Article 78581 of sci.med:
Path: bigblue.oit.unc.edu!concert!news-feed-1.peachnet.edu!emory!swrinde!ihnp4.ucsd.edu!news.cerf.net!news.cccd.edu!news.cccd.edu!not-for-mail
From: markb@spock.dis.cccd.edu (Mark Bixby)
Newsgroups: alt.support.tinnitus,alt.rock-n-roll.hard,misc.health.alternative,rec.audio.misc,rec.audio.pro,rec.music.makers,rec.music.misc,sci.med,sci.med.dentistry,sci.med.nutrition
Subject: Tinnitus Frequently Answered Questions v0.5
Followup-To: alt.support.tinnitus
Date: 20 Aug 1994 19:42:54 -0700
Organization: Coast Community College District, Costa Mesa, CA
Lines: 1230
Message-ID: <336eve$bne@spock.dis.cccd.edu>
Reply-To: markb@cccd.edu
NNTP-Posting-Host: spock.dis.cccd.edu
Summary: Questions and answers regarding tinnitus -
	ringing ears and other head noises
Xref: bigblue.oit.unc.edu alt.support.tinnitus:816 alt.rock-n-roll.hard:5063 misc.health.alternative:11421 rec.audio.misc:984 rec.audio.pro:18783 rec.music.makers:33716 rec.music.misc:108095 sci.med:78581 sci.med.dentistry:2417 sci.med.nutrition:12390

This is a draft copy of the Tinnitus FAQ.  It is a work in progress.  Areas
where I know I need more advice are delineated by "*****[]*****", but please
feel free to comment on anything.

New since last version: mostly just polishing.  Two new maskers.  The name
of the water-in-the-ear test for Meniere's.  Use of the diuretic Dyazide as
a treatment.  The FAQ is now available on the Web, but only in plaintext.  
The time draws near for v1.0 and posting to news.answers.

Newsgroups: alt.support.tinnitus,alt.rock-n-roll.hard,misc.health.alternative,rec.audio.misc,rec.audio.pro,rec.music.makers,rec.music.misc,sci.med,sci.med.dentistry,sci.med.nutrition,alt.answers,news.answers
*****[additional newsgroups?  too many newsgroups?]*****
Subject: Tinnitus Frequently Answered Questions
Followup-To: alt.support.tinnitus
Reply-To: markb@cccd.edu
Supersedes:
Expires:
Summary: Questions and answers regarding tinnitus -
	ringing ears and other head noises

Archive-name: tinnitus-faq
Posting-Frequency: monthly
Last-modified: 1994/08/20
Version: 0.5

Welcome to the Tinnitus FAQ.  At the present time, there are many questions
about tinnitus, but few definitive answers that apply to all sufferers.  If
you have any additional insights not covered in the document, please help
your fellow tinnitus sufferers by contacting the FAQ Maintainer, Mark Bixby,
at markb@cccd.edu.

In addition to being posted periodically to Usenet, this FAQ can also be found
at:

	ftp://ftp.cccd.edu/pub/faq/tinnitus.txt
	http://www.cccd.edu/faq/tinnitus.txt

Topics covered:

1) What is tinnitus?
2) What does tinnitus sound like?
3) How is tinnitus diagnosed?
4) What causes tinnitus?
5) How can I avoid getting tinnitus?
6) What are some ototoxic drugs?
7) What is Meniere's Disease?
8) What is hyperacusis?
9) What drugs, vitamins, and herbs are available for treating tinnitus?
10) What other treatments are available for tinnitus?
11) What is masking?
12) What types of ear plugs or other hearing protection are available?
13) What organizations can I turn to for more information?
14) What books can I turn to for more information?
15) What online resources are available?
16) What can I do when all else fails?
17) Where did the medical advice in the FAQ come from?
18) Who are the contributors to this FAQ?

-------------------------------------------------------------------------------

1) What is tinnitus?

Tinnitus can be described as "ringing" ears and other head noises that are
perceived in the absence of any external noise source.  It is estimated that
1 out of every 5 people experience some degree of tinnitus.  

Tinnitus is classified into two forms: objective and subjective.  Objective 
tinnitus, the rarer form, consists of head noises audible to other people in 
addition to the sufferer.  The noises are usually caused by vascular anomalies,
repetitive muscle contractions, or inner ear structural defects.  Subjective 
tinnitus is much less understood, with the causes being many and open to 
debate.  Anything from the ear canal to the brain may be involved.

Hearing loss, hearing hypersensitivity, and balance problems may or may not
be present in conjunction with tinnitus.

-------------------------------------------------------------------------------

2) What does tinnitus sound like?

Many sufferers in the online community report that their tinnitus sounds like
the high-pitched background squeal emitted by some computer monitors or 
television sets.  Others report noises like hissing steam, rushing water,
chirping crickets, bells, breaking glass, or even chainsaws.  Some report that 
their tinnitus temporarily spikes in volume with sudden head motions during 
aerobic exercise, or with each footfall while jogging.

Objective tinnitus sufferers may hear a rhythmic rushing noise caused by their
own pulse.  This form is known as pulsatile tinnitus.

-------------------------------------------------------------------------------

3) How is tinnitus diagnosed?

The following flowchart from the Cecil Textbook of Medicine, 1992 (19th ed.),
W.B. Saunders, shows the logic for diagnosing the common causes of tinnitus:

ear exam--->(audible sounds)-+-->sync w/respiration--->patent eustachian tube
   |                         |
   |                         +-->sync w/pulse--->aneurysm, vascular tumor,
   v                         |                   vascular malformation,
(no audible sounds)          |                   venous hum
   |                         |
   |                         +-->continuous--->venous hum, acoustic emissions
   v
neurological exam-->(normal)-->audiogram
   |                             |
   |                             +-->normal--->idiopathic tinnitus
   |                             |
   |                             +-->conductive hearing loss
   v                             |             |
(brain stem signs)               |             v
   |                             |     impacted cerumen, chronic
   |                             |     otitis, otosclerosis
   v                             |
multiple sclerosis,              +-->sensorineural hearing loss
tumor, ischemic                                  |
infarction                                       v
                                             BAER test
                                                 |
                                                 v
                                       +---------+--------------+
                                       |                        |
                                       v                        v
                                    abnormal (neural)      normal cochlear
                                       |                        |
                                       v                        v
                                    acoustic neuroma       noise damage
                                    other tumors           ototoxic drugs
                                    vascular compression   labyrinthitis
                                                           Meniere's Disease
                                                           perilymph fistula
                                                           presbycusis

-------------------------------------------------------------------------------

4) What causes tinnitus?

