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Author: admin, 10.01.2015. Category: Medicine For Tinnitus Over The Counter

A very recent development is the capability to do screening audiometry on one's own cellphone. The core method of pure tone audiometry is to present a series of tones in one ear, close to threshold (the loudness that the person can just barely detect), and keep dropping the intensity in 10 db steps until the person stops responding - -raising their hand or pushing a button.
There are a few places where human input is needed because there are sometimes few decisions to make during hearing testing.
Of course, there are many far more complex decisions and thought processes that can potentially present in persons with hearing disorders. For the most part, there is rarely a reason to do bone conduction if the air conduction audiogram is normal. Bone conduction testing in persons with hearing loss should be done with masking (see below) to prevent sound from the stimulated side from going over to the good side.
Practically, electrical devices (such as digital audiometers or CD players) will never drift in frequency or volume. On the other hand, mechanical devices (such as headphones, and insert headphones in particular) nearly always break down over time.
This website is designed to offer resources and information regarding hearing loss, babies, preschoolers and their families. In the assessment of hearing, one must remember that a dysfunction of the auditory system may be a manifestation of a systemic and possibly life-threatening disorder. Frequently, the patient with a conductive loss of hearing complains of tinnitus, which may be localized in one ear or in both ears, or unlocalized in the head. Sensorineural hearing loss occurs with pathology in the inner ear or along the nerve pathway from the inner ear to the brainstem. Congenital sensorineural hearing loss may result from hereditary factors, malformation of the cochlea, in utero viral infections, or birth trauma. The configuration of the audiogram demonstrating a sensorineural hearing loss may vary significantly and, in some instances, may suggest the cause of the loss. Loudness recruitment is usually associated with sensory loss of cochlear origin, which constitutes the majority of sensorineural losses. The patient with sensorineural hearing loss is usually subject to tinnitus of a somewhat different sort from that associated with conductive hearing loss.
In sensorineural losses, the audiometric Weber test is expected to lateralize to the better hearing ear.
Contrary to a commonly held misconception, sensorineural hearing loss may be helped by the use of hearing aids. The problems of differentiating cochlear dysfunction from eighth-nerve lesions have received major emphasis during the past several years. Routine pure-tone and speech testing can yield valuable information on the site of lesion during the initial phase of the differential audiologic study. As would be anticipated, lesions within the central auditory sytem are difficult to detect or localize. Ear and bead noises, the most common complaints presented to the audiologist or otolargyngologist, are frequently seen by the neurologist as well.
The perceived loudness of tinnitus in any patient may be intense enough to be highly debilitating. Most tinnitus sufferers have a concomitant loss of hearing, which may be either conductive or sensorineural. Tinnitus is a symptom of an underlying disease or specific lesion when it is perceived above the intensity levels of environmental sounds.
Assuming there is no cerumen in the external ear canal, the tympanic membrane should be inspected.
The office examination of hearing loss may include tuning fork tests of air and bone conduction. An audiologic assessment comprises pure-tone air and bone conduction testing and speech threshold and word discrimination measures.
In the measurement of bone conduction thresholds, pure tones are transmitted via a bone oscillator, usually placed on the mastoid. A speech reception threshold is the lowest intensity at which an equally weighted two-syllable word is understood approximately 50% of the time.
Speech discrimination is a tool used to assess an individual's ability to understand a speech signal at normal or above normal conversational levels. Tympanometry, static acoustic immittance, and acoustic reflex threshold measures make up the acoustic immittance test battery. The acoustic reflex threshold is the lowest intensity needed to elicit a contraction of the stapedius and tensor tympani muscles using a pure-tone stimulus. Brainstem auditory evoked potentials (BAEPs) are also known as brainstem auditory evoked responses (BAERs) or auditory brainstem responses (ABRs). The BAEP is a sensitive, noninvasive diagnostic test for the diagnosis of cerebellopontine angle tumors.
The absence of waves III and V has been seen in some patients with vestibular schwannoma and in cerebellopontine angle meningiomas. Electrocochleography (ECochG) is a method of recording the stimulus-related electrical potentials associated with the inner ear and auditory nerve, including the cochlear microphonic summating potential (SP) and the compound action potential (AP) of the auditory nerve. Therapy for auditory disorders is largely the province of the otolaryngologist and the audiologist. Contrary to a commonly held misconception, sensorineural hearing loss may be helped by the use of a hearing aid. We note that the hearing aid is the most important rehabilitative tool available for the management of sensorineural hearing loss; however, counseling should be a central focus of any management strategy for the hearing-impaired adult.
