical centers (VAMCs) (VA Informatics and Computing Infrastructure database, accessed 2012 May).
This damage occurs in a relatively orderly manner of base (high frequency) to apex (low frequency) destruction [10] primarily of the outer hair cells, which are sensory receptor cells that provide for the large dynamic range and exacting frequency selectivity that characterizes human hearing. Too often, Veterans in treatment are asked to arrange for audiological testing once debilitating hearing loss is already apparent to the patient or treatment team.
It has also become clear that audiology equipment and staffing limitations need to be overcome in order to consistently identify those patients who face the greatest risk for preventable hearing loss and to support those who need extra help and motivation to access VA’s comprehensive range of hearing loss and tinnitus rehabilitation services. COMP-VA was designed to achieve a range of customizable clinical objectives and to test all patients during treatment regardless of how sick they are or their ability to reliably take a hearing test using conventional methods.
This eliminates the need for patients to make additional trips to the VA and the need for scheduled hearing evaluations in the audiology clinic.
Sending HIPAA-compliant results from the OtoID built-in cell phone modem to a VA email address via secure text message is nearly complete. Standard air conduction testing in conventional and extended high frequencies is possible using the OtoID. Significant hearing shifts during ototoxicity monitoring have been defined by the American Speech-Language-Hearing Association (ASHA) [20] as a 20 dB decrease at any one test frequency, a 10 dB decrease at any two adjacent test frequencies, or the loss of response at any three consecutively tested frequencies where responses were previously obtained. For example, one clinical study showed that if only conventional frequency testing (?8,000 Hz) were used, 36 percent of initial (early detection) changes would have gone undetected [4], potentially missing the opportunity to prevent changes in the more functionally critical conventional frequencies. Previous studies that examined extent of preexposure hearing as a potential risk factor for ototoxicity have conflicting results [24–25].
By our estimation, at least 30 percent of patients who receive chemotherapy do, in fact, become unable to respond reliably during testing [27–28].


DPOAEs depend on the physiological status of the outer hair cells, which are the initial site of ototoxic damage and, therefore, should be sensitive to hearing shifts [31]. Using a machine learning paradigm, we established that DPOAE shift metrics, obtained by comparing DPOAE baseline results to monitoring results, alone are sensitive predictors of hearing change in the SRO region, but when DPOAEs are combined in a multivariate model with cumulative drug dose and baseline hearing levels, sensitivity increases without causing unacceptably high false positive rates. DPOAE level shifts obtained during ototoxicity monitoring that are greater than the decibel shift that marks the upper 90th percentile from the reference population identify a clinically significant DPOAE change [34]. For these individuals, chemotherapy treatments resulted in hearing shifts before the treatment was completed.
The case studies just presented illustrate how ototoxicity monitoring information can influence counseling, treatment decisions, and utilization of posttreatment audiological services for individual patients. The objectives are described in terms of the stakeholders requiring the data (who), the information being gathered (what), point in treatment to employ the test (when), basis for interpreting the results (how), and the evidence base supporting the test.
Table includes stakeholders in program (who), description of objective (what), implementation time (when), interpretation (how), and relevant citations (evidence base).
Characteristics of Tinnitus in a Population of 555 Patients: Specificities of Tinnitus Induced by Noise Trauma.
In this study, we compared tinnitus that appeared to be induced by noise trauma with that perceived to start in other circumstances in a population of 555 patients attending the specialist tinnitus clinic at the University Hospital in Montpellier, France.
To do this, we compared tinnitus induced by noise trauma with that induced in other circumstances; we studied a population of 555 patients seen in a specialist tinnitus clinic at University Hospital, Montpellier. In regard to variability over time, certain patients described their tinnitus either as stable over time or as fluctuating (usually louder at bedtime and on awakening). After otoscopy, audiometry was undertaken for each ear (air conduction, bone conduction, and speech audiometry). We analyzed the description of the sound of the tinnitus, its spatial localization, and the variability of the intensity as noncontinuous variables.
We asked the patients to classify their tinnitus with regard to spatial localization and frequency, intensity, variability with time, and duration (Table 4). Pure-tone audiograms in subjects with a history of noise trauma (NT) and those with other ear pathology.
Almost all (98.8%) of these patients said that their tinnitus was of a whistling type (see Table 4).
Correlation between the intensity of tinnitus and the hearing loss in those with a history of noise trauma (NT). In general, the patients seen tended to have a high-pitched hearing loss that is more marked on the left. The majority of tinnitus cases were linked to sound trauma after a concert, an evening at a nightclub, listening to a personal stereo, or using do-it-yourself power tools, in which one would expect both ears to have similar noise exposure. Statistical analysis showed a significant correlation between noise trauma and whistling tinnitus. With this instrument, we significantly correlated the intensity of the tinnitus with the degree of hearing loss between 2,000 and 8,000 Hz. If the age and gender are accounted for by the source of the noise trauma (concerts, discos, hunting, do-it-yourself tools), the descriptive aspects of tinnitus are strongly correlated with hearing loss as demonstrated by pure-tone audiometry.
There was no narrowness in the internal acoustic canal of the tinnitus group compared with the control group. Only one patient was found with a positive TEN test result, who was confirmed by Magnetic Resonance Imaging to have acoustic neuroma on the affected ear. The last half of the twentieth century saw considerable advances in our understanding of tinnitus from both physiological and psychological perspectives. It has been generally accepted that any severe damage along the auditory system may lead to a certain degree of hearing loss, which is generally associated with tinnitus5,6. Moreover, the incidence of tinnitus in patients with sensorineural hearing loss varies widely across studies. These observations may have several indications, such as hearing loss is not necessary in tinnitus generation, pure tone audiogram does not always indicate auditory damage, tinnitus may be a primary symptom of diseases that are only diagnosed after the occurrence of hearing loss, or several mechanisms exist in a group of patients.
The different functionality of outer and inner hair cells can also cause imbalanced activity in the dorsal cochlear nucleus which in turn causes changes at higher levels of the auditory system that may be perceived as tinnitus1.
In some studies, lower amplitude of TEOAEs13,16 or DPOAEs13,17-19 have been observed in tinnitus patients compared to in non-tinnitus controls.
All participants had no history or current external and middle ear problem, noise exposure and psychiatric problem. In this experiment, a 2f1 - f2 distortion product was used because of its established clinical value. This off frequency listening occurs when the targeted area of inner hair cells or neurons are not functioning well and is referred to as a dead region27. In this case (Subject RX), the TEN (HL) test revealed that dead regions might exist at 1.5, 3 and 4 kHz on the left ear (Table 7). Since all the subjects in this study had normal hearing, the decrease in the TEOAE and DPOAE finding may possibly be considered as the effect of cochlear dysfunction of the cochlear active mechanism, which is related to OAE generation.
Frequency analysis also showed that a significant decrease in DPOAE amplitude was mainly at the f2 frequency of 4000 to 7000 kHz. Therefore, the hearing status of these patients should be monitored for possibility of developing hearing loss later in life. Previous research has clearly demonstrated that OAE may be used to reveal subclinical OHCs damage in audiometrically normal ears13-15. Apart from difficulty hearing in background noise, she did not have any other classical symptoms of acoustic neuroma such as balance problem or poor speech discrimination scores.
