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Author: admin | 28.01.2016 | Category: Ginkgo Biloba Tinnitus

The principal types of regional and local maps in the Middle Ages were itinerary maps, maps of regions like England or Palestine, city plans, and, especially from the very late Middle Ages, maps of disputed lands or boundaries of properties.
Written itineraries were well known in the Middle Ages and were apparently used both as travelersa€™ aids and for armchair travel, often for the purpose of either actual or mental pilgrimage. The other significant extant example of an itinerary map is the one that appears in various redactions in manuscripts of Parisa€™s Chronica majora. In addition to these surviving examples of itinerary maps, the significance of the itinerary a€” especially the written or narrated itinerarya€”is demonstrated by the frequency with which itineraries served as at least one source for other types of maps.
Paris created a number of regional maps of England and Palestine, as well as two historical maps representing features of early Britain.
Matthewa€™s so-called Itinerary from London to the Holy Land, which has been reckoned with his map of Palestine, is not really a connected whole; it is the result of combining two different works, a pictorial representation of the route between London and Apulia (in southern Italy), and a sketch of the Holy Land. Matthew Parisa€™s maps of Palestine are best described as maps not so much of the Holy Land as of the Crusader kingdom, especially since a plan of the city of Acre, the principal port of the kingdom, dominates the coastline.
The Itinerary to Apulia is not, therefore, part of a pilgrima€™s guide to the Holy Land; but rather appears to be a political sketch, with the following history (from Beazley). The text of this map of Palestine is, in fact, closely related to various Intineraries of the period of Latin domination in Syria, such as Les pelerinages pour aller en Jerusalem, Les chemins et les pelerinages de la Terre Sainte, or La deuice des chemins de Babiloine (viz.
Itinerary Map from London to Bouveis, Cambridge, Corpus Christi College Library, MS 26, f.ir. Matthewa€™s little red lines become roads, inches become miles, vignettes become cities to be traversed by the viewers of his manuscripts. With the actual city lost to travelers, labyrinths created a space for virtual travel, much in the same way as Matthewa€™s maps do. The maps Matthewa€™s manuscripts contain, even the a€?lineara€? itinerary pages like the one that opens CCCC 26, are not as straightforward as they at first appear.
These labyrinthine maps of Matthew Paris are quite different from those of his contemporaries in important respects.
On the Psalter Map, beginning at the top and proceeding clockwise, we encounter the Garden of Eden, the Red Sea, a band of monstrous peoples, Britain, and the gates in the Caucus Mountains, retaining the hordes of Gog and Magog.
Matthew was not immune to the common medieval interest a€“ monastic and secular a€“ in marvels like the monstrous peoples of Africa and Asia, reflected not only by their presence on the Psalter, Hereford and Ebstorf maps, but also by their near ubiquity in texts and images of all types. Just as audiences flocked to see Henry IIIa€™s elephant, they may also flocked to see some of the world maps, such as the Hereford Map, likely displayed in Hereford Cathedral as part of a pilgrimage route dedicated to Bishop Thomas Cantilupe, who died in 1283. Matthew also chooses not to dwell in his maps on the horrifying hordes of Gog and Magog, lurking behind the Caspian Mountains, which is surprising, given his millennialism.
Matthewa€™s maps a€“ from the first legs of the itinerary, branching out from London along two paths, to the (nearly) pathless tracts of the Holy Land a€“ present a range of spatial options to the ocular traveler moving through them. But again, this invites a question: If these maps, which were likely made just after 1250, are millennial, why not populate them with prodigies, with monstrous births heralding doom, with monsters of the sorts found on the Psalter Map, or with images of the people of Gog and Magog, who appear three times on the Hereford Map, once behind their wall and twice already outside of it, released into and upon the world? Not only is the Holy Land to be inexorably lost, despite the valiant efforts of these last Crusaders, but the invasion of Europe itself is threatened by the apocalyptic Mongol hordes, believed to be Gog and Magog unleashed beyond the frontiers of civilization as harbingers of the end of the world.
This is, indeed, the moment of production for the maps, but this is not the moment (or moments) depicted on the maps, themselves. Connolly translates jurnee, the repeated inscription on the paths throughout the itineraries, as a€?one day,a€? rather than the customary a€?daya€™s journey,a€? perhaps unintentionally conjuring a sense of longing for travel by a cloistered monk a€“ one day, one day a€“ but also for the reclamation of the Holy Land a€“ one day, one day a€“ and, of course, ultimately, the return of Jesus, the end of time, the Last Judgment, and the creation of the Heavenly Jerusalem a€“ one day, one day. Connolly characterizes the performative experience of walking a labyrinth as a€?a prolonged, sometimes frustrating process,a€? but, after all its disorienting divagations, a€?[a]t the very end of the labyrinth, a straight line appears to lead you directly to the center, to arrive, metaphorically, at the holy city of Jerusalem.a€? Returning to Matthewa€™s map of the Holy Land, (CCCC 16) we find that there is a pathway charted on its largely pathless surface, a road marked out like those of the itinerary pages that precede it. Matthewa€™s maps seem to present a maze of pathways, but like the labyrinths, present a unitary destination.
Itinerary from London to Jerusalem with a description in French, similar to one in the Royal MS. Matthew Parisa€™ Itinerary from Pontremoli to Rome with images of towns, their names, and descriptions of places, with attached pieces, including the city of Rome to the right; from Matthew Parisa€™ a€?Historia Anglorum, Chronica majoraa€?, Royal 14 C.
Mascun to the Alps in Matthew Parisa€™ a€?Chronica Maioraa€?, a€?Corpus Christi College, MS 26, fol.
