VOLUME 12, NUMBER 3, SEPTEMBER 1987

THE AMERICAN TINNITUS ASSOCIATION

Abe Shulman, Jack Vernon, Gloria Reich; participants at the
/II International Tinnitus Seminar.
THIRD INTERNATIONAL TINNITUS
SEMINAR
by Susan Seidel, M.A.,CCC-A
Imagine if you will, sitting for three days from
sun-up til sun-down talking about Tinnitus! Few of
you share the excitement that I felt on June 11-13
when I was able to do just that with 180 others
whose primary professional interest is furthering
the cause for tinnitus research. To rub elbows with
people who had previously been only names at the
beginning of articles and books! To be with ENT's
and Ph.D.'s who really care about tinnitus and tin-
nitus management! I felt privileged to be a part of
that prestigious group. There were about 20 of us
from the U.S. and the rest from around the world.
The language of the conference was English but
you were surrounded by every imaginable dialect
and frequently treated to a switch to their native
tongue!
After a 23-hour marathon flight from Baltimore
to Frankfurt, including a 4-hour trip by train up the
gorgeous Rhine River dotted by castle ruins, the
conference opened that same night with an infor-
mal welcome at the town hall Rathskeller. This is a
magnificent Gothic structure in the center of old
MOnster, which was built in the 14th century. There
we registered, met our fellow participants and
began friendships and professional relationships
which flourished as the days flew by.
Early the next morning, the opening ceremony
began with a welcome from the Congress Chair-
man, Professor Dr. Harald Feldmann, ENT Depart-
ment at the University of MOnster (with an enroll-
ment of 45,000 students). His graciousness, charm
and wit were to enthrall us throughout the next four
days. His historical review of the subject of tinnitus
was fascinating and will serve to help us under-
stand and evaluate systems for its treatment. I won't
go into detail here, but I urge each of you to obtain
a copy of the proceedings of this seminar when it
is published so that you might savor the words of
Dr. Feldmann. He covers the earliest references
and descriptions of tinnitus from Pliny before 80
A.D. through Fowler's first attempts to classify tin-
nitus in 1940. He reviews the masking of tinnitus
from Aristotle to Vernon and electrical stimulation
for the supression of tinnitus from Grapengiesser
in 1801 to Shulman.
The next three days' presentation of papers was
divided into six sessions with a panel discussion
following each session: I. Mechanisms and
Pathophysiology of Tinnitus II . Classification and
Epidemiology of Tinnitus Il l. Diagnosis and Assess-
ment of Tinnitus IV. Masking of Tinnitus V. Medical,
Surgical and Psychological Approach in Treatment
of Tinnitus VI. Electrical Stimulation in Supressing
Tinnitus
The papers presented during the session on
mechanisms and pathophysiology were con-
cerned with issues involving abnormal activity in
the inner ear. Current basic research in this area
is very promising for use in tinnitus diagnosis in
the future.
Papers in the session about classification and
(Cont. on page 2)
page 1
THIRD INTERNATIONAL, cont.
epidemiology of tinnitus stressed the need for pre-
cise identification of tinnitus.
Next , papers were presented which related to
the diagnosis and assessment of tinnitus. All as-
pects of the tinnitus sufferer's health and well-being
must be evaluated in the assessment of the impact
of tinnitus.
Masking was discussed by participants who
covered such issues as the neural mechanisms
involved, the determination of masker candidates,
the adaptive response to masking, the efficacy of
masking over time, and other supplemental prog-
rams that help patients to cope with their tinnitus.
The session on medical, surgical, and
psychological approaches to tinnitus presented re-
sults from a number of drug studies and surgical
developments about which further research may
provide more definitive answers. Psychological
methods including relaxation training, biofeed-
back, and self-help groups, were reported to help
tinnitus suffers achieve an improvement in their at-
titude toward tinnitus.
The final session devoted to electrical stimula-
tion research opened with words of caution from
Dr. J. M. Aran whose work in this area has stimu-
lated other scientists to explore this area for possi-
ble tinnitus control. Electrical stimulation devices
in use in the United States and Japan were reported
to be sometimes effective. Additionally, some pro-
foundly deaf patients who have received cochlear
implants have reported tinnitus suppression. One
normal hearing patient who was implanted with a
cochlear device for the purpose of tinnitus suppres-
sion reportedly had no change in his tinnitus.
Concluding remarks were made by Dr. Ellis
Douek. Dr. Douek also gave the concluding ad-
dresses at the seminars in 1979 and 1983. In each
year Dr. Douek has reminded the participants that
while we are still unable to be precise about our
diagnoses, there are treatments presently which
are helpful to some patients, and we are able to
give hope to our patients by letting them know we
are trying.
The IV International Tinnitus Seminar will be held
in Bordeaux, France in 1991. The publication of
the proceedings of the Ill International Tinnitus
Seminar will be available in 1988. Further informa-
tion about how to obtain the book will be published
in the ATA Newsletter as soon as it becomes avail-
able.
Susan Seidel, M.A., CCC-A
Audiology
Greater Baltimore Medical Center
Facilitator - Greater Baltimore
Tinnitus Group
page 2
TINNITus
TINNITUS
IN NITUS
INN ITUS
I TUS
NIT US
IT US
rus
Professor Harald Feldmann, Chairman, Ill International
Tinnitus Seminar MOnster, West Germany.

