Tinnitus: Pathophysiology and Treatment

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These sounds are often generated by muscular structures or vascular structures in the head and neck area. Objective tinnitus can be further subdivided into 3 groups, namely, pulsatile, muscular, and spontaneous Lockwood et al. Pulsatile tinnitus is usually caused by sounds caused by turbulent blood flow that may be in sync with the cardiac cycle.

Spontaneous tinnitus has been linked to vibrations of the outer hair cells of the cochlea known as spontaneous otoacoustic emissions Penner, Subjective tinnitus is the perception of sound without any auditory stimulus. Many people experience transient tinnitus lasting seconds or minutes after exposure to loud noise. The sounds associated with subjective tinnitus have been described as ringing, hissing, water running, humming, crickets, cicadas, whistling, wind blowing, etc Stouffer and Tyler, Most patients experience a high pitch noise typically above 3,Hz Henry et al.

Pulsatile tinnitus is most often associated with a number of different vascular etiologies, including arterial bruit, dural arteriovenous shunts, paraganglioma, and venous hum. Arterial bruits may be present in arteries near the temporal bone, most commonly the pertrous carotid system Fortune et al. Dural ateriovenous shunts represent another source of pulsatile tinnitus.

Paraganglioma is a vascular neoplasm arising from paraganglia cells at the carotid bifurcation, in the jugular bulb, or along tympanic arteries. These neoplasms may generate pulsating sounds that are transmitted to the cochlea and produce objective tinnitus. Venous hums may be heard in patients with a dehiscent jugular bulb, systemic hypertension , or increased intracranial pressure.

Muscular tinnitus may be a result of spasms of the muscles of the middle ear, namely, the tensor tympani and the stapedius muscles. Myoclonus of the palatal muscles may be the cause of clicking noises, which may be indicative of an underlying neurologic disorder, such as multiple sclerosis or neuropathy. Another somatic disorder such as Eustachian tube dysfunction may cause tinnitus that is synchronous with respiratory movements Liyanage et al. Subjective tinnitus is a symptom of a number of different underlying pathophysiologic processes. Causes of subjective tinnitus include otologic, neurologic, infectious, and drug-related Lockwood et al.

Otologic cause is the most common cause of subjective tinnitus. Neurologic etiologies include head injury, whiplash, multiple sclerosis, vestibular schwannoma, and other cerebellopontine-angle tumors. Tinnitus may arise as a result of a number of infectious sources such as otitis media, Lyme disease , meningitis, or syphilis. Medications also constitute a common cause of subjective tinnitus.

Most commonly implicated drugs include salicylates, non-steroidal anti-inflammatory medication, aminoglycocide antibiotics , loop diuretics, and chemotherapy agents. Due to the vast array of possible underlying diagnoses, careful evaluation of each patient who presents with tinnitus is warranted. The first crucial step in the management of tinnitus is to distinguish between subjective and objective tinnitus, which is achieved through a complete history and physical examination.

Characterization of the sound in terms of its exact description, onset, periodicity, frequency, triggers, and associated symptoms are crucial. Other otologic complaints such as hearing loss, aural fullness, and vertigo should be documented. Triggers such as background noise, stress , or sleeplessness should be specifically questioned.

History of noise exposure, head injury, and otitis media needs to be explored. Possible ototoxic medications should be enquired. A complete head and neck examination should be performed including otologic and neurotologic evaluations. Specific attention should be directed at auscultation of periauricular area, observation of palatal movements, and changes of tinnitus with jaw clenching or eye movements. A comprehensive audiologic assessment including puretone thresholds, acoustic impedance, speech discrimination scores, and acoustic reflex threshold, should be performed.

Specialized testing may be necessary in certain cases of tinnitus. For objective tinnitus that is pulsatile, it is prudent to rule out any life-threatening diseases such as dural arteriovenous malformation, aneurysm, or skull base tumor. Skull base tumor such as paraganglioma can be evaluated by CT temporal bones. MRI can diagnose central nervous system tumors, cerebellopontine angle tumors, increased intracranial pressures, and multiple sclerosis. Once a serious medical condition has been ruled out, the treatment of tinnitus should be aimed at symptom relief. Since tinnitus is a chronic condition in most patients, the goals of management are twofold, to reduce the intensity of tinnitus and to decrease its impact and associated disability.