A A A  The principal types of regional and local maps in the Middle Ages were itinerary maps, maps of regions like England or Palestine, city plans, and, especially from the very late Middle Ages, maps of disputed lands or boundaries of properties. While monsters and marvels played an important role on mappaemundi like the Psalter, Hereford and Ebstorf, their role on Matthewa€™s maps is strongly curtailed. Park County Audiology specializes in the diagnosis and treatment of hearing loss and balance disorders. Teresa is the office manager, and has several years experience in customer care and accounting. Park County Audiology Audiologist providing hearing tests, hearing aids, accessories and fittings to: Park County, Chaffee County, and Summit County, Colorado. In the assessment of hearing, one must remember that a dysfunction of the auditory system may be a manifestation of a systemic and possibly life-threatening disorder. Frequently, the patient with a conductive loss of hearing complains of tinnitus, which may be localized in one ear or in both ears, or unlocalized in the head. Sensorineural hearing loss occurs with pathology in the inner ear or along the nerve pathway from the inner ear to the brainstem.
Congenital sensorineural hearing loss may result from hereditary factors, malformation of the cochlea, in utero viral infections, or birth trauma. The configuration of the audiogram demonstrating a sensorineural hearing loss may vary significantly and, in some instances, may suggest the cause of the loss. Loudness recruitment is usually associated with sensory loss of cochlear origin, which constitutes the majority of sensorineural losses. The patient with sensorineural hearing loss is usually subject to tinnitus of a somewhat different sort from that associated with conductive hearing loss. In sensorineural losses, the audiometric Weber test is expected to lateralize to the better hearing ear. Contrary to a commonly held misconception, sensorineural hearing loss may be helped by the use of hearing aids. The problems of differentiating cochlear dysfunction from eighth-nerve lesions have received major emphasis during the past several years. Routine pure-tone and speech testing can yield valuable information on the site of lesion during the initial phase of the differential audiologic study. As would be anticipated, lesions within the central auditory sytem are difficult to detect or localize. Ear and bead noises, the most common complaints presented to the audiologist or otolargyngologist, are frequently seen by the neurologist as well.
The perceived loudness of tinnitus in any patient may be intense enough to be highly debilitating. Most tinnitus sufferers have a concomitant loss of hearing, which may be either conductive or sensorineural. Tinnitus is a symptom of an underlying disease or specific lesion when it is perceived above the intensity levels of environmental sounds. Assuming there is no cerumen in the external ear canal, the tympanic membrane should be inspected.
The office examination of hearing loss may include tuning fork tests of air and bone conduction. An audiologic assessment comprises pure-tone air and bone conduction testing and speech threshold and word discrimination measures.
In the measurement of bone conduction thresholds, pure tones are transmitted via a bone oscillator, usually placed on the mastoid. A speech reception threshold is the lowest intensity at which an equally weighted two-syllable word is understood approximately 50% of the time. Speech discrimination is a tool used to assess an individual's ability to understand a speech signal at normal or above normal conversational levels. Tympanometry, static acoustic immittance, and acoustic reflex threshold measures make up the acoustic immittance test battery. The acoustic reflex threshold is the lowest intensity needed to elicit a contraction of the stapedius and tensor tympani muscles using a pure-tone stimulus. Brainstem auditory evoked potentials (BAEPs) are also known as brainstem auditory evoked responses (BAERs) or auditory brainstem responses (ABRs). The BAEP is a sensitive, noninvasive diagnostic test for the diagnosis of cerebellopontine angle tumors. The absence of waves III and V has been seen in some patients with vestibular schwannoma and in cerebellopontine angle meningiomas. Electrocochleography (ECochG) is a method of recording the stimulus-related electrical potentials associated with the inner ear and auditory nerve, including the cochlear microphonic summating potential (SP) and the compound action potential (AP) of the auditory nerve. Therapy for auditory disorders is largely the province of the otolaryngologist and the audiologist. Contrary to a commonly held misconception, sensorineural hearing loss may be helped by the use of a hearing aid. We note that the hearing aid is the most important rehabilitative tool available for the management of sensorineural hearing loss; however, counseling should be a central focus of any management strategy for the hearing-impaired adult. The complete evaluation of the tinnitus patient should be approached from a dual perspective. When a specific otologic cause for the tinnitus is identified, otologic management is indicated.
Research on the effectiveness of pharmacologic therapy for tinnitus, although certainly encouraging, involves medications such as carbamazepine, lidocaine, and intravenous barbiturates, whose potentially serious side effects limit their usefulness.
The use of masking as a management tool in the treatment of the tinnitus patient has met with mixed success over the years. Tinnitus maskers are designed to provide relief to the tinnitus sufferer by introducing an external masking sound into the affected ear or ears, thereby minimizing or eliminating the perception of the tinnitus. Experience with tinnitus patients reveals that many have relatively high levels of anxiety, tension, or other symptoms of chronic stress. Effective counseling is one important aspect of tinnitus management regardless of the management approaches taken with a given patient. Albans in England possessed what may be called an historical school, or institute, which was then the chief center of English narrative history or chronicle, and with a different environment might have become the nucleus of a great university.
Most of these maps appear to have belonged to separate traditions, although the extensive corpus of maps in Matthew Parisa€™s chronicles, combining as it does multiple map types, suggests the degree to which a graphically inclined author might be familiar with and able to deploy images from all the known categories of maps, in addition to other types of drawings and diagrams.
Only two maps structured as itineraries survive, the more elaborate of which is the Peutinger map (Book I, #120).
The map shows the route from England to Apulia, marking each daya€™s journey and prominent topographic features like mountains and rivers.
For example, some of the information on the Hereford world map (#226) was based on an itinerary that may show a route familiar to English traders in France. In many ways they continue the itinerary from England to Sicily (Otranto in Apulia was a common point of embarkation for Acre).
CCCC 26 contains the annals from creation to 1188, CCCC 16 from 1189 to 1253, and Royal 14 C.viii from 1254 to 1259, when Matthew died.