Just published!
TINNITUS
A Guide for Sufferers and Professionals
by Robert Slater and Mark Terry
This important new book by two British specialists provides
answers to a lot of questions, both for tinnitus sufferers
and their famHies as well as for all professionals concerned
with hearing problems. Contents include definitions, causes
and theories of tinnitus, psychological and related factors,
non-medical and medical factors influencing tinnitus, helping
yourself, drug treatment, the role of tinnitus maskers, etc.
250 pages, 1987, paperback $17.95
hardcover edition for libraries $45.00
ORDER FORM
Mail this form directly to the publisher:
Sheridan llouse Inc.,
145 Palisade St., Dobbs Ferry, N.Y. 10522
Please send me __ copy(ies) of Tinnitus: A Guide for
and Professionals. $17.95 plus $2.00 postage.
Check enclosed for $, ____ _
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All orders mull be prepaid. NYS residents please add sales taX. Canadian and o1ber
foreign customers please pay by U.S. Money Order or U.S. bank draft. Sorry, cannot
accept foreign checks.
Abraham Shulman, M.D. - Guest of Honor
Jonathan W.P. Hazell, M.D. FRCS- Research Award Recipient
GUEST OF HONOR
Ill INTERNATIONAL
TINNITUS SEMINAR
Abraham Shulman, M.D. , Associate Professor, Di-
vision of Otolaryngology, State University of New
York, Brooklyn, NY, was honored by his colleagues
at the Ill International Tinnitus Seminar. Dr. Shul-
man's address saluted the positive contributions
to tinnitus research of many scientists. Those who
were especially mentioned were Dr. Harald
Feldmann, this year's chairman, for his description
of masking curves; previous Guests of Honor Dr.
Jack Vernon for the development of acoustical tin-
nitus masking, and Dr. Juergen Tonndorf for con-
tributions to the basic science understanding of
the cochlear mechanisms.
In his address Dr. Shulman cites the responsi-
bility of the professional involved with the tinnitus
patient. He says, "Multiple disciplines have be-
come involved in this effort for attempting to estab-
lish a cure for tinnitus. All share common respon-
sibilities. It is essential that all professionals in-
volved relate to the patient and to each other. We
must listen to the history of the tinnitus patient; ad-
vise the patient of the options available for tinnitus
control; teach what we know, as well as attempt to
understand what we do not know; and lastly, have
patience with each other. Frustration may manifest
itself in both professional and patient due to the
lack of availability of a cure and the limited tinnitus
control systems accessible. We must not allow
frustration to distract us from our goal of tinnitus
control." Dr. Shulman further points out the oppor-
tunities available to the young professional to be-
come involved with tinnitus. These opportunities
can provide a framework for lifelong learning and
the ability to stay at the 'cutting edge' of science
technology. He concludes from the expectations
and experiences of the meeting that the future is
indeed bright for tinnitus treatment.

TINNITUS RESEARCH AWARD
PRESENTATION
The 1987 Hocks Memorial Award for outstanding
contributions to tinnitus research was presented to
Jonathan W.P. Hazell, F.R.C.S., at the banquet of
the Ill International Tinnitus Seminar in Munster, West
Germany, June 12, 1987. Dr. Hazell has published
extensively on the subject of tinnitus and has
served for many years as consultant to the Royal
National Institute for the Deaf and its affiliate the
British Tinnitus Association. Dr. Hazell has con-
ducted research about tinnitus under the auspices
of the Medical Research Council of Great Britain
and has helped many tinnitus patients through his
clinical work with the National Health Service and
through his own private practice. Dr. Hazell is the
editor of a new book entitled TINNITUS which has
recently been published by Churchill Livingstone,
London, England. ATA takes this opportunity to sa-
lute Dr. Hazell for his many contributions to the
growing body of knowledge about tinnitus. (An ar-
ticle about tinnitus by Dr. Hazell will appear in a
subsequent issue)

LIMITED OFFER, WHILE THEY LAST - WE WILL
SEND A FREE COPY OF THE 323 PAGE, FULLY
ILLUSTRATED BOOK :"PROCEEDINGS OF THE
II INTERNATIONAL TINNITUS SEMINAR" TO ALL
NEW CONTRIBUTORS OF $100 OR MORE.

