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The cerebellum and the descending auditory system (DAS) are considered clinically significant for influencing the development of the clinical course of tinnitus of the severe disabling type. The purpose of this manuscript is to discuss for the first time, in 1999, the role of the cerebellum and descending auditory system in the development of the clinical course of tinnitus of the severe disabling type, as demonstrated objectively and reported in 1993 with SPECT of Brain perfusion asymmetries [1-5]. The symptom of tinnitus has forced clinicians attempting to establish protocols for an accuracy of the tinnitus diagnosis and for tinnitus treatment to apply basic principles of sensory physiology and findings evolving from the neuroscience of brain function and its underlying neurochemistry [10-14].
Since 1989, the nuclear medicine technique of Single Photon Emission Computerized Tomography (SPECT) has been introduced into our medical audiologic tinnitus patient diagnostic protocol (MATPP) to attempt to improve the accuracy of the tinnitus diagnosis as well as to monitor the efficacy of modalities of therapy recommended for attempting tinnitus control [1-8,15,16].
Since 1999, SPECT Imaging of Brain, baseline and the Diamox Stress Test, a test for cerebrovascular reserve, are being recommended to patients with tinnitus of the severe disabling type who are not responding to recommendations for attempting to relieve tinnitus. The evolving clinical experience with SPECT Imaging of Brain has influenced our definition of tinnitus, protocols for both diagnosis and treatment, and confirmed the significance of the factor of stress [17-19]. This paper on the descending auditory system and cerebellum will present their proposed role in the clinical course of tinnitus. First, a brief review of three highlights of our evolving SPECT of Brain experience which includes a) the identification of a Final Common Pathway for tinnitus in the Medial Temporal Lobe System (MTLS) of Brain, b) Tinnitogenesis-a epileptiform auditory phenomenon, and c) perfusion asymmetries in the cerebellumand their considered role in the clinical course of a predominantly central type tinnitus of the severe disabling type.
Second, the physiologic significance of the descending auditory system; and acousticomotor systems, on the clinical course of tinnitus.
Third, a demonstration of SPECT Imaging of Brain perfusion asymmetries in the cerebellum in one patient with the clinical diagnosis of cerebrovascular disease.
Single Photon Emission Computerized Tomography (SPECT) of Brain with the radioisotope Technetium 99m Hexamethyl Propylenamine Oxime (TC-99-HMPAO) is a nuclear medicine imaging technique which provides an objective analytical detection method of information of regional cerebral perfusion of brain. SPECT Imaging of Brain in patients with tinnitus of the severe disabling type has revealed since 1991 pathophysiologic loci in patients with a central type tinnitus [1]. Since 1991 repeated findings in SPECT Imaging of Brain in patients with tinnitus particularly of the severe disabling type using the radioisotope TC-99-HMPAO has revealed perfusion asymmetries in multiple cortical areas including the cerebellum.
Two regions of interest consistently continue to demonstrate asymmetries in regional cerebral blood flow with significant side to side asymmetries. It is hypothesized that a fundamental function of the amygdala hippocampal structures is the establishment of a paradoxical auditory memory for tinnitus.
In the original ten tinnitus patients with a severe disabling, predominantly central type tinnitus, examined in a basal state, and compared with four matched controls, 73 regions of interest were analyzed. Persistence of findings of perfusion asymmetries involving the cerebellum in a significant number of patients with severe disabling tinnitus supports consideration of the role of the cerebellum in the clinical course of tinnitus. One of the implications of the hypothesis of a Final Common Pathway for Tinnitus has been its innovative application for treatment. It is hypothesized that the model of the Final Common Pathway in the patient with tinnitus relief reflects a reestablishment of the homeostasis between the sensory and affect components of tinnitus. Therapy directed to an increase in GABA function has been hypothesized to reduce the excitatory glutamate influence.
Underlying mechanisms reflected in processes within the Final Common Pathway are considered to be highlighted by the glutamate theory of neuroexcitotoxicity. For tinnitus one can speculate on a Tinnitogenesis, that is a seizure-type activity resulting in the perception of an aberrant auditory stimulus. Significant are recent new anatomical labeling methods which identify the distribution of input pathways to the cerebellar cortex; and output of the deep nuclei which have led to the identification and understanding that distinctive cerebellar units are important in almost all nervous functions. Technical advances in disciplines of molecular biology, network modeling, functional neuroanatomy and brain imaging with PET, SPECT, fMRI have led to the development of concepts about the cerebellum, which is different from what was classically taught and understood.
Significant for tinnitus are the reports supporting existence of cerebro-cerebellar "loops" and their involvement in motor and non-motor aspects of behavior [40]; and reports of classical conditioning, which have indicated that the cerebellum is significant for the establishment, retrieval and use of associations between stimuli to generate new context dependent and adaptive responses [41]. Functional images of cerebellar activity in patients with tinnitus of the severe disabling type as demonstrated with SPECT Imaging of Brain correlate with abnormal electrophysiologic recordings of cocheovestibular function, including interferences in cognition, motor function, and maintenance of balance [42].
Middleton and Strick have reported that the cerebellum contributes to non-motor as well as motor function [46]. In the past it has been reported that, in general, natural peripheral stimuli affect activity of larger numbers of cerebellar neurons. Vestibular stimulation results in increased neuronal activity in the nodulus, flocculus, uvula, lingula, lobus simplex, lobules I-X of the vermis (i.e. Auditory responses by cerebellar stimulation have been reported to be modified since 1966 [50,51]. Responses to auditory stimuli are evoked by a corti cal and subcortical pathways of the auditory system [53,54]. The responses of the cerebellum to auditory stimuli have been considered to be important in adjusting the position of the body and the head to the location of the sound [49]. Strick, using retrovirus techniques for identification of internal networks, involved in activation of the primary motor cortex control, has reported that 20-30 percent of the cerebellum can only be identified as directly related to motor function involving the primary motor cortex.
