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Author: admin, 08.11.2013. Category: Treatment For Tinnitus

This paper is a preliminary report from the Tinnitus Center, HSCB-SUNY, of hyperacusis in a patient population who request consultation for tinnitus of the severe disabling type.
There is a positive correlation between tinnitus and hyperacusis as well as a positive correlation between hyperacusis and the loudness discomfort level test (LDL). The present method of assessment for hyperacusis includes pure tone audiometry, LDL's, Feldmann Masking Curves and the Metz test for recruitment. A classification system exists for hearing loss and a similar system is suggested for hyperacusis.
A review of the literature reflects the difficulty encountered clinically in attempting to diagnose and treat the subjective complaint of hyperacusis.
Jastreboff and Hazell define hyperacusis as a manifestation of increased central gain evaluated by direct frequency measurements of loudness discomfort levels (LDLs). Loudness discomfort levels are most frequently used in the assessment of hyperacusis.12 What frequencies to use for the assessment and how many repetitions per judgement are not universally agreed upon.
Kotsanis and Harjes consider uncomfortable loudness level thresholds (UCLs) under 90 dB HL at 500 - 8000 Hz and 70 dB at 250 Hz as abnormal.
Forty-two consecutive cases, 29 males and 13 females, ranging in age between 20-75 years with a mean of 51.9 years with the primary complaint of subjective idiopathic tinnitus (SIT) of the severe disabling type were included in this study. Pure tone audiograms were obtained at the discrete frequencies of 250, 500, 1000, 2000, 3000, 4000, 6000, and 8000 Hz for the right and left ears for each individual. The pitch of the tinnitus was matched to frequency using a two alternative forced choice procedure.18 The ear with the tinnitus is used as the reference for the match. Loudness discomfort levels (LDLs) were obtained for each ear individually at the discrete frequencies tested on the audiogram; 250, 500, 1000, 2000, 3000, 4000, 6000, and 8000 Hz and at the frequency of the tinnitus pitch match. The difference between the pure tone threshold and the loudness discomfort level is considered the dynamic range (DR). For this study LDLs of 95 dB or greater at all frequencies are considered negative for hyperacusis.
Dynamic range was considered satisfactory or negative for hyperacusis if it was 60 dB or greater at all frequencies. Based on the results of this preliminary study, a methodology for hyperacusis assessment is proposed.
A classification system exists for hearing loss 20 and a similar one for hyperacusis is suggested in Table 1.
Thirty (71%) of the 42 patients gave a self-report of hyperacusis while 12 (29%) denied any such complaint. The incidence of hyperacusis in individuals with tinnitus has been reported as high as 40-45%.1,2 The type and severity of the tinnitus from which this figure was derived have not been specified. The LDL test indicates a higher incidence of hyperacusis than the self-report by the patient.
In addition, chi square tests indicated significant associations between self report of hyperacusis and an LDL of 90dB for at least one frequency in both ears. For the criterion of 90dB at two or more frequencies, only the right ear showed a significant association with hyperacusis self report.
Jastreboff considers hyperacusis as a pre-tinnitus state.7 However, there are many tinnitus patients who do not report hyperacusis and who exhibit a satisfactory dynamic range on test. If hyperacusis is a central phenomena, then the Feldmann masking curves may reflect this by classification as Type IV or Type V. If hyperacusis is a pre-tinnitus state, then all hyperacusic patients should develop tinnitus and all tinnitus patients should have hyperacusis.
The question which still remains unanswered is what is the significance of positive LDL and positive DR and the subjective difference.
As a loss of hearing does not reflect the severity of tinnitus, so the severity of hyperacusis does not reflect itself in loss of hearing, recruitment, or Feldmann Masking Curve type. Appreciation is extended to the Martha Entenmann Tinnitus Research Foundation and the Lionel Hampton Ear Research Foundation for its support of this effort. The aim of our study was to outline the prevalence of hyperlipidemia in patients who had high-frequency hearing loss and tinnitus due to noise exposure. Cochlear hair cells and neural and central auditory pathways are involved in the generation of subjective tinnitus [1].
Decrease in internal diameter of the vascular bed resulting from hyperlipidemia compromises the oxygen transportation capability of the blood to the cochlea, and chronic hypoxia is likely to occur by the reduction in oxygen supply of the inner ear, which in turn would lead to insufficient adjustment of the cochlear metabolism. This may result in the overproduction and accumulation of free radicals, which disturb the microcirculation of the cochlea and play an important role in ischemiainduced cochlear injury [7]. The reasons for the susceptibility to noise-induced hearing loss of patients who have been exposed to a noisy environment have been the subject of various studies. Previous data indicate that the cochlea and the central auditory system age faster and earlier in patients with hyperlipidemia and that the risk of noise-induced hearing loss is much higher [5,11]. The aim of this study was to outline the prevalence of hyperlipidemia in patients who had high-frequency hearing loss and tinnitus due to chronic noise exposure and to evaluate the risk of developing sensory hearing loss in those patients as compared to risk in control subjects. We conducted this prospective study in 120 consecutive patients with complaints of chronic subjective tinnitus of varying degrees of severity and hearing loss due to noise exposure. The patients were examined otoscopically and were reviewed by an audiometric test battery including puretone audiometer (AC-30, IAC, Copenhagen, Denmark), stapes reflex, and tympanometry (Amplaid 775, Milan, Italy). Antilipid treatment with statin derivatives was planned once-daily oral dosing for up to 1-2 years (minimum, 12.4 months). We then compared tinnitus scores and hearing levels in patients with no response to antihyperlipidemic therapy and in patients who had a normal blood cholesterol level after the treatment. The duration of tinnitus in patients with noise exposure varied from 2 months to 12 years (mean, 5.5 years). Of 22 patients in the unresponsive group, 6 had high cholesterol and triglyceride, 9 had high triglyceride, and 7 had high cholesterol only before the antilipidemic therapy. Of 20 patients in the responsive group, 7 had high cholesterol or triglyceride, 10 had high triglyceride, and 3 had high cholesterol only before the antilipidemic therapy. The difference between the pitch-match frequencies before and after therapy was not significant.
Epidemiological investigations emphasizing the relationship between hearing loss and the risk factors for coronary artery disease date back to the 1960s [18]. Spencer [19] found that 42.3% of 300 patients with different symptoms of inner-ear pathology had clearly defined hyperlipoproteinemia.
The effect of hyperlipidemia on auditory perception has been studied clinically and experimentally. The exact pathological mechanism for the hyperlipidemia-induced hearing loss remains obscure. In his study of 64 rats, Pillsbury [37] exposed half to loud noise and fed half of each subgroup a fat diet and found elevated auditory brainstem response thresholds in the hyperlipidemic animals. Studies investigating the restorative possibility of a low-cholesterol diet and antihyperlipidemic therapy on hearing loss and tinnitus are very few.
LDL apheresis has been reported to be much more effective as compared with standard prednisolone, dextran, and pentoxifylline therapy in patients with sudden hearing loss [9]. In our study, changes in tinnitus scores before and after therapy in the responsive group were significant as compared with those in the unresponsive group. Tinnitus and hearing loss are frequently encountered after an acute acoustic and blast trauma or chronic noise exposure.
The tympanic membrane displacement test (TMDT) is an attempt to record intracranial pressure (ICP) reflective of an intracranial pulse pressure amplitude wave (IPPA) transmitted to the inner ear and tympanic membrane with a probe placed into the external ear canal. METHOD: The Southampton Tympanic Membrane Displacement Analyzer was used to record spontaneous intra-aural pressure waves in 12 SIT patients. Keywords: autoregulation cerebral compliance, idiopathic intracranial hypertension, intra-aural pressure waves, intracranial pressure, intracranial pulse pressure amplitude, tympanic membrane displacement test. The complaint of subjective ear blockage (EB) is frequently associated with subjective idiopathic tinnitus.
In our evolving clinical tinnitus experience since 1979, at SUNY-Downstate Medical Center and the Martha Entenmann Tinnitus Research Center, in excess of 15,000 patients have been seen in neurotologic-audiologic consultation in whom different clinical types of tinnitus - predominantly a central-type severe disabling subjective idiopathic tinnitus (SIT) - have been identified with a medical audiologic tinnitus patient protocol (MATPP)4.
In general, a significant associated complaint in SIT patients has been of ear blockage of fluctuant intensity located in the ear(s) with the SIT complaint. Our interest in the tympanic membrane displacement test (TMDT) and ICP and idiopathic intracranial hypertension (IIH) has paralleled, since 1979, an increasingly frequent clinical experience with SIT patients in whom the following conditions are present: (1) persistent complaint of ear blockage after control of eustachian tube obstruction or secondary EH (SEH) and (2) a reduced vestibular response with caloric, sinusoidal, harmonic rotary-chair testing or the Fukuda stepping test in the absence of subjective vertigo in the SIT ear.
Our introduction to the TMD occurred in 2005, at the Fifth International Symposium: Meniere's Disease and Inner Ear Homeostasis Disorders, House Ear Institute, Los Angeles, CA. We have reported since 2006 our clinical experience with SIT in terms of the fluid dynamics between ear and brain, brain and inner ear fluid homeostasis, cochlear- or vestibular-type tinnitus, and SEH7.
It has been hypothesized that persistence of the complaint of ear blockage in the SIT ear with maintenance and control of function in the external or middle and inner ear reflects an alteration in fluid dynamics between the ear and brain, a biologic marker being alteration or elevation of ICP, reflecting IIH, highlighted by the complaint of ear blockage. The experience with the TMDT for the diagnosis of IIH associated with tinnitus, also referred to as benign intracranial hypertension and pseudotumor cerebri, has been reported. Intracranial hypertension was reported in 1981 to become manifest with neurotologic symptoms: The most common presenting symptom was pulsatile tinnitus, followed by hearing loss, dizziness or vertigo, and aural fullness13. Historically, the clinical application of the TMD for measurement of ICP is supported by animal, human, basic science, and clinical investigations. Clinically, the publications cited in the next section support the hypothesis that an abnormal and fluctuating ICP is a factor related in the clinical course of a previously described subgroup of SIT patients. Of the two fluids within the cochlea, the endolymph and the perilymph, it is the perilymph that interfaces with the footplate, and it is the pressure of this fluid that is assessed by the Cerebral and Cochlear Fluid Pressure Analyser and the TMDT technique. In the guinea pig, Bohmer20 reported that "the endolymph indirectly communicates with the intracranial fluids via the endolymphatic sac and maintains homeostasis with the perilymphatic pressure across the Reissner's and other intralabyrinthine membranes.
Perivascular or perineural routes between the intracranial and labyrinthine spaces may also provide a means of communication, but these may be significant only in cases of extremely elevated ICP or certain malformations. Clinical analysis of a trial of ICP measurement from the external auditory canal concluded that intra-aural pressure waves clearly reflect intracranial cardiovascular and respiratory pulsatility changes in cats23. In a guinea pig model, infrasound (0.1-10 Hz) within the perilymph induced longitudinal sinusoidal and gross displacement of the endolymph. Varying patency of the cochlear aqueduct and connectivity to the perilymphatic space of the cochlear labyrinth of the inner ear in human temporal bones was reported by Wlodyka27. Testing in normal subjects shows that stable TMDT results are obtained during the day and after exercise28.
Noninvasive intracranial compliance monitoring by measurement of intra-aural pressure waves, performed on neurosurgical patients, has identified certain characteristics of the intra-aural pressure pulse that may allow for noninvasive measurement of ICP and compliance34,35. The Southampton Tympanic Membrane Displacement Analyzer, commercially available as the MMS-11 Cerebral and Cochlear Fluid Pressure (CCFP) Analyser, is able to measure extremely small displacements of the tympanic membrane pressure pulses at heartbeat and respiration frequencies that are transmitted from the intracranial pulse pressure to the tympanic membrane (Figure 1).
The tympanic membrane in humans is constantly in motion, principally of cerebral cardiovascular and respiratory origin.
The ICP wave measurements can be obtained in two modes of operation: In the first, a TMD is evoked using the acoustic stapedial reflex. The mechanism of the TMD is hypothesized to be a reflection of increased ICP and perilymphatic pressure on the acoustic stapedial reflex and its action on the stapes footplate, ossicular chain, and tympanic membrane.
