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We auditorily stimulated patients affected by subjective tinnitus with broadband noise containing a notch around their tinnitus frequency. We recruited tinnitus sufferers from among patients attending the Oto-Rhino-Laryngology II Clinic of the University of Parma, Italy, in the period 2004-2006. We determined hearing sensitivity using tonal stimuli presented in octave steps, from 125 Hz to 8,000 Hz, and 1-dB increments. The experimental pitch-matching test was performed shortly after the patient had performed the loudnessmatching test using pure tones as comparison stimuli.
Conversely, in our study, an essential prerequisite for the correct application of the experimental acoustic therapy (notched broadband noise; see later) was the reliability (and repeatability) of the measurement of the tinnitus pitch. Our method was based on the classic pure tone-matching paradigm and consisted of two phases. During both the upward and downward sweeps, we stopped tone presentation every time the subject reported a match between the tone and the pitch of the tinnitus.
The second phase (termed sequential binary choice) resembled the traditional 2AFC procedure. During this phase, a number of patients reported more than one tone as matching their tinnitus pitch. We should note that any procedure of tinnitus pitch assessment is subject to many errors owing to, for example, differences in the ability of subjects to compare and discriminate among tones, the uniqueness of the tinnitus sensation, or the presence of different types of tinnitus.
The experimental design consisted of randomly assigning to each patient either the experimental sound therapy (WWN)* or one of the two control sound therapies (WN or Wa) following a double-blind procedure. We examined variation of the tinnitus parameters (F t , dB t ) over time for each patient by repeating measurements, ideally after 1, 3, and 6 months from the start of the therapy, following the same procedures of the first visit. In addition, when the subject's tinnitus pitch was reassessed during a control visit, usually the observed value of F t was not exactly the same as the one measured in the previous visit. Therefore, the following compromise criterion was adopted: A new, updated WWN acoustic sequence was constructed only when the re-measured value of F t fell outside the noise window previously determined. The temporal variation of tinnitus loudness in the three groups of patients was examined by computing the values of Δ dB t using the patient's values of dB t measured during subsequent control visits. Table 1 summarizes the characteristics of patients of each treatment group together with the clinical measurements of their tinnitus at their first visit. The average time elapsed from the beginning of the acoustic therapy and the last tinnitus measurement was similar in the three groups of patients: 148 dd (+ 20), 145 dd (+ 25), and 127 dd (+ 16), respectively, for the WN, Wa, and WWN groups. Figure 4 shows the variation of tinnitus loudness with time elapsed from the start of therapy for three patients taken as an example (one for each type of therapy) and for one subject initially receiving the Wa therapy and later re-treated with the WWN therapy (see further discussion later).
The mean decibel attenuation between 3 and 6 months of therapy was less than 1 dB in patients of the Wa group and 4-5 dB in those in the WN and WWN groups. In the four patients re-treated with the WWN therapy, the value of dBt measured at the last control visit was compared to that measured at the control visit preceding the change of therapy. Our method for the treatment of subjective tinnitus differs substantially from previous methods (but see Goldstein et el. Indeed, the most striking result of our study was the marked decrease of tinnitus loudness observed in patients after approximately 4-5 months of daily listening to the WWN sound stimulation but not seen in those listening to either the WN or the Wa sound stimulations for an equivalent amount of time. The presence of subjects without residual tinnitus in the WWN group but not in the two control groups further strengthens this conclusion.
Apart from the beneficial effects on tinnitus loudness perception, another remarkable aspect of this study was the development of a novel tinnitus pitch-matching procedure using binary comparison of tones selected by the patient in a previous test on the basis of their resemblance to tinnitus.
A potential methodological criticism that should be addressed in this study is the lack of control by experimenters over the patients' motivation or willingness to carefully follow the procedures established by the therapeutic listening program. First, both the Wa and WN therapies were equally ineffective in reducing tinnitus loudness, despite the greater tolerability and pleasantness of the first therapy according to the patients' judgment.
The key element of the WST was the auditory stimulation of tinnitus sufferers with masking noise presumably not comprising the tinnitus frequencies, often suggested to be responsible for the exacerbation of the symptom. An alternative explanation for the decreased tinnitus loudness in patients treated with WST might involve a change in the neural reorganization in the tinnitus region induced by stimulation with noise around, but not inside, the tinnitus pitch region. Introduction: Tinnitus, the perception of the sound in the absence of an external acoustic source, disrupts the daily life 1 out of every 200 adults, yet its physiological basis remains largely a mystery. 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. INTRODUCTION: The general consensus on the roles of hearing loss in triggering tinnitus seems not applicable in patients with normal hearing thresholds. OBJECTIVE: To scrutinize auditory functioning in a sample of tinnitus subjects with normal hearing thresholds and non-tinnitus normally hearing control participants using transient evoked and distortion product otoacoustic emission (TEOAE and DPOAE) and Threshold Equalising Noise (TEN) test.
METHODS: Twenty-seven tinnitus adult patients with normal hearing thresholds and 27 normally hearing volunteers were tested with TEOAE, DPOAE and TEN test. CONCLUSION: These results suggest the possible existence of subtle auditory deficit in normally hearing tinnitus patients, which may be an early sign of diseases that are only diagnosed after the onset of hearing loss.
Keywords: coustic neuroma, otoacoustic emissions, tinnitus, threshold equalising noise test. Tinnitus is defined as the perception of sound that results completely from activity within the nervous system without any corresponding mechanical, vibratory activity within the cochlea, and not related to external stimulation of any kind1. An increasing amount of epidemiology studies provide both self-reported data on tinnitus and hearing status which allows closer examination on the relationship between tinnitus and hearing status. Although some studies have different theoretical assumptions and approaches, the significance of hearing loss in tinnitus generation is not questioned. Thus, several attempts have been made to explain pathophysiology mechanisms of tinnitus in patients with normal hearing ability particularly using otoacoustic emissions (OAEs). Several studies have revealed that TEOAEs and DPOAEs can be used as a tool to detect early hearing loss before it can be diagnosed by PTA13-15.
