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Author: admin | 12.02.2016 | Category: Ear Drops For Tinnitus

Benign paroxysmal positional vertigo (BPPV) has a sudden onset that is provoked by a certain position or appears in a determined position. Barany [1] was the first to evoke BPPV in 1921, and Dix and Hallpike [2] described the characteristic torsional nystagmus in response to provocative positional testing (which was later named in their honor in 1952). Schuknecht [5] defined cupulolithiasis in demonstrating basophilic deposit on the cupula of the posterior semicircular canal.
The argument in favor of cupulolithiasis centers around a single histological finding of debris that seems to be attached to the cupula (Fig. The direction and intensity of induced nystagmus and vertigo do not reflect the position of a "heavy" cupula relative to gravity. Some argue in favor of canalolithiasis because of its compatibility with all clinical features of BPPV and nystagmus and with all arguments against cupulolithiasis (Fig. Those disagreeing with the implication of canalolithiasis cite histological findings of deposits in the semicircular canals in asymptomatic patients and the sudden onset of the disease (absence of slow buildup of clot and symptoms). Of the 70 temporal bones examined, 31 did not show significant postmortem changes, nor did they demonstrate cupulolithiasis or canalithiasis.
Kveton and Kaslegarian [11] found a posterior canal fenestration in 10 patients undergoing acoustic tumor removal via a translabyrinthine approach.
According to these studies, it appears that the existence of canalolithiasis does not always produce BPPN. After they discovered BPPN in a patient with a cerebellar glioma, Riesco and McClure [12], attributed the nystagmus to a loss of inhibition of the vestibular system by the cerebellum.
Sangstrom [16] suggested that a compression of vertebral arteries by osteophytes produced cerebral ischemia and secondary BPPN. Fluur [21] submitted the hypothesis that BPPN was produced by a perturbation of the integration of utriculoampullar information. At the Thirty-First Congress of the Neurootological and Equilibriometric Society in 2004, Barozzi and Cesarani [26] presented an interpretive model exemplifying the cybernetic theory. Several mechanisms probably are invoked, and probably interactions between various amounts of information issued from the semicircular canals and otoliths also occur. A qualitative and quantitative examination was performed on temporal bones from 5 donors with antemortem diagnoses of BPPV. The major pathological change founded in BPPV is degeneration of vestibular neurons, rather than an alteration in receptor sensitivity. The inferior vestibular ganglion of the remaining 2 temporal bones revealed a 30% loss of neurons but showed degenerative changes in saccular ganglion cells.
Several additional observations are not explained on the basis of a change in the motion mechanics of cupular displacement in the positional test. When the head is placed in the so-called Hallpike position, the hair cells in the superior part of the saccule and those in the posterior canal crista are depolarized, activating antagonistic extraocular muscles. If the posterior canal neural input were also degenerated, nystagmus would not appear in the ear with a degenerated saccular nerve.
The severity (nystagmus and nausea) of the provoked response may depend on the degree to which the saccular input is impaired.
Alleviation of the response in these patients by posterior rehabilitation maneuvers (PRMs) may result from stimulation of remaining functional units in the saccule, which inhibits activation of the posterior canal crista. Vertical benign paroxysmal positional vertigo (VBPPV) is revealed by the Hallpike maneuver that provoked the vertical benign paroxysmal positional nystagmus (VBPPN).
The usual consideration is that, if one of these characteristics is missing, the vertigo is not a VBPPN. The VBPPN is suppressed when, before testing and with the patient in a sitting position, the contralateral ear is irrigated with cold or warm water [38]. In 1994, Steddin and Brandt [47] reported characteristic clinical findings involving the anterior canal.
After the completion of a full otoneurological examination and the exclusion of a central nervous disease, the best results are obtained by "liberatory maneuvers." Many maneuvers have been proposed by several authors. In cases of failure, the techniques of habituation, such as the vestibular habituation training of Norre and Beckers [76], or another training maneuver, such as that of Fujino et al.
In those rare cases in which the maneuvers or exercises fail, surgical treatment is possible, including semicircular posterior canal nerve section [80] or obliteration of the canal [81].
Reported here are some statistics collected by me on 190 cases of VBPPV, 30 cases of HBPPV, and 10 cases of ABPPV. The Semont maneuver employed in 190 cases of VBPPV resulted in disappearance of symptoms after only one maneuver in 170 cases. The Royal Belgian Ear, Nose and Throat Society recently published guidelines on vertigo and dizziness [82].
Liberatory maneuvers allowed a very quick disposition of all the symptoms of BPPV in the majority of cases. A 64-year-old man with left-sided tinnitus since September 2003 underwent left atrial catheter ablation for atrial flutter that he had been experiencing since 1999. Owing to its multifactorial origin (Table 1) [1], tinnitus presents a treatment challenge [2]. For his paroxysmal atrial flutter, the patient had undergone right atrial catheter ablation in spring 2002, with a short-lived effect.
Immediately after waking from anesthesia, the patient recognized that the left-sided tinnitus had completely disappeared. Clinical neurological investigation revealed ptosis on the left side, hypoacusis on the left side, slight wasting of the tongue edges, generally absent deep-tendon reflexes, slight wasting of the thighs, a deficit of elbow extension of 5 degrees bilaterally, postural tremor, gynecomastia, and turning to the right by 45 degrees on Unterberger's treadmill test.
To reproduce the curative effect of propofol or fentanyl on the tinnitus, the patient was scheduled to undergo a second injection with propofol and fentanyl. The causes of left-sided ptosis, fasciculations, muscle cramps, easy fatigability, the generally reduced deep-tendon reflexes, or elevation of some muscle enzymes in this patient remain speculative, as results from nerve conduction studies, electromyography, and creatine-kinase analysis were repeatedly normal.
This case study shows that high-dose intravenous fentanyl and propofol may transiently discontinue unilateral, idiopathic tinnitus.
In this report, we present the preliminary results of responses to inaudible sounds within the normal auditory spectrum. Over a period of 6 months, we conducted a study of 34 consecutively selected patients who experienced tinnitus, attended our Tinnitus Research Clinic, and agreed to participate in this study.
The audiological assessment consisted of a pure-tone audiogram, tympanometry, speech audiometry, and assessment of spontaneous otoacoustic emissions (Madsen Celesta, Madsen Electronics, Denmark). The initial step was to introduce a pulsed pure tone at a frequency the same as that of the tinnitus frequency until complete masking was achieved. The majority of patients experienced return of their tinnitus as soon as the suppressing stimulus was switched off. The majority of the audio grams were consistent with a sensorineural hearing loss mainly affecting the high frequencies. Rajan [8,9] believed in a protective function of the crossed olivocochlear bundle, which drives OHCs. Le Page [10] believed in an excitatory drift in the operating point of IHCs controlled by the OHCs.
Patuzzi [11] emphasized the role of the endocochlear potential in sensitizing IHCs and producing excessive firing of the auditory nerve, leading to tinnitus.
The electromodel of the auditory system also regards the inter-hair cell relationship as an important function of the auditory system.
Sensitivity regulation of IHCs, therefore, seems to be an important and inherent mechanism in the cochlea that operates close to the threshold level and regulates gain of IHCs. Pierson and Møller [12] found at one recording location two sources of cochlear microphonics that were 180 degrees out of phase. In our study, a frequency higher than that of the apparent tinnitus was used to administer the suppression stimulus. No consistent interval was found between the tinnitus frequency and the suppression frequency.
The absence of spontaneous otoacoustic emissions (SOAEs) confirms the presence of dysfunctional OHCs.
In four patients, contralateral suppression - but with stimuli beyond threshold and starting stimulation at the tinnitus frequency with a narrow-band noise-was tried and was successful.
The presented results demonstrate a suppression mechanism for peripheral tinnitus using subthreshold stimuli. The detection level is addressed with the introduction of an audible wide-band masking noise, chosen in the belief that masking tinnitus is frequency-independent.
Taking into consideration that tinnitus suppression is not frequency-independent, we can now change the detection level of tinnitus by the introduction of a low-intensity, audible, frequency-specific, and tinnitussuppressing signal instead of a wide-band masking noise. Tinnitus suppression therapy is an approach based on a physiological model at the tinnitus detection level and a neurophysiological model at the level between detection and reaction. A portion of this study was presented at the Inner Ear Biology Meeting, September 7-10, 2002, at Liege, Belgium.
The web site provides information on research into a cure for tinnitus, including a discussion of The Hearing Restoration Project. Founded in 1958, the HHF is devoted to preventing and curing hearing loss through groundbreaking research. Depression is a state of depressed mood characterized by feelings of sadness, despair, and discouragement.
Depression is a disease that belongs in the practices of psychiatrists, psychologists, and psychosomatically oriented family physicians.
In contrast to normal sadness or the grief that accompanies the loss of a loved one, clinical depression is sadness without any apparent reason and is persistent and severe. From our neurootological data bank and from archives of the Neurootologisches Forschungsinstitut der 4-G-Forschung e.V. All patients included in this study underwent systematic neurootometric and equilibriometric analyses.
The equilibriometric measurements were experimental neurophysiological investigations in which ENG represents only the recording part. For establishing comparisons between various stimulus intensities, the so-called vestibular stimulus response intensity comparison (VESRIC) was used. The hearing pathways are analyzed by means of pure-tone audiometry of the hearing threshold in all patients. The results of the polygraphic ENG together with the three-channel ECG represented the experimental investigations using the caloric test (Table 3). CCG served for objectively and quantitatively measuring the responses of the vestibular spinal standing test and stepping test (Table 4).
In one form of dysthymic disorder, "masked depression," either the patient or the physician may not readily recognize the mood disturbance.
By means of our special neurootological investigations and methods, we tried to control for various aspects of the characteristics of the selected 134 patients in relation to depressive disorders.
Among the nausea symptoms, the weaker nausea signs, such as malaise without vomiting, is much more frequent than in average NODEC samples. As regards visual disturbances, we noted an unusually high incidence of visual abnormalities, such as illusions of movements (oscillopsia) and, especially, double vision.
An evaluation of the caloric vestibuloocular nystagmus test showed that the central nystagmus frequency (see Table 3) had a tendency toward higher values, indicating an increased lability of this vestibuloocular regulation process. In analyzing the cardiac responses during perrotatory and postrotatory stimulations with rotations toward the right and left, we again observe (Fig. In combining results of the caloric test with ipsidirectional test results of the rotatory intensity-damping during the perrotatory phase (see Fig.
Evaluation of the stepping CCG (see Table 4) exhibits a reduced displacement (a little lateral sway, as if the patients are afraid to move too much and too far). In summarizing the results of this study, we came to the conclusion that some prominent findings include a high occurrence rate for the subjective complaint of instability and the sensation of rocking in the field of vertigo and a very high score for malaise in nausea. When taken together, the vestibuloocular nystagmus responses due to monaural (caloric) and binaural (perrotatory) stimulations, the so-called decruitment phenomena, are unusually frequent in our statistics, which suggests a central tendency in the tested persons to overshoot downregulations in their vestibuloocular nystagmus. The CCG evaluation of the stepping test also exhibits a restriction in movement as to longitudinal displacements. This article is based on a lecture presented at the Thirtieth Annual Neurootological and Equilibriometric Society Congress, Porto, Portugal, April 3-5 ,2003. Sensorineural hearing loss in elderly patients (presbycusis) relatively often coexists with annoying tinnitus (termed presbytinnitus [PT] by Claussen). Sensorineural hearing loss in elderly patients- presbycusis (PC)-results from atrophy of hair cells in the organ of Corti, degeneration of nerve fibers in the cochlear ganglion and the cochlear nuclei, impaired blood supply of the spiral ligament and the vascular stripe, and atrophy of the spiral ligament and rupture of the cochlear duct [1].