BIBLIOGRAPHY NOTICE
The ATA now offers a Tinnitus Bibliography contain-
ing over 1300 references listed in alphabetical
order by author. It is available to ATA members for
$25.00 (plus $1.00 shipping and handling for or-
ders from outside the United States). We also offer
a bibliography search service from which members
may obtain listings of articles on a particular subject
area of tinnitus. Some of these subject headings
are TMJ, physical trauma, noise, diving & tinnitus,
and hearing loss. For these and other subject list-
ings, there is a basic search fee of $5.00 plus an
additional charge of .25 per source over 15
sources. For more information contact:
page 3
ATA TINNITUS BIBLIOGRAPHY
PO BOX 5
PORTLAND, OR 97207

TINNITUS AND ALLERGY
by Soraya Hoover, M.D., Houston, TX
SUMMARY: This study involves 75 consecutive pa-
tients presenting with tinnitus as their main com-
plaint. All were subjected to thorough clinical,
neuro-otological, audiological and hematological
testing in search of an aetiology. It was found that
in 57 patients (76%) the tinnitus had an allergic
patho-physiology. Diagnosis and treatment to-
gether with the results are presented.
INCIDENCE OF THE CAUSES OF TINNITUS IN 75 PATIENTS
0 Drug Induced (1) m Fistula/Inner Ear (1)
0 T.M.J. Dlsus. (1) 811 Loud Noise Trauma (3)
Acoustic Neuroma (1) 0 Wax (3)
Flg.1
DIAGNOSTIC PROCEDURE:
le
Reaction (45)
ll!l om .. Exlerna (2)
0 lnlecllve 0\lles
Media (6)
a) History - listing onset and precipitating factors
of the tinnitus; any drugs or vitamins being taken;
all symptoms, allergic or otherwise.
b) Examination- thorough general and E.N.T. clin-
ical , blood tests, CT scans and X-rays.
c) Measurement- using the "Tinnitus Synthesizer"
which generates two different tones and a white
noise. Synthesizer output can be changes from .1
to 25 KHz in steps of .1 KHz.
d) Audiological- Ascending air bone audiogram,
noting location of the tinnitus. Valsalva maneuver
and tympanometry for determining Eustachian tube
function.
e) Blood testing- Rast method for estimating the
IGE. In the presence of Eustachian tube obstruc-
tion, Rhino-sinusitis, or a tinnitus match in the low
frequencies (away from the maximum hearing loss
area). Inhalants found in the geographical area as
well as the most frequently eaten foods are tested.
f) Allergy testing - intradermal provocative food
antigen tests for frequently eaten foods and those
identified in RAST test. This singles out the foods
affecting the tinnitus, causing pressure in the ears,
or causing vertigo. (these foods may be producing
other symptoms as well)
g) Journal - patients are asked to keep a daily
diary of the onset, increase in intensity, or any
change in their tinnitus. Also recorded are the onset
of any other allergic symptoms, such as asthma,
urticaria, migraine, mouth ulcers, heart burn, etc.
The circumstances in which the symptoms occur
is also noted.
h) Diet- patients are advised to follow a simple,
four-day rotating diet, without iced drinks. Patients
are asked to note any aggravation of ear symptoms
if they use tobacco products. All beverages, al-
coholic, caffeinated, or not, are to be noted.
i) E.N.G. testing is done if one or more foods pro-
duces vertigo or fullness of the ears. Sometimes
repeat audiograms are taken.
The use of these diagnostic procedures iden-
tified 57 of the group of 75 patients, (76), to have
tinnitus related to allergy. Of these, the 22 who had
patent Eustachian tubes and normal ears, reco-
vered completely. Elimination of the offending
foods cleared the tinnitus and produced a measur-
able improvement in hearing. The duration of tin-
nitus for this group ranged from 2 weeks to 3
months with an average of 8 weeks. The remaining
35 patients had complete Eustachian tube obstruc-
tion and varying degrees of Rhino-sinusitis and/or
secretory otitis media. Immediate allergic reactions
to food or smoking were displayed by 23 of these
35. The tinnitus and allergic symptoms persisted
for 2-4 months before showing 80-100 improve-
ment. The duration of tinnitus for this group ranged
from 3 months to 5 years with an average of 15
months. Four of these patients had myringotomy
procedures to relieve middle ear pressure. Two
had deviated nasal septa that were surgically cor-
rected with a resultant opening up of the Eustachian
tube and improvement in the tinnitus and in hearing
function.
TREATMENT: A) In all 57 patients the allergy was
controlled by the complete elimination of the of-
fending factors and immuno-therapy. This regime
continued for 4 to 6 weeks, or indefinitely if rein-
troduction of the substances continues to precipi-
tate ear symptoms. For those patients experiencing
immediate reactions to allergens, and whose Eus-
tachian tubes, noses and sinuses were free of dis-
ease, the only treatment was to eliminate the offend-
ing substances and to have those who smoke stop
smoking.
B) Patients who had Rhino-sinusitis and obstructed
Eustachian tubes received the following additional
(Cont. on page 5)
page 4
TINNITUS AND ALLERGY, cont.
treatment.
1) Control of the infection in the nose, sinus,
middle ears, and Eustachian tubes was ac-
complished with ten day courses of anti- biotics in
rotation.
2) Mucolytics were given with the anti- biotics.
Other decongestants were discouraged during the
course of the infection.
3) In ears with persistent Eustachian tube
obstruction, where tinnitus is severely aggravated
by recurrent acute Rhinosinusitis and secretory
otitis media, myringotomy, suction and insertion of
T tubes is done. Each recurrent attack is controlled
as in 1) and 2) above. These attacks are noticeably
less frequent as patients continue on immuno-
therapy.
e
0
0.
E
,.
"' ...
c;,


