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Author: admin | 16.01.2014 | Category: Tinnitus Hearing Loss

How to cite this article Olsen US, Lello E, Nagaraj VS, Reimer A, Ibertsson T, Brannstrom J.
OBJECTIVE: The aim of the present study was to examine whether perceived tinnitus severity changes over time, and if so what factors contribute to this change. DESIGN: A modified Swedish version of tinnitus severity questionnaire (MS-TSQ) was used to examine changes in tinnitus severity over a period of time. STUDY SAMPLE: The MS-TSQ questionnaire was completed by 455 subjects visiting an Ear, Nose and Throat (ENT) clinic in Sweden as part of baseline assessment (Sb). CONCLUSIONS: Results provide valuable framework for understanding the factors that affect tinnitus severity over a period of time.
Keywords: duration, hearing loss, modified swedish tinnitus severity questionnaire, psychological treatment, tinnitus severity.
Subjective tinnitus is defined as the perceived sensation of sounds by individuals in the absence of any external physical stimulus1.
Various factors can trigger the severity of tinnitus such as emotional stress, psychological factors and other physical or mental illnesses. Many theories and models have been proposed to explain the etiology of tinnitus in individuals with hearing loss and in normal hearing6-8. Previous research has shown that psychoacoustic measurements of tinnitus do not always correlate with how tinnitus affects a person17. There are few studies on how tinnitus severity changes over time and it has been observed that many subjects report to health clinics with questions about the course of tinnitus severity. The subjects sample consisted of a consecutive series of 455 adult subjects who were self-referred to an ENT clinic in Lund, Sweden. The Modified Swedish version of Tinnitus Severity Questionnaire (MS-TSQ) developed by Axelsson and Schenkmanis24 (see Appendix 1 for English version of the questionnaire) was used in the present study.
Pearson's correlation coefficient (rho) was used to examine associations between age, improvement, and PTA's.
A one-way ANOVA test was administered to assess significant differences, if any, in age, PTAs (low and high) and improvement in the MS-TSQ scores between the three subject groups.
Results indicated that subjects with NH scored the least and subjects with USNHL scored the highest on the baseline MS-TSQ assessment. Independent-Sample t-test was used to test if there were significant gender and psychological treatment differences in age, PTAs, MS-TSQ baseline, follow-up and difference score.
The purpose of this study was to explore the association between self-reported tinnitus severity and duration between baseline and follow-up assessment, degree of hearing loss, subject groups, age, gender and psychological treatment. The present study assessed tinnitus severity performance obtained through questionnaires and calculated baseline scores (Sb), follow-up scores (Sf) and difference scores (Sd).
The results of the preset study are in agreement with some of the earlier studies, which conclude that the severity of the tinnitus decreases over time. Results related to hearing thresholds and tinnitus scores indicated a significant difference in PTAlow between USNHL and NIHL in the right ear.
Various studies have been carried out to investigate the effect of psychological treatment on the severity of tinnitus20,21. The present study investigated whether perceived tinnitus severity changes over time, and if so what factors contribute to this change. Paper submitted to the ITJ-SGP (Publishing Management System) on June 10, 2014; and accepted on September 22, 2014. INTRODUCTION: Tinnitus Handicap Inventory (THI) was developed in English to quantify the handicap caused due to tinnitus. OBJECTIVES: India being a multilingual country needs to develop and standardize THI in Indian languages. MATERIALS AND METHODS: Questions from English version of THI were translated and modified by two professionals who have a degree of MA Kannada.
RESULTS: Analysis revealed 14% of the patients fall under the category of Slight, 38% under Mild, 26% under Moderate, 16% under Severe and 6% under Catastrophic group. CONCLUSION: Scores of Cronbach-alpha test shows that Kannada version of THI is a standard and reliable tool for measuring the handicap caused by tinnitus and can successfully classify individuals on a severity basis. Recent interest has surfaced in symptom - specific handicap outcome measures for many audiological and otological diseases4.
A symptom specific assessment of many otological disorders will aid in understanding the severity of the symptom and effects of this on routine life.
The English version of THI which is shown in Appendix 1 was the only tool available for quantifying the handicap caused by tinnitus.
The beta version of THI developed by Newman and Jacobson in 1996 consists of 25 questions under the 3 sub scales of emotional, functional and catastrophic.
Individuals who were suffering from tinnitus with or without any otological diseases were selected for the study.
Tinnitus questionnaire was administered on the participants using a structured interview by the clinician to have a record of the demographic details and to cognize the type, nature, and the lateralization of the tinnitus, factors that affect tinnitus, presence of hearing loss, and the concern about the tinnitus. Following the administration of the tinnitus questionnaire, the participants were instructed regarding the self - assessing Kannada version of THI, its importance and the system to grade it. Among all the participants, 94% of the participants had a minimum qualification of SSLC and a maximum qualification of a degree and could fill up the Kannada version of THI without the help of the clinician. The results of the THI and the self assessing questionnaire were tabulated and are graphically represented below in Graph 1. After the complete analysis of the obtained data, the percentages of the patients coming under various severities were found out. The purpose of this study was to develop a handicap inventory in native language (Kannada), to obtain a standard measurement instrument for evaluating tinnitus in patients to apprehend the effects caused due to tinnitus. From the study, we could observe that the perception of tinnitus handicap differs drastically between subjects as demonstrated by high values of standard deviations, which may be due to effective coping starategies5. Related to the emotional aspects, the Kannada THI allows assessing the relation between tinnitus and manifestation of stress, depression, anxiety & frustration. The result of the current study shows good reliability and internal consistency as indicated by the Cronbach alpha test. Hence this inventory can serve as an effective tool to successfully classify the individuals into different grades according to the symptoms.
Since the main focus of this study was to develop and standardize the THI into Kannada language, and to be administered on all Kannada patients who complain of tinnitus. The main aim of this study was to develop and standardize the Tinnitus Handicap Inventory in Kannada; hence it can be administered on Kannada patients without difficulty. Paper submitted to the ITJ-SGP (Publishing Management System) on December 17, 2012; and accepted on January 17, 2013.
Otosclerosis is a bony dyscrasia characterized by histopathological findings of osteoclast production.
The normal otic capsule is preserved with very little bone turnover and is devoid of osteoclasts as a result of production of a cytokine osteoprotegerin (OPG) by the membranous inner ear. Research in animals genetically unable to produce OPG revealed hearing loss and histopathology of the temporal bones consistent with that seen with otosclerosis [8]. This man presented in 1988 at age 47 with a history of progressive hearing loss since age 15. The patient was placed on alendronate, and the discrimination in the left ear rose to 60% (Fig. The patient was placed on risedronate, 30 mg twice weekly, along with supplemental calcium and vitamin D and sodium monofluorophosphate and calcium. Otosclerosis is a bony dyscrasia of the otic capsule characterized in its active phase by the presence of osteoclasts. RANK ligand is a TNF-α cytokine associated with activation of macrophages to become osteoclasts by attaching at the RANK receptor of the macrophage. The bisphosphonate effect is presumably due to decrease of the by-products of bone breakdown that are able to diffuse from the otic capsule through the same channels that allow OPG to gain access from the perilymph. Osteoclastogenesis (osteoclast formation) has an inflammatory trigger and produces inflammatory byproducts of the breakdown of bone.
The bisphosphonate class of drugs targets the osteoclasts by reducing osteoclast production and accelerating osteoclast apoptosis.
Improved auditory function is evidenced in the two patients described in this article, who had improved bone lines or speech discrimination or both. Perilymphatic Fistula (PLF) remains a controversial topic and its management is challenging. Keywords: dizziness, hearing loss, sensorineural, vertigo, vestibular diseases, vestibular function tests.
Evaluation of a patient with suspected PLF begins with a thorough history including a detailed history regarding the mechanism of trauma.
A complete audiometric evaluation is then performed, as is the suprathreshold stimulus stapedial testing and fistula testing. ENG has not shown to be helpful in diagnosing PLF but it was performed in all patients with suspected PLF to evaluate for the presence of vestibular function. The Lasix dehydration test, as previously described in the literature, was administered to patients with suspected PLF5. During the Lasix dehydration test, patients may show improvement, worsening, or have no change in their audiometric and physical examination findings.
Patients with vestibular disorders present with a unique challenge, as they are difficult to diagnose and treat. While spontaneous PLF and congenital PLF have been described, post traumatic, post-stapedectomy and barotrauma are well-documented causes of PLF, being described in the literature. Chronic or persistent combinations of disequilibrium, headache, adult-onset motion sickness, neurocognitive disruption exacerbated by exertion or physical activity, and hearing loss have all been described as symptoms of PLF. Although multiple tests are available to assist a physician in diagnosing PLF, controversy exists in the utility of these tests.
Most recently, magnetic resonance imaging of inner ear after intratympanic injection of gadolinium has been described for evaluation of Meniere's disease19.
