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We auditorily stimulated patients affected by subjective tinnitus with broadband noise containing a notch around their tinnitus frequency. We recruited tinnitus sufferers from among patients attending the Oto-Rhino-Laryngology II Clinic of the University of Parma, Italy, in the period 2004-2006. We determined hearing sensitivity using tonal stimuli presented in octave steps, from 125 Hz to 8,000 Hz, and 1-dB increments.
The experimental pitch-matching test was performed shortly after the patient had performed the loudnessmatching test using pure tones as comparison stimuli. Conversely, in our study, an essential prerequisite for the correct application of the experimental acoustic therapy (notched broadband noise; see later) was the reliability (and repeatability) of the measurement of the tinnitus pitch.
Our method was based on the classic pure tone-matching paradigm and consisted of two phases. During both the upward and downward sweeps, we stopped tone presentation every time the subject reported a match between the tone and the pitch of the tinnitus. The second phase (termed sequential binary choice) resembled the traditional 2AFC procedure. During this phase, a number of patients reported more than one tone as matching their tinnitus pitch. We should note that any procedure of tinnitus pitch assessment is subject to many errors owing to, for example, differences in the ability of subjects to compare and discriminate among tones, the uniqueness of the tinnitus sensation, or the presence of different types of tinnitus. The experimental design consisted of randomly assigning to each patient either the experimental sound therapy (WWN)* or one of the two control sound therapies (WN or Wa) following a double-blind procedure. We examined variation of the tinnitus parameters (F t , dB t ) over time for each patient by repeating measurements, ideally after 1, 3, and 6 months from the start of the therapy, following the same procedures of the first visit. In addition, when the subject's tinnitus pitch was reassessed during a control visit, usually the observed value of F t was not exactly the same as the one measured in the previous visit. Therefore, the following compromise criterion was adopted: A new, updated WWN acoustic sequence was constructed only when the re-measured value of F t fell outside the noise window previously determined.
The temporal variation of tinnitus loudness in the three groups of patients was examined by computing the values of Δ dB t using the patient's values of dB t measured during subsequent control visits. Table 1 summarizes the characteristics of patients of each treatment group together with the clinical measurements of their tinnitus at their first visit. The average time elapsed from the beginning of the acoustic therapy and the last tinnitus measurement was similar in the three groups of patients: 148 dd (+ 20), 145 dd (+ 25), and 127 dd (+ 16), respectively, for the WN, Wa, and WWN groups. Figure 4 shows the variation of tinnitus loudness with time elapsed from the start of therapy for three patients taken as an example (one for each type of therapy) and for one subject initially receiving the Wa therapy and later re-treated with the WWN therapy (see further discussion later). The mean decibel attenuation between 3 and 6 months of therapy was less than 1 dB in patients of the Wa group and 4-5 dB in those in the WN and WWN groups.
In the four patients re-treated with the WWN therapy, the value of dBt measured at the last control visit was compared to that measured at the control visit preceding the change of therapy.
Our method for the treatment of subjective tinnitus differs substantially from previous methods (but see Goldstein et el. Indeed, the most striking result of our study was the marked decrease of tinnitus loudness observed in patients after approximately 4-5 months of daily listening to the WWN sound stimulation but not seen in those listening to either the WN or the Wa sound stimulations for an equivalent amount of time. The presence of subjects without residual tinnitus in the WWN group but not in the two control groups further strengthens this conclusion. Apart from the beneficial effects on tinnitus loudness perception, another remarkable aspect of this study was the development of a novel tinnitus pitch-matching procedure using binary comparison of tones selected by the patient in a previous test on the basis of their resemblance to tinnitus. A potential methodological criticism that should be addressed in this study is the lack of control by experimenters over the patients' motivation or willingness to carefully follow the procedures established by the therapeutic listening program.
First, both the Wa and WN therapies were equally ineffective in reducing tinnitus loudness, despite the greater tolerability and pleasantness of the first therapy according to the patients' judgment.
