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How to cite this article Nicolas-puel C, Akbaraly T, Lloyd R, Berr C, Uziel A, Rebillard G, Puel J, et al. We undertook this prospective study with 555 patients attending a specialist tinnitus clinic at University Hospital, Montpellier, France, between 1998 and 2003. The semiological analysis of tinnitus covered several parameters, and each patient completed a questionnaire. For spatial localization, patients were asked to describe their symptoms as being either left- or rightsided or as nonlateralized. Intensity was measured on a visual analog scale graded from 0 to 100, where 0 corresponded to an absence of tinnitus and 100 indicated the loudest tinnitus imaginable.
We considered the length of history, age at presentation, intensity of the tinnitus, and any associated hearing loss as continuous variables. Table 1 details the population that was seen within a specialist tinnitus clinic (N = 555).
Generally, patients were able to describe the circumstances in which they noticed the appearance of their tinnitus (Table 2). Analysis of the audiograms of the tinnitus patients showed a predominantly left-sided hearing loss, particularly in the higher frequencies (data not shown).
In this study, we focused on those patients who said that the onset of their tinnitus began after noise trauma.
Whereas in the overall population patients showed a mainly left-sided high-frequency hearing loss ( > 4,000 Hz), patients in the noise trauma population had similar hearing loss in each ear (Fig. Our study, undertaken in the context of a specialist tinnitus clinic at the University Hospital, Montpellier, shows that tinnitus affects both genders equally. In contrast to other tinnitus patients, those with a history of noise trauma demonstrated similar hearing losses in each ear and showed no difference in side of lateralization or nonlateralization of their tinnitus. In this study, almost all the patients who had a history of noise exposure said that their tinnitus was of a highpitched whistling frequency. In this study, we evaluated the intensity of tinnitus after noise trauma by using a visual analog scale. The vast majority of patients with noise trauma described their tinnitus as high-pitched and stable over time. This study shows that noise trauma appears to provoke a high-pitched whistling tinnitus that is stable over time, occurs in either ear, and usually appears in men who are, on average, younger than the general tinnitus population. The authors thank the Fond d'Aide a la Qualite des Soins de Ville Languedoc-Roussillon for his support in statistical analysis of the data. How to cite this article Oliveira CA, Negreiros JR J, Cavaicante IC, Bahmad JR F, Venosa AR.
The cause of objective tinnitus provoked by palatal and middle-ear myoclonus may be identified by magnetic resonance imaging of the central nervous system in the Guilliain-Mollaret triangle or it may be idiopathic. The production of objective tinnitus by myoclonus has been reported in the literature as being related to palatal [1-4] or middle-ear myoclonus [5-9].
The tensor tympani muscle (TTM) and the stapedius muscle (SM) are involved in middle-ear myoclonus. The TVPM increases tension in the soft palate and opens the eustachian tube when it contracts.
This brief review of anatomy and physiology provides important notes: The TVPM and the TTM both are supplied by the fifth cranial nerve, and both have insertions in the cartilaginous portion of the eustachian tube.
In 1983, Rock [10] described some patients who were able to provoke objective tinnitus by forcefully closing their eyelids (forceful eyelid closure syndrome).
In 1981, Klochoff [9] described patients with TTM contractions due to severe emotional distress and anxiety. We present two cases of objective tinnitus caused by myoclonus, neither of which is accompanied by a documentable lesion in the central nervous system.
A 40-year-old woman came to us complaining of bilateral clicks heard continuously in both ears and starting suddenly 4 years previously.
At otomicroscopy, we could see movement of the manubrium of the malleus and of the posterior quadrant of the tympanic membrane synchronous with the noises in both ears, although they were stronger in the left. The results of neurological examination, MRI with gadolinium enhancement of the brain, and computed tomography of the temporal bones were normal. On follow-up, patient 1 stated that the clicks again were bothering her and, indeed, they could be heard by the examiner when he put his ear close to the patient's ear.
At otomicroscopy, no movement could be seen in either side, even though the clicks were evident. Some reports cite objective tinnitus associated with a previous episode of facial paralysis [8] and report high-frequency continuous objective tinnitus cured by sectioning of the SM tendon [7].
The first case that we presented herein clearly shows the occurrence of both palatal and TTM myoclonus synchronous with the noises.
Stapedial reflex was present in the right ear of patient 1 and was absent in the left (worse) ear.
