Somatic Modulation of Tinnitus: Test Reliability and Results after Repetitive Muscle Contraction Training

[Somatosensory tinnitus]

BACKGROUND

Somatosensory tinnitus represents a clinically significant subgroup of chronic tinnitus. Although not completely understood, increasing evidence suggests interactivity between the somatosensory and auditory systems is responsible for both the development and maintenance of tinnitus.

OBJECTIVES

The aim of this study is to provide an overview of the evaluation of somatosensory tinnitus and to propose an examination protocol to support the diagnosis and treatment of this patient group.

MATERIALS AND METHODS

In addition to patient history, various clinical examination maneuvers are presented to establish the diagnosis of somatosensory tinnitus.

RESULTS

The maneuvers can be divided into examinations of the cervical spine, temporomandibular joint, and soft tissue near the jaw. The maneuvers should be performed in a quiet environment and usually in comparison between sides.

CONCLUSION

Accurate and efficient diagnosis of somatosensory tinnitus is essential to initiate appropriate treatment. The clinical maneuvers presented here are well suited for this purpose.

Pilot study on the role of somatic modulation in hyperacusis

BACKGROUND

Hyperacusis is a reduced tolerance to sounds that often co-occurs with tinnitus. Both symptoms have convergent as well as divergent characteristics. Somatic modulation, changes in pitch or loudness during certain movements, is common in patients with a primary complaint of tinnitus. However, thus far, this is not documented in patients with hyperacusis.

OBJECTIVES

This study aimed to examine the influence of somatic manoeuvres on the perception of external sounds in patients with a primary complaint of hyperacusis.

METHODOLOGY

In this prospective cross-sectional pilot study, 18 patients with a primary complaint of hyperacusis were recruited at the Tinnitus Treatment and Research Center Antwerp (TINTRA). While patients listened to a 1 kHz broadband noise of 30 dB sensation level, six neck manoeuvres (flexion, extension, lateroflexion left/right, traction and compression), three jaw manoeuvres (protrusion, laterotrusion left/right) and one placebo manoeuvre (hand on head) were performed. The primary outcome measure was the change in the perception of the presented sound in terms of loudness and intrusiveness between baseline and each modulation measured by a visual analogue scale (VAS).

RESULTS

No overall significant changes were found; however, individual results indicated that five patients presented a clinically relevant change of more than three points out of ten on VAS in terms of hyperacusis after at least one of the executed somatic manoeuvres.

CONCLUSIONS

This pilot study did not demonstrate an overall significant change in hyperacusis after somatic manoeuvres but does not rule out the possibility of somatic modulation in some hyperacusis patients.

TRIAL REGISTRATION

The protocol of this prospective cross-sectional pilot study was registered on clinicaltrials.gov with registration number NCT04693819.

Methods, Applications, and Limitations of Somatic Maneuvers for the Modulation of Tinnitus

The modulation of tinnitus through somatic maneuvers is a well-documented phenomenon in tinnitus patients with somatic disorders. The purpose of this study was to review the methods, applications, and limitations of somatic maneuvers. First, 35 somatic maneuvers proposed by various research groups were summarized according to four body areas (jaw, head and neck, eye, and limbs), following which their applications and limitations were assessed. Although some studies have shown that somatic maneuvers can aid in screening for somatic tinnitus and may help alleviate symptoms with repeated practice, the limited number of studies and inconsistent results among studies make it difficult to draw definitive conclusions. Therefore, follow-up studies are required to overcome these limitations and determine whether the treatment of somatic disorders can also aid in alleviating somatic tinnitus.

Anterior Cervical Decompression and Fusion Surgery for Cervical Spondylosis with Concomitant Tinnitus: A Multicenter Prospective Cohort Study

OBJECTIVE

Cervical spondylosis is often accompanied by tinnitus. Up to now, there is a lack of large samples and prospective studies to investigate the effect of anterior cervical decompression and fusion (ACDF) on tinnitus associate with cervical spondylosis. To this end, we performed a prospective cohort study to assess the effectiveness of ACDF on the relief of tinnitus.

METHODS

This was a multicenter, prospective, cohort clinical study. Between August 2017 and August 2018, 174 patients with cervical spondylosis accompanied by tinnitus were enrolled, with a follow-up of 12 months. Among the 174 patients, 142 received anterior cervical surgery (surgery group) and 32 received conservative treatment (conservative group). The primary end point was the mean change in scores on the tinnitus functional index (TFI). The secondary end points included tinnitus loudness, modified Japanese orthopaedic association scores (mJOA) for spinal cord function, and visual analogue scale (VAS) for neck pain. All the above indexes were measured before treatments and at 1, 3, 6, and 12 months after treatments. One-way analysis of variance and paired samples t-test was adopted for statistical analysis.

