Comparison of Surgeons' Assessment of the Extent of Vestibular Schwannoma Resection with Immediate Post Operative and Follow-Up Volumetric MRI Analysis.

(1) Background: Incomplete excision of vestibular schwannomas (VSs) is sometimes preferable for facial nerve preservation. On the other hand, subtotal resection may be associated with higher tumor recurrence. We evaluated the correlation between intra-operative assessment of residual tumor and early and follow-up imaging. (2) Methods: The charts of all patients undergoing primary surgery for sporadic vestibular schwannoma during the study period were retrospectively reviewed. Data regarding surgeons' assessments of the extent of resection, and the residual size of the tumor on post-operative day (POD) one and follow-up MRI were extracted. (3) Results: Of 109 vestibular schwannomas meeting inclusion criteria, gross-total resection (GTR) was achieved in eighty-four, near-total (NTR) and sub-total resection (STR) in twenty-two and three patients, respectively. On follow up imaging, volumetric analysis revealed that of twenty-two NTRs, eight were radiographic GTR and nine were radiographic STR (mean volume ratio 11.9%), while five remained NTR (mean volume ratio 1.8%). Of the three STRs, two were radiographic GTR while one remained STR. Therefore, of eighteen patients with available later follow up MRIs, radiographic classification of the degree of resection changed in six. (4) Conclusions: An early MRI (POD#1) establishes a baseline for the residual tumor that may be more accurate than the surgeon's intraoperative assessment and may provide a beneficial point of comparison for long-term surveillance.

Content Validity of a High-Fidelity Surgical Middle Ear Simulator: A Randomized Prospective International Multicenter Trial.

OBJECTIVE: After demonstration of face validity of a surgical middle ear simulator (SMS) previously, we assessed the content validity of the simulator with otolaryngology residents. STUDY DESIGN: Multicenter randomized prospective international study. SETTING: Four academic institutions. METHODS: Novice participants were randomized into control, low-fidelity (LF), and high-fidelity (HF) groups. Control and LF produced 2 recordings from 2 attempts, and HF produced 4 recordings from 10 attempts, with trials 1, 4, 7, and 10 used for scoring. Three blinded experts graded videos of the simulated stapedectomy operation using an objective skills assessment test format consisting of global and stapedotomy-specific scales. RESULTS: A total of 152 recordings from 61 participants were included. Baseline characteristics did not differ significantly between groups. Depending on the step of the operation, inter-rater reliability ranged from 24 to 90%. For LF and HF, years of training was significantly associated with improved scores in certain objective skills assessment test subparts. HF outperformed the control group on stapes and global scores ( p < 0.05). The HF group demonstrated improvement in global score over trials, but plateaued after four trials. Scores varied greatly for participants from different institutions in certain operative steps, such as transecting incudostapedial joints, likely due to differences in instrumentation and time elapsed since manufacture. CONCLUSION: Practice with SMS led to better performance in both global and stapes-specific scores. Further studies are needed to examine construct validity and to create otology-appropriate grading systems. Variables like instrumentation and decline in flexibility of the simulator after 12 months greatly affect performance on the simulator.

Hypercoagulability in Vestibular Schwannoma Surgery.

OBJECTIVE: Patients with vestibular schwannoma who harbor a genetic predisposition for venous thromboembolism require special consideration when determining optimal therapeutic management. The primary objective of the current study was to provide recommendations on treatment of hypercoagulable patients with vestibular schwannoma through a case series and review of the literature. PATIENTS: Two patients who underwent resection of vestibular schwannomas. INTERVENTIONS: Surgical resection and diagnostic testing. MAIN OUTCOME MEASURES: Postoperative venous thromboses. RESULTS: One patient who underwent resection of vestibular schwannoma and suffered several postoperative thrombotic complications consistent with a clinical thrombophilia. One patient with known Factor V Leiden deficiency who underwent resection of vestibular schwannoma followed by postoperative chemoprophylaxis with a direct factor Xa inhibitor and experienced an uneventful postoperative course. CONCLUSIONS: In patients with a known propensity for venous thromboembolism, the skull base surgeon should consider nonsurgical management. If the patient undergoes surgical resection, we recommend careful effort to minimize trauma to the sigmoid sinus. In addition, the surgeon may consider retrosigmoid or middle fossa approaches. Best practice recommendations include the use of pneumatic compression devices, early ambulation, and consideration of postoperative prophylactic anticoagulation in patients with a known genetic predisposition.

