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We proposed a method for patient selection and application of criteria for predicting success with bone-conduction external acoustic stimulation using high-audio-frequency sound in the ranges of 10-20 kHz and 20-26 kHz for individuals with subjective idiopathic tinnitus (SIT) of the severe disabling type. This study reports on a method for patient selection for the use of external bone-conduction acoustic stimulation using high-audio-frequency stimulation with ultra-high-frequency (UHF) sound in the range of 10,000-20,000 Hz and with ultrasonic (US) high-frequency sound in the 20,000- to 26,000-Hz range for individuals with subjective idiopathic tinnitus (SIT) of the severe disabling type. The first step in providing efficient tinnitus treatment has been hypothesized to be patient selection.
UHF-US external acoustic stimulation is available commercially from two devices that have been reported to provide significant relief of severely disabling tinnitus [3,4]. For UHF-US external acoustic stimulation to be most effective, responses must be positive at 10-14 kHz. Because the amount of energy increases proportional to frequency given a constant mass (head) to be detected by the ear, patient UHF hearing would appear to be a valuable parameter in predicting success in tinnitus treatment. The goal of this study was to present the results of the application of criteria for predicting success with a bone-conduction external acoustic stimulus using either UHF or US ranges in providing relief for patients with tinnitus of the severe disabling type. Of 52 consecutive patients who received UHF-US stimulation for relief of SIT of the severe disabling type, 22 reported tinnitus relief. The application of either high-frequency tinnitus treatment device is summarized in Figure 3. What is interesting to note is that individuals with severe deafness and some high-frequency hearing report US as high-pitched.
Classic acoustic stimulation audiograms measuring 250-8,000 Hz do not predict success with high-audiofrequency stimulation or degree of tinnitus relief to be obtained. UHF for tinnitus relief has been found to be most effective when residual neuronal function exists in the acoustic ranges of 10,000-14,000 Hz, with thresholds no greater than 40-50 dB HL.
Of 52 consecutive patients for whom high-audiofrequency stimulation using UHF or US was recommended for attempting tinnitus relief, 22 reported relief. This study reports on the long-term benefit of ultra-high-frequency masking with the UltraQuiet device.
This study reports on the long-term benefit of ultra-high-frequency masking with the UltraQuiet (UQ) device. Well accepted is that if maskers overlap in frequency with the tones to be masked, masking is likely to occur, its degree related to masker intensity.
Because tinnitus can usually be masked (at least partially) for some period by a variety of sounds, one commonly used procedure is to assess wide-range masking, termed minimal masking levels (MMLs), using a variety of frequencies, including broad- or narrowband noise [12]. Theoretically, stimulation above the tinnitus frequency may supplement or assist the neurological reprogramming at the cortex and perhaps restore the normal-frequency spatial relationship. The goal of this study was to evaluate the long-term efficacy of using UltraQuiet high-frequency bone-conduction therapy for treating tinnitus, using pre- and postbehavioral assessment of tinnitus loudness, tinnitus anxiety, and tinnitus severity. Fifteen subjects (3 female, 12 male) with subjective idiopathic tinnitus of the severe disabling type participated in the study. The stimulus was produced using Kyma Version 5 software with a Capybara 320 Sound Computation Engine, and it was recorded on a compact disk (CD). The transducer is a custom-made aluminum ceramic bimorph with a high-frequency limit of some 50 kHz. The UltraQuiet stimulus parameters, or sound features, were chosen to optimize the activation of auditory cortical neurons. Classification of masking curve type according to Feldmann's system was applied to the masking data, and we measured loudness discomfort levels at 250-8,000 Hz. To assess, in a preliminary fashion, the effects of treatment length, we randomly assigned subjects to one of three groups. Before each stimulation session, subjects completed three outcome measurements: the tinnitus intensity index, the annoyance index, and the tinnitus severity index [1].
The questionnaire results for measures of tinnitus intensity and annoyance were not significantly different over the course of therapy sessions, although a drop in the mean level for each was noted on the last few trials. We examined the relationship among high-frequency MMLs, tinnitus pitch, tinnitus intensity, and Feldmann masking curves. The use of high-frequency bone conduction stimulation using the UltraQuiet therapy system resulted in longterm reduction in tinnitus severity during therapy, and that tinnitus relief lasted for at least 2 months after therapy in most subjects in this study.