AllERGIC SYMPTOMS FROM WHICH THE PATIENTS
RECOVERED WITH AllERGY TREATMENT
Verngo, 0" & 011
Headache
Otll<.at1a
Hu1Jng Lon
Nual Obt1tut.llon
Eye- Symptomt
Hyptttomnla
Ftngert / Fac:r/ llp
Oty Cough/ HadClng
ht Pa!ntOnlnage
Hurl 9Ufl'l & Gl Symptom
HOI FSutht't
Mt-nt al Co11h1tlon
'
10
Number ol Patients
Fig. 2
"
FOODS AND FACTORS INDUCING TINNITUS
Da1ty Prodvt:lt
Potl
Whnl
Cotlu
Chkll tn
Choc:olalt
Corn
Egg
Bu t
Polatott
Smo-. tng
lol'l'laiOet
Ak:oho'
Brocco
Car tic
Oufd().Of Pollnt
Pinto Scant
Ric
Apl>lf'
81'11
OnAon
Or noe
Ptanult


s
"
18
Tu r==.,;__ ______ ______ _,
Number ol Pallenls
lntldtncc- or loodt and faclort Inducing Tlnnllut ueordlng to paUtntt dlarlu. loOowl.n9
dluulne4 rolallng dltl tor 4 wtth
Fig. 3
DISCUSSION: The criteria for 'Al lergic Tinnitus' are:
Fluctuation in intensity, frequency, and manifesta-
tion. Occurrence in the lower frequencies- away
from the high frequency hearing loss.
Of the allergic sample, 45 patients (79) had im-
mediate allergic reactions establishing a connec-
tion between their ti nnitus and the offending factors.
These people were able to achieve relief of their
tinnitus, clearance of other allergic symptoms, and
improvement in hearing by the elimination of the
offending factors (foods, drink, and smoking).
Editors note: This article has been edited substantially for space
reasons. If you would like a copy of the complete article and
ref erences please contactS. Hoover, M.D., 150 W. Parker # 705,
Houst on, TX n076.
GLOSSARYFOR 'TINNITUS
AND ALLERGY'
Allergen
Deviated
Nasal Septum
E. N. G.
Hematological
A substance capable of inducing allergy
Where the dividing wall of nasal septum
the nose is pushed aside (can cause
problems with related structures such
as Eustachian tubes.)
Electronystagmography- records changes
in eye movements induced by electrical
stimulation. (Provides information on
vestibular system.)
Relating to the study of the blood lgE
An antibody that produces hypersensitive
reactions
Immuno-therapy Passive immunization of an individual
Intradermal
Mucolytic
Myringotomy
by desensitization administration of
preformed antibodies
All ergy tests where provocative
substances are placed test
between the skin layers and monitored
for change.
A mucus dissolving agent
Surgical incision of the tympanic membrane
(ear drum)
Neuro-otological Having to do with the neNes of the ear
Patho-physiology Relating to the study of disordered function
Rastmethod
or the function in diseased tissues.
Radioallergosorbent test which measures
for the presence of certain antibodies
Rhino-sinusitis Inflammation of the nasal mucosa and
sinuses
Secretory Otitis- Inflammation of the ear Media
where fluid collects in middle ear and can
interfere with hearing.
Tympanometry An indirect measurement of middle ear
function
Valsalva A maneuver whereby air is forcibly exhaled
against closed nostrils and mouth causing
increased pressure in the middle ear and
Eustachian tubes.

