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Author: admin, 22.10.2013. Category: Treatment For Tinnitus

INTRODUCTION: The general consensus on the roles of hearing loss in triggering tinnitus seems not applicable in patients with normal hearing thresholds. OBJECTIVE: To scrutinize auditory functioning in a sample of tinnitus subjects with normal hearing thresholds and non-tinnitus normally hearing control participants using transient evoked and distortion product otoacoustic emission (TEOAE and DPOAE) and Threshold Equalising Noise (TEN) test. METHODS: Twenty-seven tinnitus adult patients with normal hearing thresholds and 27 normally hearing volunteers were tested with TEOAE, DPOAE and TEN test. CONCLUSION: These results suggest the possible existence of subtle auditory deficit in normally hearing tinnitus patients, which may be an early sign of diseases that are only diagnosed after the onset of hearing loss. Keywords: coustic neuroma, otoacoustic emissions, tinnitus, threshold equalising noise test.
Tinnitus is defined as the perception of sound that results completely from activity within the nervous system without any corresponding mechanical, vibratory activity within the cochlea, and not related to external stimulation of any kind1. An increasing amount of epidemiology studies provide both self-reported data on tinnitus and hearing status which allows closer examination on the relationship between tinnitus and hearing status. Although some studies have different theoretical assumptions and approaches, the significance of hearing loss in tinnitus generation is not questioned. Thus, several attempts have been made to explain pathophysiology mechanisms of tinnitus in patients with normal hearing ability particularly using otoacoustic emissions (OAEs). Several studies have revealed that TEOAEs and DPOAEs can be used as a tool to detect early hearing loss before it can be diagnosed by PTA13-15. The contradict findings from previous research motivates researchers to find alternative theories to explain tinnitus mechanisms in tinnitus patients with normal hearing thresholds.
This study investigated 27 tinnitus subjects (42 tinnitus ears and 12 contralateral non-tinnitus ear) with normal hearing thresholds who were recruited from Welsh Hearing Institute, University Hospital of Wales. Full history taking and otoscopy examination were carried out at the beginning of the session. TEOAEs test was performed using unfiltered clicks of 80 µs duration presented in non-linear modes.
The stimulus comprised of a pair of primary pure tones (f1 and f2) at a frequency ratio equal to 1.22. The basic principle of this test is to control for "off-frequency listening" from occurring by using a broad band noise (the threshold equalising noise). This research has received the ethical approvals from the School of Applied Community and Health Studies (SACHS), University of Bristol Human Participants Ethics Committee and the South East Wales Research Ethics Committee. Initially, the left and right of DPOAE results were compared within the tinnitus and control groups.
Then, the differences of overall mean DPOAE amplitude between tinnitus and control ear were compared. Various hypotheses have been put forward to explain tinnitus generation in normal hearing patients. Decreased TEOAE amplitudes were observed in 35.7% of the tinnitus subjects with normal hearing sensitivity.
A statistically significant increase in DPOAE amplitude was observed in tinnitus ears at f2 frequency of 1414 Hz.
The fact that tinnitus patients with normal hearing have a significantly higher percentage of abnormal TEOAEs and a limited frequency of DPOAE than the controls may suggest that OHC dysfunction may be pivotal in tinnitus generation. In the current study, the percentage between abnormal TEOAE and DPOAE in both groups had no statistically significant difference. In the field of tinnitus, however, only two studies reported the application of TEN(HL) test in tinnitus patients with normal hearing24,25. Based on systematic review, no research on the application of TEN test in detecting acoustic neuroma has been published. No published data was found on the application of a TEN test in detecting acoustic neuroma. This study showed that subtle cochlear problem may exist in tinnitus patients before it is significantly appeared in the audiogram.
Thanks to University Hospital of Wales, UK for providing the facilities to conduct this research. This study was supported by the University of Bristol, UK and Ministry of Higher Education (MOHE) Malaysia and Universiti Kebangsaan Malaysia (UKM) as parts of the first author's PhD research. Paper submitted to the ITJ-SGP (Publishing Management System) on February 17, 2014; and accepted on February 20, 2014.
