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Inner ear disorders that increase hearing sensitivity (such as SCD) can cause pulsatile tinnitus.
There are some very large blood vessels -- the carotid artery and the jugular vein -- that are very close to the inner ear (see diagram above). This is a congenital anomaly in which the internal carotid can present as a middle ear mass. Dural Arteriovenous fistulae (DAVF) cause loud noises, synchronous with the pulse, that can often be heard by others with a stethescope, or sometimes by simply putting one's ear next to the person's head. To be certain there is no DAVF at all, 6 vessel DSA is suggested by the interventional radiologists.
Radiosurgery is mainly reserved for cases that persist after embolization, but some authors use the opposite order -- radiosurgery first, followed by a clean up embolization (e.g.
Recurrence of fistulae may appear, possibly due to release of growth factors associated with local tissue hypoxia, following occlusion of the DAVF. It may seem silly to say this, but in our opinion, it is generally not worth taking on a significant risk of having a stroke to attempt to get rid of a noise in one's head with embolization.
The human auditory system is usually divided into 3 parts-- the inner, middle and outer ear. The middle ear starts at the eardrum and comprises also the ossicles, which are connected to the oval window of the cochlea.
Another function of the eardrum is to separate air in the auditory canal from that in the middle ear, which is connected to the larynx via the eustachian tube. It's worth spending some time examining the function of the cochlea, which is depicted schematically below.
The cochlea is ultimately responsible for converting sounds to electrical signals that encode both the frequency content and spectral amplitude.
The cochlea is a somewhat spiral-shaped organ comprising two fluid-filled regions, the scala vestibuli and the scala timpani. The shape of the scala media, bounded on one side the Reissner's membrane and the other by the tectorial membrane is specialized such that the tectorial membrane vibrates maximally at locations determined by the frequency content of the sound signal.
The concept of a correlation between fluid pressure wave maxima and the frequency content of a sound signal is called the Place Theory of Hearing.
The critical band describes the zones of the basilar membrane that respond maximally to particular frequencies of pure tones. We can first test what happens as two identical frequencies are separated by slowly changing the frequency (pitch) of one of the function generators.
The textbook speaks of a 'courseness of tone' just when the beats get fast and just before we can distinguish two tones. We can also set up one function generator to frequency modulate the other about some central frequency. Earlier we mentioned a neural processing technique called sharpening that allows us to hear very small changes in frequency. As mentioned earlier, the amplitude response (dynamic range) of the human ear is very broad.
Technically speaking, sound intensity levels are expressed in Bels (named after Alexander Graham Bell), and a decibel is one tenth of a Bel.
Further, a 30 dB decrease in sound intensity is a reduction by a factor of 1,000 (divide original intensity by 1,000). The decibel scale of SIL corresponds to what we hear, in that a 10dB increase in SIL is heard as the same change in loudness, irrespective of the starting sound level.
There are other tidbits in the textbook, including an interesting discussion of fundamental tracking. The reduced pressure between the vocal folds causes them to pull together and nearly close, causing air pressure to build up in the trachea below the folds.
The lips are generally used to set the frequencies of the lowest formants, while the tongue, soft palate and other parts are used to shape the 'vocal tube' to emphasize or deemphasize higher frequency formants. It would be helpful to see some wave shapes, Fourier spectra and spectragraphs for various formants, best simulated by singing single note vowel sounds such as 'oo,' 'ah,' and 'ee'. If there is a 'guest soprano' in class on Tuesday, we can record and examine what happens when that individual sings high notes. OBJECTIVES: The purpose of this retrospective review was to investigate the benefit of VBRT for soldiers with symptoms of dizziness following blast exposure with and without documented vision problems.
RESULTS: Soldiers with dizziness and vision disorders showed protracted recovery following VBRT and no change in perceived dizziness handicap after participation in VBRT. CONCLUSION: Additional therapeutic considerations, including coupling VBRT with specialized vision therapy may be beneficial for resolving symptoms and improving functional outcome. In the military, the most common causes of mTBI from an external force are direct blunt force trauma to the head, rapid changes in acceleration or deceleration, and atmospheric pressure changes caused by bomb blasts5. Primary blast injuries result from the impact of the shock wave to the body's surface, often affecting the more susceptible air and fluid filled organs such as the lungs, brain and sensory structures in the middle and inner ears. The presence of dizziness after injury is considered adverse prognostic indicator and may be the most persistent symptom of mTBI that unfavorably affects clinical outcome as well as disease course6.