The TMDT is postulated to provide a "signature" of the underlying neurological disorder in terms of CSF hydrodynamics36. All patients selected according to the preceding protocol (n = 12) between July 2007 and March 2012 underwent a neurotologic examination of the head and neck, including microscopical examination of the ear canals and tympanic membrane for evidence of pulsation and auscultation of the ear canals, head, and neck. The 12 selected patients were further classified into two groups, the first group of 6 patients undergoing the TMDT on a single date and the second group of 6 undergoing TMD on sequential test dates.
Neurotologic and otologic physical examination identified integrity of the external ear canal and tympanic membrane with no spontaneous signs of labyrinthine irritation. TMD recordings were obtained in the two groups of patients to observe the temporal course of the ICP in SIT.
ICP is normally 7-15 mm Hg for a supine adult and becomes negative (averaging-10 mm Hg) in the vertical position. The subject of this case report is a 71-year-old white man with SIT, the quality of which was a high-pitched "ee" of constant duration located in the left ear.
Associated complaints included hypertension, left-ear blockage that fluctuated with tinnitus intensity, nasal allergy, occasional unsteadiness, occasional frontal headache, head pressure, memory interference, and occasional delay in speech expression.
The patient demonstrated a fluctuating ICP with sequential TMD testing between July 2007 and March 2012, prior to and after treatment with Diamox (Figures 4, 5). Significantly, objective improvement was noted in the TMD recording from abnormal IPPA ICP to normal, as noted in the elevated amplitude between July and September 2007 and in the normal IPPA amplitude and modulation by respiration between October 2007 and August 2008. Tinnitus treatment results targeting ICP as a manifestation of IIH with Diamox were positive in the short term (n = 2). In a preselected group of SIT patients (n = 12) resistant to attempts for tinnitus relief with instrumentation or medication, an abnormal ICP has been identified (n = 10).
The fluctuations in the categories of the TMD recordings in the same patient at single or sequential recording dates are clinically considered to be a reflection of the dynamic state of the ICP and compliance in the presence of SIT and the influence of the environment and presence or absence of CNS disease. The results of a normal or abnormal ICP and reduced or normal compliance in this cohort of SIT patients supports clinical consideration of the presence of an IIH and indication for treatment.
Spontaneous TMD recordings of intra-aural pressure waves were obtained in this cohort of SIT patients. The clinical significance of abnormal ICP and IIH as factors influencing the clinical course of SIT is suggested by the TMDT results we have obtained.
The essential requirements of the TMDT are integrity and patency of the external ear canal, an intact tympanic membrane, and an intact ossicular chain. Clinical and basic science efforts at identifying the clinical significance of brain pulsatility have been ongoing for in excess of 60 years39.
This report of using the TMD lends credence to the application of brain pulsatility to support the diagnosis of IIH in a particular cohort of SIT patients.
The term congestive inner ear was first introduced in patients with increased ICP secondary to tumors40.
Otologic and neurotologic experiences with the TMDT were reported for a series of patients whose diagnoses included pulsating tinnitus, IIH, Meniere's disease, perilymphatic fistula, perilymphatic hypertension, arterial stenosis, and Arnold-Chiari syndrome. The cohort of SIT patients in this TMD study all had nonpulsatile, predominantly central-type, severe disabling subjective idiopathic tinnitus (SIT) resistant to attempts for tinnitus relief with instrumentation or medication, with associated neurotologic complaints highlighted by ear blockage and sensorineural hearing loss and CNS complaints highlighted by headache, head pressure, and cognitive interference in memory or speech expression or both. The associated complaint of ear blockage or aural fullness is clinically hypothesized to reflect fluctuation in the ICP of a persistent IIH. Cerebral blood flow autoregulation (CBA) is the process by which cerebral blood flow is maintained at a constant level in normal brain.
The pressure - volume relationship among ICP, volume of CSF, blood, and brain tissue and cerebral perfusion pressure is known as the Monro-Kellie doctrine or the Monro-Kellie hypothesis (1783). The issue of compliance has also been reported in experimental findings related to inner ear fluid pressure and to the effects of pressure changes on cochlear function in the guinea pig.
The concept of compliance and its extrapolation from the ratio of the volume-pressure curve, obtainable with the TMD as a high amplitude of the cardiovascular pulse pressure, is significant for its clinical translation for evaluating the status of homeostatic function in both ear and brain. EH is an enlargement of the endolymphatic space with a bulge of Reissner's membrane into the scala vestibuli of the cochlear labyrinth.
The finding with TMDT of an elevated IPPA in the SIT ear, which supports the diagnosis of IIH in the present cohort of nonpulsatile SIT patients, is the basis of the following questions and hypothesis: Is the SEH that has been clinically identified in some SIT patients since 1981 with the MATPP and that is supported by vestibular testing in some SIT patients with and without vertigo a clinical manifestation of a IIH?
We suggest that the volume-pressure relationships in a confined space be applied clinically to the ear as they have been for the brain. It is hypothesized for some, but not all, EH and SEH patients that the IPPA, reflecting alterations in volume - pressure relationships in brain, is transmitted to the ear predominantly by one or both of two routes - via the cochlear aqueduct or via pressure on the endolymphatic sac. The teaching from brain of compartmentalization of the effects of pressure and flow, which, although related physical phenomena, differ in the location for their measurement, are suggested to apply to the ear: That is, pressure pulses propagate at the speed of sound and the location for their measurement are not specific, but flow pulsations are site-specific39.
This is the first known report of the clinical application of inserting an external probe device into the external ear canal (Tympanic Membrane Pressure Analyser [Marchbanks] in a cohort of nonpulsatile, predominantly central-type severe disabling tinnitus patients (SIT) suspected to have an elevated ICP reflective of an associated IIH.
In two groups of these preselected SIT patients, IPPA was demonstrated to be elevated and abnormal and to fluctuate in the clinical course of the SIT (overall abnormality in 10 of the12 patients). The patient preselection protocol used for identifying an elevated ICP and IIH in a particular cohort of SIT patients and the positive results reported for its identification with the TMDT in 10 of our 12 patients supports the continued use and modification of the TMDT reflective of an evolving clinical experience. The IPPA is reflective of the ICP and was identified with spontaneous single and serial recordings in 10 of 12 SIT patients with postural testing (supine, 30 degrees, and 45 degrees).
The IPPA abnormality, reflective of an increased ICP, is clinically considered to be a factor - not an etiology - for SIT, and is considered to influence the clinical course of SIT in a particular cohort of patients with a predominantly central-type tinnitus.
Extracranial identification of an IPPA and ICP with the TMDT in the clinical course of SIT has a dual function: identifying ICP as a factor influencing the tinnitus diagnosis, and objectively monitoring the efficacy of ICP-targeted therapy. The TMDT results of the identification and association of IIH, IPPA, and ICP in this observational report lends support to the clinical impression of an underlying ICP reflective of IIH and a basis for treatment in SIT patients such as those in our particular cohort. The principles of brain pulsatility are clinically considered to be applicable to the physiology of the inner ear and otologic and neurotologic complaints of hearing loss, tinnitus, vertigo, and ear blockage. Brain Electrical Activity Mapping of Vestibular Evoked Potentials (BEAM-VestEP) is a new technology for investigation of the spatial and temporal properties of a rotationally-induced brain electrical events. A special data bank containing more than 400 BEAM-VestEP investigations on more than 300 persons, either symptom free volunteers or neurotological patients suffering from vertigo, tinnitus, sudden hearing loss, acoustic tumors, balance disorders, has been created for this study.
Functional neuroimaging in neurootology with Brain Electrical Activity Mapping (BEAM) has been introduced to record cortical Vestibular Evoked Potentials (VestEP) in response to a rotatory stimulus.
Brain Electrical Activity Mapping (BEAM) is a special electrophysiological imaging procedure providing a graphic and quantitative recording of responses to a stimulus related electroencephalogram (EEG) event. Since 1990 the Vestibular Evoked Potentials have been recorded in response to short lasting angular accelerations (Vestibulo-Sensory Reflex - VSR) in the Department of Neurootology, University of Würzburg.
VestEP recordings with BEAM provides a graphic and quantitative recording of responses of the patient to a rotatory stimulus.
This paper is a review of our clinical experience with Brain Electrical Activity Mapping of Vestibular Evoked Potentials. Furthermore, the routine Evoked Potential (EP) study is based mainly on two dimensions; amplitude and latency.
That is why in this study we have used a new approach of Vestibular Evoked Potentials by means of Brain Electrical Activity Mapping (VestEP-BEAM approach) in order to investigate the spatial and temporal properties of the rotationally evoked brain electrical events. Properties of the vestibular stimulation: The vestibular stimuli applied in this study were repetitive short-lasting rotatory movements (repetitive angular accelerations, clockwise and counterclockwise in consecutive serial trials) of the whole subject's body around a vertical axis. Altogether 25 stepwise rotations are averaged for each one of the CW and CCW-directed rotations. In addition, individual hearing protectors (Bilsom Propp-o-Plast, Sweden) are applied to both ears of the subject to avoid possible acoustic contribution to the rotationally evoked potentials. The initial reference data were obtained on 58 subjects, free from neurological and neurootological diseases and subjective complaints.
The denomination of the VestEP-components have been performed with respect to the negative peaks (the only exception is the IVth component, which is the most dominant and stable positive peak).
The scalp location of the electrodes is a factor also influencing the VestEP-component latencies. The statistical analysis by means of the t-criterion test revealed significant latency differences of the various VestEP-components in dependance of the electrode location within the antero-posterior plane (Longitudinal Line Analysis).
The presence of some degree of interhemispheric asymmetry in VestEP component latencies (Transversal Line Asymmetry) is also to be mentioned.
Furthermore, the VestEP-latencies produced by rotation directed to the left (ROTL-stimulus) also look to be slightly shorter in comparison to those obtained by ROTR-stimulus, at least for some of the electrode derivations (Labyrintb-related Asymmetry). Amplitude Mapping of the prominent VestEP peaks reveals high specific BEAM images demonstrating the space distribution of the principle VestEP components over the scalp. Furthermore, the amplitude maps of the VestEPs can be presented in consecutive time steps of 5 msec ("Animation", "cartooning effect"). In our field experiments we also tried to find an objective measure for the vestibulo-cortical acceleration threshold. For finding an optimal stimulation profile with respect to the stimulus impact applied we have compared various BEAM responses at different accelerations.
There exists a moderately expressed inter-individual variability of the VestEP acceleration thresholds between the healthy persons. General information from all four display-modes of the BEAM of the evoked potentials (EP) are considered in establishing a neurootological diagnosis. Accordingly, we have extended the method with a multichannel display of the brain isoelectric contours during a specific vestibular stimulation such as rotation.
Additionally, we have registered the threshold sensitivity of the vestibular endorgan and pathways to the acceleration stimulus.
This combined approach increases significantly the clinical information and diagnostic power of the VestEPBEAM method. Based on the latency values of the principle VestEP components in our study we can conclude that the particular response registered by our experimental paradigm is most likely generated at cortical levels; both in the primarily vestibular and in the non-specific associative areas.
Quite interesting and promising are the data obtained from amplitude mapping of the VestEP components (amplitude dimension analysis). We expect that in the near future the VestEP-study will even more prove to be an useful tool for both research and diagnosis in the field of neurootology.
Using electronystagmography, we tested 100 patients (ages 65-80 years) manifesting the clinical signs of presbyvertigo, for the purpose of demonstrating their visuoocular reflexes. Taking this finding into consideration, we undertook to evaluate vestibular function on the basis of selected tests in young normal subjects and in elderly patients, whom we defined as aged 65 years or older.
The investigations were performed in 100 patients (48 male, 52 female) aged 65 to 80 years (group 1) and in 40 normal volupteers (19 male, 21 female) aged 20 to 25 years (group 2).
Each person (in both groups) underwent subjective and objective examinations including electronystagmographic analysis, which estimated spontaneous, positional, gaze, optokinetic, and cervical nystagmus, according to the test from J.B. We found no significant difference between the two groups in the frequency of positional and gaze nystagmus, which confirmed the findings in a previous study by Brunner et al. However, the pathology demonstrated on the eye-tracking tests in our first group was similar to that demonstrated previously by Kornhuber [6] and Bodo [4]. All our data obtained in the group of elderly subjects revealed that presbyvertigo was a consequence not only of disabilities of vestibular and visual organs but also of dysfunction of the frontal and occipital brain lobes and cerebellum. The disturbances of visual-vestibular integration in the elderly are believed to playa leading role in the presence of presbyvertigo. Thirty-three years ago, craniocorpography (CCG) was designed as a nonelectronic, simple office recording procedure for head and body movements in equilibriometry. Initially, the regular CCG test procedure combined a stepping test [7, 8] with a standing test (Romberg) [9]. For US-COMP-CCG testing, we use the evaluation of run-time differences of ultrasound impulses between a sender and several receivers at fixed positions within the laboratory. For recording and measuring head and shoulder positions in the typical vestibular spinal tests, such as the standing test [6, 9, 15] and the stepping test [6-8, 15], as well as for NEFERT [15], four ultrasound markers are applied.
