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Auditory and Vestibular Pathways: Anatomy

Auditory and Vestibular Pathways: Anatomy

The auditory and vestibular pathways are anatomically related but discrete pathways that permit conscious perception Perception The process by which the nature and meaning of sensory stimuli are recognized and interpreted. Psychiatric Assessment of and reaction to sound and spatial orientation Spatial orientation Change in position or alignment in response to an external stimulus. Psychiatric Assessment. Stimulation of specialized hair cells in the cochlea Cochlea The part of the inner ear (labyrinth) that is concerned with hearing. It forms the anterior part of the labyrinth, as a snail-like structure that is situated almost horizontally anterior to the vestibular labyrinth. Ear: Anatomy and vestibular apparatus excite and send signals through partitions of the vestibulocochlear nerve Vestibulocochlear nerve The 8th cranial nerve. The vestibulocochlear nerve has a cochlear part (cochlear nerve) which is concerned with hearing and a vestibular part (vestibular nerve) which mediates the sense of balance and head position. The fibers of the cochlear nerve originate from neurons of the spiral ganglion and project to the cochlear nuclei (cochlear nucleus). The fibers of the vestibular nerve arise from neurons of scarpa's ganglion and project to the vestibular nuclei. The 12 Cranial Nerves: Overview and Functions (CN VIII) to the brainstem, where they synapse Synapse The junction between 2 neurons is called a synapse. The synapse allows a neuron to pass an electrical or chemical signal to another neuron or target effector cell. Synapses and Neurotransmission on various targets, send and receive other projections, and ultimately contribute to spatial orientation Spatial orientation Change in position or alignment in response to an external stimulus. Psychiatric Assessment and perception Perception The process by which the nature and meaning of sensory stimuli are recognized and interpreted. Psychiatric Assessment of sound.

Last updated: 5 Apr, 2022

Editorial responsibility: Stanley Oiseth, Lindsay Jones, Evelin Maza

Contents

Auditory Pathway

The auditory pathway of the brain Brain The part of central nervous system that is contained within the skull (cranium). Arising from the neural tube, the embryonic brain is comprised of three major parts including prosencephalon (the forebrain); mesencephalon (the midbrain); and rhombencephalon (the hindbrain). The developed brain consists of cerebrum; cerebellum; and other structures in the brain stem. Nervous System: Anatomy, Structure, and Classification begins with the external auditory canal External Auditory Canal Otitis Externa and includes the middle/ inner ear Inner ear The essential part of the hearing organ consists of two labyrinthine compartments: the bony labyrinthine and the membranous labyrinth. Ear: Anatomy and eventually the brainstem nuclei before sending final signals to the primary auditory cortex Primary auditory cortex The region of the cerebral cortex that receives the auditory radiation from the medial geniculate body. Cerebral Cortex: Anatomy in the temporal lobe Temporal lobe Lower lateral part of the cerebral hemisphere responsible for auditory, olfactory, and semantic processing. It is located inferior to the lateral fissure and anterior to the occipital lobe. Cerebral Cortex: Anatomy.