Further evidence of repeated opening and closing of the eustachian tube caused by the TVPM myoclonus is offered in our second case: Even though the tympanic membrane was perforated, we still could see rhythmical movements of the needle of the impedance bridge, probably indicating repeated pressure and volume changes in the middle ear (see Fig.
What seems to be clear is that at least part of the noise is caused by the slapping together of the eustachian tube walls, as stated by Pulec et al.
From a practical standpoint, one must always search for both palatal (TVPM) and middle-ear (TTM) myoclonus in patients with tinnitus symptoms.
This research was presented in part at the Twenty-Ninth Neurootological and Equilibriometric Society Congress, Bad Kissingen, Germany, March 14-l7, 2002. All the information on this website is published in good faith and for general information purpose only. From our website, you can visit other websites by following hyperlinks to such external sites. Please be also aware that when you leave our website, other sites may have different privacy policies and terms which are beyond our control. After a long time suffering from tinnitus disease, the ear ringing has stopped thanks to the author of tinnitus miracle book. Oct 23, 2014 - Men suffering erectile dysfunction in New Zealand are now able to buy sildenafil from specially trained pharmacists without a GP's prescription. Characteristics of Tinnitus in a Population of 555 Patients: Specificities of Tinnitus Induced by Noise Trauma.
In this study, we compared tinnitus that appeared to be induced by noise trauma with that perceived to start in other circumstances in a population of 555 patients attending the specialist tinnitus clinic at the University Hospital in Montpellier, France.
To do this, we compared tinnitus induced by noise trauma with that induced in other circumstances; we studied a population of 555 patients seen in a specialist tinnitus clinic at University Hospital, Montpellier. In regard to variability over time, certain patients described their tinnitus either as stable over time or as fluctuating (usually louder at bedtime and on awakening).
After otoscopy, audiometry was undertaken for each ear (air conduction, bone conduction, and speech audiometry). We analyzed the description of the sound of the tinnitus, its spatial localization, and the variability of the intensity as noncontinuous variables. We asked the patients to classify their tinnitus with regard to spatial localization and frequency, intensity, variability with time, and duration (Table 4).
Pure-tone audiograms in subjects with a history of noise trauma (NT) and those with other ear pathology. Almost all (98.8%) of these patients said that their tinnitus was of a whistling type (see Table 4). Correlation between the intensity of tinnitus and the hearing loss in those with a history of noise trauma (NT). In general, the patients seen tended to have a high-pitched hearing loss that is more marked on the left. The majority of tinnitus cases were linked to sound trauma after a concert, an evening at a nightclub, listening to a personal stereo, or using do-it-yourself power tools, in which one would expect both ears to have similar noise exposure. Statistical analysis showed a significant correlation between noise trauma and whistling tinnitus.
With this instrument, we significantly correlated the intensity of the tinnitus with the degree of hearing loss between 2,000 and 8,000 Hz. If the age and gender are accounted for by the source of the noise trauma (concerts, discos, hunting, do-it-yourself tools), the descriptive aspects of tinnitus are strongly correlated with hearing loss as demonstrated by pure-tone audiometry. The tensor veli palatini muscle (TVPM) and the levator veli palatini muscle (L VPM) are involved in palatal myoclonus. The TIM arises from the cartilaginous part of the eustachian tube, the adjacent part of the greater wing of the sphenoid, and from its 20- to 25-mm-Iong semicanal; its tendon inserts in the neck of the malleus. The L VPM elevates the soft palate and probably assists in the opening of the eustachian tube by the TVPM. In contrast, the SM and the L VPM are supplied by different cranial nerves and by the pharyngeal plexus, and neither has insertions in the cartilaginous portion of the eustachian tube. These patients had hearing losses in the lower frequencies, whereas hearing was normal in the higher frequencies. Most often, palatal myoclonus is related to documentable lesions in the central nervous system (Guilliain-Mollaret triangle). Still unclear is whether middle-ear and palatal myoclonus are different entities or usually appear together. The origin of the sounds also is in doubt: Are they produced by the eustachian tube walls slapping together or by TTM contractions or by both, and is the SM important in the production of the tinnitus?
