N ~ W S L ~ T T ~ ~

VOLUME 3, NO. 3 Sept, 1978

INFORMATION FROM U.O.H.S .C.
TINNITUS CLINIC
Jack Vernon
As of this writing we have had i n operat ion a Tinnitus
Clinic for slightly over two years . The cl inic is i n
t he Department of Otolaryngology (Ear,Nose, & Throat )
at the University of Oregon Health Sciences Center.
To date, 513 tinnitus patients have been seen in our
clinic. Each person filled out a questionnaire so
that information about this population of patients
is available. They have come from as far away as
Canada, Iran, India, and Guatamala; not just from
the state of Oregon.
In discussing tinnitus with each patient, it in-
variably turns out that they are interested in infor-
mation about other patients who suffer in common
with them. Thus, it seemed likely that some of the
information contained i n the questionnaire might be
of interest to the readers of the ATA Newsletter.
Fortunately, about thi s time there came to our lab-
oratory a graduate student in Audiology who agreed
to undertake the laborious task of compiling sta-
tistics from the questionnaire. I am greatly in-
debted to Marybeth Young for the job she has done.
Age of Patients
The tinnitus population we see are not mostly young
people. Fifty-eight percent of our groups of patients
fall between the ages of 45 - 65, and 18% are from
65 - 80 years of age. The oldest patient we have
seen was 85 and the youngest was 14. Between the
ages of 20- 35 we find 11% of our patients.
There is no specific cause or kind of tinnitus which
is indicative of any particular age group. Each age
category finds every kind of tinnitus present with
the slight exception that the very young tend to have
congenital problems while the older groups are more
apt to have noise-induced tinnitus.
THE AMER ICAN TINNITUS ASSOCIATION
Male/Female Ratio
Initially the patients were almost 50% female and 50%
male. As the clinic has continued, however, the ratio
has shifted to 65% males and 35% females.
Duration of Tinnitus Cases
We have requested the medica l community to refer only
to us cases of severe tinnitus. These cases should be
those that have endured past a six months period. The
largest group, those whose tinnitus is of five or more
years in duration, constitute 42% of our population.
It is not unusual to see patients who have endured
tinnitus for 20 years. It is not uncommon for the World
War II veteran to have acquired a minor case of tinnitus
around 1943, or so, which over the years has gradually
increased in severity.
Monaural vs. Binaural
We question each patient very closely as to where the
tinnitus is located. It is our opinion that eventually
it may be possible to determine where the trouble is
initiated in the auditory system. The localization of
the tinnitus sensation may be one piece of information
important to such a determination. For the most part,
patients are able to precisely locate their tinnitus
for us.
In 37% of the cases the tinnitus is confined to only
one ear. Of this group, 16% have it in the right ear
and 21 % have it in the left ear. The largest group,
58%, have it in both ears .
Usually the two ears have tinnitus of t he same pitch but
often the loudness is unequal. It is fairly rare to
find the pitch in one ear differing from that in the
other ear, but it does happen. It is easy to confuse
loudness and pitch so that often the bilateral patient
will report that the tinnitus sounds different in the
two ears. In most cases, it is only the loudness which
differs. I do vividly recall one patient, however,
who had three distinct kinds of tinnitus. In the left
ear the pitch of this tinnitus corresponded to a fre-
quency of lBOO Hz, and in the right ear it was 3200 Hz.
The third tinnitus located in the middle top of the
head and was of an intermediate pitch.
There are only 5% of our patients who localize the
tinnitus "within the head" and then usually in the
back center of the head. That may sound like a rather
bizzare location but it is a real phenomena which can
be easily duplicated. If under ear phones we present
to each ear separately the same tone at equal loudness,
the observer will not hear sounds at the ears but
rather will localize the sound in the center of the
head. The localization within the head can be made to
shift by slightly increasing the loudness of one tone
over the other. The shift of localization will be to-
ward the louder side.
The localization of tinnitus within the head may be
due to equal presentations from each ear and it may
also be due to tinnitus produced by head injury.
