Intratympanic Instillation Research Articles

Clinicoaudiological evaluation of hearing improvement in patients with sensorineural hearing loss using intratympanic platelet rich plasma versus steroid injection

<p><strong>Background: </strong>SNHL is a heterogenous disorder, which can arise due to damage to pathway for sound impulses from the hair cells of inner ear to auditory nerve. This study is<strong> </strong>to evaluate and compare the effect of intratympanic instillation of PRP in patients having sensorineural hearing loss with steroid therapy.</p><p><strong>Methods: </strong>A<strong> </strong>prospective observational study carried out in the department of ENT, NSCB medical college Jabalpur. The cases were selected who presented with sensorineural hearing loss and mixed hearing loss with intact TM. Total of 54 cases were enrolled in the study from 1March, 2020 to 31 August 2021.Preoperative PTA was recorded. 0.5 ml of intratympanic platelet rich plasma and 0.5 ml of steroid dexamethasone administered. Postoperative PTA was done after 15 days of intratympanic injection and results recorded.</p><p><strong>Results</strong>: In our study the mean age of the participants was 40.4 years. Bilateral and gradual hearing loss were common in the present study. The improvement from baseline to follow up period was higher in PRP group compared to DEXA group. It is statistically significant (p=0.001). The improvement in hearing loss is decreasing with the increase in age. The study revealed that hearing improvement with PRP is better than steroid.</p><p><strong>Conclusions: </strong>The study concluded that the hearing improvement was more with single injection of PRP than dexamethasone.</p>

Assessment of visual sensation, psychiatric profile and quality of life following vestibular schwannoma surgery in patients prehabituated by chemical vestibular ablation.

Preoperative chemical vestibular ablation can reduce vestibular symptoms in patients who have gone through vestibular schwannoma resection. The goal of this study was to determine whether chemical vestibular prehabituation influences the patients' post-operative perception of visual stimulation, mental status and quality of life. We also tried to find out whether increases of optokinetic nystagmus, measured by routine electronystagmography, correlate with subjective symptoms. We preoperatively administered (2 months prior to surgery) 0.5 - 1.0 mL of 40 mg/mL nonbuffered gentamicin in three intratympanic instillations in 11 patients. Head impulse and caloric tests confirmed reduction of vestibular function in all patients. The control group consisted of 21 patients. Quality of life in both groups was evaluated using the Glasgow Benefit Inventory, the Glasgow Health Status Inventory and the Dizziness Handicap Inventory questionnaires. Visual symptoms and optokinetic sensation were evaluated using a specific questionnaire developed by our team and by measuring gains preoperatively and postoperatively in both groups using routine electronystagmography. The psychological profile was evaluated using the Zung Self-Rating Depression Scale and the Generalised Anxiety Disorder Assessment questionnaires. There were no statistically significant differences between both groups with regards to the results of the questionnaires. Patients who received preoperative gentamicin were less sensitive to visual stimulation (P<0.10) and many of them had a significantly higher gain in the optokinetic nystagmus than the control group in the preoperative stage. Pre-treatment with gentamicin helps to lower anxiety levels in patients and improves their general postoperative status. Pre-treated patients are also less sensitive to optokinetic stimulation. ClinicalTrials.gov, NCT03638310.

Proposal of a Treatment Strategy for Eosinophilic Otitis Media Based on Middle Ear Condition.

We classified eosinophilic otitis media (EOM) into three grades (G1-G3) based on the middle ear mucosal thickness and aimed to establish a treatment strategy for EOM based on these pathological categories. Retrospective cohort study. Tertiary referral center. We evaluated 136 ears of 68 patients (38 women, 30 men; average age, 56.1 yr; range, 32-80 yr) with bilateral EOM, including 14 surgically treated ears. Diagnostics and treatment. Treatment responses to intratympanic instillation of triamcinolone acetonide (TA) and surgery. G1 (mild) cases of EOM responded well to intratympanic TA. G2 (moderate) cases required both TA and systemic glucocorticoids. G3 (severe) cases with granulation were unresponsive to but tolerated the treatment. In 14 ears, granulation tissue was surgically removed and the area was covered with a gelatin sponge containing TA. After the surgery, the severity level of EOM decreased from G3 to G2 in 12 ears, and hearing improved in 4 ears. Three ears showed normalization of the tympanic membrane, and seven ears had less otorrhea. Risk factors for granulation (G3) were the presence of bacterial infection (p = 0.017) and diabetes mellitus (HbA1c of ≥6.5%) (P = 0.039) (odds ratios of 4.55 and 3.95, respectively). This study showed that G3 EOM was unresponsive to conservative glucocorticoid treatment and required granulation tissue removal. Classification based on the middle ear pathology is useful for determining the most appropriate and successful treatment for EOM.