These contain images of cities, connected by clearly marked roads inscribed journee [a daya€™s journey]. This mode of associating travela€™s a€?microa€? with its a€?macro,a€? as it were, was of increasing significance in the 13th century, when pavement labyrinths were either first used in European churches or were newly popular. And by presenting its audiences with a richly meaningful image of the city of Jerusalem a€“ one whose centrality in the nave mimicked that citya€™s centrality in the world and whose fundamental geometry signaled a cosmic architecture a€“ this pavement triggered associations with the city, both in its earthly and historic instance and with its future, heavenly instantiation, and it did so as it invited its audiences to perform an imagined pilgrimage to this sacred center. Labyrinths allowed church visitors to travel short distances in the densely confined knots of their paths, while simultaneously travelling to the very a€?centera€? of the world, emphatically emphasized by their symmetrical forms. Perhaps unsurprisingly, they are filled with problems, and become a€?very muddled and confusing,a€? with cities that are a€?misplaceda€? or appear twice.
The well-known Psalter Map, for example, is a typical mappamundi, displaying the entire ecumene, that is, the inhabitable world, as known to 13th century English cartographers (#223). Wonders of this sort are not incidental to the function of medieval maps like the Psalter; rather, they are essential components thereof, supplying a necessary antipode to a central Jerusalem, rooted in biblical and patristic texts. Matthew represented marvels known from monster cycles like the Marvels of the East and the Liber monstrorum, and from contemporary narratives about cultural others like the a€?Tartarsa€? a€“ a medieval Christian term for the Mongols a€“ but also from personal observation, such as the elephant given by Louis IX to Henry III, which appears as one of the prefatory images appended to CCCC 16. As Dan Terkla writes in a€?The Original Placement of the Hereford Mappa Mundi,a€? Imago Mundi, vol.
They are wholly absent from the itinerary maps, and appear in a limited scope on the Holy Land maps a€“ CCCC 16). Roughly centered, on either side of the gutter and just above the wall of Acre, are two large blocks of text.
These are not, to my observation, a common feature of the maps, and of course I cannot speculate on the date of this erasure. In contrast, the Ebstorf map, for example, gives us a gory presentation of these cannibal hordes. For Matthew and his contemporaries, there existed only one future, and its expected arrival was nearly coincident with his creation of the maps. One response might be that the sorts of monsters found on the Psalter Map and other mappaemundi were seen as normal elements of creation, rather than as portents of the apocalypse.
Returning to Matthewa€™s off-center image of Jerusalem, we find that the three structures it contains are not as they were at the time of the mapa€™s creation.
The journey may be long a€“ at least 46 days in Lewisa€™s reckoning a€“ and the path may not be singular or even, further out on the journey, marked at all, but one day, one day, one day, for Matthew anda€?his monastic audience, one day the reader would at last arrive. Their path from town to town has the appearance of being perpetually straight and direct, but in fact would twist and turn. Just beneath Jerusalem, inscribed in red and oriented ninety degrees counter-clockwise to the rest of the map, again following our orientation from our bodies, forward, we read le chemin de Iafes a Ierusalem [a€?the road from Jaffa to Jerusalema€?]. Here we seem to see movements in space as we traverse the paths a€“ initially forking for Matthew, but ultimately as singular on his maps as on the labyrinths. This is surely the case, more often than not, but medieval maps are frequently anagogic, pointed a spiritual meaning only to be realized in a heavenly future.
The extension of its city walls to the left show the fortifications constructed by St Louis during his crusade in 1252-4. Babylon of Egypt).A  The first of these is of 1231, the second of 1265, the third of 1289-1291, but it is probable that earlier redactions of the last two already existed in Matthewa€™s time, and were used by him.
The journey may be long a€“ at least 46 days in Lewisa€™s reckoning a€“ and the path may not be singular or even, further out on the journey, marked at all, but one day, one day, one day, for Matthew andhis monastic audience, one day the reader would at last arrive. Services include hearing tests, cerumen (ear wax) irrigation, hearing aid sales, hearing aid repairs (all brands) and assistive listening devices. Halligan accepts most insurance companies including Medicare, United Health Care, Anthem, Aetna, Cigna, etc. Foreman has experience diagnosing and treating hearing loss and balance disorders, and has worked with patients of all ages. She enjoys hiking, fishing, exploring the mountains, and watching college football in the fall. Therefore, the examiner, in addition to obtaining a history of the past, present, and familial audiologic and otologic complaints, should also elicit a history of complaints referable to other systems. An abnormality within the outer or middle ear results in a conductive loss of hearing due to an inefficient transmission of sound to the inner ear system. The bone conduction thresholds are normal, but air conduction results suggest a decrease in hearing sensitivity. A pure sensorineural impairment exists when the sound-conducting mechanism (outer and middle ear) is normal in every respect, but a disorder is present in the cochlea or auditory nerve. Generally, the patient with sensorineural loss reports a constant ringing or buzzing noise, which may be localized in either ear or may not be localized.
Audlometrically, sensorineural loss is characterized by overlapping air and bone conduction thresholds.
Current technology uses full dynamic range compression to increase significantly the effectiveness of amplification. The patient's behavior will reflect attributes of both a conductive and a sensorineural disorder.
In fact, this area has been emphasized to the extent that some audiologists have limited their concept of differential audiology primarily to tests that assist localizing the defect within the sensorineural mechanism.
For example, a pure-tone configuration that is often seen in patients with a presumptive diagnosis of Meniere's disease is a unilateral hearing loss most pronounce in the low-frequency range. In fact, many central auditory dysfunctions are not demonstrated by conventional audiologic measurements.


Up to 32% of the adult population has tinnitus, with 20% of the population rating their condition as severe. Most patients with sensorineural hearing loss report tinnitus to be a high-frequency tone, but tinnitus associated with conductive hearing loss tends to be low in frequency. Whether or not the patient's complaint is one of hearing loss, a basic assessment of auditory function should be part of the neurologic examination.
The neurologist should be able to recognize an inflamed, bulging, or scarred drum and should note whether there is perforation of the tympanic membrane, blood behind the eardrum, or a pulsating blue mass that may indicate a glomus jugulare tumor. Tuning forks at a frequency of 256 or 128 Hz should not be used because of the vibrations they produce by bone conduction, which the patient may mistake for Hound; 512 Hz is the lowest useful frequency. The Weber test is based on the principle that the signal, when transmitted by bone conduction, will be localized to the better-hearing ear or the ear with the greatest conductive deficit.