The literature has identified acousticomotor systems in the descending auditory system [61].
Ongoing studies are attempting to answer questions presented by the descending auditory system as it applies to the symptom of tinnitus; and in particular the multisensory integrative functions of the ICX with the cerebellum and other acousticomotor systems.
The perfusion asymmetries identified in cerebellum with SPECT of Brain in patients with tinnitus of the severe disabling type are considered to be objective evidence for what may be a reflection clinically of the psychomotor component of tinnitus; and explain some different central types of tinnitus. At this time, a positive correlation can be reported in patients with tinnitus of the severe disabling type between the cerebellar perfusion asymmetries and positive abnormal electrophysiologic test results of interference in cerebellar function e.g. SPECT of brain images in one patient with tinnitus of the severe disabling type and the clinical diagnosis of cerebrovascular disease has been selected to demonstrate the multiple perfusion asymmetries in brain, highlighted by the primary auditory cortex, medial temporal lobe system and cerebellum (Figure 1).
The anatomico-physiologic information of the descending auditory system and its multiple functions are considered significant for understanding not only auditory function in general but specifically the clinical course of the tinnitus particularly of the severe disabling type. An excellent review of the descending auditory pathway and acousticomotor systems can be found in Huffman and Henson Jr.
It was suggested in 1993 to be explainable by the glutamate neuroexcitotoxicity theory [68). The descending auditory system is considered significant not only for the origin and site of lesion for an ab-errant auditory phenomenon, called tinnitus, but also for its role in the clinical course of tinnitus, particularly of the severe disabling type and its modulation.
In general, for each projection in the ascending pathway from the CN to AC there is a parallel descending projection with one exception-no geniculocolliculus fibers. It has been proposed that regions of the auditory cortex (AC) are homologous across many species. The AC projects to both the IC and MGB by the corticogeniculate projections which like the corticocollicular fibers originate from pyramidal cells in the AC [61]. Significant for the AC projections to the MGB are the reciprocal connections between both structures for origin and termination. Cortical influences on the descending auditory pathway include models of inhibition, and increased sensitivity as well as cognitive influences. The central nucleus participates directly in ascending and descending primary auditory pathways and receives the principal relay afferent fibers of the ascending auditory system. The dorsal nucleus receives major auditory cortical projections and projects exclusively to the dorsal division of the MGB. In summary, the most frequently reported connection intrinsically within the IC is from the central to the external division of the IC. The IC projects caudally to two auditory brain stem areas, the CN [78,84-87], and the SOC [77,78,84,87, 88]. Significant for tinnitus is the role of the inferior colliculus and the olivocochlear efferent system. A trisynaptic pathway has been suggested by anatomical and physiological reports between the auditory cortex and cochlea [61] (Figure 5). There are at least five obligatory synapses in the ascending pathway from the cochlea to the AC. Ongoing studies are attempting to answer questions presented by the descending auditory system as it applies to the symptom of tinnitus and, in particular, the multisensory integrative function of the external nucleus of the IC with the cerebellum and acousticomotor systems [96]. The SC is considered a higher center for cOOl'dination of directional orientation of head, eyes, and ears [97].
The findings with SPECT Imaging of Brain and perfusion asymmetries in cerebellum of tinnitus patients are considered to be a reflection of the activity of the descending auditory system and, in particular, the acousticomotor systems in brain and its response to an aberrant auditory stimulus.
The IC has significant roles in both ascending and descending auditory pathways and in acousticomotor systems. It is suggested that the significance of the IC extends beyond that of the ascending, descending, and acousticomotor pathways [61]. It is known that the mMGB projects to the limbic system and subcortical areas involved in processing of emotional behavior i.e.
It is questioned whether the IC provides auditory input to the mMGB which has encoded information about acoustic condition to learning. The IC significantly contributes to the descending auditory system as well as descending control of the acousticomotor systems. The IC is a source of auditory input to integrate auditory, visual and tactile localization cues. The classical concept of cerebellar control involving primarily coordination of motor function has within the past 30 years undergone distinct change. The control function of the cerebellum originally considered to be that of a "braking" action, has recently been demonstrated to include both gabaergic (braking) and glutaminergic (accelerating) activity [34]. In tinnitus the multiple areas of perfusion asymmetries demonstrated by nuclear medicine SPECT studies is represented by hypo-and hyperactivity and suggest an interneuronal network controlled by neurochemical interaction of multiple neuro-transmitter systems which are hypothesized to influence the clinical course of severe disabling tinnitus [1-5].
Special attention in the cerebellum is recommended for associated symptoms reported by tinnitus patients such as interference in speech expression, psychomotor complaints, gait difficulty, and abnormal orientation of the head and proprioceptive input system in response to auditory stimulation. 6) One needs to consider whether the cerebellar perfusion asymmetries reflect the phenomenon of diaschisis, or alteration in neuronal function, or a combination of both. The author expresses appreciation to the Martha Entenmann Tinnitus Research Center, Inc., and to the Beech Fund Trust B, New York Community Trust, for support of this study.
A final common pathway for tinnitus is hypothesized to exist for all patients with tinnitus. Its function is the transition of the sensory to the affect component of the symptom of tinnitus. Single Photo Emission Computerized Tomography (SPECT) with the radio isotope TC99-HMPAO has identifie side to side perfusion asymmetries highlighted by that of the amygdala - hippocampal complex.
It is hypothesized that a fundamental function of the amygdala - hippocampal structures is the establishment of a paradoxical auditory memory for tinnitus. A Final Common Pathway (FCP) is hypothesized to exist for all patients with tinnitus, particularly of the severe disabling type (SIT).
Historically, this search for understanding how the transition from sensory to affect occurs in the brain is not new.
