Timothy C. Hain, MD. Hearing Page Page last modified: January 23, 2015
Other pages on this site about tinnitus: acupuncture anesthetics cervical tinnitus masking .euromonicspalinacusis placebospulsatile TENS tinnitus-oaetensor tympani and stapedius myoclonus tinnitus
Index of this page : Tinnitus defined Causes Diagnosis Treatment If You Have Tinnitus
This document is not written for or intended for use in legal proceedings.
Tinnitus (pronounced "tin-it-tus") is an abnormal noise in the ear (note that it is not an "itis" -- which means inflammation). Tinnitus is common -- nearly 36 million Americans have constant tinnitus and more than half of the normal population has intermittent tinnitus. Another way to summarize this is that about 10-15% of the entire population has some type of constant tinnitus, and about 20% of these people (i.e. about 1% of the population) seek medical attention (Adjamian et al, 2009). Similar statistics are found in England (Dawes et al, 2014) and Korea (Park and Moon, 2014).
About six percent of the general population has what they consider to be "severe" tinnitus. That is a gigantic number of people ! Tinnitus is more common with advancing age. In a large study of more than 2000 adults aged 50 and above, 30.3% reported having experienced tinnitus, with 48% reporting symptoms in both ears. Tinnitus had been present for at least 6 years in 50% of cases, and most (55%) reported a gradual onset. Tinnitus was described as mildly to extremely annoying by 67%.(Sindhusake et al. 2003)
Tinnitus can come and go, or be continuous. It can sound like a low roar, or a high pitched ring. Tinnitus may be in both ears or just in one ear. Seven million Americans are so severely affected that they cannot lead normal lives.
The most common types of tinnitus are ringing or hissing ringing, whistling (high pitched hissing) and roaring (low-pitched hissing). Some persons hear chirping, screeching, or even musical sounds.
Note however that tinnitus nearly always consists of fairly simple sounds -- for example, hearing someone talking that no one else can hear would not ordinarily be called tinnitus -- this would be called an auditory hallucination. Musical hallucinations in patients without psychiatric disturbance is most often described in older persons, years after hearing loss, but they have also been reported in lesions of the dorsal pons (Schielke et al, 2000).
Another way of splitting up tinnitus is into objective and subjective. Objective tinnitus can be heard by the examiner. Subjective cannot. Practically, as there is only a tiny proportion of the population with objective tinnitus, this method of categorizing tinnitus is rarely of any help. It seems to us that it should be possible to separate out tinnitus into inner ear vs everything else using some of the large array of audiologic testing available today. For example, it would seem to us that tinnitus should intrinsically "mask" sounds of the same pitch, and that this could be quantified using procedures that are "tuned" to the tinnitus.
|Distribution of Persons with tinnitus|
|Population||Percent with Tinnitus||Percent with Hearing Loss||Reference|
|Older than 50||20%||Moller, 2007|
|65-70||12%||35%||Adams et al, 1999|
Tinnitus is commonly accompanied by hearing loss, and roughly 90% of persons with chronic tinnitus have some form of hearing loss (Davis and Rafaie, 2000; Lockwood et al, 2002). On the other hand, only about 30-40% of persons with hearing loss develop tinnitus. According to Park and Moon (2004), hearing impairment roughly doubles the odds of having tinnitus, and triples the odds of having annoying tinnitus.
Less commonly, it may be accompanied by hyperacusis (an abnormal sensitivity to sound).
|Structures of the ear. Most tinnitus is due to damage to the cochlea (#9 above)|
Henry et al (2005) reported that noise was an associated factor for 22% of cases, followed by head and neck injury (17%), infections and neck illness (10%), and drugs or other medical conditions (13%). The rest of their patients could not identify an event.
Park and Moon (2004) reported the odds ratio for tinnitus according to many factors. They examined results from 10,061 Koreans.
|Chronic otitis media||1.53|
Thus it can see that there are numerous factors that are weakly correlated with tinnitus, and that hearing impairment is the most strongly associated. It is surprising that TMJ's correlation is nearly as high as hearing impairment, and more than depression or stress.