The complete evaluation of the tinnitus patient should be approached from a dual perspective. When a specific otologic cause for the tinnitus is identified, otologic management is indicated. Research on the effectiveness of pharmacologic therapy for tinnitus, although certainly encouraging, involves medications such as carbamazepine, lidocaine, and intravenous barbiturates, whose potentially serious side effects limit their usefulness. The use of masking as a management tool in the treatment of the tinnitus patient has met with mixed success over the years.
Tinnitus maskers are designed to provide relief to the tinnitus sufferer by introducing an external masking sound into the affected ear or ears, thereby minimizing or eliminating the perception of the tinnitus. Experience with tinnitus patients reveals that many have relatively high levels of anxiety, tension, or other symptoms of chronic stress.
Effective counseling is one important aspect of tinnitus management regardless of the management approaches taken with a given patient. We will be provided with an authorization token (please note: passwords are not shared with us) and will sync your accounts for you. 1Department of Otolaryngology-Head and Neck Surgery, Washington University School of Medicine, St. 2Department of Radiology, Mallinckrodt Institute of Radiology, Washington University School of Medicine, St. Objective: Language acquisition was assumed to proceed normally in children with unilateral hearing loss (UHL) since they have one functioning ear. Results: Lower FA of left lateral lemniscus was observed for children with UHL compared to their NH siblings, as well as trends toward differences in other auditory and non-auditory regions. A few studies have used DTI to investigate the neuroanatomic properties of auditory processing regions in patients with hearing loss. This study protocol was approved by the Human Research Protections Office (HRPO) at the Washington University School of Medicine. Cognitive ability was assessed by the Wechsler Abbreviated Scale of Intelligence (WASI) (Wechsler, 1999).
The images were preprocessed and transformed into modified (Talairach and Tournoux, 1988) space using the following methods.
The 15 regions of interest selected for analysis are listed in Table 1 and fall into two groups. Regions were located and sampled after the MPRAGE scans were transformed into Tailarach space over three to four slices each by one independent rater under the supervision of an experienced neuroradiologist. Because multiple variables can predict outcomes, we used multiple linear or logistic regression modeling to evaluate the role of age and UHL simultaneously with the specific DTI parameters which were statistically significant or trending toward significance in bivariate analysis on the educational outcomes of interest.
Though NH subjects performed better on all aspects of the cognitive testing, these differences were not all statistically significant (Table 3).
DTI parameters were compared separately on the left and right side of the brain; for instance, the FA of the right auditory radiation of the UHL group vs. Paired comparisons between the left and right sides of structures were performed for the UHL and NH groups. In general, FA correlated positively and MD negatively with test scores for children with UHL (data not shown). Multiple logistic regression analyses were performed similarly for IEP and speech therapy as the dependent variables. Hopefully, in the next 10 years or so, most of the testing may be done by the public as software is becoming available to test hearing on smartphones and similar devices.
This is just a part of the entire human auditory range, which extends between 20 and 20,000 hz. Then the person testing the hearing goes back up in 5 db steps until the person starts responding again. The insert earphones have the advantage that they block out environmental noise, and they also have less of a tendency to be heard by the other ear. The reason to do this is to prevent sound from the side being tested from going over to the good side.
WRS has some limitations - - most of us don't communicate with monosyllabic speech, so a good score on the WRS may not necessarily correlated with good functional performance. Every single part of the system that you use should be calibrated - -the electrical device that produces the sound, and the headphones or speakers that deliver the sound. Once their intensity is checked, formal electrical calibrations are more likely to cause trouble (i.e.
This is not a severe hearing loss and ordinarily very little benefit would be obtained from a hearing aid.
We think the most promising avenue is exploring more home testing -- we think smartphones with appropriate software, could hugely improve accessibility of hearing testing.
Therefore, the examiner, in addition to obtaining a history of the past, present, and familial audiologic and otologic complaints, should also elicit a history of complaints referable to other systems. An abnormality within the outer or middle ear results in a conductive loss of hearing due to an inefficient transmission of sound to the inner ear system.
The bone conduction thresholds are normal, but air conduction results suggest a decrease in hearing sensitivity. A pure sensorineural impairment exists when the sound-conducting mechanism (outer and middle ear) is normal in every respect, but a disorder is present in the cochlea or auditory nerve. Generally, the patient with sensorineural loss reports a constant ringing or buzzing noise, which may be localized in either ear or may not be localized. Audlometrically, sensorineural loss is characterized by overlapping air and bone conduction thresholds.