During posttherapy interviewing, we noted partial masking of the tinnitus by the UltraQuiet system throughout the trial in all patients (although not in every session). Frequency range of stimulation is critical in the auditory cortical reprogramming approach of the UltraQuiet system; however, any reduction in the amount of masking required to eliminate (or partially eliminate) tinnitus also is important. Alternatively, we could argue that the energy around 6 kHz was predominant in our subjects owing to mild to moderate sensorineural hearing loss. RI, which refers to a decrease in the perceived intensity of the tinnitus for a time after the masking stops, was first reported by Feldmann [12]. Because the UltraQuiet stimulus generally overlaps with high-frequency tinnitus and the presentation is just above threshold stimulation (~6 dB SL), inhibition should be facilitated.
Treating tinnitus patients with the UltraQuiet device is more difficult when their tinnitus is of the severe problematic type.
Problematic tinnitus is most likely related to changes in the auditory pathway and consequent reactions in various areas of the brain. The authors acknowledge the support of Sound Technique Systems, LLC, in this study and the assistance of Robert Guinta. How to cite this article Valente JPP, Pinheiro LAM, Carvalho GM, Guimaraes AC, Mezzalira R, Stoler G, Paschoal JR, et al. OBJECTIVES: To evaluate the correlation between the degree of discomfort caused by tinnitus and the hearing loss level.
RESULTS: 107 patients were studied and there was no correlation between the degree of annoyance of tinnitus with hearing loss, age, gender, presence of dizziness, of neck pain, headache, changes of the temporomandibular joint, the use of caffeine or excessive intake of carbohydrates. CONCLUSION: Dizziness, neck pain, headache and caffeine abuse are prevalent complaints in patients with tinnitus. In the literature, some factors possibly related to the nuisance caused by tinnitus have been tested, such as age, gender, presence of vestibular symptoms and hearing loss15,16,17,18. Therefore, the main objective of our study was to evaluate the correlation of the degree of discomfort caused by tinnitus with hearing loss. We conducted a clinical epidemiological study with a retrospective analysis of medical records of patients seen at the Otolaryngology Service of the State University from Campinas, in the period from February 2009 to April 2010. The study included patients over 18 years who had unilateral or bilateral tinnitus with normal hearing or sensorineural hearing loss. Patients with pulsatile tinnitus or infectious disease of the external and middle ear were excluded. To measure the degree of discomfort caused by tinnitus, the patients were evaluated by visual-analogue scale (VAS), graduated from zero to ten.
For associated clinical symptoms, there was a high prevalence of patients with dizziness, neck pain and headache. The correlation between the degrees of discomfort related to the tinnitus and the three groups separately showed that 48% of the patients in group I (normal hearing) rated their tinnitus as severe.
Most studies in the literature show that the prevalence of patients with tinnitus and normal hearing is around 8% to 10%28. We know there is a close relationship between tinnitus and audiometric conditions and also in situations of normal hearing22. In the literature, most studies suggest that hearing loss, regardless of its degree, is related to greater inconvenience caused by tinnitus8,29,36,37. Specifically evaluating patients in group I, a high prevalence of psychoaffective disturbs such as depression and anxiety disorder was found. In this study we found no difference within the group of patients with hearing loss (groups II and III), consistent with several other studies which have been published39,40,41.
Concerning the related clinical symptoms, a high prevalence of patients with dizziness, neck pain, headache and abuse of caffeine was found, which could be acting as triggering factors or worsening of tinnitus.
In this study it was concluded that the degree of annoyance of tinnitus, using the visual analogue scale, was higher in patients without hearing loss and in females, but there was no statistical significance. Disciplina de Otorrinolaringologia, Cabeca e Pescoco - Universidade Estadual de Campinas (UNICAMP) - Campinas - SP - Brasil.
Disciplina de Otorrinolaringologia, Cabeca e Pescoco - UNICAMP Faculdade de Ciencias Medicas, PO Box: 6111. Paper submitted to the RBCMS-SGP (Publishing Management System) on October 12, 2011; and accepted on August 16, 2012. Ultra-High-Frequency Ultrasonic External Acoustic Stimulation for Tinnitus Relief: A Method for Patient Selection . Ultra-high-frequency (UHF) stimulation for tinnitus relief has been found to be most effective when residual neuronal function exists in the acoustic ranges of 10-14 kHz, with thresholds no greater than 40 - 50 dB sound pressure level (SPL).
High-frequency stimulation has proved to be effective in tinnitus treatment, presumably owing to neuro-reprogramming rather than simple masking [1]. Accurate patient selection - or, more precisely, patient matching to the high-pitch tinnitus treatment modality (UHF or US) for individuals with severe disabling tinnitus - can result in long-term inhibition of tinnitus by external bone-conduction acoustic stimulation with sound in the ranges of 10-20 kHz and 20-26 kHz [2]. We based patient selection criteria on test results from the audiometric data of UHF audiograms. Tinnitus treatment stimuli for the UltraQuiet device (left panel) and the ultrasonic HiSonic device (right panel).