It is very well accepted that tinnitus often is "centralized" -- while it is usually initiated with an inner ear event, persistent tinnitus is associated with changes in central auditory processing (Adjamian et al, 2009). Sometimes this idea is used to put forth a "therapeutic nihilism" -- suggesting that fixing the "cause" -- i.e. inner ear disorder -- will not make the tinnitus go away. This to us seems overly simplistic -- while it is clear that the central nervous system participates in perception of sounds, and thus must be a participant in the "tinnitus" process, we think that it is implausible that in most cases that there is not an underlying "driver" for persistent tinnitus.
Supporting the idea that central reorganization is overestimated as "the" cause of tinnitus, a recent study by Wineland et al showed no changes in central connectivity of auditory cortex or other key cortical regions (Wineland et al, 2012). Considering other parts of the brain, Ueyama et al (2013) reported that there was increased fMRI activity in the bilateral rectus gyri, as well as cingulate gyri correlating with distress. Loudness was correlated with values in the thalamus, bilateral hippocampus and left caudate. In other words, the changes in the brain associated with tinnitus seem to be associated with emotional reaction (e.g. cingulate), and input systems (e.g. thalamus). There are a few areas whose role is not so obvious (e.g. caudate). This makes a more sense than the Wineland result, but of course, they were measuring different things. MRI studies related to audition or dizziness must be interpreted with great caution as the magnetic field of the MRI stimulates the inner ear, and because MRI scanners are noisy.
Another way to look at it is to look at the areas of the body that can initiate tinnitus.
Most tinnitus comes from damage to the inner ear, specifically the cochlea (the snail like thing on the right of figure 1, labeled '9').
In pulsatile tinnitus, people hear something resembling their heartbeat in their ear. Click on the link above for more details.
In our opinion, people are very quick to blame drugs for their tinnitus, but it is rare that this is borne out.
Many medications also can cause tinnitus (see list below). Generally this is thought to arise from their effect on the cochlea (inner ear).
Drugs that commonly cause or increase tinnitus -- these are largely ototoxins.
- NSAIDS (motrin, naproxen, relafen, etc)
- aspirin and other salicylates
- Lasix and other "loop" diuretics
- "mycin" antibiotics such as vancomycin (but rarely macrolides such as azithromycin)
- quinine and related drugs
- Chemotherapy such as cis-platin
Antidepressants are occasionally associated with tinnitus (Robinson, 2007). For example, Tandon (1987) reported that 1% of those taking imiprimine complained of tinnitus. In a double-blind trial of paroxetine for tinnitus, 3% discontinued due to a perceived worsening of tinnitus (Robinson, 2007). There are case reports concerning tinnitus as a withdrawal symptom from Venlafaxine and sertraline (Robinson, 2007). In our clinical practice, we have occasionally encountered patients reporting worsening of tinnitus with an antidepressant, generally in the SSRI family.
Often people bring in very long lists of medications that have been reported, once or twice, to be associated with tinnitus. This unfortunate behavior makes it very hard to care for these patients -- as it puts one into an impossible situation where the patient is in great distress but is also unwilling to attempt any treatment. Specialists who care for patients with ear disease, usually know very well which drugs are problems (such as those noted above), and which ones are nearly always safe.
As tinnitus is essentially subjective, malingering of tinnitus as well as psychological causes of tinnitus is certainly possible. In fact, auditory hallucinations (such as hearing voices) are common in schizophrenia.
In malingering, a person claims to have tinnitus (or more tinnitus), in an attempt to gain some benefit (such as more money in a legal case). See this page concerning malingering of hearing symptoms.
There is a high correlation between anxiety depression and the annoyance/severity of tinnitus (Pinto et al, 2014).
Persons with tinnitus should be seen by a physician expert in ear disease, usually an otologist or a neurotologist.
There should be an examination of the ears with an otoscope. Wax should be removed, and the examiner should note whether the ear drum is intact, inflamed, scarred, or whether it is moving.
The eyes should be examined for papilloedema (swelling of a portion of the back of the eye called the "optic disk") as increased intracerebral pressure can cause tinnitus. Because papilloedema is so rare, and tinnitus is so common, it is very unusual to find this dangerous condition.
The TMJ joints of the jaw should be checked as about 28% of persons with TMJ syndrome experience tinnitus. TMJ is very common too.
