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Author: admin, 20.11.2013. Category: Treatment For Tinnitus

We will be provided with an authorization token (please note: passwords are not shared with us) and will sync your accounts for you. Objective: To describe the quantitative treatment outcomes of patients undergoing acoustic coordinated reset (CR) neuromodulation at a single independent audiology practice over a 22- to 26-week period as part of an open label, non-randomized, non-controlled observational study. Conclusion: Acoustic CR neuromodulation therapy appears to be a practical and promising treatment for subjective tonal tinnitus.
Tinnitus is the involuntary perception of sound, in the absence of corresponding auditory stimuli, which is perceived as originating within an individual’s ears or head. There is a strong evolving body of evidence that suggests that subjective tinnitus perception is linked to some form of peripheral audiological insult.
However, it is important to note that there is a growing amount of evidence that implies that the actually salient conscious perception of tinnitus requires the involvement of a significant network of brain areas (14, 15).
There is currently no European Medicines Agency (EMA) or Food and Drug Administration (FDA) approved pharmacotherapies available for the treatment of subjective tinnitus.
Acoustic coordinated reset (CR) neuromodulation is a non-invasive desynchronizing stimulation therapy that aims at counteracting pathological neural synchrony in subjects with subjective tonal tinnitus (6, 19). This article reports the experience of a cohort of adult patients suffering from chronic subjective tonal tinnitus when treated with acoustic CR Neuromodulation over a 22- to 26-week period within an independent audiology clinic setting.
A total of 66, fee paying, participants (44 male and 22 female) ranging in age from 31 to 76 years (with a mean of 57 years and a SD of 13 years) completed 22–26 weeks of therapy. The level of patient tinnitus severity was measured prior to the initiation of therapy using the tinnitus handicap inventory (THI) (26). Visual analog scale for perceived tinnitus loudness and annoyance were utilized as the primary outcome measurement. The tinnitus handicap questionnaire (THQ) (28) was used as the secondary outcome measurement.
The subject’s characteristic tinnitus frequency was assessed using a manufacturer designed pure tone matching protocol, where the intensity and frequency of the matching tone were controlled by an audiologist and the patient.
Patients were then stimulated for a 22- to 26-week treatment period using a portable acoustic device (T30 CR neurostimulator) coming with ear phones adapted from receiver-in-the-ear-canal (RIC) hearing aids that ensured that the subject’s auditory meatus was not occluded by the headphone receiver. The temporal, spatial, and frequency characteristics of the generated tones were determined via the CR algorithm [Ref.
Patients were seen at four subsequent follow up appointments, post fitting, in order to have the characteristic pitch of their tinnitus rematched. Descriptive statistics was used for each of the four variables (THQ, VAS loudness, VAS annoyance, and tinnitus pitch) and the three time points. The recording of VAS scores at follow up appointments, compared to baseline, revealed a significant reduction for both tinnitus loudness and annoyance. Sixty-four of the patients surveyed experienced a change in their pitch matched percept frequency, at 12 and 24 weeks, which required the neurostimulator system to be retuned to the newly perceived frequency.
A small number of subjects within this investigation recorded a THI score of 16 points or less, which is described as being only audible in quiet environments and having no impact upon sleeping or daily activities (32). The primary objective of this article is to report whether tinnitus sufferers could experience a reduction in tinnitus symptoms from acoustic CR neuromodulation therapy when it is delivered in an outpatient setting. It is interesting that while patients with slight THI category scores did not report a clinically significant score change with respect to the THQ the psychoacoustic parameters of percept loudness and annoyance did decrease in a much more significant way. Acoustic CR neuromodulation was well tolerated with all patients reporting, at the 24-week follow up consultation, of being able to commit to the required daily usage routine.
This investigation would also benefit from being repeated as a clinical trial with the addition of a control group of patients who receive counseling and appropriate amplification as this would provide a direct comparison intervention with which to gage the intervention under scrutiny. Self-help.tools materials are designed to be usable by clients with minimal or no intervention from a therapist.