The Rinne test is probably the most commonly used tuning fork test, but the name is usually mispronounced: It is German, not French, and is accentuated on the first syllable (Rin'neh).
Threshold is defined as the lowest intensity (measured in decibels) at which an individual can detect a pure tone or speech signal more than 50% of the time. Most commonly, a phonetically balanced word list of 50 one-syllable words is presented to the patient at a suprathreshold level. Tympanometry is a measure of middle ear mobility when air pressure in the external canal is varied. Immittance measures are obtained at +200 mat H2O (first point of compliance, or C1) find again at the point at which the tympanic Membrane is most compliant (second point of compliance, C2). The introduction of an intense sound into the ear canal results in a temporary increase in middle ear impedance. These physiologic measures can be used to evaluate the auditory pathways from the ear to the upper brainstem.
This test is used to differentiate cochlear from eighth-nerve hearing defects and, on some occasions, demonstrates an auditory abnormality when behavioral audiometric testing is still normal.
Such patients often have marked hearing deficits with poor discrimination on behavioral testing, suggesting retrocochlear disease. This measure is beneficial in the differential diagnosis of certain types of sensory disorders, such as Meniere's disease or cochlear hydrops.
However, the neurologist interested in neuro-otology should have some knowledge of therapy to promote appropriate referrals. However, hearing aids only compensate for loss of sensitivity, but the manner in which increased loudness is achieved may reduce distortion and significantly increase discrimination in certain situations. There are many assistive devices on the market, and new systems and modifications are appearing at an accelerating rate.
In addition, the hearing-impaired should receive counseling both before and after the provision of amplification. The patient with tinnitus, regardless of location, type, or severity, must first have a thorough otologic and audiologic examination.
When a lesion or disease process is not identifiable, then tinnitus management is more difficult. There is some suggestion that relatively low doses may prove effective in tinnitus management.
The audiologist should remain cognizant of factors such as the patient's perception of the pitch and loudness and the overall spectral intensity of the masking signal. Although the use of tinnitus maskers has not proved universally successful, masking is still a feasible technique that cannot be ignored. Many patients are frightened by tinnitus and need a careful and clear explanation of the disorder, coupled with firm reassurance from both the neurologist and the audiologist.
A 12th or early 13th century copy of a Late Antique original, the map has usually been studied for what it can tell us of ancient cartography or of the interest in the ancient world on the part of the 15th century German humanists who rediscovered it.
Suited to its location in a chronicle, the map serves a historical purpose in demonstrating the route of a well-known contemporary diplomatic expedition, Richard of Cornwalla€™s expedition to Sicily in 1253 as the claimant to the crown, although the map contains information drawn from multiple journeys and routes.
For example, the Hereford map incorporates an itinerary through France and possibly one in Germany. Of the historical maps, one is a sketch showing the location of four pre-Roman roads in Britain. I will concentrate on the maps appended to the beginning of the first volume, though similar maps appear at the start of all three volumes, suggesting their great importance to Matthewa€™s conception of the Chronica, his major work. Each column, then, represents a segment of the voyage from London, at the base of the first column of folio i r, through Sienna, at the top of the final column of the itinerary on f.
It is worth mentioning that the Psalter Map is only a few inches tall, and that the whole codex fits comfortably in the hand, unlike Matthewa€™s larger, more cumbersome (and ever-expanding) volume.
In essence, the center is presented as sacred and the margins as problematic, potent, and potentially monstrous, but also thereby seductive and attractive.
This may result from the shift from counterpunctual arrangement of sacred center and monstrous margins on the Psalter, Ebstorf and Hereford maps, among others, to the less clearly structured arrangement of Matthewa€™s maps. Both are of a somewhat marvelous vein: to the left of the gutter, we read of Bedouins, whose description is reminiscent of wonders texts like the Marvels of the East.
In the Chronica and contemporary accounts, Gog and Magog are conflated with the two most prominent cultural Others perceived as threats to 13th century a€?Christendoma€™: Jews and Mongols. Second, and more importantly, the choice to include or exclude such images might have been predicated on chronology. If those mental wanderings took them to the right destination, they would realize the function of the labyrinths rather than contradict them.
Very quickly however, the labyrinth focuses your concentration on the path, else you are likely to stray from it. In walking a labyrinth, virtual pilgrims orient themselves to its shifting orientation; in traversing the itinerary, the world is bent, reorienting itself constantly to our perspective, making the shift to the trackless conclusion, the map of the Holy Land, all the more powerful.
However, since the endpoints on Matthewa€™s maps and at the centers of the labyrinths are the Heavenly Jerusalem, the motion is as chronological as it is geographical. That is, while medieval maps are organized spatially, they are in a sense oriented temporally.
The de-centered maps of Matthew, unlike the labyrinths or the Psalter Map and its cognates, do not announce their radial orientation toward Jerusalem. At the upper left is the enclosure in which Alexander confined Gog and Magog, but Matthew notes that they have now emerged in the form of Tartars. Albans, a portion of the supposed Pilgrim-road, as far as southern Italy, is given in another shape, together with the Schema Britanniae. She earned her Doctorate in Audiology from the Arizona School of Health and Sciences, a division of the Kirksville College of Osteopathic Medicine in 2001. We’re proud to offer our services to clients in the surrounding areas including Conifer, Bailey, Fairplay, Buena Vista, Lake George, Breckenridge, Hartsel and Alma.
