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Author: admin, 13.02.2014. Category: Tinnitus Causes And Cures

Electrical stimulation of the median nerve at the wrist can cause tinnitus (Moller and Rollins, 2002). In general, it is thought that cervical input can modulate hearing related neural structures in the brainstem (Shore et al, 2007). Vanneste et al (2010) reported that tinnitus sometimes responds to Transcutaneous electrical nerve stimulation (TENS) of upper cervical nerve (C2). Levine (2007) suggested that cervical treatment was most successful in individuals with asymmetrical tinnitus (on matching), but normal hearing threshholds. We have encountered patients who respond to cervical epidural steroids injections(CESI) at other levels too (C4-C5). Levine also reviewed electrical stimulation (a few reports), trigger point injections of the cervical and jaw muscles, and TMD treatments.
With respect to incidence (the table above is about prevalence), Martinez et al (2015) reported that there were 5.4 new cases of tinnitus per 10,000 person-years in England.
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%). Thus it can see that there are numerous factors that are weakly correlated with tinnitus, and that hearing impairment is the most strongly associated. Most tinnitus comes from damage to the inner ear, specifically the cochlea (the snail like thing on the right of figure 1, labeled '9'). Patients with Meniere's disease often describe a low pitched tinnitus resembling a hiss or a roar. Tinnitus can also arise from damage to the nerve between the ear and brain (8th nerve, labeled 6, auditory nerve). Tinnitus arises more rarely from injury to the brainstem (Lanska et al, 1987), and extremely rarely, to the brain itself (e.g. Tinnitus can be associated with Basilar Artery Migraine (BAM), and also tinnitus can be more bothersome when one is having a migraine (Volcy et al, 2005), like sound and light and smells.
In our opinion, people are very quick to blame drugs for their tinnitus, but it is rare that this is borne out.
Often people bring in very long lists of medications that have been reported, once or twice, to be associated with tinnitus. As tinnitus is essentially subjective, malingering of tinnitus as well as psychological causes of tinnitus is certainly possible. 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). Schecklmann et al (2014) suggested that tinnitus is associated with alterations in motor cortex excitability, by pooling several studies, and reported that there are differences in intracortical inhibition, intra-cortical facilitation, and cortical silent period. Cartoon of the middle ear showing muscles that attach to ossicles (ear bones), and ear drum. ABR (ABR) testing may show some subtle abnormalities in otherwise normal persons with tinnitus (Kehrle et al, 2008). We occasionally recommend neuropsychological testing using a simple screening questionnaire -- depression, anxiety, and OCD (obsessive compulsive disorder) are common in persons with tinnitus. Microvascular compression of the 8th nerve is not a significant cause of tinnitus (Gultekin et al.
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. Disrupted sleep is the most significant complaint, and affects between 25-50% of tinnitus patients.
The algorithm that we use in our practice to diagnose and treat tinnitus is here (a PDF graphic). The bottom line is that it is unusual (although not impossible) for people to get substantial relief from medication, devices, or surgery. Pan et al (2015) reported in a survey of 258 patients with tinnitus, that 38% reported that noise made tinnitus better, and 15% that relaxation made it better. There is a small literature concerning use of intravenous and local anesthesia for tinnitus. 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.
Pramipexole was recently reported effective for tinnitus in a study of 40 patients with age related hearing loss in Hungary.
While Hearing aids are often recommended as treatment of tinnitus, according to Hoare(2014) from the Cochrane Databse, the quality of evidence for their effect is so poor that no conclusion can be made. Cochlear implants, which are used for severe bilateral unaidable hearing loss, usually improve tinnitus (Amoodi et al, 2011). These are devices based on the idea that tinnitus is usually worst when things are very quiet. A discussion of the Neuromonic's masking device can be found by clicking on the link above. Friedland and associates (2008) reported results of brain electrical stimulation in 8 patients. Occasionally persons with Meniere's disease have relief or reduction of tinnitus from transtympanic gentamicin. Microvascular compression syndrome, in theory, may cause tinnitus, but we have had very little success when the few patients we have seen with this syndrome have undergone surgery.
Tinnitus usually improves in profoundly deaf individuals who undergo cochlear implantion (Olze, 2015). Avoid exposure to loud noises and sounds, avoid environments that are very quiet (as this makes tinnitus more noticeable). Internet based psychological treatments have been available for about 15 years, and have considerable promise (Andersson et al, 2015).
Tinnitus Retraining Therapy (TRT) is a method of treating tinnitus helpful for some (Wang et al, 2003). We sometimes refer patients for TRT, but the time required and general lack of health insurance support for long term psychotherapy are significant barriers. Plein et al (2015) suggested that the quality of published studies concerning clinical trials for tinnitus were suboptimal, and in fact, only 20% of 147 had a low risk of bias. Dawes P, Fortnum H, Moore DR, Emsley R, Norman P, Cruickshanks K, Davis A, Edmondson-Jones M, McCormack A, Lutman M, Munro K. Hoare DJ, Kowalkowski VL, Kang S, Hall DA.Systematic review and meta-analyses of randomized controlled trials examining tinnitus management.