The two types of PT are type I, the minority group (in which PT develops as a primary initial complaint in association with a preexisting high-tone sensorineural hearing loss), and type II, the majority group (in which the PT history is long-standing, with a recent exacerbation, significant preexisting sensorineural hearing loss, subjective hearing loss, deterioration in speech discrimination, and significant systemic complaints) [2,6,7]. Relatively many elderly individuals suffering from PT also have different grades of sensorineural or mixed hearing loss; therefore, the aims of sound therapy obtained by tinnitus generators in normally hearing subjects can be accomplished by fitting with hearing aids those individuals complaining of PT. The purpose of this study was to evaluate the conditions and patient-based outcome of fitting PT patients with hearing aids. In evaluating tinnitus characteristics, we asked each patient to compare his or her tinnitus to a pure tone or noise to assess its pitch.
All patients in the examined group underwent neurological examination and computed tomography or magnetic resonance imaging of the central nervous system to exclude cerebellopontine-angle pathology. We confirmed these results after 7 days during the follow-up visits: 22 patients with bilateral complaints required bilateral fitting, and 11 with unilateral tinnitus were fitted with one hearing aid each. Patients with PT require thorough diagnostic procedures to exclude life-threatening causes of their complaints, and they must be thoroughly informed about results [14]. The evaluation of subjective tinnitus intensity is accomplished using a scale, usually ranging from 0 to 10 [13,15]. Correlation between hearing threshold elevation scores at tinnitus frequency and tinnitus intensity (in decibels), together with the results of otoacoustic emissions, could confirm that the main defect causing both the PC and the PT sensory component was cochlear damage. Degenerative changes might have involved not only the cochlea, which was confirmed in otoacoustic emissions recordings, but retrocochlear parts of the auditory pathway (low scores on speech discrimination, which is a very sensitive test for pathologies of the central segments of the auditory pathway) [1].
Rosenhall [3] proved that a lifetime of exposure to noise is likely to have negative effects on hearing, but determining the interaction between noise-induced hearing loss and age-related hearing loss is difficult. The results of this study confirm the effectiveness of fitting the majority of PT patients with hearing aids. The effectiveness of fitting in the subject group of patients depended on speech discrimination scores before fitting. INTRODUCTION: Sudden deafness is characterized by an abrupt onset, often idiopathic and tinnitus is present, and becomes the main complaint in up to 80% of patients. OBJECTIVE: To review carefully all studies of the past 10 years on sudden deafness and tinnitus and analyze the effectiveness of oral and intratympanic steroids for tinnitus control in eight patients with sudden deafness and severe disabling tinnitus. METHOD: An analytical prospective in which 64 patients after sudden deafness with tinnitus were monitored and 08 of these suffering with severe disabling tinnitus underwent hearing evaluation and application of the Tinnitus Handicap Inventory and Visual Analogue Scale before, during and after sudden deafness treated with oral and intratympanic steroids. Sudden sensorineural hearing loss (SSHL) was first described by De Kleyn in 1944 and defined as a hearing loss of at least 30 dB in three sequential frequencies in the standard pure-tone audiogram over 3 days or less1.
Population studies of SSHL show a wide distribution, ranging from 5 to 30 cases per 100.000 per year, with an average of 50-60 years and no sex preference. Hypotheses are proposed to explain the pathogenesis of sudden hearing loss as the vascular, the viral, the autoimmune and the rupture of membranes one.
Patients with tinnitus and SSHL are very frustrated by residual tinnitus even after accomplishment of the treatment for SSHNL. All patients received information about the risks and expectations of therapy and signed a free informed consent form. Next, salvage therapy with intratympanic methyl-prednisolone was offered to XX patients with a diagnosis of SHL, after systemic therapy failed and no improvements were demonstrated audiometrically. All patients underwent tonal and vocal audiometry and speech recognition rate analysis done by audiologists before and after treatment. Prior to any procedure, patients were oriented as to the risks and expectations about the procedure and signed a free informed consent form. After intratympanic application of the steroid, the patient remained in the supine position and cervical rotation at 45? for 30 minutes to maximize exposure of the round window membrane to the solution.
The criteria for defining successful recovery after therapy vary in the literature on intratympanic therapy.
All patients underwent Questionnaire Tinnitus Handicap Inventory (THI)5 and the Visual Analogue Scale (VAS) to assess quantitatively and qualitatively the therapeutic response in relation to tinnitus. The search strategy employed in the literature review was guided by the combination of two descriptors indexed in MeSH (Medical Subject Headings): sudden deafness and tinnitus. Most of the patients had vertigo associated with sudden deafness, being classified as mild in 75% of cases and severe in 12.5%. We performed a literature search with the following aliases: sudden hearing loss and tinnitus. Their ages ranged from 26-73 years with a mean of 39,5 years and the ear most affected was the left ear (n = 5). In this study, we chose to intratympanic corticosteroid associated with oral corticosteroids and showed that this association was particularly effective in relation to tinnitus, from the eight cases analyzed, seven of these showed a significant improvement verified by THI and EVA.
Several factors may affect the prognosis of the PANSS (eg, hearing loss severity, symptoms duration before treatment, vertigo, type of audiogram, and the patients ages).
Regarding hearing improvement, only two patients had good responses to therapeutic intervention.
Given the results, we note that in addition to the proposed intervention, especially those cases where there were no improvement or even where there were worsening of symptoms over time, there are other recommended therapies such as cognitive-behavioral and Tinnitus Retraining Therapy. Some therapies for tinnitus tend to focus on the impact of noise on the quality of life and humor, and include antidepressants, anticonvulsants and benzodiazepines, or attempt to mask their own noise with white noise generators.
In 2005, a review of published randomized clinical trials addressing the correlation between sudden sensorineural hearing loss and tinnitus and treatment by hyperbaric oxygen therapy (HBOT).
The sudden sensorineural hearing loss (SSHL) is a considerable diagnostic challenge because it can be caused by many different diseases and there is still no definitive treatment for PANSS universally accepted. In search of a therapeutic approach, the efficacy of enoxaparin sodium associated with venous hemofiltration was studied. In 2008, Ishida et al.15 investigated how the symptoms of ear fullness, tinnitus and otoacoustic emissions (OAE) varied over the course of recovery thresholds in pure tone audiometry in SSHL. Kleinjung et al.16, in 2009, described the case of a man of 55 years who suffered from tinnitus in the right ear as a result of a SSHL. Hikita-Watanabe et al.17, in 2010, in an article entitled "Tinnitus as a prognostic factor of sudden deafness", rebound that in the group "buzzing rare" there was a worst prognosis to hear than in the group "buzz often". In 2012, Fioretti et al.18 described the case of a 67 years-old women with severe and disabling tinnitus in the right ear, hyperacusis and mild headache. In 2012, a research was also conducted by Ramos et al.10, in which the authors assessed the effectiveness of cochlear implants in patients with SSHL and disabling tinnitus.
The tinnitus severity was assessed using the Tinnitus Handicap Inventory (THI) and the Visual Analogue Scale (VAS) before and after deployment. Given the results, it can be concluded that the reduction of tinnitus after cochlear implantation may be due to several mechanisms such as habituation, acoustic masking, direct stimulation of the cochlear nerve and reorganization of cortical areas. Michiba et al.19, in 2013, highlighted the fact that many patients are frustrated with the SSHL residual buzz, even after complete SSHL treatment. The hearing improvement rate was determined by comparing the thresholds before and 6 months after initiation of treatment.
The improvement of hearing thresholds were significantly correlated with improvement in the score of tinnitus 6 months after initiation of treatment compared with before treatment. Generally, subjective feelings for the ringing residual 6 months after initiation of SSHL treatment are almost the same as 24 months after treatment. Patients that carriers sudden deafness and severe disabling tinnitus, and underwent intratympanic and oral corticosteroids showed, in this study, significant reduction or remission of tinnitus. Paper submitted to the ITJ-SGP (Publishing Management System) on September 4, 2013; and accepted on October 4, 2013. How to cite this article Nardo WD, Cianfrone F, Scorpecci A, Cantore I, Giannantonio S, Paludetti G. Tinnitus is a common symptom which often becomes disabling, affecting the emotional and psychosocial dimensions of life. Tinnitus is a quite common symptom, not infrequently reported by patients as a bothersome and upsetting experience severely affecting the emotional and psychosocial dimensions of life and sometimes impairing the patients' ability to perform daily life activities. As reported by basic and clinical research, lesions are more often localized within the auditory periphery and concern hairy cells. Our methods for patient enrollment, informed consent, psychoacoustic testing, placement of a transtympanic electrode, electrical stimulation, data analysis, and follow-up were reviewed and approved by our institutional review board and are in accordance with the Helsinki Declaration. In our clinic, we enrolled 11 patients (7 women and 4 men) affected by postlingual monaural or binaural profound hearing loss and with severe and disabling tinnitus in the worse ear. When the hearing loss was gradual in onset, patients underwent auditory brainstem response (ABR) recordings before their deafness became profound, and results were consistent with a peripheral origin of their disease. The stimulation system we used is a Cochlear Promontory Stimulator Z10012 (Cochlear Ltd., Lane Cove, NSW, Australia), an active platinum-iridium needle electrode and a silver surface electrode located on the ipsilateral mastoid region.
Characteristics of the study population, including age, cause of hearing loss, and duration of tinnitus, are shown in Table 1; tinnitus pitch, loudness, and MML as measured immediately before the electrical stimulation session are shown in Table 2.
The most effective frequencies of electrical stimulation for tinnitus suppression or reduction were 50 Hz and 100 Hz. Conversely, factors such as tinnitus duration and patient's age appear to be associated with the THI outcome: Four of the six patients having had tinnitus for less than 5 years had a complete or partial benefit from the procedure, whereas only one of five patients with more than 5 years of tinnitus showed a THI score reduction after 1 month.
The effectiveness of electrical stimulation on tinnitus is well-known, thanks to studies on groups of patients affected by bilateral profound sensorineural hearing loss and undergoing cochlear implantation, the majority of whom report suppression or attenuation of tinnitus after device hookup [15-18]. Despite the remarkable amount of evidence pointing to a beneficial and lasting effect of EPS on tinnitus, studies generally describe the clinical effects of the procedure rather than focusing on the mechanisms underlying tinnitus suppression, so that at present there are many questions-and no certainty-as to how EPS should work.
Whether EPS can restore some degree of normal firing in the cochlear nerve of humans affected by tinnitus is at present unknown.
Alternatively, suggested mechanisms through which a positive current delivered to the promontory or to the cochlea may work on nerve fibers include hyperpolarization of axons, with subsequent inhibition of spontaneous discharge rates [27], and even a reflex increase in microcirculation in the auditory pathway [21].
A temporary alteration of acoustic nerve firing cannot account for the long-term effect (at least 1 month) of a 60-second promontory stimulation such as the one we administered to our study patients. Finally, a possible effect of EPS on the cortical reorganization [31-34] underlying tinnitus must be assumed, as a positron emission tomography (PET) study has shown that electrical stimulation delivered to the promontory and round-window region causes activation of the primary auditory cortex and some of the surrounding association areas [35].
As for the tinnitus-associated psychosocial impairment, THI administration allowed us to appreciate a reduction of the THI score in five patients 1 month after transtympanic stimulation, which means most of the negative emotional, affective, and psychosocial impacts of tinnitus abated. Considering our preliminary results, we think more expansive series are necessary to precisely define the features that the electrical stimulation should possess to suppress tinnitus. Aside from the optimal parameters of stimulation, clinical features that predict EPS success should be outlined more precisely for a correct selection of candidates who could derive the utmost benefit from the procedure. In conclusion, we assume that EPS is to be considered per se a worthwhile attempt at tinnitus suppression, being quite easy to administer and successful in the majority of cases.