Born and raised in south Louisiana, she earned her bachelor?s degree in Communication Disorders from Louisiana State University (Geaux Tigers!). The first few minutes spent talking with the patient or relatives will help to define the direction the inquiry should take. When the loss of hearing is due to pathology in the cochlea or along the eighth cranial nerve from the inner ear to the brainstem, the loss is referred to as a sensorineural hearing loss. The patient with a conductive hearing loss typically demonstrates decreased sensitivity across all frequencies. As mentioned, there exists some ambiguity among audiologists, neurologists, and otologists concerning what is a retrocochlear and what is a central problem. These individuals have no difficulty understanding speech at normal intensities in a quiet environment, since low-frequency hearing is unimpaired. The recruiting patient with sensory loss will not hear low-intensity sounds at all and may just barely hear sounds of moderate intensity, but the recruitment of loudness May cause moderately loud sounds to be perceived as uncomfortably loud. In general, the pitch of tinnitus tends to be higher In sensorineural impairment than in conductive impairment. The tympanogram is typically normal, and acoustic reflexes may be present, elevated, or absent. Causes of mixed hearing loss may be any combination of the conditions described above for conductive and sensorineural hearing loss. The neurologist's interest in sensorineural hearing loss is with regard to the possibility of a cerebellopontine angle tumor. In sharp contrast, patients with eighth-nerve lesions frequently present a unilateral hearing impairment most evident in the high frequencies and poor speech discrimination. Individuals with known lesions in the central auditory tracts may not manifest any significant hearing loss when tested by conventional  pure-tone audiometry. Tinnitus may be considered a significanct symptom when its intensity so overrides normal environmental sounds that it invades the consciousness.
However, knowledge of the pitch of the tinnitus is of little diagnostic benefit other than allowing for the gross dichotomy of conductive versus neural pathology. Tinnitus may precede or follow the onset of a loss in hearing, or the two may occur simultaneously. The complaint may be an early symptom of a tumor in the internal auditory meatus or in the cerebellopontine angle; a glomus tumor, or a vascular abnormality in the temporal bone or skull. Objective tinnitus may be vascular (an arteriovenous malformation or fistula) or mechanical in origin. It is usually not very disturbing, and the patient can be easily distracted from the tinnitus by other stimuli. The external ear should be inspected with an otoscope to determine the patency of the external ear canal and the integrity of the tympanic membrane.
Excellent descriptions of tympanic membrane findings may be found in modern texts of otology.
The test can determine the type of hearing impairment when the two ears are affected to different degrees.
The Rinne test is a comparison of the patient's hearing sensitivity by bone conduction and air conduction. The presence of decreased air conduc-tion thresholds and normal sensitivity by bone conduction suggests abnormality in the external ear or middle ear system and is termed a conductive hearing loss.
Comparison of the speech reception threshold and the pure tone average serves as a check on the validity of the pure-tone thresholds.
Results are graphically represented, with pressure along the x axis and compliance along the y axis.
The point at which the tympanic membrane is most compliant allows maximum transmission of energy through the middle ear cavity.
This phenomenon occurs bilaterally; however, it is typically measured in one ear at a time. In addition, ABR threshold testing may be used to determine behavioral threshold sensitivity in infants or uncooperative patients. The Amplitudes of the SP and AP are measured And are of primary interest in evaluating an ear for increased endolymphatic pressure.
Modern hearing aids use the latest microcircuitry and signal-processing techniques, such as digital filtering, to improve significantly the effectiveness of amplification.
Lastly, cochlear implants have proven to be extremely beneficial for individuals with severe to profound hearing loss who receive minimal benefit from amplification. Given no underlying otologic disease, there is at present no effective surgery or medical therapy for the treatment of tinnitus.
The actual efficacy of tinnitus maskers in the average tinnitus patient is probably less than 30%.
Biofeedback as a treatment in the management of tinnitus was first reported in the literature in the mid-1970s.
In light of the various effects tinnitus may have on a given patient, counseling must be directed toward all of the patient's difficulties, not this specific problem in isolation. It is, however, extremely important to remember the commitment of time and resources involved in producing the medieval copy: the question then arises of what this map meant to the society that found the human and financial resources to copy it. Parisa€™ map of Palestine draws on the kind of information about the length of the journey from city to city that would normally be found in an itinerary as an indication of scale for the map. Harvey has suggested that the maps of England and the Holy Land might be seen as enlargements of the end points of the itinerary.
Daniel Connolly in his book The Maps of Matthew Paris: Medieval Journeys through Space, Time and Liturgy writes that Matthew began the Chronica majora a€?as a fairly strict copy up to about 1235, of Roger Wendovera€™s Flores historiarum [Flowers of History].
There is, though, a more substantive manner in which the itineraries break down their apparent linearity: they a€?forka€? from the very start, with two paths diverging from London. Still, the Psalter Map remains a strong point of comparison for two reasons: first, it was made within perhaps a dozen years of Matthewa€™s maps. While Iain Macleod Higgins (Defining the Eartha€™s Center) is correct that a€?the viewer of a circular map can never quite lose sight of a well-marked center, since the very shape of the map keeps onea€™s gaze circling around it,a€? by the same logic, we cannot lose sight of the periphery for long, and the visual attention given to the monstrous peoples of the South, as well as the other peripheral points of interest, keep pulling the gaze back. Matthew managed through his texts, marginal illustrations and maps, to bring the whole of the world and its history, from Creation to the present, from sacred Jerusalem to the monstrous elephant, to himself and his monastic brethren.
In contrast, a€?[t]he main audience for [Matthewa€™s] maps doubtless was the brethren at St. Unlike these other maps, Matthewa€™s maps of the Holy Land de-center Jerusalem and, since it is not replaced with anything else, they do not have a clearly defined umbilicus.
To the right, more promisingly, we find a passage that begins, in Lewisa€™s translation, a€?There are many marvels in the Holy Land, of which [only a few] shall be mentioned.a€? However, these marvels are, in comparison to the Wonders of the East and other such texts, somewhat anemic. Indeed, these beasts a€“ fairly ordinary to modern eyes a€“ do appear just above the two- faced people in the Beowulf manuscripta€™s version of the Wonders of the East. Muslims occupied the Holy Sepulcher, as well as the Temple of Solomon a€“ home of the Knights Templar a€“ and the Temple of the Lord by 1250. By tracing their routes on foot or on their knees, virtual pilgrims would hope to reap spiritual rewards akin to those gained on pilgrimage, effecting peregrinatio in stabilitate a€“ that is, pilgrimage without moving.
