2019 Tinnitus Research Review Series: Somatic Tinnitus

Dr Sarah Michiels discusses our understanding of somatic tinnitus

Dr Sarah Michiels discusses our understanding of somatic tinnitus


Create successful ePaper yourself

Turn your PDF publications into a flip-book with our unique Google optimized e-Paper software.



REVIEW<br />

SERIES<br />

<strong>2019</strong><br />

SOMATIC/<br />



Dr Sarah Michiels<br />

<strong>Tinnitus</strong> <strong>Research</strong> <strong>Review</strong> <strong>Series</strong> <strong>2019</strong>

<strong>Tinnitus</strong> <strong>Research</strong> <strong>Review</strong> <strong>Series</strong> <strong>2019</strong><br />

Copyright © British <strong>Tinnitus</strong> Association <strong>2019</strong>.<br />

Editors: Veronica Kennedy & Nic Wray<br />

The editors would like to thank all the contributors<br />

for their support and enthusiasm. We would also<br />

like to thank the copyright owners of the images<br />

and figures reproduced in this publication for<br />

their permission to reproduce them either directly<br />

or via licence. We believe that all such work has<br />

been acknowledged, but please contact Nic<br />

Wray on nic@tinnitus.org.uk if any have been<br />

inadvertently omitted.<br />

British <strong>Tinnitus</strong> Association<br />

Unit 5 Acorn Business Park<br />

Woodseats Close<br />

Sheffield<br />

S8 0TB<br />

www.tinnitus.org.uk<br />

info@tinnitus.org.uk<br />

0114 250 9933<br />

Registered charity no. 1011145. Company limited<br />

by guarantee no.2709302, registered in England.

SOMATIC/<br />




Principal <strong>Research</strong> Fellow<br />

University of Antwerp/Antwerp University<br />

Hospital<br />

Sarah Michiels graduated as a master in<br />

rehabilitation sciences and physiotherapy from<br />

the Antwerp University College in 2005 and as a<br />

master in manual therapy from the Free University<br />

of Brussels in 2008. She completed her PhD on<br />

the role of the physical therapist in diagnosis and<br />

treatment of patients with tinnitus, with Professors<br />

Paul Van de Heyning and Willem De Hertogh, at the<br />

University of Antwerp in 2015.<br />

Currently, she works at the University of Antwerp<br />

and Antwerp University Hospital as a principal<br />

research fellow, continuing her research on<br />

somatic tinnitus.<br />

Dr Sarah Michiels<br />

Definitions<br />

The somatosensory system is a part of the<br />

sensory nervous system. This is a complex<br />

network of sensory and neurons that respond to<br />

changes at the surface or inside the body. These<br />

changes can include movement, pressure, touch,<br />

temperature or pain.<br />

<strong>Somatic</strong> (also called somatosensory) tinnitus<br />

(ST) is a subtype of subjective tinnitus, where<br />

changed somatosensory information from the<br />

cervical spine or jaw area causes or changes a<br />

patient’s tinnitus perception.<br />

Since Levine’s first publication in 1999 (1),<br />

several animal and human studies have found<br />

connections between the somatosensory system<br />

of the cervical (neck) and temporomandibular<br />

(jaw joint) area and the cochlear nuclei (CN),<br />

offering a physiological explanation for ST<br />

(2-4). According to these studies, cervical or<br />

temporomandibular somatosensory information<br />

is transported to the brain by neural fibres from<br />

cell bodies located in the dorsal root ganglia or<br />

the trigeminal ganglion. Some of these fibres<br />

also project to the central auditory system. This<br />

enables the somatosensory system to influence<br />

the auditory system by altering spontaneous<br />

rates or synchrony of firing among neurons in the<br />

CN, inferior colliculus or auditory cortex. In this<br />

way, the somatosensory system is able to alter<br />

the pitch or loudness of the tinnitus (5).<br />

<strong>Tinnitus</strong> <strong>Research</strong> <strong>Review</strong> <strong>Series</strong> <strong>2019</strong>

