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INTRODUCTION: Musical training positively influences the cortical plasticity of the brain and has proven to be effective in treating chronic tinnitus. OBJECTIVES: A neuro-music therapy concept, the "Heidelberg Neuro-Music Therapy" treatment was developed and evaluated.
MATERIALS AND METHODS: N = 135 patients (mean age 47 years) with chronic, tonal tinnitus attended a standardized protocol for Neuro-Music Therapy (either "standard therapy" ST or "compact therapy" CT). CONCLUSIONS: The "Heidelberg Neuro-Music Therapy" is a method with fast onset and long lasting effect for patients with "tonal" tinnitus. Apart from emotional disturbances such as anxiety, depression, sleep impairments or irritation1, the main complaints of the persons concerned with ringing in the ear are difficulties in concentrating their attention2 and in auditory perception3. Data from human neuroimaging support the hypothesis of a final common pathway for tinnitus6 and propose a compromised "noise cancellation mechanism"7 to be liable for the enduring tinnitus percept. It is known that pleasant music verifiably reduces activities in the amygdala and enhances activity in nucleus accumbens and thalamus8,9.
Disadvantages are the rather lengthy application and the passive "sounding" of the tinnitus instead of an active exposition to the tinnitus sound. Therefore a short-term Neuro-Music Therapy based on active treatment modules seems to be fruitful in treating chronic tinnitus. The novel treatment according to the "Heidelberg Model of Neuro-Music Therapy" is based on the notion that tinnitus is experienced as an auditory percept - just as musical stimuli are experienced as auditory percepts. Two standardized protocols for tinnitus music therapy were defined: a "standard therapy" (ST) and a "compact therapy" (CT) (see patient flow-chart). All patients receive a comprehensive psycho-educative counseling in order to establish a cognitive model of tinnitus20. As the specific modules used in therapy are based on the individual tinnitus sound, a tinnitus-equivalent has to be set up by means of a commercially available sinus generator.
In the Resonance Training the patient learns a vocal exercise stimulating the cranio-cervical resonating cavities. The Neuroauditive Cortex Training uses tone sequences performed live by the therapist on a piano which have to be vocally imitated by the patient. The Tinnitus Reconditioning offers coping mechanisms related to stress control along with a sound based habituation procedure. During the relaxation exercise, the tinnitus sound will be integrated intermittently into the background music. Patients were eligible if they suffered from chronic tinnitus (duration > six months) which could be musically compiled (distinct frequency) and had no psychiatric co-morbidity.
Since patients were recruited nationwide it was not possible to randomize the patients to the groups in the true sense of the word. Based on data from a pilot study23 we calculated the a priori power and thus estimated the minimum control group size with the power analysis program "GPOWER"24 to n = 15. As part of the medical history, psychosomatic and audiologic co-morbidities as well as socio-demographic data and tinnitus characteristics were assessed.
On the whole 69% of the patients presented with high frequency hearing loss (> 20 dB hearing impairment present in at least three test frequencies > 3000 Hz) and about 42% presented with low frequency hearing loss (> 30 dB hearing impairment present in at least one test frequency 0-2000 Hz).
Due to the stratified group allocation, no group differences in socio-demographic data were obtained. Patients in the music therapy groups ST and CT received a treatment according to the "Heidelberg Model of Neuro-Music Therapy" as described above. Patients in the control group PT received a psychosocial intervention based on psychological tinnitus treatment strategies25 combined with placebo music therapy elements. Assessment of tinnitus symptoms was performed three times, at admission ("pre"), at discharge ("post") and six months after therapy ("follow-up FU"). Apart from statistical significance, individual changes were assessed according to the concept of clinical significance27. At discharge all patients of the music therapy groups had the opportunity to rate their subjective therapy satisfaction.
Statistical analysis of the data was performed using parametrical and non-parametrical tests in SPSS 16 (SPSS Inc.