The key element of the WST was the auditory stimulation of tinnitus sufferers with masking noise presumably not comprising the tinnitus frequencies, often suggested to be responsible for the exacerbation of the symptom.
An alternative explanation for the decreased tinnitus loudness in patients treated with WST might involve a change in the neural reorganization in the tinnitus region induced by stimulation with noise around, but not inside, the tinnitus pitch region.
Isle of Man Hearing Solutions is the leading provider of the latest evidence-based tinnitus treatments on our Island. As Chairman of the British Tinnitus Association IOM Support Group and one of the corporate members  of the the British Tinnitus Association we are ideal placed to discuss and offer the latest highly personalised advice and a commitment to audiological best practices to significantly reduce your tinnitus symptoms and hearing loss.
Many people experience an occasional ringing in the ears or you may hear a sound such as roaring, buzzing, hissing, or whizzing noise.
Tinnitus is a conscious awareness of a sound in the ears or head that is not due to an external noise. A significant number of people who experience tinnitus symptoms do become severely distressed by the sounds. It is the turbulent bloodflow that is heard directly by the inner ear, and it usually occurs in time with the heart beat (pulsatile tinnitus). Tinnitus often occurs in conjunction with an auditory impairment, for instance after an acute loss of hearing.
For individuals with long-term tinnitus, one or more of the causes above have, at some point, led to an auditory malfunction. Once they have become hyperactive and synchronous in this way, the nerve cells simulate a tone that the brain ‘hears’ ? We are an independent award-winning hearing clinic that always puts you and your hearing needs first.
Our expertise is offering you the very best way to protect and take care of your natural hearing. We understand that hearing loss is a very personal and sensitive issue, therefore we treat every patient with the utmost compassion. Tinnitus masking is carried out by providing an external sound that reduces the annoyance of the tinnitus through either disguising it, suppressing it, or making it more pleasant. Controlled studies of maskers have shown small effects (Dobie, 1999), and a recent Cochran review (Hobson et al, 2012), suggested that there was limited data, poor studies, and lack of strong evidence of an effect. The purpose of testing for tinnitus is to assess hearing, and tinnitus matching -- to quantify the tinnitus. The most effective way to do masking is to find out what type of noise suppresses your tinnitus (if any), and then make arrangements to expose yourself to this noise.
One may also go about this in a formal way -- measure your tinnitus, determine if a hearing aid is needed, determine the masking sound that works, and implement a masking stimulus using some sort of personal sound playback system.
Hearing aids can be bought with masking stimuli built in, or with blue-tooth that allows one to broadcast masking to one's hearing aid. The main way that this approach differs from conventional masking is that the sound is filtered, and customized to the tinnitus frequency.
Strauss et al (2015) reported another type of masking, using a notch filter that removes sound at the tinnitus frequency from hearing aids might be helpful. Sound Therapy is free innovative software released by Micro-DSP from the tinnitus diagnostic and treatment portfolio. 1.The selection of sound management replies on the tinnitus testing results, specifically the outcomes of tinnitus pitch match which can be obtained from our TinniTest software or from any tinnitus assessment findings available.
2.Sound Therapy can be upgraded to more comprehensive software, Tinnitus Manager which has more than 60 different sounds to match a wide range of frequencies.
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.
The Windowed Sound Therapy: A New Empirical Approach for an Effective Personalized Treatment of Tinnitus. We assessed the long-term effects on tinnitus perception in patients listening to notched noise stimuli (referred to as windowed sound therapy [WST]) by measuring the variation of subjects' tinnitus loudness over a period of 2-12 months. Epidemiological surveys indicate that the sensation caused by the tinnitus is present in 5-15% of the human population.
All subjects of the study were patients reporting a ringing or hissing sound in one or both ears (Table 1) and willing to take part voluntarily in the experiment and to scrupulously follow the assigned therapy.
With a few exceptions, we noted that all patients had, in one or both ears, a more or less pronounced hearing loss at frequencies above 3-4 kHz, an important predisposing factor for the occurrence of tinnitus [9]. We stopped the procedure when a patient reported that the pitch of the comparison stimulus was similar to the tinnitus pitch.