The Mental Health Research Group at the University of Huddersfield developed a self-help pack for anxiety. Cognitive Behavioral Therapy (CBT) is a popular, evidence-based form of psychological therapy. We noted that attenuation across a dry skull is similar for a vibrator placed on the frontal, parietal, or occipital bones [1,4]; however, a dry skull is much different from a living head in terms of its acoustic properties.
An alternative view [12] is that ultrasound propagates principally owing to the piezoelectric properties of bone itself [13,14].
Five young, normal-hearing adults (three male, two female; mean age, 31 years), one young, profoundly deaf adult woman (aged 29, with no measurable audiometric hearing), and the first author served as subjects. The vibratory stimuli consisted of 2-second tone pulses of 25 and 62.5 kHz delivered to the body using a stacked quartz crystal (Wilcoxon Research F9). The maximal power was maintained within the upper limits as defined by the Occupational Safety and Health Administration [15]. A test of the role of BC as a principle-if not exclusive-mechanism of ultrasonic hearing was replicated as suggested [12].
We measured interaural attenuation in a single cadaver in both a fresh and an embalmed state. With a transducer placed on the ankle or lower part of the tibia, we could detect demodulation of the 1,000-Hz tone or speech by the left microphone. Using a mastoid reference, we found that generally the energy applied to the transducer must be increased as the distance from that site increases. Consistent with our previous reports [1-4], there is only about a 10 to 15 dB attenuation across the skull, depending on frequency, resonance, and antiresonance; this remains the case up to 80,000 Hz. Electrical BC as exemplified by the use of the Tonndorf Audiometer (model 500, Audimax, Wayne, NJ) is employed regularly in assessing high-audiofrequency hearing in our patients [20-22]. As a consequence of little separation of ears by BC, the masking dilemma is present even at higher frequencies (> 10 kHz), including electrical BC (Tonndorf) audiometry [23] and into the ultrasonic range (> 20 kHz). There is little interaural attenuation for BC hearing extending to the upper reaches of audible ultrasonic detection (~ 80 kHz). To determine whether hearing aids can help, you should have your hearing evaluated by an audiologist to find out if a hearing loss is present. If hearing loss is not present then your audiologist can recommend other effective ways to manage your tinnitus. Janet Brown, MA, CCC-SLP, Janet Brown, MA, CCC-SLP spent twenty years in practice at the Veterans Administration Medical Center and at the National Rehabilitation Hospital in Washington, DC. Specifically, with regards to medical issues, always seek the advice of your physician or other qualified health provider with any questions you may have regarding a medical condition. BrainLineMilitary.org is supported by generous grants fromthe Bob Woodruff Foundation and the Infinite Hero Foundation. This means that you will not need to remember your user name and password in the future and you will be able to login with the account you choose to sync, with the click of a button.
This page doesn't support Internet Explorer 6, 7 and 8.Please upgrade your browser or activate Google Chrome Frame to improve your experience. Patients had their tinnitus severity recorded prior to the initiation of therapy using the tinnitus handicap inventory in order to categorize patients into slight up to catastrophic impact categories. However, due to the lack of a control group it is difficult to reach an absolute conclusion regarding to what extent the observed effects are related directly to the acoustic CR neuromodulation therapy.
This phenomenon can affect all age groups (1), but is more likely to affect individuals who are over the age of 60 (2).
Even subjects who have normal audiometric thresholds have been shown to have outer hair cell damage (3) and dead cochlea regions (4).
MEG has been used to investigate long-range cortical networks of individuals with tinnitus and demonstrated that information flow from the global network to the temporal cortex correlated positively with the strength of tinnitus distress (16).
The CR algorithm has been developed computationally and is designed to desynchronize neural networks by reducing the strength of synaptic connectivity between neurones within the cell population (6, 20, 21).