There is a second pathway, also rubricated and turned ninety degrees, at the right edge of the map. Yes, they are oriented toward the east, but on several mappaemundi, beyond the east, it is Jesus who rises.
Instead, they challenge the viewer to work though them slowly, meditatively, to explore and wander as we do in life. She was the Director of Marketing and Sales for Bernafon, a hearing aid manufacturer, prior to opening her practice in 1989. She moved to Colorado for graduate school, and graduated from the University of Colorado at Boulder with her Doctorate in Audiology, summa cum laude. During her military service, she earned a Master degree in Human Relations from the University of Oklahoma, and a Masters degree in Human Resources from the American Military University.
The examination of the patient, the complaints, and the preliminary audiologic findings determine how inclusive the examination must be and what subsequent tests must be ordered. Patients may exhibit both conductive and sensorineural loss, which is referred to as a mixed hearing loss.
For the purposes of this discussion, we define retrocochlear as between the cochlea and the brainstem (see below). This disruption of normal loudness function may be painful to the individual and require the use of variable compression circuitry should the patient pursue hearing aid use. In addition, the patient may report that tinnitus is only present at night or when background noise is minimal, when in fact it is always present, but the patient perceives it only in quiet environments. The audiometric findings for a typical sensorineural hearing loss are displayed in Figure 7.12. The conductive component of the mixed hearing loss may be corrected by successful medical or surgical treatment, but the sensorineural component is not reversible.
Although many referrals for audiologic evaluation are made for this reason, we must emphasize that even the more sophisticated special auditory tests cannot determine the specific pathology underlying the disorder. Although such generalizations may describe a substantial number of cases falling into these two categories, numerous exceptions are encountered with either cochlear or neural pathology.
Total removal of one hemisphere of the brain in humans has not resulted in any major change of auditory sensitivity in either ear. The patient experiencing tinnitus may describe the sound as ringing, roaring, hissing, whistling, chirping, rustling, clicking, or buzzing, or use other descriptors. Because tinnitus may be a characteristic symptom of a number of disorders, a complete medical and audiologic evaluation is an important initial step in the management process. This type of tinnitus can result from a lesion involving the external ear canal, tympanic membrane, ossicles, cochlea, auditory nerve, brainstem, and cortex.


Moderate tinnitus is more intense and is constantly present; the patient is conscious of the tinnitus when attempting to concentrate or when trying to sleep. At times it may be helpful to inspect the mobility of the eardrum by increasing pressure within the external canal, using a hand-held pneumatic bulb attached by tubing to an outlet in the otoscope.
The stem of a vibrating tuning fork is placed on the skull in the midline, and the patient is asked to indicate in which ear the mound is heard. A normal individual will perceive the air-conducted sound as louder than, or the same as, bone-conducted sound. Generally, discrimination ability decreases proportionately with an increase of hearing impairment.
Contralateral reflexes are measured by stimulating one ear and measuring the reflex from the contralateral ear.
The most consistent and reproducible potentials are a series of five submicrovolt waves that are seen within 10 msec of an auditory stimulus. Both medical and surgical therapies are appropriate, depending upon the nature of the disorder.
The patient with an isolated symptom of a persistent, yet unexplained, tinnitus should receive follow-up examinations at definite intervals when initial medical, otologic, and neurologic studies reveal no evidence of disease.
These early studies reported the use of biofeedback as effective in the relief of tinnitus or the associated annoyance produced by it. It has been plausibly explained in the context of the strong interest in the classical world that we have already seen influencing the toponyms of later medieval world maps; however, more research should be done to elucidate the importance and the influence of this map. In 1240, or soon after, Matthew started writing, covering the material from 1235 and continuing to the middle of 1258, at which time another hand takes over.a€? These maps, along with the marginal images throughout the Chronica, have been securely attributed to Matthew himself and, according to Suzanne Lewis in her The Art of Matthew Paris in the Chronica Majora a€?may be regarded in large part as original conceptions and inventions,a€? rather than derivatives of traditional models. Second, unlike some mappaemundi, including Hereford (#226) and Ebstorf (#224), the Psalter Map was not freestanding.
Indeed, two of the three sites were originally Muslim structures a€“ the Temple of Solomon was a mosque and the Temple of the Lord was the Dome of the Rock a€“ and they had reverted to Muslim control by the time the maps were made. The labyrinth is at first a challenge of some dexterity, and so it also foregrounds your sense of balance and of bodily position relative to it.
The maps echo and invoke the actual experience of pilgrimage, which a€“ like modern travel a€“ was surely bewildering, disorienting, but also amazing. The Hereford, Ebstorf, and the Psalter maps are all oriented not only toward Earthly Paradise at their eastern extreme, but beyond it to the creator of that paradise.
They become all the more powerful, therefore, when their off-center, deemphasized Jerusalem turns out to be the only and inevitable end. She served on the Board of the Audiology Foundation of America, and currently sits on the Ethics board of the American Academy of Audiology.
Halligan is excited to offer audiology services to the mountain community.  Kelly enjoys hiking, playing with her dog Riley, and gardening. Central hearing loss (or central auditory dysfunction) is present when a lesion exists in the central auditory pathway beyond the eighth cranial nerve; for instance, in the cochlear nucleus in the pons or in the primary or association auditory cortex of the temporal lobe.
Generally, the low frequencies are defined as the range from 250 Hz to 750 Hz, the middle frequencies as 1000 Hz to 3000 Hz, and the high frequencies as 4000 Hz to 8000 Hz on the standard audiogram.
An MRI may indicate the presence of an abnormality somewhere in the nervous system, but it does not necessarily define the nature of the pathology.
