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This study reports on the long-term benefit of ultra-high-frequency masking with the UltraQuiet device.
This study reports on the long-term benefit of ultra-high-frequency masking with the UltraQuiet (UQ) device.
Well accepted is that if maskers overlap in frequency with the tones to be masked, masking is likely to occur, its degree related to masker intensity.
Because tinnitus can usually be masked (at least partially) for some period by a variety of sounds, one commonly used procedure is to assess wide-range masking, termed minimal masking levels (MMLs), using a variety of frequencies, including broad- or narrowband noise [12]. Theoretically, stimulation above the tinnitus frequency may supplement or assist the neurological reprogramming at the cortex and perhaps restore the normal-frequency spatial relationship. The goal of this study was to evaluate the long-term efficacy of using UltraQuiet high-frequency bone-conduction therapy for treating tinnitus, using pre- and postbehavioral assessment of tinnitus loudness, tinnitus anxiety, and tinnitus severity. Fifteen subjects (3 female, 12 male) with subjective idiopathic tinnitus of the severe disabling type participated in the study.
The stimulus was produced using Kyma Version 5 software with a Capybara 320 Sound Computation Engine, and it was recorded on a compact disk (CD). The transducer is a custom-made aluminum ceramic bimorph with a high-frequency limit of some 50 kHz. The UltraQuiet stimulus parameters, or sound features, were chosen to optimize the activation of auditory cortical neurons. Classification of masking curve type according to Feldmann's system was applied to the masking data, and we measured loudness discomfort levels at 250-8,000 Hz. To assess, in a preliminary fashion, the effects of treatment length, we randomly assigned subjects to one of three groups.
Before each stimulation session, subjects completed three outcome measurements: the tinnitus intensity index, the annoyance index, and the tinnitus severity index [1]. The questionnaire results for measures of tinnitus intensity and annoyance were not significantly different over the course of therapy sessions, although a drop in the mean level for each was noted on the last few trials. We examined the relationship among high-frequency MMLs, tinnitus pitch, tinnitus intensity, and Feldmann masking curves. The use of high-frequency bone conduction stimulation using the UltraQuiet therapy system resulted in longterm reduction in tinnitus severity during therapy, and that tinnitus relief lasted for at least 2 months after therapy in most subjects in this study. During posttherapy interviewing, we noted partial masking of the tinnitus by the UltraQuiet system throughout the trial in all patients (although not in every session). Frequency range of stimulation is critical in the auditory cortical reprogramming approach of the UltraQuiet system; however, any reduction in the amount of masking required to eliminate (or partially eliminate) tinnitus also is important.
Alternatively, we could argue that the energy around 6 kHz was predominant in our subjects owing to mild to moderate sensorineural hearing loss.
RI, which refers to a decrease in the perceived intensity of the tinnitus for a time after the masking stops, was first reported by Feldmann [12]. Because the UltraQuiet stimulus generally overlaps with high-frequency tinnitus and the presentation is just above threshold stimulation (~6 dB SL), inhibition should be facilitated.
Treating tinnitus patients with the UltraQuiet device is more difficult when their tinnitus is of the severe problematic type.
Problematic tinnitus is most likely related to changes in the auditory pathway and consequent reactions in various areas of the brain. The authors acknowledge the support of Sound Technique Systems, LLC, in this study and the assistance of Robert Guinta. 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. Transverse fracture 20% of all temporal bone fractures Caused by frontal or occipital blows Fracture line at 90 0 to long axis of petrous pyramid Starts in middle cranial fossa (close to foramen lacerum), crosses petrous pyramid transversely & ends at foramen magnum. Surgical treatment Primary closure with multi-layer technique using cartilage + muscle + fascia + fat + bone wax Approaches: Trans-canal, Trans-mastoid, Middle cranial fossa, Combined (middle fossa + trans- mastoid). Distortion product otoacoustic emission (DPOAE) is a widely used differential diagnostic method for diagnosing inner ear disorders.