Firstly, it implies that a TEN test may offer a quick, inexpensive and non-invasive method for retrocochlear screening.
In their study, they found 7 out of 8 auditory neuropathy patients with abnormal TEN test results. The finding also supported the possible clinical advantage of the TEN test as a screening tool for retrocochlear problem. Risk factors for tinnitus in a population of older adults: the blue mountains hearing study. Characteristics of tinnitus and etiology of associated hearing loss: a study of 123 patients.
The more the worse: the grade of noise-induced hearing loss associates with the severity of tinnitus.
Tinnitus with normal hearing sensitivity: extended high-frequency audiometry and auditory-nerve brain-stem-evoked responses. The effect of the number of averaged responses on the measurement of transiently evoked otoacoustic emissions in newborns. Dead regions in the cochlea: diagnosis, perceptual consequences, and implications for the fitting of hearing aids. Transient and distortion product evoked oto-acoustic emissions in normal hearing patients with and without tinnitus. DPOAE in estimation of the function of the cochlea in tinnitus patients with normal hearing.
Tinnitus and 2f1-f2 distortion product otoacoustic emissions following salicylate overdose. Ten(HL)-test results and psychophysical tuning curves for subjects with auditory neuropathy. Because no curative therapeutic approach is available-neither pharmacological nor surgical-the main focus lies in treatments that enhance the habituation of tinnitus. Of these, 1.5% reported that their daily life was greatly affected by the tinnitus, and some 1 % believed that it interfered with their occupation. Noise or acoustic trauma may induce decoupling of the OHCs from the tectorial or the basilar membrane. As each inner ear is connected with both brain halves, one part of the neurons leads from the nucleus cochlearis to the nucleus olivaris superior of the same side, whereas the other part crosses over to the opposite side. This takes up the descending paths from the cortex itself and from the corpus geniculatum mediale.
Calculating DPOAE growth functions can illustrate the activity of hair cells and possible compensation mechanisms after injury.
The DP slope, however, increased with increasing hearing loss and, therefore, did correlate with the hearing threshold, revealing pathological alteration. Around the tinnitus frequency, the DP levels were up to 10 dB higher than at the maximum hearing loss.
Corresponding to the threshold run, the slope increased rapidly on the low-frequency side of the notch but gradually decreased on the high-frequency side.
Here, the DP level decrease between 2 and 4 kHz corresponded to the increasing hearing loss, resembling most of the nontinnitus ears. Acting as controls were 41 normally hearing nontinnitus individuals (average age, 33.5 years). Decreased DP levels and increased growth functions seem to be proof of diminished sensitivity and tuning of the cochlear amplifier. This dysfunction is mainly the result of disturbances in the cortical network of auditory processing that leads either to ineffective or diminished efferent control of the auditory pathway [9] or to an efferent overactivity on all levels, including that of the OHCs. Therein, the cortical reflection of incoming sound or electric activity leads, via smaller or ineffective efferent inhibition, to hyperactivity in the OHCs, where it then can be recorded. Antiarrhythmic agents such as lidocaine can stop tinnitus in perhaps 50% of cases but only temporally for the time of infusion [29]. This ability of the auditory perception can be developed and trained even in older people by using the filter capacities of the efferent system, with its effects on all parts of the auditory pathway, including the OHCs. Thus, training of these central auditory abilities and functions [34] is a promising approach to facilitate tinnitus and hyperacusis habituation [14]. Physiology of cochlear efferent and afferent neurons: Direct comparisons in the same animal. Salicylate and quinine selectively increase spontaneous firing rates in secondary auditory cortex. Wandel in Diagnostik und Therapie: Auditorische reiz- und ereigniskorrelierte Potentiale und Magnetfelder in der audiologischen Diagnostik.
Contingent Magnetic Variation (CMV) Studied with Stimuli Close to the Hearing Threshold in Normal Subjects and Tinnitus Patients.
The level and growth behavior of the 2f1-f2 distortion product otoacoustic emission and its relationship to auditory sensitivity in normal hearing and cochlear hearing loss. The ipsilaterally evoked olivocochlear reflex causes rapid adaptation of the 2f1-f2 distortion product otoacoustic emission. Otoakustische Emissionen und Tinnitus: DPOAE, eine Messmethode zum objektiven Nachweis des auf der Ebene der auBeren Haarzellen entstehenden Tinnitus? Distortion product otoacoustic emissions in patients with innerear highfrequency hearing loss and tinnitus. Der Round Window Cath zur Lokaltherapie des Innenohres - Ergebnisse einer plazebokontrollierten, prospektiven Studie bei chronischem Tinnitus. Hearing therapy: A way to intensify auditory perception in the treatment of chronic tinnitus.
The Pre Residual Inhibition Therapy, contra-lateral acoustic reflexes and Tinnitus Handicap Inventory scores were compared to post Residual Inhibition Therapy, contra-lateral acoustic reflexes and Tinnitus Handicap Inventory scores. Use of this treatment has shown 90% of the subjects with tinnitus relief and 10% with modification in tinnitus with minimal reliefs7. Questions in the questionnaire probed to know the onset (sudden or gradual), progression (static or progressive), nature of the tinnitus (intermittent, continuous), ear experiencing tinnitus (right, left or both ears) and duration of tinnitus persistence.
Thresholds of each subject were found out using both air conduction and bone conduction mode. Four individuals reported of reduction in tinnitus loudness, 3 reported of complete termination of tinnitus and 3 reported of no change in the tinnitus. The influence of masking level that deepens the residual inhibition as it goes above the level required to mask tinnitus17 or due to the impedance offered by the cochlear dead region even in normal hearing individuals with tinnitus18 could have yield poorer results.
Similarly, the literature reports that few subjects experience increase in the tinnitus loudness than the decrement which lasts for a duration less than one minute20. Residual inhibition will be effective with longer exposure to target stimulus and subjects who experience no residual inhibition in the initial stages may experience it after regular exposure to target sound21.
Residual inhibition functions overlap tinnitus spectra and the region of auditory threshold shift. Evaluation and Selection of Maskers and Other Devices Used in the Treatment of Tinnitus and Hyperacusis.
With improved survivability following cancer treatment, Veterans treated with cisplatin are approached with the dual goals of effective treatment and preserved quality of life. Cisplatin is an antineoplastic agent used for the treatment of a variety of adult cancers, including bladder, testicular, gynecologic, head and neck, and lung. Damage also occurs to the marginal cells of the stria vascularis [11–14], which provides the electrochemical drive for the outer hair cells and spiral ganglion cells of the auditory nerve. This testing must then be coordinated with a patient’s already overburdened treatment schedule and into audiology clinic time slots that are routinely scheduled months in advance. Further, the VA’s existing mechanisms for tracking patients throughout the system need to be exploited in order to ensure patients receive the audiological services they may need at various stages of cancer treatment and survivorship.