Mahboubi H, Ziai K, Brunworth J, Djalilian HR.Accuracy of tinnitus pitch matching using a web-based protocol. Piccirillo JF, Garcia KS, Nicklaus J, Pierce K, Burton H, Vlassenko AG, Mintun M, Duddy D, Kallogjeri D, Spitznagel EL Jr.Low-frequency repetitive transcranial magnetic stimulation to the temporoparietal junction for tinnitus Arch Otolaryngol Head Neck Surg. Schecklmann M1, Landgrebe M2, Kleinjung T3, Frank E1, Rupprecht R1, Sand PG1, Eichhammer P1, Hajak G2, Langguth B1.
Wineland AM, Burton H, Piccirillo J.Functional Connectivity Networks in Nonbothersome Tinnitus. INTRODUCTION: Musical training positively influences the cortical plasticity of the brain and has proven to be effective in treating chronic tinnitus. OBJECTIVES: A neuro-music therapy concept, the "Heidelberg Neuro-Music Therapy" treatment was developed and evaluated.
MATERIALS AND METHODS: N = 135 patients (mean age 47 years) with chronic, tonal tinnitus attended a standardized protocol for Neuro-Music Therapy (either "standard therapy" ST or "compact therapy" CT). CONCLUSIONS: The "Heidelberg Neuro-Music Therapy" is a method with fast onset and long lasting effect for patients with "tonal" tinnitus.
Apart from emotional disturbances such as anxiety, depression, sleep impairments or irritation1, the main complaints of the persons concerned with ringing in the ear are difficulties in concentrating their attention2 and in auditory perception3. Data from human neuroimaging support the hypothesis of a final common pathway for tinnitus6 and propose a compromised "noise cancellation mechanism"7 to be liable for the enduring tinnitus percept. It is known that pleasant music verifiably reduces activities in the amygdala and enhances activity in nucleus accumbens and thalamus8,9. Disadvantages are the rather lengthy application and the passive "sounding" of the tinnitus instead of an active exposition to the tinnitus sound.
Therefore a short-term Neuro-Music Therapy based on active treatment modules seems to be fruitful in treating chronic tinnitus.
The novel treatment according to the "Heidelberg Model of Neuro-Music Therapy" is based on the notion that tinnitus is experienced as an auditory percept - just as musical stimuli are experienced as auditory percepts. Two standardized protocols for tinnitus music therapy were defined: a "standard therapy" (ST) and a "compact therapy" (CT) (see patient flow-chart). All patients receive a comprehensive psycho-educative counseling in order to establish a cognitive model of tinnitus20. As the specific modules used in therapy are based on the individual tinnitus sound, a tinnitus-equivalent has to be set up by means of a commercially available sinus generator. In the Resonance Training the patient learns a vocal exercise stimulating the cranio-cervical resonating cavities. The Neuroauditive Cortex Training uses tone sequences performed live by the therapist on a piano which have to be vocally imitated by the patient. The Tinnitus Reconditioning offers coping mechanisms related to stress control along with a sound based habituation procedure.
During the relaxation exercise, the tinnitus sound will be integrated intermittently into the background music.
Patients were eligible if they suffered from chronic tinnitus (duration > six months) which could be musically compiled (distinct frequency) and had no psychiatric co-morbidity.
Since patients were recruited nationwide it was not possible to randomize the patients to the groups in the true sense of the word. Based on data from a pilot study23 we calculated the a priori power and thus estimated the minimum control group size with the power analysis program "GPOWER"24 to n = 15.
As part of the medical history, psychosomatic and audiologic co-morbidities as well as socio-demographic data and tinnitus characteristics were assessed. On the whole 69% of the patients presented with high frequency hearing loss (> 20 dB hearing impairment present in at least three test frequencies > 3000 Hz) and about 42% presented with low frequency hearing loss (> 30 dB hearing impairment present in at least one test frequency 0-2000 Hz).
Due to the stratified group allocation, no group differences in socio-demographic data were obtained. Patients in the music therapy groups ST and CT received a treatment according to the "Heidelberg Model of Neuro-Music Therapy" as described above.
Patients in the control group PT received a psychosocial intervention based on psychological tinnitus treatment strategies25 combined with placebo music therapy elements.
Assessment of tinnitus symptoms was performed three times, at admission ("pre"), at discharge ("post") and six months after therapy ("follow-up FU").
Apart from statistical significance, individual changes were assessed according to the concept of clinical significance27.
At discharge all patients of the music therapy groups had the opportunity to rate their subjective therapy satisfaction.
Statistical analysis of the data was performed using parametrical and non-parametrical tests in SPSS 16 (SPSS Inc. In order to predict parameters possibly influencing therapy outcome, a logistic regression model (CATREG, SPSS 16.0) was calculated using TQ-score immediately after therapy as an indicator for therapy success as a dependent variable. Analysis of TQ scores revealed a highly statistically significant reduction pre-post (p p =.913).