With all the aforementioned uncertainties, treatment of this condition is certainly open to discussion. We discuss these cases in light of the previously described literature and some ideas our own. Nasoendoscopy with a 4-mm zero-degree rigid endoscope (Storz Endoscopy of America Inc ., Culver City, CA) showed movement of the soft palate synchronous with the sounds and revealed stronger pulses on the left side. We could see the TTM contracting rhythmically after exposure, but the SM was totally quiet. At otomicroscopy, movement of the posterior quadrant of the tympanic membrane-but not of the manubrium of the malleus-could be seen in both ears.
Audiometry showed conductive hearing loss in the left ear compatible with the tympanic membrane defect (Fig. His impression was that movements of the tubal muscles caused the noises reported in tinnitus. These symptoms seem to be different from the clicking noise we have discussed and probably are associated with synkinesis of the facial muscles (tinnitus triggered by closing the eyes) and SM.
Section of both TTM tendons did not eliminate the clicking but rendered it much weaker and tolerable to the patient and her bed partner.
However, during surgery, we watched the SM under the microscope for a long time and did not witness any contraction of this muscle. Both muscles are supplied by the fifth cranial nerve and belong to the same group of muscles. It is our contention that most cases of myoclonus will have a cause somewhere in the Guilliain-Mollaret triangle. While we strive to provide only quality links to useful and ethical websites, we have no control over the content and nature of these sites. My name is Martha Ferguson & I developed this website to share my reviews of Tinnitus Miracle ebook. Pfizer, the makers of Viagra , will now also sell this medicine in New Zealand men to access treatment for a healthier sex life. Patients had consulted for persistent tinnitus for 7 years from the onset of their symptoms.
Taking account of the sound level in discos and clubs and from personal stereos (especially when listened to through headphones), one can anticipate the advent of an entire new generation of tinnitus sufferers. Also, they were asked for a description of the sound; most patients were able to describe their tinnitus as whistling or buzzing. Complementary investigations, such as otoacoustic emissions, evoked auditory potentials, videonystagmography, computed tomography, and magnetic resonance imaging scans, were undertaken as necessary to help to diagnose any hearing loss. There was a broad age range of patients, from 11 to 91 years, with the average age at presentation in the clinic being 54 ± 15 years.
Tinnitus was often attributed to ear pathology (34.8%) or, in fewer cases, to another illness (10%). Within this category were concerts (53%), discotheques (35%), and prolonged use of personal stereos, especially when listened to through headphones (12%). However, the degree of hearing loss was significantly lower than that in patients suffering from other ear pathology (Fig.
Graphs show the average hearing loss in dB (± standard error of the mean) measured in the right ear (R, circles) and the left ear (L, crosses). Statistical analysis demonstrated a significant correlation between tinnitus precipitated by noise trauma and the perception of it as a whistling type. In 79.5% of cases, patients described their whistling tinnitus as stable over time (see Table 4).
The correlation between tinnitus intensity, as measured on a visual analog scale (white circles), and the hearing loss (black circles) gives a coefficient that becomes greater as the hearing loss becomes greater. From a descriptive point of view, the tinnitus described by the patients in this study was mainly whistling, was stable with time, and was perceived on the left side.
This being the case, we propose two hypotheses: (1) Fluctuating tinnitus tends to stabilize after a certain length of time or (2) fluctuating tinnitus may disappear, whereas longstanding tinnitus is stable. Assessing tinnitus and prospective tinnitus therapeutics using a psychophysical animal model. Cisplatininduced hyperactivity in the dorsal cochlear nucleus and its relation to outer hair cell loss: Relevance to tinnitus. From the literature, one can perceive the following unanswered questions: (1) Are palatal and middle-ear myoclonus different entities or do they usually appear together?
The first muscle originates from the edge of the greater wing of the sphenoid bone, adjoining petrosphenoidal fissure, and lateral wall of the eustachian tube.
The TTM pulls the malleus medially, increasing tension in the tympanic membrane, and the SM pulls the stapes footplate away from the oval window. In 1995, the same author [11] studied 428 patients who had no complaint of tinnitus and found retraction of the manubrium and posterior middle one-third of the tympanic membrane in 107 patients (25%) under the microscope during forceful eyelid closure. These authors showed that their patients heard sounds immediately after the onset of electrical activity in the region of the eustachian tube walls.
