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Program and sound volume selections can be adjusted quickly and easy via the digital program selection keys,available for different level of hearing loss at any enviroment. Recent studies have indicated that the pathophysiological basis for tinnitus may be abnormal activity in the auditory areas of the brain rather than aberrant activity in the periphery. Tinnitus is the sensation of hearing a sound when no external auditory stimulus is present [1]. A variety of tinnitus treatments have been tried, but hearing aids, maskers, drugs, and surgical interventions thus far have not been shown to be very effective [10, 11]. In general, antidepressants appear to work best for those who are depressed or anxious, who have more severe tinnitus, or who are treated for a longer time with an adequate dose of medication [13]. Recent studies have suggested that the pathophysiological basis for chronic tinnitus is neural activity in the brain rather than aberrant activity in the peripheral auditory system [17-22].
These theories suggest that overactive feedback loops in the brainstem-thalamus-auditory cortex may be the underlying mechanism of this problem. Furthermore, the perception of tinnitus has been observed to be enhanced when the person perceiving the subjective noise "attends" to it and associates it with unpleasant emotions [28]. This model for the etiology of tinnitus suggests that, though tinnitus may be triggered by events in the periphery, the mechanisms that cause tinnitus to be a persistent and annoying condition are in the brain [32,33]. Given this theoretical background, we have approached the problem of tinnitus treatment by using customized sound-more specifically, a replica of the subjective tinnitus experience-to reduce the overactive sound-processing circuits. After completion of pilot study 1, we implemented a more formalized and longer-duration protocol. We selected subjects between the ages of 20 and 60 years if they exhibited "primary tinnitus" as defined by Dr.
In study 2, prior to recording of the EEG and eventrelated potentials (ERP), subjects had bilateral audiograms using adult routine clinical procedures with appropriate level of contralateral masking as needed. Study 2 subjects underwent an otoscopic examination, tympanogram, and ipsilateral acoustic reflex screening. The perceptual experience of tinnitus was characterized in both studies using a successive approximation technique. Auditory stimulation in both studies consisted of sine waves generated by a function generator (Goldstar FG2002C; LG Precision, Seoul, South Korea). Audiograms were taken from 7 of the tinnitus subjects and 13 of the control subjects in study 1. Most subjects indicated changes in their tinnitus perceptions very soon after beginning CST, in one case even after trying out the habituation sound for only a few minutes in the laboratory. In four of the five subjects who completed the 3 weeks of CST, hearing threshold at the frequency closest to the subject's tinnitus pitch improved by 10 dB or more (Fig.
The EEG recording procedure required the determination of hearing thresholds prior to each session. In study 1, we assessed the short-term effects of habituation on the electrophysiology by recording the N100 component from tinnitus and control subjects before and after 1 hour of CST. In study 2, comparison of the N100 responses (slope) before and after 3 weeks of CST showed a decrease in the intensity dependence in response to the 4-kHz tinnitus frequency tones (Fig.
Recent studies indicate that an altered afferent input to the auditory pathway may be the initiator of a complex sequence of events resulting in the generation of tinnitus at the central level of the auditory nervous system [17]. The hearing loss observed at the tinnitus frequencies raises the possibility that the stronger intensity dependence observed in the responses of tinnitus subjects to tinnitus frequency tones may have been caused by recruitment (abnormal loudness growth) rather than tinnitus. The observed changed intensity dependence of the auditory N100 response in tinnitus subjects in the present studies and in previously published findings [19,27,50- 52] indicate that tinnitus is accompanied by a reorganization of the tonotopic map in the auditory cortex.
Our studies on the effectiveness of CST were conducted without a placebo treatment and were not blinded.
Possible conflict of interest: Authors are shareholders in Tinnitus Otosound Products, LLC, a company developing diagnostic and treatment methods for tinnitus. How to cite this article:Samelli AG, Matas CG, Carvallo RM, Gomes RF, de Beija CS, Magliaro FC, Rabelo CM. How to cite this URL:Samelli AG, Matas CG, Carvallo RM, Gomes RF, de Beija CS, Magliaro FC, Rabelo CM. There is a program for noisy environments, one for listening to music or TV, and a Telephone-coil (T-coil) program for listening to the telephone. The US Food and Drug Administration (FDA) has not approved any drugs for treatment of tinnitus, though some studies have focused on medications, including benzodiazepines [12] and antidepressants [13].