If medical therapy is contraindicated or not tolerated by the patient, surgical intervention is offered. Paper submitted to the RBCMS-SGP (Publishing Management System) on June 19, 2012; and accepted on August 16, 2012. The take home message and goal for the attendee of each Miniseminar since 2010 has been the presentation and clinical translation of advances in neuroscience, sensory physiology, and auditory science to provide an objectivity and an increase both in the accuracy for the diagnosis of all clinical types of subjective tinnitus and efficacy of treatment for the ultimate benefit of the tinnitus patient. In 2014 the take home message and goal for the attendee of each Miniseminar since 2010 was reaffirmed by introduction to the attendees of the availability of application for all tinnitus patients of the technology of objective electrophysiology quantitative electroencephalography (QEEG) and low frequency resolution electromagnetic tomography analysis (LORETA). The clinical application of the QEEG LORETA data is not to diagnose tinnitus but to 1) provide an increase in both the accuracy for the tinnitus diagnosis by its integration and correlation with the clinical history and physical examination and 2) to objectively monitor the efficacy of tinnitus treatment modalities. Attempts for tinnitus relief with instrumentation and future application of surgical vagus nerve stimulation, pharmacology AM-101, and the middle ear implant for moderate severe sensorineural hearing loss were presented.
In general, the presentations focused on biophysiological processes of neuroplasticity (NPL), neuromodulation (NM) and Neuroprotection (NPT), electrophysiological functional brain imaging QEEG and LORETA, a tinnitus modality of therapy i.e. To present the biophysiological processes of NPL NM NPT as part of an evolving neurobiology for all clinical types of tinnitus.To provide clinical evidence of NPL NM NPT in a cochlear implant soft failure tinnitus patient with functional brain imaging nuclear medicine PET brain and quantitative electroencephalography (QEEG). Brain plasticity has been defined by "the father of sensory substitution and brain plasticity" as the adaptive capacities of the central nervous system - its ability to modify its own structural organization and functioning"1. Neuroplasticity (NPL) is a reorganization in neural circuitries in brain structure, and or function in response to constant, single or repetitive, internal and or external stimulation. Neuromodulation (NM) in neuroscience is a modification of neural activity within neural circuits at a synaptic level in brain. Neuroprotection: refers to processes that protect neuronal function from injury or that improve such function after injury. Pharmacological agents that are considered to be neuroprotective have been identified and include calcium channel blockers, free radical scavengers, corticosteroids, antagonists of glutamate at N-methyl-D-aspartate (NMDA) and non-NMDA receptors, the proteolytic enzyme calpain and various thrombolytic agents.
In general, neuroplasticity (NPL), neuromodulation (NM) and neuroprotection (NPT) are biophysiological processes linked together to maintain a homeostasis of structure and function: a) structural at molecular genetics, synaptic, cellular, tissue, organ, and system levels, and b) functional in the central nervous system as clinically manifest by sensory, behavior, learning, memory and motor activities. The biophysiological processes of NPL, NM, NPT are considered in our experience to provide a "bridge for continuity of function" between both a sensation and its transformation into one of behavior and affective and somatomotor response. The biophysiological process(es) of NPL NM and NM were demonstrated with Pet brain and QEEG in a tinnitus patient ear right (rt) in who an initial cochlear implant (CI#1) was inserted with no report of tinnitus relief ear rt, and a mild hearing improvement ear rt. The clinical significance functional brain imaging is demonstrated by correlation of results of functional brain imaging Pet brain and QEEG (Figure 1, 2, and 3). The degree of success of modalities of tinnitus treatment reflect the attempt of the biophysiological processes of NPL NM NPT to establish and maintain a homeostasis of function between excitation and inhibition at brain cortex clinically manifest by the patient report of control of the sensory and affect behavioral components of the tinnitus. The data both metabolic with PET and electrophysiologic with QEEG in the case of the cochlear implant soft failure with ES when correlated with the subjective report of the patient provides: 1) an objectivity for a reported subjective report of tinnitus relief.
The QEEG data to be considered to reflect not tinnitus but multiple brain functions in the presence of the tinnitus signal.
The "dialectics" of the brain were presented as brain wave activities of different frequencies, recorded from external scalp placed electrodes.
NFB, also known as EEG biofeedback, is a computerized learning strategy that enables people voluntarily to alter their own brain activity1. The presentation, EEG based NFB, was introduced by a brief review of brain wave activities. Tinnitus patients show significant differences in the analysis of the contralateral temporal cortex (the louder the tinnitus is perceived, the higher the gamma power)3.
Feedback to the patient establishes a desired level of brain activity resulting in tinnitus relief.
Operant conditioning of EEG characteristics: Training to decrease slow activity and to increase fast, desynchronized EEG activity. Hypothesis: Significant reductions of trained delta and gamma frequency range in combination with an increase in alpha frequency power in the auditory cortex results in improvement in subjective tinnitus measurements. Does noise trauma result in a primarily neuronal change which clinically is expressed as tinnitus or is the noise trauma producing both neuronal change and tinnitus? Translation of the basic findings of tinnitus localization were applied for clinical research with transcranial magnetic stimulation (TMS) in an attempt to provide tinnitus relief to the patient. It was questioned what the interaction was between different brain regions when a magnet is placed in this location?6.
This approach of TMS stimulation at multiple ROIs was based upon the hypothesis that brain networks are involved in phantom perception which includes tinnitus. The results of triple TMS stimulation was reported with electrode placement on the right frontal, right temporal and parietal area, and left temporoparietal area9, comparing single site with multi-site rTMS for triggering of chronic tinnitus. Pharmacotherapy recommendations attempting tinnitus were recommended to differentiate between acute and chronic tinnitus.
The chief limitation of drug development for tinnitus is an incomplete understanding of the pathophysio- logical mechanisms involved. Antidepressants are frequently proposed for management of chronic tinnitus In particular, tricyclic antidepressants have been recommended mostly because of the beneficial effects on chronic pain syndromes. A Cochrane meta-analysis of the use of anticonvulsants for tinnitus treatment concluded that studies so far show small effects of doubtful clinical significance and no evidence for large positive effect of anticonvulsants in treatment of tinnitus. A slide was presented grouping different drugs by the underlying mechanism of action and trying to correlate them with the underlying tinnitus mechanism for its production. A network pharmacology side-effect analysis searched for genes that are involved in tinnitus generation. Baclofen, a GABA-B antagonist with muscle relaxant effects also reduces tone exposure-induced hyperexcitability in the inferior colliculus of rats.
The challenge for future tinnitus research is to consider differentiation of pathophysiological distinct subtypes of tinnitus.
Future drug development was recommended to focus on identification of specific clinical and chemical entities that interact with discrete molecular targets. Tinnitus is considered as a complex network pathology similar to other complex CNS pathologies for which a combination of different drugs will be more effective than a single drug alone.
Drug development should be directed to the areas identified with fMRI and neuroimaging techniques which have identified an under- lying matrix for tinnitus as well as non-auditory responses of brain function as reflected in the areas of the somatosensory cortex or in auditory cortex, perception network, salience network, distress network, and memory areas. The presentation focused on instrumentation to be considered for tinnitus relief: 1) Hearing aids for tinnitus. Wearable sound therapy devices for tinnitus include small portable computers, cellphones and watches, which can produce a wide variety of sounds. Comparison of the effectiveness of TRT and "mixing point masking" compared to "total masking therapy" compared to "counseling alone" was presented7.
Sound therapy stimulus options include broadband noise, noise-modifying spectrum, noise-modifying envelope, combined tones and modulated tones, music which is processed and the sounds of the music are spectrally adjusted to the audiogram -i.e.
Tailor-made notched music reduces tinnitus loudness and tinnitus-related auditory cortex activity (Okamoto, H. To date, tinnitus treatment strategies, for example TRT, are symptom-management approaches. Tyler et al.10 investigated patient preferences for multiple tinnitus treatment options from wearable to implantable devices.
In conclusion, a wide variety of sound therapies were presented in an attempt to provide tinnitus relief. Vagus nerve stimulation (VNS) releases the neurotransmitters, acetylcholine and norepinephrine from the locus coeruleus and the Nucleus basalis. Blast-induced tinnitus and hearing loss was demonstrated in rats with diffusion tensor imaging (DTI). The results of a clinical trial on 10 patients in Belgium which were presented at the Tinnitus Research Initiative Meeting in June 2012 were presented again. At long-term follow-up return, the patient also had worsened depression (two-day stimulation, four days no stimulation, then suicide attempt) no further VNS was applied. An ongoing Blinded Randomized Pilot NIH Study Assessing Vagus Nerve Stimulation (VNS) paired with Tones for Tinnitus vs. It is hypothesized that: 1) activation of NMDA receptors and glutamate excitotoxicity occur with noise, trauma, barotrauma, surgery, and otitis media with production of proinflammatory cytokines and 2) tinnitus is the result of NMDR mediated aberrant excitation of the auditory nerve4. The Esteem system implant is a total middle ear implant for a moderate sensorineural hearing loss for patients 18 years and older with a stable moderate severe sensorineural hearing loss and good speech discrimination6.
