Pulse tinnitus symptoms quiz,how to stop noise in my ears,ear plugs for airplane noise novel,herbs and tinnitus xanax - Step 2

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INTRODUCTION: The otoacoustic emission test is useful in monitoring hearing changes not yet detectable in pure-tone audiometry, as well as in monitoring cochlear damage caused by exposure to noise. OBJECTIVE: To evaluate distortion product otoacoustic emissions in normal-hearing workers exposed to different occupational noise doses.
CONCLUSION: The otoacoustic emissions are worse in the exposed groups compared to the unexposed group and the greater are the noise dose, worse are the results. The complaint of subjective ear blockage (EB) is frequently associated with subjective idiopathic tinnitus. In our evolving clinical tinnitus experience since 1979, at SUNY-Downstate Medical Center and the Martha Entenmann Tinnitus Research Center, in excess of 15,000 patients have been seen in neurotologic-audiologic consultation in whom different clinical types of tinnitus - predominantly a central-type severe disabling subjective idiopathic tinnitus (SIT) - have been identified with a medical audiologic tinnitus patient protocol (MATPP)4.
In general, a significant associated complaint in SIT patients has been of ear blockage of fluctuant intensity located in the ear(s) with the SIT complaint. Our interest in the tympanic membrane displacement test (TMDT) and ICP and idiopathic intracranial hypertension (IIH) has paralleled, since 1979, an increasingly frequent clinical experience with SIT patients in whom the following conditions are present: (1) persistent complaint of ear blockage after control of eustachian tube obstruction or secondary EH (SEH) and (2) a reduced vestibular response with caloric, sinusoidal, harmonic rotary-chair testing or the Fukuda stepping test in the absence of subjective vertigo in the SIT ear. Our introduction to the TMD occurred in 2005, at the Fifth International Symposium: Meniere's Disease and Inner Ear Homeostasis Disorders, House Ear Institute, Los Angeles, CA. We have reported since 2006 our clinical experience with SIT in terms of the fluid dynamics between ear and brain, brain and inner ear fluid homeostasis, cochlear- or vestibular-type tinnitus, and SEH7. It has been hypothesized that persistence of the complaint of ear blockage in the SIT ear with maintenance and control of function in the external or middle and inner ear reflects an alteration in fluid dynamics between the ear and brain, a biologic marker being alteration or elevation of ICP, reflecting IIH, highlighted by the complaint of ear blockage. The experience with the TMDT for the diagnosis of IIH associated with tinnitus, also referred to as benign intracranial hypertension and pseudotumor cerebri, has been reported.
Intracranial hypertension was reported in 1981 to become manifest with neurotologic symptoms: The most common presenting symptom was pulsatile tinnitus, followed by hearing loss, dizziness or vertigo, and aural fullness13. Historically, the clinical application of the TMD for measurement of ICP is supported by animal, human, basic science, and clinical investigations. Clinically, the publications cited in the next section support the hypothesis that an abnormal and fluctuating ICP is a factor related in the clinical course of a previously described subgroup of SIT patients. Of the two fluids within the cochlea, the endolymph and the perilymph, it is the perilymph that interfaces with the footplate, and it is the pressure of this fluid that is assessed by the Cerebral and Cochlear Fluid Pressure Analyser and the TMDT technique. In the guinea pig, Bohmer20 reported that "the endolymph indirectly communicates with the intracranial fluids via the endolymphatic sac and maintains homeostasis with the perilymphatic pressure across the Reissner's and other intralabyrinthine membranes. Perivascular or perineural routes between the intracranial and labyrinthine spaces may also provide a means of communication, but these may be significant only in cases of extremely elevated ICP or certain malformations. Clinical analysis of a trial of ICP measurement from the external auditory canal concluded that intra-aural pressure waves clearly reflect intracranial cardiovascular and respiratory pulsatility changes in cats23. In a guinea pig model, infrasound (0.1-10 Hz) within the perilymph induced longitudinal sinusoidal and gross displacement of the endolymph. Varying patency of the cochlear aqueduct and connectivity to the perilymphatic space of the cochlear labyrinth of the inner ear in human temporal bones was reported by Wlodyka27. Testing in normal subjects shows that stable TMDT results are obtained during the day and after exercise28.
Noninvasive intracranial compliance monitoring by measurement of intra-aural pressure waves, performed on neurosurgical patients, has identified certain characteristics of the intra-aural pressure pulse that may allow for noninvasive measurement of ICP and compliance34,35. The Southampton Tympanic Membrane Displacement Analyzer, commercially available as the MMS-11 Cerebral and Cochlear Fluid Pressure (CCFP) Analyser, is able to measure extremely small displacements of the tympanic membrane pressure pulses at heartbeat and respiration frequencies that are transmitted from the intracranial pulse pressure to the tympanic membrane (Figure 1). The tympanic membrane in humans is constantly in motion, principally of cerebral cardiovascular and respiratory origin. The ICP wave measurements can be obtained in two modes of operation: In the first, a TMD is evoked using the acoustic stapedial reflex. The mechanism of the TMD is hypothesized to be a reflection of increased ICP and perilymphatic pressure on the acoustic stapedial reflex and its action on the stapes footplate, ossicular chain, and tympanic membrane. The TMDT is postulated to provide a "signature" of the underlying neurological disorder in terms of CSF hydrodynamics36.
All patients selected according to the preceding protocol (n = 12) between July 2007 and March 2012 underwent a neurotologic examination of the head and neck, including microscopical examination of the ear canals and tympanic membrane for evidence of pulsation and auscultation of the ear canals, head, and neck. The 12 selected patients were further classified into two groups, the first group of 6 patients undergoing the TMDT on a single date and the second group of 6 undergoing TMD on sequential test dates. Neurotologic and otologic physical examination identified integrity of the external ear canal and tympanic membrane with no spontaneous signs of labyrinthine irritation. TMD recordings were obtained in the two groups of patients to observe the temporal course of the ICP in SIT. ICP is normally 7-15 mm Hg for a supine adult and becomes negative (averaging-10 mm Hg) in the vertical position. The subject of this case report is a 71-year-old white man with SIT, the quality of which was a high-pitched "ee" of constant duration located in the left ear.
Associated complaints included hypertension, left-ear blockage that fluctuated with tinnitus intensity, nasal allergy, occasional unsteadiness, occasional frontal headache, head pressure, memory interference, and occasional delay in speech expression. The patient demonstrated a fluctuating ICP with sequential TMD testing between July 2007 and March 2012, prior to and after treatment with Diamox (Figures 4, 5).