The overall reduction in the music therapy groups can be explained by significant changes in distinct sub-scales of the TQ, especially of "E = emotional problems" (p p p p p >.05). According to the concept of "clinical significance", more than 80% of the patients the music therapy groups (ST and CT) achieved a reliable reduction in their tinnitus scores from admission to discharge and could thus be categorized as "responder". On a subjective level, 67% of the patients treated with music therapy regarded their symptoms as "better", 22% observed no change and 11% stated to be worse off. Apart from immediate therapy-related effects, there could be other factors influencing therapy outcome ("moderator variables"). In order to set the results in the context of existing therapies, a psychologically based treatment group was used as control group. Animal models 29 as well as results from research on tinnitus treatments30 suggest the use of very specific stimuli, i.e. The "Heidelberg Model of Neuro-Music Therapy" on the other hand integrates some well known psychological techniques and strategies in order to reduce the tinnitus sensitivity by means of an immediate exploration of the tinnitus sounds by the patient. The rather low positive feedback rate of the Neuroauditive Cortex Training (only about a quarter of the patients rated this module as helpful) might have been due to the wording during the therapy. The Resonance Training is a purely vocal exercise that stimulates the auditory pathway by means of somatosensory innervations and enables the patients to control their tinnitus perception. It is known that there are manifold cross-modalities in processing somatosensory and auditory stimuli 35. The Neuroauditive Cortex Training contains a detailed "intonation-training" with purpose-built musical stimuli, based on the individual tinnitus frequency in order to increase the patients" discriminative abilities and enhance their attentive skills.
In chronic tinnitus characteristic auditory cortical reorganizations are traceable, which seem to be frequency specific 40,41. Tinnitus Reconditioninghas distinct features in that it combines musical distractors with psychophysiological relaxation and imagination of mental well-being. Since the application of the "well-being image" is linked to acoustic stimuli (relaxation music, tinnitus equivalent sound), the connection "well-being image - relaxation - tinnitus reduction" can be explained in terms of classical conditioning 46.
The neurological basis seems to be in an endogenous system located in the medial temporal lobe system (MTLS) 6 and the reticular formation (RF) 47. On the whole, music therapy is a method with short duration, fast onset and long lasting effect for patients with "tonal" tinnitus and light to moderate tinnitus severity (Figure 1 and 2). Paper submitted to the RBCMS-SGP (Publishing Management System) on April 1, 2012; and accepted on August,16, 2012. We will be provided with an authorization token (please note: passwords are not shared with us) and will sync your accounts for you. Background: Many patients show modulation of tinnitus by gaze, jaw or neck movements, reflecting abnormal sensorimotor integration, and interaction between various inputs. Tinnitus is an auditory perception, experienced in the absence of any external or internal auditory stimulus (perception of a sound without a recordable source). On the other hand, the somatosensory system, especially when involving head and neck regions, also seems to be strongly interrelated to tinnitus.
Postural stabilization is based on multiple sources of information namely, somatosensory, proprioceptive, vestibular, visual, oculomotor, and auditory. The investigation adhered to the tenets of the Declaration of Helsinki and was approved by the Institutional human experimentation committee. Tinnitus was modulated by jaw movements in 14 patients, head movements in 10 patients, muscle pressure in 9 patients, eye movements in 3 patients, and global muscular effort in 2 of the patients.
The pathological conditions being present at the onset of tinnitus were either otological (right otitis media (2), left otosclerosis surgery, bilateral noise induced hearing loss, sensorineural hearing loss) or neuro-muscular (acoustic neuroma – left for subject T18 and right for subject T9, right meningioma, meningitis, left head trauma with TMJ luxation, cervicalgia, abdominal, or orthopedic surgery).
Audiometry thresholds were normal in 7 patients, and demonstrated high frequency sensorineural hearing loss in 12 subjects, middle frequency sensory neural hearing loss in 2 subjects, and total unilateral cophosis in 2 patients (acoustic neuroma patients). In summary, the pathophysiological mechanisms underlying the tinnitus percept probably vary among patients.
During all posturography tests, subjects were required to fixate a target placed at eye level.
In this paper we study subjects with somatic tinnitus who spontaneously noticed a modulation of their subjective tinnitus perception in pitch or intensity after any kind of movement or muscular exercise or muscular pressure.
For both groups of subjects almost all postural parameters were significantly lower for the eyes open condition as opposed to the eyes closed condition.
A significant interaction between the group and the vision (eyes open, eyes closed) was observed for the FFTx only. The key finding here is that tinnitus patients show a specific deficit in lateral body sway only. The general idea is that sensory input from muscles or structures outside the ear can cause or change tinnitus.
Similarly, Moller et al (1992) found that tinnitus modulated with electrical stimulation at the wrist. Our experience has been that it is rare (about 20%) that tinnitus is affected by acupuncture.

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). We don't find this statistic much use as tinnitus is highly prevalent in otherwise normal persons. It is surprising that TMJ's correlation is nearly as high as hearing impairment, and more than depression or stress. 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.
