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Author: admin | 18.03.2014 | Category: Tinnitus Causes And Treatments

The perception of tinnitus is the result of changes in the auditory system, which leads to an increase in the neuron activity from the inner ear to the brain.
A number of healthcare professionals specialize in tinnitus treatment and can help if you have symptoms. How to cite this article Mahmoudian S, Lenarz M, Esser K, Salamat B, Alaeddini F, Dengler R, Farhadi M, et al. INTRODUCTION: Residual inhibition (RI) is the temporary inhibition of tinnitus by use of masking stimuli when the device is turned off. OBJECTIVE: The main aim of this study was to evaluate the effects of RI induced by auditory electrical stimulation (AES) in the primary auditory pathways using early auditory-evoked potentials (AEPs) in subjective idiopathic tinnitus (SIT) subjects.
MATERIALS AND METHODS: A randomized placebo-controlled study was conducted on forty-four tinnitus subjects. CONCLUSION: The observed changes in AEP associated with RI suggested some peripheral and central auditory alterations. McFadden defined that "tinnitus is the conscious expression of a sound that originates in an involuntary manner in the head of its owner, or may appear to him to do so"1,2.
Although the RI phenomenon is one of the few methods that may temporally relieve tinnitus, only few studies on RI have been published until now11.
Through the electrophysiological approaches, we may be able to determine the manner for abnormal brain electrical activity in the auditory pathway and provide quantitative information regarding tinnitus and RI phenomenon. Since the transmission time-interval is a presentation of the progress of neural excitation from the distal portion of auditory nerve to the inferior colliculus of the brainstem, this interval has been referred to as brainstem transmission time (BTT) (Figure 1).
It is possible that the neural mechanisms involved in the RI phenomenon are similar to those that cause tinnitus10,35. This cross-sectional and randomized, placebo-controlled trial was conducted on 44 adults (32 males, 12 females) suffering from severe subjective idiopathic tinnitus (SIT) referred to the ENT and Head & Neck Research Center of Hazrate Rasoul Hospital for an evaluation and management of their tinnitus during 2010 and 2011. Additionally, the subjects were considered homogenous because of the constant and steady-state feature of their tinnitus. The screening tests included history taking, medical examinations, temporal bone imaging, an audiological evaluation (pure tone audiometry and tympanometry) and tinnitus psychoacoustic measurement (pitch and loudness matching) were performed for all tinnitus subjects. All studied subjects was initially received AES for three different durations of 60, 120 and 180 seconds delivered to the tinnitus ear.
With respect to the responses to AES, the subjects were enrolled into one of two pre-defined groups, including subjects with RI and those with non-residual inhibition (NRI). A few minutes following AES, the inhibitory effects on perceived tinnitus loudness (residual inhibition) were estimated using a visual analogue scale (VAS) and pitch-match and loudness balance tests.
The subjective criteria for evaluating tinnitus after AES using a psychoacoustic tinnitus assessment included diminishing or worsening of tinnitus loudness by at least 2 dB SL and reduction or increment in the pitch of tinnitus at least by 1000 Hz. We used a tinnitus evaluation device (TinnED®, designed in Research Center of Otolaryngology; Head and Neck of IUMS), which has 6 channels to reconstruct the most troublesome tinnitus (MTT) with a similar frequency and intensity. AES was applied by inserting an active surface tympanic membrane electrode through the external auditory canal into the posterior inferior of the tympanic membrane and placing silver surface electrode on the forehead and delivered by a stimulation system (promontory stimulator; cochlear company, Australia) used for evaluating cochlear implant (CI) candidates.
An analysis of variance was used to analyses the differences between the RI, NRI and PES controls for auditory pure tone averages (PTA).
An ANOVA assessed the statistical significance between the RI, NRI and PES controls for the auditory pure tone averages (PTA). When rating the average pre-stimulation tinnitus loudness, the subjects rated their tinnitus as greater than 6 on a 10-point visual analogue scale. A repeated measures ANOVA was used to test for differences of PMT and LMT pre-and post-AES among the RI, NRI and PES control groups. The present study evaluated the alterations occurring in early auditory evoked potentials and brainstem transmission time associated with RI induced by AES in tinnitus subjects.
It appears that the neurophysiological mechanisms involved in RI could be related to both pre- and post-synaptic effects of AES followed by an increase of synchronized neural discharges and inhibition of the abnormal activity of the cochlear nerve. Tonndorf outlines the situation for most cochlear damage associated with tinnitus: the stronger inner hair cells (with large diameter nerve fibers) remain relatively undamaged, while the delicate outer hair cells (with small diameter nerve fibers) are destroyed. Using an ECochG test, the CAP amplitude indicated a significant increase associated with RI induced by AES. Since previous studies suggested neural alterations related to the AEPs properties in tinnitus subjects17,38, the current study used the measurement of BTT as a considerably more stable and invariant parameter in evaluate tinnitus RI phenomenon34. Many studies also stated that the majority of tinnitus forms result from a loss of inhibition in central auditory structures35.
Also, a comparison of auditory nerve fiber discharges by AES in animal studies indicates that electrical stimulation causes discharge synchronizations in wide groups of nerves.
Despite above mentioned facts, the possible mechanisms involved in causing tinnitus RI using electrical trigger have not been precisely recognized, and the origin of this phenomenon in the brain has not yet been obviously recognized.
The current study conducted to examine the neural mechanisms of RI induced by AES in the first ten ms after stimulation include neurogenic responses arising from the auditory nerve to the inferior colliculus of the brainstem. Iran National Science Foundation (INSF), Otolaryngology and Head & Neck Research Center, Iran University of Medical Sciences (IUMS). This study was financially and technically supported by the Iran National Science Foundation (INSF), ENT and Head & Neck Research Center, Iran University of Medical Sciences (IUMS), Tehran, Iran, and the Otorhinolaryngology Department of Hannover Medical University (MHH).
Institution: Department of Otorhinolaryngology, Medical University of Hannover (MHH), Hannover, Germany ENT and Head & Neck Research Center, Iran University of Medical Sciences. Paper submitted to the ITJ-SGP (Publishing Management System) on April 9, 2014; and accepted on April 15, 2014. The development of the Tinnitus Cognitions Questionnaire (TCQ), a scale designed to assess positive and negative cognitions associated with tinnitus, is described. The assessment of psychological distress or handicap experienced by tinnitus sufferers has been the subject of recent research. The measures already mentioned were designed primarily to measure the extent of distress or handicap associated with tinnitus. In the last decade, a steady growth of interest has occurred in the development of psychological methods for helping people to cope with tinnitus. The aim of this article is to report on the development of a measure (the TCQ) designed to assess the content of a person's cognitions in relation to tinnitus. The version of the TCQ presently described was a revised adaptation of an earlier form of the questionnaire. The negative items (1-13) are scored 0-4, whereas the positive items (14-26) are reverse-scored: 4-0. The TCQ and various other self-report measures were administered to 200 subjects drawn from three separate samples.
For a subset of 32 subjects (20 from sample 1 and 12 from sample 2) who represented subjects assigned to waiting-list control conditions in two treatment outcome studies [13,14], responses to the TCQ were available from two administrations separated by a period of 6-8 weeks.
Besides completing the TCQ, subjects were administered a number of additional self-report questionnaires.
The THQ is a self-report questionnaire designed to measure perceived degree of handicap due to tinnitus [3]. The TEQ is a self-report questionnaire designed to assess dimensions of complaint about tinnitus [1,2]. The Beck Depression Inventory (BDI), a widely used self-report measure of depression, presents good evidence in support of its reliability and validity [25,26]. The Automatic Thoughts Questionnaire (ATQ) was devised by Hollon and Kendall [27] as a measure of the frequency of occurrence of automatic thoughts associated with depression. The Locus of Control of Behavior Scale (LCB) is a 17-item self-report scale designed to assess locus of control of behavior [28]. The TCQ was examined for several psychometric properties, including internal consistency (Cronbach' s alpha, item-total correlations) and test-retest reliability. The means and standard deviations of the TCQpositive, TCQ-negative, TCQ-total, TRQ, TEQ (full scale and subscales), THQ, BDI, LCB, and ATQ are presented in Table 1.
An inspection was made of the percentage of subjects who responded in each of the five levels for the individual items.
The internal consistency of the TCQ was examined by Cronbach's coefficient alpha and by computing itemtotal correlations.
A principal-components factor analysis was performed using varimax rotation with Kaiser normalization to investigate the factorial structure of the TCQ.
Factor 1 accounted for 31.4% of the variance and consisted of all the positive cognitions (items 14-26). Pearson-product moment correlations among the TCQ-negative item scores, TCQ-positive item scores, and TCQ-total scores were examined. Correlations among the TCQ-total, TCQ-positive, TCQ-negative, and other measures of tinnitus distress and general psychopathology were computed.
Overall, the TCQ-total displays moderate correlations with most other tinnitus-related measures, such as the TRQ, the THQ, and the TEQ-total. The development of a new scale designed to assess reported engagement in negative and positive cognitions in response to tinnitus has been described. The lack of association between negative and positive thoughts about tinnitus may be interpreted within the states-of-mind model advanced by Schwartz [29] and Schwartz and Garamoni [30] (see also Schwartz [31] and Schwartz & Michelson [32]).
How to cite this article Nicolas-puel C, Faulconbridge RL, Guitton M, Puel J, Mondain M, Uziel A.
The aim of this study was to highlight the clinical characteristics of tinnitus and to attempt a quantitative assessment in relation to any underlying etiologies. Tinnitus constitutes an important public health problem; it is estimated that in France alone, there are 5 million tinnitus sufferers. One hundred twenty-three patients were treated in a specialist tinnitus clinic at Gui de Chauliac1 Hospital, Montpellier, France, between 1998 and 2000 [1]. The assessment was based on a questionnaire that was used to evaluate the clinical aspects of tinnitus (see the appendix at end of article).
When asked, patients usually liken the sound of their tinnitus to environmental noise, such as the sound of the wind or the sound of an insect.