Tympanometry showed right and left middle-ear volume variations synchronous with the clicks. We sectioned the TTM tendon, after which the woman noticed remarkablly diminished tinnitus on completion of the procedure; however, after 2 weeks, the symptom had returned. The boy had many infections in this ear and eventually experienced a perforation of the tympanic membrane, which was central and dry at the time of examination.
Air-bone gap on the left is probably due to the tympanic membrane perforation and is not related to the tinnitus. Since then, most reports on this subject refer to palatal myoclonus and follow Politzer's ideas [1-5, 11].
Severe emotional distress and anxiety have been reported as causes of rhythmical TTM contractions and are said to be cured by relaxation techniques and section of the TTM tendon [9]. However, also clear is that the palatal myoclonus is an important component of the clicks: After section of the TTM, we still observed wavy movement of the posterior quadrant of the tympanic membrane at otomicroscopy, which was confirmed by the impedance bridge.
Possibly the absence of recordable reflex in the left ear was due to the strong rhythmical contraction of the TTM masking the reflex, but we cannot exclude the possibility of SM myoclonus not seen during surgery.
Patient 1 had a repeat examination 3 days before this writing, results of which showed no abnormalities in the Guilliain-Mollaret triangle.
SM contribution to the clicks is possible but unlikely because it is supplied by a different cranial nerve (nerve VII) and it is a small muscle (four times smaller than the TTM semicanal).
Section of the TTM is an easy and safe procedure and may solve the problem (as in patient 1). Affected patients must be followed up closely, because such lesions may become apparent at a later date. Palatal myoclonus as a cause of objective tinnitus: A report of six cases and a review of the literature. Impedance Fluctuation and a "Tensor Tympani Syndrome." In RL Penha, W Pizarro (eds), Proceedings of the Fourth International Symposium on Acoustic Impedance Measurement.
These links to other websites do not imply a recommendation for all the content found on these sites. Among these tinnitus patients, 17% described their tinnitus as starting after excessive noise exposure.
Depending on the variables under analysis, a Student's t-test or chisquared testing was undertaken. In 15.9% of cases, the tinnitus appeared in association with psychological problems, such as emotional trauma, depression, or episodes of stress or anxiety. Next most prevalent was firearm use (16.2%), the majority related to hunting or shooting as a leisure activity. The intensity of tinnitus perception was significantly correlated with the degree of hearing loss measured between 2,000 and 8,000 Hz.
Note that the greatest correlation coefficients occur in the highest frequencies of hearing loss. Although not statistically significant, this latter finding is in accordance with other studies showing that hearing loss and tinnitus are generally more noticeable on the left side [8]. This link correlates with an earlier study on a smaller population showing that a whistling type of tinnitus was correlated with a high-frequency hearing loss and that a buzzing type of tinnitus was correlated with a low-frequency hearing loss [7].


These results agreed with our previous study of 58 patients [7], which showed that the intensity of stable whistling tinnitus is perceived as increasingly strong as the highfrequency loss is more marked. Only a longitudinal study of tinnitus patients will allow us to clarify these hypotheses further. However, this attempt at categorizing patients' tinnitus as a function of both the etiology and the semiology allows us to evaluate better the medical and psychological treatment of these tinnitus patients. The SM arises from the pyramidal process, and its tendon inserts in the neck of the stapes. He also found increased impedance at maximum compliance during forceful eyelid closure in 75% (321 patients) . They hypothesised that the noises were caused by the slapping of the eustachian tube walls as they closed.
Nasoendoscopy with the rigid 4-mm zero-degree endoscope (Storz) showed palatal movements (as described in patient 1) on both sides, although they were stronger on the left side.
Few reports, however, refer to middle-ear myoclonus, and the source of the noises is said to be the TTM rhythmical contractions [6,11 ,12]. This outcome probably represents the repeated opening of the eustachian tube by the TVPM myoclonus, and the clicking probably originates from the slapping together of the tube walls when closing, as stated by Pulec et al. Nonetheless, in more than 20 years of practice in Brazil, we have seen only two cases of idiopathic palatal and middle-ear myoclonus.
The TTM also has insertions in the cartilaginous eustachian tube and could contribute to tubal opening. If such a procedure is insufficient to cure the disorder, clonazepam might help but may not be tolerated and may lead to habit formation.
The patients who had a history of noise trauma had a symmetrical hearing loss, and no difference was seen in lateralization of tinnitus perception. Approximately 7% of the adult population judge their tinnitus to be sufficiently severe to warrant consulting a doctor [2].
