tinnitus today march 2000 vol 25, no 1

7/23/2019 Tinnitus Today March 2000 Vol 25, No 1

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March 2000 Volume 25, Number 1Tinnitus TodayTHE JOURNAL OF THE AMERICAN TINNITUS ASSOCIATION

In This Issue:

"To promote relief, prevention, and the eventual cure of tinnitus forthe benefit of present and future generations"Since 1971

Education -Advocacy - Research - Support

Alternative Manageme.nt ofTinnitus, Part II- Herbal RemediesQuinine and its Effects on Outer Hair CellsTinnitus - An international View


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Tinnitus T o d ~ y Editorial andAvertising ofices: American Tnnitus A s s o c i a ~ o n , PO. Box5, PortlandOR 97207 503/248-9985, 800/634-8978 [email protected], www.ato.orgEditorial and Advertising offices: AmericanTinnitus Association, P.O. Box 5, Portland, OR97207, 503/248-9985, 800/634-8978,[email protected], www.ata.orgExecu tive Director: Steve Laubacher; Ph.D.Editor: Barbara Thbach nick SandersTmnitus Thday is published quarterly in March .June, September, an d December. It is mailedto Am erican Tinnitus Association do nors anda selected list of tinnitus patients and professionals wh o treat tinnitus. Circulation isrotated to 80,000 annually.American Tinn itus Associat ion is a non-p ro fithuman heal th and welfare age ncy unde r 26USC sa! (c)(3).Copyright 2000 by American TinnitusAssociation. No part of this publication ma ybe reproduced, stored in a retrieval system,o.r transmitted in any form, or by an y means,withou t the prior written pe rm ission of thePublisher. ISSN : 0897-6368Executive DirectorSteve Laubacher, Ph.D . Portland, ORBoard of DirectorsPaul Meade. Tigard, OR, ChairmanJoel Alexander, Park Ridge, NJJames 0. Chinnis, Jr., Ph.D Manassas. VAW. F. S. Hopme ier, St. Louis, MOGary P. Jacobson, Ph.D., Detroit, MlSidney Kleinman, Chicago, ILStephen Nagler, M.D., Atlanta, GAKathy Peck, San Francisco, CAJohn Nichols, Scottsdale, A ZDan Purjes, New York, NYSusan Seidel, M.A., CCC-A, 'Tbwson, MDTi m So10s, Lenexa, KSJack A. Vernon, Ph.D., Portland, ORMegan Vidis, Chicago, ILHonorary DirectorsThe Honorable Mark 0. Hatfield,U.S. Senate, Retired'Tbny Randall. Ne w York. NYWilliam Shatner, Los Angeles, CAScientific AdvisorsRonald G. Am edee, M.D., New Orleans, LARobert E. Brummett, Ph.D., Portland, ORJack D. Clemis. M.D., Chicago, ILRobert A. Dobie, M.D., Sa n Antonio, TXJohn R. Emmett, M.D., Memphis, TNBarbara Goldstein, Ph.D., New o ~ k , NYJohn w. House, M.D., Los Ange les, CACary P. Jacobson. Ph.D., Detroit, MlPawel J. Jastreboff, Ph.D., Atlanta. GAWilliam H. Martin, Ph.D., Portland, ORDouglas. Mattox, M.D., Atlanta, CAMary B. Meikle, Ph.D., Portland, ORJ_ Gail Neely, M.D., St. Louis, MORobert E. Sandlin, Ph.D., 1 Cajon, CAAlexander J. Schleunlng, 11, M.D.,Portland, ORMichael D. Seidman, M.D.,West Bloomfield, MlAb raham Shulman, M.D., Brooklyn, NYRaben Sweetow, Ph.D., San fi'ancisco. CARichardS . '!Yler, Ph.D., Iowa City. lA

Cover: *Meadowlands, oil on linen,24 x 30', by Gail WeTls-Hess.Inquiries to Gail We lls-Hess at800-776-4245 or [email protected].

The Journal of the American Tinnitus AssociationVolume 25 Number 1, March 2000Tinnitus, ringing in the ears or head noises, is experienced by as manyas 50 million Americans. Medical help is often sought by those whohave it in a severe, stressful, or life-disrupting form.Table of Contents7 New Scientific Advisory Committee Members8 Thwa.rds the Cure

by Cheryl McGinnis9 Quinine and its Effects on Outer Hair Cells

by Richard Hallworth, Ph.D., and John K. Jarboe, M.D.10 Alternative Management of Tinnitus, Part ITby Michael D. Seidman, M.D.13 Support Networl{ Volunteers

by Cheryl McGinnis14 An International View - The 6th International

Tinnitus Seminarby Ross Coles16 Thank You Members and Donors!

by Jessica Allen1 7 Tinnitus Caused by Sudden Intense Changes in Pressure

by Mary Meikle, Ph.D.18 And the Winner Is ..by Rachel D. Wray20 Banjoistically Yours

by Rick Lovelady, Ph.D., Th.M.24 A Call for Committee VolunteersRegular Features4 From the Executive Directorby Steve Laubacher, Ph.D.5 From the Editor

Putting it 1bgetherby Barbara Thbachnick Sanders6 Letters to the Editor22 Questions and Answers

by Jack A. Vernon, Ph.D.24 Special Donors and 'D:ibu esThe Publisher reserves the right to reject or edit any manuscript received for publicationand to reject any advertising deemed unsuitable for Tinnitus 7bday. Acceptance of advertising by Tinnitus Today does not constitute endorsement of the advertiser, its productsor services, nor does Tinnitus Today make any claims or guarantees as to the accuracy orvalidity of the advertiser's offer. The opinions expressed by contributors to TinnitusToday are not necessarily those of the Publisher, editors, staff, or advertisers.

American Tinnitus Association Tinnitus Thc/ay/March 2000 3


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FROM THE EXECUTIVE DIRECTORby Steve Laubacher, Ph.D.I would like to thank all ofthose who responded sogenerously to ou r HolidayAppeal. We will be using allof the proceeds from thisAppeal to reach out tothose who have tinnitusand who are not currentlyinvolved with ATA either asmembers or as friends. Wewill be asking you to identifY anyone whom you might know along withfriends or family who would like to know moreabout tinnitus and ATA. In fact, some of you willalso begin to see ATA public service announce-ments in your local papers and on television andradio stations. Several people who contributedalso wrote notes and letters raising several questions that I would like to try and answer.

First, some of you have asked for a clarification of ou r Appeals policy. Presently, the ATABoard of Directors has author ized two appeals.The first appeal (part of our annual campaign)will be over the Holiday season and the second(usually devoted to Research) will be in thespring. I would like to stress again that althoughdollars are important we do not want anyone tofeel pressured.Second, several have expressed the need to bebetter informed as to ATA activities an d researchefforts. We have responded to this by trying tomake sure that a "live" person as opposed to ananswering machine will be available to takephone calls from 9 to 3 Pacific Time. I havealso asked Cheryl McGinnis, ATA Director ofResearch, to devote considerable time to reviewing relevant research throughout the world andto bring back that information to our staff andmembers. You will begin to see the fruits of herlabor in Tinnitus 'Ibday along with other information that will, hopefully, give you the knowledge

an d confidence that ATA is working aggressivelyto solve this problem and at least reduce itseffects. You will also begin to see some dramaticimprovement to our Internet World Wide Webpage that will significantly increase ease of useand include substantive updates on both reliefand research.Finally, some have questioned what our longterm plans are for research an d cure. The longrange direction an d success ofATA will be adirect result of ou r long-range planning. Theseefforts are still underway though at a slower pace

4 T!nn icus Thday/March 2000 American T innitus Association

than I had originally projected. Those of you wvo lunteered to work with us on long-range planing will be contacted and involved within ouplanning process where possible. I would agailike to invite interested parties to volunteer foone of our committees by contacting RobinJennings, Laura Grimes, or myself. We still haseveral vacancies on the Human Resource,Resource Development, and Business committ(Please refer to the "Call for CommitteeVolunteers" on page 21.)

As we move into a new century we shouldbe hopeful that together we will be able to beatinnitus through relief or cure or at least develmethods for successful1y coping with this problem. I t is ATA's intention to serve as a catalystachieve these purposes and our ability to addrthese goals should be the yardstick against whour success is measured. 18

Events CalendarMid-Atlantic Regional Tinnitus ConferenWhat's New in Tinnitus Research ManagementApril l, 2000 - 8:30 a.m .- 4:30p .m.Ceill Institute, Voo rhees, NJGuest Speakers: Steve Laubacher, Ph.D.;Richard Salvi, Ph .D .; Steph en Nagler, M.D.;Max Ronis, M.D.; James Sumerson, M.D.Fees: $15 per patient, $45 per professional(CEUs offered)For more information, contact:Dhyan Cassie, M.A. , CCC-APhone: 856-983-8981Eighth Annual Conference on th eManagement of the Tinnitus PatientSeptember 21-23, 2000The University of Iowa, Iowa CityFor professionals & tinnitus patientsGuest Speakers: Michael B1ock , Ph.D ., StarkeyLaboratories; Steve Laubacher, Ph.D. , ATA;Meredith Eldridge, General HearingInstruments; Steven Nagler, M.D., Physician;Anne Mette-Mohr, Psychologist; Eva Brix,Relaxation Therapist; Norma Mraz, M.A.,AudiologistFor more information, contact: Cheryl J. SchlotPhone: 319-384-9757 Fax: 319-353-6739rich-tyle [email protected], www.medicin e.uiowa.edu/ otolaryngology/news/ news.


