The rationale and general plan of the National Study of Hearing (NSH) as well as some overall tinnitus prevalence data are outlined in the accompanying paper (IHR,1984) and in previous work (IHR, 1981a, b).

Tinnitus, in most instances, is a symptom of a disease process which defies clear identification. The multiplicity of sites of origin and the mechanisms of production are truly a diagnostic and therapeutic dilemma. The clinician can, however, easily recognize the classic presentation of acute and chronic inflammatory disease.

Immunology and ear diseases finally have met each other. There are several ear diseases associated with hearing loss, vertigo, tinnitus. These include Menière's Disease, otosclerosis and autoimmune sensorineural hearing loss. These diseases have immunologic manifestations.

McCabe (1979) described 18 cases of sensorineural deafness having clinical and laboratory features suggestive of an auto-immune etiology. This condition was characterized by a prolonged period of pro-gressive deafness over weeks or months, rather than hours, days or years. It is usually bilateral, asymmetrical and the cochlear is always involved. Other features of this disorder are facial paralysis and vestibular dysfunction. Tissue destruction of the tympanic membrane and middle ear and mastoid may also occur. These responded well to a high dose of steroid therapy and cyclophosphamide. A total of 42 cases of this disorder were diagnosed in McCabe's series as of January, 1982 (McCabe and Harker, 1982). Two-thirds of the patients had vestibular symptoms of low grade without spells and the reduction in caloric responses paralleled the hearing loss.

A short form of the Minnesota Multiphasic Personality Inventory was administered to 146 clinical patients who were assigned to one of four groups: Group I, tinnitus only; Group II, hearing loss and tinnitus, tinnitus primary; Group III, hearing loss and tinnitus, hearing loss primary; and Group IV, hearing loss only. The purpose of the study was to determine whether there were measurable characteristics unique to the tinnitus patient. Elevations were noted for all four groups on Scales 8, 6, 3, and 2, showing significant differences between the groups who suffered from tinnitus as opposed to those whose primary complaint was hearing loss. The tinnitus patients, especially those with only tinnitus, had social adjustment problems that were not evidenced for patients with impaired hear-ing. Indications are that the patient with an inveterate hearing loss is better able to cope with tinnitus than the patient who is suddenly and unaccountably afflicted with tinnitus.

Personality and coping mechanisms are related to a patient's perception of his tinnitus. Although the occurrence of tinnitus is not unusual, the nature of tinnitus varies in patients from infrequent, barely noticeable sound to an unrelenting, absorbing disturbance of critical significance. Tinnitus is a subjective complaint. The same level of tinnitus may be described by one patient as intolerable and by another as barely noticeable.

Although the literature teems with articles on tinnitus in adults, it appears that investigations on tinnitus in children are few and far between. A survey of the literature revealed that, spanning 11 years since our first article (Nodar, 1972), only the work of Graham (1981) specifically addressed tinnitus in children (Table I). In a recent publication, McFadden (1982) dedicated two paragraphs to tinnitus in children, citing the two studies mentioned above. It is apparent that McFadden either did not read or did not understand at least one of the articles (Nodar, 1972) since his figures are grossly erroneous. The previous observations, coupled with gentle prodding from Dr. A. Schulman (New York), led to this report which will address three issues: (1) our first study of tinnitus in children; (2) a recent study of tinnitus in children; and (3) a philosophical discussion of the phenomenon we call tinnitus, our approach to its investigation, and why relief from it is evasive, inconsistent and often non-existent.

At the first International Tinnitus Seminar in New York and at the CIBA Foundation Symposium on Tinnitus in London (Graham, 1979, 1981) I reported the results of surveys carried out on children of secondary school age with sensorineural deafness who were attending partial hearing units or schools for the deaf in the Inner London Area. I shall summarize the findings of these surveys, describe the protocol that we use for examining and investigating children with tinnitus, describe some characteristic findings in children we have investigated and suggest some practical steps that can be taken to help children whose tinnitus is troublesome or annoying

An intact central nervous system and its integration with organs of special sense are the basis for our being able to function in our environment. The modification of the function of either component by the ingestion of food stuffs or chemicals (organic or inorganic) puts the organism at a disadvantage.

We now come to our final session concerning treatment methods and results. We are very honoured to have with us here a number of internationally-distinguished individuals in various specialties, particularly otolaryngology. We now have the treatment session divided into three sections: one section for treatment that will control tinnitus by masking; the second for medical treatment; and the third for surgical treatment. I have selected moderators for each of these sections who are international in their experience as well as in their reputations. First, for the section on tinnitus masking, I have asked Mr John C. Ballantyne, of London, England, to chair the section. He is editor of the Journal of Laryngolgy and Otology. We are honoured to have him with us.