SURVEY RESULTS NOW AVAILABLE
RESULTS FROM THE TINNITUS SURVEY CON-
DUCTED IN JUNE 1986 ARE NOW READY TO
MAIL. YOU MAY RECEIVE A FREE COPY OF
THE SURVEY RESULTS BY SENDING A LARGE
SELF-ADDRESSED STAMPED (22) ENVELOPE
WITH THE WORD SURVEY WRITTEN IN THE
LOWER LEFT HAND CORNER.
page 5
THE AGING EAR
by Dennis C. Fitzgerald, M.D., Washington, D.C.
Reprinted with permission of American Family
Physician where it appeared in complete form in
the February, 1985 issue.
Reprint requests for the complete article and refer-
ences should be addressed to Dennis C.
Fitzgerald, M.D. , 106 Irving St NW, Washington,
DC 20010.
Patients with ear disorders generally fall into
two broad age groups: children with secretory or
suppurative otitis media and middle-aged adults
who begin to show signs of degenerative disorders.
This article reviews some of the numerous auditory
and vestibular disorders that are common in the
middle years.
The External Ear
Approximately 6 percent of all skin cancers
occur on the ear, most often as the result of cumula-
tive sun exposure. Squamous cell carcinoma is the
most common type and typically develops on the
posterosuperior portion of the pinna. In its earliest
stage, the lesion appears as a firm painless, pale
'outgrowth' with surface scaling. Eventually the sur-
face disrupts, with the formation of an ulcer with a
raised edge. Treated early, squamous cell car-
cinoma has an exceedingly high cure rate, but the
cure rate drops significantly if the lesion is ignored
u ~ t i l it has become large and ulcerative (possibly
w1th adenopathy signifying metastasis).
The second most common type of skin cancer
is basal cell carcinoma. It initially appears as a flat
or slightly raised lesion, which then develops a
rolled edge with a penetrating ulcer. The 'rodent
ulcer' progresses by circumferential and deep
growth. These carcinomas are less li kely to metas-
tasize than squamous cell carcinomas. Local exci-
sion or chemosurgery is the treatment of choice.
Often confused with skin cancer of the ear is a
curious and frequently troublesome nodular growth
on the superior helix, called chondrodermatitis
nodularis chronica helicis. Thought to be caused
by exposure to cold weather, these nodules may
be exquisitely tender and the surface may scale.
If the diagnosis is in question, a simple excisional
page 6
biopsy will differentiate this entity from a malignant
lesion.
Malignant tumors can also occur in the external
ear canal. Any patient with a painful, bleeding,
nonhealing ulcer in the external canal should be
referred to an otologist for biopsy and treatment.
Often these tumors are misdiagnosed as persistent
external otitis and are treated for months with ear-
drops, resulting in loss of precious time.
The Middle Ear
The middle ear is relatively free of degenerative
disorders, except for otosclerosis and tym-
panosclerosis.
OTOSCLEROSIS
Otosclerosis is a hereditary disorder charac-
terized by foci of new bone growth on the medial
wall of the middle ear. The most common site of
involvement is the area just anterior to the footplate
of the stapes. As new bone accumulates, it im-
pinges on the footplate and progressively leads to
fixation of the footplate. Conductive hearing loss
ensues. The hearing loss often begins in the sec-
ond or third decade of life, but the patient usually
does not develop a hearing handicap until after
the fourth decade.
Stapedectomy has become the standard treat-
ment for otosclerosis. When surgical therapy is con-
traindicated, the patient's hearing can be improved
with the use of a hearing aid.
TYMPANOSCLEROSIS
Tympanosclerosis is the term used to describe
the sclerotic changes that occur in the tympanic
membrane and middle ear mucosa as the late re-
sult of infections of the middle ear cleft. A clue to
this condition is the presence of chalky white
plaques in the tympanic membrane. These are
often without consequence, but if there is an ac-
companying hearing loss the process may involve
the ossicular chain. These sclerotic changes are
thought to be slowly progressive, and hearing loss
does not occur until later in life.
Tympanosclerosis is treated by surgical re-
moval and reconstruction of the ossicles.
The Inner Ear
Disorders of the inner ear fall into the realm of
neurotology, a subspecialty of otolaryngology deal-
ing with the inner ear and the central processing
of auditory and vestibular information. Building on
the classic information of otology, neurology and
neurosurgery for a more sophisticated approach
to these difficult disorders. The most common dis-
orders of the inner ear in the middle years are sen-
sorineural hearing loss and tinnitus.
(Cont. on page 7)
AGING EAR, cont.
SENSORINEURAL HEARING LOSS
Age-related sensorineural hearing loss is consi-
dered to be a physiologically normal consequence
of living in today's world. This disorder, termed pre-
sbycusis, is the most common form of hearing im-
pairment in the United States. We tend to identify
a sensorineural hearing loss as presbycusis not
because of any distinctive characteristics but be-
cause of its association with concurrent signs of
aging. The diagnosis is often made by exclusion
of the more definable causes of sensorineural im-
pairment . Genetic factors undoubtedly play a role
in determining the age at which this progressive
hearing loss begins. Even a 40-year-old person
can be the victim of an aging ear, although a 60-
year-old person is a more likely victim.
Presbycusis can be described as an otherwise