During the recording procedure, as depicted in Figure 2, each of the markers is producing 20 very short sound impulses per second, which impulses are triggered by the same computer that transfers them to the markers on the subject (see arrows Lc to Lm).
The technical precision of this system allows one to measure the locations and the flow of the locations of the markers at a 0.1-mm discrimination level.
Storing in a data bank the serial marker positions during, for instance, a i-minute test duration allows the drawing of 2-,3-, or n-dimensional images, such as real or virtual trajectories, of each of the recorded marker movements on the head or the shoulders, either separately or together, or images that depict the changing interrelations of these parameters. The performance of NEFERT requires little additional preparation as compared with the application of USCOMP-CCG (see Fig.
Before the test is begun, the voluntary movement procedure is explained by the instructor or the investigator.
In phase 1, the test subject is asked to stand upright with eyes open and head in the normal position (see Fig. In phase 2, on the instructor's command, the subject should bend forward maximally (see Fig.
In phase 3, again on the instructor's command, the subject should extend backward maximally (see Fig.
The investigator controls the time intervals for the three sets of instructions (phases 1-3) by a time bar presented on the computer screen (see Fig. Quantitative evaluations allow judgments about the dimensions of movements at the marker sites on the head and on the shoulders during NEFERT. The disparities between the linear measures-for instance, between forehead and occiput-result from the angular components within the real movements, which are reflected against cartesian planes by our evaluation programs. To summarize the planar dimensions provided in Table 2 in a metric spatial extension of the frame boxes encapsulating the three-dimensional locus curves of the four markers, we use volume calculations in liters, as shown in Table 3. For making determinations about complete motor activity at the four marker positions in comparison to the graphs of Figure 3, we measure the entire movement cycle for each marker in the three cartesian planes (see Fig. The dynamic aspect of the data presented in Table 4 can also be exhibited in velocity tables depicting I minute of NEFERT performance (Table 5).
Recently, new applications for CCG have been devised, among them the assessment of neck-related tinnitus [16] and whiplash injuries.
Neuroradiological examination revealed a lesion within the alar ligaments of the head plinth joint COIC II C2. By means of audiometric testing, we were able to confirm a severe right-sided hearing deficit and a minor left-sided deficit. In this neurootological case, we also investigated by means of US-COMP-CCG and NEFERT to confirm the complaints about a posttraumatic head and neck movement disorder.
The locus curves shown in Figure 4A-C and in Figure 5A-C have a lateral (x), a longitudinal (y), and a vertical (z) dimension in 0.01 centimeters, which are measured within the array of data points. To summarize the planar dimensions of Table 7 in a metric spatial extension of the frame boxes encapsulating the three-dimensional locus curves of the four markers in Table 8, we used the volume calculations (expressed in liters as a comprehensive measure for space) depicted earlier in Table 3.
For making determinations about complete motor activity at the four marker positions in Table 8 as compared with the graphs of Figure 5 (a severe reduction being evident in a comparison with Table 3 and Figure 4), we measured the entire movement cycle for each marker in the three cartesian planes (see Fig. The dynamic aspect of the data presented in Table 9 can also be exhibited in velocity tables during 1 minute of NEFERT performance (Table 10). This 50-year-old female patient with late whiplash injury syndrome exhibits a significant reduction of head, neck, and shoulder mobility in the I-minute NEFERT, as compared with a normal adult. This article serves to introduce the newly designed US-COMP-CCO and NEFERT together with our multidimensional evaluation software HUSP A TRAC. Vibrations between 20 and 20,000 cycles per second are interpreted as sound by a normal healthy person. It is important to realize that the term 'dB' can have different meanings and is not a fixed value like the volt or the meter etc. Unfortunately you cannot use our pictures, as we do not have the copyright, but only have the right to use them on our website.
To play the media you will need to either update your browser to a recent version or update your Flash plugin. We think, like Shulman and others,12,13 that the cochleovestibular system should be considered as a whole and studied as such. The aim of this study is to evaluate the changes in the neurootological evaluation of the patients suffering from tinnitus. We investigated 44 patients, 19 men and 25 women, with a mean age of 48-years (standard deviation being 12).
2) When specifically asked 18% of our sample mentioned unsteadiness or other equilibrium disturbance. Pure Tone Audiometry - The values for the mean and standard deviation of the hearing loss in dB are shown in Table 2. We found that 58% of the patients in our sample had a normal auditory level, considered a hearing level, which is equal or better than 20 dB HL for all frequencies. Caloric Tests - For statistical purposes the caloric response is quantified by using the central frequency of the nystagmus - defined as the number of nystagmus beats during the period of 30 seconds of maximal response.
Considering the two subgroups A and B representing the existence or absence of vestibular symptoms, the results are shown in Table 9. Rotatory tests - The values for the mean and standard deviation of the number of nystagmus beats in the rotatory test are shown in Table 10.
Even though a small percentage of patients complain about disequilibrium (less than 20% in our study), many of them have abnormal vestibular responses (more or less 60%). In conclusion, we would like to strongly recommend that any tinnitus patient, whether or not he or she has any vestibular symptoms, to be completely evaluated, in terms of auditory and vestibular functions. Forty-two consecutive patients seen from January to August 1995 were reviewed for this preliminary report. The incidence of hyperacusis in individuals with tinnitus has been reported as high as 40-45%.1,2 Clinical experience based on 4000 patients seen for the primary complaint of subjective idiopathic tinnitus (SIT) of the severe disabling type indicates that not every patient with tinnitus has hyperacusis and not every patient with hyperacusis has tinnitus.
This paper is a preliminary report from the Tinnitus Center, HSCB-SUNY, ofhyperacusis in a patient population who request consultation for tinnitus of the severe disabling type. The American Tinnitus Association defines hyperacusis as an unusual condition in which an individual's ears are unable to tolerate ordinary environmental sounds. There is significant variability in the interpretation of test data recommended for its identification.
The difference between the pure tone threshold and the LDL at the frequency being tested is the dynamic range (DR). When thresholds are equal to or above 90 dB HL at 500 - 8000 Hz and 70 dB at 250 Hz they are considered as normal.
To the limits of neurotologic physical examination no positive findings were reported for any of the subjects. In the questionnaire, the patient was asked whether they find loud sounds to be unpleasant both prior to or following the onset of tinnitus. Tympanometry and acoustic reflex thresholds were obtained for those individuals who could tolerate the procedures.
The patient was instructed to indicate when the sound delivered through the earphone from the audiometer became uncomfortable to the ear - not just loud, but uncomfortable. Hyperacusis should be considered positive if the LDL is 90 dB or less at two or more frequencies or if the dynamic range is 55 dB or less at any frequency. Hyperacusis should be considered negative when LDLs are 95 dB or greater at all frequencies and if the dynamic range is 60 dB or greater at all frequencies.
If we use the criteria of 90 dB or less at any frequency the incidence is 86% for the right ear and 83% for the left ear. Additional numbers of patients are being evaluated to explore this finding and to examine its significance. Will these patients eventually develop an increasing sensitivity to sound i.e., hyperacusis?
This is important with respect to diagnostics and may explain why treatment results are positive with some hyperacusic patients and not with others. There is a positive correlation between tinnitus and hyperacusis as well as a positive correlation between hyperacusis and the loudness discomfort level test. Hyperacusis occurs with normal hearing as well as with hearing loss in individuals with tinnitus of the severe disabling type.
A standardized new methodology for assessment of hyperacusis is recommended to include a battery of tests: Pure tone audiometry, LDLs, Feldmann Masking Curves, and the Metz test for recruitment. A classification system exists for hearing loss and a similar system for hyperacusis is suggested.
Kotsanis C, Harjes C: Pilot study - effects of auditory enhancement training on speech, language, hyperacusis and behavior.
Iastreboff PI: Presentation Fifth International Tinnitus Seminar, Portland, Oregon, July 1995. Feldmann H: Homolateral and contralateral masking of tinnitus by noise bands and by pure tones.
Low-Cholesterol Diet and Antilipid Therapy in Managing Tinnitus and Hearing Loss in Patients with Noise-Induced Hearing Loss and Hyperlipidemia. We investigated the role of a low-cholesterol diet and antihyperlipidemic therapy to alleviate the severity of tinnitus and possibly promote hearing gain after therapy in patients with acoustic trauma. Analysis of the epidemiological data indicates that exposure to noise is widespread and is one of the most common causes of tinnitus, which leads to various somatic and psychological disorders and interferes with the quality of life [2]. Auditory perception in such cochleas is very sensitive to reduction of the oxygenation in the inner ear [6]. Platelet aggregation and blood viscosity due to high lipid levels will intensify inner-ear damage owing to slowing of microcirculation and will contribute to the development of both progressive and sudden hearing loss [8,9]. Gratton and Wright [10] demonstrated the accumulation of lipid in the stria vascularis and outer hair cells in chinchillas after experimentally induced hypercholesterolemia, which might intensify the detrimental effect of ototoxic drugs or noise. We instituted a low-cholesterol diet and antihyperlipidemic therapy to investigate whether any benefit accrued in terms of hearing gain and tinnitus relief. The project was approved by the local medical research ethical committee, and we obtained informed consent from each patient. Audiometric tests included air- and boneconduction thresholds for pure tones of 125-8,000 Hz, tests of speech reception and speech discrimination, contralateral and ipsilateral reflex measurements, and tympanometry.
Measurement of loudness of the tinnitus was based on subjective assessment by the patients. Daily dosage ranged from 10 to 40 mg for simvastatin (Zocor) and from 10 to 80 mg for atorvastatin calcium (Lipitor). Average ages of patients in the unresponsive and the responsive groups were 39 and 42 years, respectively. Wilcoxon and Mann-Whitney U tests were used to compare the pretreatment data with the posttreatment results and to compare the results of responders and nonresponders.
None of these patients demonstrated any drop to normal ranges in cholesterol or triglyceride values after the treatment. When those patients were asked to qualify the severity of their tinnitus, seven rated their tinnitus as the same (35%), two rated it as increased (10%), seven rated it as decreased (35%), and four had no tinnitus (20%). The correlation between serum lipids and auditory dysfunction has been investigated before, and it has been reported that sensorineural hearing loss is more prominent in those with high levels of cholesterol, triglyceride, and lowLDL and in patients with low HDL concentration [18-23]. Increased blood viscosity and atherosclerosis of the cochlear vessels reduce the blood perfusion of the cochlea and promote hearing impairment [6,8,19,20,23,24]. When patients were required to qualify the severity of their tinnitus, 35% of the patients in the responsive group rated their tinnitus as decreased, and 20% of patients reported no tinnitus. Even though other factors making the patients susceptible to noise-induced hearing loss should be considered, on the basis of present results it can be concluded that the incidence of hyperlipidemia is high among patients with noise-induced hearing loss and that significant improvement in lowered intensity of tinnitus and in average hearing thresholds at higher frequencies can be achieved after lowering patients' serum lipid level [43]. The tympanic membrane displacement test and tinnitus: preliminary report on clinical observations, applications, and implications.
Twelve tinnitus patients, divided into two groups, who were resistant to attempts to achieve tinnitus control or relief were selected for the TMDT. The results reported in the literature complement and alter conventional medical teaching focusing on brain pulsation, absolute intracranial pressure, and brain disease. Patients selected for the TMDT were divided into two groups: Group 1 (n = 6) recordings were obtained on one session test date, and group 2 (n = 6) recordings were obtained sequentially on different session test dates.


Tinnitus treatment results targeting ICP as a manifestation of IIH with Diamox were positive in the short term in 2 patients and incomplete in 3. Site(s) of lesion include, but are not limited to, frequent obstruction in the external ear canal, interference in eustachian tube function and aeration of the middle ear(s), and endolymphatic hydrops (EH) of the inner ear.