The pathophysiologic mechanism of trauma to the vestibular end organ is not fully understood. Treatment of dizziness and imbalance following TBI often includes physical therapy and medications for the acute symptoms. A retrospective review of 104 charts of active duty Army soldiers that were enrolled in a traumatic brain injury treatment center was conducted at an active duty military installation in the southern United States. The post-traumatic stress disorder (PTSD) checklist-military version (PCL-M) is a 17-item measure that is widely used in the DoD and the Department of Veterans Affairs and has excellent reliability and validity. DHI (Dizziness Handicap Inventory) developed by Jacobson & Newman23 is a measure of the self-perceived level of handicap associated with the symptom of dizziness [23]. A VBRT certified physical therapist evaluated soldiers during their initial intake assessments at the WRRC and post-VBRT therapy.
The Dynamic Visual Acuity (DVA) test quantified the extent of visual acuity loss due to the combined influences of underlying vestibular pathology and adaptive responses on image stabilization (e.g. The Sensory Organization Test of Computerized Dynamic Posturography (SOT) quantifies biomechanical changes to postural control through evaluation of a person's ability to use sensory system input to maintain upright (quiet) stance during increasingly challenging conditions.
Lastly, some of the soldiers were referred for further vestibular evaluation, and were assessed by a board certified Audiologist.
Mean, standard deviations, and range of questionnaire results and assessment measure scores were calculated. The potential mechanisms involved in blast injury are still being explored; however, vestibular dysfunction and visual changes rank among the most common symptoms following blast exposure29. The purpose of this study was to investigate the benefit of VBRT for soldiers with symptoms of dizziness following blast exposure with and without documented vision problems. Brown et al.33 reported on functional improvement on walking tasks and reported disability as indicated on the DHI of individuals categorized with central vestibular disorders.
DVA and SOT of computerized dynamic posturography are common functional outcome measures in blast rehabilitation programs32. It was also evident from this current study that soldiers with a complaint of dizziness secondary to mTBI had an increased likelihood of co-morbid conditions such as PTSD, depression and anxiety which is consistent with reports in other studies6,37,38.
In summary, soldiers with dizziness and vision problems may not benefit from VBRT at that same rate as soldiers without vision problems. Institution: University of Nebraska-Lincoln, Department of Special Education and Communication.
Paper submitted to the ITJ-SGP (Publishing Management System) on January 31, 2013; and accepted on February 31, 2013. If the carotid fails to develop correctly during fetal life, the inferior tympanic artery enlarges to take it's place. DAVF recieve blood through meningeal arteries or meningeal branches of cerebral arteries and drain directly through a dural sinus or venous channel tributary of a venous sinus through dilated deep veins (Signorelli et al, 2014). The Cognard states that type I and II DAVFs drain directly into dural sinuses, the difference being antegrade flow in the type I, and retrograde flow in the type II. Successful treatment requires occlusion of the venous recipient, as occlusion of the arteries alone can be associated with recruitment of more venous drainage (Adamczyk et al, 2012). Surgery is sometimes preferred for fistulae draining into the superior sagittal or dominant transverse sinus when embolization might result in an undesirable sacrifice of the dural venous sinus. This can be compared to the human eye, which can detect light frequencies (colors) that vary by less than a factor of 2. As mentioned before, the eardrum and the ossicles provide preamplification of sound signals. Holes in the eardrum allow unwanted, rapid equilibration between canal and middle ear pressures, which ultimately reduces the preamplication of sounds, particularly for lower frequencies.
It even detects phase differences between signals from the same source detected at each ear for purposes of location. Sounds signals transmitted by the ossicles to the oval window set up pressure waves within fluids in the scala vestibuli which travel down a narrowing chamber (the scala vestibuli) and continue along the scala tympani.
These localized vibrations cause shearing of the stereocillia (or hair cells) which, in turn, excite electrical impulses in the organ of corti which ultimately drive signals along the auditory nerve. An experimental observation that two pure tones separated by an octave (a factor of 2 in frequency) excite equally-spaced regions along the sensor-studded basilar membrane.