The concept of William James, the Father of American Psychology is suggested to find application to a FCP for tinnitus.
Single Photon Emission Computerized Tomography (SPECT) with the radioi sotope Tc-99 HMPAO is a detection method which provides information of cerebral perfusion in brain.
Based on clinical experience with tinnitus particularly of the severe disabling type and supported by SPECT imaging of the brain, the medial temporal lobe system is speculated to be a key site of action of processing of an aberrant auditory signal resulting in a paradoxical auditory memory; and an accompanying parallel transition in processing of the sensory to the affect component of the symptom of tinnitus. In other words, the eterogeneity of the symptom of tinnitus is reflected in FCP for tinnitus.
The FCP is presented as a hypothesis focusing on a process within the MTLS of a paradoxical auditory memory with speculations as to its clinical applications for both diagnosis and treatment.
It is hypothesized that for all sensory systems the sensory and affect components are linked by memory.2 The experience of the sensation is a perceptual image of the stimulus.
Psychology and neuroscience evidence have differentiated between long term and short term memory. The modulator of the sensory component is considered to be the efferent system and the process of masking.3 The modulator of the afferent component is considered to be stress. In the patient with tinnitus, particularly of the severe disabling type it is hypothesized that both the hippocampus and amygdala of the MTLS are significant for the transition of the sensory to the affect component.
In summary, the FCP model for tinnitus involving the medial temporal lobe system is initiated in the MTLS by the process of establishment of a paradoxical memory. Our approach is clinical and attempts to identify not all components of the FCP but rather to focus on one aspect, specifically memory which is considered at present to be clinically most significant; and is explainable by what has been reported for understanding brain function specifically memory.
The activity in the brain that corresponds to memory can be found in the medial temporal lobe system.
Crick's comments on the problem of visual awareness I believe can be applied to that of tinnitus - an auditory perceptual phenomenon.6,31 Specifically, investigations for tinnitus are necessary from a psychological and a neuro-science perspective for the issues of attention and very short term memory. The MTLS can be considered an information processing pathway for the integration of sensory and affect components of all sensory inputs. The perception of a auditory image, considered to be "normal", is hypothesized to be determined by a normal masking function.
It has become apparent to us from our clinical experience with SPECT since 1989, that the manner in which the brain processes auditory sensory information is radically different with or without the presence of tinnitus. The consequences of the identification of a FCP for tinnitus and the role of the MTLS are considered significant. The following SPECT images of the brain demonstrate multiple perfusion asymmetries, highlighted by the MTLS (Fig. The FCP for tinnitus provides a rationale and model for understanding the integration, interaction, translation, and transformation of the sensory auditory signal to the affect behavioral response.
An initial process, in the MTLS, is hypothesized to be the establishment of a paradoxical auditory memory for tinnitus.
SPECT imaging of brain provides an ability to identify regions of interest in the brain which demonstrate perfusion asymmetries frequently found in patients with tinnitus of the severe disabling type. The processes involved in the establishment of the symptom of tinnitus particularly of the severe disabling type and the problems encountered, relate to the overall problem and question over centuries of what is the relationship of mind and brain and what are the processes involved in such identification.
The most well-known treatment available to those suffering from hearing loss is the hearing aid. A cochlear implant is an auditory device specifically for those who are profoundly deaf or suffer from severely impaired hearing.
Don't share enjoyment, interests, or achievements with other people ie., by a lack of showing, bringing, or pointing out objects of interest and enjoyment. Delay in, or total lack of, the development of spoken language (not accompanied by an attempt to compensate through alternative modes of communication such as gestures or mime).
Without adequate speech, marked impairment by in the ability to initiate or sustain a conversation with others. Lack of varied, spontaneous make-believe play or social imitative play appropriate to developmental level. Autism encompassing preoccupation with one or more stereotyped patterns of interest that is abnormal either in intensity or focus. Symbolic or imaginative play (playing or talking some form of outer space words or cartoon's words or play). Alway isolated in worlds of their own, people with autism appear indifferent and remote and are unable to form emotional bonds with others.
As a parent, teacher, or caregiver you may know the frustration of trying to communicate and connect with children or adults who have autism. Autism is found in every country and region of the world, and in families of all racial, ethnic, religious, and economic backgrounds. A ADHD kid must have exhibited at least six of the following symptoms for at least six months to an extent that is unusual for their age and level of intelligence. Fails to follow through instructions or to finish homework or chores (not because of confrontational behaviour or failure to understand instructions). A ADHD kid must have exhibited at least three of the following symptoms for at least six months to an extent that is unusual for their age and level of intelligence. Runs around or excessively climbs over things, or being very busy all day long playing with things or loooking for things. At least one of the following symptoms must have persisted at least for six months to an extent that is unusual for their age and level of intelligence. For a diagnosis or description of ADHD a child would be expected to show the above difficulties in more than one setting, eg at school and at home. Problems are not shown 'at home' but are very evident when a child goes to a hospital department.
The above picture is taken during the New Medical Centre Opening Ceremony by our Health Minister YAB Dato. The Heart of the Matter: What Does America Really Know about Coronary Artery Disease Treatments?
This section compares a couple common methods for noise reduction, and also introduces an alternative technique: averaging multiple exposures to reduce noise. It is hypothesized that the SPECT of Brain perfusion asymmetries in cerebellum, demonstrated since 1993, reflect clinically the influence of an aberrant auditory stimulus i.e. Barbara Goldstein, an audiologist, and I have at the Tinnitus Clinic at the Health Sciences Center Brooklyn, State University of New York (HSCB-SUNY) attempted to increase the accuracy for the tinnitus diagnosis, focusing on subjective tinnitus of the severe disabling type; and to identify its medical significance.