<strong>Somatic</strong>/somatosensory tinnitus<br />

<strong>Tinnitus</strong> modulation criteria<br />

The patient is able to modulate the tinnitus by voluntary movement of the head, neck, jaw or eyes<br />

The patient is able to modulate the tinnitus by somatic manoeuvres (e.g. jaw clench)<br />

<strong>Tinnitus</strong> is modulated by pressure on myofascial trigger points<br />

Table 1: <strong>Tinnitus</strong> modulation abilities that strong suggest a somatosensory influence on tinnitus<br />

Prevalence<br />

Widely varying prevalence figures of ST have<br />

been reported in literature. In a recent study (6),<br />

using data from 1262 patients with tinnitus, ST<br />

was present in 12%. This is in accordance with<br />

the 16% prevalence reported by Ward et al (7) in<br />

2015. Other studies though, reported prevalences<br />

of between 43 and 83% of patients with tinnitus<br />

(7-13). The most important reason for this wide<br />

variation is probably the lack of unambiguous<br />

diagnostic criteria for ST.<br />

Diagnosis<br />

In order to overcome this issue, we started<br />

a Delphi process to reach consensus about<br />

ST diagnosis among ST experts. The Delphi<br />

method allows experts to work towards a mutual<br />

agreement by conducting a circulating series of<br />

questionnaires and releasing related feedback<br />

to further the discussion with each subsequent<br />

round.<br />

In total, 13 ST experts from 10 different countries<br />

completed this process. During the final<br />

consensus meeting, the group of experts agreed<br />

on a list of criteria, that if present, strongly<br />

suggest an influence of the somatosensory<br />

system on the patient’s tinnitus (Tables 1 to 3).<br />

This consensus recommends aspects of tinnitus<br />

modulation, tinnitus characteristics (such as<br />

varying pitch and loudness), and accompanying<br />

<strong>Tinnitus</strong> <strong>Research</strong> <strong>Review</strong> <strong>Series</strong> <strong>2019</strong><br />

<strong>Tinnitus</strong> characteristics<br />

<strong>Tinnitus</strong> and neck or jaw pain complaints<br />

appeared simultaneously<br />

<strong>Tinnitus</strong> and neck or jaw pain symptoms<br />

aggravate simultaneously<br />

<strong>Tinnitus</strong> is preceded by a head or neck trauma<br />

<strong>Tinnitus</strong> increases during bad postures<br />

<strong>Tinnitus</strong> pitch, loudness and/or location are<br />

reported to vary<br />

In the case of unilateral tinnitus, the<br />

audiogram does not account for unilateral<br />

tinnitus<br />

Table 2: <strong>Tinnitus</strong> characteristics that strongly<br />

suggest a somatosensory influence on tinnitus<br />

symptoms that are strongly suggestive of ST in<br />

an individual patient, while acknowledging that<br />

the individual presentation of the condition can<br />

vary from patient to patient.<br />

To prevent under or over-diagnosis, it is important<br />

to keep in mind the experts’ footnotes. When<br />

looking at the ‘modulation’ items for instance,<br />

our consensus meeting panel recognised the<br />

importance of somatic modulation, especially<br />

by voluntary movements, for the ST diagnosis,<br />

but added that the absence of this ability does<br />

not rule out ST. Hence, somatic modulation<br />

should not be used as a simple ‘yes/no’ criterion

<strong>Somatic</strong>/somatosensory tinnitus<br />

Accompanying symptoms<br />

<strong>Tinnitus</strong> is accompanied by frequent pain in the cervical spine, head or shoulder girdle<br />

<strong>Tinnitus</strong> is accompanied by the presence of tender myofascial trigger points<br />

<strong>Tinnitus</strong> is accompanied by increased muscle tension in the suboccipital muscles<br />

<strong>Tinnitus</strong> is accompanied by increased muscle tension in the extensor muscles of the cervical spine<br />