The contradict findings from previous research motivates researchers to find alternative theories to explain tinnitus mechanisms in tinnitus patients with normal hearing thresholds. This study investigated 27 tinnitus subjects (42 tinnitus ears and 12 contralateral non-tinnitus ear) with normal hearing thresholds who were recruited from Welsh Hearing Institute, University Hospital of Wales. Full history taking and otoscopy examination were carried out at the beginning of the session.
TEOAEs test was performed using unfiltered clicks of 80 ┬Ás duration presented in non-linear modes. The stimulus comprised of a pair of primary pure tones (f1 and f2) at a frequency ratio equal to 1.22. The basic principle of this test is to control for "off-frequency listening" from occurring by using a broad band noise (the threshold equalising noise). This research has received the ethical approvals from the School of Applied Community and Health Studies (SACHS), University of Bristol Human Participants Ethics Committee and the South East Wales Research Ethics Committee. Initially, the left and right of DPOAE results were compared within the tinnitus and control groups.
Then, the differences of overall mean DPOAE amplitude between tinnitus and control ear were compared.
Various hypotheses have been put forward to explain tinnitus generation in normal hearing patients. Decreased TEOAE amplitudes were observed in 35.7% of the tinnitus subjects with normal hearing sensitivity.
A statistically significant increase in DPOAE amplitude was observed in tinnitus ears at f2 frequency of 1414 Hz. The fact that tinnitus patients with normal hearing have a significantly higher percentage of abnormal TEOAEs and a limited frequency of DPOAE than the controls may suggest that OHC dysfunction may be pivotal in tinnitus generation. In the current study, the percentage between abnormal TEOAE and DPOAE in both groups had no statistically significant difference. In the field of tinnitus, however, only two studies reported the application of TEN(HL) test in tinnitus patients with normal hearing24,25.
Based on systematic review, no research on the application of TEN test in detecting acoustic neuroma has been published.
No published data was found on the application of a TEN test in detecting acoustic neuroma. This study showed that subtle cochlear problem may exist in tinnitus patients before it is significantly appeared in the audiogram. Thanks to University Hospital of Wales, UK for providing the facilities to conduct this research. This study was supported by the University of Bristol, UK and Ministry of Higher Education (MOHE) Malaysia and Universiti Kebangsaan Malaysia (UKM) as parts of the first author's PhD research. Paper submitted to the ITJ-SGP (Publishing Management System) on February 17, 2014; and accepted on February 20, 2014.
The Windowed Sound Therapy: A New Empirical Approach for an Effective Personalized Treatment of Tinnitus. We assessed the long-term effects on tinnitus perception in patients listening to notched noise stimuli (referred to as windowed sound therapy [WST]) by measuring the variation of subjects' tinnitus loudness over a period of 2-12 months.
Epidemiological surveys indicate that the sensation caused by the tinnitus is present in 5-15% of the human population. All subjects of the study were patients reporting a ringing or hissing sound in one or both ears (Table 1) and willing to take part voluntarily in the experiment and to scrupulously follow the assigned therapy.
With a few exceptions, we noted that all patients had, in one or both ears, a more or less pronounced hearing loss at frequencies above 3-4 kHz, an important predisposing factor for the occurrence of tinnitus [9]. We stopped the procedure when a patient reported that the pitch of the comparison stimulus was similar to the tinnitus pitch. The difference between the two measurements was the estimated loudness of the patient's tinnitus (dB t [decibels SL]). Pure tones were generated with a function generator (Kenwood model FG-273; Kenwood Corporation, Taiwan) connected to a custom portable electronic switchboard (left, right, binaural), and the output signal was sent to a pair of Sennheiser HD 202 (Sennheiser Sales, Dublin, Ireland) closed-cup headphones. Pure tones are commonly used for measuring the pitch of both noise-like and tonal tinnitus [10].
In such cases, the frequency value of the matching tone was noted, and the tone sweep was resumed, starting from the frequency at which it had been interrupted. We asked subjects which of the previously identified tones were more similar to the pitch of their tinnitus. This could happen for several reasons: presence of different kinds of tinnitus, such as a ringing associated to hissing tinnitus, presence of multiple tinnitus spectral peaks [13], or octave confusion. WWN was constructed from a 10-minute sequence of white noise generated by the white noise generation function of a suitable software for sound analysis (AVISOFT; Avisoft Bioacoustics, Berlin, Germany). For these reasons, the width of the erased band of WWN was set prudently to a value double the width of the critical band of the tinnitus frequency. Spectral characterization of the three sound therapies with decibel values in relative units. This was expected, as any procedure of pitch assessment is inherently imprecise for reasons already discussed. In this case, the patient was asked to return the old disk and listen to a new disk that contained the usual 8-minute sequence of equalized broadband noise recorded after a notch centered at the new tinnitus frequency or frequencies was created following the method explained earlier. Conversely, the presence of two control treatments allowed the effectiveness of the WWN therapy to be established regardless of the type of comparison stimuli used for the measurement of tinnitus loudness. The number of control visits (and re-measurements of dB t ) varied from one to seven per patient. When subsequent visits of the patient fell within the same temporal class, only the value of dBt measured during the last visit within the class was considered for analysis. If the difference among means was statistically significant, we used the multiple-comparisons procedure of the Kruskal- Wallis test to test the difference of mean value between pairs of treatments. Patients of the three groups did not differ significantly regarding gender ratio, mean age, mean hearing loss, and mean value of tinnitus parameters.
In the WWN-treated patient, tinnitus intensity decreased by 12 dB after only 1 month of therapy and by 15 dB at the end of the observation period (after 7 months).
Variation of tinnitus loudness over time in four patients (indicated with a different symbol) taken as an example.