In order to predict parameters possibly influencing therapy outcome, a logistic regression model (CATREG, SPSS 16.0) was calculated using TQ-score immediately after therapy as an indicator for therapy success as a dependent variable. Analysis of TQ scores revealed a highly statistically significant reduction pre-post (p p =.913). The overall reduction in the music therapy groups can be explained by significant changes in distinct sub-scales of the TQ, especially of "E = emotional problems" (p p p p p >.05). According to the concept of "clinical significance", more than 80% of the patients the music therapy groups (ST and CT) achieved a reliable reduction in their tinnitus scores from admission to discharge and could thus be categorized as "responder". On a subjective level, 67% of the patients treated with music therapy regarded their symptoms as "better", 22% observed no change and 11% stated to be worse off. Apart from immediate therapy-related effects, there could be other factors influencing therapy outcome ("moderator variables"). In order to set the results in the context of existing therapies, a psychologically based treatment group was used as control group. Animal models 29 as well as results from research on tinnitus treatments30 suggest the use of very specific stimuli, i.e. The "Heidelberg Model of Neuro-Music Therapy" on the other hand integrates some well known psychological techniques and strategies in order to reduce the tinnitus sensitivity by means of an immediate exploration of the tinnitus sounds by the patient.
The rather low positive feedback rate of the Neuroauditive Cortex Training (only about a quarter of the patients rated this module as helpful) might have been due to the wording during the therapy. The Resonance Training is a purely vocal exercise that stimulates the auditory pathway by means of somatosensory innervations and enables the patients to control their tinnitus perception. It is known that there are manifold cross-modalities in processing somatosensory and auditory stimuli 35. The Neuroauditive Cortex Training contains a detailed "intonation-training" with purpose-built musical stimuli, based on the individual tinnitus frequency in order to increase the patients" discriminative abilities and enhance their attentive skills. In chronic tinnitus characteristic auditory cortical reorganizations are traceable, which seem to be frequency specific 40,41.
Tinnitus Reconditioninghas distinct features in that it combines musical distractors with psychophysiological relaxation and imagination of mental well-being. Since the application of the "well-being image" is linked to acoustic stimuli (relaxation music, tinnitus equivalent sound), the connection "well-being image - relaxation - tinnitus reduction" can be explained in terms of classical conditioning 46.
The neurological basis seems to be in an endogenous system located in the medial temporal lobe system (MTLS) 6 and the reticular formation (RF) 47. On the whole, music therapy is a method with short duration, fast onset and long lasting effect for patients with "tonal" tinnitus and light to moderate tinnitus severity (Figure 1 and 2). Paper submitted to the RBCMS-SGP (Publishing Management System) on April 1, 2012; and accepted on August,16, 2012. We will be provided with an authorization token (please note: passwords are not shared with us) and will sync your accounts for you.
The editor and reviewers' affiliations are the latest provided on their Loop research profiles and may not reflect their situation at time of review. Chronic tinnitus is associated with neuroplastic changes in auditory and non-auditory cortical areas. Tinnitus is the perception of sound in the absence of a corresponding external auditory stimulus. But although increasing knowledge about tinnitus generation has been revealed by neuroscientific research during the last decades, the pathophysiology of tinnitus is still incompletely understood and there exists no well established causally oriented treatment (Langguth et al., 2013). Due to these limitations, it is important to collect and combine information from different methods in order to obtain an elaborate knowledge about the neuronal correlates of chronic tinnitus. Here, we investigated the effects of single sessions of low-frequency rTMS over the left and right temporal and prefrontal cortices on oscillatory brain activity. Patients with chronic bilateral tinnitus, who had consulted the multidisciplinary Tinnitus Clinic of the University of Regensburg, were included in the study.
Twenty four patients with chronic tinnitus were included in the study, but only the data of 20 patients could be analyzed. Pulses were delivered with a Medtronic system (Medtronic, USA) and a passive-cooled figure of eight coil (MCF B-65).
After recording, EEG data were filtered with a high-pass filter of 1 Hz and a low-pass filter of 45 Hz and segmented into epochs of 2 s skipping the first and last two segments of the recording.
After preprocessing which was done with EEGLAB (Delorme and Makeig, 2004), data were converted into Fieldtrip format (Oostenveld et al., 2011) for power spectrum analysis. Otitis media is inflammation of the middle ear; however, many doctors consider otitis media to be either inflammation or infection of the middle ear. Sign up to stay informed with the latest womens health updates on MedicineNet delivered to your inbox FREE! Tinnitus is the perception of an insistent, unpleasant ringing, buzzing or other consistent noise, located in or near the skull but without a definable external source. Tinnitus is often perceived as a ringing or persistent high tone very close to or within the ear. Tinnitus is often regarded as a symptom of auditory conditions, such as damage to the tissues in the ear that control the perception of tones and frequencies.