Twenty-one subjects were pre-existing hearing aid users who reported that their prescriptions improved their quality of life, 28 subjects did not have a sufficient loss to warrant the use of amplification, and 17 subjects had tried hearing aids in the past 4 years but did not report that they had benefited from their prescriptions.
VAS loudness and VAS annoyance tinnitus metrics have demonstrated a significant convergent validity with the TQ and test–retest reliability has determined the minimum identifiable clinical difference (MICD) to be 10 points for a 100 point VAS scale (22, 27). Prior to completing VAS and THQ, patients were required to cease active stimulation for a minimum of 15 min. This method was found to be very time consuming with the approximate unilateral pitch matching time being of 45 min in duration. A readjustment of the stimulation parameters could occur at these visits if the matched tinnitus frequency had changed.
Of the seven patients who recorded a THQ at 24 weeks no beneficial clinical effect was revealed with scores remaining remarkably static at both outcome appointments (mean change at 24 weeks was 5.9%).
This may be explained by tinnitus having a very low-emotional impact on subjects in this group making the THQ metric very resistant to change even if tinnitus loudness and annoyance were decreased by the therapy. This would also serve to determine what degree of improvements may have occurred as a result of a placebo effect.
However, considering that the majority of patients were shown to experience a progressive improvement in symptoms in contrast to the effect of previous structured interventions serves to make placebo induced effects improbable.
By using these preparations, we concluded that fluid conduction is essential in the propagation of sound across the head, whereas the bone pathway is far less effective in that regard. As ultrasound can propagate by fluid conduction [9-11], we will explore ultrasonic frequency mapping over the body, not just the head, and through the use of a cadaver extend our ultrasonic intra-aural study to 80,000 Hz.
In fact, the osseous nonlinearities (apatite crystals) could be the source of demodulated, amplitude-modulated ultrasound, which presumably is the mechanism involved in electric BC hearing using the Tonndorf audiometer.
Additionally, a dry skull obtained randomly from the anatomical collection at the Anatomy and Neurobiology Department of Virginia Commonwealth University, Richmond, Virginia, and the head of a very recently deceased (4 hours) middleaged male adult (~50 years of age) were used for vibratory measurements using intense levels for frequencies >50 kHz. For simplicity, the data are portrayed as decibels of attenuation using the mastoid threshold as the reference.


The mastoid-tomastoid attenuation values ranged from 5 to 21 dB over the frequency range of 25-80 kHz. However, stimulation of the ankle and tibia did result in an audible highpitched tone, much like placing the transducer directly on the head [7,9] at a somewhat reduced volume. First, mastoid detection is somewhat better than that in other head locations, but neck and sternum are very effective stimulation areas, with less specificity in location. That is, it takes ~5 dB more energy to detect ultrasound at other distant head regions, with two important exceptions: the neck and selected portions of the thorax. This site approximates the mastoid in sensitivity; intuitively this should not be the case, given the distance from the ear. There is a clear osseous route; however, numerous blood vessels in communication with the thorax could also serve as propagation channels after local amplification. When the output power remains within the Occupational Safety and Health Administration limits, 62.5 kHz is less audible. Briefly, the audiometer consists of Mylar-coated electrodes placed over the mastoids, with the head electrically coupled into a low-voltage circuit.
Masking can be delivered by either air conduction or bone conduction, but calibration for deep insertion in frequencies can be difficult. Deep-insert air conduction is recommended for BC and electrical BC for frequencies below 20 kHz. Some conditions associated with tinnitus include traumatic brain injury, noise-induced hearing loss, medications, Meniere’s disease, circulation disorders, eighth nerve tumors, and impacted ear wax. Audiologists are health care professionals who evaluate and manage hearing loss, tinnitus, and balance.
