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Tinnitus is the perception of sound within the human ear not including the perception of sound outside the ear.
Tinnitus is not a disease, but a condition that can result from a wide range of underlying causes: neurological damage multiple sclerosis, ear infections, oxidative stress, foreign objects in the ear, nasal allergies that prevent (or induce) fluid drain, wax build-up, and exposure to loud sounds. Tinnitus may be an accompaniment of sensorineural hearing loss or congenital hearing loss, or it may be observed as a side effect of certain medications (ototoxic tinnitus). Tinnitus is the perception of sound within the ear or head, without a corresponding external stimulus for that sound.
Tinnitus may be described as a buzzing, ringing, roaring, clicking, booming, hissing, whistling or cicada-like noise. Objective tinnitus is generated by musculoskeletal and vascular structures that are in close proximity to the cochlea. Consider a review of medicines - have there been any new medicines started, including any over-the-counter medicines? A live insect in the ear canal may produce noises that are described in a similar way to tinnitus. Hit the tuning fork lightly on your knee, elbow or firm surface and hold the base on the patient's forehead. A normal result is when the sound is heard again - air conduction is greater than bone conduction. If the cause of tinnitus is found to be an underlying condition that is treatable in primary care, e.g. Tinnitus often disturbs sleep and the tiredness that results may then compound the problem. Many people with tinnitus seek quietness in an attempt to gain relief from the noise of their tinnitus. Distraction with day to day activities (leisure or work) and regular exercise can be effective. The evidence to support the use of pharmacological treatments for tinnitus is inconclusive.
Thank you to Dr Ron Goodey, Otolaryngologist, Auckland for expert guidance in developing this article. This paper is a preliminary report from the Tinnitus Center, HSCB-SUNY, of hyperacusis in a patient population who request consultation for tinnitus of the severe disabling type.
There is a positive correlation between tinnitus and hyperacusis as well as a positive correlation between hyperacusis and the loudness discomfort level test (LDL). The present method of assessment for hyperacusis includes pure tone audiometry, LDL's, Feldmann Masking Curves and the Metz test for recruitment. A classification system exists for hearing loss and a similar system is suggested for hyperacusis. A review of the literature reflects the difficulty encountered clinically in attempting to diagnose and treat the subjective complaint of hyperacusis.
Jastreboff and Hazell define hyperacusis as a manifestation of increased central gain evaluated by direct frequency measurements of loudness discomfort levels (LDLs).
Loudness discomfort levels are most frequently used in the assessment of hyperacusis.12 What frequencies to use for the assessment and how many repetitions per judgement are not universally agreed upon. Kotsanis and Harjes consider uncomfortable loudness level thresholds (UCLs) under 90 dB HL at 500 - 8000 Hz and 70 dB at 250 Hz as abnormal. Forty-two consecutive cases, 29 males and 13 females, ranging in age between 20-75 years with a mean of 51.9 years with the primary complaint of subjective idiopathic tinnitus (SIT) of the severe disabling type were included in this study.
Pure tone audiograms were obtained at the discrete frequencies of 250, 500, 1000, 2000, 3000, 4000, 6000, and 8000 Hz for the right and left ears for each individual. The pitch of the tinnitus was matched to frequency using a two alternative forced choice procedure.18 The ear with the tinnitus is used as the reference for the match. Loudness discomfort levels (LDLs) were obtained for each ear individually at the discrete frequencies tested on the audiogram; 250, 500, 1000, 2000, 3000, 4000, 6000, and 8000 Hz and at the frequency of the tinnitus pitch match. The difference between the pure tone threshold and the loudness discomfort level is considered the dynamic range (DR).
For this study LDLs of 95 dB or greater at all frequencies are considered negative for hyperacusis. Dynamic range was considered satisfactory or negative for hyperacusis if it was 60 dB or greater at all frequencies.
Based on the results of this preliminary study, a methodology for hyperacusis assessment is proposed.
A classification system exists for hearing loss 20 and a similar one for hyperacusis is suggested in Table 1. Thirty (71%) of the 42 patients gave a self-report of hyperacusis while 12 (29%) denied any such complaint.
The incidence of hyperacusis in individuals with tinnitus has been reported as high as 40-45%.1,2 The type and severity of the tinnitus from which this figure was derived have not been specified. The LDL test indicates a higher incidence of hyperacusis than the self-report by the patient. In addition, chi square tests indicated significant associations between self report of hyperacusis and an LDL of 90dB for at least one frequency in both ears.
