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Researchers have observed that when head-shaking nystagmus (HSN) is provoked in patients with peripheral vestibular disorders, usually (in more than 75% of cases) it beats toward the normal or unaffected ear. Head-shaking nystagmus (HSN) almost always is pathological when it is recognized under the Frenzel's glasses in darkness, and suggests a vestibular lesion of peripheral or central origin. HSN beating toward the normal ear in patients with unilateral peripheral vestibular lesions is known as deficiency nystagmus. We retrospectively analyzed clinical records of eight patients who had unilateral Meniere's disease and came to Gunma University Hospital for consultation in the period from June 1984 through June 1989. These facts suggested that the occurrence of HSN directed to the morbid ear in the recuperation period in Meniere's disease might indicate the impending recurrence of a vertigo attack in a few days.
MS, a 28-year-old woman (patient 5; see Table 1), first consulted us on August 12, 1985 with a 2-year history of frequently occurring episodic vertigo associated with right hearing loss.
Spontaneous nystagmus (SN) and HSN were not observed under the Frenzel's glasses on the day of the patient's first visit (August 12, 1985) nor on August 15. These facts suggested that the appearance of HSN directed toward the involved ear could be a warning signal for the imminent occurrence of vertigo attacks in this case. The patient wanted to have a second child, so we avoided giving medicine and sectioned both the chorda tympani and the tympanic plexus of her right ear on January 7, 1986. The occurrence of HSN beating toward the morbid ear in the recuperation period in Meniere's disease may indicate the impending recurrence of a vertigo attack in a few days. This work was presented at the Twenty-Fifth Ordinary Congress of the Neurootological and Equilibriometric Society, March 19-22, 1998. Tinnitus is associated with the most important symptoms in neurootology besides vertigo, nausea, and hearing loss. Since about 1985, via vestibular evoked potentials (VestEP) and brain electrical activity mapping (BEAM), the Wurzburg Neurootology Group of Claussen et al. For this study, we randomly selected a sample of 757 patients suffering from an endogenous tinnitus according to the tetrad of tinnitus differentiation described.
We followed with a thorough audiometric investigation to obtain measurements of the hearing threshold, the acoustic discomfort threshold, the calculation of the acoustic dynamics, tinnitus masking, impedanciometry, and stapedial muscle reflexes. In assessing the vestibulospinal pathways, we regularly applied craniocorpography (CCG) in the form of ultrasonographic computed craniocorpography (UCCCG). The test results from our analyses helped us to demonstrate that these 757 patients were suffering from an endogenous tinnitus. At the Neurootological Research Institute at Bad Kissingen, we recorded statistics from our 757 patients suffering from an endogenous tinnitus. After exploring the vertigo mechanisms, we analyzed the different sensations in hearing distortion in our patient sample (Fig.
Figure 20 shows our analysis of trigeminal nerve complaints: Although no patient reported trigeminal nerve disorders, the medical investigators found such disorders by direct inspection relative to patients' obtained medical history.
The special set of questions regarding our patients' history dealt with specific neurological disorders (Fig. Very well known is that after head and neck trauma, many patients complain of various types of tinnitus. Cardiovascular diseases were very important background disorders for our neurootological patients. We also questioned our patients about diabetes mellitus and categorized these cases with respect to their therapy. For this study, we randomly selected 757 tinnitus patients who reported that they felt better in a noisy environment. The question underlying this study is whether tinnitus is a monosymptomatic disease or is bound into a complex spectrum of complaints within a multisensory disorder.
We saw a very varied picture in the subjective descriptions of the quality of tinnitus sensations.
Of background disorders, various cardiovascular diseases showed a high occurrence rate (Fig. All in all, we must conclude that our evaluations in studying our 757 cases demonstrate that the spectrum of subjective complaints is very complex and individually mingled. Overall, our evaluation of 757 patients with endogenous tinnitus posits that the most important accompanying general diseases are cardiovascular.
From all these patterns of interactive complaints, we also must conclude that endogenous tinnitus points to a "cybernetopathia" deriving from dysfunctions at various points of the statoacoustic and interrelated supportive neurosensory pathways. This dose for infants with a body weight of three kilograms was purely aimed at preventing rickets. In Germany, all pre-formed vitamin D medications containing more than 1,000 units require a prescription.
French pharmacies have for years been selling drinkable 200,000-unit ampoules on prescription for less than 2 Euros without any problems.
The MANOS concept (Muscles , Adynamia, Nervous system , Orthostasis , Skeletal damage) covers the main symptoms of acute vitamin D deficiency . Researchers have observed that when HSN is provoked in patients with peripheral vestibular disorders, usually (in more than 75% of cases) it beats toward the normal or unaffected ear. In contrast, HSN beating toward the morbid ear in unilateral peripheral vestibular lesions may be a recovery nystagmus or an irritative nystagmus [2]. They were required to meet the following condition: In the period prior to the attacks of vertigo, for which a l0-day period preceding the attack was arbitrarily considered (the forerunning period), HSN observed using the Frenzel's glasses in darkness reversed its direction, appeared, or disappeared. Numbers of male and female patients were equal within the age range of 27-58 years (average, 47).


