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Tinnitus Article Continued...

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Zhejiang Traditional Chinese Medicine University
Researchers from Zhejiang Traditional Chinese Medicine University (Zhou et al.) find acupuncture effective for the alleviation of tinnitus due to kidney essence deficiency. [22] A group of patients with tinnitus from kidney jing deficiency were treated with acupuncture for 8 weeks. The results demonstrate that acupuncture produces long-lasting effects.

To confirm clinical efficacy, tinnitus severity was measured using the Tinnitus Handicap Inventory (THI). The THI is a 25-item questionnaire published by Newman et al. (1996). It has a maximum score of 100. The higher the score, the more severe the extent of tinnitus. Patients were evaluated using THI at 3 datapoints: 4 weeks into treatment, at the end of treatment, and 6 months after the end of treatment.

Another questionnaire was used to determine treatment efficacy. The tinnitus severity questionnaire published in 1991 at the 9th Tinnitus Conference in Tokyo classifies tinnitus into 4 tiers of increasing severity as detailed:

  • Level 1: Absence of ringing.
  • Level 2: Ringing only happens at night or in quiet environment. Work and sleep not affected.
  • Level 3: Ringing happens in any environment, but is tolerable. Work and sleep mildly affected.
  • Level 4: Ringing happens in any environment and is intolerable. Work and sleep majorly affected.

Based on the above tiers, the treatment efficacy for each patient was categorized into 1 of 4 tiers:

  • Clinical recovery: Achieved level 1.
  • Significantly effective: Ringing reduced by 2 levels.
  • Effective: Ringing reduced by 1 level.
  • Ineffective: No reduction in ringing level.

Results
The treatment effective rate for each group was derived with the following formula: [Clinical recovery + Significantly effective + Effective] / [Total number of patients in group] * 100%. The mean THI score before acupuncture was 50.87 ±11.52. Four weeks into treatment, the score fell to 27.63 ±9.05. At the end of the 8 weeks of treatment, patients achieved a mean THI score of 25.49 ±10.27. Compared with the pre-acupuncture scores, the 4-week and 8-week results indicate that acupuncture effectively alleviates tinnitus (P<0.05 for both datapoints).

Six months after the end of treatment, a follow-up recorded that patients scored 30.02 ±7.45 on average for the THI. The post-treatment results did not differ significantly from the three datapoints (P>0.05), highlighting the long-lasting effects of acupuncture. The treatment total effective rate after 8 weeks of treatment was 83.3%, indicating that acupuncture has a high efficacy rate for the attenuation of tinnitus.

Design
The study was set up as a single-arm clinical trial. A total of 72 tinnitus patients from the Acupuncture Division of Zhejiang Chinese Medicine University Affiliated No. 3 Hospital participated in the study. There were 32 males, 40 females, aged between 35–74 years, with a mean age of 54.6 years and had durations of illness between 1 week to 15 years. Diagnoses for tinnitus were made based on both biomedical and Traditional Chinese Medicine (TCM) diagnostic criteria. Biomedical diagnostic criteria for tinnitus were in accordance with the 1st edition of “Practical Otorhinolaryngology” published by People’s Medical Publishing House (1998):

  • Main clinical symptoms: Subjective tinnitus, presenting as cricket-like sounds, whistling/ringing, machinery sounds, roaring etc. Occurring in one or both ears. Intermittent or continuous. May be accompanied by hearing loss or dizziness.
  • Physical signs: No ear deformities. No inflammation of ear canal. Eardrums functioning well and not damaged. No anomalies detected in nasopharynx. Severe cardiac or nervous system diseases ruled out.
  • Clinical examination: Routine audiological tests including acoustic immittance testing and pure tone audiometry. Inner ear and intracranial CT. Inner ear and intracranial MRI.

TCM diagnostic criteria for tinnitus from kidney essence deficiency were in accordance with “Standards of Diagnosis and Therapeutic Effect for Diseases and Patterns in Chinese Medicine” defined by the State Administration of Traditional Chinese Medicine, as well as “Guiding Principles for Clinical Study of New Chinese Medicines” published by the Ministry of Health of China (1993):

  • Cricket-like ringing in the ear, gradually increasing in intensity.
  • Deafness in severe cases.
  • Accompanied by dizziness, lower back pain or soreness, spermatorrhea, thin-taut pulse or thin-weak pulse, red tongue. Alternatively: accompanied by weak limbs, lower back coldness, impotence, premature ejaculation, deep-thin pulse, or pale tongue with thin and white coating.