Current technology uses full dynamic range compression to increase significantly the effectiveness of amplification. The patient's behavior will reflect attributes of both a conductive and a sensorineural disorder. In fact, this area has been emphasized to the extent that some audiologists have limited their concept of differential audiology primarily to tests that assist localizing the defect within the sensorineural mechanism. For example, a pure-tone configuration that is often seen in patients with a presumptive diagnosis of Meniere's disease is a unilateral hearing loss most pronounce in the low-frequency range.
In fact, many central auditory dysfunctions are not demonstrated by conventional audiologic measurements. Up to 32% of the adult population has tinnitus, with 20% of the population rating their condition as severe. Most patients with sensorineural hearing loss report tinnitus to be a high-frequency tone, but tinnitus associated with conductive hearing loss tends to be low in frequency. Whether or not the patient's complaint is one of hearing loss, a basic assessment of auditory function should be part of the neurologic examination. The neurologist should be able to recognize an inflamed, bulging, or scarred drum and should note whether there is perforation of the tympanic membrane, blood behind the eardrum, or a pulsating blue mass that may indicate a glomus jugulare tumor. Tuning forks at a frequency of 256 or 128 Hz should not be used because of the vibrations they produce by bone conduction, which the patient may mistake for Hound; 512 Hz is the lowest useful frequency. The Weber test is based on the principle that the signal, when transmitted by bone conduction, will be localized to the better-hearing ear or the ear with the greatest conductive deficit.
The Rinne test is probably the most commonly used tuning fork test, but the name is usually mispronounced: It is German, not French, and is accentuated on the first syllable (Rin'neh).
Threshold is defined as the lowest intensity (measured in decibels) at which an individual can detect a pure tone or speech signal more than 50% of the time.
Most commonly, a phonetically balanced word list of 50 one-syllable words is presented to the patient at a suprathreshold level. Tympanometry is a measure of middle ear mobility when air pressure in the external canal is varied. Immittance measures are obtained at +200 mat H2O (first point of compliance, or C1) find again at the point at which the tympanic Membrane is most compliant (second point of compliance, C2). The introduction of an intense sound into the ear canal results in a temporary increase in middle ear impedance. These physiologic measures can be used to evaluate the auditory pathways from the ear to the upper brainstem. This test is used to differentiate cochlear from eighth-nerve hearing defects and, on some occasions, demonstrates an auditory abnormality when behavioral audiometric testing is still normal. Such patients often have marked hearing deficits with poor discrimination on behavioral testing, suggesting retrocochlear disease. This measure is beneficial in the differential diagnosis of certain types of sensory disorders, such as Meniere's disease or cochlear hydrops.


However, the neurologist interested in neuro-otology should have some knowledge of therapy to promote appropriate referrals. However, hearing aids only compensate for loss of sensitivity, but the manner in which increased loudness is achieved may reduce distortion and significantly increase discrimination in certain situations.
There are many assistive devices on the market, and new systems and modifications are appearing at an accelerating rate. In addition, the hearing-impaired should receive counseling both before and after the provision of amplification. The patient with tinnitus, regardless of location, type, or severity, must first have a thorough otologic and audiologic examination. When a lesion or disease process is not identifiable, then tinnitus management is more difficult. There is some suggestion that relatively low doses may prove effective in tinnitus management. The audiologist should remain cognizant of factors such as the patient's perception of the pitch and loudness and the overall spectral intensity of the masking signal. Although the use of tinnitus maskers has not proved universally successful, masking is still a feasible technique that cannot be ignored. Many patients are frightened by tinnitus and need a careful and clear explanation of the disorder, coupled with firm reassurance from both the neurologist and the audiologist. This means that you will not need to remember your user name and password in the future and you will be able to login with the account you choose to sync, with the click of a button. This page doesn't support Internet Explorer 6, 7 and 8.Please upgrade your browser or activate Google Chrome Frame to improve your experience. However, children with UHL score poorly on speech-language tests and have higher rates of educational problems compared to normal hearing (NH) peers. Twenty nine children with severe-to-profound UHL were compared to 20 siblings with NH using IQ and oral language testing, and MRI with DTI.
Correlation analyses showed associations between several DTI parameters and outcomes in children with UHL. Although children with UHL have performed worse on speech-language tests, it is less clear that the side of hearing impairment influences cognitive abilities. In a prior investigation in this study cohort, differences in resting state functional connectivity MRI (rs-fcMRI) were found in areas associated with auditory processing, executive function and memory formation between children with UHL and NH controls (Tibbetts et al., 2011). Participants with UHL were defined as having severe-to profound sensorineural UHL by pure tone audiometry, with pure tone averages (PTA) ≥70 dB hearing level (HL) in the affected ear. Informed consent was obtained from all parents of subjects and pediatric assent obtained from all minor participants.