What do we hear when, instead, if we start with identical frequencies and slowly move them apart? This is useful for observing the minimal frequency variation where we can hear a difference in tones-- called the Just Noticeable Difference (or JND).
This process evidently uses the higher frequency content (think overtones) of signals to improve (fundamental) frequency resolution. The ear can sense variations in pressure of 1 part in 10,000,000,000 (10^10th) of atmospheric pressure.
The decibel is set up so that every increase in sound intensity level by a factor of ten corresponds to a 10dB increase. In other words, we would interpret an increase of SIL from 10 to 20 dB as an equivalent change in loudness to that from 80 to 90 dB. This phenomenon is observed when we hear two successive overtones (but not the fundamental) of an overtone series. Air moving faster through constrictions in the vocal folds (gaps between them, etc.) creates a reduced pressure via the Bernoulli principle. The speaker or singer controls the frequency of the source sound by tensioning the vocal flaps, and controls amplitude by varying the average air pressure available just below the vocal folds. The latter causes serves to shorten the length of the resonant cavity-- opening ones mouth widely moves the position of the pressure node to just inside the mouth for example. Guitar players, think of how you change where you pick in order to emphasize higher overtones or not. Impact of visual disorders on vestibular and balance rehabilitation therapy outcomes in soldiers with blast injury. In a deployment setting, soldiers are typically sustaining attacks from explosions or blasts by rocket-propelled grenades (RPGs) and improvised explosive devices (IEDs). Secondary blast injuries are the result of propelled fragments flying through the air; these fragments may cause penetrating injuries. Incidence of dizziness or imbalance secondary to mTBI ranges from 24%-83% and potentially up to 90%6,9,10.
In one of the few long-term studies on untreated patients with mild head trauma injury, vertigo persisted in 59% of patients after five years of recovery11. Dual sensory disorders must be taken into consideration during vestibular evaluation and treatment because many related activities depend on sensory input from the visual system and may even overshadow a balance disorder. For a majority of functional vestibular deficits, Vestibular Balance Rehabilitation Therapy (VBRT) is often appropriate.
Furthermore, the purpose of this study was to investigate the benefit of VBRT for individuals with history of dizziness resulting from blast exposure and visual disorders as opposed to individuals without visual disorders. The investigators retrospectively analyzed de-identified records of patients who were referred to the program from August 2010 through March 2011 and whom were later accepted into a TBI program.
The primary care intake questionnaire packet given at the WRRC included several neuro-psychological tests; the results of four tests were included in the retrospective review. The items on the PCL-M correspond to the Diagnostic and Statistical Manual Fourth Edition (DSM-IV) diagnostic criteria for PTSD. The optometrist evaluated visual acuity through use of the Snellen chart, observed ocular structure and overall health, and assessed extra ocular movements.
The audiologist determined if the soldier was a candidate for videonystagmography (VNG) and caloric testing, or rotary chair testing based on present complaints and functional status.


Soldier data was grouped by those with dizziness resulting from the blast exposure, with and without visual disorders. A correlation scatter plot of each soldier with history of dizziness resulting from blast exposure for PCL-M score and PHQ9 score. A correlation scatter plot of each soldier with history of dizziness resulting from blast exposure for PHQ9 score and Pre-VBRT DHI score. A correlation scatter plot of each soldier with history of dizziness resulting from blast exposure for PCLM score and Pre-VBRT DHI score.
The results of the repeated-measures ANOVAs with custom contrast for fixed effects for group differences (those with and without visual disorders post-blast exposure) on the VBRT pre-and-post measures were performed.
Panels on the left: Increase in Gaze stabilization test (GST) and Sensory Organization test (SOT) scores represent better performance over time between patients with and without vision disorders. The ambient vision system is necessary for performing activities of daily living including gaze stability and quiet stance30.
Specifically, this study was proposed to determine if soldier with vision disorders improved at the same rate as those without vision disorders. Functional as well as subjective symptoms improve post-rehabilitation33; however, the rate of improvement is dependent upon the type of disorder and the severity of the disorder at the pre-therapy baseline session33,34.
Mean improvements were noted in all central disorder groups (cerebellar dysfunction, stroke, central vestibulopathy, mixed central & peripheral vestibulopathy and post-trauma); however, those with cerebellar dysfunction showed the least improvement on the functional disability measures.