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From th e Ed i t o r

PUTTING IT TOGETHERby Barbara Tabachnick SandersTinnitus has always been ajigsaw puzzle, and a confounding one at that. Twenty-nineyears ago, we didn't knowhow many pieces there wereto the puzzle, or even whatthe completed picture wouldlook like. But we were determined, and decided to pu t ittogether anyway.

At first, we stared at the pieces. Slowly wearouped them by color, found the ones with theflat edges, and built the outside frame. I t was adecade of work. Twenty-nine years later, the restof the pieces are starting to fit into place.

Tinnitus research has taken a subtle ye t extraordinary technological turn over the last twoyears. Scientists are starting to think "outside theenvelope" -beyond that which has been done -using computer models and brain imaging .devices in combinations that hadn't been tnedbefore. They are looking microscopically at thebrain's role in tinnitus perception because theanswers are in there. Our research efforts aremoving forward with nine new grants ready toreview for funding. 'Treatments like TRT andmasking are being refined and used with growingsuccess, and pharmaceuticals are being tested bydrug companies and studied in clinics.(Ironically, years ago, ATA had money earmarkedfor research bu t there were few researchers togive it to. Thday, there is an abundance ofresearch to fund, so much so that we have to lookfor new fund raising strategies. This is a muchmore desirous predicament to be in since it is fareasier to raise money than it is to find dedicatedtinnitus scientists with good ideas!)

Tinnitus prevention is a different story, and alarge part of this unfinished puzzle. I t is a statistical reality that more people than ever beforehave tinnitus. The percentage and the number ofpeople with tinni tus have grown, and we th.inkwe know why. We think it's because of the mtolerable yet mysteriously acceptable noise levels ofour music and sporting recreation, our work andmilitary environments , and our personal entertainment equipment. These noisy powerhousesare combining to deafen us early in life and ere-

ate internal noises for us to hear instead. Ofcourse there could be other things that havecontributed to this tinnitus epidemic, like foodadditives or what's in our drinking water or cellphones. Their long-term effects on human healthare not known . But we do know what excessivelyloud noise does to the auditory system. Andknowing that, we are obligated to help peopleprotect their ears from it.

Here is where you come in.When you read through this issue of TinnitusTbday you will see that we're asking for your helpleft and right. We want you to head to your localmovie theaters and tell the managers to turn thevolume down. If your tinnitus was the result of

an air bag deployment, we want you to considerbeing part of a research study. We want you tovolunteer for committees and start self-helpgroups. We want you to take our n e ~ brochuresto libraries, doctors' offices, and semor centers soothers can reach us for help and support us too.We want you to take our videos and posters tolocal schools and tell second graders a thing ortwo about tinnitus and how to avoid it.Why do we ask? People with tinnitus arewithout a doubt the most convincing and themost compelling ambassadors when it comes toteaching people unaffected by tinnitus a b o ~ t tinnitus. No one knows tinnitus better or w1shesharder that it had never happened. We areasking for your help because you are the bestones to ask.Your efforts and ours together are propellingus to the resolution of tinnitus whether you taketime to answer a telephone call from a distraughttinnitus patient or if we give money to a tinnitusresearcher. Everything we do for tinnitus movesus towards a cure, moves us to the end of tinnitus, to the last puzzle piece in place, and to anew beginning. a

NEXT ISSUE:Stephen Nagler, M.D., tinnitus clinic d i r ~ c -tor an d ATA Board member, will report on h1svisit to Israel and his meeting there with Dr.Zecharya Shemesh and other Israeli tinnitusspecialists.

American Tinnitus Association Tinnitus 1bday!March 2000 5


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Letters to the EditorFrom time to time, we include lettersfrom our members about their experiences with "non-traditional" treatments.We do so in the hope that the information offered might be helpful. Please readthese anecdotal reports carefully, consultwith your physician or medical advisor;and decide for yourself ifa given treatment might be right for you. As always,the opinions expressed are strictly thoseof the letter writers and do not reflect anopinion or endorsement by ATA.Anx iety and Tinnitus

In "Soaring" (Dec., 1999) editor BarbaraThbachnick Sanders describes how she overcameher dread of turbulence while flying due to thedemystification of turbulence by an unusuallyempathetic pilot. Her experience illustratesdemystification, one of the principles of TinnitusRetraining Therapy.

I have another example of fear-induced inten-sification of symptoms that was relieved bydemystification by a knowledgeable professional.I developed tinnitus and hyperacusis at the age of53 just a few months after the onset of a panic/anxiety disorder. The demystification was provided by the empathetic Dr. Claire Weekes in Hopeand Help for your Nerves, a wonderfully insightfulbook on anxiety attacks. In a nutshell, odd butharmless sensations arouse fear, causing adrenaline and other hormones to surge, that in turncause more odd sensations. At this point, onegets caught in a "panic circle" where one's ownfears perpetuate the frightening condition.

I wonder how many cases of tinnitus are dueto over-sensitized nerves that could be desensitized by accepting the symptoms, "floating" orrelaxing past them, and letting more time pass.I recommend Dr. Weeks' book to anyone whobelieves that his or her tinnitus symptoms maybe anxiety related.7bm Shuford369 Paseo de Playa #601Ventura, CA 93001

Neck misalignment and tinn itusSince childhood, I've lived with curvaturethe spine. In 1995, I strained my back and dev

oped chronic back pain to the point where Icould not bend my neck backwards. I startedphysical therapy but my muscles did not respto treatment. And about the same time, I discoered that I had TMJD (temporomandibular jawjoint dysfunction).Within a year, I developed tinnitus, the kin

that varies from a tone to static, and from softloud. Sometimes it is accompanied by earacheor headaches. I went to two audiologists whotested my hearing and, finding no hearing lossdeclared that they were unable to help me.Fortunately, I met a physical therapist who habeen in an accident in which one of her neckvertebrae had been temporar ily dislocated. Shdeveloped tinnitus that disappeared as soon asher neck was put back into proper alignment.Lights began to go on and I started to wonderabout physical-mechanical causes of tinnitus.David G. Austin, D.D.S. , M.S., who was treatinme for TMJD, suggested that I also see DouglaPaul, D.C., a chiropractor who specializes in thupper cervical spine. Dr. Austin told me thatwhen muscles are in spasm, "pain chemicals" spread to the nerves of the inner ear and causirritation. Because all of the nerves in the bodru n through the upper cervical spine, any pressure against these major nerve bundles can caa misfiring of the nerves sending muscles intospasm and causing the nerves to "wither." Aftetwo months of treatments with Dr. Paul, I lookin the mirror and noticed that I was actuallystanding up straight for the first time in my46 years. I also began to notice the associationbetween my neck and my ears. If my neck isof alignment, my ears are noisy. After I have mneck aligned, I notice quiet again. My experiemade me start to wonder about the many eldepeople who develop tinnitus without having bexposed to damaging noise. Could it be posturerelated? An extremely high number of elderlypeople stand in poor posture. Many also haveosteoporosis. Degeneration of the neck vertebrcoupled with years of poor posture, added uppressure on the upper cervical nerve bundles ultimately, for me, tinnitus.

Mary C. Meyers1016 Portlock Dr.Columbus, OH 43228


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NEW SCIENTIFIC ADVISORY COMMITTEE MEMBERSDouglas Mattox, M.D.

Dr. Douglas Mattox, an ENT physician atEmory University in Atlanta, GA, has workedclosely with Dr. Pawe1 Jastreboff for severalyears. I t is through Jastreboff that he becamefamiliar with ATA and the problems surroundingtinnitus relief. Dr. Mattox spoke to us about hisnew role as an ATA Scientific AdvisoryCommittee (SAC) member.

"The ult imate goal of ATA's Scientific AdvisoryCommittee is to serve as a grant review boardand to identify research projects of merit.Mechanically, that's the goal. Philosophically, Ithink our job is to attract new money and newbrains to solve the problem oftinnitus. Throughmy work with Pawel Jastreboff, I've becomeinterested in a pharmacological approach to

Letters (continued)New BookOffersHope

I am a member ofATA with a serious hyperacusis and tinnitus problem. You who know mealso know that my life as a working R.N. andaddictions counselor for 39 years has gone awaybecause of these disorders. I do no t understandthe lack of successful treatment for many diseases. But we're trying and doing all we can.Unfortunately, millions of us have been to professionals who've said, "Tinnitus and hyperacusis?Learn to live with it." People are just notinfom1ed and educated an d it isn't their fault.Everyone who has tinnitus and hyperacusis is

not debilitated by the disorders. But many of usare. Many of us are on disability and cannotwork. Many of us have lost our jobs and homesand relationships, and feel we have no way out.We need to know that there is hope on the horizon. Because of that, I am writing in support of abook by Carol Lee Brook, 7brtured by Sound-Beyond Human Endurance. I t is a real, honest,humorous (if that's possible), and true story thatwill give readers like me the thread of hope weneed to live because of having read it. I am verygrateful to Ms. Brook - very!

Kathy Brock, R.N., B.S., CADCBOO 'Il..uelve Oaks Pky.Woodstock, IL 60098-4316815-338-2718, [email protected]

tinnitus relief Currently there are some classesof drugs that have been studied for this purpose,but they are not yet useful. Some new drugapproaches need to be tried.

"ATA has recruited a significant amount ofmoney for research. As a member of theScientific Advisory Committee, I hope to helpATA spend the money wisely."Richard Tyler, Ph.D.

Dr. Rich 1Y le r is a professorof otolaryngology andDirector of Audiologyin the Department ofOtolaryngology-Headan d Neck Surgery at Th eUniversity of Iowa, in IowaCity. He is also a long-timeprofessional devotee to theissue of tinnitus. ATA hasfunded several of hi s tinni

tus research projects since 1984. In 1991, Dr.1)'ler organized and still continues to chair theannual Tinnitus Patient Management meeting fortinnitus professionals and patients.

