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This study reports on the long-term benefit of ultra-high-frequency masking with the UltraQuiet device.
This study reports on the long-term benefit of ultra-high-frequency masking with the UltraQuiet (UQ) device.
Well accepted is that if maskers overlap in frequency with the tones to be masked, masking is likely to occur, its degree related to masker intensity. Because tinnitus can usually be masked (at least partially) for some period by a variety of sounds, one commonly used procedure is to assess wide-range masking, termed minimal masking levels (MMLs), using a variety of frequencies, including broad- or narrowband noise [12]. Theoretically, stimulation above the tinnitus frequency may supplement or assist the neurological reprogramming at the cortex and perhaps restore the normal-frequency spatial relationship.
The goal of this study was to evaluate the long-term efficacy of using UltraQuiet high-frequency bone-conduction therapy for treating tinnitus, using pre- and postbehavioral assessment of tinnitus loudness, tinnitus anxiety, and tinnitus severity. Fifteen subjects (3 female, 12 male) with subjective idiopathic tinnitus of the severe disabling type participated in the study. The stimulus was produced using Kyma Version 5 software with a Capybara 320 Sound Computation Engine, and it was recorded on a compact disk (CD). The transducer is a custom-made aluminum ceramic bimorph with a high-frequency limit of some 50 kHz. The UltraQuiet stimulus parameters, or sound features, were chosen to optimize the activation of auditory cortical neurons. Classification of masking curve type according to Feldmann's system was applied to the masking data, and we measured loudness discomfort levels at 250-8,000 Hz. To assess, in a preliminary fashion, the effects of treatment length, we randomly assigned subjects to one of three groups.
Before each stimulation session, subjects completed three outcome measurements: the tinnitus intensity index, the annoyance index, and the tinnitus severity index [1].
The questionnaire results for measures of tinnitus intensity and annoyance were not significantly different over the course of therapy sessions, although a drop in the mean level for each was noted on the last few trials. We examined the relationship among high-frequency MMLs, tinnitus pitch, tinnitus intensity, and Feldmann masking curves. The use of high-frequency bone conduction stimulation using the UltraQuiet therapy system resulted in longterm reduction in tinnitus severity during therapy, and that tinnitus relief lasted for at least 2 months after therapy in most subjects in this study. During posttherapy interviewing, we noted partial masking of the tinnitus by the UltraQuiet system throughout the trial in all patients (although not in every session). Frequency range of stimulation is critical in the auditory cortical reprogramming approach of the UltraQuiet system; however, any reduction in the amount of masking required to eliminate (or partially eliminate) tinnitus also is important. Alternatively, we could argue that the energy around 6 kHz was predominant in our subjects owing to mild to moderate sensorineural hearing loss. RI, which refers to a decrease in the perceived intensity of the tinnitus for a time after the masking stops, was first reported by Feldmann [12].
Because the UltraQuiet stimulus generally overlaps with high-frequency tinnitus and the presentation is just above threshold stimulation (~6 dB SL), inhibition should be facilitated. Treating tinnitus patients with the UltraQuiet device is more difficult when their tinnitus is of the severe problematic type.
Problematic tinnitus is most likely related to changes in the auditory pathway and consequent reactions in various areas of the brain.
The authors acknowledge the support of Sound Technique Systems, LLC, in this study and the assistance of Robert Guinta. We proposed a method for patient selection and application of criteria for predicting success with bone-conduction external acoustic stimulation using high-audio-frequency sound in the ranges of 10-20 kHz and 20-26 kHz for individuals with subjective idiopathic tinnitus (SIT) of the severe disabling type. This study reports on a method for patient selection for the use of external bone-conduction acoustic stimulation using high-audio-frequency stimulation with ultra-high-frequency (UHF) sound in the range of 10,000-20,000 Hz and with ultrasonic (US) high-frequency sound in the 20,000- to 26,000-Hz range for individuals with subjective idiopathic tinnitus (SIT) of the severe disabling type. The first step in providing efficient tinnitus treatment has been hypothesized to be patient selection. UHF-US external acoustic stimulation is available commercially from two devices that have been reported to provide significant relief of severely disabling tinnitus [3,4]. For UHF-US external acoustic stimulation to be most effective, responses must be positive at 10-14 kHz. Because the amount of energy increases proportional to frequency given a constant mass (head) to be detected by the ear, patient UHF hearing would appear to be a valuable parameter in predicting success in tinnitus treatment. The goal of this study was to present the results of the application of criteria for predicting success with a bone-conduction external acoustic stimulus using either UHF or US ranges in providing relief for patients with tinnitus of the severe disabling type. Of 52 consecutive patients who received UHF-US stimulation for relief of SIT of the severe disabling type, 22 reported tinnitus relief. The application of either high-frequency tinnitus treatment device is summarized in Figure 3. What is interesting to note is that individuals with severe deafness and some high-frequency hearing report US as high-pitched. Classic acoustic stimulation audiograms measuring 250-8,000 Hz do not predict success with high-audiofrequency stimulation or degree of tinnitus relief to be obtained. UHF for tinnitus relief has been found to be most effective when residual neuronal function exists in the acoustic ranges of 10,000-14,000 Hz, with thresholds no greater than 40-50 dB HL. Of 52 consecutive patients for whom high-audiofrequency stimulation using UHF or US was recommended for attempting tinnitus relief, 22 reported relief. Intense airborne ultrasound has been associated with hearing loss, tinnitus, and various nonauditory subjective effects, such as headaches, dizziness, and fullness in the ear. It has long been recognized that intense sound can distort vision and reduce visual acuity, presumably by overpressure of the lens [1-3]. The eye is a mechanical structure capable of sound excitation under certain conditions and constraints. The appreciation value of very-high-frequency music energy has triggered a provocative debate over the use of high digital sampling rates to capture such energy in recordings.
Five normal-hearing adults (ages 20-59 years) with no history of ocular, otic, or neural disease served as our subjects. We determined the frequency response of the eye by driving sound through the head via transducers on the skin of the head and recording from the eye.
In the next experiment, we applied airborne noise within the passband of the eye (25-60 kHz, as depicted in Fig. Broadband noise (5-70 kHz) delivered to the skull at the mastoid, occiput, or forehead excites vibration in the eye. The predicted transmission loss was determined by the acoustic mismatch between the impedance of sound in air with that of sound in ocular tissues. We did not measure the TL from the transducer to the eye; however, the air between the transducer and the eye acts as a coupling medium, and the TL may be less than air to body by an estimated 7-17 dB (Table 1). Finally, to demonstrate that the response recorded from the skin of the head represented the vibrations in the brain, we asked the subjects to perform a Valsalva maneuver, which increases cerebrospinal fluid [20]. Direct vibration of the brain can be communicated to the cochlea via intracranial fluid conduction [13,14], a pathway proposed by Ranke [11] more than 60 years ago and termed the third window by Tonndorf and Tabor [12].
It was von Gierke [23] who first proposed that audible subharmonics of ultrasound and the middle ear (air volume or ossicular displacement or both) were somehow involved in the response of workers to ultrasonic exposure. Tinnitus has commonly been associated with intense airborne ultrasound exposure [4-6], but quantification details are lacking. Musical airborne energy beyond 22 kHz has been shown to alter the electroencephalogram and evoke physiological activity in the brainstem and thalamus but only when ultrasonic musical frequencies are combined with the musical spectrum below 22 kHz. The eye is an airborne ultrasonic window to the ear and, as such, extends the range of human hearing.
An intriguing concept in cortical audio processing is that some neurons with best frequencies and frequency responses in the mid-audio range may be activated by much higher frequencies [36].
An auditory cortical neuron's sharply tuned frequency response (inverted V shape) is depicted in Figure 5A.
Nonlinear distortion produced anywhere in the bone conduction (BC) transmission path could demodulate the AM ultrasound to audible frequencies [37,38].
Propagating ultrasonic components of music toward the body induces brain and behavioral changes [7,8] but, when the body is sound-shielded, these changes are not observed [8].
Is there any evolutionary advantage in having an eye that responds to light and intense ultrasound?
Personal headphones could be supplemented or replaced with bone conduction transducers, with frequency responses extending to at least 50 kHz. Musical harmonic information is coded by place on the basilar membrane and temporally in neural firing. Eye conduction may contribute to industrial highfrequency loss and tinnitus because ultrasound and high audio frequencies overlap in terms of basilar membrane displacement patterns, especially if high audio subharmonics are generated by intense industrial devices. Partial support for this study was kindly provided by Northrop Grumman Newport News Inc., Newport News, Virginia.
Tinnitus is associated with the most important symptoms in neurootology besides vertigo, nausea, and hearing loss. Since about 1985, via vestibular evoked potentials (VestEP) and brain electrical activity mapping (BEAM), the Wurzburg Neurootology Group of Claussen et al. For this study, we randomly selected a sample of 757 patients suffering from an endogenous tinnitus according to the tetrad of tinnitus differentiation described.
We followed with a thorough audiometric investigation to obtain measurements of the hearing threshold, the acoustic discomfort threshold, the calculation of the acoustic dynamics, tinnitus masking, impedanciometry, and stapedial muscle reflexes. In assessing the vestibulospinal pathways, we regularly applied craniocorpography (CCG) in the form of ultrasonographic computed craniocorpography (UCCCG). The test results from our analyses helped us to demonstrate that these 757 patients were suffering from an endogenous tinnitus. At the Neurootological Research Institute at Bad Kissingen, we recorded statistics from our 757 patients suffering from an endogenous tinnitus.