How to cite this article Caldas FF, Silva IMC, Teixeira MS, Deperon TM, Cardoso CC, Barreto MASC, Oliveira CACP, et al. OBJECTIVE: To evaluate the prevalence of misdiagnosis of the hearing impaired children, in order to investigate the existence of Auditory Neuropathy Spectrum Disorder. METHODS: Analytical, prospective study conducted with 15 participants (30 ears) aged 10-12 years, with bilateral sensorineural hearing loss, attending a Hearing Rehabilitation Center, accompanied by a multidisciplinary team with otolaryngologist, audiologist, psychologist, teacher and social worker. The current advances in technology and in newborn hearing screening are permitting an earlier diagnosis of hearing loss, improving ENT evaluation and speech therapy focused on speech and language stimulation, aiming the development of auditory skills. The combination of speech therapy, ENT and audiology interventions added to family support and systematic use of hearing devices provides a better prognosis for hearing impaired children in general2. In the last, care assistance and technology available to outpatient services for the diagnosis of hearing loss in children often did not allow to diagnose the ANSD, whereas nowadays newborns can receive an early diagnostic of ANSD due to electroacoustic evaluation methods such as: Otoacoustic Emissions (OAE) and Auditory Brainstem Response (ABR)3.
Individuals with ANSD usually present impaired speech intelligibility and pure tone detection thresholds at levels ranging from normal to severe. Some patients with this disorder report the occurrence of fluctuations in hearing, with so-called "good hearing days" and "bad hearing days"4, besides the complaint of difficulty in understanding speech, especially in the presence of background noise5.
Objective tests, such as OAE, ABR and acoustic efferent reflexes, evaluate the function of peripheral and central auditory pathways.
The ANSD is characterized by hearing loss with absent or severely altered ABR, normal function of OHC obtained by present OAE and the presence of cochlear microphonism (CM)7.
The increasing number of newborn hearing screening programs that uses methods such as OAE and ABR is significantly contributing to the diagnostic of neural hearing loss in newborns and young infants. To evaluate hearing impaired children, aging from 10 to 12 years old, who are hearing aids users, in order to investigate the existence of Auditory Neuropathy Spectrum Disorder (ANSD). It was conducted an analytical and prospective study, with 15 children (30 ears), from a Hearing Rehabilitation Center that were accompanied by a multidisciplinary team, composed by otolaryngologist, audiologist, psychologist, teacher and social worker, in Brasilia - DF, in Brazil. A questionnaire11 was applied with parents of the participants to identify the profile of each participant in terms of prenatal, perinatal and postnatal development, facts related to development of hearing and use of hearing aids. Pure tone audiometry data (performed maximum 6 months before the beginning of this study) was extracted from patient file. The Ethics Institutional Review Committee for Research with Human Beings approved this study (Opinion no. In Table 2, the results obtained are described in electroacoustic and electrophysiological assessments that were performed.
Figure 1 shows that 26.7% of ears tested (6 participants) had auditory system pre-neural and neural evaluation results, compatible with ANSD with absent ABR and presence of CM. Figure 3 shows the result of OAE test, in the ears that had presence of OAE in isolated frequencies, but with "fail" in the final test result.
In Figure 4 there is a correlation between the duration of use of hearing aids and ears that show presence of OAE in single frequencies in children with characteristics of ANSD. The diagnosis of hearing loss in participants of this study occurred between 3 months to 11 years old. The electrophysiological measures of auditory function had a great importance in order to understand the alterations that were found in this study. Despite the plastic tube of insert phones were not tied up during the ABR test in order to confirm the presence of the CM5, OAE test was performed.
The features found in physiological tests in this study were consistent with results found in literature.
Another study with a 59 participant sample12, three of them were diagnosed with auditory neuropathy by presenting present OAEs, absent ABR and extended CM. Newborn hearing screening was not performed with participants of this study by the time they were born, since there was no implementation of universal newborn hearing screening programs in the hospitals where they were born. Some patients with ANSD have Absent OAEs, but show signs of hair cells function that are evident in the CM, which is an electric evoked potential of hair cells that can be recorded in a non-invasive way with the ABR test8.