Dr. 1)'ler joins ATA's Scientific AdvisoryCommittee and shares his thoughts on his newrole.

"I think that ATA's Scientific AdvisoryCommittee as a whole should try to work bothwith the Board of Directors an d with input fromATA's membership to identify ways th e SAC couldserve and be useful.

"It may very well be time to address questions about a cure. But since tinnitus is caused bymany different things, it could require us to findmany different kinds of cures. Fortunately, thereare a lo t of good people doing good things inmany different areas of tinnitus research."I see ATA playing a major role, not just infunding research, but in attracting scientists to

this field of research and in making the publicaware of the condition and the treatments thereare for it. Personally, I would like to see ATA persuade the government research and health careagencies to get interested in tinnitus.

"There are lots of clever and committed people on the Scientific Advisory Committee. Andthere is a lo t of good research that can be done tohelp tinnitus patients. Put these things togetherand you've got hope."a

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TOWARDS THE CUREResearch Updateby Cheryl McGinnis, ATADirector of Research and SupportAs an ATA member recentlyasserted, the one thingabout the AmericanTinnitus Association thatreally counts is the researchfunction. And onceresearchers discover theanswers we all seek, therewill be no need for an ATA

at all! There is eloquence and truth in such adirect statement. The discovery of successful

AdvertisementAlliance Tinnitus and Hearing Center

Stephen M. Nagler, M.D., FAGS - Clinic Directorintroduces a two-hour educational videotape

"Tinnitus: Learn to Live WithOUT It"Thoughts on Tinnitus Retraining Therapy

This video is not merely a vision for the future,but it discusses very practical approaches totinnitus treatment today. I t is designed primarilyas a source of information for the tinnitus patientand family, yet it contains material ofvalue for

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treatments and ultimately a cure for tinni tus ia goal shared, certainly by each individual whhas tinnitus and by the ATA. Our ScientificAdvisory Committee will meet in March, 2000in Portland to review research grant applicatioand recommend studies for ATA funding. Watcthis Tinnitus 7bday feature for updates on projects approved for funding.

A recently completed ATA-funded researchproject is summarized on the next page.This research was funded in 1998. B

HEAR for a LifetimeWe have a simple mission regarding childrto teach them that they have the power to heafor a lifetime.One way to accomplish this is by taking ou

Hear for a Lifetime posters, coloring sheets,earplugs, lessonmaterials, and20-minute videodirectly into theclassrooms. If yoare a teacher or willing adult whinterested in presenting this "turdown, walk awaand cover yourears" message tosecond and thirdgraders in your local school district, pleasecontact us (e-mail: [email protected], or phone:

800-0634-8978 ext. 216) for this free hearingconservation toolChildren who learn this lesson when they

young stand the best chance of avoiding noiseinduced hearing loss and tinnitus - maybe evfor a lifetime. Please help us i f you can. B


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Quinineand Its Effectson Outer HairC e 11 sby Richard Hal/worth, Ph.D., and John K. Jarboe, MD.The drug quinine is historically importantas one of the first anti-malarial drugs. Today itsmain use is as an over-the-counter medicationfor muscle cramps. Large doses of quinine havelong been known to induce a high frequencysensorineural hearing loss, tinnitus, and vertigo.

The vertigo is significant enough that Army pilotshave been prohibited from drinking tonic water(which contains quinine) before flying. Usuallythe symptoms are reversed by stopping quinineintake, but this is not always the case. Quinineinduced hearing loss and tinnitus have long beenthought to result from an effect on neurons of thecentral nervous system. However, salicylic acid(the active ingredient of aspirin) also causes hearing loss and tinnitus, and we now know, fromseveral studies, that salicylic acid has directeffects on one type of hair cell in the cochlea.

Given these findings, we therefore thoughtthat the possibility of quinine's action in thecochlea was worth investigating. One possibletarget is the outer hair cell. The cochlea containstwo kinds of hair cells, called inner and outerhair cells. Inner hair cells convert sound information to excitation of the auditory nerve. Outerhair cells have a less obvious bu t nonethelessvery important role in hearing. They generateforce when stimulated by sound (or electricalenergy). This force provides a vital extra step ofmechanical amplification.

We used isolated outer hair cells for ourstudy. Each cell was held in the apparatus shownin the illustration. Th e hair cell was held in avery small glass suction pipette through whichelectrical stimulation could be delivered. The cellpushed against a fine glass fiber of known stiffness. Knowing how much the fiber moved when

the cell was electrically stimulated, the forceexerted by the cell can readily be calculated. I t isnormally only picoNewtons, or millionths of amillionths of a Newton, for every thousandths ofa volt of stimulation (a Newton i.s about the forceexerted on your hand by 3.5 ounces).When we replaced the normal solutionsurrounding the cell with a quinine solution,we found that the force nearly disappeared.

Quinine's effect on force was very similar to thatof salicylic acid, which also nearly abolishes theforce. Unlike salicylic acid, however, quinine alsocaused outer hair cells to elongate. We wereunable to determine the mechanism of this elongation - none of the usual suspects was involved.While the doses of quinine used were quite high,the cells were only exposed to quinine for minutes. It is quite possible that the long term effectsof quinine are very similar to what we observed.

Th e elongation phenomenon is particularlyintriguing, because it may lead to deformation ofthe cochlea's delicate organ of Corti, which weknow would result in hearing loss, and possiblytinnitus. This is quite apart from quinine's effectson outer hair cell force. Our results suggest thatwe must also look at the inner ear when considering quinine as an agent of hearing loss andtinnitus. D

An isolated outer hair cell m the apparatus used to measureforce. The dark Ime IS tile calibrated glctss fiber.Richard Hallworth, Ph D., Department ofOtolaryngology-! lead and Neck Surgery, UniversityofTexas Health Sctence Center at San Antonio. JohnK. Jarboe, M.D., Department ofOtolaryngology,Massachusetts Eye and Ear Infirmary, Boston, MA.

American Tinnitus Association Tmmnts 'Ibday/March 2000 9


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ALTERNATIVE MANAGEMENT OF TINNITUSPart I I - Herbal Remediesby Michael D. Seidman, M.D.,FACS, Dept. ofOtolaryngology-Head and Neck Surgery, Co -Chair ofthe Complementary!Alternative Initiative, MedicalDirector-Tinnitus Center, Henry Ford Health System,6777 W Maple Rd., W Bloomfield, Ml 48323,Office: 248-661-7211, Lab: 313-876-1016,E-mail: [email protected]

For more than two thousand years, herbshave been employed in the treatment of medicalconditions. ' Combinations of Chinese herbs,exotic fruits, plant roots, and seed oils have beeneffective in the treatment of many medicaldisorders. What most of these herbal treatmentregimens lack is solid medical evidence derivedfrom double-blind research studies. This form ofexperimentation would legitimize the use ofthese non-conventional treatments. However, tothe patient whose conventional treatments havemet with failure, anecdotal stories of effectivetreatments are often proof enough to justifY theuse of an alternative intervention.I encourage you to keep your doctor advisedabout your use of herbal treatments, an d to heedyour doctor's advice should he or she offer it.Remember that herbs can act on the body'ssystems (which is why we take them!), and thatthey can interact with other herbs and with

other drugs.Ginkgo BilobaGinkgo biloba leaves have been used therapeutically for centuries by the Chinese for the treatment of asthma and bronchitis. Ginkgo biloba wasbelieved at one bme to have magical powers.Today, many feel that ginkgo has a legibmatemedicinal role. The active ingredient has beenisolated as EGB 761 an d there have been manystudies re lated to the effecbveness with a varietyof medical disorders. I t has been shown toincrease circulabon throughout the body.Numerous studies have shown th e effecbvenessof ginkgo on relieving leg cramping, decreasedcirculation to the brain, and symptoms of tinnitus.2TYPical dosages range from 120-160mg perday, divided equally at mealbmes. In Westerncountries, a standardized 50:1 concentrate of 24%ginkgoflavonoids is used, either in liquid or capsule form . Many studies showed that between 30-70% of subjects had reduced symptoms over a6-12 week period. No serious side effects wereobserved for either group.

In terms of tinnitus, a study by Hobbs in 1986proved the statistical significance of the effecbve-1 0 Tinnitus 7bday!March 2000 Ame rican Tinnitus Association

ness of treatment '"lith ginkgo extract for tinnithe ringing completely disappeared in 35% ofpatients tested, with a distinct improvement in70 days.3 Similarly, when 350 pabents with heing loss and tinnitus due to advanced age weretreated v.rith ginkgo extract, the success rate foimproved hearing and in many cases improvetinnitus was 82%.Opinions differ as to th e efficacy of thisherbal remedy. While some people with tinnitswear by Ginkgo biloba, others claim that it hano effect on their symptoms. We had hoped thth e question of the true value of this agent wobe answered conclusively last year when theresults of the first large-scale double-blind ran

domized ginkgo study were published. (One thsand tinnitus patients participated in this studat Birmingham University in the U.K.) But th eresults were no t decisive. Despite the inconclusive outcome of the study, many people withtinnitus believe that ginkgo improves theirsymptoms and will likely continue to use it.

Published studies have shown that 120 to 2mg a day of pharmaceutical-grade ginkgo extracan al1eviate tinnitus.24 The most recent humastudy showed that, in patients suffering fromreduced blood supply to the brain, ginkgo extrproduced a significant improvement in symptoof vertigo, tinnitus , headache, an d forgetfulnesThe German Commission E, considered anauthoritative reference on the medicinal use oherbs, rates ginkgo as "positive" and recomme240 mg twice pe r day for tinnitus and vertigo.