- overexposure to loud noises

Repeated exposure to loud noises such as guns, artillery, aircraft, lawn 
mowers, movie theaters, amplified music, heavy construction, etc, can cause
permanent hearing damage.  Some people report auditory fatigue from driving
automobiles long distances with the windows down.  Anybody regularly exposed 
to these conditions should consider wearing ear plugs or other hearing 
protection (see below).

- wax/dirt build-up in the ear canal

If you're experiencing tinnitus, this is one of the first things you should
check for.  NEVER try digging or suctioning the ear canal yourself or allow
a physician to do it as SERIOUS damage may result.  Numerous over-the-counter
chemical washes are available from your drugstore which will clean the ear
canal in a safe and gentle manner.

- acoustic neuromas

Acoustic neuromas are small tumors that press against the auditory nerves.
If your tinnitus is only in one ear, you should see your physician to rule
this one out.  An MRI will probably be required for a definitive diagnosis,
but one contributor's ENT felt that an MRI wasn't warranted unless frequent
dizziness was present.  Acoustic neuromas are removable by surgery.

- ototoxic drugs

Many prescription and over-the-counter drugs may cause tinnitus and/or hearing
loss that may be permanent or may disappear when the dosage is reduced or 
eliminated.  See the next section for more detail.  These drugs include:

	salicylate analgesics (aspirin)
	naproxen sodium (Naprosyn, Aleve)
	ibuprofen
	many other non-steroidal anti-inflammatories
	aminoglycoside antibiotics
	anti-depressants
	loop-inhibiting diuretics
	quinine/anti-malarials
	oral contraceptives
	chemotherapy

- severe ear infections

Many tinnitus cases onset after severe ear infections.  But this may also be
related to the use of ototoxic antibiotics (see above).

- high blood cholesterol

High blood cholesterol clogs arteries that supply oxygen to the nerves of the
inner ear.  Reducing your cholesterol level may reduce your tinnitus.

- vascular abnormalities

Arteries may press too closely against the inner ear machinery or nerves.
This is sometimes correctable by delicate surgery.

- Temporo-Mandibular Joint (TMJ) syndrome

This jaw disorder may cause tinnitus and is characterized by many symptoms,
including headaches, earaches, tenderness of the jaw muscles, dull facial pain,
jaw noises, the jaw locking open, and pain while chewing.  For a good online
document on TMJ, see:

	gopher://gopher.uiuc.edu/00/UI/CSF/health/heainfo/diseases/misc/tmj

- traumatic head injuries

Some automobile crash victims have reported a sudden onset of tinnitus.

- cochlear implant or other skull surgeries

Sometimes poking around inside the skull will accidentally damage the hearing
system.  Tinnitus can result, or even profound deafness caused by severe
inner ear infections.

- stress

Stress is not a direct cause of tinnitus, but it will generally make an 
already existing case worse.

- diet and other lifestyle choices

Like stress above, a poor diet can worsen an existing case of tinnitus.
Alcohol, tobacco, caffeine, quinine/tonic water, high fat, high sodium can
all make tinnitus worse in some people.

- food allergies

Specific foods may trigger tinnitus.  Problem foods include red wine, grain-
based spirits, cheese, and chocolate.  One contributor reported hearing tones
after consuming honey.  

- foods rich in salicylates

There is a long list of foods that are supposed to be "rich" in salicylates.
See the Shulman book listed below for details.  [Ed. note: I'm not listing the 
foods here since no data is given on exactly how rich the foods are, i.e. 
"13 mangoes = 1000mg aspirin" as a hypothetical example.]

- glaumous tumors

These tumors can cause pulsatile tinnitus.  They are confirmed with a CAT
scan or other imaging, and may be surgically removable by a delicate procedure.

- mercury amalgam tooth fillings

Researchers June Rogers and Jacyntha Crawley (P.O. Box 413, London SW7 2PT,
U.K.) have found a possible connection between mercury tooth fillings and
tinnitus.  They publish a booklet on the subject available for 6 International
Reply Coupons, and they also have a questionnaire that interested people can
fill out.  Their research suggests following a vegetarian diet, plus eating
2 raw African green chillies one day, followed by 1 chilli the next day for
temporary relief.

- marijuana

Marijuana usage may worsen pre-existing cases of tinnitus.

- Lyme Disease

Lyme is a parasitic, tick-borne disease, which in the United States is most
commonly seen in eastern states.  In some cases, tinnitus has been a side-
effect of Lyme.

Lyme disease deserves special mention partly because it is so
difficult to diagnose objectively; the commonly available serological
tests have very high rates of false negatives.  In the only study (by
McDonald) in the literature which used objective measures (histopathology)
to confirm test results, over 50% of currently infected patients were
negative by ELISA and/or Western Blot.  False positives are infrequent,
occurring primarily in pts. exposed to other nasties such as syphilis
or rocky mountain spotted fever.  So serologies can be used to confirm
but not to rule out diagnosis.

The Lyme Urine Antigen Test is a useful supplement test to serologies;
it tests for current infection, as opposed to a history of exposure.
It has some problems with low sensitivity; these can be improved by
the following regimen.  Give amoxicillin 500mg tid q5d; on days 3,4,5
take and test first-in-the morning urine specimens.  The LUAT can be
ordered by your MD from Immugenex, 1-415-424-1191.  Other, better
tests (including PCR) are under development, expected to be available
for clinical use within the next few years.

For further online information about Lyme Disease, you may send the following
command in the body of an e-mail message to listserv@lehigh.edu:

	subscribe LymeNet-L yourfirstname yourlastname

A regular newsletter is published here, and patients & physicians may exchange
their stories.

-------------------------------------------------------------------------------

5) How can I avoid getting tinnitus?

Avoid the causes listed above.  Really.  The number one cause of tinnitus is
exposure to excessively loud noise.  Either avoid these noisy situations, or
wear hearing protection as described below.  Rock concerts, movie theaters,
nightclubs, construction sites, guns, power tools, stereo headphones and 
musical instruments are just some of the things that can be hazardous to your 
ears.  Damage can result from either a single exposure or cumulative trauma.  
If you ever experience temporary ringing after a sound exposure, YOU ARE AT A
SEVERE RISK FOR TINNITUS AND/OR HEARING LOSS.