Significantly, objective improvement was noted in the TMD recording from abnormal IPPA ICP to normal, as noted in the elevated amplitude between July and September 2007 and in the normal IPPA amplitude and modulation by respiration between October 2007 and August 2008. Tinnitus treatment results targeting ICP as a manifestation of IIH with Diamox were positive in the short term (n = 2). In a preselected group of SIT patients (n = 12) resistant to attempts for tinnitus relief with instrumentation or medication, an abnormal ICP has been identified (n = 10).
The fluctuations in the categories of the TMD recordings in the same patient at single or sequential recording dates are clinically considered to be a reflection of the dynamic state of the ICP and compliance in the presence of SIT and the influence of the environment and presence or absence of CNS disease.
The results of a normal or abnormal ICP and reduced or normal compliance in this cohort of SIT patients supports clinical consideration of the presence of an IIH and indication for treatment. Spontaneous TMD recordings of intra-aural pressure waves were obtained in this cohort of SIT patients.
The clinical significance of abnormal ICP and IIH as factors influencing the clinical course of SIT is suggested by the TMDT results we have obtained. The essential requirements of the TMDT are integrity and patency of the external ear canal, an intact tympanic membrane, and an intact ossicular chain.
Clinical and basic science efforts at identifying the clinical significance of brain pulsatility have been ongoing for in excess of 60 years39. This report of using the TMD lends credence to the application of brain pulsatility to support the diagnosis of IIH in a particular cohort of SIT patients. The term congestive inner ear was first introduced in patients with increased ICP secondary to tumors40. Otologic and neurotologic experiences with the TMDT were reported for a series of patients whose diagnoses included pulsating tinnitus, IIH, Meniere's disease, perilymphatic fistula, perilymphatic hypertension, arterial stenosis, and Arnold-Chiari syndrome. The cohort of SIT patients in this TMD study all had nonpulsatile, predominantly central-type, severe disabling subjective idiopathic tinnitus (SIT) resistant to attempts for tinnitus relief with instrumentation or medication, with associated neurotologic complaints highlighted by ear blockage and sensorineural hearing loss and CNS complaints highlighted by headache, head pressure, and cognitive interference in memory or speech expression or both. The associated complaint of ear blockage or aural fullness is clinically hypothesized to reflect fluctuation in the ICP of a persistent IIH. Cerebral blood flow autoregulation (CBA) is the process by which cerebral blood flow is maintained at a constant level in normal brain. The pressure - volume relationship among ICP, volume of CSF, blood, and brain tissue and cerebral perfusion pressure is known as the Monro-Kellie doctrine or the Monro-Kellie hypothesis (1783).
The issue of compliance has also been reported in experimental findings related to inner ear fluid pressure and to the effects of pressure changes on cochlear function in the guinea pig. The concept of compliance and its extrapolation from the ratio of the volume-pressure curve, obtainable with the TMD as a high amplitude of the cardiovascular pulse pressure, is significant for its clinical translation for evaluating the status of homeostatic function in both ear and brain. EH is an enlargement of the endolymphatic space with a bulge of Reissner's membrane into the scala vestibuli of the cochlear labyrinth. The finding with TMDT of an elevated IPPA in the SIT ear, which supports the diagnosis of IIH in the present cohort of nonpulsatile SIT patients, is the basis of the following questions and hypothesis: Is the SEH that has been clinically identified in some SIT patients since 1981 with the MATPP and that is supported by vestibular testing in some SIT patients with and without vertigo a clinical manifestation of a IIH? We suggest that the volume-pressure relationships in a confined space be applied clinically to the ear as they have been for the brain.
It is hypothesized for some, but not all, EH and SEH patients that the IPPA, reflecting alterations in volume - pressure relationships in brain, is transmitted to the ear predominantly by one or both of two routes - via the cochlear aqueduct or via pressure on the endolymphatic sac. The teaching from brain of compartmentalization of the effects of pressure and flow, which, although related physical phenomena, differ in the location for their measurement, are suggested to apply to the ear: That is, pressure pulses propagate at the speed of sound and the location for their measurement are not specific, but flow pulsations are site-specific39. This is the first known report of the clinical application of inserting an external probe device into the external ear canal (Tympanic Membrane Pressure Analyser [Marchbanks] in a cohort of nonpulsatile, predominantly central-type severe disabling tinnitus patients (SIT) suspected to have an elevated ICP reflective of an associated IIH. In two groups of these preselected SIT patients, IPPA was demonstrated to be elevated and abnormal and to fluctuate in the clinical course of the SIT (overall abnormality in 10 of the12 patients). The patient preselection protocol used for identifying an elevated ICP and IIH in a particular cohort of SIT patients and the positive results reported for its identification with the TMDT in 10 of our 12 patients supports the continued use and modification of the TMDT reflective of an evolving clinical experience. The IPPA is reflective of the ICP and was identified with spontaneous single and serial recordings in 10 of 12 SIT patients with postural testing (supine, 30 degrees, and 45 degrees).
The IPPA abnormality, reflective of an increased ICP, is clinically considered to be a factor - not an etiology - for SIT, and is considered to influence the clinical course of SIT in a particular cohort of patients with a predominantly central-type tinnitus.
Extracranial identification of an IPPA and ICP with the TMDT in the clinical course of SIT has a dual function: identifying ICP as a factor influencing the tinnitus diagnosis, and objectively monitoring the efficacy of ICP-targeted therapy. The TMDT results of the identification and association of IIH, IPPA, and ICP in this observational report lends support to the clinical impression of an underlying ICP reflective of IIH and a basis for treatment in SIT patients such as those in our particular cohort. The principles of brain pulsatility are clinically considered to be applicable to the physiology of the inner ear and otologic and neurotologic complaints of hearing loss, tinnitus, vertigo, and ear blockage. University of Texas Dallas researchers have demonstrated that treating tinnitus or ringing in the ears, using vagus nerve stimulation (VNS)-tone therapy is safe and brought significant improvement to some of the participants in a small clinical trial. Sven Vanneste, PhD, and Michael Kilgard, PhD, of the School of Behavioral and Brain Sciences used a new method pairing VNS with auditory tones to alleviate the symptoms of chronic tinnitus.