One of the appealing aspects of Ginkgo bilowith regard to the treatment of tinnitus has bethe fact that it is relatively inexpensive and havery few side effects, such as increased risk fonose bleeds. However, there was one report ofwoman who, after using ginkgo for two years,developed a hemorrhage in the brain. When shdiscontinued taking ginkgo, the bleeding subsided. I t was not possible to prove if ginkgo wathe cause. It is generally advised to not takeginkgo with other blood thinning medicationslike coumadin or heparin. Some also advocatecare when mixing aspirin with ginkgo, althougthe likelihood of problems is low.All herbal preparations are not the same. Iclear that some of the less expensive brands oginkgo are less effective and produce more gastrointestinal upset. When patients who were tain g the less expensive brands changed to morerespected brands , their gastrointestinal sideeffects improved and their response was typicabetter.


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Black CohoshThe popular herb, black cohosh (Cimicifugaracemosa), has an extensive history of safe use byNative Americans who revered it as a remedy fora host of common ailments including fatigue, neuralgia, rheumatism, sore throat, asthma, bronchialspasms, bronchitis, and whooping cough.67 Blackcohosh has been used for centuries by women tostimulate menstrual flow, ease the strains of child

birth, and confer relief from pre-menstrual syndrome and menopause. With its mildly sedativeand relaxing effect, black cohosh is used also totreat anxiety, nervousness, and chronic tinnitus.Some patients have reported improvement intheir tinnitus while using this herbal preparation.There are few known health concerns regarding black cohosh, but consuming large amounts(5 grams per day) is known to cause dizziness,vomiting, lowered blood pressure, and limb pain.Black cohosh has traditionally been used to calmthe nervous system. I t is theorized that it mightimprove cerebral blood flow, providing relief from

tinnitus in some patients. The recommendeddosage ofblack cohosh for tinnitus is 20 to 40 mgper day in liquid or powder form.LigustrumLigustrum (Ligustrum lucidum) has beenadvocated by traditional herbalists for the management of tinnitus. Classically, it is considered apowerful liver and kidney protectant and supportsadrenal function. Additional teachings suggestthat it can be used for premature graying, backpain, dizziness, and tinnitus. The recommendeddosage is 400 mg three times per day. There areno known side effects with the use of this herb inthe specified dosage.MulleinMullein (Verbascum densiflorum) has a longhistory in herbal medicine. Its botanical familyname Scrophulariaceae is derived from scrofula,an old term for chronically swollen lymph glands,later identified as a form of tuberculosis. Earlyon, this herb gained reputation as a respiratoryremedy. Physicians from India to England toutedit as a treatment for coughs and chest congestion,earaches, and tinnitus.6

There has been little real research on mulleinitself, and even less study into its treatment oftinnitus. However, some patients with severetinnitus claim that it is very valuable. Mulleinseems to have a slight diuretic effect and mayalleviate inflammation thereby stabilizing thenervous system.The dosage reported to provide relief fromtinnitus is 3 to 4 grams per day. There have beenno reports of mullein causing adverse effects,except for mild irritation of the skin when incontact with the living plant,? (This herb is alsoavailable as a tea.)

PulsatillaAlthough it is recommended for certab diseases of the eyes, ears, and upper respiratorytract, and is used routinely in homoeopathy,Anemone pulsatilla has been considered somewhat dangerous as the plant itself is poisonous.The chief action of this medicine is as a depressant on the circulatory, respiratory, and nervoussystems. An overdose of this herb may causeslowed heart rate and respiration, decreased temperature, paralysis, and death. Extended skincontact can lead to blister formation.

The much lowered dose (in tincture form)of A.pulsatilla is beneficial in relief of headachesand neuralgia, and as a remedy for exhaustion.Herbalists have used this tincture for years forthe treatment of tinnitus and have shown anecdotal success.Lycium FruitLycium fruit (Lycium barbarum or Lyciumchinense) has been used effectively in the treatment of tinnitus, night blindness, dizziness, andblurred vision. This herb is also used to treatcoughs, diabetes, back pain, impotence, andnocturnal emission.4 Consult with a herbalistfor dosages.Cornus

Comus (Comus officinalis) is an example of analternative therapeutic intervention, which alonedoes not seem to relieve the symptoms of tinnitus, but when used in combination with Chinesefox glove root and Chinese yam proves to beeffective in th e treatment of tinnitus, low-backpain, and urinary frequency. 6 Preparation ofthiscombination should be done by an herbalist ornaturopathic physician. Chinese herbalists adviseagainst the usage of cornus in combination withseveral other herbs, including platycodon, siler,and stephania. Exercise caution when combiningcomus with fox glove. The heart medicat ion digitalis is a direct derivative of fox glove.Cuscuta

The active ingredients of Cuscuta chinensiscan be found in grayish yellow seeds also knownas Chinese dodder seeds. Cuscuta seeds are usedalone and in combination with astragalus seeds(Astragalus complanatus), in the treatment oftinnitus, dizziness, and blurred vision.8Foxglove RootChinese Foxglove Root (Rehmannia glutinosa)is used in the treatment of many illusive medicalconditions. This drug (which is prepared by beingcooked in wine) has been effective in treating tinnitus, lightheadedness, hearing loss, palpitations,blurred vision, constipation, and insomnia. 1 Thecooked preparation is recommended over the raw

(continued)American Tinnitus Association Tinnitus 7bday! March 2000 11


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ALTERNATIVE MANAGEMENT {continued)version for the treatment of tinnitus. Consult aChinese medkine practitioner regarding dosagesand combining Chinese foxglove root with otherherbal remedies.

The cooked Chinese foxglove root can distendthe abdomen, and has been associated with loosestools. Consequently, those with digestive problems should use this medication with caution.Caution must always be used with the preparation of foxglove, which is the origin of digitalis, asit can affect the heart.AlismaAlisma (Alisma plantago-aquatica) is a plantthat has long been prescribed as a diuretic forweak, elderly patients who cannot tolerate theeffects of the stronger conventional diuretics.This powdery, white plant is used in the treatment of tinnitus, dizziness, edema, diarrhea, anddysentery. If you use this medication in the treatment of tinnitus, discuss specific dosages andcombinations with a Chinese pharmacist ornaturopathic doctor. No health hazards are knownin conjunction with proper administration ofdesignated therapeutic dosages.6St. John's Wort, Valerian root and Kava KavaAlthough none of these herbs are routinelyconsidered for the treatment of tinnitus, they areworthy of mention. I have had two patients whonoted significant improvement of their tinnitusafter using St. John's Wort for three to fourweeks. 'TWo patients had improvement afterseveral days' use of Valerian root or Kava.

St. John's Wort (Hypericum perforatum) hasbeen used for mild to moderate depression, viralinfections, and for wound healing. I t functions asan antidepressant and should not be used in conjunction with monoamine oxidase inhibitors, antidepressants, or anti-seizure medications, norshould it be taken while pregnant. The primaryside effect is photosensitivity (one needs to avoidbeing in the sun). The recommended dosage is300 mg three times a day with food.Valerian Root (Valeriana officinalis) has beenused primarily for its ability to promote sleep.The effects of valerian root are similar to those ofsome anti-anxiety drugs. Therefore, it should notbe combined with other anxiolytics, sedatives, orantidepressants. The primary side effects aredrowsiness, withdrawal symptoms like increased

12 Tinnitus 7bday/March 2000 American Tinnitus Association

heart rate and breathing, and cardiac complictions in patients taking very high doses (530m2g up to 5 times daily) over many years. Therecommended dosage: fluid extract 1-3 ml, tab150 - 300mg 30 minutes prior to sleep.Kava Kava (Piper methysticum) is also an aanxiety drug and helps with insomnia. In higdoses it promotes sleep and can be used as amuscle relaxant. Kava should not be used inpatients with depression or during pregnancylactation. Additionally, it should not be used fmore than three months continuously withoumedical advice. The primary side effects aredrowsiness, balance disturbances, and mildgastrointestinal upset. I t should no t be takensimultaneously with central nervous systemdepressants such as alcohol, benzodiazepines,anti-psychotics. The usual dosage is 60-120 mkavalactones daily.

ConclusionTinnitus is a significant medical problemaffecting 40-50 million Americans, with 12 milion being severely affected. Once a thoroughevaluation has been performed by a qualifiedotolaryngologist, and no life-threatening condhas been identified, the opportunity for treatmstill exists. Treatment options are extensive anrange from approved protocols such as maskiand TRT to anecdotal remedies such as those sented here. While tinnitus may no t miraculodisappear with any of these therapies, many othese options can help to make the tinnitus mmanageable.m

REFERENCES1. Rudolph, Fritz, Weiss, editors. Herbal Medicine,Beaconsfield Publishers, LTD, Beaconsfield, England, 12. Holgers K.M, Axelsson A, Pringle: Ginkgo Biloba Extfor th e neatment of Tinnitus, Audiology, 1994; 33(2):85-92.3. Hobbs, Christopher: Ginkgo Elixir of Youth, BotanicPress, 1991; 50-51.4. Blumenthal, Busse, Goldberg, editors: The CompleteGerman Commision E Monographs, Integrative MedicinCommunications, Boston, Massachusetts, 1998.5. Wedel H, Calero L, Walger M: Soft-Laser/ Ginkgo Thin Chronic Tinnitus, Adv Otorhinola.ryngol, 1995; 49: 10108.6. Newall CA, Anderson LA, Phillipson JD, editors: HerMedicines, A Guide for Health-Care Professionals, ThePharmaceutical Press, London, England, 1996.7. Gruenwald J, Brendler T, Jaenicke C, editors, PhysicDesk Reference for Herbal Medicine, 1st Edition, MedicalEconomics Company, Inc, 1998.8. OnHealth Network Company, Copyright 1999,www.alt. trt.com.