If you already have tinnitus, educate your family, friends, and neighbors so
that they can keep their ears healthy.

-------------------------------------------------------------------------------

6) What are some ototoxic drugs?

In her book _When the Hearing Gets Hard_ (Insight Books 1993, ISBN 
0-306-44505-0), author Elaine Suss names several potentially ototoxic 
substances.  She lists  them in three categories: (1) substances that 
most physicians consider ototoxic; (2) substances that many physicians 
consider potentially ototoxic; and (3) substances that may be ototoxic 
in rare cases.  The ototoxic effects of the substances in the third 
list are considered to be reversible--the effects diminish when you 
stop taking the drug.  Ms. Suss does not list dosages. 

The first group includes a few antibiotics and several diuretics.  Not 
being a physician, I don't recognize them all, though Capreomycin, 
Gentamicin , Kanamycin, Neomycin, Streptomycin, Tobramycin 
sulphate, Vancomycin, and Viomycin are obviously antibiotics.  Ms. 
Suss mentions that Streptomycin is used only for certain cases of 
tuberculosis.  

The first group also includes aspirin--whose effects are usually 
reversible--and other salicylates such as Oil of Wintergreen (Ben Gay). 
The other substances in the first group are:  Amikacin, Amphotericin B 
(Fungizone), Bumetanide (Bumex), Carboplatin (Paraplatin), Chloroquine 
(Aralen), Cisplatin (Platinol), Ethacrynic acid (Edecrin), Furosemide (Lasix), 
and Hydroxychloroquine (Plaquenil). 

The second group includes the analgesic Ibuprofen (Advil) and the tricyclic
anti-depressant Imipramine (Tofranil), along with Chloramphenicol 
(Chloromycetin), lead, and quinine sulphate. 

The third group includes alcohol, toluene, and trichloroethylene, as 
well as Chlordiazepoxide (Librium), Chlorhexidene (Phisohex, Hexachlorophene), 
Ampicillin, Iodoform, Clemastin fumarate (Tavist), Chlomipramine 
hydrochloride (Anafranil), and Chorpheniramine Maleate (Chlor-trimeton 
and several others). 

Ms. Suss points out that the _Physicians Desk Reference_ (PDR) did not 
list ototoxic drugs until the 1989 and later editions.  She refers to a 
separate document, _Drug Interactions and Side Effects Index_, which is 
keyed to the PDR.  She then points out that the Index is incomplete: 
several problem drugs are not listed there. 

Although the lists of ototoxic drugs are useful, I cannot recommend this 
book to tinnitus sufferers in general because it is devoted almost 
entirely to the problems of the hearing impaired and methods for 
ameliorating them. The book mentions tinnitus primarily as a precursor 
to hearing loss.  (I do not believe that is the general case.) 

The book _Tinnitus: Diagnosis/Treatment_ (Lea & Febiger, 1991, ISBN
0-8121-1121-4) adds that ototoxic symptoms may arise days or even weeks
after the termination of aminoglycoside antibiotics.  Some of these
aminoglycosides not listed above are Netilmycin and Erythromycin.  Other 
trouble antibiotics include Colistimethate, Doxycycline and Minocycline.

-------------------------------------------------------------------------------

7) What is Meniere's Disease?

Meniere's is a very serious disease of the inner ear, resulting in extended
vertigo attacks, major hearing loss, and frequently tinnitus.  Here is one
sufferer's story:

>What are the symptoms?

In my case it started with a constant fullness in my right ear and the
constant ringing. I also noticed I wasn't hearing very well and I was
having some vertigo attacks.

Originally I had my Allergist treat me. She thought it might just be an
inner ear infection or a sinus infection. It manifested itself in the fall
which is one of my worst allergy seasons.

By Spring she referred me to an ENT.

>What tests would a physician do to diagnose it?

First was a hearing test. This was followed by an MRI to ensure there
wasn't a tumor to deal with. There was also the physical to ensure there
was no other underlying cause, including Diabetes. Then being referred to a
surgeon who specializes in this kind of thing. He did further hearing tests
and another test which I will have to get the name for you. It consists of
lights on the wall that you follow with your eyes. They also insert warm
and cold water into each ear (ENG/AU test) to measure the response; a short
vertigo spell is the result for healthy ears. There is also a special set of 
hearing tests that they do.
 
>Are there any known environmental causes, or is it one of those things that
>"just happens" to people?

One possible cause is Diabetes. Other than that no one that I have spoken
with knows. It may also be hereditary. Usually doesn't show up until later
in life 40 and beyond, and can burn itself out in 3 - 5 years. Some have it
earlier in life (me at 35) and could have it the rest of our lives.

>What are the common treatments?  Anti-vertigo drugs?  Surgical operations on
>the inner ear balance mechanisms?

The most common treatment for mild episodic Meniere's I guess would be to
rule out Diabetes and allergies. For the vertigo attacks usually the
prescription drug Antivert is used or the over the counter drug Meclizine.
Both tend to relive the vertigo. For more chronic cases a low dosage of
Valium can help. When things get bad enough the next procedure is an
Endolymphatic Transmastoid Shunt. This helps to keep some of the pressure
of the inner ear. Changes in diet can help. Removal of  sodium, caffeine and
alcohol can help. Usually a mild diuretic is prescribed.

I know of several folks who keep it under control with allergy shots and
restricting their sodium intake.

If it progresses to a point where the patient can no longer 'live' with it
an Eighth Nerve Section can be done. But according to my surgeon this is an
absolute last resort. It guarantees deafness in the ear and some patients
report balance problems at night. He also claims the risks are high with
this procedure including partial face paralysis.
 
>In general, imagine yourself back when you first encountered Meniere's.  What
>kind of summary info would have been helpful to you?

Knowing that it can be treated with medication and there is the hope that
it will burn itself out keeps me going. There does seem to be a connection
with the tinnitus and the Meniere's. I have noticed over the last two years
that the tinnitus gets worse and my hearing decreases prior to a vertigo
episode or series of vertigo episodes. 25mg of Meclizine usually has the
vertigo under control in 20 - 30 minutes for a mild attack. A severe attack
can leave you completely disoriented such that there is no real up or down.
An attack this severe usually has bouts of nausea and vomiting with it. I
find lying down in a quiet dark room helps while the medicine kicks in.
Anti-nausea drugs can help. In my case when I have had a severe episode I
usually feel 'out-of-sorts' for a couple of days.