Options and strategies for hearing restoration in pediatric neurofibromatosis type 2.

PURPOSE: In this article, we will review the mechanisms and natural history of hearing loss in neurofibromatosis type 2 (NF2) and discuss the hearing outcomes with different rehabilitation options. METHODS: Review of the published literature. RESULTS: NF2 is a rare autosomal dominant syndrome characterized by vestibular schwannomas and other intracranial and spinal tumors. Bilateral vestibular schwannomas are the hallmark of the disease which occur in 90 to 95% of the patients. As a result, hearing loss will eventually occur in almost all NF2 patients. Deafness can occur from tumor progression or from treatment of vestibular schwannomas and is among the most debilitating aspects of NF2. A number of surgical and non-surgical rehabilitation options are available for these patients including cochlear and auditory brainstem implants. The audiologic outcomes with surgical rehabilitation options have been variable but most patients are able to achieve sound awareness and benefit from auditory cues in lip reading. CONCLUSION: Early identification and treatment of NF2 patients can help in achieving better hearing outcomes in the pediatric population. An increasing number of NF2 patients are receiving open set word understanding with refinement in surgical techniques.

False-Positive Cholesteatomas on Non-Echoplanar Diffusion-Weighted Magnetic Resonance Imaging.

OBJECTIVES: To investigate false-positive findings on non-echoplanar (non-EPI) diffusion-weighted magnetic resonance imaging (DWI) in patients under surveillance post-cholesteatoma surgery. STUDY DESIGN, SETTING, SUBJECTS, AND METHODS: A retrospective review was performed on patients diagnosed with cholesteatoma who underwent surgical resection and were then followed by serial non-EPI DWI using half-Fourier acquisition single-shot turbo spin echo (HASTE) sequence. All patients had at least two annual follow-up imaging studies. RESULTS: False-positive findings were identified in four patients. The size of the suspected lesions was 4 to 12 mm. Otoendoscopy was used during all primary cases and Argon laser was used in one case. In all cases, the entire cholesteatoma was removed, and no residual disease was detected at the end of the procedures. One patient underwent revision surgery but only cartilage graft was found in the area of concern. All patients had stable or resolved hyperintense areas in the subsequent HASTE sequences. CONCLUSION: False positive findings can occur with non-EPI DWI MRI and patients need to be counseled accordingly before revision surgery. Decreasing intensity and dimension of a suspected lesion and a positive finding in an area other than the location of the initial cholesteatoma may favor a false positive. If a false positive finding is suspected when the surgeon is confident of complete resection of the cholesteatoma, an MRI can be repeated in 6 to 12 months to assess changes in the dimension and intensity of the area of concern. Cartilage grafts may cause restricted diffusion on DWI sequences.

Visual and Endocrine Recovery Following Conservative and Surgical Treatment of Pituitary Apoplexy: A Meta-Analysis.

BACKGROUND: Pituitary apoplexy (PA) can manifest with visual and endocrine defects. The literature lacks strong support for either surgical or conservative management with respect to symptomatic improvement of these deficits. This meta-analysis compared visual and endocrine outcomes in conservative and surgical treatment of PA. METHODS: A systematic literature search was performed in PubMed, Cochrane, and Ovid MEDLINE for articles published between 1988 and 2018. Recovery outcomes were binarized, such that complete and partial improvements were combined as "improvement." Primary outcome variables evaluated via a binary random-effects model were improvements in endocrine dysfunction, visual field and acuity deficits, and ophthalmoplegia or ocular nerve palsy. RESULTS: Of 483 published articles, 14 studies comprising 457 cases (259 surgical treatments and 198 conservative treatments) were included. On initial examination, 58% of patients had endocrine dysfunction, 37% had visual acuity or field deficit, and 47% had ophthalmoplegia or ocular nerve palsy. Evaluation of outcomes for surgically and conservatively treated patients yielded odds ratios of 0.609 (95% confidence interval [CI], 0.199-1.859; P = 0.383), 0.763 (95% CI, 0.307-2.374; P = 0.763), 1.167 (95% CI, 0.433-3.146; P = 0.760), and 0.801 (95% CI, 0.305-2.105; P = 0.653) for improvements in endocrine dysfunction, visual acuity dysfunction, visual field dysfunction, and ophthalmoplegia or ocular nerve palsy. CONCLUSIONS: Both surgical intervention and conservative management of PA can lead to visual and endocrine recovery, although the management decision may heavily rely on severity of initial deficits. Treatment of PA can be multifaceted and tailored to the individual case and clinical judgment. Further investigation into appropriate intervention based on longitudinal outcome data is warranted.