RESULTS

The TFI score was reduced immediately after cervical decompression surgery (from 54.7 ± 15.6 to 32.3 ± 12.5, P < 0.001) and this was sustained at 12 months (P < 0.001). The TFI score of the conservative group also decreased (from 53.9 ± 16.8 to 45.2 ± 13.6, P < 0.001), but the effect was not maintained at 12 months (P = 0.069). There was a significant improvement in tinnitus loudness (from 5.2 ± 1.6 to 2.6 ± 1.9, P < 0.001), mJOA (from 12.0 ± 1.6 to 14.2 ± 1.6, P < 0.001), and VAS for neck pain (from 58.5 ± 9.6 to 22.0 ± 16.4, P < 0.001) in the surgical group. Improvements in the surgical group were statistically significantly greater than that in the conservative group (P < 0.001).

CONCLUSION

This study indicates that anterior cervical surgery can relieve tinnitus in patients with cervical spondylosis and that tinnitus is an accompanying manifestation of cervical spondylosis.

Prevalence of Somatosensory Tinnitus in Veterans With Tinnitus

OBJECTIVES

The primary objective was to estimate the prevalence of somatosensory tinnitus (ST) among Veterans with tinnitus.

DESIGN

Three hundred four Veterans with tinnitus were phone screened for ST by performing and reporting on a series of head/neck/jaw maneuvers. A random sample of 12 individuals who screened positive and five who screened negative attended an in-person visit to confirm the presence/absence of ST.

RESULTS

Of the 304 Veterans, 12 could not complete the screening maneuvers, 205 screened positive, and 87 screened negative. A Bayesian estimator that combines phone screening and in-person exam results establishes the prevalence of ST among Veterans with tinnitus at 56% with a 90% Bayesian confidence interval of 45% to 65%.

CONCLUSIONS

At least half of Veterans with tinnitus have ST, suggesting that a sizable at-need population exists. Treatment addressing the biomechanical component has the potential to improve tinnitus symptoms.

Effect of adding a supervised physical therapy exercise program to photobiomodulation therapy in the treatment of cervicogenic somatosensory tinnitus: A randomized controlled study

OBJECTIVES

To evaluate the effectiveness of adding a supervised physical therapy exercise program to photobiomodulation therapy (PBMT) in the treatment of cervicogenic somatosensory tinnitus (CST).

METHODS

Forty patients suffering from CST with age 45-55 years were included in the study. They were assigned randomly into 2 groups, 20 per each. (Study group) Group (A) received a supervised physical therapy exercise program in addition to 20 minutes PBMT with a 650-nanometer wavelength and a 5 milliWatt power output, spot size of 1 cm2, and energy density of 6 Joules, 3 sessions per week for 8 consecutive weeks, plus traditional medical treatment. While (control group), group (B) received the same PBMT protocol, 3 sessions per week for 8 consecutive weeks in addition to the traditional medical treatment. Tinnitus visual analog scaling (VAS), tinnitus handicap inventory (THI), and cervical range of motion (ROM) were measured at baseline and after 8 weeks.

RESULTS

Mixed MANOVA showed a statistically significant reduction in tinnitus VAS, THI, and a significant improvement in cervical ROM (flexion, extension, right bending, left bending, right rotation, and left rotation) in favor of Group A (P < .05). There was a significant decrease in posttreatment VAS treatment (P > .001) MD [-2.05(-2.68:-1.41)], and THI relative to pretreatment mean difference [-5.35(-8.51: -2.19)] and a significant increase in posttreatment neck ROM in Groups A and B relative to pretreatment neck ROM (P > .001). Flexion range posttreatment MD[3.65(1.64:5.65)], Extension MD [6.55(1.35:11.75)], right bending MD[3.8(2.51:5.08)], left bending MD[1.75(0.19:3.3)], right rotation MD [3.5(1.28:5.71)] and left rotation [2.75(0.67:4.82)].

CONCLUSIONS

Adding a supervised physical therapy exercise program to PBMT showed positive and beneficial effects in the treatment of CST using VAS, THI, and Cervical ROM assessment tools.