The difference between the two measurements was the estimated loudness of the patient's tinnitus (dB t [decibels SL]).
Pure tones were generated with a function generator (Kenwood model FG-273; Kenwood Corporation, Taiwan) connected to a custom portable electronic switchboard (left, right, binaural), and the output signal was sent to a pair of Sennheiser HD 202 (Sennheiser Sales, Dublin, Ireland) closed-cup headphones. Pure tones are commonly used for measuring the pitch of both noise-like and tonal tinnitus [10]. In such cases, the frequency value of the matching tone was noted, and the tone sweep was resumed, starting from the frequency at which it had been interrupted.
We asked subjects which of the previously identified tones were more similar to the pitch of their tinnitus. This could happen for several reasons: presence of different kinds of tinnitus, such as a ringing associated to hissing tinnitus, presence of multiple tinnitus spectral peaks [13], or octave confusion. WWN was constructed from a 10-minute sequence of white noise generated by the white noise generation function of a suitable software for sound analysis (AVISOFT; Avisoft Bioacoustics, Berlin, Germany).
For these reasons, the width of the erased band of WWN was set prudently to a value double the width of the critical band of the tinnitus frequency. Spectral characterization of the three sound therapies with decibel values in relative units. This was expected, as any procedure of pitch assessment is inherently imprecise for reasons already discussed. In this case, the patient was asked to return the old disk and listen to a new disk that contained the usual 8-minute sequence of equalized broadband noise recorded after a notch centered at the new tinnitus frequency or frequencies was created following the method explained earlier.
Conversely, the presence of two control treatments allowed the effectiveness of the WWN therapy to be established regardless of the type of comparison stimuli used for the measurement of tinnitus loudness. The number of control visits (and re-measurements of dB t ) varied from one to seven per patient.
When subsequent visits of the patient fell within the same temporal class, only the value of dBt measured during the last visit within the class was considered for analysis. If the difference among means was statistically significant, we used the multiple-comparisons procedure of the Kruskal- Wallis test to test the difference of mean value between pairs of treatments.
Patients of the three groups did not differ significantly regarding gender ratio, mean age, mean hearing loss, and mean value of tinnitus parameters. In the WWN-treated patient, tinnitus intensity decreased by 12 dB after only 1 month of therapy and by 15 dB at the end of the observation period (after 7 months). Variation of tinnitus loudness over time in four patients (indicated with a different symbol) taken as an example. The mean attenuation between 7 and 12 months was less than 1 dB in patients of both the WN and Wa groups and 3 dB in those of the WWN group. Results showed a remarkable reduction of tinnitus loudness in the three patients who were initially given the Wa therapy (one of them recovered from tinnitus; see Fig. Furthermore, about two-thirds of the differences were below 1 kHz, and approximately one-half of the differences were below 0.6 kHz.
These acoustic stimulations are standard for each subject; they are not personalized in relation to the tinnitus frequency that characterizes the subjective tinnitus. Furthermore, patient's estimation of tinnitus loudness showed a clear negative relationship with the time of WST application; loudness decreased by approximately 1 dB per month of application of the therapy (see Fig. This procedure yielded pitch estimates characterized by low between-session variability (mean absolute difference of 1.1 kHz between the tinnitus pitch measured at the initial visit and at the first control visit after 1-2 months).
This could weaken the conclusions of our study if the patient's "at-home" listening behavior had been affected by the type of acoustic therapy they received.
Second, tinnitus loudness did not decrease significantly with months of application of the sound therapy by patients of the two control groups. This discrepancy, however, may be easily explained by considering the rough clinical procedure used in our study for finding pitch matches suitable for the loudnessmatching test.
In our study, the pitchmatching test conducted during audiological evaluation was aimed solely at obtaining a matching tone only approximately resembling the tinnitus frequency, the tinnitus pitch being accurately measured in a separate experimental test (see under Methods).
