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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 proposed a method for patient selection and application of criteria for predicting success with bone-conduction external acoustic stimulation using high-audio-frequency sound in the ranges of 10-20 kHz and 20-26 kHz for individuals with subjective idiopathic tinnitus (SIT) of the severe disabling type. This study reports on a method for patient selection for the use of external bone-conduction acoustic stimulation using high-audio-frequency stimulation with ultra-high-frequency (UHF) sound in the range of 10,000-20,000 Hz and with ultrasonic (US) high-frequency sound in the 20,000- to 26,000-Hz range for individuals with subjective idiopathic tinnitus (SIT) of the severe disabling type. The first step in providing efficient tinnitus treatment has been hypothesized to be patient selection. UHF-US external acoustic stimulation is available commercially from two devices that have been reported to provide significant relief of severely disabling tinnitus [3,4]. For UHF-US external acoustic stimulation to be most effective, responses must be positive at 10-14 kHz. Because the amount of energy increases proportional to frequency given a constant mass (head) to be detected by the ear, patient UHF hearing would appear to be a valuable parameter in predicting success in tinnitus treatment. The goal of this study was to present the results of the application of criteria for predicting success with a bone-conduction external acoustic stimulus using either UHF or US ranges in providing relief for patients with tinnitus of the severe disabling type. Of 52 consecutive patients who received UHF-US stimulation for relief of SIT of the severe disabling type, 22 reported tinnitus relief. The application of either high-frequency tinnitus treatment device is summarized in Figure 3. What is interesting to note is that individuals with severe deafness and some high-frequency hearing report US as high-pitched. Classic acoustic stimulation audiograms measuring 250-8,000 Hz do not predict success with high-audiofrequency stimulation or degree of tinnitus relief to be obtained. UHF for tinnitus relief has been found to be most effective when residual neuronal function exists in the acoustic ranges of 10,000-14,000 Hz, with thresholds no greater than 40-50 dB HL. Of 52 consecutive patients for whom high-audiofrequency stimulation using UHF or US was recommended for attempting tinnitus relief, 22 reported relief. The positive medical history of sonovestibular symptoms was confirmed objectively by CDP with sound stimulation with a high statistical significance.
The phenomenon of sound-induced vestibular symptoms and signs, termed the Tullio phenomenon (TP), has been known for six decades.
The effect of inducing nystagmus and vestibular symptoms by acoustic stimulation depends on the functional integrity of the vestibular labyrinth alone and is reproduced in animals when the cochlea has been ablated. Subsequently, TP was studied in terms of its physiological mechanism [4-9], nystagmic eye movements produced in response to intense sound [6,10-12], and the performance on a force platform with an acoustically stimulated vestibular system [10,13-15]. The presence of the TP was noted also in normal subjects (guinea pigs, monkeys, and humans) [19,20] and later even was found to be ubiquitous in normal subjects [21].
Previous reports show that the TP is provoked by a wide range of acoustic stimuli in terms of modes of delivery, intensity, and frequency.
Most authors agree that the middle frequencies are the most effective in producing the TP in patients with inner ear pathology (Table 1) [6,12,14,15,24-26]. Vestibular dysfunction has been characterized in terms of deficits in the vestibuloocular reflex system and the vestibulospinal reflex system. Posturography is an approach to the assessment of vestibular dysfunction that uses a force platform and provides various measures that reflect postural stability, such as the amount of body sway. The TP has been studied only by nystagmographic methods and by static posturography, as mentioned. The changes in postural stability were monitored by CDP when subjects attempted to maintain balance on the platform under stimulation with sound. A pure-tone sound of 110 dB at 1,000 Hz generated by a portable audiometer was delivered by air conduction in continuous mode through earphones. The extent of otological disease was established and documented in every case by history, physical examination, and audiometry. In addition, most subjects with audiovestibular disorders (groups A and B) underwent ENG with sound stimulation for the detection of spontaneous nystagmus, as in the classic method for the detection of the TP.
The three study groups were matched in terms of age; consequently, differences between ages were not significant when compared statistically, as shown in Table 3. The subjects in this study were not matched in terms of quantitative results of diagnostic tests; therefore, the gravity of their disorder did not constitute a prerequisite for their selection.
The 40 patients investigated first were classified according to their clinical diagnosis (Table 4).