If we view a system with two inputs-one coherent signal and one source of white noise-and with one output that is some function of the inputs and the internal dynamics of the system, two possibilities ensue.
Second, if we increase the intensity of white noise on one of the inputs, the SNR on the output will increase. We carried out our experiments in 10 healthy, normally hearing persons between the ages of 23 and 26 years; 20 ears were evaluated, and 240 measurements were taken.
The experimental setup for contralateral white-noise stimulation and measurements can be seen in Figure 2. Former examinations at our institution showed that after exposure to high-intensity white noise, the DPOAE signals increase in a fashion similar to that of the phenomenon of stochastic resonance [2]. Nine out of ten hearing aid users say that their hearing aids are useful in the workplace, surveys have found. Surveys conducted in seven countries among people with hearing loss show that hearing aid users find their hearing aids to be useful in the workplace.
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What binoculars do to improve your vision, the Sonic Super EarĀ® does to improve your ability to hear the sounds around you. Items displaying this symbol are blind accessible.These items can be used without sighted assistance. A commercial product, UltraQuiet provides a new form of high-frequency bone conduction therapy.
In the case of masking tinnitus by an external noise, this relationship is more the exception than the rule. The masking stimulus is raised in 5-dB steps, and patients are asked whether their tinnitus is still audible. The stimulation must be very high in spectral content to accomplish this above the tinnitus pitch requirement. Music appears be a more effective tinnitus masker than is noise [19], possibly owing to the involvement of more central and cognitive processes. The CD recording stimulus consisted of digitally processed music (44.1-kHz sampling rate) with playback in the 10- to 20-kHz range.
Spectrum of the high-frequency bone-conducted stimulation ranges from approximately 6 kHz to 20 kHz. The transducer is coupled to the skin and held in place with a band, much as are traditional clinical boneconduction transducers. Cortical neurons have been shown to be sensitive to frequency edges, temporal patterns, and frequency or intensity transitions [20]. We presented outcome questionnaires to establish a baseline of functioning; these included the tinnitus intensity index, the annoyance index, and the tinnitus severity index [1,21,22]. No one indicated a poorer result, and those four reporting no change in their tinnitus did indicate improvement on measures of tinnitus intensity or severity after therapy treatment. That is, as a group, the patients with problematic tinnitus indicated a significant reduction in severity over the course of the treatment trials. Effects of high-frequency therapy on three outcome measures - tinnitus severity, intensity, and annoyance - as evaluated by questionnaires completed after each therapy session.
For some patients at some frequencies, reductions in MMLs were as high as 25-45 dB in one ear (Fig.
Decrease in the minimum masking levels (MMLs) for the six patients who received brain imaging before and after therapy.
Mean minimum masking levels for all subjects when patient and ear data are collapsed reveals a frequency-specific pattern.
Individual variability in this small sample of patients with problematic tinnitus precluded any detailed analysis, but tinnitus intensity ratings exceeding 50 dB were associated with improvement on the overall tinnitus relief questionnaire and were associated with a high-frequency pitch match.
Relationship among minimal masking level changes (by frequency), Feldmann masking curve (FMC) types, and pitch and loudness matches in all subjects.
Hearing thresholds before and after therapy generally suggest improvement after therapy; however, the pattern was complex and included elevation in some frequencies. Threshold was established before each session but, given the problems in detecting a stimulus in the presence of tinnitus (even in skilled hands), the level of UltraQuiet therapy may have been as little as 2-3 dB SL for some patients in some sessions. Patients in the 10-session group averaged just above "no change," whereas those in the 12- and 14- session groups averaged above "slight improvement." What must be emphasized is that these patients with problematic tinnitus have had limited therapeutic success with other treatment modalities.


The tinnitus relief was inferred from a pattern of lower weekly scores on the tinnitus severity scale and reduction in MMLs. Owing to stringent adherence to the protocol approved by the Western Institutional Review Board, we made no effort to increase the stimulation level in an attempt to produce complete masking.