All participants who presented characteristics of the ANSD in this study were fitted with hearing aids, and showed present OAEs in isolated frequencies.
The results of this study have identified characteristics related to ANSD in 26.7% of ears tested, 6 participants with age over 10 years old.
This study leads to a reflection on the lack of early diagnosis in ANSD that may have hindered the adequate intervention with hearing aids, hearing tests, and specific therapeutic monitoring in this population.
Paper submitted to the ITJ-SGP (Publishing Management System) on September 7, 2013; and accepted on October 7, 2013. Our staff performs comprehensive hearing testing on patients of all ages, including infants. An audiogram, or hearing test, is an assessment of a patient’s hearing which is recorded on a graph. During the testing, the patient wears earphones and is asked to raise their hand or press a button when a sound is presented. When small children are tested, they are asked to perform a simple task such as placing a chip into a box or pointing to a picture when the sound or word is heard. When testing infants, sound is presented via a speaker rather than an earphone, and when the child turns toward the source he or she is rewarded by the appearance of a lighted puppet.
When these behavioral methods of testing can not be performed, other methods of hearing testing are available.
Auditory Brainstem Response testing (ABR) is also a method of determining the threshold of hearing.
In a Dix-Hallpike test, a patient lies down on his or her back, with the head turned to the side.
Following diagnosis, patients with BPPV are treated with repositioning exercises by our audiologists. Specializing in Treatment Options for Hearing Loss, Dizziness, and Ringing or Buzzing Ears. Nevada Hearing and Balance Center is a family owned company that utilizes board certified audiologists, a compassionate office staff, and state-of-the-art technology to diagnose and treat hearing and balance disorders. You are invited to call us at 896-0031 to schedule your initial consultation and begin the road to better health. Measurement of subtle auditory deficit in tinnitus patients with normal audiometric thresholds using evoked otoacoustic emissions and threshold equalizing noise tests.
The absence of hearing loss on the audiogram in this group of patients poses a serious challenge to the cochlear theories in explaining tinnitus generation in this group of patients. For many years, progress towards finding the effective treatments for tinnitus was hindered by vague understanding of its underlying pathologic mechanisms.
The association between hearing loss and tinnitus has been well documented in the previous literature2-4.
Some studies found a correlation between severity of tinnitus and degree of hearing loss3,8 while others found no such correlation9. On the other hand, clinical observations have shown that 8 to 10 per cent of tinnitus patients had normal audiometric thresholds12. It is hypothesised that outer hair cells damage results in stereocilia decoupling from the tectorial membrane, thus causing them to depolarise and subsequently resulting in tinnitus perception1. An association of tinnitus with the changes in amplitude of TEOAEs and DPOAEs has been reported. One study by Weisz et al.24 proposed that subtle auditory abnormality may also arise from the inner hair cells (IHCs) dysfunction. The subjects who were attending the Institute from January to December 2010, were identified by an audiology physician and audiologists based in this hospital.
Then, all subjects underwent basic audiological tests which include pure tone audiometry and tympanometry. Off-frequency listening occurs when the presented stimulus is being picked up by other parts of the cochlea instead of the targeted frequency area of the cochlea.


From the analysis, the parameters of the TEOAEs for tinnitus ears are not significantly different from the control ears.
Since no statistically significant difference was observed between both ears, further statistical analyses were performed using combined data from both sides together. Distribution of the number of test frequencies with abnormal DPOAE in tinnitus and control ears.
Based on the chi-square analysis, tinnitus ears have a statistically significant higher percentage of abnormal DPOAEs at some frequencies, mainly at 2000 and 4000 Hz regions (Table 4). For example, it has been postulated that the different level of functionality between OHCs and IHCs (the Jastreboff's discordant dysfunction theory) can generate an unbalanced stimulation of dorsal cochlear nucleus's cells which produces abnormal neural activity. Abnormal DPOAE amplitudes were also found in this group, particularly at high frequency regions, but in a slightly lower percentage than the TEOAE. For example, in Shiomi et al.19, the mean amplitudes of the DPOAE were significantly decreased in tinnitus patients with normal hearing than in normally hearing controls. One possible explanation for this finding is that it may be due to OHCs hypersensitivity, as reported in some previous research.
