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Tl N N ITUS Facts, Theories, anc! Trealments DENNIS McFADDEN Working Group 89 CommiDee on Hearing, Bioacoustics, and Biomechanics Commission on Behavioral and Social Sciences and Education National Research Council NATIONAL ACADEMY PRESS Washington, D.C. 1982

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Tl N N ITUS Facts, Theories, anc! Trealments DENNIS McFADDEN Working Group 89 CommiDee on Hearing, Bioacoustics, and Biomechanics Commission on Behavioral and Social Sciences and Education National Research Council NATIONAL ACADEMY PRESS Washington, D.C. 1982

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NOTICE: The project that is the subject of this report was approved by the Governing Board of the National Research Council, whose members are drawn from the councils of the National Academy of Sciences, the National Academy of Engineering, and the Institute of Medicine. m e members of the committee responsible for the report were chosen for their special competences and with regard for appropriate balance. This report has been reviewed by a group other than the authors according to procedures approved by a Report Review Committee consisting of members of the National Academy of Sciences, the National Academy of Engineering, and the Institute of Medicine. The National Research Council was established by the National Academy of Sciences in 1916 to associate the broad community of science and technology with the Academy's purposes of furthering knowledge and of advising the federal government. The Council operates in accordance with general policies determined by the Academy under the authority of its congressional charter of 1863, which establishes the Academy as a private, nonprofit, self-governing membership corporation. The Council has become the principal operating agency of both the National Academy of Sciences and the National Academy of Engineering in the conduct of their services to the government, the public, and the scientific and engineering communities. It is administered jointly by both Academies and the Institute of Medicine. The National Academy of Engineering and the Institute of Medicine were established in 1964 and 1970, respectively, under the charter of the National Academy of Sciences. This work relates to Department of the Navy Contract N00014-80-C-0159 issued by the Office of Naval Research under Contract Authority NR 201-124. However, the content does not necessarily reflect the position or the policy of the Department of the Navy or the government, and no official endorsement should be inferred. The United States government has at least a royalty-free, nonex- clusive and irrevocable license throughout the world for government purposes to publish, translate, reproduce, deliver, perform, dispose of, and to authorize others so to do, all or any portion of this work. Library of Congress Cataloging in Publication Data Main entry under title: Tinnitus: facts, theories, and treatments. Prepared by: Working Group 89, Committee on Hearing, Bioacoustics, and Biomechanics, Commission on Behavioral and Social Sciences and Education, National Research Council Bibliography: p. Includes index. 1. Tinnitus. I. McFadden, Dennis. II. National Research Council (U.S.). Working Group 89. [DNLM: 1. Tinnitus. WV 272 M168t] RF293.8.T56 1982 617.8 82-19028 ISBN 0-309-03328-4 Available from NATIONAL ACADEMY PRESS 2101 Constitution Avenue, N.W. Washington, D.C. 20418 Printed in the United States of America First Printing, November 1982 Second Printing, August 1984

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Working Group 89 DENNIS McFADDEN (Chairman), Department of Psychology, University of Texas at Austin (psychoacoustics) LUCILLE BECK, Audiology and Speech Pathology Service, Veterans Administration Medical Center, Washington, D.C. (audiology) JORGEN FEX, Laboratory of Neuro-otolaryngology, National Institute for Neurological and Communicative Disorders and Stroke, National Institutes of Health (research otolaryngology/neurophysiology) LLOYD KAUFMAN, Department of Psychology, New York University (psychophysics) MERRILYNN PENNER, Department of Psychology, University of Maryland (psychoacoustics) ABRAHAM SHULMAN, Division of Otolaryngology and Communi- cation Sciences, Downstate Medical Center, State University of New York (clinical otolaryngology) ROBERT L. SMITH, Institute for Sensory Research, Syracuse University (auditory neurophysiology) JUERGEN TONNDORF, Department of Otolaryngology, College of Physicians and Surgeons of Columbia University (research otolaryngology) PATRICK M. ZUREK, Research Laboratory of Electronics, Massachusuetts Institute of Technology (psychoacoustics) iii