Patients' medical history focused on two pertinent symptoms: tinnitus and dizziness (Table 5), with special stress on severity, duration, and precipitating factors. Table 6 exhibits the results of audiological tests: pure-tone audiometry, speech reception thresholds, and performance intensity function for phonetically balanced words (speech discrimination scores). For the statistical approach of the results obtained in CDP before, during, and after acoustic stimulation, we calculated the means of the composite equilibrium scores and the mean individual sensory ratio scores for each study group in each trial.
For purposes of simplicity and a better expression, we preferred to plot the mean composite score and mean vestibular ratio obtained by the three study groups, instead of the individual scores achieved by each subject.
Because the composite score is an average of all sensory conditions, it reflects the overall on-feet stability of the subject. The variation among the three study groups was examined by means of one-way ANOVA followed by Bonferroni multiple range test (Table 9).
Because in the study of the TP we were interested in both the overall equilibrium and the vestibular system in particular, the vestibular ratio score given by the CDP software was investigated next. Once again the one-way ANOVA followed by the Bonferroni mUltiple range test (Table 11) analyzed the variation among the three study groups. The vision preference is one of the sensory ratios provided by the sensory analysis of the CDP's software.
The sensory analysis revealed a variety of disequilibrium types or sensory organization patterns according to the specific sensory system responsible for imbalance (Table 13).
A more intriguing pattern-the combined vestibular and vision dysfunction-was observed in some group A patients on trials 2 and 3 (20% and 25%, respectively).
A last sensory organization pattern observed on sound delivery in two patients in group A was a vestibular dysfunction combined with vision preference. The current study focused on the postural stability of normal subjects and patients with otological impairments and on a third group of patients with similar otological disorders accompanied by a history of sonovestibular symptoms.
Hadj-Djilani [14,15] studied the performance on the force-plate under sound stimulation with exactly the same sound stimulus that we delivered in our work (1,000 Hz, 110 dB SPL).
Our normal subjects and the patients with inner ear impairments without a medical history of Tullio symptoms showed no significant change in postural stability. The occurrence of vestibular disturbance complicated by vision dysfunction during exposure to strong acoustic stimuli in patients suffering from Tullio symptoms is not surprising, given the exposure of the hyperirritable "Tullio" ears to intense noise as a general excitation and discomfort. The diagnosis of vestibular malfunction related to sound exposure may be of crucial clinical significance, beyond the obvious medicolegal implications.
An additional goal of this study had been to evaluate and compare the sensitivities of CDP and ENG in detecting vestibular impairment in the study participants. CDP and ENG were compared in a retrospective study of a mixed population of 375 patients with complaints of dizziness and imbalance [34]. Two additional retrospective studies [35,36] compared CDP and ENG results in patients with confirmed vestibular system deficits. Because of the nonoverlapping nature of the two tests, the foregoing three studies concluded that both vestibuloocular and vestibulospinal tests were essential components in the diagnostic workup. We have managed to learn since the inception of this study that many patients who experience attacks of vertigo when exposed to loud noise complain of these symptoms solely in circumstances of noisy environment. A 43-year-old active ambulance driver was referred to the Otolaryngology Department of Bnai-Zion Medical Center 2 years before his admission to the current study.
A constant, very disturbing tinnitus of alternately low and high pitch had been complicating his condition ever since. The pure-tone audiogram exhibited a bilateral hearing loss of notched configuration in the higher frequencies, typical of NIHL (Fig.
Prior to his admission to this study, the patient underwent ENG that revealed neither spontaneous nor gaze nor positional nystagmus, with no evidence of any vestibular pathology. His temporary unsteadiness provoked by sound occurred because of an underlying vestibular dysfunction, as indicated by sensory analysis: The vestibular ratio is very low (Fig 6).
This work constitutes the final wrap-up of the preliminary study presented at the Twenty-Fourth Neurootological and Equilibriometric Society Congress, 1997, and subsequently published in the International Tinnitus Journal 3:2, 1997. Your use of this website constitutes acknowledgement and acceptance of our Terms & Conditions. De gevoeligheid (dynamisch bereik) van het menselijk oor en ook onze in-ear monitors wordt uitgedrukt in decibel (dB).
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.