The mean attenuation between 7 and 12 months was less than 1 dB in patients of both the WN and Wa groups and 3 dB in those of the WWN group. Results showed a remarkable reduction of tinnitus loudness in the three patients who were initially given the Wa therapy (one of them recovered from tinnitus; see Fig.
Furthermore, about two-thirds of the differences were below 1 kHz, and approximately one-half of the differences were below 0.6 kHz.
These acoustic stimulations are standard for each subject; they are not personalized in relation to the tinnitus frequency that characterizes the subjective tinnitus. Furthermore, patient's estimation of tinnitus loudness showed a clear negative relationship with the time of WST application; loudness decreased by approximately 1 dB per month of application of the therapy (see Fig. This procedure yielded pitch estimates characterized by low between-session variability (mean absolute difference of 1.1 kHz between the tinnitus pitch measured at the initial visit and at the first control visit after 1-2 months).
This could weaken the conclusions of our study if the patient's "at-home" listening behavior had been affected by the type of acoustic therapy they received.
Second, tinnitus loudness did not decrease significantly with months of application of the sound therapy by patients of the two control groups. This discrepancy, however, may be easily explained by considering the rough clinical procedure used in our study for finding pitch matches suitable for the loudnessmatching test. In our study, the pitchmatching test conducted during audiological evaluation was aimed solely at obtaining a matching tone only approximately resembling the tinnitus frequency, the tinnitus pitch being accurately measured in a separate experimental test (see under Methods). Jastreboff and Jastreboff [21] stressed the importance of ensuring that the sound-enriched environment provided with the TRT should not contain sounds causing annoyance and exacerbation of the tinnitus sensation.
The auditory stimulation of patients with waterfall noise recorded underwater (Wa therapy) did not contain significant energy in the frequency range above 3-4 kHz (where hearing loss usually occurs and most tinnitus sensations pitch) and, furthermore, appeared to be better tolerated as compared to the stimulation with white noise (WN sound therapy). For instance, it has been hypothesized the overrepresentation of the edge frequencies before the hearing loss region is responsible for the tinnitus sensation [1]. The generation of tinnitus is commonly linked with the impaired functioning of the outer hair cells (OHC) inside the cochlea. Relation of distortion product otoacoustic emission and tinnitus in normal hearing patients: A pilot study.
Impaired cochlear function correlates with the presence of tinnitus and its estimated spectral profile. Investigation of olivocochlear and middle ear muscle reflexes with contralateral suppression of DPOAEs in real time; [abstract]. 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. Measurement of subtle auditory deficit in tinnitus patients with normal audiometric thresholds using evoked otoacoustic emissions and threshold equalizing noise tests. The absence of hearing loss on the audiogram in this group of patients poses a serious challenge to the cochlear theories in explaining tinnitus generation in this group of patients. For many years, progress towards finding the effective treatments for tinnitus was hindered by vague understanding of its underlying pathologic mechanisms.
The association between hearing loss and tinnitus has been well documented in the previous literature2-4. Some studies found a correlation between severity of tinnitus and degree of hearing loss3,8 while others found no such correlation9. On the other hand, clinical observations have shown that 8 to 10 per cent of tinnitus patients had normal audiometric thresholds12. It is hypothesised that outer hair cells damage results in stereocilia decoupling from the tectorial membrane, thus causing them to depolarise and subsequently resulting in tinnitus perception1. An association of tinnitus with the changes in amplitude of TEOAEs and DPOAEs has been reported. One study by Weisz et al.24 proposed that subtle auditory abnormality may also arise from the inner hair cells (IHCs) dysfunction. The subjects who were attending the Institute from January to December 2010, were identified by an audiology physician and audiologists based in this hospital. Then, all subjects underwent basic audiological tests which include pure tone audiometry and tympanometry. Off-frequency listening occurs when the presented stimulus is being picked up by other parts of the cochlea instead of the targeted frequency area of the cochlea.
From the analysis, the parameters of the TEOAEs for tinnitus ears are not significantly different from the control ears.
Since no statistically significant difference was observed between both ears, further statistical analyses were performed using combined data from both sides together. Distribution of the number of test frequencies with abnormal DPOAE in tinnitus and control ears. Based on the chi-square analysis, tinnitus ears have a statistically significant higher percentage of abnormal DPOAEs at some frequencies, mainly at 2000 and 4000 Hz regions (Table 4). For example, it has been postulated that the different level of functionality between OHCs and IHCs (the Jastreboff's discordant dysfunction theory) can generate an unbalanced stimulation of dorsal cochlear nucleus's cells which produces abnormal neural activity.
Abnormal DPOAE amplitudes were also found in this group, particularly at high frequency regions, but in a slightly lower percentage than the TEOAE. For example, in Shiomi et al.19, the mean amplitudes of the DPOAE were significantly decreased in tinnitus patients with normal hearing than in normally hearing controls.
One possible explanation for this finding is that it may be due to OHCs hypersensitivity, as reported in some previous research.
Abnormal TEOAEs and DPOAE in the tinnitus patients also imply that they may have subtle cochlear damage that is not yet appearing on the audiogram.
This finding might suggest that both tests were sensitive to detect minor OHCs dysfunction.
Unexpectedly, the use of a TEN test in the current study has led us to find an acoustic neuroma in a patient.
Sincere thanks to Ministry of Higher Education (MOHE), Malaysia, Universiti Kebangsaan Malaysia (UKM) and University of Bristol for providing sponsorship to pursue this PhD study. Program Audiologi, Pusat Pengajian Sains Rehabilitasi, Fakulti Sains Kesihatan - Universiti Kebangsaan Malaysia - Kuala Lumpur - AC - Malaysia.
We tested the effectiveness of WST using non-notched broadband noise and noise of water as control sound therapies.
