(Educational Piece by Kim Cusack- Read time 4-5mins)
I started treating somatosensory tinnitus (ST) almost by chance. In the course of treating orofacial pain conditions, a cranial nerve screen is performed in the initial consultation. In doing so, we screen the auditory nerves and also ask about any changes in hearing/sounds. I was surprised by the number of clients who said that they were tinnitus sufferers.
It is estimated that one in 10 adults will be tinnitus sufferers. It is important to note that most tinnitus is as a result of hair cell damage and hearing loss due to noise exposure. We also know that stress is a very important factor in tinnitus manifestation. A combination of noise exposure and stress is the most common cause of tinnitus. Unsurprisingly, in US studies, most war veterans were tinnitus sufferers.
Up to 1 in 10 in the population can be affected by tinnitus at some stage in their life.
Despite this, recent research has begun to focus on the relationship between the cervical spine and TMJ structures as they relate to tinnitus. A 2014 study found that the prevalence of tinnitus was 8 times higher in participants with temporomandibular disorder (TMD) (30 of 82 [36.6%]) than in participants without TMD (38 of 869 [4.4%]). All participants of this study presenting with unilateral TMD and unilateral tinnitus showed these conditions on the same side. Stomatognathic therapy (a combination of dental appliance and physiotherapy) improved tinnitus symptoms in 11 of 25 participants (44%).
These figures appear to be in keeping with my own clinical experience and so posed the question: How do we identify this subgroup of people; the somato-sensory tinnitus sufferers so that we can better understand who we should treat? How do we manage expectations when 44% of tinnitus sufferers may respond to conservative management based on this study?
In 2018, a consensus study published a Diagnostic Criteria for Somatosensory Tinnitus. This has further assisted me in ascertaining who may respond to physiotherapy involvement. Questions I will ask tinnitus sufferers are
1. Can you modulate (change) your tinnitus?
2. Do the characteristics of your tinnitus relate to your neck/jaw?
3. Is your tinnitus accompanied by orofacial dysfunction?
Below are tables taken from the consensus study that warrant discussion.
It is important to decipher this information carefully. If clients have answered yes to just one box, a single criterion can potentially lead to over-diagnosis. Furthermore, it is not uncommon to have co-morbidities present and so there has to be a causal relationship with regard to TMD/neck injury and tinnitus. If they are happening concurrently but do not relate to each other it is less likely to be ST, especially if audiology results show considerable hearing loss. For this reason, it is important to discuss the nature of your tinnitus with your ENT, audiologist, GP and physiotherapist before deeming the tinnitus to be somatic in origin.
So, if after discussion with your practitioner, you appear to have somatosensory tinnitus - what are the treatment strategies available, and are they effective?
A 2019 systematic review showed that there is low-quality evidence for a positive effect of conservative temporomandibular disorders treatment on tinnitus complaints. The combination of splint therapy and exercise treatment is currently the best investigated treatment approach, showing a decrease in tinnitus severity and intensity. Despite the low level of evidence and the methodologic issues in the included studies of this review, it is noteworthy that all included studies show positive treatment effects.
Higher quality randomised controlled trials are needed to decipher what exact treatment strategy is best of ST sufferers.
As a clinician, I advocate a multi-pronged approach. Up to 50% of tinnitus sufferers experience anxiety and depression as a result of their tinnitus, commonly known as tinnitus distress. In the 1990s Dr Pavol Jastreboff outlined a neurophysiological model for tinnitus. The auditory system is linked to the limbic system (the brain centre that regulates emotion and memory)- this tells us how threatened versus how safe we feel.
Our hearing becomes hypersensitive and hypervigilant when we feel threatened, ill at ease, over stimulated and exhausted. When we are running on adrenaline our auditory system is heightened. That is why after a scary movie we are hyper aware of creaking pipes, noises from the neighbours and left listening out for danger.
When we are rested and content our hearing “zones out” - this is how we can fall asleep watching television.
Therefore, treatment should be aimed at targeting the structures at fault but also the stress that can exacerbate tinnitus. A combination of cognitive behavioural therapy, mindfulness, relaxation techniques should be considered in combination with physiotherapy and dental management.
Top 5 Coping strategies for Management of Tinnitus
Reduce stress levels with yoga, meditation, mindfulness etc
Eliminate stimulants such as caffeine, nicotine, alcohol, sugar - this will help to reduce physiological stress on an already stressed system
If related to your neck/TMj structures seek guidance and treatment from a healthcare practitioner - there is a free ebook available for TMJ sufferers on the website
Discuss medication with GP - some medications are linked to tinnitus development and some may help to reduce our anxiety related to it
Hearing aids, neuromodulating devices and sound generators may be of help and should be discussed with your ENT/audiologist
Yours in health,
Kim
Kim is one of the only physiotherapists specialising in TMJ (Jaw) / Face in Ireland. She qualified from University College Dublin with a First Class Honours Degree in Physiotherapy and has 8 years experience treating TMJ disorder, face and neck related conditions. Her passion for this area was cemented having suffered from symptoms of this disorder personally.