Abnormal TEOAEs and DPOAE in the tinnitus patients also imply that they may have subtle cochlear damage that is not yet appearing on the audiogram. This finding might suggest that both tests were sensitive to detect minor OHCs dysfunction. Unexpectedly, the use of a TEN test in the current study has led us to find an acoustic neuroma in a patient. Sincere thanks to Ministry of Higher Education (MOHE), Malaysia, Universiti Kebangsaan Malaysia (UKM) and University of Bristol for providing sponsorship to pursue this PhD study.
Program Audiologi, Pusat Pengajian Sains Rehabilitasi, Fakulti Sains Kesihatan - Universiti Kebangsaan Malaysia - Kuala Lumpur - AC - Malaysia. The participants underwent ENT examination and audiological assessment: tympanometry, acoustic reflexes, otoacoustic emissions test and Auditory Evoked response. Within the selected eight ears, six (75%) showed presence of otoacoustic emissions test in isolated frequencies and two (25%) ears had otoacoustic emissions test even in the presence of the isolated frequencies. The development of these skills with focus on auditory information and appropriate speech expression is only possible due to technological devices such as cochlear implants and hearing aids1.
Nonetheless some children, even under ideal conditions of stimulation and support since early childhood, shows auditory and language skills in a level below from what is expected for children of the same age. Unlikely patients with sensorineural hearing loss that present clinical features compatible with impaired function of the inner and outer hair cells, patients with clinical evidence of ANSD have normal function of outer hair cells (OHC)4.
It has been seen that the ANSD affects the individual's ability to process quickly changes in the acoustic signal, which means that it affects the auditory temporal process4.
Although measures of auditory behavior of central function provide general information on communication performance, objective measures show high sensitivity in neural testing6. Through tests such as OAE and ABR, it is possible to identify if the eighth cranial nerve (vestibulocochlear) function is altered, considering that in ANSD cases the OHC function may be normal5. From this population, children that were screened and presented abnormal ABR and presence of OAE were the first ones where the presence of a neural hearing impairment was suspected8.
The amplification given by hearing aids is used to improve the loss of sensitivity and it usually results in good outcomes to speech perception. Middle ear disorders evidenced in tympanometry results were considered as exclusion factor. They belong to a family of three children with hearing loss with late diagnostic, this is due to the inexistence of newborn hearing screening by that time and to the degree of hearing loss that was not as impactful to the development of auditory skills, so it took time to parents to realize that their children have hearing loss. FROM These ears, 6 (75%) showed presence of OAE in isolated frequencies and 2 ears (25%) absence in OAE. Similar data was observed in a study7 where 218 deaf children were evaluated and, in most cases, were diagnosed between 11 months to 12 years of age (mean age 4 years). In this test cochlear function responses were obtained in some isolated frequencies, what maintains the reliability of the CM research, which is also a response from the cochlear function. In a study where 10 patients were evaluated in order to find the presence of ANSD, 8 showed evidence of auditory neuropathy. Four other participants had absent OAEs and present ABR, although, when the polarity of stimulus were inverted it was observed a mirror image, which is compatible with CM. There is therefore no way to know whether or not these children would have the present OAE in all frequencies, indicating integrity of the cochlear function (OHC). In other studies there is no information whether this loss of cochlear function that happens in ANSD begins at high frequencies or low frequencies, or even if it occurs randomly.
The same was observed in another study14 where 18 ears (11.7%) with ANSD fitted with hearing aids.