An increasing number of researchers argue that tinnitus is a disorder of the connections between the inner ear and certain areas of the brain. Some scientists had developed a theory that tinnitus was associated with deficiencies in vitamin B12. Chronic inflammation of the middle ear (otitis media) may also be associated with some cases of tinnitus. Tinnitus related to otitis media may be improved by surgery to correct damage caused by this inflammation.
Heidelberg Neuro-Music Therapy for chronic-tonal tinnitus - treatment outline and psychometric evaluation. But more than 80% of the music therapy patients (both ST and CT) revealed a reliable improvement ("responder") compared to 44% in the PT group. A number of potential working factors accounting for the treatment success are highlighted. The main reason seems to be the permanent awareness of the tinnitus and the diminished ability to habituate to the sounds4. According to these assumptions, the tinnitus sounds originate from lesions in the auditory pathways. Therefore the patients shall be enabled to actively control the sounds in order to reorganize the underlying neuronal mechanisms maintaining the tinnitus17. The overall therapeutic dose rate (500 minutes of therapy) was equal just as were the intervention modules (including the counseling). The aim is not to reproduce a psychometrical pitch-matched tone but rather a sound that is subjectively equivalent to the patients" "ear sounds". A systematic and targeted training of inaccurately intonated musical sounds enables the patients to exert influence on their auditory processes since they learn to actively filter out irrelevant information and to concentrate on relevant acoustic stimuli. By means of music as calming background stimulus, the balance between the activity of the sympathetic and the parasympathetic branches of the autonomic nervous system shall be restored. The volume is adapted to the individual hearing level compensating for a potential hearing deficit.
The therapy concept was announced by press releases (newspapers and magazines, radio and TV) and offered to patients at the outpatient department of the local ENT-clinic of the university hospital.
The therapy was designed as group intervention with five weekly sessions a 90 minutes and an additional individual counselling (50 minutes) leading to therapy duration of 500 minutes equal to the music therapy intervention. The main outcome criteria were the absolute scores of the German version of the tinnitus questionnaire ("Tinnitus-Fragebogen", abbreviated "TQ") by Goebel and Hiller26 as well as the relative decrease in TQ scores.
They had to answer three specific questions a) "Was your tinnitus percept changed by the music therapy?" (Answers: worsened - unaffected - improved) and b) "Which elements from therapy did you consider helpful?" (open question). In the logistic regression demographic, therapy and tinnitus related factors were entered in the model to define those factors that are associated with tinnitus and may therefore contribute to therapy success.
Therefore there is an urge for a short term therapy with preferably minimal effort but long lasting effect.
In terms of treatment outcome this group was target underperforming since just less than half of the patients achieved the desired symptom reduction. At the core of the "Heidelberg Model of Neuro-Music Therapy", the patients are actively "confronted" with their individual tinnitus sounds and are told to deal with their tinnitus explicitly instead of trying to take no notice of the tinnitus. These modules enhance the self-determination and the control beliefs of the patients since they learn techniques in order to actively influence their tinnitus. The patients possibly did not know the scientific label of the intervention thus the answers in the feedback-sheet were blurred because the patients could not label this intervention.


One specific of the "Heidelberg Model of Neuro-Music Therapy" is the establishment of a tinnitus-equivalent sound. Many patients can voluntarily change the percept of their tinnitus by for example teeth clenching, pressure on the occiput, forehead, vertex and temples, head turning and shoulder abductions 36.
Frequency discrimination training may interrupt the cortical representations that are generating tinnitus 42,43.
This module increases the auditory filtering and supports a modified emotional processing of the tinnitus sound. The MTLS is suspected to be responsible for the establishment of a "tinnitus memory" similar to the pain memory.