We used chi-squared testing to study any associations between two variables in a class, ANOVA testing to study variables in the same class and continuous variables, and Pearson correlation coefficients to compare two continuous variables.
This difference may be explained by the age difference between the two groups, as the patients exposed to noise trauma were, on average, 10 years younger. In addition, in patients with no history of noise exposure, the hearing loss is significantly greater in the left ear than in the right, at frequencies greater than 4,000 Hz (asterisk). In whichever age group, hearing loss is less obvious in those patients with a history of noise trauma (white symbols) than in those without (black symbols). It is not easy to compare our results using a visual analog scale with those studies wherein patients are asked to evaluate the frequency and intensity of their tinnitus with an external sound, usually a pure tone generated by an audiometer [12,13]. In addition, such a step allows us to better define those populations that are similar to the experimental models of tinnitus and on which therapeutic strategies are being developed [14-20]. In 2000, Jero and Salmi [5] stated that palatal myoclonus may be idiopathic, but this is extremely rare. After the second procedure, the patient was much improved for 2 months, although she still could hear the clicks in both ears.
The tensor tympani muscle tendon has been cut on both sides; therefore, the volume oscillations are due to the tensor veli palatini muscle myoclonus opening the eustachian tube repeatedly. In the right ear, he also had clicks that were less intense and not as easily provoked by the aforementioned maneuvers. As the left tympanic membrane had a large central perforation, these oscillations of volume and pressure are due to the tensor veli palatini muscle myoclonus opening the eustachian tube repeatedly. Some reports suggest simultaneous rhythmical contractions of the SM as part of middle-ear myoclonus. Also clear is that TTM myoclonus produces noise in the middle ear when vibrating the ossicular chain. Botulinum toxin injected in the TVPM certainly would work but might cause palatal dysfunction and would have to be repeated for a lifetime; the eustachian tube probably would malfunction as well. Ieteicama deva ir 50 mg, registracijas apliecibas pieskirsanu un ieteikumus par Viagra lietosanu. This subset of patients was mainly male and on average was 10 years younger than other tinnitus patients.
When questioned, 5% of German adults stated that they had irritating tinnitus, 1% of adults considered themselves handicapped by their tinnitus, and 0.5% were unable to live a normal life [3]. All the data, whether in a table or in text, are expressed as the mean plus or minus the standard deviation. Tinnitus precipitated by use of machinery accounted for 11.6% (mainly such do-it-yourself tools as drills and grinders.
To determine the influence of age on the hearing loss, we performed a stratified study on two groups of patients with demonstrable hearing loss, whether or not they had a history of noise trauma: those 40 years old and older and those younger than 40 years.
Among those aged 40 years or younger, the difference is significant at 250, 500, 1,000, and 8,000 Hz, whereas in those older than 40, the difference is significant only in the lower frequencies (250, 500, and 1,000 Hz). Leisure noise appeared to be the principal cause, especially amplified music, whether from a concert or a disco. In our study, the small number of patients who had been exposed to firearm noise did not permit significant study. In these cases, patients were able to perceive the external sound only if it were presented 5-15 dB above their auditory threshold, which poses a problem with interpretation. The second muscle arises from the inferior surface of the apex of the petrous bone medial to the eustachian tube, and its tendon merges with the upper and posterior surface of the palatal aponeurosis.
The patient was placed on clonazepam for 2 weeks, after which she reported a decrease in the noises; however, she discontinued the medicine because of excessive drowsiness.
The intact tympanic membrane on both sides prevented any pressure variation large enough to be recorded. The noises in the left ear were easily heard by the examiner without getting close to the patient. Our plan is to perform a tympanoplasty in the left ear and to section the TTM tendon at the same time. In this population, the hearing loss is significantly less than that measured in the other patients, even allowing for their younger age. For more clarity, data plotted in the graphs are expressed as the mean plus or minus the standard error of the mean.
Among those younger than 40, hearing loss at 250, 500, 1,000, and 8,000 Hz was significantly less in the patients with a history of noise trauma. Note the characteristic notch in the audiogram at 6,000 Hz in those younger patients with a history of noise trauma. This would explain an average age of this group of tinnitus sufferers 10 years younger than that of the other tinnitus patients. For example, should tinnitus that has been measured at 10 dB above the auditory threshold be considered as low intensity (only 10 dB) or stronger than the hearing loss would suggest? We present two cases of idiopathic palatal and middle-ear myoclonus and discuss these cases in light of the literature and of some ideas of our own.
