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06.01.2015

Tinnitus test, what is ringing sound in ears - PDF Review

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A ringing, swishing, or other noise in the ears or head when no external sound is present is called tinnitus. In rare cases, tinnitus can be a symptom of a serious medical problem such as a brain aneurysm or acoustic nerve tumor. To diagnose tinnitus, a doctor will do a physical examination and ask you about your history, including whether the tinnitus is constant, intermittent, or pulsating (like the heartbeat, called pulsatile tinnitus), or if it is associated with hearing loss or loss of balance (vertigo or vestibular balance disorders). Treatment for tinnitus depends on the underlying cause and may include medications in addition to home remedies.
Key words: compensation, hearing disorders, loudness matching, loudness perception, malingering, pitch matching, pitch perception, rehabilitation, reliability of results, tinnitus, tinnitus diagnosis. Abbreviations: ANOVA = analysis of variance, HL = hearing level, LM = loudness match, PM = pitch match, PVAMC = Portland VA Medical Center, SD = standard deviation, SL = sensation level, SPL = sound pressure level, TES = Tinnitus Evaluation System, VA = Department of Veterans Affairs, VHA = Veterans Health Administration. Chronic tinnitus is the persistent sensation of hearing a sound that exists only inside the head. Special audiological tests are effective in detecting deliberate exaggeration of hearing loss [10-11], but no documented test exists that is capable of detecting the presence or absence of tinnitus.
Any type of audiometric test for tinnitus diagnosis may rely at least partly upon the demonstration of response reliability. We completed a pilot study to investigate the potential for LM functions to detect differences between 12 subjects with tinnitus versus 12 subjects without tinnitus [16].
Study inclusion criteria were intended to identify two groups of individuals: those who experienced chronic tinnitus (tinnitus subjects) and those who did not experience tinnitus (nontinnitus subjects). Following the conventional hearing threshold evalua-tion, subjects completed a baseline questionnaire that asked their age, sex, veteran status, and tinnitus status. To ensure that the tinnitus and nontinnitus groups exhibited approximately the same degree of hearing loss, we matched subjects by hearing loss with respect to both their low (0.5, 1, 2 kHz) and high (3, 4, 6 kHz) frequency average hearing thresholds (in decibel HL). Audiometric testing was conducted in a double-walled sound-attenuated suite (Acoustic Systems Model RE-245S, ETS Lindgren; Cedar Park, Texas).
The TES Module also serves as a control device (user interface), enabling patients to easily control stimulus parameters and respond to tests.
All-new programming was required to support the new platform and to create new testing capabilities. All testing data are stored via connectivity to a Microsoft Access database (Microsoft Corp; Redmond, Washington). The management interface is used to manage patient information, create and configure test session templates (preconfigured test scenarios), launch test sessions, and report on test results. As a single integrated device with earphones (ER-4B, Etymotic Research, Inc; Elk Grove Village, Illinois) permanently attached, the TES Module is calibrated independently in the laboratory and then sent out to a testing site. Prior to conducting the tinnitus matching tests, we carefully instructed the nontinnitus subjects to ensure that they responded to all testing as if they were attempting to prove that they did in fact experience chronic tinnitus. Tinnitus matching requires patients to make a clear distinction between the tinnitus perception and the matching tones. This sequence of testing (average hearing threshold followed by average LM) was then repeated at the next higher test frequency (1,260 Hz) followed by the remainder of the test frequencies in ascending order.
When hearing thresholds and tinnitus LMs had been obtained at all 13 test frequencies, on-screen instructions were shown to explain the PM task.
The previously described testing was conducted during two sessions that were at least 3 days apart.
Within- and between-session correlations were computed for the dB SPL LMs and compared between the tinnitus and nontinnitus subjects. Within-subject PM variability (five observations for each of the two tests within the two test sessions) was pooled within and across subjects and compared between the tinnitus and nontinnitus subjects on the premise that subjects with tinnitus would exhibit less variability in pitch matching.
Demographic and audiometric characteristics of tinnitus subjects (n = 36) and nontinnitus subjects (n = 36). Tables 2 and 3 show the LM means (and standard errors) in decibel SPL and decibel SL, respectively, for the sessions and runs in the tinnitus and nontinnitus subjects for 1 to 16 kHz. Across-subject mean loudness matches (dB sound pressure level) for tinnitus subjects (n = 36) and nontinnitus subjects (n = 36).