Gottshall et al.35 found that DVA scores improved within 4 weeks post VBRT in individuals with vestibular deficits, whereas GST scores did not show significant improvements until 12 weeks after initial therapy. Memorandum from the Assistant Secretary of Defense for Health Affairs, (ASD(HA)), Traumatic Brain Injury: Definition and Reporting.
Audiology - Veteran's Administration, Tennessee Valley Healthcare System - Nashville - AC - United States. Accordingly, other possibilities for vascular tinnitus include dehiscence (missing bone) of the jugular bulb -- an area in the skull which contains the jugular vein, and an aberrantly located carotid artery.
It enters the skull through it's own foramen, courses through the medial part of the middle ear, and then rejoins the petrous ICA (Branstetter and Weissman, 2006). DAVF are thought to be acquired and are associated with intracranial surgery, ear infection, tumor, hypercoagulability, puerperium, and trauma. According to De Keukeleire et al (2011), Type I DAVs are low risk and need be treated only if symptoms are intolerable.
The reason for this order is that embolization might obscure the target for the radiosurgery if performed first. The dynamic range-- the difference between the quietest and loudest sounds we can hear-- is about 130dB (decibels, we'll get to these in a while) which corresponds to a factor of 10^12th (that's 10,000,000,000,000).
The eardrum is also equipped with a specialized muscle-- the tensor tympani muscle-- which can help dampen loud sounds and protect the inner ear. The cochlea is where pressure waves in fluids, excited by movement of the stirrup bone against the oval window, are converted into electrical impulses that travel up the auditory nerve to the brain. The round window at the far end of the combined chambers is set up to minimize reflections of pressure waves which would travel backwards.
The stereocillia and organ of corti rest upon the basilar membrane which is about 3.5 cm long and contains about 30,000 nerve endings (hair cells).
It also corresponds to about 15 percent in frequency, slightly less than a minor third in musical terms. We can experiment by discerning what our frequency resolution is for square waves as opposed to sine waves (the latter have minimal overtone content when produced by our function generator). Loud sounds cause pain (the effective upper limit) at about 1 part in 10,000 (10^4th) of atmospheric pressure. Because the dynamic range of human hearing is very large (factor of 1,000,000), and because the frequency response of the ear is non-linear (the same ratio between two frequency stimuli is always perceived to be the same musical interval), we use the logarithmic decibel (dB) to express sound intensity level (SIL). You will often see loudspeaker specifications indicating the frequencies where sound intensity is halved, or decreased by 3dB. The neural mechanism of the ear recognizes the two overtones as part of a harmonic series and will be heard as the fundamental.
Those sound waves are filtered by changing the shape of the vocal tract comprising the larynx, the pharynx above it, the mouth and the nasal cavity. An analogy is a perfume atomizer, where air is blown across a small opening above a bottle of perfume and the low pressure at the orifice draws out very small beads of perfume into the air stream. Thus, the vocal folds are regularly closing and opening, creating sound by varying pressure in the larynx above. The resonant frequencies of this chamber are controlled by altering the shape of these cavities and, thus, serve to filter the sounds produced.
Vestibular and balance rehabilitation therapy (VBRT) is often recommended to alleviate symptoms of dizziness and improve functional performance; however, it is uncertain if this is the most appropriate therapeutic method for soldiers with complaints of dizziness stemming from vision problems. A blast caused by the detonation of an IED initiates with a peak positive pressurization (shock wave) followed in time by a negative pressurization.
Tertiary blast injury may occur when the individual is thrown from the blast into a solid object such as an adjacent wall or even a steering wheel. For the soldier with blast injury and mTBI, it is possible that peripheral vestibular pathology, visual impairment, central pathology, peripheral neuropathies, musculoskeletal injuries, vascular disorders, certain medications, and proprioceptive changes all contribute to dizziness. Additionally, patients with mild TBI who have symptoms of dizziness and imbalance often experience a slower recovery and are less likely to return to work than patients without dizziness10.