<strong>Tinnitus</strong> is accompanied by temporomandibular disorders<br />

<strong>Tinnitus</strong> is accompanied by teeth clenching or bruxism<br />

<strong>Tinnitus</strong> is accompanied by dental diseases<br />

Table 3: Accompanying symptoms that strongly suggest a somatosensory influence on tinnitus<br />

for diagnosing ST. Although the use of somatic<br />

manoeuvres to assess tinnitus modulation was<br />

voted in, some experts believe that the use of<br />

these manoeuvres as a single criterion can<br />

potentially lead to over-diagnosis.<br />

It must also be noted that items, such as:<br />

‘tinnitus accompanied by frequent pain in<br />

the head, neck or shoulder girdle’ or ‘tinnitus<br />

accompanied by temporomandibular disorders’,<br />

should be used with a certain prudence if they<br />

are the only criterion present. This is because<br />

tinnitus and neck or jaw problems can also<br />

co-occur without a causal relation (14). On the<br />

other hand, when these items are combined with<br />

another criterion, such as ‘tinnitus and neck or<br />

jaw pain complaints appeared simultaneously’<br />

or ‘the patient is able to modulate the tinnitus<br />

by voluntary movement of the head, neck, jaw<br />

or eyes’, the likelihood of a ST diagnosis gets<br />

stronger.<br />

Treatment<br />

Several techniques and approaches have been<br />

suggested for the treatment of ST, but generally,<br />

ST treatment can be categorized in techniques<br />

directed to the cervical spine, techniques directed<br />

to the temporomandibular area and bimodal<br />

stimulation treatment.<br />

Cervical spine treatment<br />

Figure 1: Cervical spine.<br />

Image: BodyParts3D, © 2008 Life Sciences Integrated Database<br />

Center licensed by CC Display-Inheritance 2.1 Japan<br />

A systematic literature review published in<br />

2016 (15) was able to identify four (randomized)<br />

controlled trials investigating the effect of<br />

cervical spine treatment on tinnitus severity.<br />

<strong>Tinnitus</strong> <strong>Research</strong> <strong>Review</strong> <strong>Series</strong> <strong>2019</strong>