All patients had serviceable hearing to 12 kHz, but hearing improvement may have been related to relative frequency sensitivity of the UltraQuiet stimulus.
In an individual with hearing loss and tinnitus, RI may last for a few seconds or minutes but can last days or weeks [2,31]. The acceptance of RI over questionnaire data is understandable in an effort to obtain a more "physiological" metric. What effect the increase in stimulation level from 6 dB SL to 12 dB SL would have on the effect of masking, on further reduction in MMLs, and on increased RI remains to be explored. When contrasted to normal controls and tinnitus patients who tolerate their tinnitus, patients with problematic tinnitus showed less habituation in middle latency potentials [36]. The emerging picture is that of an initial insult to the ear or brain (or both) followed by an increase in the tinnitus frequency cortical map, which could increase dyssynchrony-synchrony and loudness and reduce habituation.
Department of Otolaryngology, State University of New York, Downstate Medical Center, Brooklyn, and Martha Entenmann Tinnitus Research Center, Forest Hills, New York. 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.
Delayed onset & incomplete facial paralysis: oral Prednisolone for 2 weeks + observation B. Combined approach for large defect (>2cm), multiple defects, or defects that extend anteriorly.
First, if we increase the intensity of white noise on one of the inputs, the signal-to-noise ratio (SNR) on the output will decrease.
All persons had a pure-tone threshold in every frequency between 0 and 10 dB and have had normal distortion product otoacoustic emission intensity plots (known as DP-grams). After reaching approximately a 40- to 50-dB SPL noise intensity, the DPOAE amplitude begins to decrease. Results showing the amplitude increase of the distortion product otoacoustic emission with 0- to 80-dB white-noise stimulation (white noise intensities on the inset to the right). The only condition is that you provide a direct link to the specific article you use on the page where you quote us. To assess its effectiveness in tinnitus treatment, we selected 15 patients with problematic tinnitus and randomly assigned them to three variations of the medical-audiological tinnitus patient protocol modified for the UltraQuiet study. Logically, high-frequency masking should provide effective relief in persons with severe problematic tinnitus.
The UltraQuiet device delivers amplitude-modulated musical-type stimulation in the range of 10-20 kHz suitable for this purpose.
We specifically investigated the use of the UltraQuiet device for providing relief, masking, and RI in individuals with problematic tinnitus of the severe disabling type. The stimulus consisted of synthesized music digitally processed and used to modulate a carrier at 16 kHz. The CD was played through a custom-made amplifier into a piezoelectric bone-conduction transducer. Some energy occurs around 6 kHz, owing to the transducer's fundamental resonance and the high-pass filter slope. In other words, features that are found in speech, music, or amplitudefrequency modulation were incorporated into the stimulus to facilitate auditory cortical activation. Audiological evaluation included pure-tone audiometry, speech audiometry, tinnitus pitch and loudness matching, the measurement of RI, and masking curves to establish MMLs at 250-8,000 Hz using both narrowband and white noise. One week after the last intervention session, we repeated the audiological evaluation and administered the outcome questionnaires to assess any changes. Group 1 received stimulation twice weekly for 2 weeks, stopped the stimulation for 2 weeks, then received stimulation twice weekly for 3 weeks, for a total of 10 sessions. The stimulation lasted 30 minutes for the first session and 1 hour for all succeeding sessions. Some patients indicated more improvement than others, but the trend in all patients was an increase in tinnitus relief. Note the general improvement that lasted for 2 months in approximately one-half of the patients. Tinnitus severity improvement for the group was evident at the second session, gradually increasing through the twelfth session. Clearly the severity is decreasing, with a trend in that direction for anxiety and loudness.
The tinnitus pitch match most frequently occurred in the region of the hearing loss but not necessarily at the frequency with the maximal loss. Dynamic hearing levels appear related to central processes assumed to be active during and after therapy.
Note in Figure 3 that dramatic improvement in tinnitus severity occurs in session 12, as does a modest abatement of tinnitus intensity and annoyance.