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Support Network Volunteersby Ceryl McGinnis, ATA Director ofResearch and Support

The ATA Support Network involves manyvolunteers who share their telephone numbers,addresses, or as in the case with group leaders,their meeting sites. These volunteers know thefrustrations of tinnitus either because they experience i t themselves, have a loved one whoexperiences it, or they treat patients who haveit. Each has heard what has helped other peoplewith tinnitus and what has not. They know theycan help lessen the burden for someone else bybeing available, by listening with out judgment,and by relating to the effects of tinnitus.

Lorraine Cramer, long-time ATA volunteer,started the Tinnitus/Meniere's Pen-pal SupportNetwork soon after she was diagnosed withMeniere's disease in 1991. She recalls an overwhelming need to find someone who understoodfirsthand the effects that this disorder had on hereveryday life. There were no self-help groups inhe r area, so she contacted the American TinnitusAssociation with the idea of starting a pen-palgroup for others who did not live near a supportgroup or who could not attend meetings.New Self-Help Groups:Jim Henry, Ph.D.VA Medical Center (R&D -NCRAR)P.O. Box 1034Portland, OR 97207Contact: BarbaraThmbleson(503) 220-8262 x57991Lori Sweer s184 Ponderosa CircleParachute, CO 81635(970) [email protected] Willd nson38 E. Beach RoadThvernier, FL 33070(305) 852-1620e-mail:

[email protected] letter andtelephone volunteers:Ollie BeverlyP.O. Box 1542Livingston, TX 77351(409) 967-3178Mark Goode n82 N. LinwoodSomerset, KY 42501(606) 678-0980

'lbdd Greeneway(920) 831-8766George Ke lly1622 Winton AvenueHavertown, PA 19083letters only pleaseBo b LewickiP.O. Box 723Blue Jay, CA 92317(909) 337-8202Catherine Magnusen9720 County KBrussels, WJ 54204(9 20) 825-1263Robe rt Reynolds19117 Sotogrande DrivePflugerville, TX 78660letters only pleaseJohn Rhodes3665 Blair StreetCorona, CA 92879(909) 279-7934e-mail: [email protected] We aver14810 SantarosaDetroit, MI 48238(313) 861-8190Mirtha Wincele1344 Bayview CircleWeston, FL 33326(954) 389-0881

Lorraine considers her commitment to thenetwork - now 300 + strong - to be a lifelongendeavor. Over the years, she's made manychanges to th e membership list. This year, shehas added the "join date" to each pen pal on thelisting and, at the request of the newer members,e-mail addresses. You can contact Lorraine viae-mail: LCh [email protected], or byregular ma il:Lorraine Cramer434 Lewis Boulevard SESt. Petersburg, FL 33705Please include your name, address, e-mailaddress, age, hobbies, interests, details on yourexperience with tinnitus or Meniere's disease(length of time, etc.), treatment t r a t e g i e ~ you'vetried (medications, herbal remedies, copmg.

techniques, etc.), and pen pal preferences (likecertain occupations or gender). If you wish toparticipate, send $5 to Lorraine to cover themailing and printing costs.We welcome the new year, the new millennum, and our new Support Network volunteers!

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www.tinnitus-relief.comAmerican Tinnitus Association Tinnitus Thday/ March 2000 13


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An International View THE

Ross Coles

by Dr. Ross Coles,Nottingham, UK

In the last two decades,the InternationalTinnitus Seminars havebeen the main forums forpresenting new researchmaterial and for providingtinnitus professionals aplace to meet. There havenow been six seminars, held at four-year intervals. With the increasing number of researchpapers offered, th e seminars need to be heldmore frequently. The next will be held in threeyears in Fremantle, Australia, in 2002.The most recent seminar in Cambridge UKfilled four full days an d offered 91 papers a ~ d 44poster displays to 240 participants from 28 countries! The vast majority of the seminar's organization was carried out by Jonathan Hazell

( T i n n ~ t u s and Hyperacusis Centre, London, UK)and h1s staff, together with administrative support from the British Society of Audiology.Professor Richard zyler (University of Iowa,USA) gave a special lecture on the placebo effectand why it makes clinical trials in tinnitus sodifficult. He commented that this could alsobecome a treatment in itself, perhaps to be called"patient expectation nurturing."Another special lecture was given by Guest ofHonor Professor Alf Ax.elsson from Gothenburg,Sweden. He asked us to consider carefullywhether we could trust claims of high successthat were based solely on uncontrolled trials. Adisorder such as tinnitus, whose presence andseverity cannot even be objectively demonstratedand measured, is particularly prone to the powers of suggestion and placebo effect.A particularly interesting an d promising areais th e use of new imaging techniques such as

functional magnetic resonance imaging (fMRI),and positron emiss ion tomography (PET). Theseare already providing valuable information onthe areas of th e brain involved in detection, perception, an d evaluation of tinnitus and reactionto it. Eventually these techniques will becomeless expensive and more widely available andwill become very important tools for tinnitusresearch an d possibly for clinical and legalassessments. Also very exciting were th e findingsof the various neurophysiological models of

14 Tinnitus 7bday/ March 2000 American Tinnitus Association

tinnitus-related activity in the ear, nerve, andauditory tracts in the brain and their connectioThese are helping to map the parts of the braithat are involved in tinnitus, providing neuropharmacological clues on possible future reseatowards the "tinnitus pill."

One of the sessions wasdevoted to tinnitus retraing therapy, TRT, withinvited papers from threxponents of it, PawelJastreboff (Atlanta,Georgia) and JonathanHazell and CathereneMcKinney (London, UKA more neutral stance w1'" 1 taken by James Hall IIIA 1 Axe sson h ill(Nas v e, 'Tennessee). uses TRT for his patients, but interestingly notthat 72% of them were satisfied with a single idepth counseling session.

A major issue at the Seminar was whetherTRI' offers anything better or is even as good acognitive behavioral therapy (CBT). The answseems to be that both of these therapies, whenskilfully carried out, can substantially improvemost cases of troublesome tinnitus. Moreover, two treatments have much in common, in parular the detection and correction of false conctions and attitudes.Jstreboffs neurophysiological model ofheaing, and its application to tinnitus, is probalargely correct. On the other hand, I heardnothing at the Seminar, nor anywhere else, th

Jonathan Hazell

justifies the statement tit is essential to TRT's scess to base its counselistrictly on the model. Itquite likely that equallygood results could beobtained with skilled,authoritative, and expection-inducing counselinusing some other plausitheory explaining howlasting physical changesfor the better can resultfrom it. There is also no experimental justification for the rejection of tinnitus masking andother coping strategies, either in their own rigor as an adjunct to TRT. Following the thoughtgiven to us by Rich zyler and AlfAxelsson, onwonders if the results reported for TRT, all in


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TINNITUS SEMINARuncontrolled studies, are the results of heightenedexpectation, together with an authoritative explanation of tinnitus mechanism and reassurance asto its essential harmlessness.Te other component of TRT is sound therapy.As reported by Catherene McKinney, 70% ofthe patients had good or excellent results withTRT in a clinical trial. However, there was no statistically significant difference between those whoreceived only TRT counseling and those whoreceived TRT counseling plus sound therapy.

Thus, directive counseling appears to be theonly bit of TRT for which there is evidence ofeffectiveness. I t seems to be less sophisticated andless well researched than CBT. The papers on CBT

Pawel Jastreboff. Ph .D.,Sc.D.

by Jane Henry and PeterWilson (Sydney andAdelaide, Australia) and byGerhard Anderssor andLeif Lyttkens (Uppsala,Sweden) were much moreimpressive in this respect.In spite of these doubtsabout the details of TRT, itappears that many patientsare helped greatly by it.This has been an importantcontribution. In the UK,

our tinnitus services have much improved withthe advent of TRT, and TRT-related managementsor neurophysiologically-based managements(NBM) as these have been termed by the BritishTinnitus Association. Interestingly, a survey oftinnitus services used in UK has recently beencarried ou t by the National Tinnitus Helpline runby the Royal National Institute for Deaf People.Responses were received from 187 hospitals. Ofthese, 82% carried out some form ofTRT or NBM .(Six percent use TRT only, 57% use NBM only,and 20% use both TRT and NBM.)Jastreboff and Hazell, who developed TRT,

have done a great service for people with tinnitusby developing the treatment, encouraging greaterprofessional understanding of tinnitus, and providing a better organization and content of counseling therapy. But other methods of treatment,including cognitive behaviora l therapy and otherforms of counseling or TRT-like management, areequally good and sometimes less costly.The recently formed International Tinnitusand Hyperacusis Society has now assumed therole of determining the site, date, and organizer offuture inte rnational tim1itus seminars. Because of

the ever-increasing volume of research, it isenvisaged that the International TinnitusSeminars will be held even more frequently afterthe 7th seminar in 2002. There>will also be smaller annual tinnitus meetings, in association withother conferences such as those held by theAssociation for Research in Otolaryngology andby the European Federation of AudiologicalSocieties. This increase in tinnitus research andscientific meetings is good news for all of us whotreat or who are affected by tinnitus. Readers can purchase a .copy of the Proceedings ofthe 6th International Tinnitus Seminar from TheTinnitus and Hyperacusis Centre, 32 DevonshirePlace, London WlN lPE, United Kingdom,www. tinnitus.org.