She is the current director of Health Care Services at the American Speech-Language-Hearing Association. The Content is not intended to be a substitute for medical, legal, or other professional advice, diagnosis, or treatment. Never disregard professional medical advice or delay in seeking it because of something you have read on the Web Site. Also, as the observed patient group was made up of paying clients it is unknown as to whether this could have caused any additional placebo like effects to influence the final results. This peripheral damage is thought to result in central neural plastic changes that affect the balance between excitatory and inhibitory processes leading to a potential promotion of increased afferent activity (5) and neural synchronicity (6). This provides evidence for the concept that percept salience is linked to an altered functional interaction between auditory and non-auditory brain areas. Treatments that are commonly utilized in order to improve quality of life include patient counseling (regarding etiology and prognosis), hearing aids, sound therapy, and cognitive behavioral therapy (17). In order to desynchronize a synchronized focus in the tonotopically organized auditory cortex, four acoustic tones are delivered with different frequencies centered on the characteristic frequency of the participant’s tinnitus percept (19). Pure tone audiometry revealed subjects to have sensorineural hearing losses, which ranged from mild to moderate – severe (Figure 1A). This formula reflects the non-linear tonotopic organization of the auditory cortex and utilizes the matched frequency of each participant’s tinnitus percept. The effect size was also calculated for all outcome measures using the mean and SD of the scores. VAS scores were recorded from the same individuals plus one additional patient at 24 weeks. A similar reduction of tinnitus loudness and distress has been shown in a randomized proof-of-concept trial (19), an outpatient study (TRI conference 2011, Buffalo, NY, USA, Abstract H. We think that this relatively short observation period after stimulation offset is not long enough to name these effects long-term effects, but clear sustained effects were observable.
An extended test period to 52 weeks or beyond would provide more information on the sustainability of the intervention therapeutic effect.
A spontaneous resolution of symptom is also improbable due to the sustainable nature of the tinnitus percept in the majority patients surveyed as part of this investigation. The results of the patient population that are reported in this manuscript were obtain from patients treated at a London based clinic owned by The Tinnitus Clinic Ltd. Thus, there is little ear isolation beyond 10 dB even up to 80 kHz, extending the masking dilemma in cases of unilateral hearing loss. Bennett [12] assumed that the principle operating in electric BC hearing also applies to all forms of ultrasonic hearing and proposed a simple test (which we performed) to clarify the role of bone in BC. Contact force was continually monitored, as variations in force would translate into changes in attenuation owing to coupling disparities. The vibration recording from the dry skull (weighing 501 g) was carried out using the procedure outlined by Cai et al. This was accomplished by using a commercial ultrasonic hearing aid (HiSonic, Misonx, Farmington, NY).
For normal-hearing subjects, the neck site was nearly as sensitive as the mastoid, but the head sites were 5-6 dB poorer than the mastoid. The embalming preservative did increase the attenuation values below 50 kHz but only some 5 dB, likely owing to the increased viscosity of the embalming fluid (Fig. The attenuation from mastoid to mastoid is plotted for a dry skull used in this study (dry) and for dry-skull data from Cai et al. We also detected speech from ankle stimulation, but no systematic intelligibility study was carried out.
Second, the low-level interaural attenuation of bone-conducted sound extends from the low audiometric to the high audible ultrasonic frequencies, extending caution in regard to masking. The neck is only 3-4 dB less sensitive than the mastoid, accounting for the frequent reports that ultrasound could be evoked by stimulation of this area (see Lenhardt [7,9] for review). This is true in both the conventional audiometric frequencies ( 10-20 kHz) and ultrasonic frequencies (> 20 kHz). The mastoid should not necessarily be considered the optimal site for high-frequency BC therapy.
Ultra-highfrequency ultrasonic external acoustic stimulation for tinnitus relief: A method for patient selection.
Eyes as fenestrations to the ears: A novel mechanism for high-frequency and ultrasonic hearing. Ultra-highfrequency acoustic stimulation and tinnitus control: A positron emission tomography study.