In a report by Weichel & Colyer14, 66% of military with TBI were also found to have combat ocular trauma. This specialized form of physical therapy includes postural stability training, gait training, canalith repositioning therapy, and visual training that targets impaired vestibulo-ocular reflex function and gaze stability. Each service member obtained a DHI score greater than zero indicating perceived dizziness complaint that was additionally used to verify the dizziness inclusion criteria. The OQ (Outcome Questionnaire) measured a wide variety of symptoms of distress, difficulties in interpersonal relationships, social roles, and general quality of life20. The PCL-M scale ranges from 1 (not at all) to 5 (extremely); scores higher than 50 are considered clinically significant.
The PHQ-9 is based directly on the diagnostic criteria for major depressive disorders in the DSM-IV and is widely used for psychometric purposes.
A score greater than 10 is considered clinically significant and scores ranging from 0-30 indicates mild, 31-60 moderate, and 61-100 severe handicap. At that time the optometrist entered a diagnosis and offered prescriptions for infections or updated spectacles for visual acuity. Once the trigger velocity was reached, the optotype would appear and the patient was asked to again identify the orientation of the E.
Participants will be asked to step onto a platform machine and stand on a square forceplate, while securely harnessed to the sides of the platform to protect from falling.
Independent t-tests were performed to compare differences in Neuropsychological Intake Assessment scores and health characteristics between the two groups. The most common noted diagnosis were convergence 62% (n = 13), saccadic 43% (n = 9), and accommodative 38% (n = 8) insufficiency. Filled circles represent soldiers with vision disorders; open circles represent soldiers without vision disorders. Two soldiers presented with clinically significant caloric unilateral weakness values (30% and 31%); both soldiers also were diagnosed with visual disorders.
The results indicated that soldiers with vision disorders did not improve at the same rate as those without vision disorders.
Our results indicated that standard VBRT was ineffective for improving GST results for those soldiers with vision disorders; in fact a slight decrease in performance was noted after VBRT.
The use of vision therapy may also play an important role in the rehabilitation of the mTBI patients, specifically for those that have dual sensory disorders. Traumatic brain injury, posttraumatic stress disorder, and postconcussive symptom reporting among troops returning from Iraq.
Comparison of concussive symptoms, cognitive performance, and psychological symptoms between acute blast- versus nonblast-induced mild traumatic brain injury. Hearing impairment and traumatic brain injury among soldiers: special considerations for the audiologist. Visual impairment and dysfunction in combat-injured servicemembers with traumatic brain injury. Program development and defining characteristics of returning military in a VA Polytrauma Network Site.
Characterizing self-reported dizziness and otovestibular impairment among blast-injured traumatic amputees: a pilot study. Validating the primary care posttraumatic stress disorder screen and the posttraumatic stress disorder checklist with soldiers returning from combat. Characteristics and rehabilitation outcomes among patients with blast and other injuries sustained during the Global War on Terror.
A case-oriented approach exploring the relationship between visual and vestibular disturbances and problems of higher-level mobility in persons with traumatic brain injury. Tracking recovery of vestibular function in individuals with blast-induced head trauma using vestibular-visual-cognitive interaction tests. Evidence of central and peripheral vestibular pathology in blast-related traumatic brain injury.
Traumatic brain injury, posttraumatic stress disorder, and post concussive symptom reporting among troops returning from Iraq. Vision therapy for oculomotor dysfunctions in acquired brain injury: a retrospective analysis. Neural mechanisms underlying neurooptometric rehabilitation following traumatic brain injury. An enlarged jugular bulb on the involved side is common in persons with venous type pulsatile tinnitus. Radiosurgery by itself has a low succes rate as the only treatment (Signorellli et al, 2014). To avoid conflicts of interest, ideally the expert should work for another medical insitution. This mechanism isn't foolproof, there is a time lag between when loud sounds are sensed and when the muscle is completely activated. Sound pressure waves within the scala vestibuli are propagated through the Reissner's membrane into the scala media, which contains a fluid with different properties than those in the other scala. The neural mechanism has evolved to receive this broad range of pitch and narrow it down to a more precise frequency range-- a process called sharpening.
The rate at which the folds open and closed is controlled by tension which is controlled by muscles.
Thinking about the boundary conditions of this chamber, we note that the bottom of the larynx, just above the vocal folds is a pressure antinode.