The study, which took place in Antwerp, Belgium, involved implanting 10 tinnitus sufferers with a stimulation electrode directly on the vagus nerve.
Half of the participants demonstrated large decreases in their tinnitus symptoms, with three of them showing a 44% reduction in the impact of tinnitus on their daily lives. According to Vanneste, more than 12 million Americans have tinnitus severe enough to seek medical attention, of which 2 million are so disabled that they cannot function normally. Researchers at Antwerp University Hospital and MicroTransponder Inc also contributed to the study. You must have JavaScript enabled in your browser to utilize the functionality of this website.
We have gained experience in examining the otolithic organ with what we call electrootolithography [1].
Electrootolithography is useful in the hands of experienced audiologists who have the ability to detect the window of activity within the evolving time-series signal on a monitor. To overcome these problems and with the aim of developing a robust signal-processing method for routine clinical evaluation, we investigated several different statistical methods. For recording, the active electrode remained in the tympanic recess after electrocochleography; the reference electrode was fixed on the ear lobe, and the common ground electrode was fixed just beneath the frontal hairline.
Several responses also were obtained from subjects subjected to the sound of a tuning fork (512 Hz) held in front of the external ear canal, after clenching the teeth and shaking the head. This method presents statistical information showing the median, twenty-fifth, and seventy-fifth percentiles shown as the top and bottom of the boxes with error bars showing the cutoffs and minimum-maximum values (SigmaPlot version 8.02). Table 1 gives a numerical data description of the scaling behavior in head resting versus ipsilateral and forward head tilt in a subject without vestibulocochlear symptoms. Instead of a numerical data description, a visual format, such as box plots, provides the same statistics. Figure 3 shows the interquartile range analysis in a normal subject, comparing ipsilateral with contralateral and forward head tilt with backward head tilt. In normal subjects, we typically found that the interquartile range coefficient (Q m) of ipsilateral head tilt was always larger than the interquartile range coefficient of contralateral head tilt, representing the response of the utriculus.
This relationship could be expressed in a new ratio between the Qm coefficients (Equation 2).
Recordings in resting position during teeth clenching showed an immediate and obvious response (Fig. Figure 6 compares resting position with the presentation of a 512-Hz tuning fork to the test ear.
To reduce interference from muscle activity or a disturbance from a moving electrode in the tympanic recess-or even contamination by the semicircular canals-we performed recordings using a tilt table while subjects were completely relaxed.
We usually performed recordings over a period of 3-5 seconds while swiftly tilting the head. The recordings of a patient after the removal of an acoustical neuroma from the left ear are shown in Figure 9.
Figure 10 shows the response of a patient with benign paroxysmal positioning vertigo before canalith repositioning and before the otolithic organ had recovered. Short-lived positioning attacks of vertigo are generally conceded to result from movement of dislodged, gravitysensitive otoconia that somehow found their way into a semicircular canal.
Benign paroxysmal positioning vertigo, therefore, is an ideal clinical condition in which to study the electrical response of the inner ear before and after treatment and to compare responses with normal subjects.
In contralateral head tilt and backward head tilt, possibly owing to inhibition, cross-striolar or commissural, response of the vestibular nerve is comparatively reduced. Our results are consistent with the clinical presentation of symptoms but also give us additional information based on the unique anatomical arrangement of hair cells in the otolithic organ [5].
In the sacculus, we can distinguish between an anterior portion and a posterior portion of the macula, and the polarization of the hair cells along the reversal line of the striola is opposite that of the utriculus (Fig. Also here, the unique arrangement of hair cells and the size of the coefficients can give us a clue as to where in the sacculus the deficit is to be expected. We usually performed recordings over a period of 3-5 seconds while subjects swiftly tilted the head. Though the quality of electrootolithography is dependent on the experience of the examiner and therefore is a far more subjective test, performing the amplitude range analysis test is easier, and it is more objective. We do not believe that the movement of otoconia is responsible for the abnormal box-plot pattern in benign paroxysmal positioning vertigo.
We are routinely performing amplitude range analyses of the otolithic organ, although the results with this technique can be regarded as preliminary.
Finally, this technique can be transferred to the caloric examination of the lateral semicircular canal. From examining directly all three units of the inner ear with a single electrode placed in the tympanic recess, our understanding of inner-ear disorders is gradually changing. Benign paroxysmal positioning vertigo is a suitable clinical condition in which to examine the inner ear's response to head tilting in roll and in pitch using electrocochleography techniques.
Amazing all-natural Tinnitus breakthrough permanently eliminates Tinnitus issues without drugs or surgery. Site(s) of lesion include, but are not limited to, frequent obstruction in the external ear canal, interference in eustachian tube function and aeration of the middle ear(s), and endolymphatic hydrops (EH) of the inner ear. Additional significant ear complaints have included vertigo, high- and ultra-high-frequency sensorineural hearing loss greater than expected for the age of the patient, and hyperacusis. The MATPP identified the ear blockage to be obstruction in the external ear canal, interference in eustachian tube function and aeration of the middle ear(s), or SEH of the inner ear. Among the presentations were "Intracranial Pressure Waves and Inner Ear Homeostasis Disorders" by Robert J.
This ongoing clinical experience has been the basis for the fluid dynamics vascular theory of brain and inner ear function in traumatic brain injury as a translational hypothesis for the diagnosis and treatment of SIT8. In addition, this article shares with the reader the evolution of a new science of brain pulsatility with application for otologic and neurotologic complaints of hearing loss, tinnitus, ear blockage, and vertigo, which complements conventional medical teaching focusing on brain pulsation, absolute ICP, and brain disease. Headache, chronic fatigue, "brain fog," tinnitus, visual obscurations, dizziness, and sometimes hearing loss are the principle symptoms of IIH.
The most common etiology was benign intracranial hypertension syndrome (pseudotumor cerebri). The question of whether papilledema in the eye, and inner-ear complaints, including ear blockage, hearing loss, and vertigo, are analogous manifestations of an elevated ICP is not new. Identification and treatment of this abnormal ICP may improve diagnostic accuracy and treatment for this particular cohort of SIT patients. Positive endolymphatic-perilymphatic pressure gradients are secondary to and not the primary cause of hydrops formation. Experiments in the cat have demonstrated that labyrinthine pressure mirrors that of the cerebrospinal fluid (CSF) and that no change in labyrinthine pressure can be measured if the cochlear and vestibular aqueducts are sealed21,22. Though the displacements are very small, they cause a large endocochlear potential change (> 20 mV)24. Reissner's membrane was visualized by confocal microscope in an isolated temporal bone of a guinea pig. Cochlear aqueduct patency is known to be reduced with increasing age, falling to 50% in subjects older than 40 years and 30% in those older than 60.