ALH-L1005 attenuates endotoxin induced inner ear damage

ObjectiveTo assess whether this compound (ALH-L1005) is conceivably an effective agent in protecting against cochlear damage induced by LPS. Materials and methodsTube formation using human umbilical vein endothelial cell (HUVEC) and matrix metalloproteinase (MMP)-9 inhibition assay was performed. 24 guinea pigs were randomly divided into three groups. Intratympanic instillation of LPS (n=8) as negative control, instillation of oxytetracycline 1h after LPS as positive control (n=8), and intratympanic instillation of ALH-L1005 (n=8) 1h after LPS were considered experimental group. Evaluation by auditory brainstem response (ABR) measurement, cochlear blood flow, and blood–labyrinth barrier (BLB) permeability were performed. Cochlear hair cells were observed by field emission-scanning electron microscopy (FE-SEM). MMP-9 activation was measured by gelatin zymography. ResultsFor HUVEC, the tube formation was suppressed in a dose dependant manner. ALH-L1005 inhibited the MMP-9 activity prominently. It also attenuated the elevation of LPS-induced hearing threshold shift and recovery of CBF. By FE-SEM, cochlear hair cells could be preserved in experimental group. ALH-L1005 significantly reduced the BLB opening compared to LPS group. Active MMP-9 expression could be detected in the LPS group. In contrast to ALH-L1005 group, active MMP-9 expression was not detected. ConclusionOur results conclude that ALH-L1005 showed a protective effect in the cochlear lateral wall damage induced by LPS.

Novel techniques for the diagnosis of Ménièreʼs disease

This review will consider the newly developed and emerging diagnostic techniques with real or potential clinical application to the diagnosis of Ménière's disease. Several new diagnostic modalities have been introduced, which have the potential to help diagnose endolymphatic hydrops. These include cervical and ocular vestibular evoked myogenic potentials, cochlear hydrops analysis masking procedures, and three-dimensional fluid-attenuated inversion recovery MRI following intratympanic instillation of gadolinium. Diagnosis of Ménière's disease has classically been of a clinical rather than a procedural nature. Despite the many recent advances in diagnostic testing which show potential applicability for aiding in diagnosis of Ménière's disease, each has limitations which prevent immediate utility. For now, Ménière's disease remains best diagnosed through the standard American Academy of Otolaryngology - Head and Neck Surgery clinical inclusionary and exclusionary criteria.

Matrix metalloproteinase inhibitor attenuates cochlear lateral wall damage induced by intratympanic instillation of endotoxin

ObjectiveOxytetracycline and ilomastat are inhibitors of matrix metalloproteinases (MMPs). Their efficacy in protecting against cochlear damage induced by the intratympanic instillation of lipopolysaccharide (LPS), as a means of inducing labyrinthitis, was investigated. Materials and methodsExperiments were performed in 21 young male guinea pigs. Intratympanic instillation of LPS was done in the control group (n=7). Intratympanic instillation of oxytetracycline or ilomastat was done after LPS instillation in the experimental group. Measurements of auditory brainstem response (ABR) and cochlear blood flow (CBF) were performed. The organ of Corti was evaluated by field emission scanning electron microscopy (FE-SEM). The blood–labyrinth barrier (BLB) integrity was evaluated with Evans blue uptake. Gelatin zymography was used to assess the expression of active MMP-2 and MMP-9. ResultsEars treated with MMP inhibitors were significantly protected from hearing loss compared to the LPS group. In LPS group, there was a significant decrease of CBF. However, experimental group displayed a statistically significant recovery of CBF. FE-SEM revealed hair cell damage in the LPS-treated group, but hair cells presented a normal appearance in MMP inhibitors. The LPS group showed a marked increase of Evans blue extravasation in the cochlea. However, MMP inhibitors significantly reduced the BLB opening. Active MMP-9 was expressed in the LPS group. Treatment with MMP inhibitors attenuated active MMP-9 expression. ConclusionThe MMP inhibitors oxytetracycline and ilomastat protect from cochlear lateral wall damage caused by LPS-induced labyrinthitis.