This program includes an individualized pretreatment prediction model that identifies the likelihood of hearing shift from cisplatin and supports both manual and automated hearing testing with a newly developed portable audiometer capable of performing the recommended procedures on the chemotherapy unit during treatment. To accomplish this, researchers at the NCRAR designed and engineered a portable ototoxicity identification device, the OtoID, that can provide reliable and accurate hearing thresholds on the hospital ward during treatment [17]. The automated mode prompts the user when headphone placement is incorrect and employs catch trials to achieve bias-free threshold estimates.
Automated testing combined with telehealth capabilities provides major advantages of the OtoID over current modes of ototoxicity monitoring. However, the sensitive range for ototoxicity (SRO) technique [19] is also supported by COMP-VA. ASHA’s criteria for a significant hearing shift when used with the SRO result in a reliable test [5,18].
Further, use of the SRO screening protocol together with tests to rule out ear disease or obstruction (otoscopy, tympanometry) reduces testing time substantially in comparison to the full diagnostic evaluation that is commonly done, which includes otoscopy, tympanometry, air and bone conduction, and speech testing. Differences across studies can be understood in terms of the differences in testing methodology, specifically the different test frequency ranges used. Using data from our recently completed ototoxicity research project at NCRAR, 50 of the 118 (41%) study subjects treated with cisplatin became untestable at some point in their treatment due to fatigue, illness, disease progression, or unwillingness to go to a sound suite for testing [2]. DPOAEs are elicited using two tones that are close in frequency and presented simultaneously. Because there is no commonly accepted gold standard of outer hair cell damage in humans, test accuracy can never be completely known for this method. Importantly, in a separate trial investigating DPOAE test performance for detecting ototoxicity, only 10 percent of ears had to be excluded for a lack of DPOAEs at baseline [2]. One patient opted to change medication; the other patient’s disease necessitated that he continue with the planned regimen. An audiometric baseline evaluation was completed, at which time he presented with normal hearing through 4,000 Hz sloping to a moderate loss of hearing at 6,000 and 8,000 Hz in both ears. At the audiometric baseline evaluation, he presented with normal hearing through 2,500 Hz sloping to a moderately-severe hearing loss at 8,000 Hz with a high-frequency limit of hearing of 10,000 Hz in both ears. Tinnitus screening and educational clinical objectives (objectives 5 and 6, respectively) are not included in the table. Patients had consulted for persistent tinnitus for 7 years from the onset of their symptoms. Taking account of the sound level in discos and clubs and from personal stereos (especially when listened to through headphones), one can anticipate the advent of an entire new generation of tinnitus sufferers.
Also, they were asked for a description of the sound; most patients were able to describe their tinnitus as whistling or buzzing. Complementary investigations, such as otoacoustic emissions, evoked auditory potentials, videonystagmography, computed tomography, and magnetic resonance imaging scans, were undertaken as necessary to help to diagnose any hearing loss. There was a broad age range of patients, from 11 to 91 years, with the average age at presentation in the clinic being 54 ± 15 years.
Tinnitus was often attributed to ear pathology (34.8%) or, in fewer cases, to another illness (10%). Within this category were concerts (53%), discotheques (35%), and prolonged use of personal stereos, especially when listened to through headphones (12%). However, the degree of hearing loss was significantly lower than that in patients suffering from other ear pathology (Fig. Graphs show the average hearing loss in dB (± standard error of the mean) measured in the right ear (R, circles) and the left ear (L, crosses).
Statistical analysis demonstrated a significant correlation between tinnitus precipitated by noise trauma and the perception of it as a whistling type. In 79.5% of cases, patients described their whistling tinnitus as stable over time (see Table 4).
The correlation between tinnitus intensity, as measured on a visual analog scale (white circles), and the hearing loss (black circles) gives a coefficient that becomes greater as the hearing loss becomes greater. From a descriptive point of view, the tinnitus described by the patients in this study was mainly whistling, was stable with time, and was perceived on the left side. This being the case, we propose two hypotheses: (1) Fluctuating tinnitus tends to stabilize after a certain length of time or (2) fluctuating tinnitus may disappear, whereas longstanding tinnitus is stable. Assessing tinnitus and prospective tinnitus therapeutics using a psychophysical animal model. Cisplatininduced hyperactivity in the dorsal cochlear nucleus and its relation to outer hair cell loss: Relevance to tinnitus. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.AbstractObjective. More commonly, various studies have shown that sensorineural hearing loss plays an important role in tinnitus generation. Therefore, the absence of hearing loss on the audiogram in this group poses a serious challenge to the aforementioned theories in explaining tinnitus generation in tinnitus patients with normal hearing. In the study, they investigated the inner hair cells functions in 11 chronic tinnitus patients with normal hearing thresholds using Threshold Equalising Noise (TEN) test and found 8 of them with possible inner hair cells problems. The results were presented as a distortion-product audiogram i.e the amplitude of the 2f1 - f2 DPOAE was plotted against the f2 from 1000 to 6169 Hz. The broad band noise is designed to produce almost equal masked thresholds over a wide frequency range, for listeners with normal hearing and hearing impairment but without dead regions28.
The abnormal TEOAEs in the tinnitus group were present for 1 and 4 kHz mostly, while in the control group, the abnormalities were mostly at 4 kHz.
A t-test revealed that with regard to mean amplitude of TEOAE for tinnitus ears, there were no statistically significant differences for all frequencies tested (p > 0.05).
Later, the mean amplitude of DPOAE for tinnitus and control ears against the corresponding f2 was compared.
From 20 tinnitus patients with abnormal OAEs, 13 of them exhibit either failed TEOAE or DPOAE results. According to this theory, discordant dysfunction can occur without affecting the audiometric hearing thresholds when the OHCs are partially damaged and where the IHCs are intact. Stated differently, abnormal or poor OAE results may be the indicator of subtle cochlear damage before the abnormality affects hearing sensitivity and appears on the audiogram. Thus, the similar findings indicate that DPOAE measurement can offer a frequency specific measurement for the detection of subtle localised cochlear damage even before affecting pure tone thresholds34.
The high percentage of TEOAE abnormality at 4 kHz for the control ears may suggest that the hearing status of these participants also needs to be monitored. Nonetheless, only the difference between numbers of abnormal TEOAE in tinnitus and control ears reached a statistically significant level. The former study suggested that tinnitus generation in their group of participants may be due to the effect of deafferentation of the neuron.
Secondly, tinnitus patients may have a serious problem that triggers the tinnitus perception despite having normal hearing thresholds and normal OAE test results.
Patients with auditory neuropathy are known to have problems with transmission of the auditory signal to the brain, thus abnormal TEN test results in this group of patients were assumed to be due to the neuron dysfunction. However, more research needs to be carried out in this area in order to support the current finding. Habituation occurs in almost 5 0% of affected patients as a normal process, leading to a complete compensation. These data, published by the German Tinnitus League (DTL) [1], probably are the same for all industrialized countries. Ionic channels of the OHCs may tear off, viral toxins or other toxic agents may influence stimulus transduction in the hair cells, and stimulus transmission may be disturbed at the synaptic level.