Additional significant ear complaints have included vertigo, high- and ultra-high-frequency sensorineural hearing loss greater than expected for the age of the patient, and hyperacusis. The MATPP identified the ear blockage to be obstruction in the external ear canal, interference in eustachian tube function and aeration of the middle ear(s), or SEH of the inner ear. Among the presentations were "Intracranial Pressure Waves and Inner Ear Homeostasis Disorders" by Robert J.
This ongoing clinical experience has been the basis for the fluid dynamics vascular theory of brain and inner ear function in traumatic brain injury as a translational hypothesis for the diagnosis and treatment of SIT8. In addition, this article shares with the reader the evolution of a new science of brain pulsatility with application for otologic and neurotologic complaints of hearing loss, tinnitus, ear blockage, and vertigo, which complements conventional medical teaching focusing on brain pulsation, absolute ICP, and brain disease. Headache, chronic fatigue, "brain fog," tinnitus, visual obscurations, dizziness, and sometimes hearing loss are the principle symptoms of IIH. The most common etiology was benign intracranial hypertension syndrome (pseudotumor cerebri).
The question of whether papilledema in the eye, and inner-ear complaints, including ear blockage, hearing loss, and vertigo, are analogous manifestations of an elevated ICP is not new. Identification and treatment of this abnormal ICP may improve diagnostic accuracy and treatment for this particular cohort of SIT patients.
Positive endolymphatic-perilymphatic pressure gradients are secondary to and not the primary cause of hydrops formation.
Experiments in the cat have demonstrated that labyrinthine pressure mirrors that of the cerebrospinal fluid (CSF) and that no change in labyrinthine pressure can be measured if the cochlear and vestibular aqueducts are sealed21,22. Though the displacements are very small, they cause a large endocochlear potential change (> 20 mV)24.
Reissner's membrane was visualized by confocal microscope in an isolated temporal bone of a guinea pig.
Cochlear aqueduct patency is known to be reduced with increasing age, falling to 50% in subjects older than 40 years and 30% in those older than 60. In brain, a pressure volume curve has been described based on the exponential pressure - volume relationship in the cranium.
These normative data also demonstrate large intersubject differences; nevertheless, the correlation of test results within one individual is high.
The TMD displacements are intra-aural waves of different morphologic types, measured in nanoliters and in milliseconds of time, reflective of the pulsatility in brain. In most people, a fluid connection exists between the intracranial fluid and the fluids of the inner ear. Increased ICP results in increased perilymphatic pressure, outward resting position of the stapes footplate, and inward movement of the tympanic membrane on reflex contraction of the stapedial muscle. Exclusion patient criteria included all clinical types of tinnitus not classified as SIT, obstruction in the external ear canal, active middle-ear or inner-ear disease, and pregnancy. The tinnitus evaluation included pure-tone air and bone conduction, 250- to 8000-Hz speech audiometry, tympanometry, and ultra-high-frequency audiometry. All patients were males aged 30-72 years who were resistant to conventional attempts for tinnitus relief with instrumentation or medication, and all were hypothesized to have a possible increased ICP based on associated clinical complaints and findings.
Immitance testing with the Grason Stadler Portable Handheld Tympanometer (Grason Stadler Eden Prairie, MN) revealed normal type A tympanograms.
The tests were performed with the CCFP Analyser to obtain recordings of the waveforms of spontaneous displacement of the tympanic membrane accompanying testing in three positions - supine, 30-degree, and 45-degree - and reverse. Tinnitus summary, group 1: Tympanic membrane displacement (TMD) in a cohort of patients with nonpulsatile, predominantly central-type severe disabling subjective idiopathic tinnitus.
Tinnitus summary, group 2: Tympanic membrane displacement (TMD) in a cohort of patients with nonpulsatile, predominantly central-type severe disabling subjective idiopathic tinnitus. Eight fell into the B and D waveform categories (abnormal IPPA and reduced CC), whereas two fell into the A and D waveform categories (normal IPPA and reduced CC).
This objective improvement correlated with a reported subjective reduction in SIT intensity, which continued with fluctuation until March 2012.
The SIT relief is reflective of fluctuation in the ICP and the multifactorial conditions influencing brain pulsatility. This preliminary report of the clinical application of the TMDT for identifying an abnormal IPPA ICP in a particular cohort of SIT patients is considered to have accomplished the goals of the project. IPPA ICP with TMDT Spontaneous recordings of abnormal IPPA ICP were identified with the TMDT in groups 1 and 2 for a preselected SIT population suspected clinically of having an abnormal ICP. Direct and or indirect measurements of the ICP are considered to be relative, not absolute, values. Both ICP and compliance may be factors influencing the clinical course of SIT in a preselected cohort of affected patients: Identification and treatment of these factors may influence the associated complaints cited previously and also may influence the clinical course in this particular cohort of SIT patients. The test-retest reliability of the TMD was positive, as demonstrated by the repeated TMD results recorded in both group 1 and 2 patients (see Figures 3,4). The clinical significance to the patient of restoring the ICP from abnormal to normal for tinnitus relief was positive for the interval of TMDT testing reported at this time. A patent cochlear aqueduct or an alternative intracranial-labyrinthine fluid communication route is required for ICP and compliance assessment. Introduction of the TMD is but one of a number of approaches for external identification of the ICP.
Its clinical translation for tinnitus relief awaits larger clinical trials and outcome determinations that differentiate for SIT between control of the ICP and IIH and patients' report of tinnitus relief. Auditory function was studied in 25 patients with IIH and supratentorial tumors, the majority of whom had hearing loss.
The conclusion was that TMDT was a valuable addition to the armamentarium of neurotologists and useful in identifying IIH in cases of pulsating tinnitus44.
The etiology of the IIH is presumed to be cerebrovascular arterial hypertensive disease, not venous disease, based on the clinical history of this patient cohort.The pathophysiology is incomplete but we hypothesize that the disease features in this cohort reflect fluctuation in IIH, which is in turn reflective of alterations in the intracranial cardiovascular and respiratory wave pulsations. Transmission of the CSF increased intracranial cardiovascular and respiratory wave pulsations primarily via the cochlear aqueduct affects the perilymphatic compartment of the cochlear labyrinth24,25. Briefly, fluctuation in cardiac output has two effects on intracranial dynamics - temporal changes on pressure and flow.
Cerebral blood flow is determined by multiple factors including blood viscosity, degree of dilatation of blood vessels, and cerebral perfusion pressure.
This hypothesis states that the cranial compartment is incompressible, and the volume inside the cranium is a fixed volume. Clinically, it can be considered to be the elasticity or rigidity of contents, fluid and solid, in a given space. A high compliance of Reissner's membrane seems to be the cause of this endolymphatic - perilymphatic pressure equalization. The significance of CC is demonstrated in the serial recordings of the TMD in the case report (see Figure 5).
In our ongoing clinical neurotologic experience for SIT since 1972, and with a focus on SIT since 1979, the occurrence of SEH has been reported to be significant, and this diagnosis has been found to influence the clinical course of SIT and associated complaints of hearing5,47. Is what is diagnosed as SEH, a particular type of EH, a clinical reflection of increased IPPA and IIH? Specifically, the primary etiology for a particular type of EH may be cardiovascular and the clinical marker may be the increased IPPA and IIH.
This view of pressure - volume alterations in brain, manifested by an increased IPPA and IIH, is considered to be supported by current thinking for hearing loss and Meniere's disease. The underlying endolymph volume change may result from a change in transport (such as if the endolymphatic sac switches from secreting fluid to resorbing fluid) so that endolymph volume declines with time without a membrane rupture taking place. A physical force, IPPA ICP, was correlated with the behavioral response to the SIT sensation with the TMDT.
Abnormal IPPA was accompanied by reduced CC in 8 of the12 patients, whereas normal IPPA was accompanied by reduced CC in 2 patients, and results were incomplete for the other 2 patients. The clinical significance of these preliminary TMDT results for overall tinnitus treatment is to be established over the long term.
The correlation of treatment efficacy for ICP control and reported subjective tinnitus relief is considered to be separate and individual for each SIT patient. Assistant Clinical Professor, Department of Otolaryngology, SUNY - Downstate Medical Center, and Director of Audiology, Martha Entenmann Tinnitus Research Center, Inc., Brooklyn, NY. Consultant Clinical Scientist, Neurological Physics Group, Medical Physics, University Hospital Southampton, NHS Foundation Trust, UK. PhD, is managing director of Marchbanks Measurement Systems Ltd., a spinoff company from Southampton University that supports research with the Tympanic Membrane Displacement Analyzer. Vestibular Evoked Potentials (VestEP) and Brain Electrical Activity Mapping A Test of Vestibular Function - A Review (1990 - 1996). The method consists of multichannel EEG registration and mapping of the brain isoelectrical contours during short-lasting repetitive angular accelerations. The principle components analysis reveals that the shortest latencies and the highest amplitudes of the VestEPs can be registered from the central transversal line of electrodes, T3-C3-Cz-C4-T4.
The initial complex ( waves I - III) is related to the activation of specific (vestibular) cortical areas. Between 1988 and 1990 the technique of EEG-Epoch method with a Fast Fourier Analysis was used to record spontaneous cortical potentials as represented in a surface related image, following caloric, rotatory, optikinetic stimulation.34,36,37,42,55,56 This technique was supplemented with the technique of producing stimulus related evoked potentials in response to vestibular, acoustic, visual, and olfactory stimulation. The spatial and temporal properties of the rotational evoked brain electrical events and their clinical implications are presented. However, they have some limitations, associated mostly with their relative high intra - and interindividual variability, high sensitivity to biological, psycho-physiological and environmental factors, insufficient information about the time and spatial distribution of the evoked activity over the cortex, etc. The onset of the positive acceleration served as a trigger impulse for starting the averaging of the EEG segments. In order to escape the habituation effect a time pause of 3 - 5 minutes is introduced between the consecutive sessions. 4), available with an option of 17 selfcontained, self-supplied DC preamplifiers PPA1 (input resistance of 400 MΩ).
A special data bank containing 400 BEAM-VestEP investigations on 300 subjects, either symptom free volunteers and neurootological patients suffering from vertigo, sudden hearing loss, tinnitus, balance disorders, have been created. The shortest latencies of the initial VestEP-components (I, II and III) can be obtained from the central transversal line area (T3 - C3 - Cz - C4 -T4 electrodes).
This time distribution of the BEAM-VestEP images also revealed a high degree of modality-related specificity.
However, some problems may appear due to the high sensitivity of the VestEP waves from the vigilance state, fatigue, drug admission, etc.
The information from a routine EP study is based on an analysis of the amplitude and latency parameters of the principle components with respect to the electrode position.
This combined VestEP-BEAM approach represents a functional neuroimaging technique for studying of the space and temporal peculiarities in the scalp distribution of the rotationally evoked brain electrical events. Supratentorial localisation sights in longitudinal and transversal plane (Interhemispheric Asymmetry, IHA).
Psychophysiology of vestibular function and its disorders; vertigo and dizziness sensation, space orientation, distortions of space and time.
Neck-related changes on vertigo pointing towards modulatory effects of somato-sensory inputs. A special advantage of our multielectrode arrangement of BEAM is that it provides additional topodiagnostic information.
The VestEP-BEAM approach 28 permits a study of all five EP dimensions, thus offering some important further additional advantages in the acquisition of neurophysiological data.
Technically, this is the simplest and easiest type of EP-mapping, because of the usually sharp VestEP-peaks. If an afferent influx of impulses occurs in vertically oriented cortical neurons at a high frequency for a longer period, then wave-like Excitatory Postsynaptic Potentials (EPSPs) will be generated at the superficial dendritic arborization.35,50 This produces a broadly spreaded depolarization of the cortical neuronal elements. Also an increasing dialog with allied disciplines of clinical neurophysiology, sensory physiology, neurology, neurosurgery, psychiatry, orthopedic surgery, traumatology, occupational medicine, and ophthalmology will be established. Brain Electrical Activity Mapping - Eine weitere objektive Projektionsebene für neurootologische Funktionspriifungen.
Speckmann EJ, Elger CEo Introduction to the neurophysiological basis of the EEG and DC Potentials.
We administered not only simple optokinetic and eye-tracking stimuli but caloric modification of each one as well (with contrary directed optokinetic trace movement). On the basis of previous examinations, it may be assumed that 4-12% of individuals reaching the age of 65 years suffer from primary or secondary dementia. The aim of our study was to compare the visuooculomotor reactions in these two groups of patients and to try to establish the origin of vertigo syndromes in the elderly.