Effectiveness of Intratympanic Dexamethasone Injection for Tinnitus Treatment: A Systematic Review and Meta-Analysis

Objectives

Intratympanic dexamethasone injection (ITDI) has been introduced as a treatment option for subjective tinnitus. However, the effects of ITDI on patients with tinnitus remain unclear. In the present systematic review and metaanalysis, we evaluated the effectiveness of ITDI for tinnitus treatment.

Methods

We searched Medline, the Cochrane Central Register of Controlled Trials, and Embase. Four double-blind randomized controlled trials that tested the efficacy of ITDI compared with a placebo were deemed eligible for a quantitative meta-analysis, while four prospective studies and seven retrospective studies reporting the effectiveness of ITDI on tinnitus treatment were included in a qualitative synthesis.

Results

In the four studies included in the quantitative meta-analysis, ITDI did not show evidence of tinnitus improvement compared with placebo (odds ratio [OR], 1.38; 95% confidence interval, 0.53-3.61). In the 11 studies included in the qualitative synthesis, seven retrospective studies without controls reported rates of tinnitus improvement after ITDI ranging from 35.9% to 91.3%. In the four prospective studies with controls, ITDI seemed to be effective when combined with other drugs for tinnitus treatment.

Conclusion

ITDI alone did not show a significant effect for treating tinnitus compared with placebo. However, the potential of combination treatment of ITDI with other drugs for tinnitus therapy should be further studied in more systematic research.

[Tinnitus: clinical and pathogenetic aspects]

The article discusses the pathogenetic and clinical features of tinnitus. It is emphasized that various causes contribute to the appearance of tinnitus, including somatic diseases, excess body weight, iatrogenies, otological diseases with an outcome in hearing loss. The anatomical and physiological features of the structure of the central part of the auditory system are considered. It is suggested that the occurrence of tinnitus is associated with the processes of maladaptive neuroplasticity caused by pathological changes in the neuronal activity of cortical structures of the CNS, and not with changes in the peripheral part of the auditory analyzer - the structures of the cochlea. The results of recent studies, including those using functional neuroimaging methods, indicate the significance of cortical connection disorders (human connectome) in patients with tinnitus. In patients with tinnitus, there are changes in regional neuronal activity and connections not only in the auditory cortex, but also in areas not directly related to the analysis of auditory afferentation. Thus, tinnitus can be considered as one of the variants of dysfunction of the human connectome, triggered primarily from the «auditory input».

Somatic Modulation in Tinnitus: Clinical Characteristics and Treatment Outcomes

OBJECTIVES

We aimed to evaluate the clinical significance of the somatic modulation test in patients with tinnitus and analyze the treatment outcomes.

MATERIALS AND METHODS

Medical records of patients who visited the tinnitus clinic at a local university hospital between October 2018 and April 2019 were retrospectively reviewed.

RESULTS

The data of 81 patients were analyzed for this study, of which 61.7% (n=51) showed tinnitus modulation after one or more neck or jaw maneuvers. Patients with narrow-band noise tinnitus tended to show maneuver-induced modulation more frequently than those with pure-tone tinnitus (85.7% vs. 53.3%, p=0.010). Neck maneuvers reduced tinnitus loudness in 29.6% of the patients, while 27.2% of patients (n=22) reported worsening of tinnitus loudness, and 23.5% of patients (n=19) reported tinnitus suppression after jaw maneuvers. None of the patients with noise exposure history reported tinnitus modulation. Backward regression analysis revealed that age was an independent risk factor for improvement (Exp [B]=0.703, p=0.034, 95% CI=0.508-0.974). However, somatic modulation or medical treatments targeting somatic modulation were not related to improvement.

CONCLUSION

Patients showing modulation after neck or jaw maneuvers have specific clinical characteristics. However, somatic modulation itself does not affect the final treatment outcome.

