DECEMBER 1988 VOLUME 12, NUMBER 4

Tinnitus Today
THE JOURNAL OF THE AMERICAN TINNITUS ASSOCIATION
"To carry on and support research and educational activities relating to the cure of tinnitus
and other defects or diseases of the ear.''
HYPERACUSIS:
WHEN THE "VOLUME-CONTROL KNOB" BREAKS
AlA'S NEW PSA'S
AL UNSER & JEFF FLOAT
SPEAK OUT FOR TINNITUS
REFLECTIONS ON
THE PATHOPHYSIOLOGY OF TINNITUS
REPORTS:
D.C. TINNITUS FORUM
NATIONAL HEARING AID SOCIETY
PHILADELPHIA REGIONAL CONFERENCE
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Page 2
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These satisfied customers
offered their comments
on the Marsona 1200
sound conditioner:
"Purchased tomasknoiseoftinnitus.
It really helps!"
D. S., San Anselmo, CA
"Excellent for masking tinnitus
noises."
J.I., Lynn,MA
"My husband has tinnitus. Our
doctor recommended this and it has
helped him tremendously. "
P.A. Van Wert, OH
"Fantastic- Best sleep in years-got rid
of headaches from lack of sleep. "
M.B., N. Hollywood, CA
What is tinnitus? It's a subjective
experience of hearing a sound, ring,
or a noise when no such external
physical sound is present. Some call
it "head noises ", "ringing", or other
similar things. The Oregon Health
Science University.
HYPERACUSIS: WHEN THE
"VOLUME-CONTROL KNOB"
BREAKS by Cliff Collins
(Cliff Collins is a free-lance journalist
living in Aloha, Oregon. He also writes
a biweekly health column in The
(Portland) Sunday Oregonian.
The year is 197 5, on a warm
Southern night. A group of friends are
at a coliseum rock concert, and one 21-
year-old obviously rather not be
there: Seated at the end of the row, he
remams frozen throughout, his teeth
gnashed together as the ear-wracking
barrage pounds in his head.
steals glances at his friends,
wondenng they could be grooving
on 120 dec1bels that are inflicting only
misery inside his skull. The H-bomb-
Ievel peaks go on for hours, and when
the kids leave, the young man hears his
friends as if through a tunnel, their
voices filtering through his ears as if
from a dreamlike distance. And there is
a ringing, louder than the sound of their
_voices, echoing like some eerie cosmic
wind.
It was just one night, that night in
the '70s, but it changed the 21-year-old's
life permanently. No more could he
encounter noise without paying a price.
His ears rang loudly for months, perhaps
for a year. From that day forward,
whenever he was around sustained
-- a moving car, sports events,
movies, music and people singing, a
crowded restaurant -- the ringing in his
head would return for a spell. Earplugs
became as essential as keys, wallet and
pocket change: he could go nowhere
without plugs at the ready.
The ears do not forget. Thirteen
years after the 21-year-old left that
concert with ears ringing, earplugs alone
often aren't enough. As so often
happens with ear injury, the worst
damage showed up a decade later. By
now, what was once an inconvenience
has become life-altering. As the years
went by, his ears became more and more
Page 3
Illustration courtesy of Rod Ambroson
sensitive to noise. The confidence he
had that earplugs would protect him was
shaken when, in early 1986, he attended
a basketball tournament. The pep bands
and the loudspeaker seemed louder than
they should; he knew never to attend a
ball game without wearing plugs, but
now, they didn't seem adequate.
For the previous decade, he self-
consciously had carried earplugs around,
popping them in surreptitiously -- like
Clark Kent slipping into the phone booth
to change clothes whenever
surrounding events dictated. He found
that more and more situations required
protection, even having to insert a plug
m the worst ear when listening to the
evening radio news at home. When he
walked down his street, cars sounded too
loud, and he had to pop in a plug.
Then, by chance, he saw an article
about tinnitus and hearing damage. It
told of the Oregon Hearing Research
Center and the American Tinnitus
Association, both based in the Portland,
Oregon, area where he lived. He
considered. going in for an ear exam, but
he thought they would think he was
weird or something; after all, his tinnitus
wasn't constant and it wasn't severe.
Also, he knew his hearing was perfect.
Iz:t fact, it seemed too perfect -- indeed,
h1s whole problem was: he could hear
Continued Page 4
HYPERACUSIS: WHEN THE "VOLUME-CONTROL
KNOB" BREAKS, continued
too well. Would those people
understand, would they think he was
crazy if he told them: everything seems
too loud?
He put the article on his desk,
returning to it about once a week, but he
didn't go see the doctors mentioned in
the story. Instead, he got a new type of
earplug, thinking that must be the
problem. He changed weightlifting
gyms, a regular hobby, trying to tind one
without loud music and noise, because
he was having to wear earplugs all the
time now when at the loud gym. It had
been this way for so long: at movies
and shows, he had to wear earplugs
because of the noise level, but that made
it hard to communicate with people he
was with. Was he shouting or
mumbling? He could not tell, but he
could hear everyone else easily through
the plugs.
By the spring of 1986, he had
become more and more depressed,
having to give up doing things he
enjoyed because most noises were too
great and the tinnitus more frequent.
Friendships deteriorated because he was
unwilling or unable to reveal his ear
problems to anyone, choosing instead to
hide them and even to deny them to
himself. In March, unable to unload a
pair of tickets he'd purchased for a
concert, he despondently walked into the
show by himself.
Expecting that the fresh new pair
of earplugs, topped off with a pair of
wax earplugs on the outside, would
protect him, he decided to give it a try.
After all, in any noisy events he had
been to since 1975, he had always worn
ear protection, and it had worked well.
If the singer was too loud, he told
himself, he would leave -- not making
the mistake now, at age 32, that he made
as a college student, when he hadn't had
the gumption to get up and walk out
because of peer pressure.
The lights went down, and a
blitzkrieg of sound pounded from the
Page 4
stage to his upper balcony. The
enormous amplifiers hanging from the
ceiling made his ears feel naked, the
wavelengths of sound bounding off his
torso. The engineers would quickly
adjust this, he thought. But when the
first song was halfway through, the
sound level was exactly the same, and he
felt his way through a sea of indignant
seatholders and made for the exit.