The following selection criteria were applied in choosing trial participants:

  • Fulfilled the above diagnostic criteria comprehensively.
  • Between 18 – 80 years of age.
  • Main clinical symptom being ringing in ear and ear fullness.
  • Constant recurrence of tinnitus for ≥1 month before consultation, or continuous tinnitus for ≥1 week.
  • No severe cardiac, neurological, renal, hematopoietic or psychological illnesses.
  • Complied with prescribed treatment during study.
  • Signed informed consent.
  • The following exclusion criteria were applied:
  • Pregnant or lactating.
  • Severe cardiac, neurological, renal, hematopoietic, or psychological illnesses.
  • Conductive or objective tinnitus caused by outer or middle ear conditions.
  • Tinnitus due to tumors.
  • Complete deafness with tinnitus.
  • <18 or >80 years old.

Patients received acupuncture for 8 weeks. A follow-up was conducted 6 months after the end of treatment. The following abdominal acupoints were selected (bilateral where applicable):

  • Zhongwan (CV12)
  • Xiawan (CV10)
  • Qihai (CV6)
  • Guanyuan (CV4)
  • Shangqu (KD17)
  • Yindu (KD19)

The following body acupoints were selected:

  • Tinggong – Afflicted side (SI19)
  • Tinghui – Afflicted side (GB2)
  • Yifeng – Afflicted side (TB17)
  • Waiguan – Both sides (TB5)
  • Hegu – Both sides (LI4)
  • Taixi – Both sides (KD3)
  • Taichong – Both sides (LV3)

Size 0.25 mm x 40 mm acupuncture needles were used. Needle insertion depths for abdominal acupoints were based on the Sancai measuring method, which outlines three insertion depths: <1 inch (Tian area), 1 inch (Ren area), and 1.5 inches (Di area). For Guanyuan, Qihai, Zhongwan, and Xiawan, needles were inserted up to a maximum of 1.5 inches. Shangqu was pierced 1 inch, and Yindu was pierced <1 inch.

After insertion, warm needle acupuncture with moxibustion was applied to Qihai and Guanyuan. Standard acupuncture protocols were followed for body acupoints. Once all needles were inserted and warmed (Qihai and Guanyuan), a 30-minute retention time was observed. One session was administered, three times per week. Two treatment cycles were administered and four weeks comprised one cycle. The 83.3% total effective rate demonstrates that this protocol is effective for the alleviation of tinnitus.

Dongzhimen Hospital
Dongzhimen Hospital researchers (Fang et al.) from a division of Beijing University of Chinese Medicine conclude that electroacupuncture is effective for the treatment of tinnitus due to liver-gallbladder heat. [23] In addition, electroacupuncture outperformed manual acupuncture.

Two groups of patients were compared in an 8-week clinical trial. One group received conventional manual acupuncture and the other received electroacupuncture. The results demonstrate that patients achieved a greater reduction in ringing with electroacupuncture than with conventional acupuncture.

Referring to the clinical efficacy evaluation guidelines set by Liu Peng, treatment efficacy was evaluated. [24] Tinnitus severity was classified into levels based on symptom presentation. The higher the severity, the higher the level. Based on the improvement in tinnitus levels before and after treatment, the treatment efficacy for each patient was categorized into 1 of 4 tiers:

  • Clinical recovery: Absence of ringing.
  • Significantly effective: Tinnitus severity decreased by ≥ 2 levels.
  • Effective: Tinnitus severity decreased by 1 level.
  • Ineffective: No reduction in tinnitus severity.

Calculation
The overall treatment effective rate for each group was derived with the following formula: [Clinical recovery + Significantly effective + Effective] / [Total number of patients in group] * 100%. The treatment significantly effective rate for each group was derived with the following formula: [Clinical recovery + Significantly effective] / [Total number of patients in group] * 100%.

Results
Electroacupuncture resulted in a significantly higher overall treatment effective rate than manual acupuncture (P<0.05). The electroacupuncture group had an 89.3% overall treatment effective rate and the manual acupuncture group had an 81.4% rate. Further, there were other differences, especially in the treatment significantly effective rate (P<0.01). The electroacupuncture group had a 78.6% treatment significantly effective rate, while the conventional acupuncture group had a 29.6% rate. The above results show that not only did more patients benefit from electroacupuncture than manual acupuncture, but each patient also benefitted to a greater extent. This suggests that electroacupuncture is a stronger treatment option for tinnitus, among the many types of acupuncture methods available.