Professor of the University of Center Plateau - UNIPLAN PhD in Health Sciences from the University of Brasilia - University of Brasilia - Brasilia - DF - Brasil. Specialist in Otology and Neurotology by Harvard Medical School, Boston, MA, USA, PhD in Medical Sciences from the University of Brasilia, Professor at Health Sciences School - University of Brasilia - Brasilia - DF - Brazil. The audiogram demonstrates how loud a sound, tone, or word needs to be presented before it can be heard by a patient. The sounds are presented at a variety of levels to determine the softest level which can be heard. The audiologists are skilled in choosing tasks appropriate for children of all ages and cognitive levels and in making them comfortable during the exam. Otoacoustic emission testing (OAE) is used to determine the cochlear, or inner ear, function. Clicking noises presented through an earphone allow measurement of the electrical response of the auditory system, from the cochlea to the brain. These maneuvers are designed to allow the calcium deposits to leave the balance canals and alleviate the condition. Only one patient was found with a positive TEN test result, who was confirmed by Magnetic Resonance Imaging to have acoustic neuroma on the affected ear. The last half of the twentieth century saw considerable advances in our understanding of tinnitus from both physiological and psychological perspectives. It has been generally accepted that any severe damage along the auditory system may lead to a certain degree of hearing loss, which is generally associated with tinnitus5,6. Moreover, the incidence of tinnitus in patients with sensorineural hearing loss varies widely across studies. These observations may have several indications, such as hearing loss is not necessary in tinnitus generation, pure tone audiogram does not always indicate auditory damage, tinnitus may be a primary symptom of diseases that are only diagnosed after the occurrence of hearing loss, or several mechanisms exist in a group of patients.
The different functionality of outer and inner hair cells can also cause imbalanced activity in the dorsal cochlear nucleus which in turn causes changes at higher levels of the auditory system that may be perceived as tinnitus1.
In some studies, lower amplitude of TEOAEs13,16 or DPOAEs13,17-19 have been observed in tinnitus patients compared to in non-tinnitus controls. All participants had no history or current external and middle ear problem, noise exposure and psychiatric problem. In this experiment, a 2f1 - f2 distortion product was used because of its established clinical value.
This off frequency listening occurs when the targeted area of inner hair cells or neurons are not functioning well and is referred to as a dead region27. In this case (Subject RX), the TEN (HL) test revealed that dead regions might exist at 1.5, 3 and 4 kHz on the left ear (Table 7). Since all the subjects in this study had normal hearing, the decrease in the TEOAE and DPOAE finding may possibly be considered as the effect of cochlear dysfunction of the cochlear active mechanism, which is related to OAE generation.
Frequency analysis also showed that a significant decrease in DPOAE amplitude was mainly at the f2 frequency of 4000 to 7000 kHz. Therefore, the hearing status of these patients should be monitored for possibility of developing hearing loss later in life. Previous research has clearly demonstrated that OAE may be used to reveal subclinical OHCs damage in audiometrically normal ears13-15. Apart from difficulty hearing in background noise, she did not have any other classical symptoms of acoustic neuroma such as balance problem or poor speech discrimination scores.
Firstly, it implies that a TEN test may offer a quick, inexpensive and non-invasive method for retrocochlear screening. In their study, they found 7 out of 8 auditory neuropathy patients with abnormal TEN test results. The finding also supported the possible clinical advantage of the TEN test as a screening tool for retrocochlear problem. Risk factors for tinnitus in a population of older adults: the blue mountains hearing study. Characteristics of tinnitus and etiology of associated hearing loss: a study of 123 patients.
The more the worse: the grade of noise-induced hearing loss associates with the severity of tinnitus.
Tinnitus with normal hearing sensitivity: extended high-frequency audiometry and auditory-nerve brain-stem-evoked responses. The effect of the number of averaged responses on the measurement of transiently evoked otoacoustic emissions in newborns.
Dead regions in the cochlea: diagnosis, perceptual consequences, and implications for the fitting of hearing aids. Transient and distortion product evoked oto-acoustic emissions in normal hearing patients with and without tinnitus. DPOAE in estimation of the function of the cochlea in tinnitus patients with normal hearing. Tinnitus and 2f1-f2 distortion product otoacoustic emissions following salicylate overdose. Ten(HL)-test results and psychophysical tuning curves for subjects with auditory neuropathy. It was found that 26.7% of the ears tested presented results that are compatible with Auditory Neuropathy Spectrum Disorder. One possible explanation for this fact is the presence of undiagnosed Auditory Neuropathy Spectrum Disorder (ANSD).
In contrast, a dysfunction of the auditory nerve may not impact auditory sensitivity significantly, but it usually jeopardizes speech understanding, which is generally poor in these cases.