For the criterion of 90dB at two or more frequencies, only the right ear showed a significant association with hyperacusis self report. Jastreboff considers hyperacusis as a pre-tinnitus state.7 However, there are many tinnitus patients who do not report hyperacusis and who exhibit a satisfactory dynamic range on test. If hyperacusis is a central phenomena, then the Feldmann masking curves may reflect this by classification as Type IV or Type V. If hyperacusis is a pre-tinnitus state, then all hyperacusic patients should develop tinnitus and all tinnitus patients should have hyperacusis. The question which still remains unanswered is what is the significance of positive LDL and positive DR and the subjective difference. As a loss of hearing does not reflect the severity of tinnitus, so the severity of hyperacusis does not reflect itself in loss of hearing, recruitment, or Feldmann Masking Curve type.
Appreciation is extended to the Martha Entenmann Tinnitus Research Foundation and the Lionel Hampton Ear Research Foundation for its support of this effort. Claims of hearing loss can sometimes result in larger monetary settlements from insurance companies or in the proceedings of litigation. In addition to malingering of hearing loss, individuals may complain of ear pain, hyperacusis and tinnitus. As hearing loss and tinnitus are subjective conditions, when there is a potential to gain by convincing another group of people that one has these disorders, it is common to encounter individuals claiming to have lost hearing or to have tinnitus. For hearing loss, this is a foolish undertaking, as there are abundant methods of showing that someone actually hears better than they admit. As is the case for malingering in general, inconsistency between subjective claims and objective measurements is often the key clue.
There are many simple methods of detection of an inconsistency between subjective claims of hearing loss (e.g. Another method of hearing testing that does not require cooperation is the auditory steady state response (ASSR) Attias et al, 2014.

A regular audiogram was not very revealing -- often people forget that audiograms basically just test every octave -- if the ear is damaged somewhere other than the tone being tested in that octave -- the audiogram can be normal. However, a more careful audiogram that covered the frequencies around the tinnitus was abnormal. Audiograms are subjective tests, and in theory at least, someone could pretend not to hear at this frequency.
From the combination of the tinnitus match, detailed and careful audiogram, and sweep OAE, it is clear that this patient has objectively confirmed inner ear damage.
The complicated perception of body position and its separate parts in space is a result of analyzed and synthesized impulses by the vestibular analyzer, by both superficial and deep proprioception, and by the ocular analyzer.
The aim of our investigation was to evaluate the effect of treatment with 8 mg and 16 mg of Betaserc on patients (workers in the transport system) with vascular auditory and vestibular disturbances. A detailed neurootological history was obtained by means of a questionnaire, and otological and neurological examinations were conducted in each patient. First, with the help of Frenzel's spectacles, we evaluated spontaneous reactions, checking for spontaneous, positional, and latent nystagmus. Figure 2 shows a decrease in complaints of vertigo (16 patients) and dizziness (14 patients) on the twentieth day in one-half of the 30 patients treated with 16 mg of Betaserc. The frequency of attacks was lower in both treated groups, but the result was considerably better after treatment with 16 mg of Betaserc.
Regarding nystagmus reactions, the general test showed the presence of different nystagmus forms-horizontal, horizontal rotatory, and rotatory-according to the phase and nosological units. On the twentieth day of treatment with 16 mg of Betaserc, we noted an improvement in the spontaneous and, especially, the latent nystagmus symptoms. We confirmed the opinion of many scientists that a larger amount of Betaserc leads more rapidly to considerable acceleration of the vestibular function recovery processes [8,9]. Complete investigation revealed decreased complaints of vertigo and dizziness (in frequency and strength of attacks) among one-half of our patients on the twentieth day of treatment with 16 mg of Betaserc. On the basis of investigations carried out, we recommend 16 mg of Betaserc three times daily in the acute phase.
It is a common, but frustrating problem for both patients and clinicians, as in many cases the cause cannot be identified and there is no single effective treatment. In some cases, referral for further investigations such as MRI is required to make a specific diagnosis. Proceedings of ‘Tinnitus Discovery': Asia-Pacific Tinnitus Symposium, 11-12 Sept 2009, Auckland, New Zealand.
Forty-two consecutive patients seen from January to August 1995 were reviewed for this preliminary report. The incidence of hyperacusis in individuals with tinnitus has been reported as high as 40-45%.1,2 Clinical experience based on 4000 patients seen for the primary complaint of subjective idiopathic tinnitus (SIT) of the severe disabling type indicates that not every patient with tinnitus has hyperacusis and not every patient with hyperacusis has tinnitus. This paper is a preliminary report from the Tinnitus Center, HSCB-SUNY, ofhyperacusis in a patient population who request consultation for tinnitus of the severe disabling type.
The American Tinnitus Association defines hyperacusis as an unusual condition in which an individual's ears are unable to tolerate ordinary environmental sounds. There is significant variability in the interpretation of test data recommended for its identification. The difference between the pure tone threshold and the LDL at the frequency being tested is the dynamic range (DR).