If you experience pretty intense tinnitus coupled with vertigo and the
inability of hold your eyes steady on an object I would suggest seeing an
ENT who knows about Meniere's. I have found that it is not well known or
understood.

-------------------------------------------------------------------------------

8) What is hyperacusis?

Hyperacusis is an extreme sensitivity to sound, where even small sounds are
perceived as painfully strong.  Usually occurs in combination with tinnitus.
May also be a side effect of certain ear/skull surgeries.

Information describing hyperacusis can be found in the ATA pamphlet
"Hyperacusis - A life-altering supersensitivity to sound".  Available
by writing or phoning them at the place listed in this FAQ.

Hyperacusis is like tinnitus in that severity and ways it exhibits itself
varies.  Severity can be as low and a mild annoyance to normal sounds
to the point where maximal ear protection cannot stop the sound of something
like a mini computer disk drive whine from causing great pain.  It differs
from recruitment, where only loud sounds are uncomfortable, in that *all* 
sounds are uncomfortable.  Apparently the ear's volume regulation system
from efferent nerve fibers lose control and the ear's "volume knob" is 
broken on maximum.  There is some overlap between hyperacusis and tinnitus.
Some tinnitus sufferers have some hyperacusic symptoms.  Further damage
might take them toward full blown hyperacusis.  Hyperacusis is caused 
almost always by loud sound, usually music.  Usually no hearing loss occurs
in the hyperacusic person.

-------------------------------------------------------------------------------

9) What drugs, vitamins, and herbs are available for treating tinnitus?

- niacin

Niacin supplements produce a temporary flushing effect that is supposed to 
pump more oxygen into the inner ear due to vasodilation.  Take niacin on an 
empty stomach for best results.  You may experience a flush ranging from a
mild sunburn to wondering about spontaneous skin combustion.  ;-)  You may
also experience a "dry mouth" sensation.

MEGADOSES OF NIACIN CAN DESTROY YOUR LIVER AND KILL YOU.  50mg twice per day
is a common dose for tinnitus.  If you experience the flush, then you are
getting the maximum benefit.

Some people report good results from niacin, other people gain nothing.  Your
mileage may vary.

- lecithin

The following anecdotal report advocates lecithin in combination with niacin
[Ed. note: my nutrition book does not cover lecithin, so I cannot speculate as 
to toxicity and side-effects]:

   After reading the tinnitus faq I emailed to my father, he replied that
he has helped a number of people cure their own tinnitus by using
Niacin and Lecithin.  His theory is that the lecithin, being an emulsifier, 
helps disperse the build up of fats in the capillaries, and the niacin
helps dilate the capillaries to let the lecithin in.
   He had meier's [sic - Meniere's?] syndrome in the 70's, and cured it this 
way.  Our neighbor, a police officer, retired on disability for the same
reason, and Dad practically cured him that way.
   I got tinnitus as a result of childhood ear infections, and it
has done nothing for me, but then, mine is not what I would call
irritating.
   It does seem that after chelation, the noise is less.

- gingko biloba

Gingko biloba leaves have been used therapeutically by the Chinese for
centuries for the treatment of asthma and bronchitis.  In western countries
a standardized 50:1 concentrate of 24% gingko flavoglycosides is used, either
in liquid or capsule form.  Gingko has been shown to increase circulation
throughout the body and the brain.

The article "Ginkgo biloba", The Lancet, Vol 340, Nov 7, 1992, pp. 1136-1139,
examines numerous studies on the efficacy of ginkgo on intermittent 
claudication (pain while walking), and cerebral insufficiency, a wide 
collection of vascular impairment symptoms including tinnitus.  Typical
dosages range from 120-160mg per day, divided equally at meal time.

Most studies showed that between 30-70% of subjects had reduced symptoms over
a 6-12 week period.  No serious side effects were observed, and any minor side
effects were not statistically significant compared to subjects treated only
with placebo.

Other references on gingko biloba:

As to tinnitus, Hobbs in reference (1) says:

   For example, in 1986 a study statistically proved the effectiveness of
   treatment with ginkgo extract for tinnitus: the ringing completely
   disappeared in 35% of the patients tested, with a distinct improvement in
   as little as 70 days!(2)

   Similarly, when 350 patients with hearing defects due to old age were
   treated with ginkgo extract, the success rate was 82%. Furthermore, a
   follow-up study of 137 of the original group of elderly patients 5 years
   later revealed that 67% still had better hearing(3).

                           References

 1.) Ginkgo Elixir of Youth; Christopher Hobbs; Botanica Press, Box 742,
     Capitola, CA 95010; 1991; pages 50-51

 2.) Tinnitus-multicenter study. A multicentric study of the ear; Meyer, B.;
     1980; Ann. Oto-Laryng. (Paris) 103:185-8

 3.) Tebonin-therapy with old hard-of-hearing people. Koeppel, F. W.; 1980;
     Therapiewoche 30: 6443-46

Here's an abstract of a recent paper in Audiology:

Holgers KM; Axelsson A; Pringle I
Ginkgo biloba extract for the treatment of tinnitus.
Department of Audiology, Sahlgren's Hospital, Goteborg, Sweden.
Language:  Eng
Source:  Audiology 1994 Mar-Apr;33(2):85-92
Unique Identifier:  94234927

Abstract:

Previous studies have shown contradictory results of Ginkgo biloba extract
(GBE) treatment of tinnitus. The present study was divided into two parts:
first an open part, without placebo control (n = 80), followed by a
double-blind placebo-controlled study (n = 20). The patients included in the
open study were patients who had been referred to the Department of Audiology,
Sahlgren's Hospital, Goteborg, Sweden, due to persistent severe tinnitus.
Patients reporting a positive effect on tinnitus in the open study were
included in the double-blind placebo-controlled study (20 out of 21 patients
participated). 7 patients preferred GBE to placebo, 7 placebo to GBE and 6
patients had no preference. Statistical group analysis gives no support to the
hypothesis that GBE has any effect on tinnitus, although it is possible that
GBE has an effect on some patients due to several reasons, e.g. the diverse
etiology of tinnitus. Since there is no objective method to measure the
symptom, the search for an effective drug can only be made on an individual
basis.

- anti-depressants, tranquilizers, and muscle relaxants

Many tinnitus sufferers become depressed from having to deal with the constant
noise.  Treating the depression may make the tinnitus seem less severe.  But
beware that certain ototoxic anti-depressants may _worsen_ tinnitus.