<strong>Somatic</strong>/somatosensory tinnitus<br />

These studies showed a positive effect of cervical<br />

spine manipulations, muscle trigger point<br />

treatment, stabilizing and mobilizing exercises,<br />

transcutaneous electrical nerve stimulation<br />

(TENS) and a combination of stretching, postural<br />

exercises and auricular acupuncture (16-19).<br />

One more recent randomized controlled trial<br />

(20) showed positive effects of a multimodal<br />

cervical spine treatment on tinnitus severity.<br />

This treatment consisted of a patient-tailored<br />

combination of manual mobilizations, muscle<br />

trigger point treatment, and stabilizing and<br />

mobilizing exercises.<br />

currently widely accepted.<br />

Although experts agreed on a set of criteria to<br />

identify patients with ST, it is still not easy to<br />

make the diagnosis, especially because patients<br />

often present with a combination of influencing<br />

factors.<br />

Once diagnosed, ST can be treated successfully<br />

with cervical spine physiotherapy or with<br />

orofacial physiotherapy combined with splint<br />

treatment. The effect of bimodal auditorysomatosensory<br />

stimulation is promising, but<br />

needs to be confirmed in larger studies.<br />

Temporomandibular treatment<br />

Currently, only three controlled trials studying<br />

the effect of temporomandibular treatment on<br />

tinnitus severity are available. These studies<br />

show that tinnitus severity significantly<br />

decreased after splint treatment combined<br />

with jaw exercises (21-23). One study did notice<br />

that this effect was only present in patients<br />

with severe to very severe tinnitus (<strong>Tinnitus</strong><br />

Questionnaire score: 47-84) and not in patients<br />

with light to moderate tinnitus (<strong>Tinnitus</strong><br />

Questionnaire score: 0 – 46).<br />

Bimodal stimulation treatment<br />

One study from Marks et al (24) shows positive<br />

effect on tinnitus loudness after bimodal<br />

stimulation treatment in 20 patients with<br />

unilateral ST. This treatment comprises a<br />

combination of auditory stimulation and<br />

electrical stimulation applied to the cervical<br />

spine or temporomandibular area. This approach<br />

is currently being tested in a large randomized<br />

controlled trial.<br />

Conclusion<br />

The existence of a tinnitus subtype where tinnitus<br />

is influenced by somatosensory information from<br />

the cervical spine or temporomandibular area is<br />

<strong>Tinnitus</strong> <strong>Research</strong> <strong>Review</strong> <strong>Series</strong> <strong>2019</strong>

<strong>Somatic</strong>/somatosensory tinnitush<br />

References<br />

[1] Levine RA. <strong>Somatic</strong> (craniocervical) tinnitus and<br />

the dorsal cochlear nucleus hypothesis. American<br />

Journal of Otolaryngology. 1999; 20(6):351-62.<br />

[2] Zhan X , Pongstaporn T, Ryugo DK. Projections of<br />

the second cervical dorsal root ganglion to the<br />

cochlear nucleus in rats. Journal of Comparative<br />

Neurology. 2006; 496:335–48.<br />

[3] Lanting CP, de Kleine E, Eppinga RN, van Dijk P.<br />

Neural correlates of human somatosensory<br />

integration in tinnitus. Hearing <strong>Research</strong>.<br />

2010; 267(1-2):78-88.<br />

[4] Shore SE. Plasticity of somatosensory inputs to<br />

the cochlear nucleus--implications for<br />

tinnitus. Hearing <strong>Research</strong>. 2011; 281(1-2):38-46.<br />

[5] Shore S, Zhou J, Koehler S. Neural mechanisms<br />

underlying somatic tinnitus. Progress in Brain<br />

<strong>Research</strong>. 2007; 166:107-23.<br />

[6] Michiels S, Harrison S, Vesala M, Schlee W. The<br />

Presence of Physical Symptoms in Patients<br />

With <strong>Tinnitus</strong>: International Web-Based Survey.<br />

Interactive Journal of Medical <strong>Research</strong>. <strong>2019</strong>; 8.<br />

[7] Ward J, Vella C, Hoare DJ, Hall DA. Subtyping<br />

<strong>Somatic</strong> <strong>Tinnitus</strong>: A Cross-Sectional UK Cohort Study<br />