Across-subject mean loudness matches (decibel sensation level) for tinnitus subjects (n = 36) and nontinnitus subjects (n = 36).
Table 4 shows the within-session LM correlations (between two test runs on the same day) for the tinnitus and nontinnitus subjects for 1,000 to 12,700 Hz. Within-session loudness-match correlations (decibel sound pressure level) for tinnitus subjects (n = 36) and nontinnitus subjects (n = 36). Medications may be prescribed in some cases, often to treat the psychological effects of anxiety or depression that may accompany the tinnitus.
Pushing a swab into the ear can cause the wax in the ear canal to become impacted against the eardrum, causing tinnitus. Ascertaining the presence of tinnitus in individuals who claim tinnitus for compensation purposes is very difficult and increasingly becoming a problem. That is, the validity of any response depends upon its reproducibility; thus, response reliabili-ty is expected to be an important component of any test developed to assess the presence of tinnitus for claims purposes.
Testing was done using a computer-automated program that had recently been modified to allow more patient control of test stimuli (through the use of a handheld control pad device). Essentially the same protocol was used, except this study used a computer-automated testing system that was completely redesigned for improved functionality. As part of the informed consent process at the start of the appointment, all candidates were told that the study was being conducted to determine the effectiveness of a new technique for measuring various aspects of tinnitus.
Subjects with tinnitus completed a written tinnitus questionnaire in which they reported the length of time they had had tinnitus, whether their tinnitus was tonal or nontonal, and whether their tinnitus was binaural or unilateral. We used the latest version of our computer-automated testing system that has undergone several revisions over a period of 10 years [16-19].
This is done most easily if the stimulus in one ear is compared to the tinnitus in the contralateral ear [21-22].


Before testing began, the program presented a series of screens describing the general testing procedures, followed by specific instructions for hearing threshold testing.
Each test frequency was presented at the output level previously selected as a tinnitus LM during the threshold and LM testing. Two test runs (thresholds, loudness matching, and pitch matching) were conducted within each session. A repeated measures analysis of variance (ANOVA) was used to assess the difference in LMs (dB SPL and dB SL) between the tinnitus and nontinnitus subjects across the four tests. This analysis was motivated by the expectation that the correlations between the two tests within a session and the correlations between sessions would be greater for the tinnitus subjects than for the nontinnitus subjects and would represent more consistent responses for the tinnitus subjects. With one exception (10,080 Hz), mean SPL LMs were consistently greater for nontinnitus than for tinnitus subjects. Most cases of tinnitus are subjective, but occasionally the tinnitus can be heard by an examiner. Other tests include an auditory brain stem response (ABR), a computerized test of the hearing nerves and brain pathways, computer tomography scan (CT scan), or magnetic resonance imaging (MRI scan) to rule out a type of rare tumor. Nicotine in tobacco products may reduce blood flow to the structures of the ear, leading to tinnitus. This study examined the potential to observe differences in loudness and pitch matches between individuals who experience tinnitus versus those who do not.
Epidemiology studies reveal that between 10 and 15 percent of all adults experience chronic tinnitus [2-7]. Because so many parameters of tinnitus are capable of being measured, any of those parameters could potentially be used for repeated testing to evaluate a tinnitus claim. Candidates with tinnitus were told that they had been invited to participate in the study because they had tinnitus that was constant and therefore could be measured.
The system enabled direct patient control of certain stimulus parameters during testing to make testing more efficient.
For most of the tests, the computer presents a starting sound and the patient turns a dial on a peripheral hardware device (TES Module) to control output level, frequency, or bandwidth of the sound.
The peripheral hardware device (TES Module) was developed to enable specialized auditory tests. The TES control pad includes a continuous rotating encoder dial that provides a single-point adjustment of a parameter of interest (programmable and determined according to the particular test or test phase). Information about test parameters is stored in an Access database, which also determines which tests to run for each session and provides parameters to control the hardware behavior. The TES uses decibel SPL because normative hearing threshold levels have not been established for frequencies above 8 kHz and because the earphones used with the TES have not been documented for conventional audiometric testing of hearing sensitivity.) Testing started when a hearing threshold was obtained at 1 kHz. Otologic problems, especially hearing loss, are the most common causes of subjective tinnitus. In the past the supplement niacin was recommended or the drug gabapentin (Neurontin, Gabarone) was prescribed but both have been shown to have no effect on reliving tinnitus. This study follows a previous pilot study we completed that included 12 subjects with and 12 subjects without tinnitus.
