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Tinnitus is an abnormal perception of a sound which is reported by patients that is unrelated to an external source of stimulation. Tinnitus is a very common disorder. It may be intermittent, constant or fluctuant, mild or severe, and may vary from a low roaring sensation to a high pitched type of sound. It may or may not be associated with a hearing loss. It is also classified further into subjective tinnitus (a noise perceived by the patient alone) or objective (a noise perceived by the patient as well as by another listener). Subjective tinnitus is common; however, objective tinnitus is relatively uncommon. The location of tinnitus may be in the ear(s) and/or in the head.

Tinnitus is a symptom much like a headache, pain, temperature, hearing loss or vertigo. With tinnitus, the reported distress is usually subjective and difficult to record and appreciate by others.

The quality of the tinnitus refers to the description by the patient of the tinnitus: It may be a ringing, buzzing, cricket, ocean, etc., type of sound. The quality may be multiple sounds or a singular sound.

Tinnitus may be produced in one or more locations, called its site of lesion. The cause of tinnitus may be singular or multiple. A peripheral (i.e., auditory nerve or cochlea) site of lesion includes dysfunction established within the auditory system that extends up to but not involving the brainstem. A central site of lesion refers to involvement of the central auditory pathways, beginning at the brainstem and involving other portions of the central nervous system.

Tinnitus is, therefore, a symptom of neurotologic disease. It may occur with a hearing loss, vertigo or pressure symptoms in the ear or it may occur alone.

Tinnitus must always be thought of as a symptom and not a disease, just as pain in the arm or leg is a symptom and not a disease. Because the function of the auditory (hearing) nerve is to carry sound, when it is irritated from any cause it produces head noise. This phenomenon is similar to the sensation nerves elsewhere. If one pinches the skin, it hurts because the nerves stimulated carry pain sensation.

A complete cochleovestibular evaluation is necessary in all patients with severe disabling tinnitus. The test battery is used to attempt to establish the site of lesion and to rule out any significant pathology which may require further treatment. There are many causes just related to the ear which would result in tinnitus. Such things as simple ear wax in the ear canal to other middle ear abnormalities may result in tinnitus. Otosclerosis (fixation of the stapes bone in the middle ear) can cause tinnitus as well as fluid in the middle ear. There are many other ear abnormalities which may cause tinnitus. A more common example would be Meniere’s disease. Sudden trauma to the inner ear such as exposure to excessively loud sounds may result in tinnitus. Tumors on the hearing nerve or other problems in the brainstem or central nervous system may also cause tinnitus. In addition, other vascular abnormalities in the skull or base of the skull may result in tinnitus.

While it could be argued that the Supreme Court decision could set some, perhaps ethereal, precedent, it is still Congress that decides whether the President will be removed. And while the Supreme Court’s decision could in some way be construed as an endorsement of the executive order, so too can Justice Sotomayor’s dissent remind Congress of the reason the travel ban was cited as an impeachable offense in the first place: “[the] appearance of discrimination that the President’s words have created.” Though Trump’s “muslim ban,” may have been rolled back enough to be constitutional, it can still evidence the President’s bigotry, and therefore could still contribute to his impeachment.

Andrew Harnik/AP

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By Frank Bowman

Yesterday Michael Horowitz, Inspector General of the Department of Justice, released his report on the conduct of the investigation into Hillary Clinton’s handling of her email accounts while she was Secretary of State. The notable take-aways from the report include:

Frankly, none of these conclusions will surprise anyone who has been following this story and has a basic knowledge of how the Justice Department works. Insofar as the entire cavalcade of misjudgments may well have elected Donald Trump to the presidency, it is deeply tragic. But in itself it is nothing more than a tale of basically well-meaning people operating in a complex institutional and political environment … and screwing up.

A notable coda to the publication of the report was the virtually simultaneous publication in the New York Times of a responsive Latasa Womens Faux Snakeskin Platform High Heels Pumps Black Dp0Pzj
by Comey in which he persists in claiming that his judgments were correct. I can’t help but find it a sad display. It reaffirms my judgment of Comey laid out in detail in InterestPrint Womens Snow Boots Light Green STPatricks Day Design Art Print Deco With Swirls and Clover Leaves Unique Designed Comfort Winter Boots Multi 1 pVlHl8xxy4
from several months ago.

Comey is an honest man, but fatally intoxicated by his own sense of unique personal rectitude. The country and the world are in the grip of a rolling crisis because in 2016 Jim Comey thought his judgment so superior to everyone else’s that the rules and norms of the U.S. Department of Justice just didn’t apply to him. The Times op-ed demonstrates either that his egotism is impenetrable or that he has built a wall of denial to protect himself from the personal devastation of admitting his mistakes.

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