To investigate the temporal variation of tinnitus, patients were asked whether the intensity of their tinnitus was stable or whether it fluctuated during the course of the day. The aim of the clinical examination was to determine any underlying etiology that would explain the presence of tinnitus.
The great majority of patients (almost 90%) presented with tinnitus associated with deafness of known etiology (Table 1). Hearing losses were divided into four groups: highfrequency (60%), low-frequency (25%), flat losses (11%), and dead ear (2%). Of the patients from the endocochlear group, 65% had stable tinnitus, and 32% had fluctuating tinnitus.
Of patients with Meniere's disease or Meniere's-like syndrome, 84% described fluctuating tinnitus. Of patients with endocochlear deafness, 77% described their tinnitus as a high-pitched whistling, and 21 % described it as a low-pitched buzzing (Fig. In our study, 58 of the 77 patients with a stable high-pitched tinnitus (77%) had a high-tone hearing loss.
This study attests to the rare incidence of objective tinnitus: There was no case of objective tinnitus in this series. The study of the etiology of the underlying deafness offers interesting results for understanding tinnitus, especially in patients with high-frequency hearing loss.
We have confirmed in this study that the general frequency of tinnitus pitch perceived by the patient is correlated in broad terms with the frequency of the hearing loss, in agreement with some other studies [7].
This study has raised interesting findings about the fluctuation of tinnitus after periods of sleep, especially in patients with low-frequency tinnitus. We have shown in this study that audiometry can be used as a simple indirect test to evaluate tinnitus, as it correlates well with a visual analog scale of tinnitus intensity in the majority of our patients.
We thank Professors Bernard Guerrier and Remy Pujol, who supported and encouraged this work. The purpose of this study was to investigate the effects of a vestibular rehabilitation program on patients with the diagnosis of migraine-associated dizziness. The occurrence of migraine headaches with secondary vestibulopathy and associated vestibular dysfunction is well documented [1-4]. However, research has shown that patients with episodic disorders, such as migraine-associated dizziness (MAD), have not responded consistently to vestibular physical therapy rehabilitation programs [13].
Thirty-four (25 male, 9 female) consecutive patients with migraine-related vestibular symptoms were treated with a customized vestibular rehabilitation program and a migraine preventive medication.
All the individuals underwent a workup that included a detailed otolaryngologic history and physical examination, standard neurological examination, and a magnetic resonance imaging scan to rule out a cerebellopontine angle lesion or other pathological findings. The vestibular rehabilitation strategy employed specific exercises designed to decrease dizziness, increase balance function, and increase general activity levels.
Specifically, the vestibular exercise program included vestibuloocular reflex exercises, cervicoocular reflex exercises, depth perception training, somatosensory retraining, and varied ambulation skill exercises. Large-amplitude head and trunk movements were also employed to increase somatosensory input. Ambulation exercises were graded in difficulty by a change in direction, performance with eyes closed, increasing speed of ambulation, proprioceptive neuromuscular facilitation, resisted balance and resisted gait, walking on soft surfaces, and stair climbing.
Patients were also instructed in a progressive aerobic exercise program of increasing time and distance and were instructed to perform the exercises twice daily at home.
All patients were treated with low-dose Neurontin as a migraine preventive medicine (100 mg twice daily).
Figure 1 demonstrates the results of the DHI, ABC, DGI, and CDP measurements before and after 6-8 weeks of treatment for all the patients studied.
The results of the time to return to work and time to remission of symptoms are presented in Figure 3. Our work demonstrates that vestibular physical therapy rehabilitation strategies produced improvement in DHI, ABC, DGI, and CDP measures for all groups studied.
As we have indicated, this study had a greater population of male subjects and a greater population of younger subjects than did previous studies [6,15,16].
In this study, we have not compared these treated patient groups to control (nontreated) groups. How to cite this article Otto V, Fischer B, Schwarz M, Baumann W, Preibisch-effenberger R. Thirty-seven patients suffering from vertigo associated with vertebrobasilar insufficiency participated in our prospective, single-center, double-blind, comparative study.
The maintenance of balance is an essential condition for the management of daily activities.
The vertebrobasilar system is responsible for the blood supply of 10 cranial nerves, all ascending and descending tracts, parts of the cortical hemispheres, and the endorgans of hearing and balance. A major concern of drug therapy in VBI is to improve impaired circulation and to restore normal perfusion of compromised areas [6].
Here we report on the efficacy and tolerability of a fixed combination consisting of the calcium channel blocker cinnarizine (20 mg) and the antihistamine dimenhydrinate (40 mg). The antivertiginous efficacy of the combination was demonstrated in a series of open studies [21-24] and in numerous controlled, double-blind, randomized clinical studies that included patients suffering from vertigo of central, peripheral, or combined central-peripheral origin.
Eligible participants were men and women who suffered from VBI and, in addition to the cardinal symptom vertigo, showed at least two of the following symptoms: impaired hearing, impaired vision, tinnitus, or headache.
We designed the study as a randomized, double-blind, reference- and placebo-controlled, single-center, phase III clinical study with three parallel groups. Patients were subjected to an entry examination (first visit, before start of treatment), an intermediate examination (second visit, after 7 ± 2 days), and a final examination (third visit, after 28 ± 2 days).
The VBI symptoms-headache, tinnitus, impaired hearing, impaired vision, aural fullness, ocular muscle pareses, and bulbar symptoms-were rated by the patients. In addition, the patients were asked about the intensities of vegetative symptoms that are often associated with vertigo. We performed Unterberger's and Romberg's tests and registered the results by craniocorpography (CCG), as described elsewhere [3]. For an objective assessment of hearing function, we performed audiometric tests according to standard procedures using pure tones, words, and numbers as criteria for assessment of hearing loss.
Tolerability assessment was based on reports of adverse events that occurred after drug intake.
Confirmatory analysis of the primary efficacy variable SM was based on its change from baseline in hierarchical order: (first) 4 weeks after start of treatment and (second) 1 week after start of treatment. Thirty-seven white outpatients were enrolled in the study to receive either the fixed combination (n = 11), betahistine (n = 13), or placebo (n = 13). The primary efficacy variable was the reduction of the mean vertigo score (SM ) in the course of the 4-week therapy. At the start of the study, all patients except one in the fixed-combination group complained about headache.
The results of the parameter lateral sway in Unterberger's and Romberg's tests are shown in Table 6.
Evaluation by Frenzel's glasses showed no clear evidence for spontaneous nystagmus in any patient either initially or in the course of the study.
Also, no significant difference was seen between patients in the three treatment groups with respect to the caloric test variables, either at baseline or in the course of the study. Both in pure-tone and the speech audiometry, the proportion of patients presenting hearing loss remained unaffected in the course of therapy with any of the study medications. The assessments by investigator and patients were similar and coincided with the decrease in vertigo symptoms observed under therapy with the fixed combination. A total of 7 of the 37 randomly assigned patients reported adverse events (AEs) in the course of the study. The investigator rated the tolerability of the study medication as good in all patients except for one patient in the betahistine group, for whom the tolerability was judged as moderate. Evaluating therapy success in patients suffering from vertigo is often difficult owing to the complexity of this disease and the lack of unambiguous apparatus-based parameters.
The efficacy of the fixed combination and its superiority over betahistine can be explained by the pharmacodynamic properties of the two medications. The present results have proven that the fixed combination of cinnarizine and dimenhydrinate is an effective treatment option in treating vertigo due to VBI.
Owing to organizational and technical changes at the ear, nose, and throat clinic of the Otto-von-Guericke University, formerly the Medical Academy, Magdeburg, at the time of the study, the investigations had to be terminated prematurely. In conclusion, the fixed combination containing 20 mg cinnarizine and 40 mg dimenhydrinate proved to be a safe and effective antivertiginous medication in the treatment of patients suffering from vertigo due to VBI.
This damage can occur from a number of sources, such as exposure to very loud sounds throughout your life or toxic medications that damage the ear. The first step is to see an audiologist who can visually inspect your ears and evaluate your hearing. Alterations in early auditory evoked potentials and brainstem transmission time associated with tinnitus residual inhibition induced by auditory electrical stimulation. All enrolled subjects based on the responses to AES, were divided into two groups of RI and Non-RI (NRI).
Synchronized discharges of the auditory nerve fibers and inhibition of the abnormal activity of the cochlear nerve by AES may play important roles associated with RI. It would be a critical step to define the factors that create these phantom sensations and develop rational treatments for this chronic and disabling disorder12. It has been shown that there is a relationship between the auditory evoked potentials (AEP) and the tinnitus phenomenon17.
It has been shown that BTT is one of the most stable features in assess of neurotological conditions34. Typical alterations in the AEP waveform associated with RI induced by auditory electrical stimulation. Aberrant increase in function of neural networks or enhancement of stimulatory synapses function or decreased function of inhibitory synapses may be responsible for impairing pathways. The tinnitus subjects included in the research received electrical stimulation in the tinnitus ear. In the current study, all included tinnitus subjects were randomly allocated into two groups: those subjects who received AES and those who received placebo electrical stimulation (PES). This action was solely performed to ensure increased competence and effectiveness of the stimulation process to generate RI prior to electrophysiological procedures.
The results of the ECochG and ABR recordings were determined and compared before and after the applying AES and PES.
Increased, unchanged or reduced less than 2 scores of VAS test were considered as NRI, 3 scales and more decrement were considered as RI. TinnED® measured four important parameters of tinnitus, including pitch-matching and loudness-matching of tinnitus (PMT and LMT), minimal masking level (MML) measured by narrow band noise to the affected ear until the tinnitus was fully covered and RI using a narrow band noise for 60 seconds when the intensity was 10 dB over MML.
Five subjects reported a complete inhibition (complete RI) of their tinnitus, and 19 subjects reported a significant attenuation of their tinnitus (partial RI). A repeated measures ANOVA was used to test for the loudness rating differences using VAS between the groups pre-and post-AES. Observed changes in the visual analogue scale (VAS) scores for tinnitus loudness, the perceived frequency of tinnitus (pitch match of tinnitus) and perceived loudness of tinnitus (loudness match of tinnitus) pre-and post-AES among the three groups of subjects using repeated measures ANOVA.
