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Tinnitus
Classification and external resources
ICD-10 H931
ICD-9 388.3
DiseasesDB 27662
MedlinePlus 003043
eMedicine ent/235
MeSH D014012

Tinnitus (pronounced /tɪˈnaɪtəs/ or /ˈtɪnɪtəs/,[1] from the Latin word tinnītus meaning "ringing"[2]) is the perception of sound within the human ear in the absence of corresponding external sound.

Tinnitus is not a disease but a symptom resulting from a range of underlying causes that can include ear infections, foreign objects or wax in the ear, nose allergies that prevent (or induce) fluid drain and cause wax build-up. Tinnitus can also be caused by natural hearing impairment (as in aging), as a side-effect of some medications, and as a side-effect of genetic (congenital) hearing loss. However, the most common cause for tinnitus is noise-induced hearing loss.

As tinnitus is often defined as a subjective phenomenon, it is difficult to measure using objective tests, such as by comparison with noise of known frequency and intensity, as in an audiometric test. The condition is often rated clinically on a simple scale from "slight" to "catastrophic" according to the practical difficulties it imposes, such as interference with sleep, quiet activities, and normal daily activities.[3]

Tinnitus is common. About one in five people between 55 and 65 years old report tinnitus symptoms on a general health questionnaire and 11.8% on more detailed tinnitus-specific questionnaires.[4]

CharacteristicsEdit

Tinnitus can be perceived in one or both ears or in the head. It is usually described as a ringing noise, but in some patients it takes the form of a high pitched whining, buzzing, hissing, screaming, humming, tinging or whistling sound, or as ticking, clicking, roaring, "crickets" or "tree frogs" or "locusts," tunes, songs, beeping, or even a pure steady tone like heard in a hearing test.[5] It has also been described as a "wooshing" sound, as of wind or waves.[6] Tinnitus can be intermittent or it can be continuous in which case it can be the cause of great distress. In some individuals, the intensity of tinnitus can be changed by shoulder, head, tongue, jaw, or eye movements.[7]

Most people with tinnitus have hearing loss,[8] in that they are often unable to properly hear external sounds which occur within the same range of frequencies as their "phantom sounds." [9] This has led to the suggestion that one cause of tinnitus might be a homeostatic response of central dorsal cochlear nucleus auditory neurons that makes them hyperactive in compensation to auditory input loss.[10]

The sound perceived may range from a quiet background noise to one that can be heard even over loud external sounds. The term "tinnitus" usually refers to more severe cases. Heller and Bergman (1953) conducted a study of 100 tinnitus-free university students placed in an anechoic chamber and found that 93% reported hearing a buzzing, pulsing or whistling sound. Cohort studies have demonstrated that damage to hearing (among other health effects) from unnatural levels of noise exposure is very widespread in industrialized countries.[11]

For research purposes, the more elaborate Tinnitus Handicap Inventory is often used.[12] Persistent tinnitus may cause irritability, fatigue, and on occasions clinical depression [13][14] and musical hallucinations.[15]

Objective tinnitusEdit

In some cases, a clinician can perceive an actual sound (e.g., a bruit) emanating from the patient's ears. This is called objective tinnitus. Objective tinnitus can arise from muscle spasms that cause clicks or crackling around the middle ear.[16] Some people experience a sound that beats in time with the pulse (pulsatile tinnitus or vascular tinnitus).[17] Pulsatile tinnitus is usually objective in nature, resulting from altered blood flow or increased blood turbulence near the ear (such as from atherosclerosis or venous hum[18]), but it can also arise as a subjective phenomenon from an increased awareness of blood flow in the ear.[17] Rarely, pulsatile tinnitus may be a symptom of potentially life-threatening conditions such as carotid artery aneurysm[19] or carotid artery dissection.[20] Pulsatile tinnitus may also indicate vasculitis, or more specifically, giant cell arteritis.

Measuring tinnitusEdit

The basis of quantitatively measuring tinnitus relies on the brain’s tendency to select out only the loudest sounds heard. Based on this tendency, the amplitude of a patient's tinnitus can be measured by playing sample sounds of known amplitude and asking the patient which he or she hears. The tinnitus will always be equal to or less than sample noises heard by the patient. This method works very well to gauge objective tinnitus (see above.) For example: if a patient has a pulsatile paraganglioma in his ear, he will not be able to hear the blood flow through the tumor when the sample noise is 5 decibels louder than the noise produced by the blood. As sound amplitude is gradually decreased, the tinnitus will become audible, and the level at which it does so provides an estimate of the amplitude of the objective tinnitus.