Effect of Ginkgo biloba extract on endotoxin-induced labyrinthitis

Objective There are no reports on the therapeutic effect of Ginkgo biloba extract (GBE) on otitis media-induced labyrinthitis. The present study examined whether GBE can protect against cochlear damage induced by intratympanic instillation of lipopolysaccharide (LPS)-induced labyrinthitis. Materials and methods Experiments were performed in 20 healthy young male guinea pigs. The control group ( n = 10) received an intratympanic instillation of LPS (20 μl, 3 mg/ml). The experimental group ( n = 10) received intratympanic instillation of LPS immediately after instillation of GBE (10 mg/kg) and then experimental groups received GBE (100 mg/kg) by intraperitoneal injection every day for 3 days. Instillation of LPS or LPS immediately after GBE was done in the right ear; the untreated left ear was considered normal. Physiological and morphological changes were evaluated. Results Statistical analysis of treatment of GBE revealed significantly less hearing loss than LPS group ( p < 0.05). The ratio of the value of cochlear blood flow (CBF) compared to untreated left side was significantly higher in the GBE treated group than in the LPS-treated group ( p < 0.05). This result indicated the recovery of CBF in GBE treated group compared to LPS treated group. In the LPS group, scanning electron microscopy revealed hair cell damage with edema. Missing stereocilia in the third layer of the outer hair cell was revealed. However, both the inner hair cells and the outer hair cells had normal appearance in the GBE group. LPS group showed that cochlear Evans blue extravasation was increased strongly in the stria vascularis, spiral limbus, and in the spiral ligament compared with the GBE treated group. Conclusion GBE significantly minimizes cochlear damage against LPS-induced otitis media with labyrinthitis in a guinea pig model. GBE has potential as an adjunctive therapy to antibiotics in the treatment of acute otitis media with complicated labyrinthitis.

High-dose intratympanic gentamicin instillations for treatment of Meniere's disease: long-term results

Conclusions: Administration of high-dose gentamicin for intractable Meniere's disease appears to be effective in achieving long-term control of vertigo. However, the safety of this route of administration with respect to the patient's hearing has not yet been sufficiently established. Objectives: The study aimed to analyze the long-term results of patients receiving high-dose intratympanic gentamicin (ITG) instillation for refractory Meniere's disease. Patients and methods: Fourteen patients with Meniere's disease according to 1995 American Academy of Otolaryngology-Head and Neck Surgery (AAO-HNS) guidelines who had failed medical (12 subjects) or surgical (2 subjects) treatment were included. Intratympanic injections of 27 mg/ml gentamicin were performed three times daily for 4 days. Vertigo control, the patients’ functional level, and their hearing threshold were all analyzed. Criteria described in 1995 by AAO-HNS were used. Results: The overall successful vertigo control rate was 92.9% over the 2-year follow-up and 85.7% at long-term follow-up (average 10 years). Hearing level as pure-tone average was worse in four patients (28.5%) after 2 years follow-up and in six patients (42.8%) after long-term follow-up, respectively. Profound sensorineural hearing loss occurred as a result of gentamicin injection in one patient (7%).

High-dose intratympanic gentamicin instillations for treatment of Meniere's disease: long-term results

High-dose intratympanic gentamicin instillations for treatment of Meniere's disease: long-term results

鼓室内ゲンタマイシン注入療法が奏功した突発性難聴後の難治性頭位めまい症の一例

Intratympanic instillation of gentamicin is currently a well-established treatment for intractable vertigo in patients with Meniere's disease. There are, however, only a few reports of this therapy in patients with non-Meniere type of vertigo. We report the case of a 68-year-old woman with the lateral semicircular canal type of benign paroxysmal positional vertigo (BPPV) following right idiopathic sudden hearing loss. The patient was annoyed by the positional vertigo for one and a half years and was successfully treated by intratympanic gentamicin instillation. She had profound hearing loss on the right side and direction-changing apogeotropic positional nystagmus. Her caloric response on the right side was severely decreased (canal paresis 80%). Intratympanic gentamicin instillation therapy was undertaken (30mg/ml/day × 5 days), following which her positional vertigo was abolished. We propose that intratympanic instillation of gentamicin may also be applicable to selected patients with long-lasting BPPV.