EPS results could help predict tinnitus response to the positioning of an implantable electrical stimulator: Patients for whom EPS proves to be effective could benefit from the implantation of an intratympanic stimulator that could be controlled by radiofrequencies from the outside. Largely unknown causes and innumerable assumed mechanisms conceivably could be involved in the generation of tinnitus. The systematic classification outlined in this article differentiates conductive from sensorineural and central tinnitus. In addition, the very common, subjective tinnitus cannot be assessed objectively; thus, no concrete evidence at all corroborates the large number of individual mechanisms that supposedly lead to tinnitus, as de-scribed in the literature. In the present situation, a systematic classification based on the anatomical and functional aspects involved in the generation of tinnitus should prove useful. The present systematic classification, parts of which actually have been discussed since 1993 [16,l7], is described here in further detail, taking both the methods of functional and anatomical systematics into account. The first stage in the systematic classification of tinnitus (Table 1) is the conventional division into objective and subjective tinnitus. From this schematic course of events, which presents a simplified form of the entire auditory system according to its functional and anatomical aspects, an uncomplicated classification can be deduced for subjective tinnitus (see Table 1).
According to function and anatomy, the following three divisions can be made: conductive tinnitus, sensorineural tinnitus, and central tinnitus [11,13]. In the case of sensorineural tinnitus, one of the three sensory functional elements of a resulting sensory tinnitus can be distinguished from extrasensory tinnitus [18]. For these purposes, central tinnitus, [1,9,11,13] can be subdivided into primary central and secondary central [9] tinnitus. Thus, the systematics presented here provide us with the framework for classifying all known causative models of the symptom tinnitus.
Tinnitus occurring with and in the same frequency range as a hearing disorder, whereby the psychoacoustic loudness is some decibels above the hearing threshold and the hearing disorder is accompanied by a partial or complete loss of TEOAE and a positive recruitment phenomenon, results in a high degree of probability from a disturbed motor function of the OHCs.
Currently, diagnosing a sensorineural tinnitus type II in exceptional cases only is possible.
If an acoustic neurinoma is detected, a sensorineural tinnitus type III is the most likely diagnosis. The combination of different tinnitus types within this systematic classification generally is acceptable. For tinnitus sensations of up to 3-5 kHz, on the basis of the coherence theory, Feldmann [7] gives guidelines to differentiate clinically between central tinnitus and the tinnitus described here as sensorineural tinnitus. Some therapeutic approaches also can be grouped according to the systematic classification presented here. If the classification is used for diagnostic purposes, the tinnitus also can be registered as compensated or decompensated.
If a diagnosis is reached by these means, clearly no single method of treatment can be found that would relieve all forms of tinnitus.
For the diagnosis of a motor disorder (OAE, recruitment), an acoustic neurinoma (ABR, NMR), and primary central disorders, specific diagnostic tools are available. At present, single forms of treatment are considered appropriate without specification for nearly all patients with tinnitus. This type of vertigo produces a nystagmus called benign paroxysmal positional nystagmus (BPPN). In 1998, I published an article entitled "A state of the art" on this subject in the review of the Royal Belgian Ear Nose and Throat Society [3]. This theory is not supported by some characteristics of this nystagmus: It does not explain, for example, the direction of the nystagmus toward the higher ear when a patient reaches body rotation of 180 degrees. All these theories, however, do not explain all instances of BPPN, such as those observed after alcohol or heavy water ingestion. Particulate matter from the membranous posterior semicircular canal was removed from one patient at the time of posterior semicircular canal occlusion for intractable BPPV symptoms and was examined using scanning electron microscopy. In experiments with a cat, Fernandez [13] found BPPN with the ablation of the cerebellum nodulus. Miehlke [17] observed BPPN secondary to trauma of the inner ear, with blood in the inner ear. Kornhuber [6] and, later, Fluur [22] demonstrated that the direct stimulation of otolithic organs did not produce BPPN. Korres [27] found frequent electronystagmography abnormalities in patients with BPPV, most commonly including canal paresis of the involved side.
The absence of basophilic deposits in the cupula and membranous canal of the posterior canal sense organ in many of the donor temporal bones with a history of BPPV. These observations support a neural concept of BPPV rather than one based on a purely mechanical hypothesis. Significant loss of superior vestibular ganglion and inferior vestibular ganglion cells was found in all temporal bones, whereas vestibular sense organs were normal.
The cause of this ganglionic degeneration is probably the reactivation of latent neurotropic viral infection [33]. The limited duration of nystagmus while provocation is maintained and the fatigability of this response cannot be explained by a change in the gravity sensitivity of the cupula. However, if the saccular macula or its neural input is degenerated, the antagonistic effect on posterior canal input is lost, and the rotatory upbeat nystagmus associated with posterior canal receptor activation is released. A degenerated or atrophic singular nerve was never encountered in more than 250 surgical exposures of this nerve in patients with chronic BPPV. It is possible that some patients may have only nausea and imbalance without nystagmus, if the saccular deficit is minimal. This form of treatment would succeed in cases in which there is sufficient residual saccular input. Characteristics include a variable latency from 2-3 to 15 seconds, a vertigo or distress sensation, a rotatory nystagmus toward the downturned ear, in which intensity increases progressively and decreases to disappear in several seconds, an inversion of the sense of rotation of the nystagmus when a patient is re-placed in a sitting position, and the suppression of VBPPN after some maneuvers. However, a study published in 1982 [37] concerning 194 cases of VBPPN (138 unilateral and 56 bilateral) noted several particular cases, including those in which one of the characteristics may be absent without central disease and any other pathology. Another research study [39] demonstrated the absence of correlation between the VBPPN and the existence of a directional preponderance syndrome of the nystagmus. In the Hallpike position, the nystagmus is down-beating, and its duration varied from 5 to 60 seconds, sometimes more. Transient Interruption of Unilateral Tinnitus by Fentanyl and Propofol in a Patient with Neuromuscular Disorder. In cases in which its cause can be identified, the success rate is higher than in idiopathic cases [3].
The man's hearing was subjectively not affected, but initial audiometry revealed impaired hearing for lower frequencies on the left side. However, at follow-up, five months after the second ablation, the tinnitus had already decreased to such a degree that it no longer affected the patient's well-being. Possible causes were arterial hypertension, increased tone of the cervical muscles, stress or cardiac rhythm abnormality, and mitochondriopathy (see Table 1). These negative results, however, do not exclude a neuromuscular disorder, such as a laminopathy or metabolic myopathy.
Patients with a conductive hearing loss, suspected retrocochlear pathology, and pulsatile tinnitus did not take part in this study. Brainstem audiometry was performed to exclude retrocochlear pathology (Biologic Navigator, Chicago, IL).
The level oftinnitus masking also was determined with a pure tone at the tinnitus frequency. In consecutive small steps, the intensity of the stimulus then was reduced until tinnitus again became audible. It also is possible that a disturbance of this relationship could lead to the phenomenon of tinnitus. He found that the temporary threshold shift, which is observed after exposure to loud sounds, is significantly reduced when the crossed olivocochlear bundle is simultaneously stimulated. The role of the OHCs is to regulate the endocochlear potential, which may be achieved through a current shunt by OHCs. As a principle of this model, IHCs that may detect electrical potentials from the tectorial membrane are primarily regarded as electroreceptors, and OHCs are primarily regarded as mechanoreceptors [6]. On the basis of the electromodel, this relationship was expected to maximize stimulation of any residual OHCs.
This selection was made on the basis of preliminary tests that have shown less effective suppression with a continuous tone. This lack of correlation may have been due to various configurations of the hearing loss or might have been due to a variability of available functional OHCs at different locations. Application of this technique is restricted, and it might not be appropriate when changes in the central auditory pathway have developed in tinnitus patients.
This would have the advantage of demonstrating immediate tinnitus reduction and would facilitate habituation. There, people who have the condition as well as healthcare professionals can learn more about tinnitus, which chronically affects 5% to 10% of the U.S. Depression ranges from normal feelings of "the blues" through dysthymia to major depression.
Depression also occurs among patients especially seeking help from a neurootologist when they present with vertigo or tinnitus. Depression may be accompanied by a variety of related symptoms, including disturbances in sleep and eating, loss of initiative, self-punishment, withdrawal and inactivity, and loss of pleasurable feelings. They contained a neurosensory network analysis through polygraphic five-channel electronystagmography (ENG) together with simultaneous electrocardiographic (ECG) recordings of the heart rhythm. For this test, the caloric warm response is defined to be stimulated with the weaker stimulus acting on one inner-ear receptor. In this analysis, we always add the pure-tone analysis of the discomfort threshold for measuring the audiometric dynamics of the inner ear.
According to our statistics, we have complete individual descriptions within the patient files. Dynamic vestibular stimulus response intensity comparison (VESRIC) sorted according to the occurrences of the 12 most frequent patterns. The investigation of the hearing pathways was evaluated by speech audiometry with respect to the three most socially important audiometric parameters (Fig. Speech audiometry evaluated according to the three important parameters: recognition of numbers and of words and loss of discrimination for the left ear.
In our study, we adopted the diagnosis from other physicians who investigated the patients prior to our evaluations. The term implies that some intrinsic biological process rather than environmental influences is the cause.
The patient complains of chronic symptoms of a somatic nature, insomnia, and loss of pleasure in everything. The same level of tinnitus may be described by one patient as intolerable and by another as barely noticeable.

Among the reported phobias, general anxiety occurred frequently, rivaling the occurrence of all the other subsymptoms.
ECG analysis revealed that downregulation of the ECG under the influence of caloric vestibuloocular stimulation is very low, if not abolished, in comparison to the situation during spontaneous recording (see Table 3). 4) that downregulation of the heart rate is incomplete or lacking with respect to the sitting spontaneous situation. Per- and postrotatory electrocardiogram (ECG) analysis during the experimental vestibuloocular investigation rotatory intensity-damping test of 134 patients suffering from depressive disorders. 2) in the VESRIC, we find only 22.39% of normal reactions within the tests of the vestibuloocular nystagmus-regulating system.
The subjective impressions of oscillopsia and double vision are also higher than in other groups of patients with neurootological complaints.
There, we find only minor incidences of broad sway patterns of the cerebellar pontomedullary dysregulation type.
Untersuchungen uber den vom Vestibularapparat des Ohres retlektorisch ausgelosten rhythmischen Nystagmus und seine Begleiterscheinung. Das Frequenzmaximum des kalorisch ausgelosten Nystagmus I als Kennlinienfunktion des gepriiften Vestibularorgans. Die quantitative Vestibularisprufung-Eine audiogrammanaloge Auswertung von Nystagmusbefunden (Schmetterlingsschema). Uber eine Gleichgewichtsfunktionsprufung mit Hilfe der Cranio-Corpo- Graphie (CCG) und Polarkoordinaten im Raume. Forschungsbericht Cranio-Corpo- Graphie (CCG)-Ein einfacher, objektiver und quantitativer Gleichgewichtstest fur die Praxis. Das impulsmarkierte Cranio-Corpo-Gramm, ein differenzierter vestibulospinaler Test mit besonderer Bedeutung fur die Arbeitsmedizin.
Uber eine Systematik der mittels der Cranio-Corpo-Graphie aufgezeichneten Kopf-Korper-Bewegungsmuster [inaugural dissertation]. Die Darstellung per- und postrotatorischer Vestibularisreaktionen mittels des Brain Electrical Activity Mapping. Uber die Registrierung des Nystagmus und anderer Augenbewegungen vermittels des Seitengalvanometers. Neue objektive registrierbare Vestibulariskorperdrehreaktionen, erhalten durch Treten auf der Stelle. Department of Otorhinolaryngology Head and Neck Surgery, Semmelweis University, Budapest, Hungary.
