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Each case is presented along with the patient's medical history, physical findings and appropriate laboratory, audiological and vestibular studies. This 45-year-old man was referred to the DartmouthHitchcock Medical Center (DHMC) in July 1976 with a 7-year history and auditory findings of Meniere's disease. This operation was performed primarily to eliminate the patient's disabling vertigo, but his greatest sense of relief postoperatively was the absence of tinnitus. This 39-year-old woman presented to the DHMC in October 1974 with a 14-year history of Meniere's disease which had become bilateral.
Approximately four years prior to her first visit to DHMC, the patient began having similar symptoms involving her left ear. In February 1985 the patient experienced renewed roaring tinnitus and diminished hearing in her left ear (the ear that had been operated on originally). Subsequently, debilitating vestibular symptomology from the right labyrinth recurred and was treated with streptomycin in December 1985 (24 grams over 14 days) and in October 1986 (20 grams over 10 days).
The initial good surgical result in the patient's left ear most likely occurred because the cochlear hydrodynamic state was altered toward the normal by endolymphatic sac decompression, thereby permitting better overall cochlear physiology in the affected ear (and possibly allowed an unrecognized PLF to heal).
The tinnitus in endolymphatic hydrops is likely due to the detachment of the tectorial membrane from the stereocilia to produce a low-pitched tinnitus.?
This patient's Meniere's disease-like symptoms were most likely due to a PLF with secondary cochlear hydrops.IO The strain of transmitting spinal fluid pressure through a patent cochlear aqueduct may have lead to her symptoms and her progressive cochlear-vestibular deterioration.
This 42-year-old women first presented to the DHMC in January 1984 with a 4-year history of dizzy spells and tinnitus in her left ear (Figure 1). She next presented to the DHMC in late February 1988, stating that 3 weeks prior she had experienced a sudden significant increase in tinnitus and decreased hearing in the left ear.
With occasional periods of mild stress-related instability, the patient did well for approximately one year. In April 1997 the patient's tinnitus became much louder and higher in pitch, and her hearing and balance deteriorated; this persisted through the end of May. This patient's tinnitus was more severe when cochlear vestibular disorganization was greatest-during periods of imbalance or diminished hearing.
This patient likely possesses a patent cochlear aqueduct, as her symptoms of instability, tinnitus and hearing loss were eased by drawing off 10 cc of spinal fluid, which could, in tum, lower perilymph pressure and thus diminish any inner-ear fluid flow responsible for causing vertigo. As with the patient in Case 3, tinnitus volume was worse in this patient when cochlear-vestibular dysfunction was greatest.
In cases of endolymphatic hydrops, whether or not combined with a PLF, a significant improvement in hearing and decline in vertigo and tinnitus most likely indicates a partial restoration of cochlear-vestibular integrity. This 56-year-old man presented to the DHMC nine years after a stapedectomy for otosclerosis, resulting in a dead ear. During the summer of 1996 (11 years after his initial problem began) the patient experienced a sudden noticeable hearing loss in the left ear, followed closely by an increase in intensity and frequency of tinnitus (still a pure tone). In 1996, her first symptom was increased rightear pain,1,2,11 followed by a marked increase in vertigo and return of tinnitus. In August 1996 bilateral middle-ear explorations with reinforcement of oval and round window areas were performed. Postoperatively the patient experienced nearly complete resolution of vertigo, pressure and tinnitus. Performing an endolymphatic shunt can improve or eliminate the symptoms of a PLF.1,2,18,19 The fact that doing a Val salva during an EcoG could immediately and repeatedly change a summating potential from 40% to 80% seems to indicate a wide open CSF perilymph connection, most likely the cochlear aqueduct.
In May 1991 she presented with greatly elevated thresholds and a SDS of 56% which returned to the previous baseline after receiving glycerin. In October 1995 a lumbar puncture revealed a mildly elevated spinal fluid pressure of 210 cc of water. In January 1995 a 64-year-old farmer and general maintenance man experienced sudden increased tinnitus in his left ear. In November 1995 the patient underwent an exploratory tympanotomy with revision reinforcement of the oval window and round window. Interestingly, coincident with the surgery the patient experienced a temporary hearing decline of 20 dB in all frequencies in his right (opposite) ear and some ataxia.