The principal vocal formants are at these frequencies, but can be manipulated simply by manipulating the tube diameter at the position of nodes and antinodes for various overtones. TBI is most commonly seen and treated injury among soldiers in the OIF and OEF wars and often presents with headaches, dizziness, and fatigue as associated symptoms. In a typical blast, the positive pressure phase is initially faster than the speed of sound and has a brief duration. With mild head injuries, this collection of factors results in rates of dizziness that range from 15%-78% and is most often due to pathologies affecting the peripheral vestibular system, CNS, or cervical structures11. Studies have attempted to document vestibular abnormalities, after mild to moderate TBI, which have yielded inconsistent findings ranging from 32%-65%13. Often the eye is unprotected from debris due to non-compliance with protective eye wear15, therefore visual disorders may stem from foreign objects damaging the globe. Extensive evidence in the rehabilitation literature has documented the efficacy of specific vestibular rehabilitation in treating individuals with dizziness and imbalance complaints18,19. If the results support this hypothesis, the need for coupling additional therapy with vestibular rehabilitation may be warranted for soldiers presenting with dizziness and visual problems post blast injury. Self-reported dizziness was verified in the primary care physician chart note or on the Dizziness Handicap Inventory (DHI) that was completed by most soldiers at entry into the program. An exempt review for retrospective data analysis was obtained through the appropriate Institutional Review Boards at Army Military Installations and a Midwestern University.
The 45-item questionnaire has a score range of 0 to 180 with subscales of symptom distress, interpersonal relations and social role.
In the context of screening soldiers post-combat, the PCL performs well using a cutoff value of 30 to 34 as an indication of PTSD symptoms21. The PHQ-9 score > 10 had a sensitivity of 88% and a specificity of 88% for major depression.


This measure has been correlated with the results of posturography tests and is considered valid and reliable. Static visual acuity (SVA) was first measured and expressed in LogMAR units (a unit describing the apparent size of an optotype based on the ratio of its absolute size to distance from the eye24. The trigger velocity speed would increase until the patient reported an incorrect orientation of the optotype; the PEST algorithm was again used to determine threshold velocities for yaw plane movements.
The SOT test has six increasingly challenging conditions designed to determine the extent to which the patient is able to maintain quiet stance during the condition. Soldier demographics, health status characteristics and summary of Neuropsychological Intake Assessment of mTBI results for those with vision disorders (n = 21) and those without vision disorders (n = 8) are summarized in Table 1. No clinically significant spontaneous or positional nystagmus was observed for the two groups.
Panels on the right: Decrease in Dynamic Visual Acuity (DVA) and Dizziness Handicap Inventory (DHI) scores represent improved performance over time between patients with and without vision disorders. Therefore, blast injury can result in impaired visual or vestibular system dysfunction leading to symptom complaints of dizziness, imbalance or spatial disorientation.
Interestingly, mean DHI scores remained the same for those with vision disorders as compared to those without vision disorders; however, those without vision disorders still had higher perceived handicap after participation in VBRT.
The central vestibulopathology and mixed central and peripheral groups showed the greatest rates of improvement post-VBRT. There has been some speculation in the recent literature that while DVA and GST are moderately correlated with one another, the tests may be measuring different mechanisms36.
It seems likely that subjective measures of dizziness are more influenced by PTSD, anxiety, and depression than objective measures of vestibular function due to the greater impact of these psychological stress symptoms over physical function37,39.
Vision therapy is a clinical approach to treat a variety of visual disorders including convergence and divergence insufficiency, saccadic disorders, and accommodative dysfunction.
Trans venous embolization is a good option when arterial feedrs are too numerous, and when the venous drainage of the DAVF can be sacrifised. It is also a poor choice for those with hemmorage, because it is slow acting (1-3 years), and more hemmorage might occur while waiting for the blood vessels to close. Another page at (hyperphysics, Georgia State University {I presume this is what gsu stands for}) is also informative. The pinna collects more sound that would normally be available at the opening of the auditory canal, thus providing a modicum of preamplification. Dynamic range also varies according to frequency, with greater sensitivity between about 1000 and 6000 Hertz (approximately, this varies by individual).