In brain, a pressure volume curve has been described based on the exponential pressure - volume relationship in the cranium. These normative data also demonstrate large intersubject differences; nevertheless, the correlation of test results within one individual is high. The TMD displacements are intra-aural waves of different morphologic types, measured in nanoliters and in milliseconds of time, reflective of the pulsatility in brain. In most people, a fluid connection exists between the intracranial fluid and the fluids of the inner ear.


Increased ICP results in increased perilymphatic pressure, outward resting position of the stapes footplate, and inward movement of the tympanic membrane on reflex contraction of the stapedial muscle. Exclusion patient criteria included all clinical types of tinnitus not classified as SIT, obstruction in the external ear canal, active middle-ear or inner-ear disease, and pregnancy. The tinnitus evaluation included pure-tone air and bone conduction, 250- to 8000-Hz speech audiometry, tympanometry, and ultra-high-frequency audiometry. All patients were males aged 30-72 years who were resistant to conventional attempts for tinnitus relief with instrumentation or medication, and all were hypothesized to have a possible increased ICP based on associated clinical complaints and findings. Immitance testing with the Grason Stadler Portable Handheld Tympanometer (Grason Stadler Eden Prairie, MN) revealed normal type A tympanograms.
The tests were performed with the CCFP Analyser to obtain recordings of the waveforms of spontaneous displacement of the tympanic membrane accompanying testing in three positions - supine, 30-degree, and 45-degree - and reverse. Tinnitus summary, group 1: Tympanic membrane displacement (TMD) in a cohort of patients with nonpulsatile, predominantly central-type severe disabling subjective idiopathic tinnitus. Tinnitus summary, group 2: Tympanic membrane displacement (TMD) in a cohort of patients with nonpulsatile, predominantly central-type severe disabling subjective idiopathic tinnitus. Eight fell into the B and D waveform categories (abnormal IPPA and reduced CC), whereas two fell into the A and D waveform categories (normal IPPA and reduced CC). This objective improvement correlated with a reported subjective reduction in SIT intensity, which continued with fluctuation until March 2012.
The SIT relief is reflective of fluctuation in the ICP and the multifactorial conditions influencing brain pulsatility. This preliminary report of the clinical application of the TMDT for identifying an abnormal IPPA ICP in a particular cohort of SIT patients is considered to have accomplished the goals of the project. IPPA ICP with TMDT Spontaneous recordings of abnormal IPPA ICP were identified with the TMDT in groups 1 and 2 for a preselected SIT population suspected clinically of having an abnormal ICP. Direct and or indirect measurements of the ICP are considered to be relative, not absolute, values. Both ICP and compliance may be factors influencing the clinical course of SIT in a preselected cohort of affected patients: Identification and treatment of these factors may influence the associated complaints cited previously and also may influence the clinical course in this particular cohort of SIT patients. The test-retest reliability of the TMD was positive, as demonstrated by the repeated TMD results recorded in both group 1 and 2 patients (see Figures 3,4). The clinical significance to the patient of restoring the ICP from abnormal to normal for tinnitus relief was positive for the interval of TMDT testing reported at this time. A patent cochlear aqueduct or an alternative intracranial-labyrinthine fluid communication route is required for ICP and compliance assessment.
Introduction of the TMD is but one of a number of approaches for external identification of the ICP. Its clinical translation for tinnitus relief awaits larger clinical trials and outcome determinations that differentiate for SIT between control of the ICP and IIH and patients' report of tinnitus relief.
Auditory function was studied in 25 patients with IIH and supratentorial tumors, the majority of whom had hearing loss. The conclusion was that TMDT was a valuable addition to the armamentarium of neurotologists and useful in identifying IIH in cases of pulsating tinnitus44.
The etiology of the IIH is presumed to be cerebrovascular arterial hypertensive disease, not venous disease, based on the clinical history of this patient cohort.The pathophysiology is incomplete but we hypothesize that the disease features in this cohort reflect fluctuation in IIH, which is in turn reflective of alterations in the intracranial cardiovascular and respiratory wave pulsations. Transmission of the CSF increased intracranial cardiovascular and respiratory wave pulsations primarily via the cochlear aqueduct affects the perilymphatic compartment of the cochlear labyrinth24,25. Briefly, fluctuation in cardiac output has two effects on intracranial dynamics - temporal changes on pressure and flow. Cerebral blood flow is determined by multiple factors including blood viscosity, degree of dilatation of blood vessels, and cerebral perfusion pressure. This hypothesis states that the cranial compartment is incompressible, and the volume inside the cranium is a fixed volume. Clinically, it can be considered to be the elasticity or rigidity of contents, fluid and solid, in a given space. A high compliance of Reissner's membrane seems to be the cause of this endolymphatic - perilymphatic pressure equalization. The significance of CC is demonstrated in the serial recordings of the TMD in the case report (see Figure 5). In our ongoing clinical neurotologic experience for SIT since 1972, and with a focus on SIT since 1979, the occurrence of SEH has been reported to be significant, and this diagnosis has been found to influence the clinical course of SIT and associated complaints of hearing5,47. Is what is diagnosed as SEH, a particular type of EH, a clinical reflection of increased IPPA and IIH? Specifically, the primary etiology for a particular type of EH may be cardiovascular and the clinical marker may be the increased IPPA and IIH. This view of pressure - volume alterations in brain, manifested by an increased IPPA and IIH, is considered to be supported by current thinking for hearing loss and Meniere's disease.
The underlying endolymph volume change may result from a change in transport (such as if the endolymphatic sac switches from secreting fluid to resorbing fluid) so that endolymph volume declines with time without a membrane rupture taking place. A physical force, IPPA ICP, was correlated with the behavioral response to the SIT sensation with the TMDT. Abnormal IPPA was accompanied by reduced CC in 8 of the12 patients, whereas normal IPPA was accompanied by reduced CC in 2 patients, and results were incomplete for the other 2 patients. The clinical significance of these preliminary TMDT results for overall tinnitus treatment is to be established over the long term.