Design
The study was set up as a double-arm clinical trial. A total of 60 patients from the Acupuncture Division of Dongzhimen Hospital at Beijing University of Chinese Medicine participated in the study. They were diagnosed with tinnitus from excessive liver-gallbladder heat between September 2014 and August 2016. Diagnoses for tinnitus were made based on both biomedical and TCM diagnostic criteria. Biomedical diagnostic criteria for tinnitus were in accordance with “TCM Otorhinolaryngology”: [25]

  • Subjective tinnitus in one or both ears, single or composite sound, intermittent or continuous.
  • Sensorineural tinnitus confirmed by audiological tests.

TCM diagnostic criteria for tinnitus from excessive liver-gallbladder heat were in accordance with “Guiding Principles for Clinical Study of New Chinese Medicines”: [26]

  • Abrupt onset of tinnitus.
  • Short duration of illness.
  • Whooshing or roaring sounds perceived.
  • Ringing often worsens due to depression or anger.
  • Accompanied by rosy complexion, red eyes, bitter taste in mouth, thirst, constipation, yellow urine, red tongue with yellow coating, rapid-taut strong pulse.
  • The following selection criteria were applied in choosing trial participants:
  • Fulfilled above diagnostic criteria (both western and TCM).
  • Did not receive vasodilative drugs, Chinese herbs, or other treatment for tinnitus in the month before the study.
  • Signed informed consent.

The following exclusion criteria were applied:

  • Underwent other forms of therapy that might influence treatment results, during the study.
  • Severe primary cardiac, neurological, renal and hematopoietic diseases.
  • Severe psychological illnesses.
  • Not receptive to acupuncture or electroacupuncture.

Participating patients were randomly allocated to either the electroacupuncture group or the manual acupuncture group. To ensure a fair comparison, the gender, age, and duration of illness were equivalent for both groups (P>0.05). Excluding patients who were disqualified during the study, the acupuncture group recorded 27 patients, 15 males, 12 females, between 27 to 63 years, mean age 48.89 ±10.22 years, duration of illness between 0.5 – 48 months, mean duration of illness 9.45 ±11.8 months. The electroacupuncture group recorded 28 patients, 12 males, 16 females, between 30 to 63 years, mean age 49.96 ±8.34 years, duration of illness between 0.67 – 44 months, mean duration of illness 9.67 ±9.83 months.

The acupuncture group received conventional manual acupuncture and the electroacupuncture group received standard electroacupuncture. Identical acupoints were selected for both groups. Both groups received treatment for 8 weeks. The following primary acupoints were selected (both sides for tinnitus in both ears, afflicted side for tinnitus in one ear):

  • Ermen (TB21)
  • Tinggong (SI19)
  • Tinghui (GB2)
  • Fengchi (GB20)
  • Gongxue (1.5 inches vertically downwards from Fengchi, aligned with the lower lip)

The following secondary acupoints were selected:

  • Taichong (LV3)
  • Xingjian (LV2)

Acupuncture Protocol
Size 0.25 mm x 40 mm disposable sterile acupuncture needles and 75% alcohol disinfectant were used. Patients were instructed to open their mouth slightly when inserting Ermen, Tinggong, and Tinghui. These three acupoints were needled to a depth of approximately 1.2 – 1.5 cun, until the patient felt a needle sensation diffusing toward the base of the ear or around the ear.

For Fengchi, the needle was inserted approximately 0.8 – 1.0 inches, oriented diagonally towards the direction of the nose tip, until soreness or fullness was felt in the acupoint. For Gongxue, the needle was inserted 0.8 – 1.0 inches deep, towards the direction of the opposite lip, until soreness or fullness was felt in the acupoint. Standard conventional acupuncture protocol was observed for Taichong and Xingjian, and needles were manipulated with the lift-thrust-rotation attenuation technique.

One 20-minute acupuncture session was administered per day, 2 times per week. A total of 2 treatment cycles were administered and 4 weeks comprised one treatment cycle.

For electroacupuncture, a pulse electroacupuncture device (Model: G6805-1A, Shanghai Huayi Medical Supplies Co., Ltd.) was used. After needles were inserted, the electroacupuncture device was connected to two pairs of acupoints, the first being Ermen and Tinghui, and the second being Fengchi and Gongxue. For each pair, the positive electrode was attached to the upper acupoint while the negative electrode was attached to the lower acupoint. Disperse-dense waves were applied. The intensity was adjusted for each patient within tolerance levels and the needles were slightly pulsing.