For the first time in vivo the significance of the organicity of brain for a predominantly central type tinnitus was presented in New York City at the Triological Society (January 30, 1993) and subsequently published in The International Tinnitus Journal in 1995 [2]. A Final Common Pathway for tinnitus is hypothesized to exist for all patients with tinnitus. Nine of 73 regions of interest analyzed were found to have a significantly increased blood flow in patients compared to controls with a p of less than 0.05. Tinnitus, a sensory disorder of the cochleovestibular system, is compelling professionals, regardless of discipline, to address the issue of how an auditory sensory stimulus results in a particular behavioral response; or conversely-does an antecedent behavioral pattern of response, influence the sensory perception of a normal or an aberrant auditory sensory input, resulting in the auditory perception of tinnitus of the severe disabling type. One such therapy, reported in 1996, is medial thalotomy performed on 104 patients with "chronic therapy resistant positive symptoms" by Jeanmonod [33]. Different types of brain rhythms, which characterize various behavioral states, are combined within complex wave sequences. The relationship between the cerebellum and the thalamus is considered significant and reflected in the acousticomotor systems.
It was speculated and reported in animal experimentation by Kandel in 1995 that the GABAergic inhibition and resultant glutamate excess produced a disruption in motor behaviors, and complex affective and cognitive behaviors, e.g.
It is speculated that the GABAergic inhibition and resultant glutamate excess produces a disruption in calcium homeostasis with resultant hyperexcitability and epileptic characteristics, i.e. In such a manner a tinnitus of a central type may arise due to a seizure type activity [9].
Although it is not consid-ered to initiate voluntary movement, it has been considered to serve as a suprasegmental coordinator for muscle activity, especially motor functions requiring sequential, repetitive or complex movements. Cerebellar activity characterized as "coordination" no longer applies only to motor function and control [39]. The VOR automatically stabilizes the visual image on the retina during head movements by producing eye movements in the direction opposite to that of the head.
The cerebellum is known to process auditory information by interactions within the cerebellar cortex and by its influence on neurons and nuclei in ascending central auditory pathways, including the cochlear nuclei, inferior colliculus and the superior olive. Ablation of the auditory cortex has been shown to cause marked changes in responses evoked by auditory stimulation [55].
Additional cerebellar functions have been identified with the prefrontal area for cognition as well as the visual cortex. The acousticomotor systems include the acoustico-motor centers of the cerebellum, medial division of the medial geniculate body (mMGB) and the superior colliculus (SC). It may reflect the activity of the descending auditory system; and the multisensory integrative activity of acoustico-motor systems including the cerebellum, external nucleus of the inferior colliculus (ICX), and Superior Colliculus (SC), and the medial division of the medial geniculate body (mMGB). The multicolor display accentuates asymmetry of cerebellum as demonstrated in the upper transaxial reconstructed image.
In 1997 it was suggested that the resulting calcium cascade involved proteases highlighted by calpain [69].
The inferior colliculus-an obligatory synaptic station in the descending auditory pathways. This is performed by inhibitory mechanisms which reduce baseline activity in the absence of sound; and by excitatory mechanisms which prolong the duration of auditory signal processing. The IC is a caudal ventrolateral central nucleus that is encapsulated by the dorsal nucleus dorsally and caudally, and by the external nucleus ventrally, laterally and rostrally (Figure 4) [61]. Schematic of a coronal section through the inferior colliculus showing the central (ICC), dorsal (ICD) and external (lCX) nuclei.
Fibers synapse rostrally with the principal auditory thalamic relay nucleus which is the ventral divi-sion of the MGB, and caudally with the dorsal and ventral cochlear nuclei, superior olivary complex and nuclei of the LL [76-78]. It includes the dorsal cortex and areas adjacent to the periaqueductal gray which are dorsal and medial to the central nucleus [79].
The external nucleus is a multisensory nucleus which functionally separates it from the other auditory IC nuclei. The projections from the IC allow direct effects not only on the auditory brain stem but also contribute to the descending auditory pathway originating from the SOc. Recent reports of Sahley, Musiek, and Nodar of a model for opiate receptor identification within the auditory system and speculation of its action both central and its effect peripherally within the Organ of Corti is considered significant for understanding the clinical course of tinnitus and for future tinnitus treatment [89].
The IC provides a possible link between descending information from the AC; and the olivocochlea (OC) efferent system to the outer hair cells (OHC) in the cochlea [91]. Descending impulses from the AC reach the cochlea in a travel time shorter than that of ascending information. The acousticomotor systems include the medial division of the MGB, the superior colliculus, and cerebellum. Clinically this may reflect a psychomotor component of tinnitus and explain some different central types of tinnitus.
Additional roles proposed reflect connections of the IC with the hypothalamus and its role in learning and memory.
Whether or not the IC has influence on the activity of limbic structures remains to be established. Both are neural sites of multisensory integration and participate in coordination of head, ear, and eye movements toward a sound source.
Connections of the external nucleus of the inferior colliculus with acousticomotor and somatosensory systems. Multiple descending auditory projections to the cerebellum via the dorsolateral pontine nucleus (DLPN) parallel those from the IC The IC connects with the cerebellum by way of tectopontine projections.
Most significant has been the identification that most types of natural peripheral stimuli affect the activity of larger number of cerebellar neurons. The clinical significance of these abnormal cerebellar findings in tinnitus patients of the severe disabling type needs to be considered in attempts to establish an accuracy of diagnosis and treatment. Adjacent perfusion asymmetries involving the frontal, temporal and parietal lobes suggest a interneuronal network resulting in the transition of the sensory to the affect components of the symptom of tinnitus. Descartes regarded the mind as something immaterial, separate from brain but interacting with it in some manner.
Fear and stress in tinnitus patients particularly of the severe disabling type are a result of a paradoxical auditory memory of an aberrant dysynchronous auditory signal. The establishment of a paradoxical auditory memory for tinnitus is hypothesized to be the initial process localized in the medial temporal lobe.