The correlation of treatment efficacy for ICP control and reported subjective tinnitus relief is considered to be separate and individual for each SIT patient. Assistant Clinical Professor, Department of Otolaryngology, SUNY - Downstate Medical Center, and Director of Audiology, Martha Entenmann Tinnitus Research Center, Inc., Brooklyn, NY. Consultant Clinical Scientist, Neurological Physics Group, Medical Physics, University Hospital Southampton, NHS Foundation Trust, UK. PhD, is managing director of Marchbanks Measurement Systems Ltd., a spinoff company from Southampton University that supports research with the Tympanic Membrane Displacement Analyzer.
Their results were published last month in the journal Neuromodulation: Technology at the Neural Interface.
Four people demonstrated clinically meaningful reductions in the perceived loudness of their tinnitus by 26 dB.
In this technique, which is similar to extratympanic electrocochleography, an electrode is placed in the tympanic recess. What is needed is a reductionist technique that can display the averaged (region-of-interest) signal in real time.
Initially, we applied a range of fractal methods using physical wavelet analysis for the examination of two types of signals (baseline resting position and head tilting) to establish first that the signals were different and, second, that this difference was statistically significant [2,3]. The active electrode was secured with tapes on the pinna so as to avoid movement during head tilting.
After obtaining a baseline response, we tested subjects in roll (ipsilateral head tilt to the electrode side and contralateral head tilt away from the electrode side, stimulating the utriculus) and in pitch (forward head tilt and backward head tilt, stimulating the sacculus). We tested four normal subjects on a tilt table so as to avoid possible contamination by the semicircular canals, and in four patients we recorded responses after a head tilt lasting 10 seconds. We have built a breakout box connected to an existing interface unit (Navigator; Biologic, Chicago, IL). The median is the pivot point above which and below which an equal number of values appear. We were particularly interested in the Qm values (seventy-fifth through twenty-fifth percentiles) of the amplitude range of each response (size of the box in the box-plot analysis). This is a suitable format for clinicians who can see at a glance, as in reading an audiogram, whether a response is diverse from the norm (Fig. Left to right: box plot of raw data for both headresting controls, followed by ipsilateral tilt, then forward tilt. Similarly, we found that the interquartile range coefficient of forward head tilt tended to be equal to or larger than the interquartile range coefficient of backward head tilt, representing the response of the sacculus. The ratio was obtained by dividing Qm of contralateral tilt by the Qm of ipsilateral tilt, representing the response of the utriculus (Equation 3).
The marked regression from the zero line creating artifacts affects the size of the box plots. Head shaking reveals major artifacts, which affect the size of the box plot, here compared with the baseline. Clenching the teeth demonstrates an immediate response, which is most likely due to muscle activity.
The box plot during this sound stimulus was larger than in resting position without stimulus. The presentation of a tuning fork to the test ear shows a strong response, suggesting that this technique is suitable for recording inner-ear responses. Tilt-table recordings show a pattern comparable to that of a swift head tilt, suggesting that contamination from the semicircular canals can possibly be ignored. Tilting the head for the 10 seconds and then recording shows a reversed pattern of the box plots, possibly due to adaptation phenomena. Box-plot analysis in a subject with benign paroxysmal positioning vertigo (BPV) before a repositioning maneuver.
The utriculus is divided by the reversal line of the striola into a medial portion and a lateral portion of the macula, and the hair cells have opposite polarization, with the kinocilia facing each other (Fig.
Hair cells of the macula utriculi are separated by the reversal line of the striola, and the hair cells have polarization opposite, with the kinocilia facing one another. Because a deficit can equally affect both the medial and the lateral portions of the utriculus, a normal coefficient could possibly be seen. Hair cells of the macula sacculi are separated by the reversal line of the striola into a posterior and an anterior portion, and the kinocilia of hair cells have an orientation opposite to the utriculus. The hair cell area of the anterior portion of the sacculus compares to the posterior portion, and responses in normal subjects are suspected to be fairly equal. The recording is performed in a relatively short period during which movement of the otoconia hardly becomes effective. We believe that contamination by muscle activity or responses from the semicircular canals can be ignored. Pilot studies so far support this assumption, and the examination of the lateral semicircular canal already forms part of our test battery using this technique.
Amplitude range analysis is a more objective test than is electrootolithography, and a statistical summary can be displayed in box plots. For the subjective idiopathic tinnitus patient, the evaluation of a persistent subjective complaint of EB, in the absence of a site of lesion in these frequent locations, has been hypothesized since 1979 to reflect a fluctuation or elevation of intracranial pressure (ICP)1-3.
The blockage persisted in the SIT ear following control of the clinically identified site of lesion of the blockage. Marchbanks and "Meniere's Disease, Secondary Endolymphatic Hydrops, and Tinnitus" by Abraham Shulman. Identification and treatment or control of ICP may be a factor influencing the clinical course, in general, of all clinical types of tinnitus and, in particular, of this cohort of SIT patients.
A case report will demonstrate the result of translation of an elevated ICP for tinnitus treatment on the clinical course of the SIT patient. Animal and human results of identification of ICP with an external probe device in the ear canal, recording tympanic membrane displacement, reflective of the IPPA and its modulation by respiration, may be translated for this subgroup of SIT patients. Sismanis14,15 noted that "pulsations of the cerebrospinal fluid, mainly originating from the circle of Willis, are transmitted to the exposed medial aspect of the venous sinuses (transverse and sigmoid), resulting in periodic compression to their walls.
An excellent summary of past efforts since 1924 both in animal and humans concluded that alterations in ICP can explain some inner-ear complaints including hearing loss, tinnitus, and vertigo.
The cochlear aqueduct is the main fluid communication route between the intracranial and perilymphatic fluids; it runs from the subarachnoid space and enters the cochlea in a niche just near the round window17-19. In experimental EH, deterioration of auditory thresholds was partially correlated to the presence of positive endolymphatic-perilymphatic pressure gradients.
Acute EH was generated by exposure of the guinea pig ear to nontraumatic low-frequency tone25. The function of the organ was followed by measuring its physiologic response after applying static pressure and repeated tone bursts of more than 80 dB26.