Though studies of newer medications are ongoing, the use of current drugs involves a substantial incidence of side effects that individuals wish to avoid or often find intolerable. Functional imaging techniques have demonstrated a relationship between the intensity of tinnitus and the degree of reorganization of the primary auditory cortex. Indeed, research from our own laboratory [27] has shown that the brain activity of tinnitus sufferers in response to sounds similar to their tinnitus is different from the response to other sounds or from the brain response to sounds of people without tinnitus. In this scenario, the person experiencing tinnitus is annoyed by the sound, thereby activating the limbic system. Subjects participated in this first experiment at different times, varying between 1 and 24 months.
The THQ consists of 27 statements relating to the impact of tinnitus on an individual's life. We obtained pure-tone air and bone conduction hearing sensitivity thresholds for the standard audiometric frequencies of 250 Hz to 8 kHz in a double-walled sound suite meeting current American National Standards Institute standards for threshold air conduction and bone conduction testing. We obtained middle-ear measures using a currently calibrated, portable Grason-Stadler GS-17 acoustic immitance Middle Ear Analyzer (Grason Stadler Inc., Madison WI). Spectrogram of a typical tinnitus habituation stimulus, showing two closely spaced narrow-band noises centered at 2,800 Hz and 3,225 Hz and a very-narrow-band noise centered at 7,417 Hz that is almost 40 dB stronger than the first two.
Data were recorded from 15 electrode sites mounted on an elastic cap and located over a variety of scalp sites (F3, Fz, F4, C3, Cz, C4, P3, Pz, P4, T3, T4, T5, T6, O1, and O2 according to the modified International 10-20 System). The intensity and duration of each stimulus were set by a specially designed programmable logarithmic amplifier that is controlled in real time by a stimulus presentation and data collection program running in ADAPT.
During study 2, they were required to wear their MPEG player and listen to the customized habituation sound for 6-8 hours daily as they went about their normal activities. One of the tinnitus subjects had mild hearing loss, and three had moderate hearing loss on the right ear, whereas five had mild hearing loss, and none had moderate hearing loss on the left ear at their tinnitus frequency.
Generally, they thought that their tinnitus was much more bearable when the habituation sound was present and that the tinnitus was less bothersome at other times.
Changes in four tinnitus subjects' hearing levels at the tinnitus frequency during habituation training.
This provided records of the tinnitus subjects' hearing thresholds at their tinnitus frequency.
For the tinnitus patients, the habituation sound was the one used in habituation training, and the stimuli used for recording the N100 component were 1,000-Hz tones and the tinnitus frequency tones. N100 intensity dependence in response to A) tinnitus frequency (4000 Hz) and B) control frequency (1000 Hz). Responses to 4-Hz tinnitus frequency tones A) before versus after customized sound therapy and B) tinnitus versus control. The results of our two studies indicate that CST aimed at this central dysfunction can reduce chronic tinnitus quickly and safely. However, the reduced intensity dependence observed in responses to 2,000-Hz tones, one octave below the tinnitus frequency, is opposite to the effect of recruitment and thus not attributed to it.
The main correlate of this reorganization in our studies was the enhanced contrast between responses to tinnitus frequency and tones approximately one octave lower than the perceived tinnitus pitch. The degree of hearing loss it may cause depends on the frequency and intermittency of the exposure. The effects of noise on histological measures of the cochlear vasculature and red blood cells: A review.
Long-term exposure to occupational noise alters the cortical organization of sound processing.
Differential impact of temporary and permanent noise-induced hearing loss on neuronal cell density in the mouse central auditory pathway. Hearing loss induced by high sound pressure level in a professional rock-and-roll musicians. Is the audiologic status of professional musicians a reflection of the noise exposure in classical orchestral music?
