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A final common pathway for tinnitus is hypothesized to exist for all patients with tinnitus. Its function is the transition of the sensory to the affect component of the symptom of tinnitus. Single Photo Emission Computerized Tomography (SPECT) with the radio isotope TC99-HMPAO has identifie side to side perfusion asymmetries highlighted by that of the amygdala - hippocampal complex. It is hypothesized that a fundamental function of the amygdala - hippocampal structures is the establishment of a paradoxical auditory memory for tinnitus. A Final Common Pathway (FCP) is hypothesized to exist for all patients with tinnitus, particularly of the severe disabling type (SIT). Historically, this search for understanding how the transition from sensory to affect occurs in the brain is not new.
The concept of William James, the Father of American Psychology is suggested to find application to a FCP for tinnitus. Single Photon Emission Computerized Tomography (SPECT) with the radioi sotope Tc-99 HMPAO is a detection method which provides information of cerebral perfusion in brain.
Based on clinical experience with tinnitus particularly of the severe disabling type and supported by SPECT imaging of the brain, the medial temporal lobe system is speculated to be a key site of action of processing of an aberrant auditory signal resulting in a paradoxical auditory memory; and an accompanying parallel transition in processing of the sensory to the affect component of the symptom of tinnitus.
In other words, the eterogeneity of the symptom of tinnitus is reflected in FCP for tinnitus.
The FCP is presented as a hypothesis focusing on a process within the MTLS of a paradoxical auditory memory with speculations as to its clinical applications for both diagnosis and treatment. It is hypothesized that for all sensory systems the sensory and affect components are linked by memory.2 The experience of the sensation is a perceptual image of the stimulus. Psychology and neuroscience evidence have differentiated between long term and short term memory.
The modulator of the sensory component is considered to be the efferent system and the process of masking.3 The modulator of the afferent component is considered to be stress.
In the patient with tinnitus, particularly of the severe disabling type it is hypothesized that both the hippocampus and amygdala of the MTLS are significant for the transition of the sensory to the affect component. In summary, the FCP model for tinnitus involving the medial temporal lobe system is initiated in the MTLS by the process of establishment of a paradoxical memory. Our approach is clinical and attempts to identify not all components of the FCP but rather to focus on one aspect, specifically memory which is considered at present to be clinically most significant; and is explainable by what has been reported for understanding brain function specifically memory. The activity in the brain that corresponds to memory can be found in the medial temporal lobe system.
Crick's comments on the problem of visual awareness I believe can be applied to that of tinnitus - an auditory perceptual phenomenon.6,31 Specifically, investigations for tinnitus are necessary from a psychological and a neuro-science perspective for the issues of attention and very short term memory. The MTLS can be considered an information processing pathway for the integration of sensory and affect components of all sensory inputs. The perception of a auditory image, considered to be "normal", is hypothesized to be determined by a normal masking function.
It has become apparent to us from our clinical experience with SPECT since 1989, that the manner in which the brain processes auditory sensory information is radically different with or without the presence of tinnitus.
The consequences of the identification of a FCP for tinnitus and the role of the MTLS are considered significant.
The following SPECT images of the brain demonstrate multiple perfusion asymmetries, highlighted by the MTLS (Fig. The FCP for tinnitus provides a rationale and model for understanding the integration, interaction, translation, and transformation of the sensory auditory signal to the affect behavioral response.
An initial process, in the MTLS, is hypothesized to be the establishment of a paradoxical auditory memory for tinnitus.
SPECT imaging of brain provides an ability to identify regions of interest in the brain which demonstrate perfusion asymmetries frequently found in patients with tinnitus of the severe disabling type. The processes involved in the establishment of the symptom of tinnitus particularly of the severe disabling type and the problems encountered, relate to the overall problem and question over centuries of what is the relationship of mind and brain and what are the processes involved in such identification.
The take home message and goal for the attendee of each Miniseminar since 2010 has been the presentation and clinical translation of advances in neuroscience, sensory physiology, and auditory science to provide an objectivity and an increase both in the accuracy for the diagnosis of all clinical types of subjective tinnitus and efficacy of treatment for the ultimate benefit of the tinnitus patient.
In 2014 the take home message and goal for the attendee of each Miniseminar since 2010 was reaffirmed by introduction to the attendees of the availability of application for all tinnitus patients of the technology of objective electrophysiology quantitative electroencephalography (QEEG) and low frequency resolution electromagnetic tomography analysis (LORETA).
The clinical application of the QEEG LORETA data is not to diagnose tinnitus but to 1) provide an increase in both the accuracy for the tinnitus diagnosis by its integration and correlation with the clinical history and physical examination and 2) to objectively monitor the efficacy of tinnitus treatment modalities. Attempts for tinnitus relief with instrumentation and future application of surgical vagus nerve stimulation, pharmacology AM-101, and the middle ear implant for moderate severe sensorineural hearing loss were presented.
In general, the presentations focused on biophysiological processes of neuroplasticity (NPL), neuromodulation (NM) and Neuroprotection (NPT), electrophysiological functional brain imaging QEEG and LORETA, a tinnitus modality of therapy i.e.
To present the biophysiological processes of NPL NM NPT as part of an evolving neurobiology for all clinical types of tinnitus.To provide clinical evidence of NPL NM NPT in a cochlear implant soft failure tinnitus patient with functional brain imaging nuclear medicine PET brain and quantitative electroencephalography (QEEG). Brain plasticity has been defined by "the father of sensory substitution and brain plasticity" as the adaptive capacities of the central nervous system - its ability to modify its own structural organization and functioning"1. Neuroplasticity (NPL) is a reorganization in neural circuitries in brain structure, and or function in response to constant, single or repetitive, internal and or external stimulation.
Neuromodulation (NM) in neuroscience is a modification of neural activity within neural circuits at a synaptic level in brain. Neuroprotection: refers to processes that protect neuronal function from injury or that improve such function after injury. Pharmacological agents that are considered to be neuroprotective have been identified and include calcium channel blockers, free radical scavengers, corticosteroids, antagonists of glutamate at N-methyl-D-aspartate (NMDA) and non-NMDA receptors, the proteolytic enzyme calpain and various thrombolytic agents. In general, neuroplasticity (NPL), neuromodulation (NM) and neuroprotection (NPT) are biophysiological processes linked together to maintain a homeostasis of structure and function: a) structural at molecular genetics, synaptic, cellular, tissue, organ, and system levels, and b) functional in the central nervous system as clinically manifest by sensory, behavior, learning, memory and motor activities. The biophysiological processes of NPL, NM, NPT are considered in our experience to provide a "bridge for continuity of function" between both a sensation and its transformation into one of behavior and affective and somatomotor response.
The biophysiological process(es) of NPL NM and NM were demonstrated with Pet brain and QEEG in a tinnitus patient ear right (rt) in who an initial cochlear implant (CI#1) was inserted with no report of tinnitus relief ear rt, and a mild hearing improvement ear rt. The clinical significance functional brain imaging is demonstrated by correlation of results of functional brain imaging Pet brain and QEEG (Figure 1, 2, and 3). The degree of success of modalities of tinnitus treatment reflect the attempt of the biophysiological processes of NPL NM NPT to establish and maintain a homeostasis of function between excitation and inhibition at brain cortex clinically manifest by the patient report of control of the sensory and affect behavioral components of the tinnitus. The data both metabolic with PET and electrophysiologic with QEEG in the case of the cochlear implant soft failure with ES when correlated with the subjective report of the patient provides: 1) an objectivity for a reported subjective report of tinnitus relief. The QEEG data to be considered to reflect not tinnitus but multiple brain functions in the presence of the tinnitus signal. The "dialectics" of the brain were presented as brain wave activities of different frequencies, recorded from external scalp placed electrodes. NFB, also known as EEG biofeedback, is a computerized learning strategy that enables people voluntarily to alter their own brain activity1. The presentation, EEG based NFB, was introduced by a brief review of brain wave activities.
Tinnitus patients show significant differences in the analysis of the contralateral temporal cortex (the louder the tinnitus is perceived, the higher the gamma power)3. Feedback to the patient establishes a desired level of brain activity resulting in tinnitus relief.
Operant conditioning of EEG characteristics: Training to decrease slow activity and to increase fast, desynchronized EEG activity. Hypothesis: Significant reductions of trained delta and gamma frequency range in combination with an increase in alpha frequency power in the auditory cortex results in improvement in subjective tinnitus measurements.
Does noise trauma result in a primarily neuronal change which clinically is expressed as tinnitus or is the noise trauma producing both neuronal change and tinnitus? Translation of the basic findings of tinnitus localization were applied for clinical research with transcranial magnetic stimulation (TMS) in an attempt to provide tinnitus relief to the patient.
It was questioned what the interaction was between different brain regions when a magnet is placed in this location?6. This approach of TMS stimulation at multiple ROIs was based upon the hypothesis that brain networks are involved in phantom perception which includes tinnitus.
The results of triple TMS stimulation was reported with electrode placement on the right frontal, right temporal and parietal area, and left temporoparietal area9, comparing single site with multi-site rTMS for triggering of chronic tinnitus. Pharmacotherapy recommendations attempting tinnitus were recommended to differentiate between acute and chronic tinnitus. The chief limitation of drug development for tinnitus is an incomplete understanding of the pathophysio- logical mechanisms involved.
Antidepressants are frequently proposed for management of chronic tinnitus In particular, tricyclic antidepressants have been recommended mostly because of the beneficial effects on chronic pain syndromes. A Cochrane meta-analysis of the use of anticonvulsants for tinnitus treatment concluded that studies so far show small effects of doubtful clinical significance and no evidence for large positive effect of anticonvulsants in treatment of tinnitus.
A slide was presented grouping different drugs by the underlying mechanism of action and trying to correlate them with the underlying tinnitus mechanism for its production. A network pharmacology side-effect analysis searched for genes that are involved in tinnitus generation. Baclofen, a GABA-B antagonist with muscle relaxant effects also reduces tone exposure-induced hyperexcitability in the inferior colliculus of rats. The challenge for future tinnitus research is to consider differentiation of pathophysiological distinct subtypes of tinnitus. Future drug development was recommended to focus on identification of specific clinical and chemical entities that interact with discrete molecular targets. Tinnitus is considered as a complex network pathology similar to other complex CNS pathologies for which a combination of different drugs will be more effective than a single drug alone. Drug development should be directed to the areas identified with fMRI and neuroimaging techniques which have identified an under- lying matrix for tinnitus as well as non-auditory responses of brain function as reflected in the areas of the somatosensory cortex or in auditory cortex, perception network, salience network, distress network, and memory areas.
The presentation focused on instrumentation to be considered for tinnitus relief: 1) Hearing aids for tinnitus. Wearable sound therapy devices for tinnitus include small portable computers, cellphones and watches, which can produce a wide variety of sounds.
Comparison of the effectiveness of TRT and "mixing point masking" compared to "total masking therapy" compared to "counseling alone" was presented7. Sound therapy stimulus options include broadband noise, noise-modifying spectrum, noise-modifying envelope, combined tones and modulated tones, music which is processed and the sounds of the music are spectrally adjusted to the audiogram -i.e.
Tailor-made notched music reduces tinnitus loudness and tinnitus-related auditory cortex activity (Okamoto, H. To date, tinnitus treatment strategies, for example TRT, are symptom-management approaches.
Tyler et al.10 investigated patient preferences for multiple tinnitus treatment options from wearable to implantable devices. In conclusion, a wide variety of sound therapies were presented in an attempt to provide tinnitus relief.
Vagus nerve stimulation (VNS) releases the neurotransmitters, acetylcholine and norepinephrine from the locus coeruleus and the Nucleus basalis. Blast-induced tinnitus and hearing loss was demonstrated in rats with diffusion tensor imaging (DTI). The results of a clinical trial on 10 patients in Belgium which were presented at the Tinnitus Research Initiative Meeting in June 2012 were presented again. At long-term follow-up return, the patient also had worsened depression (two-day stimulation, four days no stimulation, then suicide attempt) no further VNS was applied. An ongoing Blinded Randomized Pilot NIH Study Assessing Vagus Nerve Stimulation (VNS) paired with Tones for Tinnitus vs.
It is hypothesized that: 1) activation of NMDA receptors and glutamate excitotoxicity occur with noise, trauma, barotrauma, surgery, and otitis media with production of proinflammatory cytokines and 2) tinnitus is the result of NMDR mediated aberrant excitation of the auditory nerve4.
The Esteem system implant is a total middle ear implant for a moderate sensorineural hearing loss for patients 18 years and older with a stable moderate severe sensorineural hearing loss and good speech discrimination6. Limited data with Esteem was presented of 30 patients of 57 (54.4%) who reported a history of tinnitus at baseline. Through the 10-month post-implant follow-up, there were 8 reports of tinnitus as an Adverse Device Effect (ADE) - of these 5 had resolved by the 10-month follow-up and 3 were ongoing. The attendees to the 5th AAO HNS International Tinnitus Miniseminar 2014 were provided with information of the present, ongoing and future state of the art basic science and clinical medical audiological advances for understanding tinnitus theory, an evolving neurobiology for tinnitus, and its application for diagnosis and treatment for the benefit of the tinnitus patient.
Objective: Complaining of psychiatric symptoms is more common among individuals suffering from tinnitus. The word 'tinnitus' is a Latin word for 'ringing' and refers to the perception of noises in the absence of any external sound. Tinnitus is a common symptom with a prevalence of 10-15% among adults, and 1-2% of severe type among general population2-4. The aim of this study was to determine the prevalence of psychiatric disorders among chronic tinnitus patients who referred to Ear, Nose, and Throat Center of Rasoul General Hospital Clinic in Tehran, Iran. The current study was carried out as a cross-sectional design between April 2008 and June 2009. Tinnitus patients with important medical or psychiatric disorders, illiterate subjects, patients who were taking psychotropics, and or Gabapentine were excluded. Demographic variables included age, sex, educational level, marital status, occupation, were measured (Table 1). Regarding to lifetime and current clinical diagnosis, the results showed 60% (240 patients) and 55.2% (197 patients) of the study subjects were suffering from at least one mental disorder using SCID-I. Patients with at least one axis-I psychiatric diagnosis were more females and younger than other group (tinnitus patients without mental disorders) with significant difference (pp=0.01).
Regarding to psychiatric diagnosis or symptoms, there was not any significant association between THI and presence of mental disorders or the scores of GSI. This study was performed with approximately large sample and using structural interview by SCID-I to determine the psychiatric diagnosis of the study sample. In a Swedish study, the results showed that lifetime and current prevalence of major depression were 62% and 48% than the controls (21% and 7%, respectively)22. In spite of the high rate coincidence between tinnitus and mental disorders, particularly anxiety and depressive disorders, the causation cannot be directly inferred.
Depressive and anxiety disorders have been related to dysfunction of neurotransmitters such as the serotonergic system in the central nervous system. It could be speculated that patients with depressive and anxiety disorders are neurobiological prone to suffering from tinnitus sound, or presence of chronic tinnitus may predispose the individuals to depressive and anxiety disorders and vice-versa. Among different variables, psychological variables included impaired concentration, feeling depressed and perceived negative attitudes were the strongest which had correlation with low quality of life28.
Data suggest that comorbid depressive disorders may worsen the prognosis for tinnitus disability29-30.
Mental disorders themselves are usually chronic diseases and could cause serious burden on the patient and the society.
As a conclusion, the coincidence of tinnitus is more common with mental disorders specifically depressive and anxiety disorders.