Those in the first group (the elders) were tested to exclude diabetes mellitus and chronic rheumatic arthritis. These authors were of the opinion that such a result in the elderly depended on the degeneration of the cerebellar nuclei.
Some of our findings-such as characteristic Romberg test, tremor, asynergy, dysmetria, dysdiadochokinesia, and gaze nystagmus-highlighted the effect of Purkinje cell diminution on balance system disorders. The pathological data obtained from anamnesis, compound visuooculomotor tests, and cervical proof pointed out the compound character of presbyvertigo as a result of visual, vestibular, vascular, and motion system dysfunctions.
The light tracings of the head and shoulder movements were transformed through an instant camera into photographs that look like a radar image of the trails of head and shoulders floating through a spatial plane [1-3].
1), we sought to develop a special voluntary head and neck movement test mainly containing rotatory components. Position of two markers on the head (Marker A and P) and two markers on the shoulders (Marker Rand L) within a three-dimensional-space model.
Thus, very precise localization of ultrasound senders is possible through computer calculation and conversion into positioning charts. By means of a set of microphones installed in a spatial arrangement, the source of a sound signal can be concisely calculated. Two of these markers are fixed to the test subject frontally and above the occiput through a workman's hard hat, allowing the measurement of head movements. Within the receiver (UsRec), the sound impulses (Ta, Tp, Tr, Tl) are received by a fixed set of at least three microphones installed in the measurement system, from which they are received and processed by and transmitted to (arrows Lr to Lc) the computer.
In addition, the computer program has been modified in such a manner that it can also detect and exclude noisedisturbed signals (which may arrive through echo reflections) or other sources of failure.
This operation is performed by our specially designed software, HUSPATRAC (human space trail system Claussen), which currently provides us with nearly 50 different analytical designs, although ongoing development is continually increasing this number.
In patients who have difficulty in understanding, a training run of the test is recommended prior to recording. 3, index 3) and, while maintaining that position, should repeatedly rotate the head from right to left and back again (see Fig.
3, from index 4 to 5), and there should repeatedly rotate the head from right to left and back (see Fig.
Six representative HUSPATRAC graphs of a 50-year-old woman suffering from a late whiplash injury syndrome due to a traffic accident more than 2 years ago. The numerical values provided in Tables 1-5 complement the visual inspection and interpretation of the six graphs depicted in Figure 4. Furthermore, it must be noted that the "hinge" between the head and the neck is positioned on the border between the most backward and the middle third of the skull base, as the head is asymmetrically suspended in its longitudinal axis.
The velocity calculations (expressed in kilometers per hour) are related as mean velocities of the locus curves from Figure 4A-C.
However, for intracorporeal testing of head and neck mobility, NEFERT is now our test method of choice. Therefore, we undertook to demonstrate the results of NEFERT in a 50-year-old woman who suffered severe whiplash contact trauma in May 1995. Testing the reduced acoustic dynamics led to the diagnosis of an external tinnitus due to hypersensitive ear syndrome. The specific results for the patient whose test findings are depicted in Figure 5 are exhibited in Table 7. The velocity calculations are related as mean velocities of the locus curves from Figure SA-C. In this patient, most of the dynamic mobility reduction is found in the vertical direction and least in the lateral direction. These tools are very easily applied in patients with head and neck movement disorders as well as in patients in whom a neck-derived tinnitus is suspected. The only condition is that you provide a direct link to the specific article you use on the page where you quote us. Therefore, in order for the investigation of tinnitus to be complete, one must include the evaluation of the vestibular function of the ear, as well as the auditory.
The patient's head and body movements are recorded by a camera, as he performs the classical Unterberger-Fukuda's stepping test and Romberg's standing test. The main changes were found to be a deterioration in the high frequency range (> 2 kHz) and a flat neurosensorial hearing loss, Table 3.
The standing test (Romberg test) showed two cases of discrete to moderate ataxia, all the others being normal. The data are registered using the Claussen's butterfly.3,4 The values for the mean and standard deviation of the central frequency of the nystagmus in the caloric tests are shown in Table 8.
Considering the classification into two subgroups, as for the other parameters, we found no significative differences between the group which related equilibrium disorders and the group with no symptoms of disequilibrium, as one can easily see in Table 11. The supraliminal audiometry is, in our opinion, extremely important in the study of these patients. These findings show that the vestibular system of tinnitus patients is not normal, even though they feel no equilibrium related symptom.
Of these, roughly half of them have a peripheral pattern of lesion, and the others, a central pattern. Ifthis proves to be true, we should expect these patients to progressively develop other symptoms of endolymphatic hydrops such as, sensorineural hearing loss and clinical vestibular dysfunction.
Indeed, the cochleovestibular system must always be considered as a whole and studied as such.
Claussen CF, DeSa JV: Clinical Study of Human Equilibrium by Electronystagmography and Allied Tests. Claussen CF, Bergmann de Bertora JM, Bertora GO: Otoneurooftalmologia, (ed) Berlin, Heidelberg, Springer Verlag, 1988.
Claussen CF, Seabra R, Hahn A, Helms J: A Cranio-Corpo-Grafia e os testes caloricos nos doentes com neurinoma do estato-acustico. There is an absence of attempting to identify types of hyperacusis and few attempts to establish its clinical significance. Criteria for normal hearing were strict and for the purposes of this study normal hearing was considered to be thresholds of 25 dB or better at all frequencies.
What are the results of long term follow-up of tinnitus of patients who were negative by self-report for hyperacusis but demonstrate positive LDL and positive DR? In: Tinnitus 91, Proceedings of the Fourth International Tinnitus Seminar, Edited by JM Aran and R. Fortytwo hyperlipidemic patients with subjective tinnitus and hearing loss due to noise exposure were enrolled for the study. It has been reported that high-plasma cholesterol and triglyceride levels are one of the major risk factors for the development of occupational hearing loss [3-5].
It seems that noise and other metabolic disturbances have a synergistic effect on the development of tinnitus and hearing loss [5]. A diagnosis of acoustic trauma was verified by an ear, nose, and throat physician according to a clinical history of chronic noise exposure in patients who sought medical help for complaints of tinnitus and high-frequency hearing loss. Patients who had chronic otitis media or middle-ear effusion, those with an abnormal ear drum (perforation, retraction, etc.) or auditory canal, and those who had abnormal tympanometry (other than type A) were excluded. In the study, from 120 patients we chose 42 male patients (35%) with elevated cholesterol or triglyceride or both (age range, 19-60 years; mean age, 45 years).
The patients were separated into two groups: the "unresponsive" group, made up of 22 patients who had no response to either of the therapies and still had hyperlipidemia, and the "responsive" group, consisting of 20 patients who had lower cholesterol or triglyceride levels. The results of the blood lipid profiles were withheld from the individual to prevent a placebo effect with the tinnitus therapy.
The significance of the difference in patient's comments on their tinnitus after the treatment ("same," "decreased," "increased," and "disappeared") was analyzed using McNemar and chi-square tests. However, the incidence of hyperlipidemia among a selected group of patients with neurosensory hearing loss varies. They selected a group of subjects aged between 20 and 50 years and compared auditory thresholds at high frequencies and serum lipid levels. Noise and metabolic disturbances have a synergistic effect on the development of tinnitus and hearing loss. Effects of experimental cochlear thrombosis on oxygenation: Auditory function of the inner ear.
Direct effects of intraperilymphatic reactive oxygen species generation on cochlear function.
Clinical utility of LDL-apheresis in the treatment of sudden hearing loss: A prospective, randomized study. The relation of hearing in the elderly to the presence of cardiovascular disease and cardiovascular risk factors. Appearance of free radicals in the guinea pig inner ear after noise-induced acoustic trauma.
Progressive sensorineural hearing loss, subjective tinnitus and vertigo caused by elevated blood lipids. A comparison of auditory brainstem evoked potentials in hyperlipidemic and normolipidemic subjects. Exploration of the early auditory effects of hyperlipoproteinemia and diabetes mellitus using otoacoustic emissions.
Hypertension, hyperlipoproteinemia, chronic noise exposure: Is there a synergism in cochlear pathology? Effects of noise exposure and hypercholesterolemia on auditory function in the New Zealand white rabbit. Hearing improvement after therapy for hyperlipidemia in patients with chronic-phase sudden deafness.
A prospective case-controlled study of 197 men, 50-60 years old, selected at random from a population at risk from hyperlipidemia to examine the relationship between hyperlipidemia and sensorineural hearing loss.
The group 1 TMDT recordings were obtained on one session test date, and group 2 (n = 6) recordings were obtained sequentially on different session test dates. Multiple recordings were attempted in all patients to identify test-retest reliability in both groups. The SIT relief is reflective of fluctuation in the ICP and the overall issue of multifactorial brain pulsatility. For the subjective idiopathic tinnitus patient, the evaluation of a persistent subjective complaint of EB, in the absence of a site of lesion in these frequent locations, has been hypothesized since 1979 to reflect a fluctuation or elevation of intracranial pressure (ICP)1-3. The blockage persisted in the SIT ear following control of the clinically identified site of lesion of the blockage.
Marchbanks and "Meniere's Disease, Secondary Endolymphatic Hydrops, and Tinnitus" by Abraham Shulman. Identification and treatment or control of ICP may be a factor influencing the clinical course, in general, of all clinical types of tinnitus and, in particular, of this cohort of SIT patients. A case report will demonstrate the result of translation of an elevated ICP for tinnitus treatment on the clinical course of the SIT patient. Animal and human results of identification of ICP with an external probe device in the ear canal, recording tympanic membrane displacement, reflective of the IPPA and its modulation by respiration, may be translated for this subgroup of SIT patients.
Sismanis14,15 noted that "pulsations of the cerebrospinal fluid, mainly originating from the circle of Willis, are transmitted to the exposed medial aspect of the venous sinuses (transverse and sigmoid), resulting in periodic compression to their walls. An excellent summary of past efforts since 1924 both in animal and humans concluded that alterations in ICP can explain some inner-ear complaints including hearing loss, tinnitus, and vertigo.
The cochlear aqueduct is the main fluid communication route between the intracranial and perilymphatic fluids; it runs from the subarachnoid space and enters the cochlea in a niche just near the round window17-19. In experimental EH, deterioration of auditory thresholds was partially correlated to the presence of positive endolymphatic-perilymphatic pressure gradients. Acute EH was generated by exposure of the guinea pig ear to nontraumatic low-frequency tone25.
The function of the organ was followed by measuring its physiologic response after applying static pressure and repeated tone bursts of more than 80 dB26. From this, it is concluded that the TMDT gives the optimum results when testing for pressure changes within the same individual, such as changes that may occur with symptoms or treatment30,31.
A trial of ICP measurement from the external auditory canal concluded that intra-aural pressure waves clearly reflect intracranial changes in humans, thus proving Marchbanks's hypothesis33. The cardiovascular component is the predominant waveform, modulated by the respiratory component. The MMS-11 CCFP Analyser is used to provide an indirect measure of baseline (static) cerebral and cochlear pressures by the detection of low-frequency pressure waves that are emitted from the ear, a component of which is of intracranial origin. Clinically, increased ICP reflects intracranial hypertension, whereas low pressure reflects intracranial hypotension. Reduced ICP results in an inward resting position of the stapes footplate and outward displacement of the tympanic membrane on muscle contraction.17 Measurements appear to reflect cerebral autoregulation in some cases. Vestibular caloric and sinusoidal harmonic rotary-chair testing was performed on all SIT patients. Magnetic resonance imaging of brain with contrast reported no significant CNS pathology, with only occasional white matter changes, in 10 of the 12 subjects in this study. The tinnitus evaluation identified SIT, masking curve type 4; and an abnormal result on QEEG. The TMDT at that time demonstrated an abnormal ICP as measured by an increased IPPA amplitude and normal modulation by respiration, with a reduction in compliance, which correlated with a reduction in the subjective SIT relief reported in March 2012. The addition of the clinically associated complaints reported by this special cohort of SIT patients into the MATPP may be the basis for a clinical protocol for identifying abnormal ICP and the diagnosis of IIH. Specifically, the concept of compliance and the TMDT results in SIT patients with abnormal ICP and reduced compliance, normal ICP with reduced compliance and, possibly, abnormal ICP with normal compliance may supplement classical clinical thinking about the medical significance of a CNS complaint, to be based not only on the absolute value of the ICP but on the relative value of ICP and compliance, a mathematical approximation based on observed data, for brain disease diagnosis and treatment.
