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Suzanne ElvidgeCorresponding AuthorSuzanne Elvidge has been a freelance writer since 2006, and has spent the last 25 years working in science journalism, publishing, and communications. Although the ear is protected by a blood-labyrinth barrier, aminoglycosides can cross this barrier and travel into the cochlea where they enter the sensory hair cells through mechano-electrical transducer (MET) channels and kill the hair cells.
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The situation has changed greatly with gentamicin treatment in the last few years -- this document has recently been updated to reflect the very good results that have been obtained with a newer protocol - -low dose gentamicin. Disability is lessened in patients with Menieres after TTG treatment (Pfleiderer, 1998; Perez et al, 1999).
A substantial advantage of TTG treatment is low cost, compared to alternative destructive treatments (i.e. The low dose method involves using 1-2 injections of gentamicin, waiting a month between injections. In our practice in Chicago, we have had excellent results with the low-dose variant, with excellent control of dizziness (100% so far) with no hearing damage at all. A single dose treatment was reported by at the Mayo clinic, with 84% response rate of vertigo, and no change in hearing. The low dose of gentamicin over a prolonged time is likely to have a more uniform effect on the ear than brief, concentrated administrations (Pender, 2003), and also would seem likely to pose much lower risk to hearing. Rarely, even after 6 injections, vertigo cannot be induced and vestibular function remains normal. Figure 2: The goal of high dose intratympanic gentamicin treatment is to reduce or eliminate vestibular function from one ear. Figure 2 above shows the expected result of high-dose gentamicin -- spontaneous nystagmus and vertigo. The idea of the low-dose protocol is to do a small amount of permanent damage to the ear, just enough to permanently stop vertigo spells. TTG reduces the size of the summating potential of ECochG , which is a diagnostic test for Meniere's disease (Adamonis et al, 2000).
We think this conclusion is overly negative -- we think that the low dose gentamicin protocol is reasonably well established in the recent literature. When to stop treatment is also an issue, especially for the high-dose protocol with weekly injections.
In our practice in Chicago, we have had good success in using vibration induced nystagmus to decide whether or not gentamicin has had an effect. There is literature that supports the idea that VEMP's are reduced or abolished following ITG. It is very difficult to compete with the low-dose procedure in terms of results, because they are so good.
Some groups have experimented with adding other agents to gentamicin, apparently in an attempt to make the solution more viscous and less likely to run down the eustachian tube as soon as the patient sits up.
Ishiyama and associates (2007) reported pathology of the inner ear in a single patient with failed ITG (several attempts), followed by a successful labyrinthectomy. We do not think that one needs to try the numerous treatments for Meniere's that are probably placebos, as these waste time and money, and low-dose gentamicin is very effective. Commercial gentamicin, rather than being a single chemical, actually consists of 3 related compounds. Instillation of gentamicin in the middle ear to cure severe Meniere's disease is of considerable value in the control of vertigo. Meniere's disease is characterized by a combination of fluctuating hearing loss and the presence of aural fullness, tinnitus, and intense rotatory vertigo attacks. Conservative treatment, including a low-salt diet and the regulation of internal medical disorders, a stress-free life, and pharmacological therapy may help some patients such that no further treatment is necessary. Ototoxic treatment in the middle ear offers a relatively safe way to treat this disabling form of Meniere's disease, carrying with it only the risk of damage to one's hearing ability. Since 1980, sixty-nine patients with a disabling form of Meniere's disease have been treated with gentamicin instillation in the middle ear. During the period 1980-1988, gentamicin was instilled daily through the tympanic membrane until there plantation, Patient 7 suffered from Meniere's disease in the left ear. Previously, an articulation test of grammatically correct but nonsense Japanese four-segment sentences improved after electrical stimulation of the ear. The side on which the device is implanted is very important, especially in bilateral tinnitus patients.
We used a 10-khz sinusoidal wave for a carrier frequency because of the efficacy of the magnetic conduction system [15].
Otolaryngology, also known as ENT (ear, nose and throat), is the oldest medical specialty in the US which focuses on disorders of the head and neck. The following are some examples of common compounded medications used to treat ENT-related conditions. We can customize medications into many different dose forms that will help to maximize therapeutic success.