Distinct causes are microvascular compression syndrome, viral infections of the 8th nerve, and tumors of the 8th nerve. For example, Tandon (1987) reported that 1% of those taking imiprimine complained of 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. We doubt that this means that motor cortex excitability causes tinnitus, but rather we suspect that these findings reflect features of brain organization that may predispose certain persons to develop tinnitus over someone else. Wax should be removed, and the examiner should note whether the ear drum is intact, inflamed, scarred, or whether it is moving.
Because papilloedema is so rare, and tinnitus is so common, it is very unusual to find this dangerous condition. The stapedius is attached to the stapes (of course -- horseshoe object above), while the tensor tympani is attached to the ear drum. A brain MRI is used for the same general purpose and covers far more territory, but is roughly 3 times more expensive.
This is not surprising considering how disturbing tinnitus may be to ones life (Holmes and Padgham, 2009).
One would think that tinnitus would obscure perception of sound at the frequency of tinnitus, and thus be measurable through an internal masking procedure, but this approach has not been helpful.
Things that made it worse included being in a quiet place (48%), stress (36%), being in a noisy place (32%), and lack of sleep (27%).
This is because of the very high correlation between anxiety and depression with tinnitus-related annoyance and severity (Pinto et al, 2014). At that date there were 4 double-blind placebo controlled trials of antidepressants 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.
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.
This is a drug designed for heart disease, that is marketed in Europe for vertigo and tinnitus. That being said, we think If you have tinnitus associated with a hearing loss, a hearing aid is a reasonable thing to try. Nearly all states mandate a 1-month money-back guarantee built into hearing aid dispensing. Listening to the interstation static on the FM radio, tapes of ocean surf, fans, and the like may be helpful. Briefly, we think that smartphone apps are a much more efficient method of doing much the same thing. For venous tinnitus, possibilities include jugular vein ligation, occlusion of the sigmoid sinus, or closure of a dural fistula. Cochlear nerve section is reported effective in 50%, with the inevitable consequence of irreversible deafness. Rationally, the choice of treatment should depend on personality style and ones ability to suppress unwanted thoughts. This is aimed both at improving sleep and reducing anxiety, as both of these factors make tinnitus even worse.
Joining of these sorts of organizations intrinsically draws more attention to ones illness.
The author of this page feels happy that at least someone is doing trials on this difficult situation ! The effects of unilateral cochlear implantation on the tinnitus handicap inventory and the influence on quality of life. Medium-term results of combined treatment with transcranial magnetic stimulation and antidepressant drug for chronic tinnitus.
Comparison of auditory brainstem response results in normal-hearing patients with and without tinnitus. Maintenance repetitive transcranial magnetic stimulation can inhibit the return of tinnitus.
Heidelberg Neuro-Music Therapy for chronic-tonal tinnitus - treatment outline and psychometric evaluation.
But more than 80% of the music therapy patients (both ST and CT) revealed a reliable improvement ("responder") compared to 44% in the PT group. A number of potential working factors accounting for the treatment success are highlighted.
The main reason seems to be the permanent awareness of the tinnitus and the diminished ability to habituate to the sounds4. According to these assumptions, the tinnitus sounds originate from lesions in the auditory pathways.
Therefore the patients shall be enabled to actively control the sounds in order to reorganize the underlying neuronal mechanisms maintaining the tinnitus17. The overall therapeutic dose rate (500 minutes of therapy) was equal just as were the intervention modules (including the counseling).
The aim is not to reproduce a psychometrical pitch-matched tone but rather a sound that is subjectively equivalent to the patients" "ear sounds". A systematic and targeted training of inaccurately intonated musical sounds enables the patients to exert influence on their auditory processes since they learn to actively filter out irrelevant information and to concentrate on relevant acoustic stimuli.
By means of music as calming background stimulus, the balance between the activity of the sympathetic and the parasympathetic branches of the autonomic nervous system shall be restored. The volume is adapted to the individual hearing level compensating for a potential hearing deficit. The therapy concept was announced by press releases (newspapers and magazines, radio and TV) and offered to patients at the outpatient department of the local ENT-clinic of the university hospital.
The therapy was designed as group intervention with five weekly sessions a 90 minutes and an additional individual counselling (50 minutes) leading to therapy duration of 500 minutes equal to the music therapy intervention.
The main outcome criteria were the absolute scores of the German version of the tinnitus questionnaire ("Tinnitus-Fragebogen", abbreviated "TQ") by Goebel and Hiller26 as well as the relative decrease in TQ scores.
They had to answer three specific questions a) "Was your tinnitus percept changed by the music therapy?" (Answers: worsened - unaffected - improved) and b) "Which elements from therapy did you consider helpful?" (open question). In the logistic regression demographic, therapy and tinnitus related factors were entered in the model to define those factors that are associated with tinnitus and may therefore contribute to therapy success.
