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A final common pathway for tinnitus is hypothesized to exist for all patients with tinnitus. Its function is the transition of the sensory to the affect component of the symptom of tinnitus. Single Photo Emission Computerized Tomography (SPECT) with the radio isotope TC99-HMPAO has identifie side to side perfusion asymmetries highlighted by that of the amygdala - hippocampal complex. It is hypothesized that a fundamental function of the amygdala - hippocampal structures is the establishment of a paradoxical auditory memory for tinnitus. A Final Common Pathway (FCP) is hypothesized to exist for all patients with tinnitus, particularly of the severe disabling type (SIT). Historically, this search for understanding how the transition from sensory to affect occurs in the brain is not new. The concept of William James, the Father of American Psychology is suggested to find application to a FCP for tinnitus. Single Photon Emission Computerized Tomography (SPECT) with the radioi sotope Tc-99 HMPAO is a detection method which provides information of cerebral perfusion in brain. Based on clinical experience with tinnitus particularly of the severe disabling type and supported by SPECT imaging of the brain, the medial temporal lobe system is speculated to be a key site of action of processing of an aberrant auditory signal resulting in a paradoxical auditory memory; and an accompanying parallel transition in processing of the sensory to the affect component of the symptom of tinnitus. In other words, the eterogeneity of the symptom of tinnitus is reflected in FCP for tinnitus. The FCP is presented as a hypothesis focusing on a process within the MTLS of a paradoxical auditory memory with speculations as to its clinical applications for both diagnosis and treatment.
It is hypothesized that for all sensory systems the sensory and affect components are linked by memory.2 The experience of the sensation is a perceptual image of the stimulus. Psychology and neuroscience evidence have differentiated between long term and short term memory.
The modulator of the sensory component is considered to be the efferent system and the process of masking.3 The modulator of the afferent component is considered to be stress. In the patient with tinnitus, particularly of the severe disabling type it is hypothesized that both the hippocampus and amygdala of the MTLS are significant for the transition of the sensory to the affect component. In summary, the FCP model for tinnitus involving the medial temporal lobe system is initiated in the MTLS by the process of establishment of a paradoxical memory. Our approach is clinical and attempts to identify not all components of the FCP but rather to focus on one aspect, specifically memory which is considered at present to be clinically most significant; and is explainable by what has been reported for understanding brain function specifically memory.
The activity in the brain that corresponds to memory can be found in the medial temporal lobe system.
Crick's comments on the problem of visual awareness I believe can be applied to that of tinnitus - an auditory perceptual phenomenon.6,31 Specifically, investigations for tinnitus are necessary from a psychological and a neuro-science perspective for the issues of attention and very short term memory. The MTLS can be considered an information processing pathway for the integration of sensory and affect components of all sensory inputs.
The perception of a auditory image, considered to be "normal", is hypothesized to be determined by a normal masking function.
It has become apparent to us from our clinical experience with SPECT since 1989, that the manner in which the brain processes auditory sensory information is radically different with or without the presence of tinnitus.
The consequences of the identification of a FCP for tinnitus and the role of the MTLS are considered significant.
The following SPECT images of the brain demonstrate multiple perfusion asymmetries, highlighted by the MTLS (Fig. The FCP for tinnitus provides a rationale and model for understanding the integration, interaction, translation, and transformation of the sensory auditory signal to the affect behavioral response.
An initial process, in the MTLS, is hypothesized to be the establishment of a paradoxical auditory memory for tinnitus. SPECT imaging of brain provides an ability to identify regions of interest in the brain which demonstrate perfusion asymmetries frequently found in patients with tinnitus of the severe disabling type. The processes involved in the establishment of the symptom of tinnitus particularly of the severe disabling type and the problems encountered, relate to the overall problem and question over centuries of what is the relationship of mind and brain and what are the processes involved in such identification. In a continuing study at the medical school in Hanover, Germany, the researchers discovered the degree to which the patient's general well-being plays a role in connection with tinnitus. While some people examined in the study hardly noticed their tinnitus others suffered a lot from the continuous ringing or buzzing in their ears. Unfortunately you cannot use our pictures, as we do not have the copyright, but only have the right to use them on our website. To play the media you will need to either update your browser to a recent version or update your Flash plugin. Adjacent perfusion asymmetries involving the frontal, temporal and parietal lobes suggest a interneuronal network resulting in the transition of the sensory to the affect components of the symptom of tinnitus. Descartes regarded the mind as something immaterial, separate from brain but interacting with it in some manner. Fear and stress in tinnitus patients particularly of the severe disabling type are a result of a paradoxical auditory memory of an aberrant dysynchronous auditory signal. The establishment of a paradoxical auditory memory for tinnitus is hypothesized to be the initial process localized in the medial temporal lobe.