Recovery of subjective visual horizontal after unilateral vestibular deafferentation by intratympanic instillation of gentamicin

The time course of the recovery of subjective visual horizontal (SVH) after unilateral vestibular deafferentation by intratympanic instillation of gentamicin was studied. Six patients who underwent intratympanic gentamicin instillation therapy for Meniere's disease (1 man and 5 women, 32 to 69 years of age) were enrolled in this study. For comparison, SVH in 23 healthy subjects (12 men and 11 woman, 23 to 48 years of age) was also measured. The mean +/- SD of SVH in healthy subjects was 0.0 +/- 1.1 deg. All of the 6 patients showed significantly deviated SVH toward the injected side-down at the early stage after the therapy. Although one patient showed recovery of SVH to the normal range 25 days after the injection, the other patients required more time for recovery. Three patients did not show recovery to the normal range after 1 year. On the other hand, spontaneous nystagmus observed using an infrared CCD camera in total dark disappeared after 35 days (median). Patients who had normal vestibular evoked myogenic potentials before the therapy showed a tendency of delay of recovery of SVH. The reasons why the recovery of SVH took longer than the disappearance of spontaneous nystagmus are discussed in this report.

Reversible and controlled peripheral vestibular loss by continuous infusion of ropivacaine (Narop ®) into the round window niche of rats

This paper describes a method for achieving a peripheral vestibular blockade in rats by instillation of local anaesthetics over the round window membrane through a permanently implanted cannula. Being rapidly reversible, the effect of the anaesthetic drug is easily controlled by a single continuous infusion, which can be repeated at any time. The method offers a unique opportunity to study the consequence of single or repeated transient vestibular loss without any use of general anaesthetics, which may be a severe confounding factor. Such studies might shed light on balance disorders related to permanent vestibular loss or episodic vestibular dysfunction. To evaluate the method, spontaneous horizontal eye movements were recorded during the first 4 h of continuous infusion. Unilateral infusion of ropivacaine gave rise to a high-frequency spontaneous nystagmus, reaching levels that have not been documented after a surgical labyrinthectomy under general anaesthesia. This vestibulo-oculomotor behaviour is consistent with a previous report using a single intratympanic instillation of lidocaine to achieve a short-lasting vestibular blockade. In the present study, it was demonstrated that the initial high-frequency nystagmus decreased during the first 100 min of infusion before stabilizing at the same level as recorded when the effect of general anaesthesia has worn off after a surgical ablation. When the transient vestibular blockade was repeated by a second infusion during the following day, the nystagmus frequency saturated on a significantly lower level than during the first blockade. Also, serial single infusions, with recovery between each functional vestibular loss, gave rise to a less severe nystagmus. It is suggested that this phenomenon is an expression of the behavioural concept of ‘vestibular habituation’, the neural substrate of which is rather unknown.

Vestibulo-oculomotor behaviour in rats following a transient unilateral vestibular loss induced by lidocaine

The effects of a transient vestibular nerve blockade, achieved by intra-tympanic instillation of lidocaine, were studied in rats by recording horizontal eye movements in darkness. Evaluation of the dose-response relationship showed that a maximal effect was attained with a concentration of 4% lidocaine. Within 15 min of lidocaine instillation, a vigorous spontaneous nystagmus was observed which reached maximal frequency and velocity of the slow phase after about 20 min. Subsequently, the nystagmus failed for approximately half an hour before it reappeared. This could be avoided by providing visual feedback in between the recordings in darkness or by a contralateral instillation of 2.5% lidocaine. It is suggested that the failure reflects an overload of the vestibulo-oculomotor circuits.After recovery from the nerve blockade, when the gaze was stable, dynamic vestibular tests were performed. They revealed that a decrease of the slow phase velocity gain and the dominant time constant during, respectively, sinusoidal- and step stimulation toward the unanaesthetised side, had developed with the nerve blockade. These modulations were impaired by a nodulo-uvulectomy but not by bilateral flocculectomy, which is consistent with the concept of vestibular habituation.A GABAB receptor antagonist, CGP 56433A, given systemically during the nerve blockade, aggravated the vestibular asymmetry. The same effect has previously been demonstrated in both short- (days) and long-term (months) compensated rats, by antagonising the GABAB receptor.In summary, this study provides the first observations of vestibulo-oculomotor disturbances during the first hour after a rapid and transient unilateral vestibular loss in the rat. By using this method, it is possible to study immediate behavioural consequences and possible neural changes that might outlast the nerve blockade.