Further studies are needed in order to evaluate which elements of the music therapy contribute most to the overall effect and to scrutinize the proposed working factors of the modules. The treatment of tinnitus related psychological distress is part of the music therapy concept, though the duration is very short and music therapy presents a focal therapy and no in-depth psychotherapy will be possible. University Hospital for Ear, Nose, and Throat - University of Heidelberg - Heidelberg - Germany. Tinnitus outpatient department - German Center for Music Therapy Research - Heidelberg - Germany. This means that you will not need to remember your user name and password in the future and you will be able to login with the account you choose to sync, with the click of a button. This page doesn't support Internet Explorer 6, 7 and 8.Please upgrade your browser or activate Google Chrome Frame to improve your experience. About 10 years ago, repetitive transcranial magnetic stimulation (rTMS) of auditory and prefrontal cortex was introduced as potential treatment for tinnitus. Here, we suggest the use of another method which might overcome some of the above mentioned limitations: combined measurements of transcranial magnetic stimulation (TMS) and EEG to investigate differences between people with and without tinnitus in the reaction to magnetic stimulation. We concentrated on effects of 1 Hz rTMS as there is most clinical evidence for 1 Hz stimulation in chronic tinnitus. Subjects with history or presence of severe and relevant somatic, neurologic, or mental disorders were not included.
In addition participants answered questions with respect to demographic and tinnitus-related characteristics, usage of psychoactive substances, and handedness (Oldfield, 1971).
Measurements were done on the same weekday and at the same time except in two cases in the patient and in two cases in the control group. Study procedures with single sessions of repetitive transcranial magnetic stimulation (rTMS) and measurement with resting state electroencephalography (EEG). Randomization was guided by the rationale to stimulate one frontal, one temporal, and one parietal (=sham) cortical site per session (Figure 1), resulting in 24 possible combinations for the first session. Three patients did not complete both sessions and data of one patient could not be analyzed because of a high amount of artifacts in the EEG recordings. Demographic, tinnitus-related, and measurement-related data of the patient and control group.
Each stimulation protocol consisted of 200 pulses applied with 1 Hz at 60% stimulator output lasting about 3 min and 20 s. Sixty two equidistant electrodes that were mounted in an elastic cap (EasyCap, Germany) were referenced to FCz during recording. Thereafter segments were visually inspected for distinct and visible aberrations from the overall recording to identify muscle artifacts (short high frequency oscillations), single channels with low signal-to-noise ratio (zero line in the EEG, main hums, or not smooth trajectories), or other large amplitude physiological artifacts (movement artifacts). For power analyses we used the minimal number of available epochs of each measurement (all subjects and all conditions) and therefore chose the first 79 epochs of each measurement.
Perlstein received his Medical Degree from the University of Cincinnati and then completed his internship and residency in pediatrics at The New York Hospital, Cornell medical Center in New York City. Charles "Pat" Davis, MD, PhD, is a board certified Emergency Medicine doctor who currently practices as a consultant and staff member for hospitals. Phillips Answers: While there exist over-the-counter (OTC) remedies and medications that can alleviate the pain and symptoms of an ear infection, there are no OTC measures that kill the bacteria in the middle ear space that actually cause the infection.
Take the Ear Infection Quiz to learn the risks, causes, symptoms and treatments for the common ear infection (otitis media). It is not considered to be a condition in its own right, but a syndrome or symptom related to many forms of auditory damage or disorder. Age-related hearing impairments, or disorders of the circulatory system around the ear, may also be related to this complaint.
Some scientists conclude that tinnitus is in fact related to damage of the nervous tissue in or around the auditory cortex of the brain.
A recent study including 100 patients with tinnitus found that 63 of these had low vitamin B12 levels. As the natural molecule histamine is associated with the regulation of both inflammation and some auditory nervous tissue, drugs that block its receptors in the brain are currently proposed as treatments for tinnitus.
Darius Kohan is renowned for his otology expertise and has been highlighted on several outlets such as a CBS spotlight on tinnitus and is often cited in WEB MD and other medical outlets.
Tinnitus distress was assessed using the German version of the Tinnitus-Questionnaire (TQ) at admission, at discharge and six months after therapy.
Therapy impact seems to be lasting since TQ scores remained stable until follow-up at six months. For that reason the predominant wish of the patients is to get rid of the "annoying" and "intrusive" sounds5 and to regain confidence in their sense of hearing.
Usually these sounds should be blocked off by feedback connections from limbic regions before reaching the auditory cortex. Musically based interventions11,12,13 also have proven to be highly effective in treating chronic tinnitus - possibly by correcting tinnitus evoking neuronal mechanisms14. If they could actively influence their tinnitus, their control beliefs will rise and thus let down the strains15.