When thresholds are equal to or above 90 dB HL at 500 - 8000 Hz and 70 dB at 250 Hz they are considered as normal. To the limits of neurotologic physical examination no positive findings were reported for any of the subjects. In the questionnaire, the patient was asked whether they find loud sounds to be unpleasant both prior to or following the onset of tinnitus. Tympanometry and acoustic reflex thresholds were obtained for those individuals who could tolerate the procedures. The patient was instructed to indicate when the sound delivered through the earphone from the audiometer became uncomfortable to the ear - not just loud, but uncomfortable. Hyperacusis should be considered positive if the LDL is 90 dB or less at two or more frequencies or if the dynamic range is 55 dB or less at any frequency.
Hyperacusis should be considered negative when LDLs are 95 dB or greater at all frequencies and if the dynamic range is 60 dB or greater at all frequencies. If we use the criteria of 90 dB or less at any frequency the incidence is 86% for the right ear and 83% for the left ear.
Additional numbers of patients are being evaluated to explore this finding and to examine its significance. Will these patients eventually develop an increasing sensitivity to sound i.e., hyperacusis? This is important with respect to diagnostics and may explain why treatment results are positive with some hyperacusic patients and not with others. There is a positive correlation between tinnitus and hyperacusis as well as a positive correlation between hyperacusis and the loudness discomfort level test. Hyperacusis occurs with normal hearing as well as with hearing loss in individuals with tinnitus of the severe disabling type. A standardized new methodology for assessment of hyperacusis is recommended to include a battery of tests: Pure tone audiometry, LDLs, Feldmann Masking Curves, and the Metz test for recruitment.
A classification system exists for hearing loss and a similar system for hyperacusis is suggested. Kotsanis C, Harjes C: Pilot study - effects of auditory enhancement training on speech, language, hyperacusis and behavior. Iastreboff PI: Presentation Fifth International Tinnitus Seminar, Portland, Oregon, July 1995. Feldmann H: Homolateral and contralateral masking of tinnitus by noise bands and by pure tones. The audiology community has an immense repertoire of procedures available to it to detect such behavior. Predicting Hearing Thresholds in Occupational Noise-Induced Hearing Loss by Auditory Steady State Responses.
Vestibular receptors play a main role in this complex system and determine changes both in linear and angular acceleration and in gravity strength [1-3].
Arterial hypertonia or atherosclerosis is accepted to be the most common etiopathogenic factor. The patients, all transport workers, presented with vascular pathology of the vestibular and auditory analyzer. Tonal threshold audiometry was performed using a Siemens (Copenhagen, Denmark) SD-50 audiometer. The total number of patients treated with 16 mg of Betaserc was 30 (18 with central otoneurological syndrome and 12 with peripheral otoneurological syndrome). On day 45, substantial improvement was seen among one-third of the 20 patients treated with 8 mg of Betaserc. The otological and neurological status of all patients was normal before starting treatment.

Figure 3 shows the breakdown of patients according to whether they experienced spontaneous, latent, or positional nystagmus (according to Frenzy's spectacles) and to whether they were being treated with 8 mg or 16 mg of Betaserc. Subdivision of men with spontaneous (SNy), latent (LNy), and positional nystagmus (PNy) (according to Frenzel's spectacles) during treatment with 8 mg and 16 mg of Betaserc.
Better results were received after treatment with 16 mg of Betaserc, considering spontaneous and, especially, latent nystagmus symptoms. The medication is very well tolerated, has no sedative effect, and is suitable for long-term treatment of transport workers with auditory and vestibular disturbances of vascular etiology. In-ear earphones, whose sound enters directly into the ear canal without any opportunity to be deflected or absorbed elsewhere, are a common cause of tinnitus when volume is set beyond moderate levels. As tinnitus is usually a subjective phenomenon, it is difficult to measure using objective tests, such as by comparison with noise of known frequency and intensity, as in an audiometric test.
There is an absence of attempting to identify types of hyperacusis and few attempts to establish its clinical significance.
Criteria for normal hearing were strict and for the purposes of this study normal hearing was considered to be thresholds of 25 dB or better at all frequencies. What are the results of long term follow-up of tinnitus of patients who were negative by self-report for hyperacusis but demonstrate positive LDL and positive DR? In: Tinnitus 91, Proceedings of the Fourth International Tinnitus Seminar, Edited by JM Aran and R.
We purposefully limit the information on this page, but it isn't difficult to detect malingering. Pathological changes in functioning of the aforementioned systems cause vertigo [4], dizziness, a sensation of floating, noise in the ears, and balance disorders. Sensory structures, being highly differential, are more vulnerable to ischemia than are other nerve structures [5,6].