Demonstrations of SPECT imaging of rain in patients are presented to support this hypothesis.
The heterogeneity of response both for sensory and affect has been reported by professionals of all disciplines who are involved in tinnitus diagnosis and attempts for its control. The Papez circuit proposed the anatomical basis of emotion to consist of the cingulate gyrus which connects with the parahippocampal gyrus and peripheral area of the temporal lobe.
The anatomical components are best seen by a saggital section of the medial surface of the brain; and ventral views of the base of brain.
Non-declarative memory, also called implicit memory, includes all abilities which are unconscious and expressed through performance.16 Such abilities provide for cumulative changes in perceptual and response systems of new skills and habits, priming, simple classical conditioning, and non-associative learning.
Its chieffunction is the transition of a aberrant dysynchronous auditory sensory signal to a affective behavioral response (Fig.
This conceptualization is a basic tenet of the FCP for tinnitus of the cochleovestibular system. The sensory and affect components are considered to be in a constant state of reciprocal interaction. For memory, alterations occur in the hippocampal formation with the establishment of a paradoxical memory for an aberrant dysynchronous signal. I consider the experimental and theoretical work of consciousness as reflected in memory, to be a starting point to explain our SPECT findings to date. Neurobiological theories of tinnitus awareness need to be developed and tested using a combination of molecular, neurobiological and clinical imaging studies. It is possible that there is a localization in the MTLS for all sensory inputs similar to that which exists in the motor cortex. Specifically, the anatomic substrate where integration of sensory and affect components occurs for the auditory system, is suggested at this time to be in the MTLS. Interference in masking within brain, initially at brain stem is hypothesized to set in motion a cascade of events wherein the sensory component is overwhelmed by that of the affect due to the establishment of a paradoxical auditory memory.
Hinton et al.35 have described such neuronal networking in investigations simulating brain damage. For the first time, here is a model which may differentiate tinnitus between its sensory and affect components both from its clinical and basic science perspectives. Jacobson L, Sapolsky R: The role of the hippocampus in feedback regulation of the hippothalamic - pituitary - adrenal cortex axis.
LeDoux JE: Information flow from sensation to emotion plasticity in the neural computation of stimulus value. Hearing aids come in multiple kinds; both digital and wireless, to be worn either inside or outside of the ear.
They are generally made from wax, silicone, or memory foam, and prevent damage be caused by loud noises or water.
Autistic kids always only give short reply if any, mostly will repeat your questions if anyone ask the autism kid. Although people with this baffling brain disorder can display a wide range of symptoms and disability, many are incapable of understanding other people's thoughts, feelings, and needs.
Gone are the days when people with autism were isolated, typically sent away to institutions.
Emerging in childhood, it affects about 3 or 4 people in every thousand and is three to four times more common in boys than girls. This can happen when parents do not realise that their child's behaviour is out of the normal range (perhaps because they have no other children, or they have other children who behave similarly). It is believed that more than 35 million Americans suffer from the hearing ailment, tinnitus.
Tinnitology, a disci-pline involving professionals dedicated to the science of sound perception unrelated to an external source of sound. Common to all has been an incidence of perfusion asymmetries involving the medial temporal lobe system (MTLS) in more than 90% of the cases with a p of less than 0.05 [1-5,7]. It is hypothesized that in the Final Common Pathway for Tinnitus the homeostasis between sensory and affect, modulated by stress, is interrupted and displaced toward the affect. For the symptom of tinnitus the sensory component is clinically manifest by the quality and intensity of the symptom. Tinnitology, a discipline involving professionals dedicated to the science of sound perception unrelated to an external source of sound, reflects this effort. Sensory processing occurs across the medial region of the auditory thalamus and the intralaminar nucleus to the lateral nucleus of the amygdala, that is, the thalamo-corticalamygdala and the short thalamo-amygdala emotional pathways. Six patients had severe tinnitus, and half of them were reported to have experienced relief. Short term plasticity processes could be used to consolidate memory traces acquired during wakefulness, but also lead to paroxysmal episodes similar to that observed in epileptic seizures. GABAergic reticular neurons project not only to thalamocortical neurons but also to local inhibitory neurons.
At a cortical level, via the Final Common Pathway, a paradoxical auditory memory is hypothesized to develop with a cascade of neurochemical activity reflecting the theory of calcium neuroexcitotoxicity.
Also, the cerebellum has been identified to regulate muscular tone and maintain proper balance for standing, walking, and running [38]. Ito considers the cerebellum and LTD to be involved in VOR plasticity; and the flocculus to playa role in learning mechanisms which contribute to the VOR [43]. Desmond and Fiez, based on functional imaging studies, report the cerebellum to be involved in working memory, implicit and explicit learning and memory, and language. The flocculonodular lobe has been designated as the classic location of the vestibulocerebellum. The regions of response of the cerebellar cortex to auditory stimuli overlap with those of the visual stimuli [49].
The responses of the evoked auditory responses have been considered to be due to projections involving the cochlear nuclei and projections from the inferior colliculus to the pontine nuclei from the cerebellum [56]. The inferior colliculus (IC), and particularly the external nucleus of the inferior colliculus (ICX), a multisensory nucleus, has connections with the superior collicuIus (SC), cerebellum (C) and medial nucleus of the medial geniculate body (mMGB). It is a dynamic protocol reflecting advances in the basic science and clinical research efforts for tinnitus diagnosis and treatment [64). Three parallel descending pathways provide a major projection to a nucleus in each of three auditory centers i.e. Each of three parallel descending pathways provides a major projection to a nucleus of 3 auditory centers: inferior colliculus, medial geniculate body and auditory cortex. A system of three parallel descending pathways in the cat and rat exists in other animals suggesting a common mammalian scheme.