The electroacupuncture group had a 78.6% treatment significantly effective rate and the manual acupuncture group had a 29.6% rate. This demonstrates that electroacupuncture is an important treatment modality for patients with tinnitus.

 

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Herbal Medicine
Chinese medicinal herbs have been used for the treatment of tinnitus for well over 1,000 years. The following looks at a product that incorporates Chinese medicinal herbs into their formulation. Researchers at the Department of Otolaryngology at the Health Science Center in Brooklyn (New York), along with their colleagues at the The State University of New York (SUNY) Downstate Medical Center and the Martha Entenmann Tinnitus Research Center, conducted a prospective study to test the efficacy of Clear Tinnitus® for the relief of middle-ear pressure in patients with severe, disabling type tinnitus. Of the 11 patients that completed the study, 7 patients reported relief of their symptoms and 4 did not respond. While more extensive research is necessary with a larger sample size for this type of investigation, these outcomes indicate that additional research is warranted.

Tinnitus, named by the Latin term for “ringing”, is the perception of sound when there is no external sound present. [27] Despite its name, there are a range of sounds associated with tinnitus: roaring, clicking, hissing, buzzing, and, of course, ringing. The quality of sound may range from very loud to very soft, of high or low pitch, and it may be perceived unilaterally or bilaterally. In the past year, approximately 25 million people in the USA have experienced tinnitus lasting at least 5 minutes. [28] However, tinnitus may be intractable and may persist for decades.

For some patients, the sounds associated with tinnitus are a mere annoyance, periodically interrupting their routines. For others, however, the sound is constant, and its severity such that it is difficult to hear external stimuli, let alone concentrate or sleep. This may cause problems with memory and fatigue, provoking emotional anguish, anxiety, and depression. Tinnitus is often the first sign of hearing loss among the aging, but it can also affect the young and otherwise healthy individuals. Repeated exposure to loud noises, as experienced by many manual laborers and musicians, can damage the delicate sensory hair cells in the inner ear. [29] “Noise-induced hearing loss (NIHL) is the second most common acquired hearing loss following presbycusis [age-related hearing loss], and is known as an occupational disorder long ago. It was estimated in 1981 that about 9 million workers in the US are exposed to hazardous levels of noise in the workplace.” [30] Tinnitus is also common among veterans who have been exposed to repeated bomb blasts, which damage the areas of the brain that process sound; it is one of the most common service-related disabilities of those returning from the wars in Iraq and Afghanistan. [31]

Tinnitus is broadly grouped into two categories: subjective and objective. Far more common, subjective tinnitus is most likely caused by abnormal neuronal activity, resulting from a disruption or alteration in the input from the auditory pathway to the brain. Sound is received as vibrations in the cochlea, part of the inner ear, within which tiny hairs pick up the vibrations and transmit them as nerve impulses to the brain. Tinnitus associated with conductive hearing loss—caused by ear infections, wax impaction, or a dysfunction of the eustachian tube (which aerates the middle ear and removes debris)—is also considered subjective, because the sound input to the central auditory system is altered. “Loud noise, aging, Meniere’s disease, and drugs are the most common causes of subjective tinnitus”; common pharmaceuticals such as some antibiotics and antidepressants, water pills (diuretics), and aspirin may cause or exacerbate tinnitus symptoms. [32]

Some patients with tinnitus also experience hyperacusis, a discomfort associated with loud noises. Rarely, it is possible for the practitioner to use amplification tools such as a stethoscope to hear the phantom sound; these cases are considered objective tinnitus. Generally, this is caused by turbulent blood flow in the major vessels to the head, as is prevalent in atherosclerosis and conditions characterized by increased vascularization, such as tumors. Spasms of the muscles serving the palate and middle ear may also result in a perceptible noise, primarily a rhythmic clicking.

In Traditional Chinese Medicine (TCM), tinnitus is categorized by its etiology according to differential diagnostics. “Most recently, tinnitus has been divided into five types at the Third Chinese Zhong Xi Yi Je He Otolaryngology Society Annual Meeting in 2002: Wai Gan Fen Re Xing (related to respiratory infection), Gan Hou Shang Rao Xing (related to abnormal liver function), Tan Re You Jie Xing (related to the ‘hot’ state in TCM), Shen Jing Kui Xu Xing (related to kidney dysfunction) and Pi Xi Xu Ruo Xing (related to abnormal spleen function).” Of these, two can be considered conditions of excess—respiratory infection and heat—and three are associated with deficiencies—of the liver, kidney, or spleen.