Jastreboff and Jastreboff [21] stressed the importance of ensuring that the sound-enriched environment provided with the TRT should not contain sounds causing annoyance and exacerbation of the tinnitus sensation.
The auditory stimulation of patients with waterfall noise recorded underwater (Wa therapy) did not contain significant energy in the frequency range above 3-4 kHz (where hearing loss usually occurs and most tinnitus sensations pitch) and, furthermore, appeared to be better tolerated as compared to the stimulation with white noise (WN sound therapy). For instance, it has been hypothesized the overrepresentation of the edge frequencies before the hearing loss region is responsible for the tinnitus sensation [1].
If the tiny hair cells of the cochlea are damaged, for example through certain drugs, noise exposure or as part of the aging process, the cochlea becomes less good at discriminating sounds, and your hearing is affected.
Ringing noises in the ears may be caused by spasms of small muscles in the middle ear (often heard as a clicking sound) or by abnormalities of the blood vessels in and around the ear. Pulsatile tinnitus can occur when there is an increased bloodflow to the ear, such as during an infection and inflammation, but also because of anatomical abnormalities of the blood vessels. Every stimulus perceived by the ear is transmitted to and processed by the auditory cortex. We are the Island’s most experienced team, dedicated to taking care of our clients’ hearing for over 20 years. We will be with you every step of your journey from initial consultation, either at our state-of-the-art clinic or in the comfort of your own home and then, if needed, through ongoing treatment and the long term health and protection of your hearing. Nevertheless, from our own clinical experience with treating tinnitus, we think that masking is the most effective treatment of tinnitus. The stimulus is raised in 5 db steps and patients are asked whether their tinnitus is still audible. This is a collection of 6 CD's found by Mike Petroff, an individual with tinnitus, to be helpful for him, and marketed for this purpose.
This can be expensive, as they provide the same function as an app on your smartphone, but cost more than 5 smartphones put together (but of course no contract !). It is difficult to see how this approach is technically superior to the smartphone app approach. This makes the masking sound less disturbing as it does not contain useless frequencies (Paglialonga et al, 2011).


We are dubious - -it is of course impossible to placebo control two different audible interventions.
When inputting the frequency that matches the tinnitus pitch, Sound Therapy automatically recommends a sound from the comprehensive sound bank. 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. We tested the effectiveness of WST using non-notched broadband noise and noise of water as control sound therapies. Tinnitus is thought to consist of an abnormal neural activity of the auditory pathways [1].
In addition, though Jastreboff and Jastreboff [7] claimed that all types of tinnitus and intolerance to sounds can be beneficially treated with TRT, intolerances toward the wearable acoustic prostheses delivering the masking auditory stimuli (noise generators) have been reported, presumably owing to the annoyance caused by stimulation of the patient with frequencies similar to that of the tinnitus [8]. All participants were provided with informed consent, previously approved by the Ethics Committee of the School of Medicine of the University of Parma, before starting the therapy.
Some patients (~25%) experienced difficulty in performing reliable comparisons because of the markedly different perceptual quality of pure tones as compared to that of their tinnitus. Comparison tones (or NBN segments) were presented consecutively for a few seconds at the interstimulus interval of about 1 second. In a subject reporting the tinnitus only, or predominantly, in one ear, the comparison tone was presented contralaterally, whereas if the intensity of the subject's tinnitus sensation was similar in both ears, the tone to be matched was presented bilaterally.
In our case, the use of pure tones facilitated the comparison of tinnitus pitch among subjects receiving different acoustic therapies and the tracking of its variation across time (see later).
During each tone sweep, the subject was asked to manually adjust the amplitude knob of the switchboard so as to keep the tone loudness approximately similar to the loudness of the tinnitus. Usually subjects reported more than one tone as matching the pitch of their tinnitus during both the upward and downward sweeps. In the latter case, subjects were asked to choose which one between the two tones (one having double the frequency of the other) best matched their tinnitus pitch. The noise sequence was band-passed from 50 Hz to 15 kHz and equalized to compensate for the low-frequency bias of the frequency response of the earphones used for sound stimulation (see later).