All participants presented bilateral sensorineural hearing loss, from moderate to profound classified as frequency average10 and were hearing aid users. The age that caregivers' suspected hearing loss occurred between 15 days to 11 years, the age of diagnosis occurred between 3 months to 11 years, beginning of speech therapy occurred between 3 months and 11 years and the beginning of hearing aid use occurred between 12 months to 11 years. This results shows that the diagnosis of hearing loss is still happening late, even with the advances in technology for diagnostic methods.
In the literature, other authors agree that there is a higher prevalence of profound hearing loss. It was observed that 26.7 % of ears evaluated (6 participants) presented characteristics of ANSD in the pre-neural and neural auditory system assessment, revealing absent ABR with the presence of CM. This disorder is characterized by normal function of OHC (Presence of OAE and CM) and abnormal function of the auditory pathways beginning in the eighth cranial nerve (absent or severely abnormal ABR).
What showed evident in the results of OAEs in this study were OAE responses in isolated frequencies. The results showed that the decrease in the amplitude of the OAE in the ears fitted with hearing aids was higher than the non-aided ears.
Language, speech, and social-emotional development of children who are deaf or hard of hearing: the early years. O envolvimento do pai no processo de (re)habilitacao auditiva de seu filho deficiente auditivo. Guidelines for identification and management of infants and young children with auditory neuropathy spectrum disorder. Persistence of otoacoustic emissions in children with auditory neuropathy spectrum disorders. Postgraduate Speech and Audiology, Education Psychology and Audiology and Neurotology, Master of Health Sciences (UNB-DF).


This is checked from low tones to high tones and particular attention is paid to those frequencies important to the hearing and understanding of speech.
Sounds presented to the ear, usually in the high pitch range, will elicit a response from the cochlea that can be measured. This measures the ventilation of the middle ear, the mobility of the eardrum (tympanic membrane), and can determine the presence of a tympanic membrane perforation or fluid in the middle ear. BPPV occurs when otoconia, or tiny calcium deposits, normally present in the inner ear, migrate to the semicircular or balance canals making them inappropriately sensitive to gravity.
A positive Dix-Hallpike test occurs when the patient’s eyes appear to be moving, usually in a rotatory fashion.
More commonly, various studies have shown that sensorineural hearing loss plays an important role in tinnitus generation. Therefore, the absence of hearing loss on the audiogram in this group poses a serious challenge to the aforementioned theories in explaining tinnitus generation in tinnitus patients with normal hearing. In the study, they investigated the inner hair cells functions in 11 chronic tinnitus patients with normal hearing thresholds using Threshold Equalising Noise (TEN) test and found 8 of them with possible inner hair cells problems. The results were presented as a distortion-product audiogram i.e the amplitude of the 2f1 - f2 DPOAE was plotted against the f2 from 1000 to 6169 Hz. The broad band noise is designed to produce almost equal masked thresholds over a wide frequency range, for listeners with normal hearing and hearing impairment but without dead regions28. The abnormal TEOAEs in the tinnitus group were present for 1 and 4 kHz mostly, while in the control group, the abnormalities were mostly at 4 kHz. A t-test revealed that with regard to mean amplitude of TEOAE for tinnitus ears, there were no statistically significant differences for all frequencies tested (p > 0.05).
Later, the mean amplitude of DPOAE for tinnitus and control ears against the corresponding f2 was compared. From 20 tinnitus patients with abnormal OAEs, 13 of them exhibit either failed TEOAE or DPOAE results. According to this theory, discordant dysfunction can occur without affecting the audiometric hearing thresholds when the OHCs are partially damaged and where the IHCs are intact.
Stated differently, abnormal or poor OAE results may be the indicator of subtle cochlear damage before the abnormality affects hearing sensitivity and appears on the audiogram. Thus, the similar findings indicate that DPOAE measurement can offer a frequency specific measurement for the detection of subtle localised cochlear damage even before affecting pure tone thresholds34. The high percentage of TEOAE abnormality at 4 kHz for the control ears may suggest that the hearing status of these participants also needs to be monitored.
Nonetheless, only the difference between numbers of abnormal TEOAE in tinnitus and control ears reached a statistically significant level.