Components

  • Peripheral components:
    • Outer ear Outer ear The outer part of the hearing system of the body. It includes the shell-like ear auricle which collects sound, and the external ear canal, the tympanic membrane, and the external ear cartilages. Ear: Anatomy:
      • Auditory canal and tympanic membrane Tympanic membrane An oval semitransparent membrane separating the external ear canal from the tympanic cavity. It contains three layers: the skin of the external ear canal; the core of radially and circularly arranged collagen fibers; and the mucosa of the middle ear. Ear: Anatomy
      • Transfers sound waves 
    • Middle ear Middle ear The space and structures directly internal to the tympanic membrane and external to the inner ear (labyrinth). Its major components include the auditory ossicles and the eustachian tube that connects the cavity of middle ear (tympanic cavity) to the upper part of the throat. Acute Otitis Media:
      • Airspace with 3 ossicles (malleus, incus, stapes)
      • Conducts and amplifies sound
    • Inner ear Inner ear The essential part of the hearing organ consists of two labyrinthine compartments: the bony labyrinthine and the membranous labyrinth. Ear: Anatomy:
      • Fluid-filled cochlea Cochlea The part of the inner ear (labyrinth) that is concerned with hearing. It forms the anterior part of the labyrinth, as a snail-like structure that is situated almost horizontally anterior to the vestibular labyrinth. Ear: Anatomy
      • Tonotopy of basilar membrane: low frequency heard at apex and high frequency heard at base
      • Vibration Vibration A continuing periodic change in displacement with respect to a fixed reference. Neurological Examination transduced via hair cells → auditory nerve signaling (CN VIII) → brainstem
  • Central components:
    • Consist of the organ of Corti and brainstem auditory nuclei
    • Afferent Afferent Neurons which conduct nerve impulses to the central nervous system. Nervous System: Histology fibers convey information from the organ of Corti → auditory nuclei in the brainstem:
      • Cochlear nuclei: located at the dorsolateral side of the brainstem at the pontomedullary junction
      • Superior olivary nuclei: located in the pons Pons The front part of the hindbrain (rhombencephalon) that lies between the medulla and the midbrain (mesencephalon) ventral to the cerebellum. It is composed of two parts, the dorsal and the ventral. The pons serves as a relay station for neural pathways between the cerebellum to the cerebrum. Brain Stem: Anatomy
      • Lateral lemniscal nuclei: tract of axons Axons Nerve fibers that are capable of rapidly conducting impulses away from the neuron cell body. Nervous System: Histology in the brainstem carrying auditory information to the inferior colliculus Inferior colliculus The posterior pair of the quadrigeminal bodies which contain centers for auditory function. Brain Stem: Anatomy of the midbrain Midbrain The middle of the three primitive cerebral vesicles of the embryonic brain. Without further subdivision, midbrain develops into a short, constricted portion connecting the pons and the diencephalon. Midbrain contains two major parts, the dorsal tectum mesencephali and the ventral tegmentum mesencephali, housing components of auditory, visual, and other sensorimotor systems. Brain Stem: Anatomy
      • Inferior colliculus Inferior colliculus The posterior pair of the quadrigeminal bodies which contain centers for auditory function. Brain Stem: Anatomy: located in the midbrain Midbrain The middle of the three primitive cerebral vesicles of the embryonic brain. Without further subdivision, midbrain develops into a short, constricted portion connecting the pons and the diencephalon. Midbrain contains two major parts, the dorsal tectum mesencephali and the ventral tegmentum mesencephali, housing components of auditory, visual, and other sensorimotor systems. Brain Stem: Anatomy
      • Medial geniculate body of the thalamus Thalamus The thalamus is a large, ovoid structure in the dorsal part of the diencephalon that is located between the cerebral cortex and midbrain. It consists of several interconnected nuclei of grey matter separated by the laminae of white matter. The thalamus is the main conductor of information that passes between the cerebral cortex and the periphery, spinal cord, or brain stem. Thalamus: Anatomy: part of thalamic relay system
      • Auditory cortex: located in the anterior and posterior transverse temporal areas
Nuclei involved in auditory sensation

This image illustrates the nuclei involved in auditory sensation. Each of the parts plays an important role in the conduction of auditory information from CN VIII up to the cortex.

Image by Lecturio.

Circuitry of pathway

Outer ear Outer ear The outer part of the hearing system of the body. It includes the shell-like ear auricle which collects sound, and the external ear canal, the tympanic membrane, and the external ear cartilages. Ear: Anatomy → inner ear Inner ear The essential part of the hearing organ consists of two labyrinthine compartments: the bony labyrinthine and the membranous labyrinth. Ear: Anatomy → depolarization Depolarization Membrane Potential of cochlear hair cells in the cochlea Cochlea The part of the inner ear (labyrinth) that is concerned with hearing. It forms the anterior part of the labyrinth, as a snail-like structure that is situated almost horizontally anterior to the vestibular labyrinth. Ear: Anatomy → both the ipsilateral and contralateral superior olivary nucleus Nucleus Within a eukaryotic cell, a membrane-limited body which contains chromosomes and one or more nucleoli (cell nucleolus). The nuclear membrane consists of a double unit-type membrane which is perforated by a number of pores; the outermost membrane is continuous with the endoplasmic reticulum. A cell may contain more than one nucleus. The Cell: Organelles → lateral lemniscus → inferior colliculus Inferior colliculus The posterior pair of the quadrigeminal bodies which contain centers for auditory function. Brain Stem: Anatomy → medial geniculate bodies Geniculate Bodies Part of the diencephalon inferior to the caudal end of the dorsal thalamus. Includes the lateral geniculate body which relays visual impulses from the optic tract to the calcarine cortex, and the medial geniculate body which relays auditory impulses from the lateral lemniscus to the auditory cortex. Thalamus: Anatomy of the thalamus Thalamus The thalamus is a large, ovoid structure in the dorsal part of the diencephalon that is located between the cerebral cortex and midbrain. It consists of several interconnected nuclei of grey matter separated by the laminae of white matter. The thalamus is the main conductor of information that passes between the cerebral cortex and the periphery, spinal cord, or brain stem. Thalamus: Anatomy → auditory cortex of temporal lobe Temporal lobe Lower lateral part of the cerebral hemisphere responsible for auditory, olfactory, and semantic processing. It is located inferior to the lateral fissure and anterior to the occipital lobe. Cerebral Cortex: Anatomy