Registrierung, Beitragseinreichungund Programminfos">Fur Teilnehmer: Registrierung, Beitragseinreichungund ProgramminfosXI. Uneri and Turkdogan [3] examined 34 children (ages 4-18 years) having paroxysmal dizziness or vertigo attacks or both. Examining the prevalence of migraine and migraine equivalents in children of school age (N = 314), Russel and Abu-Arafeh [4] found that benign paroxysmal vertigo is common in children and that, although it is seldom diagnosed, it appears to cause few major problems for the affected children.
Other less frequent causes include trauma [7], Meniere's disease [8,9], cerebellopontine angle tumor [10], seizure, postmeningitic vertigo [11], acute vestibular neuritis, and juvenile rheumatoid arthritis. By stabilography, examined parameters were worse in a diabetic group in comparison to controls, reaching statistical significance in younger children [13], and were better in diabetic patients with a longer history of the disease.
Meniere's disease in children is rare, and its clinical appearance is not as typical as in adults. Acetylsalicylic acid (aspirin) and other nonsteroidal antiinflammatory drugs can also cause tinnitus, deafness, and vertigo [14]. In the majority of cases, vestibular dysfunction appears together with cochlear dysfunction.
The vestibulospinal pathways are controlled by craniocorpography recordings of the standing test [16] and the stepping test [17,18].
All the tests are related to standardized test evaluations of the major databanks of NODEC I-IV. More than one-half of our sample group complained of subjective hearing loss, which is very frequent for this young age range. The equilibriometric, objective, and quantitative investigation results of polygraphic electronystagmography of spontaneous and caloric vestibuloocular nystagmus are shown in Table 2.
The rotatory acceleration test stimulates the right and left inner-ear vestibular canals in opposite directions.
During the rotatory intensity-damping test, we recorded the electrocardiographic reactions. Pathology from childhood to adolescence carries physical, cognitive, motor, linguistic, perceptual, social, emotional, and neurosensory characteristics. Physiological and clinical vertigo syndromes commonly are found as a combination of four principal phenomena: perceptual (vertigo), oculomotor (nystagmus), postural (dystaxia), and vegetative (nausea, vomiting).
A large number of children suffering from vertigo have additional problems in daily life, such as learning disabilities, reduced attention, decreased endurance and concentration capacity, disturbances of precise motor functions, and hyperactive behavior [19]. This research was presented at the Thirty-First Congress of the Neurootological and Equilibriometric Society, Bad Kissingen, Germany, March 26-28, 2004. All of 1,420 children seen for clarification of a hearing disorder or to follow up for known difficulty in hearing were questioned as to whether they experienced tinnitus. The number of patients who suffer from tinnitus has risen clearly within the last decades, and the frequency of tinnitus in children has increased. We questioned as to whether they had tinnitus l,420 children seen for clarification of a hearing disorder or to follow up known hardness of hearing.
A total of 102 children, their parents, or the people who had referred them to us said at the interview that tinnitus had appeared or was still present. The frequent appearance of tinnitus in connection with the deterioration of an existing sensorineural hearing loss was striking in the patients in our group.
We compared the information of children with normal hearing and of those with existing hardness of hearing.
Seven-year-old patient 1 was introduced to us a few weeks after she suffered a case of bacterial meningitis because she complained of tinnitus and could no longer hear well. In the case of patient 1, the cause of the lesions was bacterial meningitis, damage from which can be localized in both inner ears or in the peripheral area of the nerve statoacusticus (eighth cranial nerve) (Fig. Patient 2 was an ll-year-old girl who came to examination with a presumptive diagnosis of hearing loss.
At the beginning of the checkup that we performed almost a year later (summer 2000), the diagnosis was still uncertain. In the case of patient 2, we assumed a disturbance in sensory perception because she experienced difficulty in hearing, although the audiometric test results were normal.
Patient 4, a 12-year-old girl, was introduced to our clinic because of hearing problems in the right ear. The results of this study show that 102 (7.2%) of 1,420 children examined in our center complained of tinnitus.
The accumulation of hearing disorders among our patients, however, is not representative of the population as a whole but rather is explained by the function of our facilities, which provides support to children who are hard of hearing and to their families. The contributions of Nodar [1, 2], of Graham and Butler [3], and of Shulman [4] are considered landmarks in the field of pediatric tinnitus [5, 6]. Compared with that of adults, the level of disability connected with tinnitus was altogether lower in the children. We received information about possible causes of the appearance of tinnitus from a large number of the patients.
The mechanisms of development of tinnitus were, however, not as clear in a large proportion of the children. In the military, the most common causes of mTBI from an external force are direct blunt force trauma to the head, rapid changes in acceleration or deceleration, and atmospheric pressure changes caused by bomb blasts5. Primary blast injuries result from the impact of the shock wave to the body's surface, often affecting the more susceptible air and fluid filled organs such as the lungs, brain and sensory structures in the middle and inner ears. The presence of dizziness after injury is considered adverse prognostic indicator and may be the most persistent symptom of mTBI that unfavorably affects clinical outcome as well as disease course6. The pathophysiologic mechanism of trauma to the vestibular end organ is not fully understood. Treatment of dizziness and imbalance following TBI often includes physical therapy and medications for the acute symptoms.
A retrospective review of 104 charts of active duty Army soldiers that were enrolled in a traumatic brain injury treatment center was conducted at an active duty military installation in the southern United States.
The post-traumatic stress disorder (PTSD) checklist-military version (PCL-M) is a 17-item measure that is widely used in the DoD and the Department of Veterans Affairs and has excellent reliability and validity. DHI (Dizziness Handicap Inventory) developed by Jacobson & Newman23 is a measure of the self-perceived level of handicap associated with the symptom of dizziness [23]. A VBRT certified physical therapist evaluated soldiers during their initial intake assessments at the WRRC and post-VBRT therapy.
The Dynamic Visual Acuity (DVA) test quantified the extent of visual acuity loss due to the combined influences of underlying vestibular pathology and adaptive responses on image stabilization (e.g. The Sensory Organization Test of Computerized Dynamic Posturography (SOT) quantifies biomechanical changes to postural control through evaluation of a person's ability to use sensory system input to maintain upright (quiet) stance during increasingly challenging conditions. Lastly, some of the soldiers were referred for further vestibular evaluation, and were assessed by a board certified Audiologist. Mean, standard deviations, and range of questionnaire results and assessment measure scores were calculated.
The potential mechanisms involved in blast injury are still being explored; however, vestibular dysfunction and visual changes rank among the most common symptoms following blast exposure29. The purpose of this study was to investigate the benefit of VBRT for soldiers with symptoms of dizziness following blast exposure with and without documented vision problems. Brown et al.33 reported on functional improvement on walking tasks and reported disability as indicated on the DHI of individuals categorized with central vestibular disorders. DVA and SOT of computerized dynamic posturography are common functional outcome measures in blast rehabilitation programs32. It was also evident from this current study that soldiers with a complaint of dizziness secondary to mTBI had an increased likelihood of co-morbid conditions such as PTSD, depression and anxiety which is consistent with reports in other studies6,37,38. In summary, soldiers with dizziness and vision problems may not benefit from VBRT at that same rate as soldiers without vision problems.
Institution: University of Nebraska-Lincoln, Department of Special Education and Communication.
Paper submitted to the ITJ-SGP (Publishing Management System) on January 31, 2013; and accepted on February 31, 2013. We have gained experience in examining the otolithic organ with what we call electrootolithography [1]. Electrootolithography is useful in the hands of experienced audiologists who have the ability to detect the window of activity within the evolving time-series signal on a monitor. To overcome these problems and with the aim of developing a robust signal-processing method for routine clinical evaluation, we investigated several different statistical methods. For recording, the active electrode remained in the tympanic recess after electrocochleography; the reference electrode was fixed on the ear lobe, and the common ground electrode was fixed just beneath the frontal hairline. Several responses also were obtained from subjects subjected to the sound of a tuning fork (512 Hz) held in front of the external ear canal, after clenching the teeth and shaking the head. This method presents statistical information showing the median, twenty-fifth, and seventy-fifth percentiles shown as the top and bottom of the boxes with error bars showing the cutoffs and minimum-maximum values (SigmaPlot version 8.02). Table 1 gives a numerical data description of the scaling behavior in head resting versus ipsilateral and forward head tilt in a subject without vestibulocochlear symptoms.
Instead of a numerical data description, a visual format, such as box plots, provides the same statistics. Figure 3 shows the interquartile range analysis in a normal subject, comparing ipsilateral with contralateral and forward head tilt with backward head tilt. In normal subjects, we typically found that the interquartile range coefficient (Q m) of ipsilateral head tilt was always larger than the interquartile range coefficient of contralateral head tilt, representing the response of the utriculus.
This relationship could be expressed in a new ratio between the Qm coefficients (Equation 2). Recordings in resting position during teeth clenching showed an immediate and obvious response (Fig. Figure 6 compares resting position with the presentation of a 512-Hz tuning fork to the test ear.
To reduce interference from muscle activity or a disturbance from a moving electrode in the tympanic recess-or even contamination by the semicircular canals-we performed recordings using a tilt table while subjects were completely relaxed. We usually performed recordings over a period of 3-5 seconds while swiftly tilting the head.
The recordings of a patient after the removal of an acoustical neuroma from the left ear are shown in Figure 9. Figure 10 shows the response of a patient with benign paroxysmal positioning vertigo before canalith repositioning and before the otolithic organ had recovered.
Short-lived positioning attacks of vertigo are generally conceded to result from movement of dislodged, gravitysensitive otoconia that somehow found their way into a semicircular canal.
Benign paroxysmal positioning vertigo, therefore, is an ideal clinical condition in which to study the electrical response of the inner ear before and after treatment and to compare responses with normal subjects. In contralateral head tilt and backward head tilt, possibly owing to inhibition, cross-striolar or commissural, response of the vestibular nerve is comparatively reduced. Our results are consistent with the clinical presentation of symptoms but also give us additional information based on the unique anatomical arrangement of hair cells in the otolithic organ [5].
In the sacculus, we can distinguish between an anterior portion and a posterior portion of the macula, and the polarization of the hair cells along the reversal line of the striola is opposite that of the utriculus (Fig. Also here, the unique arrangement of hair cells and the size of the coefficients can give us a clue as to where in the sacculus the deficit is to be expected.
We usually performed recordings over a period of 3-5 seconds while subjects swiftly tilted the head. Though the quality of electrootolithography is dependent on the experience of the examiner and therefore is a far more subjective test, performing the amplitude range analysis test is easier, and it is more objective. We do not believe that the movement of otoconia is responsible for the abnormal box-plot pattern in benign paroxysmal positioning vertigo. We are routinely performing amplitude range analyses of the otolithic organ, although the results with this technique can be regarded as preliminary. Finally, this technique can be transferred to the caloric examination of the lateral semicircular canal.
From examining directly all three units of the inner ear with a single electrode placed in the tympanic recess, our understanding of inner-ear disorders is gradually changing. Benign paroxysmal positioning vertigo is a suitable clinical condition in which to examine the inner ear's response to head tilting in roll and in pitch using electrocochleography techniques. The aim of our study was to outline the prevalence of hyperlipidemia in patients who had high-frequency hearing loss and tinnitus due to noise exposure. Cochlear hair cells and neural and central auditory pathways are involved in the generation of subjective tinnitus [1]. Decrease in internal diameter of the vascular bed resulting from hyperlipidemia compromises the oxygen transportation capability of the blood to the cochlea, and chronic hypoxia is likely to occur by the reduction in oxygen supply of the inner ear, which in turn would lead to insufficient adjustment of the cochlear metabolism. This may result in the overproduction and accumulation of free radicals, which disturb the microcirculation of the cochlea and play an important role in ischemiainduced cochlear injury [7].
The reasons for the susceptibility to noise-induced hearing loss of patients who have been exposed to a noisy environment have been the subject of various studies.
Previous data indicate that the cochlea and the central auditory system age faster and earlier in patients with hyperlipidemia and that the risk of noise-induced hearing loss is much higher [5,11].
The aim of this study was to outline the prevalence of hyperlipidemia in patients who had high-frequency hearing loss and tinnitus due to chronic noise exposure and to evaluate the risk of developing sensory hearing loss in those patients as compared to risk in control subjects. We conducted this prospective study in 120 consecutive patients with complaints of chronic subjective tinnitus of varying degrees of severity and hearing loss due to noise exposure. The patients were examined otoscopically and were reviewed by an audiometric test battery including puretone audiometer (AC-30, IAC, Copenhagen, Denmark), stapes reflex, and tympanometry (Amplaid 775, Milan, Italy).
Antilipid treatment with statin derivatives was planned once-daily oral dosing for up to 1-2 years (minimum, 12.4 months). We then compared tinnitus scores and hearing levels in patients with no response to antihyperlipidemic therapy and in patients who had a normal blood cholesterol level after the treatment. The duration of tinnitus in patients with noise exposure varied from 2 months to 12 years (mean, 5.5 years). Of 22 patients in the unresponsive group, 6 had high cholesterol and triglyceride, 9 had high triglyceride, and 7 had high cholesterol only before the antilipidemic therapy. Of 20 patients in the responsive group, 7 had high cholesterol or triglyceride, 10 had high triglyceride, and 3 had high cholesterol only before the antilipidemic therapy.
The difference between the pitch-match frequencies before and after therapy was not significant. Epidemiological investigations emphasizing the relationship between hearing loss and the risk factors for coronary artery disease date back to the 1960s [18].
Spencer [19] found that 42.3% of 300 patients with different symptoms of inner-ear pathology had clearly defined hyperlipoproteinemia.
The effect of hyperlipidemia on auditory perception has been studied clinically and experimentally. The exact pathological mechanism for the hyperlipidemia-induced hearing loss remains obscure. In his study of 64 rats, Pillsbury [37] exposed half to loud noise and fed half of each subgroup a fat diet and found elevated auditory brainstem response thresholds in the hyperlipidemic animals. Studies investigating the restorative possibility of a low-cholesterol diet and antihyperlipidemic therapy on hearing loss and tinnitus are very few.
LDL apheresis has been reported to be much more effective as compared with standard prednisolone, dextran, and pentoxifylline therapy in patients with sudden hearing loss [9]. In our study, changes in tinnitus scores before and after therapy in the responsive group were significant as compared with those in the unresponsive group.
Tinnitus and hearing loss are frequently encountered after an acute acoustic and blast trauma or chronic noise exposure. Nowadays, the neurosensorial disorders, which appreciably diminuate the quality of the life, are in a continuous increase all over the world. Table 1 presents the main causes responsible for this phenomenon, as well as the extent to which they influence the increase of each type of neurosensorial disorders.
In Germany during 1992, we had to deal with about 200,000 cases of whiplash injuries due to traffic accidents. Basically, the following types of post-traumatic syndromes due to whiplash injuries can be differentiated, as there does not exist one single disease pattern (Table 2). Tinnitus occupy a special place between the complaints of the patients suffering from the Late Whiplash Injury Syndrome (LWIS).
Tinnitus is an acoustical phenomenon which is perceived without having an extrinsic source of sound.
Already in 1994, Claussen has reported the results of a study, which compared the data from 206 cases of late whiplash injury syndrome, who were in medical attention only for treatment purposes, with those from 41 neurootological expertise cases after whiplash injury.