Measures, such as tone decay, acoustic reflex measures, acoustic reflex decay, and speech discrimination at high-intensity levels must be used to distinguish between eighth-nerve, extraaxial, and intraaxial brainstem dysfunction. Although most patients report the tinnitus to be constant, others report it to be intermittent, fluctuating, or pulsating. Objective tinnitus of vascular origin may also be a referred bruit from stenosis in the carotid or vertebrobasilar system. Severe tinnitus may disable individuals to the extent that they are unable to concentrate on little other than the tinnitus itself. The cerumen should be removed, if possible, with warm water lavage using a syringe with a 5- to 8-cm piece of rubber tubing affixed to the end to avoid injury to the ear.
Little or no mobility of the tympanic membrane suggests fluid or a mass behind the drum, or a fixed ossicular chain. The usual location described for placement is the forehead; but better locations are the nasal bones or teeth when a stronger bone conduction stimulus is required. Hearing is considered normal when threshold sensitivity is between 0 and 25 dB for frequencies of 250 to 8000 Hz (Fig. However, there is an exception in conductive hearing loss in which discrimination ability remains relatively good because the inner ear system is normal.
Values below 0.25 cm3 of equivalent volume indicate a stiff or non-compliant middle ear system. Type A curves have normal mobility and pressures and typify normal hearing and seniorineural hearing loss with normally functioning middle ear systems.
These potentials are recorded by averaging 1000 to 2000 responses from click stimuli by use of a computer system and amplifying the response (Fig. Abnormal interwave latencies (I–III or I–V) are the most specific and Sensitive abnormalities seen with cerebello-pontine angle tumors. Tinnitus may be the first symptom of a disorder, appearing long before any other symptom, including hearing loss. Biofeedback is quite effective for enhancing relaxation, as are traditional relaxation procedures. These interconnections are especially striking in the rich cartographic production of Matthew Paris. On the peripheries of both maps, we see the Garden of Eden, the Red Sea, a plethora of monstrous peoples, and the hordes of Gog and Magog (feasting in bloody cannibalism, on the Ebstorf and also, perhaps, on the Hereford). In CCCC 26, the center would be just east of (that is, above) the crenellated wall of Acre.
In a sense, this follows the logic of the mappaemundi discussed above; we appear to have zoomed in on the center of these maps, to focus on the area around Jerusalem, which would necessitate cropping the worlda€™s monstrous fringe.
Like medieval labyrinths, Matthew Parisa€™s maps were not mazes per se, in that there are not alternate routes leading to dead ends: both contain singular paths.
At the same time, there is a loss of your sense of a€?placea€? in the church as orientations are constantly shifting and revolving. So, too, while these maps are centered on Jerusalem, this umbilical point presses the viewer to consider the future. The first columns contain cities connected by clearly marked paths; these are followed by columns with cities still arranged in clearly linear fashion, but without the marked paths. Foreman is licensed and certified, and has been practicing audiology in the Denver metro area. Not only should the results from the audiologic test battery be integrated, but also these data should be used With the neurologic, otoneurologic, and radiologic information for the maximum diagnostic accuracy.
In addition to these organic types of hearing loss, one should also consider functional hearing loss. Acquired sensorineural hearing loss may be caused by noise exposure, acoustic tumor, head injury, infection, toxic drug effects, vascular disease, or presbycusis. With a mixed loss, both air and bone conduction thresholds are elevated, but bone conduction thresholds are better than air conduction thresholds.
The audiologic tests, however, highlight patterns of auditory behavior that are generally associated with cochlear or neural involvement. Tinnitus may be perceived as high- or low-pitched tone, a band of noise, or some combination of such sounds. Tinnitus associated with Meniere's syndrome is often low pitched and continuous and is described as a hollow seashell sound or very loud roaring. If water lavage has not removed impacted cerumen, a neurologist should refer the patient to an otolaryngologist for removal. In unilateral hearing losses, lateralization to the poorer-hearing ear indicates an element of conductive impairment in that ear. When testing by bone conduction, the stem fork should be placed firmly on the mastoid, as near to the posterosuperior edge of the ear canal as possible.
Poor discrimination ability in the presence of relatively good hearing sensitivity may suggest retrocochlear pathology such as acoustic neuroma and should be aggressively pursued by the clinician. The abnormal prolongation or absence of wave V at increased click rates is also characteristic of retrocochlear pathology. Surgery is the primary therapy for hearing loss caused by otosclerosis, usually manifested as a conductive type of hearing loss, as described above. When medical and otologic examinations fail to disclose a remediable cause for the tinnitus, or when a diagnosis is ascertained for which no known medical therapy is presently available, the tinnitus patient should undergo further evaluation to determine the most appropriate nonmedical avenue for, rehabilitation. CCCC 26 opens, following the flyleaves reused from a manuscript of canon law, with a series of linked maps running from folio i recto through iv recto (the lowercase Roman numerals indicate the status of these folios as prefatory). The Psalter Map is one of two that form a sort of series, like Matthewa€™s maps, with one more geographical and one more linear, text replacing itinerary but no less clearly directional and effacing of actual geographic arrangement. Jerusalem a€“ so ardently central on the Psalter Map a€“ is shunted off to the right by Matthew.
However, if we assume some consistency of geographical space from map to map, Matthewa€™s expansive map, filling the complete manuscript opening and extending out onto added flaps of vellum, does reach to the margins of the world. Matthewa€™s paths seem to fork out from London, but ultimately all converge at one geo-chronological endpoint, at a place that is also a time: the Heavenly Jerusalem, at the center of the physical world and simultaneously the end of human history. Its movements to and fro, back and forth create a regular and somewhat wearying effect that combines with the hypnotic vision of the pavement receding beneath your alternating steps.
Then, the linearity ends, and we are left with images that are more conventionally a€?map-likea€? in their appearance. The diagnosis of functional hearing loss is made when an individual claims to have a hearing loss, but discrepancies in objective test measures suggest that the loss does not exist or is exaggerated. The difference between the two thresholds, referred to as the air-bone gap, represents the amount of the conductive component present.
Normal measures mentioned above, such as tone decay or acoustic reflex, strongly suggest an eighth-nerve lesion.