Objective tinnitus, however, is quite uncommon. Often patients with pulsatile tumors will report other coexistent sounds, distinct from the pulsatile noise, that will persist even after their tumor has been removed. This is generally subjective tinnitus, which, unlike the objective form, cannot be tested by comparative methods.

If a subject is focused on a sample noise, they can often detect it to levels below 5 decibels, which would indicate that their tinnitus would be almost impossible to hear. Conversely, if the same test subject is told to focus only on their tinnitus, they will report hearing the sound even when test noises exceed 70 decibels, making the tinnitus louder than a ringing phone. This quantification method suggests that subjective tinnitus relates only to what the patient is attempting to hear. Whilst it is tempting to assume that patients actively complaining about tinnitus have simply become obsessed with the noise, this is only partially true. The noise is often present in both quiet and noisy environments, and can become quite intrusive to their daily lives. The problem is involuntary; generally complaining patients simply cannot override or ignore their tinnitus.

Subjective tinnitus may not always be correlated with ear malfunction or hearing loss. Even people with near-perfect hearing may still complain of it. Tinnitus may also have a connection to memory problems, anxiety, fatigue or a general state of poor health.[citation needed]

Mechanisms of subjective tinnitusEdit

One of the possible mechanisms relies on otoacoustic emissions. The inner ear contains thousands of minute hairs, called stereocilia, which vibrate in response to sound waves and cells which convert neural signals back into acoustical vibrations. The sensing cells are connected with the vibratory cells through a neural feedback loop, whose gain is regulated by the brain. This loop is normally adjusted just below onset of self-oscillation, which gives the ear spectacular sensitivity and selectivity. If something changes, it's easy for the delicate adjustment to cross the barrier of oscillation and tinnitus results. Listening to loud music kills hair cells, and studies have shown that as hair cells are lost, different neurons are activated, activating auditory parts of the brain and giving the perception of sound.[citation needed]

Other possible mechanisms of how things can change in the ear is damage to the receptor cells. Although receptor cells can be regenerated from the adjacent supporting Deiters cells after injury in birds, reptiles, and amphibians, in mammals it is believed that they can be produced only during embryogenesis. Although mammalian Deiters cells reproduce and position themselves appropriately for regeneration, they have not been observed to transdifferentiate into receptor cells except in tissue culture experiments.[21][22] Therefore, if these hairs become damaged, through prolonged exposure to excessive decibel levels, for instance, then deafness to certain frequencies occurs. In tinnitus, they may falsely relay information at a certain frequency that an externally audible sound is present, when it is not.

The mechanisms of subjective tinnitus are often obscure. While it is not surprising that direct trauma to the inner ear can cause tinnitus, other apparent causes (e.g., temporomandibular joint disorder (TMJD or TMD) and dental disorders) are difficult to explain. Research has proposed that there are two distinct categories of subjective tinnitus: otic tinnitus, caused by disorders of the inner ear or the acoustic nerve, and somatic tinnitus, caused by disorders outside the ear and nerve but still within the head or neck. It is further hypothesized that somatic tinnitus may be due to "central crosstalk" within the brain, as certain head and neck nerves enter the brain near regions known to be involved in hearing.[23]

Studies by researchers at the University of Western Australia suggest that tinnitus is caused by increased neural activity in the auditory brainstem where the brain processes sounds, causing some auditory nerve cells to become overexcited. The basis of this theory is that most people with tinnitus also have hearing loss[8] and the frequencies they cannot hear linking to the subjective frequencies of their tinnitus.[9] Models of hearing loss and the brain support the idea that a homeostatic response of central dorsal cochlear nucleus neurons could result in them being hyperactive in a compensation process to the loss of hearing input.[10] This in turn is related to changes in the genes involved in regulating the activity of those nerve cells. This proposed mechanism suggests possible treatments for the condition, involving the normalization or suppression of overactive neural activity through electrical or chemical means.[24]

While most discussions of tinnitus tend to emphasize physical mechanisms, there is strong evidence that the level of an individual's awareness of their tinnitus can be stress-related, and so should be addressed by improving the state of the nervous system generally, using gradual, unobtrusive, long-term treatments.[citation needed][25]