The basis for awarding a tinnitus disability is that the tinnitus is (1) at least recurrent (intermittent) and (2) related to military service [8-9].
Jacobson et al., however, reported results from an experiment that showed test-retest reliability of LMs to be similar between individuals with and those without tinnitus [13]. The key is to determine which test, or combination of tests, will be most effective in accomplishing this purpose. No other screening criteria were applied because the intent was to simulate real-life individuals who might be attempting to claim the presence of tinnitus. Candidates who did not have tinnitus were told that they could represent individuals who might want to claim tinnitus when they do not actually experience it. The present fifth-generation system is referred to as the Tinnitus Evaluation System (TES). Patient responses made with the TES Module encoder dial and response buttons are recorded to the same database from which the test session parameters are read. The management interface presents configuration options through the test session configuration dialogs, in which tests and their parameters can be preset into session templates to allow an operator to easily run many patients through the same battery of tests. A testing interface program checks the device's calibration time stamp and compares it with the one already stored in the database. Subjects determined on their own how they would respond in a consistent manner in spite of their nonexistent tinnitus. They were queried to ensure that they understood that they would be matching tones in one ear to an imagined tinnitus in the contralateral ear. To ensure that the subjects understood pitch and loudness, we included a series of instruction screens that explained the concepts prior to performing tinnitus loudness matching.
Tinnitus and nontinnitus subjects were similar in age, sex, veteran status, and mean hearing thresholds (Table 1). SL LMs were essentially equal between the tinnitus and nontinnitus subjects across the frequencies. The number of tinnitus disability claims has increased dramatically during this decade (Figure 1). The only difference was that individuals without tinnitus generally provided LMs at higher levels. Tinnitus loudness matching has been shown to be very reliable with tinnitus patients, but the Jacobson et al. Reliability of the LMs was at least as good for the nontinnitus group as for the tinnitus group, both within and across sessions. Any screening criteria other than the presence or absence of tinnitus might have introduced bias to the samples.
Testing sessions can then be launched by selecting a patient record and preconfigured template.


If newer calibration data are available, they are downloaded from the TES Module, saved in the database, and used in testing to provide calibrated stimulus levels. If the tinnitus was perceived to be symmetrical, then the stimulus ear was determined randomly. In session 2, the tinnitus subjects showed significantly greater correlations in 4 of the 12 frequencies.
As of October 2008, 558,232 veterans had been awarded tinnitus service-connection disability.* Among veterans returning from the Iraq and Afghanistan wars, tinnitus is the most common service-connected disability (67,689 veterans in 2008). In addition, pitch matches (PMs) were obtained from each subject, which involved subject selection of the frequency that most closely matched the pitch of the tinnitus from the different test frequencies.
The operator can override the template tests' default values of some parameters on a per-session basis. Between-group differences revealed that the tinnitus subjects had (1) greater decibel sound pressure level loudness matches, (2) better between-session loudness-match reliability, (3) better pitch-match reliability, and (4) higher frequency pitch matches. These concerns have prompted our overall effort to develop tests that can help ensure that a tinnitus disability is accurately rated and that allow for reexamination whenever a need exists to verify the continued existence of tinnitus. A special test template was devised to enable the device to be calibration-checked on-site at regular intervals. These findings support the data from our pilot study with the exception that decibel SL loudness matches were greater for the tinnitus subjects in the pilot study.
The result of pitch matching was that the mean PMs for the tinnitus group were significantly higher in frequency than for the nontinnitus group.
The reporting module of the management interface uses preformatted reports for presenting test results from the response database. Objective tinnitus usually is caused by vascular abnormalities of the carotid artery or jugular venous systems.