Tinnitus with otosclerosis is also low pitched, is described as a buzzing or roaring sound, and may be continuous or intermittent. Lateralization to the better-hearing ear suggests that the problem in the opposite ear is sensorineural. The stem should not touch the auricle of the external canal, which should be held to the side by the examiner's fingers. Responses above 25 dB are classified by degree as mild, moderate, severe, moderately severe, and profound (Fig. Abnormalities associated with reduced mobility of the tympanic membrane in associated middle ear structures include otitis media, otosclerosis, and large cholesteatomas.
Middle ear abnormalities or significant sensorineural hearing losses may elevate or obliterate the acoustic reflexes.
The anatomic correlates of the five reliable potentials have only been roughly approximated. Increased absolute latencies of all waves, compared with responses from the other ear or with clinical normative data, may signify a conductive deficit. We are able to choose our path to the Holy Land a€“ should we, leaving London, travel via the main route, Le Chemin a Rouescestre [the Road to Rochester] or the side route, le chemin ver la costere et la mer [the road toward the coast and the sea]?
Indeed, before the late-13th century insertion of additional prefatory miniatures, it was positioned before its text as a sort of frontispiece, as are Matthewa€™s, and was also one of a series of maps.
He adds an inscription referring to Jerusalem as a€?the midpoint of the world,a€? which seems visually contradicted by his map, whereas such an inscription would have been redundant on the Psalter Map. At the upper left corner of the foldout flap along the folioa€™s left edge, as if to ensure the clarity of their separation from the Holy Land, are the peoples of Gog and Magog, visually implied by the wall of the Caspian Mountains, held there until the end of time, when they are to be released to rampage across the face of the earth.
Instead, it presents the period before, but also simultaneously, the period after, the transient, lost glory of the Crusader Kingdom and the immutable glory of the Heavenly Kingdom to come. Like the labyrinthsa€™ single paths, Matthewa€™s many roads can only guide the viewer toward one destination. Most images function spatially, not linearly, but the itinerary pages present a line or course of travel; a route, much as a text would. A patient with a conductive loss has good discrimination ability if the speech signal is of sufficient intensity.
Continuous bilateral or unilateral high-pitched tinnitus often accompanies chronic noise-induced hearing loss, presbycusis, and hearing loss due to ototoxic drugs.
Touching the external ear itself could give false results because of vibration of the auricle. Ossicular chain discontinuity is the most common cause of excessive tympanic membrane mobility. Retrocochlear pathology and facial nerve disorders may also affect contralateral and ipsilateral acoustic reflexes. Wave I of the BM) is a manifestation of the action potentials of the eighth nerve and is generated in the distal portion of the nerve adjacent to the cochlea. Once in the Holy Land (CCCC 16), we are free to choose any routes we desire, as the roads themselves disappear (up until the very end, as will be discussed below).
The Psalter Map, like medieval labyrinths, is emphatically centered on Jerusalem a€“ following a new 13th century trend a€“ and around its circumference, we find points of great interest.
The Caspian Mountains, restraining the hordes of Gog and Magog, actually touch the very margins of the world on the Psalter and Ebstorf Maps, and nearly do so on the Hereford Map. They prepare and condition the viewer, raising an expectation that the maps will function in a linear fashion, and thereby convey motion in time as well as space.
A number of drugs such as aminoglycosides, quinidine, salicylates, indomethacin, carbamazepine, propranolol, levodopa, aminophylline, and caffeine, may produce tinnitus with or without associated hearing loss. Responses at 500 Hz, 1000-Hz, and 2000 Hz are averaged together to compute the pure-tone average (PTA). Upon hearing that the Mongols a€“ feared by Christians to be the apocalyptic hordes a€“ are making progress toward Europe, he imagines that continental Jews a€?assembled on a general summons in a secret place, where one of their number who seemed to be the wisest and most influential amongst thema€? instructs them to undertake a complex plot to smuggle arms to the Mongols, so that they can defeat the Christians. The final segment of the path a€“ le chemin de Iafes a Ierusalem [the road from Jaffa to Jerusalea€?] a€“ realizes this expectation.
Extremely high equivalent middle ear volume and low static compliance suggest tympanic membrane perforation. Type C curves have normal mobility and negative pressure at the point of maximum mobility (negative pressure is considered significant, for treatment when more negative than –200 mm 1.120).
Wave III IN thought to be generated at the level of the superior olive, and waves IV and V are generated in the rostral pons or in the midbraln near the inferior colliculus. Matthewa€™s fantasy is not merely xenophobic, but outright eschatological, a vital distinction in the context of the maps of CCCC 26.
Type As represents normal middle ear pressure but reduced mobility, suggesting limited mobility of the tympanic membrane and middle ear structure, commonly seen in fixation of the ossicular chain. The complex anatomy of the central auditory pathway, with multiple crossing of fibers from the level of the cochlear nuclei to the inferior colliculus, makes interpretation of central disturbances in the evoked responses difficult.
If the Mongols (or the Jews, or for that matter, the Mongols and Jews, or even the Jewish Mongols) are the hordes of Gog and Magog, then they have already broken out of the gate prophesied to contain them until the apocalypse.
It reads, Le chemin de laphes a Alisandre.a€? This seems to be a vestige, a latent echo of the itinerarya€™s multiple paths. Bone conduction will be heard better than air conduction when there is a deficit in the conduction mechanism; this is referred to as a negative Rinne.
Excellent reviews of the generation or the potential and interpretation of abnormality are found in recent contributions. This pattern indicates a flaccid tympanic membrane due to disarliculatlon of the ossicular chain or partial atrophy of the eardrum. When testing by bone conduction, the examiner should not forget to have the patient remove his or her eyeglasses: the earpiece can interfere with proper placement of the stem of the tuning fork or give inappropriate conduction or vibratory information. Although tuning fork tests allow the examiner to distinguish conductive and sensorineural loss and, in some cases, lateralize the symptomatic ear, it does not evaluate the degree of impairment or the effects of that impairment on speech understanding.




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