Somatosensory Tinnitus (From Past To Now)

Somatosensory tinnitus (from past to now) Tanit Ganz Sanchez, MD, PhD TINNITUS RESEARCH INITIATIVE

Let’s see “strange” cases of tinnitus…

Finger-evoked tinnitus (FET) • 78 year-old right handed male • Bilateral profound SNHL for 30y + bilateral high-pitch T since adolescence • Last 2-3years: additional hissing in LE when moving middle finger of L hand up / down – Only during movement with no fatigue – The quicker the movement, the higher the T – Not present with passive or isometric finger movement Cullington. Neurology, 2001

Cutaneous-evoked tinnitus (CET) 2 cases after unilateral surgical ablation of A/V pathways • 66y-o ♀, left paraganglioma removal • 47y-o ♂, right vestibular - After ±6m: CET in the L hand schwannoma removal (washing dishes, dressing) - After ±1m: CET in the R hand (touching fingertips/thumb) Courtesy: Anthony Cacace

World tendency of subtyping tinnitus and treating accordingly sound muscular, metabolic intolerance tactile, visual disorders influence pulsatile or unilateral myoclonus tinnitus profound deafness normal etc, etc, etc.... audiometry musical or verbal hallucinosis

How it started (to me)… • Levine’s presentation during VI ITS (Cambridge, 1999) • 68% of 70 TP were able to modulate tinnitus with muscle contractions maneuvers…

Reproducing the experience… control group and risk factors Sanchez et al: The influence of voluntary muscle contraction in tinnitus onset and modulation. Audiol Neurotol, 2002. -121 TP and 100 controls (matched G/A) - 16 maneuvers of H&N & limbs muscle contractions for 5’’ each (Levine, 1999) - patients apply the moderate force against movement

Muscle contraction maneuvers H&N muscles Limbs muscles 1. forced mandible occlusion 10. locking fingers, pulling far 2. pression occipit 11. right shoulder abduction 3. pression in front 12. left shoulder abduction 4. pression in vertex 13. flexion of the right hip 5. pression in mandible 14. flexion of the left hip 6. pression in R tempora 15. abduction of both hips 7. pression in L tempora 16. adduction of both hips 8. head rotation to R 9. head rotation to L

34,7% 1. Tinnitus modulation 65,3% in tinnitus patients (n=121) modulation + modulation - Levine, 1999 = 68% 50 increase decrease 40 30 20 10 0 increase decrease both quality Sanchez et al, 2002

2. Tinnitus onset in controls (n=100) 86% 14% Sanchez et al, 2002 onset + onset - Abel & Levine (2004) = 50%

H&N muscles contractions modulated or triggered tinnitus more often than limbs muscles * p < 0.01

Up to this point… • We understood that the 16 maneuvers could evoke T modulation, mainly the 9 ones from H&N • Question: are they reliable to do so? • Next step…

Doubts: are somatic maneuvers of H&N muscles reliable? 1. forced mandible occlusion TEST 2. pression occipit (n=38) 3. pression in front 4. pression in vertex 5. pression in mandible 7-day 5’’ each interval 6. pression in R tempora 7. pression in L tempora 8. head rotation to R 9. head rotation to L RETEST Sanchez et al. Annals, 2007

Results Incidence of T modulation in test and retest 70% 60% 63,20% 57,90% 50% 40% 42,10% 36,80% 30% 20% 10% 0% teste reteste modulação + modulação - Kappa = 0,45; p = 0,005 (concordant)

Results Effect of maneuvers on T 80% 77,3% 70% 60% 58,3% 50% 40% 30% 29,2% 20% 18,2% 10% 12,5% 4,5% 0% teste reteste worsepiora improve worse+improve melhora piora+melhora Wilcoxon: p = 0,14

Up to this point… • We understood that the 9 maneuvers of H&N evoked T modulation in a reliable way • Temporary increase of T was the main effect, which seemed to decrease in retest (although non significant) • Question: would it be possible to “habituate” tinnitus by repeating the 9 maneuvers, as in a “training”? • Next step…

Training 2x/d, 9 maneuvers, 2m (aiming to stop the modulation) 57.9 55.3 80 77.3 60 70 50 42.1 44.7 60 40 50 42.9 42.9 30 40 30 19.2 20 14.2 20 10 10 4.5 0 0 Before After training Before After training Modulation + Modulation - Worse Improve Both Same rate of modulation Change in pattern of after training modulation after training!! Sanchez et al. Annals, 2007

And then… a cure of GET! • V.B.A., 39 y-o ♀, with pure GET for the last 4 y (no T in neutral position) T in RE T in LE Sanchez et al, 2007

Clinical data • normal ENT exam • bilateral profound SNHL (R since youth: unknown origin; L 4 years: exeresis of vestibular schwannoma) • image exams compatible with surgery • VAS=10, THI = 66

Treatment • Repetition of gaze in vertical / horizontal • Each maneuver: 10 times, sustained for 1’’ • Repetition of the series at home 2x/day

Treatment • After 2w: abolition of T downwards “90% improvement” upwards no improvement in horizontal • After 3w: stability of response • Orientation: ↑ no of repetition to 20 • After 2w: abolition of T downwards “90% improvement” upwards slight improvement in horizontal

Treatment • Orientation: keep 20x, but ↑ duration of sustaining (5’’) • After 4w: abolition of T downwards abolition of T upwards “40% improvement” to R; “80%” to L • After 3w: total remission in all directions (total 14w) • No recurrence (cure) since June 2006 Sanchez et al, 2007

Cure with different responses! Faster improvement with increase in number Slower response with increase in duration Diversity of involved neural processes...