Disgusted, he drove home, never
removing the plugs he always wore
when driving. He arrived home,
vacuumed the house, took our his
earplugs, and went to bed. His tinnitus
seemed worse than usual, and he slept
little. By morning, he was frantic. Not
only had the tinnitus grown much worse,
but it also had taken on new forms.
Now there were low-pitched sounds like
a distant buzz-saw, middle-pitched
sounds, and the usual background high-
pitched ringing. But there was
something else: the volume on the world
was turned up to full.
The pages of the newspaper
seemed loud as he turned them. When
he set a glass down on the table, the
noise was uncomfortably loud. He put
his plugs in, which seemed to do nothing
to shut out noise. The doorknob latch
sounded like the blow of a
sledgehammer. The ringing of a phone
was unbearable. Driving in the car was
impossibly loud, and he went to buy a
pair of industrial earmuffs, wearing them
in addition to earplugs.
For many months afterward, he
left the house infrequently. Everyday
sounds were too loud, no matter how
much protection he wore. Running
water and normal voices were
unacceptable, even with protection.
Earplugs were necessary 24 hours a day,
supplemented with earmuffs when
outdoors or driving. He had reached the
point of being disabled before he sought
help, finally going to the Oregon
Hearing Research Center to see Dr. Jack
A. Vern on, the center's director.
He was relieved somewhat when
Dr. Vernon was able to attach a name to
the condition. He called it hyperacusis,
or hypersensitive hearing. His clinic had
seen a handful of others with the
condition, and most had also had
tinnitus. What was unusual was that
none of the patients had any measurable
hearing loss, most -- like this 32-year-old
-- had no impressive noise history, such
as years of exposure to loud sounds in
the workplace. In some cases,
hyperacusis came on suddenly, without
any discernable provocation.
The patient corresponded with
others who had hyperacusis, some living
in other countries. He and his parents
contacted ear specialists and other
doctors throughout the country, hoping to
obtain information that might help in
treating hyperacusis. It would be more
reassuring if noise was the only apparent
cause, but contact with other sufferers
and doctors revealed that was not the
case.
In fact, several medical instances
of hyperacusis turned up. Oral surgeons
say that hyperacusis is seen frequently in
patients who undergo jaw and facial
operations, but its duration generally
ends a few weeks after the surgery.
Dentists who specialize in treating TMJ
syndrome (temporomandibular or jaw-
joint problems) report that hyperacusis
and tinnitus are sometimes symptoms
associated with TMJ disease. In
addition, neurologists say they see
hyperacusis in Tay-Sachs disease, a rare,
inherited disorder of the central nervous
system seen in infants and small
children. In addition, audiologists and
otolaryngologists report cases of
hyperacusis in patients who have been
exposed to noise, frequently a single
event or a single blast, such as from a
gunshot or a cordless phone.
The general feeling among
medical specialists is that hyperacusis is
a comparatively rare problem, one that
sometimes improves or resolves itself
over time. During its acute phases,
however, it can be devastating,
disrupting lives and psyches, and costing
patients jobs, money, and relationships.
In that way, of course, it is like severe
tinnitus, and those unfortunate enough to
have hyperacusis frequently have tinnitus
also, a double threat to their peace of
mind. But just the fact that it sometimes
does improve over time is reason to
hope.
Today, the 21-year-old is 34, and
after reaching their zenith nearly three
years ago, his hyperacusis and even his
tinnitus have diminished in severity --
extremely slowly -- certainly -- but
surely. Dr. Vernon and other experts
believe hyperacusis differs from a
condition known as recruitment, an
abnormal growth in the perception of
loudness that is not uncommon in people
with hearing loss. For them, loud noises
are painful. For those with hyperacusis,
all sounds are uncomfortable.
- What is it that makes a small
percentage of the population develop
hyperacusis while the vast majority does
not? Does this patient's increased
sensitivity to light, making night driving
almost impossible, relate neurologically
to hyperacusis? Why do people with no
history of hearing problems, no exposure
to abnormally loud sounds, and even no
hearing loss, sometimes develop the
disorder inexplicably?
These questions can be answered
only if enough researchers take an
interest in the problem to seek answers.
If noise was the only factor in causing
hyperacusis, everyone with noise
exposure, tinnitus or hearing loss would
also have hyperacusis. Fortunately, that
is not the case, but science must take
heed of the few who do.
Page 5

BEST WISHES NEIGHBORS!
We have recently had word from
Elizabeth Eayrs of Toronto, Ontario, that
the incorporation of the Tinnitus
Association of Canada has been
completed. We wish you great success
and look forward to exchanging news
and views often. Canadians are welcome
to continue their membership in AT A
and we are quite sure that the TAC will
welcome members from the states.
PHILADELPHIA REGIONAL
TINNITUS CONFERENCE
Nearly four hundred people came
together on October 22, 1988, to
participate in a day long conference
featuring workshops on various aspects
of tinnitus. The meeting was keynoted
by Dr. Ralph Naunton, Director
NINCDS, National Institutes of Health,
Washington, DC.
Workshops throughout the day
focussed on topics of interest to tinnitus
sufferers and professionals, and included:
Electrical Stimulation, Dr. Abraham
Shulman; Research, Dr. Max Ronis and
. Dr. Robert Sataloff; Autosuggestion,
David H. Shulman and Dr. Frances
Rothman; Drug Therapy, Dr. Frank
Marlowe; Exercise and Nutrition, Rhoda
Babis; Family Support, Robert Luthman;
Maskers and Hearing Aids, Dr. E. Robert
Libby; Stress Therapy, Dr. Arthur
Hochberg and Dr. Clorinda Margolis;
and Support Facilities (Self-Help
Groups), Susan Seidel and Dr. Gloria
Reich.
The volunteers from the various
self-help groups in the northeast region
worked long and hard to make this
meeting a resounding success. Special
thanks are owed to the Delaware Valley
Tinnitus Group and to Dhyan Cassie
without whom this meeting could not
have happened. Our best wishes to
Dhyan as she and her husband move on
to new challenges in Mexico.
Dr. Ralph Naunton, Director, National Institute
Neurological and Communicative Disorders,
Keynote Speaker.
Conference attendees at the opening session.
Dr. Arthur Hochberg leads a stress therapy
workshop.