We conducted UHF audiometry using both air-conduction high-frequency audiometry (HFA) with the Beltone 2000 audiometer and electrical HFA (EHFA) with the Tonndorf audiometer. The application of the criteria for patient selection predicted tinnitus relief in 20 of the 22. Individuals with no measurable high-frequency hearing will report US as the quality of the highest pitch they possess. In our experience, the UHF audiogram is predictive of success with bone-conduction external acoustic stimulation using high audio frequency. US acoustic stimulation is recommended for patients with audiometric thresholds of 5 0 - 6 0 dB HL for frequencies of 10,000-14,000 Hz. In those 52 consecutive patients, the application of the criteria recommended for patient selection predicted tinnitus relief in 20 of the 22 who reported tinnitus relief. Department of Otolaryngology, State University of New York, Downstate Medical Center, Brooklyn, and Martha Entenmann Tinnitus Research Center, Forest Hills, New York. Departments of Biomedical Engineering, Otolaryngology and Emergency Medicine, Virginia Commonwealth University, Richmond, Virginia. A commercial product, UltraQuiet provides a new form of high-frequency bone conduction therapy. In the case of masking tinnitus by an external noise, this relationship is more the exception than the rule. The masking stimulus is raised in 5-dB steps, and patients are asked whether their tinnitus is still audible. The stimulation must be very high in spectral content to accomplish this above the tinnitus pitch requirement.
Music appears be a more effective tinnitus masker than is noise [19], possibly owing to the involvement of more central and cognitive processes.
The CD recording stimulus consisted of digitally processed music (44.1-kHz sampling rate) with playback in the 10- to 20-kHz range. Spectrum of the high-frequency bone-conducted stimulation ranges from approximately 6 kHz to 20 kHz. The transducer is coupled to the skin and held in place with a band, much as are traditional clinical boneconduction transducers. Cortical neurons have been shown to be sensitive to frequency edges, temporal patterns, and frequency or intensity transitions [20]. We presented outcome questionnaires to establish a baseline of functioning; these included the tinnitus intensity index, the annoyance index, and the tinnitus severity index [1,21,22]. No one indicated a poorer result, and those four reporting no change in their tinnitus did indicate improvement on measures of tinnitus intensity or severity after therapy treatment.
That is, as a group, the patients with problematic tinnitus indicated a significant reduction in severity over the course of the treatment trials.
Effects of high-frequency therapy on three outcome measures - tinnitus severity, intensity, and annoyance - as evaluated by questionnaires completed after each therapy session. For some patients at some frequencies, reductions in MMLs were as high as 25-45 dB in one ear (Fig. Decrease in the minimum masking levels (MMLs) for the six patients who received brain imaging before and after therapy. Mean minimum masking levels for all subjects when patient and ear data are collapsed reveals a frequency-specific pattern. Individual variability in this small sample of patients with problematic tinnitus precluded any detailed analysis, but tinnitus intensity ratings exceeding 50 dB were associated with improvement on the overall tinnitus relief questionnaire and were associated with a high-frequency pitch match.
Relationship among minimal masking level changes (by frequency), Feldmann masking curve (FMC) types, and pitch and loudness matches in all subjects. Hearing thresholds before and after therapy generally suggest improvement after therapy; however, the pattern was complex and included elevation in some frequencies. Threshold was established before each session but, given the problems in detecting a stimulus in the presence of tinnitus (even in skilled hands), the level of UltraQuiet therapy may have been as little as 2-3 dB SL for some patients in some sessions. Patients in the 10-session group averaged just above "no change," whereas those in the 12- and 14- session groups averaged above "slight improvement." What must be emphasized is that these patients with problematic tinnitus have had limited therapeutic success with other treatment modalities. The tinnitus relief was inferred from a pattern of lower weekly scores on the tinnitus severity scale and reduction in MMLs.


Owing to stringent adherence to the protocol approved by the Western Institutional Review Board, we made no effort to increase the stimulation level in an attempt to produce complete masking. All patients had serviceable hearing to 12 kHz, but hearing improvement may have been related to relative frequency sensitivity of the UltraQuiet stimulus. In an individual with hearing loss and tinnitus, RI may last for a few seconds or minutes but can last days or weeks [2,31].