Shibboleth is an access management service that provides single sign-on to protected resources. How to cite this article Matsushima J, Sakai N, Uemi&# N, Miyoshi&# S, Sakajiri&# M, Ifukube&# T. An electrical tinnitus suppressor developed at the Hokkaido University was implanted in two women and five men, aged 44-77 years old. The AI registered at a severe level in five patients and a moderate level in two patients before implantation of the suppressor. The TII registered as extreme in all patients before implantation of the suppressor, although the intensity of tinnitus varied from patient to patient according to the loudness balance test. After the operation, at TST, AI, and TII results were positively correlated (p =.01), though there was no correlation among these parameters before the operation.
There is a clear agreement among implant groups that the majority of patients can experience tinnitus suppression while using an implanted electrical tinnitus suppressor [1].
An electrical tinnitus suppressor incorporating the use of an extracochlear stimulator has been developed at Hokkaido University [2].
Although we often speak of tinnitus as if it were a single entity, tinnitus actually consists of sensory and affective components [5].
The differences in the degree of affective disorders that patients perceive are explained by a stress model for tinnitus [7].
Such affects as insomnia, annoyance, anxiety, and interference in communication capability that are induced by tinnitus would constitute stress that is highly associated with patients' quality of life.
Therefore, a good assessment of the impact of tinnitus on patients' lives should be based on the amount of stress induced by tinnitus.
Few questionnaires are available to ascertain the degree of tinnitus that would affect patients' lives [9,10]. Patient 1, 57-year-old woman, complained chiefly of bilateral hearing loss and tinnitus in the left ear.
Patient 2, a 61-year-old woman, complained chiefly of bilateral hearing loss and right-ear tinnitus at the first consultation. Patient 5, a 67-year-old man, was chiefly concerned with bilateral hearing loss as a result of ear infections in childhood and tinnitus in both ears. In Patient 7, a 44-year-old man, audiography showed moderate hearing loss in the right ear due to Meniere's disease. The electrical tinnitus suppressor consists of an external coil inside a behind-the-ear type of hearing-aid case and an implanted coil in the mastoid [3]. Seven patients in whom a tinnitus suppressor was implanted received three self-evaluative tests in April 1996: the TST, the tinnitus intensity index (TII), and the annoyance index (AI).
Annoyance refers to interference in lifestyle-that is, vocational, recreational, and social activities as well as sleep. Tinnitus in six patients disappeared for several hours to a half-day after electrical promontory stimulation at the outpatient clinic Table 2.
Before device implantation, five patients registered an extreme level on the TST, one patient was at a moderate level, and one was at a severe level.
All patients reported an extreme score on the TII before device implantation, although the intensity of tinnitus varied from patient to patient based on the loudness balance test. The TII finding revealed the loudness of tinnitus as perceived by the patients before and after the operation; the implanted tinnitus suppressor was effective for improving the sensory component in all patients.
The AI scores revealed a severe level in five patients and a moderate level in two patients before device implantation. Patient 1 experienced a small amount of persistent tinnitus in the left ear all day after device implantation in the right ear, although tinnitus reappeared during a common cold and when the patient was very tired. Patient 2 abandoned use of the stimulator because of the electrode trouble she experienced in 1996. Patient 3 experienced tinnitus disappearance for several hours in the implanted ear after 30 minutes of stimulation. Patient 4 has experienced no tinnitus in the unimplanted ear after usage of the suppressor. In Patient 5, tinnitus in the unimplanted ear has completely disappeared, and tinnitus in the implanted ear usually disappears after several electrical stimulations per day.
Patient 6 had never experienced relief from tinnitus since the first consultation at our outpatient clinic. After use of the suppressor, hearing in Patient 7 improved to normal (Figure 4) and tinnitus completely disappeared except when he was suffering from a common cold or from extreme tiredness. We recommended two female and five male tinnitus patients for implantable tinnitus suppressors. Patients selected for the implantable suppressor should have experienced tinnitus disappearance for more than a few hours after electrical promontorium tympani stimulation at an outpatient clinic. In addition, the intensity of alternating current stimulation for tinnitus relief was emphasized because the stimulator is designed to be portable. Previously, we reported the outcome of treatment of tinnitus with an implanted tinnitus suppressor in 3 of 7 patients considered in this study [11]. For Patient 2 in the earlier report, we noted that the effect on tinnitus suppression was unstable. The third report in our earlier publication (concerning Patient 6 from the present study) noted that the patient experienced tinnitus all day despite using the stimulator twice daily.