Physiotherapy assessment and treatment of chronic subjective tinnitus using mechanical diagnosis and therapy: a case report

Objectives: Tinnitus is the perception of sound without any external auditory stimulus. Cervicogenic somatic tinnitus (CST) is a subset in which symptoms are modulated by maneuvers of the neck. The evidence for effective diagnosis and treatment of CST is limited. Mechanical Diagnosis and Therapy (MDT) is a biopsychosocial assessment and management system that uses the response to mechanical forces to classify clinical presentations accurately. The purpose of this case report is to describe the MDT assessment and management of a patient with chronic subjective tinnitus.Methods: A 67-year-old female with a 5-year history of left-sided subjective tinnitus, neck pain, and headache was referred for physiotherapy. Outcome measures included the Visual Analogue Scale (VAS), Tinnitus Handicap Inventory (THI), and Neck Disability Index (NDI). She was evaluated and treated according to MDT principles with management consisting of individualized directional preference exercises and postural correction.Results: Significant improvements in symptoms, cervical range of motion, function, and psychosocial status were observed over the long-term. At 6 months, THI scores dropped from 62/100 to 18/100 and NDI scores dropped from 18/50 to 3/50.Discussion: A comprehensive MDT assessment led to a classification of Derangement, with treatment focusing on tailored self-management. Contrary to other interventions described for CST, the patient was able to make significant and lasting changes to her symptoms without the need for any externally applied interventions. The emphasis on self-management dovetails well with the biopsychosocial model of care. This case provides preliminary evidence for the utility of screening for Derangement in conservative tinnitus assessments.Level of Evidence: 4.

Subtyping patients with somatic tinnitus: Modulation of tinnitus and history for somatic dysfunction help identify tinnitus patients with temporomandibular joint disorders

OBJECTIVE

Determine in a cohort of patients with normal hearing and chronic tinnitus if self-reported history for temporomandibular joint (TMJ) dysfunction and a positive modulation of tinnitus in the TMJ region could be suggestive of an underlying TMJ disorder.

PATIENTS AND METHODS

The study included 226 patients presenting to the Head and Neck Service of our University Hospital. Following audiological and somatic tinnitus evaluation, patients were divided into two groups. The study group (n = 134) included subjects that met both the following criteria: A) a self-reported history for TMJ dysfunction and B) a positive modulation of tinnitus following somatic maneuvers in the TMJ region. The control group (n = 92) included patients with similar demographic and tinnitus characteristics that did not meet the proposed criteria for somatic tinnitus. Afterwards, patients underwent clinical TMJ evaluation in the Service of Clinical Gnathology of our University.

RESULTS

One hundred thirty-one patients (57.9%) received a clinical diagnosis of TMJ disorder according to DC/TMD Axis I; 79.1% in the study group and 27.2% in the control group. Ninety-five (42.1%) patients were negative for TMJ disorders; 20.9% in the study group and 72.8% in the control group. A significantly higher number of TMJ disorders was found in patients in the study group compared to the control group (p<0.0001). Most patients had joint disorders (67.2%), followed by other (29.8%) and pain disorders (29%). Logistic regression analysis in the study group showed that female gender was more prevalent in patients with TMJ disorders.

CONCLUSION

Our findings in patients with chronic tinnitus and normal hearing suggest that self-reported history for somatic dysfunction and modulation of tinnitus, when occurring simultaneously in the TMJ region, can be useful to preliminarily identify patients with TMJ disorders.

Somatosensory tinnitus: Current evidence and future perspectives

In some individuals, tinnitus can be modulated by specific maneuvers of the temporomandibular joint, head and neck, eyes, and limbs. Neuroplasticity seems to play a central role in this capacity for modulation, suggesting that abnormal interactions between the sensory modalities, sensorimotor systems, and neurocognitive and neuroemotional networks may contribute to the development of somatosensory tinnitus. Current evidence supports a link between somatic disorders and higher modulation of tinnitus, especially in patients with a normal hearing threshold. Patients with tinnitus who have somatic disorders seems to have a higher chance of modulating their tinnitus with somatic maneuvers; consistent improvements in tinnitus symptoms have been observed in patients with temporomandibular joint disease following targeted therapy for temporomandibular disorders. Somatosensory tinnitus is often overlooked by otolaryngologists and not fully investigated during the diagnostic process. Somatic disorders, when identified and treated, can be a valid therapeutic target for tinnitus; however, somatic screening of subjects for somatosensory tinnitus is imperative for correct selection of patients who would benefit from a multidisciplinary somatic approach.