The acceptance of RI over questionnaire data is understandable in an effort to obtain a more "physiological" metric. What effect the increase in stimulation level from 6 dB SL to 12 dB SL would have on the effect of masking, on further reduction in MMLs, and on increased RI remains to be explored.
When contrasted to normal controls and tinnitus patients who tolerate their tinnitus, patients with problematic tinnitus showed less habituation in middle latency potentials [36]. The emerging picture is that of an initial insult to the ear or brain (or both) followed by an increase in the tinnitus frequency cortical map, which could increase dyssynchrony-synchrony and loudness and reduce habituation. The limitations caused by tinnitus are related to psychological factors, mood changes and psychiatric conditions, while other factors related to discomfort caused by tinnitus are being studied.
Materials and Methods: A retrospective study of the patients treated at the Otolaryngology Service of the State University from Campinas for 15 months, using the Visual-Analogue Scale to classify the degree of discomfort by tinnitus.
Some patients describe tinnitus as loud and intense, which may trigger psychosocial disorders and compromise their quality of life4,5.
The THI is the most accepted method to evaluate tinnitus, because of its easy application, interpretation and the fact that it addresses several aspects of the patient?s quality of life13,14. In the genesis of tinnitus, the consensus is that hearing loss acts as one of the main triggers at the onset of tinnitus19, beyond a discussion of a common pathway that integrates all the central relationships of tinnitus20,21. In addition, the presence of associated clinical symptoms and general data were also evaluated. For the analysis epidemiological data such as gender and age; and clinical features like the presence of unilateral or bilateral tinnitus, dizziness, headache, neck pain, temporomandibular joint disorder (TMJD) and abuse of caffeine or carbohydrates were used. Distribution of population (n = 107) in the groups classified according to hearing loss group I (n = 23), Group II (n = 38) and Group III (n = 46). Distribution of age groups classified according to the hearing loss, Group I (n = 23), Group II (n = 38) and Group III (n = 46).
Distribution of patients according to gender in the groups classified according to the hearing loss, Group I (n = 23), Group II (n = 38) and Group III (n = 46). Some authors also demonstrated the great value of associated symptoms like those described above26. Epidemiological studies show that one third of the population has experienced the sensation of tinnitus at least once in life. Concerning the three groups separately, it was observed that in group I (normal hearing) there was a higher prevalence of patients below 45 years old. Heller and Bergman in 1953 showed that 94% of normal hearing patients reported sensation of tinnitus in completely quiet environments34.
Considering the patients with hearing loss (groups II and III), this percentage was 28%, suggesting that patients with tinnitus and normal hearing are more related to tinnitus annoyance.
Several studies indicate that these disturbances are mainly involved in the genesis and perpetuation of tinnitus39. Ultrasonic (US) acoustic stimulation is recommended for patients with audiometric thresholds greater than 50-60 dB SPL for frequencies of 10-14 kHz. To be detected by the human ear, US frequencies must be approximately 100 dB more intense than thresholds at 8 kHz. Because calibration procedures were different, thresholds at 8 kHz served as a reference such that all thresholds for higher frequencies are in decibels above it.
In this review, we included patients presenting with the primary complaint of tinnitus and identified as having tinnitus of the severe disabling type. Both used amplitude modulation; however, the HiSonic is spectrally narrower and perhaps an octave higher. For HFA using air conduction, we measured thresholds at 10,000-20,000 Hz in 1,000-Hz intervals in 5-dB steps ranging from 0 to 120 dB SPL. The patients who reported success with UHF-US fulfilled the audiometric criteria as mentioned earlier.
Food and Drug Administration for treating individuals with less than 60 dB HL in the high frequencies and to operate at just above threshold.
UHF-US external acoustic stimulation is recommended for attempting tinnitus relief in a selected tinnitus population with thresholds no greater than 50-60 dB SPL in the 10,000- to 14,000-Hz ranges. Ultra-high-frequency audiometry is considered essential for the selection of candidates for high-audiofrequency stimulation using either UHF or US for attempting tinnitus relief.
Ultra-highfrequency stimulation and tinnitus control: A positron emission tomography study. To assess its effectiveness in tinnitus treatment, we selected 15 patients with problematic tinnitus and randomly assigned them to three variations of the medical-audiological tinnitus patient protocol modified for the UltraQuiet study. Logically, high-frequency masking should provide effective relief in persons with severe problematic tinnitus. The UltraQuiet device delivers amplitude-modulated musical-type stimulation in the range of 10-20 kHz suitable for this purpose. We specifically investigated the use of the UltraQuiet device for providing relief, masking, and RI in individuals with problematic tinnitus of the severe disabling type.