In the present group of patients, vertigo attacks occurred from 6 hours to 8 days (average, 3.2 days) after the observation of HSN beating toward the morbid ear.
Usually the vertigo attacks lasted for some 3-4 hours, accompanied by nausea and, at times, vomiting, by a sensation of fullness or pressure of the right ear, and by increased tinnitus or other auditory symptoms.
Cercine (a diazepam) and Merislon (betahistine mesylate) were prescribed for the patient, but she had an episode on August 17 at home. On October 30, HSN was provoked to the left but, on November 7, it appeared in the opposite direction. The immediate administration of a hyperosmotic diuretic in this stage of Meniere's disease successfully may suppress the recurrence of vertigo attacks. Often, we find multisensory syndromes combined with tinnitus, hearing impairment, vertigo, and nausea. Low-tone tinnitus is more frequently found in Meniere's disease and some other cochleo-apical disorders.
In the high-tone range, most frequently tinnitus is matched and related to such conditions as noise trauma, whiplash, head and skull trauma, cardiovascular failures, stress, and toxic events, including pharmaceutical use, nicotine or drug abuse, and acoustic neuromas. Owing to the size of the workload, we limited ours efforts to constructing a sample from those 757 patients randomly selected from a major group of neurootological patients (we process more than 10,000 files of neurootological patients, many of whom suffer from one or another type of tinnitus). We then conducted objective and quantitative electrophysiological measurements of the acoustic pathways via otoacoustic emissions, acoustic brainstem-evoked potentials, and acoustic late or cortical evoked potentials. We performed vestibulospinal recording of the CCG with the Romberg standing test and the Unterberger-Fukuda stepping test using USCCG and the human space trail. However, for this study, we present the broad spectrum of subjective complaints as reported by the patients with a broad variety of findings.
This is shown for instance, in Figures 6 and 7, wherein the typical tinnitus phenomena are matched on different hearing zones in the audiograms of the right and left sides.
Therefore, we prepared a specific, detailed analysis of the background of head and neck trauma (Fig.
Our search presented us with a great amount of data (more than 500 parameters per case), which we transferred into a digital version of the databank to preserve the anonymity of this sample of patients. The other identification indicators (weight, height, body mass index, and average systolic and diastolic blood pressure) lie within the expected range of this sample taken for Germany. For vegetative symptoms, such as the occurrence of nausea in perhaps one of four patients, see Figure 9.
Acoustic, vestibular, and behavioral and psychosomatic symptoms are intertwined and seemingly interact with one another. In a subsequent publication, we will deal with the outcome of the objective and quantitative measurements in audiology, equilibriometry, and the like in our group of 757 cases of endogenous tinnitus. This finding presumably reflects the changeable pathophysiological state of the labyrinth of Meniere's disease.
These facts have led us to consider that HSN beating toward the morbid ear may warn of impending vertigo recurrence in Meniere's disease and that the attack of vertigo may be avoided if the patient is treated properly during this pathological state of the inner ear. When the HSN showed a biphasic pattern [2,3] , only the first phase was considered in the present analysis.
The observation periods of each patient were from 2 months to 1 year and 10 months (average, 1 year and 3 weeks). In three of these patients, the immediate administration of isosorbide, a hyperosmotic diuretic [4], in this stage successfully suppressed the recurrence of vertigo attacks. From more than 10,000 cases, we evaluated 757 randomly selected neurootological patients suffering from endogenous tinnitus. However, what could be proved by various authors since 1985 is that endogenous tinnitus is significantly related to dysfunctions in the human temporal lobe (Brodmann area 41). We administered a full spectrum of neurootometric testing to all 757 patients; the investigation protocol for thorough data analysis (more than 500 parameters) included five procedures. After all the files of the patients were transferred into digital lists and nets of digital data, we could select the various groups of complaints to derive a representative statistic.
The most frequent quality of tinnitus distortion reported was a whizzing sound in either ear or in both (54.02%).
Figure 21 demonstrates a specific differentiation with respect to facial nerve paralysis cases. We easily designated a group of patients who demonstrate a genuine objective sound in the head as experiencing bruits. In future, this must be taken into consideration in developing a spectrum of therapeutic procedures not only in the field of pharmacotherapy but in psychotherapy and physiotherapy and in applying such physical measures as magnetotherapy.
We found diabetes mellitus more frequently in the group with the exogenous or unmaskable tinnitus, whereas hyperlipidemia was reported twice as often in the group with endogenous or maskable tinnitus as in those with the unmaskable type. On the functional state of central vestibular structures in monaural symptomatic tinnitus patients. About the Strength of the Neck in Linking the Head to the Trunk as Measured by the US-CCG . Interdisciplinary clinical vertigo studies in whiplash lesions to the ligamenta alaria by means of dynamic MRI-findings in combination with ultrasound cranio-corpo-graphy (USCCG). Medical classification of tinnitus between bruits exogenous and endogenous tinnitus and other types of tinnitus.