From this, it is concluded that the TMDT gives the optimum results when testing for pressure changes within the same individual, such as changes that may occur with symptoms or treatment30,31. A trial of ICP measurement from the external auditory canal concluded that intra-aural pressure waves clearly reflect intracranial changes in humans, thus proving Marchbanks's hypothesis33. The cardiovascular component is the predominant waveform, modulated by the respiratory component. The MMS-11 CCFP Analyser is used to provide an indirect measure of baseline (static) cerebral and cochlear pressures by the detection of low-frequency pressure waves that are emitted from the ear, a component of which is of intracranial origin. Clinically, increased ICP reflects intracranial hypertension, whereas low pressure reflects intracranial hypotension.
Reduced ICP results in an inward resting position of the stapes footplate and outward displacement of the tympanic membrane on muscle contraction.17 Measurements appear to reflect cerebral autoregulation in some cases. Vestibular caloric and sinusoidal harmonic rotary-chair testing was performed on all SIT patients. Magnetic resonance imaging of brain with contrast reported no significant CNS pathology, with only occasional white matter changes, in 10 of the 12 subjects in this study. The tinnitus evaluation identified SIT, masking curve type 4; and an abnormal result on QEEG.
The TMDT at that time demonstrated an abnormal ICP as measured by an increased IPPA amplitude and normal modulation by respiration, with a reduction in compliance, which correlated with a reduction in the subjective SIT relief reported in March 2012. The addition of the clinically associated complaints reported by this special cohort of SIT patients into the MATPP may be the basis for a clinical protocol for identifying abnormal ICP and the diagnosis of IIH. Specifically, the concept of compliance and the TMDT results in SIT patients with abnormal ICP and reduced compliance, normal ICP with reduced compliance and, possibly, abnormal ICP with normal compliance may supplement classical clinical thinking about the medical significance of a CNS complaint, to be based not only on the absolute value of the ICP but on the relative value of ICP and compliance, a mathematical approximation based on observed data, for brain disease diagnosis and treatment. These claims are supported by a recent article that concluded that the pulsatility of the ICP may be more relevant than static ICP in the diagnostic setting for patients with IIH38.
The spontaneous, not the evoked, mode of elicitation of intraaural pressure waves is recommended for TMD testing in SIT patients, specifically to avoid a potential increase in tinnitus intensity that may accompany the audiological threshold recommended for eliciting the acoustic reflex in the evoked mode of the TMD. However, our clinical experience with SIT is the basis for recommending interval examination, including repeat TMD testing, to establish the clinical significance of ICP identification and treatment for long-term tinnitus relief and the diagnosis of IIH. Long-term follow-up is recommended in a large specific cohort of SIT patients to establish the incidence of abnormal ICP and IIH and the medical significance of such findings for long-term tinnitus relief. Transmission of CSF to perilymph was hypothesized to be via the cochlear aqueduct and was the etiology of the hearing loss41.
Intracranial subarachnoid CSF pressure transmission onto the endolymphatic sac results in an initial increased pressure into the endolymphatic duct, which, over time, results in EH and SEH. Specifically, pressure pulses are not dependent on location and can be measured anywhere within the cranium, whereas flow pulsations are highly dependent on location of measurement.
The cerebral blood flow is equal to the cerebral perfusion pressure divided by the cerebrovascular resistance45.
The cranium and its constituents (blood, CSF, and brain tissue) create a state of volume equilibrium, such that any increase in volume of one of the cranial constituents must be compensated by a decrease in volume of another44. Graphically, the compliance of a system is inverse to the slope of the pressure - volume curve.
In experimental EH, endolymphatic pressure is higher (> 100 Pa) than perilymphatic pressure. Specifically, a reduction in CC with a normal IPPA ICP preceded an increase in IPPA ICP and a reported subjective reduction in tinnitus relief.
Is the primary origin and pathophysiology of the otologic histopathophysiologic correlate of EH the brain and not the ear? The result via pressure on the endolymphatic sac influences volume, pressure, and compliance changes in the endolymphatic duct, which, over time, results in extension and distention of Reissner's membrane into the scala vestibuli. Specifically, "endolymphatic hydrops may initially not be pathologic, and the symptoms arising from hydrops may be mild or negligible, but .
In the normal cochlea, the rate of longitudinal endolymph flow is extremely low, so that flow does not make a significant contribution to the homeostasis of ions in endolymph. This application involved recording and demonstrating with single and serial spontaneous recordings an abnormality of the intraaural pulse pressure waves and fluctuation in the ICP, supportive for the presumption of IIH. Fluid dynamics vascular theory of brain and inner-ear function in traumatic brain injury: A translational hypothesis for diagnosis and treatment. Inflammatory disease and trauma involving middle ear and inner ear: Central nervous system disease and cerebrovascular disease. The search for idiopathic intracranial hypertension: An investigation of cerebral to cochlear pressure transfer as a direct cause of reversible and irreversible audiological disorders.
Otologic manifestations of benign intracranial hypertension syndrome: Diagnosis and management. Cochlear and cerebrospinal fluid pressure: Their interrelationships and control mechanisms.
Hydrostatic pressure in the inner ear fluid compartments and its effects on inner ear pressure. A trial of intracranial pressure measurement from external auditory canalexperimental analysis. Longitudinal endolymph movements and endocochlear potential changes induced by stimulation at infrasonic frequencies.


Acute endolymphatic hydrops generated by exposure of the ear to non-traumatic low frequency tone. Compartmental analysis of compliance and outflow resistance of the cerebrospinal fluid system. Tympanic membrane displacement test in regular assessment in eight children with shunted hydrocephalus. Non-invasive perilymphatic pressure measurement in normal hearing subjects using the MMS- 10 Tympanic Membrane Displacement Analyser. A trial of intracranial pressure measurement from external auditory canal - clinical analysis. Applications of the Marchbanks transcranial-cerebral sonography technique in neurootology: Preliminary report. Brain and inner-ear fluid homeostasis, cochleovestibular-type tinnitus, and secondary endolymphatic hydrops. VNS is an FDA-approved method for treating various illnesses, including depression and epilepsy. The participants had lived with tinnitus for at least a year prior to participating in the study, and showed no benefit from previous audiological, drug, or neuromodulation treatments.
The breakout box collected raw data and diverted them to a new data acquisition system for further processing of the incoming signals.
If the array has equal numbers of values, the median is the average of the two middle numbers. The Qm values were used for statistical analysis (Student's t-test) and ultimately led to a new coefficient describing the response of the utriculus and the sacculus. The lower one-half of the diagram contains the interquartile range analyses, displayed in box plots. Equally, the ratio representing the sacculus was obtained by dividing the Qm of backward head tilt by the Qm of forward head tilt (Equation 4). These artifacts should be discarded before the final analysis, and most likely they are the result of an electrode movement in the tympanic recess. The difference was obvious and showed that this technique will record innerear responses, although the recordings look very much like microphonics.