Tricyclic anti-depressants, such as Nortriptyline and benzodiazepines, such as 
Alprazolam (Xanax) were used in one study in which some people reported 
improvement.
 
Possible reasons:
 
(1) Patients just think they feel better.
 
(2) Since these drugs are central nervous system depressants, auditory 
    responsiveness diminishes.
 
(3) Tinnitus is stress-related - i.e. muscle tension in neck & jaw
    restricts blood and lymph flow.
 
Alprazolam (Xanax)

A double-blind study with placebo control showed 76% of the subjects benefited
with tinnitus reductions of at least 40%, whereas only 5% of the placebo
subjects had an improvement.  Try 0.5mg at bedtime.  Can be addicting, and may
make you feel excessively mellow.

Klonopin

Same class of drug as Xanax, but somewhat less effective and less addictive.

A word of warning:

Big-time antidepressants like the tricyclics and Prozac cannot be
expected to have an effect if the tinnitus sufferer does not suffer
from an affective disorder originating in brain chemistry.  Minor
tranquilizers may help.  But people should beware of trusting their
friendly local internist/GP to prescribe drugs of this type.  Current
knowledge of psychopharmacology is essential.  GP prescriptions of
these drugs have messed up more facets of people's lives than just
their hearing.

- anti-convulsants

Carbamazepine (Tegretol), phenytoin (Dilantin), primidone (Mysoline), valproic
acid (Depakene) have all shown some effectiveness in reducing tinnitus.  But
there is no standard dosage for tinnitus applications, and some of these drugs
may cause serious side-effects that require careful monitoring via blood
chemistry and other tests.

- intravenous lidocaine

An initial injection of lidocaine followed by an IV drip may provide temporary
relief to some sufferers.

- tocainide hydrochloride

This is an oral relative of lidocaine thought to act in a similar manner.

- histamine

On p.32 of Conn's Current Therapy, 1994, W.B. Saunders Co., MDs Jack C. Clemis
and Sally McDonald write "The authors' choice for pharmacotherapy is histamine.
In a study awaiting publication, nearly 70% of patients treated with histamine
achieved complete or partial resolution of their symptoms."

- anti-histamine

[Ed. note: Yes, I realize this is in contradiction with the above paragraph.]
The theory is that the mild sedative effect eases anxiety, and that mucous 
reduction allows the inner ear to dry out, thus relieving cochlear pressure.

- meclizine

This is an over-the-counter (USA) anti-vertigo drug.  While it is obviously 
relevant to the severe vertigo that comes with Meniere's, there was one
anecdotal report submitted to this FAQ by a tinnitus sufferer who did not
_have_ vertigo but took meclizine to successfully reduce his tinnitus.

- DMSO

The following appeared in a recent article in Alternatives regarding tinnitus:

"Ask your doctor to review the following article, Annals of the New 
York Academy of Sciences  75:243:468:74.  'In this study,15 patients were 
suffering from tinnitus. Every four days 2 milliliters of a medicated DMSO
solution containing anti-inflammatory and vasodilatory compounds were applied
locally to the external auditory canals of their ears.  They were also given
an intramuscular injection of DMSO at the same time.

'After one month, 9 of the 15 patients had a total cessation of the tinnitus 
and it didn't return during the one year observation period. It was diminished 
in two others and in the remaining four it became only an occasional problem 
instead of permanent (cold temperatures seemed to be the main factor causing 
it to return).

'In addition, all of the five patients that were suffering from vertigo noted
significant improvement...'

- vinpocetine

The following is an anecdotal report concerning vinpocetine, a drug that is
NOT registered in the United States.  A search of the Physician's Desk
Reference and several CDROM databases turned up nothing on the drug or its
manufacturer.  Be skeptical, but also remember that some of today's wonder 
drugs were once new and unregistered.  Judge for yourselves:

	I started taking vinpocetine (a nootropic drug available
mail-order from Europe) a couple months ago, and my tinnitus (due to
listening to a walkman for the entire eighties) is now almost gone.
Occasionally the tinnitus will re-occur, but I think that's due to what
I happen to be eating (or not eating) that day, as the FAQ states. 

	In short, vinpocetine cured what I thought was incurable, and made
me a whole-lot happier -- especially since I'm in the music industry and
depend on my ears.

	From what I understand, vinpocetine repairs damaged nerve cells,
among other things. There are no side effects -- you don't notice anything
while taking it except that you may remember things better, and your
tinnitus may improve.

	"VINPOCETINE: A side effect free synthetic derivative of
vincamine. Vinpocetine is three to four times as potent as vincamine at
improving cerebral circulation and overall is OVER TWICE as potent as
vincamine in humans. Vinpocetine has wide ranging effects and can be used
to improve memory, treat stroke, menopausal symptoms, macular
degeneration, impaired hearing and tinnitus. The usual oral starting dose
is 1-2 tablets three times daily, to be followed by a maintenance dose of
1 tablet three times daily for a longer period of time. Vinpocetine has
not been reported to interact with other drugs and may be used in
combination." -- 'Recommended Dosages' sheet from Interlab.

	You can order vinpocetine by sending a letter to Interlab asking
for an order form. Currently, vinpocetine is US$26 for 100 tablets. For
Canadians, you can only order a three month personal supply at a time. For
Americans, you may need a doctor's prescription, and can only order a
three month personal supply at a time. Call your government's "Customs"
agency, or "Food and Drug" administration to be sure.

	Interlab
	BCM box 5890
	London
	WC1N 3XX
	England

> How did you find out about vinpocetine?  Did you explicitly try it for
> tinnitus, or was it for some other condition and the tinnitus cure was an
> unexpected side-effect?  Did a doctor recommend it to you?

	I read about it in a document regarding drugs that the FDA won't 
approve because they don't consider the problem the drug cures important 
enough (such as tinnitus.) It was on the net somewhere -- I don't have it.

	I got it specifically for tinnitus. A doctor didn't recommend it 
-- I "prescribed" it to myself. I have a degree is psychology, so I'm not 
completely in the dark as to its effects.	
 
> The literature from the manufacturer almost has that "too good to be true" 
> ring to it.  Have you ever seen any other literature on this drug that 
> didn't come from the manufacturer?

	Nothing really substantial, except personal reports from people 
who say it works with them.

> Do you have any info regarding undesirable side-effects or toxicity levels?