Hearing Difficulty and Risk of Mortality.

OBJECTIVE: Investigate whether hearing difficulty has an influence on the risk of mortality. METHODS: A nationally representative sample of individuals 18 years or older with data available for hearing and mortality status was selected from the National Health Interview Surveys (NHIS) 2005-2009. Self-perceived hearing status was regrouped as excellent/good, a little to moderate trouble, a lot of trouble, and deaf. Other independent variables investigated were demographics and comorbidities. Univariate analysis was performed to calculate the incidence of mortality, and 95% confidence intervals (CI) and multivariate analysis adjusted for demographics and comorbidities was performed to calculate odds ratios (OR) of mortality. Those with excellent/good hearing were considered as reference for ORs. RESULTS: Of 215.6 million Americans (mean age = 45.9 years; 51.7% female), approximately 16.0% (95% CI, 15.6%-16.3%) considered their hearing less than excellent or good. The 5-year mortality rate was 4.2% (95% CI, 4.0%-4.3%). In the univariate analysis, the mortality rate increased with the degree of hearing difficulty from 3.0% in excellent/good hearing to 19.5% in a lot of trouble hearing and 17.8% in deaf. With multivariate analysis, adjusted ORs of mortality were 1.5 (95% CI, 1.3-1.7) in those who had a lot of trouble hearing and 1.6 (95% CI, 1.1-2.3) in those who were deaf. CONCLUSION: Hearing difficulty may be associated with an increased risk of mortality, and this risk may correlate with the degree of hearing difficulty.

Vision Outcomes in Early versus Late Surgical Intervention of Pituitary Apoplexy: Meta-Analysis.

BACKGROUND: Pituitary apoplexy (PA) is defined by hemorrhage and necrosis of the pituitary gland, often acute in onset, and frequently in the setting of an existing pituitary adenoma. Our objective was to conduct a meta-analysis of the available literature on vision outcomes following surgical intervention for PA on the basis of the timing from apoplexy to surgery (ATS). METHODS: A thorough literature search of the published English-language literature was performed in PubMed, Ovid, and Cochrane databases using the key words ("pituitary apoplexy") and ("surgery" or "vision") from database inception to August 2018 was conducted. The primary outcome variable evaluated using a binary random-effects model was vision recovery outcomes (metric: odds ratio). RESULTS: Of 234 articles found, 12 articles containing 200 patients met our eligibility criteria. The mean age was 46.1, with a male-to-female ratio of 2.9:1. A total of 86% of PA patients presented with visual deficits (ATS <7 days in 93 and >7 days in 79 patients). In patients with an ATS <7 days, 97.8% experienced visual recovery, compared with 84.8% with an ATS >7 days (odds ratio 2.6 [95% CI 0.94-7.31]; P value = 0.07). CONCLUSIONS: Despite readily accepted guidelines provided by the United Kingdom advocating for early surgical intervention in PA, the rates of vision outcomes we report demonstrate >80% recovery for patients in both the early and late surgical intervention group. As such, conservative management may be warranted for early stabilization before surgical intervention in PA patients with respect to vision outcomes.

Factors Influencing Access to Cochlear Implantation in Deaf and Hard-of-Hearing Children in Southern California.

OBJECTIVE: To determine the epidemiologic relationship of family demographics and educational resources with parental knowledge of and willingness for their children to receive cochlear implantation (CI) for deaf and hard-of-hearing (DHH) children. METHODS: A total of 213 parents of DHH children were surveyed at local schools, specialized camps, and clinics in Southern California. Data on parents were solicited, including income, insurance status, education level, hearing status, primary language, and motivations towards CI. RESULTS: Sixty-six surveys were included in the analysis. Three of these patients had already undergone CI, thus of the 63 children without CI, 59% had been presented with the option of CI by a healthcare professional and 27% were willing to have their child undergo CI. Willingness for children to undergo CI was statistically higher in families with an annual income less than $15,000 or more than $75,000 (p = 0.02), and children enrolled in specialized schools for DHH (p = 0.02). The leading reasons for unwillingness to undergo CI were risks of surgery (17%) and discouragement from others (14%). CONCLUSION: A significant gap exists between the number of CI candidates and families and willingness to undergo CI. The difference could be related to socioeconomic status and the patient's school type. This underscores the importance of parental education through the use of a multi-disciplinary team to ensure all hearing rehabilitation options are explained.