Four factors likely contributed to long-term tinnitus relief: ultra-high-frequency masking, RI, neurological reprogramming, and habituation. The strategy of using high frequencies at low levels was designed to potentially provide some partial masking but, more important, was designed to aid in tinnitus neurological reprogramming and habituation. This is suggested by the six cohort patients in whom positron emission tomography scans were obtained. High-frequency stimulation, both in the high audiofrequencies (UltraQuiet) [2] and in ultrasonic frequencies [11], have resulted in RI. We observed (by interview at the end of therapy but not by formal testing) RI lasting approximately 5 minutes. The conclusion of Shulman [15] suggests that a brain-imaging index in conjunction with high-frequency audiometry may be the technique of choice in objectively assessing tinnitus relief from auditory therapy if neurological reprogramming and habituation are the essential processes as hypothesized.
Cortical reprogramming as a consequence of sensorineural hearing loss has been well established [33, 34]. In view of the degree of improvement and results with the limited number of sessions in our study, a reasonable expectation is improved results with an increased level of stimulation (12 dB SL) and an increased number of sessions over time. Additionally, auditory brainstem response differences between tinnitus patients and controls further suggest that auditory path- way transmission may influence abnormal habituation.
Such a condition could hyperactivate the medial temporal and prefrontal lobes, resulting in problematic tinnitus characterized by annoyance, and could trigger autonomic reactions. Ultra-highfrequency acoustic stimulation and tinnitus control: A positron emission tomography study.
Functional inactivation of the amygdale before but not after auditory fear conditioning prevents memory formation. Local improvement in auditory frequency discrimination is associated with hearing-loss slope in subjects with cochlear damage. Loudness perception and frequency discrimination in subjects with steeply sloping hearing loss: Possible correlates of neural plasticity. Test-retest reliability of pure-tone thresholds from 0.5 to 16 kHz using Sennheiser HDA 200 and Etymotic Research ER-2 earphones. High-frequency (8 to 16 kHz) reference thresholds and intrasubject threshold variability relative to ototoxicity criteria using a Sennheiser HDA 200 earphone. Environmental enrichment improves response strength, threshold, selectivity, and latency of auditory cortex neurons. Abnormal auditory mismatch response in tinnitus sufferers with high frequency hearing loss is associated with subjective distress level.
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. This is the system with linear characteristics, which has linear or mildly nonlinear internal dynamics. Thus, the studied system must usually be bistable and must have at least two inputs-coherent periodic signal and white noise. For clarity reasons, amplitudes of distortion product otoacoustic emissions only between 2,000 and 4,000 Hz are plotted.
Distortion-product otoacoustic emission (DPOAE) following pure tone and wideband noise exposures. Die Pegelzunahme von Distorsionsproduktemissionen des Menschen durch kontralaterale Beschallung niedriger Intensitat HNO 45:378-384, 1997.
We assessed tinnitus relief by questionnaires directed at weighing patient response to overall effectiveness, tinnitus loudness, tinnitus severity, and tinnitus annoyance.


The effect of this expansion on connections to the limbic system and other cortical areas is not known, nor have the tuning characteristics of these "recruited" neurons been measured. Preliminary clinical reports were encouraging [2] and a calibration procedure, anchored to international standards, was followed [18]. The pitch match to the tinnitus for 14 of the 15 subjects was high-pitched, matching to either a pure-tone or a narrowband noise or a combination of both, with frequencies between 3 and 16 kHz; 1 subject had a low-pitched tonal tinnitus at 450 Hz. Group 2 received stimulation twice weekly for 3 weeks, stopped the stimulation for 2 weeks, then received stimulation twice weekly for 3 weeks, for a total of 12 sessions. Further improvement may be present but is obscured by the duration parameters of the three groups. The mean data are perhaps as revealing; when patient and ear data are collapsed, a high-frequency reduction in masking is observed (Fig.
Although we saw an increase in some thresholds in some patients, twice as many thresholds improved as those that decreased. Nonetheless, the frequency range of masking is important in obtaining neurological reprogramming and inhibition [16,18].