Pathophysiology, Diagnosis and Treatment of Somatosensory Tinnitus: A Scoping Review

Somatosensory tinnitus is a generally agreed subtype of tinnitus that is associated with activation of the somatosensory, somatomotor, and visual-motor systems. A key characteristic of somatosensory tinnitus is that is modulated by physical contact or movement. Although it seems common, its pathophysiology, assessment and treatment are not well defined. We present a scoping review on the pathophysiology, diagnosis, and treatment of somatosensory tinnitus, and identify priority directions for further research. Methods: Literature searches were conducted in Google Scholar, PubMed, and EMBASE databases. Additional broad hand searches were conducted with the additional terms etiology, diagnose, treatment. Results: Most evidence on the pathophysiology of somatosensory tinnitus suggests that somatic modulations are the result of altered or cross-modal synaptic activity within the dorsal cochlear nucleus or between the auditory nervous system and other sensory subsystems of central nervous system (e.g., visual or tactile). Presentations of somatosensory tinnitus are varied and evidence for the various approaches to treatment promising but limited. Discussion and Conclusions: Despite the apparent prevalence of somatosensory tinnitus its underlying neural processes are still not well understood. Necessary involvement of multidisciplinary teams in its diagnosis and treatment has led to a large heterogeneity of approaches whereby tinnitus improvement is often only a secondary effect. Hence there are no evidence-based clinical guidelines, and patient care is empirical rather than research-evidence-based. Somatic testing should receive further attention considering the breath of evidence on the ability of patients to modulate their tinnitus through manouvers. Specific questions for further research and review are indicated.

Differences Among Patients That Make Their Tinnitus Worse or Better

PURPOSE

Our objective was to identify activities that influence tinnitus and to determine if conditional probabilities exist among such variables.

METHOD

Two hundred fifty-eight patients were asked the following two questions: "When you have your tinnitus, which of the following makes it worse?" and "Which of the following reduces your tinnitus?"

RESULTS

Things that made tinnitus better included noise (31%) and relaxation (15%). Things that made tinnitus worse included being in a quiet place (48%), stress (36%), being in a noisy place (32%), and lack of sleep (27%). Almost 6% of patients suggested coffee/tea and 4% said certain foods made their tinnitus worse. Conditional probabilities indicated that for those whose tinnitus is not worse in quiet, it is usually not reduced by noise. For those whose tinnitus is not worse in noise, it is usually not reduced in quiet.

CONCLUSION

There are dramatic differences among patients. Such differences need to be considered in planning treatments.

Diagnostic Value of Clinical Cervical Spine Tests in Patients With Cervicogenic Somatic Tinnitus

BACKGROUND

Tinnitus can be related to many different etiologies, such as hearing loss or a noise trauma, but it also can be related to the somatosensory system of the cervical spine. The diagnosis of cervicogenic somatic tinnitus (CST) is made when the predominant feature is the temporal coincidence of appearance or increase of both neck pain and tinnitus.

OBJECTIVE

The aim of this study was to assess the diagnostic value of clinical cervical spine tests in people with CST.

DESIGN

A cross-sectional study was conducted.

SETTING

The study was conducted at a tertiary referral center.

PATIENTS

Consecutive adult patients with chronic subjective nonpulsatile tinnitus were included. Exclusion criteria were vertigo, Ménière disease, middle ear pathology, intracranial pathology, cervical spine surgery, whiplash trauma, and temporomandibular dysfunction.

MEASUREMENTS

A full ear, nose, and throat examination was conducted to classify patients into CST and non-CST groups. The physical therapist examination included completion of the Neck Bournemouth Questionnaire (NBQ) and the following clinical cervical spine tests: manual rotation test, adapted Spurling test (AST), trigger point tests, and tests for strength and endurance of the deep neck flexors.

RESULTS

Eighty-seven patients with tinnitus were included, of whom 37 (43%) were diagnosed with CST. The diagnosis of CST becomes less likely with NBQ scores of <14 points (sensitivity of 80%, likelihood ratio [LR] of 0.3, and posttest probability of 19%). Absence of trigger points corresponded to an LR of 0.3, a sensitivity of 82%, and a posttest probability of 22%. A positive manual rotation test and AST indicate a higher probability of CST (LR of 5, specificity of 90%, and posttest probability of 78%).

LIMITATIONS

A limited number of clinical cervical spine tests were used in this study. Although tests with good validity and reliability were included, additional tests could provide more information on cervical spine dysfunction in patients with CST.

CONCLUSIONS

Clinical cervical spine tests can support the diagnostic process for CST. An NBQ score of <14 points and the absence of trigger points can help to exclude CST. In contrast, a positive manual rotation test and AST can help to include CST. In future studies, these tests should be included in a multidisciplinary assessment of patients with suspected CST.