Already the differentiation between afferent and efferent supply of the hair cells [7] shows the existence of complicated regulating loops controlling the entire auditory pathway, with Corti's organ situated at the peripheral end. From there, efferent fibers run to all subordinate brain centers that, in the end, reach again the OHCs of the inner ear [9,10]. Another group of tinnitus patients showed a congruent relation between DP levels and threshold and also a congruent relation between threshold and slope or growth function. Auditory brainstem responses were recorded, and the wave I -V interpeak interval was measured in an attempt to exclude retrocochlear pathology. Only with a lowering primary tone level does the DP-gram reflect the audiogram notch, which decreases by some 20 dB. Most distinctly, the DP level decreased at lower primary levels, as indicated by the spread of the DP-grams, changing the DP growth functions to a linear process.
DPOAEs were recorded according to the described paradigm in a session with and without a contralateral sound stimulus of 60 dB HL. The recorded audiological data play an important role in our understanding of tinnitus generation in at least some patients. HH Naumann, C Herberhold, E Kastenbauer (eds), Oto-Rhino-Laryngologogie in Klinik und Praxis, Band 1 Ohr.
Presented at the Second Annual Meeting of the German Society for Audiology (DGA), Munich, 1999. In L Deecke, C Baumgartner, G Stroink, SJ Williamson (eds), Biomagnetism: Fundamental Research and Clinical Applications. Presented at the Seventh International Tinnitus Seminar, Fremantle, Western Australia, 2002. However, few postulated etiologies can be attributed to age, exposure to loud noise, earwax blockage, air bone changes, Meniere's disease, tempro-mandibular joint disorders, head or neck injuries, acoustic neuroma, etc. Literature has also reported the experience of residual inhibition in more than 8 out of 10 persons with tinnitus8 and reduction in tinnitus loudness by 39%9. Total ten subjects with a complaint of tinnitus persisting for more than two weeks were recruited. The insignificant result to the success of RIT can be attributed to the influence of identification level of tinnitus expertise, the inability to match the tinnitus exactly due to overlapping of tinnitus frequency in some subjects and the effect of RIT lasting for few seconds or minutes8. However, only 54% subjects experienced complete silence in total 46 subjects with tinnitus and who underwent.
Proceedings of the Vth International Tinnitus Seminar; 1995 July 12-15, Portland, Oregon, USA. Oregon: Oregon Hearing Research Center, Department of Otolaryngology, Oregon Health & Science. This article describes COMP-VA, a comprehensive ototoxicity monitoring program developed for VA patients receiving cisplatin. If trends continue, more than 4,000 Veterans will receive cisplatin this year, with more than 50 percent sustaining a permanent hearing shift and 39 percent developing new tinnitus [1–3]. A main mechanism of cisplatin ototoxicity is associated with the production of free radicals [15]. Further, these appointments include lengthy diagnostic testing when a narrowly focused hearing screening done at each cisplatin-treatment visit would seem to be a better approach.
Also included are two objective test methods for identifying outer hair cell changes and predicting audiogram changes using distortion-product otoacoustic emissions (DPOAEs). The automated test mode saves audiological professional time by having the patient conduct the behavioral hearing screening portion of the monitor visit.
The SRO technique is proposed as the behavioral hearing test method of choice for ototoxicity monitoring, as long as the Veteran is able to provide reliable hearing results despite the exhaustion caused by chemotherapy treatment. The SRO technique is also sensitive (94% detection) regardless of whether the SRO falls above 8,000 Hz [19,21] or below 8,000 Hz [4].
Extensive audiometric evaluations, typically done in the audiology clinic, are best saved until the patient has finished treatment and, perhaps, is ready to pursue hearing aid amplification.
Hearing tests lose sensitivity for subjects with good preexposure hearing when testing does not include frequencies near the high frequency hearing limit. Responses are influenced by hearing loss at the DPOAE frequency (2f1-f2), the eliciting frequencies (f1 and f2, where f1 < f2), and comparatively higher frequencies coded by more basal cochlear regions [29,32–33]. Providing objective techniques for identifying shifts in behavioral pure-tone thresholds when a patient is unable to provide reliable hearing test results, due to extreme illness or fatigue characteristic of chemotherapeutic treatment, is a very important and often overlooked programmatic component.
However, a false positive rate of DPOAE change can be estimated for a tester or group of testers using group variability from a nonexposed control group. Experience has shown that DPOAE measures are maximally sensitive to ototoxicity if they are within one octave of the behaviorally tested SRO [3]. Associated audiometric data for the patient described in case study 1 are presented in the “Clinical Objectives for COMP-VA” section. His high frequency limit of hearing was 12,500 and 11,200 Hz in the right and left ears, respectively.
We envision that these clinical objectives would be tailored to the needs and preferences of the audiologists, oncology teams, and individual patients. Among these tinnitus patients, 17% described their tinnitus as starting after excessive noise exposure.
Depending on the variables under analysis, a Student's t-test or chisquared testing was undertaken. In 15.9% of cases, the tinnitus appeared in association with psychological problems, such as emotional trauma, depression, or episodes of stress or anxiety.
Next most prevalent was firearm use (16.2%), the majority related to hunting or shooting as a leisure activity. The intensity of tinnitus perception was significantly correlated with the degree of hearing loss measured between 2,000 and 8,000 Hz. Note that the greatest correlation coefficients occur in the highest frequencies of hearing loss. Although not statistically significant, this latter finding is in accordance with other studies showing that hearing loss and tinnitus are generally more noticeable on the left side [8]. This link correlates with an earlier study on a smaller population showing that a whistling type of tinnitus was correlated with a high-frequency hearing loss and that a buzzing type of tinnitus was correlated with a low-frequency hearing loss [7]. These results agreed with our previous study of 58 patients [7], which showed that the intensity of stable whistling tinnitus is perceived as increasingly strong as the highfrequency loss is more marked. Only a longitudinal study of tinnitus patients will allow us to clarify these hypotheses further. However, this attempt at categorizing patients' tinnitus as a function of both the etiology and the semiology allows us to evaluate better the medical and psychological treatment of these tinnitus patients. To investigate the compression of the vestibulocochlear nerve in the etiology of the tinnitus in the normal hearing ears with temporal bone computed tomography scans. There were no anatomical differences in the etiology of tinnitus rather than physiological degeneration in the nerves.
Evidence showed a higher incidence of tinnitus patients with sensorineural hearing loss compared with conductive hearing loss7.
In addition, not all individuals with hearing loss experience tinnitus, and not all tinnitus patients have hearing loss. While the theories seem cannot fit in this minority group, evidence obtained from this group may have huge implication for a better tinnitus mechanisms understanding as well as assist in developing and shaping tinnitus management. The studies reported that tinnitus subjects were found to have increased TEOAEs20,21 or DPOAEs22,23 compared with non-tinnitus counterparts. Thabet25 attempted to replicated the earlier study by investigating 20 normally hearing unilateral tinnitus patients with TEN test and TEOAE.