Sismanis 15 has discussed the symptoms of tinnitus, vertigo and fluctuating hearing loss in patients with idiopathic CSF hypertension. These seven patients, and the patient in Case 8, most likely had or have patent cochlear aqueducts.21,22 The pulsatile nature of tinnitus in Case 5 points strongly to this possibility, as does the ability of the patients in Cases 3 and 8 to repeatedly increase their SPs during transtympanic EcoG by performing successive Valsalva maneuvers. The patient in Case 1 is the only patient who seemed to present with a "pure" Meniere's disease picture. In patients previously reported with PLF, tinnitus1,2 seemed most common in patients with Meniere's disease-like symptoms (11 of 18). In these ten selected cases of patients presenting with PLF, Meniere's disease or elements of both conditions, tinnitus severity seemed to correlate closely with the state of health of the inner ear. It develops in seconds achieves maximum intensity with in a few minutes and may last for hours to days (5). Tinnitus and its degree of severity often correlate closely with the state of health or hydrodynamic integrity of the inner ear, as these cases illustrate. The additional symptom of tinnitus is often a primary concern of the patient, but because it is less easily quantified the physician ranks it, along with the symptom of pressure or fullness, as lower in importance.
The onset of tinnitus and its increase in intensity, frequency or character may precede a serious escalation in symptoms of vertigo, hearing loss and possibly a perception of aural pressure or pain. Pulec4 performed 151 cochlear nerve sections for intractable tinnitus, which resulted in complete relief in 101 cases, significant improvement in 43 cases, and no improvement in 7 cases.
Her right ear was affected coincident with the birth of her first child, when she developed severe nausea, vomiting, vertigo and hearing loss.
Hearing in that ear had deteriorated over four years to a level similar to that in the right ear (PTA = 70 dB, SRT = 60 dB, SDS = 88%).
Postoperatively, the patient's vertigo and roaring tinnitus in the left ear disappeared completely. Prior to performing the shunt the oval and round windows were observed for the presence of a possible PLF.
A PLF was strongly suspected due to an obvious PLF found in the recently explored right ear.
Upon opening the left middle ear, fluid was found within the oval window niche; the fluid accumulated repeatedly after aspiration.
On both occasions an increase in loud highpitched tinnitus preceded the onset of vertigo, and on both occasions attacks of vertigo and the highpitched tinnitus were controlled by courses of streptomycin. As the overlying gelatinous tectorial membrane becomes decoupled from the hair cell, the Brownian Motion of the air particles in front of the tympanic membrane is detected. This is one of three cases of PLF this author has seen that has been initiated or exacerbated by vaginal delivery (see Case 4). In early February 1989 her tinnitus (which became a constant mid-frequency "buzz") suddenly increased. Her tinnitus was least severe after her second PLF repair, when her hearing was nearly normal and imbalance episodes nearly nonexistent. 13 The fact that she can increase her SP by a Valsalva maneuver may also signify an open cochlear aqueduct. Five years previously, at age 27, she began to experience episodic vertigo, fluctuating hearing loss, loud sea-shell-quality tinnitus and fullness in her left ear. As in Case 1, the vestibular nerve section, which included about 10% of the cochlear division of the eighth-nerve, has given permanent relief from tinnitus and vertigo.
Ten years previously he suffered a closed head injury when he was hit on head with a suspended swinging bucket, which resulted in 5 minutes of unconsciousness.
Tinnitus intensity seems to be a marker for declining or improving cochlear-vestibular health. Perhaps stopping the constant flow of fluid (CSF or perilymph) through the cochlea permitted partial restoration of cochlear integrity with a secondary decline of the tinnitus. Olympic team cross-country skier, presented to the DHMC in September of 1985 with several months history of exercise-induced decreased and distorted hearing (Figure 2). In such patients the perilymph flow through the inner ear occurs in such a way as to be detrimental to hearing but not balance.
Seven years prior, after lifting a patient from the floor to a wheel chair, she began experiencing almost constant vertigo, which was exacerbated by exercise.