Inspection of the eardrum may sometimes demonstrate subtle movements due to contraction of the tensor tympani (Cohen and Perez, 2003). Tensor tympani myoclonus causes a thumping. Another muscle, the stapedius, can also make higher pitched sounds. See this page for more. Opening or closing of the eustachian tube causes a clicking. The best way to hear "objective tinnitus" from the middle ear is simply to have an examiner with normal hearing put their ear up next to the patient. Stethoscopes favor low frequency sounds and may not be very helpful.
|Type of middle ear tinnitus||Sound||Ear Drum|
|Tensor tympani||Thump, inaudible to examiner||Indentation|
|Stapedius||Tick, can be heard by examiner||
|ETD||Click, can be heard by examiner||Nothing|
|Cartoon of the middle ear showing muscles that attach to ossicles (ear bones), and ear drum. The stapedius is attached to the stapes (of course -- horseshoe object above), while the tensor tympani is attached to the ear drum. While useful, be aware that there are multiple errors in this illustration from Loyola Medical School. With permission, from: http://www.meddean.luc.edu/lumen/meded/grossanatomy/dissector/mml/images/stap.jpg|
Based on tests, tinnitus can be separated into categories of cochlear, retrocochlear, central, and tinnitus of unknown cause.
Patients with tinnitus often undergo the tests listed above.
The audiogram sometimes shows a sensorineural deficit. This may be due to true loss of hearing, or due to masking from the tinnitus.
Tinnitus matching is helpful to identify the frequency and intensity of the tinnitus. This is a simple procedure in which the audiologist adjusts a sound until a patient indicates that it is the same as their tinnitus. Most patients match their tinnitus to the region of their hearing loss (Konig et al, 2006; Mahboubi et al, 2012).
ABR (ABR) testing may show some subtle abnormalities in otherwise normal persons with tinnitus (Kehrle et al, 2008). The main use of ABR (ABR test) is to assist in diagnosing tinnitus due to a tumor of the 8th nerve or tinnitus due to a central process. A brain MRI is used for the same general purpose and covers far more territory, but is roughly 3 times more expensive.
Tympanograms or acoustic reflex tests can sometimes show a rhythmic compliance change due to a middle ear vascular mass or due to contraction of muscles in the middle ear.
The physician may also request an OAE test (which is very sensitive to noise induced hearing damage), an ECochG (looking for Meniere's disease and hydrops, an MRI/MRA test (scan of the brain), a VEMP (looking for damage to other parts of the ear) and several blood tests (ANA, B12, FTA, ESR, SMA-24, HBA-IC, fasting glucose, TSH, anti-microsomal antibodies).
Sweep OAE testing can be very helpful in medicolegal contexts, as noise induced tinnitus should be accompanied by a "notch" in the sweep OAE.
We occasionally recommend neuropsychological testing using a simple screening questionnaire -- depression, anxiety, and OCD (obsessive compulsive disorder) are common in persons with tinnitus. This is not surprising considering how disturbing tinnitus may be to ones life (Holmes and Padgham, 2009). Persons with OCD tend to "obsess" about tinnitus. Treatment of these conditions may be extremely helpful.
Branstetter and Weissman (2006) reviewed the radiological evaluation of tinnitus. They favor contrast-enhanced MRI to detect tumors of the inner ear area. Of course, tumors are a very rare cause of tinnitus, as tinnitus is at least 100 times more common than tumors of the inner ear area.
Causes that can be seen on radiological testing of continuous tinnitus include: (Branstetter and Weissman)
Microvascular compression of the 8th nerve is not a significant cause of tinnitus (Gultekin et al. 2008).
In persons with pulsatile tinnitus, additional tests maybe proposed to study the blood vessels and to check the pressure inside the head. Gentle pressure on the neck can be performed to block the jugular vein but not the carotid artery. The Valsalva maneuver reduces venous return by increasing intrathoracic pressure. If there is a venous hum, this usually abates or improves markedly. If the pulsation is arterial, these tests have no effect.
According to Branstetter and Weissman, entities that can cause unilateral pulsatile tinnitus include
Other entities that can sometimes be seen on radiological testing and that can cause pulsatile tinnitus, include AVM's, aneurysms, carotid artery dissection, fibromuscular dysplasia, venous hums from the jugular vein (found in half the normal population), vascular tumors such as glomus, ossifying hemangiomas of the facial nerve, osseous dysplasias such as otosclerosis and Paget's, elevated intracranial pressure.