Transient-evoked otoacoustic emissions in a group of professional singers who have normal pure-tone hearing thresholds.
Relationships between behavior, brainstem and cortical encoding of seen and heard speech in musicians and non-musicians.
Musical experience limits the degradative effects of background noise on the neural processing of sound. Preattentive cortical-evoked responses to pure tones, harmonic tones, and speech: Influence of music training.
Changes of the neurotransmitter serotonin but not of hormones during short time music perception. Burden of disease from environmental noise: Quantification of healthy life years lost in Europe. Kevin Carroll, who had designed prosthetics for other animals (including dogs, an ostrich and a duck), volunteered to help.
It trimmer instruments can be adjusted with controls called trimmers which are on the instrument itself. However, such reorganization can be reversed through training-induced changes in the response pattern of cortical neurons.
However, tinnitus sensations can be constant, loud, and annoying to the point that the sufferer is emotionally affected by this sensation. Finally, psychotherapy for tinnitus does help some, but it is aimed at mitigating the psychological effects of the problem rather than the sound itself.
This suggests that aberrant activity exists in the sound-processing circuits for sounds that the tinnitus sufferer hears. A feedback mechanism under control of the limbic system is assumed to give rise to an increased generation of tinnitus-related activity [29,30]. These studies support the idea that tinnitusrelated neuronal activity is confined to certain isofrequency regions of the auditory cortex.
We describe two studies: an initial pilot study (study 1) and one with a more formalized protocol (study 2). We first required tinnitus subjects to complete the Tinnitus Handicap Questionnaire (THQ) [44], and subsequently we audiometrically evaluated all subjects and recorded their EEGs. Susan Gold, MS, CCC-A, of the University of Maryland Medical Center, Tinnitus and Hyperacusis Clinic. It contains three subscales relating to mental health, hearing, and attitude toward tinnitus [44].
We used a Macio MA-41 portable audiometer (Maico Diagnostics, Eden Prairie MN) with a current calibration sticker for the pure-tone testing.


In response to the subjects' statements, sounds were synthesized using highprecision, general-purpose sound synthesis software. Auditory stimuli of five different intensities were presented through insert earphones (Eartone 3A transducers with Earl link foam eartips; Cabot Safety Co, Indianapolis IN).
The intensity of the habituation sound was set by the individual so that the tinnitus perception was slightly louder than the habituation sound. The hearing tests in study 2 (Table 1) showed mostly normal hearing in both tinnitus and control subjects at 1 kHz and 2 kHz. For CST to be effective, the stimulus has to be audible but must not be so loud as to mask the tinnitus itself.
However, in one case, a 10-dB improvement in one ear was offset by a 10-dB decrement in the other ear.
For control subjects, the stimuli used for recording the N100 component were 1,000-Hz and 4,000-Hz tones.
Note that tinnitus subjects showed slightly higher slopes to their tinnitus tones than to the controls' 1,000-Hz tone, both before and after habituation. Furthermore, the intensity dependence of the control 2-kHz tones (approximately one octave below the tinnitus frequency) was also significantly decreased in tinnitus subjects. This tinnitus suppression may reflect aspects of "residual inhibition" (RI), though distinct mechanisms may be involved as well. Rather, we attribute this effect on intensity dependence to lateral inhibition caused by the tinnitus-related activity in auditory cortex. After 3 weeks of CST, the intensity dependence of responses to tinnitus frequency tones was decreased, rendering the responses to tinnitus frequency tones more similar to responses from normal subjects to tones in the same frequency range.
However, to conceive of a placebo condition that is truly blinded is difficult, because CST subjects have to undergo the sound-matching process to create their own habituation stimulus. Transient reduction of tinnitus intensity is marked by concomitant reductions of delta band power. Changes in spontaneous neural activity immediately after an acoustic trauma: Implications for neural correlates of tinnitus. Tinnitus sensitization: Sensory and psychophysiological aspects of a new pathway of acquired centralization of chronic tinnitus.