When last seen I week before the writing of this article, she was on no medication and stated that the clicks were perfectly tolerable and that she did not wish further medication. Sis zales nedrikst Ka jau noteikti esat dzirdejusi, Viagra tiek lietota, lai arstetu impotenci viriesiem, Viagras lietosana , ja taja pat laika lietojat jebkadus medikamentus, kas satur Alkohola lietosana islaicigi var ietekmet speju sasniegt erekciju. Acheter cialis veritable, Pharmacie lafayette prix viagra , Viagra avec ordonnance Prix officiel du viagra en pharmacie. Statistical analysis showed a significant correlation between a history of exposure to noise trauma and the presence of a high-pitched "whistling" tinnitus. However, we observed no significant difference in hearing loss at 2,000, 4,000, and 6,000 Hz (see Fig. Other sources of noise trauma were firearm use and do-it-yourself power tools, which would explain the overwhelming male majority in this noise exposure subgroup.
Eggermont and Roberts [11] demonstrated that the frequency of tinnitus is closely correlated to audiometric hearing loss. With tinnitus measurable in this way at 5-15 dB above the threshold, would one have to say that the intensity of tinnitus depends on hearing threshold and that a proportional relationship exists between tinnitus and hearing threshold?
The superior cerebellar peduncle joins the dentate and the red nuclei, and the olivodentate tract joins the dentate nucleus and the inferior olive. Lai efekts butu vislabakais, ieteicams pirms Viagra lietosanas nelietot parak daudz alkohola. The presence of whistling tinnitus was significantly correlated with high-frequency hearing loss. In France, a study involving the population around Nice produced results similar to those of other countries with regard to the prevalence of tinnitus [4].
Finally, whatever the pathology responsible for the appearance of tinnitus, patients had suffered for an average of 7 years before being seen in the tinnitus clinic.
In other words, the frequency spectrum of tinnitus is inversely proportional to auditory threshold. Only a study comparing the two types of tinnitus intensity evaluation (audiometric-based pitch matching and visual analog scale) will allow clear answers to those questions. These authors believed that the great majority of palatal myoclonus cases have a documentable lesion in the aforementioned structures. May 13, 2002 - Viagra , ko agrak pazina ar nosaukumu sildenafils, tika izstradata ka sirds antidepresantu un prethistamina preparatu lietosana ), so faktoru Apr 18, 2012 - Pilns visu Viagra izraisito nevelamo blakusparadibu apraksts ir atrodams zalu lietosanas instrukcija . The intensity of tinnitus, measured using a visual analog scale, appeared to be stronger than the measured hearing loss would suggest.
A further French study focusing on the quality of life of 603 tinnitus sufferers showed clearly that in 26% of patients, tinnitus created difficulties in everyday life [5]. This may be related to the fact that this study was undertaken in a hospital setting, which tends to be a secondary or tertiary referral clinic for patients with tinnitus. If this were the case, one would expect that the whistling tinnitus noticeable after noise trauma would have a spectrum predominating in high frequencies. However, the correlation between hearing loss and intensity of tinnitus that we measured in this study suggests that a visual analog scale is the tool of choice to help us to understand the incapacitating character of tinnitus associated with noise trauma. Working with monkeys in 1984, Fitzgerald [3] showed that lesions in the inferior olivary tract caused palatal myoclonus. The presence of tinnitus engenders notable modifications of behavior and a clear deterioration in quality of life.
Among those who were 40 years old or older, hearing loss between 250 and 1,000 Hz was significantly greater in the patients who did not experience noise trauma, although we observed no significant difference at 2,000, 4,000, 6,000, and 8,000 Hz. Their hypothesis was that the continuous sound was caused by tetanic contractions of the TTM and SM muscles.
Irritability, stress, anxiety, and deterioration in quality of sleep are frequently described both by tinnitus patients themselves and by their families [5]. These results show that whatever a patient's age, those with a history of noise trauma has less hearing loss than did those with other etiologies of hearing loss. Mar 2, 2005 - A«PfizerA» zila A« Viagra A» aicina viriesus Ir nelielas atskiribas to kimiskaja sastava, lietosana un blakusparadibas.
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