The stimulus consisted of synthesized music digitally processed and used to modulate a carrier at 16 kHz.
The CD was played through a custom-made amplifier into a piezoelectric bone-conduction transducer. Some energy occurs around 6 kHz, owing to the transducer's fundamental resonance and the high-pass filter slope. In other words, features that are found in speech, music, or amplitudefrequency modulation were incorporated into the stimulus to facilitate auditory cortical activation. Audiological evaluation included pure-tone audiometry, speech audiometry, tinnitus pitch and loudness matching, the measurement of RI, and masking curves to establish MMLs at 250-8,000 Hz using both narrowband and white noise. One week after the last intervention session, we repeated the audiological evaluation and administered the outcome questionnaires to assess any changes. Group 1 received stimulation twice weekly for 2 weeks, stopped the stimulation for 2 weeks, then received stimulation twice weekly for 3 weeks, for a total of 10 sessions. The stimulation lasted 30 minutes for the first session and 1 hour for all succeeding sessions. Some patients indicated more improvement than others, but the trend in all patients was an increase in tinnitus relief. Note the general improvement that lasted for 2 months in approximately one-half of the patients. Tinnitus severity improvement for the group was evident at the second session, gradually increasing through the twelfth session. Clearly the severity is decreasing, with a trend in that direction for anxiety and loudness. The tinnitus pitch match most frequently occurred in the region of the hearing loss but not necessarily at the frequency with the maximal loss.
Dynamic hearing levels appear related to central processes assumed to be active during and after therapy. Note in Figure 3 that dramatic improvement in tinnitus severity occurs in session 12, as does a modest abatement of tinnitus intensity and annoyance. Four factors likely contributed to long-term tinnitus relief: ultra-high-frequency masking, RI, neurological reprogramming, and habituation.
The strategy of using high frequencies at low levels was designed to potentially provide some partial masking but, more important, was designed to aid in tinnitus neurological reprogramming and habituation.
This is suggested by the six cohort patients in whom positron emission tomography scans were obtained. High-frequency stimulation, both in the high audiofrequencies (UltraQuiet) [2] and in ultrasonic frequencies [11], have resulted in RI.
We observed (by interview at the end of therapy but not by formal testing) RI lasting approximately 5 minutes. The conclusion of Shulman [15] suggests that a brain-imaging index in conjunction with high-frequency audiometry may be the technique of choice in objectively assessing tinnitus relief from auditory therapy if neurological reprogramming and habituation are the essential processes as hypothesized. Cortical reprogramming as a consequence of sensorineural hearing loss has been well established [33, 34]. In view of the degree of improvement and results with the limited number of sessions in our study, a reasonable expectation is improved results with an increased level of stimulation (12 dB SL) and an increased number of sessions over time. Additionally, auditory brainstem response differences between tinnitus patients and controls further suggest that auditory path- way transmission may influence abnormal habituation. Such a condition could hyperactivate the medial temporal and prefrontal lobes, resulting in problematic tinnitus characterized by annoyance, and could trigger autonomic reactions. Ultra-highfrequency acoustic stimulation and tinnitus control: A positron emission tomography study. Functional inactivation of the amygdale before but not after auditory fear conditioning prevents memory formation.
Local improvement in auditory frequency discrimination is associated with hearing-loss slope in subjects with cochlear damage.
Loudness perception and frequency discrimination in subjects with steeply sloping hearing loss: Possible correlates of neural plasticity.
Test-retest reliability of pure-tone thresholds from 0.5 to 16 kHz using Sennheiser HDA 200 and Etymotic Research ER-2 earphones. High-frequency (8 to 16 kHz) reference thresholds and intrasubject threshold variability relative to ototoxicity criteria using a Sennheiser HDA 200 earphone.
Environmental enrichment improves response strength, threshold, selectivity, and latency of auditory cortex neurons. Abnormal auditory mismatch response in tinnitus sufferers with high frequency hearing loss is associated with subjective distress level. In its most common form, tinnitus is presented as a phantom sensation which is not associated with an external sound stimulus1. Some studies show that the limitations caused by tinnitus are related to psychological factors, such as mood swings, irritability and psychiatric diseases6,7,8,9. However, previous studies have shown that EVA, in which the patient classifies his discomfort related to tinnitus from 1 to 10, has a good correlation with the THI10-14.
However, hearing loss and its relationship with the distress associated with tinnitus is still controversial. All patients underwent complete ENT examination and pure tone audiometry, testing the following frequencies: 250, 500, 1,000, 2,000, 3,000, 4,000, 6,000 and 8,000 Hz. They were classified in three degrees of discomfort: mild (0-3), moderate (4-7) and severe (8-10). When compared to the level of discomfort related to tinnitus (VAS), none of the factors evaluated showed statistically significant results.