Subtyping Somatic Tinnitus: A Cross-Sectional UK Cohort Study of Demographic, Clinical and Audiological Characteristics

Somatic tinnitus is the ability to modulate the psychoacoustic features of tinnitus by somatic manoeuvres. The condition is still not fully understood and further identification of this subtype is essential, particularly for the purpose of establishing protocols for both its diagnosis and treatment. This study aimed to investigate the characteristics of somatic tinnitus within a large UK cohort using a largely unselected sample. We believe this to be relatively unique in comparison to current literature on the topic. This was investigated by using a total of 608 participant assessments from a set of recognised tinnitus and audiology measures. Results from a set of chi-square tests of association found that amongst the individuals with somatic tinnitus, a higher proportion had pulsatile tinnitus (different from heartbeat), were under the age of 40, reported variation in the loudness of their tinnitus and reported temporomandibular joint (TMJ) disorder. The same pattern of results was confirmed using a multivariate analysis of the data based on logistic regression. These findings have strong implications towards the profiling of somatic tinnitus as a distinct subtype of general tinnitus.

Intratympanic dexamethasone plus melatonin versus melatonin only in the treatment of unilateral acute idiopathic tinnitus

PURPOSE

The aim of our study was to determine whether the combination of intratympanic (IT) corticosteroid with melatonin could be associated with decreased tinnitus in patients with unilateral acute idiopathic tinnitus developed within 3months.

MATERIALS AND METHODS

We evaluated this hypothesis through a prospective, randomized, controlled, double-blinded trial. Patients included in the study were randomly allocated into two groups: Group A - comprising 30 patients, received melatonin and IT dexamethazone, and Group B - including 30 patients receiving melatonin alone. After 3 months, improvement in tinnitus was assessed using different outcome measures: tinnitus loudness score, tinnitus awareness score, Tinnitus Handicap Inventory (THI), Pittsburgh Sleep Quality Index (PSQI) and Beck Depression Inventory (BDI).

RESULTS

We have demonstrated significant improvements in each of the above mentioned outcomes subsequent to treatment in both groups. However, patients in the IT dexamathazone and melatonin group attained statistically significant better outcomes. Besides, the differences in improvement rate and cure rate were highly significant between the two groups, favoring the IT dexamethazone and melatonin group.

CONCLUSIONS

Our preliminary study demonstrated that IT dexamethazone plus melatonin is efficient in improvement of idiopathic unilateral tinnitus developed within 3 months.

Physical therapy treatment in patients suffering from cervicogenic somatic tinnitus: study protocol for a randomized controlled trial

BACKGROUND

Tinnitus occurs in a large part of the general population with prevalences ranging from 10% to 15% in an adult population. One subtype is cervicogenic somatic tinnitus, arising from cervical spine dysfunctions, justifying cervical spine assessment and treatment. This study aims to investigate the effect of a standardized physical therapy treatment, directed to the cervical spine, on tinnitus. Additionally, a second aim is to identify a subgroup within the tinnitus population that benefits from physical therapy treatment.

METHODS AND DESIGN

This study is designed as a randomized controlled trial with delayed treatment design. Patients with severe subjective tinnitus (Tinnitus Functional Index (TFI) between 25 and 90 points), in combination with neck complaints (Neck Bournemouth Questionnaire (NBQ) >14 points) will be recruited from the University Hospital of Antwerp. Patients suffering from tinnitus with clear otological etiologies, severe depression, traumatic cervical spine injury, tumors, cervical spine surgery, or conditions in which physical therapy is contra-indicated, will be excluded.After screening for eligibility, baseline data such as TFI, NBQ, and a set of cervical biomechanical and sensorimotor tests will be collected. Patients are randomized in an immediate therapy group and in a group with a delayed start of therapy by 6 weeks. Patients will receive physical therapy with a maximum of 12 sessions of 30 min for a 6-week program. Data from the TFI and NBQ will be collected at baseline (week 0), at the start of therapy (weeks 0 or 6), at the end of therapy (weeks 6 or 12), 6 weeks after therapy (weeks 12 or 18), and 3 months after therapy (weeks 18 or 24). Secondary outcome measures will be collected at baseline and 6 weeks after the therapy (weeks 12 or 18), as the maximal therapy effect on the cervical spine dysfunctions is expected at that moment.

DISCUSSION

This study is the first to investigate the effect of a standardized physical therapy treatment protocol on somatic tinnitus with a prospective comparative delayed design and with blinded evaluator for baseline, end of therapy, and 6 and 12 weeks after therapy.