Therefore there is an urge for a short term therapy with preferably minimal effort but long lasting effect. In terms of treatment outcome this group was target underperforming since just less than half of the patients achieved the desired symptom reduction. At the core of the "Heidelberg Model of Neuro-Music Therapy", the patients are actively "confronted" with their individual tinnitus sounds and are told to deal with their tinnitus explicitly instead of trying to take no notice of the tinnitus. These modules enhance the self-determination and the control beliefs of the patients since they learn techniques in order to actively influence their tinnitus. The patients possibly did not know the scientific label of the intervention thus the answers in the feedback-sheet were blurred because the patients could not label this intervention.
One specific of the "Heidelberg Model of Neuro-Music Therapy" is the establishment of a tinnitus-equivalent sound.
Many patients can voluntarily change the percept of their tinnitus by for example teeth clenching, pressure on the occiput, forehead, vertex and temples, head turning and shoulder abductions 36.
Frequency discrimination training may interrupt the cortical representations that are generating tinnitus 42,43. This module increases the auditory filtering and supports a modified emotional processing of the tinnitus sound. The MTLS is suspected to be responsible for the establishment of a "tinnitus memory" similar to the pain memory. Further studies are needed in order to evaluate which elements of the music therapy contribute most to the overall effect and to scrutinize the proposed working factors of the modules. The treatment of tinnitus related psychological distress is part of the music therapy concept, though the duration is very short and music therapy presents a focal therapy and no in-depth psychotherapy will be possible. University Hospital for Ear, Nose, and Throat - University of Heidelberg - Heidelberg - Germany. Tinnitus outpatient department - German Center for Music Therapy Research - Heidelberg - Germany. This means that you will not need to remember your user name and password in the future and you will be able to login with the account you choose to sync, with the click of a button. This page doesn't support Internet Explorer 6, 7 and 8.Please upgrade your browser or activate Google Chrome Frame to improve your experience. Postural control is based on multi-sensory integration (visual, vestibular, somatosensory, and oculomotor) and indeed there is now evidence that posture can also be influenced by sound. Subjective tinnitus must be differentiated from objective tinnitus which is induced by the perception of an internal, vascular, or muscular noise that can actually be recorded. Nevertheless, subjective tinnitus is thought to result from hyperactivity and neuroplastic reorganization of cortico-subcortical auditory and non-auditory networks following acoustic deafferentation induced by cochlear or auditory nerve damage (Eggermont and Roberts, 2004). Written informed consent was obtained from all subjects after the nature of the procedure had been explained. One condition elicited tinnitus modulation in 11 patients, two conditions in 9 patients, and three in the remaining 3 patients. Yet, this group of patients is homogeneous because of their spontaneously modulated tinnitus following different types of movements. Subjects maintain an upright and standardized Romberg position (feet placed side-by-side forming an angle of 30° with both heels separated by 4 cm). These parameters were described in previous studies (Kapoula and Le, 2006; Le and Kapoula, 2006, 2008).
Group mean values for each parameter of posturography for the control and tinnitus groups (16) matched for sex and age.
The ANOVA run on data for the wavelet analysis showed that the PII and the power spectrum of the antero-posterior (PIy) and medio-lateral sway (PIx) for all frequency bands were significantly higher under the eyes closed condition than under the eyes open condition. The values from these parameters were significantly higher for the tinnitus group than for controls (see asterisks in Table 2).
Post hoc analysis revealed higher values for these parameters in tinnitus subjects than in controls (see asterisks in Table 2).
Note that this classification is based on the clinical examination based on every day life, not on what patients reported during our laboratory testing. For subjects with left tinnitus (bilateral or unilateral), SDx was significantly higher under lateral gaze conditions (tinnitus or non-tinnitus side) as compared with the center gaze condition. Significant interaction between gaze position and subgroup of tinnitus subjects: for subjects with left tinnitus only (as determined in text) medio-lateral body sway is optimal for the straight ahead gaze position but deteriorated significantly when looking away, on either side.
Such results confirm that vision and related oculomotor signals provide better stability in tinnitus subjects, as is the case for controls (Kapoula and Le, 2006).
The values for this parameter were particularly high for the eyes closed condition in the tinnitus subjects. Before we discuss this we should highlight the absence of overall postural deficits in such patients affecting other parameters, particularly the surface. As of course the median nerve sends input to the spinal cord, and cervical injuries are known to occasionally cause tinnitus, this is consistent with the general idea that sensory input from nearly any source can (rarely) cause or modulate tinnitus.
It seems to us that their study is more about how many persons with tinnitus were detected by the health care system -- and that it is more a study of England's health care system than of tinnitus. According to Park and Moon (2004), hearing impairment roughly doubles the odds of having tinnitus, and triples the odds of having annoying tinnitus. Loudness was correlated with values in the thalamus, bilateral hippocampus and left caudate.
Somatic tinnitus means that the tinnitus is coming from something other than the inner ear. In a double-blind trial of paroxetine for tinnitus, 3% discontinued due to a perceived worsening of tinnitus (Robinson, 2007). 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. It seems to us that response to carbamazepine is not a reliable indicator of microvascular compression as this drug stabilizes nerves and lowers serum sodium. While useful, be aware that there are multiple errors in this illustration from Loyola Medical School.