The mean difference in the inter-peak latency intervals of I-III, III-V and I-V pre- and post-AES were not significant in either group (Table 4). This study was performed in the first ten ms after stimulation to identify the effects of tinnitus and RI in neurogenic responses arising from the distal portion of acoustic nerve to the inferior colliculus of the brainstem.
This auditory deafferentation can cause an increase in spontaneous activity of auditory nerve fibers.
When inhibitory deficits occur, synchronous neural activity, which is normally limited by feed-forward inhibition to acoustic features in the stimulus (normal auditory perception), may develop spontaneously among neuronal networks in the affected auditory cortical regions and generate the sensation of tinnitus25,46. An electrical stimulus delivered to the round window sensory transduction47 and directly drives both outer hair cells (OHCs) somatic and hair-bundle motility48,49. Therefore, we could not conclude whether the RI produced by AES was induced by action on the entire nerve or on some restricted fibers related to tinnitus pitch. Therefore, more comprehensive neuroscientific studies are required to better understand the mechanisms behind this phenomenon. Department of Otorhinolaryngology - Medical University of Hannover (MHH), Hannover, Germany and ENT and Head & Neck Research Center, Iran University of Medical Sciences - Hannover - AC - Germany. Department of Otolaryngology - Charite - Universitatsmedizin Berlin, Berlin, Germany - Hannover - Germany. Auditory Neuroethology & Neurobiology Lab, Institute of Zoology - University of Veterinary Medicine Hannover.
Department and Research Center of ENT and Head & Neck Surgery - Iran University of Medical Sciences. Tinnitus Cognitions Questionnaire: Development and Psychometric Properties of a Measure of Dysfunctional Cognitions Associated with Tinnitus. Psychometric analyses of the TCQ are examined, with a total of 189 subjects from three separate samples. A second type of instrument should be developed to study more precisely the coping characteristics of tinnitus patients.
Earlier approaches consisted mainly of biofeedback and relaxation techniques, but emphasis in recent years has shifted toward the use of cognitive therapy techniques involving either attention control methods or the examination and modification of thoughts and beliefs about tinnitus [12-20]. This questionnaire may be a useful tool in research on the cognitive processes involved in coping with tinnitus.
The original questionnaire consisted of 20 items constructed on the basis of clinical experience obtained during interviews with tinnitus sufferers. The scoring procedure involves the simple addition of the number circled by the respondent for items 1-13 and the addition of reverse-scored items 14-26. Sample 1 consisted of 60 subjects referred by an audiological department of a veterans' hospital. The responses to these two administrations were used for the calculation of test-retest reliability.
The TRQ is a 26-item self-report scale designed to assess the psychological distress associated with tinnitus [4].
The THQ consists of 28 items that describe potential effects of tinnitus on hearing, lifestyle, health, and emotional status. A measure of depression was included to provide a more general index of emotional state not directly linked to tinnitus.
This term refers to the extent to which people perceive events as a consequence of their behavior and, therefore, potentially under personal control. A principal-components factor analysis was performed using varimax rotation with Kaiser normalization. The difference in mean TCQ-total scores among the three samples was investigated with a one-way analysis of variance. As can be seen from these means, the sample can be characterized as exhibiting mild to moderate depressive symptomatology (the BOI) and moderate to severe tinnitus-related distress (the TRQ, TEQemotional distress) and handicap (TEQ-total, THQ). Factor 2 accounted for 26.0% of the variance and consisted of all the negative cognitions (items 1-13). The TCQ-total correlated more highly with the subscales of the TEQ, which measure emotional distress (TEQ-ED) and irrational beliefs (TEQ-IB), than with the auditory perception subscale (TEQ-AP). The TCQ may assist clinicians in identifying patients who have a high reported level of negative thoughts about tinnitus and a low frequency of endorsement of positive thoughts. Kuk FK, Tyler RS, Russell D, Jordan H: The psychometric properties of a Tinnitus Handicap Questionnaire.
Halford JBS, Anderson SD: Tinnitus severity measured by a subjective scale, audiometry and clinical judgement.
Henry JL, Wilson PH: Psychometric properties of several measures of the psychological impact of tinnitus.
Kirsch CA, Blanchard EB, Parnes SM: Psychological characteristics of individuals high and low in their ability to cope with tinnitus.
Henry JL, Wilson PH: An evaluation of two components of cognitive therapy in the management of chronic tinnitus. Jakes SC, Hallam RS, Rachman S, Hinchcliffe R: The effects of reassurance, relaxation training and distraction on chronic tinnitus sufferers. Lindberg P, Scott B, Melin L, Lyttkens L: Long-term effects of psychological treatment of tinnitus. Lindberg P, Scott B, Melin L, Lyttkens L: Behavioral therapy in the clinical management of tinnitus. Characteristics of Tinnitus and Etiology of Associated Hearing Loss: A Study of 123 Patients.
We undertook to study a population of 123 patients attending a tinnitus clinic between 1998 and 2000.
Although previous studies have been descriptive, few have attempted a quantitative assessment of tinnitus qualities, such as its intensity, and have correlated it with the etiology of any associated hearing loss.
To allow its easy use during normal otological clinic visits, the questionnaire was based on a vertigo and hearing loss questionnaire already in use, and it was limited to certain aspects. The frequency composition of tinnitus is extremely difficult both to describe and to understand, especially for those patients with low-pitched or complex tinnitus, even when using an audiometer or a synthesizer to define tinnitus pitch [2]. If the latter was the case, we asked them to evaluate this fluctuation on a visual analog scale, with the maximum value corresponding to the loudest intensity during the course of the day and the minimum value corresponding to the weakest intensity. All patients underwent a full otological, audiological, and vestibular examination, which included audiometry, evoked otoacoustic emissions (OAEs), evoked auditory brainstem potentials, and videonystagmoscopy (two CCD cameras mounted on lightproof goggles). All but one of the patients with tinnitus seen in this specialist clinic had an associated hearing loss. Evoked OAEs were performed in the first 50 patients only, because the high incidence of hearing thresholds greater than 30 dB in our patients meant that OAE assessment contributed little to the evaluation of the etiology. Patients with active endolymphatic hydrops described fluctuation of their tinnitus during vertiginous attacks but, interestingly, also every day between crises, even when they thought that their hearing was stable. Obviously, our hospital population was selfselected and does not necessarily reflect the true epidemiology of tinnitus.
This type of subjective tinnitus reflected a cochlear problem in the majority of cases: More than 80% were associated with an endocochlear hearing loss.
A strong correlation was seen between clinical characteristics of tinnitus and the nature of the cochlear pathology. By simply having three categories of tinnitus pitch in the questionnaire (high pitch, low pitch, or other), we have avoided some of the problems associated with pitch matching using an audiometer. Many studies report tinnitus associated with sleep disturbance, but a literature review does not reveal any other studies reporting such marked increase in tinnitus on waking. We believe that it is important to develop this clinically based approach, and we will continue to investigate further correlations in our clinic.
Gui de Chauliac (1300- 1368) was a physician associated with the Montpellier School of Medicine; he wrote what became the standard book on surgery for the next two centuries.
Vestibular physical therapy rehabilitation has been established as a useful intervention in the management of patients with a wide range of vestibular disorders [5-7]. The purpose of this study was to investigate the effects of a vestibular physical therapy rehabilitation program used in conjunction with preventive migraine medications for patients presenting with MAD. We administered to each patient a functional test battery consisting of an impulse head-thrust test, a Fukuda step test, a Romberg test, a tandem Romberg test, and a dynamic gait index (DGI) [7].

Exercises to decrease dizziness focused on exposure to specific stimuli for habituation or attenuation of the dizziness response in the brain. The vestibuloocular reflex exercises, cervicoocular reflex exercises, and depth perception training were graded in difficulty based on increases of head motion, object motion, and progression of body positioning from sit to stand to ambulation. These exercises included the proprioceptive neuromuscular facilitation techniques of slow-reversal head and neck patterns, modified chopping and lifting for head and trunk in progression from supine to sitting and standing postures, and total body mass rolling activities.
During ambulation, patients were challenged with distracting stimuli, which included stationary obstacles, moving objects, and ball skills.
They were monitored by the physical therapist twice the first week and once weekly for the subsequent 7 weeks.
Analysis of outcomes measures for patients who suffered mild head injury (posttraumatic closed-head-injury migraine-associated dizziness and posttraumatic closed-headinjury migraine-associated dizziness and benign positional vertigo groups).
Time required for return to work and for symptoms resolution after initiation of treatment for each group and for the entire study. We analyzed the time required to return to work and the time required for remission of symptoms.
Because the final outcome data of all groups were the same, we can now compare this entire group of patients to a control group of untreated patients.
Treatment of Vertebrobasilar Insufficiency-Associated Vertigo with a Fixed Combination of Cinnarizine and Dimenhydrinate. This complex physical performance is based on finely tuned brain processing of sensory inputs provided by the vestibular, visual, and proprioceptive systems and the cognitive system. Anticoagulant and antiplatelet therapies may serve to reduce the incidence of stroke after transient ischemic attacks [12].
This fixed combination has been used successfully in Germany for 25 years for the treatment of peripheral, central, or combined types of vertigo.
The results of these studies provided evidence for a synergistic effect of cinnarizine and dimenhydrinate at doses reduced by up to two and a half times as compared to the doses commonly used in monotherapy [25-30]. Diagnosis of VBI had to be confirmed by the presence of typical abnormalities in specific examination tests. It was conducted in accordance with the principles of good clinical practice and the Declaration of Helsinki (1989 revision).
On the occasion of each visit, patients underwent an efficacy evaluation that was based primarily on the patients' assessments of the intensities of their vertigo symptoms.
For evaluation purposes, the scores for the symptoms of nausea, vomiting, sweating, and tachycardia were integrated to a mean vegetative score (VM), which was analyzed in the same way as was SM.