The purpose of this study was to verify the conditions of improvement in patients treated for PT. Clearly, many individual cases of PC do not constitute a specific type but have mixtures of these pathological types and are termed mixed PC [1].
The management of PT is challenging, and treating physicians need to have a very compassionate attitude toward affected patients.
The role of the initial interview in assessing severity of complaints and classifying individuals into appropriate therapeutic groups cannot be overestimated [11]. Properly fitted hearing aids amplify the level of background noise and thus reduce the perception of PT [8,9,12]. Patients evaluated the intensity of tinnitus at the loudness level when the tone or noise stimulating the impaired ear masked the patient's tinnitus. We then asked all patients to complete a questionnaire to answer a set of questions concerning the history of their symptoms (the time and circumstances of the onset of complaints), previous treatment, history of exposure to excessive noise, tolerance of loud sounds, character of the tinnitus, circumstances when it was aggravated and subsided, self-assessed hearing, ear diseases, ototoxic treatment, awareness of the tinnitus during the daytime (percentage), scaled loudness, and the impact that the tinnitus had on rest, sleep, and work. We then informed them about the use of the fitting according to the character of the complaints and their individual manner of living. The majority of examined individuals did not remember the circumstances of the onset of their complaints, apart from acute onset in three patients.
This information should be presented sensitively and in such a way that it is readily understood by the patient, as tinnitus patients often are afraid of brain pathology that might endanger them [15]. The scale used in this examination also included questions referring to the influence of the tinnitus on rest, sleep, and work. The fact that in some patients in this group the improvement was not satisfactory or no improvement accrued could be explained by more complex etiology of the complaints in those individuals.
The most commonly accepted assumption is a simple accumulating effect of noise and aging on hearing, particularly on cochlear pathology [3]. In patients with unilateral sensorineural hearing loss and tinnitus, fitting the impaired ear exclusively was effective. Eight patients treated with intratympanic and oral corticosteroids were selected, just two patients showed improvement over the hearing but seven of them showed big improvement in their tinnitus, which was demonstrated by an improvement in the values of the degrees of severity of tinnitus.
In most cases, there is a unilateral hearing loss, with bilateral involvement reported en less than 5%1. However, the current trend is to consider the sudden deafness as a disease of multifactorial etiology2. In idiopathic cases, the oral corticosteroids are widely used, although the supporting evidence is weak. However, there are few theories trying to explain its mechanism, one of than associates this symptom with a maladaptive attempts of a cortical reorganization process due to peripheral deafferentation4. The majority ask doctors about the prognosis of residual tinnitus at the final day of medical treatment for SSNHL. From June 2011 to July 2013, 64 patients with a diagnosis of sudden sensorineural hearing loss were seen at the otorhinolaryngology outpatient and emergency unit of our Center, Eight was suffering from severe disabling tinnitus.
A detailed clinical history was taken, followed by an otoneurological examination, and an initial audiological assessment by tonal and vocal audiometry, impedance testing, speech recognition rate (SRR), laboratory tests, and an image exam (magnetic resonance imaging with contrast of the inner auditory canal). Eight patients suffering from severe disabling tinnitus agreed to undergo rescue therapy and signed the free informed consent form to be included in this study.
All patients with fluctuating hearing loss or suspected Meniere's disease were also excluded from this study. A second injection was done if there was any possibility that the first injection was not adequate. A 20 dB improvement at 0.5, 1 and 2KHz, or a 20% improvement in discrimination was enough to consider the intervention as successful.
In the Visual Analogue Scale (VAS) score ranges from 1 to 10, where 10 represents the highest degree of tinnitus severity.
However, corticosteroids seem to have universal acceptance and are the ones with proven effectiveness. Such treatments aim to improve inner ear oxygenation and include vasodilators, plasma expanders, steroids and anticoagulants11. In the EVA, it is observed that 100% of patients had a score greater than or equal to 7 and a significant reduction in scores of patients 1, 2, 3, 4, 7 and 8, in order to reduce at least two points on score and the same was observed in the degree of severity in THI (Table 1). Patient 2, despite their age, presents a clinical STD (sexually transmitted disease) that could prevent or reduce the effectiveness of the proposed treatment. The administration of hyperbaric oxygen is based on the argument that both the hearing loss and the tinnitus may result from a hypoxic event in the cochlea, and that hyperbaric oxygen therapy may be able to reverse the oxygen deficit.
Eight patients were followed with improvement in SSHL auditory thresholds (Group A) and eight patients with poor hearing improvement (Group B), to elucidate the behavior of these symptoms in your ongoing recovery.
Several therapeutic efforts including intravenous steroids and graft in the round window showed no positive responses. All subjects had SSHL, although the group "short" had a better prognosis than the group "longer duration" when restricted to SSHL accompanied by tinnitus. Ten patients with sudden hearing loss and severe-profound unilateral tinnitus associates were implanted with a mean age of 42.7 years deployment.
It was conducted a prospective study that analyzed gender, laterality and age of patients, along with changes in the level of hearing and tinnitus, after scoring early SSHL to determine the prognostic factors of residual tinnitus after the last day of treatment for SSHL. The tinnitus was assessed subjectively by a questionnaire before, 6 and 24 months after initiation of treatment.
The scores of tinnitus in all three items were significantly better 6 months after initiation of treatment comparing with the last treatment.
Especially younger patients with hearing improvement achieve an improvement of tinnitus in the period between 6 and 24 months after initiation of treatment. Specialist in Otology and Neurotology by Harvard Medical School, Boston, MA, USA, PhD in Medical Sciences from the University of Brasilia, Professor at Health Sciences School - University of Brasilia - Brasilia - DF - Brazil. There are many reports describing tinnitus suppression or attenuation through electrical stimulation of the ear, provided either by cochlear implants or by transtympanic stimulation. The subsequent change in the acoustic nerve fiber excitation pattern triggers an immediately successive elaboration by neural centers and then, after some time, the priming of neural plasticity phenomena. Many studies have described attempts at suppressing tinnitus by means of electrical stimulation, delivered both transcutaneously [3-9] and transtympanically [10-12].
The anesthetic procedures consisted in careful cleansing of the external auditory canal and local administration of lidocaine to anesthetize the tympanic membrane for 5 minutes.
Table 3 lists data concerning the modalities and the effects of EPS, such as pulse rate of the delivered stimulus, threshold, discomfort level, and best tinnitus-suppressing frequencies for each patient. For lower frequencies of stimulation, electrical intensity for tinnitus suppression or attenuation was just above auditory threshold, whereas for high frequencies of stimulation, it was quite near maximum acceptable level in the majority of patients. THI scores obtained immediately before and 1 month after EPS are shown in Table 4, which also provides information about pre- and poststimulation partial scores relative to the three categories (emotional, functional, and catastrophic) comprising the THI.
As for patients' age, four of the five subjects reporting longer-lasting benefit from the procedure were younger than 50 years. Our short-term and long-term results are consistent both with the evidence provided by such studies on cochlear implants and with recent works on transtympanic electrical stimulation [20-22].
The "masking" hypothesis, which was among the earliest proposed [23], has long been considered too simplistic and insufficient, because in some cases tinnitus reduction can be obtained by means of subliminal electrical pulse rates. Very few reports are currently available about a real-time monitoring of nerve fiber activity during and immediately after peripheral electrical stimulation.
In fact, the lasting residual inhibition we observed in some of them implies that central stations along the auditory pathway are likely to be involved as well. Other PET studies report that the electrical stimulation produced by a cochlear implant can reduce the signs of abnormal activity supposed to be associated with tinnitus in the primary auditory and associated cortices and in brain areas of the limbic system [36].
This outcome seems to suggest that electrical stimulation also affects the activity of association areas (limbic system) that are notoriously closely intertwined with the neural pathways involved in tinnitus pathogenesis and play a very important role in producing negative emotional correlates of tinnitus, such as anxiety and annoyance. However, even the results on our small series seem to indicate that tinnitus suppression occurs mostly at lower pulse rates (50 and 100 Hz) and at an intensity of stimulation between threshold and minimum discomfort level, although in two of our patients, tinnitus suppression was achieved through subthreshold stimuli.
Our results suggest that recent onset of tinnitus and a patient's age can be predictive of tinnitus suppression, although selection criteria deserve deeper investigations in larger series. Considering the recent achievements of cochlear implant "soft surgery," which allows preservation of residual hearing, cochlear implants could definitely be used to suppress intractable tinnitus in patients with unilateral profound hearing loss [38]. Indeed, tinnitus is so complex and so manifold that a systematic classification could prove helpful.
Sensorineural tinnitus is subdivided into motor (type I), transduction (type II), transformation (type III), and extrasensory tinnitus (type IV), central tinnitus being subclassified as primary and secondary (centralized) tinnitus. In the same way that the visual system can react to disturbances only symptomatically by reducing the ability to see or by "seeing stars", all disorders of the auditory system lead to a reduction in hearing ability or to tinnitus (or to both) without exception. The various models can then be incorporated into the classification, regardless of their scientific evaluation. It will enable physicians to classify the large number of causative mechanisms for tinnitus by a more simplified means, to reach a basis for general understanding. To comprehend subjective tinnitus, Figure 1 schematically depicts the individual functional and anatomical steps involved in sound processing, with the middle ear, inner ear, and brain roughly outlined. Systematics of possible generation mechanisms of subjective tinnitus, developed from Zenner et al.
This allows every conceivable proposition for a pathophysiological, causative mechanism of tinnitus to be classified in the same way that the physiological courses of events divide the entire auditory system. In principle, sensory and extrasensory tinnitus include all possible cochlear and neural (auditory nerve) tinnitus models. The pathogenesis of primary central tinnitus is to be found exclusively in the brain; it develops independently of the inner or middle ear. Noises perceived in the outer auditory canal with a microphone or a stethoscope are an indication of objective tinnitus.
If, as did Feldmann [7], one assumes a uniform disruptive mechanism to be responsible for both the hearing disorder and tinnitus-in cases of noise induction of aminoglycosides, this is virtually certain; in other cases, it suggests a high probability-a sensorineural tinnitus type I can be diagnosed. A circulatory disturbance of the inner ear (proving difficult for detection) indicates sensorineural tinnitus type IV (reduced blood circulation in the stria vascularis); in cases involving dramatic hypoxia, this leads to a tinnitus type III (swelling of the nerve fiber endings). The fact that a secondary central tinnitus can be diagnosed is exemplified by phantom tinnitus, which still continues even after neurectomy.
This is especially true of secondary central tinnitus, which always is triggered by a different form of tinnitus. Tinnitus that can be heard in one or both ears is generated in the ear; a tinnitus perceived in the head may be regarded as central. The exact description, depending on the course of the disorder, is acute, subacute, or chronic.
A secondary central tinnitus can be diagnosed, partially at least, with psychological methods. This disease occurs frequently and constitutes approximately 50% of acute vertigo complaint in my practice. Those who argue against cupulolithiasis point to the absence of BPPV attacks with slow head tilt (> 6 sec) and of typical vertigo with linear head accelerations.
Positive factors include the positioning of the nystagmus toward the uppermost ear as induced by 180-degree head tilt, providing indirect proof of canalolithiasis. Initially, Jongkees [14] and, earlier, Cope and Ryan [15] in another publication hypothesized that cervical trauma or degenerative lesions, as spondylosis, disturbed proprioceptive information to the vestibular system and figured in the origin of BPPN. In 2003, Vibert [28] found a correlation between BPPV and osteopenia or osteoporosis in women with BPPV who were at least 50 years of age.
The excitability of the posterior canal in the affected ear was found to be lower than that of the anterior semicircular canal. The assessment of vestibular ganglion cell loss revealed an approximately 50% loss in the superior vestibular ganglion of all 5 temporal bones and in the inferior vestibular ganglion of 3 temporal bones with BPPV. These features are more consistent with a refractory state of first-order vestibular neurons.