PreventionEdit

Tinnitus and hearing loss can be permanent conditions, and therefore precautionary measures are advisable. If a ringing in the ears is audible following lengthy exposure to a source of loud noise, such as a music concert or an industrial workplace, it means that lasting damage may already have occurred.[26]

Prolonged exposure to sound/noise levels as low as 70 dB can result in damage to hearing (see noise health effects). For musicians and DJs, special musicians' earplugs play a huge role in preventing tinnitus and can lower the volume of the music without distorting the sound and can prevent tinnitus from developing in later years. For anyone using loud electrical appliances, such as hair dryers, vacuum cleaners or noisy environments such as building sites where earmuffs are impractical, earplugs are also helpful in reducing noise exposure. For operating lawn mowers, hammer drills, grinders, and similar, earmuffs may be more appropriate for hearing protection.

It is also important to check medications for potential ototoxicity. Ototoxicity can be cumulative between medications, or can greatly increase the damage done by noise. If ototoxic medications must be administered, close attention by the physician to prescription details, such as dose and dosage interval, can reduce the damage done.[27]

Causes of subjective tinnitus Edit

Tinnitus can have many different causes, but most commonly results from otologic disorders – the same conditions that cause hearing loss. The most common cause is noise-induced hearing loss, resulting from exposure to excessive or loud noises. But tinnitus, along with sudden onset hearing loss, may have no obvious external cause. Ototoxic drugs can cause tinnitus either secondary to hearing loss or without hearing loss, and may increase the damage done by exposure to loud noise, even at doses that are not in themselves ototoxic.[28]

Tinnitus is also a side-effect of some oral medications, such as aspirin, and may also result from an abnormally low level of serotonin activity. It is also a classical side effect of Quinidine, a Class IA anti-arrhythmic. Over 260 medications have been reported to cause Tinnitus as a side effect[29]. In many cases, however, no underlying physical cause can be identified.

Causes of tinnitus include:[30]

TreatmentEdit

There are many treatments for tinnitus that have been claimed, with varying degrees of statistical reliability:

Objective tinnitus:

  • Gamma knife radiosurgery (glomus jugulare)[35]
  • Shielding of cochlea by teflon implant[36]
  • Botulinum toxin (palatal tremor)[37]
  • Propranolo and clonazepam (arterial anatomic variation)[38]
  • Clearing ear canal (in the case of earwax plug)[39]
  • Using a Neurostimulator [40]

Subjective tinnitus:

  • Drugs and nutrients
    • Lidocaine, injection into the inner ear found to suppress the tinnitus for 20 minutes, according to a Swedish study.[41]
    • Benzodiazepines (lorazepam, clonazepam) in small doses
    • Tricyclics (amitriptyline, nortriptyline) in small doses[42]
    • Avoidance of caffeine, nicotine, salt[43][44][45]
    • The consumption of alcohol has been found to both increase and decrease the severity of tinnitus. Therefore, alcohol's effect on the severity of tinnitus is dependent on the causes of the individual's affliction and cannot be considered a treatment.[45][46]
    • Zinc supplementation (where serum zinc deficiency is present)[47][48][49]
    • Acamprosate[50]
    • Etidronate or sodium fluoride (otosclerosis)[51]
    • Lignocaine or anticonvulsants (usually in patients responsive to white noise masking)[52]
    • Carbamazepine[53]
    • Melatonin (especially for those with sleep disturbance)[54]
    • Sertraline[55]
    • Vitamin combinations (Lipoflavonoid)[56]
  • Electrical stimulation
    • Transcranial magnetic stimulation or transcranial direct current stimulation[57][58]
    • Transcutaneous electrical nerve stimulation[59]
    • Direct stimulation of auditory cortex by implanted electrodes[60]
    • Berthold Langguth, German neurologist would apply an electric or magnetic current for stimulation over the head of the patient to reduce ringing sound. Dirk De Ridder, Belgian neurosurgeon implanted electrodes to the brain of sufferers to normalise overactive neurons. Cambridge scientists also found that lidocaine, an anaesthetic reduces the sound in 2/3 of patients for 5 minutes, but it needs another drug to suppress its dangerous effects.[61]
  • Surgery
    • Repair of perilymph fistula[62]
  • External sound
    • Low-pitched sound treatment has shown some positive, encouraging results.(UC, Irvine press release)
    • Tinnitus masker (white noise, or better 'shaped' or filtered noise)[63]
    • Tinnitus retraining therapy[64][65]
    • Auditive stimulation therapy (music therapy)[66]
    • Auditive destimulation therapy (also called "notched music" therapy) uses individually designed music with the patients' favorite music altered to remove the musical tones that match the aural frequencies associated with their tinnitus. The removal of these tones alleviates the tinnitus by destimulating brain activity for these specific frequencies.[67]
    • Compensation for lost frequencies by use of a hearing aid.[68]
    • Ultrasonic bone-conduction external acoustic stimulation[69][70]
    • Avoidance of outside noise (exogenous tinnitus)[71]
  • Psychological