Ultra-High-Frequency Ultrasonic External Acoustic Stimulation for Tinnitus Relief: A Method for Patient Selection . Ultra-high-frequency (UHF) stimulation for tinnitus relief has been found to be most effective when residual neuronal function exists in the acoustic ranges of 10-14 kHz, with thresholds no greater than 40 - 50 dB sound pressure level (SPL). High-frequency stimulation has proved to be effective in tinnitus treatment, presumably owing to neuro-reprogramming rather than simple masking [1]. Accurate patient selection - or, more precisely, patient matching to the high-pitch tinnitus treatment modality (UHF or US) for individuals with severe disabling tinnitus - can result in long-term inhibition of tinnitus by external bone-conduction acoustic stimulation with sound in the ranges of 10-20 kHz and 20-26 kHz [2]. We based patient selection criteria on test results from the audiometric data of UHF audiograms. Tinnitus treatment stimuli for the UltraQuiet device (left panel) and the ultrasonic HiSonic device (right panel).
We conducted UHF audiometry using both air-conduction high-frequency audiometry (HFA) with the Beltone 2000 audiometer and electrical HFA (EHFA) with the Tonndorf audiometer. The application of the criteria for patient selection predicted tinnitus relief in 20 of the 22. Individuals with no measurable high-frequency hearing will report US as the quality of the highest pitch they possess. In our experience, the UHF audiogram is predictive of success with bone-conduction external acoustic stimulation using high audio frequency.
US acoustic stimulation is recommended for patients with audiometric thresholds of 5 0 - 6 0 dB HL for frequencies of 10,000-14,000 Hz.
In those 52 consecutive patients, the application of the criteria recommended for patient selection predicted tinnitus relief in 20 of the 22 who reported tinnitus relief. Department of Otolaryngology, State University of New York, Downstate Medical Center, Brooklyn, and Martha Entenmann Tinnitus Research Center, Forest Hills, New York. Departments of Biomedical Engineering, Otolaryngology and Emergency Medicine, Virginia Commonwealth University, Richmond, Virginia.
The Tullio phenomenon evaluated by computed dynamic posturography (CDP) under acoustic stimulation is reflected in postural unsteadiness, rather than in the classic nystagmus. This establishes the described method as a sensitive testing technique for validating the existence of the Tullio phenomenon in patients with a variety of disorders of the inner ear, especially chronic noise-induced hearing loss and acute acoustic trauma. In his early works on labyrinthine physiology, Pietro Tullio [1-3] described how sound stimuli caused pigeons to sway in the plane of the horizontal semicircular canals when minute holes were created in these canals.
Blecker and deVries [4] showed that a microphonic, analogous to the cochlear microphonic, can be recorded from the cristae of the fenestrated semicircular canal of the pigeon and that the frequency response of this crystal microphonic parallels the frequency response curve for the TP.
No difference in body sway was observed according to whether sound was delivered with monaural or binaural stimulation [13]. Lowfrequency noise (50-400 Hz) was shown also to induce responses in the vestibular neurons [9] by direct influence on vestibular end organs [3,9], and its influence on vestibular function was studied with infrasound stimuli of 25, 50, and 63 Hz at 130-132 dB [13,17]. Tests of the vestibuloocular reflex system-caloric irrigation, vertical axis rotation of the entire body, and ENG evaluations of spontaneous and positional nystagmus -provide information about the symmetry of a vestibular lesion affecting the horizontal semicircular canals. One of the latest versions, computed dynamic posturography (CDP) (Equitest), attempts to ferret out the effects of various sensory inputs to the brain and to relate them to overall on-feet balance and stability [27-29]. We could not find any study of vestibular responsiveness to acoustic stimulation evaluated by CDP in the literature. Mean composite equilibrium scores in three consecutive sensory organization tests; the second trial was carried out with acoustic stimulation In conditions 5 and 6.