The nystagmus of posterior canal BPPV, therefore, may result from inadequate inhibition from the saccular macula, especially its superior part.
Manzari [35] suggested that recurrent BPPV is related with volumetric abnormalities of the vestibular aqueduct. It is the demonstration that a complete otoneurological examination has to be reached to reveal the origin of the affection and to give a prognosis for the success of treatment.
The author also found a syndrome in which the VBPPN exists for some days to some weeks, disappears, and reappears after a variable period. Some cases demonstrate a complex situation with a mixture of two VBPPVs [47] or a combination of HBPPV and VBPPV [52-54].
This device, with a Web module consisting of a series of slides that outline the steps of the PRM, is particularly useful to teach the PRM and demonstrates its superiority over standard classroom instruction.
In a 2005 meta-analysis of nine controlled studies consisting of 505 patients, Withe et al.
In 2004, Barozzi and Cesarani [26] proposed a new treatment with relaxation and vestibular electrical stimulation in patients resistant to two maneuvers or with recurrent vertigo.
In the failed cases of vestibular habituation training, success was achieved in 9 cases in a maximum of 2 weeks, and failure in 1 case resulted in spontaneous remission after 6 weeks. The pathology, symptomatology and diagnosis of certain common disorders of the vestibular system. Current view of the mechanism of benign paroxysmal positioning vertigo: Cupulolithiasis or canalolithiasis?
Tierexperimental Untersuchungen uber die Ursache und den Ort des Auslosung des peripheren Lagennystagmus. Uber Lagerungnystagmus unter desonderer Berucksichtigung des gegenlaufigen transitorischen Provokationnystagmus bei lage Wechsel in des Sagittalebene.
Observations upon the mechanism of positional nystagmus of the so called benign paroxysmal type.
Benign paroxysmal positional vertigo in older women may be related to osteoporosis and osteopenia.
Horizontal otolith ocular responses to lateral translation in benign paroxysmal positional vertigo.
Evaluation of the vertical semi-circular function by the pendular rotation test: A study of patients with benign paroxysmal positional vertigo. Enlarged vestibular aqueduct (EVA) related with recurrent benign paroxysmal positional vertigo (BPPV). Apogeotrophic type of direction-changing positional nystagmus related to slow vertebrobasilar blood flow. Benign paroxysmal vertigo of the horizontal canal: A form of canalolithiasis with variable clinical features.
Continuous vertigo and spontaneous nystagmus due to canalolithiasis of the horizontal canal. Bow and lean test to determine the affected ear of horizontal canal benign paroxysmal positional vertigo. Assessment and treatment of anterior canal benign paroxysmal positional vertigo using the canalith repositioning maneuver (CRM). Anterior semicircular canal benign paroxysmal positional vertigo and positional downbeating nystagmus. Combined horizontal and posterior canal benign paroxysmal positional vertigo in three patients with head trauma.
Modified liberatory maneuver: Effective treatment for benign paroxysmal positional vertigo. Vertige positionnel paroxystique benin, un fauteuil au service du diagnostic et du traitement: description et interet. Epley's maneuver in benign paroxysmal positional vertigo associated with Meniere's disease. Exercise treatment for paroxysmal positional vertigo: Comparison of two types of exercises.
Effectiveness of treatment techniques in 923 cases of benign paroxysmal positional vertigo.
At that time, the patient was receiving metoprolol, ramipril, allopurinol, pentoxifylline, and betahistine. Nerve conduction studies and electromyography revealed a carpal tunnel syndrome exclusively.
Arguments against propofol are that no anti-tinnitus effect of the substance has been previously reported and that it may cause muscle rigidity [6]. Following the electromodel of the auditory system, a mechanism exists that is driven by mechanosensitive outer hair cells (OHCs), that operates close to and below threshold level , and prevents tinnitus by suppressing inner hair cells (lHCs) . Hearing was considered normal when the hearing level in all frequencies tested (250 Hz-8 kHz) remained below 20 dB. The pulse had a frequency of 2 Hz and a rise time and falloff time of 125 msec, with a sound-free interval of 125 msec . This was followed by an increase in the stimulus frequency until tinnitus once more became inaudible. While the sound stimulus remained inaudible, five patients (14.7%) experienced reduction in the intensity of their tinnitus.
Tinnitus in this model is due to reduction of the population of OHCs, these being unable to generate suppression of IHCs because of lack of suppressive displacement of the tectorial membrane. Gain or sensitivity of IHCs is regulated by mechanosensitive OHCs that produce a positive summating potential and determine the magnitude of IHC suppression. The hypothesis presented by the electromodel of the auditory system was an attractive concept that inspired the design of this study, as it could lead to a simple clinical application.
The other maximal amplitude of microphonics is created more apically and originates from IHCs. 2) that shows the tonotopic location of cochlear events at threshold level: The response of IHCs occurs apical to where suppression is produced by OHCs. A pure tone presented at a frequency of 4 kHz is probably detected at a location apical to the maximal amplitude of the traveling wave. Possibly the residual OHCs were insufficient to achieve complete suppression in the five patients (14.7%) who had only partial tinnitus reduction. It also is possible that the variability was due to octave confusion, which was present in a number of our patients.
If a patient did not have sufficient functional OHCs that could be recruited, no positive effect would be obtained from stimulation. However, SOAEs were also absent in five tinnitus patients with normal hearing, four of whom were older than 50 years; the absence of SOAEs in this age group can be expected [14].
One explanation is that contralateral stimulation activates the crossed olivocochlear bundle, which drives OHCs, increasing their microphonics and positive summating potential: This would exert some suppression effect on IHCs. Therefore, a reasonable step would be to determine whether tinnitus suppression plays a complementary role in an already existing treatment modality that addresses the central component of tinnitus. Our findings indicate that a frequency-specific sound should be used, one that is different from the tinnitus frequency.
In some patients, functional OHCs can be mobilized with a frequency-specific and tinnitus-dependent sound stimulus just below threshold level. Neurophysiological model of tinnitus: Dependence of the minimal masking level on treatment outcome. Effect of electrical stimulation of the crossed olivocochlear bundle on temporary threshold shift in auditory sensitivity: I. Effect of electrical stimulation of the crossed olivocochlear bundle on temporary threshold shift in auditory sensitivity: II. Endogenous depression has been identified with a specific symptom complex: psychomotor retardation, early morning awakening, weight loss, excessive guilt, and lack of reactivity to the environment.
More generally, modern medicine acknowledges depression as a mental disorder characterized by feelings of worthlessness, guilt, sadness, helplessness, and hopelessness, experienced either as individual symptoms or in combination with others. These electrophysiological data were recorded within our neurootometric vestibular laboratories. The maximum responses to the four caloric partial tests and the spontaneous nystagmus were plotted onto the Claussen butterfly chart. The patient is also connected to seven electrodes around the eyes for a five-channel ENG and electrodes at the limbs for a three-channel ECG and then is connected to amplifiers and the recording devices.
A NODEC comprising a list and a statistical analysis of the entire sample of 134 patients has been established. The results of the VESRIC are shown in Figure 2 with respect to the 12 most frequent patterns (of 81 possible VESRIC codes) describing the cybernetic status of vestibuloocular pathway regulation.
Combining the caloric with the perrotatory part of the rotatory intensity-damping test (RIDT) with the caloric warm response, we can establish the so-called VESRIC. Many patients presenting with repeated complaints of physical symptoms to physicians who are not psychiatrists are, in fact, suffering from chronic depression. Neurootological experience shows that persons with severe tinnitus experience excessive stress.
Comparison of height and weight revealed a tendency toward a slight overweight (see Table 1). The duration of single vertigo attacks shows a tendency to longer episodes; the vertigo does not occur as a momentary flash.
Thus, tinnitus together with vertigo are important subjective complaints within this group of 134 patients complaining of depressive disorders.
This tendency is underscored in Figure 1, in evaluating the 12 most frequent caloric butterfly patterns in trinary coding. Conversely, upregulation in the sense of a sympathetic tonus during the postrotatory nystagmus phase is much too small. During the standing test, the longitudinal head sways are much longer than the lateral sways.
In comparing this with vestibuloocular nystagmus dysregulation, we were led to conclude that the majority of pathological processes must occur in the upper brainstem together with supratentorial structures. Observation on the directional preponderance of caloric nystagmus resulting from cerebral lesions. We fitted with hearing aids 33 PT patients (ages 60-89 years) and questioned them about subjective hearing results. Some 11% of patients with PC complain of annoying tinnitus [2-5], termed presbytinnitus (PT) by Claussen [2,6], the term specific for the symptom of tinnitus in aged patients and reflecting cochleovestibular dysfunction [7]. Statements that "there is nothing that can be done" are highly inappropriate and should be avoided [10]. The procedure requires thorough explanation of the idea of sound therapy for tinnitus, as many patients with minor sensorineural hearing loss suffer from PT only and are unwilling to wear hearing aids [13]. Subjects included in the study were exclusively those who had declared that tinnitus was very annoying to them, at least as much as the hearing loss. We evaluated the intensity of tinnitus and its impact on a patient's life along a scale ranging from 0 to 10. Effect evaluation was conducted in a soundproof room immediately after fitting and after a week of wearing the hearing aids.
To determine the existence of significant differences between the improvement scores and the variables, we performed an unpaired t -test. History of ear diseases was negative in all cases; 18 individuals had been previously treated with oral piracetam, Ginkgo biloba , betahistine, or vinpocetine (or both), without result. All individuals with PT had pathological results of otoacoustic emissions reproduction scores below 70% at the frequency range 2-4 kHz.
Elderly patients suffering from intense PT are ready to accept the fitting, even when their hearing is relatively good, which was confirmed in the affected group of patients.
In patients with subjectively louder tinnitus, areas of impaired hair cells are most probably wider than in individuals with minor complaints. However, both a lessthan- additive effect and a supra-additive effect have been proposed [3,7].
The improvement scores and tinnitus characteristics did not correlate with a history of prolonged exposure to excessive noise.
Randomisierte Doppelblindstudie zur Wirkung von Extractum Ginkgo biloba bei Schwindel und Gangunsicherheit des alteren Menschen.
Characteristics of tinnitus and etiology of associated hearing loss: A study of 123 patients. Effects of tinnitus retraining therapy (TRT) for patients with tinnitus and subjective hearing loss versus tinnitus only.
In many cases, the etiology remains unknown and constitutes a major challenge, even after complete otologic evaluation, and these cases are classified as idiopathic sudden deafness3.
Intratympanic dexamethasone has been trialled in patients with sudden sensorineural hearing loss, because it provides a high concentration of steroids in the labyrinth in animal models1, although its evidence are conflicting. This study was approved by the institutional review board of the Medical School and the University Hospital in which it was carried out. Below are the details of inclusion criteria, the audiometric assessment, application technique, analysis of The Tinnitus Handicap Inventory and Analogue Visual Scale for Tinnitus and outcome of recovery of Hearing Loss and Tinnitus. The speech recognition rate (SRR) was based on the percentage of correct answers for monosyllables.
EMLA cream was placed in the outer ear canal and the tympanic membrane and left for 30 to 45 minutes, after which it was removed. Failure of oral prednisolone therapy was absence of improvement, as just described, after 14 days of treatment.
In relation to the mean-tone, obtained as a result of the following classifications: mild (25%), moderate (25%), severe (25%) and deep (25%). Sudden hearing loss can occur mainly in the age group 43-53 years7, with equal gender distribution.