A discrepancy was demonstrated among these patients regarding the degree of annoyance and tinnitus intensity before the operation.
Subjective improvement in hearing was reported in the ear with tinnitus relief after combination therapy of tinnitus masking and external electrical stimulation, although no change in the hearing threshold was demonstrated by audiometric testing [13].
The patients have been investigated with electronystagmography, dynamic posturography, pure-tone audiometry, and speech audiometry before and after the gentamicin treatment. Six patients were given three instillations, whereas 25 patients were given four instillations (either according to the quadruple method or via a repeated dual method). With use of the initial method of daily drug instillation until the effect was obvious, three ears became deaf. For patients treated by the original unlimited method, the mean hearing loss after treatment was 12 dB.
We wished to determine whether the pure-tone threshold level was predictive of the hearing result after treatment. After gentamicin treatment, the endolymph-producing dark cells in the stria vascularis are damaged and, possibly, their function is diminished [12,13]. Dynamic posturography reveals that in the weeks immediately subsequent to gentamicin treatment, an ataxia is present that gradually disappears and, after 3 months, is no longer detectable [16]. Without vestibular rehabilitation and physiotherapy, there is a risk for some permanent ataxia and slight vertigo. In addition to the shunt operation, other surgical procedures such as labyrinthectomy or vestibular nerve sectioning might be performed. She writes about pharmaceuticals, consumer healthcare and medicine, and the healthcare, pharmaceutical and biotechnology industries. Because of their broad-spectrum effect, they are often used as first-line treatment for suspected sepsis in newborn babies, often before infection is confirmed. These cells, which translate sound into electrical signals, cannot regenerate once damaged, and the risk increases with rising dose and longer duration of treatment. The main alternative to the mechanism being destruction of dark cells is the hypothesis that there is a partial damage to the vestibular hair cells. 2004) reported that low-dose methods have significantly poorer vertigo control (66.7% overall).
If low-dose does indeed reduce pressure in the inner ear, it may be that hearing will deteriorate to a lesser extent.
We routinely recommend use of half-dose gentamicin in persons having this done who are over the age of 70. We don't think that this conjecture is correct, but it would be an interesting project for a researcher to investigate.
The treatment is stopped when vertigo ensues, indicating that the gentamicin is affecting the inner ear. At this point, treatment is stopped and another method of eliminating vestibular function is used (such as labyrinthectomy). This causes an imbalance between the two ears, and a spontaneous nystagmus or jumping of the eyes.
This made sense as in a meta-analysis of variant methods was recently reported by Chia and others (Chia, Gamst et al.


There would seem to be little advantage in experimenting with streptomycin as gentamicin works very well without appreciable risk to hearing when given at long intervals.
A variant of titration method might be to continue injecting until the VEMP is greatly diminished. It is also difficult to understand the rationale of putting in a constant infusion of a drug, when it is well known from animals that gentamicin accumulates in the ear over many months.
It is hard to see how a drug that goes in and out of the ear in 3 days, costs quite a bit to the insurance system, and is associated with significant risks (of perforation) could make much positive difference to a lifelong illness. We see little reason why any other procedure should be advocated, unless low-dose gentamicin has already failed. We don't think that use of steroids here is a good idea, as it seems to bring on another complication.
We presume that these individuals have a better ability to either adapt to vestibular lesions or recover from them. Oddly, we have found a few major medical centers, or even entire large metropolitan areas that seem to be unaware of the low dose gentamicin option. Examples of procedures that are probably placebos or at least only slightly effective, are the Menniett device, intratympanic steroids, and endolymphatic shunt surgery. The Effect of Intratympanic Methylprednisolone and Gentamicin Injection on Meniere's Disease. Chemical labyrinthectomy for the worse ear of adult Nigerians with bilateral Meniere's disease: preliminary report of treatment outcomes. The drug causes diminished endolymph production and, most often, a peripheral vestibular loss. The attacks are accompanied by intense nystagmus, which often changes direction during an attack.
However, if conservative treatment is unsuccessful, pressure treatment or an endolymphatic shunt operation may be necessary.