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16/28

Thank You Members and Donors!By Jessica Allen, ATA Director of Resource DevelopmentDear Members,Your response to our annual campaignhas overwhelmed us all. On behalfofthe Board ofDirectors and staffofATAplease accept our sincere gratitude.Your combined gifts have given us over$100, 000 toward our new memberrecruitment and tinnitus awarenesscampaigns.

This funding allows us to begin print andmedia campaigns in several major cities startingin February encouraging interest and newmember enrollment in ATA . The ATA Web sitewill also see a revision making it more userfriendly with more frequent updates. You canexpect to see changes to our Web site(www.ata.org) by this June.

All of this means increased public awareness,more scientific research, and more relief to thoseexperiencing tinnitus. Thank you, again. Yoursupport is making this h a p p ~ n . The American Tinnitus Association has alsobeen blessed with some significant donations.We will begin honoring these wonderful humanitarians in this issue of Tinnitus Tbday.Ann Spencer Simon(June 13, 1918- December 10, 1999)

Ann Spencer Simon ofThcson, Arizona, whohad tinnitus, has generously gifted ATA with thesum of $100,000. Ann became a member of ATAin 1993. Ann was an accomplished artist and willbe remembered for her paintings depicting whimsical satires on the foibles of modem life. Herunique style reflected her interest in politics an dthe events of the time. Ann's own words tendedto match the vitality of he r paintings, as she isquoted as saying, "When my sense of outrage isstirred by bigotry, hypocrisy, smugness or greed,I do what comes naturally - which is skewer theenemy with a paint brush."

Ann was the youngest daughter of RobertSpencer and Margaret Fulton Spencer. RobertSpencer was a highly regarded impressionist16 Tinnitus Thday! March 2000 American Tinnitus Association

painter, and his works are displayed in cities as New York City, Buffalo, Pittsfield, and NewHope. Margaret Fulton Spencer was the firstwoman architect to graduate from MIT, and swas also an accomplished painter. After the dof Robert Spencer, Margaret Fulton Spencer aher children moved to 1\.1cson an d purchasederal acres ofland where she designed and buithe Rancho de las Lomas ranch. The ranch is owned by the family, and Ann returned toRancho de las Lomas for the last years of her

An n studied art in Paris an d at the ArtStudent's League in New York. She lived in mplaces during her life: New Hope, Paris, NewYork City, Santa Barbara, Carmel, an d ThcsonDuring her life, Ann's paintings were displayeseveral galleries and she was identified in WhWho of American Painting.

Ann was predeceased by her husband, LoSimon, an d is not survived by an y children. Ais survived by a niece. We convey our sympatto her niece an d gratitude to her estate for thithoughtful and generous bequest. II

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TINNITUS CAUSED BY SUDDEN, INTENSECHANGES IN AIR PRESSUREby Mary B. Meikle, Ph.D., and Susan E. Griest, MPH,Department of Otolaryngology, Oregon Health SciencesUniversity and VA National Center for Rehabilitative AuditoryResearch, Portland, ORTnnitus severe enough to require clinicalattention can be caused by many things,including damaging levels of sound, headinjury, various illnesses, ear diseases or trauma,and other less common causes. One of the mostinteresting and unusual causes for tinnitus isbarotrauma - damage to the ear caused by large,abrupt changes in the air pressure surroundingan individual.Normally the air pressure within the middleear (the space enclosed by the ear drum) isequalized to the outside air pressure wheneverthe Eustachian tube opens (such as when weyawn, or when our ears "pop"). But sometimesequalization cannot occur, causing pain, feelingof intense pressure, and sometimes bleeding orrupture of the eardrum. Hearing damage and/ortinnitus may then result.

Te Tinnitus Data Registry (a collection of dataobtained over many years from patients at

the Tinnitus Clinic of the Oregon HealthSciences University in Portland, Oregon) enablesus to study tinnitus caused by barotrauma.Although barotrauma is a relatively rare cause fortinnitus, the Registry now includes data from several thousand patients and provides a number ofbarotrauma cases. We found a total of 17 patients(about 7/10 of 1%) who reported barotrauma asthe cause of their tinnitus.

Nearly all of the barotrauma patients reportedthat their tinnitus started suddenly - seven ofthem during scuba diving, five of them in airplanes, one in a submarine, and four duringother types of pressure changes. One of thosefour was working inside a ventilation duct whenthe exit ports suddenly snapped shut, causing aninstant pressure drop. Another was working witha high-pressure air hose when he lost control ofit, releasing a blast of pressurized air into hisnose and Eustachian tubes. Nearly all of the barotrauma patients felt immediate loss of hearing aswell as intense pressure and pain.

In many ways, the barotrauma group is quitesimilar to the overall Clinic group who have no t

undergone barotrauma. For example, barotraumapatients exhibit fairly high-pitched tinnitus(ranging from a low of 2,800 Hz to a high of12,000 Hz), similar to the overall group ofpatients where tinnitus below 2,500 Hz is rare.Likewise, hearing varies greatly among the barotrauma patients, some having excellent hearingwhile others show extensive hearing losses. Thetinnitus is usually localized to the poorer-hearingear in both the barotrauma group and the overallClinic population. When tested with a standardband of masking noise supplied by a tinnitussynthesizer, effective masking was obtained in94% of the barotrauma group (about the samepercentage as in the overall Clinic population).Tere are, however, some intriguing differences between the barotrauma patients andthe other patients. While the majority of nonbarotrauma patients experience tinnitus consisting of only on e sound, 70% of the barotraumagroup experience tinnitus that is quite complex,consisting of a number of different sounds.Secondly, whereas more patients in the overallClinic group report tinnitus worse on the left, thebarotrauma group includes more people with tinnihls worse on the right (52% as opposed to 32%in the overall group). A small percentage ofpatients in each group reported tinnitus localized11in the head."

Most patients in the barotrauma group didnot seek treatment for their tinnitus immediately, perhaps hoping that the tinnitus would goaway on its own. As a result, the condition of themiddle or inner ear immediately following barotrauma was unknown in most. However, in twocases the eardrum showed signs of tearingimmediately post-trauma, and in another casesurgical repair for perilymph fistula had beendone. Only three patients in the barotraumagroup reported a problem with dizziness, indicating that barotrauma affected mainly the auditoryportion of the inner ear, leaving the nearbyvestibular (balance) mechanisms intact.

Although barotrauma is an uncommon causefor tinnitus, it is clear that it can cause significantdistress. We hope that our observations mayprove helpful to those involved in research ortherapy concerned with the damaging effects ofbarotrauma upon th e ear. II

American Tinnitus Association Tinnitus Thday/ March 2000 17


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And the Winner Is by Rachel D. Wray, ATA Director ofAdvocacy andInformation &Resources

It's Oscar time! Every year in March, gowns arechosen, tuxes are cleaned, and the Hollywoodglitterati begin preparing gushing acceptancespeeches thanking everyone from elementaryschool teachers to th e guy on the corner. Sappyspeeches aside, if you're like me, you'll hunkerdown later this month with friends an d a bigbowl of popcorn, staying glued to the televisionfrom best supporting actress to best picture.

And maybe you'll idly wish that an award, orperhaps a harsh fine, were given to the loudestpicture. Certainly there'd be a lo t of contenders.

One of the many complaints we receive hereat ATA is how movies have gotten consistentlylouder. Armageddon, for example, reached 120 dB(decibels) when it played in the theatres a fewsummers ago, an d action-packed movies like itare often measured near 110 dB during climacticscenes. When Phantom Menace opened last summer, one theatre in Oregon held a ''blast yourears" showing, promising extra-loud volume forthose fans who wanted to feel th e so-called rushof truly surround sound. Many of you, however,aren't fans of that kind of movie experience. Youknow that exposure to high noise levels can contribute to eventual hearing loss and/or tinnitusespecially i f th e exposure is for more than a fewminutes-or exacerbate existing hearing problems. Still, the trend has been established.

Since breakthroughs in multichannel digitaltechnology in 1987, movie sound has become asignificant industry, as much a part of the filmingprocess as camerawork. Director/producerGeorge Lucas stresses this point: "Sound is 50

percent of the motion picture experience."~ ~ ~ ~ ~ ~ ~ ~ ~ Currently, three multichannel digi-tal audio formats are used in

commercial theatres: DolbyDigital, DTS (DigitalTheater Systems) DigitalSound, an d Sony DynamicDigital Sound (SDSS) .Digital sound produces

higher and cleanerpeaks of sound

18 Tinnitus '10day / March 2000 American Tinnitus Association

levels-often five times greater than the samesoundtrack offered in th e more traditional anaaudio.

From a technological standpoint, this is allvery well and good. But from a hearing consertion perspective, the advent of digital audio waproblematic because for many, it turned a seeingly enjoyable activity-movie watching-intan uncomfortable, often painful event. Becausloud movie volumes, many of you walk out wpreviews open with seemingly off-the-chartsvolume. Some of you don't bother to go at all,preferring to wait until films are released onvideo so that you can control the volume at hwith your remote.

Gtrol, however, is often yours at your locaineplex, even i f you don't know it. At ATAur tinnitus education an d prevention programs focus on how much control you do havas a listener, as a citizen, and as a consumer. Panother way, you vote by where and how youspend your money and your time. The movietheatre industry is like many others, where thcustomer is nearly always right. Plus, in anindustry made more competitive by video stoand satellite dishes, most theatre chains wantprovide exceptional service. Accordingly, mosmovie theatre representatives maintain that threspond to customers' requests an d complaintturning the volume down. In some cases, eveone complaint is enough to lower th e sound.