Dr. Gloria Reich, Executive Director, American
Tinnitus Association, Closing Speaker
Photos courtesy of Joseph A/am
Page 6
NATIONAL HEARING AID
SOCIETY CONVENTION AN
"EAR OPENER" FOR ATA'S
EXECUTIVE DIRECTOR
It is true that one never learns
better than through experience and with
that in mind I decided that this was the
year personally to attend the NHAS
annual convention. I entered the
registration hall on first of
the convention expectmg to see a httle
activity prior to the stated hour of
opening. What I walked into was. a
milling throng of thousands of hearmg
specialists who were registering for the
many continuing education courses and
convention activities that were to occupy
them for the next four days. I quickly
set up ATA 's traveling exhibit and began
to answer questions and hand out AT A
brochures and Newsletters. It was
particularly pleasant to meet many of the
people who are actually providi_ng help
to patients with tinnitus and hearmg loss.
Many of those who came to the booth
are well known to AT A having
participated in our educational programs
and referral network for many years.
There were also visitors who had no idea
that we existed and were delighted to
find a source of information for their
clients.
The real "ear openers" were the
commercial exhibits at the convention. I
consider myself a fairly sophisticated
hearing-aid user, having worn them for
about 15 years now and demanding
nothing short of perfection in
performance. I was awed by the .range
of aids available and of the expernse of
the people marketing them. There are so
many choices available to the
professionals who serve us that almost
anyone should be able to . have
hearing problems solved w1th a htgh
degree of satisfaction. The most
exhibits for me were those pertammg to
assistive listening devices. Like many of
us I have gotten along pretty well with
my hearing aids al<?ne but there are
situations where a httle more help is
Page 7
needed. I already have amplified
handsets on all of my telephones both at
home and in the office, and I carry a
portable telephone amplifier when I
travel. I use a loop system at home for
the TV in my dining room and kitchen.
I can hear the set alright when I'm
sitting looking at it, but the loop
allows me to turn my back on tt,
listenino via the telephone switches on
my hearlng aids, and fix dinner or wash
dishes. I use another type of listening
device when I watch TV in the bedroom.
It is a direct plug-in from my aids to the
TV audio output. Many other helpful
devices were being exhibited -- lights to
alert one to sounds such as smoke
alarms doorbells, telephones and so
' .
forth -- devices to help us hear m
theaters and concerts -- personal devices
so that conversations can take place in
situations that are usually far too noisy
for most hearing-aid users to be able to
understand speech, these and more!
We'll be telling you about some of
these products in future issues and most
likely will be asking you for your
personal experiences with them as well.
Another feature of the NHAS
convention was the presentation of
recognition awards to long standing
members. We were pleased to see that
several of AT A's good friends had been
so honored. Included were: Dorothy I.
Bazonski, James Delk, Robert Harmon,
Leslie P. Leale, Leo F. Seelig, and
Donald S. Willett. Congratulations to all
of you!

Participant in
Combined
Federal
Campaign
AL UNSER SPEAKS OUT FOR
TINNITUS
The Portland, Oregon Business
Journal of September 19th carried the
announcement of a public relations
award to Odyssey Productions for their
press release "Odyssey Productions
Shoots Al Unser." Actually, Odyssey
made a public service announcement
featuring AI Unser and Olympic Gold
Medalist Jeff Float. These PSAs are
now being aired by more than 150 TV
stations nationwide and overseas through
the Armed Forces Radio & TV Network.
Al's script closed with the line "
... and ask 'em why AI Unser volunteered
to say this." Many people did ask why
AI became an AT A volunteer. He told
the film crew that it was because he
suffered from tinnitus and hearing loss
himself and wanted to do his part to try
to prevent others from needlessly
damaging their ears. Fortunately for
young drivers there are now
sophisticated technologies available
which enable them to wear ear protectors
while at the same time staying in radio
contact with their pit crews.
Please remember -- more than half
of the people who suffer from tinnitus
can recall significant noise exposure that
may have caused their ear noises. These
people more than likely also suffer from
impaired hearing caused by that same
noise. By helping AT A to educate the
public about potential threats to hearing
you can assure that future generations
will have the knowledge ro protect
themselves against loud noise.
JEFF FLOAT SPEAKS OUT FOR
TINNITUS
Jeff's hearing problem began after
a childhood illness. His coping style has
always been to excell in spite of the
hearing problem. This style was
successful for Jeff - you '11 remember that
in 1984 he was Swim Team Captain and
won two Gold Medals in the Olympic
Games. Jeff is now a successful
businessman in northern California but
he finds time to help people with hearing
difficulties understand their problems and
deal with them. Yes, he has tinnitus too.
The accompanying pictures were
taken on location at the Tualatin Valley
Recreational Center in Aloha, Oregon
where three public service
announcements featuring Jeff were
filmed.
ATA' s director serves as makeup artist when the
camera reveals dark circles under J e.ff s eyes.
Jeffs hearing-aid is visible in this photo.
Can you spot it?
Odyssey Productions camera crew
tracks J elf as he swims a lap.
J elf s backstroke has winning form.
Photos courtesy of Theodore E. Reich
Page 8
WASHINGTON, DC TINNITUS
FORUM REPORT
Standing Room Only was the
situation for the September 26th Tinnitus
Forum held at the Grand Hyatt Hotel in
Washington, DC. More than 200 people
came from as far away as Toronto,
Ontario to hear the latest news about
tinnitus. Gloria Reich opened the
meeting and introduced the speakers.
The first speaker was Jack Vernon
whose description of how masking was
developed utilized slides of patients'
audiograms from the early years of
masker development. These slides
provided a base for Dr. Vernon to show
how each case "taught us something
about masking". The audience appeared
to be riveted in their seats and surely
must have come away knowing more
than they ever had before.
Jack A. Vernon. Ph.D. Abraham Shulman, M.D.
The second speaker, Abe Shulman,
presented the physician's view of the
patient with severe disabling tinnitus.
He spoke about the development of
various tests to determine etiology and
ways of objectivising tinnitus reporting.
Dr. Shulman referred to the work of Dr.
Harald Feldmann saying that Tinnitus is
not like a natural sound, requiring
special protocols and treatment.
Page 9
The next speaker, Sam Hopmeier,
presented the clinical view from a
hearing specialist's point of view. Mr.