Practically, MRI/MRA or CT is often suggested in younger patients with unilateral pulsatile tinnitus. In older patients, pulsatile tinnitus is often due to atherosclerotic disease and it is less important to get an MRI/MRA. A lumbar puncture may be considered if there is a possibility of benign intracranial hypertension. More invasive testing includes the "balloon occlusion test", where a balloon is blown up in the internal jugular vein to see if it eliminates tinnitus. These are very rarely done.
Impact of Tinnitus
Holmes and Padgham (2009) reviewed the impact of tinnitus on persons lives. Severe tinnitus is associated with anxiety, distress, sleep disturbance, and sometimes depression.
Disrupted sleep is the most significant complaint, and affects between 25-50% of tinnitus patients.
Poor attention and concentration are commonly reported. About 42% of survey respondents reported that tinnitus interfered with their work.
Tinnitus often has negative effects on personal relationships.
The algorithm that we use in our practice to diagnose and treat tinnitus is here (a PDF graphic). After a diagnostic step, there are many branch points involving treatment trials.
The bottom line is that it is unusual (although not impossible) for people to get substantial relief from medication, devices, or surgery. In fact, "obsessing" about tinnitus, generally tends to make it more persistent and worse. Thus paradoxically enough, doctors tend to discourage reading of web pages like this one, or joining of support groups. Most people "get used" to tinnitus, and learn to "tune it out". When this doesn't happen, the treatments that work the best for tinnitus are those that alter ones emotional state -- antidepressants and antianxiety drugs, and ones that allow you to get a full night's sleep.
The bad news in more detail : Dobie (1999) reviewed the 69 randomized controlled trials of tinnitus treatments. According to Dr. Dobie, no treatment can yet be considered "well established" in terms of providing replicable long-term reduction of tinnitus impact, in excess of placebo effects. Support and counseling are probably helpful as are tricyclic antidepressants in severe cases. Benzodiazepines, newer antidepressants and electrical stimulation deserve further study. More recently, Hoare et al (2011) reviewed 28 randomized controlled trials. They concluded "The efficacy of most interventions for tinnitus benefit remains to be demonstrated conclusively. In particular, high-level assessment of the benefit derived from those interventions most commonly used in practice, namely hearing aids, maskers, and tinnitus retraining therapy needs to be performed." Antidepressants were the only drug class to show any evidence of potential benefit.
But don't lose all hope: Dobie made the point that tinnitus is likely multifactorial, and the usual study design is likely not well chosen for this situation. A study design where initially an open-label study is performed, followed by a randomized placebo controlled trial might find patient groups that respond to a medication. This seems very logical.
If a specific cause for tinnitus is found, then your physician may be able to eliminate the noise. Examples of specific causes include medication, tumors, infections, Meniere's disease, TMJ and otosclerosis. Tinnitus due to the tensor tympani can be treated by transection of that muscle. To find a specific cause it may require a fairly extensive workup including X-rays and blood tests. However, even after extensive workup, most causes of tinnitus go undiagnosed.
If a specific cause of tinnitus is not found, it is unlikely that the tinnitus can be gotten rid of. At best, one might get partial relief from some of the strategies to be described in the next few paragraphs. However, even though treatment may not be available, tinnitus should be checked into, as tinnitus may be a warning sign of a serious disorder such as a tumor of the 8th nerve, or other disorder which may impair hearing. Tinnitus does tend to gradually get better, but many persons with severe tinnitus still experience distress 5 years later. Tolerance of tinnitus increases with time. (Andersson et al, 2001).
Medications may occasionally help lessen the noise even though no cause can be found. In general, we are not at all enthused about medication treatment as the side effects can be substantial and the results are often unimpressive. In randomized clinical trials, for the most part, the agents under study have failed to demonstrate elimination of tinnitus more frequently than have placebos (Dobie RA, 1999).
Medication to deal with the psychological fallout of tinnitus is often useful -- antidepressants and anti-anxiety medications can be very helpful. This is because of the very high correlation between anxiety and depression with tinnitus-related annoyance and severity (Pinto et al, 2014). We are not suggesting here that anxiety/depression causes tinnitus -- but rather that tinnitus is associated with some treatable psychiatrical disturbances.
Medications that are well accepted in treatment of Tinnitus
- Lorazepam or klonazepam (in low doses). These are "benzodiazepines", mainly used for anxiety (Gananca et al, 2002; Dobie, 2003)
- Amitriptyline or nortriptyline (again in low doses). These are "tricyclic antidepressants".