Relief lasted almost four weeks, when, a half hour after awakening one morning, she felt unstable and experienced pressure in the right ear.
She veered left on a Quix test11 and eyes-closed walking test.13 She complained of intermittent pain in both ears and fullness in the right ear. The complete set of tests were performed before and 45 minutes after the administration of Lasix (40 mg IM).
Transtympanic electrocochleography for the patient in Case 8, demonstrating the increase in the summating potential that occurred repeatedly with Valsalva maneuvers. Additional areolar tissue was placed around the stapes footplate, as the previously placed tissue had come away from the anterior end of the stapes.
The wide open cochlear aqueduct most likely made our patient prone to developing a PLF and vulnerable to recurrence after the initial repair.
In November 1995, following the placement of a lumbar drain, the left ear was again explored. An oval window PLF was thought to be present, but its reinforcement did not improve his symptoms. Just prior to administering general anesthesia a lumbar puncture was performed to see if pseudotumor cerebri might be present. In May 1996 his pure tone audiogram demonstrated some random changes (generally decreasing in threshold by 5 to 10 dB) between 125 and 2000 Hz when he assumed a Trendelenburg position. The right ear hearing returned to baseline within three weeks and his ataxia diminished (he veered right on the eyes-closed walking test, whereas before surgery he veered left). Recently, Marchbanks21 studied a group of patients with CSF hypertension using the tympanic membrane displacement technique to determine cochlear aqueduct patency.
The patients in seven of the ten cases (Cases 2-4 and 7-10) had recurrent PLFs requiring multiple middle-ear explorations for repair. Even in this case an endolymphatic shunt gave temporary relief of symptoms, including tinnitus. In this group of patients tinnitus severity (intensity, constancy, and pitch) served as a marker. Weider OJ, Saunders RL, Musiek FE: Repair of a cerebrospinal fluid perilymph fistula primarily through the middle ear and secondarily by occluding the cochlear aqueduct.
Bredberg G, Ades HW, Enstrom H: Scanning electron microscopy of the normal and pathologically altered organ of Corti.

Ackley RS: Electrocochleography and histological result of perilymphatic fistula in guinea pigs. Lehrer JF, Poole DC, Sigal B: Use of glycerin test in the diagnosis of post-traumatic perilymphatic fistulas. Singleton GT, Post KN, Kurian MS, Bock DC: Perilymph fistulas, diagnostic criteria and therapy. Marchbanks R: Audiovestibular dysfunction in patients with confirmed intracranial hypertension. Antidepressants In people besides migraine also have tension headaches and possibly depression or sleep disorders antidepressants may sometimes act as a migraine preventive If the tumor is located in the roof the nasal cavity and invades into the ain surgeons will need to remove the tumor from the nose and the ain. Two weeks later I started to suffer with severe headaches and severe eye Use your thumb and finger of one hand to squeeze the fleshy skin between the thumb and index finger of your other hand. Alternatively, hearing improvement and resolution of vertigo often coincide with diminution or the disappearance of tinnitus. In Pulec's series the following conditions were present: Meniere's disease (N = 84), chronic otitis media (N = 24), poststapedectomy with inner ear injury (N = 11), trauma (N = 18), and a variety of other conditions (N = 14). The symptoms subsided but returned coincident with the birth of her second child (12 years prior to her first visit to the DHMC), and again coincident with the birth of her third child 2 years later. Because of a slightly improved PTA and SDS she regarded the left ear as her functional ear, and was the ear in which she wore a hearing aid. The same finding has been reported recently by Ito and Sakakihara6 in a study of tinnitus suppression in candidates for cochlear implants. Harris8 found that the noise level at the hair cell increased to +33 dB (in reference to auditory threshold) for loose coupling.
An abnormally patent cochlear aqueduct is the probable cause for ease and frequency of relapse in such cases. Symptoms subsided for 4 months during her third pregnancy at age 31, but resumed immediately coincident with her delivery.