	Non-toxic at any level, no side-effects. It's available OTC (Over 
The Counter) in Europe and South America. It is not available in North 
America because drug laws stipulate that a drug has to cure an existing 
condition before it can be approved. I guess tinnitus isn't a real 
problem to them. The only way we can find out if it really works is if 
several people try it and report back. I doubt tinnitus is something that 
placebo response can overcome, and I'm sure that if other peoples tinnitus 
was as annoying as mine, they'll jump at the chance to try vinpocetine.

- sodium fluoride

May be helpful when the tinnitus is due to cochlear otosclerosis.

- vasodilators

Vasodilators like niacin, gingko biloba, and prescription drugs for 
hypertension increase blood flow inside the skull, raising the oxygen
available for good nerve health.

- zinc

The cochlea has the body's greatest concentration of zinc.  Supplements of
90-150 mg per day may be beneficial in some cases.  BUT BEWARE: high levels
of zinc interfere with the body's absorption of copper, leading to anemia.
Several studies have identified the 150mg dosage as leading to toxicity
problems.  Zinc therapy when prescribed by physicians is often accompanied
by frequent blood tests to monitor copper levels.

- diuretics

Diuretics may be prescribed when Meniere's Disease is present.  One
contributor reported tinnitus relief from Dyazide.  But be aware that some
diuretics are ototoxic and can worsen or even cause tinnitus.

-------------------------------------------------------------------------------

10) What other treatments are available for tinnitus?

- surgery

For tinnitus caused by acoustic neuromas, vascular abnormalities, and TMJ
syndrome.  But note above in the Causes section that tinnitus, hyperacusis,
or even profound deafness can _result_ from ear/skull surgery.

- maintain a healthy diet & lifestyle

This means no tobacco, no alcohol, no caffeine, low fat, low sodium.  This may
not cure your tinnitus, but there are other well-proven health benefits.  Other
less obvious foods like quinine/tonic water should also be avoided.

- biofeedback

Useful as a stress reduction tool, biofeedback may help some people.

*****[comments from someone who's been there?]*****

- accupuncture

May provide temporary relief to some people.  One contributor reports
significant relief that enabled him to avoid the heavy-duty anti-depressants
that his Western physician had prescribed.

- stress reduction

Many people say their tinnitus is more active when they're tired and stressed
out.  Get a good night's sleep and avoid unnecessary stress.

- hearing aids

Some people with severe tinnitus may benefit from hearing aids that bring
normal speech sounds above the background tinnitus sounds.

- cranial sacral therapy

There is anecdotal evidence of help for tinnitus through cranial sacral
therapy by osteopaths and chiropractors.

- electrical stimulation

Various electrode placements with various voltages & frequencies may provide
some relief.  External, ear canal, transtympanic, middle ear, and cochlear
electrodes have all been tried.  Side effects may include pain, and 
alterations to sense of taste & smell.

- surgically severing the auditory nerves

The treatment of last resort.  You will be totally deaf.  But beware - if
your tinnitus originates somewhere inside the brain, you will be totally deaf
AND still have tinnitus.

-------------------------------------------------------------------------------

11) What is masking?

Masking is the technique of producing external "white noise" sounds that will
mask the tinnitus and make it less distracting.  Masking machines come in both
in-the-ear and portable models that produce sounds ranging from random white
noise to waterfalls to surf, etc.  Many people find that tuning a regular FM
radio to an empty frequency and listening to the static beneficial.  Another
popular method is to run an electric fan.  If you have an audio CD player,
consider putting on a nature sounds (ocean, jungle, whales, etc) CD in auto-
repeat mode before going to bed.  Some masking machine vendors:

Ambient Shapes, Inc.
P.O. Box 5069
Hickory, NC  28603
USA
+1 800 438 2244
+1 704 324 5222

Product #1550, the Marsona Tinnitus Masker.  An external masker with over
3000 settings.  US$249.

The Sharper Image
650 Davis Street
San Francisco, CA  94111
USA
+1 800 344 4444

Product #SI420, Portable Sound Soother, US$120, and product #SI430, Digital
Sound Soother XS, US$170 (same as previous product but includes an AM/FM
radio).  Both products feature alarm clocks and three classes of sound: White 
Noise, Seaside, and Countryside.  You get primary sounds such as waves and 
crickets, plus random auxilary sounds such as fog horns, buoy bells, doves, 
owls, etc.  Both the primary and auxilary sounds have independently adjustable 
volume.  [Ed. note: my mother is a satisfied PSS user.]

*****[insert masker models, prices, manufacturers, phone numbers here]*****

-------------------------------------------------------------------------------

12) What types of earplugs or other hearing protection are available?

Wearing ear plugs protects your ears from new damage as well as allowing them
to rest without external stimuli.  Noise attenuation may vary by frequency,
so if you're a musician you may want to shop around for ear protection with
fairly flat frequency response.  Hearing protection devices are assigned
Noise Reduction Ratings (NRRs) by their manufacturers under laboratory
conditions and may not reflect Real World performance.  Maximal noise reduction
(about 50dB NRR) can be achieved by wearing canal plugs in combination with 
muffs, but *some* noise will still be perceived via bone conduction of the 
skull in extremely loud situations.  The following classes of hearing 
protection devices are available:

- moldable ear canal plugs

Moldable ear plugs come in foam, silicone, and wax and fit into the ear canal
itself.  Because they are moldable, a tight fit is always obtained.  These are 
the best hearing protection devices available today, with NRRs ranging from 
15-33dB.  Cheap, available in drugstores, and reusable.

- custom ear plugs

These plugs are made from impressions taken of the customer's ear canal.  NRRs
range from 27-29dB, with the cost typically US$30-70.  You generally order
these through a hearing specialist who will take the impressions.

- filtered musician's ear plugs

A variation on custom plugs that offer even sound attenuation across a broad
spectrum of frequencies.  NRRs range from 15-20dB, and cost ranges from
US$50-150.

- ear muffs

These over the ear devices are more comfortable than canal plugs, and have
NRRs that range from 23-29dB.  But they are very bulky and obviously can't
be worn discretely.

- active sportsman's ear muffs

These are active (possibly amplifying), powered devices that pass normal 
levels of sound, but will attenuate extremely loud impulse-type noises similar 
to gunshots, etc.  They are typically sold through gun catalogs and sporting
goods stores, and when used in combination with plugs can achieve near-maximal
NRRs of about 50dB.