Hopmeier began helping tinnitus patients
by utilizing hearing aids more than 20
years ago. He has been successfully
fitting patients with maskers for many
years. His analogy of tinnitus being like
a dog chasing his tail brought home the
message that sometimes when a person
has tinnitus and tries unsuccessfully to
relieve it, the problem worsens and
becomes circular. It is important to
break that vicious cycle with some sort
of palliative action.
Bob Johnson spoke very briefly
about the tinnitus clinic in Oregon,
where more than 5000 patients have
been seen for their tinnitus, and then
turned to the many questions that had
been received from the audience. The
aforementioned speakers were joined by
Douglas Breithaupt on a question and
answer panel. The panelists answered
questions until it became so late that
people had to leave. We will try to
incorporate some of the questions in
future journal articles.
W. F. S. (Sam) Hopmeier Robert M. Johnson, Ph.D.
Photos courtesy of Erwin A. Siegel
DEAR ABBY - AGAIN!!!
Once again AT A has been the
target of a major publicity thrust with
the publication of an item about tinnitus
in the Dear Abby column early in
September. That particular item was not
carried in very many of the cities that
use her syndicated column, but even so,
we have received approximately 8,000
requests for information during the past
six weeks. This heightened activity has
presented us with a need for a significant
amount of volunteer help. In fact, ATA
has grown so much in the past two years
that it appears we will need a regularly
scheduled volunteer staff on a continuing
basis. We are fortunate to have a group
of about ten people in the Portland area
who are willing to come to our aid
several times a month.

1989 PLANNED SEMINAR AND
MEETING SCHEDULE
The following Public Forums for tinnitus
are planned for 1989. Mark your 1989
calendar if you live near one of these
cities.
New Orleans, Louisiana, September 1989
Miami, Florida, October 1989
St. Louis, Missouri, November 18, 1989
Additionally, ATA plans to conduct a
seminar for physicians, audiologists and
other hearing professionals. Course
material is now being prepared. Several
self-help group leaders have indicated
interest in conducting regional meetings
during 1989.

WE
SUPPORT
Doris Bender, Sally Benson, Pat Daggett, and
Betty Mathis working to answer the deluge of
mail inquiries.

ATA ANNOUNCES
RESEARCH AWARD
It is our pleasure to announce a
recent research grant made to Dr.
Douglas H. Morgan of the TMJ Research
Foundation. Dr. Morgan will be
investigating possible relationships
between TMJ dysfunction and tinnitus.
Page 10
REFLECTIONS ON THE
PATHOPHYSIOLOGY OF
TINNITUS
by ProfDr. Harald Feldmann
A complete theory of the
pathophysiology of tinnitus would be the
ideal basis for a classification and
rational treatment, but nobody can
present such a theory today; instead we
have to content ourselves with
hypotheses. However, there are many
reasons why we should discuss the
pathophysiology of tinnitus, even if it is
all hypothetical. I will mention only
one, a very practical reason.
In counselling a tinnitus patient
one important approach is to help him
rationalize his disease. Tinnitus can
deeply effect a patient to the point that
he fears becoming insane, simply
because he lacks an intellectual
understanding of this disorder. If he is
offered an explanation of the mechanism
causing this disorder, he is more easily
set into a position to detach himself from
it. This is part of a cognitive therapy.
How can we know anything about
the pathophysiology of tinnitus?
In some ear diseases, such as
acoustic trauma and Meniere's disease,
the morphologic basis of the hearing loss
is well-known, and it is reasonable to
assume that it is also the basis of the
concomitant tinnitus. One puzzling
mystery, however, is that in a given
disease, some patients have tinnitus
whereas some do not, despite identical
etiology and hearing loss. This indicates
that the pathology generating tinnitus
probably is of a submicroscopic nature,
still beyond detectability for techniques
currently available.
Psychoacoustic experiments with
tinnitus have yielded valuable insights
into some aspects of its pathophysiology.
Such experiments are measuring pitch
and loudness of tinnitus, searching for
beats between tonal tinnitus and external
acoustic stimuli, studying the maskability
of tinnitus by external acoustic and
electric signals.
Page 11
Professor Doctor Harald Feldmann, Universitat
Munster, West Germany
Recent experimental data have
revolutionized our knowledge about
normal hearing and have a strong
bearing on our understanding of tinnitus.
I will mention only a few.
Kemp in 1987 discovered that the
normal ear emits acoustic signals,
spontaneously or evoked by acoustic
stimuli: the oto-acoustic emissions, and
studies on isolated outer hair cells have
revealed a wealth of new insights into
their function.
We know that there is a tonotopic
organization of hair cells in the cochlea:
the units at the basal end are stimulated
by high frequencies, those at the apical
end by low frequencies. This tonotopic
organization is maintained throughout the
nuclei and higher centers of the auditory
system. Hoke, in our department,
investigating acoustically evoked
magnetic fields in the brain, could
demonstrate that there is also a topic
arrangement of loudness in the auditory
cortex. This means that each acoustic
signal is represented in the auditory
cortex in a two-dimensional matrix made
up of frequency and intensity. One can
imagine how a disarrangement of this
matrix could account for the common
observation that tinnitus often is felt as
of unbearable intensity, yet matched with
an external signal it seems to have only
the sensation level of 5 dB or less. In
fact, we found evidence that tinnitus
shows in certain parameters of the
electromagnetic fields of the brain.
Continued Page 12
REFLECTIONS ON THE
PATHOPHYSIOLOGY OF TINNITUS, continued
Now turning to pathophysiology of
tinnitus in detail I will start with the
small but important group of objective
tinnitus.
In my experience, objective
tinnitus is not easily detected, and the
patient usually consults a number of
doctors before a proper diagnosis is
made. Objective tinnitus can be caused
either by vascular or by muscular
lesions.
Vascular tinnitus is caused by
pathologic turbulances within blood
vessels, producing a rushing, pulsating
noise, synchronous with the heartbeat. It
can be identified by auscultation or
recorded with a device used for heart
murmurs.
Objective tinnitus caused by
muscular lesions can also be auscultated
at the ear canal or recorded by
microphone or impedance audiometry.
The muscular noises are intermittent and
sound like clicks. If they are due to
opening movements of the Eustachian
tube, they are associated with rhythmic
contractions of the palatal velum, which
can easily be seen. Another type of
muscular noise, also click-like in
character, is produced by spasmodic
contractions of the stapedial muscle.