A respiratory infection is described by TCM as pathogenic wind attacking the exterior, and is treated by releasing the exterior. Heat conditions associated with tinnitus belong to the liver and gallbladder channels; extreme heat stirs up wind and flames upwards to harass the upper reaches of the channels. To relieve these symptoms, an acupuncturist clears the heat and pacifies the resultant wind. Liver yin deficiency has different symptoms but the same effect: deficient liver yin leads to a preponderance of liver yang (heat), which the relatively deficient yin fails to anchor, so the liver yang, or heat, rises upwards. In these cases, it is necessary to clear the deficient heat while simultaneously nourishing liver yin, the underlying cause of the deficiency.

Kidney deficiency may produce tinnitus in two ways. Kidney yin deficiency leads to deficient heat rising, and the treatment also requires clearing heat while nourishing the yin of the kidneys. Alternatively, a hypofunction of the kidney denies essential qi the energy necessary to ascend and fill the orifices; in such cases, it is necessary to nourish the kidney essence. While traditional texts do not include the spleen as an etiological factor in the development of tinnitus, spleen deficiency causes phlegm-damp accumulation in the body, which is a factor in the pathogenesis of both atherosclerosis and tumors; thus, this type is most likely associated with the audible sounds of objective tinnitus.

Summary
The aforementioned research indicates that acupuncture and herbal medicine are effective modalities for the alleviation of tinnitus. An intractable disorder, the treatment of tinnitus has long been a challenge for all medical practitioners, including licensed acupuncturists. The research demonstrates important protocols that may bring significant relief to patients with tinnitus. Patients with tinnitus are encouraged to consult with their local licensed acupuncturists to discuss treatment options.

 

 

References
1 Song SX, Wang CY, Yin CP. Randomized comparative research on Yishenrougantongluotang brew in treating nervous tinnitus J. Practical TCM Internal Medicine Journal, 2013, 27(3): 45-47.

2 Wang SJ. Clinical observation of integrative medicine in treating nervous tinnitus J. Hubei TCM University Journal, 2014, 16(2): 90-92.

3 Qu R, Gao SL. Clinical findings on TCM and western integrative medicine in treating nervous tinnitus J. Chinese TCM Journal, 2007, 10: 70-71.

4 Hong YL, Xu HB, Huang CL. Clinical analysis of postauricular closed treatment with lidocaine in treating nervous tinnitus J. Journal of Otolaryngology and Ophthalmology of Shandong University, 2011, 25(6): 30-32.

5 Kong WJ. Diagnosis and treatment of tinnitus (1) J. Journal of Clinical Otorhinolaryngology Head and Neck Surgery, 2010, 24(1): 35-40.

6 Zhang SY. Observation of effect of abdominal acupuncture in treating nervous tinnitus 118 cases J. Chinese Journal of Traditional Medical Science and Technology, 2010, 17(3): F004.

7 Chi Q. Exploration of treatment methods of nervous deafness and tinnitus J. Chinese Journal of Clinical Rational Drug Use, 2013, 6(4): 11-12.

8 Cheng Y, Zhao RX, Zhu XC. Clinical research on acupuncture in treating nervous tinnitus J. Journal of Zhejiang University of Traditional Chinese Medicine, 2008, 32(1): 135-136.

9 Wang JX, Liang JW. Qinggantongqiao method in treating tinnitus and deafness 86 cases J. Yunnan Journal of Traditional Chinese Medicine and Materia Medica, 2010, 31(6): 26.

10 Li XQ, Wang X. Immediate blood pressure lowering effect of acupuncture on Taichong acupoint in treating hypertension from rising liver-yang 65 cases J. Journal of Traditional Chinese Medicine, 2008, 49(7): 622-624.

11 Gao WB. Acupuncture Six Jue: Modern acupuncture for neurological diseases M. Beijing: China Press of Traditional Chinese Medicine, 2007: 269.

12 Chen G. Clinical Observation on Acupuncture Combined with Chinese Medicine in Treating Tinnitus of Live-fire Flaring-up Pattern J. 2016, 11(5): 888-890.