The presence of DP amplitude was accepted as valid when the signal to + 2 SD noise floor ratio exceeded 3 dB and the absolute DPOAE amplitude was at least - 10 dB SPL at each individual f2. Table 2 shows the normal and abnormal TEOAEs at each frequency tested in both the tinnitus and control group. Generally, an independent t-test showed no statistically significant differences observed between tinnitus and control ears at all frequencies except for frequency 1414, 4757, 5187 and 6169 Hz (Table 5).
Meanwhile, from 16 control ears with abnormal OAEs, 10 ears exhibit either failed TEOAE or DPOAE results.
The ABR showed absent wave V at 70 dBnHL in the left ear and normal ABR waveforms in the right ear, which were correlated with the TEN test results, suggesting of abnormal neural function. Therefore, in this current study, we sought to determine whether the measurement of TEOAE and DPOAE may reveal subtle cochlear abnormality in tinnitus patients with normal audiometric thresholds.


Although the difference between numbers of abnormal DPOAE in tinnitus and control ears failed to reach a significant level, mean amplitude of tinnitus ears at frequency region of 2000 and 4000 Hz were statistically significantly lower than the control ears.
They suggested that it could be the result of reduced afferent input to the central auditory system due to cochlear lesion, thus resulting in a decreased OHC efferent activity and ultimately leading to OHC hypersensitivity. TEOAE measurement stimulates the whole basilar membrane of the cochlear, which means it gives more global information. Furthermore, dead regions normally exist in those who have hearing thresholds of 60 dB HL and above28. In other words, even though dead regions normally exist in patients with hearing loss of more than 55 dBHL, normal hearing people can also have a 'dead region' which may be due to retrocochlear abnormality. Similarly, the abnormal result in Subject RX in the current study may also be because of the problem in neurons rather than in the inner hair cells.
MRI revealed a large vestibular schwannoma in the left cerebello-pontine angle which was compressiong the brainstem and cisternal portion of the VIIIth cranial nerve.This study showed that subtle cochlear problem may exist in tinnitus patients before it is significantly appeared in the audiogram. This finding is based on the ability of the auditory perception to habituate random noise and focus on important acoustic information. Strain may cause spasms of the precapillary blood vessels, resulting in temporary malnutrition of the cochlea.
In the inner ear, sounds are mainly treated according to the discrimination of place (tonotopy) and time, whereas in higher brain centers and auditory neurons, more and more complex sound patterns are involved. Through further stations of the sound paths via corpus geniculatum mediate and the radiatio auditiva, the auditory cortex is reached. Besides providing three-dimensional hearing, a major advantage of such a complex sound path is a sophisticated hearing ability in high-noise areas or in the presence of disturbing sounds. Exactly one-half of patients (110) reported high-frequency, tonal tinnitus; the other 110 did not. Even at lower primary tone levels, the DP level did not decrease with increasing hearing loss. With contralateral stimulation, the tuning curves of the cochlea and the acoustic nerve flatten. Presumably, this matches only for so-called motor tinnitus, the type of tinnitus confined to destruction or decoupling of the OHCs [4]. They are also very helpful for the counseling of patients and for preventing further frustrating and expensive therapeutic failures. In contrast to the reasons behind tinnitus3 quoted normal hearing individuals with presence of tinnitus. In air conduction testing, frequencies 250 Hz, 500 Hz, 1000 Hz, 2000 Hz, 4000 Hz and 8000 Hz were checked.
On obtaining baseline, frequency specific narrowband noise was delivered to the ear experiencing tinnitus for duration of 60 sec.
Studies have reported that presence of any phobia related to tinnitus or any negative thought about tinnitus will lead to slow desensitization of tinnitus.
Follow-up report of three subjects in the literature study has shown no change in tinnitus even after exposure to target stimulus for a run of 2 to 3 weeks RIT15.
The program includes an individualized pretreatment prediction model that identifies the likelihood of hearing shift given cisplatin dose and patient factors.
Importantly, in our experience, the average age of Veterans entering treatment is 60 yr and most report a history of significant noise exposure [4–5], which accounts for the high rate of preexisting hearing loss in this population. Overabundance of these unstable molecules overloads intracellular antioxidant enzymes and leads to a cascade of damaging oxidative reactions and upregulation of programmed cell death. The primary goal of COMP-VA is early detection of ototoxicity in order to optimize both audiological outcomes and therapeutic management of patients receiving cisplatin chemotherapy.
Additionally, the OtoID measures the ambient room noise at earphone level before each tone presentation.
Once the patient completes self-testing and the results are received in the audiology clinic, the audiologist can then travel to the treatment unit, complete additional tests (otoscopy and tympanometry, screen-fail follow-up testing if necessary), and discuss results with the patient and the oncology team, ensuring that fully informed and timely treatment decisions can be made. The SRO technique was designed to identify hearing shifts within an individualized range of relatively high frequencies so that treatment changes can be considered, if deemed necessary, to prevent hearing loss from spreading to the frequencies considered most important for understanding speech (those up to 4,000 Hz). The theorized basis for this high sensitivity is that the high frequency-coded base is the most physiologically vulnerable area within the cochlea to cisplatin-related damage, and this damage progresses from base to apex.
Although current ASHA and AAA guidelines urge that DPOAE testing be included programmatically, little guidance is currently given as to how to interpret the findings. In practice, we have found that there are many instances in which drug-induced pure-tone threshold shifts are restricted to a DPOAE frequency range that did not have a valid response at the baseline test session. The patients who had a history of noise trauma had a symmetrical hearing loss, and no difference was seen in lateralization of tinnitus perception.
Approximately 7% of the adult population judge their tinnitus to be sufficiently severe to warrant consulting a doctor [2]. We used chi-squared testing to study any associations between two variables in a class, ANOVA testing to study variables in the same class and continuous variables, and Pearson correlation coefficients to compare two continuous variables. This difference may be explained by the age difference between the two groups, as the patients exposed to noise trauma were, on average, 10 years younger.
In addition, in patients with no history of noise exposure, the hearing loss is significantly greater in the left ear than in the right, at frequencies greater than 4,000 Hz (asterisk).
In whichever age group, hearing loss is less obvious in those patients with a history of noise trauma (white symbols) than in those without (black symbols). It is not easy to compare our results using a visual analog scale with those studies wherein patients are asked to evaluate the frequency and intensity of their tinnitus with an external sound, usually a pure tone generated by an audiometer [12,13]. In addition, such a step allows us to better define those populations that are similar to the experimental models of tinnitus and on which therapeutic strategies are being developed [14-20]. Jastreboff & Jastreboff11 reported that about 27% of totally deaf patients do not have tinnitus, whereas 20% of normal hearing people have tinnitus. This is because the results obtained from this special group may directly related to the tinnitus perception, but not to the concomitant hearing loss. The test was performed in a sound treated room where the ambient noise was maintained between 20 to 40 dB A. The difference between the two groups is highly significant at frequencies of 1, 1.5 and 2 kHz, but not at 3 and 4 kHz. The decrease in DPOAEs amplitude over a limited frequency range in DP-gram found in tinnitus patients with normal hearing may be a susceptible area representing minor cochlear pathology. Similarly, a more recent study by Sztuka et al.35 attributed the increase in DPOAE amplitude in tinnitus patients with normal hearing as a result of increased motility of the OHCs due to decreased neural activity in the auditory nerve.