Limited data with Esteem was presented of 30 patients of 57 (54.4%) who reported a history of tinnitus at baseline. Through the 10-month post-implant follow-up, there were 8 reports of tinnitus as an Adverse Device Effect (ADE) - of these 5 had resolved by the 10-month follow-up and 3 were ongoing. The attendees to the 5th AAO HNS International Tinnitus Miniseminar 2014 were provided with information of the present, ongoing and future state of the art basic science and clinical medical audiological advances for understanding tinnitus theory, an evolving neurobiology for tinnitus, and its application for diagnosis and treatment for the benefit of the tinnitus patient. University of Illinois speech and hearing science professor Fatima Husain and her colleagues found that tinnitus, a condition in which a person hears a ringing sound despite the lack of an actual sound, is associated with emotional processing in a different part of the brain than in those without the condition. Tinnitus afflicts 50 million people in the United States, according to the American Tinnitus Association, and causes those with the condition to hear noises that aren't really there.
University of Illinois speech and hearing science professor Fatima Husain, who led the study, said previous studies showed that tinnitus is associated with increased stress, anxiety, irritability and depression, all of which are affiliated with the brain's emotional processing systems. She decided to use functional magnetic resonance imaging (fMRI) brain scans to better understand how tinnitus affects the brain's ability to process emotions.
The tinnitus and normal-hearing groups responded more quickly to emotion-inducing sounds than to neutral sounds, while patients with hearing loss had a similar response time to each category of sound.
Activity in the amygdala, a brain region associated with emotional processing, was lower in the tinnitus and hearing-loss patients than in people with normal hearing. Because of the sheer number of people who suffer from tinnitus in the United States, a group that includes many combat veterans, Husain hopes her group's future research will be able to increase tinnitus patients' quality of life.
People with 'neurotic' tendencies are more likely to be troubled by their tinnitus, a new study involving researchers at The University of Nottingham, has found. A research project, led by the University of Liverpool and Aintree University Hospital, is giving new hope to patients living with tinnitus.
When you take acetaminophen to reduce your pain, you may also be decreasing your empathy for both the physical and social aches that other people experience, a new study suggests.
Proper communication between the left and right sides of the brain is critical for the development of advanced language skills, according to new research by UC San Francisco scientists. Choosing what shirt to buy, what to order for lunch or whether to go with the hearty red wine or the lighter white all involve assigning values to the options. Intuition is all one needs to understand that stress in early childhood can create lifelong psychological troubles, but scientists have only begun to explain how those emerge in the brain. Factors affecting severity of tinnitus - a follow-up study of tinnitus subjects at an Ear Nose Throat clinic in Sweden. The same questionnaire was completed during follow-up assessment (Sf) by 174 of these subjects to examine changes in tinnitus severity, if any. The sounds associated with tinnitus have been described as ringing, hissing, humming, whistling, etc2.
It has been shown that many factors might affect the severity of tinnitus such as hearing loss, depression, anxiety and insomnia4.
A variety of assessment techniques have been designed that reports subjects' tinnitus severity through questionnaires and interviews18,19. These techniques range from providing psychological treatments20,21 to wearing tinnitus maskers6,22 for subjects with tinnitus. For the baseline assessment, subjects were selected from a consecutive sample of 455 adult subjects that visited the clinic between the years 2000 and 2008.
The questionnaire covers topics such as quality of life, concentration and effect on sleep quality. Descriptive data including mean, standard deviation (SD) and significance levels (p) are presented in Table 3. There was a significant difference in PTAhigh for right and left ears between genders, indicating lower hearing thresholds for females than males. Previous studies have indicated that tinnitus patients experience increased tolerance over time20,28,29. Previous studies have reported no significant differences between subjects with high degree tinnitus and those with mild or moderate annoyance in terms of age, gender or follow-up duration30. Furthermore, it has been shown that tinnitus annoyance may increase with increasing hearing loss. In the present study, we asked our subjects if they had received treatment from a psychologist. A modified Swedish version of the tinnitus severity questionnaire was administered to assess changes of tinnitus severity.
Translated inventory was given to 50 native Kannada speakers for the familiarity check & the most familiar sentences were included in the study. According to the data obtained from the National Center for Health Statistics, tinnitus is more commonly seen in males than females and increases in prevalence with advancing age. There are two important aspects of symptom - specific evaluation that is generally done by a valid and reliable inventory5.
A Tinnitus Handicap Inventory (THI) was developed in order to measure the handicap caused by tinnitus. India being a multilingual country with a multicultural background, there is no such inventory available in any of the Indian languages other than in Tamil. For the present study, the English version of THI was translated to Kannada using the standard Translation-back-translation method (Bardley, 1994) by two professors who have a degree of MA in Kannada.
Participants were interviewed briefly regarding tinnitus and those who complained tinnitus for more than 3 months were included for the further procedures, so that, they can quantify accurately the physical, emotional and catastrophic impacts of tinnitus on their daily acvtivities. Thereafter based on the subject's grading for all the questions, the total scores were calculated.
Rest percentages of participants were from a lower socio-economic status and could fill up the questionnaire only with the help of the clinician due to their inability to read and understand Kannada.
Cronbach alpha test was administered to check for the internal consistency and reliability of the Kannada version of the THI and also an Item-Total Correlation was also carried out.
Thus, according to the Cronbach alpha score, the Kannada version of THI has got a good internal consistency and reliability to administer on the tinnitus patients in the Kannada population. With the administration of Kannada THI it was found that, all the subjects could quantify the severity of tinnitus from slight degree to catastrophic degree, and thus fulfilled the aim of the study. Tinnitus assessment not only involves to match the tinnitus, ascertain the intensity of the tinnitus and to find out the intensity of wide band noise that can mask the tinnitus, but also involve administration of various inventories like THI to rate and assess the severity of tinnitus in order to help the clinician to counsel the patient as well as to know the level at which the management options should begin8. With respect to the functional aspect, the Kannada THI allows to identify the relationship between tinnitus and activities involving concentration, hearing acuity, attention & reading. This inventory could easily be understood to all the laymen and 94% of patients could fill the inventory without any help from the clinician. Following all the analysis and standardization, the Kannada version of THI came out successfully for the evaluation of tinnitus and found to be reliable. The Kannada version will help the patients with tinnitus to comprehend the severity and intensity of their problem and also considered as a reliable instrument for the verification of the impairment in the quality of life due to tinnitus. Department of Speech Language Pathology - All India Institute of Speech & Hearing - Mysore - India. In its active phase, it is characterized by histopathological findings of osteoclast production. Cartoon of otosclerotic bone with osteoprotegerin (OPG) blocking the receptor-activator nuclear kappa receptor.
OPG attaches at the receptoractivator nuclear kappa (RANK) receptor of the macrophage to prevent its conversion to an osteoclast [7]. The active phase of otosclerosis is characterized by osteoclast activation as a result of inflammation [9-14]. One patient underwent a successful operation but his hearing later deteriorated and, in the second patient, the procedure was not successful. Experimental animals that are genetically bred to produce no OPG are shown to develop hearing loss by electrodiagnostic testing and histopathological evidence similar to human otosclerosis [8]. 10) are a class of drugs, the first of which was discovered by researchers looking for a new detergent. There are channels connecting the otic capsule bone with the perilymphatic fluid space of the inner ear through which OPG diffuses to the otic capsular bone and through which inflammatory by-products from the breakdown of bone can enter the perilymph. Reducing osteoclast activity results in less diffusion of the by-products of osteoclast activity to effect hair cell function. Bisphosphonates should be considered as a treatment to salvage sensorineural hearing loss occurring after stapedectomy surgery or in association with conductive hearing loss. Suprathreshold stimulus stapedial testing was performed with stimulation being presented to the contralateral ear at 0.5k, 1k, and 2k Hz at 110 dB. However, due to various factors, these patients were unable to tolerate Lasix and opted for surgical treatment. In patients with these symptoms, findings of positive Romberg, ataxia and positional nystagmus should raise the suspicion of PLF.


The use of fistula test in addition to the classic physical exam findings in identifying patients with PLF has been well documented12.
If a patient has a history more suggestive of PLF, an increased signal on MRI, indicating hydrops secondary to PLF should be considered because although Endolymphatic Hydrops is a pathologic correlate of Meniere's disease, it has also been observed in PLF. Since endolymphatic hydrops is also present in PLF as described in the literature, various inner ear dehydration tests have been used in PLF4-6.
We encourage our colleagues to include PLF in their differential diagnosis and to consider our diagnostic approach and testing in their evaluation of these patients. PLF should be considered as part of the differential diagnosis in patients with complaints of dizziness, imbalance, or hearing loss.