Already Patient 4 also showed no change in auditory thresholds, showed a significant change in their tinnitus. Significant increase of 25% was found in the hearing threshold of patients undergoing this type of therapy, but in relation to tinnitus, the study was not conclusive13. Seven patients (70%) treated with enoxaparin sodium and venous hemofiltration (group A) had reduced subjective tinnitus and four patients (40%) showed a complete hearing recovery after the first procedure. Given the failure of the rapies performed, it was suggested the cochlear implant that, according to the authors, is a routine procedure for patients with profound bilateral sensorineural hearing loss, and succeeded, some reports showed a suppression of tinnitus as a side effect after implantation. This indicates that the tinnitus by itself cannot be a problem sign in the prognosis of hearing, but may be an essential sound for the early recovery of the damaged auditory system. Shortly after the standard fitting procedure, the patient reported a reduction of tinnitus, hyperacusis, and the headache disappeared completely in the follow-up of 3, 6 and 12 months.
Seven patients experienced an improvement inTHI in different degrees and in only one patient there was no change. 44 patients with SSHL were followed, all treated with systemic steroids administration for 2 weeks and oral ingestion of vasoactive drugs and B12 vitamin for 6 months. Among the comparison between 6 and 24 months after initiation of treatment, there was no significant change.
Oral vs intratympanic corticosteroid therapy for idiopathic sudden sensorineural hearing loss: a randomized trial. Intratympanic dexamethasone injections as a treatment for severe, disabling tinnitus: does it work?
Cochlear implant in patients with sudden unilateral sensorineural hearing loss and associated tinnitus. Hyperbaric oxygen therapy for idiopathic sudden sensorineural hearing loss and tinnitus: a systematic review of randomized controlled trials. Sodium enoxaparin and venovenous hemofiltration in treating sudden sensorineural hearing loss and tinnitus.
Otoacoustic emissions, ear fullness and tinnitus in the recovery course of sudden deafness. Curing tinnitus with a Cochlear Implant in a patient with unilateral sudden deafness: a case report.
Our study project aims to assess the effects of electrical promontory stimulation (EPS) on persistent disabling tinnitus.We enrolled 11 patients affected by postlingual monoaural or binaural profound hearing loss and disabling tinnitus in the worse ear. Therefore, tinnitus could be due to central nervous system reorganization as a long-term consequence of a peripheral alteration [1,2]. Recently, attempts have been made at relieving chronic intractable tinnitus by delivering electrical stimuli directly to the auditory cortex [13,14]. Furthermore, to exclude the most common central causes of tinnitus (acoustic neuroma, vascular lesion, neurovascular conflict), all patients underwent brain magnetic resonance imaging with gadolinium.
The questionnaire was introduced into the tinnitus assessment battery in order to give the clinician a quick and effective tool for evaluating tinnitus and for classifying patients clinically [19].
We performed transtympanic electrical stimulation with direct continuous positive current at levels ranging from 0 to 500 µA.
No association was found among tinnitus pitch and loudness, MML, and effect of electrical stimulation. Finally, there seemed to be no association between the cause of hearing loss and the benefits derived from EPS. The dorsal cochlear nucleus (DCN) and the inferior colliculus (IC) could be plausible candidates, given the amount of evidence pointing to them as tinnitus generators [28,29], although there is currently a paucity of direct evidence of their role in humans [30]. To confirm this, functional brain imaging should be improved so as to reliably identify central areas of tinnitus-related activity.
In particular, the issue of using subthreshold or suprathreshold electrical stimulation should be addressed with special attention in future studies: Subthreshold stimulation would be better, avoiding replacement of tinnitus with an unpleasant and intrusive sound, just as often happens with maskers. Specific features, such as recent onset of tinnitus and patients' young age, appear to be associated with a better outcome and should therefore be considered as major factors for patient selection. Expanding the biological basis of tinnitus: Cross-modal origins and the role of neuroplasticity. Treatment of tinnitus with transcutaneous electrical nerve stimulation improves patients' quality of life. Tinnitus suppression by electrical promontory stimulation (EPS) in patients with sensorineural hearing loss.
Response of the auditory nerve to sinusoidal electrical stimulation: Effects of high-rate pulse trains. Improved temporal coding of sinusoids in electric stimulation of the auditory nerve using desynchronizing pulse trains. Electrocochleographic analysis of the suppression of tinnitus by electrical promontory stimulation. Summary of evidence pointing to a role of the dorsal cochlear nucleus in the etiology of tinnitus.
Lateralized tinnitus studied with functional magnetic resonance imaging: Abnormal inferior colliculus activation. Functional MR imaging of the auditory cortex with electrical stimulation of the promontory in 35 deaf patients before cochlea implantation.
Quantitative electroencephalography power analysis in subjective idiopathic tinnitus patients: A clinical paradigm shift in the understanding of tinnitus, an electrophysiological correlate. Here represented is a systematic classification that is suitable for scientific communication, for explaining tinnitus models to affected patients in the course of tinnitus counseling, and as a basis for rational diagnosis of and therapy for tinnitus.

For this reason, a broad number of mechanisms can be responsible for the onset of tinnitus, as has been discussed in the literature.
Even some apodictic statements have claimed that one model is responsible for (nearly) all forms of tinnitus: Circulatory disturbances represent one example of this form of misuse. The signal can be made out, which begins at the point when sound enters the ear and leads to vibrations of the ossicles in the middle ear, which then are transferred to the inner ear. To classify the tinnitus models with respect to the three sensory functional elements, an easy approach is to number them consecutively [16,17]. Secondary central tinnitus is based on the fact that conductive and sensorineural tinnitus can be perceived only as such when the signal is processed in the brain.
Systematics can be used clinically in cases in which case history, etiology (if known), and the accompanying audiological examinations allow conclusions of clinical relevance to be made. During one of the initial steps, noise leads to physiological damage of the molecular structure of the stereocilia of the OHCs, thus disrupting their motor function. Apart from these rare events, an additional centralized component of a sensorineural tinnitus canbe considered, especially in cases of extreme emotional overlap with secondary symptoms.
Indeed, some therapies available are designed for specific disorders: drugs for improving blood circulation (sensorineural type IV), caroverine [20] in the case of excitotoxic tinnitus (sensorineural type III), and lidocaine and calcium antagonists in the case of ion channel disorders (sensorineural types I, II, IV).
Disorders associated with sensorineural tinnitus types II and III (apart from acoustic neurinoma) still are lacking reliable diagnostic procedures.
The therapeutic problem of tinnitus can be resolved only if more sophisticated diagnostic instruments become available, enabling the classified diagnosis of tinnitus.
Focal metabolic activation in the predominant left auditory cortex in patients suffering from tinnitus.
Concomitant salicylate-induced alterations of outer hair cell subsurface cisternae and electromotility. Receptor pharmacological models for inner ear therapies with emphasis on glutamate receptors. Neural mechanism of tinnitus: The Pathological Ensemble Spontaneous Activity of the Auditory System.
Tinnitusmodelle zur Verwendung bei der Tinnituscounsellingtherapie des chronischen Tinnitus. Tinnitus-associated spontaneous otoacoustic emissions: active outer hair cell movements as a common origin? Supporters of canalolithiasis emphasize its compatibility with features of horizontal BPPV and nystagmus. These authors compared 73 patients without BPPV symptoms who were undergoing labyrinthine surgery (vestibular schwannoma excision or labyrinthectomy) and 26 patients with BPPV who were undergoing the posterior semicircular canal occlusion procedure. Electron microscopy demonstrated within the membranous labyrinth particles that appeared to be of mixed proteinaceous and mineral content. These authors noted the absence of significant changes of the LVOR, and they explained that fact either by minor utricular damage, which is functionally irrelevant, or by central compensation of a chronic unilateral deficit. In 2003, Gacek [32] suggested that the pathophysiological mechanism responsible for a position-induced vestibuloocular response in this disorder is neural rather than a mechanical stimulation of the sense organ.
The absence of nystagmus in patients with subjective symptoms when provoked by the positional stimulus is also difficult to explain on the basis of gravitysensitive deposits in the endolymph.
In a similar way, lateral canal BPPV may represent decreased utricular inhibition of lateral canal activation.
It is also essential to remember that important metabolism dysfunction or abnormalities of the function of the central nervous system may be at the origin of liberation of deposits from the otoliths in the semicircular canals. When the VBPPN is very important in the contralateral Hallpike position, a rotatory nystagmus toward this side can occur. B1, Movement of otoconias induces ampullopetal deflexion of the ampulla → left horizontal nystagmus = geotropic nystagmus. We propose to use the recommendations of the Royal Belgian Ear, Nose and Throat Society to diagnose and treat this type of vertigo. Paris: Societe Francaise d'Oto-rhino-laryngologie et de Chirurgie de la Face et du Cou, 2007. Presented at the Thirty-first Congress of the Neurootological and Equilibriometric Society, Bad Kissingen, Germany, March 2004. Discontinuation of tinnitus after administration of fentanyl and propofol has not been reported in the literature thus far. At the beginning of the procedure, the patient received local anesthesia with lidocaine, which the treating physician carefully avoided to inject intraarterially.
Ten days after the intervention, left-sided, highfrequency tinnitus recurred, associated with vertigo, nausea, and vomiting. A magnetic resonance imaging scan of the brain showed multiple, small white-matter lesions in the parietal region bilaterally. A cervicogenic cause was largely excluded, as physiotherapy of the cervical spine was ineffective.
Our study was limited in that the cause of tinnitus could not be definitively discovered and we could not determine whether fentanyl, propofol, or both were responsible for the therapeutic effect. A masking device, however, is not always accepted by a tinnitus patient, as it introduces yet another noise, and listening to it can be unpleasant.
In tinnitus sufferers, this natural and inherent suppression mechanism is suspected to be faulty . These patients were suspected to have insufficient functional OHCs, which were regarded as essential for suppression.
The character of the tinnitus varied from a ring to a hiss, whistle, buzz, and cicada-like sounds.
A hearing loss was regarded as mild when the average hearing level at three neighboring frequencies was between 20 and 40 dB and as moderate when the average was between 40 and 65 dB . The introduction of a pulsed suppression tone resulted from preliminary tests that have shown less effective suppression when a continuous tone was applied. A gradual increase in the stimulus frequency and a gradual decrease in the stimulus intensity were continued until a level was reached at which neither the applied stimulus nor tinnitus could be heard .
In seven (20.6% ,) tinnitus could not be suppressed, and even masking was unable to influence the intensity of the tinnitus. The suppression frequency was always found to be higher than the tinnitus frequency, but no clear relationship emerged regarding the frequency difference.
Figure 1 is a representative audiogram in which the tinnitus frequency, suppression frequency, and suppression level are indicated. Penner [7] suggested that tinnitus results from a local increase in the firing rate due to loss of normal suppression .
Diminished OHC function may lead to diminished IHC suppression close to the threshold level . The results of this study support this hypothesis, but how could its mechanism be explained?
The maximal amplitude of the traveling wave coincides with the maximum of OHC microphonics. Tinnitus is found at the location of IHCs that lack suppression, and the frequency of tinnitus is probably the same as the tuned frequency of the IHCs. The maximal amplitude of the traveling wave coincides with the maximal amplitude of the cochlear microphonics of the outer hair cells (CM, OHC) but not with the maximal amplitude of cochlear microphonics of the inner hair cells (CM, IHC).
The seven (20.6%) who did not respond to this treatment may have had tinnitus of a central origin.
A similar outcome was observed when a narrow-band noise was applied to the tinnitus-affected ear, and we were unable to suppress below threshold level. Despite the lack of correlation, we observed a frequency dependency for tinnitus suppression. Nevertheless, this absence must have a bearing on the functionality of OHCs, as not a single tinnitus patient in our study demonstrated SOAEs. Such a treatment modality is tinnitus retraining therapy, which has at its core the detachment of the emotional response from tinnitus. Presented at the Seventh International Tinnitus Seminar, March 5-9, 2002, Fremantle, Australia.