unexplainable, bilateral, high-tone loss occurring
in an older person. There are no other specific
clinical or audiometric features ( Figures 1 and 2).
Patients with this disorder typically complain of dif-
ficulty in 'understanding' words, especially in noisy
environments such as cocktail parties. Women's
voices are more difficult to understand since they
tend to be higher pitched than men's voices.
Our appreciation of speech involves a complex
processing of sound and comprehension. Aging
not only may alter function of the peripheral end-
organ but also may slow the central processing of
this information. As the hearing loss progresses,
the person may gradually begin to refrain from join-
ing in conversations. Embarrassment over answer-
ing questions incorrectly often causes the person
only to join in one-to-one conversations or discus-
sions in which the subject matter is very famili ar.
In other words, 'he hears only what he wants to
hear'.
The exact pathology of presbycusis remains
poorly understood but undoubtedly involves de-
generation of supporting cells of the organ of Corti,
loss of neurons in the auditory pathways, vascular
and metabolic disorders, and loss of elasticity of
the basilar membrane of the inner ear. Also, we
must consider the consequences of 40 or 50 years
of exposure to such noises as airplanes, au-
tomobiles, music and so forth. Beyond avoidance
of excessive noise, little can be done to prevent
presbycusis.
The hearing impairment, however, can be im-
proved with a hearing aid. Unfortunately, many
people mistakenly assume that hearing aids are of
little value in the aging ear. The tendency of the
elderly to leave their aids in dresser drawers is
legendary. In the past five years, improvements
have been made in hearing aids so that most pa-
tients with presbycusis can be helped, provided
the device is properly chosen and fi tted. The entry
of audiologists with expertise in hearing aid selec-
125
0
10
20
30
:0 40
~
.,
] so
~
~ 60
~
~ 70
~
c
- 80
90
100
110
120
250
( ~
Frequency in hertz (Hz)
500 1,000 2,000 4,000 8,000
A
~ A
~ A
--(
A
.,
~ '
FIGURE 1. Audiogram showing mild to moderate sensorineural hearing loss.
The most common cause is presbycusis. (ll=bone conduction; O =air
conduction)
FIGURE 2. Similar to the audiogram of presbycusis is the pattern occurring
with hereditary, progressive hearing loss. A hereditary component should
be suspected only when the hearing loss occurs at a relatively young age.
(ll =bone conduction; 0 =air conduction)
.:0
~
"'
]
'2
"0
=
~
;;;
c
~
.E
125
0
10
20
30
40
50
60
70
80
90
100
110
120
Frequency in hertz (Hz)
250 500 l ,000 2,000 4,000 8,000
A
--(
~ : A
--
A
~ A
--( ~ (
tion and dispensing has brought tremendous prog-
ress to this once poorly managed process.
NOISE-INDUCED HEARING LOSS
In the past several years, there has been a
growing awareness of the hazards of excessive
noise in the workplace. Now that industry is held
liable for noise-induced hearing loss in workers,
we are seeing increased use of ear protection.
(Cont. on page B)
page 7
AGING EAR, cont.
Noise exposure produces a characteristic pat-
tern of hearing loss, which is bilateral and is max-
imal in the 4 to 6kHz region (Figure 3). However,
assigning liability is fraught with problems. For
example. if a person who works in a boiler room is
also an avid skeet shooter and snowmobiler, it
would be difficult to attribute noise induced hearing
loss to a single cause.
Leaving the legal issues aside, it is clear that
we have the obligation to recognize the detrimental
effects of excessive noise on the inner ear. Preven-
tion of hearing loss requires avoidance or at least
ear protection.
Management of noise-induced hearing loss is
the same as that for presbycusis: the patient should
be fitted with a well-chosen hearing aid.
TREATABLE CAUSES OF BILATERAL HEARING LOSS
There is an impressive array of treatable disor-
ders that may cause the development of bilateral
sensorineural hearing loss. No longer is the diag-
nosis of bilateral sensorineural hearing loss a direct
ticket to a hearing aid. Surgically correctable
causes include Meniere's disease (Figure 4) and
perilymphatic fistula. Causes amenable to medical
management include syphilitic labyrinthitis (Figure
5), serous labyrinthitis, hypothyroidism, renal dis-
ease, cochlear otosclerosis (Figure 6), hyper-
cholesterolemia, diabetes mellitus, obesity, food in-
tolerance, Refsum's syndrome, hyperviscosity syn-
dromes (polycythemia, macroglobulinemia) and
autoimmune disorders.
UNILATERAL HEARING LOSS
One must remember that not all cases of sen-
sorineural hearing loss are due to aging or noise
exposure, or both. A unilateral hearing loss, for
example, is almost never due to presbycusis, and
only when there is a definite history of acoustic
trauma to one ear (e.g., a firecracker) can noise
be seriously considered as the cause of a unilateral
loss.
Unilateral hearing loss, as well as unilateral tin-
nitus, demands a search for an acoustic neuroma.
This may require a series of diagnostic tests. The
operative mortality rate for removal of an acoustic
neuroma has been reduced from 5 percent to less
than 0.5 percent, largely because these benign
tumors can now be diagnosed at an early stage.
With computer-assisted hearing tests (auditory-
evoked brainstem responses) and newer- genera-
tion computed tomographic scanners, tumors as
small as 2 to 3 mm can be detected.
Other peripheral disorders that can cause un-
ilateral sensorineural hearing loss include
125
0
10
20
30
.:0 40
:g
"'
] 50