Demonstrations of SPECT imaging of rain in patients are presented to support this hypothesis.
The heterogeneity of response both for sensory and affect has been reported by professionals of all disciplines who are involved in tinnitus diagnosis and attempts for its control. The Papez circuit proposed the anatomical basis of emotion to consist of the cingulate gyrus which connects with the parahippocampal gyrus and peripheral area of the temporal lobe. The anatomical components are best seen by a saggital section of the medial surface of the brain; and ventral views of the base of brain.
Non-declarative memory, also called implicit memory, includes all abilities which are unconscious and expressed through performance.16 Such abilities provide for cumulative changes in perceptual and response systems of new skills and habits, priming, simple classical conditioning, and non-associative learning. Its chieffunction is the transition of a aberrant dysynchronous auditory sensory signal to a affective behavioral response (Fig. This conceptualization is a basic tenet of the FCP for tinnitus of the cochleovestibular system. The sensory and affect components are considered to be in a constant state of reciprocal interaction. For memory, alterations occur in the hippocampal formation with the establishment of a paradoxical memory for an aberrant dysynchronous signal. I consider the experimental and theoretical work of consciousness as reflected in memory, to be a starting point to explain our SPECT findings to date. Neurobiological theories of tinnitus awareness need to be developed and tested using a combination of molecular, neurobiological and clinical imaging studies.
It is possible that there is a localization in the MTLS for all sensory inputs similar to that which exists in the motor cortex.
Specifically, the anatomic substrate where integration of sensory and affect components occurs for the auditory system, is suggested at this time to be in the MTLS. Interference in masking within brain, initially at brain stem is hypothesized to set in motion a cascade of events wherein the sensory component is overwhelmed by that of the affect due to the establishment of a paradoxical auditory memory. Hinton et al.35 have described such neuronal networking in investigations simulating brain damage. For the first time, here is a model which may differentiate tinnitus between its sensory and affect components both from its clinical and basic science perspectives. Jacobson L, Sapolsky R: The role of the hippocampus in feedback regulation of the hippothalamic - pituitary - adrenal cortex axis. LeDoux JE: Information flow from sensation to emotion plasticity in the neural computation of stimulus value. The latter often end up in a vicious circle of sleep disorders, and some even suffer from depression. The only condition is that you provide a direct link to the specific article you use on the page where you quote us. Localization of brain action is now possible and is being investigated with both Positron Emission Tomography (PET) and Single Photon Emission Computer Tomography (SPECT) brain imaging. The transition is acknowledged to be complex, involving an integration of multiple neuronal networks within the brain.
The underlying mechanism is that of dysynchronization, that is, a lack of synchrony or interference in timing of the discharge rate and phase locking of the auditory signal having a location peripheral, central or both. To date 48 patients were selected for SPECT imaging of the brain identified with the MATPP to have severe disabling tinnitus of the central type. The clinical application of this hypothesis for present and future tinnitus diagnosis and treatment is conside d significant. It includes the subcallosal, cingulate, and parahippocampal gyri, the hippocampal formation, and the dentate gyrus. The temporal lobe connects with the hippocampus (AMMONS horn) via the temporoammonic tract. The entorhinal cortex is a major source of projections at the hippocampus and in turn receives input from adjacent perirhinal, parahippocampal cortices. Final Common Pathway for Tinnitus - The Medial Temporal Lobe System (Presentation at the Charles Univ. It is hypothesized based on our tinnitus experience that in the normal auditory system a sequence of auditory images, results first in establishment of an auditory memory for a sensory input, both short and long term; and secondarily a positive affective behavioral response. It is possible that there may be further or additional localization for a particular sensation.
Feldmann reported the difference in interaction of signal and masker in patients with and without tinnitus by masking curves. SPECT findings at this time suggest a common neural pathway and not an abstract algorithmic description.
The FCP is a biological model which is an outgrowth of our ongoing attempts to integrate the basic sciences with our clinical experience for the diagnosis and treatment of all types and subtypes of tinnitus.
Presented at the Fourth International Seminar Inner Ear Medicine and Surgery, July 1994, Snowmass, Colorado. Observations of simultaneous auditory brainstem responses with monaural stimulation in the tinnitus patient.