Instead of producing the fundamental with a very large pipe, the overtones for that fundamental frequency are played at the right proportions (using a smaller pipe) to trick the ear into hearing the fundamental (low) frequency. Some men can produce a falsetto voice-- producing nearly sinusoidal sound by highly tensioning the vocal folds. The other end, at the opening of the mouth, is a pressure node like the end of an open tube. A more recent report from the DoD4, estimates that 194,561 soldiers have sustained a mild traumatic brain injury (mTBI) from the year 2000 through 20125. The over pressurization wave is immediately followed by a negative pressure phase that is longer in duration and slower in velocity6,7. Finally, quaternary blast injury can result in a severe blast related trauma brought on from significant blood loss associated with traumatic amputations or even from inhalation of toxic gases resulting from the explosion. For patients with blast injuries and mTBI vestibular pathology should always be considered.
However, other more common visual symptoms result from blast injury including convergence, accommodation and ocularmotor dysfunction16. PHQ-9 scores of 0-4 represents no depression, 5-9 minimal symptoms, 10-14 mild depression or dysthymia, 5-19 represents moderately severe depression and greater than 20 represents severe depression22. With the head still, SVA will be determined by asking the participant to identify the orientation (right, left, up or down) of the optotype E. Pearson Correlation Coefficients were computed to assess relationships between average Neuropsychological Intake Assessment scores and GST, DVA, SOT and DHI average scores. No significant differences were observed between the two groups based on demographic and health status characteristics. Soldiers with and without vision disorders participated in rotational chair assessment; however, no significant differences were observed between rotational chair gain, phase and asymmetry values. Given that the mechanisms involved in blast exposure are not fully understood, it is plausible that the individuals without vision disorders had additional central disorders hindering improvement with standard VBRT. Of note, all patients continued to report symptoms of dizziness and perceived handicap after VBRT. It is difficult to understand based on this retrospective review if the difficulties with GST performance was truly due to VOR dysfunction or central mechanisms.
Exercises designed to enhance the visual system and adaptive processes are incorporated into the visual therapy program40,41.
The risk of hemmorage increases with direct drainage into cortical veins (Signorelli et al, 2014). On the other hand, radiosurgery is likely a more durable long term treatment than embolization alone. The area of the eardrum (tympanic membrane) is about 15 times that of the oval window dividing the inner and middle ear. We recall from earlier lectures that the overtone series for this type of chamber are odd harmonics.
In summary, TBI resulting from blast exposure can be much more complex compared to TBI from other causes. Loss of peripheral vestibular information creates greater dependence on visual and proprioceptive components of the sensory system11.
Afferent and efferent visual dysfunction may result from damage to an optic nerve, extra-ocular muscle damage or cranial nerve function, and visual processing disorders from cerebral injury including hemorrhages and diffuse axonial brain injury15. Central and peripheral vestibular function was also assessed with head thrust, head shake, and Dix-Hall pike testing. If identified correctly, the E was reduced until the participant successfully identifies the correct E orientation for three of five successive trials, based on the Parameter Estimation by Sequential Testing (PEST) algorithm. If a patient has a vestibular system deficit, the maximum movement velocities over which the VOR system provides effective compensation would decrease. Composite equilibrium scores on a scale of 0 (excessive sway) to 100 (no body sway) were obtained. Preliminary analysis was performed to ensure no violation of the assumptions of normality, linearity and homoscedasticity.
In addition, mean gain, phase and asymmetry scores were within the normal range for both groups (see Table 2).
Additionally, normal vestibular function was observed via rotational chair testing for both groups. This further supports that while those with central disorders (including visual disorders) do improve with VBRT, they do not improve at the same rate as those with peripheral vestibular dysfunction. It is possible that soldiers with dizziness and vision problems also had substantial difficulty with cervical range of motion, leading to the unchanged head velocity after VBRT. In a study by Hudac et al.42, it was found that adjusting visual processing with corrective prisms impacted neural processing.
The overtone content (amplitudes of the odd harmonic overtones) can be adjusted by shaping the resonant cavities, forming vocal formants. In the study by Lew et al.17, the rate of visual impairment at a VA polytrauma rehabilitation center was 52% compared with only 20% for all other sources of injury to the body resulting from blast exposure17.
Therefore, subjects were excluded if they sustained a penetrating head injury or sustained mTBI from any other than an explosion (e.g. Next, the participant were asked to complete the perception time test (PTT) by keeping his head still and correctly identifying the orientation of the E flashing on the computer screen, set at a fixed 0.2 logMAR size above the established SVA baseline.