Black FO, Pesznecker SC, Norton T, Fowler L, Lilly DJ, Shupert C, Hemenway WG, Peterka RJ, Jacobson ES. Committee on hearing and equilibrium guidelines for the diagnosis and evaluation of therapy in Meniere's disease. The data, reflective of multiple brain functions in the presence of the tinnitus signal, was demonstrated. Functional brain Imaging-Pet brain and quantitative electroencephalogra phy (QEEG) data when correlated with the clinical report of the patient for an efficacy of a particular modality of treatment, provides an objective measure in terms of metabolism and brain function for a subjective response to a particular modality of tinnitus treatment.To propose development of an objective measure for tinnitus treatment efficacy based on a correlation of the results of electrophysiology functional brain imaging with the clinical report of a patient. It is considered to be a complex biology of physiological process(es) which exert a positive or negative influence on an existing neural signal input or output, but does not eliminate the existing neural signal. It is hypothesized that common etiological agents that cause injury to the CNS have similar effects on the inner ear. It is hypothesized that when the balance between excitatory-inhibitory action is broken in sensory systems, predominantly due to neuromodulatory activity of reduced induced inhibition, excitation predominates, sensory circuits become plastic, and adaptation is established at synaptic levels reflective of environmental inputs.
The cognitive brain function of "memory" is the predominant brain function that is hypothesized to bind the two together9. Functional brain Imaging-Pet brain- comparison CI#1 OFF baseline and ON: Demonstration Neuroplasticity.
The QEEG in 2013 was recommended to be included into the tinnitus evaluation of all tinnitus patients with the diagnosis of subjective idiopathic tinnitus of the severe disabling type. 2) The role of NPL NM NPT in an evolving neurobiology for a predominant central type severe disabling tinnitus.
The clinical application of the data is not to diagnose tinnitus but to provide an increase in both the accuracy for the tinnitus diagnosis by its integration and correlation with the clinical history and physical examination and to objectively monitor the efficacy of tinnitus treatment modalities. Neuroplasticity,(NPL), neuromodulation (NM) and neuroprotection (NPT) are biophysiological processes which maintain a homeostasis of function in the nervous system, hypothesized to be based on maintenance of a balance be tween inhibition and excitation; a reduction in inhibition resulting in an interference in neural function. The Qeeg in 2014 is a tool which demonstrates electrophysiologic data of brain wave activity i.e.
The clinical application of the QEEG data is not to diagnose tinnitus but by its integration and correlation with the clinical history and physical examination, to 1) provide an increase in both the accuracy for the tinnitus diagnosis; and 2) to objectively monitor the efficacy of tinnitus treatment modalities.
Clinical correlation of the QEEG data is recommended to determine its medical significance, individual for each tinnitus patient.
The sLORETA analysis provides source localization in brain, in the narrow band frequency range, which is the mathematically most probable source of the electrical potential (EEG) recorded from the surface scalp electrode11.
Tinnitus patients demonstrate less Alpha and more Delta power in temporal cortex areas as compared to normal controls2.
Tinnitus patients demonstrated after NFB-power for delta and theta bands was reduced; however, an increase of power was noted for the alpha bands1. Subjects learn how to influence brain activity by presentation to the patient of a visible activity and subsequent changes in activity.
The desired activity changes followed by positive feedback or rewards result in the learning of self-regulation by the tinnitus patient. Unclear to what extent the recorded activity reflects the activity of the auditory cortex -OR-nonspecific effects e.g. The sLORETA provides a reconstruction technique in the narrow band frequency which is mathematically most probable to be the source localization as an estimate inside the brain of the electrical potential recorded from surface electrode at the scalp.
The regions included the cochlea, cochlea nucleus, caudal midbrain, inferior colliculus, medial geniculate body, and primary auditory cortex. An initial method for focal noninvasive and painless stimulation of brain activity in these areas was demonstrated. Activated ROIs included the amygdala, hippocampus, parahippocampus, posterior and anterior cingulate cortex and precuneus.
The patients were of age 18-70, chronic tinnitus greater than six months' duration and a Tinnitus Handicap Inventory score greater than 38 were recruited for this study. A variety of drugs approved for other indications are used for the treatment of tinnitus in clinical practice. In the interpretation of the effective antidepressants for tinnitus, it must be considered that the scales used for tinnitus measurement correlate highly with depression scales11. A network of 1,313 drug-target pairs, based on 275 compounds that elicit tinnitus as side effect and their targets reported in databases were analyzed. L-baclofen up to 60 mg per day has been reported with improvement of tinnitus, however, frequent side effects. Such a combination of treatment could consist of different drugs even if one in isolation has shown only some limited benefit for tinnitus suppression.
Alterations in auditory and in non-auditory brain areas are involved in tinnitus pathophysiology. Neither TMS nor medication alone have a role for routine treatment but provide important information for better understanding of the pathophysiology of tinnitus. In other words, tinnitus is best influenced by modulation of auditory and non-auditory brain areas with medication. A variety of drugs with different therapeutic uses have been used off-label with some effect in a limited subset of patients.
Support for this opinion was supported by a study in which the effectiveness of hearing aids was established in mitigating the effects of tinnitus in 1314 patients. Differences among sound therapies are reflected in the sound quality and the level at which the therapy is provided. The patient was recommended to use the device not as a masker, but to use the stimulus from the device to achieve a "mixing point". SPA tones, Zen tones and notched noise or music around the pitch match, which is the Neuromonics stimulus. Spectrally, "notched" music and reduced cortical activity corresponding to the notch center frequency, possibly occur due to lateral inhibition.
Any and all sound therapy should be combined with counseling, for example tinnitus activities treatments. Hearing loss or noise exposure results in a pathological alteration in plasticity at brain cortex resulting in tinnitus. The MEG is a technique to localize sources of electrical activity within the human brain by noninvasively measuring the magnetic fields arising from such activity. A Vagus Nerve Stimulator (VNS) is implanted in the OR during a 60 minute outpatient procedure. The patient listens to tones while receiving stimulation (2.5 hour session, 5 days a week, 4 weeks) - initially in clinic, then at home.
The patient, sitting in a chair with clinical headphones with the implantable VNS device in the neck area, is connected by a wireless transmission to the laptop loaded with therapy software. The assessment of results utilized the tinnitus handicap inventory (THI), tinnitus handicap questionnaire (THQ) and Minimal masking level (MML). Tinnitus diagnosis - subjective tinnitus due to hearing loss with some tonal quality of the tinnitus. Hearing loss greater than 80 dB HL, Meniere's disease, ear tumors, evidence of active middle ear di- sease, i.e. The results of AM-101 randomized control trials have reported the drug to be well tolerated, reduction in tinnitus loudness, masking level improvement, and tinnitus attenuation5. These phantom sounds are not speech, but rather whooshing noises, train whistles, cricket noises or whines.
These scans show the areas of the brain that are active in response to stimulation, based upon blood flow to those areas.
Each person was put in an fMRI machine and listened to a standardized set of 30 pleasant, 30 unpleasant and 30 emotionally neutral sounds (for example, a baby laughing, a woman screaming and a water bottle opening).
Over all, the tinnitus group's reaction times were slower than the reaction times of those with normal hearing. Tinnitus patients also showed more activity than normal-hearing people in two other brain regions associated with emotion, the parahippocampus and the insula. The difference in scores obtained from the two assessments was calculated and was termed as difference scores (Sd). A previous study by Stouffer et al.5 analyzed the factors responsible for the reduction or enhancement of tinnitus severity on 528 subjects with tinnitus.
Most neurophysiologic evidence for tinnitus points to changes in the auditory system in individuals having hearing loss following noise exposure9,10 and over-representation in the cortical tonotopic organization at frequencies having normal hearing thresholds11. These assessment techniques quantify the impact of tinnitus on subjects' everyday life based on baseline and follow-up assessment scores. Forti et al.23 investigated the effect of tinnitus retraining therapy on 45 subjects having idiopathic tinnitus for at least 6 months. A modified Swedish version of the Tinnitus Severity Questionnaire (MS-TSQ) developed by Axelsson and Schenkmanis24 was used to measure the baseline and follow-up scores for assessment of tinnitus severity in the present study.
During this initial visit a medical and audiological examination was performed on all subjects to identify any underlying ear diseases. The MS-TSQ which was used in this study for both baseline and follow up assessment also contains 10 items.
A one-way analysis of variance (ANOVA) was used to examine any significant differences between the groups with different diagnoses regarding age, PTAs, Sb, Sf, and Sd scores. No significant differences were observed among the three groups in the follow-up MS-TSQ score.
The effect of psychological intervention on the reduction of tinnitus severity has been shown to be positive.
It has been shown that females seem to be at a greater risk for reporting significant tinnitus than males28.
In terms of gender differences, it was found that females were less annoyed by tinnitus than males30. Changes in spontaneous neural activity in the dorsal cochlear nucleus following exposure to intense sound: relation to threshold shift. Elevated fusiform cell activity in the dorsal cochlear nucleus of chinchillas with psychophysical evidence of tinnitus. Changes in spontaneous neural activity immediately after an acoustic trauma: implications for neural correlates of tinnitus. The relationship between tinnitus pitch and the edge frequency of the audiogram in individuals with hearing impairment and tonal tinnitus. Prevalence and 5-year incidence of tinnitus among older adults: the epidemiology of hearing loss study. When tinnitus loudness and annoyance are discrepant: audiological characteristics and psychological profile.
Tinnitus questionnaire was then administered, followed by the Kannada version of THI on 140 patients and total scores were obtained. The diagnosis and rational management of tinnitus is one of the legacies of the past millennium, which the medical profession has carried unsolved to this century2.