The acoustic stimulation of the WN sound therapy was white noise in the frequency range 0.05-15 kHz equalized as shown in the figure to compensate for the poor low-frequency response of the earphones (see Methods section for details).
These procedures aimed at obtaining a balanced design with an approximately equal number of subjects treated with the experimental therapy and with the control therapies (WN or Wa) and, at the same time, avoiding any possible bias in the process of data collection owing to, for example, the differential treatment of patients by the experimenters because of the type of therapy assigned. These noncompliant patients were not counted in the analysis, thereby reducing the sample to 49 patients. For each visit, we noted the number of days (dd) elapsed from the date of the start of therapy (usually within 1 week from the first visit) and the date of the control visit. This was necessary to ensure that each patient contributed only one measurement value (if available) to the class mean value. Of the 49 patients who started acoustic therapy, 2 in the WWN group, 3 in the WN group, and 1 in the Wa group withdrew before the first control visit.
However, in the WWN group, the decrease was large (about -12 dB, corresponding to approximately a 75% decrease), whereas in the two other groups, the decrease was negligible (around -2 dB, corresponding to approximately a 10% decrease). By contrast, in two patients receiving the control therapies, tinnitus intensity was initially increased by about 5 dB, showing only minor fluctuations during subsequent control visits. Decibel units on the y-axis are mean values (+1 SE) of ∆dBt computed for three subsequent temporal classes using dBt measurements in subsequent control visits of the same patient.
4 for an example) and no change of tinnitus loudness in the subject who was initially assigned to the WN therapy. Thus, our sound therapy (WST) was tailored to the frequency characteristics of patients' tinnitus. Indeed, analysis of the percentage of those withdrawing from each treatment group indicates that the WN therapy is the least tolerated, whereas the WWN therapy is the best tolerated by patients. Third, in a few patients reporting subjective beneficial effects by the Wa therapy, the measure of the tinnitus loudness did not vary appreciably over the study period. The purpose of TRT is the reduction of the alarm reaction associated with the tinnitus sensation by altering the connections between the limbic and autonomic nervous systems (responsible for the alarm reaction) and the auditory system [5]. Conversely, tinnitus pitch is often located inside the hearing loss region toward the audiogram's edge frequencies, a phenomenon having strong analogy with the one described for the occurrence of the Zwicker tone using notched noise [22]. A comparison of variability among measurements of subjective tinnitus and objective stimuli. Psychoacoustic characterization of the tinnitus spectrum: Implications for the underlying mechanisms of tinnitus. Acoustic communication in two freshwater gobies: Ambient noise and short-range propagation in shallow streams. Usually these noises are masked in everyday life by all the noise going on in the world around us.
Coming back to the piano; the broken keys have created their own permanent tone even without the keys being struck by the pianist. We are passionate about giving you the very finest audiological experience in Europe – it is what we love to do! If you need a hearing aid or have one already with bluetooth, this is a cheap way to go about it. 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 found a significant long-term reduction of tinnitus loudness in subjects treated with notched noise but not in those treated with control stimulations.
However, the physiological mechanisms and persistence of the sensation of the tinnitus have still not been fully clarified. Indeed, anecdotal clinical evidence suggests that the exacerbation of the tinnitus sensation by exposure to sounds comprising the tinnitus frequency is a common complaint from patients suffering from tinnitus.
Initially (first visit), each participant subject received an audiogram and tinnitus loudness and pitch-matching tests. In such cases, we instead used narrow-band noise (NBN) of one-third of an octave, having a pitch similar to the tinnitus frequency (according to patient judgment) of tones. It must be stressed, however, that during the loudness-matching test, no effort was made to obtain the best match to tinnitus pitch, this being determined in a separate, experimental test (see later). Of course, the perceptual quality of a tone stimulus seldom corresponds to subjects' tinnitus sensation. The frequency values identified by the subject in the two sweep tests were grouped and ordered from the lowest to the highest. It might happen that the patient was undecided about the two alternatives when these were of similar frequency. Wa stimulation was an 8-minute sequence of stream noise recorded underwater with a hydrophone placed close to a stream cascade [16] (see Fig. Patients were also asked to regulate the listening volume to a level approximately matching the loudness of their tinnitus. In such cases, the patient usually informed the experimenters about the change that occurred.