The patient often has the impression that
an insect is plucking at his tympanic
membrane.
For cases of objective tinnitus
usually an adequate medical or surgical
treatment is available.
In subjective tinnitus the situation
is much more complicated. The question
usually raised first, concerns the site of
lesion: is it peripheral or central? I
doubt if there is a clear answer to that
question in all cases. The auditory
system involves a complicated peripheral
organ and a highly complex meshwork
of ascending and descending pathways,
forming feedback loops. The aim to
pinpoint a disorder, generating tinnitus,
in such a network is very questionable.
Page 12
This is demonstrated by the fate of
patients suffering from tinnitus after ear
surgery, as reported by Douek. At first,
after the operation, the damage
manifesting itself by sensorineural
hearing loss, vestibular dysfunction, and
tinnitus was clearly located in the
peripheral organ. To alleviate the
tinnitus further surgery was carried out: a
total destruction of the cochlea, and
finally a section of the auditory nerve.
After each intervention there was a short
relief of tinnitus, but then it recurred.
This shows that the site where the
tinnitus was generated must have shifted
centrally after each intervention. Despite
this experience, which seems to prove
that the site of tinnitus generation is
elusive, it is reasonable to discuss
possible mechanisms that might give rise
to tinnitus.
In the cochlea, there are
approximately 15,000 outer hair cells
arranged in three rows, and 5,000 inner
hair cells in one row. The outer hair
cells are coupled to the tectorial
membrane by their stereocilia. They
have contractile elements like muscle
cells, enabling them to perform slow
tonic contractions and fast oscillations.
They are richly innervated by descending
nerve fibres, but they have only scarce
connections to ascending nerve fibres.
Thus they do not contribute directly to
the hearing sensation, their task is
monitoring and boosting the mechanical
stimulation of the inner hair cells.
Studies of the oto-acoustic
emissions and psycho-acoustic masking
experiments indicate that the fast
oscillations of the outer hair cells, which
are the source of oto-acoustic emissions,
are not involved in the generation of
tinnitus. Their slow tonic contractions,
however, brought about by changes of
the osmolarity of the endolymph, might
very well cause tinnitus. They would
pull down the tectorial membrane, which
in tum would bend the stereocilia of the
inner hair cells, thus triggering neural
discharges. This could explain tinnitus
in Meniere's disease, endolymphatic
hydrops and some cases of sudden
deafness, where alterations of the
osmolarity of endolymph play an
important role.
In the mner hair cells, the
transformation of mechanical vibrations
into biochemical and electrophysiological
signals takes place. Nearly all the
ascending fibres, about 95%, arise from
the inner hair cells. In the membrane of
the hair cells, there are submicroscopic
channels, each specialized to gate the
passage of one particular ion: potassium-
channel, chloride-channel, calcium-
channel. Shearing movements of the
stereocilia, as affected by the travelling
wave along the cochlear partition, open
the potassium-channel and trigger a
cascade of reactions involving other ion-
channels, depolarization, release of
neurotransmitters, and finally activate the
neural synapses. Thus a nervous
impulse is triggered and a signal is
transported to higher levels.
This process is phase-locked to the
upward movement of the stimulating
vibration. Therefore the information
regarding the frequency of a signal is
coded twice: through the place along the
basilar membrane, where the hair cells
are stimulated by the travelling wave,
according to the place theory, and
through the frequency or repetition rate
of the neural spikes, according to the
periodicity theory. There is evidence
that the pitch of tinnitus generated in the
cochlea is dominated by the place of
lesion and not by the periodicity of
discharges of the neural units.
The assumption that the pitch of
tinnitus might be represented by the
periodicity of discharges is defeated by
the fact that it is not possible to produce
beats between a tonal tinnitus and an
external tone of appropriate frequency.
Another strong argument is the fact that
the pitch of tinnitus usually remains
constant for years. It would almost
require a crystal controlled oscillator to
produce a signal of so constant a
frequency. What and where should that
be?
On the other hand it is well
conceivable that the place of damage is
Page 13
identical with the place where pathologic
neural discharges are generated,
producing tinnitus, and that this place
remains constant for years. The pitch of
tinnitus is often related to the maximum
hearing loss in the audiogram, i.e. the
maximum damage in the cochlea, for
instance in cases of acoustic trauma.
Thus for explaining the pitch of tinnitus
the place theory seems adequate, and not
the periodicity pitch.
How could the pathologic
discharges in a certain place come
about?
It is very likely that in damaged
inner hair cells neural discharges are
triggered without an acoustic stimulus,
and this would give rise to the sensation
of tinnitus. In the normal acoustic
stimulation of an inner hair cell shearing
movements of the stereocilia open and
close ion-channels at the apical cell
membrane. If there is a defect of these
ion channels or in other parts of the
membrane, this would result in a leakage
of certain ions, which would be
tantamount to pathologic discharges
without acoustic stimulus.
In the auditory system, in the
absence of any external stimulus, there is
a spontaneous activity of neurons at all
levels with firing rates ranging to about
100 per second for the individual unit,
but this represents the sensation of
absolute silence. Only if the spontaneous
activity is modulated in some way, we
perceive a sound. Such a modulation is
brought about by acoustic stimuli and it
consists in a increase or decrease in the
discharge rate of single fibres.
Pathology at any level of the system
may also produce such a modulation of
discharges, e.g. by defects of ion-
channels. Another type of modulation of
the spontaneous activity is a
synchronization of discharges in adjacent
fibres. In normal hearing it is brought
about by phase-locking of the discharges
to the acoustic signal. In the pathologic
situation such a synchronization of
spontaneous activity might be induced by
a partial breakdown of the myelin
Continued Page 14
REFLECTIONS ON THE
PATHOPHYSIOLOGY OF TINNITUS, continued
sheaths of individual nerve fibres,
resulting m direct electrical contact
between axons. The fibres in the
auditory nerve and ganglion cells are
packed densely and the myelin
are so thin that they can easily be
damaged by mild trauma..
the mechanism generatmg tmmtus m
eighth nerve tumor, head trauma, and
irritation of the eighth nerve by vascular
compression.
There certainly is a great variety
of disorders that can give rise to the
sensation of tinnitus. We must learn
more about the normal function of the
hearing system. It is the basis for an
understanding of the pathophysiology of
tinnitus and in the future it should
become the basis for a rational treatment.