Tinnitus dyssynchrony-synchrony theory: A translational concept for diagnosis and treatment.
Dynamical properties of a plastic neural network model for tinnitus therapy and inhibition of oscillation using noise stimulus. Experimental-neuromodeling framework for understanding auditory object processing: Integrating data across multiple scales.
ADAPT (Analog Data Acquisition and Processing Tools)-a software system for PC-compatible computers, designed to be used in neuro- and psychophysiological experiments, and for analysis and monitoring of various parameters of human spontaneous and event related brain potentials. Residual inhibition functions in relation to tinnitus spectra and auditory threshold shift. We address this problem by using customized sounds that reproduce the subjective experience to reduce overactive auditory circuits.
Chronic sound sensations of tinnitus affect approximately 17% of the general US population [1-3], or approximately 44 million people, and approximately 33% of the elderly [4]. In one study, tinnitus subjects with depression treated with nortriptyline had decreased depression levels, functional disability, and tinnitus loudness [15,16].
We have hypothesized that mechanisms of lateral inhibition in the auditory areas of the brain act to confine the activity, driving the tinnitus sound perception to regions representing specific frequencies in the central auditory cortex and increasing the contrast between tinnitus-related activity in these regions and spontaneous activity in adjacent regions.
The increased perception can then lead to increased annoyance, completing a positive feedback cycle that will render tinnitus persistent and annoying. Moreover, it has been shown that the changes in the size of the tonotopic map in the auditory cortex can be induced by training [35]. The rationale behind the use of white noise is to generate a decreased signal-to-noise ratio between the tinnitus-related neuronal activity and random background activity in the auditory system.
Customized sound therapy (CST) involves an initial session with a sound specialist, during which a "customized" sound is created for each individual and closely mimics the subjective tinnitus.
Primary-tinnitus subjects are those presenting to the otology clinic with a main complaint of tinnitus, regardless of type and degree of hearing sensitivity.
The audiometer has standard Telephonic THD-39 earphones with MX-41-AR ear cushions (Audiometrics, Oceanside CA) and a standard Radioear B-71 bone vibrator (Radioear Corp., New Eagle PA).
We obtained initial baseline auditory brainstem response and auditory middle latency responses for each subject using a currently calibrated and certified electrically safe Biologic Brain Atlas (Advanced Biologic Corp., Toronto, Quebec, Canada) evoked potential machine with ER-3 insert earphones. The tinnitus sound is synthesized according to the description provided by the subjects using the program "pcmusic" [46]. Experience from study 1 indicated that subjects had difficulty in distinguishing the continuous habituation sound from their tinnitus.
At 4 kHz, four of eight tinnitus subjects had mild or moderate hearing loss in their right ear, and five of eight subjects had mild hearing loss in their left ear. Therefore, the intensity settings that tinnitus subjects used on their noise generator gave an estimate of the loudness of the tinnitus. Some subjects reported changes in the sound quality of their tinnitus, so that their habituation sound was no longer a match for their tinnitus perception. Nonetheless, they were carried out under defined conditions so that changes in the measurements reflected changes in hearing threshold. Both tinnitus and the recruitment due to hearing loss may have influenced the intensity dependence of the N100 response to tinnitus frequency tones.
RI is the temporary suppression of tinnitus that occurs after the offset of an appropriate masking stimulus [48,49]. The main difference between tinnitus sufferers and controls manifested itself in the response to tones one octave below the tinnitus frequency (2 kHz in our studies).
Consequently, all study subjects will know whether they are being habituated to a sound mimicking their tinnitus or to a "placebo" sound.
The input to the circuit is a NuBus clock signal with specifications that call for a 75 percent duty cycle at 10 MHz-a square wave that's high for 75 ns and low for the remaining 25 ns. The results of two preliminary studies indicate that customized sound therapy (CST*) aimed at this central dysfunction reduces tinnitus quickly and safely.
Of this group, estimates project that some 10- 12 million individuals will experience tinnitus problems sufficiently serious to seek professional help [5,6].