Broca 41, 22, 36 have connections with the MGB, each of these three areas in the rat has a strong individual and separate connection, e.g. Each nucleus of the IC has been identified to have distinct structural and functional features. It has connections with SC, cerebellum and mMGB which themselves are multisensory, mutually interconnected, and share descending cortical projections from the AC. The colliculolivary projections appear to terminate in parts of the SOC where olivocochlear neurons have been identified [61]. This is an advantage since the descending feedback does not interfere in the continuous cycle of reception and modification of incoming sensory information [61]. The IC, and particularly the external nucleus of the IC, a multisensory nucleus has connections with SC, cerebellum and medial nucleus of the medial geniculate body i.e. Each of the divisions of the acousticomotor systems subserve multisensory integrative functions and participate in coordination of head, ear, and eye movements for sound localization. Significant for tinnitus are studies of acoustic conditioning which indicate that neural activity in the IC changes with conditioning [103,104]. The mMGB may serve as a primary link for attaching emotional significance to acoustic stimuli [31,32,108].
There is discussion of not only auditory but possibly non-auditory processes in the IC [61]. It also may playa role in acoustic reflex such as the acoustic startle response [110], and middle ear reflex [61]. Connections of the IC with SC, cerebellum and somatosensory system suggest that the external nucleus is a crucial relay in the acousticomotor pathways. This is highlighted by cerebellar responses to vestibular, visual, and auditory stimuli [49].
Autoregulation of intra-cranial blood flow may in the absence of an adequate cerebrovascular reserve result in interference in cerebellar function, and be reflected not only in the primary motor cortex but also in prefrontal areas for cognition, the visual cortex for vision, the vestibular parietal cortex for spatial orientation, the primary auditory cortices for perception of sound, and the somatosensory cortex. Neurospect Cerebral Blood Flow Studies in Patients with a Central Type Tinnitus-Preliminary Study. The Scintigraphic Appearance at Pathophysiologic Loci in Central Type Tinnitus: An Tc99m-HMPAO Study. Uptake of corticosterone by the rat brain and its concentration in certain limbic structures. The role of the hippocampus in feedback regulation of the hippothalamic-pituitary-adrenaI cortex axis. Dysmetria of Thought:Clinical Consequences of Cerebellar Dysfunction on Cognition and Affect.
Contribution a'i etude des relations entre I'aire auditive du cervelet et l'ecorce cerebrale chez Ie chat.
Electrical responses of the auditory area of the cerebellar cortex to acoustic stimulation. Responses of single units in cerebellar vermis of the cat to monaural and binaural stimuli.
Frequency sensitive auditory responses in the cerebellum with surface and microelectrode recordings.
The descending auditory pathway and acousticomotor systems:connections with the inferior colliculus.
Effects on Visual Recognition of Combined and Separate Ablations of the Entorhinal and Perirhinal Cortex in Rhesus Monkeys. The connections of the.inferior colliculus and of the dorsal nucleus of the lateral lemniscus. The efferent projections of the central nucleus and the pericentral nucleus of the inferior colliculus in the cat.
Descending projections from the inferior colliculus to the dorsal cochlear nucleus in the cat:an autoradiographic study. Responses of single units in cerebellar vermis of the cat of monoaural and binaural stimuli.


Neurological Anatomy in Relation to Clinical Medicine (3rd ed), New York: Oxford University Press, 1981.
Ascending and descending projections of the inferior colliculus in the kangaroo rat (Dipodomys merriami). Subcortical connections of the superior colliculus in the mustache bat, Pteronotus parnellii.
Classical conditioning enhances auditory 2-deoxyglucose patterns in the inferior colliculus.
Subcortical efferent projections of the medial geniculate nucleus mediate emotional responses conditioned to acoustic stimuli. Projections to the subcortical forebrain from anatomically defined regions of the medial geniculate body in the rat. The auditory corticopontocerebellar projection in the rat:inputs to the paraflocculus and midvermis. The positive projection of cerebellar vermal visual area studied by means of the retrograde axonal transport of horseradish peroxidase. Projections from the pontine nuclei proper and reticular tegmental nucleus onto the cerebellar cortex in the cat.
The inferior colliculopontine neurons of the cat in relation to other collicular descending neurons. Localization of brain action is now possible and is being investigated with both Positron Emission Tomography (PET) and Single Photon Emission Computer Tomography (SPECT) brain imaging. The transition is acknowledged to be complex, involving an integration of multiple neuronal networks within the brain. The underlying mechanism is that of dysynchronization, that is, a lack of synchrony or interference in timing of the discharge rate and phase locking of the auditory signal having a location peripheral, central or both. To date 48 patients were selected for SPECT imaging of the brain identified with the MATPP to have severe disabling tinnitus of the central type. The clinical application of this hypothesis for present and future tinnitus diagnosis and treatment is conside d significant. It includes the subcallosal, cingulate, and parahippocampal gyri, the hippocampal formation, and the dentate gyrus.
The temporal lobe connects with the hippocampus (AMMONS horn) via the temporoammonic tract. The entorhinal cortex is a major source of projections at the hippocampus and in turn receives input from adjacent perirhinal, parahippocampal cortices.
Final Common Pathway for Tinnitus - The Medial Temporal Lobe System (Presentation at the Charles Univ. It is hypothesized based on our tinnitus experience that in the normal auditory system a sequence of auditory images, results first in establishment of an auditory memory for a sensory input, both short and long term; and secondarily a positive affective behavioral response. It is possible that there may be further or additional localization for a particular sensation. Feldmann reported the difference in interaction of signal and masker in patients with and without tinnitus by masking curves. SPECT findings at this time suggest a common neural pathway and not an abstract algorithmic description. The FCP is a biological model which is an outgrowth of our ongoing attempts to integrate the basic sciences with our clinical experience for the diagnosis and treatment of all types and subtypes of tinnitus. Presented at the Fourth International Seminar Inner Ear Medicine and Surgery, July 1994, Snowmass, Colorado. Observations of simultaneous auditory brainstem responses with monaural stimulation in the tinnitus patient.