Reassurance in patients with benign etiologies of tinnitus is often helpful for patients. A number of medications have been studied in the treatment of tinnitus, however, only a small number including Nortriptyline, Amitriptyline, Alprazolam, Clonazepam, and Oxazepam demonstrated limited benefits over placebo Dobie, The use of these medications for tinnitus treatment should be cautioned.

The studies with Gabapentin are inconclusive; one demonstrated improved scores of annoyance from tinnitus but a variable effect on tinnitus loudness in patients with tinnitus due to trauma specifically Bauer and Brozoski, Another study found that it was ineffective with severe idiopathic tinnitus Piccirillo et al. Intravenous lidocaine has demonstrated short-term improvement in patients with low-pitched tinnitus Murai et al. Intratympanic injection of Dexamethasone has been shown to be effective in some cases of idiopathic tinnitus such as sudden sensorineural hearing loss or autoimmune inner ear disease Slattery et al.

Non-medicinal treatments that have been studied with some success include the following: 1 Tinnitus retraining therapy , 2 Masking, 3 Biofeedback and stress reduction programs, and 4 Cognitive behavioral therapy. Tinnitus retraining therapy TRT aims to bypass or override abnormal auditory cortex neural connections. TRT involves facilitating habituation to the tinnitus signal by a combination of retraining counseling and sound therapy with broad band noise as well as environmental sounds Han et al.

The long term impact of TRT is limited Dobie, and it can take up to one to two years to observe stable effects. Masking devices are designed to produce low level sounds to help eliminate the perception of tinnitus Vernon and Meikle, Cognitive behavioral therapy CBT in the setting of tinnitus teaches patients to alter their psychological response to the symptom by learning coping strategies and distraction skills. Tinnitus is the presenting symptom for a number of different diseases ranging from benign to life-threatening conditions.

As a clinician, one should differentiate between subjective and objective tinnitus in order to formulate further testing and make appropriate recommendations in terms of management. Even with the recent medical advances, no treatment has been found to be uniformly effective in the treatment of tinnitus.

It is prudent to deal with each patient individually and discuss the risks and benefits of each treatment option through a strong doctor-patient relationship. Ahmad N, Seidman M. Tinnitus in the older adult: epidemiology , pathophysiology and treatment options.

Drugs Aging , American Tinnitus Association. Andersson G, Lyttkens L. See Table 1 for a summary of somatic maneuvers. Even when the patient cannot self-modulate tinnitus, it may be altered by other kinds of stimuli, using maneuvers to increase activity of the trigeminal nerve such as passive muscular palpation to find myofascial trigger points MFT , relaxation, and massage Simmons et al. Records describing studies on the treatment of somatosensory tinnitus were included and are reviewed here by treatment category.

Case controlled studies and cross-sectional studies were summarized in Appendix 5 in Supplementary Material. Studies have accounted the benefits for tinnitus of treating temporomandibular disorder TMD. However, it has also been found that that severe tinnitus is less likely to improve with TMD therapy Wright and Bifano, a. Another similar study has shown that younger patients with moderate tinnitus were more likely to experience relief of their tinnitus through TMD therapy Wright and Bifano, b.


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Tinnitus severity as a predictor of the effectiveness of TMD therapy has already been proposed by others including Erlandsson et al. The presence of fluctuating tinnitus is another factor that may associate with TMD treatment effectiveness e. One form of TMD treatment is occlusal splint therapy Attanasio et al. In their study involving this treatment in patients presenting with chronic subjective tinnitus Attanasio et al. Patients were subjected to treatment with a neuromuscular occlusal splint for 6 months using the splint at night time and rated for the severity of tinnitus using point visual analog scale and Tinnitus Handicap Inventory THI; Newman et al.

Post-treatment THI scores were reduced in all groups but was most pronounced in the TMD experience or predisposed groups. The authors concluded that, once otologic disorders and neurological diseases are excluded, that clinicians should refer patients for an evaluation of the temporomandibular joint and subsequently to treat patients with TMD or a predisposition to it. Wright suggested oro-myofunctional therapy as an effective alternative to occlusal splints therapy. Patients were provided a dental orthotic and TMD self-care instructions. Follow-up telephone calls 6 months after completion of TMD therapy revealed that all patients maintained their symptom improvements.