Shulman and Goldstein [24] interpreted these as changes in the congruence or dyssynchrony in cortical regions in the auditory and frontal cortices. This leads to increased tinnitus perception and to what most tinnitus sufferers hear-a tone or group of tones, as opposed to cacophonous noise containing all frequencies.
In short, individuals experiencing tinnitus unintentionally condition themselves to aggravate tinnitus through negative reinforcement.
Taken together, these findings suggest that the observed tinnitus-related changes in the organization of the auditory cortex are the result of the involuntary learning process described earlier. This background activity is achieved by introducing a quasirandom, stimulus-related signal in all of the parallel, tonotopic channels of the auditory system.
This is followed by a period of several weeks to months during which the individual listens to the customized sound for several hours every day while going about normal daily activities.
On a separate day, subjects' tinnitus sound experiences were characterized and recorded on an MP3 sound player. Behavioral loudness discomfort levels (LDLs) were also recorded at each frequency in both ears using pulsed pure tones with a 200-msec duration and 50% duty cycle.
Auditory brainstem response and auditory middle-latency response two-channel recordings followed clinical recording and analysis parameters outlined in Ferraro's Laboratory Exercises in Auditory Evoked Potentials [45]. In an iterative process, the resulting sound was played back to the subjects, who responded with suggested adjustments, such as altering the pitch, number of components, balance, or quality of the synthetic sound. Within each series, 80 stimuli of different intensities, for a total of 400 stimuli, were presented in random order and at intervals varying randomly between 1 and 3 seconds. Hence, to help individuals compare the loudness of their tinnitus to that of the habituation sound, we instructed them to use the pulsed version of their customized sound. Conversely, only 2 of 12 control subjects had mild or moderate hearing loss in their left ear, and only 1 of 12 control subjects had moderate hearing loss in the right ear.
Though most subjects did not keep a detailed log of the volume settings on their MP3 players, clearly the volume setting required for the habituation sound to be just audible over the subject's internal tinnitus perception decreased over time, in one case so much that the subject exhausted the available intensity settings and the stimulus had to be resynthesized at a lower intensity.
When a new habituation sound mimicking the changed tinnitus perception was synthesized, the subjects reported the CST to be as effective as before. The first threshold measured was set to 0 dB normalized hearing level (nHL), and all other measurements were plotted with reference to it.
Because CST caused a lowering of the subjects' hearing thresholds at frequencies near their perceived tinnitus pitch, these results reflect an effect of CST, regardless of whether the observed change is caused by a decrease of tinnitus-related neuronal activity or decreased recruitment due to lowered hearing thresholds.
Some participants in this study described immediate relief, effects on the THQ, and changes in hearing threshold within 3 weeks.
The change in the EEG pattern induced by CST manifests in responses to the tinnitus frequency. However, to assess the efficacy of CST in a crossover trial with comparable therapies might be possible, as that study design would not require a placebo condition and blinding.
To generate the 20-MHz signal, the circuit produces a 25-ns negative-going pulse, delayed 50 ns from the falling edge of the 10-MHz NuBus clock input at point E. Participants described immediate relief, showed changes on the Tinnitus Handicap Questionnaire, and reported changes in hearing threshold within 3 weeks.
Approximately 20% suffer to a degree that their quality of life and productivity are impaired [7]. Similarly, magnetoencephalography (MEG) studies [25] have reported increased gamma-band activity in a resting condition in individuals with tinnitus. Shulman [31] demonstrated the changes in cortical and limbic regions in tinnitus subjects as compared to controls and hypothesized a final common pathway for tinnitus. Because training-induced changes in the response pattern of cortical neurons can be reversed by habituation, we hypothesize that habituation will ameliorate tinnitus.
TRT is available currently, but it is expensive, time-consuming, of long duration, and only incompletely effective. Furthermore, subjects' tinnitus had to be present all the time with constant sound quality. We instructed each subject to push the signal button when an increasing continuous pulsed pure tone reached a subjective loudness level that represented initial annoyance.