Die Differenzierung zwischen endogenem und exogenem Tinnitus [The differentiation between endogenous and exogenous tinnitus]. We retrospectively analyzed clinical records of eight patients who had unilateral Meniere's disease and carne to Gunma University Hospital for consultation in the period from 1984 through 1989.


This finding presumably reflects the changeable pathophysiological state of the labyrinth, such as endolymphatic hydrops, of Meniere's disease. Audiometric examination revealed a mild sensorineural low-tone loss in the right ear, with normal hearing in the opposite ear. First, we classified the 10,000 patients into those suffering from the basic tetrad of tinnitus forms: bruits, endogenous (maskable) tinnitus, exogenous (nonmaskable) tinnitus, and other syndromes such as the slow brainstem syndrome. Patients with a maskable or endogenous tinnitus prefer covering up their tinnitus by external sounds. We found typical shortenings in the latencies of the vestibular evoked quantitative electroencephalography (QEEG), an enlarged DC shift of the vestibular evoked QEEG, and typical cortical electrical burst expansion in three phases on the brain surface as shown by BEAM.
First we recorded a thorough neurootological history with a systematic preprinted history scheme of Neurootologisches Anamneseschema Claussen (Neurootological History Scheme). As the sum of all the tinnitus spots being masked amounts to 141.74%, we were able to derive that nearly one-half of the sample suffered from a bilateral maskable tinnitus.
The majority of patients (consistent through all age groups) reported so-called whiplash-related tinnitus problems after a car accident. The frequently reported sensation of a roaring in the right or the left ear occurred in only 0.13% (left ear) in our sample. In Vertigo, Nausea, Tinnitus and Hearing Loss in Central and Peripheral Vestibular Diseases . In JM Aran, R Dauman (eds), Proceedings of the Fourth International Tinnitus Seminar, Bordeaux, 1991 . All patients satisfied the following condition: In the period prior to the attacks of vertigo, for which a l0-day period preceding the attack was arbitrarily considered (the forerunning period), HSN reversed its direction, appeared, or disappeared. The right-ear deafness remained in the 25-to 45-dB range, with normal hearing in the left ear. Next, we examined all the patients otologically, including bilateral microscopical inspection of the outer ear, ear canal, and tympanic membrane. They also reported posttraumatic complaints of whiplash injury (also consistent through all the age groups but especially frequent in the age group 30-40 years). Significantly different from the group identified as having endogenous tinnitus are the behavior and the sensation of those with exogenous tinnitus or nonmaskable tinnitus, who find relief in a completely silent environment. The majority of our patients described their tinnitus as lasting from one to several years (as seen in Fig. We found that 3.70% of patients complained about a reduced acuity in their taste (hypogeusia). When HSN showed a biphasic pattern, only the first phase was considered in this present analysis. Twenty days thereafter (October 9), the patient came to the hospital because she had an episode early that morning. Car accidents and whiplash occur more frequently in the younger age groups, whereas reports of cerebral concussions are more frequent in the old-age group (> 70 years).
Finally, via our complex neurootometric tests, we demonstrated slowing deregulations in the statoacoustic pathways. We heard no complaints about trigeminal disorders; however, we found both peripheral and central facial nerve paresis, though in a small number (see Fig. 28) played a minor role in our sample, as was evident for the major hormonal diseases (Fig.
In the period before the attack, HSN reversed its direction from the normal to the morbid ear five times in four patients, appeared toward the morbid ear in three patients, and disappeared from one beating toward the normal ear before the forerunning period of vertigo attacks in one patient. The statistical results demonstrate that tinnitus is interconnected to a multifactorial disease background with a broad spectrum of individual complaints.
Only 0.13% of our patients described a subjective roaring sound in the left ear, whereas none attributed it to right ear. In such cases, the visual acuity problems were corrected most frequently by use of eye glasses (74.50%). These findings suggest that the occurrence of HSN directed to the morbid ear in the recuperation period in Meniere's disease might indicate the impending recurrence of a vertigo attack in a few days.
On October 17, SN could not be observed any longer, but HSN still appeared to the right, and the patient experienced vertigo attacks on October 20 and 22. Finally, the topodiagnostics of the functional neurootometric analysis shows that this type of endogenous tinnitus constitutes decidedly more central than peripheral statoacoustic pathology. Astonishingly, even the number of occurrences of basic neurological disorders (paralysis, paresthesias, apoplexies, epilepsia, Parkinson's disease, and brain tumors) was very low (as shown in Fig. In the present group of patients, vertigo attacks occurred from 6 hours to 8 days (average, 3.2 days) after the observation ofHSN beating toward the morbid ear. The high-frequency tinnitus often develops close to the C5 dip and can be masked below the hearing threshold (see Fig.
Clearly, a typical interrelation of tinnitus with a single major disease group is highly unlikely. In three of these patients, the immediate administration of isosorbide (a hyperosmotic diuretic) in this stage successfully suppressed the recurrence of vertigo attacks. A clinical diagnosis was made of classic Meniere's disease involving the right ear (Table 2).



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