Pathway of sound

Image depicting the pathway of sound from the cochlea Cochlea The part of the inner ear (labyrinth) that is concerned with hearing. It forms the anterior part of the labyrinth, as a snail-like structure that is situated almost horizontally anterior to the vestibular labyrinth. Ear: Anatomy to the level of the auditory cortex with multilevel axial Axial Computed Tomography (CT) slices through the brainstem

Image: “Auditory Pathway” by Jonathan E. Peelle. License: CC BY 4.0

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Vestibular Pathway

The vestibular pathway of the brain Brain The part of central nervous system that is contained within the skull (cranium). Arising from the neural tube, the embryonic brain is comprised of three major parts including prosencephalon (the forebrain); mesencephalon (the midbrain); and rhombencephalon (the hindbrain). The developed brain consists of cerebrum; cerebellum; and other structures in the brain stem. Nervous System: Anatomy, Structure, and Classification begins with the utricle and saccule, with additional input from the semicircular canals. Information eventually reaches the brainstem nuclei before sending final signals to the thalamus Thalamus The thalamus is a large, ovoid structure in the dorsal part of the diencephalon that is located between the cerebral cortex and midbrain. It consists of several interconnected nuclei of grey matter separated by the laminae of white matter. The thalamus is the main conductor of information that passes between the cerebral cortex and the periphery, spinal cord, or brain stem. Thalamus: Anatomy and cerebellum Cerebellum The cerebellum, Latin for “little brain,” is located in the posterior cranial fossa, dorsal to the pons and midbrain, and its principal role is in the coordination of movements. The cerebellum consists of 3 lobes on either side of its 2 hemispheres and is connected in the middle by the vermis. Cerebellum: Anatomy.

  • Monitors the orientation Orientation Awareness of oneself in relation to time, place and person. Psychiatric Assessment of the body with respect to gravity and stimulates the vestibulospinal tracts to elicit compensatory movements
  • Head position relative to gravity is sensed by the 2 otolith organs Otolith Organs Vertigo, the utricle and saccule:
    • Utricle: oriented horizontally
    • Saccule: oriented vertically
  • Angular acceleration of the head is sensed by the 3 semicircular canals.
  • Hair cells in the utricle, saccule, and semicircular canals are displaced based on their position relative to gravity, leading to depolarization Depolarization Membrane Potential and stimulation of the vestibular portion of CN VIII.
  • Afferent Afferent Neurons which conduct nerve impulses to the central nervous system. Nervous System: Histology fibers of the vestibular apparatus convey information to 4 pairs of vestibular nuclei Vestibular nuclei The four cellular masses in the floor of the fourth ventricle giving rise to a widely dispersed special sensory system. Included is the superior, medial, inferior, and lateral vestibular nucleus. Vertigo (superior, lateral, inferior, and medial) in the medulla and pons Pons The front part of the hindbrain (rhombencephalon) that lies between the medulla and the midbrain (mesencephalon) ventral to the cerebellum. It is composed of two parts, the dorsal and the ventral. The pons serves as a relay station for neural pathways between the cerebellum to the cerebrum. Brain Stem: Anatomy.
    • Vestibular nuclei Vestibular nuclei The four cellular masses in the floor of the fourth ventricle giving rise to a widely dispersed special sensory system. Included is the superior, medial, inferior, and lateral vestibular nucleus. Vertigo inputs:
      • 1st-order afferents in vestibular ganglion
      • Cerebellum Cerebellum The cerebellum, Latin for “little brain,” is located in the posterior cranial fossa, dorsal to the pons and midbrain, and its principal role is in the coordination of movements. The cerebellum consists of 3 lobes on either side of its 2 hemispheres and is connected in the middle by the vermis. Cerebellum: Anatomy: flocculonodular lobe Flocculonodular lobe Cerebellum: Anatomy
    • Vestibular nuclei Vestibular nuclei The four cellular masses in the floor of the fourth ventricle giving rise to a widely dispersed special sensory system. Included is the superior, medial, inferior, and lateral vestibular nucleus. Vertigo outputs:
Intricate pathways of the vestibular system