From the wide range of acoustic stimuli used to provoke a sonovestibular response, we favored one of low intensity that efficiently, yet safely, elicits a Tullio response. Some patients were investigated by imaging studies (computed tomography or magnetic resonance imaging). Informed consent was obtained from the subjects, and the experimental protocol was approved by the local Ethics (Helsinki) Committee and the Israeli Ministry of Health. The only criteria in our choice were the established diagnosis of an audiovestibular disease and an accurate medical history concerning the presence or absence of sonovestibular complaints. The two dominating categories in this study, comprising a majority of 80% (70% in group A and 90% in group B), were patients demonstrating hearing loss caused by noise. By definition, all patients with sonovestibular complaints (clustered in group A) had to be suffering from either lightheadedness, true vertigo, or plain disequilibrium, with or without nausea and vomiting. The binaural hearing loss percentage was based on the pure-tone thresholds at the speech frequencies of SOO, 1,000, 2,000, and 3,000 Hz and were calculated according to the formula used by the American Medical Association [32]. For a more accurate evaluation of hearing loss, basic statistical tests were run on several audiometric parameters. This was accomplished by the alternate binaural balance test administered to patients with a difference of 2S dB or more between the hearing thresholds of the two ears at the test frequency. As we have seen, this presumption about the nonsimilarity of the two sets of subjects with otological disorders eventually was proved partially correct. Vestibular ratios scores obtained in computed dynamic posturography in three consecutive sensory organization tests, the second under stimulation with sound. Switching to this representation is correct as long as the mean follows the trend of most individual values in the group. The trend over repeated trials of SOT was studied by ANOVA for repeated measurements, followed by the Bonferroni test for repeated measurements, applied to the average composite score (Tables 7,8). The trend over repeated trials of SOT was again studied by making use of the ANOVA for repeated measurements, followed by the Bonferroni test for repeated measurements (Table 10; see also Table 8). It reflects the degree to which affected patients rely on visual information to maintain balance, even when the information is incorrect. In this pattern, the sensory ratio of condition 4 to condition 1 is abnormal, whereas those of the remaining pairs are within the normal range (the equilibrium scores for condition 4 are abnormally low relative to the scores on condition 1).
In this pattern, the sensory ratios on both SOT condition 5 to condition 1 and condition 4 to condition 1 are abnormal, with normal 2 to 1 and 3 and 6 to 2 and 5 ratios. Our two sets of pathological patients were picked by definition with regard to the medical history of inner ear disease and to the exclusion of neurological (somatosensory), orthopedic, and vision dysfunction. Both the ratio for conditions 5 and 1 and the paired analysis of conditions 3 and 6 relative to conditions 2 and 5 were abnormal. Accomplishing that would have enabled a correct parallel and eventual contrast between the results and effectiveness of the two vestibular tests in evaluating the TP. The postural responses were monitored on the Equitest (the CDP) in three consecutive sensory organization tests, with the second performed partially under binaural delivery of sound (1 IO dB at 1,000 Hz).
This establishes the described method as a sensitive testing technique for validating the existence of the TP in patients with a variety of disorders of the inner ear, especially chronic noise-induced hearing loss and phonal trauma, even when employing stimuli of harmless intensities (110 dB) and short durations (6 × 20 sec). Three sensory systems are involved in the maintenance of balance: vestibular, visual, and somatosensory. As mentioned, ENG recordings were not made in some cases for a multitude of reasons, and the testing protocols were not identical in the remaining subjects.
CDP abnormalities were documented in 55% of the cases, whereas ENG revealed abnormality in only 26% of the patients. In these more homogenous groups of 46 and 52 patients, ENG and CDP abnormalities were equally prevalent and occurred in approximately 50% of the cases. The contrast between ENG findings and CDP findings in the particular case of patients with sonovestibular symptoms, however, is an interesting aspect and remains one of our objectives for the future. Others may suffer anyway, but their symptoms are significantly exacerbated during sound stimulation. He presented with a history of dizziness attacks triggered suddenly by noise, such as loud music or at weddings, or the whine of jet engines on aircraft flying at low altitude. He had been an otherwise healthy person, except for a peptic ulcer, silent at the time of our investigation, for which he had been administered antacids and H2-receptor blockers in the past. ENG with acoustic stimulation included a 60-second continuous recording of ocular movements during binaural stimulation with the pure tone of 110 dB at 1,000 Hz. Individual and composite scores obtained from a patient with noise-induced hearing loss and the Tullio phenomenon in the sequence of three consecutive computed dynamic posturography sensory organization tests (SOTs). Sensory ratio scores obtained from the same patient as in Figure 5 (with noise-induced hearing loss and the Tullio phenomenon) in the sequence of three consecutive computed dynamic posturography sensory organization tests .
Hierdoor blijft maximaal een paar kubieke cm ruimte over tussen het trommelvlies en de inears; een perfecte akoestische basis om alle details van muziek te horen terwijl het volume laag kan blijven. Deze luchttrillingen  (frequenties) worden aangeduid in hertz (Hz) of kilohertz (KHz =1000 Hz).