Parents also indicated whether children required speech therapy, special educational accommodations or special services at school, or an individualized educational program (IEP).
We used standardized performance IQ, verbal IQ, and full scale IQ scores along with vocabulary T-scores as educational outcomes.
A 9-parameter rigid body alignment registered all frames in all runs and was used for motion correction of each subject. Regions of interest (ROIs) used for DTI measurements placed on anatomical T1-weighted MRI scan.
Additional regions of interest (ROIs) used for DTI measurements placed on anatomical T1-weighted MRI scan; all are non-auditory ROIs. ROI location was traced on the MPRAGE anatomy, but guided using coregistered T2-weighted images to avoid cerebrospinal fluid, and FA images to capture fiber centers. Educational performance variables were compared with Mann-Whitney U-tests between the UHL and NH groups and between the right and left UHL groups. Paired Wilcoxon signed rank-test of DTI parameters between sides (right and left) were performed within each of the groups. For the regression analyses, a p-value less than 0.05 was considered statistically significant. Demographic characteristics of normal hearing (NH) children and children with unilateral hearing loss (UHL). Comparisons between unilateral hearing loss (UHL) group and the normal hearing group (NH) for educational outcome variables, and right unilateral hearing loss (right UHL) and left unilateral hearing loss (left UHL) groups. The FA of the left lateral lemniscus and the FA of the left subcortical white matter of Heschl's gyrus trended toward being lower in the left UHL group.
In all UHL subjects, the right side FA was greater than the left side FA in both auditory and non-auditory regions, with the exception of the superior temporal gyrus, middle cingulate gyrus, anterior limb of the internal capsule, centrum semiovale and the anterior corona radiata (Table 5). Though there were many trends toward significance in the NH group, there were no significant correlations. Spearman rho correlation values between educational outcomes and DTI parameters (fractional anisotropy, FA; mean diffusivity, MD) in auditory and non-auditory regions of interest (ROI) in participants with normal hearing (NH), unilateral hearing loss (UHL), right UHL or left UHL.
As with the correlation analyses, FAs were generally positively related to test scores while MDs were negatively associated with test scores (Table 7).
The FAs of the bilateral middle cerebellar peduncles were negatively related to the need for speech therapy (Table 8). This will free up the audiologists to handle the difficult cases and give them more time to help people select hearing aids. This will probably drastically change how hearing testing is done as one can now test hearing right away. Neverthless, most audiometers are designed so that they cannot go as low or high as most good stero systems. There are special symbols for the conditions underwhich the hearing test is done (see below). Their main disadvantage is that they are a little trickier to use (one has to insert them properly), and also that they give wrong readings in persons who have perforations of their ear drums. The first few minutes spent talking with the patient or relatives will help to define the direction the inquiry should take.
When the loss of hearing is due to pathology in the cochlea or along the eighth cranial nerve from the inner ear to the brainstem, the loss is referred to as a sensorineural hearing loss. The patient with a conductive hearing loss typically demonstrates decreased sensitivity across all frequencies. As mentioned, there exists some ambiguity among audiologists, neurologists, and otologists concerning what is a retrocochlear and what is a central problem.
These individuals have no difficulty understanding speech at normal intensities in a quiet environment, since low-frequency hearing is unimpaired.
The recruiting patient with sensory loss will not hear low-intensity sounds at all and may just barely hear sounds of moderate intensity, but the recruitment of loudness May cause moderately loud sounds to be perceived as uncomfortably loud. In general, the pitch of tinnitus tends to be higher In sensorineural impairment than in conductive impairment. The tympanogram is typically normal, and acoustic reflexes may be present, elevated, or absent.
Causes of mixed hearing loss may be any combination of the conditions described above for conductive and sensorineural hearing loss. The neurologist's interest in sensorineural hearing loss is with regard to the possibility of a cerebellopontine angle tumor. In sharp contrast, patients with eighth-nerve lesions frequently present a unilateral hearing impairment most evident in the high frequencies and poor speech discrimination.