Gentamicin intratympanic treatment for Meniere's disease was developed by Lange, [1-3] and later used by Beck and Schmidt [4] and Ödkvist et al.
For ipsilateral tinnitus patients, the side of implantation was the ear having the worst hearing threshold.
However, Shulman [5] reported that electrical stimulation with transtympanic electrode placement produced a sensation of vibration, auditory perception, electrical masking, tinnitus suppression, and pain. We compared the burst wave of a 10-kHz frequency with the continuous sinusoidal wave of a 10-khz frequency.
Lange G: Die Indikation zur intratympanalen Gentamycin- Behandlung der Meniereschen Krankheit.
Beck C, Schmidt C: Ten years of experience with intratympanally applied streptomycin (gentamycin) in the therapy of morbus Meniere. Magnusson M, Padoan S: Delayed onset of ototoxic effects of gentamicin in treatment of Meniere's disease.
Tran Ba Huy P, Deffrennes D: Aminoglycoside binding sites in the inner ears of guinea pigs.
It replaces the multiple user names and passwords necessary to access subscription-based content with a single user name and password that can be entered once per session. However, the AI improved after the operation, being moderate in three patients and mild in two, and achieving no level in two patients. After device implantation, the TII did not register any level in two patients, was mild in another two patients, was moderate in yet two more patients, and was severe in a patient whose device had electrode trouble. However, implantation for tinnitus suppression previously was not performed in patients with nearly normal hearing because of the cost and potential damage to the cochlea. This device is likely to result in minimal damage to the cochlea because the stimulating electrode is near the round window. The sensory component is a sound sensation, whereas the affective components are many, including insomnia, annoyance, anxiety, and interference in communication capability [6].
It is hypothesized that both the hippocampus and the amygdala of the medial temporal lobe system are significant for transition from the sensory to the affective component.
The tinnitus stress test (TST) is a tool for monitoring the efficacy of treatment, control, and relief procedures for tinnitus. She has suffered from chronic otitis media that has resulted in bilateral eardrum perforations. In procedure A, each of 16 questions was equally weighted and scored on a 5-point rating scale. The index was rated by each individual as 0 for no tinnitus and 7 for the loudest imaginable. The AI was rated by each individual as mild (1 or 2), moderate (3, 4, or 5), or severe (6 or 7). The duration of residual tinnitus inhibition with the implanted suppressor was similar to that at the outpatient clinic except in one patient in whom the electrode broke free from the promontory.
Post-operatively, the results of TST improved except in one patient who experienced electrode trouble (Figure 2). After the operation, results of the TII reveal no level in two patients, a mild level in two other patients, a moderate level in two patients, and a severe level in a single patient (Figure 3). Only Patient 6 did not experience tinnitus disappearance, although the intensity was diminished relative to that before the operation.
Tinnitus did not disappear in the implanted ear if the patient was suffering from a common cold or was very tired.
The tinnitus weakened so dramatically after the operation that he was satisfied with the suppressor. No vertigo, ear blockage, headache, or worsening of residual hearing level was reported either.
For patient selection, we emphasized the evaluation of residual tinnitus suppression after transtympanic electrical stimulation.
Patient 6 never experienced the disappearance of tinnitus at an outpatient clinic, and so in this patient we could not guarantee tinnitus disappearance even if he continued to use the implantable device.
In our earlier report, Patient 1 still experienced slight tinnitus all day after using the device, and tinnitus reappeared during a common cold or when the patient was tired. When the patient began using the device, she experienced little tinnitus all day after 1 hour or more of stimulation two or three times daily.
All patients before the operation thought that the intensity of tinnitus was the loudest imaginable.
Patient 5 also reported improvement in his hearing" but the hearing threshold did not improve after use of the implantable suppressor. It should be noted, however, that among the 69 patients involved in this study, only 3 failures of the vertigo treatment were seen. The quadruple method caused a mean hearing loss of 8 dB, whereas in the patients treated by the dual strategy, no mean hearing loss was noted. In Figure 3, a comparison is made between the pure-tone threshold before treatment and the change in pure-tone average after treatment. Also, the vestibular epithelium is damaged or destroyed, causing a unilateral vestibular loss that results in a destruction type of nystagmus and caloric loss [14].