Radiosurgery of Glomus Tumors of Temporal Bone: a Meta-analysis.

OBJECTIVE: 1) Perform a meta-analysis of the available data on the outcomes of stereotactic radiosurgery (SRS) for the treatment of temporal bone glomus tumors (GT), and 2) evaluate the collective outcomes of SRS treatment with respect to tumor control. DATA SOURCES: A thorough literature search of the published English-language literature from 2011 to 2016 was performed in PubMed, Ovid, and Cochrane databases using the keywords ("Gamma Knife" or "CyberKnife" or "linear accelerator" or "radiosurgery") and ("glomus jugulare" or "jugular paraganglioma" or "glomus tympanicum"). STUDY SELECTION: Studies reporting outcomes of SRS for temporal bone GT were included. DATA EXTRACTION: Of 45 articles found, 15 studies met our inclusion and exclusion criteria and were selected for qualitative and quantitative analyses totaling 511 patients. DATA SYNTHESIS: Average margin dose, modality, isodose line, volume decrease, follow-up duration, and tumor control rate data were extracted and analyzed. CONCLUSION: Gamma Knife was the most commonly implemented radiosurgery modality and was used in eight studies. The mean marginal dose varied between 13.2 and 20 Gy. The pooled tumor control rate was 95.4% (95% CI: 93.6-97.2%) over a median follow-up duration ranging between 27.4 and 148 months. Clinical data on outcomes of SRS for the treatment of GTs are sparse and primarily limited to single institutional analyses, with considerable variation in tumor volume and follow-up duration. This meta-analysis provides an in-depth analysis of the available data in the literature and reviews the reported outcomes. Future studies on SRS for GT should include data on tumor growth before radiation as well as follow-up periods sufficiently long to identify true tumor control.

Self-reported Hearing Difficulty and Risk of Accidental Injury in US Adults, 2007 to 2015.

IMPORTANCE: Accidental injuries are a leading cause of morbidity and mortality in the United States. Hearing problems may be associated with an increased risk for such injuries. OBJECTIVE: To investigate associations between hearing difficulty and risk of accidental injuries among US adults. DESIGN, SETTING, AND PARTICIPANTS: Cross-sectional analysis of responses of a nationally representative sample of 232.2 million individuals 18 years or older who participated in the National Health Interview Survey from 2007 to 2015 and responded to the questions related to the hearing and injury modules. MAIN OUTCOMES AND MEASURES: The main outcome variable was accidental injury in the preceding 3 months. Hearing status was self-reported as "excellent," "good," "a little trouble," "moderate trouble," "a lot of trouble," and "deaf." Prevalence of accidental injuries was analyzed based on demographic characteristics and hearing status. Odds ratios (ORs) and 95% CIs for injuries adjusted for demographics were calculated for degrees of hearing difficulty. A secondary outcome was association of hearing status with type of injury and was classified as driving related, work related, or leisure/sport related. RESULTS: Of 232.2 million US adults, 120.2 million (51.7%) were female, and 116.3 million (50.1%) considered their hearing to be less than excellent. Accidental injuries occurred in 2.8% of survey respondents. In comparison with normal-hearing adults (those with self-rated excellent or good hearing), the odds of accidental injury were higher in those with a little trouble hearing (4.1%; OR, 1.6; 95% CI, 1.5-1.8), moderate trouble hearing (4.2%; OR, 1.7; 95% CI, 1.4-1.9), and a lot of trouble hearing (4.8%; OR, 1.9; 95% CI, 1.6-2.3). Work- and leisure-related injuries were more prevalent among those with self-perceived hearing difficulty. Multivariate analysis, adjusted for age and sex, revealed leisure-related injuries was most consistently associated with various degrees of hearing difficulty. Odds ratios were 1.2 (95% CI, 1.0-1.4) in those with a little trouble hearing, 1.4 (95% CI, 1.1-1.9) in those with moderate trouble hearing, and 1.5 (95% CI, 1.1-2.2) in those with a lot of trouble hearing. CONCLUSIONS AND RELEVANCE: Hearing difficulty is significantly associated with accidental injury, especially injury related to work or leisure. Increased awareness about hearing difficulty and its proper screening and management may assist in decreasing accidental injury.

Migraine-Related Aural Fullness: A Potential Clinical Entity.