After exploring the vertigo mechanisms, we analyzed the different sensations in hearing distortion in our patient sample (Fig. Figure 20 shows our analysis of trigeminal nerve complaints: Although no patient reported trigeminal nerve disorders, the medical investigators found such disorders by direct inspection relative to patients' obtained medical history. The special set of questions regarding our patients' history dealt with specific neurological disorders (Fig. Very well known is that after head and neck trauma, many patients complain of various types of tinnitus. Cardiovascular diseases were very important background disorders for our neurootological patients. We also questioned our patients about diabetes mellitus and categorized these cases with respect to their therapy.
For this study, we randomly selected 757 tinnitus patients who reported that they felt better in a noisy environment.
The question underlying this study is whether tinnitus is a monosymptomatic disease or is bound into a complex spectrum of complaints within a multisensory disorder. We saw a very varied picture in the subjective descriptions of the quality of tinnitus sensations.
Of background disorders, various cardiovascular diseases showed a high occurrence rate (Fig.
All in all, we must conclude that our evaluations in studying our 757 cases demonstrate that the spectrum of subjective complaints is very complex and individually mingled. Overall, our evaluation of 757 patients with endogenous tinnitus posits that the most important accompanying general diseases are cardiovascular. From all these patterns of interactive complaints, we also must conclude that endogenous tinnitus points to a "cybernetopathia" deriving from dysfunctions at various points of the statoacoustic and interrelated supportive neurosensory pathways. While there are many purported treatments for tinnitus, a treatment is NOT the same thing as a cure. What does the scientific literature have to say about whether or not there is a tinnitus cure? By the term cure, the definition, to the layman, is obvious: a reliable method of completely ending the problem at hand.
What kind of response can you get to our therapy using Notched White Noise therapy in the MP3 format? Actualmente estamos en el proceso de mineria de nuestros propios datos para determinar cuales son las frecuencias de tinnitus mas comunes son .
Tinnitus is a condition that causes a person to frequently experience a ringing sensation in their ears. How to cite this article Valente JPP, Pinheiro LAM, Carvalho GM, Guimaraes AC, Mezzalira R, Stoler G, Paschoal JR, et al. OBJECTIVES: To evaluate the correlation between the degree of discomfort caused by tinnitus and the hearing loss level.
RESULTS: 107 patients were studied and there was no correlation between the degree of annoyance of tinnitus with hearing loss, age, gender, presence of dizziness, of neck pain, headache, changes of the temporomandibular joint, the use of caffeine or excessive intake of carbohydrates. CONCLUSION: Dizziness, neck pain, headache and caffeine abuse are prevalent complaints in patients with tinnitus. In the literature, some factors possibly related to the nuisance caused by tinnitus have been tested, such as age, gender, presence of vestibular symptoms and hearing loss15,16,17,18. Therefore, the main objective of our study was to evaluate the correlation of the degree of discomfort caused by tinnitus with hearing loss. We conducted a clinical epidemiological study with a retrospective analysis of medical records of patients seen at the Otolaryngology Service of the State University from Campinas, in the period from February 2009 to April 2010. The study included patients over 18 years who had unilateral or bilateral tinnitus with normal hearing or sensorineural hearing loss. Patients with pulsatile tinnitus or infectious disease of the external and middle ear were excluded. To measure the degree of discomfort caused by tinnitus, the patients were evaluated by visual-analogue scale (VAS), graduated from zero to ten. For associated clinical symptoms, there was a high prevalence of patients with dizziness, neck pain and headache. The correlation between the degrees of discomfort related to the tinnitus and the three groups separately showed that 48% of the patients in group I (normal hearing) rated their tinnitus as severe. Most studies in the literature show that the prevalence of patients with tinnitus and normal hearing is around 8% to 10%28.
We know there is a close relationship between tinnitus and audiometric conditions and also in situations of normal hearing22. In the literature, most studies suggest that hearing loss, regardless of its degree, is related to greater inconvenience caused by tinnitus8,29,36,37.
Specifically evaluating patients in group I, a high prevalence of psychoaffective disturbs such as depression and anxiety disorder was found. In this study we found no difference within the group of patients with hearing loss (groups II and III), consistent with several other studies which have been published39,40,41.
Concerning the related clinical symptoms, a high prevalence of patients with dizziness, neck pain, headache and abuse of caffeine was found, which could be acting as triggering factors or worsening of tinnitus. In this study it was concluded that the degree of annoyance of tinnitus, using the visual analogue scale, was higher in patients without hearing loss and in females, but there was no statistical significance. Disciplina de Otorrinolaringologia, Cabeca e Pescoco - Universidade Estadual de Campinas (UNICAMP) - Campinas - SP - Brasil.
Disciplina de Otorrinolaringologia, Cabeca e Pescoco - UNICAMP Faculdade de Ciencias Medicas, PO Box: 6111. Paper submitted to the RBCMS-SGP (Publishing Management System) on October 12, 2011; and accepted on August 16, 2012. How to cite this article Goldstein BA, Shulman A, Lenhardt ML, Richards DG, Madsen AG, Guinta R. Masking of tinnitus by noise can produce residual inhibition, a persistence in the reduction in tinnitus after the noise is removed.
The ultimate goal in tinnitus therapy is the longterm inhibition or elimination of the tinnitus. Not only is the frequency of the noise not important in tinnitus masking in many cases, but tinnitus can be masked by noise not containing the subjective tinnitus frequency at all. Two other studies using much higher-frequency ultrasound (500 kHz) demonstrated conflicting results.
Forward masking of tones is a well-known psychophysical effect in which a masking tone can prevent detection of a tone after the masker is cut off. Typically, RI lasts for only a few seconds or minutes but occasionally can persist substantially longer.
UltraQuiet therapy provides patterned auditory stimulation in the high audio and ultrasonic ranges (10-20 kHz) using a bone conduction transducer (Figure 1). The subjects were nine adults with severe disabling tinnitus (seven male, two female; age range, 35-72 years). The tinnitus treatment stimulus was produced using Kyma Version 5 software with a Capybara 320 Sound Computation Engine (Symbolic Sound Corporation, Champaign, IL) and was recorded on a compact disk. The subjects listened to the tinnitus treatment stimu lus for eight sessions (twice weekly for 4 weeks), begin-ning with 30-minute sessions and increasing to 60-minute sessions. All eight subjects who completed the study reported abatement of their tinnitus symptoms during the course of treatment. Subjects occasionally reported an "afterimage" of the stimulus after the sessions, but this was not perceived as aversive and, in some cases, seemed to enhance the suppression of tinnitus. The response of the patients suggests that the UltraQuiet therapy is able to induce RI of tinnitus for a duration substantially longer than that of conventional masking noise.
The Jastreboff approach uses broadband noise but at levels that are adjusted low enough to avoid masking the tinnitus. Several studies have demonstrated cerebral cortex changes specifically associated with tinnitus. Shulman [20] hypothesi zed that a final common pathway for tinnitus exists for all patients with tinnitus, based on the identification by single-photon emission computed tomography (SPECT) of brain of side-to-side perfusion asymmetries, highlighted by the medial temporal lobe system, which includes the amygdalahippocampus complex. Tinnitus is different from simple cortical reorganization in which adjacent areas expand to fill the region no longer receiving input from the cochlea.
We gratefully acknowledge the support of Sound Technique Systems, LLC, and the Martha Entenmann Tinnitus Research Center. UltraQuiet is a proprietary tinnitus treatment developed by Sound Technique Systems, LLC, with patents pending. A commercial product, UltraQuiet provides a new form of high-frequency bone conduction therapy.
In the case of masking tinnitus by an external noise, this relationship is more the exception than the rule.
The masking stimulus is raised in 5-dB steps, and patients are asked whether their tinnitus is still audible. The stimulation must be very high in spectral content to accomplish this above the tinnitus pitch requirement. Music appears be a more effective tinnitus masker than is noise [19], possibly owing to the involvement of more central and cognitive processes.
The CD recording stimulus consisted of digitally processed music (44.1-kHz sampling rate) with playback in the 10- to 20-kHz range.
Spectrum of the high-frequency bone-conducted stimulation ranges from approximately 6 kHz to 20 kHz. The transducer is coupled to the skin and held in place with a band, much as are traditional clinical boneconduction transducers.
Cortical neurons have been shown to be sensitive to frequency edges, temporal patterns, and frequency or intensity transitions [20]. We presented outcome questionnaires to establish a baseline of functioning; these included the tinnitus intensity index, the annoyance index, and the tinnitus severity index [1,21,22]. No one indicated a poorer result, and those four reporting no change in their tinnitus did indicate improvement on measures of tinnitus intensity or severity after therapy treatment.
That is, as a group, the patients with problematic tinnitus indicated a significant reduction in severity over the course of the treatment trials. Effects of high-frequency therapy on three outcome measures - tinnitus severity, intensity, and annoyance - as evaluated by questionnaires completed after each therapy session. For some patients at some frequencies, reductions in MMLs were as high as 25-45 dB in one ear (Fig. Decrease in the minimum masking levels (MMLs) for the six patients who received brain imaging before and after therapy.
Mean minimum masking levels for all subjects when patient and ear data are collapsed reveals a frequency-specific pattern. Individual variability in this small sample of patients with problematic tinnitus precluded any detailed analysis, but tinnitus intensity ratings exceeding 50 dB were associated with improvement on the overall tinnitus relief questionnaire and were associated with a high-frequency pitch match. Relationship among minimal masking level changes (by frequency), Feldmann masking curve (FMC) types, and pitch and loudness matches in all subjects.