On the Functional State of Central Vestibular Structures in Monaural Symptomatic Tinnitus Patients. People of calmer disposition and a general sense of well-being suffer far fewer psychological effects from the continuous buzzing or ringing in the ears. Underlying mechanisms are hypothesized to exist and to be highlighted by a diminution of inhibition mediated by gamma aminobutyric acid (GABA) due to disconnection from excitatory (glutamate) inputs.
It is considered to transcend the classica thinking of tinnitus as an auditory signal restricted to the auditory pathway.
The limbic system is a term used to include the limbic lobe and associated subcortical nuclei (amygdaloid complex, septal nuclei, hypothalamus, epithalamus and other thalamic nuclei). The frontal, temporal, parietal lobes project to the perirhinal, parahippocampal cortices from unimodal and polymodal areas.
A paradoxical memory modulates the transition between the sensory and behavioral component of tinnitus.
It is speculated that for tinnitus the amygdala is significant for the alteration in emotional behavior described by the patient.
It is speculated that the primary auditory cortex projects to the hippocampus and amygdaloid complex. The masking curves "can be thought of as contour lines of the neural elements involved in processing signal and masker."34 Tinnitus is believed to produce or reflect a instability or interruption in auditory masking function. The future is to identify neural networks and to create idealized computer simulates of groups of neurons. For auditory perception this includes the inner ear and Organ of Corti; transmission within the ascending auditory system to registration of impulses within the auditory cortex.
Blockage of GABA mediated inhibition results in Tinnitogenesis, a epileptiform auditory phenomena.
The clinical manifestations of the affective behavior of the tinnitus patient can be considered to be components of the FCP for tinnitus.
Physiologic evidence suggests functional differences between the various components although most are related to visceral or behavioral activities (Fig. The mamillary body connects with the anterior nucleus of the thalamus via the mamillothalamic tract. Severe memory impairment associated with hippocampal and amygdala lesions were attributed not to the addition of the amygdala to the hippocampal lesion but instead to the addition of cortical regions that lie adjacent to the amygdala and that are necessarily damaged when the amygdala is removed or impaired. This sequence of events is hypothesized to exist in general for other sensory systems and specifically for the cocheovestibular system.
The central efferent system at a cortical and subcortical level at brainstem is speculated to control the masking capability of the auditory system. In the future, as the clinical experience of multiple disciplines increases for the symptom of tinnitus, it is predicted that additional components will be identified.
The anterior nucleus of the thalamus connects with the cingulate gyrus via the superior thalamic peduncle, thus completing the circuit.
The entorhinal cortex was suggested to be the principle route by which information from the neocortex reaches the hippocampus. Other aberrant sensations experienced by patients include hyperacusis, dysacusis, vertigo, etc. For tinnitus such abilities may reflect cumulative changes in perceptual and response systems and for the development of new skills and habits personified by increasing attention to tinnitus and inability to "cope" with tinnitus. The reciprocal projections between the entorhinal cortex, hippocampus and amygdala result in an emotional response. The degree of inhibition regulated by GABA function is hypothesized to be reflected in the degree of development of the paradoxical memory for tinnitus. Kassirer stated it well in discussing a visual image in clinical medicine that "often we are creating mental models of physical models. Additional feeding pathways to the circuit were described to include the septal and olfactory regions and amygdala. Increasing attention and a probable relationship to sleep phenomena also is considered to be a reflection or projection from the amygdala to sleep areas in cortex. The reciprocal interconnections between primary and secondary associated auditory cortices and vestibular cortices of the cochleovestibular system reflect multiple neuronal networks which have the capability to adapt to changes reflecting alteration in sensory input and output due to different factors influencing neuronal activity of the cochleovestibular system and other systems at a cortical and subcortical levels. Young (1991) considered for depression that the location of cortisol control to be not in the hypothalamus but rather in the hippocampus.26 It is proposed for tinnitus that a cycle can be established wherein reciprocal projections between hippocampus, amygdala, entorhinal cortex and hypothalamus vary in the degree of control of cortisol levels resulting in further strengthening of an already established paradoxical memory with resultant additional negative affect behavioral manifestations of emotion, fear, anxiety, depression, etc. Neuronal networks are hypothesized to exist which in the past were identified as primary and secondary areas.
It is conceived that the excitatory action of the amino acid glutamate may result in more than one physiological function. It is speculated that the GABAergic inhibition and resultant glutamate excess produces a disruption in calcium homeostasis.

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