Briefly, CCG is a diagnostic procedure by which characteristic light patterns corresponding to the head-body sway of an affected patient are recorded. Gaze nystagmus was examined under the following conditions: glance to the right, to the left, straight ahead, and upward. Nystagmus was induced by irrigation of the external auditory canal of the left and the right ear with 20 ml water at either 30  or 44  C.
We performed pure-tone threshold audiometry at increasing frequencies, considering the left and right ears separately. The events were reported spontaneously by the patients, observed by the investigator, or reported by the patients in response to general questioning by the investigator. Comparison between the therapy groups (the Kruskal- Wallis test) showed an imbalance in initial distribution at the 20% significance level. Change of the mean vertigo score, SM (primary efficacy variable), in the course of the study. The three therapy groups were homogeneous with respect to initial distribution of headache as evaluated according to localization and type.
Initially, all further symptoms were homogeneously distributed among the therapy groups, except for higher mean scores of tinnitus and impaired hearing in the placebo group (Table 4).
Statistical analysis of the initial distribution of all parameters derived from CCG indicated comparability of the therapy groups.
More than one-half of the patients in each therapy group initially showed a positional nystagmus in at least one position. As to brainstem evoked response audiometry, no significant difference was noted between the therapy groups, either at baseline or in the course of therapy (not shown).
Accordingly, approximately 73% of the patients in the fixed-combination group, but only 36% of patients in the betahistine group, assessed their health condition as much improved or very much improved at the end of the study. Regarding the patients' judgments, statistical calculation showed a significant difference between the treatments (p = .019, Fisher's exact test), with the fixed combination showing the best ratings. Primarily, the crucial criterion for evaluating therapy success is the subjective severity of vertigo symptoms tormenting the patient. The antivertiginous effect of betahistine is considered to rely mainly on improvement of microcirculation in the inner ear [32,33].
These findings are consistent with those from previous studies, which demonstrated a high antivertiginous efficacy of the fixed combination in the treatment of patients suffering from vertigo of peripheral vestibular, central vestibular or-very common in medical practice-combined peripheral-central vestibular origin and Meniere's disease. By that time point, 37 patients had completed the study instead of 60, as initially planned. It showed a favorable benefit-risk ratio and a therapeutic success rate that significantly exceeded that of betahistine. Often, the brain perceives the sound throughout most of the day, or just in quiet situations. Work with your audiologist to find a good support network and devise methods to reduce stress and improve relaxation.
The results of the electrocochleography (ECochG), auditory brain stem response (ABR) and brain stem transmission time (BTT) were determined and compared pre- and post-AES in the studied groups. Further comprehensive studies are required to determine the mechanisms of RI more precisely. Feldman reported in his classic studies that many subjects with tinnitus experienced a brief elimination of their tinnitus following the application of a masking stimulus3. RI can also be contrasted with tinnitus inhibition produced by auditory electrical stimulation (AES)7,8,13,14.
Previous studies has made it clear that both tinnitus and residual inhibition phenomenon (RI) involved a number of regions of the auditory system18-21 and numerous electrophysiology and neuroimaging investigations have shown that tinnitus is associated with abnormal activity in the auditory system22-24. These investigators have found that BTT to be significantly more stable and it is independent to intensity and frequency of stimulus. In order to compensate for the tinnitus signal, the processing of auditory stimuli in the presence of tinnitus-related activity may require an increase in firing rate of neurons, the use of more neural substrate, or a combination of both36. In the subjects with bilateral tinnitus, AES was administered in the ear with predominant or louder tinnitus.
The subjects were examined by an ENT specialist for head and neck disorders, a neurologist for neurologic disorders, an internist for other medical diseases and a psychiatrist for psychological disorders. In the current study, the subjects' RI group was (I) and another group was entitled NRI, which included (II) and (III).
The accuracy of the calibrating equipment was sufficient to determine that the TinnED® was within the tolerances permitted by the American Standard Specification for Audiometers, S3.6-2004. The responses were recorded with a vertical montage of four-disk Ag-AgCl electrodes (noninverting on the vertex (Cz), grounded on the forehead, and inverting the electrodes on each mastoid). The CAP amplitudes were calculated from baseline to N1, and the ABR I, III and V amplitude waves were calculated from baseline to their respective peaks. Bipolar burst of alternating current (square pulses) were applied in the tinnitus ear for 500 ms (a pulse rate of 1 Hz) and a frequency modulation of 50 Hz. Carry-over effects were estimated using the interaction between period, main and sequence effects.
The main goal of this study was to evaluate the RI induced by AES through the primary auditory pathways to better understand the neural mechanisms involved in RI. Therefore, the RI induced by AES might be explained by interference with tinnitus generating circuits consisting of auditory nerve fibers, cochlear nucleus, inferior colliculus and whereby modification of cortical activity. In the present study, the CAP amplitudes and latencies were measured at the identical intensity levels (CAP threshold + 20 dB SPL) before and after AES (Figure 1). AES reduced the level of tinnitus-related activity as it reduced the loudness of the tinnitus percept.
AES reduces the spontaneous firing of the ipsilateral and contralateral cochlear nerves, probably owing to the reactivation of the efferent system. Electrical impulses directly stimulate the cochlear nerve with no effect bypasses on hair cells50.
It appears that many factors could be responsible for RI and are involved in suppressing tinnitus. Suppression of tinnitus by electrical stimulation: a contribution to the history of medicine. Repetitive transcranial magnetic stimulation in veterans with debilitating tinnitus: a pilot study. Residual inhibition functions overlap tinnitus spectra and the region of auditory threshold shift. The functional neuroanatomy of tinnitus: evidence for limbic system links and neural plasticity. Electrocochleographic analysis of the suppression of tinnitus by electrical promontory stimulation. The analogy between tinnitus and pain: a suggestion for a physiological basis of chronic tinnitus. Auditory event related potentials in chronic tinnitus patients with noise induced hearing loss. Expanding the biological basis of tinnitus: crossmodal origins and the role of neuroplasticity. Final common pathway for tinnitus: theoretical and clinical implications of neuroanatomical substrates. Cochlear-motor, transduction and signal-transfer tinnitus: models for three types of cochlear tinnitus. Tinnitus Retraining Therapy (TRT) as a method for treatment of tinnitus and hyperacusis patients. Lateralized tinnitus studied with functional magnetic resonance imaging: abnormal inferior colliculus activation. Auditory nerve and brain-stem evoked responses in normal, autistic, minimal brain dysfunction and psychomotor retarded children. Mathematical expression of relationship between auditory brainstem transmission time and age. Noradrenergic and serotonergic projections to the superior olive: potential for modulation of olivocochlear neurons. Electrical Stimulation-Tinnitus Inhibition: The Dynamic Range of Electrical Tinnitus Inhibition, a Predictable Test.
Mechanical responses of the organ of corti to acoustic and electrical stimulation in vitro. A number of these measures have been subjected to factor analyses, the results of which suggest several different dimensions of tinnitusrelated distress.
The emotional distress factor consisted of statements that reflected "anxious or depressed mood and associated thoughts" (p. The THQ [3] was developed as a measure of perceived degree of handicap associated with tinnitus.
Such measures may assist the researcher in identifying the particular features of coping with tinnitus that lead to good or poor adaptation to the problem. This latter approach is based on the cognitive restructuring method advanced by Beck et al. Correlations between the TCQ and other measures may reveal important relationships between thinking content, other psychological attributes, and emotional states.
This original version was administered to 69 tinnitus subjects attending the audiology department of a veterans' hospital. Sample 2 consisted of 50 subjects, and sample 3 consisted of 90 subjects, all of whom responded to media advertisement.
The items describe some of the potential effects that tinnitus might have on lifestyle, general well-being, and emotional state. Notably, data for the THQ are available only for subjects in samples 1 and 2 who participated in two treatment outcome studies [13,14]. Notably, data for the ATQ is available only for the 50 subjects in sample 3 who participated in a treatment outcome study [14]. Only those factors having eigen values of one or more were considered, and items were included in a factor only if they had a factor loading of 0.40 or more and their highest loading was on that factor.
A significant difference in mean TCQ-total scores was observed among the three samples, with sample 1 obtaining a significantly higher mean TCQ-total score as compared with samples 2 and 3.
Item-total correlations (corrected for exclusion of the item to be correlated) are presented in Table 2. Note that the positive items were reverse-scored; thus, the higher the score on the positive scale, the more dysfunctional are the cognitions. In each case, the TCQ-negative scale had higher correlations than either the TCQ-total or TCQ-positive scale with these other tinnitus-related measures. Factor analysis yielded two factors that were interpreted as negative cognitions and positive cognitions. Operationally, a low proportion of positive thoughts in relation to the total of negative plus positive thoughts is said to characterize moderate or severe psychopathology, with precise ratios being provided to define the ranges involved at each level of severity. Their answers on a questionnaire allowed detailed evaluation of the characteristics of tinnitus, including such variables as the circumstances in which the tinnitus was first noticed and evaluation of its intensity and frequency. If the assessment did not uncover any obvious precipitating events, the tinnitus was considered to have arisen spontaneously. Tinnitus that was present on some days but entirely absent on others was designated as intermittent (Fig.
Three categories of tinnitus emerged from our survey: tinnitus with a stable intensity over time, tinnitus perceived to fluctuate in relation to periods of sleep, and tinnitus perceived as intermittent (present on certain days but not on others).
If it was necessary for diagnosing the hearing loss, we also performed supplementary investigations: videonystagmography when hearing loss was associated with vertigo, magnetic resonance imaging when retrocochlear hearing loss was suspected, or magnetic resonance angiography, Doppler imaging of the local vasculature, and tomodensitometry of the temporal bone to evidence vascular problems.
Even though deafness had not been described by any of the patients, audiometry unmasked in each patient a high-frequency loss that was more marked (10 dB) in the ear affected with tinnitus. At age 23, he described his tinnitus as "creaking"; it was precipitated by movement of his head. Because such a significant number of patients with tinnitus had an endocochlear hearing loss (8l.3%), we looked in more detail at this subgroup. Each portion of the chart represents tinnitus associated with endocochlear deafness according to its variability of intensity over time. It is interesting to note that the remaining 16% of patients with Meniere's disease or syndrome had had it for more than 5 years; they had a stable hearing loss and no vertiginous attacks for 2 years, and they described their tinnitus as stable (see Fig.