Hearing thresholds before and after therapy generally suggest improvement after therapy; however, the pattern was complex and included elevation in some frequencies. Threshold was established before each session but, given the problems in detecting a stimulus in the presence of tinnitus (even in skilled hands), the level of UltraQuiet therapy may have been as little as 2-3 dB SL for some patients in some sessions.
Patients in the 10-session group averaged just above "no change," whereas those in the 12- and 14- session groups averaged above "slight improvement." What must be emphasized is that these patients with problematic tinnitus have had limited therapeutic success with other treatment modalities.
The tinnitus relief was inferred from a pattern of lower weekly scores on the tinnitus severity scale and reduction in MMLs. Owing to stringent adherence to the protocol approved by the Western Institutional Review Board, we made no effort to increase the stimulation level in an attempt to produce complete masking. All patients had serviceable hearing to 12 kHz, but hearing improvement may have been related to relative frequency sensitivity of the UltraQuiet stimulus. In an individual with hearing loss and tinnitus, RI may last for a few seconds or minutes but can last days or weeks [2,31].
The acceptance of RI over questionnaire data is understandable in an effort to obtain a more "physiological" metric. What effect the increase in stimulation level from 6 dB SL to 12 dB SL would have on the effect of masking, on further reduction in MMLs, and on increased RI remains to be explored. When contrasted to normal controls and tinnitus patients who tolerate their tinnitus, patients with problematic tinnitus showed less habituation in middle latency potentials [36]. The emerging picture is that of an initial insult to the ear or brain (or both) followed by an increase in the tinnitus frequency cortical map, which could increase dyssynchrony-synchrony and loudness and reduce habituation.
Department of Otolaryngology, State University of New York, Downstate Medical Center, Brooklyn, and Martha Entenmann Tinnitus Research Center, Forest Hills, New York.
Ultra-High-Frequency Ultrasonic External Acoustic Stimulation for Tinnitus Relief: A Method for Patient Selection .
Ultra-high-frequency (UHF) stimulation for tinnitus relief has been found to be most effective when residual neuronal function exists in the acoustic ranges of 10-14 kHz, with thresholds no greater than 40 - 50 dB sound pressure level (SPL). High-frequency stimulation has proved to be effective in tinnitus treatment, presumably owing to neuro-reprogramming rather than simple masking [1]. Accurate patient selection - or, more precisely, patient matching to the high-pitch tinnitus treatment modality (UHF or US) for individuals with severe disabling tinnitus - can result in long-term inhibition of tinnitus by external bone-conduction acoustic stimulation with sound in the ranges of 10-20 kHz and 20-26 kHz [2]. We based patient selection criteria on test results from the audiometric data of UHF audiograms. Tinnitus treatment stimuli for the UltraQuiet device (left panel) and the ultrasonic HiSonic device (right panel).
We conducted UHF audiometry using both air-conduction high-frequency audiometry (HFA) with the Beltone 2000 audiometer and electrical HFA (EHFA) with the Tonndorf audiometer. The application of the criteria for patient selection predicted tinnitus relief in 20 of the 22. Individuals with no measurable high-frequency hearing will report US as the quality of the highest pitch they possess.
In our experience, the UHF audiogram is predictive of success with bone-conduction external acoustic stimulation using high audio frequency. US acoustic stimulation is recommended for patients with audiometric thresholds of 5 0 - 6 0 dB HL for frequencies of 10,000-14,000 Hz. In those 52 consecutive patients, the application of the criteria recommended for patient selection predicted tinnitus relief in 20 of the 22 who reported tinnitus relief. Departments of Biomedical Engineering, Otolaryngology and Emergency Medicine, Virginia Commonwealth University, Richmond, Virginia.
Eyes as Fenestrations to the Ears: A Novel Mechanism for High-Frequency and Ultrasonic Hearing.
Yet, when people detect ultrasonic components in music, ultrasound adds to the pleasantness of the perception and evokes changes in the brain as measured in electroencephalograms, behavior, and imaging.
Eye conduction of airborne sound could explain hearing loss and tinnitus in young workers exposed to intense ultrasound (typically cleaners) [4-6] and could explain the perplexing phenomenon that ultrasonic energy influences judgments of music quality and induces changes in electroencephalographic and positron emission tomographic examinations [7,8].
Conventional wisdom [9] since the 1930s has been that high-frequency energy to only 14 kHz was needed to recreate music faithfully. Many instruments produce energy well beyond 20,000 Hz at high levels [10]; even the human voice is capable of ultrasonic output if sufficient vocal effort is mustered (personal observation, 1990).
The endolymphatic and cochlear aqueducts (or, frankly, any vascular connection to the cochlea) could act as acoustic fluid pathways, much as the oval or round windows act as aerial pathways. The eye is a fluid globe that will offer an impedance mismatch to sound in air, much like that of an ear with a fluid-filled middle-ear space.
Specifically filtered white noise (10-100,000 Hz) was applied through a custom-designed aluminum ceramic transducer placed on the skin of the head (mastoid, occiput, and forehead). 1B) as sound anterior to the center of the globe and recorded the response from the skull in one subject. The ultrasonic beam was directed at the forehead or into the ear canal as an additional control. Specifically, acoustic impedance (Z) is the product of density, expressed in kilograms per cubic meter, and ultrasonic velocity, expressed in expressed in meters per second.
The head is driven with filtered white noise with a 2- to 50-kHz passband; eyelid recordings are obtained from piezoelectric film sensors as before. Frequency response of two subjects with increased cerebrospinal fluid pressure after performance of a Valsalva maneuver. Thus, transmission of airborne ultrasonic frequencies through the eye to the ear via intracranial fluid conduction helps to explain two mysteries in the human extended range of hearing. Displacement of the round and oval windows as release mechanisms for eye-induced brain vibration could certainly interact with the ossicular chain, producing a detectable audio component. Prevention of hearing loss and tinnitus involves remaining uncoupled from ultrasonic vibrations. The effect is based on the combination of two coherent acoustic routes, one conventional and one solely ultrasonic [7,8]. Personal headphones could be supplemented or replaced with bone conduction transducers with frequency responses > 50 kHz. The mechanics of ocularly transmitted ultrasound should be similar in all other respects to ultrasound delivered to the skin of the head or neck as vibration [15], with the eventual activation of the auditory cortex in normalhearing and deaf individuals [31,32].
Specifically, amplitude modulation (AM) outside of a neuron's response can be sufficient for activation. Consistent with the current finding is that the eye is the input window into the ear for high-frequency airborne sound and music. A considerable body of literature reports on sound-vision interactions in humans with forward-facing eyes [40, 41]. The frequency response is in the low ultrasonic range, and this type of hearing is termed eye conduction.
Such transducers are already in use for medical treatment of tinnitus and can be readily modified for personal musical use (see Fig. Ultrasound might contribute to the musical harmonic structure and provide more high-frequency treble emphasis in instruments, such as the cymbals, triangles, trumpets, violins, and oboes. Often, we find multisensory syndromes combined with tinnitus, hearing impairment, vertigo, and nausea.
Low-tone tinnitus is more frequently found in Meniere's disease and some other cochleo-apical disorders.

In the high-tone range, most frequently tinnitus is matched and related to such conditions as noise trauma, whiplash, head and skull trauma, cardiovascular failures, stress, and toxic events, including pharmaceutical use, nicotine or drug abuse, and acoustic neuromas. Owing to the size of the workload, we limited ours efforts to constructing a sample from those 757 patients randomly selected from a major group of neurootological patients (we process more than 10,000 files of neurootological patients, many of whom suffer from one or another type of tinnitus).
We then conducted objective and quantitative electrophysiological measurements of the acoustic pathways via otoacoustic emissions, acoustic brainstem-evoked potentials, and acoustic late or cortical evoked potentials. We performed vestibulospinal recording of the CCG with the Romberg standing test and the Unterberger-Fukuda stepping test using USCCG and the human space trail. However, for this study, we present the broad spectrum of subjective complaints as reported by the patients with a broad variety of findings.
This is shown for instance, in Figures 6 and 7, wherein the typical tinnitus phenomena are matched on different hearing zones in the audiograms of the right and left sides. Therefore, we prepared a specific, detailed analysis of the background of head and neck trauma (Fig.
Our search presented us with a great amount of data (more than 500 parameters per case), which we transferred into a digital version of the databank to preserve the anonymity of this sample of patients. The other identification indicators (weight, height, body mass index, and average systolic and diastolic blood pressure) lie within the expected range of this sample taken for Germany. For vegetative symptoms, such as the occurrence of nausea in perhaps one of four patients, see Figure 9. Acoustic, vestibular, and behavioral and psychosomatic symptoms are intertwined and seemingly interact with one another.
In a subsequent publication, we will deal with the outcome of the objective and quantitative measurements in audiology, equilibriometry, and the like in our group of 757 cases of endogenous tinnitus.
It manifests as a constant ringing, buzzing, or humming sound in the ear not associated with any external sound. There are treatments that may or may not help a subset of patients suffering from tinnitus, but they’re certainly not cures. La mayoria de la gente tiene una frecuencia de tinnitus unico que coincide con el patron de perdida auditiva de alguna manera. Alors que la gravite de la sonnerie peut varier, une personne sur cinq personnes est pense a souffrir d’acouphenes. It is often a sign of noise-induced hearing loss, but it can also be caused by an underlying medical condition, stress or ear wax buildup.