This image demonstrates the intricate pathways of the vestibular system.
Note the flow Flow Blood flows through the heart, arteries, capillaries, and veins in a closed, continuous circuit. Flow is the movement of volume per unit of time. Flow is affected by the pressure gradient and the resistance fluid encounters between 2 points. Vascular resistance is the opposition to flow, which is caused primarily by blood friction against vessel walls. Vascular Resistance, Flow, and Mean Arterial Pressure of information. Depolarization Depolarization Membrane Potential of hair cells in the inner ear Inner ear The essential part of the hearing organ consists of two labyrinthine compartments: the bony labyrinthine and the membranous labyrinth. Ear: Anatomy sends auditory information to the vestibular ganglia, which transmits this information to the vestibular nuclei Vestibular nuclei The four cellular masses in the floor of the fourth ventricle giving rise to a widely dispersed special sensory system. Included is the superior, medial, inferior, and lateral vestibular nucleus. Vertigo (also receives input from the cerebellum Cerebellum The cerebellum, Latin for “little brain,” is located in the posterior cranial fossa, dorsal to the pons and midbrain, and its principal role is in the coordination of movements. The cerebellum consists of 3 lobes on either side of its 2 hemispheres and is connected in the middle by the vermis. Cerebellum: Anatomy).
From here, the vestibular nuclei Vestibular nuclei The four cellular masses in the floor of the fourth ventricle giving rise to a widely dispersed special sensory system. Included is the superior, medial, inferior, and lateral vestibular nucleus. Vertigo send information to CN III, IV, and VI to dictate eye movement. The vestibular nuclei Vestibular nuclei The four cellular masses in the floor of the fourth ventricle giving rise to a widely dispersed special sensory system. Included is the superior, medial, inferior, and lateral vestibular nucleus. Vertigo also send information to the thalamus Thalamus The thalamus is a large, ovoid structure in the dorsal part of the diencephalon that is located between the cerebral cortex and midbrain. It consists of several interconnected nuclei of grey matter separated by the laminae of white matter. The thalamus is the main conductor of information that passes between the cerebral cortex and the periphery, spinal cord, or brain stem. Thalamus: Anatomy, cerebellum Cerebellum The cerebellum, Latin for “little brain,” is located in the posterior cranial fossa, dorsal to the pons and midbrain, and its principal role is in the coordination of movements. The cerebellum consists of 3 lobes on either side of its 2 hemispheres and is connected in the middle by the vermis. Cerebellum: Anatomy, and medial and lateral vestibulospinal tracts, allowing for perception Perception The process by which the nature and meaning of sensory stimuli are recognized and interpreted. Psychiatric Assessment, integration, and adjustments of body position within space.

Image by Lecturio.

Vestibular pathway outputs

Table: Vestibular pathway outputs
Anatomical structure Function
Cranial nerve nuclei Control over eye movements
Thalamus Thalamus The thalamus is a large, ovoid structure in the dorsal part of the diencephalon that is located between the cerebral cortex and midbrain. It consists of several interconnected nuclei of grey matter separated by the laminae of white matter. The thalamus is the main conductor of information that passes between the cerebral cortex and the periphery, spinal cord, or brain stem. Thalamus: Anatomy Conscious perception Perception The process by which the nature and meaning of sensory stimuli are recognized and interpreted. Psychiatric Assessment of movement and gravity through connections to cortex
Cerebellum Cerebellum The cerebellum, Latin for “little brain,” is located in the posterior cranial fossa, dorsal to the pons and midbrain, and its principal role is in the coordination of movements. The cerebellum consists of 3 lobes on either side of its 2 hemispheres and is connected in the middle by the vermis. Cerebellum: Anatomy ( flocculonodular lobe Flocculonodular lobe Cerebellum: Anatomy) Coordination Coordination Cerebellar Disorders of postural adjustments
Lateral vestibulospinal tract Walking upright
Medial vestibulospinal tract Assisting in integration of head and eye movements