In this case series, we set out to describe the clinical entity of isolated, prolonged aural fullness (AF) and its relationship with migraine. Patients with isolated, persistent AF for 6 months or more were included with all possible etiologies ruled out. Migraine dietary and lifestyle changes and medical migraine prophylactic therapy were prescribed to all. Eleven patients were included (mean age, 52 years). Six (54%) patients fulfilled International Headache Society criteria for migraine with or without aura. Changes in perceived sensation of AF using the visual analog scale and quality of life questionnaires resulted in a statically significant improvement ( P < .001, 95% confidence interval [CI], 4.7 to 6.72, and P < .001, 95% CI, -5.3 to -2.7, respectively). As such, an improvement of isolated, prolonged AF with migraine lifestyle changes and prophylactic treatment may suggest an etiological association between migraine and prolonged aural fullness.

Prevalence, Characteristics, and Treatment Patterns of Hearing Difficulty in the United States.

IMPORTANCE: Hearing loss is one of the most prevalent chronic conditions in the United States and has been associated with negative physical, social, cognitive, economic, and emotional consequences. Despite the high prevalence of hearing loss, substantial gaps in the utilization of amplification options, including hearing aids and cochlear implants (CI), have been identified. OBJECTIVE: To investigate the contemporary prevalence, characteristics, and patterns of specialty referral, evaluation, and treatment of hearing difficulty among adults in the United States. DESIGN, SETTING, AND PARTICIPANTS: A cross-sectional analysis of responses from a nationwide clustered representative sample of adults who participated in the 2014 National Health Interview Survey and responded to the hearing module questions was carried out. MAIN OUTCOMES AND MEASURES: Data regarding demographics as well as self-reported hearing status, functional hearing, laterality, onset, and primary cause of the hearing loss were collected. In addition, specific data regarding hearing-related clinician visits, hearing tests, referrals to hearing specialist, and utilization of hearing aids and CIs were analyzed. RESULTS: Among 239.6 million adults, 40.3 million (16.8%) indicated their hearing was less than "excellent/good," ranging from "a little trouble hearing" to "deaf." The mean (SD) age of participants was 47 (0.2) years with 48.2% being men and 51.8% women. Approximately 48.8 million (20.6%) had visited a physician for hearing problems in the preceding 5 years. Of these, 32.6% were referred to an otolaryngologist and 27.3% were referred to an audiologist. Functional hearing was reported as the ability to hear "whispering" or "normal voice" (225.4 million; 95.5%), to "only hear shouting" (8.0 million; 3.4%), and "not appreciating shouting" (2.8 million; 1.1%). Among the last group, 5.3% were recommended to have a CI, of which 22.1% had received one. Of the adults who indicated their hearing from "a little trouble hearing" to being "deaf," 12.9 million (32.2%) had never seen a clinician for hearing problems and 11.1 million (28.0%) had never had their hearing tested. CONCLUSIONS AND RELEVANCE: There are considerable gaps between self-reported hearing loss and patients receiving medical evaluation and recommended treatments for hearing loss. Improved awareness regarding referrals to otolaryngologists and audiologists as well as auditory rehabilitative options among clinicians may improve hearing loss care.

Antibiotic prophylaxis in clean-contaminated head and neck cases with microvascular free flap reconstruction: A systematic review and meta-analysis.

BACKGROUND: Optimal antibiotic prophylaxis duration in head and neck clean-contaminated free-flap cases is unknown. METHODS: A systematic review/meta-analysis was conducted using PubMed/MEDLINE, Cochrane Library, Web-of-Science, and Scopus databases. RESULTS: Of the 3755 searched articles, 5 articles were included for a total of 861 patients. The recipient surgical site infection risk was significantly higher in patients receiving prophylactic antibiotics for ≤24 hours compared to >24 hours (relative risk [RR] 1.56; 95% confidence interval [CI] 1.13-2.14). In the post hoc multivariate analysis based on available individual-level data on 697 patients from 3 studies, the risk of surgical site infection for ≤24 hours versus >24 hours was not significant after adjusting for antibiotic type (RR 1.09; 95% CI 0.78-1.55). When compared to ampicillin-sulbactam, patients who received clindamycin prophylaxis had an increased likelihood of recipient surgical site infection (RR 2.85; 95% CI 1.95-4.17). CONCLUSION: Less than or equal to 24 hours of antibiotic prophylaxis in head and neck clean-contaminated free-flap is likely sufficient but a strong conclusion remains elusive. Clindamycin prophylaxis increases the risk of recipient surgical site infection. Further prospective trials are necessary to clarify.