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. Thus paradoxically enough, doctors tend to discourage reading of web pages like this one, or joining of support groups. Three out of four trials resulted in a favorable outcoume (Nortriptyline, Paroxetine, Sertraline).
On the other hand, Hoekstrat et al (2011) suggested that in general these drugs do not work for tinnitus.
This study suggested that Botox might improve tinnitus to a small extent (7 improved with active, 2 improved with placebo). Be sure that you try the hearing aid before buying one, as tinnitus is not always helped by an aid. Given that smartphone apps do the same thing as tinnitus maskers, and that most newer hearing aids are blu-tooth capable, we see little reason to pay for a masker-hearing aid when one already owns a cell phone. Generally though, hearing aids or implantable devices are much more successful than surgery. Surgery seems worth considering only in extreme situations - -the tinnitus is extremely loud, very distressing, and there is a methodology to decide whether or not the tinnitus can be improved with surgery. On the other hand, very few individuals with tinnitus are deaf enough to qualify for cochlear implants. Tinnitus distress was assessed using the German version of the Tinnitus-Questionnaire (TQ) at admission, at discharge and six months after therapy. Therapy impact seems to be lasting since TQ scores remained stable until follow-up at six months. For that reason the predominant wish of the patients is to get rid of the "annoying" and "intrusive" sounds5 and to regain confidence in their sense of hearing. Usually these sounds should be blocked off by feedback connections from limbic regions before reaching the auditory cortex.
Musically based interventions11,12,13 also have proven to be highly effective in treating chronic tinnitus - possibly by correcting tinnitus evoking neuronal mechanisms14. If they could actively influence their tinnitus, their control beliefs will rise and thus let down the strains15. Purpose-built music therapeutic interventions were merged to modules and integrated into a standardized manual. During the interval between the sessions, the patients have to exercise themselves in Resonance Training for three minutes every hour.
For this purpose, before the training session starts, the patients have to set the background music to a convenient level such that they can easily listen to the music while still being able to follow verbal instructions from the therapist. Only patients coming from the proximity of Heidelberg were allocated in a randomized way (computer generated) either to the ST group or the PT group.
The regression analysis reveals a highly significant relationship between the tinnitus score and the independent variables (p 2= 0.43).
The proposed therapy concept "Heidelberg Model of Neuro-Music Therapy" seems to be a potential completion of the therapy spectrum. Given that this group received also placebo music therapeutic elements (active listening to preselected musical pieces) and an individual counseling, it seems reasonable to argue that the positive and long lasting effect of the music therapy according to the "Heidelberg Model of Neuro-Music Therapy" is due to the far more specific and active musical training aiming directly at the individual tinnitus sound.

There exists a variety of procedures using a combination of counseling and acoustic stimulation.
In doing so, the duration of the therapy does not exceed ten weeks (standard therapy) and can even be compacted to five days (compact therapy). Many patients stated though that they would enjoy singing or listening to music subsequent to the therapy. Levine 37 proposed interactions between auditory perception and somatosensory input at the dorsal cochlear nucleus.
Experimental data indicate that it is more efficient to train at normal hearing frequencies rather than in the region of hearing loss or tinnitus frequency 44,45. Biocybernetics of attention in the tinnitus decompensation: An integrative multiscale modeling approach. Development and psychometric adequacy of the screening version of the tinnitus handicap inventory. Final common pathway for tinnitus: theoretical and clinical implications of neuroanatomical substrates.
Intensely pleasurable responses to music correlate with activity in brain regions implicated in reward and emotion.
The rewards of music listening: response and physiological connectivity of the mesolimbic system. Auditive stimulation therapy as an intervention in subacute and chronic tinnitus: a prospective observational study. A multi-centre study on the long-term benefits of tinnitus management using Neuromonics Tinnitus Treatment. Listening to tailor-made notched music reduces tinnitus loudness and tinnitus-related auditory cortex activity.
A cognitive model of tinnitus and hyperacusis; a clinical tool for patient information, appeasement and assessment.
Musiktherapie bei Tinnitus: Interdisziplinare Pilotstudie zur Uberprufung des Heidelberger Modells. Clinical significance: a statistical approach to defining meaningful change in psychotherapy research. Enriched acoustic environment after noise trauma reduces hearing loss and prevents cortical map reorganization.
Treatment of tinnitus with a customized, dynamic acoustic neural stimulus: underlying principles and clinical efficacy. Cross-modal interactions of auditory and somatic inputs in the brainstem and midbrain and their imbalance in tinnitus and deafness.
The effect of a new treatment based on somatosensory stimulation in a group of patients with somatically related tinnitus. Auditory discrimination training for tinnitus treatment: the effect of different paradigms. Auditory perceptual learning at normal hearing frequencies affects changes in tinnitus intrusiveness and percept.
Tinnitus suppression by low-rate electric stimulation and its electrophysiological mechanisms. Classical conditioning as the basis for the effective treatment of tinnitus-related distress. The dorsal cochlear nucleus as a participant in the auditory, attentional and emotional components of tinnitus.