Only 2% of patients were unable to categorize their tinnitus into either of these categories. Each portion of the chart represents tinnitus associated with endocochlear deafness according to its frequency characteristics. This correlation was calculated for those patients with stable, high-pitched tinnitus and a high-pitched hearing loss. Studies that use an audiometer or synthesizer for pitch matching have found the process to be very difficult, both because of the difficulty that patients have in matching complex tinnitus and because of the possible modulation of the tinnitus by the external sound [8].
He recommended fumigation of the ear with ox urine , vinegar, and myrrh for certain cases of tinnitus. However, historically, vestibular physical therapy rehabilitation has been reserved for patients with complaints of consistent dizziness, imbalance, or other vestibular dysfunctions that are reproduced with movement activities. These authors reported significant improvement in functional outcomes in their patient population after vestibular physical therapy rehabilitation.
All the patients had migraine headaches as classified by the international headache system [14]. Each patient also underwent a sensory organization test, a motor control test, and an adaptation test on computerized dynamic posturography (CDP). Group A consisted of six patients with idiopathic migraine-associated dizziness (IMAD); these patients had at least a 2-year history of migraines and at least 6 months of vestibular symptoms and had failed to respond to medical therapy. Balance retraining involved exercises designed to improve organization of sensory information for balance control and coordination of muscle responses.
The somatosensory exercises were graded in difficulty by narrowing the base of support, making the surface uneven, changing the surface from firm to soft, or the wearing of distortion lenses to decrease visual preference. Patient compliance to the home exercise program was surveyed by the physical therapist during patient visits. Comparisons using a one-way ANOVA were performed between pre- and posttreatment test results for all the patients, for each group of patients, and to compare groups. The posttraumatic groups' mean ages were younger than the mean ages for the nontraumatic groups.
An improvement in the dizziness handicap index (DHI) is demonstrated by a reduced posttreatment score. These two groups were composed primarily of active-duty military personnel engaged in strenuous physical activity, and they were at a high risk for head trauma. This is advantageous because a comparison of all treated to all nontreated patients will allow for a more statistically powerful analysis. Certainly a controlled study comparing medicated to nonmedicated individuals would be helpful. Physical therapy for migraine-related vestibulopathy and vestibular dysfunction with history of migraine. Vestibular rehabilitation after low-dose microcatheter gentamicin treatment for Meniere's disease. Randomized controlled trial of vestibular rehabilitation combined with cognitive-behavioral therapy for dizziness in older people.
Physical therapy for migraine-related vestibulopathy and vestibulardysfunction with history of imigraine.
The primary efficacy end point was the decrease of the mean vertigo score (SM), which was based on the patients' assessments of 12 individual vertigo symptoms after 4 weeks of treatment. Data mismatch induced by unusual and therefore unadapted stimulation of the intact sensory systems, or pathological dysfunction of any of these afferent components or of the brain centers integrating these signals, leads to vertigo [1,2]. Cerebrovascular disease is a common cause of vertigo symptoms, particularly in older patients [5]. Calcium antagonists are a useful alternative, especially in cases of atherosclerotic origin [13]. The rationale for using the combination is derived from the modes of action of its constituents: Owing to its calcium antagonistic properties, cinnarizine regulates calcium influx into vestibular cells of the labyrinth and improves cerebral circulation [16-18], whereas dimenhydrinate mainly exerts a regulatory effect on the vestibular nuclei and adjacent vegetative centers in the brainstem [19,20]. The ethics committee at the Otto-von-Guericke University, formerly the Medical Academy, Magdeburg, reviewed and approved the study documents.
As the primary efficacy end point, the change of the mean vertigo score (SM) after 4 weeks was used as a parameter for vertigo intensity.
From these patterns, we determined deviation of the patient to the right or to the left (angular deviation), body spin, staggering of the patient's head and body (lateral sway), and longitudinal deviation using Unterberger's test, and anteroposterior shift and lateral shift using Romberg's test. We determined positional nystagmus by monitoring the eyes for nystagmus in the following positions: supine with head downward, sitting up, and dorsal with head to the right and to the left, respectively. In addition, speech audiometry served to evaluate hearing loss for words and numbers and of speech discrimination capacity. The three therapy groups were comparable with respect to demographic variables and medical history. SM was defined as the mean of the patients' judgments of six vertigo symptoms and vertigo in consequence of six factors giving rise to vertigo (see Efficacy Measures).
Descriptive analysis of the effects of the therapy is based on the number of patients still reporting headache after 4 weeks of therapy (Table 3). As in the case of vertigo symptoms, the vegetative symptoms were reduced more effectively by the fixed combination than by the comparators.
The patients judged the intensity of the four symptoms of nausea, vomiting, sweating, and tachycardia (see Efficacy Measures). Only patients in the placebo group initially showed slightly lower values for lateral sway (Unterberger's test) as compared to the fixed-combination group (p = .130). The number of patients with positional nystagmus decreased insignificantly in the course of therapy with betahistine and the fixed combination but increased under placebo (not shown).
The ratings of slightly improved and not improved were each given by one patient in the fixedcombination group, whereas no patients in this group considered their health condition to be deteriorated.
The reduction of symptom intensity is the most direct and important parameter for the evaluation of a patient's vertigo complaints in the course of an antivertigo treatment. In these randomized, double-blind, placebo-controlled or reference-controlled clinical studies, the efficacy and tolerability of the fixed combination was superior to various standard treatments, including betahistine [25-30].
From the observed results, it seems likely that the superiority of the fixed combination compared to betahistine would have been even more pronounced had the initially intended number of patients been investigated. A direct effect of calcium antagonists in the inner ear: Blockade of abnormal calcium increase in outer hair cells of the guinea pig. Effects of diphenhydramine and dimenhydrinate on vestibular neuronal activity of cat: A search for the locus of their antimotion sickness action. Fixed low-dose combination of cinnarizine and dimenhydrinate in the treatment of vertigo: A double-blind, randomized, single actives- and placebo-controlled 3-center parallel group 4-week clinical study in 246 adult patients. Fixed combination of cinnarizine and dimenhydrinate versus betahistine dimesylate in the treatment of Meniere's disease: A randomized, doubleblind, parallel group clinical study. Efficacy and tolerability of a fixed combination of cinnarizine and dimenhydrinate versus betahistine in the treatment of otogenic vertigo-a double-blind, randomised clinical study. Treatment of vertigo due to acute unilateral vestibular loss with a fixed combination of cinnarizine and dimenhydrinate: A doubleblind, randomized, parallel-group clinical study.
Efficacy and tolerability of a fixed combination of cinnarizine and dimenhydrinate in treatment of vertigo- analysis of data from five randomised, double-blind clinical studies.
The effect of Serc (betahistine hydrochloride) on the circulation of the inner ear in experimental animals.
Inhibitory effect of betahistine on polysynaptic neurons in the lateral vestibular nucleus. Inhibition of voltagegated calcium currents in type II vestibular hair cells by cinnarizine. Effects of cinnarizine on calcium and pressure-dependent potassium currents in guinea pig vestibular hair cells. Continued awareness of the tinnitus sound can result in emotional disturbance, such as irritation, frustration, or anger.
If tinnitus affects your quality of life by reducing your sleep, affecting your performance at work, making tasks in your everyday life less enjoyable, or reduces your ability to concentrate, you may benefit from some sort of intervention. In these cases, an audiologist is the most skilled and appropriate professional to evaluate and treat the problem.
He also reported that Grapergiesser initially suppressed tinnitus by transcutaneous electrical stimulation using Volta's Platinum-Zinc cell4. In 1981, Vernon & Meikle15 speculated that the mechanism of RI may be related to mechanisms that suppress pain for a period of time after electrical stimulation. Most hypotheses postulate that the generation of tinnitus is associated with cochlear or acoustic nerve or central auditory dysfunction and their interactions25-28.
BTT is defined as the time interval between the initial earlobe-negative wave (the response of the auditory nerve - the 'input' to the brain stem) and earlobe-positive wave from the inferior colliculus region (the 'output' of the brain stem). The experiment reported in this paper was guided by the hypothesis that alterations in activity seen during residual inhibition can return the abnormal neural activity to normal levels. Thus, the responses among the subjects were divided into two groups, including those subjects who had tinnitus residual inhibition (RI) and those who had tinnitus non-residual inhibition (NRI). Each subject provided informed consent in accordance with the Declaration of Helsinki, Committee on Ethics at the ENT and Head & Neck Research Center of Iran University of Medical Sciences (IUMS) prior to participating in the study. The identical procedure as AES was repeated, except that the electric current produced by the device was turned off.
We generated different pairs of pitch sounds at 11 frequencies (from 125 Hz to 12 kHz); we then decreased or increased the pitch (which was not similar to tinnitus), after which the subjects were asked to identify which pitch best matched the pitch of their tinnitus.
Contact impedance indicators for the disk electrodes were less than 2 Kohms except for the inserted ECochG electrode, which was maintained at less than 5 Kohms. The time-interval between the peaks wave I (auditory-nerve response) and the vertex negative wave following wave v (endpoint of wave V descending part) was measured as an auditory brainstem transmission time (BTT) (Figure 1). The AES intensity varied among the subjects with tinnitus according to their tolerance and satisfaction level. Making an analogy with a neural theory regarding chronic intractable pain, Tonndorf then suggests that, acoustic masking with its relatively short RI might mechanically re-activate the large diameter, inner-hair-cell fibers in largely the same manner as the large-diameter pain fibers are temporarily re-activated by scratching or by vibratory stimulation. Therefore, there was minimal chance that the increased CAP amplitude and thresholds reflected the recruitment phenomenon. It can be due to more neural synchronization process of the auditory pathway associated with RI induced by AES.
RI induced by AES can cause an increase in GABAergic shaping of the nerve activity when it reaches the inferior colliculus.