60
c
'; 70
.!!
c
- 80
90
100
110
120
250
Frequency i n hertz (Hu
500 1,000 2,000 4,000 8,000
r"'
""'

""'
/
""'

FIGURE 3. Audiogram showing noise-induced hearing loss. Hearing im-
pairment is most marked at 4,000 Hz, with recovery at 8,000 Hz. (l1=bone
conduction;
FIGURE 4. Audiogram showing sensorineural hearing loss in the lower fre-
quencies (250 to 1.000 Hz) This pattern indicates the probability of Meniere's
disease. (l1=bone CC?nduction; 0 =air conduction)
125
0
10
20
30
40
"'
] 50

60
c
;;; 70

c
- 80
90
100
110
120
250
'
.6.
Frequency in hertz (Hz)
500 I ,000 2,000 4,000 8,000
/
6. 6.

A/

otosclerosis, Meniere's disease, trauma, chronic
infection, meningiomas and cholesteatomas.
SUDDEN HEARING LOSS
A treatable condition with several etiologies,
sudden hearing loss is often dismissed by both the
patient and the physician as a 'stopped-up ear'
due to a head cold. In reality, sudden hearing loss
is a medical emergency. If treatment is not started
promptly, permanent sensorineural hearing loss
(Cont on page 9)
page 8
AGING EAR, cont.
Frequency in hertz (Hz)
125
0
250 500 1 000 2,000 4,000 8,000
10
20
30
:a 40
:2
"'
] 50
g
60
?:
70
!!!
c:
- 80
90
100
11 0
120
1.
v/
2.

3.
A

-----(
A
--
A
A
--<
b-e__
A
--(

A A
----(


FIGURE 5. A composite of three serial showing progressive loss
over a span of several months, whicl is consistent with a syphilitic etiology.
Appropriate treatment can correct such a loss. conduct10n:
conduction)
FIGURE 6. Audiogram showing "mixed loss" due to otosclerosis. Bone conduc-
tion is better than air conduction. However. both scores are lower than normal
(shaded art'a). conduction; O =air conduction)
125
0
10
20
30
250
:a 40
:2
"'
1l 50
g

?:
70

c:
- 80
90
100
110
120
can occur.
Frequency in hertz (Hz)
500 1 ,000 2,000 4,000 8,000

/
----(
----
-------
>-
One etiology is a perilymphatic fistula which
occurs after a sudden rise in cerebrospinal fluid
pressure. This pressure rise is transmitted to the
inner ear fluid (peri lymph), causing a rupture of the
oval and/or round window. The result is a sudden
hearing loss, often accompanied by positional ver-
tigo (Figure 7). This disorder is treated primarily
with bed rest, but if the patient's hearing does not
page 9
125
0
10
20
30
:a 40
:2
"'
1l 50

60
?:
70
!!!
c:
- 60
90
100
110
120
Frequency 1n hertz (Hz)
250 500 1 ,000 2,000 4,000 6.000
A
t:. t:. t:. t:.

FIGURE 7. Audiogram showing a severe. flat loss. If this
developed suddenly, it could be due to perilymphatiC fslula, trauma, VJral J!l-
tJess or vascular insufficiency. (6-bone COrlduction; conductiorl)
rapidly return, surgical repair of the rupture must
be undertaken.
A more common cause of sudden hearing loss
in middle-aged people is vascular occlusion of the
labyrinthine artery. Prompt treatment with vas-
odilators will often reverse this sudden loss.
TINNITUS
Tinnitus is an almost universal accompaniment
to any sensorineural hearing loss. The prevalence
of tinnitus matches that of presbycusis in the popu-
lation from 40 to 60 years of age. Most people with
tinnitus consider it a mild nuisance at worst, but
some have been driven to suicide to escape severe
head noise.
Considerable research is being directed toward
this long-ignored symptom. Since tinnitus has more
than one cause, we cannot expect to find a 'silver
bullet'. The chance of ameliorating it is highest
when the underlying cause is a treatable otologic
disease. Therapy for nonspecific tinnitus includes
vasodilators, drugs that affect neurotransmission,
proper diet, amplification with hearing aids, tinnitus
maskers, and biofeedback.
Peripheral Vertigo
The peripheral vestibular system includes the
eighth cranial nerve and the labyrinthine portion of
the inner ear (semicircular canals, utricle and sac-
cule).
Probably the most common type of disequilib-
rium is that caused by the degenerative changes
of aging. Subjective orientation of the body in space
(Cont. on page 10)
AGING EAR, cont.
in controlled by the cerebellum, with input from
three systems: visual, vestibular and propriocep-
tive. Dysfunction of any of these systems may pro-
duce dizziness or disequilibrium. It is possible for
a person to have disorders affecting all three com-
ponents; for instance, a 60-year-old man might
have cataracts, diabetic peripheral neuropathy and
mild cerebrovascular insufficiency of the inner ear.
This is a clear example of how degenerative
changes can produce vertigo and/or disequilib-
rium.
Degenerative changes rarely cause true whirl-
ing vertigo, but disequilibrium with quick body
movements can have as a component a degenera-
tive inner ear disorder. Unfortunately, vestibular
diagnostic tests are not specific enough to differen-
tiate the effects of aging from other treatable disor-
ders.
Contrary to popular medical belief, true
peripheral vertigo can occur on a vascular basis
without other brainstem signs of vertebrobasilar in-
sufficiency. The inner ear is one of the few organs
that have no collateral circulation. The blood supply
is delivered solely by the internal auditory artery,