These claims are supported by a recent article that concluded that the pulsatility of the ICP may be more relevant than static ICP in the diagnostic setting for patients with IIH38. The spontaneous, not the evoked, mode of elicitation of intraaural pressure waves is recommended for TMD testing in SIT patients, specifically to avoid a potential increase in tinnitus intensity that may accompany the audiological threshold recommended for eliciting the acoustic reflex in the evoked mode of the TMD. However, our clinical experience with SIT is the basis for recommending interval examination, including repeat TMD testing, to establish the clinical significance of ICP identification and treatment for long-term tinnitus relief and the diagnosis of IIH. Long-term follow-up is recommended in a large specific cohort of SIT patients to establish the incidence of abnormal ICP and IIH and the medical significance of such findings for long-term tinnitus relief.
Transmission of CSF to perilymph was hypothesized to be via the cochlear aqueduct and was the etiology of the hearing loss41. Intracranial subarachnoid CSF pressure transmission onto the endolymphatic sac results in an initial increased pressure into the endolymphatic duct, which, over time, results in EH and SEH. Specifically, pressure pulses are not dependent on location and can be measured anywhere within the cranium, whereas flow pulsations are highly dependent on location of measurement. The cerebral blood flow is equal to the cerebral perfusion pressure divided by the cerebrovascular resistance45.
The cranium and its constituents (blood, CSF, and brain tissue) create a state of volume equilibrium, such that any increase in volume of one of the cranial constituents must be compensated by a decrease in volume of another44. Graphically, the compliance of a system is inverse to the slope of the pressure - volume curve. In experimental EH, endolymphatic pressure is higher (> 100 Pa) than perilymphatic pressure.
Specifically, a reduction in CC with a normal IPPA ICP preceded an increase in IPPA ICP and a reported subjective reduction in tinnitus relief. Is the primary origin and pathophysiology of the otologic histopathophysiologic correlate of EH the brain and not the ear?
The result via pressure on the endolymphatic sac influences volume, pressure, and compliance changes in the endolymphatic duct, which, over time, results in extension and distention of Reissner's membrane into the scala vestibuli. Specifically, "endolymphatic hydrops may initially not be pathologic, and the symptoms arising from hydrops may be mild or negligible, but .
In the normal cochlea, the rate of longitudinal endolymph flow is extremely low, so that flow does not make a significant contribution to the homeostasis of ions in endolymph. This application involved recording and demonstrating with single and serial spontaneous recordings an abnormality of the intraaural pulse pressure waves and fluctuation in the ICP, supportive for the presumption of IIH. Fluid dynamics vascular theory of brain and inner-ear function in traumatic brain injury: A translational hypothesis for diagnosis and treatment. Inflammatory disease and trauma involving middle ear and inner ear: Central nervous system disease and cerebrovascular disease. The search for idiopathic intracranial hypertension: An investigation of cerebral to cochlear pressure transfer as a direct cause of reversible and irreversible audiological disorders. Otologic manifestations of benign intracranial hypertension syndrome: Diagnosis and management. Cochlear and cerebrospinal fluid pressure: Their interrelationships and control mechanisms. Hydrostatic pressure in the inner ear fluid compartments and its effects on inner ear pressure. A trial of intracranial pressure measurement from external auditory canalexperimental analysis.
Longitudinal endolymph movements and endocochlear potential changes induced by stimulation at infrasonic frequencies. Acute endolymphatic hydrops generated by exposure of the ear to non-traumatic low frequency tone. Compartmental analysis of compliance and outflow resistance of the cerebrospinal fluid system.
Tympanic membrane displacement test in regular assessment in eight children with shunted hydrocephalus. Non-invasive perilymphatic pressure measurement in normal hearing subjects using the MMS- 10 Tympanic Membrane Displacement Analyser.
A trial of intracranial pressure measurement from external auditory canal - clinical analysis.
Applications of the Marchbanks transcranial-cerebral sonography technique in neurootology: Preliminary report. Brain and inner-ear fluid homeostasis, cochleovestibular-type tinnitus, and secondary endolymphatic hydrops. The later complex (waves IV - VI) reflects the supramodal cortical proceedings with sensory information (cognitive components). The technique has provided new insights into the origin and quality of complaints of vertigo and tinnitus.
Speculations with respect to its clinical significance and implications for diagnosis and.treatment are presented. In order to reduce the emotional stress and muscle artifacts we have used a slow deceleration (not a sudden stop) as a stop stimulus. The total session time for a person lasted for about 30 minutes including the time for electrode montage. The biosignals are transmitted to the main amplifier via a slip ring assembly, containing 17 slip rings, each one with twin sliding contacts. In order to minimize the eye movement artifacts, gaze fixation is introduced through a structured fixation target, rotating with the chair. A few montage schemes and programs are employed, some of them including the middle line electrodes Fz and Cz. The frequency band of the recorded spontaneous brain electrical activity is determined by a low frequency cutoff of 0.1 Hz and a high-frequency cut-off of 35 Hz. In addition, a few children (9-11 years) as well as a few older persons (37- 55 years) were investigated in order to appreciate the age-related variabi lity in the VestEP-properties. A-Mode of single electrode EEG-curves with BEAM-images related to cursor-selected typical wave patterns.
Both clockwise (CW) and counterclockwise (CCW) accelerations basically elicit similar waveform patterns, although some differences or peculiarities exist among the clinically healthy persons (Table 2).
The shortest latencies of the later components (IV, V and VI) can be registered from more frontally located brain regions: Fp1, Fp2, Fz (Fig. Diagram of the latency distribution of the first component of the vestibular evoked potentials over the scalp in (msec). Amplitude Mapping of the IIIrd component of the Vestibular Evoked Potential (VestEP), obtained from a 21-year-old healthy man. Classical interpretation of the evoked potential data in terms of latency and amplitude provides only a twodimensional basis of differentiation between the normal and abnormal functional state of the investigated sensory structures and pathways. The prolonged depolarization of the superficial structures caused by sensory afferentation will express itself by a negative shift in EEG, resp. Spectral Analysis of the Nystagmus and the Simultaneous Cortical Activity (preliminary Study).
Differentialdiagnose und Differentialtherapie von Schwindel und Ohrensausen beim alten Menschen. Ohrgeräusche - Neurootologische Gesichtspunkte zur Differentialdiagnose und Differentialtherapie. Combined Analysis of horizontal and vertical optokinetic Nystagmus Reactions by means of ENG and Brain Mapping. Los potenciales evocados equilibriometricos por medio del BEAM - y su importancia en el diagnostico y tratamiento de los pacientes con vertigo. The International Tinnitus Journal (ITJ): A New Platform for Clinical and Scientific Tinnitology. On the Functional State of Central Vestibular Structures in Monaural Symptomatic Tinnitus Patients. Vestibular late evoked potentials, a complementary tool for neurootological topodiagnostics in dizzy patients. Our first findings about the late acoustical evoked potentials, with full cortical response representation.


The Influence of Betahistine on the Vestibular Evoked Potentials in Patients with Peripheral Vestibular Disorders. Long-latency rotational evoked potentials in subjects with and without bilateral vestibular loss. Recording of shortlatency vestibular evoked potentials induced by acceleration impulses in experimental animals:current status of the method and its applications.
Recording of short latency vestibular evoked potentials to acceleration in rats by means of skin electrodes. Visually Evoked Potentials and their Evaluation in Brain Electrical Activity Mapping (BEAM).
Extended Normative Data on Vestibular Evoked Potentials Displayed by Brain Electrical Acitivity Mapping.
Uber die kombinierte Verwendung von akustisch und visuell evozierten Potentialen in der Neurootologie. Die Darstellung per- und postrotatorischer Vestibularisreaktionen mittels des Brain Electrical Activity Mapping. Vestibular Evoked Potentials - a New Method for Study of the Combined Factors of Environmental Factors.
The results were compared with those obtained in a group of 40 healthy subjects between the ages of 20 and 25 years.
This group was formed in such a way as to contain only those in reasonably good health without previous brain diseases that required a sudden intervention. Our data proved that only the optokinetic and eye-tracking stimulations together with cervical maneuver were able to distinguish the reaction produced by both young and elderly subjects. A new nystagmographic test for the elicitation of sub-clinical vertebro-basilar insufficiency and poor cochleo-vestibular vascularisation. Response of the optokinetic nystagmus in the old-aged with regard to primary diseases caused by old age.
This objective and quantitative equilibrium test was developed especially for the West German Berufsgenossenschaften (labor security surveillance boards) as a field test for occupational medical purposes. The conventional photooptical CCG has proved to be an important tool for equilibriometric field and office investigations [11-14]. This test, which has been dubbed the neck flexion, extension, and rotation test (NEFERT), differs substantially from the longitudinal lateral vertical head sliding test, which contains mainly linear components.
Patient is wearing a helmet bearing two ultrasound markers (UsMr-A and P) and a shoulder fixation bearing two other ultrasound markers (UsMr-R and L). There a fourdimensional digital array of position data is processed and deposited by means of a specific computer program. A systematic set of simple instructions must be given orally to the technically prepared test subject and can be stressed by a poster (Fig. In phase 1, the upright test subject with head up (index 1) is requested to rotate the head repeatedly from right to left and backward (index 2) for 20 seconds. The subject then should repeatedly rotate the head maximally from the right to the left side and back again (see Fig. 3, index 6) over a 20-second interval, until the instructor indicates that the subject should stop and assume the initial head position (see Fig. During the investigation, a preliminary graphical test result is presented by means of a polar coordinate type chart, showing the head rotations with respect to the shoulder rotations in a horizontal plane on the computer screen. Moreover, many types of frequency analyses and other derived dynamic parameter analyses are applied.
Neurootologically, the patient exhibits a cervicoencephalic syndrome resulting in multisensory neurootological deficits. As these six graphs are drawn for a specific person who is undergoing the NEFERT, we obtain a simple series of characteristic data about that subject, including age, gender, size, and weight (Table 1). This then leads to rotational circles of different diameters created by the forehead and the occiput in the horizontal and the veltical planes. Using this test, we can graphically and numerically display the dynamic test parameters (as shown earlier) and permanently record the mobility of the neck through relative head-neck rotation [15]. Our NEFERT investigation dates from July 1997, at which time the patient was exhibiting a late whiplash injury syndrome of the cervicoencephalic type. However, the neurootological network analysis, based on an equilibriometric, audiometric, olfactometric, and gustometric workup, unveiled a combined peripheral and central disequilibrium, including disturbances of the spontaneous and the caloric tests as well as several optokinetic nystagmus tests. This case shows clearly that the extensions of the patient's movements in all planes are much reduced in comparison with those of a normal adult: The differences between Tables 2 and 7 are obvious. The results in Table 9 show remarkable reductions of the wavelengths of execution of NEFERT in the tested patient as compared with a normal adult (see Table 4). She appears to try to carry her body and her head as smoothly erect as possible so as not to provoke irritations through vertical head shaking. This combination of techniques is an important achievement in equilibriometry, providing a new and important tool for regular and general neurootological investigations.
Uber eine Gleichgewichtsfunktionsprufung mit Hilfe der Cranio-Corpo-Graphie (CCG) und Polarkoordinaten im Raume. Die Cranio-Corpo-Graphie (CCG), eine einfache photooptische Registriermethode für vestibulospinale Reaktionen.
Epidemiologische und arbeitsmedizinische Erkenntnisse wr Entwicklung eines berufsgenossenschaftlichen Grundsatzes "Absturzgefahr." Arbeitsmed Kolloquium. Cranio-Corpo-Graphy (CCG), a simple objective and quantitative whole-body as well as intracorporal posturography. Forschungsbericht CranioCorpo-Graphie (CCG)-Ein einfacher, objektiver und quantitativer Gleichgewichtstest für die Praxis. Neue objektive registrierbare Vestibulariskorperdrehreaktionen, erhalten durch Treten auf der Stelle. Vestibulospinal testing using cranio-corpo-graphy in patients suffering from acoustic neuroma.
Cranio-corpo-graphy, an Objective and Quantitative Representation of Movement Patterns During the Stepping and Standing Test. Cranio-corpo-graphy (CCG)-30 years of equilibriometric measurements of spatial head, neck and trunk movements. This approach is justified in a tinnitus patient because the cochleovestibular system is a unit and acts as a whole. We excluded from this study, those patients who had an identifiable middle ear disease, such as chronic otitis, tympanic perforations, or tympanosclerosis. For this study we only considered the measurements made with the higher intensity (120 dB SPL). The patient is asked to use a hard hat with two small electrical bulbs in the saggital plain; one above the forehead and the other above the occiput.