Six subjects felt annoyed by the therapy and refused to continue before the first control visit (see Results).
If these subjects are included in the total count of patients treated, the number voluntarily withdrawing from the therapy in the WWN, WN, and Wa groups amounted to three, four, and seven, respectively, the highest percentage being in the WN group (about 30% of subjects) and the lowest being in the WWN group (about 15% of subjects; Fig. Figure 5 reports the variation of the mean value of ΔdBt, with time elapsed from the start of the therapy, for the three groups of patients.
Decibel units on the y-axis are values of ∆dBt computed using dBt measurements in subsequent control visits of the same subject (date on the x-axis).
We tested the effectiveness of the therapy using two types of control sound treatments: nonnotched noise (WN) or waterfall noise recorded underwater (Wa). However, the WWN group had the lowest percentage of those who withdrew (around 15% of subjects compared to 28% in the WN group and 23% in the Wa group) among the three treatment groups, suggesting that WST was the sound therapy best tolerated by patients (presumably owing to the lack of annoyance caused by the stimulation of the patient with frequencies similar to that of the tinnitus).
Thus, WST determined an objective and significant reduction of patient's tinnitus loudness and, hence, it appeared to be an effective sound therapy for the treatment of tinnitus. Therefore, to the extent that these differences might correspond to a different listening behavior by patients in relation to the sound therapy they received, the decrease of tinnitus severity observed among the group of patients receiving the WWN therapy could partly be explained by their (supposed) higher tolerance and stamina in motivation to listen to the therapy as compared to patients receiving the control therapies. Likewise, other patients treated with the WWN and reporting no subjective improvement of their tinnitus sensation showed in fact a decrease of tinnitus loudness measured over time. Therefore, the observed effectiveness of the WST in reducing tinnitus loudness appears consistent with the neurophysiological model of tinnitus underlying TRT [5].
One possibility is that Wa stimulation had poor masking effects on tinnitus in most patients, implying that the alarm reactions induced by tinnitus persisted in Wa-treated subjects. Thus, a conceivable hypothesis is that a stimulation of the edge frequencies, but not the tinnitus region, by the noise frequencies just below the notched region has occurred during the listening of the WWN sound treatment. An estimated seven million people in the UK have experienced tinnitus at one time or another.
If you cannot hear sounds in the outside world so well, you tend to notice the natural noises inside your head much more because they are not being masked by the environmental noises. 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. These results point to the importance of the personalized sound treatment of tinnitus sufferers for the development of an effective tinnitus sound therapy.
This observation has been the foundation of our approach to the treatment of tinnitus and the key element for the development of an effective personalized sound therapy. This may partly explain the high betweensession variability of pitch-matching measurements often reported in the literature [11-13]. Therefore, before testing the patients for the first time, they were instructed in how to use the apparatus and make the tinnitus pitch-tone comparisons.
This occurred frequently, as many subjects identified matching tones of similar frequency during the upward and downward sweeps. We note that the distinction made here between single- and multi-pitched tinnitus was intended solely for the development of an appropriate tinnitus therapy; it may or may not have a relationship with the internal spectrum of the tinnitus. Therefore, the noise energy between the two broken lines is missing in the WWN sound therapy. In case of marked hearing loss in one ear, subjects were advised to regulate the listening volume using the ear of best hearing. Conversely, the key feature of the WWN therapy is the construction of a noise window around the tinnitus pitch, implying that the window features should track any observed change (real or supposed) of the value of F t . Thus, sound stimulation of patients of the two control groups was not personalized on the basis of frequency characteristics of patient's tinnitus. Possible sources of between-session variability of pitch matches are, for example, the multipitched nature of many tinnitus percepts [13], the change of tinnitus pitch with time after application of the sound therapy [10] (Lugli et al., unpublished data), or judgment errors by patients.