Tinnitus is thought to consist of an abnormal neural activity of the auditory pathways [1]. In addition, though Jastreboff and Jastreboff [7] claimed that all types of tinnitus and intolerance to sounds can be beneficially treated with TRT, intolerances toward the wearable acoustic prostheses delivering the masking auditory stimuli (noise generators) have been reported, presumably owing to the annoyance caused by stimulation of the patient with frequencies similar to that of the tinnitus [8].
All participants were provided with informed consent, previously approved by the Ethics Committee of the School of Medicine of the University of Parma, before starting the therapy.
Some patients (~25%) experienced difficulty in performing reliable comparisons because of the markedly different perceptual quality of pure tones as compared to that of their tinnitus.
Comparison tones (or NBN segments) were presented consecutively for a few seconds at the interstimulus interval of about 1 second.
In a subject reporting the tinnitus only, or predominantly, in one ear, the comparison tone was presented contralaterally, whereas if the intensity of the subject's tinnitus sensation was similar in both ears, the tone to be matched was presented bilaterally. In our case, the use of pure tones facilitated the comparison of tinnitus pitch among subjects receiving different acoustic therapies and the tracking of its variation across time (see later).
During each tone sweep, the subject was asked to manually adjust the amplitude knob of the switchboard so as to keep the tone loudness approximately similar to the loudness of the tinnitus. Usually subjects reported more than one tone as matching the pitch of their tinnitus during both the upward and downward sweeps. In the latter case, subjects were asked to choose which one between the two tones (one having double the frequency of the other) best matched their tinnitus pitch. The noise sequence was band-passed from 50 Hz to 15 kHz and equalized to compensate for the low-frequency bias of the frequency response of the earphones used for sound stimulation (see later). The acoustic stimulation of the WN sound therapy was white noise in the frequency range 0.05-15 kHz equalized as shown in the figure to compensate for the poor low-frequency response of the earphones (see Methods section for details).
These procedures aimed at obtaining a balanced design with an approximately equal number of subjects treated with the experimental therapy and with the control therapies (WN or Wa) and, at the same time, avoiding any possible bias in the process of data collection owing to, for example, the differential treatment of patients by the experimenters because of the type of therapy assigned. These noncompliant patients were not counted in the analysis, thereby reducing the sample to 49 patients. For each visit, we noted the number of days (dd) elapsed from the date of the start of therapy (usually within 1 week from the first visit) and the date of the control visit. This was necessary to ensure that each patient contributed only one measurement value (if available) to the class mean value. Of the 49 patients who started acoustic therapy, 2 in the WWN group, 3 in the WN group, and 1 in the Wa group withdrew before the first control visit. However, in the WWN group, the decrease was large (about -12 dB, corresponding to approximately a 75% decrease), whereas in the two other groups, the decrease was negligible (around -2 dB, corresponding to approximately a 10% decrease). By contrast, in two patients receiving the control therapies, tinnitus intensity was initially increased by about 5 dB, showing only minor fluctuations during subsequent control visits. Decibel units on the y-axis are mean values (+1 SE) of ∆dBt computed for three subsequent temporal classes using dBt measurements in subsequent control visits of the same patient. 4 for an example) and no change of tinnitus loudness in the subject who was initially assigned to the WN therapy. Thus, our sound therapy (WST) was tailored to the frequency characteristics of patients' tinnitus. Indeed, analysis of the percentage of those withdrawing from each treatment group indicates that the WN therapy is the least tolerated, whereas the WWN therapy is the best tolerated by patients.
Third, in a few patients reporting subjective beneficial effects by the Wa therapy, the measure of the tinnitus loudness did not vary appreciably over the study period. The purpose of TRT is the reduction of the alarm reaction associated with the tinnitus sensation by altering the connections between the limbic and autonomic nervous systems (responsible for the alarm reaction) and the auditory system [5].
Conversely, tinnitus pitch is often located inside the hearing loss region toward the audiogram's edge frequencies, a phenomenon having strong analogy with the one described for the occurrence of the Zwicker tone using notched noise [22].
A comparison of variability among measurements of subjective tinnitus and objective stimuli. Psychoacoustic characterization of the tinnitus spectrum: Implications for the underlying mechanisms of tinnitus. Acoustic communication in two freshwater gobies: Ambient noise and short-range propagation in shallow streams.
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.
Only one patient was found with a positive TEN test result, who was confirmed by Magnetic Resonance Imaging to have acoustic neuroma on the affected ear. The last half of the twentieth century saw considerable advances in our understanding of tinnitus from both physiological and psychological perspectives. It has been generally accepted that any severe damage along the auditory system may lead to a certain degree of hearing loss, which is generally associated with tinnitus5,6. Moreover, the incidence of tinnitus in patients with sensorineural hearing loss varies widely across studies.
These observations may have several indications, such as hearing loss is not necessary in tinnitus generation, pure tone audiogram does not always indicate auditory damage, tinnitus may be a primary symptom of diseases that are only diagnosed after the occurrence of hearing loss, or several mechanisms exist in a group of patients. The different functionality of outer and inner hair cells can also cause imbalanced activity in the dorsal cochlear nucleus which in turn causes changes at higher levels of the auditory system that may be perceived as tinnitus1. In some studies, lower amplitude of TEOAEs13,16 or DPOAEs13,17-19 have been observed in tinnitus patients compared to in non-tinnitus controls. All participants had no history or current external and middle ear problem, noise exposure and psychiatric problem.
In this experiment, a 2f1 - f2 distortion product was used because of its established clinical value. This off frequency listening occurs when the targeted area of inner hair cells or neurons are not functioning well and is referred to as a dead region27.