In the present work we oncentrated our attention upon those cases of LWIS who were labeled and treated by numerous other doctors and representants of insurance companies as so-called "trifle-cases". In the third subsample were included those cases who suffered from the so-called Hypersensitive Ear Syndrome (HES) (Claussen 1985). The audiometrical results then were underpinned through analyses of the acoustical pathway. The subdivision of the main sample from the point of view of the above described criteria is presented in Table 6. Table 7 shows that in all the samples other sensorial disturbances are considerably present. Table 8 combines the data concerning the hearing disturbances with those concerning the tinnitus. When analyzing the qualitative characteristics of the ear sensations, the highest incidence of the complaints is found in the sample of patients with maskable tinnitus (Table 9). Two of the 91 patients were notable to make a personal estimation concerning the evolution of their disease. The results of these complex and sensorial investigations showed that in nearly all the patients tinnitus was not an isolated phenomenon, being mostly associated to other multi sensorial neurootological functional disturbances. As all the cases come to us with a very rich medical, hospital, litigation, and expertise documentation accumulated in the peri od of time following the accident, however, including also pre-accidental patient information, we get comple e information about the evolution of the disease, the inte mediary symptoms and the preexisting medical result and diagnosis. The problem of tinnitus as a consequence of whiplash injury is intensively discussed in the neurootological literature since 1928.
In 1928 tinnitus is ment oned by Barré and Lieou as being the most frequent sym tom in the patients with cervi cospinal injury. In most of the patients investigated by these authors, tinnitus appears as a result of the so-called "degenerative cervico-spinal injury syndrome". Shulman, who is considered as one of the pioneers and an exceptional specialist in the field of the tinnitus research, shows in his book about the modern diagnosis and therapy of tinnitus, that the severe, disabling tinnitus is usuallly associated with anxiety psychosis. The observation of Shulman, that in most of the tinnitus cases, there coexists a high tone sensorineural hearing loss, is valid for the patients investigated by us, too. Fürther on, Shulman shows that about 20% of the patients with severe tinnitus also have vertigo complaints.
Based upon the numerous observations from all over the world, concerning the late complications of the whiplash injury, we can affirm that even the simple, non-contact whiplash injury can be the cause of long lasting, cronic polisensorial disturbances. Adjacent perfusion asymmetries involving the frontal, temporal and parietal lobes suggest a interneuronal network resulting in the transition of the sensory to the affect components of the symptom of tinnitus. Descartes regarded the mind as something immaterial, separate from brain but interacting with it in some manner. Fear and stress in tinnitus patients particularly of the severe disabling type are a result of a paradoxical auditory memory of an aberrant dysynchronous auditory signal. The establishment of a paradoxical auditory memory for tinnitus is hypothesized to be the initial process localized in the medial temporal lobe. Demonstrations of SPECT imaging of rain in patients are presented to support this hypothesis.
The heterogeneity of response both for sensory and affect has been reported by professionals of all disciplines who are involved in tinnitus diagnosis and attempts for its control.
The Papez circuit proposed the anatomical basis of emotion to consist of the cingulate gyrus which connects with the parahippocampal gyrus and peripheral area of the temporal lobe.
The anatomical components are best seen by a saggital section of the medial surface of the brain; and ventral views of the base of brain. Non-declarative memory, also called implicit memory, includes all abilities which are unconscious and expressed through performance.16 Such abilities provide for cumulative changes in perceptual and response systems of new skills and habits, priming, simple classical conditioning, and non-associative learning. Its chieffunction is the transition of a aberrant dysynchronous auditory sensory signal to a affective behavioral response (Fig. This conceptualization is a basic tenet of the FCP for tinnitus of the cochleovestibular system. The sensory and affect components are considered to be in a constant state of reciprocal interaction. For memory, alterations occur in the hippocampal formation with the establishment of a paradoxical memory for an aberrant dysynchronous signal.
I consider the experimental and theoretical work of consciousness as reflected in memory, to be a starting point to explain our SPECT findings to date. Neurobiological theories of tinnitus awareness need to be developed and tested using a combination of molecular, neurobiological and clinical imaging studies. It is possible that there is a localization in the MTLS for all sensory inputs similar to that which exists in the motor cortex. Specifically, the anatomic substrate where integration of sensory and affect components occurs for the auditory system, is suggested at this time to be in the MTLS.
Interference in masking within brain, initially at brain stem is hypothesized to set in motion a cascade of events wherein the sensory component is overwhelmed by that of the affect due to the establishment of a paradoxical auditory memory. Hinton et al.35 have described such neuronal networking in investigations simulating brain damage. For the first time, here is a model which may differentiate tinnitus between its sensory and affect components both from its clinical and basic science perspectives. Jacobson L, Sapolsky R: The role of the hippocampus in feedback regulation of the hippothalamic - pituitary - adrenal cortex axis. LeDoux JE: Information flow from sensation to emotion plasticity in the neural computation of stimulus value.
The data, reflective of multiple brain functions in the presence of the tinnitus signal, was demonstrated. Functional brain Imaging-Pet brain and quantitative electroencephalogra phy (QEEG) data when correlated with the clinical report of the patient for an efficacy of a particular modality of treatment, provides an objective measure in terms of metabolism and brain function for a subjective response to a particular modality of tinnitus treatment.To propose development of an objective measure for tinnitus treatment efficacy based on a correlation of the results of electrophysiology functional brain imaging with the clinical report of a patient.
It is considered to be a complex biology of physiological process(es) which exert a positive or negative influence on an existing neural signal input or output, but does not eliminate the existing neural signal. It is hypothesized that common etiological agents that cause injury to the CNS have similar effects on the inner ear.
It is hypothesized that when the balance between excitatory-inhibitory action is broken in sensory systems, predominantly due to neuromodulatory activity of reduced induced inhibition, excitation predominates, sensory circuits become plastic, and adaptation is established at synaptic levels reflective of environmental inputs. The cognitive brain function of "memory" is the predominant brain function that is hypothesized to bind the two together9.
Functional brain Imaging-Pet brain- comparison CI#1 OFF baseline and ON: Demonstration Neuroplasticity. The QEEG in 2013 was recommended to be included into the tinnitus evaluation of all tinnitus patients with the diagnosis of subjective idiopathic tinnitus of the severe disabling type. 2) The role of NPL NM NPT in an evolving neurobiology for a predominant central type severe disabling tinnitus.
The clinical application of the data is not to diagnose tinnitus but to provide an increase in both the accuracy for the tinnitus diagnosis by its integration and correlation with the clinical history and physical examination and to objectively monitor the efficacy of tinnitus treatment modalities. Neuroplasticity,(NPL), neuromodulation (NM) and neuroprotection (NPT) are biophysiological processes which maintain a homeostasis of function in the nervous system, hypothesized to be based on maintenance of a balance be tween inhibition and excitation; a reduction in inhibition resulting in an interference in neural function. The Qeeg in 2014 is a tool which demonstrates electrophysiologic data of brain wave activity i.e. The clinical application of the QEEG data is not to diagnose tinnitus but by its integration and correlation with the clinical history and physical examination, to 1) provide an increase in both the accuracy for the tinnitus diagnosis; and 2) to objectively monitor the efficacy of tinnitus treatment modalities.
Clinical correlation of the QEEG data is recommended to determine its medical significance, individual for each tinnitus patient.
The sLORETA analysis provides source localization in brain, in the narrow band frequency range, which is the mathematically most probable source of the electrical potential (EEG) recorded from the surface scalp electrode11.
Tinnitus patients demonstrate less Alpha and more Delta power in temporal cortex areas as compared to normal controls2. Tinnitus patients demonstrated after NFB-power for delta and theta bands was reduced; however, an increase of power was noted for the alpha bands1. Subjects learn how to influence brain activity by presentation to the patient of a visible activity and subsequent changes in activity. The desired activity changes followed by positive feedback or rewards result in the learning of self-regulation by the tinnitus patient. Unclear to what extent the recorded activity reflects the activity of the auditory cortex -OR-nonspecific effects e.g. The sLORETA provides a reconstruction technique in the narrow band frequency which is mathematically most probable to be the source localization as an estimate inside the brain of the electrical potential recorded from surface electrode at the scalp. The regions included the cochlea, cochlea nucleus, caudal midbrain, inferior colliculus, medial geniculate body, and primary auditory cortex. An initial method for focal noninvasive and painless stimulation of brain activity in these areas was demonstrated.
Activated ROIs included the amygdala, hippocampus, parahippocampus, posterior and anterior cingulate cortex and precuneus. The patients were of age 18-70, chronic tinnitus greater than six months' duration and a Tinnitus Handicap Inventory score greater than 38 were recruited for this study. A variety of drugs approved for other indications are used for the treatment of tinnitus in clinical practice. In the interpretation of the effective antidepressants for tinnitus, it must be considered that the scales used for tinnitus measurement correlate highly with depression scales11. A network of 1,313 drug-target pairs, based on 275 compounds that elicit tinnitus as side effect and their targets reported in databases were analyzed. L-baclofen up to 60 mg per day has been reported with improvement of tinnitus, however, frequent side effects. Such a combination of treatment could consist of different drugs even if one in isolation has shown only some limited benefit for tinnitus suppression. Alterations in auditory and in non-auditory brain areas are involved in tinnitus pathophysiology. Neither TMS nor medication alone have a role for routine treatment but provide important information for better understanding of the pathophysiology of tinnitus.
In other words, tinnitus is best influenced by modulation of auditory and non-auditory brain areas with medication. A variety of drugs with different therapeutic uses have been used off-label with some effect in a limited subset of patients.
Support for this opinion was supported by a study in which the effectiveness of hearing aids was established in mitigating the effects of tinnitus in 1314 patients. Differences among sound therapies are reflected in the sound quality and the level at which the therapy is provided. The patient was recommended to use the device not as a masker, but to use the stimulus from the device to achieve a "mixing point". SPA tones, Zen tones and notched noise or music around the pitch match, which is the Neuromonics stimulus. Spectrally, "notched" music and reduced cortical activity corresponding to the notch center frequency, possibly occur due to lateral inhibition.
Any and all sound therapy should be combined with counseling, for example tinnitus activities treatments. Hearing loss or noise exposure results in a pathological alteration in plasticity at brain cortex resulting in tinnitus. The MEG is a technique to localize sources of electrical activity within the human brain by noninvasively measuring the magnetic fields arising from such activity. A Vagus Nerve Stimulator (VNS) is implanted in the OR during a 60 minute outpatient procedure.
The patient listens to tones while receiving stimulation (2.5 hour session, 5 days a week, 4 weeks) - initially in clinic, then at home. The patient, sitting in a chair with clinical headphones with the implantable VNS device in the neck area, is connected by a wireless transmission to the laptop loaded with therapy software.
The assessment of results utilized the tinnitus handicap inventory (THI), tinnitus handicap questionnaire (THQ) and Minimal masking level (MML).
Tinnitus diagnosis - subjective tinnitus due to hearing loss with some tonal quality of the tinnitus. Hearing loss greater than 80 dB HL, Meniere's disease, ear tumors, evidence of active middle ear di- sease, i.e. The results of AM-101 randomized control trials have reported the drug to be well tolerated, reduction in tinnitus loudness, masking level improvement, and tinnitus attenuation5. The aim of this study is to determine the psychiatric diagnosis and symptoms of patients with chronic tinnitus. It is the medical term for any kinds of sound that people hear in one or both ears, or come from the middle of their head1.
From 2350 Patients with chronic tinnitus, which have been registered at the Research Center of Ear, Nose, and Throat of Rasoul General Hospital, 400 adult aged 18 years or older who were accessible and could participate were enrolled in this study. All study subjects had taken no medication for a long period before being included in the study. The Structured Interview for DSM-III-R (SCID-I) as a diagnostic instrument for DSM-III-R axis I psychiatric disorders was used to identify mental disorders. Farsi version was provided with test-retest reliability (Yule's Y) for diagnosis 120 International Tinnitus Journal, Vol. According to GSI score, they are categorized to two groups of less than 0.7 (as cut off score) and more. Our study showed that more than 50% of study subjects were suffering from mental disorders for lifetime or currently in which depression and anxiety disorders were more common. Using larger sample in 2006 by the same researchers, the study results revealed that 46% of the study sample had any current Axis I disorder; and 54%, no current Axis I disorder.
Severe tinnitus certainly has an impact on a patient's daily life and may cause psychological discomfort; on the other hand, the presence of depression and anxiety may reduce the patience of the individual to tolerate the chronic stress and overestimate the severity of tinnitus. Serotonin is involved in modulation of sensory processing in the primary auditory cortex24-25. For better understanding, stress-diathesis model which assumed for the first time for the schizophrenia, and other psychosomatic disorder such as pain and depression26 was applied for tinnitus and depressive disorders27. Depression will be the second most common disease in the community to impose burden and disability31.
Vandad SH, Asadi SM, Mohammadi MR, Amini H, Kaviani H, Semnani Y, Shabani A, Shahrivar Z, Davari Ashtiani R, Hakim Shooshtar M, Sadigh A, Roodsari Jalali M. Ear, Nose, Throat, Head and Neck Research Center, - Tehran University of Medical Sciences - Tehran - AC - Brazil. Mental Health Research Center - Tehran University of Medical Sciences - Tehran - Ivory Coast (Cote d'Ivoire). Community Medicine - Tehran University of Medical Sciences - Tehran - Ivory Coast (Cote d'Ivoire). Otitis media and middle-ear effusion could be the most common causes of vertigo in children, but problems exist in detecting the other causes of vertigo. Regarding the medical history of the group, chronic headache attacks consistent with migraine were reported in 12 children, and motion sickness was reported in 30 (some patients experiencing both conditions).
In common with previous studies, these authors found that benign paroxysmal vertigo appears to be related to migraine.
The triad of vertigo, tinnitus, and deafness are not usually elicited; diagnosis is often made after years of follow-up and batteries of investigations [8,9]. One hypothesis attributes these outcomes to a reactive immunological mechanism, but this hypothesis has been confirmed only in exceptional cases.


Examining a group of 72 children (ages 4-14 years) with unilateral sensorineural hearing loss of probable viral origin and concomitant vestibular affects, Melagrana et al. All patients complaining of vertigo either with or without hearing loss and tinnitus presented for our neurootological investigation. We also performed an acoustic analysis: pure-tone audiometry, tympanometry, speech audiometry, and brainstem evoked response audiometry.
They comprise data from approximately 30,000 neurootological patients and normal controls, spanning ten decades of life and both genders. Regarding the history of our patients, we found the parameter frequencies outlined in Table 1. A spontaneous ECG was defined as an electrocardiographic response during the culmination phase of the nystagmus reaction in the supine position without any stimulation.
We saw few site differences between perrotatory right- and left-beating nystagmus, whereas postrotatory rightand left-beating nystagmus show a major laterality, with higher activities in postrotatory left-beating nystagmus. Baseline is an electrocardiogram obtained with the subject in a seated position with a spontaneous nystagmus beating to the right or to the left. To compile the best results, we recorded speech audiometry, which gave us an impression of the patients' social understanding. Associated with ages 8 to 14 or 15 years especially are very special traits of a rollover in data processing with respect to balance regulation. These four cardinal manifestations of vertigo are related to different levels of the vestibular analyzer and require different methods of investigation. Because of the variability in symptoms, no specific therapy exists for children with learning disabilities. The interview was carried out after a hearing test was conducted, which was based on play audiometry or normal pure-tone threshold audiometry, depending on the age of the child. The interview was carried out after the hearing test, which was based on play audiometry or normal pure-tone threshold audiometry, depending on the age of the child. The deterioration did not happen in a way similar to that in acute hearing loss but more slowly. In many of the children examined in our center, meningitis was the cause of acquired hearing disorders. Wheezing or beeping and murmur are the most frequent sensations characterized by the children questioned. The hearing test showed residual hearing on the right side; on the left side, it revealed moderate sensorineural hearing loss with a mild hearing loss in the low and high frequencies. Pure-tone threshold audiogram of a 7-year-old girl (patient 1) with leftsided tinnitus after meningitis. During the course of the examination, however, it was discerned that the curves of bone conduction eventually lay at 0 dB and the curves of air conduction at 5-15 dB, whispered speech was finally understood from 4 meters, and normal speech was understood on both sides from more than 6 meters away. She remains under pressure at school, however, and the tinnitus in conjunction with the alleged hearing difficulty are likely signs of emotional pressure (Fig.