Tn L Cremer (ed), Proceedings of the Third International Congress on Acoustics, Stuttgart, 1959. Les oto-emissions spontanees: Resultats chez des sujets normaux ou presentant des acouphenes.
The site discusses the causes of tinnitus and explains the various treatments available to people who suffer from its often-tormenting symptoms.
Additionally, the vestibular spinal pathways were analyzed by means of ultrasound computerized craniocorpography (US-COM-CCG), recording head and shoulder movements from above.
This chart allows for the discrimination of 81 different test responses, of which some occur in frequencies of more than 1% and some in frequencies of less than 1%; several never have been found among our patients.
The perrotatory stimulus, however, is a step-shaped stimulus and is applied simultaneously to the right and to the left inner-ear vestibular apparatus. The test results of the RIDT are measured from the registration and thereafter are plotted numerically and graphed into the L-chart of the RIDT. The social hearing of the test persons is investigated by means of standard speech audiometry, with hearing threshold for numbers and monosyllable words. Such statistics as age, height, and weight have been recorded to describe the group of persons within the study (Table 1).
When combining the right beating nystagmus and the left beating nystagmus characteristics, we get the charts of the VESRIC, which can be graphed or expressed by trinary coding (0 = normal , I = inhibited, 2 = disinhibited) with four digits (pos. Even a reactivated depression is characterized by a sad or hopeless mood, pessimistic thinking, a loss of enjoyment and interest in one's usual activities and pastimes, reduced energy and vitality, increased fatigue, slowness of thought and action, loss of appetite, and disturbed sleep and insomnia.
As a result, patients may demonstrate a cluster of hysterical defenses or a serious degree of depression.
Among the vertigo symptoms, the feeling of instability is the leading subsymptom, occurring in more than 55%, followed by the feeling of rocking (as if the patient were in a boat) in approximately 53%.
Of 81 possible caloric butterfly patterns, the most frequent is the normal pattern in approximately 30%. All this points to a significantly reduced vegetative reactivity within this group of patients.
Such an accumulation of decruitment phenomena in a ranking of the most frequent VESRIC patterns is very unusual.
Speech audiometry shows in the right and in the left ear a major spread for the loss of discrimination.
We saw a high incidence of home accidents in this study group, which is contrary to the usual occurrence of traffic accidents. In C-F Claussen, MV Kirtane, K Schlitter (eds), Vertigo, Nausea, Tinnitus and Hypoacusia in Metabolic Disorders. Assessment tools included comprehensive audiology and a subjective self-assessment survey of tinnitus characteristics. PT usually occurs in the poorer hearing ear, and PT individuals have a significant reduction in communication skills [7]. At the same time, this group of patients is relatively reluctant to accept methods of treatment that require active training and are used in normally hearing patients with tinnitus. Each individual underwent tympanometry, pure-tone audiometry, subjective tinnitus evaluation, uncomfortable-hearing-level assessment, and otoacoustic emission, auditory brainstem response, and speech audiometry (verbal test) recordings.
At the follow-up visit, we additionally asked the patients about the number of hours a day that they could comfortably wear the aids and the most common benefits and ramifications of the fitting. Subsequently, we calculated Spearman's correlation coefficients to determine whether significant relationships existed between variables.
One patient had been unsuccessfully treated with noise generators; 16 gave a history of prolonged exposure to excessive noise. All patients tolerated the hearing aids very well; 20 with bilateral tinnitus declared "shifting" of the tinnitus toward the unfitted ear while wearing only one unit. Background noise supplied by the hearing aids influences a greater number of the hair cells, giving significantly greater improvement in those subjects than in patients with subjectively quieter tinnitus, which was observed in the group of patients under discussion. The absence of difference between results obtained in subgroups of patients with positive and negative histories of prolonged exposure to excessive noise may be explained by the fact that, as in PC, noise-induced damage of the auditory pathway structures is observed most frequently within the cochlea [3].
Patients with bilateral PT should be fitted with bilateral hearing aids to avoid shifting of the PT toward the unfitted ear, observed in patients with bilateral complaints who wore only one hearing aid. Only 2 patients had improvement of hearing (from severe to normal, mild to normal), keeping unchanged all other results and no worsening (Table 2 and Figure 2). Patient 8, 73 years, has hypertension and diabetes, as well as probable hearing loss due to presbycusis before the episode of sudden deafness. In group B, eight patients (80%) treated with conventional therapy showed a reduction of subjective tinnitus and hearing score also improved in eight patients (80%) - the hearing remained unchanged in two patients (20%). All patients in both groups had ear fullness and tinnitus in association with the onset of the SSHL. One year after the onset of symptoms on the right side, the cochlear implant was performed, and resulted in a complete suppression of tinnitus after activating the implant. It was concluded that, according to the survey of tinnitus, the time factor is the most reliable item for subjective tinnitus. EPS was performed with direct continuous positive current delivered by an active platinum-iridium needle electrode connected to a promontory stimulator device.
Nonetheless, given the invasiveness of cortical stimulation and the uncertainty of its beneficial effect on tinnitus, and also considering the as-yet-undefined criteria of patient selection for such a treatment option, we believe that electrical promontory stimulation (EPS) still deserves attention on account of its good rate of success and of its low invasiveness.
We obtained from each patient a complete history and ear, nose, and throat physical examination. On the whole, 9 of the 11 patients (81.8%) had immediate benefit from EPS relative to their tinnitus.
In vivo monitoring of electrical activity in these centers during and after electrical stimulation delivered to the promontory or to the cochlea would be an optimal method to ascertain whether changes occur in the DCN and IC in response to EPS.
No other reports address the central effects of electrical stimulation on tinnitus in humans , though other noninvasive, promising techniques, such as quantitative electroencephalography, could well serve the purpose of a precise monitoring of EPS brain effects as long as they become more reliable in defining central correlates of tinnitus [37]. Nevertheless, just as one cannot deduce the pathophysiology from the symptom of hearing loss alone, without case history or further medical evidence, the symptom of tinnitus alone does not allow one to deduce the mechanism involved in its generation. The sensorineural component of the hearing process follows, comprising three functional, anatomical steps. Thus, tinnitus associated with the first functional element, the cochlear amplification mechanism, is termed motor tinnitus [8,10,14,16,19] or sensorineural tinnitus type I. Mechanisms leading to a response in which the perception of tinnitus first triggered peripherally but then manifesting itself in the brain independently of the original source in the ear can be subsumed within the group termed secondary central tinnitus (centralized tinnitus, or the less scientific but comprehensible term phantom tinnitus, being synonyms).
This then would form a rational basis to indicate a specific therapy for all diagnosed cases. In February 2008, 800 references about the subject were found in PubMed (Medline) on the Internet. Additionally, they searched microscopically for the presence of particulate matter within the lumen of the membranous labyrinth of 70 archived temporal bones without a history of BPPV. These data suggest that further studies must be undertaken before the theory of endolymphatic particle migration can be confirmed as the etiology of positional vertigo. Uemura and Cohen [20] demonstrated the inhibitory influence, on positional nystagmus, of a rostral lesion of the descending vestibular nucleus that receives information from otolithic organs. Loss of the inhibitory action of otolith organs on canal activation caused by degeneration of otolith neurons (saccular, utricular) is a possible explanation of the brief canal response induced by the positional stimulus. Therefore, the concept of a gravity-sensitive change in semicircular canal physiology in BPPV is inadequate to explain most of the ocular response features of this disorder. B2, Movement of otoconias induces ampullofugal deflexion of the cupula → right horizontal nystagmus = apogeotropic nystagmus.
A single session successfully resolves positional nystagmus 72% of the time; symptoms spontaneously resolve at 3 weeks in one-third of patients. The main variables include bilateral disease or location of disease other than in the posterior canal. In conclusion, high-dose intravenous fentanyl and propofol transiently discontinue unilateral, idiopathic tinnitus. Initially, the sound was a low-frequency permanent noise evoking the feeling of a water-filled left ear.
Results of ultrasonographic investigation of the carotid arteries, otolaryngologic investigation, and audiometry all were normal.
The cardiac rhythm abnormality was excluded because it had persisted for 4 years, whereas the tinnitus had persisted for only 3 months. Arguments against fentanyl are that it increases the intracranial pressure and causes muscle rigidity. An improvement has been achieved with the concept of tinnitus retraining therapy in which masking noises are maintained at a reduced level [3,4]. Some argue that remaining functional OHCs could be recruited with sound stimuli and that these sound stimuli would possibly be effective just below threshold level , as this is the level at which OHCs may reduce IHC activity. Four selected patients (see Table 1) had experienced suppression of their tinnitus with contralateral low-level narrow-band noise stimulation. In some cases, the suppression frequency was very close to the tinnitus frequency, and in others it was widely separated. The tinnitus frequency and suppression frequency did not coincide with the frequency of maximum hearing loss.
Penner could demonstrate, in subjects with tinnitus, that two-tone forward-masking patterns are decidedly different in the normal region and the tinnitus region. However, this is not the location of the maximum of IHC microphonics at the same frequency; these are more apical. This may be explained by the phenomenon of the critical bandwidth, whereby a narrow-band noise is perceived as being louder because it has a much lower threshold than does a pure tone in patients with a sensorineural hearing loss [13]. In all our patients who responded to suppression, the stimulus levels were within the normal speech range and well below a 65-dB hearing level.
This is achieved through a process of habituation by focusing on the so-called detection level of tinnitus and the so-called level between detection and reaction [3,4].
This physiological model could be the basis of tinnitus suppression therapy , which promises to become a valuable addition to current treatment options. In the field of depression, we found an overlapping activity between psychiatry and neurootology.
For this purpose, test persons were marked on the head and shoulders with ultrasound markers.
The results of our investigations of depressive patients are transferred into the spreadsheets of the Microsoft Excel program. The subjective history of the patients in this study having depressive disorders in relation to their aforementioned neurootological complaints and the duration of their vertigo attacks, visual disturbances, hearing loss, and tinnitus were systematically catalogued. Remarkable is that the subsymptom of a lifting sensation (as if riding on a flying carpet and the like) statistically occurs nearly twice as frequently in average neurootological data banks (8.2%). This means, conversely, that 7 of 10 patients have a pathologically dysregulated vestibuloocular caloric response. It points toward a labile regulation disturbance within central pathways, which easily can fall into states of blockades.
All patients had very good tolerance of the hearing aids; 28 reported that they had considerable reduction in PT intensity. Patients with mixed hearing loss and hyperacusis (subjectively increased sensitivity to sounds, uncomfortable hearing level curve ascending at high frequencies) were excluded from the study. We calculated the reduction of tinnitus intensity by subtracting the intensity score obtained after fitting from the score before fitting.
In all patients, the complaints were aggravated in silent surroundings: 22 patients compared intensity of their tinnitus to sounds at 40 dB and louder. An unpaired t -test confirmed statistical significance of relationships between improvement scores and the tinnitus intensity before fitting and between improvement scores and speech discrimination scores before fitting. The procedure is well tolerated and relatively easy to perform as outpatient procedure performed under local anesthesia (topical), general anesthesia can be avoided, most patients understand the concept of intratympanic therapy and easily accepts the proposed therapy. Regarding the THI scores, it ranged from 58 to 96, prior to initiation of therapy, 8-82 and 30 days after. Such comorbidities could not justify the improvement in hearing thresholds after the proposed therapy. None of the patients experienced side effects from this treatment, and the authors concluded that this option can be beneficial as adjuvant therapy for hearing improvement in patients with PANSS, but cost factors are the main obstacles to the use of this therapy14.