Individuals with known lesions in the central auditory tracts may not manifest any significant hearing loss when tested by conventional  pure-tone audiometry. Tinnitus may be considered a significanct symptom when its intensity so overrides normal environmental sounds that it invades the consciousness. However, knowledge of the pitch of the tinnitus is of little diagnostic benefit other than allowing for the gross dichotomy of conductive versus neural pathology. Tinnitus may precede or follow the onset of a loss in hearing, or the two may occur simultaneously. The complaint may be an early symptom of a tumor in the internal auditory meatus or in the cerebellopontine angle; a glomus tumor, or a vascular abnormality in the temporal bone or skull. Objective tinnitus may be vascular (an arteriovenous malformation or fistula) or mechanical in origin. It is usually not very disturbing, and the patient can be easily distracted from the tinnitus by other stimuli. The external ear should be inspected with an otoscope to determine the patency of the external ear canal and the integrity of the tympanic membrane. Excellent descriptions of tympanic membrane findings may be found in modern texts of otology. The test can determine the type of hearing impairment when the two ears are affected to different degrees.
The Rinne test is a comparison of the patient's hearing sensitivity by bone conduction and air conduction.
The presence of decreased air conduc-tion thresholds and normal sensitivity by bone conduction suggests abnormality in the external ear or middle ear system and is termed a conductive hearing loss. Comparison of the speech reception threshold and the pure tone average serves as a check on the validity of the pure-tone thresholds. Results are graphically represented, with pressure along the x axis and compliance along the y axis. The point at which the tympanic membrane is most compliant allows maximum transmission of energy through the middle ear cavity.
This phenomenon occurs bilaterally; however, it is typically measured in one ear at a time.
In addition, ABR threshold testing may be used to determine behavioral threshold sensitivity in infants or uncooperative patients. The Amplitudes of the SP and AP are measured And are of primary interest in evaluating an ear for increased endolymphatic pressure. Modern hearing aids use the latest microcircuitry and signal-processing techniques, such as digital filtering, to improve significantly the effectiveness of amplification. Lastly, cochlear implants have proven to be extremely beneficial for individuals with severe to profound hearing loss who receive minimal benefit from amplification.
Given no underlying otologic disease, there is at present no effective surgery or medical therapy for the treatment of tinnitus.
The actual efficacy of tinnitus maskers in the average tinnitus patient is probably less than 30%. Biofeedback as a treatment in the management of tinnitus was first reported in the literature in the mid-1970s. In light of the various effects tinnitus may have on a given patient, counseling must be directed toward all of the patient's difficulties, not this specific problem in isolation.
Diffusion tensor imaging (DTI) is an imaging modality used to measure microstructural integrity of brain white matter. Regression analyses revealed relationships between educational outcome variables and several DTI parameters, which may provide clinically useful information for guidance of speech therapy. It was previously assumed that because children with UHL had one functioning ear, speech acquisition and language comprehension skills developed normally. According to the REA hypothesis, children with right UHL should have greater difficulties with language skills than those with left UHL. In light of DTI changes reported in prior studies of hearing loss, the goal of this study was to determine how UHL influences the development of white matter tracts in the brain. All scores were standardized to a mean of 100 with a standard deviation (SD) of 15, except for the vocabulary T-score, which is standardized to a mean of 50 and SD of 10.
Resampling was done by a 3-dimensional cubic spline interpolation and transformed to a Talairach atlas space using a single common atlas derived from adult and child brains via a warping mechanism (Burgund et al., 2002).
The second group are non-auditory regions that are considered important white matter areas that are commonly sampled in DTI studies of the brain.
The FA and MD values in the ROIs were measured and averaged over consecutive slices for a more accurate measurement than a single slice would give, thus minimizing the risk of type I error. Correlations between educational variables and DTI parameters were explored using Spearman's rho coefficient.
There were no significant differences in gender, age, racial composition, handedness or rates of prematurity between the NH and UHL groups. However, NH individuals trended toward higher scores on the verbal component of the cognitive tests (Table 3). FA values trended toward being higher in the NH group than in the UHL group in two auditory regions and two non-auditory regions. In the UHL group, the FA and the MD of several ROIs correlated significantly with several different educational parameters, such as full IQ, verbal IQ, IEP, and speech therapy (Table 6).
When an otologist and audiologist or technicianwork together as a team, the otologist should tell the audiologist or technician whether or not bone is needed even if hearing is normal.
Of course your CD player's volume should be calibrated so that the volume of words presented is identical to the volume from your audiometer. Poor performance overestimates everyday communication impairment for patients with high frequency hearing loss.
So there is a conflict between the financial needs of one's hearing equipment vendor and patient care.
The examination of the patient, the complaints, and the preliminary audiologic findings determine how inclusive the examination must be and what subsequent tests must be ordered.