Pure-tone threshold audiograms from an ll-year-old girl (patient 2) with tinnitus of probable psychogenic origin. In 1996, he complained of a sensory hearing loss bordering on deafness in the right ear and only residual hearing in the left ear. Pure-tone threshold audiograms from a 13-year-old boy (patient 3) with progressive hearing loss and tinnitus. Pure-tone threshold audiogram from a 12-year-old girl (patient 4) with tinnitus, hearing loss, and vertigo after head trauma. Only 27 (26.4%) of the 102 children with tinnitus had come to the examination primarily because of existing tinnitus concurrent with normal hearing.
Nodar found in a group of children screened for hearing impairment that 13% with normal hearing had tinnitus. Many children first indicated tinnitus during questioning, and it was also a surprise for parents to learn that their child had tinnitus. The most frequent information given (in 29.4%) was the progression of an existing hardness of hearing.
This condition might also represent a noise-induced hearing loss in the inner ear, which may be caused by powered hearing aids that are not adjusted correctly or limited sufficiently. Because children seldom complain about their tinnitus, their problems must always be taken seriously. In a deployment setting, soldiers are typically sustaining attacks from explosions or blasts by rocket-propelled grenades (RPGs) and improvised explosive devices (IEDs).
Secondary blast injuries are the result of propelled fragments flying through the air; these fragments may cause penetrating injuries.
Incidence of dizziness or imbalance secondary to mTBI ranges from 24%-83% and potentially up to 90%6,9,10. In one of the few long-term studies on untreated patients with mild head trauma injury, vertigo persisted in 59% of patients after five years of recovery11.
Dual sensory disorders must be taken into consideration during vestibular evaluation and treatment because many related activities depend on sensory input from the visual system and may even overshadow a balance disorder. For a majority of functional vestibular deficits, Vestibular Balance Rehabilitation Therapy (VBRT) is often appropriate. Furthermore, the purpose of this study was to investigate the benefit of VBRT for individuals with history of dizziness resulting from blast exposure and visual disorders as opposed to individuals without visual disorders. The investigators retrospectively analyzed de-identified records of patients who were referred to the program from August 2010 through March 2011 and whom were later accepted into a TBI program.
The primary care intake questionnaire packet given at the WRRC included several neuro-psychological tests; the results of four tests were included in the retrospective review. The items on the PCL-M correspond to the Diagnostic and Statistical Manual Fourth Edition (DSM-IV) diagnostic criteria for PTSD. The optometrist evaluated visual acuity through use of the Snellen chart, observed ocular structure and overall health, and assessed extra ocular movements. The audiologist determined if the soldier was a candidate for videonystagmography (VNG) and caloric testing, or rotary chair testing based on present complaints and functional status. Soldier data was grouped by those with dizziness resulting from the blast exposure, with and without visual disorders. A correlation scatter plot of each soldier with history of dizziness resulting from blast exposure for PCL-M score and PHQ9 score. A correlation scatter plot of each soldier with history of dizziness resulting from blast exposure for PHQ9 score and Pre-VBRT DHI score.
A correlation scatter plot of each soldier with history of dizziness resulting from blast exposure for PCLM score and Pre-VBRT DHI score.
The results of the repeated-measures ANOVAs with custom contrast for fixed effects for group differences (those with and without visual disorders post-blast exposure) on the VBRT pre-and-post measures were performed. Panels on the left: Increase in Gaze stabilization test (GST) and Sensory Organization test (SOT) scores represent better performance over time between patients with and without vision disorders. The ambient vision system is necessary for performing activities of daily living including gaze stability and quiet stance30.
Specifically, this study was proposed to determine if soldier with vision disorders improved at the same rate as those without vision disorders. Functional as well as subjective symptoms improve post-rehabilitation33; however, the rate of improvement is dependent upon the type of disorder and the severity of the disorder at the pre-therapy baseline session33,34. Mean improvements were noted in all central disorder groups (cerebellar dysfunction, stroke, central vestibulopathy, mixed central & peripheral vestibulopathy and post-trauma); however, those with cerebellar dysfunction showed the least improvement on the functional disability measures. Gottshall et al.35 found that DVA scores improved within 4 weeks post VBRT in individuals with vestibular deficits, whereas GST scores did not show significant improvements until 12 weeks after initial therapy.
Memorandum from the Assistant Secretary of Defense for Health Affairs, (ASD(HA)), Traumatic Brain Injury: Definition and Reporting. Audiology - Veteran's Administration, Tennessee Valley Healthcare System - Nashville - AC - United States. In this technique, which is similar to extratympanic electrocochleography, an electrode is placed in the tympanic recess.
What is needed is a reductionist technique that can display the averaged (region-of-interest) signal in real time.
Initially, we applied a range of fractal methods using physical wavelet analysis for the examination of two types of signals (baseline resting position and head tilting) to establish first that the signals were different and, second, that this difference was statistically significant [2,3]. The active electrode was secured with tapes on the pinna so as to avoid movement during head tilting.
After obtaining a baseline response, we tested subjects in roll (ipsilateral head tilt to the electrode side and contralateral head tilt away from the electrode side, stimulating the utriculus) and in pitch (forward head tilt and backward head tilt, stimulating the sacculus). We tested four normal subjects on a tilt table so as to avoid possible contamination by the semicircular canals, and in four patients we recorded responses after a head tilt lasting 10 seconds. We have built a breakout box connected to an existing interface unit (Navigator; Biologic, Chicago, IL). The median is the pivot point above which and below which an equal number of values appear.
We were particularly interested in the Qm values (seventy-fifth through twenty-fifth percentiles) of the amplitude range of each response (size of the box in the box-plot analysis).
This is a suitable format for clinicians who can see at a glance, as in reading an audiogram, whether a response is diverse from the norm (Fig. Left to right: box plot of raw data for both headresting controls, followed by ipsilateral tilt, then forward tilt. Similarly, we found that the interquartile range coefficient of forward head tilt tended to be equal to or larger than the interquartile range coefficient of backward head tilt, representing the response of the sacculus.
The ratio was obtained by dividing Qm of contralateral tilt by the Qm of ipsilateral tilt, representing the response of the utriculus (Equation 3). The marked regression from the zero line creating artifacts affects the size of the box plots. Head shaking reveals major artifacts, which affect the size of the box plot, here compared with the baseline. Clenching the teeth demonstrates an immediate response, which is most likely due to muscle activity. The box plot during this sound stimulus was larger than in resting position without stimulus. The presentation of a tuning fork to the test ear shows a strong response, suggesting that this technique is suitable for recording inner-ear responses.
Tilt-table recordings show a pattern comparable to that of a swift head tilt, suggesting that contamination from the semicircular canals can possibly be ignored. Tilting the head for the 10 seconds and then recording shows a reversed pattern of the box plots, possibly due to adaptation phenomena. Box-plot analysis in a subject with benign paroxysmal positioning vertigo (BPV) before a repositioning maneuver. The utriculus is divided by the reversal line of the striola into a medial portion and a lateral portion of the macula, and the hair cells have opposite polarization, with the kinocilia facing each other (Fig. Hair cells of the macula utriculi are separated by the reversal line of the striola, and the hair cells have polarization opposite, with the kinocilia facing one another. Because a deficit can equally affect both the medial and the lateral portions of the utriculus, a normal coefficient could possibly be seen.
Hair cells of the macula sacculi are separated by the reversal line of the striola into a posterior and an anterior portion, and the kinocilia of hair cells have an orientation opposite to the utriculus. The hair cell area of the anterior portion of the sacculus compares to the posterior portion, and responses in normal subjects are suspected to be fairly equal. The recording is performed in a relatively short period during which movement of the otoconia hardly becomes effective. We believe that contamination by muscle activity or responses from the semicircular canals can be ignored. Pilot studies so far support this assumption, and the examination of the lateral semicircular canal already forms part of our test battery using this technique. Amplitude range analysis is a more objective test than is electrootolithography, and a statistical summary can be displayed in box plots. Low-Cholesterol Diet and Antilipid Therapy in Managing Tinnitus and Hearing Loss in Patients with Noise-Induced Hearing Loss and Hyperlipidemia. We investigated the role of a low-cholesterol diet and antihyperlipidemic therapy to alleviate the severity of tinnitus and possibly promote hearing gain after therapy in patients with acoustic trauma. Analysis of the epidemiological data indicates that exposure to noise is widespread and is one of the most common causes of tinnitus, which leads to various somatic and psychological disorders and interferes with the quality of life [2]. Auditory perception in such cochleas is very sensitive to reduction of the oxygenation in the inner ear [6]. Platelet aggregation and blood viscosity due to high lipid levels will intensify inner-ear damage owing to slowing of microcirculation and will contribute to the development of both progressive and sudden hearing loss [8,9]. Gratton and Wright [10] demonstrated the accumulation of lipid in the stria vascularis and outer hair cells in chinchillas after experimentally induced hypercholesterolemia, which might intensify the detrimental effect of ototoxic drugs or noise. We instituted a low-cholesterol diet and antihyperlipidemic therapy to investigate whether any benefit accrued in terms of hearing gain and tinnitus relief.
The project was approved by the local medical research ethical committee, and we obtained informed consent from each patient.
Audiometric tests included air- and boneconduction thresholds for pure tones of 125-8,000 Hz, tests of speech reception and speech discrimination, contralateral and ipsilateral reflex measurements, and tympanometry. Measurement of loudness of the tinnitus was based on subjective assessment by the patients.
Daily dosage ranged from 10 to 40 mg for simvastatin (Zocor) and from 10 to 80 mg for atorvastatin calcium (Lipitor).
Average ages of patients in the unresponsive and the responsive groups were 39 and 42 years, respectively. Wilcoxon and Mann-Whitney U tests were used to compare the pretreatment data with the posttreatment results and to compare the results of responders and nonresponders. None of these patients demonstrated any drop to normal ranges in cholesterol or triglyceride values after the treatment. When those patients were asked to qualify the severity of their tinnitus, seven rated their tinnitus as the same (35%), two rated it as increased (10%), seven rated it as decreased (35%), and four had no tinnitus (20%). The correlation between serum lipids and auditory dysfunction has been investigated before, and it has been reported that sensorineural hearing loss is more prominent in those with high levels of cholesterol, triglyceride, and lowLDL and in patients with low HDL concentration [18-23].
Increased blood viscosity and atherosclerosis of the cochlear vessels reduce the blood perfusion of the cochlea and promote hearing impairment [6,8,19,20,23,24].
When patients were required to qualify the severity of their tinnitus, 35% of the patients in the responsive group rated their tinnitus as decreased, and 20% of patients reported no tinnitus.
Even though other factors making the patients susceptible to noise-induced hearing loss should be considered, on the basis of present results it can be concluded that the incidence of hyperlipidemia is high among patients with noise-induced hearing loss and that significant improvement in lowered intensity of tinnitus and in average hearing thresholds at higher frequencies can be achieved after lowering patients' serum lipid level [43]. Some of the most frequent sensorineural disorders are the visual disorders, the hearing loss, the tinnitus and the vertigo.
The present work presents a certain neurosensorial disorder related to the head, namely the tinnitus of traumatic etiology. The consequences of the trauma can appear immediatel y after the accident, but most frequently, the traumatic incident is followed by a period of more or less clinical silence and the symptoms become evident only after hours, days or months. The orthopedic as well as the radiological findings mostly are unsatisfactory with respect to the neurosensorial disturbances.
Of a special interest for the present work are the disturbances described as the "cervico-encephalic syndrome." This group also frequently follows a whiplash injury. In all the cases, the neurootological disorders were late complications of a whiplash injury. As Table 5 shows, these patients had complaints of the LWIS for a long time, and were repeatedly investigated by many different medical specialists prior of coming to us. The percentage distribution of the most important non-acoustical subjective symptoms in the above described samples of patients is presented in Table 7.
The clinical experience showed that in the case of the LWIS, symptoms like otalgia or pressure in the ear may accompany tinnitus. Many patients reported the presence of several complaints and disturbances which we considered as being complications of the tinnitus (Table 11). The vestibulo-ocular and retino-ocular reactions are investigated by the method of polygraphic electronystagmography and the vestibulo-spinal reaction by cranio-corpo-graphy with simultaneous computer analysis. Because of the medical expertise questioning, a clear differentitation between the disturbances brought about the accident and thos already pre-existing or having other causes must be done for each of the cases. Decher reports in 1966, that 41% of 500 patients with a history of cervico-spinal injury complain of tinnitus. In many cases the disturbances are also caused by vascular problems in the posterior cranial fossa, due to a narrowing of the vertebral artery in the cervical region. Because of their permanent presence, the ear noises often become intolerable and are seriously disturbing the daily personal life. We also frequently find this stato-acoustical combination in our tinnitus patients with a cervico-encephalic syndrome, due to a whiplash injury. As it was shown above, tinnitus plays a special role in the complex mosaic of these multisensorial neurootological functional disturbances. Localization of brain action is now possible and is being investigated with both Positron Emission Tomography (PET) and Single Photon Emission Computer Tomography (SPECT) brain imaging. The transition is acknowledged to be complex, involving an integration of multiple neuronal networks within the brain. The underlying mechanism is that of dysynchronization, that is, a lack of synchrony or interference in timing of the discharge rate and phase locking of the auditory signal having a location peripheral, central or both. To date 48 patients were selected for SPECT imaging of the brain identified with the MATPP to have severe disabling tinnitus of the central type. The clinical application of this hypothesis for present and future tinnitus diagnosis and treatment is conside d significant. It includes the subcallosal, cingulate, and parahippocampal gyri, the hippocampal formation, and the dentate gyrus.
The temporal lobe connects with the hippocampus (AMMONS horn) via the temporoammonic tract. The entorhinal cortex is a major source of projections at the hippocampus and in turn receives input from adjacent perirhinal, parahippocampal cortices. Final Common Pathway for Tinnitus - The Medial Temporal Lobe System (Presentation at the Charles Univ. It is hypothesized based on our tinnitus experience that in the normal auditory system a sequence of auditory images, results first in establishment of an auditory memory for a sensory input, both short and long term; and secondarily a positive affective behavioral response.
It is possible that there may be further or additional localization for a particular sensation.
Feldmann reported the difference in interaction of signal and masker in patients with and without tinnitus by masking curves. SPECT findings at this time suggest a common neural pathway and not an abstract algorithmic description. The FCP is a biological model which is an outgrowth of our ongoing attempts to integrate the basic sciences with our clinical experience for the diagnosis and treatment of all types and subtypes of tinnitus.
Presented at the Fourth International Seminar Inner Ear Medicine and Surgery, July 1994, Snowmass, Colorado. Observations of simultaneous auditory brainstem responses with monaural stimulation in the tinnitus patient. On the Functional State of Central Vestibular Structures in Monaural Symptomatic Tinnitus Patients.
Both Qeeg and LORETA were presented in the context of functional brain imaging, which also includes demonstration of alterations in metabolism with nuclear medicine, eg SPECT and PET. The resulting alterations in synaptic transmission and neuronal network function depend on the extent of calcium signaling and NMDA activation in response to different patterns of stimulation2,3,8.