These results compared well with those obtained from a subject sitting at the edge of an examination table and swiftly tilting the head (Fig. Box plots also show a marked digression of the median (lower bar in the box) from the mean (upper bar in the box). This reversed pattern of the box sizes was typical for benign paroxysmal positioning vertigo. The contralateral interquartile range ratio is larger than the ipsilateral interquartile range ratio, suggesting a deficit in the right utriculus.
The coefficient ratio of the utriculus has returned to normal, and the coefficient ratio of the sacculus has remained within normal limits. The Dix-Hallpike maneuver is also suitable for reviewing the treatment outcome after canalith repositioning. In amplitude range analysis, interquartile ranges will consequently be smaller, owing to a reduced vestibular nerve response.
Ipsilateral head tilt mainly stimulates the medial macula utriculi, whereas contralateral head tilt will mainly stimulate the lateral macula utriculi. However, in that case, an interaural difference in the size of the boxes is to be expected. Thus, forward head tilt will mainly stimulate the anterior portion of the macula sacculi, and backward head tilt will stimulate mainly the posterior portion. Forward head tilt will mainly stimulate the anterior portion of the sacculus, whereas backward head tilt will mainly stimulate the posterior portion. Thus, different clinical techniques will give different results, and adhering to a specific technique is necessary so as to obtain consistent results.
Those researchers found that the medial portion of the utriculus has a hair cell area comparatively larger than the lateral portion. Clinical experience with benign vertigo demonstrates the existence of a delay of several seconds before a nystagmus is observed in the Dix-Hallpike maneuver or the patient experiences vertigo. The rule is that the cochlea, the otolithic organ, and the semicircular canals are all part of a combined response to an insult inflicted on the inner ear, although individual responses and the combination therein may vary. Normal subjects show a different pattern as compared with those from patients with benign paroxysmal positioning vertigo.
Sstatistical approaches to temporal frequency analysis of otolithic responses-signal processing with physical wavelets, fractals, other filters and Mathematica. Organization of the sensory hairs in the gravity receptors in utricle and saccule of the squirrel monkey. Response to static tilt of peripheral neurons innervating otolith organs of the squirrel monkey. Discussions after our presentations allowed us to share our evolving experiences with SIT and TMDT and to consider the potential role of TMD and brain pulsatility for SIT in general and for SEH specifically. The result may be increased efficacy for tinnitus relief with existing modalities of instrumentation or medication9-11. The identification and translation for treatment and control of ICP as a manifestation of IIH may influence the clinical course of this patient subgroup.
These periodic compressions convert the laminar blood flow into turbulent flow, resulting in vibrations of the vessel walls and production of pulsatile tinnitus".
This same report supported the existence of an "obligatory" interrelationship between ear and ICP16.
A change in pressure, however, occurred later than the first deterioration in auditory function.
A 3-minute, 200-Hz tone at 115 dB was sufficient to generate an acute EH condition in 29 guinea pigs25.
An ear probe inserted into the ear canal of the ear to be tested is connected to the analyzer. In the second operational mode, TMD is spontaneous: That is, baseline ICP is extrapolated based on measurement of the ongoing spontaneous displacement of the tympanic membrane, hypothesized to be reflective of ICP waves principally of cerebral cardiovascular and respiratory origin.
These two incomplete TMD recordings were associated with an inability to maintain an adequate seal of the probe in the ear canal.
Abnormal amplitude and modulation were reported in July and September 2007, November 2008, and March 2012, concurrent with subjective reports of elevated intensity of the patient's SIT. The initial manifestation of benign intracranial hypertension syndrome as perilymphatic fistula was presented in three cases40. It is hypothesized that fluctuation in the degree of the abnormal ICP and compartmentalization of the increased pressure effect within the cochlear and vestibular labyrinths of this transmitted pulsation on the underlying sensorineural tissue become clinically manifest in gradually increasing complaints of ear blockage, tinnitus, vertigo, and hearing loss in some SIT patients. Pressure measurement is usually restricted to the lateral ventricle, cisternum magnum, or brain parenchyma.
The serial recordings with the TMD speculatively provide a monitor for recording of CBA (see Figure 4). With an increase in ICP, the concurrent reduction in intracranial compliance results in an increase in the pulse wave amplitude. These pressure gradients occur only in late stages of hydrops, probably when Reissner's membrane has lost its high compliance after long-standing distension20.
Is the finding with the TMDT at this time in a preselected cohort of SIT patients of an increased IPPA ICP support for consideration that the IPPA and cardiovascular disease may be an etiology for a subgroup of EH, SEH, and Meniere's disease patients? The net effect of both routes of IPPA transmission, in ear as in brain, is a reduction in compliance as the pressure within each compartment is increased, with interference in underlying structure and function and clinical manifestations of hearing loss, tinnitus, vertigo, and ear blockage. However, recent studies in our lab suggest that when endolymph volume is disturbed, longitudinal flows may be induced that play a part in the recovery of normal volume.
In: Proceedings of the Fifth International Symposium on Meniere's Disease and Inner Ear Homeostasis Disorders. Electrical pulses were generated from an external device for this study, but future work could involve using internal generators, eliminating the need for clinical visits. Generally, roll is conceded mainly to stimulate the utriculus, whereas pitch mainly stimulates the sacculus. The quality of recordings also can vary, as the chosen averaging frequency might not be exactly in tune with a harmonic of an individual response frequency.
Our aim was to perform data acquisition and analysis that can show at a glance, as in reading an audiogram, whether a response differs from the norm.
Initially, we used physical wavelet analysis for data classification after acquisition [4].
Although the differences are quite obvious, they might not be a suitable format for clinicians. Note that these recordings have been conducted under extreme and nonphysiological conditions to test the responsivity of the method. The interquartile range calculation (Equations 3 and 4) showed a reversed pattern, where contralateral tilt and backward tilt now showed a larger interquartile range.
These fluctuations had a frequency of 72 cycles per minute and coincided with the patient's pulse.