The former study suggested that tinnitus generation in their group of participants may be due to the effect of deafferentation of the neuron. Secondly, tinnitus patients may have a serious problem that triggers the tinnitus perception despite having normal hearing thresholds and normal OAE test results. Patients with auditory neuropathy are known to have problems with transmission of the auditory signal to the brain, thus abnormal TEN test results in this group of patients were assumed to be due to the neuron dysfunction.
However, more research needs to be carried out in this area in order to support the current finding. This is because the auditory nerve is the main pathway to the transmission of neural code for speech. From these ears, 75% showed present OAEs in isolated frequencies, however, without reaching the criterion "pass" in the test. These results emphasize the possible role of amplification in the reduction of otoacoustic emissions in ANSD14. A device can be placed behind the ear to help differentiate between middle ear or inner ear (cochlea) disorders.
This is a valuable screening study for newborns and for patients who are unable to respond by conventional means. The ABR can also be used to determine the ability of the auditory nerve to conduct sound energy. As a result, when patients turn the affected ear down, a severe sensation of vertigo develops. Evidence showed a higher incidence of tinnitus patients with sensorineural hearing loss compared with conductive hearing loss7.
In addition, not all individuals with hearing loss experience tinnitus, and not all tinnitus patients have hearing loss.
While the theories seem cannot fit in this minority group, evidence obtained from this group may have huge implication for a better tinnitus mechanisms understanding as well as assist in developing and shaping tinnitus management.
The studies reported that tinnitus subjects were found to have increased TEOAEs20,21 or DPOAEs22,23 compared with non-tinnitus counterparts. Thabet25 attempted to replicated the earlier study by investigating 20 normally hearing unilateral tinnitus patients with TEN test and TEOAE. The presence of DP amplitude was accepted as valid when the signal to + 2 SD noise floor ratio exceeded 3 dB and the absolute DPOAE amplitude was at least - 10 dB SPL at each individual f2.
Table 2 shows the normal and abnormal TEOAEs at each frequency tested in both the tinnitus and control group. Generally, an independent t-test showed no statistically significant differences observed between tinnitus and control ears at all frequencies except for frequency 1414, 4757, 5187 and 6169 Hz (Table 5).
Meanwhile, from 16 control ears with abnormal OAEs, 10 ears exhibit either failed TEOAE or DPOAE results. The ABR showed absent wave V at 70 dBnHL in the left ear and normal ABR waveforms in the right ear, which were correlated with the TEN test results, suggesting of abnormal neural function.
Therefore, in this current study, we sought to determine whether the measurement of TEOAE and DPOAE may reveal subtle cochlear abnormality in tinnitus patients with normal audiometric thresholds. Although the difference between numbers of abnormal DPOAE in tinnitus and control ears failed to reach a significant level, mean amplitude of tinnitus ears at frequency region of 2000 and 4000 Hz were statistically significantly lower than the control ears. They suggested that it could be the result of reduced afferent input to the central auditory system due to cochlear lesion, thus resulting in a decreased OHC efferent activity and ultimately leading to OHC hypersensitivity.
TEOAE measurement stimulates the whole basilar membrane of the cochlear, which means it gives more global information.
Furthermore, dead regions normally exist in those who have hearing thresholds of 60 dB HL and above28. In other words, even though dead regions normally exist in patients with hearing loss of more than 55 dBHL, normal hearing people can also have a 'dead region' which may be due to retrocochlear abnormality. Similarly, the abnormal result in Subject RX in the current study may also be because of the problem in neurons rather than in the inner hair cells. MRI revealed a large vestibular schwannoma in the left cerebello-pontine angle which was compressiong the brainstem and cisternal portion of the VIIIth cranial nerve.This study showed that subtle cochlear problem may exist in tinnitus patients before it is significantly appeared in the audiogram. In general, amplification may not improve understanding of speech when the auditory nerve is compromized8,9. Thus, the absence of OAEs or presence in isolated frequencies does not exclude the ANSD diagnosis13. An audiologist may order this test with certain individuals who have tinnitus in one ear or asymmetric hearing loss.