Thus, even though hearing loss is frequently associated with tinnitus perception, subjective tinnitus can be triggered or modulated by non-auditory events.
Such influence may be mediated via the vestibular system causing shifts in the lower limbs and in the body.
High pitch tone tinnitus was perceived by 13 patients, broad band noise (white noise) by 5, and a mix of both types by 5.
Unusually stressful circumstances were indicated by 13 patients; these patients had a mean score of 171 on the Holmes and Rahe stress questionnaire (Miller and Rahe, 1997). This is in keeping with previous reports of the high prevalence of hearing impairment in tinnitus (Nicolas-Puel et al., 2002). Such close distance requires convergence of the eyes and is known to produce optimal postural stability in controls (Kapoula and Le, 2006; Le and Kapoula, 2006). The factors were the group (tinnitus versus controls) and the vision condition (eyes open versus eyes closed). There was also a significant effect on the cancelling time of the antero-posterior (CTy) and medio-lateral sway (CTx). The power index for high frequencies of the medio-lateral body sway is only significantly higher in tinnitus patients under the eyes closed condition.
In contrast, no significant difference between the three conditions was observed for subjects with right tinnitus. This indicates appropriate recruitment of patients excluding cases with acute vestibular syndrome. In 33 people with no tinnitus whatsoever, these procedures elicited tinnitus in almost 60%. Similar statistics are found in England (Dawes et al, 2014) and Korea (Park and Moon, 2014). Practically, as there is only a tiny proportion of the population with objective tinnitus, this method of categorizing tinnitus is rarely of any help.
In other words, the changes in the brain associated with tinnitus seem to be associated with emotional reaction (e.g.
In a large study of tinnitus, avoidance of occupational noise was one of two factors most important in preventing tinnitus (Sindhusake et al. Tinnitus from a clear cut inner ear disorder frequently changes loudness or pitch when one simply touches the area around the ear.
The muscles that open the jaw are innervated by the same nerve, the motor branch of 5, that controls the tensor tympani in the ear.
There are case reports concerning tinnitus as a withdrawal symptom from Venlafaxine and sertraline (Robinson, 2007).
Nevertheless, this quality of tinnitus probably justifies a trial of oxcarbamazine (a less toxic version of carbamazepine). Lainez and Piera suggested that the mechanism was reduction of peripheral inputs from cervical, temporal, frontal and periauricular pathways. 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. If tinnitus is reduced by intratympanic lidocaine injection, it seems reasonable to us that surgical treatment may also be effective (for unilateral tinnitus). According to the inventor of TRT, the goal of counseling is to reclassify tinnitus into the category of a neutral stimulus. The western heptatonic musical tonality forms the basis of the active music therapy procedures. The most common side effects are headache and laryngitis if the exercise is not executed properly, either too often, too long or with too much pressure. Group differences of sociodemographic data and audiometric tinnitus characteristics were analyzed with the c2-test or univariate analysis of variance (ANOVA). About 80% of the patients accomplished a reliable decrease of tinnitus pathology in the course of music therapy and about two thirds of the patients describe their tinnitus symptoms as "improved" after therapy. Often the musical stimuli are spectrally modulated in order to account for hearing impairments31,32 and are incorporated as a passive means patients have to listen to for rather lengthy intervals (months up to years).
The main parts of the therapy consist of active music therapy modules; hence there is no need and no purpose for spectrally changing the music used. We therefore propose that it is possible to alter the internal tinnitus spectrum by means of the Neuroauditive Cortex Training, which represents a specific perceptual training within the normal hearing frequencies.
RF neurons coordinate sensory and motor functions and influence cortical activity via the thalamus.
This study examines the quality of postural performance in quiet stance in patients with modulated tinnitus. Fluctuations in perceived intensity or pitch after voluntary or induced head and neck movements or isometric contractions is spontaneously described by many individuals presenting subjective tinnitus. The question addressed in this study is whether or not tinnitus (a fantom sound) could act in a similar fashion on postural control. Thirteen patients perceived their tinnitus more so (T5, T17) or totally (11) in their left ear, eight of the subjects more so (6) or totally (T19, T21) in their right ear, and the two remaining patients had bilateral tinnitus equally perceived between the two ears. Even if stress is not the direct cause of tinnitus it can be considered as a trigger of tinnitus intrusiveness (Andersson and Westin, 2008; Hesser and Andersson, 2009). Eight patients, among whom were included the two patients with a history of surgically treated acoustic neuroma, experienced dizziness at some point during the tinnitus time course. Participants in this experiment included patients 1 through 16 shown in Table 1 and the controls.
Yet, it should be emphasized that all patients had a chronic history of tinnitus, with a duration of more than 1 year, the mean duration being 5.6 years. Importantly, we found significant difference between tinnitus and controls for most of the parameters concerning the medio-lateral sway data (SDx, FFTx, and the Px). 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.
The exact prevalence of TMJ associated tinnitus is not established, but presumably it is rather high too. In our clinical practice, we have occasionally encountered patients reporting worsening of tinnitus with an antidepressant, generally in the SSRI family. 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.