Severity
Remember we have requested that only patients with
severe tinnitus be referred to us . Thus, what follows
here is undoubtedly infl uenced by that selective
factor.
Each patient is asked to rank the severity of his tin-
nitus on a sclae of 1 - 10 with 10 being the worst.
Sixty-nine percent of our people rank their severity
from 6 - 10.
This subjective evaluation is of interest to us be-
cause there is no objective measure which corresponds
to the severity of tinnitus. For exampl e, severity
of tinnitus does not correlate with the loudness of
tinnitus as one would imagine. When external sounds
are increased in loudness until they match the loud-
ness of the patient's tinnitus the resulting match
usually has a sensation level of 5 - 10 dB, which is
a very little sound when you consider that normal con-
versation may reach you at a sensation level of 55 -
60 dB.
We have seen tinnitus louder than 5 - 10 dB; indeed,
we have seen it at 40 dB in a few patients and even at
70 dB in one patient. All of these patients experi-
ence loud tinnitus which was severe, but as one would
agree tinnitus need not be loud in order to be severe.
Severity seems to relate to some other facet of t in-
nitus than its loudness.
Constant vs. Fluctuat ing Ti nnitus
Occasionally we have a patient show up at the clinic
with the exclamation, "I left my tinnitus at home to-
day". These patients have fluctuating tinnitus so
that on some days it is all but gone while on other
days it is extremely severe.
It is not uncommon for this kind of tinnitus to have
been generated by a head injury although we have seen
cases where the cause is unknown; indeed, in most
cases the cause of the tinnitus is unknown. -----
One very frustrating thing about fluctuating tinnitus
is that the patient never knows when the tinnitus will
be upon them. The coming and going does not follow
any set pattern and can unexpectedly interrupt any
activity. In some of these cases masking has pro-
duced a regularization of the coming and going
that at least the patient knows when to expect bad
times.
We find that 68% of our patients have a constant form
of tinnitus while 32% have it in its fluctuating form.
We do not find any one particular kind of tinnitus
which is characterized either constant or fluctuating.
Pitch of the Tinnitus
The pitch of a sound is the psychological attribute of
that sound which corresponds to its frequency. That
is, frequency is a physical, measurable, attribute of
sound, while pitch is the psychological, subjective,
correlate of it. We place great importance upon the
identification of the pitch of each patients' tinnitus.
That information helps us determine whether or not
masking is appropriate for the patient and if so what
kind of masking will be needed.
In a general way, tinnitus comes in two rough classes:
tinnitus and noise tinnitus both of which have
an identifiable pitch. The pitch of the noise type
is more difficult to determine. In our population,
59% of the patients have tonal tinnitus whi l e 25% have
the noise type. The remainder, 16% have a combination
form which is usually expressed as " .. a tonal type of
tinnitus plus some noise" .
2
In all cases the pitch of the tinnitus is identified by
a matching procedure. Physical sounds are presented to
the patient until one is found which closely resembles
their tinnitus. With this procedure there are two very
important points to consider: First of all, the physical
sounds must be at the loudness level of the patients '
tinnitus. If the physical sounds are too intense the
patient wil l experience great difficulty in matching
pitch and, for some, it is an impossible task.
Secondly , the first identification selected by the pa-
tient is. very apt to be off by about one octave. Thus,
one must check various octave points around the identi-
fied point. If, for example, we have been moving stea-
dily upward in pitch and at 2000 Hz the patient indi-
cates a match with his tinnitus it is then imperative
that 4000 Hz also be checked. When this matching is
properly done it turns out that the octave above the
first identification is the true identification in about
7 out-of 10 cases.
Utilizing the proper match of pitch, 63% of our patients
have tinnitus between 2000 - 7000 Hz. Only 21% located
it below 2000 Hz and 16% above 7000 Hz. We conclude
from this that a great majority, 84%, have high fre-
quency tinnitus; that is, a tinnitus with a pitch which
corresponds to 2000 Hz or higher.