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. Ultrasonic (US) acoustic stimulation is recommended for patients with audiometric thresholds greater than 50-60 dB SPL for frequencies of 10-14 kHz. To be detected by the human ear, US frequencies must be approximately 100 dB more intense than thresholds at 8 kHz.
Because calibration procedures were different, thresholds at 8 kHz served as a reference such that all thresholds for higher frequencies are in decibels above it. In this review, we included patients presenting with the primary complaint of tinnitus and identified as having tinnitus of the severe disabling type. Both used amplitude modulation; however, the HiSonic is spectrally narrower and perhaps an octave higher.
For HFA using air conduction, we measured thresholds at 10,000-20,000 Hz in 1,000-Hz intervals in 5-dB steps ranging from 0 to 120 dB SPL. The patients who reported success with UHF-US fulfilled the audiometric criteria as mentioned earlier.
Food and Drug Administration for treating individuals with less than 60 dB HL in the high frequencies and to operate at just above threshold.
UHF-US external acoustic stimulation is recommended for attempting tinnitus relief in a selected tinnitus population with thresholds no greater than 50-60 dB SPL in the 10,000- to 14,000-Hz ranges. Ultra-high-frequency audiometry is considered essential for the selection of candidates for high-audiofrequency stimulation using either UHF or US for attempting tinnitus relief. Ultra-highfrequency stimulation and tinnitus control: A positron emission tomography study. With such a method, the dangerous effects of noise-induced instability can be assessed and prevented. This vestibular microphonic can be recorded from any of the vestibular end organs and has been observed in many species. A scan of the literature for the different stimuli used in different studies reveals that the sound pressure levels used to elicit a TP in healthy subjects were higher than those used in subjects with pathologies of the ear. These vestibular tests, however, do not characterize the vestibular deficit in terms of patients' functional status (the ability to stand and walk) because such patients are evaluated in "passive" positions in which balance is not required. CDP includes test conditions in which the platform and visual environment are moved to reduce subjects' ability to use visual and proprioceptive information for balance.
Static posturography falls short of revealing pure vestibular malfunction, manifested clinically as unsteadiness when standing or walking. This SPL is well within safety limits (Table 2) in accordance with the Illinois Occupational Diseases Act [30] and the Occupational Safety and Health Administration Regulation [31].
All patients with abnormal visual, orthopedic, and neurological function (other than audiovestibular disorders) were excluded from the study. Therefore, patients in group A were intrinsically a "dizzier" and (as demonstrated later) a more "unstable" set of subjects than were those in group B.
Single-factor analysis of variance (ANOVA) revealed insignificant differences among hearing loss percentages, speech reception thresholds, and speech discrimination scores of the two pathological groups (see Table 6). These study groups harbor a discrepancy with regard to symptomatology, whereas objective audiometry revealed a similar degree of hearing impairment. In this way, excessive clutter in the illustration is avoided without generating any statistical error in this case. Thus, the severity of dizziness in these patients (as indicated by history) found a confirmation in terms of posturography by showing a worse balance even in the absence of sound. In group A, the vestibular component of the equilibrium again demonstrates a decrease on stimulation with sound (see Fig 3).
Thus, we got a confirmation of what theoretically was expected; the impaired on-feet stability is (at least in part) explained by a flawed vestibular system in patients with TP. The vision preference scores did not show a large variation, either over consecutive trials or across study groups (Table 12).


The initial proportion of vestibular dysfunction increased on acoustic stimulation to 55% in group A but subsequently decreased in the third trial.
As we know from the literature, this pattern is not observed commonly in patients with impairment limited to the vestibular system but rather are suggestive of central nervous system pathology, possibly in addition to that of the vestibular system.
CDP performances demonstrated that 90% of the 40 subjects (groups A and B) showed either normal balance or vestibular dysfunction solely.
In these cases, the average equilibrium scores for conditions 3, 5, and 6 were not only below the normal limits but were abnormally low relative to the scores on conditions 1 and 2. Regrettably, not all 60 study subjects underwent ENG recording under stimulation with sound, and some of those who did were not evaluated identically in terms of duration of exposure to the acoustic stimulus for various reasons. In comparing our results to those found in previous works in which static posturography methods were used, we must take note of the controversy surrounding the subject in the literature. In these works, they studied the TP using low-frequency sound (25-63 Hz, 130 dB SPL) and observing the change in stability on a static posturograph. This stimulus is well within the noise exposure standards and therefore is safe, with a temporary threshold shift the only unwanted effect it produces. When vestibular damage occurs and remains undiagnosed, the overall function of balance relies only on the other two systems. Conclusions based on such a methodological incongruity of the two diagnostic tests could be erroneous. Hence, CDP provided the only documented evidence of pathology in approximately 30% of the cases.