However, there was no statistically significant difference between the three groups (Table 3). A possible explanation for this finding might be the fact that the work has been performed in Otoneurology, in which the main complaint is tinnitus and not hearing loss.
Sanchez in 2005 also observed that the average age of patients with tinnitus and normal audiometry was lower compared to patients with hearing loss23.
Riga in 2007, by testing for suppression of otoacoustic emission distortion products, suggested that patients with normal hearing may have a dysfunction of the cochlear efferent system, specifically the medial olivocochlear bundle35. Savastano in 2008, using the THI, found a higher number of patients who rated the annoyance by tinnitus in the group with moderate normal audiometry38.
Another hypothesis that could explain a greater discomfort in patients with normal hearing would be the impossibility of adaptation of a hearing aid in these patients.
It is noteworthy that the diagnostic accuracy is essential to any attempt to relieve tinnitus42. Benzodiazepines and GABAergics in Treating Severe Disabling Tinnitus of Predominantly Cochlear Origin. Adaptacao para a lingua portuguesa do questionario Tinnitus Handicap Inventory: validade e reprodutibilidade. Final Common Pathway for Tinnitus: Theoretical and Clinical Implications of Neuroanatomical Substrates. Abnormal auditory mismatch response in tinnitus sufferers with high-frequency hearing loss is associated with subjective distress level. Avaliacao da relacao entre severidade do zumbido e perda auditiva, sexo e idade do paciente.
Impact of Tinnitus on Quality of Life, Loudness and Pitch Match, and High-Frequency Audiometry.
Tinnitus with normal hearing sensitivity: extended high-frequency audiometry and auditory nerve brain-stem-evoked responses.
Hearing disorders in the population: first phase findings of the MRC national study of hearing.
Guidelines for the grading of tinnitus severity: the results of a working group commissioned by the British Association of Otolaryngologists, Head and Neck Surgeons, 1999.
A Clinical Study of the Efferent Auditory System in Patients With Normal Hearing Who Have Acute Tinnitus.


The aetiology of tinnitus: risk factors for tinnitus in the UK population-a possible role for conductive pathologies. Fifty-two consecutive patients seen for the primary complaint of SIT of the severe disabling type received a trial of either UHF or US bone-conduction acoustic stimulation.
One is acoustic stimulation of the residual peripheral neuronal function in the UHF range of 10-14 kHz and audiometric thresholds of 40-50 dB sound pressure level (SPL). Note that ultrasonic frequencies are 80-100 dB above the thresholds at 8 kHz, whereas high audio frequencies are much lower. In each case, a transducer is placed on the mastoid, and the stimulation level is ascertained by determining sensation level. After application of the proposed criteria, we selected UHF-US external electrical stimulation for trials to provide tinnitus relief. In EHFA, the head is capacitively coupled into a circuit, and audio tones are amplitude-modulated on a 60-kHz carrier. US can be cancelled when it must pass through the skull, which has many vibratory antiresonances. Presented at the conference Hearing Loss in Children, Amplifon, Milan, Italy, July 2-3, 2004. Poster presented at the Twenty-First Annual Meeting of the Association for Research in Otolaryngology, St.
We assessed tinnitus relief by questionnaires directed at weighing patient response to overall effectiveness, tinnitus loudness, tinnitus severity, and tinnitus annoyance. The effect of this expansion on connections to the limbic system and other cortical areas is not known, nor have the tuning characteristics of these "recruited" neurons been measured. Preliminary clinical reports were encouraging [2] and a calibration procedure, anchored to international standards, was followed [18].
The pitch match to the tinnitus for 14 of the 15 subjects was high-pitched, matching to either a pure-tone or a narrowband noise or a combination of both, with frequencies between 3 and 16 kHz; 1 subject had a low-pitched tonal tinnitus at 450 Hz.
Group 2 received stimulation twice weekly for 3 weeks, stopped the stimulation for 2 weeks, then received stimulation twice weekly for 3 weeks, for a total of 12 sessions.
Further improvement may be present but is obscured by the duration parameters of the three groups.
The mean data are perhaps as revealing; when patient and ear data are collapsed, a high-frequency reduction in masking is observed (Fig.
Although we saw an increase in some thresholds in some patients, twice as many thresholds improved as those that decreased.