In the central ear, it improves histaminergic neurotransmission by blocking presynapsis H3 receptors, it increases histamine release in synapses, and it normalizes the exciting processes in vestibular nuclei of the medulla oblongata [7]. The otoneurological investigation was conducted before and on the twentieth and the forty-fifth days of treatment in the Department of Neurology and Neurootology of the National Multiprofile Transport Hospital, King Boris III, Sofia. Examination of the vestibular system was directed at both spontaneous and provoked reactions. The total number of patients treated with 8 mg of Betaserc was 20 (12 with central otoneurological syndrome and 8 with peripheral otoneurological syndrome). Complaints of vertigo remained in 6.7% of the 16 vertigo patients receiving 16 mg of Betaserc, as compared to 20% of the 11 vertigo patients treated with 8 mg of Betaserc. No pathological change was found after tonal audiometry; the results were within normal limits (hearing decrease of 5-10 dB, mainly for the high-frequency zone) for those older than 36 years.
On the twentieth day after treatment, the percentage of patients with values of less than 1.50 (within normal limits) was increased by 40% (12 patients) in those treated with 16 mg of Betaserc and by 20% (4 patients) when treated with 8 mg of Betaserc. Also, the symmetry of reaction was considerably improved after above-threshold provocation, mainly in terms of duration, slow-phase speed, and amplitude. It is important to identify people who are hearing genuine sounds generated within the body (objective tinnitus) or have some other underlying treatable condition. This led us to explore whether or not there was any correlation or statistical verification between the two phenomena. If the acoustic reflex level is less than 60 dB above threshold of hearing at a given frequency recruitment is considered positive.
If we use the criteria of 90 dB or less at two or more frequencies, the incidence is 83% for the right ear and 79% for the left ear. It may be that the non-self-report patients who qualify according to the 90 dB criteria are at risk of hyperacusis, despite the fact that they do not report any symptoms of it. Will medical or audiologic intervention prevent them from becoming hyperacusic and, if so, what modalities are to be considered? Someone who claims to be deaf on audiometry, but has normal OAE tests, is likely to be pretending. The main symptom in neurootological clinical practice - vestibular vertigo - is common among disturbances of cerebral hemodynamics and the blood supply of peripheral and stem parts of the vestibular analyzer.
During the investigation, patients were given either only 16 mg of Betaserc three times daily or 8 mg of Betaserc three times daily, as those with arterial hypertonia underwent simultaneous antihypertensive treatment.
Vertigo and dizziness were the main symptoms of patients with otoneurological disease, and the symptoms often were accompanied by noise in the ears, hearing decrease, and balance disorders. Complaints of dizziness remained in 10% of the 14 dizziness patients treated with 16 mg of Betaserc, as compared to 25% of the 9 dizziness patients treated with 8 mg of Betaserc.
These data correlate with the results of above-threshold provocation, objectified by electronystagmography (Fig. As compared to static body changes, better results were registered in kinetic changes on the twentieth day of treatment with 16 mg of Betaserc. Arterial pressure was not influenced during treatment with either 8 mg or 16 mg of Betaserc. Results of coordinating and statokinetic tests were also improved after treatment of patients with 16 mg of Betaserc, as better results were achieved in body kinetic indices. The present method of assessment and a classification system for hyperacusis will be presented. In no case of self-report of hyperacusis (N=30), did both the LDL and DR indicate negative results.
There was an incidence of 34%, Type IV curves, considered clinically to represent central problems.
This finding led us to use the medicine Betaserc (betahistine dihydrochloride), which has both peripheral and central effects and brings to normal the imbalance in the vestibular system. The results of the respective treatment of patients with balance disorders, hearing decrease, and noise in the ears are nearly identical. This correlation may support the concept of different types of hyperacusis and could explain why some individuals respond to treatment and others do not. Of the nine who did not report hyperacusis, only two were substantiated by test results while the other seven had one or both tests positive. Considering the duration, slow-phase speed, amplitude, and organization of nystagmus, symmetry of reaction is considerably improved after above-threshold provocation and 45 days treatment with 16 mg of Betaserc. If one accepts the thought for discussion that tinnitus is a pre-condition for hyperacusis, does this not suggest that there are different types of hyperacusis reflecting a difference in clinical types of tinnitus with the same or different site(s) of lesion? Is hyperacusis a unitary symptom or are there different types of hyperacusis as there are different types of tinnitus? Of the 12 individuals not complaining of hyperacusis, four had LDLs and DRs substantiating the absence of hyperacusis. This suggests that hyperacusis may be present in individuals with tinnitus before they become symptomatic.
The value of this test would be to identify such individuals and provide treatment before they become symptomatic for hyperacusis.

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