The evoked potential recording protocols sequentially programmed into the Brain Atlas were the same for each subject. In response to these suggestions, we modified the sound description file and repeated the process until the subjects reported that the synthesized sound matched their subjective tinnitus experience well. The EEG was amplified by 10,000 and band-pass filtered between 0.01 and 100 Hz at 3 dB down.
This facilitated the determination of the requisite intensity, at which point they could switch over to the continuous sound for the habituation itself.
After 1 hour of habituation, the hearing threshold at the tinnitus frequency was lowered by as much as 15 dB nHL.
Observations from one subject indicate that most of the tinnitus relief is gained during the first 4-8 weeks of CST. However, the contrast between responses to tinnitus frequency tones and tones one octave below the tinnitus frequency was not changed after 3 weeks of CST.


We also saw changes in the intensity dependence of the auditory N100 in tinnitus patients, supporting the idea that tinnitus reflects a reorganization of tonotopic maps in the auditory cortex. This translates to between 2% and 3% of the population whose lives are adversely affected by tinnitus [8,9]. Studies in experimental animals and humans have suggested that tinnitus is associated with a synchronized hyperactivity in the auditory cortex and proposed that the underlying pathophysiological mechanism is thalamocortical dysrhythmia. More precise methods of habituation have been suggested by computational models of tinnitus [37-41]; for a review, see Husain, [42,43]. This external sound appears to calm the internal overactive circuits and is not associated with annoyance and anxiety. Subjects were initially interviewed at the Otolaryngology Clinic to ensure that they met all exclusionary criteria. The LDL was repeated at each standard test frequency to determine whether the initial level was stable or adjusted upward.
We required subjects to document the time during which the sound player was used and the intensity settings. Over several weeks of habituation training, we observed hearing thresholds at the tinnitus frequency to decrease by as much as 25 dB nHL. After this initial period, apparently wearing the sound device regularly is unnecessary, and the experience with this one subject indicates that using the habituation sound occasionally as needed may be sufficient.
Therefore, whether longer CST treatments can completely reverse the cortical reorganization associated with tinnitus remains to be seen. Finally, applying the 25-ns pulse to the set input of a set-reset input, results in a 10-MHz square wave at F.
The main correlate of this reorganization was the enhanced contrast between responses to the perceived tinnitus pitch and tones approximately one octave lower. Estimates anticipate that the number of serious tinnitus cases will increase significantly over the next few years. Hence, decreased auditory stimulation results in decreased firing rate and decreased lateral inhibition. These models explain how a decreased auditory input resulting from a peripheral hearing deficit can give rise to a specific tinnitus pitch. One contained a pulsed version of the subjects' tinnitus sound (250-msec pulse duration, 50% duty cycle), and the other was a 180-sec-long continuous sound.
For stimulus presentation and data acquisition and analysis, the ADAPT scientific software [47] was used. After 3 weeks of CST, the intensity dependence to the tinnitus pitch decreased, making these responses more similar to those from normal subjects responding to tones in the same frequency.
When the tinnitus sound itself is used as a habituation stimulus, Langner's model predicts that the tinnitus should disappear. Directive counseling would tend to draw the individual's attention to the tinnitus, whereas habituation is designed to draw attention away from the tinnitus.
We recorded responses to pure-tone sounds at and below the tinnitus frequency before and after the 1-hour habituation treatment. Two subjects dropped out after reporting strange sounds from their MP3 player that seemed to make their tinnitus worse. We then downloaded the digitized sound into a small portable digital sound playback device (MPEG-player). The underlying rationale for CST is to draw subjects' attention away from their tinnitus, and reports indicate that though subjects readily perceive their tinnitus and the habituation sound if they choose to, CST helps them to ignore their tinnitus.
In summary, decreasing cochlear input into the central auditory pathway may induce apoptosis in the neurons, which reduces cell density in the ventral cochlear nucleus.
This model also assumes that the limbic system is a necessary component for stabilizing the tinnitus perception. In one case, the cause of the disturbing sounds was a defective MP3 player; in the other case, the disturbing sounds were caused by an artifact in the conversion of the digitized sound from the WAV to the MP3 file format.