Nonetheless, the frequency range of masking is important in obtaining neurological reprogramming and inhibition [16,18]. Those patients with the best thresholds beyond 10 kHz exhibited the best behavioral and physiological activity [15]. The question of the minimal number of trials needed to note tinnitus relief, given that choices were limited to 10, 12, and 14 sessions, can be answered only by stating that 10 session of therapy (and probably fewer) are not as effective as 12 and 14 sessions, on the basis of questionnaire results after therapy. Patients with problematic tinnitus appear not to exhibit normal habituation, and this can influence their perception of tinnitus loudness. Although we readily recognize that the neural substrate of problematic tinnitus encompasses much more than the auditory pathway, the role of the auditory pathway in masking, RI, neurological reprogramming, and habituation is significant [37]. In GE Reich, JA Vernon (eds), Proceedings of the Fifth International Tinnitus Seminar 1995. Poster presented at the Twenty-First Annual Meeting of the Association for Research in Otolaryngology, 1999. Presented at the Thirty-First Congress of the Neurootological and Equilibriometric Society, Bad Kissingen, Germany, March 25-27,2004. In 2004, Weisz showed that patients with hearing loss at high frequencies are more subjectto tinnitus nuisance22. As for their gender, 72% of patients were women, with similar distribution among the three groups (Figures 2 and 3). Comparing the buzzing nuisance related to the presence or absence of hearing loss (Group I x II + III) no statistically significant difference was observed.
In: Proceedings of the Sixth International Tinnitus Seminar - The Tinnitus and Hyperacusis Center. In: Proceedings of the Fifth International Tinnitus Seminars The Tinnitus and Hyperacusis Center.
A second is the integrity of the brain cortex for neuronal reprogramming as demonstrated in metabolic activity seen in positron emission tomography (PET) of brain.
In other words, the minimal residual neuronal responses necessary for obtaining tinnitus relief with UHF external acoustic stimulation require a threshold no greater than 60 dB SPL at 10-14 kHz.
Each individual received a trial of either UHF or US bone-conduction stimulation for 0.5 to 1 hour [1]. With demodulation, owing to the nonlinearities of the skin, tones are perceived as conventional audiometric tones. Additionally, we performed audiological measures (including pure-tone and speech audiometry, minimal masking levels, pitch and loudness matching, and residual inhibition).
That is, tinnitus masking may be a complicated product of peripheral and central processes, and sounds outside of traditional psychoacoustic ranges can be effective with tinnitus [2], including ultrasound masking delivered through bone conduction [11]. If neural space expansion of the tinnitus frequency (or frequencies) is associated with synchronized activity, ignoring an attentiongenerating tinnitus percept that could readily arise may be impossible.
The UltraQuiet system has a maximum output of 53 dB hearing level (HL) when it is massloaded to the artificial mastoid with 5.4 Newtons of force applied.
Group 3 received stimulation twice weekly for 4 weeks, stopped the stimulation for 1 week, then received stimulation twice weekly for 3 weeks, for a total of 14 sessions. The threshold for stimulation was established, and the stimulation was presented 6 dB above threshold or 6-dB sensation level (SL). That is, for the latter sessions, the number of patients being tested dropped, owing to the session limitations for each of the three treatment groups. No consistent pattern was noted between Feldmann masking curve type and tinnitus pitch match (Fig. If highfrequency stimulation is essential for auditory cortical reprogramming, the sensitivity to such stimulation should be an essential variable. What should be noted is that the stimulating intensity was only 6 dB SL, and this may not have been sufficient energy to elicit RI in the other patients, a metric to be systematically studied in the future. If the auditory cortex has reprogrammed, stimulation with very high frequencies might stabilize and reverse the process and perhaps restore the normal frequency map.
According to these serial measures, therapy of fewer than 12 sessions would not be as satisfactory as therapy lasting 12 and 14 sessions. A plastic auditory pathway treated with a stimulus specifically designed for highpitched tinnitus may, with time, provide long-term relief.
In that model, damage to peripheral organs act as triggers of tinnitus, and is supported by events that occur in the central auditory pathway, such as maladaptive neuroplastic processes and phenomena such as hyperactivity of the auditory cortex.
As for a correlation between age and gender with a degree of discomfort caused by tinnitus through the EVA, there was no significant difference (Table 1). Finally, comparing groups II and III (respectively loss in patients with high frequency and loss in patients in general), no difference was found.
