The symptom of tinnitus is likely shared by several underlying pathologies. It is funda-mental to the investigation and treatment of tinnitus to be able to reliably quantify different types of tinnitus. In one experi-ment we required patients to increase the level of a broadband noise until it just masked their tinnitus. Regardless of where in the head they perceive their tinnitus, in most patients the minimum level (in sound pressure level or sensation level) required to mask the tinnitus is similar in both ears. In a few other patients, the tinnitus cannot be masked or requires high levels in the contra-lateral ear. We have found this masking procedure valuable in measuring tinnitus following the administration of tocainide. In some patients the tocainide seemed to reduce the magnitude of the tinnitus (required lower masker levels to mask the tinnitus) whereas in others there was some evidence that the tinnitus got worse (higher masker levels were required). In another experiment, we quantified tinnitus percep-tion following the termination of a masker. Several different patterns were evident. After the termination of the masker, the tinnitus either (a) returned to normal immediately, (b) returned immediately but was at a softer loudness, (c) was absent for a time before gradually returning to normal, (d) was absent for a time before abruptly returning to normal, or (e) was louder than normal before gradually returning to normal. Increasing masker duration and masker level prolonged the effects.

A classification of tinnitus may use the following scheme (Fig. 1): There are spon-taneous attributes of tinnitus, which can easily be explored or evaluated more or less accurately by comparison with calibrated external sounds.

Tinnitus is a symptom of many disorders affecting the auditory system. While Impedance Audiometry provides no specific etiologic information about tinnitus, it is a useful diagnostic tool to localize various types of auditory dys-function. This paper sketches usefulness of impedance testing in diagnosis of retro-cochlear lesions, in otosclerosis and in objective tinnitus.

“I am just as deaf as I am blind,” wrote Helen Keller. “The problems of deafness are deeper and more complex, if not more important, than those of blindness. Deafness is a much worse misfortune. For it means the loss of the most vital stimulus—the sound of the voice that brings language, sets thoughts astir, and keeps us in the intellectual company of man.”

This paper will present an overview of the clinical experience that has been accumu-lated by the Division of Otolaryngology Center for Communication Sciences, Downstate Medical Center, Brooklyn, New York, using auditory brainstem response (ABR) in the tinnitus patient. This work has been ongoing since 1977. Our observations of ABR in the tinnitus patient have been reported to stimulation with tone and broad band clicks. They are observations, not conclusions. We reported in 1981, a clinical test—“Simultaneous Binaural Auditory Brain Response” with monaural stimula-tion for attempts to locate central tinnitus (SABR).

Patients presenting with complaints of tinnitus had extensive neurotological test-ing. The purpose was to determine:

1. Which tests could be of topographic diagnostic capability.

2. Which tests could be of value in therapeutic management.

Computerized Ocular Tracking (PTT) and Rotary Testing (SHA) are being performed as part of the neurotologic evaluation of patients with a chief complaint of tinnitus. The results which I shall report today are presented as observations and a follow-up to a preliminary report presented 25 July 1982. They support our clinical impression of a significant incidence of involvement of the vestibular system in the tinnitus patient.

This paper is to attempt to show an objective correlation between the symptoms of tinnitus and the subsequent, if any, onset of symptoms consistent with those of Menière's disease. Tinnitus associated with Menière's disease is low frequency in quality and characterized as roaring and buzzing. The tinnitus and fluctuant hearing loss may precede the attack of vertigo by days, months, or even years (Hester, 1982). These correlations seem to center around the frequency of the tinnitus. Since pitch matching is tonal in character (McFadden, 1982), accuracy of this procedure is of questionable value. Pitch matching procedures are subject to octave errors—that is, settings for a match that are actually twice or one-half the frequency of the sound being matched (Vernon, 1982). Clinical historical judgement and pitch match testing were combined to identify the frequency of tinnitus below 4000 Hz, between 4000 and 8000 Hz, and above 8000 Hz. Clinical observations have led to the subjective conclusions that in many cases, but not all, tinnitus is the harbinger of Meniere's disease.

Just as the various words used to describe pain are helpful to physicians in identifying the probable cause of the pain, the words used by tinnitus patients to describe their tinnitus sounds may prove useful for categorizing tinnitus and, eventually, for identifying the cause(s) of the tinnitus. We here report preliminary attempts to analyze verbal descriptions of tinnitus sensations obtained from a large population of tinnitus patients.

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.