So when you object, for instance, to managat Regal Cinemas, the largest theatre chain incountry, or United Artists Theatre Circuit, themanagers respond by setting th e movies' audifader-volume in hi-fi speak-below the studiocalibration setting. The calibration setting issimply th e volume recommended by the movstudio for best listening. When theatres use threcommended calibration setting, they are plaing back th e film exactly as th e director intendWhen they don't, parts of the movie, like dialogue, are harder to understand, prompting stimore complaints from the audience. What's atheatre manager to do?

A glut of negative newspaper and magazinarticles on movie volumes have been publisheover the last few years, and theatre owners arundoubtedly sensitive to th e complaints. Evenindustry mouthpieces like Variety and TheHollywood Reporter have asked how loud is tooloud. Sound engineering conferences held symposiums on the contentious issue and suggest


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earplugs for sound engineers who mixed thesoundtracks. Studios eventually considered thebacklash from consumers and the media, andinternal task forces have been developed todecide how to best employ the latest soundadvances. "People were abusing the technology,"Ioan Allen, vice president of Dolby IndustriesInc., says. "Most directors are fairly sensible," hebegins, then trails off before adding, "I t gotannoying but not medically dangerous."Tis annoyance has not yet led to industrywide agreement on how loud movies shouldbe, especially since different types of moviesmight require different volumes. But the variousplayers did agree on one thing: the previews arejust too noisy, reaching peaks that are as much as10 dB louder (10 times louder!) than the featurepresentations. The loud previews, called trailers,prompted the most complaints from consumers,bu t when theatre managers responded by turningdown the audio faders, the feature presentationssuffered by no longer being set to the appropriatecalibration setting. Because pa trons go to themovies to see the feature presentations and no tthe trailers, it was the latter that had to change.

Eventually, the Trailer Audio StandardsAssociation was formed, led by loan Allen, whoserves as technical chairman. This task force,with members from all facets of the movie andsound engineering industries, adopted standardsthat went into effect in June 1999, mandatingthat trailer volumes cannot exceed 87 dB-Leg."Leg" refers to the loudness over time-or, inengineering language, "the level of a steady-statetone with the equivalent level in terms of potential hearing damage as a level time-variantsignal." (You should see the formula that accompanies this definition!) Tf trailers exceed thismaximum level, they are no t approved by theMotion Picture Association of America and therefore cannot be shown in movie theatres.

Because trailer volumes are now more closelyaligned with the volumes of feature presentations, a National Association of Theatre Ownersrepresentative explains, volume complaints intheatres have been reduced. If you haven't beento the movies in a while, you hopefully willnotice a difference. But this is not to say thatsome movies are no longer too loud. While mostfeature presentations are calibrated between 70and 85 dB, there are still peaks of excess noise asloud as 110 dB . Those high-decibel peaks are usually not sustained for more than a few moments,which many audiologists say is acceptable formost people's ears. Acceptable, however, doesn'talways equal good. While most people might not

feel long-term effects from exposure, the occasional person will suffer ear damage. And peoplewith existing hearing problems will be the mostuncomfortable, often choosing to forgo movies,an activity they previously enjoyed.Perhaps that person is you. If so, instead ofchanging your Saturday matinee plans, speak upin movie theatres. Understand that as a consumer, you have the right to express your con

cerns. Chances are, most theatre managers willrespond accordingly by accommodating yourrequest for lower volume- except now, theywon't have to lower the volume quite as much asthey did in the past. Also understand that theindustry is trying to meet the needs of many people, and some progress has already been madeand should be commended. Another option is tochoose pictures earlier in the day, when thevolume is less intense; films shown later in theevening, when a younger crowd attends, areusually louder. (Changing that generationalpredilection is a subject for another column.)And just in case, have a spare pair of earplugs inyour pocket. While you have more power thanyou think, you can't control everything. HResource:National Association of Theatre Owners4605 Lankershim Boulevard, Suite 340North Hollywood, CA 91602-1891Phone: (818) 506-1 778Fax: (818) 506-0269

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American Tinnitus Association Tinnitus Thday/ March 2000 19


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BanjoisticallyYOURSA Musician Copesw ith T inn i tus

by Rik LoveladYt Ph .D, Th.M.In the midst of a successful career as anEnglish professor and part-time musician, in thefall of 1995 I experienced a severe sound shockin my recording studio. I had just gotten a new,

powerful microphone. And in my haste to tryit out, without turning down the mixer volume,I received a high-pitched, devastating sound blastfrom the speakers.With continuous ringing in my ears, I sought

out a local ENT for possible treatment. Afterexamining me, he chuckled (inexcusably) andtold me that I had tinnitus with recruitment anda high-frequency loss. Then he fitted me withcustom, protective earplugs and told me tono t listen to loud noises.In desperation I sought further consulta-

tion with another ENT who took my plight seriously, but the pronouncement was the same. Iwas having difficulty tolerating noises that rangedfrom the clinking of a glass to musical presentations in church. But most painfully, my musical

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20 Tinnitus 1bday! March 2000 American Tinn itus Association

and recording activities were all bu t curtailedand I thought that music, for me, was over.

At that time I had been developing someexpertise as a jazz banjoist - you know,Dixieland an d Roaring 'TWenties fare. That kinpercussive string music can be quite penetratSo I practiced and performed a bit with theearplugs (ER-15 an d ER-25 attenuators, moldeEtymotic Research), but I never

.fi. heard the full, bright sound of twonderful banjos I was playinghave five of them.)I t had been the assertive, ringing

sound of the banjo that first attrame to the instrument, and now bedeprived of its natural sound, I feltaesthetically cheated. I was hearingdull, thud-like, choppier sound insteI wanted to take a chance an d play wout earplugs. But the prospect of abadoning the earplugs led to a fear thabanjo's volume, timbre, and pitch in

combination would further exabate my tinnitus. I decided obrief test with single notesAt first it was a shock, bugradually built up a tolertion level. Then I movedprogressively to the chorand melody and evenbeyond that, to rapid struming. Within a month, I wback to playing with Dixielabands. Since that time I have

been able to record two of my owbanjo CDs and solo at large events all over thcountry. 1b top it off, I am now a director of tFretted Guild ofAmerica, which preserves anpromotes the instrument and style of music fwhich it is known, additionally funding projeto enable young people to acquire and play thinstruments.

In my ears I still have a ringing sensationthat sounds like the whine of electric power lthat one sometimes hears along a country roaPlaying my string instruments or listening tomusic in the studio or in the concert hall tendexcite the damaged nerve endings in my ears.Most of the time I choose to ignore the sensatby concentrating in other matters. And with arest from intense sound activity for a couple odays1 th e higher level of ringing subsides.Of course this procedure might not work everyone. But simply by exploring the possibiof doing something that was very dear to me,was able to renew my personal contribution tthe lives of many other people, bringing smilefaces through th e joyous sound of the banjo, while my ears are still ringing. II


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MAKE YOUR MARKACALL FOR COMMITTEE VOLUNTEERS!The time commitment is minimal.The monthly meetings are held viatelephone. Your ideas are needed!We are currently recruiting for thefollowing committees:Human Resources Committee

We are in need! If you have a background oran interest in developing board operating standards and proposing staff personnel policies,please consider serving on this committee.Program Committee

If you are interested in proposing guidelinesand developing recommendations for theInformation & Resources program, supportgroups, Tinnitus Tbday, an d the research grantawards process, le t us know.

Finance CommitteeIf finance is your game, then this committeewould like your name. This committee reviewsand proposes investment policies and fiscalprocedures.

Resource Development CommitteeDo you have great (or even good) fund raisingideas? Do you enjoy public relations? Consider

joining this committee and we'll even throw inenrollment and retention of members!

Complete the application below and forwardit to Laura Grimes at the ATA office.

AMERICAN TINNITUS ASSOCIATION BOARD COMMITTEE APPLICATION

AMERICANTINNITUSASSOCIATION

P.O. Box 5Portland, OR 97207503 / 248-9985800 / 634-8978

Name:Address:Telephone: (Daytime) (Evening)Fax:E-mail:Thank you for your interest in serving on an American Tinnitus Association BoardCommittee. Please indicate on which committee you would prefer to serve:0 Business 0 Human Resources 0 Resource Development 0 ProgramPlease identify any skills, knowledge, or contacts that you bring to ATA.

Signature: Date:Please return this completed form to Laura Grimes at the ATA office. You may photo-copy the form i f you need more. Feel free to attach additional pages, your resume, orany materials you feel would be helpful.