TRIAL REGISTRATION

12 September 2013, ClinicalTrials.gov: NCT02016313.

Stimulus timing-dependent plasticity in dorsal cochlear nucleus is altered in tinnitus

Tinnitus and cochlear damage have been associated with changes in somatosensory-auditory integration and plasticity in the dorsal cochlear nucleus (DCN). Recently, we demonstrated in vivo that DCN bimodal plasticity is stimulus timing-dependent, with Hebbian and anti-Hebbian timing rules that reflect in vitro spike timing-dependent plasticity. In this in vivo study, we assessed the stimulus timing dependence of bimodal plasticity in a tinnitus model. Guinea pigs were exposed to a narrowband noise that produced a temporary elevation of auditory brainstem response thresholds. A total of 60% of the guinea pigs developed tinnitus as indicated by gap-induced prepulse inhibition of the acoustic startle. After noise exposure and tinnitus induction, stimulus timing-dependent plasticity was measured by comparing responses to sound before and after paired somatosensory and auditory stimulation presented with varying intervals and orders. In comparison with Sham and noise-exposed animals that did not develop tinnitus, timing rules in verified tinnitus animals were more likely to be anti-Hebbian and broader for those bimodal intervals in which the neural activity showed enhancement. Furthermore, units from exposed animals with tinnitus were more weakly suppressed than either Sham animals or exposed animals without tinnitus. The broadened timing rules in the enhancement phase in animals with tinnitus, and in the suppressive phase in exposed animals without tinnitus was in contrast to narrow, Hebbian-like timing rules in Sham animals. These findings implicate alterations in DCN bimodal spike timing-dependent plasticity as underlying mechanisms in tinnitus, opening the way for a therapeutic target.

Stimulus-timing dependent multisensory plasticity in the guinea pig dorsal cochlear nucleus

Multisensory neurons in the dorsal cochlear nucleus (DCN) show long-lasting enhancement or suppression of sound-evoked responses when stimulated with combined somatosensory-auditory stimulation. By varying the intervals between sound and somatosensory stimuli we show for the first time in vivo that DCN bimodal responses are influenced by stimulus-timing dependent plasticity. The timing rules and time courses of the observed stimulus-timing dependent plasticity closely mimic those of spike-timing dependent plasticity that have been demonstrated in vitro at parallel-fiber synapses onto DCN principal cells. Furthermore, the degree of inhibition in a neuron influences whether that neuron has Hebbian or anti-Hebbian timing rules. As demonstrated in other cerebellar-like circuits, anti-Hebbian timing rules reflect adaptive filtering, which in the DCN would result in suppression of sound-evoked responses that are predicted by activation of somatosensory inputs, leading to the suppression of body-generated signals such as self-vocalization.

New trends in tinnitus management

Tinnitus is a perception of sound in absence of sound stimulation. Tinnitus in many cases cannot be eliminated by conventional medical treatment with drugs or surgery. Some people who begin to notice tinnitus, whether spontaneous or induced by noise, trauma or other insult, will experience spontaneous resolution, but many patients will have persistent tinnitus. For some of them, tinnitus sensation will be joined by tinnitus suffering, with many adverse effects like anxiety, depression and sleep disorders. For these tinnitus sufferers the psychological and acoustic approach proposed by the Tinnitus Retraining Therapy and Acoustic Desensitization Protocol may be helpful. Periodically new treatments are suggested like low-frequency repetitive transcranial magnetic stimulation and sequential phase shift sound cancellation treatment based on the frequency and loudness matching of the tinnitus. The aim of this work is to review modern considerations for the treatment of tinnitus.

Diagnosis and management of somatosensory tinnitus: review article

Tinnitus is the perception of sound in the absence of an acoustic external stimulus. It affects 10-17% of the world's population and it a complex symptom with multiple causes, which is influenced by pathways other than the auditory one. Recently, it has been observed that tinnitus may be provoked or modulated by stimulation arising from the somatosensorial system, as well as from the somatomotor and visual-motor systems. This specific subgroup -somatosensory tinnitus - is present in 65% of cases, even though it tends to be underdiagnosed. As a consequence, it is necessary to establish evaluation protocols and specific treatments focusing on both the auditory pathway and the musculoskeletal system.

Qigong for the treatment of tinnitus: a prospective randomized controlled study

OBJECTIVE

Tinnitus is a frequent disorder which is very difficult to treat. Qigong is a mindful exercise and an important constituent of traditional Chinese medical practice. Here we performed a randomized controlled trial to evaluate the effect of a Qigong intervention on patients with tinnitus. We hypothesized that especially tinnitus patients with somatosensoric components may benefit from the mind-body technique of Qigong.