Integrity of CI#1 confirmed with persistence of increased tinnitus, cochlear implant soft failure. The application of the QEEG for tinnitus is recommended to be called, the Electroencephalotinnitogram (TCG). The deviation from the normal electrical patterns in these structures likely is reflected in suboptimal functioning. The abnormal Qeeg provides objective evidence of brain wave oscillations to support the clinical recommendation of innovative pharmacologic therapy attempting tinnitus relief, e.g.
The brain that changes itself: stories of personal triumph from the frontiers of brain science. Neuroprotective Drug Therapy: A Medical and Pharmacological Treatment for Tinnitus Control. Noise, Calpain, Calpain Inhibitors, and Neuroprotection: A Preliminary Report of Tinnitus Control.
Unilateral cochlear ablation produces greater loss of inhibition in the contralateral inferior colliculus. Brain wave recordings are obtained initially and during presentation of subsequent alterations in activity.
Tinnitus percep- tion and distress is related to abnormal spontaneous brain activity as measured by magnetoencephalography. Neurotherapy and drug therapy in combination for adult ADHD, personality disorder and seizure disorder: a case report. Although the localization of the tinnitus with brain neuroimaging results are inconsistent in the literature, regions of interest demonstrating brain activation, in general, involve auditory and non-auditory regions. Initially, a magnet was placed on the scalp at a level above the external ear, towards the midline of the scalp i.e. Were these areas of activation acting alone or represented interconnections between different brain systems of activity, highlighted by activity between the prefrontal, parietal cortices, and the anterior insula. Initially, sensory deafferentation causes neuroplastic change which in the case of phantom pain results in an increased activation of the somatosensory cortex (SSC), and in the case of tinnitus, activation of the primary auditory cortex (PAC). A total of 50 patients were needed to detect the clinical relevant change of tinnitus severity. The patients received rTMS treatment on 10 consecutive days using either multi-site rTMS protocol.
Noise-induced hearing loss also is a form of acute tinnitus by exposure to loud noise 85 db and higher.
Therefore, the reduction of tinnitus severity with antidepressants may at least partially be a pure coincidence of antidepressant effect of the investigated drugs. A quantitative score was used to identify emergent significant targets that were more common than expected at random. For example, antidepressant melitracen and antipsychotic lupentoxil which is shown to be superior as an add-on medication to Klonopin. Pharmacological approaches are limited to treatment of comorbidities such as depression, anxiety, or insomnia.
Long-term effects of repetitive transcranial magnetic stimulation (rTMS) in patients with chronic tinnitus. Transcranial magnetic stimulation for the treatment of tinnitus: effects on cortical excitability. Neuroimaging and neuromodulation: complementary approaches for identifying the neuronal correlates of tinnitus. Comparing single-site with multisite rTMS for the treatment of chronic tinnitus - clinical effects and neuroscientific insights: study protocol for a randomized controlled trial. The "mixing point" was defined by Jastreboff as "where the patient perceives that the tinnitus sound and the external sound start to mix or blend together. Disagreement was expressed to "historically" accepted ideas and protocols that all tinnitus patients should avoid silence or that silence may be bad for tinnitus patients. Ouvindo sob medida musica dentada reduz loudness zumbido e audi- atividade do cortex tory relacionados com o zumbido. The tonotopic map at auditory cortex was demonstrated when normal, distorted as with tinnitus and following VNS with Tones Pairing. The patient also had mild hoarseness during stimulation for the first two weeks, namely unable to tolerate standard settings. The primary objective is to provide additional and better controlled evidence that VNS coupled with precisely timed tones in subject suffering from moderate-to-severe subjective tinnitus is an effective treatment for tinnitus. Left hemisphere fractional anisotropy increase in noise-induced tinnitus: a diffusion tensor imaging (DTI) study of white matter tracts in the brain. Blockade of cochlear NMDA receptors prevents long-term tinnitus during a brief consolidation window after acoustic trauma. Efficacy and safety of AM-101 in the treatment of acute inner ear tinnitus-a double-blind, randomized, placebo-controlled phase II study.
Materials and Methods: Four hundred patients with chronic tinnitus from the registry of Otorhinolaryngology Research Center of Rasoul General Hospital, Tehran, Iran were enrolled. Some underlying causes were defined for tinnitus including ear infections, foreign objects or wax in the ear, and damage from load noises. From the list of registry, among those who were living in Tehran were called and invited to participate in this study. The corresponding figures for the highrisk tinnitus patient were major depression (52%); any current anxiety disorder (49%) and any current Axis I disorder (81%)23. In this regard, considering tinnitus as a significant stressor, people react differently depending on their vulnerability to stress.
Comorbidities of mental disorders with tinnitus certainly will enhance the burden of disease and reduce remarkably the quality of life of the individuals. Vigorous attention to the mental health part of the tinnitus and choosing appropriate management may help the patients tolerate the stress caused by tinnitus and assist them to adjust in their daily activities. The prevalence of hearing impairment and reported hearing disability among adults in Great Britain. Assessment of psychopathological aspects and psychiatric comorbidities in patients affected by tinnitus.
Psychological profile and somatic complaints between help-seeking and non-help-seeking tinnitus subjects.
Internet administration of the Hospital Anxiety and Depression Scale in a sample of tinnitus patients.
Psychometric adequacy of the Tinnitus Handicap Inventory (THI) for evaluating treatment outcome. Symptom checklist -90-R: Administrative scoring and procedures manual, NCS Pearson, Minneapolis (1994). The study of mental health of medical student of Mazandaran University of Medical Sciences in 2000.
Psychiatric disorders in tinnitus patients without severe hearing impairment: 24 month follow-up of patients at an audiological clinic.
Auditory evoked potentials as indicator of brain serotonergic activity-first evidence in behaving cats. Intensity dependence of auditory evoked potentials as indicators of central serotonergic neurotransmission-new hypothesis.
The authors found spontaneous vestibular nystagmus (41%) and benign paroxysmal positional nystagmus (59%).
Possible mechanisms that can explain the aura in migraine or the paroxysmal vertigo disorder are an ischemia by vasodilatation due to abnormal accumulation of vasoactive substances (prostaglandin, serotonin, tyramine) or a neural dysfunction located in a specific area mediated by neurons containing serotonin [5,6].
The evaluation of vertigo in children requires a questionnaire for extensive and complete history recording, audiograms, and vestibular function tests. According to some authors, the therapy for Meniere's disease in children is mainly based on drug treatment, but when the disease has progressed, intratympanic gentamicin injections and endolymphatic sac decompression (or, in some cases, nerve section) might be performed subsequently.
The theory of the cyclooxygenase pathway, currently the most widely accepted, is based on the ability of nonsteroidal antiinflammatory drugs to inhibit the cyclooxygenase pathway of arachidonic acid metabolism, leading to prostaglandin depletion and an increase in leukotrienes.
Sometimes, when children could not cooperate with us or because of their behavior, we had to forgo some investigations. For our study, we transferred all the test results into a special Excel spreadsheet (Microsoft), some of which we used for demonstration here.
Most of the complaints are related to low blood pressure; however, in a few cases we also found complaints of hypertension. Quite a few young patients had head and neck trauma, mostly due to traffic accidents and home accidents and, less frequently, to sports accidents. When we synoptically fit together the four results of the caloric tests (right warm, right cold, left warm, left cold), we use trinary coding. In combining the monolateral caloric warm response as a nystagmus response on a weak stimulus with the perrotatory binaural stimulus as a supraliminal stronger stimulus, we can establish the vestibular response intensity comparison (VSRIC [20]), for which we used trinary coding.
We saw thereafter that the four caloric responses-ECGs at 44°C right and left and ECGs at 30°C right and left-systematically depicted lowering heart rates, which is systemic and may be due to an action of the vagal system. In the postrotatory reactions, we observed sympathicotonia in postrotatory left-beating nystagmus, which showed a higher release of the ECG rhythm (Figs. The more sensitive test is stepping craniocorpography (CCG), using the stepping test of Unterberger and Fukuda [17,18]. We used a trinary coding scheme for the four parameters-displacement, lateral sway, angular deviation, and body spin-depicted in Figure 4. It is astonishing that the parameters of understanding double-digit numbers and monosyllabic words and loss of discrimination are much more pathological in the left ear than in the right ear (Table 3). Early and Later Lesions in the Auditory and Vestibular System in Children and Juveniles After Meningitis. Are there any disturbances in vestibular organ of children and young adults with type I diabetes? The influence of metabolic disturbances present in diabetes mellitus type I on vestibulo-spinal reflexes in children and young adults.
Electronystagmography findings in child unilateral sensorineural hearing loss of probable viral origin. Neue registrierbare Vestibularis-Korperdreh- Reaktionen, erhalten durch Treten auf der Stelle. When being interviewed, l02 children reported that tinnitus had appeared or was still present.
Their complaints are minimized or not taken seriously by adults, particularly those of more sensitive children. Supplementary tests included those of otoacoustic emissions, auditory evoked potentials, and impedance audiometry.
It was so distinctive, however, that children, along with their parents, noticed the deterioration in their hearing.
In a large number of them, the hearing fluctuated after a long period of meningitis, in which tinnitus might have been present simultaneously. In affected children, cerebral damage with lesions of central processing structures must originate from head trauma at a very early age, from oxygen deficiency during birth, from infections, and the like. Some children claimed difficulty in hearing and wanted hearing aids, although their hearing was normal.
She was a good pupil but, in school, her teachers observed that within the last 2 months her reactions were diminished when she was addressed. The tympanogram and the transitory evoked otoacoustic emissions were within normal ranges on both sides.
We discussed degeneration of the right inner-ear structures, which might be responsible for the tinnitus (Fig. One year before the examination, she suffered skull or brain trauma in a car accident, after which her symptoms appeared. As a result of our findings, it can be assumed that there is a commotio labyrinthi on the right side.
In this study, children with sensory hearing loss showed a 59% occurrence of tinnitus, and 3% complained spontaneously about tinnitus. The deterioration in those who were hard of hearing was found to be more serious than was the tinnitus itself. The damage to the sensory epithelium of the inner ear by hearing aids was discussed recently and remains controversial, with the result that some children with residual hearing are not being properly provided with hearing aids [18-20]. Hearing loss or impaired equilibrium (or both) frequently develop during or after a period of meningitis.
In these children, pressure situations in school and in the parental home play an important role in tinnitus development (60%).
The diagnostic workup should exclude metabolic disturbances, possible damage to the sensory level of the central nervous system, and evaluation of the circulation. Die Bedeutung der In-situ-Messung zur Einschatzung der wirksamen Horgerate-Verstarkung bei hoheren Schalldruckpegeln. Fruh- und Spatschaden im auditiven und vestibularen Bereich nach Meningitis im Kindes- und Jugendalter. A blast caused by the detonation of an IED initiates with a peak positive pressurization (shock wave) followed in time by a negative pressurization. Tertiary blast injury may occur when the individual is thrown from the blast into a solid object such as an adjacent wall or even a steering wheel. For the soldier with blast injury and mTBI, it is possible that peripheral vestibular pathology, visual impairment, central pathology, peripheral neuropathies, musculoskeletal injuries, vascular disorders, certain medications, and proprioceptive changes all contribute to dizziness. Additionally, patients with mild TBI who have symptoms of dizziness and imbalance often experience a slower recovery and are less likely to return to work than patients without dizziness10. In a report by Weichel & Colyer14, 66% of military with TBI were also found to have combat ocular trauma. This specialized form of physical therapy includes postural stability training, gait training, canalith repositioning therapy, and visual training that targets impaired vestibulo-ocular reflex function and gaze stability.
Each service member obtained a DHI score greater than zero indicating perceived dizziness complaint that was additionally used to verify the dizziness inclusion criteria. The OQ (Outcome Questionnaire) measured a wide variety of symptoms of distress, difficulties in interpersonal relationships, social roles, and general quality of life20. The PCL-M scale ranges from 1 (not at all) to 5 (extremely); scores higher than 50 are considered clinically significant. The PHQ-9 is based directly on the diagnostic criteria for major depressive disorders in the DSM-IV and is widely used for psychometric purposes. A score greater than 10 is considered clinically significant and scores ranging from 0-30 indicates mild, 31-60 moderate, and 61-100 severe handicap. At that time the optometrist entered a diagnosis and offered prescriptions for infections or updated spectacles for visual acuity.
Once the trigger velocity was reached, the optotype would appear and the patient was asked to again identify the orientation of the E. Participants will be asked to step onto a platform machine and stand on a square forceplate, while securely harnessed to the sides of the platform to protect from falling. Independent t-tests were performed to compare differences in Neuropsychological Intake Assessment scores and health characteristics between the two groups. The most common noted diagnosis were convergence 62% (n = 13), saccadic 43% (n = 9), and accommodative 38% (n = 8) insufficiency.
Filled circles represent soldiers with vision disorders; open circles represent soldiers without vision disorders. Two soldiers presented with clinically significant caloric unilateral weakness values (30% and 31%); both soldiers also were diagnosed with visual disorders. The results indicated that soldiers with vision disorders did not improve at the same rate as those without vision disorders. Our results indicated that standard VBRT was ineffective for improving GST results for those soldiers with vision disorders; in fact a slight decrease in performance was noted after VBRT.
The use of vision therapy may also play an important role in the rehabilitation of the mTBI patients, specifically for those that have dual sensory disorders. Traumatic brain injury, posttraumatic stress disorder, and postconcussive symptom reporting among troops returning from Iraq. Comparison of concussive symptoms, cognitive performance, and psychological symptoms between acute blast- versus nonblast-induced mild traumatic brain injury.
Hearing impairment and traumatic brain injury among soldiers: special considerations for the audiologist.
Visual impairment and dysfunction in combat-injured servicemembers with traumatic brain injury.
Program development and defining characteristics of returning military in a VA Polytrauma Network Site.
Characterizing self-reported dizziness and otovestibular impairment among blast-injured traumatic amputees: a pilot study. Validating the primary care posttraumatic stress disorder screen and the posttraumatic stress disorder checklist with soldiers returning from combat.
Characteristics and rehabilitation outcomes among patients with blast and other injuries sustained during the Global War on Terror. A case-oriented approach exploring the relationship between visual and vestibular disturbances and problems of higher-level mobility in persons with traumatic brain injury. Tracking recovery of vestibular function in individuals with blast-induced head trauma using vestibular-visual-cognitive interaction tests. Evidence of central and peripheral vestibular pathology in blast-related traumatic brain injury. Traumatic brain injury, posttraumatic stress disorder, and post concussive symptom reporting among troops returning from Iraq.
Vision therapy for oculomotor dysfunctions in acquired brain injury: a retrospective analysis. Neural mechanisms underlying neurooptometric rehabilitation following traumatic brain injury. The breakout box collected raw data and diverted them to a new data acquisition system for further processing of the incoming signals.
If the array has equal numbers of values, the median is the average of the two middle numbers. The Qm values were used for statistical analysis (Student's t-test) and ultimately led to a new coefficient describing the response of the utriculus and the sacculus.
The lower one-half of the diagram contains the interquartile range analyses, displayed in box plots. Equally, the ratio representing the sacculus was obtained by dividing the Qm of backward head tilt by the Qm of forward head tilt (Equation 4).
These artifacts should be discarded before the final analysis, and most likely they are the result of an electrode movement in the tympanic recess.
The difference was obvious and showed that this technique will record innerear responses, although the recordings look very much like microphonics.