Purpose-built music therapeutic interventions were merged to modules and integrated into a standardized manual. During the interval between the sessions, the patients have to exercise themselves in Resonance Training for three minutes every hour. For this purpose, before the training session starts, the patients have to set the background music to a convenient level such that they can easily listen to the music while still being able to follow verbal instructions from the therapist. Only patients coming from the proximity of Heidelberg were allocated in a randomized way (computer generated) either to the ST group or the PT group. The regression analysis reveals a highly significant relationship between the tinnitus score and the independent variables (p 2= 0.43). The proposed therapy concept "Heidelberg Model of Neuro-Music Therapy" seems to be a potential completion of the therapy spectrum.
Given that this group received also placebo music therapeutic elements (active listening to preselected musical pieces) and an individual counseling, it seems reasonable to argue that the positive and long lasting effect of the music therapy according to the "Heidelberg Model of Neuro-Music Therapy" is due to the far more specific and active musical training aiming directly at the individual tinnitus sound. There exists a variety of procedures using a combination of counseling and acoustic stimulation. In doing so, the duration of the therapy does not exceed ten weeks (standard therapy) and can even be compacted to five days (compact therapy). Many patients stated though that they would enjoy singing or listening to music subsequent to the therapy. Levine 37 proposed interactions between auditory perception and somatosensory input at the dorsal cochlear nucleus. Experimental data indicate that it is more efficient to train at normal hearing frequencies rather than in the region of hearing loss or tinnitus frequency 44,45.
Biocybernetics of attention in the tinnitus decompensation: An integrative multiscale modeling approach. Development and psychometric adequacy of the screening version of the tinnitus handicap inventory.
Final common pathway for tinnitus: theoretical and clinical implications of neuroanatomical substrates.
Intensely pleasurable responses to music correlate with activity in brain regions implicated in reward and emotion. The rewards of music listening: response and physiological connectivity of the mesolimbic system. Auditive stimulation therapy as an intervention in subacute and chronic tinnitus: a prospective observational study. A multi-centre study on the long-term benefits of tinnitus management using Neuromonics Tinnitus Treatment. Listening to tailor-made notched music reduces tinnitus loudness and tinnitus-related auditory cortex activity. A cognitive model of tinnitus and hyperacusis; a clinical tool for patient information, appeasement and assessment.
Musiktherapie bei Tinnitus: Interdisziplinare Pilotstudie zur Uberprufung des Heidelberger Modells.
Clinical significance: a statistical approach to defining meaningful change in psychotherapy research.
Enriched acoustic environment after noise trauma reduces hearing loss and prevents cortical map reorganization.
Treatment of tinnitus with a customized, dynamic acoustic neural stimulus: underlying principles and clinical efficacy.
Cross-modal interactions of auditory and somatic inputs in the brainstem and midbrain and their imbalance in tinnitus and deafness. The effect of a new treatment based on somatosensory stimulation in a group of patients with somatically related tinnitus. Auditory discrimination training for tinnitus treatment: the effect of different paradigms.
Auditory perceptual learning at normal hearing frequencies affects changes in tinnitus intrusiveness and percept. Tinnitus suppression by low-rate electric stimulation and its electrophysiological mechanisms. Classical conditioning as the basis for the effective treatment of tinnitus-related distress.
The dorsal cochlear nucleus as a participant in the auditory, attentional and emotional components of tinnitus.
The resulting changes in tinnitus loudness are interpreted in the context of rTMS induced activity changes (neuroplasticity).
The rationale of this approach is that the way how the brain reacts to a specific stimulation protocol differs between people with and without tinnitus. However, treatment effects are only small and individually highly variable (Langguth et al., 2012).
Intake of psychotropic medication, participating in rTMS interventions within 1 year before the present study and wearing metal implants were further exclusion criteria.
Furthermore, hearing level was measured with a standard audiogram using frequencies ranging from 125 Hz to 8 kHz (Madsen Midimate 622D; GN Otometrics, Denmark).