We use an Electronystagmograph with three channels recording the vertical and horizonal movements of the eye. These abnormalities in the graphic elements are very important and should always be looked for very carefully. Therefore, the great majority of them (70%) had at least one abnormality in the vestibular testing.
Therefore, we think that these patients should be periodically re-evaluated in order to determine any development of the disease or diseases. This led us to explore whether or not there was any correlation or statistical verification between the two phenomena. If the acoustic reflex level is less than 60 dB above threshold of hearing at a given frequency recruitment is considered positive. If we use the criteria of 90 dB or less at two or more frequencies, the incidence is 83% for the right ear and 79% for the left ear. It may be that the non-self-report patients who qualify according to the 90 dB criteria are at risk of hyperacusis, despite the fact that they do not report any symptoms of it. Will medical or audiologic intervention prevent them from becoming hyperacusic and, if so, what modalities are to be considered?
All patients who were required to complete the questionnaire and who were subjected to clinical examination were military personnel. A pure-tone signal was presented continuously at 50-Hz intervals at between 10- and 20-dB levels. We placed all these patients on a low-cholesterol diet or antihyperlipidemic therapy (Table 2). When patients were asked to qualify the severity of their tinnitus, 10 rated their tinnitus as the same (47%), 9 rated it as increased (42%), 2 rated it as decreased (9%), and 1 patient had no tinnitus (2%). Lowry and Isaacson [12] reported 20% hyperlipoproteinemia among 100 patients with bilateral hearing loss. Lipidosis of the inner ear has been postulated by Nguyen and Brownell [33] as an alternate mechanism. Insufficient perfusion of the cochlea due to increased blood viscosity and microthrombosis related to hyperlipidemia has been claimed to cause susceptibility to noiseinduced hearing loss [35]. We found in our study that the incidence of hyperlipidemia among patients with noiseinduced tinnitus and hearing loss was 35%. Characteristics of tinnitus and etiology of associated hearing loss: A study of 123 patients. Patient selection with the medical audiologic tinnitus patient protocol (MATPP) identified all to have a nonpulsatile, predominantly central-type severe disabling subjective idiopathic tinnitus (SIT) resistant to attempts for tinnitus relief with instrumentation or medication. An attempt for treatment and control of an elevated ICP with or without reduced cerebral compliance (CC) was recommended in 4 patients. These positive findings support clinical and basic science investigations previously reported in the literature.
Discussions after our presentations allowed us to share our evolving experiences with SIT and TMDT and to consider the potential role of TMD and brain pulsatility for SIT in general and for SEH specifically.
The result may be increased efficacy for tinnitus relief with existing modalities of instrumentation or medication9-11. The identification and translation for treatment and control of ICP as a manifestation of IIH may influence the clinical course of this patient subgroup. These periodic compressions convert the laminar blood flow into turbulent flow, resulting in vibrations of the vessel walls and production of pulsatile tinnitus". This same report supported the existence of an "obligatory" interrelationship between ear and ICP16. A change in pressure, however, occurred later than the first deterioration in auditory function. A 3-minute, 200-Hz tone at 115 dB was sufficient to generate an acute EH condition in 29 guinea pigs25.
An ear probe inserted into the ear canal of the ear to be tested is connected to the analyzer.
In the second operational mode, TMD is spontaneous: That is, baseline ICP is extrapolated based on measurement of the ongoing spontaneous displacement of the tympanic membrane, hypothesized to be reflective of ICP waves principally of cerebral cardiovascular and respiratory origin. These two incomplete TMD recordings were associated with an inability to maintain an adequate seal of the probe in the ear canal.
Abnormal amplitude and modulation were reported in July and September 2007, November 2008, and March 2012, concurrent with subjective reports of elevated intensity of the patient's SIT. The initial manifestation of benign intracranial hypertension syndrome as perilymphatic fistula was presented in three cases40.
It is hypothesized that fluctuation in the degree of the abnormal ICP and compartmentalization of the increased pressure effect within the cochlear and vestibular labyrinths of this transmitted pulsation on the underlying sensorineural tissue become clinically manifest in gradually increasing complaints of ear blockage, tinnitus, vertigo, and hearing loss in some SIT patients.
Pressure measurement is usually restricted to the lateral ventricle, cisternum magnum, or brain parenchyma. The serial recordings with the TMD speculatively provide a monitor for recording of CBA (see Figure 4).
With an increase in ICP, the concurrent reduction in intracranial compliance results in an increase in the pulse wave amplitude. These pressure gradients occur only in late stages of hydrops, probably when Reissner's membrane has lost its high compliance after long-standing distension20. Is the finding with the TMDT at this time in a preselected cohort of SIT patients of an increased IPPA ICP support for consideration that the IPPA and cardiovascular disease may be an etiology for a subgroup of EH, SEH, and Meniere's disease patients?
The net effect of both routes of IPPA transmission, in ear as in brain, is a reduction in compliance as the pressure within each compartment is increased, with interference in underlying structure and function and clinical manifestations of hearing loss, tinnitus, vertigo, and ear blockage. However, recent studies in our lab suggest that when endolymph volume is disturbed, longitudinal flows may be induced that play a part in the recovery of normal volume. In: Proceedings of the Fifth International Symposium on Meniere's Disease and Inner Ear Homeostasis Disorders.
Electrophysiologic recordings suggest that the symptoms of tinnitus and vertigo are related to activities of the upper gyrus of the temporal lobe with extension to other major areas of cerebral cortex.
The chair is used in a semilighted room, permitting the examination to be carried out in total darkness or in an illuminated environment. Altogether 19 scalp located electrodes are used in order to study the scalp topography of the VestEP. The grapho-elements of the evoked EEGs namely in the central section of the EEG locations determine the spreads of the electrical field - visualized over the cortex.
Mean data obtained by rotation-to-the-Ieft (ROTL-stimulus) and rotationto-the-right (ROTR-stimulus) in healthy persons. Moving more frontally or more occipitally from the transversal line area (T3-C3-Cz-C4-T4 line) the response progressively reduces in its amplitude. Mean data obtained by rotation-to-the-left (ROTL-stimulus) and rotation-to-the-right (ROTR-stimulus) in healthy persons. Consequently, the potential differences between the referential point (which is electrically "silent" in practical plan) and each one of the scalp electrodes (which is electronegative in respect to the reference point) reflect not only the amplitudes of the VestEP-components but also the degree (or gradient) of their relative electronegativity.
Excerpta Medica, International Congress Series, 1087, Elsevier Publishers, Amsterdam, Lausanne, New York, Oxford, Shannon, Tokyo, 231-234, 1995. Excerpta Medica, International Congress Series, 1087, Elsevier Publishers, Amsterdam, Lausanne, New York, Oxford, Shannon, Tokyo, 395-398, 1995. Proceedings of the 3rd European Congress of the European Federation of Oto-RhinoLaryngological Societies EUFOS, Budapest June 1996, Editors: O.
In the older group, we observed a statistically significant increased frequency of asymmetry of optokinetic nystagmus and pathological patterns revealed by the eyetracking test and caloric modification of both the optokinetic and eye-tracking tests. These symptoms coexist with both disabilities of optic and vestibular organs and arthrosis or vascular deficit. Optokinetic and eye-tracking stimulations were given separately and during postcaloric nystagmus. A comparison of the electronystagmographic data in the first and the second tested groups is shown in Figure 1.
Optokinetic asymmetry and increased latency time of caloric modification of the optokinetic test were noted statistically more frequently in the first group. In: CF Claussen, MY Kirtane, D Schneider (eds), Proceedings of the Neurootological and Equilibriometric Society.
In 1983, it was officially introduced into occupational medicine in West Germany through the digital G41 of the West German Berufsgenossenschaften [4-6]. Very shortly after the test is performed, the results of the investigations are available, making this nearly an on-line charting procedure [6, 10].
The performance of the NEFERT, its recording and evaluation in relation to our US-COMP-CCG, are presented along with a clinical example.
A computer unit depicted in the lower right-hand corner (PosAnalysator [position analyzer]) is triggering the ultrasound impulses.
Several computer programs then establish a numerical analysis and spatial as well as temporal images of each of the markers.
In phase 2, at the command of the instructor, the upright test subject must maximally bend forward (index 3) and in this position repeatedly rotate the head from right to left and backward (index 4) for 20 seconds. The locus curves, especially as shown in Figure 4A-C, have a lateral (x), a longitudinal (y), and a vertical (z) dimension in centimeters, which are measured within the array of data points. Even 2 years after the trauma, the patient continued to report headache, neck pain and neck sprain, loss of personal dri ve and efficacy, forgetfulness, concentration disturbances, weakness, sleeping problems, anxiety, irritation, and loneliness. Now CCO can even more efficiently solve the problem of dynamically measuring the mobility of the neck-for instance, in late whiplash injury syndromeby means of our newly designed test procedure for measuring yaw, pitch, and roll movements in the voluntary head movement portion of NEFERT, as recorded and evaluated by means of the US-COMP-CCO in conjunction with our special software, HUSPATRAC. We have applied this method regularly and successfully for more than S years in our Bad Kissingen neurootological laboratory.
Presented at the Sixth International Symposium of Posturography, Kyoto, Japan, September 17-19.
The lateral sway is assumed to be related with central disorders and the angular deviation with peripheral lesions. We found a pathological unilateral weakness in 30% of the cases, and a pathological directional preponderance in 14% of cases. These abnormalities were classified as a peripheral lesion in 32% of cases and for a central lesion in 38%. The present method of assessment and a classification system for hyperacusis will be presented.
In no case of self-report of hyperacusis (N=30), did both the LDL and DR indicate negative results. There was an incidence of 34%, Type IV curves, considered clinically to represent central problems.
We excluded on the basis of their response to the questionnaire or clinical examination subjects who had a history of familial hearing loss, head trauma, collagen disease, neurological or hormonal disturbance, addiction to alcohol, or ototoxic drug therapy. The main criteria for response to the antihyperlipidemic therapy was defined as a return to normal cholesterol or triglyceride levels after therapy or at least a 40% drop from either of the initial blood cholesterol or triglyceride levels if the values were slightly above the normal limits.
The latter authors showed that the lateral wall of outer hair cells from guinea pig cochlea incorporates water-soluble cholesterol.
Axelsson and Lindgren [34] matched 78 men at age 50 years with high serum cholesterol levels to 75 randomly selected 50-year-old men and found significant correlation between noise exposure and high cholesterol level.
In this cohort of SIT patients, the ear blockage persisted after treatment of SEH in the SIT ear. Therefore, positive endoperilymphatic pressure gradients may contribute to, but are not the only cause of, hearing impairment". Diaphragm movements in the sensor attached to the probe track tympanic membrane movements to record the tympanic membrane displacement, which is recorded as a volume displacement and is reflective of the ICP. Raw-data analysis of the intracranial waveforms has been supplemented by systems analysis, all of which is providing clinical markers of disease in brain and fluid dynamic relationships with eye and ear, thereby improving the accuracy of diagnosis of the complaint and its site of lesion. An update of this initial experience and its translation for treatment of both perilymphatic fistula and EH was reported in ten cases43. This hypothesis is supported by the evidence of animal and human studies previously cited in this article. Flow measurement varies with magnitude and pulsatility of the flow, the type of fluid, and the location. The measurement of the compliance is not direct but rather indirect extrapolation of the ratio of volume change to pressure change. These flows may be directed toward the cochlear apex (when endolymph volume is reduced) or toward the cochlear base (when endolymph volume is increased).
The onset of the positive acceleration phase serves as a trigger impulse for starting the averaging process. The stimulus profile is programmed by a Schneider function generator and has the shape showed in Fig. The amplification and paper monitoring of the row EEG is done by means of a 17 channel PICKER SCHWARZER Encephaloscript ES 16000 (input impedance of 100 MΩ). The responses are monitored on-line and subsequently processed on a: PICKER SCHWARZER Brain Surveyor BS 2400 (Fig. The shortest latencies can be registered from the central (Cz, C3, C4) and temporal (T3, T4, T5, T6) cortical areas.
The highest negativity shift dominate over both central areas, more expressed over the right hemisphere.