These results compared well with those obtained from a subject sitting at the edge of an examination table and swiftly tilting the head (Fig. Box plots also show a marked digression of the median (lower bar in the box) from the mean (upper bar in the box). This reversed pattern of the box sizes was typical for benign paroxysmal positioning vertigo. The contralateral interquartile range ratio is larger than the ipsilateral interquartile range ratio, suggesting a deficit in the right utriculus.
The coefficient ratio of the utriculus has returned to normal, and the coefficient ratio of the sacculus has remained within normal limits. The Dix-Hallpike maneuver is also suitable for reviewing the treatment outcome after canalith repositioning.
In amplitude range analysis, interquartile ranges will consequently be smaller, owing to a reduced vestibular nerve response.
Ipsilateral head tilt mainly stimulates the medial macula utriculi, whereas contralateral head tilt will mainly stimulate the lateral macula utriculi.
However, in that case, an interaural difference in the size of the boxes is to be expected. Thus, forward head tilt will mainly stimulate the anterior portion of the macula sacculi, and backward head tilt will stimulate mainly the posterior portion. Forward head tilt will mainly stimulate the anterior portion of the sacculus, whereas backward head tilt will mainly stimulate the posterior portion. Thus, different clinical techniques will give different results, and adhering to a specific technique is necessary so as to obtain consistent results. Those researchers found that the medial portion of the utriculus has a hair cell area comparatively larger than the lateral portion. Clinical experience with benign vertigo demonstrates the existence of a delay of several seconds before a nystagmus is observed in the Dix-Hallpike maneuver or the patient experiences vertigo. The rule is that the cochlea, the otolithic organ, and the semicircular canals are all part of a combined response to an insult inflicted on the inner ear, although individual responses and the combination therein may vary. Normal subjects show a different pattern as compared with those from patients with benign paroxysmal positioning vertigo. Sstatistical approaches to temporal frequency analysis of otolithic responses-signal processing with physical wavelets, fractals, other filters and Mathematica. Organization of the sensory hairs in the gravity receptors in utricle and saccule of the squirrel monkey.
Response to static tilt of peripheral neurons innervating otolith organs of the squirrel monkey. Fortytwo hyperlipidemic patients with subjective tinnitus and hearing loss due to noise exposure were enrolled for the study. It has been reported that high-plasma cholesterol and triglyceride levels are one of the major risk factors for the development of occupational hearing loss [3-5].
It seems that noise and other metabolic disturbances have a synergistic effect on the development of tinnitus and hearing loss [5].
A diagnosis of acoustic trauma was verified by an ear, nose, and throat physician according to a clinical history of chronic noise exposure in patients who sought medical help for complaints of tinnitus and high-frequency hearing loss.
Patients who had chronic otitis media or middle-ear effusion, those with an abnormal ear drum (perforation, retraction, etc.) or auditory canal, and those who had abnormal tympanometry (other than type A) were excluded. In the study, from 120 patients we chose 42 male patients (35%) with elevated cholesterol or triglyceride or both (age range, 19-60 years; mean age, 45 years).
The patients were separated into two groups: the "unresponsive" group, made up of 22 patients who had no response to either of the therapies and still had hyperlipidemia, and the "responsive" group, consisting of 20 patients who had lower cholesterol or triglyceride levels. The results of the blood lipid profiles were withheld from the individual to prevent a placebo effect with the tinnitus therapy.
The significance of the difference in patient's comments on their tinnitus after the treatment ("same," "decreased," "increased," and "disappeared") was analyzed using McNemar and chi-square tests. However, the incidence of hyperlipidemia among a selected group of patients with neurosensory hearing loss varies.
They selected a group of subjects aged between 20 and 50 years and compared auditory thresholds at high frequencies and serum lipid levels. Noise and metabolic disturbances have a synergistic effect on the development of tinnitus and hearing loss. Effects of experimental cochlear thrombosis on oxygenation: Auditory function of the inner ear. Direct effects of intraperilymphatic reactive oxygen species generation on cochlear function. Clinical utility of LDL-apheresis in the treatment of sudden hearing loss: A prospective, randomized study. The relation of hearing in the elderly to the presence of cardiovascular disease and cardiovascular risk factors.
Appearance of free radicals in the guinea pig inner ear after noise-induced acoustic trauma. Progressive sensorineural hearing loss, subjective tinnitus and vertigo caused by elevated blood lipids. A comparison of auditory brainstem evoked potentials in hyperlipidemic and normolipidemic subjects. Exploration of the early auditory effects of hyperlipoproteinemia and diabetes mellitus using otoacoustic emissions.
Hypertension, hyperlipoproteinemia, chronic noise exposure: Is there a synergism in cochlear pathology? Effects of noise exposure and hypercholesterolemia on auditory function in the New Zealand white rabbit. Hearing improvement after therapy for hyperlipidemia in patients with chronic-phase sudden deafness. A prospective case-controlled study of 197 men, 50-60 years old, selected at random from a population at risk from hyperlipidemia to examine the relationship between hyperlipidemia and sensorineural hearing loss. The incidence and variety of the head and neck injuries due to traffic accidents have extremely increased in recent years.
Statistically, about 80% of the cases with whiplash injuries due to traffic accidents recover within a few months.
Therefore many of these patients are under suspicion of malingering, or their disturbances are considered as being of a psychic type. They develop as the result of the years long lasting cronification degenerative processes of the lesions induced by the trauma incident. Likewise, in none of these cases a cerebral commotion or a cerebral concussion could be established after the accident. Therefore, the audiological investigations by the tinnitus masking method mostly cannot determine the presence of the tinnitus' at the moment of the examination.
Their presence can be due to traumatical changes induced during the accident in the maxillary sinuses, as well as in the temporomandibular joints. Thereby taken into consideration only hearing losses of perception type, assessed by the bone conduction testing. The vestibulo-vegetative reactions are permanently monitored by a simultaneous EKG-registration. In our study, the multisensorial neurootological disturbances were caused in nearly all the patients, by the whiplash injury (Table 16).
The degree of the psychical impairment is directly depending on the intensity of the tinnitus. By means of the modern functional neurootological network analysis we can contribute much to clarify and to verify the disabling complaints which appear in the late whiplash injury syndrome.
Underlying mechanisms are hypothesized to exist and to be highlighted by a diminution of inhibition mediated by gamma aminobutyric acid (GABA) due to disconnection from excitatory (glutamate) inputs. It is considered to transcend the classica thinking of tinnitus as an auditory signal restricted to the auditory pathway.
The limbic system is a term used to include the limbic lobe and associated subcortical nuclei (amygdaloid complex, septal nuclei, hypothalamus, epithalamus and other thalamic nuclei).


The frontal, temporal, parietal lobes project to the perirhinal, parahippocampal cortices from unimodal and polymodal areas. A paradoxical memory modulates the transition between the sensory and behavioral component of tinnitus.
It is speculated that for tinnitus the amygdala is significant for the alteration in emotional behavior described by the patient. It is speculated that the primary auditory cortex projects to the hippocampus and amygdaloid complex. The masking curves "can be thought of as contour lines of the neural elements involved in processing signal and masker."34 Tinnitus is believed to produce or reflect a instability or interruption in auditory masking function. The future is to identify neural networks and to create idealized computer simulates of groups of neurons. For auditory perception this includes the inner ear and Organ of Corti; transmission within the ascending auditory system to registration of impulses within the auditory cortex.
The program in 2014, "Modalities Tinnitus Treatment", was presented as the fifth of a series of AAO-HNS Miniseminars, which over the past 4 years has had as its goal the providing to the AAO HNS membership and guests, state of the art tinnitus information, both clinical and basic science, for clinical translation to the patient for an objectivity and an increased accuracy for the tinnitus diagnosis for all clinical types of tinnitus and its translation for treatment. Multiple ongoing processes and levels of activity are involved at organ, tissue, cellular, synaptic and molecular genetic locations. It is conceptualized to be a process which can alter the circuitry in brain wave activity associated with tinnitus and the responses to modalities of tinnitus treatment4.
The chief etiologies to be considered include ischemia, trauma, or hemorrhage, and neurodegenerative disease. Removal CI#1 and reinsertion CI#2 resulted in hearing improvement and reported tinnitus relief10. Clinically, the stage of the QEEG clinical application in 2014 for tinnitus is considered analogous to the EKG for cardiology in the 1930s. Included are activation in the anterior cingulate cortex, the prefrontal cortex, the amygdala, and hippocampus.
It was hypothesized that the activated ROIs reflected different dynamic overlapping brain networks and should be considered as targets for the treatment of tinnitus with TMS. The awareness of the stimulus arises when the activity is connected to a larger co-activated awareness or perceptual network.The perceptual network involved the anterior cingulate cortex (ACC), dorsal cingulate cortex (dACC), and posterior cingulate cortex (PCC), precuneus, parietal, and frontal cortices.
Changes in brain structure and activity were evaluated using functional magnetic resonance image and EEG in the resting state.
Off-label drug use in the treatment of tinnitus includes antiarrhythmic, anticonvulsants, angiolytics, glutamate receptor antagonist, antidepressants, and muscle relaxants.
There has been report of some improvement in tinnitus associated with improvement of depression and anxiety. It was recommended that "hearing aid use without providing background sound" is not beneficial. Hearing loss has been associated with identification of an increased spontaneous firing in specific regions of the ascending central auditory system. Following VNS in combination with Tones Pairing the initial distortion accompanied by increased excitability and spontaneous firing and synchrony at cortex was seen on the tonotopic map to be restored to normal as demonstrated with decreased excitability, reduced synchrony and spontaneous activity. The study instruments were Structured Clinical Interview for DSM-III-R, axis I psychiatric disorders, Tinnitus Handicap Index (THI) and Symptom Check List-90-Revised. Chisquare and Fisher's Exact tests were used to compare categorical variables across gender groups. In this study, the score of THI did not showed any significant correlation with presence of psychiatric diagnosis and the Global Severity Index of SCL.
In selected cases, electroencephalography, hematological evaluation, and imaging of the brain or temporal bone should be performed. They examined 95 children and young adults 6-28 years of age and found that type 1 diabetes causes disturbances in different parts of the vestibular organ but mostly in its central part.
At the authors' department, the incidence of Meniere's disease in pediatric patients with vertigo was 2.9%. The patients completed an extensive questionnaire of the NODEC III type, and then we performed a series of neurootometric investigations according to our neurootological network system. Also, cases with cardiac insufficiency were related to vertigo and to a low rate of diabetes and kidney disorders.
The results for the standing-test CCGs exhibited the parameters of longitudinal sway and lateral sway.
We evaluated the four principle parameters-displacement, lateral sway, angular deviation, and body spin-with mean and standard deviation. This is often the case when tinnitus does not appear to be connected with any illness or other problems. Vestibular examination with electronystagmographic recording and posturography was performed in some children.
The parents could not offer reasons for this deterioration, as there was no sign of medical illness.
The appearance of tinnitus could also be seen in 36 children in certain situations (Table 5). The vestibular examination showed profound functional loss of the right labyrinth, with spontaneous nystagmus to the left; the function of the left labyrinth was normal.
In 1997, he came to a checkup and reported a deterioration of hearing that we were able to confirm.
A minimal temporal bone fissure is also conceivable; however, this condition could not be proved by x-ray examination (Fig. Degenerative processes and hereditary factors probably playa large role in inner-ear disorders [5,8,13,14-16]. We have since discovered that children with hearing disabilities are seriously dependent on powered hearing aids with respect to their hearing and speech development. TBI is most commonly seen and treated injury among soldiers in the OIF and OEF wars and often presents with headaches, dizziness, and fatigue as associated symptoms. In a typical blast, the positive pressure phase is initially faster than the speed of sound and has a brief duration.
With mild head injuries, this collection of factors results in rates of dizziness that range from 15%-78% and is most often due to pathologies affecting the peripheral vestibular system, CNS, or cervical structures11. Studies have attempted to document vestibular abnormalities, after mild to moderate TBI, which have yielded inconsistent findings ranging from 32%-65%13. Often the eye is unprotected from debris due to non-compliance with protective eye wear15, therefore visual disorders may stem from foreign objects damaging the globe.
Extensive evidence in the rehabilitation literature has documented the efficacy of specific vestibular rehabilitation in treating individuals with dizziness and imbalance complaints18,19. If the results support this hypothesis, the need for coupling additional therapy with vestibular rehabilitation may be warranted for soldiers presenting with dizziness and visual problems post blast injury. Self-reported dizziness was verified in the primary care physician chart note or on the Dizziness Handicap Inventory (DHI) that was completed by most soldiers at entry into the program. An exempt review for retrospective data analysis was obtained through the appropriate Institutional Review Boards at Army Military Installations and a Midwestern University. The 45-item questionnaire has a score range of 0 to 180 with subscales of symptom distress, interpersonal relations and social role. In the context of screening soldiers post-combat, the PCL performs well using a cutoff value of 30 to 34 as an indication of PTSD symptoms21. The PHQ-9 score > 10 had a sensitivity of 88% and a specificity of 88% for major depression. This measure has been correlated with the results of posturography tests and is considered valid and reliable. Static visual acuity (SVA) was first measured and expressed in LogMAR units (a unit describing the apparent size of an optotype based on the ratio of its absolute size to distance from the eye24. The trigger velocity speed would increase until the patient reported an incorrect orientation of the optotype; the PEST algorithm was again used to determine threshold velocities for yaw plane movements.
The SOT test has six increasingly challenging conditions designed to determine the extent to which the patient is able to maintain quiet stance during the condition. Soldier demographics, health status characteristics and summary of Neuropsychological Intake Assessment of mTBI results for those with vision disorders (n = 21) and those without vision disorders (n = 8) are summarized in Table 1. No clinically significant spontaneous or positional nystagmus was observed for the two groups. Panels on the right: Decrease in Dynamic Visual Acuity (DVA) and Dizziness Handicap Inventory (DHI) scores represent improved performance over time between patients with and without vision disorders. Therefore, blast injury can result in impaired visual or vestibular system dysfunction leading to symptom complaints of dizziness, imbalance or spatial disorientation. Interestingly, mean DHI scores remained the same for those with vision disorders as compared to those without vision disorders; however, those without vision disorders still had higher perceived handicap after participation in VBRT. The central vestibulopathology and mixed central and peripheral groups showed the greatest rates of improvement post-VBRT.
There has been some speculation in the recent literature that while DVA and GST are moderately correlated with one another, the tests may be measuring different mechanisms36. It seems likely that subjective measures of dizziness are more influenced by PTSD, anxiety, and depression than objective measures of vestibular function due to the greater impact of these psychological stress symptoms over physical function37,39. Vision therapy is a clinical approach to treat a variety of visual disorders including convergence and divergence insufficiency, saccadic disorders, and accommodative dysfunction. Generally, roll is conceded mainly to stimulate the utriculus, whereas pitch mainly stimulates the sacculus. The quality of recordings also can vary, as the chosen averaging frequency might not be exactly in tune with a harmonic of an individual response frequency.
Our aim was to perform data acquisition and analysis that can show at a glance, as in reading an audiogram, whether a response differs from the norm.
Initially, we used physical wavelet analysis for data classification after acquisition [4]. Although the differences are quite obvious, they might not be a suitable format for clinicians.