Patients may exhibit both conductive and sensorineural loss, which is referred to as a mixed hearing loss.
For the purposes of this discussion, we define retrocochlear as between the cochlea and the brainstem (see below). This disruption of normal loudness function may be painful to the individual and require the use of variable compression circuitry should the patient pursue hearing aid use.
In addition, the patient may report that tinnitus is only present at night or when background noise is minimal, when in fact it is always present, but the patient perceives it only in quiet environments. The audiometric findings for a typical sensorineural hearing loss are displayed in Figure 7.12.
The conductive component of the mixed hearing loss may be corrected by successful medical or surgical treatment, but the sensorineural component is not reversible.


Although many referrals for audiologic evaluation are made for this reason, we must emphasize that even the more sophisticated special auditory tests cannot determine the specific pathology underlying the disorder. Although such generalizations may describe a substantial number of cases falling into these two categories, numerous exceptions are encountered with either cochlear or neural pathology.
Total removal of one hemisphere of the brain in humans has not resulted in any major change of auditory sensitivity in either ear. The patient experiencing tinnitus may describe the sound as ringing, roaring, hissing, whistling, chirping, rustling, clicking, or buzzing, or use other descriptors. Because tinnitus may be a characteristic symptom of a number of disorders, a complete medical and audiologic evaluation is an important initial step in the management process. This type of tinnitus can result from a lesion involving the external ear canal, tympanic membrane, ossicles, cochlea, auditory nerve, brainstem, and cortex. Moderate tinnitus is more intense and is constantly present; the patient is conscious of the tinnitus when attempting to concentrate or when trying to sleep. At times it may be helpful to inspect the mobility of the eardrum by increasing pressure within the external canal, using a hand-held pneumatic bulb attached by tubing to an outlet in the otoscope. The stem of a vibrating tuning fork is placed on the skull in the midline, and the patient is asked to indicate in which ear the mound is heard.
A normal individual will perceive the air-conducted sound as louder than, or the same as, bone-conducted sound.
Generally, discrimination ability decreases proportionately with an increase of hearing impairment.
Contralateral reflexes are measured by stimulating one ear and measuring the reflex from the contralateral ear. The most consistent and reproducible potentials are a series of five submicrovolt waves that are seen within 10 msec of an auditory stimulus.
Both medical and surgical therapies are appropriate, depending upon the nature of the disorder. The patient with an isolated symptom of a persistent, yet unexplained, tinnitus should receive follow-up examinations at definite intervals when initial medical, otologic, and neurologic studies reveal no evidence of disease.
These early studies reported the use of biofeedback as effective in the relief of tinnitus or the associated annoyance produced by it.
The purpose of this pilot study was to investigate differences in fractional anisotropy (FA) and mean diffusivity (MD) in hearing- and non-hearing-related structures in the brain between children with UHL and their NH siblings. Parents provided demographic data and indicated whether children had a need for an individualized educational program (IEP) or speech therapy (ST). Our aims were to compare the microstructural integrity of white matter tracts using DTI in hearing-related and non-hearing-related brain regions between children with UHL and their NH siblings; and to examine relationships between various educational outcome variables and the DTI parameters (FA and MD) of hearing-related regions. All subjects underwent audiometry, cognitive testing for IQ scores, language testing, and MRI scanning. After the registration steps, the diffusion data was processed with locally written software using a log linear algorithm into DTI parameter data using the commonly used tensor model (Basser et al., 1994).
The approximate MNI coordinates for these ROIs are listed in Table 1 (each subject's regions are slightly different). Etiology of hearing loss did not differ significantly between the right UHL and left UHL groups. In addition, children with UHL had a significantly greater need for IEPs (45%) and speech therapy (41%) than children with NH (5% for both IEPs and speech therapy). The FA of the left uncinate fasciculus was negatively correlated with Performance and Full IQ, the MD of the right posterior limb of the internal capsule was negatively associated with Verbal IQ, while the FA of the left middle cerebellar peduncle was associated with need for speech therapy.
Central hearing loss (or central auditory dysfunction) is present when a lesion exists in the central auditory pathway beyond the eighth cranial nerve; for instance, in the cochlear nucleus in the pons or in the primary or association auditory cortex of the temporal lobe. Generally, the low frequencies are defined as the range from 250 Hz to 750 Hz, the middle frequencies as 1000 Hz to 3000 Hz, and the high frequencies as 4000 Hz to 8000 Hz on the standard audiogram.