These findings imply that TMD was affecting the patients' otologic symptoms. Usually it includes splints therapy, therapeutic exercises for the lower jaw and occlusal adjustment in combination with counseling. For a long time, scientists have investigated the effects of dental and stomatognathic therapies in tinnitus Junemann, ; Gelb and Arnold, ; Dolowitz et al. It is important to note that the authors discussed an individual therapeutic strategy with each patient before the start of treatment. The authors suggested long term studies are conducted to assess the outcome and advised caution when interpreting current epidemiological data.

Chiropractic therapy is a correction therapeutic treatment of an abnormal movement pattern through the manipulation of the vertebral column and extremities. Only three studies related to chiropractic treatment of tinnitus were identified and all three were case studies. Alcantara et al. The authors reported a complete relief from the TMD symptoms, including tinnitus, after only 9 treatments 2 months.

The treatment involved the application of high-velocity low amplitude adjustments. Kessinger and Boneva also reported progress in a year-old patient who received upper cervical specific chiropractic care which resulted in improvements in vertigo, tinnitus, and hearing loss. These authors concluded that the success of chiropractic therapy was due to improvement in cervical spine function.

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DeVocht et al. The patient suffered daily from unremitting jaw pain for 7 years accompanied by headache, tinnitus, decreased hearing, and a feeling of congestion in her right ear. Twenty months of chiropractic treatment resulted in total resolution of all symptoms except fullness of the right cheek.

Combined with chiropractic care, muscular relaxation through massage and stretching exercises is used in clinical practice. For instance, evidence suggests that palpation of masseter, pterygoid, and sternocleidomastoid muscles or myofascial trigger points can modulate tinnitus Rocha et al. Latifpour et al. The authors compared self-training of stretching, posture training, and acupuncture, targeting muscle symmetry and balance in the jaw and neck, and later reported an improvement of tinnitus in the treatment group.

In this blinded study they observed immediate and long term 3 months improvements in the treatment group. Another therapy worth noting here; in a pilot study with 11 patients, Kaute reported improvement in vestibular disturbances through the method of Arlen's Atlas Therapy, normally applied to whiplash-injured patients, concluding it to be indicated where tinnitus may be caused by neck muscle tension. This study suggest that muscular relaxation may play a significant role in the treatment of tinnitus but high quality explanatory studies i.

Somatic modulation therapy treatment aiming to modulate the intensity of a given symptom, by movement has rarely been studied beyond case studies. Sanchez et al. The authors found it to have a significant effect on the modulation patterns but not in the daily perception of tinnitus. In the case of a year-old woman who developed gaze-evoked tinnitus after surgery to remove a left vestibular Schwannoma, therapy consisted of a repetitive gaze training and tinnitus was resolved after 14 weeks Sanchez and Akemi, In another case, a year-old man with severe tinnitus noticed an improvement through tactile stimuli to the ipsilateral postauricular area, head rotation, opening of the mouth, and clenching teeth and mandible lateralization Sanchez and Akemi, In another case of tinnitus improvement through tactile stimulation was reported in a single patient by Emmert et al.

Recent evidence reported a significant improvement in tinnitus using transcutaneous electrical nerve stimulation Herraiz et al. Trans-electrical nerve stimulation TENS of areas of skin close to the ear increases the activation of the dorsal cochlear nucleus through the somatosensory pathway and may augment the inhibitory role of this nucleus on the CNS and thereby ameliorate tinnitus Herraiz et al. Vanneste et al. Herraiz et al. Standardizing the indications and method could increase the efficacy of electrical stimulation in somatic tinnitus according to most authors.

These results are promising so further controlled trials are warranted. Only one relevant record describing a pharmaceutical treatment was included. In this case study McCormick and Walega reported the successful treatment of refractory somatic tinnitus with cervical epidural injection of 80 mg triamcinolone acetonide. The patient was year-old male with previous history of bacterial otitis media. No surgical treatment studies specific to somatosensory tinnitus were identified.