The extent of visual acuity loss is predicted by comparison of the GST velocities to those encountered during daily life activities in question (e.g. A multivariate approach to repeated-measures ANOVA with custom contrast for the fixed effects was performed to evaluate performance pre-and-post VBRT. There was also no significance differences noted on SVV testing between the two groups; however, those with vision disorders displayed SVV off axis to the right mean values outside the normal range (see Table 2). Therefore, dizziness resulting from blast exposure may be due to associated brain injury rather than peripheral vestibular system dysfunction31. The results reported herein also support that individuals with central disorders as indicated by visual dysfunction did not improve same rate as those without vision disorders.
This is the aim of future work to explore differences in DVA and GST performance after head injury. This intervention appeared to facilitate the appropriate integration of information between the visual pathways and improved processing across proprioceptive, kinesthetic, vestibular, cognitive, and language domains42. The ossicles-- three bones called the hammer, anvil and stirrup, also provide about 3x preamplification. Examination with P300 testing documented diminished amplitudes and prolonged latencies suggesting damage to the visual cortex and or visual pathways that connect the eyes to the cortical visual centers may be affecting those afflicted with TBI17. Participant scores obtained on the Dynamic Visual Acuity testing (DVA), Gaze Stabilization Test (GST) and Computerized Dynamic Posturography, Sensory Organization test (SOT) were included in the data analysis.
PTT identified the minimum target presentation time (in milliseconds) to be used during DVA and GST testing. Interestingly, mean DHI scores remained the same for those with vision disorders as compared to those without vision disorders after VBRT; however, those without vision disorders still had higher perceived handicap after participation in VBRT. Additional work with visuospatial training41 show some promise for improving visual performance post-TBI. Furthermore, the investigators noted that the majority of patients showed normal to near-normal corrected visual acuity and visual fields; however, 75% self-reported a vision problem, including photosensitivity (59%).
Soldiers included in the retrospective review were referred to the TBI family practice and underwent three consecutive weeks of specialty appointments including; TBI primary care physician, optometry, occupational therapy, mental health, physical therapy and if medically indicated neurology, audiology or otolaryngology.
Nevertheless, subjective visual vertical findings were outside of the normative range for individuals with vision disorders. Again, it is possible that the individuals without vision disorders had additional central disorders hindering improvement with standard VBRT, or that additional time in rehabilitation was needed. Continued support of vision rehabilitation efforts is necessary to address best-practice care for blast-injured military. After the completion of the intake appointments a multi-disciplinary team (Multi-D) convened to determine if a soldier would be a rehabilitation candidate and developed a treatment plan. After achieving the desired velocity, the optotype E was flashed on the computer screen based on PTT score. This finding may be attributed to damage to the peripheral or central vestibular system including the brainstem, cortex and cerebellum15; therefore, further prospective examination of SVV findings is warranted. When we grouped patients according to vision disorders, significant differences were noted in functional balance performance and perceived handicap after VBRT; however, if we grouped the participants according to different diagnostic categories the outcomes may have been different. A multi-disciplinary approach for evaluation and remediation of these patients is necessary to review and modify individual treatment goals as traditional rehabilitation methods may be not sufficient for reducing symptoms complaints and improving functional performance. The presence of these vision-related problems indicated a high prevalence in this post-combat population with TBI. To our knowledge, this is the first report exploring the VBRT outcomes in blast exposed soldiers with history of dizziness, when categorized by the presence of vision disorders. These soldiers continued treatment within each specialty as indicated in the clinical treatment plan.
The size of the E decrease based on correct responses; threshold was established based on PEST algorithm.
Therefore, the effect of VBRT should be further explored prospectively in blast exposed soldiers and in a larger sample to determine the clinical relevance of our findings. For example, the typical length of therapy was two to three times weekly over the course of approximately eight weeks for VBRT in physical therapy. After the completion of each specialty therapy the Multi-D team determined the point at which the soldier was medically fit to return to duty and medically acceptable to be discharged from the treatment program.



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  • lya Tinnitus, mainly broken cochlear hair cells that produce excess amounts.
  • sladkaya And teens is otitis (pronounced: -tie-tus.