Also, if a full effect of gentamicin is not experienced with a few instillations of the drug, a risk for vertigo attacks remains.
The labyrinthectomy offers relief from the attacks of vertigo but also abolishes hearing totally and so should not be used. If correctly applied, gentamicin treatment is the method of choice and should be attempted before destructive surgery is even considered.
She has written for a variety of magazines and journals, including Nature Biotechnology, Life Science Leader, New Scientist, Start-Up and Chemistry & Industry, and has authored a number of industry reports and ebooks. Several authors have reported that tinnitus or fullness may improve substantially after TTG (e.g.
Most authors find that the control of vertigo is comparable to vestibular nerve section (about 90%).
The low dose variant is relatively new, and there is not nearly as much data concerning outcome as the high-dose variant. Recent studies in animals suggest that the type-I hair cells are the most sensitive, and the type-II hair cells are more resilient.
In other words, the treatment is continued until there is evidence of damage to the inner ear. It should be noted, however, that small mammals like this have much thinner round window membranes than humans, and therefore may get a much larger amount of gentamicin over the same period of time. We have also noted that all patients with successful low or high-dose gentamicin have strong vibration induced nystagmus. However, we have encountered one patient, who had migraine misdiagnosed as Meniere's, and who had 2 injections of gentamicin.
2004), the weekly titration method of delivery had the best results with both the best vertigo control and a trend towards less overall hearing loss. However, there are sometimes situations where one wants to get a lot of drug in fast, and accept more risk to hearing. As has been mentioned already - - given the clear superiority of small-dose gentamicin over multiple dose protocols, there no longer seems to be any reason to give more than 1-2 injections, so titration is not really an issue. A problem with this idea is that the injection itself might cause a conductive hearing loss that interferes with the VEMP.
They suggested that potential sources of recurrent vertigo in the patient include the contralateral ear (unlikely as labyrinthectomy worked), the saccule of the ipsilateral side (unlikely that saccule was spared by a drug that affected rest of the inner ear), and the severely damaged utricle (again unlikely).
This good experience is similar to the experience of others, even when they are less cautions than we are(Olusesi et al, 2014). It is best to go somewhere else if your otologist suggests that you will need 4 injections, or wants to repeat the injections in less than 1 month. It would be interesting to know if use of the compound that is most vestibulotoxic might cause better results than the mixture of compounds. After vestibular rehabilitation, led by a physiotherapist, the ataxia should be resolved as a result of central compensation. During the initial attacks, a hearing loss can usually be unveiled with pure-tone audiometry and, during the periods between attacks, the hearing may return to normal.
Some patients with Meniere's disease reach a state of repeated severe vertigo attacks that diminish the quality of life.
Four had been operated on using the shunt method and had experienced relapse of the disease process. Patient 7 underwent endolymphatic shunt surgery in the left ear at another hospital in February 1997. Therefore, improved hearing after electrical stimulation may be due to improved cognitive processing in the central auditory system in addition to improved hearing at the cochlea. Hence, the suppressor was implanted in the ear with tinnitus in patients 2 and 7 because the hearing threshold in that ear was worse than that of the other ear. For example, in Patient 4, the intensity of tinnitus was the same in both ears, but the hearing level of the right ear was slightly worse than that of the left ear. According to a sensagram proposed by Shulman [5], auditory sensation was preceded by tinnitus suppression. When the burst wave of a 10-kHz chiem' damage is minimized if the dual method of gentamicin administration is used.
Presented at the Third International Symposium on Meniere's Disease, Rome; Italy, October 20-23, 1993. Based on the idea that cochlea hair cells and neural cells are from same developmental origin, the effect of LLLT on hearing loss in animal models is evaluated. Residual inhibition results found at outpatient clinics and at the homes of patients with implanted suppressors were closely correlated except in one patient in whom the device's electrode was free from the promontorium tympani. After the operation, the TST improved except in one patient whose device had electrode trouble.
In addition, the small size of the implanted chip coil (6 mm wide, 5 mm thick, and 10 mm long) in the mastoid contributes to the avoidance of injury risk [3,4]. The severity of the affective component is not always commen-surate with the severity of the sensory component. The transition is purported to be modulated by the influence of stress, according to the level of cortisone [7].