This fact has produced a proolem for our masking pro-
gram which is the ability to produce maskers capable
of producing energy at these high frequencies. The
tinnitus maskers are made from components which are
used to produce hearing aids.
Hearing aids on the other hand have been produced pri-
marily to facilitate the of speech, and speech
frequencies are primari ly belol' around 3000 Hz. Thus,
there has been little need for the 1ndustry to repro-
rluce th" hi ghor freq11<>ncjos Hap.efully that i tuati!)r_
is now beginning to change as we have clammored for
more and more high frequencies in the tinnitus maskers.
There is currently available a High-frequency Masker
which routinely reproduces a substantial amount of
energy out to 7000 Hz. There is even an experimental
model which reaches considerably higher frequencies.
Recently, using one of these experimental units we
successfully masked a young patient whose tinnitus
was at 15,000 Hz. That case, by the way, is the
highest-pitched tinnitus we have seen.
Head Injuries
We have had approximately 35% of our patients report
head i nj uri es \I hi ch seemed to be the cause of their
tinnitus. So often we are asked " .what caused lll)l
tinnitus?" and in most cases we do not know. There
are many known causes of tinnitus but in most in-
dividual cases it is all but to determine
the cause. One cannot help but make some guesses
and one such case is when the tinnitus occurs fo 1-
lowing head trauma.
These cases are usually more difficult to manage than
are the other sorts of tinnitus. Not infrequently ,
post head-trauma tinnitus fluctuates wildly yielding
to masking on some days but not on others. Such a
situation is difficult on the patient, requiring more
than the normal amount of adjustment and understanding.
One interesting and possibly significant item has
arisen in the case of post head-trauma tinnitus. In
some cases when the tinnitus is located in one ear
only, masking into both ears is vastly superior to
that in the affected ear alone. Thus some of these
pa tients v1ear one masker on their "good" d?.ys and
two maskers on the "bad" days.
Noise Exposure
I t is well known that exposure to excessive amounts of
noi se can not only produce hearing loss but severe tin-
nitus as well. We find that almost half our patients
(48%, mostly men) have suffered noise-induced hearing
loss. It is possible that the same exposure may have
also produced their tinnitus.
One thing is very sure, exposure to loud noise will make
almost any tinnitus worse. Thus, we admonish our pa-
tients to avoid loud noises at all costs. Often they
get fitted with custom made ear plugs (the best kind) so
as t o continue their occupation and/or recreational pur-
sui t s.
Tinnitus and Noise-induced Hearing Loss
We have seen a total of 231 patients with what appears
to be some form of noise-induced hearing loss. Origi-
nally, we guessed that noise-induced tinnitus should dis-
play some specific characteristics such as perhaps a
characteristic pitch; however, this does not seem to be
the case. The pitch of these 231 patients appear every-
where as the following table will show.
Frequency to Pitch
of Tinnitus
Percentage
1000 Hz - or less
1000 Hz - 4000 Hz
4000 Hz - 10 kHz
10 kHz - above
5%
38%
55%
2%
About all one can say is that in the majority of noise-
induced cases the tinnitus will be between 1000Hz and
10 kHz. But that same statement can be made for just
about all our patients.
The conclusion we come to is that wide exposure to exces-
sive amounts of noise can produce tinnitus nevertheless
and that tinnitus is not distinctive by its pitch.
Tinnitus and Hearing Aids
We have seen tinnitus patients who have normal hearing but
such cases are rare, about 8 - 10%. Thus, a large ma-
jori ty, about 90%, of our patients have had a hearing loss
when they visited our clinic. Thus, one would assume
that a large majority of them would also have worn a
hearing aid. Not so, only 15% came to us with hearing
aids!
3
If we look at our patients in terms of hearing losses
(and define this to be a 25 dB loss or greater) then 92%
of them have a hearing loss. Only 1% showed a loss re-
stricted to frequencies below 1000 Hz, 39% have rather uni-
form losses across all frequencies, and 52% have losses
restricted to 2000 Hz and above. Not all of these patients
would qualify as candidates for hearing aids but many more
than 15% do need amplification.