On the Functional State of Central Vestibular Structures in Monaural Symptomatic Tinnitus Patients. Often, language and intelligence fail to develop fully, making communication and social relationships difficult.
In most cases, the problems become more noticeable as the child slips farther behind other children the same age. Girls with the disorder, however, tend to have more severe symptoms and lower intelligence. Attention deficit hyperactivity disorder (ADHD) and attention deficit disorder (ADD) refer to a range of problem behaviours associated with poor attention span.
It may also be because the problems are mild, or because the family has handled the attention lack at home in such a way that it is not evident there is a major problem, or because the child is very young.
Understand what digital image noise is, and whether there’s anything you can do about it.
SPECT of Brain perfusion asymmetries in the cerebellum have been demonstrated in 60-70% of tinnitus patients of the central type. Adjacent perfusion asymmetries involving the frontal, temporal and parietal lobes have suggested an interneuronal network resulting in the transition of the sensory to the affect components of the symptom of tinnitus.
It is a result of alteration in all tinnitus patients of a basic function of the auditory system, namely, auditory masking.
For the affect component, it is the behavioral and emotional response of the patient to the presence of the tinnitus sensation. The search for understanding how the transition occurs from sensory to affect in brain is not new [13,29].
Feedback loops exist at brain stem, thalamus, temporal lobe, and the medial temporal lobe system.
A relationship has been demonstrated between GABAergic thalamic reticular and local circuit neurons and their effects on thalamocortical neurons. It is speculated that any system or mechanism or drug that blocks GABA mediated inhibition can produce a seizure type activity [37]. Our clinical experience with routine vestibular testing in patients with tinnitus particularly of the severe disabling type has revealed significant incidence of occurrence of abnormalities in vestibular testing in tinnitus patients who do and do not report interference in balance function [9,44,45].
Motor and non-motor functions are reported to be distributed within different regions of the human cerebellar cortex [47].
The extensive distribution of vestibular stimulation to the cerebellum reflects the input of the vestibular nuclei in the brainstem to the lateral reticular nucleus, which, in turn, has input to multiple locations in the vermis and paravermis of cerebellum.
In addition, other cerebellar neurons respond selectively to movement of the auditory stimulus [56]. A similar approach was applied for tinnitus applying basic neurotologic teaching for complaints of hearing loss and vertigo.
The anatomical and physiological characteristics of these projections are similar to those that reach the IC. The cerebellum may also have some influence directly on the ascending core auditory system via the acousticomotor systems. For auditory information processing caudal to the Ie, bilateral projections have not been described. A frequency selective increase in metabolic response has been demonstrated in the IC with associa-tive classical conditioning of an acoustic stimulus to a unconditioned stimulus [105]. The DLPN is the principal brain stem relay nucleus projecting to those areas in the cerebellum responsive to acoustic stimuli [112-115]. Underlying mechanisms are hypothesized to exist and to be highlighted by a diminution of inhibition mediated by gamma aminobutyric acid (GABA) due to disconnection from excitatory (glutamate) inputs. It is considered to transcend the classica thinking of tinnitus as an auditory signal restricted to the auditory pathway. The limbic system is a term used to include the limbic lobe and associated subcortical nuclei (amygdaloid complex, septal nuclei, hypothalamus, epithalamus and other thalamic nuclei). The frontal, temporal, parietal lobes project to the perirhinal, parahippocampal cortices from unimodal and polymodal areas. A paradoxical memory modulates the transition between the sensory and behavioral component of tinnitus. It is speculated that for tinnitus the amygdala is significant for the alteration in emotional behavior described by the patient. It is speculated that the primary auditory cortex projects to the hippocampus and amygdaloid complex. The masking curves "can be thought of as contour lines of the neural elements involved in processing signal and masker."34 Tinnitus is believed to produce or reflect a instability or interruption in auditory masking function.
The future is to identify neural networks and to create idealized computer simulates of groups of neurons. For auditory perception this includes the inner ear and Organ of Corti; transmission within the ascending auditory system to registration of impulses within the auditory cortex. If you prefer a phone consultation simply call 1-888-HEAR-CLEAR to connect with a hearing expert in your area. Many people with autism engage in repetitive activities, like rocking or banging their heads, or rigidly following familiar patterns in their everyday routines. These may include impulsiveness, restlessness and hyperactivity, as well as inattentiveness, and often prevent children from learning and socialising well. In those cases it is quite reasonable for parents not to consider that their child has an attention deficit problem. Electrophysiologic support for this finding includes interference in ocular fixation suppression of the vestibulocular (VOR) with rotation and position testing.
Significant are the reports by McEwen of the high concentration of steroid receptors and benzodiazepine receptors in the hippocampus [21-24] and of stress by Sapolsky [25,26].
For the psychomotor component, behavioral motor changes reflected in facial and body movements have been reported [27,28]. The LTS bursts reflect deinactivation of calcium channels which result in a membrane hyper-polarization by either a loss of excitation or an increase of inhibition. Significantly, our tinnitus patients with significant cerebellar abnormalities, have all demonstrated failure of fixation suppression of the VOR with eyes open upon rotation [42]. There is a convergence in the cerebellum from the vestibular inputs as well as inputs activated by afferents which control eye and head position.
The three sets of connections are mutually exclusive and provide a system of multiple parallel feedback loops between the AC and the IC.
The overall result can be an increased excitatory synaptic transmission in response to an acoustic signal even though inhibition is a common feature in the descending neural systems. There are multiple feedback loops between the inferior colliculus, MGB and the auditory cortex [80-83]. In the rat discharge rates of the IC and the CN to an acoustic stimulus (condition stimulus) increase when paired with an unconditioned stimulus.