Conversely, the number of abnormal DPOAE in tinnitus ears was not statistically significantly different from the controls. They found that outer hair cells damage (assessed by TEOAE) was more common in normally hearing tinnitus patients than inner hair cells damage. In this case, the positive TEN (HL) results may not be due to inner hair cells damage but maybe because of poor processing efficiency that is associated with neural problems due to compression of large vestibular schwannoma on the VIIIth nerve38.
However, caution should be taken in interpreting the TEN test results as 10 dB-above-thresholds criteria is just a binary criteria that means passing or failing the TEN test, but does not mean dead or not dead.
According to our audiological data, 9 0% of tinnitus patients have deficits in inner-ear function as a generator of tinnitus, mainly in the outer hair cells. The main outcome of this study shows that many people experience or suffer from tinnitus, but only a small proportion suffer to an extent requiring treatment. As a rule, the patients estimated the loudness of the tinnitus somewhat above the audiometric threshold around the tinnitus frequency. In the region of normal hearing below 3 kHz, the DP-grams were widely spaced at lower primary tone levels but lay close together at the higher levels, indicating compressive growth.
Taking into account the amount of hearing loss around the tinnitus, these high DP levels are fairly surprising and could result in incorrect conclusions about cochlear integrity. Also, high slopes were found between 2 and 3 kHz, possibly revealing a disturbance that was not reflected in the behavioral audiogram (Fig. Regarding the DPOAE recordings, contralateral sound decreases the emissions; thus, the amplitudes are reduced.
As opposed to the traditional paradigm-tinnitus as an ear disease, today, tinnitus is accepted as a brain disorder4.
This suppression of tinnitus provides brief relief which lets victims to exert some control over the trouble. Subjects with mild to moderate severity (score ranging from 18 to 56) were considered for the study. However, in bone conduction testing, frequencies 250 Hz, 500 Hz, 1000 Hz, 2000 Hz, and 4000 Hz were checked.
This explains the part of neuro-physiological model, where annoyance or displeasure although not strongly evoked stimulate limbic and autonomic systems producing intrusive and aversive emotions and reducing the quality of life. It supports both manual and automated hearing testing with a newly developed portable audiometer capable of performing the recommended procedures on the chemotherapy unit during treatment. Depleting the natural defense system of cells leaves them especially susceptible to further ototoxic damage with each additional treatment. This goal is to be accomplished using a team-based approach made possible in large part by delivering COMP-VA services chairside on the oncology treatment unit.
If the ambient noise exceeds ANSI S3.1–1999 maximum permissible ambient noise levels (MPANLs), the tone is not presented and the patient is instructed to either wait until the room is quiet or move to a quieter location. In such cases, we have found that DPOAEs obtained at comparatively lower f2 frequencies are still useful for predicting hearing shifts, either because DPOAEs are sensitive to preclinical damage or are influenced by threshold shifts at comparatively higher frequencies than the eliciting primaries [2].
Following his first dose of cisplatin (cumulative dose = 200 mg), he became neutropenic, which resulted in a 2 wk delay in his cisplatin treatment. This subset of patients was mainly male and on average was 10 years younger than other tinnitus patients. When questioned, 5% of German adults stated that they had irritating tinnitus, 1% of adults considered themselves handicapped by their tinnitus, and 0.5% were unable to live a normal life [3]. All the data, whether in a table or in text, are expressed as the mean plus or minus the standard deviation. Tinnitus precipitated by use of machinery accounted for 11.6% (mainly such do-it-yourself tools as drills and grinders. To determine the influence of age on the hearing loss, we performed a stratified study on two groups of patients with demonstrable hearing loss, whether or not they had a history of noise trauma: those 40 years old and older and those younger than 40 years. Among those aged 40 years or younger, the difference is significant at 250, 500, 1,000, and 8,000 Hz, whereas in those older than 40, the difference is significant only in the lower frequencies (250, 500, and 1,000 Hz). Leisure noise appeared to be the principal cause, especially amplified music, whether from a concert or a disco. In our study, the small number of patients who had been exposed to firearm noise did not permit significant study. In these cases, patients were able to perceive the external sound only if it were presented 5-15 dB above their auditory threshold, which poses a problem with interpretation. A prospective nonrandomized study of 30 bilateral tinnitus and 30 normal hearing patients enrolled in this study. Tinnitus can originate from any part of the auditory system [2].Most of the time the etiology of nonpulsatile tinnitus is not known. It can be assumed that the role of sensorineural hearing loss as a tinnitus generator is complex and the mechanism of tinnitus may rely on the presence of other contributing factors such as damage to specific hair cells or the auditory nerve fibers. This appears to support the hypothesis that a reinforced mechanical distortion is generated by cochlear hyperactivity that can be the source of the tinnitus. DPOAE is more frequency specific and thus is expected to be more sensitive in detecting subclinical abnormality in cochlear function over TEOAE. Their finding supports the theory that outer hair cells abnormality may be an important factor in the tinnitus mechanism37.
For this reason, more research needs to be carried out on the clinical benefit of the TEN test before applying this method clinically.
This occurrence can be verified by registration of distortion products of otoacoustic emissions. This is certainly owing to the normal habituation process, which allows for people who have tinnitus to no longer experience it as disturbing. In the notch region and around the tinnitus, the DP-grams were widely spaced and actually equidistant, revealing linear growth. Accordingly, if tinnitus is influenced by malfunction or is even due to deregulation of efferent auditory control, it should be interesting to examine the effects of lateral inhibition (via contralateral sound) with tinnitus patients. Tinnitus can be rated as mild to catastrophic level thereby having severe effects on social and emotional status, poor job performances, relationships and social functioning5. Possible reasons for tinnitus suppression are stated as temporary desensitization by brain on exposure to tinnitus matched frequency noise11 and influence of overlapping central mechanism12. This inventory helped to rate the severity of tinnitus and to know its severity on day today life.
Recruitment of the subject for further testing asked for threshold ranging from -10 to 25dBHL. Post first sitting with a time gap of 1-2 minutes, contra-lateral acoustic reflexes were retested.
The created negative feelings to a person cannot be treated purely by only audiological help. It also includes objective methods for identifying outer hair cell changes and predicting audiogram changes using distortion-product otoacoustic emissions.
Furthermore, health-related quality of life concerns are important to oncologists because improved treatments and early diagnoses have increased long-term cancer survivability. The resultant peripheral hearing loss from this cell damage has been shown to be dose dependent in both animals [11] and humans [16]. Three weeks after his first dose (cumulative dose = 190 mg) and just before his second dose, a monitor evaluation revealed an ASHA-significant hearing change (average +10 dB shift) at 10,000 to 12,500 Hz in the right ear with normal otoscopy and tympanometry. Before the second dose of cisplatin, the audiologist detected ASHA-significant hearing changes from 3,000 to 10,000 Hz in the right ear and 3,000 to 8,000 Hz in the left ear in the presence of normal otoscopy and tympanometry.