The tinnitus described by this patient was white noise at an intensity of 95 dB in the right ear and 75 dB in the left ear.
Endolymphatic shunt surgery was performed 2 years before implantation of the tinnitus suppressor but failed to improve this patient's hearing loss or to decrease the number of vertigo attacks. The electrical stimulator weighs approximately 300 g, and the electrical pulse is provided by 100-V alternating current. Briefly, the silicon-covered coil is implanted in the mastoid after mastoidectomy using a postauricular incision. The TIl was rated by each individual as mild (1 or 2), moderate (3, 4, or 5), or severe (6 or 7). Six patients' responses registered as no or mild level on the TST, and only one patient still reported an extreme level on this test.
Filled bars show the level on the tinnitus stress test before the operation, whereas open bars indicate postoperative levels.
Tinnitus in two patients who registered as no level disappeared for the entire day, although tinnitus reappeared if the patient suffered from a common cold or was severely tired.
Filled bars show the scores on the tinnitus intensity index and annoyance index before the operation, whereas open bars indicate postoperative scores.
Patient 2, in whom the electrode was problematic, still perceived her tinnitus as the loudest imaginable because the suppressor did not work well. Three patients were at a moderate level, two were at a mild level, and two registered no level after the operation. A positive correlation after the operation (at the .01 level of significance using the t-test) was observed although no correlation was observed among those tests before the operation. The TII was lower than that before the implantation because tinnitus that reappeared was weaker than the preoperative condition.


Tinnitus did not disappear in the implanted ear when the patient suffered from a common cold or was very tired. Therefore, the TST, AI, and TII dramatically improved in this man after device implantation.
No patient experienced extrusion of the wire under the external skin, although the stimulating electrode has broken free from the promontorium tympani in one patient. The degree of tinnitus suppression using the implanted device was consistent with that reported from outpatient clinics, as shown in Table 2; that is, the duration of residual inhibition using the suppressor was not longer in home users of the device than at outpatient clinics, but tinnitus intensity improved. As expected, Patient 6 did not experience tinnitus disappearance after use of the implanted suppressor.
The patient was becoming so dependent on the device that the stimulation time extended to four or more times per day.
However, not all patients were severely affected by tinnitus even while reporting that it was the loudest imaginable. One patient had a labyrinthectomy, and 2 others had vestibular nerve sectioning after the gentamicin treatment failed. With use of the dual method, no ear has lost hearing, but one ear that was re-treated and ultimately received a total of four doses of gentamicin experienced a pure-tone threshold increase of 65 dB.
In the latter group, there was a mean 0.3 dB gain and a median hearing improvement of 5 dB. No correlation exists between the pretreatment level and the change in threshold after gentamicin treatment. Vestibular nerve sectioning is associated with a 20% risk for added hearing loss, which exceeds the risk for hearing loss that is associated with gentamicin treatment. The risk for cochlear damage is minimized if the dual method of gentamicin administration is used. TTG treatment is also intrinsically of very low risk, especially compared to nerve section. However, right now, in our practice in Chicago as well as in other highly specialized settings, the low-dose protocol has become routine, as we think that it has even less risk and very good results.
We also see no logical reason to combine dexamethasone (an intratympanic steroid) with streptomycin (an ototoxic antibiotic). As vibration works so well, and we would not think that someone should be even doing gentamicin injections without the capability to do video-frenzel goggles, this idea doesn't seem to us to be worth pursuing. It would also be interesting to know if different drug companies versions of gentamicin vary in their composition. Fifteen to twenty percent of the patients experience an added hearing loss in the treated ear, although this percentage is reduced if the treatment is given as a single instillation on 2 consecutive days.
As a rule, the vertigo attacks are present for some time and then absent for a longer period of months or even years. In those instances, sur-gical sectioning of the vestibular nerve may be helpful, though this type of surgery carries some risks for damage to hearing and to the facial nerve and even the intracranial structures. Ten of the patients had been treated with pressure-chamber therapy but either had not responded or had suffered a relapse. In Patient 1, the hearing threshold in the left ear (with tinnitus) was better than that of the right ear (without tinnitus), as shown in Figure 1. Shulman [5] also suggested that the most desirable outcome is to attain the tinnitus suppression threshold before auditory sensations are experienced. Hearing loss animal models were established, and the animals were irradiated by 830-nm diode laser once a day for 10 days.