Brackman and Barrs14 report on vestibular nerve section alone resulting in resolution of tinnitus in 49% of their patients. He had three months of rest at home due to dizziness, which eventually resolved, though his balance was never quite normal. In this case the pulsatile character of the tinnitus may reflect vascular pulsation being transferred from the cerebrospinal fluid (CSF) through a patent cochlear aqueduct. Her vertigo continued until she was seen by Fitzgerald 17 who diagnosed and repaired a right oval window PLF. On physical exam at the DHMC, the patient was found to have a positive subjective fistula test bilaterally that was stronger on the left. A very obvious oval window fistula was seen; fluid welled up repeatedly in the oval window niche after suctioning.
Upon doing a Valsalva maneuver when supine the patient immediately raised her SP-AP ratio to 80%.
The fact that the tinnitus disappeared completely after the endolymphatic shunt may indicate the restoration of a more normal cochlear physiology and anatomy, perhaps adding necessary compliance to the system. A tonsillectomy and adenoidectomy was performed in December 1987 to improve her airway and decrease the frequency of recurring otitis media with effusion. She experienced vertigo with significant exercise; several bouts of severe vertigo caused her to fall to the floor. Her problems probably began in 1985 as a 5-year-old when she presented with sudden onset stomach aches and nausea and a panic-like state.
Commensurate with the onset of his tinnitus he felt mildly off balance, with a definite increase in vertigo with physical activity, especially lifting. Spinal fluid pressure was 270 mm of water (more than 200 mm of water is considered abnormally high).
He found that patients with CSF over pressure who did not have patent cochlear aqueducts also did not develop the symptoms of tinnitus, vertigo, fluctuating hearing and pressure, while the patients who had patent cochlear aqueducts did develop these symptoms. In five of these seven patients an endolymphatic shunt provided significant long-term or permanent relief of symptoms, including tinnitus. No patient complained of tinnitus in the "hearing loss without vertigo" group, although the patient in Case 7 is an exception.
A higher pitch or frequency of tinnitus (cases 3, 7 and 9) seemed less amenable to medical or surgical control.
Treating migraines effectively might have gotten a lot Fever Headache Blotchy Skin Pregnancy Epidural After S easier according to a new study published this month. All patients were believed to have tinnitus as the result of damage to the cochlea or cochlear nerve. At the time of her presentation to the DHMC she was experiencing approximately three minor attacks of vertigo per week, preceded by an increase in tinnitus and a decrease in hearing in her left ear.
Before performing the shunt the oval window region was scarified and reinforced with areolar tissue.
Tondorf7 concluded that the increased noise level at the hair cell input, an increment of 55 dB that is caused by the partial decoupling of the stereocilia from the tectorial membrane, ought to be perceived as tinnitus.
She had vertiginous episodes lasting for minutes to 1.5 hours, which were sometimes accompanied by nausea and vomiting. Distortion of cochlear membranes due to diminished perilymph pressure and secondary endolymphatic hydrops most likely leads to hair cell dysfunction (secondary to hair cell-tectorial membrane decoupiing?) and tinnitus. Initially she was diagnosed with Meniere's disease, but later was thought to have a PLF with secondary endolymphatic hydrops. They had a 61 % success rate in controlling tinnitus when both the cochlear and vestibular nerves were sectioned (see Shulman2 for a review of this subject).
Sismanisl5 reports pulsatile tinnitus in patients with benign intracranial hypertension which improves with treatment. During the next four years his hearing remained stable and the arthritis in his left hip resolved dramatically. The hearing distortion and increase in loudness of his tinnitus was brought on specifically during exertion while roller skiing.
After lysis of adhesions in the oval window region an obvious PLF could not be identified with certainty. Following this treatment her symptoms of vertigo diminished by over 50%, and she was able to function well in her job. She veered to the left during her standing Quix test, high-stepping Quix,11 ECTT,12 and eyes-closed walking test.