Jastreboff & Jastreboff11 reported that about 27% of totally deaf patients do not have tinnitus, whereas 20% of normal hearing people have tinnitus.
This is because the results obtained from this special group may directly related to the tinnitus perception, but not to the concomitant hearing loss.
The test was performed in a sound treated room where the ambient noise was maintained between 20 to 40 dB A. The difference between the two groups is highly significant at frequencies of 1, 1.5 and 2 kHz, but not at 3 and 4 kHz.
The decrease in DPOAEs amplitude over a limited frequency range in DP-gram found in tinnitus patients with normal hearing may be a susceptible area representing minor cochlear pathology. Similarly, a more recent study by Sztuka et al.35 attributed the increase in DPOAE amplitude in tinnitus patients with normal hearing as a result of increased motility of the OHCs due to decreased neural activity in the auditory nerve. Conversely, the number of abnormal DPOAE in tinnitus ears was not statistically significantly different from the controls. They found that outer hair cells damage (assessed by TEOAE) was more common in normally hearing tinnitus patients than inner hair cells damage. In this case, the positive TEN (HL) results may not be due to inner hair cells damage but maybe because of poor processing efficiency that is associated with neural problems due to compression of large vestibular schwannoma on the VIIIth nerve38.
However, caution should be taken in interpreting the TEN test results as 10 dB-above-thresholds criteria is just a binary criteria that means passing or failing the TEN test, but does not mean dead or not dead. It can be assumed that the role of sensorineural hearing loss as a tinnitus generator is complex and the mechanism of tinnitus may rely on the presence of other contributing factors such as damage to specific hair cells or the auditory nerve fibers.
This appears to support the hypothesis that a reinforced mechanical distortion is generated by cochlear hyperactivity that can be the source of the tinnitus.
DPOAE is more frequency specific and thus is expected to be more sensitive in detecting subclinical abnormality in cochlear function over TEOAE. Their finding supports the theory that outer hair cells abnormality may be an important factor in the tinnitus mechanism37.
For this reason, more research needs to be carried out on the clinical benefit of the TEN test before applying this method clinically. By contrast, in other cases, TEOAE and DPOAE results showed poor or absent emissions in tinnitus patients with sensorineural hearing loss, even in those ears with normal hearing16,19,36. In this current study, the result may possibly be due to subtle cochlear abnormality also existing in non-tinnitus participants with normal hearing.
However, results from both studies may be more compelling if they included a retrocochlear test.
The TEN test appears to be a potential non-invasive and quick test of inner hair cells function.
The mean pure tone audiometric thresholds of tinnitus and control groups are shown in Table 1. The tumour was compressing the brainstem and cisternal portion of the VIIIth cranial nerve.
These variations can be explained by postulating that it is most likely to reflect different cochlear mechanisms underlying tinnitus generation due to different cochlear pathological changes in tinnitus ears37. The result of the current study is consistent with Thabet's study in which only one subject was found with a dead region, on the left ear.
Nonetheless, it is too early to make a conclusion based on the aforementioned two studies on tinnitus. An independent t-test revealed that there was no significant difference in hearing thresholds between tinnitus patients and controls at all frequencies except at 6 and 8 kHz. Thus, the variability of findings in this study may possibly be because of different mechanisms existing in the normally hearing tinnitus patients. According to Jastreboff37 however, there are different levels of dysfunction from the OHC up to the higher auditory pathways.
At both these frequencies, tinnitus patients had significantly higher thresholds than control individuals. He hypothesised that in some patients, though the level of dysfunction is undetectable by TEOAE, it may be sufficient to produce tinnitus.
Therefore, this study aimed to investigate subtle cochlear abnormality in tinnitus patients with normal hearing thresholds using evoked OAEs (TEOAEs and DPOAEs) and TEN test. Contrarily, in some, the level of abnormality is detectable but not enough to trigger tinnitus. Therefore, Jastreboff's hypothesis is a possible explanation as to why not all hearing loss patients present with tinnitus, and not all tinnitus patients present with hearing loss.



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  3. POLAT writes:
    The Ears Tinnitus which help inner ear overall health and pop so a lot.
  4. Seven_Urek_2 writes:
    People who have more extreme.