The limitations caused by tinnitus are related to psychological factors, mood changes and psychiatric conditions, while other factors related to discomfort caused by tinnitus are being studied.
Materials and Methods: A retrospective study of the patients treated at the Otolaryngology Service of the State University from Campinas for 15 months, using the Visual-Analogue Scale to classify the degree of discomfort by tinnitus. Some patients describe tinnitus as loud and intense, which may trigger psychosocial disorders and compromise their quality of life4,5. The THI is the most accepted method to evaluate tinnitus, because of its easy application, interpretation and the fact that it addresses several aspects of the patient?s quality of life13,14. In the genesis of tinnitus, the consensus is that hearing loss acts as one of the main triggers at the onset of tinnitus19, beyond a discussion of a common pathway that integrates all the central relationships of tinnitus20,21.
In addition, the presence of associated clinical symptoms and general data were also evaluated. For the analysis epidemiological data such as gender and age; and clinical features like the presence of unilateral or bilateral tinnitus, dizziness, headache, neck pain, temporomandibular joint disorder (TMJD) and abuse of caffeine or carbohydrates were used. Distribution of population (n = 107) in the groups classified according to hearing loss group I (n = 23), Group II (n = 38) and Group III (n = 46). Distribution of age groups classified according to the hearing loss, Group I (n = 23), Group II (n = 38) and Group III (n = 46). Distribution of patients according to gender in the groups classified according to the hearing loss, Group I (n = 23), Group II (n = 38) and Group III (n = 46).
Some authors also demonstrated the great value of associated symptoms like those described above26. Epidemiological studies show that one third of the population has experienced the sensation of tinnitus at least once in life. Concerning the three groups separately, it was observed that in group I (normal hearing) there was a higher prevalence of patients below 45 years old.
Heller and Bergman in 1953 showed that 94% of normal hearing patients reported sensation of tinnitus in completely quiet environments34. Considering the patients with hearing loss (groups II and III), this percentage was 28%, suggesting that patients with tinnitus and normal hearing are more related to tinnitus annoyance. Several studies indicate that these disturbances are mainly involved in the genesis and perpetuation of tinnitus39.
Masking of tinnitus by noise delivered through a tinnitus masker either alone or in conjunction with a hearing aid has been one of the most effective therapies but, In most cases, the relief is short-term, primarily occurring while the masking noise is present [1]. This is a very short-duration phenomenon, however, normally lasting less than 100 msec, and may correspond to the time required for the receptors to regain their sensitivity [2]. Hazell and Wood [13] reported a few cases in which 15 minutes of masking noise resulted in RI of tinnitus for the entire day. The stimulus consisted of music digitally processed and used to modulate a signal in the 10-to 20-kHz range.
Some subjects also reported a subjective improvement in heari ng, but this was not supported by the posttreatment audiometric resu lts.
The initial process is the development of a paradoxical memory for an aberrant auditory stimulus.
In tinnitus, a region of the cortex is spuriously responding in a manner analogous to epileptiform activity, but we contend that it can be remapped to patterned auditory stimuli above the frequency of the tinnitus, presented through bone conduction, with a consequent reduction in tinnitus. Martin Lenhardt holds an equity position in Sound Technique Systems and serves as vice president of research and technology. To assess its effectiveness in tinnitus treatment, we selected 15 patients with problematic tinnitus and randomly assigned them to three variations of the medical-audiological tinnitus patient protocol modified for the UltraQuiet study. Logically, high-frequency masking should provide effective relief in persons with severe problematic tinnitus. The UltraQuiet device delivers amplitude-modulated musical-type stimulation in the range of 10-20 kHz suitable for this purpose. We specifically investigated the use of the UltraQuiet device for providing relief, masking, and RI in individuals with problematic tinnitus of the severe disabling type. The stimulus consisted of synthesized music digitally processed and used to modulate a carrier at 16 kHz. The CD was played through a custom-made amplifier into a piezoelectric bone-conduction transducer. Some energy occurs around 6 kHz, owing to the transducer's fundamental resonance and the high-pass filter slope. In other words, features that are found in speech, music, or amplitudefrequency modulation were incorporated into the stimulus to facilitate auditory cortical activation.
Audiological evaluation included pure-tone audiometry, speech audiometry, tinnitus pitch and loudness matching, the measurement of RI, and masking curves to establish MMLs at 250-8,000 Hz using both narrowband and white noise. One week after the last intervention session, we repeated the audiological evaluation and administered the outcome questionnaires to assess any changes.
Group 1 received stimulation twice weekly for 2 weeks, stopped the stimulation for 2 weeks, then received stimulation twice weekly for 3 weeks, for a total of 10 sessions.
The stimulation lasted 30 minutes for the first session and 1 hour for all succeeding sessions. Some patients indicated more improvement than others, but the trend in all patients was an increase in tinnitus relief.
Note the general improvement that lasted for 2 months in approximately one-half of the patients. Tinnitus severity improvement for the group was evident at the second session, gradually increasing through the twelfth session. Clearly the severity is decreasing, with a trend in that direction for anxiety and loudness.
The tinnitus pitch match most frequently occurred in the region of the hearing loss but not necessarily at the frequency with the maximal loss. Dynamic hearing levels appear related to central processes assumed to be active during and after therapy.
Note in Figure 3 that dramatic improvement in tinnitus severity occurs in session 12, as does a modest abatement of tinnitus intensity and annoyance. Four factors likely contributed to long-term tinnitus relief: ultra-high-frequency masking, RI, neurological reprogramming, and habituation. The strategy of using high frequencies at low levels was designed to potentially provide some partial masking but, more important, was designed to aid in tinnitus neurological reprogramming and habituation. This is suggested by the six cohort patients in whom positron emission tomography scans were obtained. High-frequency stimulation, both in the high audiofrequencies (UltraQuiet) [2] and in ultrasonic frequencies [11], have resulted in RI.
We observed (by interview at the end of therapy but not by formal testing) RI lasting approximately 5 minutes. The conclusion of Shulman [15] suggests that a brain-imaging index in conjunction with high-frequency audiometry may be the technique of choice in objectively assessing tinnitus relief from auditory therapy if neurological reprogramming and habituation are the essential processes as hypothesized. Cortical reprogramming as a consequence of sensorineural hearing loss has been well established [33, 34]. In view of the degree of improvement and results with the limited number of sessions in our study, a reasonable expectation is improved results with an increased level of stimulation (12 dB SL) and an increased number of sessions over time. Additionally, auditory brainstem response differences between tinnitus patients and controls further suggest that auditory path- way transmission may influence abnormal habituation. Such a condition could hyperactivate the medial temporal and prefrontal lobes, resulting in problematic tinnitus characterized by annoyance, and could trigger autonomic reactions. Ultra-highfrequency acoustic stimulation and tinnitus control: A positron emission tomography study. Functional inactivation of the amygdale before but not after auditory fear conditioning prevents memory formation. Local improvement in auditory frequency discrimination is associated with hearing-loss slope in subjects with cochlear damage.
Loudness perception and frequency discrimination in subjects with steeply sloping hearing loss: Possible correlates of neural plasticity. Test-retest reliability of pure-tone thresholds from 0.5 to 16 kHz using Sennheiser HDA 200 and Etymotic Research ER-2 earphones. High-frequency (8 to 16 kHz) reference thresholds and intrasubject threshold variability relative to ototoxicity criteria using a Sennheiser HDA 200 earphone. Environmental enrichment improves response strength, threshold, selectivity, and latency of auditory cortex neurons. Abnormal auditory mismatch response in tinnitus sufferers with high frequency hearing loss is associated with subjective distress level. Ultrasonic (US) acoustic stimulation is recommended for patients with audiometric thresholds greater than 50-60 dB SPL for frequencies of 10-14 kHz.
To be detected by the human ear, US frequencies must be approximately 100 dB more intense than thresholds at 8 kHz. Because calibration procedures were different, thresholds at 8 kHz served as a reference such that all thresholds for higher frequencies are in decibels above it. In this review, we included patients presenting with the primary complaint of tinnitus and identified as having tinnitus of the severe disabling type. Both used amplitude modulation; however, the HiSonic is spectrally narrower and perhaps an octave higher. For HFA using air conduction, we measured thresholds at 10,000-20,000 Hz in 1,000-Hz intervals in 5-dB steps ranging from 0 to 120 dB SPL. The patients who reported success with UHF-US fulfilled the audiometric criteria as mentioned earlier. Food and Drug Administration for treating individuals with less than 60 dB HL in the high frequencies and to operate at just above threshold.
UHF-US external acoustic stimulation is recommended for attempting tinnitus relief in a selected tinnitus population with thresholds no greater than 50-60 dB SPL in the 10,000- to 14,000-Hz ranges. Ultra-high-frequency audiometry is considered essential for the selection of candidates for high-audiofrequency stimulation using either UHF or US for attempting tinnitus relief. Ultra-highfrequency stimulation and tinnitus control: A positron emission tomography study. How does the airborne ultrasound get into the ear to create such polaropposite human effects? Further, it is well documented that acoustic energy, including ultrasound, can pass into the eye [3]. Further electroencephalographic and positron emission tomographic changes were documented when frequencies beyond 22 kHz were presented along with conventional audio frequencies [7,8] to human listeners. These fluid pathways were termed the third window of Ranke by Tonndorf and Tabor [12], who later demonstrated cochlear function after sealing both the round and oval windows; thus, for the basilar membrane to be displaced, some compliant window is necessary.