For further details and references
see: Harald Feldmann: Pathophysiology
of Tinnitus. In: Tinnitus,
Pathophysiology and Management.
Edited by Masaaki Kitahara, M.D. Igaku-
Shoin, Tokyo, New York 1988, p.7-35.

BIBLIOGRAPHY SERVICE
ATA's Tinnitus Bibliography
service has been available for about a
year and is being utilized more
frequently as people learn of its
existence.
The service may be used in two
major ways: of the
bibliography (a hst . of
1600 writings relatmg to tmmtus,
including author, where published and
date of publication) at a price of $25 to
AT A members/$ 50 to non-members.
Hard copies of articles may then be
selected and ordered from this list. Our
charge for copying the articles is $0.10
per page, plus postage and handling. .
If an individual is interested m
only one or two specific subjects, they
may request a subject search at a charge
of $5.00 per search and then sel.ect
articles to be copied from the resultmg
list.
Neither the bibliography nor the
subject search includes copies of the
actual articles. These lists are merely
tools for selecting articles.

"COPING WITH TINNITUS"
e STRESS MANAGEMENT & TREATMENT
e TINNITUS MANAGEMENT IS OfTEN
COMPLICATED BY ANXIETY AND STRESS
e NOW A UNIQUE 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 of tinnitus
control such as systematic relaxation procedures wh1ch help the
patient cope with the tension of tinnitus.
Subjects with tinnitus are being taught ways to relax. as ?fa
total tinnitus program which may heanng tinmtus
maskers and progressive muscle relaxation based on of
conditioning. Relaxation procedures are usually easily mastered can be performed da1ly m the
i\111 \ patient's home environment It has been demonstrated that the relaxation response can release muscle
tension, lower blood pressure and slow heart and breath rates. . . .
9
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$5 et nll"d''''<) has successfully treated for many years chronic pain, tension headaches, msomma and many other
0 conditions. . . dd'ti 1


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Page 14
TINNITUS: PERSPECTIVE FROM
A CHRONIC SUFFERER
By David A. Barber
(Ed. Note. Mr. Barber is an ATA
volunteer and leader of a tinnitus self-
help group. This article first appeared
in the June 1988 issue of SHHH.)
Again this morning for the
umpteenth time like a track star who
explodes from the starting blocks, I
leaped soaking wet from the shower and
dashed eight or nine steps, grabbed the
bedroom telephone and... nothing. Last
week while doing my regular morning
exercises, and no more than five feet
from the telephone with the ringing bell
set to full loudness, I almost missed that
long distance phone call from my aunt.
What is going on? Is it really ringing or
not?
Estimates by the Public Health
Agency put the number of chronic
tinnitus sufferers at some 36 million
Americans. "More than seven million
people are afflicted so severely that they
cannot lead normal lives," and reported
cases of suicide emphasize the important
need for increasing funds for research.
Like one of the estimated 35
million persons with tinnitus or "head
noise", I frequently cannot distinguish
between an actual or outside the head
sound and the loud ringing inside my
head, subjective tinnitus.
For some, the incessant noise they
describe may vary from a hissing, or
sizzling, or humming to a clear tone,
ocean roar, whistle or even voices. I
have found over a period of some 25
years that the primary change for me has
been one of intensity or volume.
The first time I recall noticing the
ringing sound was when I was a college
student walking across campus. It began
as an intermittent sound in either ear
alternately. The ringing was sudden and
unusual, but it also went away as quickly
Page 15
as it came. Over the next few months
however, the ringing became more
regular, more mtense and finally,
constant in both ears. Since that time, in
the early 60's, it seems that I have
pursued relief from the ringing from
nearly every type of health care
professional who exists.
On a cold rainy afternoon I
entered the counselors warm, cozy office.
I had been referred to him by the
campus testing and advisement center. I
remember vividly his piercing question.
"Do you love your father more than you
love your mother?" I was immediately
confronted with guilt and fear. As a
result, I avoided talking to anyone about
the ringing noise in my head.
After being informed that I was
rejected by the Air Force advanced
ROTC officers training program because
of a hearing loss which exceeded
acceptable military standards, I again
began to seek treatment.
The chiropractor, a friendly young
man, suggested that the s-shape of my
spine was responsible for pinching a
nerve and restricting blood circulation to
the inner ear. He recommended a
program. After several x-rays, sessions
of manipulation, and shoe lifts, this poor
college kid was running no only short of
capital but also patience.
"A deviated septum is creating
unequal air pressure in the eustachian
tube", I was told by the ear, nose and
throat specialist I had been referred to.
He recommended a nose operation. For
days my fraternity brothers good
naturedly teased me about my two black
eyes and swollen nose.
Following graduation I began a
high school teaching career and felt quite
successful in the rural farming
community with small sized classes. At
the urging of the state education director
I accepted a promotion to a larger high
school with 35 or more students per
class. Sophomores have an uncanny
ability to detect teacher glaws. George
was a bright but mischievous teen who
tested all his teachers. I remember how
he delighted in making sounds from the
back of the classroom. He knew that I
could not tell where they were coming
from. I was soon taking three
tranquilizers a day to teach six classes
and conduct agriculture project visits.
The ringing accompanied by a
sensorineural hearing loss was all it took
to end my high school teaching career
that year.
With an agriculture background,
college training and high school teaching
experience I made a rather easy
transition to county extension agent.
Within a few years, however, I realized
that I was missing too much in my
professional assignment, and was fitted
with my first hearing aid. The
adjustment was difficult at first and I
dreamed that with improved hearing the
ringing would go away.
By the mid 70's tinnitus was
severely affecting my lifestyle. With
three children, three businesses, a wife
attending college and increased
responsibilities resulting from job
promotions, I could not relax or sleep. I
was running on nervous energy. My
ears were ringing "out of sight."
An otolaryngoligist recommended
biofeedback. This technique taught me
how to concentrate on relaxing my mind
and body muscles. The therapist related
how he could control his own tinnitus
caused by a motorcycle accident.
Unable to continue the expense after
months of therapy, I found little relief
from tinnitus, and by now was dealing
poorly with family and job frustrations.