The effects on the cochlear nerve, the synchronization of auditory nerve fiber discharges, inhibition of the abnormal activity of the auditory nerve caused by modulated GABAergic shaping of the nerve activity in the inferior colliculus, serotonergic projections from the Raphe Nuclei and in the inferior colliculus, reactivation of the efferent system over time, revival of the neural coding pattern of auditory information in neural pathways can play important roles in generating RI. Factor analysis revealed two factors that were interpreted as positive cognitions and negative cognitions. 216), such as "It is unfair that I have to suffer with my noises" or "It will be dreadful if the noises never go away" (p. This line of research has been pursued most vigorously in the area of chronic pain, wherein the presence of certain coping strategies and cognitive content have been found to be associated with poor psychosocial functioning (reviewed by Wilson et al. The TCQ also might be employed as an outcome measure in studies of the effectiveness of cognitive and other types of interventions. Preliminary investigations of the psychometric properties of the original TCQ indicated that both the positive and negative items of the scale correlated positively with the total score, even without reverse scoring for the negative items. A high score represents a greater tendency to engage in negative cognitions in response to tinnitus and low engagement in positive cognitions.
Data for the LCB are available only from the 60 subjects in sample 2 who participated in one of our treatment outcome studies [13].
Pearson product-moment correlations between the TCQ and the other assessment devices also are examined.
Apparently, many of the subjects in the present sample endorsed items indicating that they engaged in negative cognitions that reflect despair, persecution, hopelessness, loss of enjoyment, a desire for peace and quiet, and beliefs that others do not understand the severity of the noise. Consistent with the results of the factor analysis, the TCQ-negative and TCQ-positive scales were found to be unrelated (r = 0.09). The correlation between the BDI and the TCQ-negative scale was higher than were the correlations between the BDI and the TCQ-positive or TCQtotal scales. The independence of the positive versus the negative questions of the scale suggests that the negative cognitions of people who experience tinnitus clearly are independent of any positive cognitions that they reportedly experience. If a high frequency of endorsement of negative thoughts were associated with a low frequency of endorsement of positive thoughts, the states-of-mind model essentially would be refuted.
Researchers might find the TCQ to be a valuable tool for inclusion on studies of coping with tinnitus. The patients each underwent a full neurootological examination with the aim of diagnosing an etiology.
The assessment of patients with tinnitus was similar to that for patients with vertigo and hearing loss, within the setting of a neurootology clinic. In each case, the patients were able to state the exact time and date of onset of their tinnitus.
In none of these four patients did clinical or vascular examination identify an underlying cause. It is impossible to say whether the deafness was linked to the head trauma (although this is likely) or whether it preceded it. Tinnitus was stable in 65 cases, fluctuant in intensity in 32 cases, and intermittent in 3 cases.
Tinnitus was perceived as a high-pitched whistling in 77 cases and as a low-pitched buzzing in 21 cases. The intensity of the tinnitus (x axis) was measured on a visual analog scale graduated from 0 to 100. In cases of active Meniere's disease or Meniere' s-like syndrome with low-frequency hearing loss, the tinnitus was almost always described as a fluctuating low-pitched noise, even between vertiginous crises.
In J-M Aran, R Dauman (eds), Tinnitus 91: Proceedings of the Fourth International Tinnitus Seminar. Criterion measurements included the dizziness handicap inventory, activities-specific balance confidence scale, computerized dynamic posturography performance, and dynamic gait index. Vestibular physical therapy rehabilitation has been used with successful outcomes after vestibular neurectomy, labyrinthectomy, and Meniere's disease [5-8]. In addition, all patients had vestibular symptoms of imbalance, true vertigo, dizziness, or unsteadiness.

In addition, we administered the dizziness handicap index (DHI) [9] and the activitiesspecific balance confidence (ABC) scale surveys [8].
Group B consisted of four patients with IMAD and benign positional vertigo (IMADBPV); they were identical to the group A patients but, in addition, had BPV as defined by a positive Dix-Hallpike test on their initial visit. General activity exercise involved a daily aerobic exercise program of progressive walking, cycling, or swimming. The other three measures-activities-specific balance confidence scale (ABC), dynamic gait index (DCI), and sensory organization test score on computerized dynamic posturography (CDP) are improved as indicated by an increase in the posttreatment score.
Both posttraumatic groups showed more improvement than did the other groups after vestibular rehabilitation procedures. A factor that might have produced this longer return-towork time in the posttraumatic groups was a more physically demanding work environment. Therefore, vertigo not only represents a cardinal symptom for vestibular disorders, but it can be associated with a wide spectrum of disorders, including internal diseases, or it may be of psychogenic origin [3,4]. Vertigo is one of the first and most frequent signs of vertebrobasilar insufficiency (VBI), with a relative incidence ranging from 50% to 80% [5]. Episodic, intense vertigo frequently represents the first and, in combination with neurosensory signs of brainstem dysfunction, the most important symptom in VBI [31].
Pregnant or lactating women or women without safe contraception during the study were also excluded. All patients received oral and written information about the study and provided written informed consent before enrollment. SM was defined as the mean of the intensities of six vertigo symptoms and vertigo as a consequence of six trigger factors, as evaluated by the patients.
At the end of the final visit, patients and the investigator rated the overall tolerability using a 4-point verbal rating scale: very good, good, moderate, or poor. An analysis of covariance was performed with adjustment of means at the end of the study, using the initial values as covariate in cases of insufficient homogeneity of the initial distributions.
Significantly greater reductions of SM found in the fixed-combination group became evident 1 week after the start of treatment (vs. The symptom had subsided completely in two patients in each of the fixed-combination and betahistine groups by the end of the treatment but was still present in all patients treated with placebo. In the fixed-combination group, tinnitus progressively diminished in the course of therapy, with a significant decrease after 4 weeks (p = .016, Wilcoxon signed rank test with respect to baseline).
Lateral sway in both tests progressively decreased in the course of the active treatments, more markedly under the fixed combination than under betahistine. In contrast, approximately one-half of the patients treated with betahistine stated a slight improvement, and two patients judged the efficacy with the ratings of not improved and deteriorated. As to the reports from the betahistine group, all AEs except one (vertigo) involved gastrointestinal system disturbances that represent known adverse drug reactions to this substance. Nevertheless, apparatus-based methods are useful to corroborate the results of the vertigo diagnosis. There is some evidence for an inhibitory activity of betahistine on polysynaptic type-I neurons in the lateral vestibular nuclei [35]. Thus, as a superior efficacy of the fixed combination in treating vertigo of various origins has been repeatedly shown, the present results further underscore the broad efficacy of the antivertiginous fixed combination.
Ein Leitfaden fur Praxis und Klinik zur Diagnostik und Therapie von Schwindel und Gleichgewichtsstorungen. Interestingly, research has shown that up to 95 percent of young normal-hearing adults experience tinnitus when placed in the right conditions. If your tinnitus is potentially caused by an underlying medical condition, we can make the appropriate referral to a physician.
In fact, one of the outstanding features of this phantom sound is that it can be inhibited by auditory external stimuli such as acoustical, electrical, and magnetic fields5-8. Previous works has assumed that the perception of tinnitus was associated with abnormally high ("tinnitus-related") neural activity in the central auditory pathways by means of AEPs measures and functional imaging. The present study evaluated the changes occurring in BTT associated with tinnitus residual inhibition induced by auditory electrical stimulation in subjects with problem-tinnitus. According to this hypothesis, efforts to understand RI phenomenon should be guided by develop in our knowledge of the underlying mechanisms of tinnitus. All subjects had intractable permanent chronic moderate to severe SIT, which had been present for 4 to more than 180 months (Table 1). Since the studied subjects has not been any experienced for electrical stimulation, prior to each study session were mentioned that they might or might not feel any sensations of AES.
The washout period for the crossover study was considered at least one week after the initial recording session.
We performed the ECochG procedure to obtain the obvious compound action potentials (CAP) using the active surfacetympanic membraneelectrode (Tymptrode), which was inserted into the lower posterior-inferior region of the external auditory canal at the point closest to the tympanic membrane.
We re-measured the ECochG and ABR parameters within a few minutes after performing AES in the RI, NRI and PES control subjects. Because of the differences in the intensity levels of electrical stimulation for generating RI among the subjects with tinnitus, we performed AES slightly above TSL at the MCL. According to gate control theory, the activity of the large diameter, inner-hair-cell fibers act to shut-off (for a time) the aberrant signaling from the small diameter, outer-hair-cell fibers.
Meanwhile the BTT is a demonstration of progress of excitation from the acoustic nerve to the inferior colliculus of the brainstem. GABA and the enzyme responsible for GABA synthesis, glutamic acid decarboxylase (GAD), and the genetic information necessary for the synthesis of GAD have been observed in the inferior colliculus of the central auditory pathway.
It seems that early AEPs to be influenced by serotonin activity in an excitatory manner mainly.
Mehrdad Salamat, MD, FAAP, FACC (Texas A & M University Health Science Center, USA) for their helpful comments on this manuscript. Cognitive theorists (notably Beck) would argue that psychological problems, such as depression, are not caused by the mere presence of the tinnitus but by the person's perception of the tinnitus. The process of improvement might also be more carefully investigated using such a measure, enabling researchers to examine relationships between changes in cognitions and adaptation to the tinnitus. These findings suggested that the respondents may have been confused by the format in which positive and negative items were interspersed and that the scale was not being used properly. In the present study, all the TCQ-positive, TCQ-negative, and TCQ-total scores were calculated. The test-retest correlation was 0.88 (retest period, 6-8 weeks), which indicates adequate stability over time. Examination of the nontinnitus cognitive measures reveals higher correlations between the A TQ and both the TCQ-total and the TCQ-negative than with the TCQ-positive subscale. In this study, no association was found between positive and negative thoughts, consistent with the view that individual subjects vary widely on the two measures.
The great majority of tinnitus patients had an endocochlear deafness and, among these patients, acoustic trauma, endolymphatic hydrops, and presbyacusis were the commonest diagnoses (32%,32%, and 23%, respectively).