If your tinnitus is accompanied by hearing loss then there is a good chance a hearing aid will not only help you hear better but will also help relieve your tinnitus. It is interesting to note that tinnitus generation is unlikely to be the result of an abnormally enhanced or hyperactive nerve firing pattern originating from the peripheral auditory system as sectioning of the auditory nerve does not, typically, eliminate tinnitus in pre-existing cases (7).
There is also data from studies that show auditory cortical γ band activity to be strongly increased, for noise exposed subjects, within the very early stages of tinnitus onset (13). However, with the possible exception of cognitive behavioral therapy, there is a lack of sufficiently large randomized control trials to demonstrate the efficacy of other commonly used interventions (18). This reduction in neural synchrony is considered to cause a decrease in the connectivity across brain areas involved in the larger salience network (15, 22). There were a total of eight patients who recorded a 0–16 point score with respect to their pre treatment THI, which is a category that has been suggested, by the THI questionnaire authors, to potentially be below the threshold of clinical significance.
THQ data from a published study of tinnitus maskers were used to estimate MICD for the metric (31) found that a difference in mean THQ score of 194 was considered significant, and represented a medium effect size.
Acoustic CR neuromodulation employs the use of an equal number of tones that are generated above and below the subject’s specific tinnitus frequency. Wurzer) and in a real life study in 200 patients suffering from chronic tonal tinnitus (25).
Christian Hauptmann is employed by Juelich Research Center; formerly working with ANM GmbH (Cologne, Germany). In the case of contralateral recordings, a second accelerometer was used (508BP, Quest Electronics, Okanawac, WI). This served as the reference for all other vibrator positions on the body, recorded in decibels, regarding sensation level (SL). We set the suppressed carrier at 25 kHz, which was modulated by either a 1-kHz tone or speech. Third, electric BC differs from direct coupled ultrasonic hearing in that the former is dependent on the bones' rectifying qualities, whereas the latter may benefit from its piezoelectric qualities.
As Ranke [18] pointed out, there exist fluid windows to the ear that include all vascular channels. There are frequencies of greater or lesser interaural attenuation owing to resonances and antiresonances that, without careful measurements, cannot be identified. The non-linearities in the skin-bone demodulate the audio tones; however, in the process the electrodes vibrate at the audio frequencies. The Web Site does not recommend or endorse any specific tests, physicians, products, procedures, opinions, or other information that may be mentioned on the Web Site.
It has also been noted that cochlea pathology causes a reduction in spontaneous firing rates in mammalian auditory nerve fibers (8). Although it is still unclear if this elevation in γ band activity is influenced by noise-induced hearing loss.
A randomized proof-of-concept trial has provided evidence for acoustic CR neuromodulation to be an effective therapy for tinnitus by demonstrating a significant improvement in visual analog scale (VAS) scores and tinnitus questionnaire (TQ) outcome measures scores for 75% of patients (19). All participants presented with tinnitus as their primary complaint with the length of time since tinnitus onset ranging from 3 months to 27 years (with a mean of 7 years and an SD of 8 years). These low category patients did, however, report of the tinnitus percept to be sufficiently bothersome to warrant their engagement in structured therapy and determined to proceed with the intervention at their discretion.


The stimulation tones are matched for loudness and presented at approximately 10–15 dBSPL above threshold. The reduction of tinnitus loudness and annoyance VAS scores, within this investigation, correlated with previous work relating to tinnitus measurement variables (33). However, the tinnitus suppression effects reduce after 4 weeks post cessation of treatment, which indicates that a continuous treatment period extending beyond 12 weeks is appropriate in order to achieve a maximal therapeutic effect. He works as consultant for Brook Henderson Group and has received research funding from the European Community, the Federal Ministry of Education and Research (Germany), the Deutsche Forschungsgemeinschaft, the Helmholtz Association. Importantly, it emphasizes that CBT is a collaborative form of therapy which requires active participation in order to be helpful. Stimulation of the upper limb was generally perceptible, with increased energy over the head sites for 25 kHz but not at 62.5 kHz. There is also good agreement between the physical properties of the live head and that of the fresh cadaver as measured by mastoid-to-mastoid attenuation below 50 kHz, with the cadaver exhibiting ~6 dB more attenuation across that range. Note the good agreement between results from the fresh cadaver and those from the live head. The neck is rich in such channels, thus confirming the fluid conduction nature of ultrasonic BC hearing that may be independent of BC.
