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N = 23), high-frequency gently sloping (N = 10) and high-frequency steeply sloping (N = 22). No cochlear dead regions detected in non-pulsatile tinnitus patients: An assessment with the threshold equalizing noise (sound pressure level) test.
Adding insult to injury: Cochlear nerve degeneration after temporary noise-induced hearing loss.
Identifying dead regions in the cochlea: Psychophysical tuning curves and tone detection in threshold-equalizing noise. A tone producing peak vibration at a particular place on the basilar membrane can be detected by off-place or off-frequency listening provided that the stimulus is sufficiently loud. The tone will not be detected at its usual place on the basilar membrane but at an adjacent place where the IHCs are functioning more effectively. This means that, for subjects with normal hearing thresholds, the masked threshold for a pure tone is the same for all frequencies over the range of 250-10 000 Hz. More specifically, the TEN level is specified as the level in a one-Equivalent Rectangular Bandwidth N (ERB N ) (132 Hz) wide band centered at 1000 Hz, where ERB N stands for the average of the auditory filter as determined for young normal-hearing subjects at moderate sound levels. Looking at the top panel, the solid curve represents the basilar membrane vibration pattern for a pure tone with a CF of.
The shaded area reflects the presence of a high-frequency DR starting at approximately 1.07 kHz. To measure absolute thresholds for frequencies below 1.07 kHz, 40 dB of basilar membrane vibration is needed (long-dashed line). As indicated by the short-dashed line, the absolute threshold value of a 1.5 kHz tone (which falls within the DR) is 67 dB.
A threshold is measurable because of the intact IHC's adjacent to the DR (= off-frequency listening). To make the tone audible again the level has to be increased so that basilar vibration just below the 1.07 kHz DR slightly exceeds 70 dB. This figure shows that for the person with a DR, the masked threshold was 30 dB higher than the unmasked threshold (97 dB vs.
This last remark demonstrates the two criteria that need to be fulfilled to determine a DR: (1) at least 10 dB of masking is required and (2) the masked threshold should be at least 10 dB higher than normal.
The TEN (HL) test is the modified version of the TEN (SPL), calibrated in dB HL which is easier to interpret as the audiometer is also calibrated in dB HL.
The frequency range of the TEN (HL) is narrowed to 250-4000 Hz and the TEN noise contains a lower crest factor. The present study aims to investigate whether cochlear DRs are more prevalent in patients suffering from tinnitus. Tinnitus, the perception of sound in the absence of an external acoustic sound source, poses a clinical problem for millions of people around the world.
One of the hypotheses on the etiology of non-pulsatile tinnitus is the existence of sharp edged cochlear DRs flanking normal functioning hair cells. 40 dB of basilar membrane vibration is needed (long-dashed line) in order to measure absolute thresholds below 1.07 kHz. The short-dashed line represents the absolute threshold value of a 1.5 kHz tone, which is 67 dB.