Zero corresponds to an absence of tinnitus; 100 corresponds to the loudest tinnitus you can imagine. One patient attending the tinnitus clinic was given a diagnosis of an acoustic neuroma, two patients of vascular loops in the internal auditory meatus, and two of cholesteatoma. Even though it was thought that his tinnitus had an origin in some head or neck joint and thus was a somatic noise, it was not possible to define it further. All patients who described their tinnitus as fluctuating in intensity described a very clear increase in intensity of their tinnitus after periods of sleep (whether nighttime or siesta). The highfrequency hearing loss (y axis) was calculated as a mean of the thresholds over three frequencies (4 , 6, and 8 kHz). After vestibular physical therapy, all subjects showed significant improvement in the dizziness handicap, activities-specific balance confidence, dynamic gait, and computerized dynamic posturography measures. The vestibular symptoms were reported as an aura prior to the headache, during the headache, or completely independent of the headache. The foregoing measurements were obtained before treatment, during treatment, and after treatment (6-8 weeks after treatment initiation).
Group C consisted of 17 patients with posttraumatic closed-headinjury migraine-associated dizziness (PTMAD); these patients had suffered a closed-head injury with a Glasgow comma scale rating of 13-15 and no loss of consciousness. Our results are unique in that our population was predominantly male and composed of a high number of posttraumatic patients.
The younger age of this group, their general high level of physical condition, and their level of motivation may have influenced this result.
The posttraumatic groups were composed of individuals who sustained a head injury in sports, military training, military combat, or motor vehicle accidents.
VBI is characterized by transient ischemic attacks, and it represents a heterogeneous disease entity with many potential causes [6-8].
Vertigo is most frequently associated with vision disturbances, patients often report nausea and vegetative symptoms, and perhaps one-third of the patients complain about severe headaches [3].
Other exclusion criteria were gastrointestinal ulcers, bronchial asthma, adrenal tumors, angle-closure glaucoma, prostate adenoma with residual urine, suspicion of compressive intracranial processes, Parkinson's disease, pheochromocytoma, alcohol abuse, acute intoxication, and convulsive disorders. We randomly assigned enrolled patients to 4 weeks of treatment with either the fixed combination of 20 mg cinnarizine and 40 mg dimenhydrinate (one tablet three times daily) or the reference medication betahistine (12 mg betahistine dimesylate per tablet, one tablet three times daily) or placebo (one tablet three times daily). The assessed symptoms at each visit were unsteadiness, staggering, rotary sensation, tendency to fall, lift sensation, swaying, and vertigo due to change of position, bowing, getting up, walking, head movements, and eye movements. Auditory brainstem responses were evaluated by means of brainstem evoked response audiometry. We performed homogeneity tests at the 20% level for the primary variable under consideration and for the parameters of age, gender, the Broca index, and body mass index.
Approximately 40% of the patients in each group were on drug therapy at the time of study onset (premedication), and some of them received more than one medication at a time. Mean scores for tinnitus showed a moderate, insignificant decrease under betahistine (p = .125) but remained nearly unaffected under placebo (see Table 4).
In patients in the betahistine group, VM showed a minor, insignificant decrease (approximately 30%) within the first week but no further improvement until the end of the study.
The judgments in the placebo group reflected the lack of efficacy of the treatment, with the rating of not improved given by eight patients and a rating of deteriorated given by three. Of the two patients reporting AEs in the fixedcombination group, one reported symptoms of an upset gastrointestinal tract (not likely to have been related to medication intake, in the opinion of the investigator, as the symptoms subsided after 2 days without interruption of treatment). In addition to thorough evaluation of case history, such tools are helpful for establishing the correct diagnosis for the individual patient.
As a result of these effects, betahistine leads to a reduction of vertigo symptoms, and it is therapeutically useful particularly for the treatment of peripheral vestibular disorders and especially Meniere's disease [36]. Its dual central and peripheral mode of action represents a distinct advantage for its therapeutic use, leading to high responder rates. It is obvious that following the offset of appropriate masking stimuli, tinnitus may remain suppressed for a short period of time. He described the similarities between chronic pain and tinnitus RI by a gate control theory.
Such activity may occur in the subcortical and cortical portions of the central auditory system29-31. In the present study, primary parts of auditory pathways were evaluated using early evoked responses provided by electrocochleography (ECochG) and auditory brainstem response (ABR). Because the different subjects with tinnitus indicated various durations of RI following AES, a time interval was considered between the sessions. VAS, LMT and PMT were administered pre-and post-AES during each session to assess tinnitus loudness changes. Finally, we administered an octave confusion test to more accurately determined tinnitus frequency. Initially, we used conductive gel on the tip of the Tymptrode before inserting it into the ear canal.
RI could be produced by prolonged activity of the masking-induced released GABA because of masking stimuli. We thank all ENT-doctors, audiologists and administrative personnel who helped us gather our data.
Correlations between the TCQ and other self-report indices of depression, automatic negative thoughts, and tinnitus-specific symptomatology are reported. At the idiographic level, the TCQ might provide utility also in therapeutic interventions using cognitive techniques, by assisting the clinician in the identification of problematic cognitions in specific patients or by providing a means by which to select patients who may benefit from cognitive therapy. Thus, a revision of the questionnaire was undertaken and involved a reorganization of the items so that the negative items and positive items were separated, with clear instructions that the first 13 items referred to negative thoughts and the final 13 items (items 14-26) referred to positive thoughts. This subscale has particular relevance to cognitive interventions for tinnitus and, therefore, was included for attention in the present study, together with the other three subscales. Scores on the set of positive items of the TCQ may not be considered to be predictive of responses to the negative items. The correlation of 0.55 between the TCQ-total scale and the TRQ (equivalent to the algebraic solution that would be achieved by calculating the ratios according to the states-of-mind methodology if one preserves the positive score without the reverse scoring) indicates a moderate relationship between the proportion of negative thoughts endorsed on the TCQ and a measure of psychological distress related to tinnitus. What should be acknowledged is that the TCQ can be considered to be only a scale designed to measure what people report their cognitions to be in response to tinnitus.
The aim of the clinical examination was to diagnose the etiology of any underlying hearing loss. Patients with migraine-associated dizziness can benefit from physical therapy intervention. We documented subjective patient reports of degree and length of imbalance perception throughout treatment. They were initially evaluated by our medical system within 2 weeks of the head injury and then were referred to our clinic. As the mechanism of injury did not affect outcome, our results have implications for treating head injuries received in high-risk, collision sports (such as football, ice hockey, boxing, and rugby). It usually results from atherosclerosis of the subclavian, vertebral, and basilar arteries with insufficient collateral circulation but may also be due to other causes, such as compression of vertebral arteries by cervical spondylosis or the subclavian steal syndrome [5,7]. In view of the pharmacological properties of the active substances in the fixed combination-in particular the cerebral selectivity of the calcium antagonist cinnarizine and the brainstem-regulating properties of dimenhydrinate-and encouraged by the positive results obtained in a previous open study [21], we performed this trial to investigate the antivertiginous effects of the fixed combination in VBI as compared to the effects of betahistine dimesylate. Further exclusion criteria were the concomitant use of monoamine oxidase inhibitors or aminoglycoside antibiotics.
Randomization was based on a computer-generated block sequence that ensured equal distribution of patients among the treatment groups, according to Food and Drug Administration standards.
Patients evaluated their vertigo symptom intensities on the basis of a standardized questionnaire using a graded 4-point visual analog scale ranging from 0 (no symptoms) to 3 (strong symptoms). Confirmatory efficacy analysis was based on the changes in SM during therapy as determined for the collective of patients completing the study according to protocol (per-protocol analysis).
The most frequently administered active substance was betahistine dimesylate, which had been taken by one patient of the betahistine group, three patients of the fixedcombination group, and two patients of the placebo group. Despite the superiority of the fixed combination, the comparison with betahistine was found not to be statistically significant (p = .052, Kruskal-Wallis test). The second patient in this group reported an AE involving a strong response to the caloric test. Furthermore, three patients in the betahistine group (27.3%) judged the tolerability as moderate. In our study, both subjective symptom-based and apparatus-based measures were used to measure therapy success. The combination, on the other hand, shows a dual mechanism of action acting both peripherally and centrally. In addition to a higher efficacy, the fixed combination also showed a more favorable safety profile than betahistine.
This phenomenon is known as "residual inhibition" (RI) in the tinnitus literature, although the term of "post-masking effect"9 is more neutral with regard to its possible underlying mechanisms10. A demonstration of such alterations was investigated in the occurrence of unusual increased or reduced waves in the AEPs. The purpose of this study was to investigate alterations of BTT and other parameters of early AEPs in tinnitus subjects associated with RI induced by AES. The perceived sense of tinnitus varied among the subjects and included a single high-pitch tone or noise, cricket sound, hissing, whistling or ringing. The washout period for the crossover study was considered one week after the initial recording session.
The tone pairs were adjusted to a loudness level equivalent to that of the tinnitus before each pair was presented.
Similarly, but more briefly, Vernon & Meikle15 in 1981 speculated that the mechanism of residual inhibition may be related to mechanisms that suppress pain for a period of time after electrical stimulation. Aminoxyacetic acid (AOAA), an inhibitor of GABA transaminase, has been shown in a controlled study to decrease tinnitus. These studies should contain a systematic database to evaluate procedures for optimizing RI to contrast it with AES and other intervention methods using specific measures.
The TCQ may provide a useful index of the cognitive responses of tinnitus sufferers and may be employed as a measure of change in outcome research on psychological management of tinnitus. These results of research on measures (TEQ, TRQ, THQ) of tinnitus-related distress serve to highlight the fact that reactions to and perceptions of tinnitus may vary along several dimensions, each of which may have to be evaluated by the clinician assessing a patient with tinnitus. An additional six items were developed so that an equal number of positive and negative items was ensured. That is, endorsement of only a few positive items does not indicate necessarily that a respondent would endorse a large number of negative items (and vice versa). Notably, here the conventional methodology for calculating the proportion of positive thoughts is one that involves real-time recording of verbalized thoughts for a fixed interval rather than through a self-report questionnaire; this method was not available in the present study. What is not assessed is the extent to which people actually engage in these reported cognitions.