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CommiNee on Hearing, Bioacoustics, and Biomechanics CHARLES S. WATSON (Chairman), Boys Town Institute for Communicative Disorders in Children, Omaha, Nebraska SHEILA BLUMSTEIN, Department of Linguistics, Brown University KENNETH ELDRED, Ken Eldred Engineering (KEE), Concord Massachusetts DAVID J. LIM, Otological Research Laboratories, Ohio State University Medical School JAMES D. MILLER, Central Institute for the Deaf, St. Louis, Missouri CARL E. SHERRICK, Department of Psychology, Princeton University DONALD C. TEAS, Institute for Advanced Study of Communi- cation Process, University of Florida, Gainesville PETER WESTERVELT, Department of Physics, Brown University LAURENE R. YOUNG, Man-Vehicle Laboratory, Massachusetts Institute of Technology MILTON A. WHITCOMB, StudY Director ARLYSS K. WIGGINS, Administrative SecretarY 1V

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Foreworc! Many readers who work in fields related to hearing and deafness are familiar with the reports of working groups of the Committee on Hearing, Bioacoustics, and Biomechan- ics (CHABA). These reports are prepared by special study committees, known as working groups, set up by CHABA to advise federal agencies on issues of significant national need. The original impetus for this report was a request brought to the National Academy of Sciences in 1980 by the Food and Drug Administration (FDA) of the U.S. Depart- ment of Health and Human Services. The FDA asked for assistance in evaluating the efficacy and safety of tinni- tus masking units and tinnitus instruments (masker/hearing aid combinations). The National Institute of Neurological and Communicative Disorders and Stroke (NINCDS) shared the FDA' S interest in concerns about these matters and, in ad- dition, had a broader interest in the status of knowledge about tinnitus. In response to the joint request from these two agencies, CHABA, with the approval of the Com- mission on Behavioral and Social Sciences and Education and the National Research Council, created Working Group 89 and charged it with the preparation of a general, crit- ical review of the entire topic of tinnitus, including tinnitus maskers and instruments. The performance of a working group depends strongly on the energy and wisdom of its chairman. Considerable skill and, often, diplomacy are required in preparing a final report that incorporates the scientific knowledge and opinions of a range of experts while providing the prac- tical guidance needed by those who originally raised the question. In the case of tinnitus and tinnitus masking, it was felt that the person charged with the preparation of an evenhanded review and evaluation of current knowl v

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edge should be an experienced auditory scientist who was not associated with a specific position on the issues to be studied. The broad scope of the following report, the balanced manner with which controversial questions are treated, and a light touch where many would have fallen into turgid scientific prose show how well this challenge was met by the chairman of Working Group 89, Dennis McFadden. The members of CHABA deeply appreciate the efforts of the members of Working Group 89 and especially of its energetic chairman in providing this timely report. CHARLES S. WATSON Chairman Committee on Hearing, Bioacoustics, and Biomechanics V1

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Preface Most of the work on this report was done during 1981 and early 1982, but it is not possible to specify a single cutoff date for the source materials used for the report. In some instances, no information more recent than several years old was uncovered; in other instances, preprints of articles or chapters to be published later in 1981 or 1982 were available and were used. It was not possible to be systematic, comprehensive, and up to date in all of the various literatures touched by this report, and the purely fortuitous way that some information was discovered makes it believable that important facts may have been missed. During the writing of the report, two symposium volumes on tinnitus appeared (CIBA Foundation, 1981; Shulman, 1981a); both are widely cited throughout this report, but the serious student of tinnitus is encouraged to examine the originals. In an attempt to provide as comprehensive a research bibliography as possible, some sources have been included even though they were not cited in the report for one reason or another. Much of the information on tinnitus maskers/instruments comes from a single source--the University of Oregon tin- nitus clinic. Because I wanted the review of that infor- mation to be as objective as possible, I tried to maintain a degree of distance between myself and personnel at the clinic, none of whom I have met. I did exchange several letters with Jack Vernon, the clinic's director, and he provided me with helpful comments on an early draft of the section on the efficacy of tinnitus maskers/ instruments. I wish to thank the members of the working group for their splendid assistance in preparing this report. All were generous with their time and prompt in their replies to requests for comments on my successive drafts. Their ~ V11