Note that these recordings have been conducted under extreme and nonphysiological conditions to test the responsivity of the method. The interquartile range calculation (Equations 3 and 4) showed a reversed pattern, where contralateral tilt and backward tilt now showed a larger interquartile range. These fluctuations had a frequency of 72 cycles per minute and coincided with the patient's pulse. The baseline recordings show a sinusoidal pattern at a frequency of 72 per minute, which coincided with the patient's pulse. In this case, the contralateral box was larger than the ipsilateral box, rendering a coefficient above 1.1 and suggesting a deficit in the right utriculus. In amplitude range analysis, we would consequently expect larger interquartile ranges due to an increased vestibular nerve response.
Thus, an ipsilateral tilt (bending hairs toward the kinocilia) appears mainly to stimulate the medial portion of the macula utriculi, and contralateral tilt stimulates mainly the lateral portion of the macula utriculi.
That these two different techniques stimulate different hair cell units that have different characteristics appears possible.
In squirrel monkeys, the proportion is 60:40, and one can assume that it is similar in humans.
Tilting the head in roll and in pitch also is not performed in the optimal plane of the semicircular canals, rendering movement of the otoconia more difficult. Presented at the Thirty-Second Annual International Congress of the Neurootological and Equilibriometric Society, March 23-25, Melbourne, Australia, 2005. Relation between afferent discharge properties and peripheral innervation patterns in the utricular macula. All patients who were required to complete the questionnaire and who were subjected to clinical examination were military personnel.
A pure-tone signal was presented continuously at 50-Hz intervals at between 10- and 20-dB levels. We placed all these patients on a low-cholesterol diet or antihyperlipidemic therapy (Table 2). When patients were asked to qualify the severity of their tinnitus, 10 rated their tinnitus as the same (47%), 9 rated it as increased (42%), 2 rated it as decreased (9%), and 1 patient had no tinnitus (2%).
Lowry and Isaacson [12] reported 20% hyperlipoproteinemia among 100 patients with bilateral hearing loss.
Lipidosis of the inner ear has been postulated by Nguyen and Brownell [33] as an alternate mechanism.
Insufficient perfusion of the cochlea due to increased blood viscosity and microthrombosis related to hyperlipidemia has been claimed to cause susceptibility to noiseinduced hearing loss [35]. We found in our study that the incidence of hyperlipidemia among patients with noiseinduced tinnitus and hearing loss was 35%. Characteristics of tinnitus and etiology of associated hearing loss: A study of 123 patients.
By using seat belts, shoulder harnesses and head rests the amount of direct wounds and fractures are reduced in modern motor vehicles.
Problems of evidence also arise in compensation claims calling for an additional neurootological medical expertise. By means of the modern functional neurootological network analysis we can nowadays contribute much to clarify and to verify the disabling complaints of the late whiplash injury syndrome. These cases were classified and treated as "trifle-and minor-traumas" by all the doctors and experts who have seen them prior to him.
This is very important on one side for the medical expertise and on the other hand for the correct diagnostic and therapeutical evaluation of these patients. Blockage of GABA mediated inhibition results in Tinnitogenesis, a epileptiform auditory phenomena. The clinical manifestations of the affective behavior of the tinnitus patient can be considered to be components of the FCP for tinnitus. Physiologic evidence suggests functional differences between the various components although most are related to visceral or behavioral activities (Fig.
The mamillary body connects with the anterior nucleus of the thalamus via the mamillothalamic tract. Severe memory impairment associated with hippocampal and amygdala lesions were attributed not to the addition of the amygdala to the hippocampal lesion but instead to the addition of cortical regions that lie adjacent to the amygdala and that are necessarily damaged when the amygdala is removed or impaired. This sequence of events is hypothesized to exist in general for other sensory systems and specifically for the cocheovestibular system.
The central efferent system at a cortical and subcortical level at brainstem is speculated to control the masking capability of the auditory system. The themes of the past Tinnitus Miniseminars and the rationale for the order in the selection of past themes since 2010 and selection of the theme for 2014 were reviewed. The result of the reorganization is a positive or negative alteration in structure and or function from the normal, i.e.
It was hypothesized that neuronal changes would take place in the underlying neural substrate.
A salience exists to the phantom percept reflected by activation of dACC by the anterior insula.
Twenty five (25) control subjects without tinnitus were matched for age, gender, and hearing function, and were examined once using EEG, MRI, functional MRI, and questionnaires. Investigation was recom-mended to identify the mechanisms such drug(s) have in common resulting in the clinical manifestation of tinnitus.
Other drugs have been reported with either limited efficacy and to need further controlled trials. A statistically significant relationship was identified between perceived tinnitus loudness and annoyance. The association of hearing loss and tinnitus has been identified clinically; however, there is no correlation between hearing loss and the severity of the loss. A patient with a unilateral tinnitus in the left ear demonstrated localization of high coherence in the right auditory cortex (AC), Brodmann area, BA 42. All patients to be implanted were divided into two groups; half to VNS plus tones and the remainder half to sham VNS plus tones. Biomagnetism-transdisciplinary research and exploration: proceedings of the 16th International Conference on Biomagnetism, Sapporo, Japan, August 25-29,2008. Results: The lifetime and current psychiatric disorders among patients with chronic tinnitus were 60% and 55% respectively.
For some patients, this sensation does not interfere with daily activities and for others it is significant discomfort in daily life2 and disabling and restricts social activities6-7. Three of functional effects, the emotional response and the catastrophic response to tinnitus have been described. One way analysis of variance was used to perform between and within comparison of numeric data across more than two groups. This may be due to this reason that THI is not capable of measuring the burden caused by mental disorders, therefore another instrument should be used to evaluate the burden of cumulative effect of chronic tinnitus and mental disorders. The range of vestibular organ impairment seems to depend mainly on the presence and character of hypoglycemic incidents and the duration of the disease (and, to some extent, on the compensation of diabetes). Most frequently (42.86%), the pattern s0000 occurs, which means all four caloric test characteristics were positioned in the normal range.
The three types of VSRIC can again be grouped into three subdivisions each: parallel behavior, recruitment behavior, and decruitment behavior.
All these parameters derive from the arrangement pointing to the right direction; however, the body spin overshot the normal range (n = 35). They are confronted as characteristics with the normal ranges for each of the parameters in our special chart. Although the total number of young patients investigated in our study was small (N = 35), we attempted to present a picture of this special group of patients. The most frequently obtained information (29.4%) was the progression of an existing hearing loss.
However, often to the astonishment of adults, when asked specifically, children describe the exact symptoms that prove the existence of tinnitus. The audiometric picture can be very different and varies between normal hearing and various levels of deafness. In this group, tinnitus was present in 15 children who were under pressure, in 9 in the evening, in 3 in the morning, in 5 after school, in 3 while under stress, and in 1 during noise. The hearing test at an ear, nose, and throat practice led to the assumption of a moderate hearing loss. In the pure-tone threshold audiogram (spring 1997), a deterioration was confirmed on the right side of (at most) 100 dB.
We detected a profound hearing loss on the right side, which could be verified with transitory evoked otoacoustic emissions.
We also found that children's toys, toy pistols, and noise during leisure activities represent important factors in the emergence of hearing disorders and tinnitus, as shown by a number of researchers [21-25]. A more recent report from the DoD4, estimates that 194,561 soldiers have sustained a mild traumatic brain injury (mTBI) from the year 2000 through 20125. The over pressurization wave is immediately followed by a negative pressure phase that is longer in duration and slower in velocity6,7.
Finally, quaternary blast injury can result in a severe blast related trauma brought on from significant blood loss associated with traumatic amputations or even from inhalation of toxic gases resulting from the explosion.
For patients with blast injuries and mTBI vestibular pathology should always be considered. However, other more common visual symptoms result from blast injury including convergence, accommodation and ocularmotor dysfunction16. PHQ-9 scores of 0-4 represents no depression, 5-9 minimal symptoms, 10-14 mild depression or dysthymia, 5-19 represents moderately severe depression and greater than 20 represents severe depression22.
With the head still, SVA will be determined by asking the participant to identify the orientation (right, left, up or down) of the optotype E. Pearson Correlation Coefficients were computed to assess relationships between average Neuropsychological Intake Assessment scores and GST, DVA, SOT and DHI average scores. No significant differences were observed between the two groups based on demographic and health status characteristics.
Soldiers with and without vision disorders participated in rotational chair assessment; however, no significant differences were observed between rotational chair gain, phase and asymmetry values.
Given that the mechanisms involved in blast exposure are not fully understood, it is plausible that the individuals without vision disorders had additional central disorders hindering improvement with standard VBRT.
Of note, all patients continued to report symptoms of dizziness and perceived handicap after VBRT. It is difficult to understand based on this retrospective review if the difficulties with GST performance was truly due to VOR dysfunction or central mechanisms. Exercises designed to enhance the visual system and adaptive processes are incorporated into the visual therapy program40,41. Ten patients had normal hearing levels; the majority had a symmetrical mild sensorineural hearing loss sloping toward the high frequencies. Typically, ipsilateral and forward head tilt show larger box plots than do contralateral and backward head tilt.
Also here, we observed that boxes of ipsilateral head tilt were larger than boxes of contralateral head tilt. We believe that the reversed pattern was most likely due to adaptation phenomena or that responses came from different areas of the maculae.
The frequency of these fluctuations and the strength of the response seemingly remained during stimulation in roll and in pitch.
One technique might preferentially stimulate irregular discharging units, which are suspected to be located in the striola, whereas another technique might preferentially stimulate regular discharging units, which are suspected to be located in the extrastriolar region [6]. Those results compare well with our findings, in which the coefficient of the sacculus response hovers around 0.9 instead of around 1. Above all, experience with electrootolithography shows that a successful repositioning can eliminate positioning attacks of vertigo but not necessarily a remaining instability during quick head movement. We excluded on the basis of their response to the questionnaire or clinical examination subjects who had a history of familial hearing loss, head trauma, collagen disease, neurological or hormonal disturbance, addiction to alcohol, or ototoxic drug therapy. The main criteria for response to the antihyperlipidemic therapy was defined as a return to normal cholesterol or triglyceride levels after therapy or at least a 40% drop from either of the initial blood cholesterol or triglyceride levels if the values were slightly above the normal limits. The latter authors showed that the lateral wall of outer hair cells from guinea pig cochlea incorporates water-soluble cholesterol. Axelsson and Lindgren [34] matched 78 men at age 50 years with high serum cholesterol levels to 75 randomly selected 50-year-old men and found significant correlation between noise exposure and high cholesterol level. However, the energy impact upon a person, sitting in a car involved in a traffic accident of the surprise-rear-end-collision type, is absorbed in the head and neck through an abrupt hyperextension and hyperflexion movement, which also is called the whiplash injury mechanism.
Once more it reflects the uncertainty of the doctors as it concerns the neurosensorial disturbances, and appeared as late complications of the whiplash injury. For this Dutch team, the neurootological investigations are of an exceptional importance for a correct judgement of the patients with whiplash injury, as namely they can reveal the long lasting degenerative and cronification processes following the trauma.
In the future, as the clinical experience of multiple disciplines increases for the symptom of tinnitus, it is predicted that additional components will be identified. The anterior nucleus of the thalamus connects with the cingulate gyrus via the superior thalamic peduncle, thus completing the circuit.
The entorhinal cortex was suggested to be the principle route by which information from the neocortex reaches the hippocampus. Other aberrant sensations experienced by patients include hyperacusis, dysacusis, vertigo, etc. For tinnitus such abilities may reflect cumulative changes in perceptual and response systems and for the development of new skills and habits personified by increasing attention to tinnitus and inability to "cope" with tinnitus. The reciprocal projections between the entorhinal cortex, hippocampus and amygdala result in an emotional response.
The degree of inhibition regulated by GABA function is hypothesized to be reflected in the degree of development of the paradoxical memory for tinnitus. Kassirer stated it well in discussing a visual image in clinical medicine that "often we are creating mental models of physical models. There is a constant learning process in which the phantom percept becomes associated with chronicity and reflected in distress of the patient reflected in a nonspecific distress network i.e. The neurobiological model used for this study was that described by Schlee and Collins which involve several brain regions all of which can be stimulated with different frequencies in a different order and with a varying number of stimuli7. This includes a HMG-CoA reductase, atorvastatin, the vasodilators cyclandelate, furosemide, herbal products, Ginkgo biloba, melatonin, Prostaglandin E1, misoprostol, L type calcium blocker amlodipine, phosphodiesterase type 5 inhibitor, Vardenafil, and minerals including zinc10. In other words, the frequency of the tinnitus is removed from the music that is being used as the stimulus. The increase in spontaneous firing is converted, translated, transformed at the thalamocortical level resulting in a synchronization of multiple brain wave oscillations of different frequencies, which in primary and secondary auditory cortices is perceived by the patient as tinnitus.
After 20 days, there was a massive expansion of the auditory cortex map specific to the paired tone.
The maximal frequency was determined from a graph that displayed the coherence level for all the frequencies in this particular region of interest.
Tinnitus symptoms have been linked to various psychological and psychosomatic disorders8-10. On the other hand, depression and anxiety might not have direct effect on the severity of tinnitus and therefore, the comorbidity of psychiatric disorders did not have significant effect on the severity of THI in this study.
Simultaneously with electronystagmography, we recorded the cardiac reactions by a three-channel electrocardiogram (ECG) scheme. We found higher frequencies of vertigo with rocking movements (as if on board ship) and of rotating sensations (as if riding a carousel) than of blackouts or instability. This is followed in frequency by a typical peripheral pattern with a monolateral inhibition of warm left and cold left in 7.14% of subjects. Meningitis is an important cause of hearing loss and of tinnitus and could be identified in 20% of our patients. The aim of our study was to analyze the appearance, characteristics, and frequency of tinnitus in children. In 12, we found that symptoms were caused by problems in the parental home and in their social environment or by the pressure of high performance requirements. At the interview, this patient told us that she had hearing problems and a feeling of tinnitus in the form of a wheeze for approximately 10 minutes in the morning. In particular, distinctive damage to the inner-ear structures is seen in connection with bacterial meningitis [26]. In summary, TBI resulting from blast exposure can be much more complex compared to TBI from other causes.
Loss of peripheral vestibular information creates greater dependence on visual and proprioceptive components of the sensory system11. Afferent and efferent visual dysfunction may result from damage to an optic nerve, extra-ocular muscle damage or cranial nerve function, and visual processing disorders from cerebral injury including hemorrhages and diffuse axonial brain injury15. Central and peripheral vestibular function was also assessed with head thrust, head shake, and Dix-Hall pike testing. If identified correctly, the E was reduced until the participant successfully identifies the correct E orientation for three of five successive trials, based on the Parameter Estimation by Sequential Testing (PEST) algorithm. If a patient has a vestibular system deficit, the maximum movement velocities over which the VOR system provides effective compensation would decrease. Composite equilibrium scores on a scale of 0 (excessive sway) to 100 (no body sway) were obtained. Preliminary analysis was performed to ensure no violation of the assumptions of normality, linearity and homoscedasticity. In addition, mean gain, phase and asymmetry scores were within the normal range for both groups (see Table 2). Additionally, normal vestibular function was observed via rotational chair testing for both groups. This further supports that while those with central disorders (including visual disorders) do improve with VBRT, they do not improve at the same rate as those with peripheral vestibular dysfunction. It is possible that soldiers with dizziness and vision problems also had substantial difficulty with cervical range of motion, leading to the unchanged head velocity after VBRT. In a study by Hudac et al.42, it was found that adjusting visual processing with corrective prisms impacted neural processing. However, the principle of this averaging is different, as we do not employ multiple stimuli; instead, we stimulate once only. In addition, averaging is not phase-locked to the maximum amplitude of the response; therefore, the signal varies in strength. If the data array is an odd number, Q1 includes the median; Q1 is known as the twenty-fifth percentile.