Those patients with the best thresholds beyond 10 kHz exhibited the best behavioral and physiological activity [15]. The question of the minimal number of trials needed to note tinnitus relief, given that choices were limited to 10, 12, and 14 sessions, can be answered only by stating that 10 session of therapy (and probably fewer) are not as effective as 12 and 14 sessions, on the basis of questionnaire results after therapy. Patients with problematic tinnitus appear not to exhibit normal habituation, and this can influence their perception of tinnitus loudness. Although we readily recognize that the neural substrate of problematic tinnitus encompasses much more than the auditory pathway, the role of the auditory pathway in masking, RI, neurological reprogramming, and habituation is significant [37].
In GE Reich, JA Vernon (eds), Proceedings of the Fifth International Tinnitus Seminar 1995. Poster presented at the Twenty-First Annual Meeting of the Association for Research in Otolaryngology, 1999.
Presented at the Thirty-First Congress of the Neurootological and Equilibriometric Society, Bad Kissingen, Germany, March 25-27,2004.
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?
Changes in thresholds of DPOAE curves can provide us important information on the activity of the OHCs. Figure 1B shows the behavior of a system with linear (or mildly nonlinear) properties (the "classic" case). The DPgrams were taken at measure-tone intensities of sound pressure levels 60 and 70 dB, respectively.
Figure 3 illustrates an example of our results showing the DPOAE intensity plotted against the measured frequencies. The noise of the hair cells themselves does not influence the results shown in Figure 3, because the applied noise intensity was much greater than the noise at the cellular level [3]. Their and our results do not match, yet the issues clearly show that there is an increase in some of the DPOAE amplitudes.
The surveys were carried out in Italy, United Kingdom, France, Germany, Switzerland, Norway and Japan in 2012. Additionally, we performed audiological measures (including pure-tone and speech audiometry, minimal masking levels, pitch and loudness matching, and residual inhibition). That is, tinnitus masking may be a complicated product of peripheral and central processes, and sounds outside of traditional psychoacoustic ranges can be effective with tinnitus [2], including ultrasound masking delivered through bone conduction [11].
If neural space expansion of the tinnitus frequency (or frequencies) is associated with synchronized activity, ignoring an attentiongenerating tinnitus percept that could readily arise may be impossible. The UltraQuiet system has a maximum output of 53 dB hearing level (HL) when it is massloaded to the artificial mastoid with 5.4 Newtons of force applied.
Group 3 received stimulation twice weekly for 4 weeks, stopped the stimulation for 1 week, then received stimulation twice weekly for 3 weeks, for a total of 14 sessions. The threshold for stimulation was established, and the stimulation was presented 6 dB above threshold or 6-dB sensation level (SL). That is, for the latter sessions, the number of patients being tested dropped, owing to the session limitations for each of the three treatment groups. No consistent pattern was noted between Feldmann masking curve type and tinnitus pitch match (Fig. If highfrequency stimulation is essential for auditory cortical reprogramming, the sensitivity to such stimulation should be an essential variable. What should be noted is that the stimulating intensity was only 6 dB SL, and this may not have been sufficient energy to elicit RI in the other patients, a metric to be systematically studied in the future.
If the auditory cortex has reprogrammed, stimulation with very high frequencies might stabilize and reverse the process and perhaps restore the normal frequency map. According to these serial measures, therapy of fewer than 12 sessions would not be as satisfactory as therapy lasting 12 and 14 sessions. A plastic auditory pathway treated with a stimulus specifically designed for highpitched tinnitus may, with time, provide long-term relief.
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. More measurements must be carried out to investigate this phenomenon and to account for the specific frequencies involved in the amplitude changes. The figures were published in an article about the EuroTrak and JapanTrak surveys in The Hearing Review, March 2013. All patients showed some long-term gains, and most exhibited relief in at least one measurement parameter, providing support for the use of high-frequency vibration in the treatment of tinnitus. Growing evidence suggests that high-frequency masking is desirable in cases of high-frequency tinnitus [2,11].