The data in Table 1 reveal physical attenuation from the mastoid to various body regions of interest for 25 and 62.5 kHz in five normal-hearing subjects (mean values) and one profoundly deaf subject based on behavioral thresholds referenced to the threshold of the right mastoid. The use of a fresh cadaver preparation was essential in making repeated measures at very high intensities (measured in acceleration re 1 g and then referenced to 145 dB SPL in water, as reported previously) [8]. Thus, the stimulation to the electrodes is electrical, but the induced effect is vibratory.
These observations serve to implicate activity changes in central structures as being the causal factor for the phantom percept generation. Forty-two of the subjects had received tinnitus therapy previously via audiologists and psychologists in both independent and socialized healthcare clinics. The presentation cycle consists of four tones played in a randomized order over three stimulation cycles followed by a pause in stimulation that lasts the equivalent time period of two presentation cycles. No correlation, for treatment effect, was determined with respect to patient age, gender, and audiometric configuration. The same study also reported that TQ scores progressively improved for subjects who participated in an additional 24 weeks of therapy once the blinded trial had been completed. The Nitesh Patel declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.
We monitored sound generation, if any, by this application at the tibia with a microphone and by monitoring aurally with the subject (MLL) listening. The totally deaf subject could not detect 62.5 kHz and could detect only 25 kHz at her mastoid, neck, clavicle, and sternum and all with almost equal sensitivity. The peaks and troughs in the fresh cadaver data likely represent brain resonances and antiresonances [1,2,9].
The same cadaver was embalmed after the first measurement, and the attenuation from mastoid to mastoid changes somewhat, likely owing to the increased viscosity of the embalming fluid.
The neck may, in fact, be as sensitive as the mastoid, as there is a greater mismatch in impedance between soft tissue and bone using the brass-encased crystal transducer that we employed. These values would also argue against a pure BC route from the sternum to the ear, given the little attenuation measured behaviorally. By placing a piezoelectric film sensor, constructed of a piezoelectric polymer polyvinylidene fluoride [17], between the electrodes and skin, the full amplitude modulation signal is recorded. If untreated, tinnitus can cause concentration difficulties and sleep disturbances as well as affect personal relationships and mental health.
Cortical map reorganization has previously been suggested as being a central correlate for the emergence of tinnitus (9). It is also interesting to note that a significant number of trial participants also experienced a reduction in the characteristic frequency of their tinnitus over the course of the study (19). The specific type of therapy utilized in these centers was diverse in nature and included diverse counseling methods, hearing aid prescriptions, tinnitus retraining therapy, sound therapies, and cognitive behavioral therapy. These results support our findings that in an outpatient setting a treatment for 36 weeks is most probably favorable as compared to a 12 weeks treatment.
A water balloon was secondarily placed in the dry skull to simulate a brain, because water has about the same acoustic properties [17].
Though the ultrasonic hearing aid device is FDA-approved for hearing loss, the energy level was rapidly increased from minimum to maximum.
With this in mind, sternum sensitivity is also demonstrated for both frequencies in the normal-hearing subjects. Note that the pattern of interaural attenuation is the same for the fresh and embalmed conditions, and only the range of attenuation differs (smaller for the embalmed). Nonetheless, the data show generally only a 5 dB increase in attenuation across the ultrasonic frequency range of measurement. Piezoelectric transducers [17] have acoustic impedance similar to soft tissue and can be very effective in transmitting ultrasound. There is a fourth possibility: that thoracic ultrasonic vibration could excite a tactile response via sensory hairs in the respiratory tract owing to airborne ultrasound- induced standing waves. By placing an accelerometer on the skin near the electrodes, the demodulated audio vibration is also recordable [24].