See also Edit

ReferencesEdit

  1. American Tinnitus Association | Home | Help For Ringing In The Ears
  2. Dictionary of tinnitus - Merriam-Webster Online Dictionary.
  3. Guidelines for the Grading of Tinnitus Severity. URL accessed on 2009-12-31.
  4. Demeester K, van Wieringen A, Hendrickx JJ, Topsakal V, Fransen E, Van Laer L, De Ridder D, Van Camp G, Van de Heyning P. (2007). Prevalence of tinnitus and audiometric shape, B-ENT. 3 Suppl 7:37-49. PMID 18225607.
  5. RNID.org.uk: Information and resources: Tinnitus: About tinnitus: What is tinnitus
  6. MedlinePlus Encyclopedia 003043
  7. Simmons R, Dambra C, Lobarinas E, Stocking C, Salvi R. (2008). Head, Neck, and Eye Movements That Modulate Tinnitus. Semin Hear. 29(4):361-370. PMID 19183705
  8. 8.0 8.1 Nicolas-Puel C, Faulconbridge RL, Guitton M, Puel JL, Mondain M, Uziel A. (2002). Characteristics of tinnitus and etiology of associated hearing loss: a study of 123 patients.Int Tinnitus J. 8(1):37-44. PMID 14763234
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  10. 10.0 10.1 Schaette R, Kempter R. (2006). Development of tinnitus-related neuronal hyperactivity through homeostatic plasticity after hearing loss: a computational model. Eur J Neurosci. 23(11):3124-38. PMID 16820003
  11. Holgers KM, Pettersson B (2005). Noise exposure and subjective hearing symptoms among school children in Sweden. Noise & Health 7 (27): 27–37.
  12. Newman CW, Jacobson GP, Spitzer JB (Feb 1996). Development of the Tinnitus Handicap Inventory. Arch Otolaryngol Head Neck Surg. 122 (2): 143–8.
  13. Berrios G E & Rose G S (1992) Psychiatry of subjective tinnitus: conceptual, historical and clinical aspects. Neurology, Psychiatry and Brain Research 1: 76-82
  14. Berrios G E, Ryley J R & Garvey N (1988) Psychiatric Morbidity in subjects with inner ear disease. Clinical Otolaryngology 13: 259-266
  15. Berrios G E (1990) Musical hallucinations: a historical and clinical study. British Journal of Psychiatry, 156: 188-194
  16. ENT Health Information > Hearing > Tinnitus
  17. 17.0 17.1 RNID.org.uk: Information and resources: Our factsheets and leaflets: Tinnitus: Factsheets and leaflets
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  19. Moonis G, Hwang CJ, Ahmed T, Weigele JB, Hurst RW (2005). Otologic manifestations of petrous carotid aneurysms. AJNR Am J Neuroradiol. 26 (6): 1324–7.
  20. Selim M, Caplan LR (Jun 2004). Carotid Artery Dissection. Curr Treat Options Cardiovasc Med. 6 (3): 249–253.
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  22. White PM, Doetzlhofer A, Lee YS, Groves AK, Segil N (Jun 2006). Mammalian cochlear supporting cells can divide and trans-differentiate into hair cells. Nature 441 (7096): 984–7.
  23. Engmann, Birk: Ohrgeräusche (Tinnitus): Ein lebenslanges Schicksal? PTA-Forum. Supplement Pharmazeutische Zeitung. 1997 July
  24. includeonly>"Tinnitus cure 'is a step closer'", BBC News (news.bbc.co.uk), 2009-03-25. Retrieved on 2009-03-27.
  25. Cause of Tinnitus. Paralumun.com. URL accessed on 2009-05-18.
  26. Posted by 4HL on October 28, 2005 4:00 AM. Hearing Loss News and Articles: Hear loud and clear. 4hearingloss.com. URL accessed on 2009-05-18.
  27. IngentaConnect Drug-induced Otoxicity: Current Status
  28. Brown RD, Penny JE, Henley CM, et al. (1981). Ototoxic drugs and noise. Ciba Found Symp. 85: 151–71.