Both categories, especially the former, undergo extensive and protracted workup as the usual diagnostic tests fail to reveal the gravity of their otoneurological disease. He described these attacks as short (minutes), mainly lasting through the duration of the noise but sometimes beyond that, and always accompanied by nausea. As compared to relatively good overall equilibrium (composite score, 78) and competent sensory systems on the first trial (see Fig. The second trial was performed with acoustic stimulation during conditions 5 and 6, whereas the other two were quiet SOTs in the regular mode. Responses of squirrel monkey vestibular neurons to audiofrequency sound and head vibration.
Influence of pressure loading to the external auditory canal on standing posture in normal and pathological subjects. Tullio phenomenon and postural stability: experimental study in normal subjects and patients with vertigo. Effects of increasing intensity levels of intermittent and continuous 1000 Hz tones on human equilibrium.
Adaptation to alter support and visual conditions during stance: patients with vestibular deficits. Effect of visual support surface references upon postural control in vestibular deficit subjects.
Computerized dynamic posturography: its place in the evaluation of patients with dizziness and imbalance. Comparison between dynamic posturography and ENG recordings in patients with peripheral vestibular disorders. Dat lijkt ons alleen van belang voor vleermuizen, en die worden van die hoge frequenties aantoonbaar knap zenuwachtig. 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. Fifty-two consecutive patients seen for the primary complaint of SIT of the severe disabling type received a trial of either UHF or US bone-conduction acoustic stimulation. One is acoustic stimulation of the residual peripheral neuronal function in the UHF range of 10-14 kHz and audiometric thresholds of 40-50 dB sound pressure level (SPL).
Note that ultrasonic frequencies are 80-100 dB above the thresholds at 8 kHz, whereas high audio frequencies are much lower.
In each case, a transducer is placed on the mastoid, and the stimulation level is ascertained by determining sensation level. After application of the proposed criteria, we selected UHF-US external electrical stimulation for trials to provide tinnitus relief. In EHFA, the head is capacitively coupled into a circuit, and audio tones are amplitude-modulated on a 60-kHz carrier. US can be cancelled when it must pass through the skull, which has many vibratory antiresonances. Presented at the conference Hearing Loss in Children, Amplifon, Milan, Italy, July 2-3, 2004.
Poster presented at the Twenty-First Annual Meeting of the Association for Research in Otolaryngology, St.
This should be carried out preferably by means of CDP with acoustic stimulation for an objective corroboration of their complaint before continuing activity in a noisy environment, thus preventing dangerous loss of balance when exposed to noise. Tullio observed the currents created in the labyrinthine fluids in response to sound by watching the motion of dye particles introduced into the endolymph and perilymph.
Furthermore, information gathered from these studies may indicate that the vestibular response-evoking threshold intensity varies with the frequency of the stimulus: Normal subjects evidence sonovestibular responses at midfrequency range (l,000 Hz) over 120 dB [23].
CDP constitutes a comprehensive sensorial function test of the equilibrium by virtue of its inherent feature of isolating the vestibular, visual, and somatosensory contribution to overall balance, unlike older posturography techniques that served as mere systemic balance tests. We deem CDP a very appropriate technique for investigating the interaction between balance and sound within the labyrinth.
According to these noise exposure safety standards, subjects can be exposed safely to 110 dB for a half-hour daily before any otological damage would occur. Subsequently, we summarized all the relevant medical information supplied by history and the battery of audiological tests. The findings were not suggestive of any correlation between recruitment and the presence or absence of sonovestibular symptoms.