If your institution uses Shibboleth authentication, please contact your site administrator to receive your user name and password. Some patients can accept tinnitus with little affective disorder, although they still perceive a tinnitus sensation. The location of cortisol control under stress is considered to be in the hippocampus, not in the hypothalamus [8]. The objective of this article is to evaluate benefits of the implanted tinnitus suppressor on the basis of the TST.
Audiography revealed profound mixed deafness in the right ear and slight sensorineural deafness in the left ear. The frequency of the tinnitus was 125 Hz at an intensity of 50 dB in the right ear and 125 Hz at an intensity of 65 dB in the left ear. The Pt-Ir ball electrode, covered with polyalcoholic gel, is placed on the promontorium tympani, and the return electrode is fixed to the subcutaneous tissue at the tip of the mastoid. Ten items-questions 1, 2, 4, 5, 7-9, 12, 14, and 15-were given zero points for a response of "not at all," 1 point for "a little bit," 2 points for "moderate," 3 points for "quite a bit," and 4 points for "extremely." The remaining seven items-questions 3, 4, 6, 10, 11, 13, and 16-received double the points for each category. The two patients with a mild TII level sometimes perceive tinnitus, indicating that the effects of one-time stimulation sometimes were not long-lasting enough to relieve tinnitus altogether. In Patient 2, the AI results worsened after the operation (from moderate to severe), owing to the electrode problem.
For others, the maximum current was set at less than 600 μA owing to the requirement for a more intense current to make tinnitus disappear. It should be noted that even during the era of unlimited numbers of gentamicin instillations, some patients had a nystagmus response after two, three, or four installments (Figure 2) [10,11]. The head-shaking test may unveil a unilateral vestibular loss, but other clinical tests will be negative.
Furthermore, if vestibular nerve severing is not performed by an extremely experienced surgeon, the complications can be severe.
Compared to labyrinthectomy, TTG treatment is also lower in risk because there is no need for general anesthesia. Because this procedure works so well, the experiments of the past that we detail below have all become somewhat irrelevant. It seems much more logical to us to use these one at a time rather than mixing them together.
As the problem in the past has mainly been hearing toxicity, procedures that are aimed to increase the dose delivered to the ear would seem irrational unless the ear is already deaf.
After several years and many attacks, the hearing loss does not return to normal between attacks.
To exclude other lesions in the internal meatus and the posterior fossa, imaging studies were performed with magnetic resonance imaging or computed tomography. In July 1997, we treated the left ear with electrical promontory stimulation for tinnitus relief. In addition, this patient uses a hearing aid in the left ear because hearing in her right ear is too poor to benefit from hearing aid use. In bilateral tinnitus patients, the effect on tinnitus in ears without the implant is very encouraging. According to his theory, our patients with implantable devices are the most desirable candidates for electrical suppression of tinnitus.
Gentamicin should be used particularly in patients who suffer a significant and severe hearing loss, and these patients should be warned about the possibility of additional hearing deficit.
However, some patients are disturbed by affects (especially the severe disabling type of tinnitus). She visited our outpatient clinic with concerns about the discharge from both ears and increased hearing loss in the left ear. On August 11, 1992, the patient had visited our outpatient clinic with complaints of ear discharges and bilateral hearing loss. These categories addressed standard of living, socialization, coping with anger, depression, and fear. The duration of the residual inhibition was so much longer than that of other patients that the number of uses per day (once or twice) is smaller than that of other patients.
Because of the limitations of the stimulator, the maximum current delivered to the promontorium tympani, however, appeared to be less than 300 μA.
Initially, this apparent dependency was attributed to the patient's personality, not to problems with the electrode, which were the actual cause. Nonetheless, a positive correlation at the .01 level of significance was observed among the postoperative TII, AI, and TST scores [12].