The baseline recordings show a sinusoidal pattern at a frequency of 72 per minute, which coincided with the patient's pulse. In this case, the contralateral box was larger than the ipsilateral box, rendering a coefficient above 1.1 and suggesting a deficit in the right utriculus. In amplitude range analysis, we would consequently expect larger interquartile ranges due to an increased vestibular nerve response. Thus, an ipsilateral tilt (bending hairs toward the kinocilia) appears mainly to stimulate the medial portion of the macula utriculi, and contralateral tilt stimulates mainly the lateral portion of the macula utriculi. That these two different techniques stimulate different hair cell units that have different characteristics appears possible.
In squirrel monkeys, the proportion is 60:40, and one can assume that it is similar in humans. Tilting the head in roll and in pitch also is not performed in the optimal plane of the semicircular canals, rendering movement of the otoconia more difficult.
Presented at the Thirty-Second Annual International Congress of the Neurootological and Equilibriometric Society, March 23-25, Melbourne, Australia, 2005.
Relation between afferent discharge properties and peripheral innervation patterns in the utricular macula. In this cohort of SIT patients, the ear blockage persisted after treatment of SEH in the SIT ear.
Therefore, positive endoperilymphatic pressure gradients may contribute to, but are not the only cause of, hearing impairment". Diaphragm movements in the sensor attached to the probe track tympanic membrane movements to record the tympanic membrane displacement, which is recorded as a volume displacement and is reflective of the ICP.
Raw-data analysis of the intracranial waveforms has been supplemented by systems analysis, all of which is providing clinical markers of disease in brain and fluid dynamic relationships with eye and ear, thereby improving the accuracy of diagnosis of the complaint and its site of lesion.
An update of this initial experience and its translation for treatment of both perilymphatic fistula and EH was reported in ten cases43. This hypothesis is supported by the evidence of animal and human studies previously cited in this article.
Flow measurement varies with magnitude and pulsatility of the flow, the type of fluid, and the location. The measurement of the compliance is not direct but rather indirect extrapolation of the ratio of volume change to pressure change. These flows may be directed toward the cochlear apex (when endolymph volume is reduced) or toward the cochlear base (when endolymph volume is increased). Ten patients had normal hearing levels; the majority had a symmetrical mild sensorineural hearing loss sloping toward the high frequencies.
Typically, ipsilateral and forward head tilt show larger box plots than do contralateral and backward head tilt. Also here, we observed that boxes of ipsilateral head tilt were larger than boxes of contralateral head tilt. We believe that the reversed pattern was most likely due to adaptation phenomena or that responses came from different areas of the maculae. The frequency of these fluctuations and the strength of the response seemingly remained during stimulation in roll and in pitch.
One technique might preferentially stimulate irregular discharging units, which are suspected to be located in the striola, whereas another technique might preferentially stimulate regular discharging units, which are suspected to be located in the extrastriolar region [6]. Those results compare well with our findings, in which the coefficient of the sacculus response hovers around 0.9 instead of around 1.
Above all, experience with electrootolithography shows that a successful repositioning can eliminate positioning attacks of vertigo but not necessarily a remaining instability during quick head movement.
Notable additional associated complaints are head pressure, headache, and cognitive complaint(s) of interference in memory and speech expression - in short, a combination of ear and brain function complaints.
In agreement with accepted CSF mechanics, these pressure waves are seen to increase in amplitude as the mechanical compliance of the CSF system declines with increasing ICP. The 2007 to 2012 TMDT recordings demonstrated (1) normal amplitude of the cardiovascular pressure wave (IPPA) with abnormal modulation by respiration and reduced CC in October 2007 and (2) fluctuation of CC (reduced and abnormal in October 2007 and August 2008, normal in November 2007, and abnormal in March 2012). The TMD measurement of the cardiovascular and respiratory intracranial pulsations is predominantly that of the subarachnoid compartment of the intracranial CSF system37.
The conditions under which flows can be induced and the role they play in volume regulation are presently being studied. However, the principle of this averaging is different, as we do not employ multiple stimuli; instead, we stimulate once only.
In addition, averaging is not phase-locked to the maximum amplitude of the response; therefore, the signal varies in strength. If the data array is an odd number, Q1 includes the median; Q1 is known as the twenty-fifth percentile.
Because patients generally-and particularly the elderly-had problems in holding the head in a tilted position and more artifacts were seen, we no longer use this method. We also observed more artifacts, possibly due to the movement of the electrode in the tympanic recess. The remaining instability is due to a continuing measurable deficit in the otolithic organ [1]. In this cohort of SIT patients, in whom the complaint of ear blockage is marked, experience has been limited with, or patients have proven resistant to, attempts at tinnitus relief with medication and instrumentation targeting conditions in ear or brain identified with the MATPP to influence the clinical course of SIT. Types 2 and 3 are intra-aural pressure waves that are associated with respiration; in type 3, the amplitude of the cardiovascular pulse varies with the phase of the respiration. Significant is the compartmentalization already in place in the anatomic distribution of the fluid systems of the inner ear. A concept has been proposed that a disturbance of the resorption system in the endolymphatic sac would cause a "backing-up and an accumulation of endolymph, resulting in the development of hydrops""49. Because the vestibular organ shows rhythmicity, the responses that are averaged are phase-locked to a harmonic of an individual response frequency.
Generally, we observed a vestibular pattern of voltage changes during raised intracranial pressure [4]. We digitized raw data from the electrodes and plotted as voltage amplitude versus time using a medically rated analog-todigital converter. This suggested that interference from muscle activity or contamination by the semicircular canals can possibly be ignored; when using a tilt table, they could be avoided.
Conversely, a positive Dix-Hallpike maneuver indicates only that otoconia have found their way into a semicircular canal. The type 4 intra-aural pressure wave has been named the M wave, is of unknown origin, and was not demonstrated at this time. Brainstem audiometry showed normal tracings and latencies in all these subjects, and none suggested retrocochlear pathology. Normally, we recorded the baseline and four head-tilt positions, and we displayed individual box plots for comparison. If the data array is an odd number, Q3 includes the median; Q3 is known as the seventy-fifth percentile.
The maneuver does not indicate whether the otolithic organ has a deficit, and we might find a normal response of the otolithic organ.
Measurement of the IPPA of the cardiovascular component is the objective measurement of the ICP and perilymphatic cochlear pressure. We displayed ratios for the utriculus and sacculus to classify the shape of the data distribution.
An acoustical neuroma had been removed from his left ear 6 months before this investigation.
Box plots are useful in exploratory data analysis when two or more data sets are being compared.




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