However, MEG data demonstrating altered spectral power, in subjects experiencing tinnitus, suggest that this does not adequately explain the emergence of the percept in a satisfactory manner (4). The results obtained in the randomized proof-of-concept trial (19) were confirmed in a real life study in 200 patients suffering from chronic tonal tinnitus (25).
Treatment was provided at charge, and this could have biased findings in some unpredictable fashion.
The same procedure used for threshold detection was repeated using 25-and 62.5-kHz tones to measure attenuation across the skull.
Because of the potentially intense exposure to someone with normal hearing, only the first author served as a subject in this experiment, using due care. Cadaver mastoid-to-mastoid attenuation is about 20 dB when ignoring resonances and antiresonance.
The peaks and troughs in the data are most likely reflections of resonances and antiresonances, damped to some degree by the embalming fluid.
A line at 25 dB attenuation separates these measurements into the dry-skull group and those with brains intact or simulated (water-filled). The impedance difference between the transducers is about 3 dB, the same order of threshold difference found in this study.
We did note that vibrator position is not as important in that a larger area seems equally sensitive.
This concept was applied to airborne ultrasound for the nasal and oral cavities and is consistent with standard acoustic theory [19].
The THQ was used as an outcome measure and although this questionnaire was developed and validated with great rigor and is used widely [see Ref. As an intermediary between the water-filled skull and a living head, we tested the head of a very recently deceased male (fresh cadaver) of approximately 50 years of age with no signs of head or neck trauma, who apparently died of natural causes. However, responses were obtained using more powerful stimulation of an ultrasonic hearing aid (discussed later). The overall conclusion is that there is little (~15 dB) attenuation across the mastoids in the ultrasonic region when skull contents (brain and fluid) are intact. Taken as a whole, there is approximately 15 dB attenuation at 25 kHz between mastoids when a brain is present, suggesting that fluid (brain and vascular contents) play a notable role in propagation of ultrasound from ear to ear. Vibrator position was not as critical on the neck as compared to the mastoid for detecting ultrasound; nonetheless, an idiosyncratic area of best sensitivity was identifiable in all subjects.
The fact that the neck and mastoid areas were equally sensitive would also argue against a possible respiratory tract mechanism, but it cannot be excluded.
Though piezoelectric properties of bone, acting as a rectifier, can demodulate an electric ultrasonic signal (as in the Tonndorf system), no such demodulation occurs for direct-contact ultrasonic bone vibration (for a proposed mechanism see [9]). We fitted the transducer and accelerometer in the same fashion as in the living subjects; however, the intensity of the ultrasonic stimulation, especially for frequencies >50 kHz, was increased (+30 dB) until we obtained reliable measurements.
Thus, only low levels of vibration produced strictly ipsilateral stimulation for the wet skull with intact contents. From a clinical perspective, a transducer that was completely out of sight and could deliver ultrasonic, modulated tinnitus therapy of modulated speech would garner much cosmetic appeal. It is important that, in the case of electrical BC, if electrodes are placed around dry bones, no audio demodulation occurs and no audio sound is heard [12]; in contrast, direct ultrasound vibration readily propagates in dry bones, as evidenced in this study. The data on a dry or wet (brain and vascular contents intact) skull is neatly separated from the wet skull, as seen in Figure 2, by the values above and below 25 dB of attenuation. We calculated the interaural attenuation after physical measurement of head or skull diameter (range, 13.4-14 cm).
The condition of only dry bone does impede sound transmission from side to side but not so in the presence of fluid (or brain), verifying fluid conduction.



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