At each session three rTMS protocols were tested and four EEG recordings (before and after each rTMS intervention) were done. In the second session the contralateral stimulation (sham stimulation was unchanged for both measurements) sites were stimulated in the same order as in the first session. Stimulation intensity was set to a fixed value of 60% stimulator output and not adjusted to the individual motor threshold as stimulation was done through the EEG cap hampering exact motor threshold measurements. After the fast fourier transformation using a hanning window (Fieldtrip parameters mtmfft and hanning) the power spectrum of each channel, condition, and subject was normalized by dividing the power of each frequency bin by the mean power of the whole power spectrum. In a second step, we substracted the baseline-corrected data of the sham condition from the baseline-corrected data for the different active conditions (stimulation site specific changes minus sham-induced change). After serving an additional year as Chief Pediatric Resident, he worked as a private practitioner and then was appointed Director of Ambulatory Pediatrics at St. There he was involved in research in radiation biology and received the Huisking Scholarship. This inflammation often begins with infections that cause sore throats, colds or other respiratory problems, and spreads to the middle ear. Other cases may be related to exposure to very loud or destructive levels of noise, such as from an explosion, industrial equipment or farming equipment. Others have found associations between increased activity in further brain regions, age of tinnitus onset and distress caused by the syndrome.
However, treating this deficiency had no significant effects on the complaint in these patients. Other new and emerging treatments for tinnitus focus on the potential indicated by the studies into its links with abnormal brain activity, as mentioned earlier.


The western heptatonic musical tonality forms the basis of the active music therapy procedures.
The most common side effects are headache and laryngitis if the exercise is not executed properly, either too often, too long or with too much pressure.
Group differences of sociodemographic data and audiometric tinnitus characteristics were analyzed with the c2-test or univariate analysis of variance (ANOVA).
About 80% of the patients accomplished a reliable decrease of tinnitus pathology in the course of music therapy and about two thirds of the patients describe their tinnitus symptoms as "improved" after therapy.
Often the musical stimuli are spectrally modulated in order to account for hearing impairments31,32 and are incorporated as a passive means patients have to listen to for rather lengthy intervals (months up to years).
The main parts of the therapy consist of active music therapy modules; hence there is no need and no purpose for spectrally changing the music used.
We therefore propose that it is possible to alter the internal tinnitus spectrum by means of the Neuroauditive Cortex Training, which represents a specific perceptual training within the normal hearing frequencies. RF neurons coordinate sensory and motor functions and influence cortical activity via the thalamus. Here, we investigate the effect of single rTMS sessions on oscillatory power to probe the capacity of rTMS to interfere with tinnitus-specific cortical plasticity. Decreased output from the cochlea leads to neuroplastic changes along the auditory pathway including changes of the spontaneous firing rate, evoked activity and tonotopic reorganization.
Nevertheless we have to be aware that each of these methods has both strengths and weaknesses. We aimed at testing if this procedure can be used (1) as marker for altered neuroplasticity in chronic tinnitus (pre- to post-rTMS effects); and (2) as indicator for rTMS induced tinnitus loudness reduction.
The control group was recruited by advertisements and matched for age, sex, handedness, education, and hearing level. The TMS motor threshold was assessed with the EEG cap on the head at the beginning of each session.
The 24 possible combinations were randomized before study begin for the patient and control group separately. We measured 20 healthy controls which were comparable to the patients for age, sex, handedness, education, and hearing level. Nevertheless, motor threshold was determined in each participant by beginning the search for the hot spot in the area of C3 followed by stepwise adjustment of the stimulation intensity.
The data excluding electrodes with low signal-to-noise ratio (maximum of five per measurement) was then subjected to an infomax independent component analysis in order to identify artifact components. These baseline- and sham-controlled data of patients and controls were compared in an unpaired t-test using a non-parametric permutation test (Fieldtrip parameter montecarlo) with 1000 iterations and a cluster correction to control for alpha inflation due to multiple testing of 63 electrodes.
Infections can be caused by viruses or bacteria, and can be acute or chronic.Acute otitis media is usually of rapid onset and short duration. Tinnitus may have a significant negative impact on the life quality of those affected by it.
Different research groups have concluded that chronic tinnitus may be associated with an impaired connection between the cerebral cortex, which controls advanced functions such as memory, perception of the environment and cognition, and the thalamus, which supplies the cortex with sensory information.