An MRI may indicate the presence of an abnormality somewhere in the nervous system, but it does not necessarily define the nature of the pathology. Measures, such as tone decay, acoustic reflex measures, acoustic reflex decay, and speech discrimination at high-intensity levels must be used to distinguish between eighth-nerve, extraaxial, and intraaxial brainstem dysfunction.
Although most patients report the tinnitus to be constant, others report it to be intermittent, fluctuating, or pulsating. Objective tinnitus of vascular origin may also be a referred bruit from stenosis in the carotid or vertebrobasilar system. Severe tinnitus may disable individuals to the extent that they are unable to concentrate on little other than the tinnitus itself. The cerumen should be removed, if possible, with warm water lavage using a syringe with a 5- to 8-cm piece of rubber tubing affixed to the end to avoid injury to the ear.
Little or no mobility of the tympanic membrane suggests fluid or a mass behind the drum, or a fixed ossicular chain. The usual location described for placement is the forehead; but better locations are the nasal bones or teeth when a stronger bone conduction stimulus is required.
Hearing is considered normal when threshold sensitivity is between 0 and 25 dB for frequencies of 250 to 8000 Hz (Fig. However, there is an exception in conductive hearing loss in which discrimination ability remains relatively good because the inner ear system is normal. Values below 0.25 cm3 of equivalent volume indicate a stiff or non-compliant middle ear system. Type A curves have normal mobility and pressures and typify normal hearing and seniorineural hearing loss with normally functioning middle ear systems. These potentials are recorded by averaging 1000 to 2000 responses from click stimuli by use of a computer system and amplifying the response (Fig. Abnormal interwave latencies (I–III or I–V) are the most specific and Sensitive abnormalities seen with cerebello-pontine angle tumors. Tinnitus may be the first symptom of a disorder, appearing long before any other symptom, including hearing loss. Biofeedback is quite effective for enhancing relaxation, as are traditional relaxation procedures. Imaging data from 12 children had to be excluded from analysis, due to movement artifact (n = 1), inability to lie still in the scanner (n = 1), inadequate data acquisition (n = 7) and inadequate data due to the presence of metallic devices (orthodontic appliances, n = 2, and a bone-anchored hearing aid, n = 1). Because both language tests use a standardized scale, they were combined as language outcomes for analysis. The only trends between groups among mean diffusivities were in the MD of the in right subcortical white matter of Heschl's gyrus and left putamen. For both NH and UHL subjects, right sided MD was significantly lower than left sided MD in most structures.
For children with right UHL, the MD of the right middle cerebellar peduncle was highly correlated with Verbal IQ, and the FA of both right and left uncinate fasciculus were highly correlated with both Performance and Full IQ.
Not only should the results from the audiologic test battery be integrated, but also these data should be used With the neurologic, otoneurologic, and radiologic information for the maximum diagnostic accuracy.
In addition to these organic types of hearing loss, one should also consider functional hearing loss.
Acquired sensorineural hearing loss may be caused by noise exposure, acoustic tumor, head injury, infection, toxic drug effects, vascular disease, or presbycusis. With a mixed loss, both air and bone conduction thresholds are elevated, but bone conduction thresholds are better than air conduction thresholds.
The audiologic tests, however, highlight patterns of auditory behavior that are generally associated with cochlear or neural involvement. Tinnitus may be perceived as high- or low-pitched tone, a band of noise, or some combination of such sounds. Tinnitus associated with Meniere's syndrome is often low pitched and continuous and is described as a hollow seashell sound or very loud roaring. If water lavage has not removed impacted cerumen, a neurologist should refer the patient to an otolaryngologist for removal.
In unilateral hearing losses, lateralization to the poorer-hearing ear indicates an element of conductive impairment in that ear. When testing by bone conduction, the stem fork should be placed firmly on the mastoid, as near to the posterosuperior edge of the ear canal as possible. Poor discrimination ability in the presence of relatively good hearing sensitivity may suggest retrocochlear pathology such as acoustic neuroma and should be aggressively pursued by the clinician. The abnormal prolongation or absence of wave V at increased click rates is also characteristic of retrocochlear pathology. Surgery is the primary therapy for hearing loss caused by otosclerosis, usually manifested as a conductive type of hearing loss, as described above. When medical and otologic examinations fail to disclose a remediable cause for the tinnitus, or when a diagnosis is ascertained for which no known medical therapy is presently available, the tinnitus patient should undergo further evaluation to determine the most appropriate nonmedical avenue for, rehabilitation. However, a large case-control study did not find intellectual differences based upon side of hearing impairment (Lieu et al., 2010). Water in brain tissues diffuses faster parallel to white matter tracts as compared to perpendicular, a property known as anisotropy. Thus, the analysis included 29 children with UHL (13 right UHL, 16 left UHL) and 20 siblings with NH. In general, FA was greater and MD lower in the NH group than in the UHL group, but this did not reach statistical significance in most regions. For children with left UHL, both the MD and FA of the left middle cerebellar peduncle were strongly correlated with speech therapy. The diagnosis of functional hearing loss is made when an individual claims to have a hearing loss, but discrepancies in objective test measures suggest that the loss does not exist or is exaggerated. The difference between the two thresholds, referred to as the air-bone gap, represents the amount of the conductive component present.