A well expressed tendency for an amplitude decrease and a latency increase of the VestEP-waves can be seen with the progressive decrease of the acceleration rate. Thus, mapping of the amplitudes of the negative VestEP components means spatial visualisation of the gradients of the electronegativity over the scalp.
Atlas der Elektronystagmographie (Atlas der neurootologischen Untersuchungstechnik, Registrierkurven, Befundauswertung, Schwindeldiagnostik). XV Congreso Nacional de la Sociedad Espanola de ORL y Patologia Cervicofacial, 27 - 46, 1993.
We discuss the hypothetical predominant localization of age-dependent changes, with emphasis on the disturbances of visual-vestibular integration, on the basis of data obtained from anamnesis and other electronystagmographic findings.
Oosterveld [1] demonstrated a vertigo syndrome called presbyvertigo (presbyastasia) in 41-61 % of the elderly population. In Figure 2 is depicted the differences in statistical significance between the young and elder groups. Bodo [4] did not observe similar disabilities in the elder patients, a finding contrary to that reached by Wilke et al. In people older than 65 years, cervical nystagmus was suspected to appear, according to the experiments performed by Oosterveld [1]. For the recording of complex simultaneous movements at different body points-such as, for instance, the head and the shoulder-calculating a single spot or position and its traces in space is insufficient. Behind and above patient is the ultrasound receiving unit (UsRec), containing several ultrasound microphones and data processors, which receive sound traces from the head (Ta, Tp) and shoulders (Tr, Tl).
In phase 3, again at the instructor's command, the upright test subject must maximally extend backward (from index 4 to 5) and there repeatedly rotate the head from right to left and backward (index 6) for a 20-second interval. The head rotations, especially for the forehead and occiput in maximal flexion, are broad and well synchronized. As expected, the highest velocities during 1 minute of NEFERT occur at the level of the head, especially at the forehead marker.
Furthermore, the patient was suffering from vertigo, including dizziness, falling toward the right, blackouts, and instability, accompanied by sweating, palpitations, dyspnea, nausea and vomiting, blurred vision, and oscillopsia.
As expected, the highest velocities during I minute of NEFERT occur at the level of the head, especially at the forehead marker.
In a future study, we plan to present the statistical standards of major samples together with a broader spectrum of applications.
The profile of these patients is then analysed by our neurootological routine evaluation, which comprises the history taking and audiometric as well as equilibriometric investigations. The nystagmus may be elicited by a variety of stimuli, either vestibular, optokinetics or others. We would like to emphasise the fact that we found abnormal vestibular tests in tinnitus patients with no vestibular complaints.
This correlation may support the concept of different types of hyperacusis and could explain why some individuals respond to treatment and others do not. Of the nine who did not report hyperacusis, only two were substantiated by test results while the other seven had one or both tests positive. The difference between tinnitus scores in the unresponsive and responsive groups and the change in tinnitus scores before and after therapy in the responsive group were significant.
None of the patients had cerebrovascular disease, hypertension, electrolyte imbalance, cranial nerve deficit, or clinical signs of peripheral neuropathy. Then, the pitch-match frequency threshold of the tinnitus was measured as the tinnitus loudness match of the pure-tone stimulus presented with a 1-dB increase of tinnitus frequency. Morizono and Paparella [30], using cholesterolfed rabbits, showed increased auditory dysfunction with time at all frequencies. This uptake of cholesterol is accompanied by an increased stiffness of the cells, which may impair the cells' electromotile response. Enhancement of cochlear action potentials and auditory brainstem responses has been demonstrated after limited intake of cholesterol.
However, patients were at the chronic phase, more than 1 month from the onset of the hearing loss.
Clinical concern is for the presence of an increased ICP reflecting an idiopathic intracranial hypertension (IIH) which, if not identified and treated, may be a factor influencing the clinical course of this particular cohort of SIT patients, highlighted by persistent ear blockage and associated complaints as described. Notable additional associated complaints are head pressure, headache, and cognitive complaint(s) of interference in memory and speech expression - in short, a combination of ear and brain function complaints. In agreement with accepted CSF mechanics, these pressure waves are seen to increase in amplitude as the mechanical compliance of the CSF system declines with increasing ICP. The 2007 to 2012 TMDT recordings demonstrated (1) normal amplitude of the cardiovascular pressure wave (IPPA) with abnormal modulation by respiration and reduced CC in October 2007 and (2) fluctuation of CC (reduced and abnormal in October 2007 and August 2008, normal in November 2007, and abnormal in March 2012).
The TMD measurement of the cardiovascular and respiratory intracranial pulsations is predominantly that of the subarachnoid compartment of the intracranial CSF system37. The conditions under which flows can be induced and the role they play in volume regulation are presently being studied. 4), supplying facilities for spatial and chronological analysis of both spontaneous and evoked brain electrical activity (Brain Electrical Activity Mapping, BEAM) 28. The latencies over the left parietotemporal region seem to be mild shorter than those in the corresponding areas in the right hemisphere. Therefore, the CMS is arranged for the recording of several acoustic markers simultaneously. The olfactory investigation, carried out by means of the target olfactogram, displayed an allotriosmia on the patient's right side in the form of a cacosmia. In comparison to the values of the normal person, this patient exhibits a remarkable dynamic movement reduction in kilometers per hour during 1 minute of voluntary neck flexion, extension, rotation movements. We routinely use the calorics with an air stimulator, irrigating the ear during 30 seconds, at a rate of approximately 5-6 Iitres per minute at the temperature of 45 and 27 degrees Celsius. If one accepts the thought for discussion that tinnitus is a pre-condition for hyperacusis, does this not suggest that there are different types of hyperacusis reflecting a difference in clinical types of tinnitus with the same or different site(s) of lesion? It seems that the order of destruction and the high-frequency nature of the auditory dysfunction are correlated not only with the frequency and severity of the noise exposure but with the presence of the secondary pathology, as the formation of vasoactive lipid peroxidation products after intense noise is similar to the condition seen in metabolic damage to the organ of Corti [7,14-17]. In a survey of 44 patients with cochlear-type hearing loss, Booth [26] found hyperlipidemia in 28% of the men and 10% of the women.
These authors observed hearing improvement of more than 10 dB in 9 of the 12 patients after antihyperlipidemic therapy.
In this cohort of SIT patients, in whom the complaint of ear blockage is marked, experience has been limited with, or patients have proven resistant to, attempts at tinnitus relief with medication and instrumentation targeting conditions in ear or brain identified with the MATPP to influence the clinical course of SIT. Types 2 and 3 are intra-aural pressure waves that are associated with respiration; in type 3, the amplitude of the cardiovascular pulse varies with the phase of the respiration.
Significant is the compartmentalization already in place in the anatomic distribution of the fluid systems of the inner ear. A concept has been proposed that a disturbance of the resorption system in the endolymphatic sac would cause a "backing-up and an accumulation of endolymph, resulting in the development of hydrops""49.
An epoch of 1000 ms, following the onset of the stepwise acceleration stimulus is used for analysis of the rotationally evoked brain electrical events. During the recording procedure, each marker is producing 20 very short sound impulses per second, which impulses are triggered by the same computer that transfers them to the markers on the subject (arrows Lc to Lm). The shoulder tracings appear below and to the left of the tracings of the head in the form of dots.
In addition to these symptoms, the patient reported a severe disabling tinnitus in both the ears, which she described as high-pitched and hissing, as if a train were running through her head.
Therefore, we also calculated the differences between the values of Tables Sand 10, assuming the values of Table S (for a normal person) represented 100% of the values of Table 10 (in a 50-year-old female patient). We concluded that many tinnitus patients, even those who had no vestibular symptoms, showed some disturbances in the vestibular tests. The recording camera picks up the patients light tracings as reflected through a convex mirror, which is attached to the ceiling above the camera. We usually perform the rotatory tests with an acceleration of three degrees per second square during 30 seconds and then there is a relapsing time of three minutes with constant velocity, therefore, with no vestibular stimulation.
An unexpectedly low discrimination score is, in our experience, highly suspicious of a retrocochlear lesion, namely an acoustic neurinoma.
In this manner, preventive measures may provide restorative support to the injured cochlea. We required all patients to rate their tinnitus from 1 to 10, with 10 being loudest (Table 1).
The type 4 intra-aural pressure wave has been named the M wave, is of unknown origin, and was not demonstrated at this time. Peak-to-peak amplitudes and principal component latencies are measured and subsequently computed on a personal computer (Macintosh) for their averaged values and standard deviations. The head rotation positions for the forehead and occiput in lateral view are represented by dots, which are connected by flat circular lines.
The head rotations, especially for the forehead and occiput in maximal flexion, are very small and reduced in the coverage of the surface.
This fact highlights the need for a complete cochleovestibular investigation in all patients complaining about tinnitus.
Therefore, the craniocorpogram looks like a radar image of the head and shoulder movements.
The optokinetics are made in this period by asking the patient to open hislher eye and look forward. In fact, we have in our sample, two cases of neurinomas that presented with tinnitus as the first and only symptom. We also found some cases where in one ear we have a normal response with the warm stimulation and an inhibited response with the cold stimulation. Is hyperacusis a unitary symptom or are there different types of hyperacusis as there are different types of tinnitus?
Of the 12 individuals not complaining of hyperacusis, four had LDLs and DRs substantiating the absence of hyperacusis. This suggests that hyperacusis may be present in individuals with tinnitus before they become symptomatic. Each level was defined by short explanations to simplify the patients' grading of their tinnitus. Measurement of the IPPA of the cardiovascular component is the objective measurement of the ICP and perilymphatic cochlear pressure. The computer unit calculates the spatial positions of all four ultrasound markers and instantly displays on the screen a (radar image-like) graph including all four head and shoulder movement traces (lower right-hand corner). We think, after Claussen, that this pattern is highly suggestive of an irritative state of the peripheral organ, as for instance, in endolymphatic hydrops. The value of this test would be to identify such individuals and provide treatment before they become symptomatic for hyperacusis.
The software within the computer is handling the protocol, the procedure, and the movement analysis online. Viewing frontally on the tracings, the shoulders are lateral to and below the head tracings in the form of dots.
So, we would like to emphasize the fact that, in our sample, while only 18% of the patients related an equilibrium problem, 66% of the patients had an abnormal vestibulometric evaluation. The head rotation positions for the forehead and occiput in lateral view are represented by small lines with very little vertical elevation.
Lateral analysis of the small bands of minor shoulder movements below and above the widely oscillating and overlaid two bands of head movements extending from the start (left border) to the end (right border). Especially during maximal flexion, the frontal head rotations extend over the entire space defined between the shoulders. Viewing frontally on the tracings, the shoulders are on both sides laterally and much below the tracings of the head in the form more of compressed lines than of vertically elevated dots. Head rotations of the forehead and occiput are remarkably small and are extensively overlaid in their arches except for the downward-directed distance during the last phase (phase 3, Oc Ph3) of the occipital marker. Longitudinal analysis of the small bands of minor shoulder movements located in the lower part of the plot.
Chart is separated into three sections by the steep flexion movement at the end of phase 1 and the steep extension movement by the end of phase 2 of the neck flexion, extension, and rotation test (NEFERT). Lateral analysis of the small bands of minor shoulder movements below and above the small and slowly oscillating two bands of head movements, extending from start (left border) to finish (right border). Especially during maximal flexion, the frontal head rotations do not range sufficiently to cover the entire space defined between the shoulders. Especially during maximal extension (phase 3), the frontal head movements dip behind the curves of both shoulders.
Longitudinal analysis of the small bands of minor shoulder movements, located in the lower portion of the plot. The chart is visibly separated into only two sections by the steep extension movement at the end of phase 2 of the neck flexion, extension, and rotation test (NEFERT). Being in a complete phase shift, these are located in the lower part of the plot, and above them are depicted the head movements. The chart is separated into three sections by the small occipital upward flexion movement at the end of phase I and the steeper occipital downward extension movement at the end of phase 2 of NEFERT. Especially during maximal extension (phase 3), the frontal and especially the occipital head movements dip behind the curves of both shoulders, although with small oscillations. Especially during maximal flexion (phase 2) and maximal extension (phase 3), the excursions of the two head movements are well synchronized.
Vertical analysis of the very small bands of vertically oscillating shoulder movements, located in the extreme lower portion of the plot, above which are depicted the head movements, with very small vertical elevations.
The chart is separated into two sections by the occipital downward extension movement at the end of phase 2 of NEFERT. The time chart extends from start (left border) to finish (right border), with very few oscillations.




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