Hearing with a fluidfilled middle ear is not only possible but the degree of loss is small (on the order of 30 dB). We established stimulating parameters and recording techniques over a 2-year period using six additional subjects. We measured the input to the head with a Buel and Kjaer (B&K) high-frequency accelerometer placed on the transducer while mass-loaded to the head.
We modified the same type of transducer that delivered contact sound to the skull to produce a narrow beam of airborne ultrasound by fabricating a foam gasket with a 2-mm aperture.
When that band of noise was presented as an airborne sound directed at the eye, we measured vibration of the brain and skull at the mastoid, occiput, and forehead in the same frequency range of 25-60 kHz. There is considerable acoustical similarity among the soft tissues suggesting little impedance mismatches contributing to transmission loss.
Data in Figure 2 would predict little attenuation for sound passing from the eye to the brain in regard to changes in substrate density; only distance would determine transmission loss. It is argued that an increase in cerebrospinal fluid will damp the vibration in the brain while not substantially altering the spectrum.
Increased cerebrospinal fluid increases the damping in the brain, which would lower the intensity of the spectrum recorded from both skull and brain. A number of authors [4-6] have documented harmful, intense airborne ultrasound effects on people. Such a middle ear-induced audio component would "sound" like a demodulation and could be misinterpreted as demodulation of the primary tone.
Each signal stimulates a separate area on the basilar membrane that would be integrated into a whole as any conventional complex auditory pattern. Such transducers are already in use for medical treatment of tinnitus [29,30] and can be readily modified for personal musical use (Fig.
If ultrasound is demodulated in the brain [15], the ear would be stimulated at or near brain resonance (14-15 kHz); thus, the auditory cortex that codes high audio frequencies will be involved. Because ultrasound is coded as high-frequency sound, there is no reason to believe that this is not a potential mechanism. Stimulation of high frequencies outside the frequency response has been shown to cause some neurons to fire.
Ultrasonic skull vibration does vary from individual to individual on the basis of geometries [26], but this does not necessarily imply nonlinearities. There is no need to postulate an additional unknown somatosensory route to the ears [8]; nonetheless, the concept of multisensory coding in music perception is intriguing. Evaluation of acoustic wave propagation velocities in the ocular lens and vitreous tissues of pigs, dogs, and rabbits. The role of biological system other than auditory air-conduction in the emergence of the hypersonic effect. Auditory cortical responses to amplitude modulations with spectra above frequency receptive fields: Evidence for wide spectral integration. From more than 10,000 cases, we evaluated 757 randomly selected neurootological patients suffering from endogenous tinnitus.
However, what could be proved by various authors since 1985 is that endogenous tinnitus is significantly related to dysfunctions in the human temporal lobe (Brodmann area 41).
We administered a full spectrum of neurootometric testing to all 757 patients; the investigation protocol for thorough data analysis (more than 500 parameters) included five procedures.
After all the files of the patients were transferred into digital lists and nets of digital data, we could select the various groups of complaints to derive a representative statistic. The most frequent quality of tinnitus distortion reported was a whizzing sound in either ear or in both (54.02%).
Figure 21 demonstrates a specific differentiation with respect to facial nerve paralysis cases. We easily designated a group of patients who demonstrate a genuine objective sound in the head as experiencing bruits.
In future, this must be taken into consideration in developing a spectrum of therapeutic procedures not only in the field of pharmacotherapy but in psychotherapy and physiotherapy and in applying such physical measures as magnetotherapy.
We found diabetes mellitus more frequently in the group with the exogenous or unmaskable tinnitus, whereas hyperlipidemia was reported twice as often in the group with endogenous or maskable tinnitus as in those with the unmaskable type. On the functional state of central vestibular structures in monaural symptomatic tinnitus patients.
About the Strength of the Neck in Linking the Head to the Trunk as Measured by the US-CCG . Interdisciplinary clinical vertigo studies in whiplash lesions to the ligamenta alaria by means of dynamic MRI-findings in combination with ultrasound cranio-corpo-graphy (USCCG). Medical classification of tinnitus between bruits exogenous and endogenous tinnitus and other types of tinnitus. Die Differenzierung zwischen endogenem und exogenem Tinnitus [The differentiation between endogenous and exogenous tinnitus]. It is an annoyance, but also a hindrance; many sufferers eventually have to succumb to hearing aids to compensate for the nonstop droning. Sin embargo, nadie , hasta el momento, ha trazado lo que la distribucion de frecuencias de tinnitus es en la poblacion.
Symptoms of tinnitus include a ringing or buzzing sound in the ears without an external source identified, but some people may hear other sounds. In its most common form, tinnitus is presented as a phantom sensation which is not associated with an external sound stimulus1. Some studies show that the limitations caused by tinnitus are related to psychological factors, such as mood swings, irritability and psychiatric diseases6,7,8,9. However, previous studies have shown that EVA, in which the patient classifies his discomfort related to tinnitus from 1 to 10, has a good correlation with the THI10-14. However, hearing loss and its relationship with the distress associated with tinnitus is still controversial.
All patients underwent complete ENT examination and pure tone audiometry, testing the following frequencies: 250, 500, 1,000, 2,000, 3,000, 4,000, 6,000 and 8,000 Hz. They were classified in three degrees of discomfort: mild (0-3), moderate (4-7) and severe (8-10).
When compared to the level of discomfort related to tinnitus (VAS), none of the factors evaluated showed statistically significant results. However, there was no statistically significant difference between the three groups (Table 3). A possible explanation for this finding might be the fact that the work has been performed in Otoneurology, in which the main complaint is tinnitus and not hearing loss. Sanchez in 2005 also observed that the average age of patients with tinnitus and normal audiometry was lower compared to patients with hearing loss23. Riga in 2007, by testing for suppression of otoacoustic emission distortion products, suggested that patients with normal hearing may have a dysfunction of the cochlear efferent system, specifically the medial olivocochlear bundle35. Savastano in 2008, using the THI, found a higher number of patients who rated the annoyance by tinnitus in the group with moderate normal audiometry38. Another hypothesis that could explain a greater discomfort in patients with normal hearing would be the impossibility of adaptation of a hearing aid in these patients. It is noteworthy that the diagnostic accuracy is essential to any attempt to relieve tinnitus42. Benzodiazepines and GABAergics in Treating Severe Disabling Tinnitus of Predominantly Cochlear Origin.
Adaptacao para a lingua portuguesa do questionario Tinnitus Handicap Inventory: validade e reprodutibilidade. Final Common Pathway for Tinnitus: Theoretical and Clinical Implications of Neuroanatomical Substrates.
Abnormal auditory mismatch response in tinnitus sufferers with high-frequency hearing loss is associated with subjective distress level. Avaliacao da relacao entre severidade do zumbido e perda auditiva, sexo e idade do paciente. Impact of Tinnitus on Quality of Life, Loudness and Pitch Match, and High-Frequency Audiometry. Tinnitus with normal hearing sensitivity: extended high-frequency audiometry and auditory nerve brain-stem-evoked responses. Hearing disorders in the population: first phase findings of the MRC national study of hearing. Guidelines for the grading of tinnitus severity: the results of a working group commissioned by the British Association of Otolaryngologists, Head and Neck Surgeons, 1999. A Clinical Study of the Efferent Auditory System in Patients With Normal Hearing Who Have Acute Tinnitus. The aetiology of tinnitus: risk factors for tinnitus in the UK population-a possible role for conductive pathologies. This report highlights long-term inhibition of tinnitus by UltraQuiet therapy, a new technique that employs patterned sound in the 10-to 20-kHz range, presented through bone conduction.
In a phenomenon called residual inhibition [RI], however, the reduced intensity of the tinnitus persists for some time after the masking noise is removed. Clearly, a therapeutic technique for tinnitus that did not require continuous masking noise would be of great benefit.
They contrasted this with forward masking of two acoustic tones, whereby increasing masker duration beyond approximately 400 msec generally produces no increase in the amount of forward masking. These authors wanted to know whether maskers could be designed to be maximally efficient in producing RI and whether the incidence and extent of RI could be predicted from the type of tinnitus.
The compact disk was played through a custom-made amplifier into a piezoelectric bone conduction transducer. Central nervous system involvement in tinnitus has been found at both subcortical and cortical levels.
The concept is that the annoyance of tinnitus depends on a subcortical conditioned response that creates distress through a link to the limbic system. The idea is to enhance background neural activity within the auditory pathways and to habituate the tinnitus signal at a subcortical level. Recent studies that are especially significant include those of Shulman [20], Llinas and Pare [21], Jeanmonod et al.
Adjacent perfusion asymmetries involving the frontal, temporal, and parietal lobes suggest an interneuronal network in the medial temporal system, resulting in the transition of the sensory to the affective component of the symptom of tinnitus. Llinas and Pare [21] hypothesized that low-threshold calcium spike bursts were at the origin of parkinsonian tremor, action tremor, neurogenic pain, or absence epilepsy and tinnitus. These authors found a marked shift of the cortical representation of the tinnitus frequency into an area adjacent to the expected tonotopic location. These researchers used positron emission tomographic imaging techniques to look at cerebral blood flow in patients with tinnitus and mapped neural responses to probe tones. They reported a thalamocortical dysrhythmia marked by an increased low-frequency rhythmicity in the frequency band of 4-8 Hz. Role ofIntrinsic Neuronal Oscillations and Network Ensembles in the Genesis of Normal and Pathological Tremors.