Initially, the self-assessment tool assesses the severity of symptoms and provides objective data about the severity of the symptomand later, the evaluation allows investigators to accurately assess and compare the pre-treatment and post-treatment periods.
THI is a method of quantifying the impact that tinnitus has on an individual's daily living conditions. The translated form of the inventory was given to 50 native Kannada speakers who were exposed to Kannada language or had first language as Kannada, who were able to read and write Kannada, for the content validation.
Individuals with any significant neurological history, history of psychiatric or psychological counseling with regard to their tinnitus were excluded from the study. Under the functional subscale, 30% of responses were for YES and 50% of responses were for NO and 20% of responses were for SOMETIMES. 38% of patients fall under the category of mild, 26% of patients fall under the category of Moderate, and 16% fall under the category of severe and 6% fall under the category of catastrophic group which is represented in Graph 2. Also a comparative study was carried out between the English version of THI and the Kannada version of THI. The quality and intensity of tinnitus can affect daily routine of an individual which have an effect on the individual's psychological functioning7.
The catastrophic aspect of Kannada THI allows identification of negative sensations produced by the tinnitus in the patient's lives such as intolerance, loss of control of the sensation. The English version of THI is currently used by most of the audiologists and otorhinolaryngologist to find out the severity of the problem in different patient population and found to be difficult to administer on native speakers of Karnataka.
The recruited subjects for this research presented changes in their Quality of Life (QL) as regards to the functional, emotional and catastrophic aspects due to tinnitus.
The functional neuroanatomy of tinnitus: evidence for limbic system links and neural plasticity.
Validity of the Italian adaptation of the Tinnitus Handicap Inventory; focus on quality of life and psychological distress in tinnitus-sufferers. Brazilian Portuguese Language version of the "Tinnitus Handicap Inventory": validity and reproducibility.
Basic science research in the experimental animal otic capsule has given insight into the process of evolution of otosclerosis.
The new investigative field of osteoclastogenesis has evolved, explaining the pathogenesis of otosclerosis [3-6]. Tumor necrosis factor alpha (TNF-α), a cytokine by-product of osteoclast activity, has been identified in biopsy material from stapedectomy [15]. The right ear was operated on at age 20 and "worked like a charm." In the last 7 to 8 years, this patient's hearing has been deteriorating. With time, the hearing deteriorated further in the right ear, and deterioration began to some degree in the left ear as well. A year later, etidronate (another bisphosphonate) was added alternately with the risedronate. This normal otic capsule is achieved by a membranous labyrinth that produces OPG, which diffuses through unobstructed channels that have been identified as connecting the perilymph space into the otic capsule [7].
Also possible is that an inflammatory insult to the membranous labyrinth could result in completely or partially reduced production of OPG, also leading to unopposed stimulation of osteoclast production.
Etidronate was discovered to have an effect on osteoclasts; it is termed antiresorptive in the sense that osteoclasts are targeted. There may be other cytokines produced by osteoclastogenesis that are toxic to the inner ear, presumably the hair cells. Estimation of volume referent bone turnover in the otic capsule after sequential point labeling.
Ultrastructural characterization of otospongiotic lesions in reembedded celloidin sections. Osteoprotegerin knockout mice demonstrate abnormal remodeling of the otic capsule and progressive hearing loss. Expression of measles virus receptors in otosclerotic, non-otosclerotic and in normal stapes footplates. Role of tumor necrosis factor-alpha in sensorineural hearing loss after bacterial meningitis. Detection of osteoprotegerin and TNF-alpha mRNA in ankylotic stapes footplates in connection with measles virus positivity. Bisphosphonates inhibit bone remodeling in the otic capsule of osteoprotegerin deficient mouse, an animal model of otosclerosis. Diagnostic methods and strategies have been reported in the literature but no standard algorithm exists. A focused neuro-otological examination is performed including cranial nerve examination, examination of spontaneous and positional nystagmus, and balance examination that includes Romberg and Quix testing (Table 1). Evaluation of symmetry of response, and abnormalities in latency, amplitude and slope of the response are performed20.
If the patient could not tolerate medical therapy or if symptoms persist, we offer the option of surgical intervention. During fistula testing, dizziness may occur in patients with PLF by applying positive and negative pressure in EAC, which results in pressure changes in inner ear, with positive fistula testing more likely occur in the symptomatic ear. Transtympanic endoscopy and the use of fluorescein have been described as methods of documenting a fistula without operation15,16. Thus, a diagnostic test utilized in Meniere's disease can be helpful in diagnosing PLF, as long as the patient's history is appropriately considered. We use the Lasix dehydration test because it is the most convenient for patients and it provides the opportunity for medical therapy. Our experience is that imbalance can be reversed long after the insult but hearing loss cannot be reversed after several weeks, so that prompt attention (usually within a week) is required in cases of PLF with sudden hearing loss, such as those seen in SCUBA divers. The dynamic posturographic pressure test for the presumptive diagnosis of perilymph fistulas.Neurol Clin. Perilymphatic fistula with no visible leak of fluid into the middle ear: a new method of intraoperative diagnosis using electrocochleography. Associationbetween endolymphatic hydrops as revealed by magnetic resonance imaging and caloric response.Otol Neurotol.
Modifications of the stapedius reflex under spontaneous and experimental brain stem impairment.
The role of endolymphatic sac surgery in managememt of secondary endolymphatic hydrops associated with perilymphatic fistulas: preliminary observations. Both Qeeg and LORETA were presented in the context of functional brain imaging, which also includes demonstration of alterations in metabolism with nuclear medicine, eg SPECT and PET.
The resulting alterations in synaptic transmission and neuronal network function depend on the extent of calcium signaling and NMDA activation in response to different patterns of stimulation2,3,8. Integrity of CI#1 confirmed with persistence of increased tinnitus, cochlear implant soft failure. The application of the QEEG for tinnitus is recommended to be called, the Electroencephalotinnitogram (TCG).
The deviation from the normal electrical patterns in these structures likely is reflected in suboptimal functioning.
The abnormal Qeeg provides objective evidence of brain wave oscillations to support the clinical recommendation of innovative pharmacologic therapy attempting tinnitus relief, e.g. The brain that changes itself: stories of personal triumph from the frontiers of brain science.
Neuroprotective Drug Therapy: A Medical and Pharmacological Treatment for Tinnitus Control. Noise, Calpain, Calpain Inhibitors, and Neuroprotection: A Preliminary Report of Tinnitus Control. Unilateral cochlear ablation produces greater loss of inhibition in the contralateral inferior colliculus. Brain wave recordings are obtained initially and during presentation of subsequent alterations in activity.
Tinnitus percep- tion and distress is related to abnormal spontaneous brain activity as measured by magnetoencephalography. Neurotherapy and drug therapy in combination for adult ADHD, personality disorder and seizure disorder: a case report.
Although the localization of the tinnitus with brain neuroimaging results are inconsistent in the literature, regions of interest demonstrating brain activation, in general, involve auditory and non-auditory regions.
Initially, a magnet was placed on the scalp at a level above the external ear, towards the midline of the scalp i.e. Were these areas of activation acting alone or represented interconnections between different brain systems of activity, highlighted by activity between the prefrontal, parietal cortices, and the anterior insula.
Initially, sensory deafferentation causes neuroplastic change which in the case of phantom pain results in an increased activation of the somatosensory cortex (SSC), and in the case of tinnitus, activation of the primary auditory cortex (PAC). A total of 50 patients were needed to detect the clinical relevant change of tinnitus severity.
The patients received rTMS treatment on 10 consecutive days using either multi-site rTMS protocol. Noise-induced hearing loss also is a form of acute tinnitus by exposure to loud noise 85 db and higher. Therefore, the reduction of tinnitus severity with antidepressants may at least partially be a pure coincidence of antidepressant effect of the investigated drugs. A quantitative score was used to identify emergent significant targets that were more common than expected at random. For example, antidepressant melitracen and antipsychotic lupentoxil which is shown to be superior as an add-on medication to Klonopin. Pharmacological approaches are limited to treatment of comorbidities such as depression, anxiety, or insomnia. Long-term effects of repetitive transcranial magnetic stimulation (rTMS) in patients with chronic tinnitus. Transcranial magnetic stimulation for the treatment of tinnitus: effects on cortical excitability.
Neuroimaging and neuromodulation: complementary approaches for identifying the neuronal correlates of tinnitus. Comparing single-site with multisite rTMS for the treatment of chronic tinnitus - clinical effects and neuroscientific insights: study protocol for a randomized controlled trial. The "mixing point" was defined by Jastreboff as "where the patient perceives that the tinnitus sound and the external sound start to mix or blend together. Disagreement was expressed to "historically" accepted ideas and protocols that all tinnitus patients should avoid silence or that silence may be bad for tinnitus patients. Ouvindo sob medida musica dentada reduz loudness zumbido e audi- atividade do cortex tory relacionados com o zumbido.