- SSRI medications (Bilici et al, 2013)
Comment. Benzodiazepines and tricyclics probably mainly change emotional responses to tinnitus. Any sort of relief, however, is important.
Robinson (2007) reviewed use of antidepressants for tinnitus. At that date there were 4 double-blind placebo controlled trials of antidepressants for tinnitus. Three out of four trials resulted in a favorable outcoume (Nortriptyline, Paroxetine, Sertraline). The fourth trial of Trimipramine reported an 8dB increase. Robinson reported that tinnitus in depressed patients appears more responsive to antidepressants than in non-depressed patients. Mechanisms for impovement were suggested to be direct effects of increased serotonin on auditory pathways, or indirect effects of tinnitus on depression or anxiety.
We have also had some patients get relief from other antidepressants including the SSRI family and SNRI family, and especially with low dose venlafaxine, which we find helps in reducing central sensory syndromes such as allodynia as is found in migraine headache.
The anticonvulsants such as mysoline may affect some patients who have tinnitus due to 8th nerve irritation. Mysoline (Primidone) contains phenobarbital, which is sedating. On the other hand, Hoekstrat et al (2011) suggested that in general these drugs do not work for tinnitus. This is not very surprising.
There is a small literature concerning use of intravenous and local anesthesia for tinnitus. See this link for more.
Botox for tinnitus:
Lainez and Piera (2007) reviewed the single paper published concerning use of Botox for tinnitus. Stidham et al (2005) injected botox into the area of the ear(above, and 2 places behind), the arm, and compared with placebo. This study suggested that Botox might improve tinnitus to a small extent (7 improved with active, 2 improved with placebo). Lainez and Piera suggested that the mechanism ws reduction of peripheral inputs from cervical, temporal, frontal and periauricular pathways.
Liu et al (2011) reported use of botox for tinnitus due to tensor tympani myoclonus, by inserting gelfoam with botox through a perforation in the tympanic membrane. This method appears to us to be overly invasive.
Atorvastatin (Lipitor). A recent trial in older people showed that atorvastatin had no effect on the rate of hearing deterioration but there was a trend toward improvement in tinnitus scores over several years. (Olzowy et al, 2007). A trial of simvistatin and ginkgo together was ineffective (Canis, Olzowy et al, 2009)
Campral, is a medication FDA approved for treatment of abstinent alcoholics. A paper from south America reported that it is effective for tinnitus. This is an off-label use of this medication. At this writing (4/09), we think it is ineffective. Because it is easily available in the US, and has a rather benign side effect profile, we think that it is a good candidate for medication trials. We have had no success with it in a few patients.
Pramipexole was recently reported effective for tinnitus in a study of 40 patients with age related hearing loss in Hungary. (Sziklai and others, 2011). It seems very unlikely to us that a dopamine agonist should be useful in tinnitus. This work needs to be confirmed by others.
Trimetazidine. This is a drug designed for heart disease, that is marketed in Europe for vertigo and tinnitus. It's brand name is Vasterel. The author of this page has had no experience with this medication for Meniere's. Some authors indicate that it is a placebo. (anon, 2000)
Anticonvulsants. According to Hoeksra et al, there is no evidence that anticonvulsants have a "large positive effect" on tinnitus, but a small effect (of doubtful clinical significance) has been demonstrated. They reviewed studies of gabapentin, carbamazepine, lamotrigine and flunarizine. (We were not aware flunarizine was an "anticonvulsant", as it is not approved in the USA for any clinical use).
Shim et al (2011) reported that for acute subjective idiopathic tinnitus, the combination of alprazolam and intratympanic dexamethasone injections was significantly higher (75%) than treatment with alprazolam alone (50%). As it would be difficult to placebo control an intratympanic treatment, we think that this conclusion needs confirmation.
Hearing aids and other devices called "maskers" may also help alleviate tinnitus.
This is a tricky business. If you have tinnitus associated with a hearing loss, a hearing aid is a reasonable thing to try. Be sure that you try the hearing aid before buying one, as tinnitus is not always helped by an aid.
We see no reason to get 2 hearing aids at the same time, for treatment of tinnitus. Nearly all states mandate a 1-month money-back guarantee built into hearing aid dispensing.