The functional anatomy of tinnitus: Evidence for limbic system links and neural plasticity. Assessing tinnitus and prospective tinnitus therapeutics using a psychophysical animal model. Thalamocortical dysrhythmia: A neurological and neuropsychiatric syndrome characterized by magnetoencephalography. Plastic changes in the auditory cortex induced by intensive frequency discrimination training. We assessed tinnitus relief by questionnaires directed at weighing patient response to overall effectiveness, tinnitus loudness, tinnitus severity, and tinnitus annoyance.
The effect of this expansion on connections to the limbic system and other cortical areas is not known, nor have the tuning characteristics of these "recruited" neurons been measured. Preliminary clinical reports were encouraging [2] and a calibration procedure, anchored to international standards, was followed [18]. The pitch match to the tinnitus for 14 of the 15 subjects was high-pitched, matching to either a pure-tone or a narrowband noise or a combination of both, with frequencies between 3 and 16 kHz; 1 subject had a low-pitched tonal tinnitus at 450 Hz.
Group 2 received stimulation twice weekly for 3 weeks, stopped the stimulation for 2 weeks, then received stimulation twice weekly for 3 weeks, for a total of 12 sessions. Further improvement may be present but is obscured by the duration parameters of the three groups.
The mean data are perhaps as revealing; when patient and ear data are collapsed, a high-frequency reduction in masking is observed (Fig.
Although we saw an increase in some thresholds in some patients, twice as many thresholds improved as those that decreased.
Nonetheless, the frequency range of masking is important in obtaining neurological reprogramming and inhibition [16,18]. Those patients with the best thresholds beyond 10 kHz exhibited the best behavioral and physiological activity [15]. The question of the minimal number of trials needed to note tinnitus relief, given that choices were limited to 10, 12, and 14 sessions, can be answered only by stating that 10 session of therapy (and probably fewer) are not as effective as 12 and 14 sessions, on the basis of questionnaire results after therapy. Patients with problematic tinnitus appear not to exhibit normal habituation, and this can influence their perception of tinnitus loudness. Although we readily recognize that the neural substrate of problematic tinnitus encompasses much more than the auditory pathway, the role of the auditory pathway in masking, RI, neurological reprogramming, and habituation is significant [37].
In GE Reich, JA Vernon (eds), Proceedings of the Fifth International Tinnitus Seminar 1995. Poster presented at the Twenty-First Annual Meeting of the Association for Research in Otolaryngology, 1999. Presented at the Thirty-First Congress of the Neurootological and Equilibriometric Society, Bad Kissingen, Germany, March 25-27,2004. Fifty-two consecutive patients seen for the primary complaint of SIT of the severe disabling type received a trial of either UHF or US bone-conduction acoustic stimulation. One is acoustic stimulation of the residual peripheral neuronal function in the UHF range of 10-14 kHz and audiometric thresholds of 40-50 dB sound pressure level (SPL). Note that ultrasonic frequencies are 80-100 dB above the thresholds at 8 kHz, whereas high audio frequencies are much lower. In each case, a transducer is placed on the mastoid, and the stimulation level is ascertained by determining sensation level. After application of the proposed criteria, we selected UHF-US external electrical stimulation for trials to provide tinnitus relief. In EHFA, the head is capacitively coupled into a circuit, and audio tones are amplitude-modulated on a 60-kHz carrier. US can be cancelled when it must pass through the skull, which has many vibratory antiresonances. Presented at the conference Hearing Loss in Children, Amplifon, Milan, Italy, July 2-3, 2004.

Poster presented at the Twenty-First Annual Meeting of the Association for Research in Otolaryngology, St. Surprisingly, ultrasound passes first through the eyes; thus, the eye becomes but another window into the inner ear.
What has not been examined in any of these studies is the possibility that the acoustic energy that passes through the eye may also serve as a source of auditory perception. No ultrasonic route to the ear was proposed in these studies, but certainly possible is that the ultrasonic energy in music-and for that matter, industrial noise-could pass through the eye and be detected by the ear.
More recently, it has been shown that direct vibration of the brain [13,14] could elicit evoked responses from the auditory nerve, confirming that a brain can be a passive "fluid" conductor of sound, even an amplifier near resonance [15] and, at the same time, a physiological responder to the sound propagated through it. After the impedance mismatch is overcome with sufficient energy, is the eye, like the fluid-filled middle ear, capable of transmitting the absorbed sound to the brain? High-frequency stimulating transducers were custom-made ceramic aluminum bimorphs attached with tape to the skin of the skull. The assumption is that the eye dimensions are small in regard to the near field, and so scattering within the eye may not be anticipated. Air coupling to the eye might reduce the transmission loss to about 33 dB, whereas skin-brain-skull transmission loss might be as high as 50 dB (depending on frequency).
Thus, the energy leaving the eye should be more intense at the forehead than at the mastoid, correcting for impedance changes from fluid to bone. There are, nonetheless, airborne sources as intrusion alarms, which do not have audible subharmonics that can induce audible and subjective effects. This personal protection should provide ample safety; nonetheless, the current Occupational Safety and Health Administration regulations [25] regarding hearing safety in airborne ultrasound should be reviewed. A case is made here for a separate airborne ultrasonic input, but the final pathway is the same because ultrasound activates the auditory cortex in normal-hearing and deaf listeners. If the ultrasound acts directly on the base of the cochlea, just the tip of the basilar membrane would be stimulated [33], also resulting in high-frequency area activation of the auditory cortex [31].
Assuming the music scenario, conventional audio and ultrasound may drive some units, supporting the perception that ultrasonic components of music are important for apprehension. The stimulation in this case is in a form of AM that is a process in which one sound is multiplied by another. The hair cells could act as a demodulator, but the most likely demodulator is the brain itself [15]. An auditory cue can trigger a visual shift in attention, and a louder cue is more effective than a softer one.
First, we classified the 10,000 patients into those suffering from the basic tetrad of tinnitus forms: bruits, endogenous (maskable) tinnitus, exogenous (nonmaskable) tinnitus, and other syndromes such as the slow brainstem syndrome. Patients with a maskable or endogenous tinnitus prefer covering up their tinnitus by external sounds.
We found typical shortenings in the latencies of the vestibular evoked quantitative electroencephalography (QEEG), an enlarged DC shift of the vestibular evoked QEEG, and typical cortical electrical burst expansion in three phases on the brain surface as shown by BEAM.
First we recorded a thorough neurootological history with a systematic preprinted history scheme of Neurootologisches Anamneseschema Claussen (Neurootological History Scheme).
As the sum of all the tinnitus spots being masked amounts to 141.74%, we were able to derive that nearly one-half of the sample suffered from a bilateral maskable tinnitus.
The majority of patients (consistent through all age groups) reported so-called whiplash-related tinnitus problems after a car accident.
The frequently reported sensation of a roaring in the right or the left ear occurred in only 0.13% (left ear) in our sample. In Vertigo, Nausea, Tinnitus and Hearing Loss in Central and Peripheral Vestibular Diseases . In JM Aran, R Dauman (eds), Proceedings of the Fourth International Tinnitus Seminar, Bordeaux, 1991 . Tinnitus is usually caused by a loud noise or continued exposure to relatively loud noises. In 2004, Weisz showed that patients with hearing loss at high frequencies are more subjectto tinnitus nuisance22. As for their gender, 72% of patients were women, with similar distribution among the three groups (Figures 2 and 3).
Comparing the buzzing nuisance related to the presence or absence of hearing loss (Group I x II + III) no statistically significant difference was observed. In: Proceedings of the Sixth International Tinnitus Seminar - The Tinnitus and Hyperacusis Center.
In: Proceedings of the Fifth International Tinnitus Seminars The Tinnitus and Hyperacusis Center.
Nine subjects participated in a study of the efficacy of this tinnitus suppression technique. This report presents the preliminary results of tinnitus treatment with a new technique intended to induce RI: UltraQuiet therapy.
This finding opens up the possibility that tinnitus could be masked by sound outside the speech range entirely, which would offer the advantage of not interfering with speech reception.
The term residual inhibition refers to a decrease in the perceived intensity of the tinnitus for a time after the masking noise stops. However, the factors resulting in persistence of inhibition and the mechanism are not well understood. They found that RI increased with masker intensity, but the relationship to duration was not clear. UltraQuiet therapy differs from the conventional masker in that none of the sound overlaps the range of reported tinnitus. The goal of the therapy is to habituate this response so that the tinnitus is no longer perceived.
The much more rapid reduction of tinnitus by UltraQuiet therapy suggests that subcortical habituation is not a sufficient explanation. The deprived area of the cortex reorganized and became responsive chiefly to the frequencies intact at the cochlea.
Underlying mechanisms are hypothesized to exist and to be highlighted by a diminution of inhibition mediated by γ-aminobutyric acid (GAB A) due to a disconnection from excitatory (glutamate) inputs. They also found a strong positive correlation between the strength of the tinnitus and the amount of cortical reorganization.
Two other recent studies made a good case for treatment-induced cortical reorganization as therapy for neurological conditions. In: GE Reich, JA Vernon (eds), Proceedings of the Fifth International Tinnitus Seminar 1995.
Presented at the meeting of the American Academy of OtolaryngologyHead and Neck Surgery, Denver, CO, September 9, 2001.
Additionally, we performed audiological measures (including pure-tone and speech audiometry, minimal masking levels, pitch and loudness matching, and residual inhibition).
That is, tinnitus masking may be a complicated product of peripheral and central processes, and sounds outside of traditional psychoacoustic ranges can be effective with tinnitus [2], including ultrasound masking delivered through bone conduction [11]. If neural space expansion of the tinnitus frequency (or frequencies) is associated with synchronized activity, ignoring an attentiongenerating tinnitus percept that could readily arise may be impossible.