The time needed for this successive approximation procedure varied, depending on the subjects' ability to describe their subjective experience of tinnitus and on their ability to characterize differences between the tinnitus they experience and the sounds being synthesized by the computer. Directive counseling in connection with CST might actually be counterproductive because it might remind subjects of the annoyance associated with untreated tinnitus and thereby draw their attention to their tinnitus rather than away from it. Next, the cell density and important structures of the central auditory pathway (central nucleus of the inferior colliculus, medial geniculate body, and primary auditory cortex) are also affected by overstimulation of the neurons and intense calcium influx.
On the basis of these models, we propose to use a frequency-specific or "custom-made" sound similar to an individual's tinnitus for habituation purposes.
Halfway through the training period, we scheduled a second session to characterize the tinnitus sound to ensure that the stimulus still matched the subjects' tinnitus perception. In one case, data were excluded because the subject did not wear the MP3 player for the requisite time and was not present for the follow-up examination owing to scheduling conflicts.
Because it produces effects after only a few weeks of treatment without involving directive counseling or requiring frequent regular visits to health care professionals, CST is expected to provide quick and lasting relief from tinnitus at relatively low cost. We conjecture that using a customized sound and mimicking the tinnitus as closely as possible should be highly efficient in reducing the perception of tinnitus. After 3 weeks, all subjects underwent a second EEG and audiological assessment and a final clinical evaluation. Before beginning CST, we required subjects to confirm that the habituation sound matched their tinnitus during two or more sessions separated by at least a week. Further, though adding a replica of the annoying sound that tinnitus patients experience would appear to be even more annoying, the method of playing the replica at the same volume as the experienced sound minimizes any discomfort.
Adjustments to the stimulus were needed for some subjects after CST had progressed a few weeks.
It seemed clear that this was owing to changes in the characteristics of the tinnitus itself rather than a mismatch in the initial sounds.
Hence, recent studies on music-induced hearing loss have adopted advanced audiological measurements (high frequency audiometry and otoacoustic emission) for the early identification of these damages, even before the changes can be detected by conventional audiometry. The present studyIn the present study, we evaluated peripheral and central auditory pathways in professional musicians (with and without hearing loss) compared to non-musicians.
Under all conditions, the mean intensity of the clicks was 78 - 83 peSPL, and 200 sweeps were recorded for each ear.
The response level was determined by measuring the signal-to-noise ratio with an analysis time window of 4 - 20 ms. The nonlinear transient click of 80-μ s duration was presented at a rate of 50 Hz, in alternating blocks. The individuals were tested in a sound booth, in a quiet room.The electrophysiological tests (Auditory Brainstem Response - ABR, and Cognitive Potential - P300) were carried out in an electric- and sound-attenuated testing room. The ABR measurements were duplicated to ensure fidelity.The oddball paradigm was used in the P300 recordings.
This paradigm was based on distinguishing between a target stimulus repeated randomly (20% of the time) and the non-target stimuli, with frequent repetition (80% of the time). Frequencies were 1000 Hz for the frequent stimuli (non-target) and 1500 Hz for the rare (target) stimulus. Standard Bio-logic TDH49 headphones were used to deliver the sound stimuli for the electrophysiological tests.Latency and amplitude of the waves were analyzed.
The P300 were analyzed after subtracting the curves resulting from the rare and frequent stimulus (of the same ear), and were measured at the most positive point (amplitude), from 250 to 600 ms.For the statistical analyses, the Kolmogorov-Smirnov test was applied to determine normality of the variable distribution. We used the Analysis of Variance (ANOVA) and Tukey's test for quantitative analysis and Chi-square (Fisher's exact test and Mantel-Haenszel) for qualitative analysis. Thus, both ears of the individuals in each group were grouped and 16 musician subject responses (32 ears) were compared with 16 non-musician subject responses (32 ears).