We do not make recommendations to all patients who visit
us, about 23% of our population receive no recommendation
at all, this may be due to the fact that hearing is so de-
pressed that nothing can be done, or that the tinnitus was
so high pitched as to be unreachable, or that their tin-
nitus for unknown reasons resisted any and all forms of
masking, etc.
In any event, of those to whom we do make recommendations
48% have hearing aids recommended to them. This seems to
say that about one half the patients seen in our Tinnitus
Clinic should have been fitted with hearing aids. And,
further, to have done so might have not only improved
their hearing but might have controlled their tinnitus as
well. Our part of the country seems to be infected with
an anti-hearing aid attitude that is very difficult to
understand when one considers the benefits which can re-
sult from their use.
Tinnitus and Sleep
Initially we assumed that most sufferers of tinnitus
would experience problems with maintaining sleep. Bed-
time is usually a quiet time, often devoid of distrac-
tions, all of which would tend to make tinnitus more
obvious. As it turned out, however, only 50% of our
patients complain of sleep problems. Some of these
cases (depending upon the nature of their hearing loss
and the pitch of their tinnitus) have found that FM-
Masking works well for them. FM-Masking utilizes the
static sound (white noise) located between FM stations.
It is a c ~ n t i n u i n g noise capable of masking almost any
sound.
For other patients for whom FM-Masking does not work we
are currently developing a Tinnitus Masker capable of
being worn during sleep. It will be a soft mold all-in-
the-ear unit. The currently available Tinnitus Masker
is worn behind the ear. Such an arrangement is not com-
fortable when lying on that side although some patients
have so used their maskers and to good effect.
The currently available Tinnitus Maskers are fitted to
the patient's ear in such a way as to leave the ear as
open an possible. It is for this and other reasons
that an all-in-the-ear type of masker has not been ad-
vised or produced. The situation during sleep, however,
is different and it is then that such a unit may find
application.
Residual Inhibition
Residual inhibition is the term applied to the continu-
ation or persistence of the masking effect after the
masking sound has been turned off. In the clinic we
test for residual inhibition by completely masking the
tinnitus for one minute. At the end of the masking
period the patient is asked to describe their tinnitus.
If they are displaying residual inhibition at that time
they will say something like " .. it's gone", or " .. it's
greatly subdued", or " .. it is much less". In any of
these cases we time how long it takes to reestablish
the normal level of tinnitus. Typically after one
minute of masking,abcut 45 seconds or so are required
to return to normal.
We find that 22% of our patients have no residual in-
hibition. In this group are those patients for whom
extreme sound levels are required to achieve masking
or for whom no masking can be found which is effective.
Patients showing residual inhibition (78%) do so in one
of two ways. There are some for whom residual inhi-
bituation is complete (35%);that is, the tinnitus is
totally absent after the masking. For the remainder
(43) the residual inhibition is partial, that is, the
tinnitus is present but greatly suppressed after masking.
In order for residual inhibition to take place it is
necessary that the correct type of masking be utilized.
The masking must be appropriate for the pitch of _the
tinnitus which means that the masking noise must come
from the same frequency region as does the pitch of
the tinnitus. If tinnitus is at 5000Hz then the
masktng noise should be a band of noise centered at
5000 Hz, or if a tone is used to produce masking it
should, in this case, be a 5000 Hz tone. If tinnitus
is at 5000 Hz but a 2500 Hz tone is used to mask it
then masking can occur, but most likely residual
inhibition will not occur. In some cases then the
presence of residual inhibition can be used to help
confirm tinnitus identity.
In the daily situation where patients are wearing
tinnitus maskers they often find extended periods of
residual inhibition or quiet time as one of them put
it. We tend to feel that patients who have displayed
residual inhibition in the clinic have a good prognosis
for the use of masking but as yet do not have any data
..J
%
.,;
...
on this point. Instead, a rather dramatic case of the
opposite situation comes to mind. One lady, requiring
two tinnitus maskers, displayed no residual inhibition
at all until she had worn the maskers for over four
months.