Because patients generally-and particularly the elderly-had problems in holding the head in a tilted position and more artifacts were seen, we no longer use this method.
We also observed more artifacts, possibly due to the movement of the electrode in the tympanic recess.
The remaining instability is due to a continuing measurable deficit in the otolithic organ [1].
The difference between tinnitus scores in the unresponsive and responsive groups and the change in tinnitus scores before and after therapy in the responsive group were significant. None of the patients had cerebrovascular disease, hypertension, electrolyte imbalance, cranial nerve deficit, or clinical signs of peripheral neuropathy.
Then, the pitch-match frequency threshold of the tinnitus was measured as the tinnitus loudness match of the pure-tone stimulus presented with a 1-dB increase of tinnitus frequency.
Morizono and Paparella [30], using cholesterolfed rabbits, showed increased auditory dysfunction with time at all frequencies. This uptake of cholesterol is accompanied by an increased stiffness of the cells, which may impair the cells' electromotile response.
Enhancement of cochlear action potentials and auditory brainstem responses has been demonstrated after limited intake of cholesterol.
However, patients were at the chronic phase, more than 1 month from the onset of the hearing loss. These abrupt movements of the head and neck may have several morpho-functional consequences upon the cervical region, as well as upon the nervous and sensorial structures of the head. The characteristics of the ear noises were specifically investigated through the tinnitus masking method. Their studies and conclusions are based upon the numerous pathological electronystagmographical findings, and also the corresponding pathological audiological results.
Additional feeding pathways to the circuit were described to include the septal and olfactory regions and amygdala.
Increasing attention and a probable relationship to sleep phenomena also is considered to be a reflection or projection from the amygdala to sleep areas in cortex.
The goal is to attempt to restore and or to maintain a homeostasis of normal neural function in the peripheral and or central nervous system4. It was hypothesized that rTMS treatment protocols on brain structure and function should provide a basis for neural correlates of tinnitus8. In conclusion, Tyler stated "we believe that for some patients of tinnitus all forms of masking therapy, including those that use total masking and low-level partial masking might provide relief." Mixing point and total masking are equally effective7. It was stressed that no widespread evidence-based pharmaceutical agent is available that "cures" tinnitus at this time. It is concluded that VNS paired with a tone generates massive plasticity in the auditory cortex specific to the paired tone1. Coherence imaging in a controlled subject with no tinnitus and no neurological disorder exhibited patterns of low coherence and no areas of high coherence as seen in the tinnitus patient, specifically in the AC. It is shown that 48% to 60% of patients with chronic or disabling tinnitus have major depressive disorder (MDD)11-12. Of equal percentage is the third position in the graph, representing a central disorder with disinhibition of left cold. This, however, is followed by a monolateral recruiting phenomenon in 10% of our sample (trinary code v0010), demonstrating that peripheral vestibular inhibition can be straightened out and compensated when increasing the power of a stimulus. The second most frequent pattern was s0022, which shows a pathological deviation toward the right, including a pathological body axis spin toward the right.
We also considered as a cause of tinnitus skull or brain trauma, acute hearing loss, and stapes surgery.
Table 1 shows the audiological findings in examined children with respect to various levels of hearing loss in the right and left ears. In four children, the condition appeared after skull or brain trauma and, in three, the condition appeared after acoustic trauma. At the hearing test (summer 1999) the curves of air conduction lay within 50-60 dB on both sides; the curves of bone conduction in the similar area, however, were uncertain. We also encountered a clear cause of tinnitus resulting from skull or brain trauma, in acute hearing loss, and after stapes surgery with cerebrospinal fluid gusher [24,27]. In the study by Lew et al.17, the rate of visual impairment at a VA polytrauma rehabilitation center was 52% compared with only 20% for all other sources of injury to the body resulting from blast exposure17. Therefore, subjects were excluded if they sustained a penetrating head injury or sustained mTBI from any other than an explosion (e.g.
Next, the participant were asked to complete the perception time test (PTT) by keeping his head still and correctly identifying the orientation of the E flashing on the computer screen, set at a fixed 0.2 logMAR size above the established SVA baseline. The extent of visual acuity loss is predicted by comparison of the GST velocities to those encountered during daily life activities in question (e.g.
A multivariate approach to repeated-measures ANOVA with custom contrast for the fixed effects was performed to evaluate performance pre-and-post VBRT. There was also no significance differences noted on SVV testing between the two groups; however, those with vision disorders displayed SVV off axis to the right mean values outside the normal range (see Table 2). Therefore, dizziness resulting from blast exposure may be due to associated brain injury rather than peripheral vestibular system dysfunction31. The results reported herein also support that individuals with central disorders as indicated by visual dysfunction did not improve same rate as those without vision disorders. This is the aim of future work to explore differences in DVA and GST performance after head injury.
This intervention appeared to facilitate the appropriate integration of information between the visual pathways and improved processing across proprioceptive, kinesthetic, vestibular, cognitive, and language domains42. Because the vestibular organ shows rhythmicity, the responses that are averaged are phase-locked to a harmonic of an individual response frequency. Generally, we observed a vestibular pattern of voltage changes during raised intracranial pressure [4]. We digitized raw data from the electrodes and plotted as voltage amplitude versus time using a medically rated analog-todigital converter. This suggested that interference from muscle activity or contamination by the semicircular canals can possibly be ignored; when using a tilt table, they could be avoided. Conversely, a positive Dix-Hallpike maneuver indicates only that otoconia have found their way into a semicircular canal. It seems that the order of destruction and the high-frequency nature of the auditory dysfunction are correlated not only with the frequency and severity of the noise exposure but with the presence of the secondary pathology, as the formation of vasoactive lipid peroxidation products after intense noise is similar to the condition seen in metabolic damage to the organ of Corti [7,14-17]. In a survey of 44 patients with cochlear-type hearing loss, Booth [26] found hyperlipidemia in 28% of the men and 10% of the women.
These authors observed hearing improvement of more than 10 dB in 9 of the 12 patients after antihyperlipidemic therapy.
The state of the acoustical pathways was investigated by means of the acoustically evoked brain stem potentials as well as the acoustically evoked late (cortical) potentials. The reciprocal interconnections between primary and secondary associated auditory cortices and vestibular cortices of the cochleovestibular system reflect multiple neuronal networks which have the capability to adapt to changes reflecting alteration in sensory input and output due to different factors influencing neuronal activity of the cochleovestibular system and other systems at a cortical and subcortical levels. The phantom percept persists due to memory mechanisms involving the parahippocampus, hippocampus, and amygdala. Tinnitus patients identified combined treatment of left frontal and temporal rTMS compared to left temporal rTMS for the efficacy of tinnitus relief than single site stimulation. Significantly, after 12 months of regular listening, a target patient group of eight patients reported a significant reduction in the loudness of their subjective tinnitus. Discussion: The comorbidity of chronic tinnitus with depressive and anxiety disorders is more common.
Asplund reported among subjects with chronic tinnitus poor sleep and frequent waking were more common in men and women13. Among the main vertigo-triggering factors were the orthostatic mechanisms of getting up and head turning. The fourth bar represents a typical monolateral peripheral receptor lesion s1000 with an inhibition of the right warm and a spontaneous nystagmus to the opposite side. Other findings were a mixture of disinhibitive recruitments (v0202), parallel inhibition on both sides (v1111), monolateral decruitment phenomenon (v0001), bilateral recruitment (v1010), monolateral overshooting decruitment (v2000), monolateral parallel inhibition (v1100), monolateral parallel disinhibition (v2200), monolateral right decruitment (v0100), and monolateral parallel inhibition with an opposite site recruitment (v1110). Patterns three and four exhibit minor deficits in the lateral sway or in the lateralization toward the right side, as far as body spin is concerned. A clear frequency or intensity determination and the measuring of masking curves were not possible except in a few cases. One child had acute hearing loss, and one developed tinnitus after stapes surgery (Table 2). Whispered speech was understood on both sides from 3 to 4 meters, and normal speech was comprehended from more than 6 meters' away. The hearing ability did not appear to have deteriorated with the use of a hearing aid on the right. Examination with P300 testing documented diminished amplitudes and prolonged latencies suggesting damage to the visual cortex and or visual pathways that connect the eyes to the cortical visual centers may be affecting those afflicted with TBI17. Participant scores obtained on the Dynamic Visual Acuity testing (DVA), Gaze Stabilization Test (GST) and Computerized Dynamic Posturography, Sensory Organization test (SOT) were included in the data analysis.
PTT identified the minimum target presentation time (in milliseconds) to be used during DVA and GST testing. Interestingly, mean DHI scores remained the same for those with vision disorders as compared to those without vision disorders after VBRT; however, those without vision disorders still had higher perceived handicap after participation in VBRT. Additional work with visuospatial training41 show some promise for improving visual performance post-TBI. Brainstem audiometry showed normal tracings and latencies in all these subjects, and none suggested retrocochlear pathology. Normally, we recorded the baseline and four head-tilt positions, and we displayed individual box plots for comparison. If the data array is an odd number, Q3 includes the median; Q3 is known as the seventy-fifth percentile. The maneuver does not indicate whether the otolithic organ has a deficit, and we might find a normal response of the otolithic organ.
In this manner, preventive measures may provide restorative support to the injured cochlea. We required all patients to rate their tinnitus from 1 to 10, with 10 being loudest (Table 1). Young (1991) considered for depression that the location of cortisol control to be not in the hypothalamus but rather in the hippocampus.26 It is proposed for tinnitus that a cycle can be established wherein reciprocal projections between hippocampus, amygdala, entorhinal cortex and hypothalamus vary in the degree of control of cortisol levels resulting in further strengthening of an already established paradoxical memory with resultant additional negative affect behavioral manifestations of emotion, fear, anxiety, depression, etc. With complete total masking, the intensity level of the masker is just above the intensity level of the tinnitus.
In addition, they demonstrated reduced evoked activity in areas of the auditory cortex corresponding to the tinnitus frequency compared to patients who received an analogous placebo notched music treatment. There was only a "little relationship between tinnitus loudness and annoyance and the amount of money". This may have treatment implication to alleviate the stress and dysfunction resulted from chronic tinnitus. The benefits of antidepressants for tinnitus patients were reported and indicating an interaction between tinnitus and mental disorders14. The SCL-90-R is a 90-item self-report system inventory developed in the 1980s by Derogatis19 in which nine symptoms diminutions are being evaluated. We also demonstrate that juvenile vertigo depends not only on peripheral vestibular lesions, which partly are compensated and partly are decompensated, but also on central regulatory deficits.
No · additional information that might lead to an understanding of the hearing loss was available for 14.7% of the patients studied. Twenty-four children (23.5%) reported vertiginous complaints in addition to their tinnitus. The discrepancy between the pure-tone audiogram and measurement of hearing distance suggested a probable psychogenic hearing disorder. Furthermore, the investigators noted that the majority of patients showed normal to near-normal corrected visual acuity and visual fields; however, 75% self-reported a vision problem, including photosensitivity (59%).
Soldiers included in the retrospective review were referred to the TBI family practice and underwent three consecutive weeks of specialty appointments including; TBI primary care physician, optometry, occupational therapy, mental health, physical therapy and if medically indicated neurology, audiology or otolaryngology. Nevertheless, subjective visual vertical findings were outside of the normative range for individuals with vision disorders.
Again, it is possible that the individuals without vision disorders had additional central disorders hindering improvement with standard VBRT, or that additional time in rehabilitation was needed. Continued support of vision rehabilitation efforts is necessary to address best-practice care for blast-injured military. Each level was defined by short explanations to simplify the patients' grading of their tinnitus. Neuronal networks are hypothesized to exist which in the past were identified as primary and secondary areas. It represents a promising strategy to enhance treatment effects of rTMS and tinnitus with multisite.
With partial masking, the intensity of the masker is not sufficient to cover the intensity level of the tinnitus. This report suggests that tinnitus loudness can be significantly diminished by an enjoyable, low-cost, custom-tailored notched music treatment. The SCL- 90-R is a simple questionnaire and was translated into the official language of Iran (Persian), which is comparable to almost every Iranian, and its validity and reliability were approved in an independent study20.
In the next stage of s1001, we see a midbrain inhibition of the right-beating nystagmus and, in the pattern s2002 we have a disinhibited nystagmus preponderance pointing at the right temporal lobe, which demonstrates that the dysfunction likely shares peripheral and central sites of origin (n = 27). However, overshooting central responses are seen in pattern s2000 and (especially with a centrally enlarged lateral sway) in pattern s0200. Tinnitus is a frequent symptom in childhood and, because children seldom complain about their tinnitus, such hearing problems that they report must always be taken seriously. The tinnitus characteristics could not be specified, as they were not present on the day of examination.
After the completion of the intake appointments a multi-disciplinary team (Multi-D) convened to determine if a soldier would be a rehabilitation candidate and developed a treatment plan. After achieving the desired velocity, the optotype E was flashed on the computer screen based on PTT score.
This finding may be attributed to damage to the peripheral or central vestibular system including the brainstem, cortex and cerebellum15; therefore, further prospective examination of SVV findings is warranted. When we grouped patients according to vision disorders, significant differences were noted in functional balance performance and perceived handicap after VBRT; however, if we grouped the participants according to different diagnostic categories the outcomes may have been different.
A multi-disciplinary approach for evaluation and remediation of these patients is necessary to review and modify individual treatment goals as traditional rehabilitation methods may be not sufficient for reducing symptoms complaints and improving functional performance. We displayed ratios for the utriculus and sacculus to classify the shape of the data distribution.
Many patients reported that they would pursue surgical options and many would pay $10,000 for treatment to reduce their tinnitus.
However, more studies need to identify the nature of psychiatric disorders among tinnitus patients. Finally, pattern s0222 exhibits a combination of broadened sway with a pathological deviation toward the right side. The diagnosis should exclude metabolic disturbances, possible damage to the sensory level of the central nervous system, and circulatory disturbances. The presence of these vision-related problems indicated a high prevalence in this post-combat population with TBI.
To our knowledge, this is the first report exploring the VBRT outcomes in blast exposed soldiers with history of dizziness, when categorized by the presence of vision disorders. An acoustical neuroma had been removed from his left ear 6 months before this investigation.
Box plots are useful in exploratory data analysis when two or more data sets are being compared. In order to access this objective, we have to know more about the prevalence and types of psychiatric disorders in patients with tinnitus.
In addition, the physician should always consider emotional problems and disturbances of perception. These soldiers continued treatment within each specialty as indicated in the clinical treatment plan. The size of the E decrease based on correct responses; threshold was established based on PEST algorithm. Therefore, the effect of VBRT should be further explored prospectively in blast exposed soldiers and in a larger sample to determine the clinical relevance of our findings.
It is conceived that the excitatory action of the amino acid glutamate may result in more than one physiological function.
For example, the typical length of therapy was two to three times weekly over the course of approximately eight weeks for VBRT in physical therapy. The global severity index (GSI) is one of the three-global-index which measures the extent or depth of the individual's psychiatric disturbances. After the completion of each specialty therapy the Multi-D team determined the point at which the soldier was medically fit to return to duty and medically acceptable to be discharged from the treatment program. International Tinnitus Seminar 2014", mit der Botschafterin des Weltkongresses, US-Jazzsangerin Dianne Reeves nach der Pressekonferenz.
It is speculated that the GABAergic inhibition and resultant glutamate excess produces a disruption in calcium homeostasis. Kurt Anschutz, Geschaftsfuhrer der Deutschen Tinnitus-Stiftung Charite, wahrend der Pressekonferenz des "XI.



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