In this case (Subject RX), the TEN (HL) test revealed that dead regions might exist at 1.5, 3 and 4 kHz on the left ear (Table 7). Since all the subjects in this study had normal hearing, the decrease in the TEOAE and DPOAE finding may possibly be considered as the effect of cochlear dysfunction of the cochlear active mechanism, which is related to OAE generation. Frequency analysis also showed that a significant decrease in DPOAE amplitude was mainly at the f2 frequency of 4000 to 7000 kHz. Therefore, the hearing status of these patients should be monitored for possibility of developing hearing loss later in life. Previous research has clearly demonstrated that OAE may be used to reveal subclinical OHCs damage in audiometrically normal ears13-15. Apart from difficulty hearing in background noise, she did not have any other classical symptoms of acoustic neuroma such as balance problem or poor speech discrimination scores. Firstly, it implies that a TEN test may offer a quick, inexpensive and non-invasive method for retrocochlear screening. In their study, they found 7 out of 8 auditory neuropathy patients with abnormal TEN test results. The finding also supported the possible clinical advantage of the TEN test as a screening tool for retrocochlear problem. Risk factors for tinnitus in a population of older adults: the blue mountains hearing study.
Characteristics of tinnitus and etiology of associated hearing loss: a study of 123 patients. The more the worse: the grade of noise-induced hearing loss associates with the severity of tinnitus. Tinnitus with normal hearing sensitivity: extended high-frequency audiometry and auditory-nerve brain-stem-evoked responses. The effect of the number of averaged responses on the measurement of transiently evoked otoacoustic emissions in newborns. Dead regions in the cochlea: diagnosis, perceptual consequences, and implications for the fitting of hearing aids.
Transient and distortion product evoked oto-acoustic emissions in normal hearing patients with and without tinnitus. DPOAE in estimation of the function of the cochlea in tinnitus patients with normal hearing. Tinnitus and 2f1-f2 distortion product otoacoustic emissions following salicylate overdose. Ten(HL)-test results and psychophysical tuning curves for subjects with auditory neuropathy.
We found a significant long-term reduction of tinnitus loudness in subjects treated with notched noise but not in those treated with control stimulations. However, the physiological mechanisms and persistence of the sensation of the tinnitus have still not been fully clarified. Indeed, anecdotal clinical evidence suggests that the exacerbation of the tinnitus sensation by exposure to sounds comprising the tinnitus frequency is a common complaint from patients suffering from tinnitus.
Initially (first visit), each participant subject received an audiogram and tinnitus loudness and pitch-matching tests. In such cases, we instead used narrow-band noise (NBN) of one-third of an octave, having a pitch similar to the tinnitus frequency (according to patient judgment) of tones.
It must be stressed, however, that during the loudness-matching test, no effort was made to obtain the best match to tinnitus pitch, this being determined in a separate, experimental test (see later).
Of course, the perceptual quality of a tone stimulus seldom corresponds to subjects' tinnitus sensation. The frequency values identified by the subject in the two sweep tests were grouped and ordered from the lowest to the highest. It might happen that the patient was undecided about the two alternatives when these were of similar frequency. Wa stimulation was an 8-minute sequence of stream noise recorded underwater with a hydrophone placed close to a stream cascade [16] (see Fig. Patients were also asked to regulate the listening volume to a level approximately matching the loudness of their tinnitus. In such cases, the patient usually informed the experimenters about the change that occurred.
Six subjects felt annoyed by the therapy and refused to continue before the first control visit (see Results).
If these subjects are included in the total count of patients treated, the number voluntarily withdrawing from the therapy in the WWN, WN, and Wa groups amounted to three, four, and seven, respectively, the highest percentage being in the WN group (about 30% of subjects) and the lowest being in the WWN group (about 15% of subjects; Fig.
Figure 5 reports the variation of the mean value of ΔdBt, with time elapsed from the start of the therapy, for the three groups of patients. Decibel units on the y-axis are values of ∆dBt computed using dBt measurements in subsequent control visits of the same subject (date on the x-axis).
We tested the effectiveness of the therapy using two types of control sound treatments: nonnotched noise (WN) or waterfall noise recorded underwater (Wa).
However, the WWN group had the lowest percentage of those who withdrew (around 15% of subjects compared to 28% in the WN group and 23% in the Wa group) among the three treatment groups, suggesting that WST was the sound therapy best tolerated by patients (presumably owing to the lack of annoyance caused by the stimulation of the patient with frequencies similar to that of the tinnitus).
Thus, WST determined an objective and significant reduction of patient's tinnitus loudness and, hence, it appeared to be an effective sound therapy for the treatment of tinnitus. Therefore, to the extent that these differences might correspond to a different listening behavior by patients in relation to the sound therapy they received, the decrease of tinnitus severity observed among the group of patients receiving the WWN therapy could partly be explained by their (supposed) higher tolerance and stamina in motivation to listen to the therapy as compared to patients receiving the control therapies. Likewise, other patients treated with the WWN and reporting no subjective improvement of their tinnitus sensation showed in fact a decrease of tinnitus loudness measured over time. Therefore, the observed effectiveness of the WST in reducing tinnitus loudness appears consistent with the neurophysiological model of tinnitus underlying TRT [5].
One possibility is that Wa stimulation had poor masking effects on tinnitus in most patients, implying that the alarm reactions induced by tinnitus persisted in Wa-treated subjects.
Thus, a conceivable hypothesis is that a stimulation of the edge frequencies, but not the tinnitus region, by the noise frequencies just below the notched region has occurred during the listening of the WWN sound treatment. Objective: The objective of the investigation was to study the features of Distortion product OtoAcoustic emissions (DPOAE) in a group of tinnitus patients with normal hearing and to find out whether there is any difference in DPOAE findings in the tinnitus patients with normal hearing and in persons with normal hearing with no complaint of tinnitus. According to different reports, 85-96% of patients with tinnitus present with some levels of hearing loss and only 8-10% have normal hearing. 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.