However, these symptoms improved only in Group A, showing a significant relationship between recovery of hearing thresholds and improvement of aural fullness. Clinical improvement was also reflected by a decrease in the scores of questionnaires THI and VAS. The hearing recovery was determined by comparing the hearing levels before and after treatment and tinnitus was subjectively evaluated by using a questionnaire. The short-term effect on tinnitus was assessed during and immediately after the stimulation. Furthermore, the assumption that peripheral stimulation can effectively achieve tinnitus suppression is strengthened by the common observation that sensorineurally deaf patients undergoing cochlear implantation often experience reduction or even utter suppression of their tinnitus [15-18].
We started by delivering current at the lowest pulse rate (50 Hz) and proceeded to increase the pulse rate. Furthermore, results obtained from therapies that apply specific forms of treatments, such as certain drug therapies or retraining therapy, do not necessarily allow a firm conclusion to be drawn from the host of pathological mechanisms that might be responsible. First, the sound signal is amplified by the motor (i) of the cochlear amplifier of the outer hair cells (OHCs); then the amplified signal is transformed into an electrical signal by the final mechanoelectrical (ii) transduction of the inner hair cells (IHCs). Accordingly, tinnitus associated with the electromechanical transduction of the IHCs is designated transduction tinnitus [9,15], or sensorineural tinnitus type II.
The subdivision into primary and secondary central tinnitus, therefore, concludes every conceivable, central tinnitus model. The probability that defective hearing and tinnitus are the result of the same causative mechanism is rated much higher than the probability that they have different origins [7]. If the noise has led simultaneously to a change in the otoacoustic emissions or even to a complete loss of hearing with positive recruitment, the probability of a sensorineural type I tinnitus being diagnosed is much higher.
They did not observe any particles intraoperatively in any of the 73 patients without a history of BPPV. In such cases, the characteristics vary from one examination to the other and, in some cases, the subjects present a vertical component only.
In 2006, Asprella and Libonati [68] proposed the "strategy of the minimum stimulus" to treat semicircular canalolithiasis. Patient age, gender, method of diagnosis, and onset association with trauma had no statistically significant impact. Later on, the frequency changed and evoked an unpleasant feeling on reaching higher frequencies. Additionally, the tinnitus recurred even though atrial flutter had been successfully stopped after the second ablation. Assuming a cervicogenic origin, one can speculate that muscle relaxation during an- esthesia relieved hypertension of the cervical muscles. Here, audible noises that do not mask tinnitus are an intended and integrated part of the treatment strategy. Understanding these physiological events at the receptor level should then translate into better management of tinnitus in affected patients, as we propose in tinnitus suppression therapy.
However, she did not speculate regarding the origin of this suppression, although the subjects investigated must have had an OHC loss due to noise exposure.
In other words , the perception of a pure tone, say 4 kHz, is not at a location that corresponds to the maximal amplitude of the traveling wave. Neurootologists know that many people thus afflicted, when feeling specific vertigo sensations or tinnitus, also seek the help of a neurootologist.
The images received had the appearance of a radar picture of a head and trunk floating through time and space. In comparing the test results of the weaker supraliminal caloric warm test with a stronger supraliminal perrotatory nystagmus response, an individual VESRIC can be established. There the data are analyzed according to the capabilities of modern Excel programs, using numerical statistics and graphical displays. Also, we evaluated basic mechanisms of underlying pathology, such as former traumas and cardiovascular disorders and reports about phobias.
Often, it engenders feelings of low self-esteem, guilt, and somatic symptoms, such as eating and sleep disturbances. Just as a state of stress can be responsible for the onset or exacerbation of a tinnitus episode or even of disequilibrium, tinnitus can incite or exacerbate stress. In the details of the list, we find in first position the normals (sOOOO), followed by s0002, s2222, s0022, s2000, and si001, five patterns with typical central disturbances mainly of dysregulations within the brainstem. The vestibuloocular nystagmus tests exhibited a high rate of occurrence of centrally deregulated caloric butterfly patterns and, at the same time, a rigidity with respect to the usually occurring vagal heart-regulating reflexes. Spearman's correlation was significant for the hearing loss at the tinnitus frequency and intensity of the tinnitus (Table 1).
However, it should be emphasized again that in relation to complaints of tinnitus, it has undergone a significant change, in which catastrophic change of the degree to mild (Table 1).
Given this, the authors suggested the use of cochlear implants as a possible therapy for tinnitus persisted after sudden deafness.
Longterm effects were estimated after one month by comparing pre- and post-EPS Tinnitus Handicap Inventory (THI) scores. Our study project aims to assess the effectiveness of EPS as a treatment of persistent tinnitus induced by cochlear lesions and to try to define the most effective electrostimulation type.
Eventually, each patient was asked about tinnitus or hearing loss (or both) in his or her family.
For each presented frequency of stimulation, current intensity was slowly increased to find threshold first and then the discomfort level, and we asked patients about the effect of stimulation on tinnitus.
Patient 3 reported suppression of both tinnitus components, whereas patients 4 and 8 said that only one of the components had been reduced or suppressed, the other one remaining unchanged (see Table 3). So, even if a role for masking cannot be completely ruled out, it appears that other mechanisms play a role. The signal then is transferred synaptically from the IHCs to the afferent nerve fibers as a so-called (iii) transformation before being transferred by means of the auditory nerve. Following from this, the term transformation tinnitus [4,5,14-16], or sensorineural tinnitus type III, is used to describe disorders arising during the signal transfer from the IHCs and along the afferent nerve fibers (synonyms are cochleosynaptic tinnitus; signal transfer tinnitus). Particulate matter was observed in only 8 of 26 patients at the time of the posterior semicircular canal occlusion procedure for intractable BPPV. These authors determined that the affected side of the geotropic forms is (1) the side on which the nystagmus is more intense, (2) the side on which spontaneous inversion occurs or is more evident, and (3) the side opposite the direction of the nystagmus when the patient is brought from the seated position to the supine position. Mitochondriopathy was considered because of the patient's individual and family history and the clinical neurological examination results and because tinnitus has been reported to occur in 7% of patients with mitochondriopathy [5]. However, this assumption does not explain why the effect lasted for 10 days, although the muscle-relaxant effect of anesthesia had disappeared already.
The recent description of Ultra Quiet therapy promises a further improvement with the application of sounds outside the audible spectrum [5]. Of the 12 bilateral tinnitus patients, 7 thought the sound in the right ear was worse, and 5 thought the left ear noise was worse.
By evaluating our neurootological history data bank (Neurootological Data Evaluation-Claussen [NODEC]) as regards 6 important vertigo symptoms, we found that patients presented with a frequency of 2.10 signs per patient. Therefore, we selected for our study a sample of typical patients who presented also with a diagnosis of depression, a diagnosis that had been made externally by both psychiatrists and family physicians. The stimulus procedures underlying this investigation were the standing test of Romberg [1] and the stepping test of Unterberger [2] and Fukuda [3]. By doing so, we can find out how individual vestibuloocular circuitries respond to a change of stimulus intensity.
Thus, affected patients can get into a vicious cycle: This applies also to patients suffering from vertigo or hearing loss. Pattern s2002, lying in pathological position eight in the ranking, points toward a supratentorial dysregulation in the temporal lobe. In patients with unilateral sensorineural hearing loss and tinnitus, fitting the impaired ear is sufficient.
Therefore, if the main functional defect causing tinnitus is dysfunction of the organ of Corti (pathological recordings of otoacoustic emissions, 100% speech discrimination), fitting the patient with hearing aids could be effective for PT.
We obtained an average difference of 38.6 points among patients who reported an improvement in tinnitus before and after the course of oral steroids and intratympanic. In group A, the OAE responses appeared simultaneously with the improvement in hearing levels in five patients (63%). We performed a complete audiological assessment (pure-tone audiometry, speech audiometry, and transitory evoked otoacoustic emissions) and a study of tinnitus pitch, loudness, and minimum masking level (MML) on the day of the EPS session.
Having learned from the patients the frequency causing the best tinnitus suppression, we delivered continuous stimulation at that frequency for at least 60 seconds. After 1 month, among the eight patients who had benefited from EPS, five (45.4%) said their tinnitus was still present but that its intensity was much lower than before. One of the theories about peripheral tinnitus suggests that its origin lies in an alteration of spontaneous firing by acoustic nerve fibers. The sensory functional elements, including amplification motor, transduction, and transformation, are supported by such (iv) extrasensory elements as the stria vascularis, which is amply supplied with blood and provides a source of energy. According to this classification, the remaining extrasensory, sensorineural tinnitus mechanisms are called extrasensory tinnitus [18] or sensorineural tinnitus type IV.
In contrast, the affected side of the apogeotropic forms is (1) the side on which the nystagmus is less intense, (2) the side opposite that on which spontaneous inversion occurs, though this phenomenon is not frequent, and (3) the side to which nystagmus beats when the patient is brought from the seated position to the supine position. His family history was informative for diabetes mellitus (father, sister), renal failure (brother), heart failure and tetanus (mother), short stature (mother, sister), and liver cell carcinoma (father). Other possible causes of tinnitus (see Table 1) were excluded by a perusal of the patient's history and through appropriate investigations. Additionally, a cervical cause of the tinnitus could not be excluded definitively, as no magnetic resonance imaging scan of the cervical spine had been performed. The aim of this technique is the production of long-term residual inhibition, possibly as a result of plastic changes in the brain. When we extended the list to 11 vertigo and nausea signs, we found 2.93 signs per patients. Data for this group of 134 patients were collected for this sample in a special study in which the objective was to determine how much vertigo, dizziness, hearing loss, and tinnitus occur in combination with significant objective and quantitative findings within our neurootometric tests.
The most frequent combinations of the VESRIC patterns for both ears are also given for the patients in this study in a table of trinary test results. Tinnitus had a considerable impact (5 or more points) on rest in 19 patients, on sleep in 17, and on work in 4. Both type I and type II PT exhibit a mild, gradual, progressive hearing loss, demonstrated in audiometry as a downward sloping type of loss [7], which we confirmed in the subject group of patients.
Referring to EVA, there was a change from 7 to 10 points before therapy and from 1 to 8 points after it, in relation to intensity.
It was concluded that patients with hearing improvement PANSS (Group A) tend to have OAE responses and sensations of fullness in the ear and tinnitus improved almost simultaneously with the hearing improvement.
At the end of the procedure, we asked patients whether tinnitus was still present or had abated or disappeared.
The remaining six patients (54.6%) reported that tinnitus was unchanged or had progressively returned to its former loudness.
In a number of animal studies, this abnormal activity was brought back to a spontaneous-type nerve firing by application of an electrical stimulus [24,25]. By way of the auditory nerve, the sound signal reaches the central nervous system, where perception and cognition take place. That discontinuation of tinnitus was caused by unintentional intraatrial administration of lidocaine is rather unlikely, given the particular care with which the local anesthesia was placed, the fact that the tinnitus did not disappear immediately after injection of the local anesthetic, and the longstanding therapeutic effect (10 days).
The test results can be categorized into three groups with three subdivisions within each group. Effectiveness of fitting in the affected group of patients depended on speech discrimination scores before fitting.
Eight patients had speech discrimination scores below 80% in the verbal test performed before fitting. In relation to the nuisance, there was a change from 7 to 10 points before and 0-08 points after therapy.
The improvement scores were higher in patients with more aggravated symptoms and did not depend on history of prolonged exposure to excessive noise. Tinnitus intensity decreased immediately after fitting in 28 patients; 18 did not perceive tinnitus while wearing hearing aids. The authors concluded that patients with poor hearing improvement tend to have absent OAE and ear fullness and tinnitus persisted. The beneficial effects of EPS on tinnitus might be explained by interference with tinnitus generating circuits such as the dorsal cochlear nucleus and the inferior colliculus and by modification of cortical activity. EPS is to be considered a worthwhile attempt at tinnitus suppression, and could help select candidates for the positioning of an implantable electrical stimulator that might provide longer-term beneficial effect on tinnitus.

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