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cogent comments about style, substance, and organization contributed greatly to the content and form of the report. Beyond the members of the working group, many people contributed to the final form of this report. Milton Whitcomb, study director of the Committee on Hearing, Bioacoustics, and Biomechanics (CHABA), offered excellent counsel and guidance at critical points and, as always, proved to be an effective, genial, and unobtrusive admin- istrator. I am indebted to CHABA members Donald H. Eld- redge, William D. Neff, and Charles S. Watson for their valuable comments on the manuscript. Earleen Elkins of the National Institute of Neurological and Communicative Disorders and Stroke and Harry Sauberman of the Food and Drug Administration frequently provided me with the necessary perspective on the problem. Eugenia Grohman of the National Research Council was meticulous in her copy editing of the manuscript and did more than anyone else to render it readable and correct. Judy Searcy made preparation of the index as painless as such a job can be. And most important, the timely preparation and form of the report are due in large part to the word-processing skills of Lanier Bayliss, whose careful attention to detail and persistent good cheer are deeply appreciated. A number of my friends have noted that tinnitus is an unlikely topic for me to be reviewing and critiquing, and I am the first to agree. I do not consider myself to be an expert on tinnitus: I have never done research on the topic, nor have I ever seen a tinnitus patient. I tried to read all the material that is available on tinnitus and to draft as organized, comprehensive, and critical a summary of the topic as I could. The realities of dead- lines being what they are, not everything I hoped to do got done. However, as the reader will appreciate, any tinnitus report written in the foreseeable future will necessarily be only an interim report; far too little is known for it to be otherwise. I would appreciate hearing from readers about omissions, errors of fact or interpre- tation, and differences of opinion. DENNIS McFADDEN Chairman Working Group 89 ~ V111

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Contents 1 INTRODUCTION Overview of the Report, 1 A Definition of Tinnitus, 5 Prevalence of Tinnitus, 7 2 FACTS, THEORIES, AND ISSUES Etiology of Tinnitus, 10 Miscellaneous Unequivocal Sources of Tinnitus, 11 Tumors of the Eighth Nerve, 12 Noise Trauma and Presbycusis, 13 Mechanisms of Tinnitus, 14 Spontaneous Rates of Primary Fibers, 15 Decoupling of Stereocilia, 17 The Objective/Subjective Issue, 18 Can Tinnitus Exist in the Absence of Hearing Loss?, 23 Tinnitus in Children, 24 Possible Experimental Models of Tinnitus, 24 Meniere's Disease, 27 MEASUREMENT PROCEDURES Quality of the Tinnitus, 32 Spectral Location of the Tinnitus, 35 Pitch Matching, 35 Masking, 36 Related Masking Results, 37 Magnitude of the Tinnitus, 42 Annoyance of the Tinnitus, 45 Is the Tinnitus Monaural or Binaural?, 48 1X 1 10 32

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The Issue of Beats with Tinnitus, 51 Some Ways Tinnitus Is Not Like an External Sound, 52 Summary of Measurement Procedures, 54 4 TREATMENTS Psychological Intervention, 55 Surgery for Tinnitus, 57 Exposure to Intense Sound, 58 Drugs and Tinnitus, 59 Drugs Causing Tinnitus, 59 SalicYlates' 60 Quinine, 62 Tobacco, 63 Caffeine, 63 Alcohol, 63 Cocaine, 63 Mariiuana, 63 Oral ContracePtiveS, 63 Heavy Metals, 63 Drug Therapy for Tinnitus, 64 Niacin, 66 Vitamin A, 66 Lidocaine, 67 CarbamazePine, 72 Tocainide HYdrochloride, 74 PhenYtoin Sodium, 75 Primidone, 76 Sodium Fluoride, 76 l Sodium Valproate, 77 Sodium Amylobarbitone' 77 Alcohol, 78 Miscellaneous Drugs, 78 Conclusions About Drugs and Tinnitus, 79 Allergy and Diet, 81 Biofeedback, 82 Hypnotherapy, 83 Acupuncture, 84 Electrical Stimulation, 85 Alteration in Air Pressure, 87 Tinnitus Maskers/Instruments, 89 Efficacy of Tinnitus Maskers/Instruments, 92 m e Early Reports, 93 m e Later Reports, 94 Other RePorts, 101 Conclusions, 104 55

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Residual Inhibition, 104 Safety of Tinnitus Maskers/Instruments, 107 spectral Characteristics, 107 Intensity of Tinnitus Maskers/Instruments and Duration of Use, 110 Damage/Risk Criteria and Tinnitus Maskers/ Instruments, 114 STANDARDIZING PROCEDURES Medical Examination, 117 Audiological Examination, 119 REFERENCES AND BIBLIOGRAPHY INDEX 117 123 147