From all methods of the treatment of tinnitus, medical, masking, surgery, electrical stimulation and psychological, we believe a reliable medical treatment would be preferable because it is easy to apply. An immense variety of drugs have been used for the treatment of tinnitus (Vernon, 1977). The most reliable drugs so far on tinnitus are intravenous procaine and lidocaine (Bárány, 1935; Lewy, 1937; Melding et al., 1978; Martin and Colman, 1980; Israel et al., 1982). The fact that these drugs cannot be given orally because of the poor biological availability after oral administration, is a great disadvantage. In view of the important pharmaco-therapeutic role of lidocaine as an anti-arrhythmic drug, considerable research has been devoted to drugs with comparable anti-arrhythmic properties but permitting oral administration. This work produced tocainide (Smith, 1981), which showed a certain degree of effect on tinnitus as well (Emmett and Shea, 1980; Cathcart, 1982). Before starting a randomized double-blind controlled trial to assess the effect on tinnitus of tocainide, we studied the effect of several doses of tocainide HCl on tinnitus in order to select an appropriate dosage. Nineteen patients with obstructive tinnitus of various aetiologies were admitted to the study. There were 10 women and nine men. Their mean age was 54 years (range 22–67 years). Tocainide was administered in five different doses in a single-blind controlled trial. To be able to judge the effect under steady conditions, each dose was given for four days, as shown in Table I. On the fourth day of each period the patients had to record the degree of impediment caused by the tinitus on a six-point scale (Table II). They were also asked to report all sideeffects.

Medical treatment offers the best hope, we believe, of the various treatment methods available for the management of tinnitus.

One of the most frustrating clinical problems for both otolaryngologist and patient is having to deal with the symptom of tinnitus. From the patient's point of view, frustration stems from the fact that this often unrelenting symptom can lead to a total disruption of a productive lifestyle, and in a number of instances, proves to be a tragically fatal symptom as the patients turn to suicide as a final solution. The otolaryngologist has been frustrated because until recently he has had little more than sympathy to offer the patient. This has led to a helpless feeling between both parties.

A randomized controlled study using benzodiazepines to treat patients with chronic subjective tinnitus was performed to determine if these drugs could suppress intractable tinnitus. Trials with the antihistames meclizine, chlorpheniramine, and dexchlorpheniramine were used as the controls in the evaluation of diazepam, flurazepam, carbamazepine, oxazepam, and clonazepam. Of all the benzodiazepines studied, only oxazepam and clonazepam were significantly more effective than antihistamines in suppressing chronic tinnitus, but these two drugs alleviated the symptom in 52 per cent and 69 per cent of the individuals treated respectively. Oxazepam 30 milligrams daily or clonazepam 0.5 milligrams three times daily provides substantial control of chronic tinnitus.

There have been five recent studies of drug treatment in tinnitus in the UK using Class I anti-arrhythmic preparations. We present a new double-blind study of tocainide hydrochloride in severe, unmaskable tinnitus. No significant response is noted in any of the controlled trials to the active ingredient, and more work is needed on diagnostic criteria to see if those who do respond constitute a separate group. There was a surprisingly low incidence of placebo response and the importance of the side effects produced by the drugs in this group is stressed. The finding that three patients with profound hearing losses have had some continued benefit leads to the cautious conclusion that drug responders may be have a central component to their tinnitus.

Eight patients with bilateral Menière's disease are reported in whom intramuscular Streptomycin Sulfate (ISS) dosage was titrated in an attempt to alleviate disabling vertigo and hearing loss.

It appears possible to eliminate the vertiginous episodes, preserve or improve hearing, avoid ataxia and oscillopsia, and lessen tinnitus in most of these individuals.

At the present time, we consider this treatment regimen our first choice of therapy in people with bilateral active Menière's disease or in patients whose only hearing ear is actively fluctuating and in whom associated disabling vertigo is present.

The effect on tinnitus in 110 patients undergoing translabyrinthine vestibular nerve section is presented. The effect on tinnitus of vestibular and cochlear nerve section (VCNS) together and vestibular nerve section (VNS) alone was studied. The number of patients improved with VCNS (61 per cent) was slightly better than with VNS alone (49 per cent). VNS alone worsened tinnitus more often than VCNS. Age, side involved, sex, etiology of vertigo, severity of tinnitus, interference with sleep and activities, slope of the pre-operative audiogram, and magnitude of the hearing loss had no value in predicting the change in tinnitus following either VNS or VCNS.