A recent study, including 974 patients, indicated that hearing aids were preferable and more effective in treating blast-related tinnitus compared to noise generators.
Presuming further research confirms the findings of these studies, deep brain stimulation (a form of implant placed in the brain to correct this activity) may be a viable option for severe treatment-resistant tinnitus. Mutual stimulation via both the thalamic and paralimbic pathways ultimately lead to tonotopic changes in the auditory cortex7 while reciprocal innervations of the medial temporal lobe system give rise to memory consolidation leading to a paradoxical "tinnitus memory"6. Therefore the Neuro-Music Therapy is indicated only if the patients indentify their tinnitus as "tonal" (sinus tones). Any psychiatric disorder or ongoing medication with antidepressants or antipsychotic drugs yields to exclusion of the patients.
Selection of the musical pieces was based on the individual musical taste and preferences as well as on the emotion evoking impact of the musical pieces. Therapy outcome as assessed by the TQ and the CPT were evaluated using univariate analysis of variance (ANOVA) for repeated measure procedures.
This effect was independent of the patient"s treatment allocation to standard therapy or compact therapy. Additionally, a tinnitus-equivalent sound provides the possibility to deal with the symptoms in an immediate and direct way. Therefore an activation of cranio-cervical and cranio-facial muscles and nerves by means of the Resonance Training might correct the auditory pathway by means of indirect stimulation of the joint "relay-station" cochlear nucleus 36. Furthermore it is very important to ensure the training regime is intrinsically motivating. Stress is considered to potentiate the severity of tinnitus due to the proposed accompanying reduction and alteration in auditory masking 6.
We measured 20 patients with bilateral chronic tinnitus and 20 healthy controls comparable for age, sex, handedness, and hearing level with a 63-channel electroencephalography (EEG) system. As tinnitus is continuously perceived in most cases, resting state measurements were assumed to be best suited to identify the neuronal correlates of tinnitus.
TMS-EEG studies enable the measurement of neural reactivity (TMS evoked activity after single pulses) and of neuroplasticity (resting state measurements before and after short repetitive transcranial magnetic stimulation (rTMS) interventions) free of cognitive confounders.
The rational of this approach is to reduce putative over-activation and hyper-connectivity in chronic tinnitus (Eichhammer et al., 2003). Concerning the first question we hypothesized that neuroplastic effects of rTMS over temporal and frontal brain areas will differ between tinnitus patients and controls. The study was approved by the Ethics Committee of the University of Regensburg (12-101-0216). Motor threshold was defined as the minimal stimulation intensity at which visible muscle twitches of the fingers of the right hand were obtained in at least five out of ten pulses. The signals were digitized at a rate of 500 Hz (BrainAmp DC, Vision Recorder, Brain Products, Germany). Horizontal and vertical eye movement artifact components were removed and the remaining components were back-projected to the EEG signal space. For the baseline and sham conditions the two available measurements (one from session 1, one from session 2) were averaged. In other words we calculated the following t-test for each stimulation site: patients [(verum-baseline)-(sham-baseline)] vs. Louis University School of Medicine, he completed his Internal Medicine residency and Rheumatology fellowship at the University of California, Irvine.
He is a Clinical Professor (retired) in the Division of Emergency Medicine, UT Health Science Center at San Antonio, and has been the Chief of Emergency Medicine at UT Medical Branch and at UTHSCSA with over 250 publications.
Acute otitis media is typically associated with fluid accumulation in the middle ear together with signs or symptoms of ear infection; a bulging eardrum usually accompanied by pain, or a perforated eardrum, often with drainage of purulent material (pus, also termed suppurative otitis media).
According to the results from the regression analysis, there was - apart from tinnitus masking level - no influence of tinnitus characteristics or otological co-symptoms on therapy success. A deliberate regulation of emotional responses towards the tinnitus sounds might enhance gate control mechanisms and restore misdirected "filter functions" of thalamic and limbic areas. Educational level, intelligence, depressivity and hyperacusis were controlled for by analysis of covariance.
However, in most of the EEG-, MEG-, PET- and fMRI-resting state studies perceptual, attentional and cognitive processes during the measurement were not specified. All participants gave written informed consent after a comprehensive explanation of the procedures. In all participants, educational years, hyperacusis, depressivity and intelligence were recorded and considered in the statistical analysis.