Robinson reported that tinnitus in depressed patients appears more responsive to antidepressants than in non-depressed patients. 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. The goal of sound therapy is to decrease the strength of tinnitus-related neuronal activities (Jastreboff, 2015). Mutual stimulation via both the thalamic and paralimbic pathways ultimately lead to tonotopic changes in the auditory cortex7 while reciprocal innervations of the medial temporal lobe system give rise to memory consolidation leading to a paradoxical "tinnitus memory"6. Therefore the Neuro-Music Therapy is indicated only if the patients indentify their tinnitus as "tonal" (sinus tones). Any psychiatric disorder or ongoing medication with antidepressants or antipsychotic drugs yields to exclusion of the patients. Selection of the musical pieces was based on the individual musical taste and preferences as well as on the emotion evoking impact of the musical pieces. Therapy outcome as assessed by the TQ and the CPT were evaluated using univariate analysis of variance (ANOVA) for repeated measure procedures. This effect was independent of the patient"s treatment allocation to standard therapy or compact therapy. Additionally, a tinnitus-equivalent sound provides the possibility to deal with the symptoms in an immediate and direct way. Therefore an activation of cranio-cervical and cranio-facial muscles and nerves by means of the Resonance Training might correct the auditory pathway by means of indirect stimulation of the joint "relay-station" cochlear nucleus 36.
Furthermore it is very important to ensure the training regime is intrinsically motivating. Stress is considered to potentiate the severity of tinnitus due to the proposed accompanying reduction and alteration in auditory masking 6.
Methods: Twenty-three patients with highly modulated tinnitus were selected in the ENT service.
The study examines postural control as maintained during quiet stance in tinnitus subjects when their eyes are converged at near distance (at 40 cm), a condition where controls exhibit the greatest stability (Kapoula and Le, 2006).
Tinnitus severity and distress, and perceived laterality were evaluated with standard questionnaires. But none of them had acute clinical vestibular dysfunction at the time of testing as attested by the absence of vertigo or dizziness or spontaneous nystagmus. The factors were the group (left or left dominant versus right or right dominant tinnitus) and the gaze position (center, lateral gaze to tinnitus, and non-tinnitus side).
One could argue that the results are biased by the two patients with acoustic neuroma who underwent surgery 13 and 6 years ago (patients 9, 18; see Table 1). We have encountered patients who have excellent responses to cervical epidural steroids, and in persons who have both severe tinnitus and significant cervical nerve root compression, we think this is worth trying as treatment. Having TMJ increases the odds that you have tinnitus too, by about a factor of 1.6 (Park and Moon, 2014). Mechanisms for impovement were suggested to be direct effects of increased serotonin on auditory pathways, or indirect effects of tinnitus on depression or anxiety. According to the results from the regression analysis, there was - apart from tinnitus masking level - no influence of tinnitus characteristics or otological co-symptoms on therapy success. A deliberate regulation of emotional responses towards the tinnitus sounds might enhance gate control mechanisms and restore misdirected "filter functions" of thalamic and limbic areas. Twelve reported exclusively or predominately left tinnitus, eight right, and three bilateral. In the experiment dealing with gaze position, patients were asked after each condition to evaluate the intensity of their tinnitus on a scale from 0 to 10. We observed that the intensity of tinnitus was much greater when the eyes were closed than when the eyes were left open. Other movements such as lateral gaze, finger shoulder or hip flexion have also been described as tinnitus modulators (Levine et al., 2007).
Also, elevation of the eyes by 15° provokes postural instability while down gaze provides higher stability relative to a straight ahead gaze (Kapoula and Le, 2006). Participants in this experiment included all those patients indicated in Table 1 with the exception of T11 and T14 both of whom presented bilateral tinnitus. Some modulation of perceived tinnitus intensity was observed with gaze direction even though it was not statistically significant. Subjects were asked to fixate a target at 40 cm for 51 s; posturography was performed with the platform (Technoconcept, 40 Hz) for both the eyes open and eyes closed conditions. This study also examines the quality of postural control with lateral gaze direction in subjects with left versus right side tinnitus. It therefore follows that differences in the perceived intensity of tinnitus might possibly be subtended by attention mechanisms. The specificity of the effect on the medio-lateral sway argues against the simple causal role of attention, fatigue or other confounding factors. This makes a more sense than the Wineland result, but of course, they were measuring different things. Nevertheless, the relative reduction and the individual improvement (reliable change index) were independent from the basic TQ-value - therefore also patients with comparatively lower strains still benefit from the therapy in equal measure.
Results: For both conditions, tinnitus subjects showed abnormally high lateral body sway (SDx). 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.
For patients with left tinnitus only, medio-lateral sway increased significantly when looking away from the center. Conclusion: Similarly to external sound stimulation, tinnitus could influence lateral sway by activating attention shift, and perhaps vestibular responses.
Such abnormalities would be accentuated in left tinnitus because of the importance of the right cerebral cortex in processing both auditory–tinnitus eye position and attention.

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