In this population, the hearing loss is significantly less than that measured in the other patients, even allowing for their younger age. For more clarity, data plotted in the graphs are expressed as the mean plus or minus the standard error of the mean.
Among those younger than 40, hearing loss at 250, 500, 1,000, and 8,000 Hz was significantly less in the patients with a history of noise trauma. Note the characteristic notch in the audiogram at 6,000 Hz in those younger patients with a history of noise trauma.
This would explain an average age of this group of tinnitus sufferers 10 years younger than that of the other tinnitus patients. For example, should tinnitus that has been measured at 10 dB above the auditory threshold be considered as low intensity (only 10 dB) or stronger than the hearing loss would suggest? Schechter, “General review of tinnitus: prevalence, mechanisms, effects, and management,” Journal of Speech, Language, and Hearing Research, vol. By contrast, in other cases, TEOAE and DPOAE results showed poor or absent emissions in tinnitus patients with sensorineural hearing loss, even in those ears with normal hearing16,19,36.
In this current study, the result may possibly be due to subtle cochlear abnormality also existing in non-tinnitus participants with normal hearing. However, results from both studies may be more compelling if they included a retrocochlear test. Thus, the main origin of tinnitus is peripheral, and most patients suffer from accompanying hearing loss, even though it is sometimes mild or subjectively not even noticed. They react to the increase or decrease of frequency or to the beginning or ending of sound impulses.
Thus, the purpose of this study was to gain information on the effectiveness of Residual Inhibition Therapy as a treatment of tinnitus in normal hearing subjects experiencing tinnitus unilaterally and hence the study was undertaken. Subjects experiencing continuous tinnitus with static nature for two weeks unilaterally were shortlisted. Secondly, Immittance Audiometry (Tympanometry and Reflexometry) using calibrated Interacoustic AT (235) Immittance Audiometer with probe tone of 226 Hz was used to know the integrity of tympanic membrane and middle ear status. The obtained pre contra-lateral acoustic reflexes and post contra-lateral acoustic reflexes were compared to each other to get the effect of RIT on contra-lateral acoustic reflexes.
We describe this program of evidence-based ototoxicity monitoring protocols using a case example to give the reader an understanding of how this program would be applied, along with a plan for future work to accomplish the final stages of program development.
The approach of VA is to provide cancer management that is patient centered and directed toward improving the quality of life following treatment. The largest hearing shift was at 3,000 Hz (+30 dB average shift in the left and right ears) with lesser changes (+10 to +15 dB shifts) seen in the higher frequencies (?4,000 Hz). Statistical analysis showed a significant correlation between a history of exposure to noise trauma and the presence of a high-pitched "whistling" tinnitus.
However, we observed no significant difference in hearing loss at 2,000, 4,000, and 6,000 Hz (see Fig. Other sources of noise trauma were firearm use and do-it-yourself power tools, which would explain the overwhelming male majority in this noise exposure subgroup. Eggermont and Roberts [11] demonstrated that the frequency of tinnitus is closely correlated to audiometric hearing loss.
With tinnitus measurable in this way at 5-15 dB above the threshold, would one have to say that the intensity of tinnitus depends on hearing threshold and that a proportional relationship exists between tinnitus and hearing threshold?
The TEN test appears to be a potential non-invasive and quick test of inner hair cells function. The mean pure tone audiometric thresholds of tinnitus and control groups are shown in Table 1.
The tumour was compressing the brainstem and cisternal portion of the VIIIth cranial nerve. These variations can be explained by postulating that it is most likely to reflect different cochlear mechanisms underlying tinnitus generation due to different cochlear pathological changes in tinnitus ears37. The result of the current study is consistent with Thabet's study in which only one subject was found with a dead region, on the left ear. In almost 50% of our patients, we find hyperfunction of outer hair cells, again recorded via distortion products of otoacoustic emissions and their growth functions. Thereby, sound impulses are prepared for further treatment within the auditory cortex by the extraction of certain characteristics: Thus, only the content of information, not the entire signal, is transported to the cortex (processing of information) [8].
Type 'A' tympanogram with present ipsi-lateral and contra-lateral acoustic reflexes were considered. A “screen failure” follow-up audiogram indicated the hearing shift was confined to the ultra-high frequencies in one ear. The patient reported using a power drill on concrete without hearing protection following his first dose of cisplatin, despite being counseled by the audiologist to avoid noise overexposure. The presence of whistling tinnitus was significantly correlated with high-frequency hearing loss. In France, a study involving the population around Nice produced results similar to those of other countries with regard to the prevalence of tinnitus [4]. Finally, whatever the pathology responsible for the appearance of tinnitus, patients had suffered for an average of 7 years before being seen in the tinnitus clinic. In other words, the frequency spectrum of tinnitus is inversely proportional to auditory threshold. Only a study comparing the two types of tinnitus intensity evaluation (audiometric-based pitch matching and visual analog scale) will allow clear answers to those questions. Although tinnitus is often seen in patients with hearing loss, it can also be seen in patients with normal hearing. Nonetheless, it is too early to make a conclusion based on the aforementioned two studies on tinnitus. An independent t-test revealed that there was no significant difference in hearing thresholds between tinnitus patients and controls at all frequencies except at 6 and 8 kHz. Thus, the variability of findings in this study may possibly be because of different mechanisms existing in the normally hearing tinnitus patients. According to Jastreboff37 however, there are different levels of dysfunction from the OHC up to the higher auditory pathways.
Normal efferent reduction of distortion products through contralateral acoustic stimulation does not take place in most tinnitus patients. This can be seen in a comparison of the individual data and its range of plus or minus the standard deviation of the DP level of the normally hearing control group at the corresponding frequencies. Thirdly, Distortion Product Oto-acoustic Emission (DPOAE) was carried out using GSI Audera to rule out normal outer hair cell functioning. Oncology was notified of these early unilateral hearing changes outside the speech frequency range and their decision was to continue with the second cisplatin dose.
Because of concern that the noise exposure exacerbated the cisplatin effects, the patient was counseled again and provided new hearing protection.
The intensity of tinnitus, measured using a visual analog scale, appeared to be stronger than the measured hearing loss would suggest.
A further French study focusing on the quality of life of 603 tinnitus sufferers showed clearly that in 26% of patients, tinnitus created difficulties in everyday life [5].
This may be related to the fact that this study was undertaken in a hospital setting, which tends to be a secondary or tertiary referral clinic for patients with tinnitus.
If this were the case, one would expect that the whistling tinnitus noticeable after noise trauma would have a spectrum predominating in high frequencies. However, the correlation between hearing loss and intensity of tinnitus that we measured in this study suggests that a visual analog scale is the tool of choice to help us to understand the incapacitating character of tinnitus associated with noise trauma.