Increased degrees of neural synchronydyssynchrony could activate and continue to stimulate the amygdala, an organ known to be critical in evoking emotional and autonomic nervous responses [17].
Although the stimulus is presented on only one side of the head, it is heard binaurally through bone conduction [23]. The frequency area that exhibited the greatest effect is the octave from 3 to 6 kHz, below the lowest resonance in our transducer (6 kHz).
Annoyance and tinnitus intensity seemed to persist in most throughout the sessions, suggesting that the tinnitus, while reduced in severity, was still present. In the normal auditory system, an increase in loudness is related to an increase in neural activity.
The changes in MMLs and auditory thresholds suggest an adaptive central nervous system, responsive to high-frequency sound therapy.
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. If OHCs are injured and thus function improperly, the system stops showing nonlinear properties.
Two problems exist: One is developing an efficient, commercially viable, and calibratable transducer and the other is determining a reliable clinical-use protocol. For many patients, substituting one sound for another is not considered a significant enough improvement; additional relief is desired.
Stated another way, the frequencies that required less energy to mask tinnitus were those just below the lowest effective stimulating frequencies in the UltraQuiet system.
The UltraQuiet masking mechanism appears to be different when using conventional audiological masking at 250-8,000 Hz than when using ultra-high frequencies.
High-frequency stimulation with the UltraQuiet passband of 10-20 kHz has the added quality of disrupting the tinnitus frequency synchrony and reducing the overrepresentation, which might be verified with cortical potentials. Patients who do not exhibit normal habituation and who rate their tinnitus as loud may have more active dyssynchronous neurons involved in tinnitus perception than do patients who assess their tinnitus loudness as low. Long-term tinnitus relief cannot be solely defined by one metric as complete masking or RI on the order of hours. 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? If we have a system with periodic excitation and, with the addition of white noise, the signal-to-noise ratio on the output increases (at least for small noise intensities), we have witnessed what is called phenomenon stochastic resonance. The intensity of the contralateral white noise was changed in l0-dB increments from 0 to 80 dB SPL.
In a preliminary report [2], we found a high-frequency tinnitus device, UltraQuiet, to be efficacious. The masking stimulation, if properly chosen, may have the capacity of changing how the brain processes tinnitus, which could provide long-lasting benefit. These frequencies were on the edge of the patients' audiometric hearing loss, a region often associated with increased discrimination possibly due to neural plasticity [24,25]. With ultra-high frequency, the stimulus is apparently combined with neurological reprogramming and plasticity involving the auditory cortex. Such a situation would be predicted in the tinnitus frequency map expansion in the auditory cortex and would influence both the medial temporal lobe system and other cortical area identified as active in tinnitus [37].
Relief is a complex function of many factors arising both within and outside the auditory system, and successful treatment takes time. Between the successive measurements, approximately a I-minute pause was taken to avoid the effect of short-term high-intensity whitenoise exposure, which probably would have given false results [2]; otherwise the effect of short-time high-intensity white noise exposure would have given false results. They found frequency-dependent significant changes if the contralateral sine tone's frequency was varied from 500 Hz to 4 kHz. The MML improvement was related to the measured tinnitus pitch in that both were high-frequency (with one pitch match exception). RI increased with masker intensity, but the relationship of RI to tinnitus frequency, masker center frequency, and bandwidth was complex and varied among individuals.
Brain imaging and high-frequency audiometries seem to be important indices in quantifying tinnitus relief. 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. If there is emission, that specific ear surely exhibits nonlinear behavior, which in turn is the basic property needed for stochastic resonance. The values-wherein the DPOAE's intensity was significantly greater than without contralateral stimulation - match with ours and with those of Santaolalla et al. Often, behavioral measures are contradictory, rendering efficacy determination problematic.
The value of this test would be to identify such individuals and provide treatment before they become symptomatic for hyperacusis.
Interesting but difficult to explain are the favored frequencies, especially in the case of contralaterally or ipsilaterally applied white noise.



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