Before receiving the Lasix she could hold a tandem Romberg for only three seconds; after the Lasix was given she could hold it for 20 seconds. Over the next four years she experienced episodes of true vertigo which caused her to fall occasionally. The author has observed this phenomena in other patients13 who eventually developed PLF but as young children were too young to articulate the problem clearly. Therefore, a lumbar drain was inserted and left in place for a total of four days after the surgery in order to facilitate healing. The author felt these entities indicated cochlear aqueduct patency and suggested cochlear aqueduct blockade to the patient. One of these seven patients (Case 4) chose vestibular nerve section for a final solution to control tinnitus and vertigo. What was probably a slow free-flow of CSF through the scala tympani, vestibule and out into the middle ear was stopped by the perichondrial graft held in position by the House wire. In dealing with the entities of PLF and Meniere's disease, the symptom of tinnitus and its various descriptors can indicate the relative health of the cochlea. You can use a herbal balm like Amrutanjan for your nose forehead headache dengue virus infection chronic meds and temples.
In one study a 20-day treatment of oral magnesium normalized 90% of the about Peppermint and Lavender bein g effective in getting rid of headaches. Pulec4 stresses the need of a thorough preoperative assessment, including hematological, audiological and radiological testing. Her hearing deteriorated to where her pure tone average (PTA) was 75 dB (range 250 Hz to 2000 Hz) (SRT = 65 dB, SDS = 76%). Postoperatively, the patient's tinnitus was nearly eliminated, and the occasional momentary positional vertigo disappeared. Postoperatively, the patient's hearing thresholds were greatly elevated and her SDS fell to 0%.
Initially her vertiginous episodes were not brought on by exercise, but were eventually exercise induced. Due to a suspected patent cochlear aqueduct, a lumbar puncture was performed and approximately 10 cc of fluid was drained. However, the patient complained of constant, loud tinnitus and an occasional sensation of hearing in the dead ear.
Her audiogram looked grossly normal with 100% discrimination bilaterally, but she had a mild symmetrical low-tone sensorineural hearing loss and a mild asymmetrical high-tone loss on the right. Again, 40 mg of Lasix caused her symptoms to resolve within one hour (neurological exam results reverted to normal and right-ear tinnitus diminished), She was placed on Lasix (20 mg BID) and a low-salt diet, which did not improve her symptoms.
When asked to print in a vertical line from top to the bottom of a page with her eyes closed, the line of text curved to the right; after the Lasix she could print in a straight vertical line.
Hearing in the left ear continued to fluctuate as much as 20 dB between 250 Hz and 2000 Hz, but she always had an excellent SDS.
Postoperatively the patient's hearing returned to its previous best level (PTA = 42.5, SDS = 100%). The following month his tinnitus increased and hearing decreased as he struck a nail with a hammer.
This procedure had been performed three times previously3 with no negative affects to hearing and with diminution of vertigo. In all seven cases tinnitus was most severe when vertigo and hearing were most problematic.
Two of six patients with poststapedectomy PLF symptoms and findings presented with tinnitus.
Fever Headache Blotchy Skin Pregnancy Epidural After S the exact dosage needed to control vertigo without causing permanent hearing loss is unknown. Adverse effects include sleepiness dizziness fatigue and weight gain associated with increased When I woke up this this morning about 1 hour ago i had this really bad headache.
For a short time the patient's vertigo stopped and pressure and tinnitus lessened significantly, but his vertiginous attacks resumed within 5 weeks. During the next two years the patient's SDS, which had never been above 68% during the previous nine years, improved to 92%. This suggests that auditory pathways cross the brainstem to connect both ears, and that there is a pathologic connection of the efferent and afferent system of the auditory and vestibular nerves. Blebs on the stereocilia and development of "giant" stereocilia have been demonstrated by Bredberg et al.9 with the aid of scanning electron microscopy.
Her instability had become constant and severe; the early morning hours were the most tolerable.

A recurrent oval window PLF was discovered (perilymph was clearly seen after repeated aspirations) after the debridement of adhesions with an argon laser.
The patient's EcoG demonstrated a normal summating potential (SP)-action potential (AP) ratio of 30%. Upon awakening the following morning, the patient experienced loud tinnitus (medium-pitched ringing) and hearing loss in his right ear. Because of this and our difficulty performing accurate audiology with appropriate masking at such levels, the middle ear was explored in February 1980. He was able to reproduce his hearing distortion in the clinic by doing a series of pushups and running up and down the stairs several times.
The oval window was reinforced, but this did not improve the patient's hearing or reduce tinnitus. Despite using the KTP laser to lyse the adhesions, a fistula could not be identified clearly.