Background

One case study worth mentioning however was that of a 65 years old patient with left sided tinnitus and with left sided cervical neck pain who experienced a complete resolution of somatic tinnitus for over 1 year through radiofrequency ablation of the left C2—C3 medial branches of the dorsal ramus ipsilateral to tinnitus symptoms Gritsenko et al. Tinnitus is complex in nature and so ideally, and to achieve the best results, diagnosis and treatment should be specific to an individual patients experience.

Further research on the physiological processes that lead to somatosensory tinnitus would facilitate the development of a specific protocol and therapy targeting the auditory pathways and musculoskeletal disorders Sanchez and Rocha, c. Evidence points to a high prevalence of somatosensory tinnitus, but that it is under-investigated by clinicians and the processes underlying are still poorly studied. For instance, only very recently have the first steps been made toward understanding the genetic underpinnings of subjective tinnitus Lopez-Escamez et al.

This model proposes the integration of the neurophysiological system Jastreboff, ; Jastreboff and Jastreboff, the relation between psychophysiological and behavioral systems and the social information system, associated with the emotional experience of tinnitus Li et al. These avenues may help develop clinical strategies that adapt to patient's understanding and attitudes toward tinnitus, through social learning. What these will mean for somatosensory tinnitus is an open question.

It is important to note that an early and precise diagnosis, presents the best outcomes for the patient treatment Herraiz, Recent research on the treatment of somatosensory tinnitus has focused on bone and muscular disorders, on each structure independently or using multimodal approach including manual therapy and exercise Michiels et al. This demands different practitioners dentists, neurologists, audiologists, physiatrist etc.

Although such strategies do not target tinnitus directly, such therapies are shown to ameliorate its side effects. It is not possible to cure tinnitus through dental and TMD therapies. It is a priority to establish how TMD and somatosensory tinnitus are related and what criteria should be used to select tinnitus patients for different TMD therapies. Further research is needed to attest the efficacy of TMD therapy on tinnitus and to access the placebo effect Rubinstein, ; Tullberg and Ernberg, In addition, standardization of core measures hinders the process of any potential meta-analysis on the large datasets, which would aid the development of clinical interventions for tinnitus.

However, it will need to be tested whether these standardized outcomes are sensitive to treatment related changes in groups of patients or trail participants who have somatosensory tinnitus. Because somatosensory tinnitus is not judged a disease per se , but instead it is considered a symptom, its diagnosis and treatment were related to other disorders. Connection to hearing loss and bone and muscular disorders are evident.

With this scoping review, we intended to give the reader a broad overview of findings to date concerning somatosensory tinnitus, and encourage new systematic and integrative analyses which will hopefully bring the much-needed order to the field of tinnitus research. There is some discrepancy over the prevalence of somatosensory tinnitus; a systematic review is needed. The etiology of somatosensory tinnitus needs continued investigation. Particularly, and considering the involvement of neural plasticity, it is necessary to determine the exact processes that initiate the abnormal cross-modal plasticity of somatic-auditory interactions.

There is a lack of objective diagnostic methodology, which may misguide clinical management. Clinical guidelines that consider or are specific to somatosensory tinnitus are needed. There are many and different strategies for managing tinnitus, originating in different clinical fields audiology, neurology, psychology, etc.

Integrating such strategies, and having in mind that each patient is a singular case, may increase the success of clinical management practices for tinnitus. To support further trials and data synthesis in somatosensory tinnitus there needs to be standard research methodologies.

Theses should be developed through consensus. A therapeutic intervention combining simultaneously several types of treatment approaches may bring the best results for tinnitus relief, but such combinations may also be individual specific. HH is the guarantor of the review. DH and DK created the search strategies. DK and CN created the tables in appendix. IP contributed in data extraction and initial manuscript. HH, DH, and RC contributed equally to all other stages of the manuscript development, produced, and approved the manuscript.

Travel, subsistence, and accommodation for them to participate in Tinnet meetings has been funded by Tinnet and that has been an opportunity to enhance networking collaboration between them. HH has received a Ph. The views expressed are those of the authors and not the funder. The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest. Abel, M. Muscle contractions and auditory perception in tinnitus patients and nonclinical subjects.

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Tinnitus: Questions to reveal the cause, answers to provide relief

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Eustachian tube dysfunction (ETD) - causes, symptoms, diagnosis, treatment, pathology

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