Effect of trans-bullar gentamicin treatment on guinea pig angular and linear vestibulo-ocular reflexes.

This study provides the first systematic examination of the effects of intratympanic gentamicin instillation on vestibulo-ocular responses of guinea pigs during both Earth-vertical yaw axis and off-vertical axis rotation. A scleral search coil was sutured to the right eye of pigmented female guinea pigs prior to trans-bullar instillation of a 0.2-ml bolus of either 20 mg/ml or 40 mg/ml of gentamicin (1) into the right middle ear (unilateral treatment groups) or (2) into both ears (bilateral treatment groups). Two weeks later, eye movement responses were tested during yaw axis sinusoidal rotation at 7 frequencies (0.02, 0.05, 0.1, 0.2, 0.5, 1 and 2 Hz, 40 deg/s peak velocity) and during off-vertical axis rotation at five constant velocities (20, 40, 60, 80 and 100 deg/s), tilted 30 deg relative to the earth-vertical axis. The main result was that unilateral trans-bullar gentamicin instillation produced almost exclusively unidirectional deficits in horizontal angular vestibulocular reflex (HVOR) responses and modulation and bias responses to off-vertical axis rotation (OVAR). The HVOR gain was reduced during rotation toward the injected ear in a dose-dependent manner for frequencies of 1 Hz and lower, but there was no effect on responses during rotation toward the intact ear. Further, the modulation and bias responses to OVAR were reduced profoundly in a dose-dependent manner during rotation toward the treated ear. It is suggested that these effects indicate selective cytotoxic and/or physiologic effects of gentamicin intoxication in the inner ear or, possibly, the vestibular nerve and central nervous system.

Labyrinth Anesthesia – A Forgotten but Practical Treatment Option in Ménière’s Disease

The aim of this study was to determine the efficiency of labyrinth anesthesia – the intratympanic instillation of lidocaine – in the treatment of Ménière’s disease and to recall a forgotten method. Twenty-four patients (15 male, 9 female), aged from 19.7 to 80.6 years (mean: 47.8 years) with the clinical diagnosis of unilateral Ménière’s disease who underwent labyrinth anesthesia in our department were included in this retrospective study. After local anesthesia of the tympanic membrane, a solution of 4% lidocaine and furfuryladenine (Kinetin) was instilled into the tympanic cavity. Patient records, a questionnaire and a physical examination were used to evaluate vertigo control, hearing loss, tinnitus, and quality of life according to the AAO-HNS criteria before and after surgery. Postoperatively, 87.5% of patients reported at least a noticeable decrease of vestibular symptoms, 66.7% of these patients were free of attacks for an average of 26.5 months. Postoperative hearing was the same or even improved in 87.5% of our patients. Tinnitus was not affected in any individual. Based on the findings presented herein, we consider labyrinth anesthesia a practicable and, due to its safety, highly recommendable therapeutic option for patients suffering from Ménière’s disease.

Hearing loss following intratympanic instillation of gentamicin for the treatment of unilateral Meniere's disease.

To determine the incidence, extent, and time course of hearing loss following instillation of intratympanic gentamicin using a predetermined fixed protocol for incapacitating unilateral Meniere's disease and to determine whether such loss is associated with any identifiable risk factors. A retrospective analysis of all patients treated with intratympanic gentamicin between 1988 and 1998 using American Academy of Otolaryngology-Head and Neck Surgery reporting guidelines (1985 and 1995). A predetermined regimen using a fixed dose (gentamicin 26.7 mg/mL administered three times daily for 4 consecutive days) was used. The records of patients treated with this particular protocol were reviewed. The relationship between pretreatment hearing acuity, pretreatment bithermal caloric response, duration of symptoms, and previous treatment to post-treatment hearing were analyzed with respect to hearing. Complete vestibular and audiologic data over a minimum 2-year follow-up were available for 85 individuals. Sixty-three patients (74.1%) had unchanged or improved hearing, and 22 patients (25.9%) realized hearing loss. In 80% of the latter, it occurred during the first month post-treatment. When hearing acuity at the 1-month post-treatment interval remained unchanged (91.1%), it was likely to remain so over the next 23 months. A significantly higher incidence of profound hearing loss was noted in patients who developed hearing loss in the first month, as compared with those who developed hearing loss at a later period (p = .0207, relative risk = 1.5). Re-treatment was not associated with hearing loss. The only identifiable risk factor for developing hearing loss was pretreatment hearing acuity stages 3 and 4 (pure-tone average > 40 dB) (p = .022, relative risk = 1.5). Hearing loss is a recognized complication of treatment with intratympanic gentamicin, occurring in approximately 26% of individuals. In those individuals in whom hearing acuity has remained unchanged after the first month interval, significant worsening of hearing is unlikely, and patients can be reassured accordingly.