  29. http://stason.org/TULARC/health/body/tinnitus-ringing-ears/6-What-are-some-ototoxic-drugs.html
  30. Crummer RW, Hassan GA (Jan 2004). Diagnostic approach to tinnitus. Am Fam Physician. 69 (1): 120–6.
  31. Passchier-Vermeer W, Passchier WF (2000). Noise exposure and public health. Environ. Health Perspect. 108 Suppl 1: 123–31.
  32. Vibramycin, Vibramycin 50, Patient Information Leaflet from the eMC. Emc.medicines.org.uk. URL accessed on 2009-05-18.
  33. Online Books : "TIHKAL" - #36. 5-MEO-DET
  34. https://www.erowid.org/experiences/exp.php?ID=26540,Erowid Experience Vaults: DiPT - More Tripping & Revelations - 26540
  35. Willen SN, Einstein DB, Maciunas RJ, Megerian CA (Nov 2005). Treatment of glomus jugulare tumors in patients with advanced age: planned limited surgical resection followed by staged gamma knife radiosurgery: a preliminary report. Otol Neurotol. 26 (6): 1229–34.
  36. De Ridder D, De Ridder L, Nowé V, Thierens H, Van de Heyning P, Møller A (Dec 2005). Pulsatile tinnitus and the intrameatal vascular loop: why do we not hear our carotids?. Neurosurgery 57 (6): 1213–7; discussion 1213–7.
  37. Penney SE, Bruce IA, Saeed SR (Jul 2006). Botulinum toxin is effective and safe for palatal tremor: a report of five cases and a review of the literature. J Neurology 253 (7): 857–60.
  38. Albertino S, Assunção AR, Souza JA (2005). Pulsatile tinnitus: treatment with clonazepam and propranolo. Braz J Otorhinolaryngol. 71 (1): 111–3.
  39. hygieneexpert.co.uk Ear Care and Wax Build Up
  40. [1]Homepage from Science Institute Jülich
  41. Swedish website about tinnitus
  42. American Hearing Research Foundation Chicago, Illinois 2008
  43. Rogers, June Walker (1984). Only When I Eat: Tinnitus - Hope at Last, J.Rogers,London and Ki Publishing Richmond, Surrey.
  44. Meyerhoff WL, Mickey BE (Jun 1988). Vascular decompression of the cochlear nerve in tinnitus sufferers. Laryngoscope 98 (6 Pt 1): 602–4.
  45. 45.0 45.1 Knox GW, McPherson A (Mar 1997). Menière's disease: differential diagnosis and treatment. Am Fam Physician. 55 (4): 1185–90, 1193–4.
  46. Pugh R, Budd RJ, Stephens SD (Oct 1995). Patients' reports of the effect of alcohol on tinnitus. Br J Audiol. 29 (5): 279–83.
  47. Arda HN, Tuncel U, Akdogan O, Ozluoglu LN (Jan 2003). The role of zinc in the treatment of tinnitus. Otol Neurotol. 24 (1): 86–9.
  48. Yetiser S, Tosun F, Satar B, Arslanhan M, Akcam T, Ozkaptan Y (Oct 2002). The role of zinc in management of tinnitus. Auris, Nasus, Larynx 29 (4): 329–33.
  49. Paaske PB, Pedersen CB, Kjems G, Sam IL (Aug 1991). Zinc in the management of tinnitus. Placebo-controlled trial. Ann Otol Rhinol Laryngol. 100 (8): 647–9.
  50. Azevedo AA, Figueiredo RR (2005). Tinnitus treatment with acamprosate: double-blind study. Braz J Otorhinolaryngol. 71 (5): 618–23.
  51. Brookler KH, Tanyeri H (Jun 1997). Etidronate for the neurotologic symptoms of otosclerosis: preliminary study. Ear, nose, & throat journal 76 (6): 371–6, 379–81.
  52. Goodey RJ (1981). Drugs in the treatment of tinnitus. Ciba Found Symp. 85: 263–78.
  53. Levine RA (2006). Typewriter tinnitus: a carbamazepine-responsive syndrome related to auditory nerve vascular compression. ORL J Otorhinolaryngol Relat Spec. 68 (1): 43–6; discussion 46–7.