Ame rican Tinnitus Association Tinnints 'Ibday /March 2000 21


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QUESTIONS AND ANSWERSJock Vernon 'sPersonal Responses to Questions from our Readersby Jack A. Vernon, Ph.D., Professor Emeritus, OregonHealth Sciences University

Q Mrs. S. from Texasindicates that shehas two cochlearimplants which she hadhoped would not only provide hearing bu t also tinnitus relief. She describesher tinnitus as a headnoise that is something ofa "musical roaring." Shereports that her hearinghas improved but hertinnitus has not.A ully 90% of the patients implanted withcochlear implants obtain tinnitus relieffrom the stimulation provided by thatinstrument. Recently we reported that a patientin Israel with a cochlear implant got tinnitusreliefby playing masking sounds into hisimplant. The masking sounds were those provided from th e Moses/ Lang CD (available from theOregon Hearing Research Center, 503-494 -8032).Thus, we first recommend that you try maskingthrough your implants with the Moses/ Lang CDmasking sounds. Since describing the successwith the patient in Israel, a cochlear implantpatient in California tried similar masking butwithout an y success. The fact that the largemajority of cochlear implanted patients get relieffrom their tinnitus by action of the implantstrongly suggests that there is a need to study theeffect of electrical stimulation upon tinnitus.Q Mr. J. in Il1inois indicates that he has atotaJ hearing loss in his left ear that cameon very suddenly with violent vertigo. Heis now left with severe tinnitus in that ear. Someof the physicians he has seen recommend a surgical labyrinthectomy while others have suggested injecting gentamicin into the left inner ear. Hefeels that he has little to lose by destructive procedures but he wonders if his tinnitus will beeffected by the surgery.A nfortunately destruction of the inner earlabyrinths does not guarantee the end ofyour tinnitus. There are many cases wherethe tinnitus persisted after the hearing nerve wassectioned (or cut). I t appears that once tinnitushas been on-going for a period of time, itbecomes established somewhere in the brain an d22 Tinnitus Thday/ March 2000 American Tinni tus Association

sectioning peripheral nerves will have no effeupon it. Before you do anything, I would suggthat you try masking the left ear by introducinthe masking sound to the right ear. There are places in the brain where both ears are directlconnec ted together, at least by way of nerve pways. Often masking on one side can affect thtinnitus on the other side. You could try the gtamicin injections (which can cause hearing loor medications lil


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different sites. However, this procedure is verypainful. I suggest that you instead request thatyour eardrum be anesthetized painlessly byiontophoresis.Q will certainly do this. But what isiontophoresis?A ontophoresis is the technique of drivingchemicals through the skin by electricalstimulation. One direct current electrode isplaced in an anesthetic solution, such as lidocaine, then placed in your ear canal. The otherelectrode is placed on your upper arm to complete the circuit. The positive direct current willsend the positive ions of the solution through theeardrum and thus anesthesize it. While youreardrum is anesthetized, return to your restaurant and determine if the clanging dishes produces pain for you. You will have about twohours of anesthesia.Q did it!! And I did not experience anypain as long as the anesthesia was effective. After about three hours, I was onceagain experienced pain from loud sounds. Doesthis prove that my eardrum is responsible for thepain? I imagine that I cannot have constant anesthesia in my eardrum.

Air Bag/Tinnitus Study UnderwayHow You Can HelpKathleen Yaremchuk, M.D., at theHenry Ford Hospital in Detroit, is headinga research project to analyze the hearingdamage caused by air bag deployment.Yaremchuk's team is distributing questionnaires to people who believe that theirhearing loss, tinnitus, and/ or hyperacusiswas caused by deploying air bags. (Hearingloss is not always noticed by the patienteven when it is present. A hearing test isrecommended after exposure to an air bag

deployment.)If you qualify and are interested inparticipating in the study, please contactDr. Yaremchuk at:Henry Ford HospitalDept of Otolaryngology HNS2799 W Grand Blvd.Detroit, MI 48202phone: 313-916-3282fax: 313-982-7263email: [email protected]

A think the anesthesia demonstration clearly points to your eardrum as the cause ofthe pain, although I do no t know why itreacts to sound in this manner. Strange as thismight sound, the solution might be for you to ge ta new grafted eardrum. Ask your otologist i f thisprocedure can be done for you. This procedure iscommonly performed for patients who, for onereason or another, do not have eardrums.Three months later, Mr. C. reported that hehad a new eardrum and that he no longer experienced pain when in the presence of loud sounds.Hearing tests revealed that he had lost verylittle hearing due to the transplant. He alsoreported that thankfully he did not have to sellhis restaurant.

Notice: Many ofyou have left messages requestingthat I phone you. I simply cannot afford to meetthose requests. Please feel free to call me on anyWednesday, 9 a.m. - noon and 1 - 5 p.m. PST(503/494-2187). Or mail your questions to:Dr. Vernon c/o Tinnitus Thday, American TinnitusAssociation, P.O. Box 5, Portland, OR 97207-0005.

Pass Them OnATA's new ''first contact" informationbrochure about tinnitus and ATATo doctors:These brochures enable your patients to writeor call us - at no charge - for tinnitus information and resources.To ATA members:

These brochures are ideal forplacement in libraries, doctor'soffices, pharmacies, hospital waiting rooms, and senior centers.(Contact the places you have inmind first and obtain permissionto distribute.) This will helpthousands of people reach us fortinnitus information and for thenames of doctors, audiologists,and other health care providerswho specialize in treatingtinnitus patients.

If you would like 100 freebrochures to distribute,please send us your name,street address, e-mail address (i f youhave one), and phone number. BAmerican Tinnitus Association Tinnitus 7bday/ March 2000 23


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SPECIAL DONORS AND TRIBUTESATA's Champion Members are a remarkable Contributions to ATA's Tribute Fund willgroup of donors who have demonstrated their be used to fund tinnitus research and othercommitment in the fight against tinnitus by mak- ATA programs. If you would like this contribing a contribution or research donation of $1000 tion restricted for research, please indicate ior more. Sustaining Members have given mem- with your donation. TI:ibutes are promptly

berships or research donations at the $500-$999 acknowledged with an appropriate card to thlevel. Suppor ting and Contributing Members honoree or family of the honoree. The gifthave given memberships at the $100-499 level. amount is never disclosed.Research Donors have made research-restrict- Our heartfelt thanks to all of these speciaed contributions in any amount up to $499. donors.

Al l contributions to the American Tinnitus Association are tax-deductible.

Champion .Joseph ine K. GumpMembers Donald L. HermanChristopher V.(Contributions of$1000 Houghtonand above) J r 11Joel Alexander erry n e 'Julia R. Amaral Jim LaneyLegislativeSusan Bently CorrespondentsRobert H. Bocmer Assoc.Stephen Chandler Stephen w. LewisAnthony G. A Correa Jean R. LjungkullRob M. Crichton Suzanne A. NathanRonald K. ~ n g e r Kathy PeckClaude H. Gnzzard, 'TOny RandallW. F. Samuel Hopme1e1; N. SchaeferBC:-H IS . Martha M. SmithKha1ry A. K a ~ 1 , Ph .D. Richard K.Sidney C. Klemman StruckmeyerMIChael E. Mcgmley Milton R. ThckJohn E. Meehan William E. Tinley

John L. Mercer Chri stopher J. WeissStephen Moksnes Raymond L. WellsPhihp 0 . Morton Keith C. WintersStephen M. Nagler,M.D., FACSAaron J. OsherowJerome Ot tKenneth A. PrestonDan PurjesRobert Schiller, CF'PRonald A. SeelyeSusan J. Seidel,MA,CCC-AWanda M. ShalmonWill iam ShatnerSaul N. SilbertTimothy S. SotosPaula FrenchVanakkerenAgnes VarisJack A. Vernon, Ph .D.SustainingMembers(Contributions of$500-999)Elizabeth A. ArtandiWarren S. BenderRobert H. BoemerLaurence S. BrownAguilar ChristopherNina A. ColbertGeorge Crandall , Jr.Rob M. CrichtonJames and DonnaFijolekRichard J . F'ilancJohn J . FlavioRobert M. FullerSukey GarcetriRonald K. GrangerSeymour Greenstein

Supporting/ContributingMembers(Contributions o f$100-$499)Betty AdamsWendell M. Al1ernArthur AltaracBetty ,T. AndersonJo e H. Anderson, Jr.Ralph W. Arend, Jr.Brewster L. ArmsAlberta M. AshStephen AxelradGeorge D. BaneJoseph M. BariaH. W. BarlowEdwin N. BarnesJack BarnettPhyllis L. BarryRobert G. BashfordThelma P. BatchelderJohn BatesJanet E. BaumgartnerPeter B. BaylinsonIvan H. BehrmannJuan J . BermejoHoward G. BernettSusan BiedermanLarry BirenbaumRobert E. BodohRichard A. BoltHarold BornemanGeorge S. BovitDeborah BowerSharon E. BowyerE. Ayres Boyd

GIFTS FROM 10-16-99 to 1-15-00Glenn M. BrewerDon Br iceKathleen M. Brock1-1. Dean BrownRalph C. BrownMark Brumback, ACAKristin J. Bruno, Ph.D.William A. BurginJohn J. BurkeRichard A. BurnsWilliam R. Cagney,Ph.D.A. PauJ CamerinoEllen M. CampPeter E. CampbellCharles A. CarverDhyan Cassie, M.A.,CCC -AMary J. CavinsHoward C. CavnerStephen ChandlerGary M. ChaseCharles J . ChieffePeter DeeringChris topherJerry C. CirauloF. Lawrence Clare,M.D.Glen Heather ClarkJack D. ClemisBob CobeLois N. Cohen, CSW-ACSW-BCDGardner C. ColeRobert W. ColeMichael L. ConnollyDiana C. ConnollyBill Creeden -Don CrichtonRichard V. CripeChris GronbergRichard E. and EileenE. CronnMary F. CrosierWi lliam P. CurryElizabeth .r. CurtisRonald H. DaileyDennis M. DalyDonald W. DavisMary Kay H. DavisJohn G. DavisLinda DeaneJoseph DeckerDavid DennySamuel D. DenopoulosMary Ann DesutterDavid DewindtA. J . DianiRobert and JenniferDigisiMichael J . DoyleRalph C. Duchin

Randall C. and EliseDucoteH. Renwick DunlapSusan H .EarlWi lma EisemanJosephine M. EliasElaine S. ElliottThomas J. FallonBurdell S. FaustTom FawcettJames T. FehonMarian FeldheimMarcy FeldmanJohn W. FingerDavid E. FlatowGail A. FlemingJanet E. florentinPatti Jo FoxD. Jeanne Frant

tinnitus today march 2000 vol 25, no 1

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