Note that amplified muffs actually have a negative NRR, which is one indication
that the NRR doesn't tell the whole story for "impulse" noise such as gunshots.
These muffs detect impulse noise and turn off the amplification in time to keep
that noise from reaching the ear through the electronics.  See below for a
first-hand account of active muff performance:

    Date: 16 Apr 1992   8:36 EDT
    Subject: Re: electronic muffs

    Having just purchased a set of Peltor Tactical 7-S active muffs from
    Dillon Precision,  I'll add my two cents to the conversation.

    The T7-S's are stereo electronic muffs with a microphone on the front of
    each ear cup.  They seem to be pretty sturdy in construction.  One cup
    contains a circuit board covered with surface-mount parts and some trim
    pots.  The other contains a nine-volt battery accessible from an outside
    door (there may also be a small circuit board in there, too).  Each
    contains a small speaker, and the two are connected via a cable that
    crosses through the headband.  There is a single gain control that is
    switched to provide the on/off function.  Side-to-side balance is
    adjustable by one of the trim pots.  A small concern I have is that the
    foam mic covers may come to harm while being jostled around in my range
    bag.

    I had originally thought (from where, I don't know) that the circuit
    amplified sound according to the gain control, and shut off completely
    noises above 85dB.  In fact, the unit never actually shuts down, or if
    it does the switching is so quick and quiet that it gets lost in the
    muffled sounds coming through the muff's cups.  There is constant
    compression, so that soft sounds are boosted, and loud sounds are
    limited to 85dB or less.  The effect is strange at first, because you
    don't think there's much muffling being done, but believe me, you can
    find out real quick that the things work very well indeed.

    I used the muffs at an outdoor .22 silhouette match, then later in the
    day at a large indoor range where we were shooting .45 ACP and light .44
    mag loads.  At the match, they worked great.  I could hear the spotters,
    the range officer, and all the others.  I really didn't have a problem
    with distractions as another poster stated.  The only "problem" I had
    was that at high gain I could easily hear the road noise of cars and
    trucks passing by about a quarter-mile away.  The muffs seem to preserve
    directional information, since I don't remember having any problems
    locating sounds (like the CLANK when a ram fell over 100 yards away).

    The indoor range seemed a little different.  Gunshots sounded a bit more
    veiled, whereas outdoors they just sounded lower in intensity.  Voices
    were still easy to hear, but also sounded funny, so it was probably the
    echo in the large room.  For grins, I tried the T7-S's at the indoor
    range without turning the active circuitry on, and swapped back and
    forth between them and some Silencio Magnum CDS-80 passive muffs (rated
    at -29dB -- my previous regular muffs).  In an inactive state, the
    TS-7's were at least as effective as the Silencios.  Further, the sound
    of the shots was perceived as being about an octave lower through the
    inactive T7-S's than through the Silencios.  This was much more pleasant
    over the long run.  In fact, my buddy, who was also wearing CDS-80's,
    said that his ears were starting to hurt by the end of our indoor range
    time.  Mine were fine.  (BTW, said buddy tried the T7-S's for a few
    minutes at each place -- he's ordering his today.)

    I tried sitting in a very quiet room with the muffs turned way up.  I
    could hear my dog breathing in another room, and ripples on the surface
    of a small, nearby aquarium sounded like a set of river rapids.  I could
    hear my own breathing quite clearly, and the cloth of my shirt rustling
    as it rose and fell.  At really high gain, there was some whitish noise
    that was either the residual noise of the amplifiers, or the movement of
    air in the room.

    The muffs are very comfortable.  I wore them most of the day with no
    problem.  The ear seals are soft yet firm, and are probably more
    comfortable than the Magnum CDS-80's.  The seals and inner foam pads are
    easily removable and replaceable.  The rather sparse instruction manual
    suggests replacing them once or twice a year for hygienic reasons.

    All in all, I really like these muffs.  It would be difficult to go back
    to passive protection after being able to hear "normally" while
    shooting.  Dillon currently has the T7-S's on sale for $129.95.  Regular
    price is $170.  I have no connection with Dillon or Peltor save being a
    satisfied customer.

And an addendum to the above account:

    Date:  5 Jul 1994  13:39 EDT
    Subject: Re: muffs review

    The battery should be a nine-volt alkaline, and it will
    probably last 10-30 hours (depending on gain setting used) before you'll
    notice a drop in volume.  I have used the muffs while mowing (with a
    gasoline-powered mower), and with noisy power tools (like a circular
    saw), and they really help.  Your ears do get a bit warm and sweaty on
    a hot day, however.  Finally, I have seen pictures of new(?) Peltor
    muffs on which the foam mic covers were replaced by hard plastic grids.
    These might be an improvement.

Some hearing protection vendors:

Westone Labs
P.O. Box 15100
Colorado Springs, CO  80935
USA
+1 800 525 5071

Sells custom plugs.

Dillon Precision Products
7442 E. Butherus Drive
Scottsdale, AZ 85260-2415
USA
+1 800 762 3845 for Catalog requests
+1 800 223 4570 for Sales

Praised on rec.guns have been the "Max" earplugs and Peltor Ultimate 10 muffs.
Dillon's "stealth" catalog, The Blue Press is available at no charge

*****[product #, price, manufacturer, phone number, NRRs?]*****

-------------------------------------------------------------------------------

13) What organizations can I turn to for more information?

The following organizations all support tinnitus/hearing research and provide 
information for tinnitus sufferers.  Frequently they are the sole force
behind tinnitus research in their home countries.  Joining one of these
organizations in the best thing that you can do so that research towards
a cure will be funded.

United States
-------------
American Tinnitus Association
P.O. Box 5
Portland, OR  97207-0005
USA
+1 503 248 9985

Funds research, does lobbying, provides information, educates the public, has
professional referrals by region.  US $25 per year, check, VISA, MasterCard.

H.E.A.R. (Hearing Education and Awareness for Rockers)
P.O. Box 460847
San Francisco, CA  94146
USA
+1 415 773 9590

This is the H.E.A.R. ad from Bass Player Magazine:

CHANGE THE COURSE OF MUSIC HISTORY

Hearing loss has altered many careers in the music industry.
H.E.A.R. can help you save your hearing. A non-profit organization
founded by musicians and physicians for musicians and other music
professionals, H.E.A.R. offers information about hearing loss, testing,
and hearing protection. For an information packet, send $10.00 to:
H.E.A.R.  P.O. Box 460847 San Francisco, CA 94146
or call the H.E.A.R. 24-hour hotline at (415) 773-9590.