My boss recommended that I drive
150 miles twice weekly to another state
where acupuncture was legal, since the
treatments had done "wonders" for his
wife's migraine headaches. I cannot say
Page 16
it was a pleasant experience. By the
fourth or fifth treatment I found the
resulting pain experienced from the
needles and lack of measurable relief
from tinnitus sufficient reason to stop the
procedure.
1979 was a very bad year. My
wife of 17 years filed for divorce. The
sale of two businesses were financial
disasters and my campaign for a national
office in my professional organization
was unsuccessful. Feeling defeated and
nearly useless my productivity on the job
suffered.
A long-time friend, with a teenage
daughter who had been successfully
treated for severe headaches and ringing
in her ears, urged me to continue to seek
help for my tinnitus. At her urging I
continued to pursue a solution. 1 drove
nearly 450 miles to be evaluated by an
orthodontist who had successfully treated
patients with TMJ - temporomandibular
joint dysfunction. At the same time the
otolaryngologist recommended that I
experiment with a change in elevation.
So living at 4500 feet I gladly accepted
the opportunity to travel to sea level,
particularly since it was Mexico in the
winter.
Returning home, tanned and
rested, I was able to improve job
performance. However, within a short
time, aggravated by stress, the tinnitus
escalated to a new intensity, much worse
than I had ever experienced.
Experiments with maskers were
unsuccessful for me.
Tests for diabetes, hypoglycemia, excess
sodium and blood diseases were all
negative. Doctors recommended
nicotinic acid, salt-free diets, vitamin and
mineral supplements.
About 18 months ago I was
informed that "we", the medical
professionals with whom I had now
consulted for over 20 years, had done
about everything that could be done to
"cure" this extremely elusive malady.
Feeling frustrated with the years of
unsuccessful treatments I decided to read
and research the problem. Early
textbooks describe tinnitus as a symptom
of many otologic diseases, existing in
several forms. This seems to be a
primary reason why no single or specific
treatments have been found to be
successful.
In a study by Reich and Johnson
they found that tinnitus can have a
"deleterious effect on personality." Not
unlike the clinical patients tested at
Kresge Research Laboratory, I too, have
been plagued with symptoms of
withdrawal, depression and physical
illness. In another study by Tyler and
Baker, tinnitus sufferers were surveyed
to determine what kind of difficulties
they experienced. The effects of
difficulties were placed into four
categories; hearing, life-style, general
health and emotional problems. Results
confirmed that tinnitus can affect persons
in all categories.
In May 1986, I elected to have an
eighth nerve decompression surgery.
The procedure had been reported to be
successful in relieving tinnitus in some
60% of the patients. I am evidently one
of the 40%. (Ed. note, more recent
studies indicate only about 30% are
helped.) I have also consented to try an
experimental nutritional supplement.
Current testing results from Europe are
inconclusive. Meanwhile, I am also
participating in hypnosis therapy.
While off work for over a year
and currently on medical leave, I have
found several things which are of
importance to me. I have become
involved in a caring m1mstry at our
church. We are comforters to those who
are suffering. Two of the persons I
visited were terminal and have died.
You would be amazed at how different
our problems appear when we have a
chance to get involved in the lives of
others.
With reading and study I am
learning much more about tinnitus, its
causes, treatments and possible "cures"
in the future. Returning from isolation
and avoiding self-pity, getting involved
with others, taking classes at the
university and volunteering have all
given my life more meaning.
I have found no easy answers. I
have found, that deciding to move on is
essential.

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 ti nnitus sufferers
and their families 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 treat ment
1
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 House (nc.,
145 Palisade St. , Dobbs Ferry, N.Y. 105?2
Please send me __ copy(ies) of Tinnitus: A Guide for
Sufferers and Professionals. $17.95 plus $2.00 postage.
Check enclosed for $ ____ _
Name: ------------------------
Address: ----------------------
City, State, ZIP - --- - --------
All or(leK tle prepaid. NYS plea'< add ;ale< 14x. Canadiarl and other
foreign customers pa) by U.S. Money Order or U.S. bank draft. Sorry. cannot
accept foreign cheeh ..
SURVEY RESULTS NOW AVAILABLE
TO RECEIVE A FREE COPY OF THE SURVEY
RESULTS MENTIONED IN THE ABOVE ARTICLE,
SEND A LARGE SELF-ADDRESSED STAMPED (25)
ENVELOPE WITH THE WORD 'SURVEY' WRITTEN
IN THE LOWER LEFT HAND CORNER.
Page 17
ATA ANNOUNCES RESEARCH
AWARD
It is our pleasure to announce a
recent research grant made to Dr.
Douglas H. Morgan of the TMJ Research
Foundation. Dr. Morgan will be
investigating possible relationships
between TMJ dysfunction and tinnitus.
We have also just learned that the
American Assoiciation of Retired
Persons Andrus Foundation has approved
funding for a research project titled
"Older Americans and Tinnitus: a
demographic study". AT A is
maintaining close contact with this
project through the principal investigator,
Dr. Scott Brown, of Gallaudet
University.
"
r

Page 18
COMBINED FEDERAL
CAMPAIGN SETS HIGH GOALS
FOR 1988
THANK YOU TO ALL FEDERAL
AND MILITARY EMPLOYEES WHO
DESIGNATED ATA DURING THE
CFC. THIS YEAR IT SHOULD HAVE
BEEN EASIER THAN EVER TO
DESIGNATE. THE BROCHURES
CARRIED THE NAMES OF ALL
ELIGIBLE NATIONAL AGENCIES
WITH THEIR CODE NUMBER.
ATA'S NATIONAL CODE IS 0514.
WE HOPE YOU ALSO SAW THE
ACCOMPANYING ANNOUNCEMENT
IN THE "FEDERAL TIMES".
(ad copy that we used in Federal Times-
1 column vertical)
COMBINED FEDERAL
CAMPAIGN 1988-89 KICKOFF
CEREMONIES
AT A was pleased to be invited to
the CFC kickoff at the Naval Supply
Center in Oakland, California. Captain
Donald Antrim was a gracious host and
provided participating agencies with a
tour of the Hospital Ship Mercy. The
Mercy is one of two new hospital ships
operated by the Military Sealift
Command. These ships are floating
surgical hospitals with 1,000 bed
capacities. The ships are ready to be
deployed at any time to receive
casualties. The Mercy also has an
impressive record of charitable service
providing dental and surgical care to
thousands in Pacific ports. More than
500 people watched as the colors were
posted under sunny skies. They were
entertained by the Sixth U. S. Army
Band, heard inspirational remarks from
dignataries, and enjoyed cookies and
punch.