This is not surprising, considering that abnormal sensory preference is, in essence, the effect of a central pathology (arising from the vestibular nuclei or their higher connections), whereas all the subjects in this study were patients suffering from peripheral disease exclusively (arising from the labyrinth or vestibular nerve). The vestibular dysfunction percentages remained constant in the other two groups on repeated trials. The significance of this disclosure of a disturbance in the central connections responsible for equilibrium, triggered by acoustic stimulation in the patients with sonovestibular symptoms, has yet to be interpreted. Only 10% (two subjects in group A on trial 1 and two in group B on trial 3) revealed an inability to use input from the visual system to maintain balance. In general, patients with this kind of pattern are unable to use vestibular system inputs and are abnormally destabilized by orientationally inaccurate visual stimuli. Not only did the intense sound have no deleterious effect on the balance of normal subjects but they improved their postural stability during sound stimulation, probably through the alerting response. Thus, it can be used routinely for detecting this disturbing and potentially dangerous phenomenon in patients who complain of sudden dizziness or report protean descriptions of feeling bad when they happen to be exposed to intense noise at a concert hall, discotheque, airfield, or work. Even though the functional impact of vestibular and vision dysfunction is limited to noise exposure in such patients, they require a stable support surface reference to maintain balance (somatosensory-dependent) in those instances.
When, in addition, other sudden sensory deprivation occurs or if new relationships develop between the sensory systems involved in balance, spatial disorientation may transpire under these circumstances. Among the cases with history of head injury, 100% had CDP abnormalities, whereas ENG results were normal in all of them. Among patients with abnormal ENG and normal SOT results, the majority had compensated unilateral lesions.
Such patients' symptoms seldom improve, because the underlying damage is by and large permanent regardless of etiology.
Additionally, he mentioned occasional vertiginous attacks caused by bending forward, always quite suddenly relieved by straightening out. Speech audiometry found binaural speech reception thresholds and speech discrimination scores of 20 dB and 100% at 55 dB, respectively. 5A), our patient demonstrated a sharp decrease in his overall balance when exposed to the pure tone of 110 dB at 1,000 Hz (composite score, 52) (see Fig.
Cited by Erlich MA, Lawson W, The incidence and significance of the Tullio phenomenon in man. Geluiden met lage frequenties bevinden zich rond de 50 Hz en hele hoge soms wel over de 15 KHz, spraak bevind zich ongeveer tussen 500 Hz en 4 KHz.
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.
A second is the integrity of the brain cortex for neuronal reprogramming as demonstrated in metabolic activity seen in positron emission tomography (PET) of brain.
In other words, the minimal residual neuronal responses necessary for obtaining tinnitus relief with UHF external acoustic stimulation require a threshold no greater than 60 dB SPL at 10-14 kHz.
Each individual received a trial of either UHF or US bone-conduction stimulation for 0.5 to 1 hour [1]. With demodulation, owing to the nonlinearities of the skin, tones are perceived as conventional audiometric tones.
He noted that these currents were in perfect correspondence with the frequency of the applied tone.
At low frequencies (25-63 Hz), the minimal intensity would be 145 dB [13], whereas at frequencies up to 2,500 Hz, the vestibular responses occur only at a sound pressure level (SPL) exceeding 120-160 dB [19]. This was followed 20 minutes later by a test carried out in quiet stance in SOTs I through 4 and with acoustic stimulation in SOT 5 and SOT 6 (Fig. This duration is more than an order of magnitude larger than the total of 120 seconds for which our subjects were exposed during the sequence of two SOTs (5 and 6) repeated three times each. In vestibular dysfunction, the sensory ratio of condition 5 to condition 1 is abnormal, whereas those of the remaining pairs are within the normal range. This pattern was observed neither in those in group B nor in normal controls, whether stimulated acoustically or not.
None of the patients demonstrated somatosensory or central pathology, except for the "central" pattern exhibited by those in group A during and after exposure to sound, as discussed in the previous paragraph. As both the lack of visual and support surface inputs and conflicting visual inputs are destabilizing, these patients are more impaired functionally than are those with either vestibular dysfunction or vision preference alone.
In the absence of a stable surface, they do not make effective use of either vestibular or visual inputs [33]. Exposure to intense noise in unusual environmental settings (during flying under changing gravitational forces, diving, physical activity in darkness, or night driving) might produce conditions that in certain circumstances could even be life-threatening. In contrast, patients with normal ENG and abnormal SOT results had clear positive symptoms of vestibular system disorder.