At both these frequencies, tinnitus patients had significantly higher thresholds than control individuals. He hypothesised that in some patients, though the level of dysfunction is undetectable by TEOAE, it may be sufficient to produce tinnitus. This finding shows that central auditory functions are also disturbed in chronic tinnitus patients, leading to reduced efferent effects on the hair cells and thus impeding habituation.
Three weeks after his second dose and just before infusion with his third dose (cumulative dose = 380 mg), ASHA-significant hearing change in the right ear expanded to include the 4,000 to 12,500 Hz frequency range (average +25 dB shift) with no response to tones above 10,000 Hz. The oncology team was notified of the hearing changes but counseled the patient to proceed with cisplatin treatment to give him the best radiation therapy support. The presence of tinnitus engenders notable modifications of behavior and a clear deterioration in quality of life. Among those who were 40 years old or older, hearing loss between 250 and 1,000 Hz was significantly greater in the patients who did not experience noise trauma, although we observed no significant difference at 2,000, 4,000, 6,000, and 8,000 Hz. Many systemic diseases such as hyperthyroidism, hypertension, and hypercholesterolemia are proven in the etiology, but the pathophysiology is still unknown [5].As we know very well, tinnitus can be seen due to the pressure of the acoustic neuromas, cerebellopontine angle tumors, and vascular lesions, such as vascular loop to the eight cranial nerve reported in the literature. Therefore, this study aimed to investigate subtle cochlear abnormality in tinnitus patients with normal hearing thresholds using evoked OAEs (TEOAEs and DPOAEs) and TEN test.
Contrarily, in some, the level of abnormality is detectable but not enough to trigger tinnitus. The slope was calculated if at least three data points fell in the range between L2 = 40 and L2 = 60 dB SPL.
There was a concomitant +25 dB average shift in hearing in the left ear from 4,000 to 11,200 Hz, and middle ear function remained normal bilaterally. Irritability, stress, anxiety, and deterioration in quality of sleep are frequently described both by tinnitus patients themselves and by their families [5]. These results show that whatever a patient's age, those with a history of noise trauma has less hearing loss than did those with other etiologies of hearing loss. The development of the tinnitus can be observed due to nerve edema, degeneration, and compression in the canal.
Therefore, Jastreboff's hypothesis is a possible explanation as to why not all hearing loss patients present with tinnitus, and not all tinnitus patients present with hearing loss. We have data on diminished ability to distinguish stimuli from random noise by bilateral sound processing: The so-called bilateral masking difference test results are pathological in almost 3 0% of patients suffering from chronic tinnitus. McAlpine, “Tinnitus with a normal audiogram: physiological evidence for hidden hearing loss and computational model,” Journal of Neuroscience, vol. We concluded from our audiological data that chronic tinnitus is primarily a cochlear dysfunction, but habituation is impeded by accompanying or consecutive deficits of the central auditory pathway. The 2 wk delay in day 22 of treatment complicated by the recent hospital admission resulted in the discontinuation of day 43 treatment.
It has a deleterious effect on intrafamily relationships, especially because of the difficulty that relatives may have in understanding what the tinnitus sufferer is undergoing [6]. Material and MethodsThis study was performed in 30 bilateral tinnitus patients who were referred to the outpatient clinic and 30 patients without any ear disease between 2011 and 2012. Regarding therapeutic approaches, these central functions can be trained by hearing therapy, as we know from patients' rehabilitation. At this point, the oncology nurse practitioner and audiologist together counseled the patient regarding the potential for further hearing changes if he continued treatment with cisplatin versus the option of changing to a less toxic chemotherapy drug, but with an undetermined effect on treatment efficacy. A postexposure follow-up examination was conducted 1 mo following the second dose of cisplatin. The audiologist explained options for aural rehabilitation, including the use of hearing aids.
At that time, ASHA-significant hearing changes were noted from 2,000 to 10,000 Hz in the right ear and 2,000 to 8,000 Hz in the left ear compared with baseline measurements in the presence of normal otoscopy and tympanometry. Before the actual experimental is run, in each case the patient's pure-tone threshold is obtained by means of a conventional clinical audiometer. This patient-centered care approach involving both oncology and audiology resulted in the patient having the knowledge to make an informed decision regarding his care. Results indicated hearing loss had progressed following the second cycle to include hearing changes at 2,000 Hz in both ears averaging +48 dB shifts.
He chose to preserve his hearing, and the oncologist changed his chemotherapy drug to carboplatin, a chemotherapy drug associated with less toxicity, for his last dose. The patients with any ear complaints other than tinnitus such as chronic serous otitis media, chronic otitis media, trauma history, and external ear problems were excluded from the study. The patient underwent imaging 3 mo following his last treatment, which indicated the cancer that had spread to the lymph nodes was no longer present, and endoscopy revealed the base of tongue primary cancer had regressed completely. The patient now reported increased difficulty understanding speech, especially women and children, but denied other otologic complaints including aural fullness and changes in baseline tinnitus.
Audiological follow-up with the patient was remarkable for otalgia, a retracted tympanic membrane, and worsening hearing loss in the right ear. A repeat audiological examination was conducted again 2 mo following cessation of cisplatin treatment (approximately 6 wk following cessation of radiation therapy) and confirmed continued hearing changes through 2,000 Hz. Following treatment, he presents with a fairly flat moderately severe to severe hearing loss beginning at 2,000 Hz. The internal auditory canal inlet, mid-canal, and outlet canal lengths were measured at the most distinctive cross-section of the seventh and eighth cranial nerves bifurcation (Figure 1). He was referred to otolaryngology, where a pressure equalization tube was placed in the right ear due to eustachian tube dysfunction secondary to radiation therapy. He feels that his hearing has significantly deteriorated since treatment and has been fit with bilateral hearing aids.
Patients who were admitted to our outpatient clinic other than ear disease with the temporal bone computed tomography results were taken as control group. Gil, “Impact of tinnitus on quality of life, loudness and pitch match, and high-frequency audiometry,” International Tinnitus Journal, vol. For statistical analysis, SPSS 17.O V software was used to assess the findings of the study. Doroszewska, “Metabolic disorders in vertigo, tinnitus, and hearing loss,” International Tinnitus Journal, vol.
Badie, “Correlation between auditory function and internal auditory canal pressure in patients with vestibular schwannomas,” Journal of Neurosurgery, vol. Rosahl, “Vertigo and tinnitus caused by vascular compression of the vestibulocochlear nerve, not intracanalicular vestibular schwannoma: review and case presentation,” Skull Base, vol. Andersson, “Clients' in-session acceptance and cognitive defusion behaviors in acceptance-based treatment of tinnitus distress,” Behaviour Research and Therapy, vol. Gleeson, “An arteriovenous malformation within the internal acoustic meatus and cerebellopontine angle cistern,” Journal of Laryngology and Otology, vol. Savastano, “Meningiomas of the internal auditory canal: two case reports,” Skull Base, vol.
Nguyen, “Comparative case series of exostoses and osteomas of the internal auditory canal,” Annals of Otology, Rhinology and Laryngology, vol. Bencsik, “Vertigo, dizziness, and tinnitus after otobasal fractures,” International Tinnitus Journal, vol.



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