However, the observation that many of these subjects experienced tinnitus relief by listening to the water noise soundtrack (Lugli et al., unpublished data) does not support this interpretation. In addition, activation of the mechanism underlying the Zwicker tone must have occurred in patients listening to the WWN treatment, although none of them reported such an aftereffect, presumably because of the pitch similarity between the Zwicker tone and the tinnitus percepts.
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. In addition, no treatment can be considered efficacious in providing longterm relief from tinnitus in comparison to placebo [2].
In such cases, the operator continuously varied the knob of the tone generator within the narrow band delimited by the two frequency values to allow the subject to identify the tone best matching the tinnitus pitch. Hence, our results cannot be compared with those of studies trying to assess the form of the tinnitus spectrum [13]. As compared to the waterfall noise recorded in air, the waterfall noise recorded underwater is characterized by greater energy content at lower frequencies and larger amplitude and frequency modulation [16]. In the Wa sound therapy, most energy is concentrated in the lower part of the spectrum (bottom spectrum = mean spectrum of the 8-minute sequence of waterfall noise; see Methods).
Thus, ideally, patients subjected to the WWN therapy should receive a new windowed noise sequence almost each time at every control visit.
Thus, the overall number of subjects available for the comparative analysis of data was of 43 patients, of whom 20 were treated with WWN, 11 were treated with WN, and 12 were treated with Wa.
We did not attempt the chi-squared analysis of the proportion of those who withdrew in the three groups owing to the low number of those who withdrew, expected in each group under the null hypothesis.
Though the reliability of the method of pitch assessment proposed here awaits further testing before being asserted, our findings nonetheless point to the type of pitch-matching procedure adopted as a major factor responsible for the unreliability of pitch estimates documented in the tinnitus literature [18].
These facts do not support a supposed presence of marked differences in the at-home use of the therapy by patients of different treatment groups. One or both of these phenomena might have determined a reorganization of the neural activity of the edge frequencies resulting in the observed longterm reduction of the tinnitus percept in such patients. We also thank all personnel in the audiological laboratory of the University of Parma for their invaluable contribution to the collection of clinical data. 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. Hence, the width of the band-stop filter amounts to 1,377 Hz, being 5,462 Hz and 6,838 Hz, respectively, the lower and upper frequency extremes of the band, with the center frequency at 6,150 Hz. This is admittedly tedious and perhaps of little therapeutic significance when the re-measured value of F t is similar to the last one determined in the previous session. To explore the efficacy of the WWN therapy further, three Wa subjects and one WN subject were chosen among the group of patients reporting no relief from the therapy and were asked to abandon the assigned therapy and to start with the WWN therapy.
Finally, 7 of the 20 patients treated with WWN were given one (n = 5) or two (n = 2) updated WWN treatments during the study period (see Methods for details). Hence, the lack of direct control by the experimenters over the patient's at-home listening behavior was unlikely to be a factor potentially affecting the main conclusion of this study about the effectiveness of the WST therapy in the treatment of tinnitus. It is still rather labor intensive though as it requires tinnitus matching, creating a customized sound file, and mixing in the sound file with background music. 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.
The procedure was repeated until the tone identified up to that point was compared with the highest tone (F n) of the sequence.
Cursory examination of pitch match position in relation to the patient's audiogram showed that the matches were frequencies above that at the beginning of the region of hearing loss on the audiogram. The control-toexperimental therapy shift occurred after 3-7 months from the beginning of the experiment.
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. The goal is the reduction of subjects' tinnitus perception by providing competing auditory stimuli masking the tinnitus. This observation agrees with results by earlier and recent studies on the relationship between tinnitus pitch and hearing loss [9].
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. 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. However, no firm experimental evidence supports the effectiveness of these methods in the long term: an objective reduction of the loudness of the tinnitus or the complete recovery from tinnitus. 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.



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