Tinnitus loudness and pitch matching may have some value in an overall battery of tests for evaluating tinnitus claims. Initial evaluation of tinnitus should include a thorough history, head and neck examination, and audiometric testing to identify an underlying etiology. Unilateral or pulsatile tinnitus may be caused by more serious pathology and typically merits specialized audiometric testing and radiologic studies. In patients who are discomforted by tinnitus and have no remediable cause, auditory masking may provide some relief. Epidemiologic data reveal that approximately one fourth of persons with tinnitus are discomforted by it, whereas the remaining three fourths experience the condition without significant symptoms.3Tinnitus takes different forms and has different classification proposals. One classification system stresses distinctions between vibratory and nonvibratory types, while another system groups the different forms of tinnitus into subjective or objective classes.Vibratory tinnitus is caused by transmission to the cochlea of vibrations from adjacent tissues or organs.
Nonvibratory tinnitus is produced by biochemical changes in the nerve mechanism of hearing.Subjective tinnitus, which is more common, is heard only by the patient.
Objective tinnitus can be heard through a stethoscope placed over head and neck structures near the patient's ear.The mechanism that produces tinnitus remains poorly understood. Tinnitus may originate at any location along the auditory pathway from the cochlear nucleus to the auditory cortex. Some leading theories include injured cochlear hair cells that discharge repetitively and stimulate auditory nerve fibers in a continuous cycle, spontaneous activity in individual auditory nerve fibers, hyperactivity of the auditory nuclei in the brain stem, or a reduction in the usual suppressive activity of the central auditory cortex on peripheral auditory nerve activity.4This article discusses the causes of subjective and objective tinnitus, and techniques used for evaluating tinnitus. It is continuous and less disturbing than the tinnitus of Meniere's disease.14Ototoxic medications or substances are another common cause of bilateral tinnitus. Temporomandibular joint disorder has been associated with vertigo and tinnitus, although the exact mechanism is unclear.Various metabolic abnormalities may be associated with tinnitus. These abnormalities include hypothyroidism, hyperthyroidism, hyperlipidemia, anemia, and vitamin B12 or zinc deficiency.Many patients with tinnitus exhibit signs of psychologic disorders.
Although tinnitus may be a contributing factor to the development of depression, the common association of tinnitus and depression may be the result when depressed patients, particularly those with sleep disturbances, focus and dwell on their tinnitus more than patients who are without an underlying psychologic disorder.OBJECTIVE TINNITUSObjective tinnitus is rare. Patients with objective tinnitus typically have a vascular abnormality, neurologic disease, or eustachian tube dysfunction.4Patients with vascular abnormalities complain of pulsatile tinnitus.
This type of tinnitus is a soft, low-pitched venous hum, which can be altered by head position, activity, or pressure over the jugular vein.4Congenital arteriovenous shunts are usually asymptomatic, while the acquired type often are associated with pulsatile tinnitus. The symptoms may disappear with Valsalva's maneuver or when the patient lies down with the head in a dependent position.Evaluation of TinnitusHISTORYThe evaluation of a patient with tinnitus begins by taking a thorough history.
Precipitous onset can be linked to excessive or loud noise exposure or head trauma.LocationUnilateral tinnitus can be caused by cerumen impaction, otitis externa, and otitis media.
Tinnitus associated with unilateral sensorineural hearing loss is the hallmark of acoustic neuroma.PatternContinuous tinnitus accompanies hearing loss. Tinnitus of venous origin can be suppressed by compression of the ipsilateral jugular vein.Specific testing for sensorineural or conductive hearing loss is the next part of the examination. In the Weber test, the tuning fork is struck and placed on the midline of the forehead, the nasal bridge, or the chin. Patients with normal hearing or equal deafness in both ears hear the sound at the same level in both ears.In the Rinne test, the tuning fork is placed against the mastoid process to measure the conduction of sound by bone. When the sound can no longer be heard, the tuning fork is placed in front of the auditory canal to test air conduction. A formal audiogram establishes a base from which to pursue more advanced diagnostic testing. Pure tone testing primarily tests the function of the peripheral portion of the hearing apparatus.
Patients with unilateral or pulsatile tinnitus are more likely to have serious underlying disease and typically merit referral to an otolaryngologist.2,5 A full clinical evaluation should precede radiologic studies. Because pulsatile tinnitus suggests a vascular abnormality, the preferred imaging study is contrast-enhanced computed tomography (CT) or magnetic resonance imaging (MRI) of the brain21 (Figure 2).



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