TRIBUTES
The AT A tribute fund is designated 100% for research. Thank you to all those people listed below
for sharing memorable occasions in this helpful way. Contributions are tax deductible and will be
promptly acknowledged with an appropriate card. The gift amount is never disclosed.
IN MEMORY OF
Richrud Mishuk. U.S. Marine,
MIA in Vietnam lor 20 years
Betsy Orne
Your Dear Father (Kohn)
Your Darling Gloria (Greene)
Clyde Davis
Ezra Mermelstein
Marie Allen
Sadie Weissman
Ben Singer
Ruth Z. Reed
Bernard Edelman
Your Dear Father (Friedman)
George Hawie
Xavier Bazan, Jr.
BIRTHDAY WISHES
Marguerite Tyree
Joe Alam
Adele Alam
Joyce E. Koehler
Nieola Nastasi
Betty Portwood
Evelyn Celio
My 70th Birthday
CONTRIBUTOR
leo J. Mishuk
Jeannine T. Reid
Jean and Joe WoHson
Jean and Joe WoHson
Erin Abbott
Mr. & Mrs. Sam Eisenberg
J. Alam & T. Drucker
Steve & Sherry Possner
Rose l. Singer
Alice R. BOOrse
Jean & Joe WoHson
Jean & Joe WoHson
Mrs. Elaine Chedister
Xavier Bazan
CONTRIBUTOR
Marda Tyree
Trudy Drucker
Joe Alam & Trudy Drucker
Joe A lam & Trudy Drucker
Joseph Nastasi
Rober! E. Wilson
Thomas Zipoli
Theresa BISkin
SPONSOR MEMBERS
Joseph G. A lam
Francis C. Bennett
Bruce S. Bloom, M.D.
Richard J. Borden
Charles T. Brown
Laird Brown
Joseph CC!Illin
Ronald E. Cutmore
l. D. Daugherty
Victor Elmaleh
Dr. & Mrs. Charles Emerick
fan Getreu
Veva J. Gibbard
Anna R. Hess
Charlotte S. Hooker
Dr. Khairy A Kawi
Frank W. Koenen
Artine Kokshanian, M. D.
E. D. Marchant
Dr. Terence J. Molony
ANNUAL GIFTS FOR 1988 ARE DUE
ONLY WITH YOUR SUPPORT CAN ATA CONTINUE
TO PROVIDE INFORMATION ABOUT TINNITUS AND
FUND TINNITUS RESEARCH. PLEASE BE
GENEROUS!
In order to continue to receive Lhe AT A Newsletter 1 am
enclosing my annual contribution lO support tinnitus
research and education
_ __ .$15 -$24 Contributing Member
---'$25 -$49 Supponing Member
__ _c$50 - $99 Sustaining Member
___ $100 or more Sponsor Member
Your contribution in any amount will be greatly appreciated
but we are unable to send receipts for amounts less than $10.
Donor's Name ____________ _
Address ______________ _
City, State, Zip-----------
OPTIONAL: Tribute Fund gifts
This special gift is in the name of:
In Memory of __ (please check category)
In Honor of _Birthday _Anniversary_Other
(explain) _______________ _
Card in recognition of the occasion to be sent to:
Name _____________ _
Address ___________ _
City, State, Zip ________ _
IN HONOR OF
Jom R Emmett, M.D.
Kenneth Brookler, M.D.
Soraya Hoover, M.D.
All my loved ones
Mr. and Mrs. C. S. Colfins
Raymond H. Ball
Sandy Schlater
Harley Delong
Michael w. Goodin
New Granddaughter(Saunders)
Bill Moyers
Marcia A. Yancey
SUCCESSFUL SURGERY
Jessica Rosenberg
Neal Atkins
Josephine Meo (speedy recovery)
GOOD LUCK
Carol Ricci (New Digs)
Mr.& Mrs. Robert Maguire (new
restaurant)
CONTRIBUTOR
Dr.& Mrs. luther J. Smith II
John F. X. O'Connor
James C. Brinkley
Sara Allen
Clilf Collins
D. Huebner
John and Faye Schlater
Charles L. Williams, Jr.
Evelyn M. Goodin
Jean & Joe Wolfson
Michele Quare
Delpha M. Bain
CONTRIBUTOR
B. Friedenberg
Jean & Joe Wollson
Angela F. DeiVillat
CONTRIBUTOR
Jean & Joe Wollson
Jean & Joe Wollson
August - October 1988
Andrew Neher
Ben Ossman
Frederic W. Pullen II, M.D.
Mr. and Mrs. John H. Schlater
Kit SeaJS
Mark E. Shapiro
K. Thomas Shipley, Jr.
Dr. and Mrs. luther J. Smith, II
Sylvia Smith
Robert M. SouthaJd
AndrewS. Tarlow
Arthur W. Verharen
Michael Webber
Robert F. Weimer
Harvey Wilson
Dallas R. Woll
In Min Young, M. D.
ATA ANNOUNCES
NEW BOARD MEMBERS
The following appointments were
announced at the annual meeting of the
AT A Scientific Advisory Board.
JOHN W. HOUSE, M. D.
House Ear Institute, Los Angeles, Calif.
Dr. House will be taking the place of his
father Howard P. House, M. D. who is
stepping aside after ten years as an AT A
board member. Our thanks to both
doctors House for their continuing
friendship and help.
W.F.S. (SAM) HOPMEIER
Hopmeier, Inc. St. Louis, Missouri. Mr.
Hopmeier has been fitting tinnitus
maskers and hearing aids successfully for
more than 20 years. We are delighted to
have Sam on the AT A board.
DAN ROBERT HOCKS
Hocks Hearing Health Care Products,
Portland, Oregon. Mr. Hocks' interest in
AT A goes back many years. His father,
the late Bob Hocks, was ATA's first
national chairman. Welcome Dan.
Page 19
AMERICAN TINNITUS ASSOCIATION
P.O. BOX 5, PORTLAND, OR 97207
ISSN:0897-6368
ADDRESS CORRECTION REQUESTED
NON-PROFIT ORG
US POSTAGE
PAID
PERMIT NO 1792
PORTLAND, OR