In case of a dead region, the intensity of the tone needs to be raised substantially in order to achieve audibility again. Twenty-two patients suffered from bilateral tinnitus while eleven patients perceived a unilateral tinnitus in either the right or left ear. Pure-tone audiometry All patients received visual inspection of the eardrum by an ORL-specialist.
In addition, tympanometry was normal in all subjects so middle ear pathologies were excluded. According to current clinical standards (ISO 8253-1, 1989), air conduction threshold were measured at 125, 250, 500, 1000, 2000, 3000, 4000, 6000 and 8000 Hz using a 2-channel Interacoustics AC-40 audiometer in a soundproof booth. All the patients included in this study had a normal hearing or a sensorineural hearing loss (SNHL) as the air-bone gap never exceeded 10 dB HL. For all the analyses only those ears in which tinnitus was perceived were included in this study. Tinnitus analysis A Dutch validated version of the Tinnitus Questionnaire (TQ), [12] was completed by the majority of patients (four patients did not complete the questionnaire).
Finally, tinnitus pitch and intensity were determined through tinnitus analysis using pitch matching and loudness matching procedures. Threshold equalizing noise (SPL) procedure The TEN (SPL) test was performed in all fifty-five tinnitus ears using an original TEN (SPL) CD played by a CD player (Sony CDP-XE270) and presented through a TDH-39 supra-aural earphone. Input channel 1 on the audiometer was selected on the left side, and channel 2 was selected on the right side. The first track on the CD, a calibrating tone, was played continuously and both volume unit (VU) meters were adjusted to read 0 dB.
Subsequently, the TEN was presented with a level of 70 dB and the masked thresholds were measured in a similar way.
In case the absolute thresholds of a patient were 60 dB SPL or worse, the level of the TEN was raised. Firstly, it may be impossible to produce 10 dB of masking in patients with severe or profound SNHL because the maximum output of the audiometer is reached. Secondly, when the TEN level was considered as too loud by the patient, the level was lowered and did not provide sufficient masking, leading to inconclusive results. A full tinnitus analysis was performed on 31 ears of 21 patients (10 with bilaterally tinnitus, 11 with unilateral tinnitus). The majority of patients experienced a high-pitched tinnitus and mostly a noise-like character. The tinnitus loudness was scored on a VAS by nineteen of the thirty-three patients (of which in 11 patients with bilateral tinnitus, the VAS was also scored bilaterally).
Tinnitus intensity was measured in 26 patients and 29 patients completed the TQ of which eight patients were categorized with a degree 1, 10 with a 2 nd degree, 9 with a 3 rd and 2 with a 4 th degree. Because of time shortcomings in the daily clinical practice, all (TQ, VAS and tinnitus analysis) were not always done completely. Therefore, [Table 1] and [Table 2] do not contain data of all ears of all patients on which the TEN (SPL) was applied.
In patients suffering from bilateral tinnitus, the TEN (SPL) test was performed in both ears.


As one of the criteria for a DR states that the masked threshold should be at least 10 dB worse than the unmasked threshold, no DRs were found in these patients. In one patient with a symmetric HFSS audiogram configuration and bilateral non-pulsatile tinnitus, the unmasked threshold could not be measured bilaterally upwards from 2 kHz because of audiometer output limitation as the unmasked threshold exceeded 120 dB HL. In three other patients with a HFSS configuration (two patients with bilateral tinnitus and one with unilateral tinnitus), the unmasked threshold were measured but the TEN noise could not be set loud enough to provide sufficient masking. Therefore the results in these patients remained inconclusive for a DR located in the high frequencies.
In the present study tinnitus patients with different audiometric configurations and hearing thresholds (going from normal hearing to profound hearing loss) were tested for DRs by use of the TEN (SPL) test.
In the study of Weisz et al., (2006) a normal hearing student population suffering from tinnitus was tested of which eight out of eleven subjects were identified with a DR. However, as mentioned earlier and elucidated in [Table 3], in four patients with a HFSS configuration, unmasked or masked thresholds could not be obtained in seven tinnitus ears because of audiometer output limitations. The problem of the amount of inconclusive results of the TEN (SPL) test has been previously reported by Hornsby and Dundas (2009) where in 80% of the ears inconclusive results were found for at least one frequency and 30% at three frequencies or more. Furthermore, as tinnitus analysis showed that most patients included in this study, perceived a high pitched tinnitus, we were especially interested in the cochlear preservation at those frequencies.
Thirty-two ears of the patients included in the present study, were characterized as a HFGS (N = 10) or a HFSS (N = 22) configuration. As mentioned before, patients with high-frequency steeply sloping audiometric configurations are more likely to have a DR in that area. As the present study aimed to assess the TEN (SPL) as a clinical tool for the explanation of tinnitus, the question arises whether cochlear DRs are necessary for a tinnitus percept. It has been shown that immediately after acute (impulse) noise trauma in military personnel, 88% of the soldiers perceived a noise-induced tinnitus. However, the fact that some patients with tinnitus had no DRs and some patients with DRs had no tinnitus supports the hypothesis that the presence of a DR is neither necessary nor sufficient to induce tinnitus. While the etiology of tinnitus remains elusive in many cases, research is needed in order to identify a possible causative factor. One of the hypotheses on non-pulsatile tinnitus is the presence of cochlear DR leading to central hyperactivity. If DR can be identified by use of the TEN test, the present study does not support the concept that DR are necessary for tinnitus. Therefore, the use of the TEN test as a diagnostic tool in a tinnitus population might be of limited value. The authors would like to point out that the present study does not designate the TEN test to be unreliable as a whole but as a result of the present findings the TEN test does not provide a useful tool in the diagnostics of tinnitus patients. Further research with the TEN test in tinnitus patients is necessary in order to confirm these findings.




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