It also seems possible that a hearing aid might exacerbate tinnitus, as many people develop "ringing" of their ears after exposure to loud noise.
Cochlear implants, which are used for severe bilateral unaidable hearing loss, usually improve tinnitus (Amoodi et al, 2011).
We are generally in favor of maskers (see below). We try masking in almost all patients in our clinic.
Maskers (for more about masking, see here)
These are devices based on the idea that tinnitus is usually worst when things are very quiet. Listening to the interstation static on the FM radio, tapes of ocean surf, fans, and the like may be helpful. Pillow speakers sold by Radio Shack may be helpful in order to avoid disturbing others. This is a very cheap method.
Tinnitus maskers are devices fitted and sold by audiologists. Controlled studies of maskers have shown small effects (Dobie, 1999).
Tinnitus is often modulated by somatic input such as jaw movement. It would make sense that electrical stimulation might also modulate tinnitus. There is a small literature with some positive and negative data. This area seems to us worthy of more research.
TMS -- transcranial magnetic stimulation.
This is an investigational approach, which presently seems slightly promising. TMS involves brain stimulation using very high intensity magnetic pulses. It is somewhat similar to a "gentle" electroshock treatment, and clearly works on the brain rather than the inner ear. TMS seems to be somewhat helpful for depression and migraine, and one would think that a modality that worked for these, would also work to some extent for tinnitus. There is presently some evidence that it is helpful (Smith et al, 2007; Kleingjung et al, 2007; Mennemeier et al, 2008; Bilici et al, 2013) as well as studies suggesting it is no better than placebo (Piccirillo et al, 2011). This treatment is available only in persons who are in research environments. We are cautiously optimistic about TMS.
Friedland and associates (2008) reported results of brain electrical stimulation in 8 patients. This was an uncontrolled study. The authors concluded that this technique "warrants further investigation". Two patients had persistent improvement of pure tone tinnitus, and 6 had short periods of suppression. This seems very drastic to us.
There are numerous devices and medications for tinnitus that are probably placebos. See this page for more discussion. If a placebo works for you - - that's wonderful !
Again, bad news. Surgery should be considered when there is a clear structural reason for tinnitus that can be improved with surgery. It is also worth considering if hearing can be improved by surgery. Generally though, hearing aids or implantable devices are much more successful than surgery.
Diet: We recommend that persons with tinnitus limit salt (no added salt), and refrain from drinking caffeinated beverages, other stimulants (like tea), and chocolate. The salt restriction is intended for those who might have a subclinical form of Meniere's. Caffeine and similar substances increase tinnitus in a nonspecific fashion. Otherwise the diet should be balanced and have normal amounts of fruits and vegetables.
Alternative medicine approaches. Ginkgo-Biloba, betahistine (Serc), Zinc, and acupuncture are sometimes advocated as treatment for intractable tinnitus. There is little evidence that these agents work, but they also do not seem to be harmful. More discussion about alternative medications for Meniere's disease is available here.
Psychological help: Often, anxiety or depression which accompanies tinnitus may be as big a problem as the tinnitus itself. In this instance, consultation with a psychologist or psychiatrist expert in this field may be helpful. Hypnosis may be effective and increase tolerance to tinnitus, but randomized controlled trials are not encouraging (Dobie, 1999). If you can ignore tinnitus rather than obsess about it, this may be the best way to handle it. Medications that help people with obsessive compulsive disorder (such as the SSRI family) may be helpful. In general, we favor use of venlafaxine rather than simpler SSRIs. Tinnitus Retraining Therapy (TRT) is a method of habituation of tinnitus is helpful for some (Wang et al, 2003). It requires a considerable commitment of time. We sometimes refer patients for this.
Self Help: You might consider joining the American Tinnitus Association. (PO Box 5, Portland, OR 97207, 503-248-9985). However, if your tinnitus has been well "worked up", and there is nothing more to be done, it might be best to attempt to ignore it rather than focus more attention on it. Joining of these sorts of organizations intrinsically draws more attention to ones illness.
As of 8/2012, a visit to the National Library of Medicine's search engine, Pubmed, revealed more than 3,000 research articles with tinnitus in their title, published. In spite of this gigantic effort, very little is presently known about tinnitus, and effective treatment is generally unavailable.
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