Broadfrequency rotatory testing using pseudorandomized stimulation unveils the asymmetry that is not obvious in sinusoidal tests [15]. Another approach could be to modify aminoglycosides so that they are less likely to cross the blood-labyrinth barrier, or be taken up into the hair cells, but still retain their antibacterial activity. We are unenthused about the addition of steroids to gentamicin, or steroids to streptomycin (as discussed above). Often, the end result is an ear with a pure-tone threshold of 60-80 dB and very low speech discrimination. Patients were fully informed so that they understood the concept of a unilateral vestibular loss and the central compensation enhanced by rehabilitation. Surprisingly, hearing loss in the left ear recovered to the nearly normal level after this treatment, as shown in Figure 5. Tinnitus in the ear opposite the site of implantation in patients 4 and 5 disappeared completely postoperatively.
Therefore, we should select patients whose tinnitus suppression threshold is lower than that of the auditory sensation for the implantation. Although relief from tinnitus cannot be promised, the world literature indicates that most patients suffer less severe tinnitus after gentamicin treatment [17]. Tinnitus in the ears opposite the device implantation site in patients 4 and 5 completely disappeared. Patient 5 felt that the intensity of his tinnitus was the loudest imaginable preoperatively, although it annoyed him only slightly. Patients reported that tinnitus did not disappear if they were suffering from a common cold or were very tired. The patient reported that she was apt to pay too much attention to the existence of the implanted coil in the mastoid.
This finding indicates that patients can so much more easily manage tinnitus after use of the stimulator than before such use that tinnitus no longer scares patients.
In patients 1 and 2, the effects of middle-ear infection on the hearing threshold were taken into account.
Before the operation, we ascertained that electrical stimulation of the right ear (without tinnitus) made tinnitus disappear from the left ear. Likewise, tinnitus at the unimplanted side sometimes disappeared in Patient 3 after the operation.
Thresholds of auditory brainstem responses were evaluated before treatment, after gentamicin, and after 10 days of LLLT. The frequency of the left-ear tinnitus was 250 Hz at an intensity of 95 dB 1 month after the first visit (September 18, 1992). Bone conduction hearing thresholds before and after the operation also are shown show the bone conduction hearing thresholds on June 1994; [and] on August 11, 1992.
After use of the suppressor, the tinnitus annoyed him far less, indicating that the suppressor might be beneficial even to those patients in whom tinnitus is only slightly annoying. Takirig into account such situations as a common cold or tiredness, we should select for suppressor implantation those patients in whom less than 200 μA of maximum current is necessary to make tinnitus disappear.
She reported trying to push down the switched button of the stimulator repeatedly, but her tinnitus was not reduced. However, in Patient 7, we should not dismiss improvement in the hearing threshold (see Figure 4), although we also could not ascertain the reason for hearing threshold improvement in the ear with the implanted device. The result in Patient 1 after the implant operation was the same as that at outpatient clinics. In Patient 6, whose tinnitus did not disappear at outpatient clinics, tinnitus in both ears did not disappear but did improve after the operation.
Quantitative scanning electron microscopic (SEM) observations were done by counting remaining hair cells. Because we were afraid that the operation would worsen a preexisting hearing loss in the left ear, the suppressor device was implanted in the patient's right ear.
Finally, the patient abandoned use of the stimulator and felt despair because she thought that she could not escape from tinnitus. Approximately 9 months after the im was a response in the form of ataxia or destruction-type nystagmus. The patient's desperation caused her to feel impatient, and she registered an extreme score on the TST. In the period 1989-1992, the number of instillations was limited to four (the so-called quadruple method) [6,7]. We now are able to see the electrode tip through the eardrum and are aware that the decreasing efficacy of the suppressor was caused by problems with the electrode trouble, not by the patient's personality. Alternatively, the dual strategy was used as suggested by Magnusson and Padoan [8] in 1991, in which gentamicin is instilled on 2 consecutive days and thereafter the patient's condition is observed and drug is administered as needed; if there is a substantial caloric loss or the vertigo attacks cease, no more gentamicin is instilled. On SEM images, LLLT significantly increased the number of hair cells in middle and basal turns. After the patient was supplied with an upgraded stimulator and the free electrode again touched on the eardrum, the patient's TST score leveled off to her preoperative level. With both the dual method [8] and the quadruple method [7], one must be prepared to administer additional drug after 1 or several months. Even if the initial therapeutic regimen almost always causes a unilateral caloric loss, and some relapses occur that necessitate additional instillations of gentamicin. After LLLT treatment, both the hearing threshold and hair-cell count significantly improved.



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