The values significantly differed between the three groups for 2 and 3 kHz, and for 12.5 to 18 kHz. Nevertheless, the mean values in the musicians group (MG and HLG) were worse than in the control group. A previous study [27] found 38% sensorineural hearing loss in high frequencies and 69% absent otoacoustic emissions in orchestral musicians.
Another study [28] found 100% normal hearing, but 60% absent responses of TEOAE in rock musicians. A third study [29] observed that TEOAE was present in all evaluated singers, but with less robust responses when compared to the control group. It should be noted that these studies evaluated parameters different from those evaluated in our study and did not consider the 'partially present' values, which in our study showed a high prevalence (100%).
These professionals, with musical training and practice, increase the spontaneous attention to the sound and their sound discrimination abilities. Some authors [31] have evaluated the ABR and cortical evoked responses of musicians and non-musicians and shown that musicians have earlier responses when compared to non-musicians, indicating rapid identification and perception of sound by musicians. The auditory training through the musical experience provides a neural synchrony to the auditory system as well as faster responses to the presence of sound, as has been concluded in another study, [32] which has analyzed the ABR of musicians to speech sounds.Our results agree with those of the previous studies, although no significant differences for ABR waves were found between groups. Also, for qualitative analysis, we found that the MG and HLG had fewer individuals with alterations in ABR than the NG, a result that suggests a good integrity of the auditory brainstem response in this population.With regard to the P300 results, although three groups showed mean values within normal limits, the MG and HLG showed a shorter latency than the NG.
Some authors [33] assessed how musicians responded to pure tones, harmonics, and speech, by analyzing the components in N1, and P300 auditory evoked potentials of long latency, and compared these results with those obtained in the control group (non-musicians). They concluded that musicians regularly exposed to music showed shorter latencies for harmonic and speech stimuli, and for pure tone results they found no difference between the groups, although the musicians group had shorter latencies of the P300 wave, similar to what we found.Thus, our findings do not support the hypothesis that the central components of the auditory pathways can also be affected by acoustic overstimulation. Music tends to be intermittent, with loud passages and quiet passages intermixed, while industrial noise tends to be continuous.
Perhaps this intermittency makes the music slightly less damaging than an equal intensity of noise for a similar length of time.
However, another study [36] documented a measurable loss in the hearing function of workers in 328 construction industries in their first three years of work. Also, it is possible that a change in the circulation in the auditory pathway on a hormonal basis, if music is perceived as pleasant, makes music less damaging than noise.
This function may be caused by sounds rated as pleasant or unpleasant, which may trigger negative reactions in the entire system that results in a cascade of adverse events.Future studies with animals comparing different acoustic stimuli that resemble the characteristics of music (spectral and temporal) are important for this hypothesis to be tested. A comparison with the effects of noise can be made by checking the effects on the peripheral and central pathways of different types of stimuli.A limitation of our study is our small sample of musicians, which included guitarists and drummers only. This was done in an attempt to minimize the variety of different instruments and music exposure of professional musicians, as they may carry different audiological features.An analysis of musicians showed that drummers had worse hearing thresholds and smaller TEOAE amplitudes when compared to guitar players. Drummer players present a bigger damage most likely because of the impact noise produced by the instrument.
This approach allowed us to find that music can cause damage to the peripheral auditory pathways. Additionally, music may act as a training tool for central auditory pathways, improving the processing of acoustic information to the cortex. Future studies in which more musicians playing different instruments are included will be enlightening.However, we cannot rule out that central damage can also be caused by the music itself, when exposure occurs for long times. As indicated by others, [23],[27],[39] hearing protection measures should always be taken with this group of professionals, including engineering control measures (acoustically, the sound source distance, decreased amplification, etc.), personal protection (use of protective earplugs for musicians, with uniform attenuation of frequencies), training in placement and cleaning earplugs, educational programs, audiological monitoring, and others.
However, the electrophysiological evaluation showed that latency waves of ABR and P300 diminished in musicians, which may suggest that the auditory training of musicians, who are exposed to sound in the profession, acts as a facilitator of the acoustic signal transmission to the cortex, that is, provides a better processing of acoustic information by the central auditory nervous system.



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