METHODS

Eighty patients with tinnitus of at least 3 months duration were randomly assigned to an intervention group (n=40) consisting of 10 Qigong training sessions in 5 weeks or a waiting-list control group (n=40). Tinnitus severity was assessed with a visual analogue scale (VAS) and with a tinnitus questionnaire (TBF-12) before treatment, immediately after treatment, and 1 and 3 months after treatment.

RESULTS

Qigong did not cause any side effects and was completed by 80% of the assigned patients. Compared with the control group, Qigong participants experienced improvement in tinnitus severity, as reflected by a significant reduction in both the VAS and the TBF-12. In the subgroup of patients with somatosensoric tinnitus, Qigong effects were more pronounced, resulting in a highly significant improvement in both scales compared to the waiting-list group.

CONCLUSION

These findings suggest that Qigong interventions could be a useful complement to the therapeutic management of patients with tinnitus and especially for those with somatosensoric components. Satisfaction with the intervention, a high degree of completion, and stability of the effects for at least 3 months after the intervention further underscore the potential of Qigong in the treatment of tinnitus.

Head, Neck, and Eye Movements That Modulate Tinnitus

Recent functional brain imaging studies in humans suggest that the neural generator(s) for tinnitus may reside in the central nervous system and involve both auditory as well as nonauditory centers. The contribution of nonauditory centers in the pathogenesis and regulation of tinnitus is reinforced by studies showing that many patients have somatic tinnitus whereby movements and manipulations of the eyes, head, neck, jaw, and shoulder can modulate the loudness and pitch of their tinnitus. In most cases, the maneuvers lead to increases in tinnitus loudness or pitch rather than decreases. Our results indicate that most tinnitus patients experience only a modest change in loudness or pitch when performing these maneuvers. However, some patients report that these maneuvers significantly modulate the loudness or pitch, sometimes by a factor of 2 to 3. The high prevalence of somatic tinnitus serves to illustrate the complex multimodal interactions that exist between the auditory pathway and other sensory-motor systems innervating the head, neck, shoulders, and eyes.

Human Brain Imaging of Tinnitus and Animal Models

Because subjective tinnitus is typically localized to the ear with hearing loss, tinnitus was traditionally thought to originate from neural hyperactivity in the damaged ear. However, most studies have found that hearing loss reduces the neural outputs from the damaged cochlea. These negative findings led to the hypothesis that rinnitus arises from aberrant neural activity in the central auditory system. Positron emission tomography imaging studies performed on tinnitus patients that could modulate their tinnitus provide evidence showing that the aberrant neural activity that gives rise to tinnitus resides in the central auditory pathway. To investigate the biological basis of tinnitus in more detail, an animal model was developed that allowed behavioral measures of tinnitus to be obtained from individual rats after inducing tinnitus with high doses of salicylate or high-intensity noise. This behavioral model was used to test the efficacy of memantine, an N-methyl-D-aspartate antagonist, and scopolamine, an anticholinergic, in suppressing salicylate-induced tinnitus. Neither drug completely suppressed salicylate-induced tinnitus. To detect the physiological changes associated with tinnitus, chronic microwire electrodes were implanted in the auditory cortex and measurements were obtained from the auditory cortex before and after salicylate and noise exposures known to induce tinnitus. High doses of salicylate or high-level noise exposure generally resulted in sound-evoked hyperactivity in the electrophysiological responses recorded from the auditory cortex of awake-animals. However, anesthetic tended to suppress or abolish the hyperactivity.

Myofascial trigger point:a possible way of modulating tinnitus

In order to investigate whether myofascial trigger points can modulate tinnitus, as well as the association between tinnitus and myofascial trigger points, 94 individuals with and 94 without tinnitus, matched by age and gender, were analyzed by means of bilateral digital pressure of 9 muscles. Temporary modulation of tinnitus was frequently observed (55.9%) during digital pressure, mainly in the masseter. The rate of tinnitus modulation was significantly higher on the same side of the myofascial trigger point subject to examination in 6 out of 9 muscles. An association between tinnitus and the presence of myofascial trigger points was observed (p < 0.001), as well as a laterality association between the ear with the worst tinnitus and the side of the body with more myofascial trigger points (p < 0.001). Thus, this relationship could be explained not only by somatosensory-auditory system interactions but also by the influence of the sympathetic system.