Those patients with active Meniere's disease or Meniere's-like syndrome described a low-pitched buzzing tinnitus.
However, four patients did have a presbyacusis, and one had a mild hearing loss in the higher frequencies. The results of this study are important in considering the approach to vertiginous migraine patients with and without head injury. Finally, we recorded the length of time required for patients to return to work after the initiation of physical therapy.
These patients had no prior pathological findings or history of headaches and reported an interval of approximately 2 weeks between head injury and headaches.
The 33% rate that we report in this study does not differ from previous work in the literature.
VBI presents with characteristic symptoms and signs owing to impaired perfusion of the cerebellum, the brainstem, and the occipital cortex [8]. For the treatment of VBI-associated symptoms, including vertigo, betahistine has been described as useful [15]. Previous antivertiginous medication had to be discontinued in a 2-week washout phase prior to the start of treatment. The study medications were manufactured by Hennig Arzneimittel in accordance with good manufacturing practice. Treatment efficacy was analyzed by comparing SM changes from baseline resulting from either medication.
The intent-to-treat collective was defined as those patients for whom the primary efficacy variable was at least determined at the entry and at one further examination.
Because SM represents a parameter for the evaluation of vertigo severity and characterizes the intensity of an individual patient's vertigo sensations independently of the type of vertigo, it serves as a well-established and effective measure of therapeutic progress [25-30]. The calcium antagonist cinnarizine, similarly to betahistine, acts by enhancing circulation in the peripheral vestibular organ and in compromised intra- and extracranial areas [16, 17]. However, emphasis just in measurement of AEPs parameters (amplitude and latency) for assessment of tinnitus can be misleading. When placed properly, the electrode rested gently on the eardrum, and the gel assisted in making contact with the eardrum.
Afterwards the saline was removed from the external auditory canal prior reassessing ECochG and ABR. In addition, the inferior colliculus, the main generator of wave V, receives serotonergic input from the dorsal Raphe nucleus40. Because GABA transaminase is responsible for GABA degradation, the effect would be prolongation of the inhibitory activity of released GABA37.
In a comprehensive manual, Hallam [2] reported that the measure consists of these four factors plus somatic complaints.
Further study of the nature of these dimensions and of the sources and consequences of perceptions of tinnitus may assist us in understanding psychological adjustment to tinnitus. Halford and Anderson [11] also found that subjects who reported more severe distress from tinnitus were more anxious and depressed. Cognitive therapy begins with a detailed analysis of the kinds of thoughts (or selfstatements) in which people engage when they notice the tinnitus, especially when the tinnitus is very severe or when they are distressed. Nevertheless, a fruitful area for further research might be to apply this states-of-mind methodology to tinnitus patients.
A future study in which correlations between the TCQ and verbalized reports of thoughts during specific tasks would assist in providing further validation of the measure. Analysis of those patients with a stable high-pitched tinnitus associated with a high-frequency hearing loss shows a statistically significant correlation between the elevation of the audiometric thresholds and the loudness of the tinnitus. The quality of the bestfitting linear regression curve is indicated by r, and the number of patients by n. Group D consisted of seven patients with PTMAD and BPV (PTMADBPV); they were identical to the Group C patients but, in addition, had BPV as defined by a positive Dix-Hallpike test on their initial visit. Its main symptom-vertigo-results from an insufficient blood supply in the vestibulocerebellar complex [9].
To guarantee double-blind conditions, test medication, reference medication, and placebo were indistinguishable with respect to appearance, taste, weight, shape, and packaging.
Secondary variables of efficacy were additional VBI symptoms (see later), vegetative symptoms, and vestibulospinal, vestibuloocular, and audiometric variables. A separate intent-to-treat analysis was not performed because the two patient collectives were identical.
Of the other symptoms evaluated, bulbar symptoms and impaired vision were the next most prominent, followed by impaired hearing and aural fullness.
Statistical analysis showed a significant superiority of the fixed combination versus placebo after 4 weeks of therapy (p = .019).
No AE led to premature discontinuation of the study, and no serious or unexpected AE was encountered during the study. Recently it was shown that cinnarizine directly affects calcium ion flux at calcium channels of vestibular outer hair cells [37,38]. Despite the absence of AEs, the tolerability judgments in the placebo group were more negative, which probably resulted from the lack of efficacy in patients receiving placebo. In 1971, Harald Feldmann3 proposed a theory that RI occurred in the brain rather than the ear. Previous studies have reported using other alternatives measurement of time interval between certain waves32-34. The electrophysiological procedures consisting of ECochG and ABR were recorded before and immediately a few minutes after the applying of AES and PES. Subsequently, the auditory threshold level at that specific frequency (A) was increased in 1-dB steps until the subject reported that the external tone equaled the loudness of the tinnitus (B). The acoustic stimuli were delivered monaurally by an insert phone (ER-3; Etymotic Research, Elk Grove Village, IL) to the tinnitus ear. Also serotonin often coexists with GABA in the inferior colliculus and both acting in the suppression of fearful and aversive behavior41. Henry [7] conducted a factor analysis of the TEQ with an Australian sample and identified the following five factors: (1) emotional and cognitive distress, (2) intrusiveness, (3) auditory perceptual difficulties, (4) sleep disturbance, and (5) physical complaints.
Although these results help to identify the broad psychological features of those who cope poorly, they do not reveal the precise characteristics of the coping styles of those patients who do become depressed and anxious. The therapist teaches such people to develop skills in stopping the negative thoughts and in learning to substitute appropriate, constructive thoughts.
For a large majority of patients with tinnitus, therefore, audiometry provides an indirect test for evaluating the tinnitus. Because vestibular pathways are widely distributed in the hindbrain and because the vestibular end-organ is supplied by vertebrobasilar circulation, in VBI the vestibular system may be affected at any level: the labyrinth, the eighth cranial nerve, or the vestibular nuclei [5]. In addition, the overall efficacy of the treatment was rated by both patients and investigator after 4 weeks on a 5-point verbal rating scale: very much improved, much improved, slightly improved, not improved, or deteriorated. All statistical tests carried out on secondary variables were strictly interpreted in an exploratory manner. Two patients each in the betahistine and placebo groups terminated the study prematurely between the entry and the follow-up examinations. Again, all the symptoms showed an improvement under the fixed-combination therapy, with decreases in mean scores of more than 50% after 4 weeks. The beneficial effects of this substance class in VBI have been demonstrated both experimentally and clinically [39,40]. The visual analogue scale (VAS) for tinnitus loudness was measured pre- and post-AES and PES to monitor tinnitus loudness changes during the procedure (Figure 2).
The sound level was then slightly raised by 1-dB increments to obtain a threshold, which was slightly louder than that of the tinnitus (C). Furthermore, descending serotonergic projections from Raphe nucleus may also modulate superior olive neurons42, the generators of ABR wave III43. Sweetow [22,23] described the cognitive methods in the management of tinnitus-related distress, and some promising results have been obtained in clinical outcome studies [12-20,24]. This may explain why vertigo is the most frequent and sometimes the only symptom in VBI [10,11]. For analysis of the changes from baseline within a treatment group in the course of the study, we used the Wilcoxon signed rank test. The patients treated with betahistine showed minor improvements, and almost no change occurred during therapy in the placebo group (see Table 4).
The antivertiginous efficacy of cinnarizine in patients with cerebrovascular disorders [14] is considered to rely on an increase in blood flow to the vestibular nuclei, which in turn results in improved neuronal responsiveness of polysynaptic neurons [41]. We used the mean level of loudness between points (B) and (C) as the representative loudness of the tinnitus. Typically, VBI-associated vertigo occurs in attacks, depends on position, and is frequently associated with nystagmus, nausea, vomiting, and severe imbalance [5]. The fourth patient (betahistine group) could not continue the study because of an internal disease. This author used electrical stimuli for tinnitus inhibition and concluded that the morphology and other specifications of ABR waves in tinnitus ears changed to the normal state. All 33 patients who completed the study (11 per treatment group) fulfilled the criteria for per-protocol analysis and were included in the efficacy analysis. By means of dampening the entire medial longitudinal bundle, dimenhydrinate inhibits the spreading of impulses at the medullar vestibular nuclei [19] that are closely associated with the vegetative regulatory centers [20].
The AEPs amplitudes and latencies were administered to estimate the input-output functions. According to changes in the AEP recordings associated with RI, it can be also speculated that the RI phenomenon might be caused by increasing synchronization of neural discharges in auditory fibers and distal portion of cranial nerve VIII following the applying of AES and modulating GABAergic activity in the inferior colliculus45. Treatment compliance was confirmed by questioning the patients and by an investigator's checking of empty blister strips at the end of the study.
The vertigo symptoms and the concomitant vegetative complaints, particularly nausea and vomiting, are thereby reduced. The threshold level of the auditory evoked potentials (AEP) was determined as the minimum sound pressure level in which the detectable and reproducible waveforms of the compound action potential (CAP) for ECochG and wave V for ABR. The trigger zone at the base of the fourth ventricle in the brainstem is inhibited as well [20]. In this research, the changes in amplitude and latency of the CAP and ABR values (waves I, III, and V) were estimated at 20 dB over the AEP threshold level.
On the basis of these joined actions, the combination exerts a rapid and effective antivertiginous effect.
Hence, the fixed combination not only effectively reduced the vertigo symptoms but decreased the concomitant vegetative symptoms to a statistically significant degree as compared to placebo. Particularly the distressing symptoms of nausea, vomiting, and tachycardia had ceased after the 4 weeks of fixed-combination therapy. Also, the scores of the concomitant VBI symptoms of tinnitus, impaired hearing, and impaired vision decreased significantly under the fixed-combination therapy as compared to placebo.

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Comments to “Tinnitus associated with vertigo yahoo”

  1. Unbearable sound the sounds the inner ear, resulting in extended Vertigo attacks (dizziness and.
  2. Suffer from anxiety, which I often are suffering from.


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