Normal measures mentioned above, such as tone decay or acoustic reflex, strongly suggest an eighth-nerve lesion.
Tinnitus with otosclerosis is also low pitched, is described as a buzzing or roaring sound, and may be continuous or intermittent.
Lateralization to the better-hearing ear suggests that the problem in the opposite ear is sensorineural.
The stem should not touch the auricle of the external canal, which should be held to the side by the examiner's fingers.
Responses above 25 dB are classified by degree as mild, moderate, severe, moderately severe, and profound (Fig.
Abnormalities associated with reduced mobility of the tympanic membrane in associated middle ear structures include otitis media, otosclerosis, and large cholesteatomas.
Middle ear abnormalities or significant sensorineural hearing losses may elevate or obliterate the acoustic reflexes. The anatomic correlates of the five reliable potentials have only been roughly approximated. Increased absolute latencies of all waves, compared with responses from the other ear or with clinical normative data, may signify a conductive deficit.
Anisotropy has been used to investigate the integrity and course of white matter tracts in the brain. A patient with a conductive loss has good discrimination ability if the speech signal is of sufficient intensity. Continuous bilateral or unilateral high-pitched tinnitus often accompanies chronic noise-induced hearing loss, presbycusis, and hearing loss due to ototoxic drugs.
Touching the external ear itself could give false results because of vibration of the auricle.
Ossicular chain discontinuity is the most common cause of excessive tympanic membrane mobility. Retrocochlear pathology and facial nerve disorders may also affect contralateral and ipsilateral acoustic reflexes. Wave I of the BM) is a manifestation of the action potentials of the eighth nerve and is generated in the distal portion of the nerve adjacent to the cochlea.
Common DTI parameters include fractional anisotropy (FA), which ranges from 0 for equal diffusion in all directions to 1 for diffusion only along 1 axis, and the mean diffusivity (MD), which measures how easily water diffuses averaged over all directions, also ranging from 0 to 1. A number of drugs such as aminoglycosides, quinidine, salicylates, indomethacin, carbamazepine, propranolol, levodopa, aminophylline, and caffeine, may produce tinnitus with or without associated hearing loss.
Responses at 500 Hz, 1000-Hz, and 2000 Hz are averaged together to compute the pure-tone average (PTA).
Extremely high equivalent middle ear volume and low static compliance suggest tympanic membrane perforation. Type C curves have normal mobility and negative pressure at the point of maximum mobility (negative pressure is considered significant, for treatment when more negative than –200 mm 1.120). Wave III IN thought to be generated at the level of the superior olive, and waves IV and V are generated in the rostral pons or in the midbraln near the inferior colliculus. Restricted diffusion has been identified in several types of disease processes, including acute demyelination, certain brain tumors and acute ischemia (Mukherjee et al., 2008). Type As represents normal middle ear pressure but reduced mobility, suggesting limited mobility of the tympanic membrane and middle ear structure, commonly seen in fixation of the ossicular chain. The complex anatomy of the central auditory pathway, with multiple crossing of fibers from the level of the cochlear nuclei to the inferior colliculus, makes interpretation of central disturbances in the evoked responses difficult. Bone conduction will be heard better than air conduction when there is a deficit in the conduction mechanism; this is referred to as a negative Rinne. Excellent reviews of the generation or the potential and interpretation of abnormality are found in recent contributions. This pattern indicates a flaccid tympanic membrane due to disarliculatlon of the ossicular chain or partial atrophy of the eardrum. When testing by bone conduction, the examiner should not forget to have the patient remove his or her eyeglasses: the earpiece can interfere with proper placement of the stem of the tuning fork or give inappropriate conduction or vibratory information. Although tuning fork tests allow the examiner to distinguish conductive and sensorineural loss and, in some cases, lateralize the symptomatic ear, it does not evaluate the degree of impairment or the effects of that impairment on speech understanding.



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