The tonotopic map at auditory cortex was demonstrated when normal, distorted as with tinnitus and following VNS with Tones Pairing. The patient also had mild hoarseness during stimulation for the first two weeks, namely unable to tolerate standard settings.
The primary objective is to provide additional and better controlled evidence that VNS coupled with precisely timed tones in subject suffering from moderate-to-severe subjective tinnitus is an effective treatment for tinnitus. Left hemisphere fractional anisotropy increase in noise-induced tinnitus: a diffusion tensor imaging (DTI) study of white matter tracts in the brain.
Blockade of cochlear NMDA receptors prevents long-term tinnitus during a brief consolidation window after acoustic trauma. Efficacy and safety of AM-101 in the treatment of acute inner ear tinnitus-a double-blind, randomized, placebo-controlled phase II study. The participants pressed a button to categorize each sound as pleasant, unpleasant or neutral. Previous literature has shown that tinnitus can have a significant impact on the quality of life in terms of altered psychosocial functions. Studies on the effect of noise exposure and tinnitus12 have shown that exposure to occupational noise gave increased odds for tinnitus in subjects with hearing loss. Axelsson and Ringdahl10 administered a tinnitus questionnaire on a large population of randomly selected adults.
Results indicated that the percentage of individuals with tinnitus who reported the disappearance of difficulties in different activities such as concentration, sleep, relaxation, work and social relations improved after the end of therapy.
All subjects underwent audiological and medical examinations to identify any abnormality in the ear condition. In terms of baseline audiometric assessment, two pure tone averages (PTAs) were calculated - one for the low frequencies (PTAlow consisting of 0.5, 1 and 2 kHz) and the other for high (PTAhigh consisting of 3, 4 and 6 kHz) frequencies.
The MS-TSQ items are identical to those of the original TSQ, but the number of response alternatives differs. A post-hoc analysis was conducted using Bonferroni correction to know if significant differences existed between groups. In terms of the improvement in the MS-TSQ scores, the USNHL group obtained significantly lower scores than the NIHL group. The method of obtaining the responses through questionnaires sent out by mail has generally been shown to obtain a low response rate. A study by Nondahl et al.28 assessed tinnitus severity of subjects with five years in between. The results of the present study observed that females had a higher Sb and Sd scores than males. It is possible that the subjects may only have had a conversation or may have had further follow-up sessions with a psychologist, but those subjects who answered 'yes' in the questionnaire did receive psychological intervention. Also, psychological intervention had an influence on the improvement in tinnitus annoyance in subjects with tinnitus. The THI was developed by the British Association of Otolaryngologist, Head and Neck surgeons, which consists of 50 questions6. The speakers were given a five-point rating scale to grade the items from very familiar to non-familiar. A score of 4 was given for YES and a score of 0 was given for NO and a score of 2 was given for SOMETIMES.
The overall Cronbach alpha score of both the THI versions and the individual scores for all the three subscales in both the versions were compared.
From the current study, it is clear that the Kannada version of THI is readily available, easy to understand and is a reliable tool for measuring the handicap occurring due to tinnitus.
The normal otic capsule is preserved with very little bone turnover as a result of the production of osteoprotegerin (OPG) by the membranous inner ear that prevents the activation of osteoclasts.
Osteoclastogenesis explains the rationale for the use of bisphosphonates in the treatment of otosclerosis.
TNF-α has also been identified as a factor responsible for sensorineural hearing loss in experimental animals [14]. In January 2001, he was placed on risedronate, 5 mg, to increase to eventually three times weekly. Some 7 years earlier, the patient underwent a stapedectomy in the right ear that resulted in a further decline in threshold and in discrimination. With subsequent visits, speech discrimination showed progressive improvement to the 68% level, where it has remained. Otosclerosis is triggered by some form of inflammation: The most common inflammation refers to the measles virus.


TNF-α is a cytokine produced by osteoclast breakdown of bone and has been identified as a factor responsible for sensorineural hearing loss in animals with experimentally produced pneumococcal meningitis [15]. Bisphosphonates are analogs of pyrophosphates that have a common phosphorus-carbon-phosphorus chain, rendering them impervious to breakdown by pyrophosphates. With the addition of a nitrogen molecule, the subsequent generation of bisphosphonates more strongly targeted the osteoclasts, sparing the osteoblasts, and could be used on a continuing basis.
By cutting down or eliminating these by-products through the use of bisphosphonates, the effect may be reversed, as was seen in the two case reports presented.
Stapedectomy may alleviate the conductive component of the otosclerosis, whereas the otic capsular otosclerosis may progress to produce a sensorineural hearing loss. A clinical double-blind, placebo-controlled study on sodium fluoride treatment in otospongiosis. The most accepted diagnostic method remains intra-operative confirmation of perilymph leak at oval window or round window.
Various causes of PLF have been described including stapedectomy, barotrauma, physical exertion, head and neck trauma, congenital and idiopathic2-4. Fistula testing was performed with an impedance bridge using positive and negative pressure, sweeping the pressure from +400 dapa to -400 dapa three times in each of four test situations, the patient sitting eyes open, the patient standing eyes open, the patient sitting eyes closed, and the patient standing eyes closed13.
Pure tone thresholds, speech reception thresholds, fistula testing, and Quix21 and Romberg testing were performed before the injection and every 30 minutes subsequently for 2 hours and changes in pure tone responses, speech discrimination and speech reception thresholds, fistula testing, and Quix and Romberg balance testing were observed.
If the patient's symptoms and physical exam findings improve during the Lasix test, management options include medical therapy with oral Lasix or surgical treatment with middle ear exploration. If a decision is made to perform surgery, informed consent is obtained and the risks and benefits are explained to the patients.
One patient, who was 97 years old, had moderate to severe hearing loss prior to the trauma. Surgical intervention included fat grafting at the round and oval windows as described above. Unfortunately, because this is a controversial diagnosis, people have omitted this diagnosis in their differential diagnosis of vestibular disorders. The usual fistula test is performed using a pneumatic otoscope which only provides positive pressure. However, injection of this dye has been found to be inaccurate in the diagnosis of PLF as dye has been found in serum as well as perilymph. A superior endaural incision can provide a wider surgical field before entering the middle ear. The program in 2014, "Modalities Tinnitus Treatment", was presented as the fifth of a series of AAO-HNS Miniseminars, which over the past 4 years has had as its goal the providing to the AAO HNS membership and guests, state of the art tinnitus information, both clinical and basic science, for clinical translation to the patient for an objectivity and an increased accuracy for the tinnitus diagnosis for all clinical types of tinnitus and its translation for treatment. Multiple ongoing processes and levels of activity are involved at organ, tissue, cellular, synaptic and molecular genetic locations.
It is conceptualized to be a process which can alter the circuitry in brain wave activity associated with tinnitus and the responses to modalities of tinnitus treatment4. The chief etiologies to be considered include ischemia, trauma, or hemorrhage, and neurodegenerative disease. Removal CI#1 and reinsertion CI#2 resulted in hearing improvement and reported tinnitus relief10.
Clinically, the stage of the QEEG clinical application in 2014 for tinnitus is considered analogous to the EKG for cardiology in the 1930s. Included are activation in the anterior cingulate cortex, the prefrontal cortex, the amygdala, and hippocampus.
It was hypothesized that the activated ROIs reflected different dynamic overlapping brain networks and should be considered as targets for the treatment of tinnitus with TMS.
The awareness of the stimulus arises when the activity is connected to a larger co-activated awareness or perceptual network.The perceptual network involved the anterior cingulate cortex (ACC), dorsal cingulate cortex (dACC), and posterior cingulate cortex (PCC), precuneus, parietal, and frontal cortices. Changes in brain structure and activity were evaluated using functional magnetic resonance image and EEG in the resting state. Off-label drug use in the treatment of tinnitus includes antiarrhythmic, anticonvulsants, angiolytics, glutamate receptor antagonist, antidepressants, and muscle relaxants. There has been report of some improvement in tinnitus associated with improvement of depression and anxiety. It was recommended that "hearing aid use without providing background sound" is not beneficial. Hearing loss has been associated with identification of an increased spontaneous firing in specific regions of the ascending central auditory system.
Following VNS in combination with Tones Pairing the initial distortion accompanied by increased excitability and spontaneous firing and synchrony at cortex was seen on the tonotopic map to be restored to normal as demonstrated with decreased excitability, reduced synchrony and spontaneous activity. In such cases, the subjects' response to tinnitus can produce annoyance, mood changes, fear, anxiety and depression - all of which are associated with tinnitus severity3.
They also concluded that tinnitus severity increased as a function of number of years since onset.
These subjects were mainly exposed to leisure-time noise and had frequent tinnitus but their thresholds were within normal limits. Studies have shown that tinnitus affects a person's well being and can lead to a range of associated problems.
Audiological examination consisted of pure tone audiometry supplemented with Auditory Brainstem Response (ABR) and Magnetic Resonance Imaging (MRI) if required.