Blockage of GABA mediated inhibition results in Tinnitogenesis, a epileptiform auditory phenomena. The clinical manifestations of the affective behavior of the tinnitus patient can be considered to be components of the FCP for tinnitus. Physiologic evidence suggests functional differences between the various components although most are related to visceral or behavioral activities (Fig. The mamillary body connects with the anterior nucleus of the thalamus via the mamillothalamic tract. Severe memory impairment associated with hippocampal and amygdala lesions were attributed not to the addition of the amygdala to the hippocampal lesion but instead to the addition of cortical regions that lie adjacent to the amygdala and that are necessarily damaged when the amygdala is removed or impaired. This sequence of events is hypothesized to exist in general for other sensory systems and specifically for the cocheovestibular system. The central efferent system at a cortical and subcortical level at brainstem is speculated to control the masking capability of the auditory system. But between 18 and 36 months old, they suddenly reject people, act strangely, and lose language and social skills they had already acquired. Abnormalities in cerebellar function are considered to reflect the psychomotor component of tinnitus. The end result is the appearance of a bursting activity at the neural site and reflected clinically in a positive symptom. Consequent to the inhibition of related local neuronal circuits this could result in an excitation through dysinhibition.
A specific neurologic condition called "cerebellar cognitive affective syndrome" is proposed in which cerebellar damage leads to a dysmetria of thought. Response to visual stimuli are from neurons in multiple regions of the cerebellar cortex particularly the posterior lobe [49]. The descending auditory pathway and acousticomotor systems, connections with the inferior colliculus. The SC is generally considered a higher motor center for coordinating directional orientation of head, eyes, and ears.
The most concentrated projection is to lobule VII of the vermis; as well as lobules VI, VIII, VX, CRUS I, II and the parafloccuIus and the paramedian lobule [115]. In the future, as the clinical experience of multiple disciplines increases for the symptom of tinnitus, it is predicted that additional components will be identified.
The anterior nucleus of the thalamus connects with the cingulate gyrus via the superior thalamic peduncle, thus completing the circuit. The entorhinal cortex was suggested to be the principle route by which information from the neocortex reaches the hippocampus.
Other aberrant sensations experienced by patients include hyperacusis, dysacusis, vertigo, etc.
For tinnitus such abilities may reflect cumulative changes in perceptual and response systems and for the development of new skills and habits personified by increasing attention to tinnitus and inability to "cope" with tinnitus.
The reciprocal projections between the entorhinal cortex, hippocampus and amygdala result in an emotional response. The degree of inhibition regulated by GABA function is hypothesized to be reflected in the degree of development of the paradoxical memory for tinnitus. Kassirer stated it well in discussing a visual image in clinical medicine that "often we are creating mental models of physical models. Support for the hypothesis is demonstrated with one patient with a predominantly central type tinnitus of the severe disabling type with cerebellar perfusion asymmetries and associated electrophysiologic evidence of interference in the VOR with rotation testing.
Underlying mechanisms are hypothesized to exist and to be highlighted by a diminution of inhibition mediated by amino butyric acid (GABA) due to its disconnection from excitatory (glutamate) inputs.
Significant are the physiologic effects of the ascending, descending auditory systems and the cerebellum on the auditory signal both normal and aberrant. The positive symptoms treated included tremor, action tremor, pain, or epilepsy, tinnitus, and central nervous system (CNS) disorders. The end result could be an epileptic type seizure phenomenon reflected clinically by symptoms of interference in function of the region of brain involved. The majority of the corticocollicular fibers terminate in the dorsal and external nucleus of the IC.
The projections from the AC to both the IC and the MGB originate from the pyramidal cells in AC. Additional connections of the SC with the auditory system contribute to acousticomotor pathways and also create feedback loops (Figure 6) [61]. Additional feeding pathways to the circuit were described to include the septal and olfactory regions and amygdala. Increasing attention and a probable relationship to sleep phenomena also is considered to be a reflection or projection from the amygdala to sleep areas in cortex.
Blockage of GABA mediated inhibition results in Tinnitogenesis, a epileptiform auditory phenomenon [8,9]. Cerebellar influence on cognitive processing is considered analgous to its influence on motor processing. The reciprocal interconnections between primary and secondary associated auditory cortices and vestibular cortices of the cochleovestibular system reflect multiple neuronal networks which have the capability to adapt to changes reflecting alteration in sensory input and output due to different factors influencing neuronal activity of the cochleovestibular system and other systems at a cortical and subcortical levels. Does this neurologic syndrome reflect the tinnitus patient's complaint of interference in performance and concentration? Although this is the case for the cat, rat, and tree shrew, monkeys may be an exception [72,73]. Young (1991) considered for depression that the location of cortisol control to be not in the hypothalamus but rather in the hippocampus.26 It is proposed for tinnitus that a cycle can be established wherein reciprocal projections between hippocampus, amygdala, entorhinal cortex and hypothalamus vary in the degree of control of cortisol levels resulting in further strengthening of an already established paradoxical memory with resultant additional negative affect behavioral manifestations of emotion, fear, anxiety, depression, etc. Neuronal networks are hypothesized to exist which in the past were identified as primary and secondary areas. It is conceived that the excitatory action of the amino acid glutamate may result in more than one physiological function. It is speculated that the GABAergic inhibition and resultant glutamate excess produces a disruption in calcium homeostasis.



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Comments to «Tinnitus symptom of multiple sclerosis life»

  1. Smach_That writes:
    Moves from 1 ear to the other with out.
  2. OSCAR_DELA_HOYA writes:
    Someplace peaceful and just slow your breathing they can.
  3. AmirTeymur writes:
    Then that would imply the and cerebellum, are necessary task is to determine hidden.