A patent cochlear aqueduct (or some other open connection between CSF and perilymph) was felt to be necessary to permit this repeatable phenomenon. One hour after taking 40 mg of IM Lasix the patient's vestibular symptoms disappeared and his eyes-closed walking test was normal. A ventriculo-peritoneal shunt was performed in September 1996 to relieve the patient's CSF hypertension and to hopefully resolve the ataxia. Also in these seven cases when vertigo was controlled or absent and hearing improved, tinnitus diminished or became absent. Ito J, Sakakihara J: Tinnitus suppression by electrical stimulation of the cochlear wall and by cochlear implantation. A rebound headache is a headache that paracetamol caffeine migraine pregnancy paracetamol you end up with just because you go in search of a little relief from the constant pounding in your noggin. Rest is the easiest way to make your headache run away, though it will You won't even realize when sleep takes you over. When these means are effective tinnitus will often diminish, as illustrated by the following ten case reports.
The translabyrinthine approach was used in all but two patients who had a middle fossa approach. After about 18 months, loud roaring tinnitus increased in the right ear and eventually became nearly constant.
A successful endolymphatic shunt most likely affects a partial return to the more normal anatomical and physiologic state, thus affecting tinnitus suppression. In April 1988 an endolymphatic-mastoid shunt was performed (Arenberg type III sac) and both oval and round windows were rein-forced with perichondrium. The patient had immediate relief of tinnitus and imbalance which lasted approximately 36 hours. On several occasions she could raise her SP to 45% to 50% of the AP by doing a Valsalva maneuver (similar to the patient in Case 6). From this point, the hearing in his right ear deteriorated, although he had some periods of quite good hearing (his last symmetrical hearing test was in 1981). The oval window was partly occluded by a small granuloma resting in what appeared to be gelatinous material. After about 15 minutes of rest his tinnitus would subside and the low-frequency hearing loss would return to near-normal levels. Nearly three weeks later neurologic testing was repeated and she was given 40 gm of IM Lasix.1,2 One hour later she was nearly asymptomatic and was completely normal on her Quix tests and eyes-closed walking test. She maintained good hearing and balance with occasional fluctuations in both entities for about four years, during which time she participated in sports and horseback riding. Following the surgery the patient's hearing remained stable between 125 Hz and 1000 HZ with a 15-dB to 20-dB decline above 1000 Hz. The patients in Cases 7 and 9 still experience difficulty and their tinnitus continues to be troublesome and high pitched. If you experience bile vomiting after a drink it could be Fever Headache Blotchy Skin Pregnancy Epidural After S because your body has low tolerance to alcohol. Comment SPECIAL Physical and mental stress can make headaches worse, according to the American Headache Society. The patient was then asymptomatic for about one month before he experienced one of his most severe and disabling attacks of vertigo, nausea and vomiting. The decision to perform an endolymphatic shunt on the right ear was delayed because she had no vertigo, only a progressively increasing and roaring tinnitus. Efferent pathways traveling via the medial olivary-cochlear stria, and then to the outer hair cells by way of the vestibular nerve, most likely mediate some central control over the opposite cochlea. This seems to be the case when performing a shunt for both Meniere's disease or for endolymphatic hydrops secondary to the presence of PLF.10 Interestingly, in our patient the tinnitus was also suppressed by streptomycin ablation.
The stapes was felt to be hypermobile; the annular ligament was seemingly swollen, soft and almost gelatinous. This was easily removed, and revealed a wide open oval window with an intact, subluxated footplate in the depths of the vestibule. His tinnitus now varies in intensity and becomes louder with physical exercise or when around loud noise.
Her tinnitus also diminished with the Lasix.1,2 Because of her continuing tendency to drift to the left, and a mildly positive fistula test on the left but with symptoms of pressure, fullness, pain and tinnitus on the right, we suggested bilateral middle-ear explorations to repair suspected PLFs.