13 Wen Q. Clinical observation of acupuncture and herbs in treating tinnitus from kidney deficiency D. Harbin: Heilongjiang TCM University, 2012.

14 Liu LH, Qiu XX, Liu PN. Psychological intervention for anxiety and depression from Parkinson’s disease J. Nursing Practice and Research, 2012, 14(9): 136-137.

15 Xie Q, Ren YY, Li WG, et al. Observation the Curative Effects of the Acupuncture and Moxibustion Treatment of Transfer Focus of Excitation on Nervous Tinnitus J. Practical Clinical Journal of Integrated Traditional Chinese and Western Medicine, 2009, 9(3): 15-17.

16 Wang X. Clinical observation of acupoint thread-embedding in treating nervous tinnitus J. Zhejiang TCM University Journal, 2011, 35(4): 589-590.

17 Liu B. Clinical thinking of tinnitus clinical symptoms and differential diagnoses J. Journal of Clinical Otolaryngology Head and Neck Surgery, 2015, 22(8): 688-690.

18 Yang ZM. Acupuncture as tinnitus treatment J. Baotou Medical College Journal, 2009, 25(1): 92.

19 Yang ZM. Acupuncture as tinnitus treatment J. Baotou Medical College Journal, 2009, 25(1): 92.

20 Zheng WL. Head acupuncture vertigo and hearing area prolonged needle retention with body acupuncture in treating nervous tinnitus 60 cases J. Clinical Journal of Chinese Medicine, 2011, 3(1): 28-29.

21 Liu P. Discussion of tinnitus severity grading and clinical evaluation standards J. Chinese Journal of Otorhinolaryngology in Integrative Medicine, 2004, 12(4): 181-183.

22 Zhou CL, Gao H, Fang JQ, et al. Curative Effective Observation of Adopting Abdominal Acupuncture as the Main Therapy in Treating Nervous Tinnitus with Syndrome of Deficiency of Kidney Essence: A Report of 72 Cases J. Journal of New Chinese Medicine, 2017, 49(6): 121-123.

23 Fang X, Su BY, Li MM, et al. The Clinical Therapeutic Observation of Deep Needling Ermen(SJ 21 Tinghui(GB 2) Combine with Electroacupuncture for Hepatobiliary Fire Type Tinnitus J. Journal of Zhejiang University of Traditional Chinese Medicine, 2017, 41(6): 542-544.

24 Liu P. Discussion on tinnitus severity grading and efficacy evaluation guidelines J. Chinese Journal of Otorhinolaryngology in Integrative Medicine, 2004, 12(4): 181-183.

25 Wang SZ. TCM Otorhinolaryngology M. Beijing: China Press of Traditional Chinese Medicine, 2003: 82-89.

26 Zheng XY: Guiding Principles for Clinical Study of New Chinese Medicines S. Beijing: China Medical Science Press, 1993: 314-315.

27 Fornaro, Michele, and Matteo Martino. "Tinnitus psychopharmacology: A comprehensive review of its pathomechanisms and management." Neuropsychiatric Disease and Treatment, 2010, 209.

28 nidcd.nih.gov/health/tinnitus

29 Ibid.

30 Mehrparvar, Amir Houshang, Seyyed Jalil Mirmohammadi, Mohammad Hossein Davari, Mehrdad Mostaghaci, Abolfazl Mollasadeghi, Maryam Bahaloo, and Seyyed Hesam Hashemi. "Conventional Audiometry, Extended High-Frequency Audiometry, and DPOAE for Early Diagnosis of NIHL." Iranian Red Crescent Medical Journal 16, no. 1 (2014). Pg 1.

31 nidcd.nih.gov/health/tinnitus

32 merckmanuals.com/professional/ear,-nose,-and-throat-disorders/approach-to-the-patient-with-ear-problems/tinnitus

33 Goldstein, Barbara, Abraham Shulman, and Matthew J. Avitable. "Clear Tinnitus ® , Middle-Ear Pressure, and Tinnitus Relief: A Prospective Trial." International Tinnitus Journal 13, no. 1 (2007). pg 29.

34 Ibid, pg 31.

35 Ibid, pg 31.

36 Ibid, pg 29.

37 Goldstein, et al, Clear Tinnitus ® , Middle-Ear Pressure, and Tinnitus Relief: A Prospective Trial, pgs 30-31.

38 Ibid, pg 33.

39 Ibid.

40 Ibid, pgs 34-35.

41 Ibid, pg 35.

42 Ibid, pg 33.

 

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