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Clinical Relevance

  • Acoustic neuroma Acoustic neuroma Acoustic neuroma, also referred to as vestibular schwannoma, is a benign tumor arising from Schwann cells of the vestibular component of the cranial nerve VIII. Acoustic neuroma forms within the internal auditory meatus and extends into the cerebellopontine angle. Acoustic Neuroma: an acoustic neuroma Acoustic neuroma Acoustic neuroma, also referred to as vestibular schwannoma, is a benign tumor arising from Schwann cells of the vestibular component of the cranial nerve VIII. Acoustic neuroma forms within the internal auditory meatus and extends into the cerebellopontine angle. Acoustic Neuroma is a benign Benign Fibroadenoma tumor Tumor Inflammation of Schwann cells that involves the cranial nerves Cranial nerves There are 12 pairs of cranial nerves (CNs), which run from the brain to various parts of the head, neck, and trunk. The CNs can be sensory or motor or both. The CNs are named and numbered in Roman numerals according to their location, from the front to the back of the brain. The 12 Cranial Nerves: Overview and Functions within the cranium Cranium The skull (cranium) is the skeletal structure of the head supporting the face and forming a protective cavity for the brain. The skull consists of 22 bones divided into the viscerocranium (facial skeleton) and the neurocranium. Skull: Anatomy. Acoustic neuromas most frequently affect Affect The feeling-tone accompaniment of an idea or mental representation. It is the most direct psychic derivative of instinct and the psychic representative of the various bodily changes by means of which instincts manifest themselves. Psychiatric Assessment CV CV Vasculitides VIII but can also impact CN VII due to the location in the cerebellopontine angle Cerebellopontine angle Junction between the cerebellum and the pons. Acoustic Neuroma. Acoustic neuromas often present with hearing loss Hearing loss Hearing loss, also known as hearing impairment, is any degree of impairment in the ability to apprehend sound as determined by audiometry to be below normal hearing thresholds. Clinical presentation may occur at birth or as a gradual loss of hearing with age, including a short-term or sudden loss at any point. Hearing Loss and tinnitus Tinnitus A nonspecific symptom of hearing disorder characterized by the sensation of buzzing, ringing, clicking, pulsations, and other noises in the ear. Objective tinnitus refers to noises generated from within the ear or adjacent structures that can be heard by other individuals. The term subjective tinnitus is used when the sound is audible only to the affected individual. Tinnitus may occur as a manifestation of cochlear diseases; vestibulocochlear nerve diseases; intracranial hypertension; craniocerebral trauma; and other conditions. Cranial Nerve Palsies. Treatment is with surgical removal.
  • Hearing loss Hearing loss Hearing loss, also known as hearing impairment, is any degree of impairment in the ability to apprehend sound as determined by audiometry to be below normal hearing thresholds. Clinical presentation may occur at birth or as a gradual loss of hearing with age, including a short-term or sudden loss at any point. Hearing Loss: hearing impairments are classified into conductive hearing loss Conductive hearing loss Hearing loss due to interference with the mechanical reception or amplification of sound to the cochlea. The interference is in the outer or middle ear involving the ear canal; tympanic membrane; or ear ossicles. Hearing Loss and sensorineural hearing loss Sensorineural hearing loss Hearing loss resulting from damage to the cochlea and the sensorineural elements which lie internally beyond the oval and round windows. These elements include the auditory nerve and its connections in the brainstem. Hearing Loss. Conductive hearing loss Conductive hearing loss Hearing loss due to interference with the mechanical reception or amplification of sound to the cochlea. The interference is in the outer or middle ear involving the ear canal; tympanic membrane; or ear ossicles. Hearing Loss comes about when there is a problem transferring sound waves anywhere along the pathway from the outer ear Outer ear The outer part of the hearing system of the body. It includes the shell-like ear auricle which collects sound, and the external ear canal, the tympanic membrane, and the external ear cartilages. Ear: Anatomy, the tympanic membrane Tympanic membrane An oval semitransparent membrane separating the external ear canal from the tympanic cavity. It contains three layers: the skin of the external ear canal; the core of radially and circularly arranged collagen fibers; and the mucosa of the middle ear. Ear: Anatomy, or middle ear Middle ear The space and structures directly internal to the tympanic membrane and external to the inner ear (labyrinth). Its major components include the auditory ossicles and the eustachian tube that connects the cavity of middle ear (tympanic cavity) to the upper part of the throat. Acute Otitis Media. In cases of sensorineural hearing loss Sensorineural hearing loss Hearing loss resulting from damage to the cochlea and the sensorineural elements which lie internally beyond the oval and round windows. These elements include the auditory nerve and its connections in the brainstem. Hearing Loss, there is an error Error Refers to any act of commission (doing something wrong) or omission (failing to do something right) that exposes patients to potentially hazardous situations. Disclosure of Information in the transmission of auditory stimuli from the cochlea Cochlea The part of the inner ear (labyrinth) that is concerned with hearing. It forms the anterior part of the labyrinth, as a snail-like structure that is situated almost horizontally anterior to the vestibular labyrinth. Ear: Anatomy to the auditory nuclei.
  • Vertigo Vertigo Vertigo is defined as the perceived sensation of rotational motion while remaining still. A very common complaint in primary care and the ER, vertigo is more frequently experienced by women and its prevalence increases with age. Vertigo is classified into peripheral or central based on its etiology. Vertigo: the sensation of movement between oneself and the surroundings when no movement is actually occurring. Vertigo Vertigo Vertigo is defined as the perceived sensation of rotational motion while remaining still. A very common complaint in primary care and the ER, vertigo is more frequently experienced by women and its prevalence increases with age. Vertigo is classified into peripheral or central based on its etiology. Vertigo is not limited to a feeling of rotation Rotation Motion of an object in which either one or more points on a line are fixed. It is also the motion of a particle about a fixed point. X-rays (spinning); other forms include upward lifting, swaying, rocking, and unsystematic movement. Vertigo Vertigo Vertigo is defined as the perceived sensation of rotational motion while remaining still. A very common complaint in primary care and the ER, vertigo is more frequently experienced by women and its prevalence increases with age. Vertigo is classified into peripheral or central based on its etiology. Vertigo most often occurs due to problems within the semicircular canals.