  54. Megwalu UC, Finnell JE, Piccirillo JF (Feb 2006). The effects of melatonin on tinnitus and sleep. Otolaryngol Head Neck Surg. 134 (2): 210–3.
  55. Zöger S, Svedlund J, Holgers KM (Feb 2006). The effects of sertraline on severe tinnitus suffering--a randomized, double-blind, placebo-controlled study. J Clin Psychopharmacol. 26 (1): 32–9.
  56. Williams HL, Maher FT, Corbin KB, et al. (Dec 1963). Eriodictyol glycoside in the treatment of Meniere’s disease. Ann Otol Rhinol Laryngol. 72: 1082–101.
  57. Langguth B, Zowe M, Landgrebe M, et al. (2006). Transcranial magnetic stimulation for the treatment of tinnitus: a new coil positioning method and first results. Brain Topography 18 (4): 241–7.
  58. Fregni F, Marcondes R, Boggio PS, et al. (Sep 2006). Transient tinnitus suppression induced by repetitive transcranial magnetic stimulation and transcranial direct current stimulation. Eur J Neurol. 13 (9): 996–1001.
  59. Aydemir G, Tezer MS, Borman P, Bodur H, Unal A (Jun 2006). Treatment of tinnitus with transcutaneous electrical nerve stimulation improves patients' quality of life. J Laryngol Otol. 120 (6): 442–5.
  60. De Ridder D, De Mulder G, Verstraeten E, et al. (2006). Primary and secondary auditory cortex stimulation for intractable tinnitus. ORL J Otorhinolaryngol Relat Spec. 68 (1): 48–54; discussion 54–5.
  61. news.bbc.co.uk, New hope for tinnitus sufferers
  62. Goto F, Ogawa K, Kunihiro T, Kurashima K, Kobayashi H, Kanzaki J (Jan 2001). Perilymph fistula—45 case analysis. Auris, Nasus, Larynx 28 (1): 29–33.
  63. Filtered Noise Generator
  64. Herraiz C, Hernandez FJ, Plaza G, de los Santos G (Nov 2005). Long-term clinical trial of tinnitus retraining therapy. Otolaryngol Head Neck Surg. 133 (5): 774–9.
  65. Henry JA, Schechter MA, Zaugg TL, et al. (Feb 2006). Outcomes of clinical trial: tinnitus masking versus tinnitus retraining therapy. J Am Acad Audiol. 17 (2): 104–32.
  66. Kusatz M, Ostermann T, Aldridge D (2005). Auditive stimulation therapy as an intervention in subacute and chronic tinnitus: a prospective observational study. Int Tinnitus J. 11 (2): 163–9.
  67. Proceedings of the National Academy of Sciences
  68. OHSU Tinnitus Clinic: Comprehensive Treatment Programs including Tinnitus Retraining Therapy (TRT)
  69. Goldstein BA, Shulman A, Lenhardt ML (2005). Ultra-high-frequency ultrasonic external acoustic stimulation for tinnitus relief: a method for patient selection. Int Tinnitus J. 11 (2): 111–4.
  70. Goldstein BA, Lenhardt ML, Shulman A (2005). Tinnitus improvement with ultra-high-frequency vibration therapy. Int Tinnitus J. 11 (1): 14–22.
  71. Claussen CF (2005). Subdividing tinnitus into bruits and endogenous, exogenous, and other forms. Int Tinnitus J. 11 (2): 126–36.
  72. Andersson G, Porsaeus D, Wiklund M, Kaldo V, Larsen HC (Nov 2005). Treatment of tinnitus in the elderly: a controlled trial of cognitive behavior therapy. Int J Audiol. 44 (11): 671–5.

Further readingEdit

BooksEdit

  • Laurence McKenna; Gerhard Andersson; Baguley, David (2005). Tinnitus: A Multidisciplinary Approach, Whurr Publishers, Ltd.
  • Kevin Hogan, PhD; Jennifer Battaglino, (2007). Tinnitus: Turning the Volume Down (Revised & Expanded), Network 3000.


External linksEdit

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