In most cases the motor threshold was ≤60% stimulator output with the exception of one patient in session one and another patient in session two. For the sham condition (single blinded; patients were not informed about a placebo stimulation) the back-side of the passive cooled coil was put over the electrode position CPz with the handle pointing backwards. Finally, the data was carefully visually inspected a second time for any remaining artifacts.
Fever can be present.Chronic otitis media is a persistent inflammation of the middle ear, typically for a minimum of 3 months. This syndrome may also have deleterious effects on the emotional, psychological and functional status of the patient.
Different rTMS protocols were tested: Left and right temporal and left and right prefrontal cortices were each stimulated with 200 pulses at 1 Hz and with an intensity of 60% stimulator output. Repetitive TMS (rTMS; rhythmic repetition of single pulses at specific frequencies or with specific protocols) induces prolonged changes for up to 2 h which can be measured by resting state EEG before and after the intervention (Thut and Pascual-Leone, 2010). Thereafter the data was re-referenced to an average reference, the online-reference FCz was reconstructed, and electrodes with signal loss were interpolated.
This is in distinction to an acute ear infection (acute otitis media) that usually lasts only several weeks.
Stimulation of central parietal cortex with 6-fold reduced intensity (inverted passive-cooled coil) served as sham condition. Resting state studies assume that the tinnitus percept and the related neural changes are constant over time. Following an acute infection, fluid (an effusion) may remain behind the ear drum (tympanic membrane) for up to three months before resolving.
Nevertheless, the relative reduction and the individual improvement (reliable change index) were independent from the basic TQ-value - therefore also patients with comparatively lower strains still benefit from the therapy in equal measure. In a recent analysis a substantial variability of oscillatory brain activity during the measurements was reported (Schlee et al., 2014). To sum up, combined TMS-EEG studies enable the measurement of TMS evoked activity after single pulses (neural reactivity) and of changes in resting state activity from before to after a single sessions of rTMS (neuroplasticity). After each stimulation protocol tinnitus patients were asked to rate the loudness change of their tinnitus on a percentage scale. Chronic otitis media may develop after a prolonged period of time with fluid (effusion) or negative pressure behind the eardrum (tympanic membrane). The order of rTMS protocols was randomized over two sessions with 1 week interval in between. An alternative approach to resting state is to measure, whether the brain’s reaction to an external stimulus differs in tinnitus patients as compared to healthy controls.
For the present study we used TMS-EEG to investigate alterations of neuroplasticity in tinnitus.
Based on these findings together with numerous findings of increased temporal and prefrontal activity and connectivity in chronic tinnitus (for review, see De Ridder et al., 2011, 2014), we deduced the hypothesis that tinnitus loudness reductions are associated with reductions in gamma power. Chronic otitis media can cause ongoing damage to the middle ear and eardrum, and there may be continuing drainage through a hole in the eardrum.
Analyses on electrode level showed that people with and without tinnitus differed in their response to left temporal and right frontal stimulation. Moreover, we expected that the increased connectivity of frontal and auditory areas in tinnitus will result in remote rTMS effects in the tinnitus group.
In tinnitus patients left temporal rTMS decreased frontal theta and delta and increased beta2 power, whereas right frontal rTMS decreased right temporal beta3 and gamma power. If a tinnitus-like sound is used for stimulation it is a challenge to exactly measure the pitch and volume of the tinnitus (Hoare et al., 2014). This is the first study to show tinnitus-related alterations of neuroplasticity that were specific to stimulation site and oscillatory frequency. Other studies contrasted conditions where patients were instructed to distract or to focus on their tinnitus by using cognitive tasks (Andersson et al., 2006). The observed effects can be interpreted within the thalamocortical dysrhythmia model assuming that slow waves represent processes of deafferentiation and that high frequencies might be indicators for tinnitus loudness.
Results obtained with such techniques are confounded by activation related to the cognitive effort.
Moreover our findings confirm the role of the left temporal and the right frontal areas as relevant hubs in tinnitus related neuronal network. Our results underscore the value of combined TMS-EEG measurements for investigating disease related changes in neuroplasticity. Moreover these techniques are limited by invasiveness or low prevalence of such kind of patients, respectively (Lanting et al., 2009).



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