(small print at bottom):
Musicians speak out about hearing loss. A video made exclusively for
H.E.A.R., "Can't Hear You Knocking" c1990 Flynner Films, 17 minute VHS,
featuring Ray Charles, Pete Townshend, Lars Ulrich and other music industry
professionals spotlight the dangers and effects of hearing loss.
Send $39.95 plus S&H, $5 US/$10 Over seas to: (above address).
All donations are tax-deductible.

(even smaller print):
"CHYK" 55 minute VH-S. The Cinema Guild, NY.

Don't ask me why they first say the video is 17 minutes, then at the
bottom they say it's 55 minutes.

*****[Other orgs & countries needed; let's hear from you Canadian & 
European lurkers]*****

-------------------------------------------------------------------------------

14) What books can I turn to for more information?

Tinnitus: Diagnosis/Treatment
Abraham Shulman, M.D.
Lea & Febiger, 1991
ISBN 0-8121-1121-4

This is a several hundred page medical book covering all aspects of tinnitus.
It was used to confirm most of the medical statements in this document, and
is highly recommended.

-------------------------------------------------------------------------------

15) What online resources are available?

On the Internet, the Usenet newsgroup alt.support.tinnitus is the primary
discussion forum.  Several other peripheral newsgroups exist where people at
risk for tinnitus may be found, as well as for various health disciplines
relevant to the treatment of tinnitus.  See the Newsgroups: header of this
FAQ for details.

-------------------------------------------------------------------------------

16) What can I do when all else fails?

What caused my tinnitus?  Everyone asks that question.

For some of us, there was an illness, injury, or incident that seems
directly related to the onset of tinnitus.  I'm not sure how valuable
being able to answer this question is, but at least it seems to be
answered. 

For others, the onset is sudden, but for no obvious reason.  For these
people, it may be frustrating not knowing "why" but I'm not sure of the 
value of dwelling on this question. 

For others like myself, the onset was gradual, over the years.  Then, 
about a year ago, the pace of the onset increased to where I am now aware 
100% of the time that it's there.  If I'm active, I don't notice it.  But 
if there's a lull in my mental or physical activity or if I think about 
it, it's there.

The point I want to make with this post is:  Just as "Sh-t Happens", I'm
afraid "Tinnitus Happens", too.  And we're the victims, albeit to widely
varying degrees. 

Unless it can provide a path towards treatment (and only your doctor can
determine this), I don't think it is useful to dwell heavily on the "why". 

In my case, I fired shotguns with no ear protection when I was a kid & I
listened to some too-loud music a few times.  But that's all irrelevant
now. 

I've got tinnitus.  At present, there's no known treatment for me.  So, 
here's what I'm doing about it:

1. I accept that I have tinnitus and I've dispensed with "why".

2. I recognize that it is my problem, not the problem of my friends,
   family, & business associates.  I don't complain about it to
   anyone.

3. If, because of my tinnitus, I need to ask someone to repeat themselves,
   I simply ask.  No apologies, no explanations.

4. I will monitor my need to ask for repeats.  If I have an underlying hearing
   loss, I may need a hearing aid.  As unattractive to me as getting a
   hearing aid may be, it is my responsibility to have my hearing evaluated
   & take appropriate measures.  It is not the responsibility of the people
   around me to act as hearing aids.

5. I will attempt the various herbal remedies, giving them enough time to
   see if they're effective.  However, for my own sanity, I will accept my 
   present condition as the "zero base line".  If a remedy helps, that's a 
   "plus".  If it doesn't, I remain at the baseline.  In other words, 
   failure to be helped by a possible treatment is not a negative.  I 
   will not allow disappointment or despair at a treatment failure to
   get me down.

6. Whatever the seriousness of my tinnitus, I will remember that others
   have it much worse & still others have just been diagnosed.  These
   are the people who need my support and encouragement.  I will offer
   it when I meet them and by posting to this newsgroup.  I realize
   that by helping others, I am also helping me.

Comments always welcome.

-------------------------------------------------------------------------------

17) Where did the medical advice in this FAQ come from?

With only one small exception, none of the contributors to this FAQ are
physicians.  Contributor advice that cannot be confirmed in tinnitus books
written by M.D.s has been labelled anecdotal.  Use any of this information,
anecdotal or not, strictly at your own risk.

-------------------------------------------------------------------------------

18) Who are the contributors to this FAQ?

Unless otherwise requested, all contributors will be credited here.

Mark Bixby		markb@cccd.edu (FAQ Maintainer)

Barbara Bixby		markb@cccd.edu
Julie Bixby		markb@cccd.edu
Karl F. Bloss		blosskf@ttown.apci.com
Pete Brooks		Peter_Brooks@sj.hp.com
W. Keith Brummet	wkb@cblph.att.com
David Charlap		david@porsche.visix.com
Erik Christensen	erchrist@char.vnet.net
Michael Claes		claes@bbt.com
Scott Dayman		scott@ida.jpl.nasa.gov
Bob Dubin, DC		drdubin@aol.com
Steve Gotthardt		steveg@up.edu
Doug Gwyn		gwyn@arl.mil
Norman F. Johnson	njohnson@nosc.mil
Douglas R. Jones	djones@iex.com	
Rob McCaleb		rmccaleb@hrf.org
Paul Murphy		pmurphy@carbon.denver.colorado.edu
John Setel O'Donnell	jod@equator.com
Mark A. Pitcher		sols7520@mach1.wlu.ca
Dallas Roark		roark@kuhub.cc.ukans.edu
Mark Sharp		mvsharp@tenet.edu
Chandra Shekhar		chandy@sophia.inria.fr
Jeff Slavitz		jslavitz@netcom.com
Lori Snidow		lnsnidow@ufcc.ufl.edu
Kurt Strain		kurts@sr.hp.com
Jack Trainor		jdt@well.sf.ca.us
Allen Watson		allen_watson@quickmail.apple.com
Mike Watterson		watterson@stsci.edu
Steve Zimmerman		stevezim@crl.com
-- 
Mark Bixby                         Internet: markb@cccd.edu
Coast Community College District   1370 Adams Avenue
District Information Services      Costa Mesa, CA, USA  92626
Technical Support                  (714) 432-5064
"You can tune a file system, but you can't tune a fish." - tunefs(1M)