New possibilities in the treatment of Meniere's disease

The results of the treatment of Meniere's disease by intratympanic instillation of gentamicin in 32 patients over a 24-months period were analyzed. The receded vestibular function was found in 96.8% patients, whereas in the remaining 3.2% pronounced vestibular hypofunction was observed. One month after the treatment vertiginous attacks disappeared in all the patients. However, three months after the treatment infrequent episodes of mild degree vertigo and mild unsteadiness that did not require additional intratympanic gentamicin application appeared in 15% of the patients with Meniere's disease. The vertiginous attacks ceased or were pronouncedly reduced in 85% of the patients. The unstable vestibular hypofunction was successfully converted into stabilized, centrally compensated areflexia. Intratympanic gentamicin exerted better results than the other invasive therapies for intractable Meniere's disease.

Subjective Visual Horizontal During Follow-up After Unilateral Vestibular Deafferentation with Gentamicin

The subjective visual horizontal (SVH) was measured by means of a small, rotatable, luminous line in darkness in the upright head and body position and at 10, 20 and 30° of tilt to the right and left before, and repeatedly during a follow-up period of 1 year after intratympanic gentamicin instillations in 12 patients with recurrent vertigo attacks. This treatment caused a loss of the bithermal caloric responses on the diseased side. Shortly after treatment there was a significant tilt of SVH towards the treated side (group mean=10.6°). Repeated testing made it possible to characterize mathematically the changes with time for SVH. For the group of patients as a whole this otolithic component of vestibular compensation was best described by a power function, SVH=8.65t-0.16 degrees, where t is time in days after maximum tilt of SVH. After 1 year, SVH was still significantly tilted towards the treated side (group mean=3.16°). Gentamicin treatment also caused a significant reduction in the perception of head and body tilt towards the deafferented side, while the perception of tilt towards the healthy side did not show any significant changes. During follow-up there was a gradual improvement in the perception of tilt towards the treated side. However, a significant asymmetry in roll-tilt perception was still present 1 year after deafferentation. There was no correlation between SVH in the upright position and roll-tilt perception, suggesting that these parameters are to some extent dependent on different afferent input from the vestibular organ. They were also found to be complementary for the detection of vestibular disturbance.

Influence of the Allergic Response on the Mucociliary System in the Eustachian Tube

The effect of systemic and local allergic responses on the mucociliary system of the Eustachian tube was investigated. Egg albumin was administered to guinea pigs via the jugular vein to evoke systemic anaphylaxis in animals previously sensitized with egg albumin. Ciliary activity in the Eustachian tube of sensitized animals was significantly higher than that of control animals. However, the mucociliary clearance time of the Eustachian tube in sensitized animals was significantly longer than in control animals. Local allergic response induced by intratympanic instillation of (BPO) 61 -BGG induced cilioexcitation and prolonged mucociliary clearance in the guinea pigs sensitized with BPO-BGG. A partial loss of the inner layer of the mucus blanket of the Eustachian tube was observed under electron microscopy. In conclusion, the systemic as well as the local allergic response accelerates ciliary activity but may affect the mucus blanket and induce mucociliary dysfunction in the Eustachian tube, resulting in a predisposition to middle ear diseases.

Tinnitus: Our experience with intratympanic instillation of 2% Xylocaine.

Idiopathic subjective tinnitus is quite an obscure otopathology for over the decades. This paper deals with the results of an intratympanic instillation of 2% Xylocaine through Grommet over a six weeks time. Patients overall compliance was 26%. We suggest this method of treatment for those who have been treated unsuccessfully with drugs, acupuncture, electrical control, biofeedback etc with not much reward. Patient is warned about impending nausea and vomiting. Tinnitus is alleviated to cope with near to normal life.