She now finds about 5 hours quiet time per day where
masking is utilized the remainder of the day. Needless
to say, the phenomena of residual inhibition has in-
trigued us greatly and we are currently investigating
it. It is our hope and obligation to find ways of
extending the duration of quiet-time periods for
tinnitus patients.
At some time we will discuss residual inhibition
in detail.
THANK YOU
Volunteer, Maxine Lundquist, for an outstanding job.
Maxine has been helping ATA this summer with getting
the mailing list files sorted. Also our thanks to Joe
Scharff, Larry Holton, Betty & Chuck Mathis, Lois
Schiedel and Helene Benson who have been helping with
ATA projects.
TINNITUS WORKSHOPS
As of September 7, 1978 there have been approximately
500 persons trained in tinnitus-testing procedures.
This training has taken place at the Tinnitus Clinic in
Portland and at special seminars conducted by Dr. Jack
Vernon.
Because the Tinnitus Clinic in Portland will no longer
be scheduling observer appointments, ATA registered
tinnitus clinics will begin. Workshops-are being or-
ganized ana will take place in various locations around
the country. You may write for information!C/o Gloria
Reich, ATA, Box 5, Portland, Oregon 97207. Brochures
and registration material will be available soon.
WHAT IS ALL THIS NOISE
ABOUT MASKERS?
4
Research is underway at Kresge Hearing Research Laboratory
to understand more about how masking works to relieve
tinnitus. By understanding more about how masking works,
it is hoped that we can understand why maskers sometimes
fail to relieve tinnitus. This understanding will also
help in the development of better maskers.
In many cases masking can relieve tinnitus. It doesn't
cure it or make it go away, but covers it up with a
more acceptable sound. The masking sound can usually
be easily ignored and thus the tinnitus is also ignored.
An example of this would be patient M.R.
0
20
TINNITUS
40
60 Htor"9 Thresl>old
- Mosk111glovtl
M. R.
250 500 lk 2k 4k 6k 8k
FREQUENCY, Hz
In this case the hearing threshold (o-o) shows a
high frequency hearing loss with tinnitus present
at 6kHz, shown by the star (*). When pure tones
are used to mask the tinnitus nearly any tone of
moderate loudness will mask the tinnitus (x-x). In
this patient the masker works quite well and has
for over a year.
In thi s patient the masker works quite well and has
for over a year. In cases where masking does not
work several reasons have been found. In some cases
the maskers simply do not produce enough energy in
the region of the tinnitus. In other cases the hearing
loss is so great that the masker won't reach the tin-
nitus. That is, the masker cannot overcome the ex-
treme hearing loss.
In the case of patient A.J., who also has a high fre-
quency hearing loss and tinnitus in the 6 kHz region,
0
20
:;! 40
60
Threshold
,....._.. Mamno level
A. J.
250 500 lk 2k 4k 6k 8k
FREQUENCY, Hz
the masker does not work. Here we see
efficient masking takes place in the 4
region.
that the most
kHz to 8 kHz
However, the masker produces a wider band of sound and
thus a person hears sounds throughout the 1 kHz to
6 kHz frequency range. And it turns out that the
masker is more objectionable than the tinnitus itself.
These are some of the results that we have
obtained up to now. These studies are continuing and
we are hopeful that they will guide the way to
and mo2e efficient maskers fm- t.he :relief of tinnitus
for al,Z who suffer.
by Curtin Mitchell, Ph.D.
excerpted from a prayer
What does it mean to hear?
The person who attends a concert with his
mind on business
Hears - but does not really hear .
The man who listens to the words of his friend or
his wife, or his chi ld, and does not catch the
note of urgency: "Notice me, help me, care about me,"
Hears - but does not really hear .
On this day, 0 Lord,
Sharpen our ability to hear.
May we hear the music of the world, and the infant's
cry, and the lover's sigh.
we hear the words of our friends, and a 1 so their
unspoken pleas and dreams.