The UltraQuiet system has a maximum output of 53 dB hearing level (HL) when it is massloaded to the artificial mastoid with 5.4 Newtons of force applied. Group 3 received stimulation twice weekly for 4 weeks, stopped the stimulation for 1 week, then received stimulation twice weekly for 3 weeks, for a total of 14 sessions. The threshold for stimulation was established, and the stimulation was presented 6 dB above threshold or 6-dB sensation level (SL).
That is, for the latter sessions, the number of patients being tested dropped, owing to the session limitations for each of the three treatment groups. No consistent pattern was noted between Feldmann masking curve type and tinnitus pitch match (Fig. If highfrequency stimulation is essential for auditory cortical reprogramming, the sensitivity to such stimulation should be an essential variable. What should be noted is that the stimulating intensity was only 6 dB SL, and this may not have been sufficient energy to elicit RI in the other patients, a metric to be systematically studied in the future. If the auditory cortex has reprogrammed, stimulation with very high frequencies might stabilize and reverse the process and perhaps restore the normal frequency map. According to these serial measures, therapy of fewer than 12 sessions would not be as satisfactory as therapy lasting 12 and 14 sessions. A plastic auditory pathway treated with a stimulus specifically designed for highpitched tinnitus may, with time, provide long-term relief. A second is the integrity of the brain cortex for neuronal reprogramming as demonstrated in metabolic activity seen in positron emission tomography (PET) of brain.
In other words, the minimal residual neuronal responses necessary for obtaining tinnitus relief with UHF external acoustic stimulation require a threshold no greater than 60 dB SPL at 10-14 kHz. Each individual received a trial of either UHF or US bone-conduction stimulation for 0.5 to 1 hour [1].
With demodulation, owing to the nonlinearities of the skin, tones are perceived as conventional audiometric tones. Further, could airborne ultrasonic energy entering the eye secondarily induce tinnitus and hearing loss?
Is the eye pathway the reason that live music sounds better than recordings or the reason why ultrasonic instruments can cause hearing loss and tinnitus? To record the sound spectra from the eye, we taped a piezoelectric film sensor, constructed of a piezoelectric polymer polyvinylidene fluoride [16], over the closed eyelid, being careful not to make contact with the orbit, to detect the frequency response of the globe to white noise propagating around the skull and through the brain.
The effective band of eye frequency response is from 25 to approximately 60 kHz (double-headed arrow).
Tactile responses to airborne ultrasound have been reported in the oral and nasal cavities if the mouth is open, likely owing to a standing wave phenomenon [4] that directly stimulates epithelial cilia. Placing the aluminum transducer on the skin results in a TC of 0.3 and a transmission difference of 10 dB. The predicted difference was 10 dB (see Table 1); the measured difference was 6 dB, given the short distance along the skull. The damped tracing during the Valsalva maneuver (solid line) is some 5 dB lower in intensity in both subjects; the variability between subjects is also evident, yet consistent with the concept of the eye as an acoustic sensor for ultrasound. In a related report, swimming into a 50-kHz beam produced an audible perception, and merely immersing the jaw into water with a 50-kHz beam present produced a lower sensation [24]. Certainly our study sets forth a method of quantifying the transmission of airborne ultrasound into brain vibrations. Simply put, three tones beyond the frequency range of some auditory cortical neuron will cause it to fire.
As mentioned earlier, the ossicles can be displaced by the oval-window movement with brain vibration, resulting in an audible tone near middle-ear resonance of 3 kHz, which is not primary demodulation of the ultrasound [23]. Abrupt onset of sound can improve the detection of a subsequent flash, the opposite of masking [42]. Next, we examined all the patients otologically, including bilateral microscopical inspection of the outer ear, ear canal, and tympanic membrane.
They also reported posttraumatic complaints of whiplash injury (also consistent through all the age groups but especially frequent in the age group 30-40 years). Significantly different from the group identified as having endogenous tinnitus are the behavior and the sensation of those with exogenous tinnitus or nonmaskable tinnitus, who find relief in a completely silent environment. The majority of our patients described their tinnitus as lasting from one to several years (as seen in Fig.
We found that 3.70% of patients complained about a reduced acuity in their taste (hypogeusia). Traditional treatment has been a surgical procedure that may or may not provide effective relief for an extended period of time. In that model, damage to peripheral organs act as triggers of tinnitus, and is supported by events that occur in the central auditory pathway, such as maladaptive neuroplastic processes and phenomena such as hyperactivity of the auditory cortex. As for a correlation between age and gender with a degree of discomfort caused by tinnitus through the EVA, there was no significant difference (Table 1). Finally, comparing groups II and III (respectively loss in patients with high frequency and loss in patients in general), no difference was found.
The report also provides a basis for continued studies and discusses central mechanisms that may lead to long-term inhibition of tinnitus.
Duration increased RI only when a relatively intense masker was used; not known is whether this holds for masker durations of more than 10 minutes. Nevertheless, ultrasound was even more effective than was speechrange masking noise for tinnitus masking and producing RI in a study by Meikle et al.
The pitch match to the tinnitus for all subjects was high-pitched, matching to either a pure tone or narrow band noise with frequencies between 5 and 16 kHz (mean, 7.3 kHz). Although the stimulus is presented on only one side of the head, it is heard binaurally through bone conduction. A long-term follow-up questionnaire was administered 2-8 months after the end of the treatment; results are as follows. In TRT, the role of the sound is not to mask the tinnitus but to accomplish changes in the auditory system, including (1) decreasing the contrast between the neuronal activity that represents tinnitus and the background neuronal activity, (2) interfering with the brain's ability to detect the tinnitus signal, and (3) reducing the abnormal gain in the auditory system and thus reducing hypersensitivity.
Blockage of GABA-mediated inhibition with antagonists results in tinnitogenesis, an epileptiform auditory phenomenon [20], and in broadening of cortical neural tuning curves [25].
They pointed out the similarities between tinnitus and phantom limb pain: Both cases exhibit a loss of input from peripheral nerves accompanied by a similar reorganization of the cortex.
They also noted more widespread activation in patients with tinnitus, as compared with controls, and aberrant links between the limbic and auditory systems. All patients showed some long-term gains, and most exhibited relief in at least one measurement parameter, providing support for the use of high-frequency vibration in the treatment of tinnitus. Growing evidence suggests that high-frequency masking is desirable in cases of high-frequency tinnitus [2,11]. Increased degrees of neural synchronydyssynchrony could activate and continue to stimulate the amygdala, an organ known to be critical in evoking emotional and autonomic nervous responses [17]. Although the stimulus is presented on only one side of the head, it is heard binaurally through bone conduction [23].
The frequency area that exhibited the greatest effect is the octave from 3 to 6 kHz, below the lowest resonance in our transducer (6 kHz).
Annoyance and tinnitus intensity seemed to persist in most throughout the sessions, suggesting that the tinnitus, while reduced in severity, was still present. In the normal auditory system, an increase in loudness is related to an increase in neural activity.
The changes in MMLs and auditory thresholds suggest an adaptive central nervous system, responsive to high-frequency sound therapy.
The application of criteria for patient selection predicted tinnitus relief in 20 of the 22.
A PET of brain study identified a correlation between the UHF audiograms, the subjective reports and outcome measures of the efficacy of the UFH-UQ for tinnitus relief, and brain PET metabolic categories. Pitch matching and Feldmann masking curve data were not informative in establishing a criterion for patient selection. The thresholds are actually first established in electrical terms and then are converted to an equivalent SPL.
We also mounted calibration accelerometers either to the transducer sensors or to the skin of the skull for mass-loaded measurements. The piezoelectric film transducer acted as a sensor for calibration trials but was removed during measurements of ocular transmission. The propagation speeds and densities of the relative tissues for this study are depicted in Figure 2.
Skull-to-skull measurements are wider in frequency response, with a peak at approximately 15 kHz, presumably reflecting brain resonance as well as less attenuation. The brain, skull, and eye are coupled acoustically; with the skull essentially rigid, the compression of the brain against the skull is the source of change in Figure 3. A parsimonious explanation (not suggested by the authors) is that the eyes were responsive for the lowered threshold of ultrasound detection when the head is submerged by providing an efficient route to the ear via the brain, as the acoustic impedance of the eye and seawater are very similar (see Table 1). Though no acoustic standards have been promulgated for measuring ultrasonic sound in human bone or fluid, guidance is available [26,27]. Very-high-frequency recordings (6-21 kHz) have activated the thalamus and other regions in the brain [28] in patients who have high-frequency tinnitus; thus, the thalamus plays a role in high-frequency and ultrasonic hearing. The cilia of hair cells in the base of the basilar membrane are very short (5-10 µ), are immersed in fluid, and resonate in the ultrasonic frequencies. The product of the multiplication is the carrier, the carrier plus the modulator (C + M), and the carrier minus the modulator (C-M). Finally, a tactile response to airborne ultrasound has been reported in the oral and nasal cavities if the mouth is open, likely owing to standing wave phenomena [4]. So it appears that intense high frequencies that pass through the eye window as opposed to just surpassing the impedance barrier to the body [43] might indeed lead to multisensory coordination and, hence, survivability for humans, but there is a limit [24] that, if exceeded, may result in hearing loss and tinnitus. Car accidents and whiplash occur more frequently in the younger age groups, whereas reports of cerebral concussions are more frequent in the old-age group (> 70 years).
Finally, via our complex neurootometric tests, we demonstrated slowing deregulations in the statoacoustic pathways.