More commonly, various studies have shown that sensorineural hearing loss plays an important role in tinnitus generation. Therefore, the absence of hearing loss on the audiogram in this group poses a serious challenge to the aforementioned theories in explaining tinnitus generation in tinnitus patients with normal hearing. In the study, they investigated the inner hair cells functions in 11 chronic tinnitus patients with normal hearing thresholds using Threshold Equalising Noise (TEN) test and found 8 of them with possible inner hair cells problems. The results were presented as a distortion-product audiogram i.e the amplitude of the 2f1 - f2 DPOAE was plotted against the f2 from 1000 to 6169 Hz. The broad band noise is designed to produce almost equal masked thresholds over a wide frequency range, for listeners with normal hearing and hearing impairment but without dead regions28.
The abnormal TEOAEs in the tinnitus group were present for 1 and 4 kHz mostly, while in the control group, the abnormalities were mostly at 4 kHz. A t-test revealed that with regard to mean amplitude of TEOAE for tinnitus ears, there were no statistically significant differences for all frequencies tested (p > 0.05). Later, the mean amplitude of DPOAE for tinnitus and control ears against the corresponding f2 was compared. From 20 tinnitus patients with abnormal OAEs, 13 of them exhibit either failed TEOAE or DPOAE results. According to this theory, discordant dysfunction can occur without affecting the audiometric hearing thresholds when the OHCs are partially damaged and where the IHCs are intact. Stated differently, abnormal or poor OAE results may be the indicator of subtle cochlear damage before the abnormality affects hearing sensitivity and appears on the audiogram. Thus, the similar findings indicate that DPOAE measurement can offer a frequency specific measurement for the detection of subtle localised cochlear damage even before affecting pure tone thresholds34.
The high percentage of TEOAE abnormality at 4 kHz for the control ears may suggest that the hearing status of these participants also needs to be monitored. Nonetheless, only the difference between numbers of abnormal TEOAE in tinnitus and control ears reached a statistically significant level.
The former study suggested that tinnitus generation in their group of participants may be due to the effect of deafferentation of the neuron.
Secondly, tinnitus patients may have a serious problem that triggers the tinnitus perception despite having normal hearing thresholds and normal OAE test results.
Patients with auditory neuropathy are known to have problems with transmission of the auditory signal to the brain, thus abnormal TEN test results in this group of patients were assumed to be due to the neuron dysfunction. However, more research needs to be carried out in this area in order to support the current finding. These results point to the importance of the personalized sound treatment of tinnitus sufferers for the development of an effective tinnitus sound therapy. This observation has been the foundation of our approach to the treatment of tinnitus and the key element for the development of an effective personalized sound therapy. This may partly explain the high betweensession variability of pitch-matching measurements often reported in the literature [11-13].
Therefore, before testing the patients for the first time, they were instructed in how to use the apparatus and make the tinnitus pitch-tone comparisons.
This occurred frequently, as many subjects identified matching tones of similar frequency during the upward and downward sweeps. We note that the distinction made here between single- and multi-pitched tinnitus was intended solely for the development of an appropriate tinnitus therapy; it may or may not have a relationship with the internal spectrum of the tinnitus. Therefore, the noise energy between the two broken lines is missing in the WWN sound therapy. In case of marked hearing loss in one ear, subjects were advised to regulate the listening volume using the ear of best hearing.
Conversely, the key feature of the WWN therapy is the construction of a noise window around the tinnitus pitch, implying that the window features should track any observed change (real or supposed) of the value of F t . Thus, sound stimulation of patients of the two control groups was not personalized on the basis of frequency characteristics of patient's tinnitus. Possible sources of between-session variability of pitch matches are, for example, the multipitched nature of many tinnitus percepts [13], the change of tinnitus pitch with time after application of the sound therapy [10] (Lugli et al., unpublished data), or judgment errors by patients.
However, the observation that many of these subjects experienced tinnitus relief by listening to the water noise soundtrack (Lugli et al., unpublished data) does not support this interpretation. In addition, activation of the mechanism underlying the Zwicker tone must have occurred in patients listening to the WWN treatment, although none of them reported such an aftereffect, presumably because of the pitch similarity between the Zwicker tone and the tinnitus percepts. In this last group, the isolated presence of tinnitus indicates that it may be an initial first symptom of diseases that are only diagnosed after the onset of hearing loss. 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. Evidence showed a higher incidence of tinnitus patients with sensorineural hearing loss compared with conductive hearing loss7.
In addition, not all individuals with hearing loss experience tinnitus, and not all tinnitus patients have hearing loss. While the theories seem cannot fit in this minority group, evidence obtained from this group may have huge implication for a better tinnitus mechanisms understanding as well as assist in developing and shaping tinnitus management. The studies reported that tinnitus subjects were found to have increased TEOAEs20,21 or DPOAEs22,23 compared with non-tinnitus counterparts. Thabet25 attempted to replicated the earlier study by investigating 20 normally hearing unilateral tinnitus patients with TEN test and TEOAE. The presence of DP amplitude was accepted as valid when the signal to + 2 SD noise floor ratio exceeded 3 dB and the absolute DPOAE amplitude was at least - 10 dB SPL at each individual f2. Table 2 shows the normal and abnormal TEOAEs at each frequency tested in both the tinnitus and control group.
Generally, an independent t-test showed no statistically significant differences observed between tinnitus and control ears at all frequencies except for frequency 1414, 4757, 5187 and 6169 Hz (Table 5). Meanwhile, from 16 control ears with abnormal OAEs, 10 ears exhibit either failed TEOAE or DPOAE results. The ABR showed absent wave V at 70 dBnHL in the left ear and normal ABR waveforms in the right ear, which were correlated with the TEN test results, suggesting of abnormal neural function. Therefore, in this current study, we sought to determine whether the measurement of TEOAE and DPOAE may reveal subtle cochlear abnormality in tinnitus patients with normal audiometric thresholds. Although the difference between numbers of abnormal DPOAE in tinnitus and control ears failed to reach a significant level, mean amplitude of tinnitus ears at frequency region of 2000 and 4000 Hz were statistically significantly lower than the control ears.