May we hear you for then we will have the right
to hope that you still hear us.
LETTERS) WE GET LETTERS . I I II
Many readers have written asking about the Kresge Labora
tory, and the other services the lab provides besides
the Tinnitus Clinic.
The laboratory is affiliated with the Department of
Otolaryngology and Maxillofacial Surgery at the Uni -
versity of Oregon Health Sciences Center.
It is a research laboratory dedicated to the investi-
gation of clinical questions which pertain to hearing.
The disciplines used to carry out these studies include
electronmicroscopy, histology, psychology,
audiology and biochemical techniques.
Kresge provides Electronystagmography (balance) testing
as well as conducting all testing for the
Tinnitus Clinic; however, for the most part, patients
5
are seen in the Ear, Nose and Throat Clinic in the
Medical School. The clinic has 4 staff members, 12 resi-
dents, three nurses and a secretarial staff.
Kresge has its own animal quarters mainly housing guinea
pigs and cats. These quarters are strictly guided by the
recommendations from the American Association for Accre-
ditation of Laboratory Animal Care (AAALAC). The labora-
tory has 21 members with three pre-doctoral students.
Yearly, manuscripts on the various research projects are
published in journals such as: National Tech. Inst. for
the Deaf; Archives of Otolaryngology; Ear, Nose & Throat
Journal; Jn. of Auditory Research, Jn. of American Audi-
ology Society; Jn. of Acoustical Society of America; Oto-
rhino & Laryngology; American Journal of Physical Anthro-
pology; Jn. of Antimicrobial Chemotherapy; Current Chemo-
therapy; The Laryngoscope; Pharmindex; Acta Otolaryngology;
Contemporary Psychology; Jn. Ultrastructure Research;
Annals Oto. Rhin. and Laryngology, and many more. You may
check with your library periodically if you are inter-
ested in staying current with our research. Articles will
be found under the names of: Drs. Jack Vernon, Richard
Walloch, Robert Brummett, Catherine Smith, Mary Meikle,
Kaye Fox, Nancy Russe 11 , Robert Johnson, Curtin r1itche 11 ,
Alexander Schleuning and David DeWeese.
Please continue to let us know the kinds of subjects you
want to read in the ATA Newsletter. We appreciate letters.
A4A ;:no:.d w an>!O<me it;; ,\ledical Advisol'Y
PoOJd. Ti1.J people LJI;o haa;a (Treed to serve on this
boa..1-d >lead no i1t1oduction to most o- 'ou who Jill
t'.J'OJ'li:;c theiJ mur.e..; as the
jicl i .
mo,1t i:c,,ore! to imve them as parz; of z;he ATA
team rznd groatef'ul for the1:1' cwmtment to se1've.
f"EoiCAL A!NtSORY BoARD FOR ATA
Bob R. Alford, M.D.
Houston, Texas
Roger Boles, M.D.
San Francisco, Calif.
Howard P. House, M.D.
Los Angeles , Calif .
Bob M. Johnson, Ph.D.
Portland, Oregon
Merle Lawrence, Ph.D.
Ann Arbor, Michigan
Jerry L. Northern, Ph.D.
Denver, Colorado
Gunnar 0. Proud, M.D.
Kansas City, Kansas
George F. Reed, M.D.
Syracuse, New York
Harold G. Tabb, M.D.
New Orleans, Louisiana
Moving ??
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by supplying us with your new
address.
zip ________ _
HO'IORA!ILE C[L ClAOI>Oii
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D.C.
DAnD D. DeWHSE. II. D.
Chtman Dept. Otoloryngology
Unlvtrslty of
Sclencts
TH IOiCRABLE 0 HATftllD
States SeMie
llnhtngton, D.C.
ROSER T II HOCI:S
National Cllal...,.n ATA
Kocls Laborltorlrs
Po,.t hnd, Ort>gon
DAVID N. PlAHT
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Portla>-.d, ()roegoY! 9720(
....
I


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t1.nrzitus su .. +-[eltJrs
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