References

  1. Park, JK, & Vernick, DM. (2020). Vestibular schwannoma (Acoustic neuroma). UpToDate. Retrieved May 26, 2021, from https://www.uptodate.com/contents/vestibular-schwannoma-acoustic-neuroma
  2. Kutz, JW. (2020). Acoustic neuroma. Medscape. Retrieved May 26, 2021, from https://emedicine.medscape.com/article/882876-overview
  3. Stanton, M, & Freeman, AM. (2021). Vertigo. StatPearls. Treasure Island (FL): StatPearls Publishing. http://www.ncbi.nlm.nih.gov/books/NBK482356/
  4. Barrett, KE, Barman, SM, Boitano, S, & Reckelhoff, JF. (2017). Hearing & equilibrium. In Ganong’s Medical Physiology Examination; Board Review. McGraw-Hill Education. http://accessmedicine.mhmedical.com/content.aspx?aid=1142554680 
  5. Wipperman, J. (2021). Dizziness and vertigo. In Conn’s Current Therapy 2021, pp. 9–14. Elsevier. https://www.clinicalkey.com/#!/content/book/3-s2.0-B9780323790062000045 
  6. Walker, MF, & Daroff RB. (2018). Dizziness and vertigo. In Jameson, J, et al. (Eds.), Harrison’s Principles of Internal Medicine, 20e. McGraw Hill. https://accessmedicine.mhmedical.com/content.aspx?sectionid=192011330&bookid=2129&Resultclick=2 
  7. Kerber, K. (2021). Dizziness. DeckerMed Medicine. Retrieved September 15, 2021, from https://doi.org/10.2310/PSYCH.6089
  8. Isaacson, B. (2010). Hearing loss. Medical Clinics of North America. 94(5), 973–988. https://doi.org/http://dx.doi.org/10.1016/j.mcna.2010.05.003 
  9. Shapiro, SB, et al. (2021). Hearing loss and tinnitus. Medical Clinics of North America. 105(5), 799–811. https://doi.org/http://dx.doi.org/10.1016/j.mcna.2021.05.003 
  10. Molina, FJ. (2012). Chapter 18: Hearing loss. In Henderson, MC, Tierney, LM, & Smetana, GW. (Eds.), The Patient History: An Evidence-Based Approach to Differential Diagnosis, 2e. The McGraw-Hill Companies. http://accessmedicine.mhmedical.com/content.aspx?aid=56852049 
  11. Berkowitz, AL. (2016). The auditory and vestibular pathways and approach to hearing loss and dizziness/vertigo: Cranial nerve 8. In Clinical Neurology and Neuroanatomy: A Localization-Based Approach. McGraw-Hill Education. http://accessmedicine.mhmedical.com/content.aspx?aid=1160204039 
  12. Krogmann, RJ, & Al Khalili, Y. (2021) Cochlear Implants. StatPearls. Treasure Island (FL): StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK544280/
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