The application of criteria for patient selection predicted tinnitus relief in 20 of the 22. A PET of brain study identified a correlation between the UHF audiograms, the subjective reports and outcome measures of the efficacy of the UFH-UQ for tinnitus relief, and brain PET metabolic categories. Pitch matching and Feldmann masking curve data were not informative in establishing a criterion for patient selection. The thresholds are actually first established in electrical terms and then are converted to an equivalent SPL. All patients showed some long-term gains, and most exhibited relief in at least one measurement parameter, providing support for the use of high-frequency vibration in the treatment of tinnitus. Growing evidence suggests that high-frequency masking is desirable in cases of high-frequency tinnitus [2,11]. Increased degrees of neural synchronydyssynchrony could activate and continue to stimulate the amygdala, an organ known to be critical in evoking emotional and autonomic nervous responses [17].
Although the stimulus is presented on only one side of the head, it is heard binaurally through bone conduction [23].
The frequency area that exhibited the greatest effect is the octave from 3 to 6 kHz, below the lowest resonance in our transducer (6 kHz).
Annoyance and tinnitus intensity seemed to persist in most throughout the sessions, suggesting that the tinnitus, while reduced in severity, was still present. In the normal auditory system, an increase in loudness is related to an increase in neural activity. The changes in MMLs and auditory thresholds suggest an adaptive central nervous system, responsive to high-frequency sound therapy. This can be explained by the increased demand of women to medical services, or the greater prevalence of psychological disorders in this group, such as anxiety and depression31,32. Specifically, the best subjective reports for tinnitus relief with UHF were reported by tinnitus patients with auditory thresholds of 4 0 - 5 0 dB SPL or less for the frequency range of 10-14 kHz. Because force is equal to mass times acceleration, the amount of energy needed to move the mass of the head (15 kg) increases with frequency.
Classic acoustic stimulation audiograms measuring 250-8,000 Hz revealed individual variations in hearing thresholds similar to those reported for the total cohort of 15 patients in the UHF-UQ study [8]. The conversion algorithm favors an accurate depiction of frequencies above 8 kHz and was an ideal instrument for assessing bone-conduction thresholds for this study.
Furthermore, US is typically one-half of a full octave above the brain resonances, thus requiring more energy to demodulate the brain. Two problems exist: One is developing an efficient, commercially viable, and calibratable transducer and the other is determining a reliable clinical-use protocol. For many patients, substituting one sound for another is not considered a significant enough improvement; additional relief is desired. Stated another way, the frequencies that required less energy to mask tinnitus were those just below the lowest effective stimulating frequencies in the UltraQuiet system.
The UltraQuiet masking mechanism appears to be different when using conventional audiological masking at 250-8,000 Hz than when using ultra-high frequencies. High-frequency stimulation with the UltraQuiet passband of 10-20 kHz has the added quality of disrupting the tinnitus frequency synchrony and reducing the overrepresentation, which might be verified with cortical potentials.
Patients who do not exhibit normal habituation and who rate their tinnitus as loud may have more active dyssynchronous neurons involved in tinnitus perception than do patients who assess their tinnitus loudness as low.
Long-term tinnitus relief cannot be solely defined by one metric as complete masking or RI on the order of hours. In 2010, the same author, using the THI, found no significant correlation between degree of hearing loss and discomfort related to tinnitus24. On the other hand, when the risk factor under study is the exposure to noise, there is a higher prevalence of the male sex33. Thresholds are established for each ear separately, as EHFA is not a binaural phenomenon typical of conventional bone-conduction hearing. Consequently, more energy is required to hear US than is needed to hear high audio frequencies, although they share the same place of displacement on the basilar membrane [9]. In a preliminary report [2], we found a high-frequency tinnitus device, UltraQuiet, to be efficacious. The masking stimulation, if properly chosen, may have the capacity of changing how the brain processes tinnitus, which could provide long-lasting benefit.
These frequencies were on the edge of the patients' audiometric hearing loss, a region often associated with increased discrimination possibly due to neural plasticity [24,25]. With ultra-high frequency, the stimulus is apparently combined with neurological reprogramming and plasticity involving the auditory cortex. Such a situation would be predicted in the tinnitus frequency map expansion in the auditory cortex and would influence both the medial temporal lobe system and other cortical area identified as active in tinnitus [37]. Relief is a complex function of many factors arising both within and outside the auditory system, and successful treatment takes time. Despite of this prevalence among women, our work suggests that tinnitus-related annoyance is similar in both groups. The MML improvement was related to the measured tinnitus pitch in that both were high-frequency (with one pitch match exception). RI increased with masker intensity, but the relationship of RI to tinnitus frequency, masker center frequency, and bandwidth was complex and varied among individuals. Brain imaging and high-frequency audiometries seem to be important indices in quantifying tinnitus relief. Often, behavioral measures are contradictory, rendering efficacy determination problematic.



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