We heard no complaints about trigeminal disorders; however, we found both peripheral and central facial nerve paresis, though in a small number (see Fig. 28) played a minor role in our sample, as was evident for the major hormonal diseases (Fig. Grant Searchfield is a leading audiologist who has devoted his career to helping those who suffer from this condition, and many who suffer from this condition are now looking forward to the Dr Grant Searchfield tinnitus treatment.
This can be explained by the increased demand of women to medical services, or the greater prevalence of psychological disorders in this group, such as anxiety and depression31,32. The relationship of RI to tinnitus frequency and to masker center frequency and bandwidth was complex and varied among individuals.
On the question, "How do you feel that your overall tinnitus symptoms have changed since before you began the tinnitus treatment?" one person answered "moderately improved," five people answered "slightly improved," and two people answered "about the same." One person reported benefit lasting 4 weeks after the last treatment, one person reported benefit for 1 week, four people reported benefit for 3-5 days, and two people reported no lasting benefit.
This contrasts with the form of cortical reprogramming discussed later, in which attention may be necessary for the changes to take place, relevant to the effect of the UltraQuiet. Treatment with the anticonvulsive GABA agonist drug gabapentin reversed high-frequency-specific tinnitus and reduced hearing loss in animals [26]. Two problems exist: One is developing an efficient, commercially viable, and calibratable transducer and the other is determining a reliable clinical-use protocol. For many patients, substituting one sound for another is not considered a significant enough improvement; additional relief is desired.
Stated another way, the frequencies that required less energy to mask tinnitus were those just below the lowest effective stimulating frequencies in the UltraQuiet system. The UltraQuiet masking mechanism appears to be different when using conventional audiological masking at 250-8,000 Hz than when using ultra-high frequencies. High-frequency stimulation with the UltraQuiet passband of 10-20 kHz has the added quality of disrupting the tinnitus frequency synchrony and reducing the overrepresentation, which might be verified with cortical potentials. Patients who do not exhibit normal habituation and who rate their tinnitus as loud may have more active dyssynchronous neurons involved in tinnitus perception than do patients who assess their tinnitus loudness as low. Long-term tinnitus relief cannot be solely defined by one metric as complete masking or RI on the order of hours. Specifically, the best subjective reports for tinnitus relief with UHF were reported by tinnitus patients with auditory thresholds of 4 0 - 5 0 dB SPL or less for the frequency range of 10-14 kHz. Because force is equal to mass times acceleration, the amount of energy needed to move the mass of the head (15 kg) increases with frequency. Classic acoustic stimulation audiograms measuring 250-8,000 Hz revealed individual variations in hearing thresholds similar to those reported for the total cohort of 15 patients in the UHF-UQ study [8]. The conversion algorithm favors an accurate depiction of frequencies above 8 kHz and was an ideal instrument for assessing bone-conduction thresholds for this study. Furthermore, US is typically one-half of a full octave above the brain resonances, thus requiring more energy to demodulate the brain. In effect, the conservative estimate of 20 kHz as the upper range of hearing has resulted in a too-slow digital sampling to support high fidelity without distortions. We found the frequency transfer from the brain to the eye to be in the passband from 25 to 60 kHz. The film has the acoustic impedance of water and a flat frequency response in the range of interest, allowing relative monitoring of the peak SPL. The Valsalva maneuver supports the interpretation that the eye data reflect the acoustic properties of the brain-skull. An aftereffect of listening to the intense water-coupled tone was persistent tinnitus [24]. The lack of a mechanism for airborne sound to act on the ear directly has, no doubt, influenced the lack of research.
Musical instruments that have high-frequency and ultrasonic components are, for the most part, percussive; thus, the high audio and ultrasonic spectra would complement conventional audio frequencies consistent with the findings that the full spectrum is a better activator of the auditory system than is the ultrasound alone [7,8].
Cilia directly driven by ultrasound have been proposed as another possible mechanism in humans [34], and the concept was demonstrated in isolated turtle hair cells [35]. The statistical results demonstrate that tinnitus is interconnected to a multifactorial disease background with a broad spectrum of individual complaints.
Only 0.13% of our patients described a subjective roaring sound in the left ear, whereas none attributed it to right ear. In such cases, the visual acuity problems were corrected most frequently by use of eye glasses (74.50%). In 2010, the same author, using the THI, found no significant correlation between degree of hearing loss and discomfort related to tinnitus24. On the other hand, when the risk factor under study is the exposure to noise, there is a higher prevalence of the male sex33.
This long-term inhibition may involve a truly plastic change in the brain at the central level. In UltraQuiet therapy, the auditory stimulation, rather than the band of noise commonly used for masking, is music that has been processed and shifted in pitch.
Although their reports are only anecdotal, some of our subjects cited the perception of better hearing after the UltraQuiet trial, a finding that will be the subject of further investigation. Those authors noted that injury-induced cortical reorganization is a widely recognized phenomenon but that there is almost no information on treatment-induced plastic changes in the human brain. In a preliminary report [2], we found a high-frequency tinnitus device, UltraQuiet, to be efficacious. The masking stimulation, if properly chosen, may have the capacity of changing how the brain processes tinnitus, which could provide long-lasting benefit. These frequencies were on the edge of the patients' audiometric hearing loss, a region often associated with increased discrimination possibly due to neural plasticity [24,25].
With ultra-high frequency, the stimulus is apparently combined with neurological reprogramming and plasticity involving the auditory cortex.
Such a situation would be predicted in the tinnitus frequency map expansion in the auditory cortex and would influence both the medial temporal lobe system and other cortical area identified as active in tinnitus [37].
Relief is a complex function of many factors arising both within and outside the auditory system, and successful treatment takes time.
Thresholds are established for each ear separately, as EHFA is not a binaural phenomenon typical of conventional bone-conduction hearing. Consequently, more energy is required to hear US than is needed to hear high audio frequencies, although they share the same place of displacement on the basilar membrane [9].
If frequencies higher than 20 kHz are audible or useful, clearly sampling at 96 kHz is a necessity for true high fidelity. The threshold for hearing at 25 kHz is approximately 125 dB SPL [17], and the present stimulus was inaudible, but the induced head vibration was recordable. Animal studies are limited in that the ratio of surface area to mass is small and that fur readily absorbs ultrasound. Ultrasound may contribute to pitch perception by extending the spectrum upward in frequency and by enhancing temporal cues. All methods would result in ultrasound's having a high pitch, as documented by studies over the last 60 years [15].
AM stimulation may not be necessary to obtain this effect; it was merely the mode of stimulation in our study. Finally, the topodiagnostics of the functional neurootometric analysis shows that this type of endogenous tinnitus constitutes decidedly more central than peripheral statoacoustic pathology. Astonishingly, even the number of occurrences of basic neurological disorders (paralysis, paresthesias, apoplexies, epilepsia, Parkinson's disease, and brain tumors) was very low (as shown in Fig. Despite of this prevalence among women, our work suggests that tinnitus-related annoyance is similar in both groups. Davis and Wilde [15] demonstrated music to be a more effecti ve tinnitus masker than noise. The mean change between the pretreatment and posttreatment audiograms was less than 5 dB (Figure 5), which was not statistically significant.
Note that this is considerably different from conventional masking, wherein the acoustic stimuli encompass the tinnitus frequency; it is also different from the TRT paradigm, in which the point is to learn not to attend to the sounds. In that study, hand-muscle training led to significant enlargement of the muscle output area in the affected hemisphere.
The MML improvement was related to the measured tinnitus pitch in that both were high-frequency (with one pitch match exception). RI increased with masker intensity, but the relationship of RI to tinnitus frequency, masker center frequency, and bandwidth was complex and varied among individuals. Brain imaging and high-frequency audiometries seem to be important indices in quantifying tinnitus relief.
The transmission loss (TL) from bone to brain or eye is predictable on the basis of the acoustic properties related to tissue density and propagation speed [18].
A simple test of the eye window's role in concert music would be to assess music quality with and without goggles. Musical harmonic information is coded by place both on the basilar membrane and temporally in neural firing.
The high-frequency tinnitus often develops close to the C5 dip and can be masked below the hearing threshold (see Fig.
Clearly, a typical interrelation of tinnitus with a single major disease group is highly unlikely.
This conclusion is reinforced by the phenomenon of contralateral masking; in some patients, masking noise presented to the contralateral ear is as effective as noise presented to the ipsilateral ear, so the interaction of tinnitus and masking noise must be at some point in the auditory pathway where binaural interaction takes place [3]. They attributed the greater effectiveness of music in part to the involvement of more central and cognitive processes. It does, however, resemble the UltraQuiet system, which uses patterned stimuli well removed from the tinnitus frequency. Although they made no treatment recommendations, they noted (as already demonstrated by Shulman) that pre-and posttreatment functional imaging studies may provide objective measures of tinnitus and thus be useful in evaluating treatments. Often, behavioral measures are contradictory, rendering efficacy determination problematic.
Goggles, as used as a control in this study, eliminated the eye window for airborne ultrasound. Ultrasound might contribute to the musical harmonic structure but may just provide more high-frequency energy to emphasize the treble in such instruments as the cymbals, triangles, trumpets, violins, and oboes (see Fig. In UltraQuiet therapy, the processed music is presented through a bone con-duction transducer at a low level-approximately 6 dB above threshold-for periods of 30 minutes to 1 hour twice weekly.
The goal is to effect changes in the central nervous system mechanisms of tinnitus, resulting in long-term inhibition.

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