They suggested that it could be the result of reduced afferent input to the central auditory system due to cochlear lesion, thus resulting in a decreased OHC efferent activity and ultimately leading to OHC hypersensitivity. TEOAE measurement stimulates the whole basilar membrane of the cochlear, which means it gives more global information. Furthermore, dead regions normally exist in those who have hearing thresholds of 60 dB HL and above28.
In other words, even though dead regions normally exist in patients with hearing loss of more than 55 dBHL, normal hearing people can also have a 'dead region' which may be due to retrocochlear abnormality. Similarly, the abnormal result in Subject RX in the current study may also be because of the problem in neurons rather than in the inner hair cells. MRI revealed a large vestibular schwannoma in the left cerebello-pontine angle which was compressiong the brainstem and cisternal portion of the VIIIth cranial nerve.This study showed that subtle cochlear problem may exist in tinnitus patients before it is significantly appeared in the audiogram. In addition, no treatment can be considered efficacious in providing longterm relief from tinnitus in comparison to placebo [2]. In such cases, the operator continuously varied the knob of the tone generator within the narrow band delimited by the two frequency values to allow the subject to identify the tone best matching the tinnitus pitch. Hence, our results cannot be compared with those of studies trying to assess the form of the tinnitus spectrum [13].
As compared to the waterfall noise recorded in air, the waterfall noise recorded underwater is characterized by greater energy content at lower frequencies and larger amplitude and frequency modulation [16]. In the Wa sound therapy, most energy is concentrated in the lower part of the spectrum (bottom spectrum = mean spectrum of the 8-minute sequence of waterfall noise; see Methods). Thus, ideally, patients subjected to the WWN therapy should receive a new windowed noise sequence almost each time at every control visit. Thus, the overall number of subjects available for the comparative analysis of data was of 43 patients, of whom 20 were treated with WWN, 11 were treated with WN, and 12 were treated with Wa.
We did not attempt the chi-squared analysis of the proportion of those who withdrew in the three groups owing to the low number of those who withdrew, expected in each group under the null hypothesis. Though the reliability of the method of pitch assessment proposed here awaits further testing before being asserted, our findings nonetheless point to the type of pitch-matching procedure adopted as a major factor responsible for the unreliability of pitch estimates documented in the tinnitus literature [18]. These facts do not support a supposed presence of marked differences in the at-home use of the therapy by patients of different treatment groups.
One or both of these phenomena might have determined a reorganization of the neural activity of the edge frequencies resulting in the observed longterm reduction of the tinnitus percept in such patients. We also thank all personnel in the audiological laboratory of the University of Parma for their invaluable contribution to the collection of clinical data. The subject group consisted of 16 ears of patients, in which 6 subjects were having tinnitus in both ears while 4 subjects were having tinnitus only in one ear.
The origin of tinnitus in this group is still more obscure than in those with concomitant hearing loss. 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]. Jastreboff & Jastreboff11 reported that about 27% of totally deaf patients do not have tinnitus, whereas 20% of normal hearing people have tinnitus. This is because the results obtained from this special group may directly related to the tinnitus perception, but not to the concomitant hearing loss. The test was performed in a sound treated room where the ambient noise was maintained between 20 to 40 dB A. The difference between the two groups is highly significant at frequencies of 1, 1.5 and 2 kHz, but not at 3 and 4 kHz. The decrease in DPOAEs amplitude over a limited frequency range in DP-gram found in tinnitus patients with normal hearing may be a susceptible area representing minor cochlear pathology.
Similarly, a more recent study by Sztuka et al.35 attributed the increase in DPOAE amplitude in tinnitus patients with normal hearing as a result of increased motility of the OHCs due to decreased neural activity in the auditory nerve. Conversely, the number of abnormal DPOAE in tinnitus ears was not statistically significantly different from the controls. They found that outer hair cells damage (assessed by TEOAE) was more common in normally hearing tinnitus patients than inner hair cells damage.
In this case, the positive TEN (HL) results may not be due to inner hair cells damage but maybe because of poor processing efficiency that is associated with neural problems due to compression of large vestibular schwannoma on the VIIIth nerve38.
However, caution should be taken in interpreting the TEN test results as 10 dB-above-thresholds criteria is just a binary criteria that means passing or failing the TEN test, but does not mean dead or not dead. Hence, the width of the band-stop filter amounts to 1,377 Hz, being 5,462 Hz and 6,838 Hz, respectively, the lower and upper frequency extremes of the band, with the center frequency at 6,150 Hz.
This is admittedly tedious and perhaps of little therapeutic significance when the re-measured value of F t is similar to the last one determined in the previous session. To explore the efficacy of the WWN therapy further, three Wa subjects and one WN subject were chosen among the group of patients reporting no relief from the therapy and were asked to abandon the assigned therapy and to start with the WWN therapy.
Finally, 7 of the 20 patients treated with WWN were given one (n = 5) or two (n = 2) updated WWN treatments during the study period (see Methods for details). Hence, the lack of direct control by the experimenters over the patient's at-home listening behavior was unlikely to be a factor potentially affecting the main conclusion of this study about the effectiveness of the WST therapy in the treatment of tinnitus. All subjects were aged between 20 to 60 years with complaint of tinnitus with audiometrically normal hearing. Because the vestibular organ shows rhythmicity, the responses that are averaged are phase-locked to a harmonic of an individual response frequency.
Generally, we observed a vestibular pattern of voltage changes during raised intracranial pressure [4]. We digitized raw data from the electrodes and plotted as voltage amplitude versus time using a medically rated analog-todigital converter. This suggested that interference from muscle activity or contamination by the semicircular canals can possibly be ignored; when using a tilt table, they could be avoided. Conversely, a positive Dix-Hallpike maneuver indicates only that otoconia have found their way into a semicircular canal.