Resolution of Persistent Post-Stapedotomy Vertigo With Migraine Prophylactic Medication.

OBJECTIVE: To describe persistent post-stapedotomy vertigo (PSV) and its treatment using migraine prophylaxis. PATIENTS: A retrospective review of all patients with persistent PSV spanning 10 years at a tertiary academic hospital was performed. Patients who experienced persistent vertigo for a minimum of 3 months after surgery were included. Those with possible perilymph fistula, long prosthesis, and benign paroxysmal positional vertigo were excluded. INTERVENTIONS: All patients received instructions on migraine dietary and lifestyle changes and Vitamin B2 and magnesium. In addition, prophylactic treatment with nortriptyline, verapamil, or a combination thereof was started. MAIN OUTCOME MEASURE: Changes in vertigo frequency was the main outcome variable. The secondary outcome variables included the time period and medications necessary to achieve symptomatic resolution. RESULTS: Four women and one man with an average age of 53 years were identified that met criteria for persistent PSV indicating an incidence of 0.9% at our institution. The onset of vertigo symptoms was on average 20 days postoperatively. All five patients had daily vertigo episodes and experienced complete resolution with no vertigo episodes after treatment. Symptomatic resolution was achieved over an average of 9 weeks after initiating treatments. CONCLUSIONS: Persistent PSV beyond 3 months is a rare occurrence and its treatment can be challenging when there is no evidence of an underlying pathology. This subset of patients may be suffering from migraine, which was triggered postoperatively. Treatment with migraine prophylaxis in this cohort of patients may result in resolution of vertigo.

Vertigo in Vestibular Schwannoma Patients Due to Other Pathologies.

OBJECTIVE: To report findings from a cohort of vestibular schwannoma (VS) patients presenting with vertigo from a secondary comorbid vestibular disorder; and to discuss management strategies for this subset of patients presenting with both episodic vertigo and VS. PATIENTS: All VS patients who presented with vertigo as the primary symptom from 2012 to 2015 and endorsing no other major complaints were examined. INTERVENTION: Treatment with migraine lifestyle and prophylactic therapy, or Epley maneuver. MAIN OUTCOME MEASURE: Resolution of vertigo following medical treatment alone. RESULTS: Of the nine patients studied, seven (78%) suffered from vestibular migraine, and two (22%) experienced benign positional vertigo. All patients experienced complete resolution of symptoms after treatment. As a result of symptomatic improvement, seven patients (78%) avoided surgery in favor of observation, while two patients (22%) underwent radiosurgery due to continued tumor growth and other nonvertigo symptoms. CONCLUSION: VS patients can sometimes present with a history of recurrent episodic vertigo. The etiology of the vertigo could be due to the tumor itself or may be due to an underlying comorbidity such as vestibular migraine or benign positional vertigo. VS patients presenting with vertigo should undergo a standard vertigo history and examination to identify other potential causes of vertigo. Most VS patients in our cohort avoided intervention and had resolution of their vertigo.

Customized Versus Noncustomized Sound Therapy for Treatment of Tinnitus: A Randomized Crossover Clinical Trial.

OBJECTIVES: To determine the effectiveness of a customized sound therapy and compare its effectiveness to that of masking with broadband noise. METHODS: Subjects were randomized to receive either customized sound therapy or broadband noise for 2 hours per day for 3 months and then switched to the other treatment after a washout period. The outcome variables were tinnitus loudness (scored 0-10), Tinnitus Handicap Inventory (THI), Beck Anxiety Inventory (BAI), minimum masking levels (MML), and residual inhibition (RI). RESULTS: Eighteen subjects completed the study. Mean age was 53 ± 11 years, and mean tinnitus duration was 118 ± 99 months. With customized sound therapy, mean loudness decreased from 6.4 ± 2.0 to 4.9 ± 1.9 ( P = .001), mean THI decreased from 42.8 ± 21.6 to 31.5 ± 20.3 ( P < .001), mean BAI decreased from 10.6 ± 10.9 to 8.3 ± 9.9 ( P = .01), and MML decreased from 22.3 ± 11.6 dB SL to 17.2 ± 10.6 dB SL ( P = .005). After 3 months of broadband noise therapy, only BAI and, to a lesser degree, MML decreased ( P = .003 and .04, respectively). CONCLUSIONS: Customized sound therapy can decrease the loudness and THI scores of tinnitus patients, and the results may be superior to broadband noise.