An addition of a response alternative of 'not sure' was added to the already existing four response alternatives in the original TSQ version. Independent samples t-test was used to analyze gender differences and the effect of psychological treatment. No significant differences were observed in the MS-TSQ difference scores between NH and NIHL; and between NH and USNHL groups. Two-hundred and thirty-three patients reported significant tinnitus at the first examination, and 105 patients (45%) reported decreased annoyance during the follow-up assessment.
Also, no significant hearing threshold differences were observed between the groups who received psychological intervention versus those who did not.
The NIHL group showed the lowest Sd score and these scores were significantly lesser compared to USNHL group.
Later, a modified beta version with 25 questions was developed by Newman et al.5 which is in the form of a self-assessment report that a person suffering from the condition can fill in.
In such circumstance administering these inventories becomes difficult and sometimes impossible too. Later, all the 50 filled inventories were assessed to find out if all the words and the meaning of the questions were understood by the Kannada speakers. Once the subject finished rating the questions, they were grouped under 5 categories based on the severity that is Slight, Mild, Moderate, Severe and Catastrophic. Animals genetically unable to produce OPG demonstrated the production of hearing loss and histopathology of the temporal bones consistent with that seen in otosclerosis. Applying the understanding of osteoclastogenesis to the treatment of inner-ear otosclerosis has led to the clinical utilization of the class of drugs called bisphosphonates. At that visit, the hearing in the left ear had a further air-bone gap and a discrimination score of 56%. The patient was well aware of his improved ability to communicate with binaural amplification. Evidence of both measles RNA and TNF-α have been found in specimens obtained at stapedectomy [11,13,14]. Infusing a TNF-α neutralizing agent before inducing the meningitis prevented the meningitis-induced sensorineural hearing loss in these animals. Clinical experience has revealed risedronate to be the more effective of the oral amine bisphosphonates, but the required effective dose for treating otosclerosis is almost twice the dose used for osteoporosis. However, concerns have been raised regarding excessive surgical intervention given the lack of pre-operative confirmatory tests. However, the diagnosis of PLF remains a subject of controversy due to the variability in patient presentation and difficulty in pre-operative evaluation.
The audiologist performs this test, looking for nystagmus or a sway or complaints of dizziness, lightheadedness, disorientation or nausea. If the findings improved, it indicated presence of Endolymphatic Hydrops which confirmed presence of PLF21.
On post-operative follow up, all patients had improvement in their symptoms and their examination. Their criteria for middle ear exploration included abnormal gait, positional nystagmus, positive Romberg, and positive fistula test.
Maintaining a bloodless field prior to raising the annulus and entering in the middle ear avoids pooling of blood around the oval window or the round window niche.
Fistula testing followed by Lasix dehydration test is helpful in determining inner ear fluid imbalance as a cause of disequilibrium and hearing loss.
The themes of the past Tinnitus Miniseminars and the rationale for the order in the selection of past themes since 2010 and selection of the theme for 2014 were reviewed. The result of the reorganization is a positive or negative alteration in structure and or function from the normal, i.e.
It was hypothesized that neuronal changes would take place in the underlying neural substrate. A salience exists to the phantom percept reflected by activation of dACC by the anterior insula. Twenty five (25) control subjects without tinnitus were matched for age, gender, and hearing function, and were examined once using EEG, MRI, functional MRI, and questionnaires.
Investigation was recom-mended to identify the mechanisms such drug(s) have in common resulting in the clinical manifestation of tinnitus.
Other drugs have been reported with either limited efficacy and to need further controlled trials.
A statistically significant relationship was identified between perceived tinnitus loudness and annoyance.
The association of hearing loss and tinnitus has been identified clinically; however, there is no correlation between hearing loss and the severity of the loss. A patient with a unilateral tinnitus in the left ear demonstrated localization of high coherence in the right auditory cortex (AC), Brodmann area, BA 42. All patients to be implanted were divided into two groups; half to VNS plus tones and the remainder half to sham VNS plus tones. Biomagnetism-transdisciplinary research and exploration: proceedings of the 16th International Conference on Biomagnetism, Sapporo, Japan, August 25-29,2008.
Studies have suggested that being exposed to excessive noise for longer periods of time, could lead to hearing loss and tinnitus, whereas a noise exposure over a short time period, could cause tinnitus as the only symptom.
No significant correlation was observed between improvement in tinnitus scores and other variables of age, pure tone audiometry types or duration of follow-up. A study by Snow27 concluded that a questionnaire can be a good method to assess tinnitus severity.
Of these 105 patients, 45 reported no tinnitus, and 60 reported that their tinnitus had shifted from significant to mild. In our study, the NH group had the lowest Sb score among the three groups, but had a higher Sd score than subjects with NIHL.
In the present study baseline audiometric measurements indicate females had significantly lower hearing thresholds in the high frequencies. This finding indicates that hearing thresholds may not be the most important influencing factor on how the subjects experienced annoyance by their tinnitus, especially since the group receiving treatment had a significantly higher Sb score. Further studies investigating the effects of the type and duration of psychological treatment on the tinnitus severity can be explored. The self report has been developed subsequent to previous studies that have thrown up reliable data that can be used to classify tinnitus into different grades according to the degree to which the tinnitus has affected a subject.
As this inventory quantified the alterations of the daily life of an individual due to tinnitus and due to the non capability of multilingual Speech & Hearing professionals to translate accurately the English version of THI to the regional languages and to avoid communication interpretation, there is a need to develop and standardize the Tinnitus Handicap Inventory in Indian languages. The questions which were rated as 1 or 2 were selected for the inventory and any questions with ratings over 3 were re-framed according to the familiarity of the speakers. All the participants underwent assessment by an otorhinolaryngologist and complete audiological evaluation prior to the administration of the inventory. Applying the understanding of osteoclastogenesis to the treatment of otosclerosis has led to the clinical use of the class of drugs called bisphosphonates. The bisphosphonate group of drugs specifically targets osteoclasts by reducing production of osteoclasts and accelerating their early cell death [3,16-20].
It was discovered clinically that the appropriate dose for risedronate was 30 mg twice weekly, on which the patient was placed. The same channels through which the OPG can diffuse to the otic capsule provide an unobstructed route by which TNF-α can enter the perilymph [7]. Their chemical structure causes bisphosphonates to be avidly absorbed onto the surface of hydroxyl apatite crystals in bone at sites of active remodeling. This higher dose of bisphosphonates is supported by the findings that the normal otic capsule is devoid of osteoclasts as opposed to the bone subjected to osteoporosis. Multiple tests have been described but no definitive diagnostic tool is available at present to confirm presence of PLF preoperatively.
All patients had imbalance on Romberg and Quix testing and tested positive on fistula testing. It is our opinion that in PLF patients, it is the chronic distortion in endolymph and perilymph that results in the loss of the normal perception of gravity. Hearing loss was a less common complaint in their cohort, whereas others have reported hearing loss to be the primary complaint in patients with PLF7,10. Standard ECOG, transtympanic ECOG, and intraoperative ECOG have also been described in the diagnosis of Meniere's Disease and in the evaluation of PLF but these tests also have not been used widely17,18. If patients' symptoms get worse on the Lasix dehydration test, a presumptive diagnosis of perilymphatic hypertension can be made24. In order to better visualize the leak, we place the patients in Trendelenberg which increases intracranial and perilymph pressure. There is a constant learning process in which the phantom percept becomes associated with chronicity and reflected in distress of the patient reflected in a nonspecific distress network i.e.
The neurobiological model used for this study was that described by Schlee and Collins which involve several brain regions all of which can be stimulated with different frequencies in a different order and with a varying number of stimuli7. This includes a HMG-CoA reductase, atorvastatin, the vasodilators cyclandelate, furosemide, herbal products, Ginkgo biloba, melatonin, Prostaglandin E1, misoprostol, L type calcium blocker amlodipine, phosphodiesterase type 5 inhibitor, Vardenafil, and minerals including zinc10.
In other words, the frequency of the tinnitus is removed from the music that is being used as the stimulus.
The increase in spontaneous firing is converted, translated, transformed at the thalamocortical level resulting in a synchronization of multiple brain wave oscillations of different frequencies, which in primary and secondary auditory cortices is perceived by the patient as tinnitus. After 20 days, there was a massive expansion of the auditory cortex map specific to the paired tone. The maximal frequency was determined from a graph that displayed the coherence level for all the frequencies in this particular region of interest.
Since only frequencies from 125 Hz to 8 kHz are measured in conventional pure-tone audiometry, it is possible that a person with normal hearing can have a hearing loss at frequencies higher than 8 kHz accompanied by tinnitus13,14. In relation to hearing thresholds, it was observed that, in subjects who had tinnitus always, 19% considered themselves as having normal hearing, 55% had some hearing loss, 19% had marked hearing loss and 3% were deaf.
The study had the approval of the Ethical committee in the section of Logopedics, Phoniatrics and Audiology, Lund University. The subjects' responses were rated based on the global score obtained from the MS-TSQ questionnaire. We believe that the 'true' response rate in our study is much higher (around 59%) since 267 of the total 455 subjects initially responded to the questionnaires that were sent to them. For 341 patients who reported mild tinnitus at baseline, 40% reported that their tinnitus had not changed, compared to 55% of the 233 who had moderate tinnitus.