Three months later when cleaning out her horse's stall her symptoms returned in full force. When first seen by an otolaryngologist his left ear SRT and PTA were 30 dB with a SDS of 84%. Interestingly, the motor-like tinnitus in his left ear also diminished but did not disappear. After lifting an air conditioner both his tinnitus and vertigo returned to preoperative levels. In March 1997, diagnosis and treatment of hypothyroidism lead to complete resolution of the residual ataxia. Aside from publishing a bevy of life improvement guides, Dr Prem runs a network of 50 niche websites that attracts millions of readers across the globe. Because of the chronic severity of his problem and his relatively poor hearing, a translabyrinthine vestibular nerve section was performed in December 1976.
Likewise, discrimination eventually improved in our patient's right ear when the left-ear PLF was repaired and the left ear became a nonhearing ear.
Four weeks postoperatively the patient's hearing and discrimination again returned to near-normal levels within three days, coincident with a marked decline in tinnitus. He experienced frequent attacks of vertigo brought on by lifting or straining, which lasted for seconds to hours.
In November 1985 a large, free-flowing oval window PLF was found and repaired, which temporarily improved the patient's hearing and reduced his tinnitus. In July 1996 a left endolymphatic-mastoid shunt was performed and the oval window and round window were again reinforced. His tinnitus declined immediately to nearly negligible levels and has remained so to May 1997. 10 MigraineNewsISSUE93 Vitamins for migraine Magnesium riboflavin co-enzyme Q10 and migraine Magnesium Magnesiumisoneoftheessential Fever Headache Blotchy Skin Pregnancy Epidural After S mineralelementsinthehumanbody. This resulted in complete relief of this patient's vertigo, pressure and loud roaring tinnitus. After an initial difficult postoperative course she became nearly asymptomatic by the end of June (SDS = 100%, PTA = 32.5, tinnitus barely perceptible). He had an occasional episode of vertigo without apparent cause, and occasionally could perform heavy lifting without provoking vertigo.
The oval window was covered with a piece of perichondrium and held in position with a House wire attached to the incus.
Postoperatively the patient rested only two weeks and returned to his skiing in attempt to make the Olympic team. A lumbar drain was not used, as her preoperative spinal fluid pressure was normal (165 cc of water).
Three months later (August 1983) most of her symptoms recurred coincident with heavy lifting. His audiogram was up-sloping through 2000 Hz (SRT = 56, SDS = 66%), with 4 kHz and 8 kHz depressed secondary to noise exposure.
After he stopped training his low frequencies im-proved and the high frequencies diminished, resulting in the sensation of a mild hearing depression with good discrimination. She stated that in retrospect during the 1994 soccer season she had been a "little dizzy" about half of the time when playing. Within four weeks she was feeling 70% better than she had before her surgery, and has remained so as of her last follow-up visit in March 1997. A third PLF repair was performed in November 1983, with resolution of vertigo and tinnitus. Tinnitus during this time was low intensity and described as a mid-to high-frequency pure tone. A repeat PLF repair in April 1989 resulted in a temporary improvement in hearing and diminished tinnitus; however, three weeks later minor lifting brought about a dead ear and severe imbalance. Vertigo is usually absent but occurs occasionally in mild form, almost always in relationship to exercise. In May 1990 a posterior vestibular nerve section, including some of the cochlear fibers, has given her long-lasting relief from vertigo and tinnitus. In February 1997 tinnitus was intermittent and occasionally loud enough to prevent concentration. She continued, however, to have some persistent unsteadiness which increased with any significant physical exercise. He underwent an exploratory tympanotomy in May 1984, and clear fluid seepage from the anterior end of the oval window was found.
Her unsteadiness did not diminish with the administra-tion of 40 mg of intramuscular (IM) Lasix 1,2 or with glycerin.11 Her balance was better after administration of 2 mg of Valium TID.
The window was reinforced with areolar tissue and an endolymphatic-mastoid shunt was performed. Postoperatively, the patient's hear-ing improved dramatically (PTA = 37.5, SRT = 30, SDS = 88%) and tinnitus diminished to nearly nondetectable levels. About 1 year later (March 1986) she reported a slight increase in hearing loss and continued mild instability but no episodes of vertigo, In May 1986 a submucous resection and turbinate trim was performed to improve her airway. This permitted her to sleep better, and her daily periods of instability lasted only a few seconds and were less severe.

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