By the nature of his trade, he had been constantly exposed to the wail of the ambulance siren for almost two decades, and this had turned his everyday life for the last 7 years into a desperate condition. Capelli, 1929.) Cited by Erlich MA, Lawson W, The incidence and significance of the Tullio phenomenon in man. 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. The application of criteria for patient selection predicted tinnitus relief in 20 of the 22. A PET of brain study identified a correlation between the UHF audiograms, the subjective reports and outcome measures of the efficacy of the UFH-UQ for tinnitus relief, and brain PET metabolic categories. Pitch matching and Feldmann masking curve data were not informative in establishing a criterion for patient selection. The thresholds are actually first established in electrical terms and then are converted to an equivalent SPL. The second group (B) included 20 neurootological patients without a history of Tullio phenomenon. He also noted that at higher sound intensities, a nystagmus was produced, the frequency of which corresponded to the oscillations of the internal current. Bearing in mind that acoustic stimuli in unusual environmental conditions always affect both ears, we preferred to employ a binaural stimulation in the attempt to prove the hypothesized correlations in accordance to the hazards of quotidian reality. Thus, the equilibrium scores for condition 5 only, or for conditions 5 and 6, are abnormally low relative to the scores on condition 1.
This abnormal pattern is described as occurring in patients with balance disorders secondary to traumatic head injuries but also was reported in other patient populations. The balance functions during exposure to intense noise in such patients tend to be more impaired than in those with vestibular dysfunction, vision preference, or a combination of these pattems.
In these patients, disorders were either more central or were presumed to effect peripheral components other than the horizontal semicircular canals (vestibuloocular system). Consequently, these patients continue to seek medical assistance, and their complaints seem to be psychologically aggravated by frustration accumulated through continual visits, referrals, and failing therapy. On the third (quiet) trial, 20 minutes later, his balance recovered completely (composite score, 80) (see Fig.
Specifically, the best subjective reports for tinnitus relief with UHF were reported by tinnitus patients with auditory thresholds of 4 0 - 5 0 dB SPL or less for the frequency range of 10-14 kHz. Because force is equal to mass times acceleration, the amount of energy needed to move the mass of the head (15 kg) increases with frequency. Classic acoustic stimulation audiograms measuring 250-8,000 Hz revealed individual variations in hearing thresholds similar to those reported for the total cohort of 15 patients in the UHF-UQ study [8].
The conversion algorithm favors an accurate depiction of frequencies above 8 kHz and was an ideal instrument for assessing bone-conduction thresholds for this study.
Furthermore, US is typically one-half of a full octave above the brain resonances, thus requiring more energy to demodulate the brain. Sounds reaching the ear of the animal produced a current in the open canal, also affecting all three semicircular canals simultaneously. In the latter two tests, subjects had only the vestibular system at their disposal (with inputs from other sensory systems canceled or inaccurate).
The functional impact of this pattern dwells in the necessity of either a stable support surface or stable visual field to maintain balance. Indeed, one of our two patients with this disequilibrium pattern mentioned a head injury incurred several years prior to the current investigation (in addition to the NIHL from which he was suffering and for which he was selected).
Preferably, this should be carried out by means of CDP with acoustical stimulation for an objective corroboration of their complaint before continuing activity in a noisy environment, thus preventing dangerous loss of balance when exposed to noise. We deem the description of a typical case of TP pedagogically rewarding and suggestive of the problem and therefore appropriate. Thresholds are established for each ear separately, as EHFA is not a binaural phenomenon typical of conventional bone-conduction hearing. Consequently, more energy is required to hear US than is needed to hear high audio frequencies, although they share the same place of displacement on the basilar membrane [9]. A pure-tone stimulus of I,000 Hz at 110 dB was delivered binaurally for 20 seconds during condition 5 and condition 6 of the CDP sensory organization test. However, the current was predominant and the cristae more easily displaced in the fenestrated canal, accounting for visible movements only in the plane of this canal.
The sensory analysis of the second patient showed mainly vestibular dysfunction and only a borderline visual preference abnormality. 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. The sequence of six sensory organization conditions was performed three times with two intermissions of 15-20 minutes between the trials. From the different reactions that Tullio observed by stimulating the ears of animals, he proposed that perhaps this was to become a potential diagnostic tool with which one could recognize the seat and nature of lesions in the different parts of the labyrinth. The latter is described in the literature as accountable to, among other causes, a declining performance caused by fatigue or by exacerbation of the patient's symptoms during repeated trials [29]. This was followed 20 minutes by a trial carried out in quiet stance in sensory organizations tests (SOTs) I through 4, and with acoustic stimulation in SOT 5 and SOT 6.



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