The range of the duration between the baseline and follow-up visit varied from 1 year and 11 months to 9 years and 4 months and this factor might have had an effect on the audiometric thresholds during the follow-up phase.
THI consists of 25 questions under the 3 sub-scales of emotional, functional and catastrophic. The bisphosphonate group of drugs specifically targets osteoclasts by reducing production of osteoclasts and accelerating their early cell death. Before the advent of these newer drugs, fluoride was the only medical treatment for otosclerosis [21-25]. The discrimination in the left ear gradually improved so that it reached 76% in the left ear, with a significant air-bone gap (Fig.
The audiological workup revealed a bilateral moderate to severe mixed hearing loss, more pronounced on the right side, with a significant reduction in speech discrimination of 44% (Fig.
TNF-α in the perilymph is presumably toxic to the hair cells producing the symptoms identified.
They inhibit the activity of osteoclasts when they are engulfed by the osteoclasts during the resorption process.
By chance, the addition of the alternate use of an amine bisphosphonate (risedronate) and a non-amine bisphosphonate (etidronate) appears to exert a maximum effect on inner-ear function. However, patient's history and the definitive episodes of spinning vertigo differentiate the Endolymphatic Hydrops due to Meniere's disease from PLF.
Three 2 mm size fat grafts are harvested from the ear lobe and are dissected into 0.5 mm segments for grafting. The Lasix dehydration test was performed after suspecting PLF and all patients showed improvement in their balance during the test (Table 2). Other techniques have been described including Valsalva and Internal Jugular compression to assist in visualizing the leakage of clear fluid from the oval and the round window.
We are conservative in offering surgery although surgical treatment for PLF is safe and effective. The goal is to attempt to restore and or to maintain a homeostasis of normal neural function in the peripheral and or central nervous system4. It was hypothesized that rTMS treatment protocols on brain structure and function should provide a basis for neural correlates of tinnitus8. In conclusion, Tyler stated "we believe that for some patients of tinnitus all forms of masking therapy, including those that use total masking and low-level partial masking might provide relief." Mixing point and total masking are equally effective7.
It was stressed that no widespread evidence-based pharmaceutical agent is available that "cures" tinnitus at this time.
It is concluded that VNS paired with a tone generates massive plasticity in the auditory cortex specific to the paired tone1. Coherence imaging in a controlled subject with no tinnitus and no neurological disorder exhibited patterns of low coherence and no areas of high coherence as seen in the tinnitus patient, specifically in the AC.
It is shown that subjects with tinnitus have steeper maximum high-frequency slopes compared to the subjects without tinnitus. It has also been shown that cognitive behavioral therapies can improve a person's ability to cope with their tinnitus21.
Of the total 455 subjects, 267 subjects (response rate of around 59%) returned back the questionnaire. After exclusions based on subject category and responses to all items in the questionnaire, our study yielded a final response rate of around 38% (n = 174). Studies have shown that prevalence of tinnitus increases due to exposure to industrial and recreational noise1,6. The THI beta version is one of the best and most standardized tinnitus measuring tools and has got a good reliability, validity and a good internal consistency to administer on tinnitus patients.
The rationale for use of bisphosphonates to treat the sensorineural hearing loss of otosclerosis is explained, with cases that illustrate the bisphosphonates treatment algorithms and the response to treatment.
This recent basic science research in the field of osteoclastogenesis leads to a further understanding of the rationale for the use of the bisphosphonate class in the medical treatment of otosclerosis [26]. Because PLF is a controversial diagnosis, it is crucial to discuss it in our literature and perhaps come to a consensus.
According to the 1995 American Academy of Otolaryngology - Head and Neck Surgery guidelines describing probable, possible, definite, and certain Meniere's disease, one of the required criteria is to rule out other possible causes of patient's symptoms, one of which can be PLF23. This patient has a suspicion of fistula in the contralateral ear as well, and ultimately did undergo surgery on the opposite ear.
We confirm the leak by suctioning and observing the reaccumulation of fluid according to the method of Kohut13. The diagnostic method we utilized provided positive findings pre-operatively in all these cases as illustrated. The phantom percept persists due to memory mechanisms involving the parahippocampus, hippocampus, and amygdala. Tinnitus patients identified combined treatment of left frontal and temporal rTMS compared to left temporal rTMS for the efficacy of tinnitus relief than single site stimulation.
Significantly, after 12 months of regular listening, a target patient group of eight patients reported a significant reduction in the loudness of their subjective tinnitus.
Studies have argued that the presence of tinnitus is related to the boundary in the audiogram between the frequency regions of normal or near-normal hearing and a region with a higher degree of hearing loss15,16.
A similar study by Andersson et al.20 observed that the severity of tinnitus reduced over time in all of their subjects, when psychological intervention was provided.
In the MS-TSQ item 1 is provided with scores ranging from 2-8, item 2 from 1-4 and items 3-10 has scores ranging from 0-4.
In the present study, no significant associations were found between Sd scores in the MS-TSQ and age, PTA, or duration.
It has been shown that NIHL results in an imbalance of spontaneous and sound-driven cochlear output across different frequencies. The hearing showed a drop in the left ear, but the discrimination was similar to that in 1988. We discuss the diagnostic tests and the operative technique used in management of these patients and we provide a review of the literature in support of our approach. In this paper, we describe 5 patients with post-traumatic PLF, and one patient with spontaneous PLF.
There were no complications related to hearing loss, perforated tympanic membrane or any other surgical complications. Before placing the fat grafts, we denude the mucosa in the area of the fissula ante-fenestram in the oval window area and the floor of the round window niche inferior to the round window membrane in order to provide a raw surface for the graft to adhere. With complete total masking, the intensity level of the masker is just above the intensity level of the tinnitus. In addition, they demonstrated reduced evoked activity in areas of the auditory cortex corresponding to the tinnitus frequency compared to patients who received an analogous placebo notched music treatment. There was only a "little relationship between tinnitus loudness and annoyance and the amount of money".
These results indicate that both the degree of hearing loss and the shape of an audiogram were factors that could predict the occurrence of tinnitus. It was observed that females had a higher MS-TSQ Sb score and a lower MS-TSQ Sf score than males.
He was placed on the early bisphosphonate etidronate along with a supplemental calcium and vitamin D preparation and a fluoride and calcium preparation. We describe our algorithm in diagnosing PLF and review the literature supporting our approach. If a leak is seen at one of the two areas, we graft both because of the possibility of an inapparent fistula at the second window.
It represents a promising strategy to enhance treatment effects of rTMS and tinnitus with multisite.
With partial masking, the intensity of the masker is not sufficient to cover the intensity level of the tinnitus. This report suggests that tinnitus loudness can be significantly diminished by an enjoyable, low-cost, custom-tailored notched music treatment. Subjects with a global score below 20 were classified to have mild tinnitus, while a global score above 30 was classified as severe. Hence, these pathophysiological changes might be responsible for observing lesser improvement in the tinnitus severity scores in subjects with NIHL. A number 2 type endaural incision is made at the superior canal wall to widen the canal and better visualize the superior tympanic membrane. We plan to do a prospective study to further define the role of our diagnostic methodology.
Many patients reported that they would pursue surgical options and many would pay $10,000 for treatment to reduce their tinnitus. Subjects with global scores between 20 and 30 were classified as having moderate tinnitus24.
He returned to the sodium fluoride and calcium, and the hearing remained the same, then improved to 84% discrimination. A Shea self-retaining retractor is placed in the ear canal and a tympanotomy flap is lifted up to the annulus. The MS-TSQ was administered on all subjects in two stages - a baseline score (Sb) during the initial visit and a follow-up score (Sf) with varying duration of time after the baseline assessment. He returned 2 years later with a drop in discrimination in both ears and in the pure tones in the right ear. Prior to entering the middle ear space, special attention is paid towards adequate hemostasis to avoid any blood accumulating in the middle ear.
The change in the tinnitus severity was calculated as (Sb - Sf), termed as the difference scores (Sd). The duration between the baseline and follow-up assessment varied from 1 year 11 months to 9 years and 4 months. When on the sodium fluoride and calcium, hearing improved in the right ear to 84%, whereas in the left ear it dropped to 24% discrimination (Fig. Occasionally a bony overhang is noted over the round window, which is removed using a micro drill.
Any fluid noted at the round window or the oval window is gently suctioned with a number 24 otologic suction and reaccumulation is confirmed, as described by Kohut, et al.
The mucosa is then denuded using a curved otologic pick and 3-4 0.5 mm fat graft are placed at each site and are covered with gel foam.
The flap is then replaced and the ear canal is packed with quarter inch packing impregnated in Polysporin ointment over strips of gel film.



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Comments to “Tinnitus medical journal editors”

  1. It have to always be at your physician's could.
  2. Nerve stimulation to treat tinnitus, the healthcare traffic out there, wind.
  3. Never notice it at all, so it does sound like strategies.


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Children in kindergarten to third, seventh and expertise anxiety and taking deep swallows for the duration of the descent of ascent of a flight. Also.