of Demographic, Clinical and Audiological<br />

Characteristics. PLoS One. 2015; 10(5):e0126254.<br />

[8] Abel MD, Levine RA. Muscle contractions and<br />

auditory perception in tinnitus patients and<br />

nonclinical subjects. Cranio : the journal of<br />

Craniomandibular Practice. 2004; 22(3):181-91.<br />

[9] Levine RA, Abel M, Cheng H. CNS somatosensoryauditory<br />

interactions elicit or modulate tinnitus.<br />

Experimental Brain <strong>Research</strong>. 2003; 153(4):643-8.<br />

[10] Simmons R, Dambra C, Lobarinas E, Stocking<br />

C, Salvi R. Head, Neck, and Eye Movements that<br />

Modulate <strong>Tinnitus</strong>. Seminars in Hearing. 2008;<br />

29(4):361-70.<br />

[11] Won JY, Yoo S, Lee SK, Choi HK, Yakunina N, Le Q,<br />

et al. Prevalence and factors associated with neck<br />

and jaw muscle modulation of tinnitus. Audiology &<br />

Neuro-Otology. 2013; 18(4):261-73.<br />

[12] Michiels S, De Hertogh W, Truijen S, Van de Heyning<br />

P. Cervical spine dysfunctions in patients with<br />

chronic subjective tinnitus. Otology & Neurotology<br />

: Official Publication of the American Otological<br />

Society, American Neurotology Society [and]<br />

European Academy of Otology and Neurotology.<br />

2015; 36(4):741-5.<br />

[13] Ralli M, Greco A, Turchetta R, Altissimi G, de<br />

Vincentiis M, Cianfrone G. Somatosensory tinnitus:<br />

Current evidence and future perspectives. The<br />

Journal of international Medical <strong>Research</strong>. 2017;<br />

45(3):933-47.<br />

[14] Michiels S, De Hertogh W., Truijen S., Van de Heyning<br />

P. Cervical spine dysfunctions in patients with<br />

chronic subjective tinnitus. Otology & Neurotology<br />

: Official Publication of the American Otological<br />

Society, American Neurotology Society [and]<br />

European Academy of Otology and Neurotology.<br />

2015; 36(4):741-5.<br />

[15] Michiels S, Naessens S, Van de Heyning P, Braem M,<br />

Visscher CM, Gilles A, et al. The Effect of Physical<br />

Therapy Treatment in Patients with Subjective<br />

<strong>Tinnitus</strong> : A Systematic <strong>Review</strong>. Frontiers in<br />

Neuroscience. 2016; 10.<br />

[16] Amanda B, Manuela M, Antonia M, Claudio M,<br />

Gregorio B. Posturography measures and efficacy<br />

of different physical treatments in somatic tinnitus.<br />

The international <strong>Tinnitus</strong> Journal. 2010; 16(1):44-<br />

50.<br />

[17] Latifpour DH, Grenner J, Sjodahl C. The effect of a<br />

new treatment based on somatosensory stimulation<br />

in a group of patients with somatically related<br />

tinnitus. The international <strong>Tinnitus</strong> Journal. 2009;<br />

15(1):94-9.<br />

[18] Mielczarek M, Konopka W, Olszewski J. The<br />

application of direct current electrical stimulation of<br />

the ear and cervical spine kinesitherapy in tinnitus<br />

treatment. Auris Nasus Larynx. 2013; 40(1):61-5.<br />

[19] Rocha CB, Sanchez TG. Efficacy of myofascial<br />

trigger point deactivation for tinnitus control.<br />

Brazilian Journal of Otorhinolaryngology. 2012;<br />

78(6):21-6.<br />

[20] Michiels S, De Hertogh W, Truijen S, Van De Heyning<br />

P. The effect of cervical physical therapy in patients<br />

with cervicogenic somatic tinnitus. Manual Therapy.<br />

2016; 25:e102.<br />

[21] Erlandsson SI, Rubinstein B, Carlsson SG. <strong>Tinnitus</strong>:<br />

evaluation of biofeedback and stomatognathic<br />

treatment. British Journal of Audiology. 1991;<br />

25(3):151-61.<br />

[22] Bosel C, Mazurek B, Haupt H, Peroz I. [Chronic<br />

tinnitus and craniomandibular disorders.<br />

Effectiveness of functional therapy on perceived<br />

<strong>Tinnitus</strong> <strong>Research</strong> <strong>Review</strong> <strong>Series</strong> <strong>2019</strong>

<strong>Somatic</strong>/somatosensory tinnitush<br />

tinnitus distress]. HNO. 2008; 56(7):707-13.<br />

[23] Tullberg M, Ernberg M. Long-term effect on tinnitus<br />

by treatment of temporomandibular disorders:<br />

a two-year follow-up by questionnaire. Acta<br />

Odontologica Scandinavica. 2006; 64(2):89-96.<br />

[24] Marks KL, Martel DT, Wu C, Basura GJ, Roberts LE,<br />

Schvartz-Leyzac KC, et al. Auditory-somatosensory<br />

bimodal stimulation desynchronizes brain circuitry<br />

to reduce tinnitus in guinea pigs and humans.<br />

Science Translational Medicine. 2018; 10(422).<br />

<strong>Tinnitus</strong> <strong>Research</strong> <strong>Review</strong> <strong>Series</strong> <strong>2019</strong>

Hooray! Your file is uploaded and ready to be published.

Saved successfully!

Ooh no, something went wrong!