It can be assumed that the role of sensorineural hearing loss as a tinnitus generator is complex and the mechanism of tinnitus may rely on the presence of other contributing factors such as damage to specific hair cells or the auditory nerve fibers. This appears to support the hypothesis that a reinforced mechanical distortion is generated by cochlear hyperactivity that can be the source of the tinnitus. DPOAE is more frequency specific and thus is expected to be more sensitive in detecting subclinical abnormality in cochlear function over TEOAE. Their finding supports the theory that outer hair cells abnormality may be an important factor in the tinnitus mechanism37. For this reason, more research needs to be carried out on the clinical benefit of the TEN test before applying this method clinically. The procedure was repeated until the tone identified up to that point was compared with the highest tone (F n) of the sequence.
Cursory examination of pitch match position in relation to the patient's audiogram showed that the matches were frequencies above that at the beginning of the region of hearing loss on the audiogram. The control-toexperimental therapy shift occurred after 3-7 months from the beginning of the experiment.
Control group was comprised of 16 audiometrically normal hearing ears of persons who were age and gender matched with the subject groups and had no complaint of tinnitus.
If the OHC of the human cochlea are to be involved in the generation of tinnitus, testing of otoacoustic emissions (OAEs) could provide a reliable means of recording OHC dysfunction. 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.
By contrast, in other cases, TEOAE and DPOAE results showed poor or absent emissions in tinnitus patients with sensorineural hearing loss, even in those ears with normal hearing16,19,36. In this current study, the result may possibly be due to subtle cochlear abnormality also existing in non-tinnitus participants with normal hearing.
However, results from both studies may be more compelling if they included a retrocochlear test.
The goal is the reduction of subjects' tinnitus perception by providing competing auditory stimuli masking the tinnitus. This observation agrees with results by earlier and recent studies on the relationship between tinnitus pitch and hearing loss [9]. The TEN test appears to be a potential non-invasive and quick test of inner hair cells function. The mean pure tone audiometric thresholds of tinnitus and control groups are shown in Table 1. The tumour was compressing the brainstem and cisternal portion of the VIIIth cranial nerve. These variations can be explained by postulating that it is most likely to reflect different cochlear mechanisms underlying tinnitus generation due to different cochlear pathological changes in tinnitus ears37. The result of the current study is consistent with Thabet's study in which only one subject was found with a dead region, on the left ear. DPOAEs can be recorded with better reliability at higher frequencies than transient evoked OAE.
We displayed ratios for the utriculus and sacculus to classify the shape of the data distribution. Nonetheless, it is too early to make a conclusion based on the aforementioned two studies on tinnitus. An independent t-test revealed that there was no significant difference in hearing thresholds between tinnitus patients and controls at all frequencies except at 6 and 8 kHz.
Thus, the variability of findings in this study may possibly be because of different mechanisms existing in the normally hearing tinnitus patients.
According to Jastreboff37 however, there are different levels of dysfunction from the OHC up to the higher auditory pathways. However, no firm experimental evidence supports the effectiveness of these methods in the long term: an objective reduction of the loudness of the tinnitus or the complete recovery from tinnitus. Result and conclusion: It was observed that the amplitudes of DPOAE were significantly lower in tinnitus patients than that of persons without complaint of tinnitus, at a frequency of 1281-1560, 5120-6250, 7243-8837 Hz, which imply that decrease of DPOAEs amplitudes may be related to the presence of tinnitus. 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.
At both these frequencies, tinnitus patients had significantly higher thresholds than control individuals. He hypothesised that in some patients, though the level of dysfunction is undetectable by TEOAE, it may be sufficient to produce tinnitus.
Therefore, this study aimed to investigate subtle cochlear abnormality in tinnitus patients with normal hearing thresholds using evoked OAEs (TEOAEs and DPOAEs) and TEN test. Contrarily, in some, the level of abnormality is detectable but not enough to trigger tinnitus.
Therefore, Jastreboff's hypothesis is a possible explanation as to why not all hearing loss patients present with tinnitus, and not all tinnitus patients present with hearing loss. At the beginning of the study, random selection of patients with tinnitus of different age groups and both gender was done during the period of 6 months (January 2012 to June 2012). Study group Consisted of 10 patients, aged ranges between 20 and 65 years complaining of tinnitus with audiometrically normal hearing, among them six were having bilateral and four were having unilateral tinnitus (n: 12 + 4 = 16). Control group Consisted of 16 normal hearing individuals without tinnitus with pure tone average <25 dBHL in the better ear. Recording was done from 16 ears of the selected patients with tinnitus (the study group) and 16 ears of audiometrically normal hearing individuals without tinnitus (the control group). There are some differences in the mean DPOAE amplitude levels between the study and the control groups. Tinnitus in turn, which is an unpleasant sound, may act as a noise which resulted in a decrease of the DPOAEs amplitudes due to increase in the internal ear noises heard by the patients as ringing noises.
This noise is one of the factors that result either in the absence or decrease in DPOAEs amplitudes. In the presence of these results, tinnitus masker could be a good solution for the relief of annoyance resulted from tinnitus. Here, we would like to focus one more fact that a decrease of the DPOAE amplitude is not only a result of a cochlear insult. Efferent innervation of OHC is by the olivo cochlear neural pathway which is comprised of efferent neurons that travel from the superior olivary complex in the brainstem to cochlear hair cells. Measurements of efferent effects on OAEs have been made with efferent activity evoked by brainstem shocks or by sound in the opposite ear.
Various investigations have supported the conclusion that medial olivo cochlear system activity turns down the gain of the cochlear amplifier.
DPOAE suppression is greatest when using contralateral stimulation tones close to primary tone f2. However, in our present study, we successfully determined a statistically significant difference in three frequencies out of eight total tested frequencies. More information can be obtained using a larger sample size which will add to the knowledge about the possible link of OHC functioning and tinnitus. Thus, it can be hypothesized that there is an association between tinnitus and reduced cochlear OHC activity which indicate that the OHC of the cochlea are involved in the generation of tinnitus.
However, studies with larger patient series would be required in order to strengthen the hypothesis.



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