. .

a branch of the anterior inferior cerebellar artery.
Thus, one of the earliest signs of vertebrobasilar
insufficiency can be true peripheral vertigo. Proof
of such a disorder is exceedingly difficult to obtain,
as is documentation of an adequate vertebrobasil ar
system. Often the diagnosis is one of exclusion by
various diagnostic tests and evidence of
generalized vascular insufficiency.
BENIGN PAROXYSMAL POSITIONAL VERTIGO
Benign paroxysmal positional vertigo is a curi-
ous disorder that often occurs in the 40- to-60 age
group. Although head trauma is sometimes in the
background, this condition usually develops spon-
taneously. The precise etiology is unknown, but a
plausible cause is cupulolithiasis. Small granules
normally present in the utricle of the inner ear be-
come dislodged and float in the fluid of the inner
ear. When a critical head position is attained, these
granules come to rest on the posterior semicircular
canal ampulla, causing a abnormal neural dis-
charge. This produces a severe vertiginous
episode, which can be reproduced each time the
(Cont. on page 11)

"COPING WITH TINNITUS"
STRESS MANAGEMENT & TREATMENT
TINNITUS MANAGEMENT IS OfTEN
COMPLICATED BY ANXIETY AND STRESS
NOW A UNI QUE CASSETTE PROGRAM IS
AVAILABLE DESIGNED TO PROVIDE DAILY
REINFORCEMENT AND SUPPORT fROM THE
STRESS Of TINNITUS WITHOUT COMPLEX
INSTRUMENTATION & VALUABLE OffiCE TI ME
There is a growing interest in psychological methods of tinnitus
control such as systematic relaxation procedures which help the
patient cope with the tension of tinnitus .
Subjects with tinnitus are being taught ways to relax as part of a
total tinnitus program which may include hearing aids. tinnitus
maskers and progressive muscle relaxation based on principles of
conditioning. Relaxation procedures are usually easily mastered and can be performed daily in the
patient's home environment It has been demonstrated that the relaxation response can release muscie
tension. lower blood pressure and slow heart and breath rates.
A relaxation method has been developed entitled Metronome Conditioned Relaxation (MCR) which
has successfully treated for many years chronic pain. tension headaches. insomnia and many other
conditions.
l11e program consists of one cassette tape of Metronome Conditioned Relaxation and two additional
A
ASSOOATED tapes of unique masking sounds which have demonstrated substantial benefit whenever the patient

feels the need of additional relief. These recordings can be used to induce sleeping or as a soothing
CENTERS backdrop for activity and can be played on a simple portable cassette player.
AU. ORDl!.RS MUST Be ACCOMPANieD BY 6796 MARKET ST., UPPER DARBY, PA 19082
01f.CK VISA. MASTeRCARD. OR JNSTITtrTIONAL P.O. Phone (215) 5285222
page 10
AGING EAR, cont.
head is in that position. Usually the vertigo subsides
spontaneously, but in rare cases denervation of
the posterior semici rcular canal must be performed
to all eviate this disabling symptom.
MENIERE'S DISEASE
Vertigo may also be a part of the symptom com-
plex in Meniere's disease, a treatable cause of sen-
sorineural hearing loss. It is estimated to affect one
in 4,000 people. Fortunately, advances in
neurotologic surgery have resulted in a cure rate
of over 95 percent for the vertiginous episodes .

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CONTRIBUTOR
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(Cont. on back page 12)
page 11
We want you to be the
first to Hear ...
You know I always try to see
the humor of life, now I
want to tell you about some-
thing that isn't very funny.
It's called Tinnitus ... a con-
stant ringing in the ears .. .
head noises. And I have it.
If you have it, you're not
alone. There are ten million
ofus. Butfortunately ... there
is also the American Tinnitus
Association that can help
us deal w1th it.
Tinnitus isn't anything to
joke about. And when we
finally ~ turn off the
noises, we want you to be
the first to hear.
-TONY RANDALL
When you give
to the
Combined
Federal
Campaign
designate
AMERICAN
TINNITUS
ASSOCIATION
P.O. Box 5
Portland. Oregon 97207
TRIBUTES, Cont.
IN HONOR OF
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MhurBiaser
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Dr. JohnEmmeH
MJMO.Gowans.Jr.
C. M. Griftrths, MD
Jerry Harvey
Ethel Hudson
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Morton Jacobs
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Mrs. Gladys Muse
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Mom and Dad
BIRTHDAY
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RECOVERY
Or. Jack A. Vernon
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CONTRIBUTOR
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CONTRIBUTOR
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CONTRIBUTOR
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MAY-AUGUST 1987
SPONSOR MEMBERS:
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Efilabeth Trudell
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