We decided to try the training in patients with spontaneous complaint of modulation! • Many of them have modulation with different / more complex movements than those tested by Levine • customized training, daily repetition of muscle movements that evoke tinnitus modulation – can the training reduce this modulation? – can the training decrease the tinnitus itself?

Case 1 • 65 y-o ♀, normal hearing, bilateral T (L>R, engine) that increases with compression of temporal muscle. No further clue after routine investigation – Training: compressing temporal area, 10x, 2’’, 2x/d – After 7d, modulation began to reduce – After 2m, R modulation disappeared for several days – After 4m, R tinnitus disappeared – Left side: modulation reduced gradually but slower; T disappeared for 2 days after 10 months of training (patient decided to go on).

Case 2 • 40 y-o ♀, normal hearing and clicks in the neck during cervical flexion, “whistle” in RE only during cervical rotation to the R, stopping after 5’’ – Training with rotation to R/L, 10x, 2’’, 2x/d – After 3w, T onset became inconsistent – After 8w, subjective loudness decreased substantially

Case 3 • 72 y-o ♂, bilateral and symmetrical SNHL, bilateral “whistle” + onset of a different T when eyes were tightly closed. – Training closing eyes tightly 10x, 2’’, 2x/d – After 2w, modulation decreased – After 4w, modulation disappeared; no change in the preexisting “whistle” up to the end of evaluation period Some other cases did not respond…

At this point of knowledge, we met TRI TINNITUS RESEARCH INITIATIVE

Workgroup Somatosensory Tinnitus and Modulating Factors Carlos Herraiz, Madrid Eberhard Biessinger, Traunstein Susan Shore, Ann Arbor Jinsheng Zhan, Detroit TINNITUS RESEARCH INITIATIVE Carlijn Hoekstra, Sweden Claudia Coelho, São Paulo Tanit Sanchez, São Paulo (coordinator) Establishing the “what, when, why and how” of SST…

What is somatosensory tinnitus? • SS origin: TMJ / neck disorders • SS modulation: auditory origin with modulation during somatosensory stm – orofacial or postural movements – eye movements (GET) – tactile stimulation (CET)

Why does this happen? Inputs in shell region of DCN Non-Auditory Auditory Somatosensory: Auditory cortex Trigeminal ganglion (TG), Spinal Trigeminal Nuclei (Sp5) Fusiform cells Inferior colliculus Dorsal root ganglion (C2) Parallel fibers Dorsal column nuclei Superior Olivary complex Granule cells Shell Vestibular System Contralateral Cochlear PVCN nucleus Pontine Nuclei Reticular Formation Type II auditory nerve? Courtesy Susan Shore

Integration animal x clinical findings CN V nerve VIII nerve Wright e Ryugo, 1996; Increase in Shore, 2000; Shore, 2005 somatosensory inputs

When to consider SS tinnitus? History of: • evident H&N trauma, dental / neck manipulation • T ipsilateral to the trauma / manipulation • frequent pain (regional or fibromyalgia) • complaint of T modulation during pain episodes or muscular movements • bad postural habits: phone, computer etc

When to consider SS tinnitus? • Physical examination - Presence of modulation during tested movements • Audiometry - Symmetric hearing (normal or abnormal) with asymetric / unilateral T The single rule in Medicine: all rules have exceptions!!

How to test for SS modulation? • In the process of standardizing: • Which movements to test for modulation – jaw (forward, backward, lateral, opening, clenching) – neck (forward, backward, lateralization, rotation) • with / without resistance, 5’’ each – gaze (right, left, up, down) • the way of measuring tinnitus modulation T decrease T increase

How to manage SST? • Good management depends on a good and integrated multidisciplinary team other physicians (Neuro, Psy) audiologist “good” ENT dentist psychologist physiotherapist

First: don’t forget to evaluate TMJ / neck - The sooner, the better! - Courtesy Eberhard Biesinger

What else to have in mind to chose treatment • SS input round pinna projects to the DCN; although complex, could suppress the local hyperactivity Kanold, 2001 Zhang, Guan, 2007 • practical thing to consider: stimulate this region, even by means of different ways

Some initial, but increasing evidences • TENS in the skin around the ear ↑ activation of the DCN through SS pathway - ↑ inhibitory role of DCN on the CNS, ↓ SS tinnitus (Herraiz, Diges, 2007) • stm of acupoints around pinna produces B-endorphins / enkephalins for pain control (Xu, 2001, Okada, 2006) – as pain ≅ T, pain ↓ would expectedly relieve tinnitus – yet to start: standardized acupoints for T control (Zhang)

Another strong evidence… • P with T have almost 5 chances more to have myofascial trigger points than P without T Sanchez & Rocha, 2006 Rocha, Sanchez, Siqueira 2008

Referred pain Trigger point Referred pain to X standardized muscles Estola-Partanen, 2000 Sanchez, Rocha, 2006 Rocha, Sanchez, 2008

Muscles that modulated tinnitus more frequently DCN closer to not so ear close Rocha, Sanchez, 2008

Tinnitus Research Group, São Paulo T and active MTP R n=17 Active Group Control Group n=9 digital deactivation of MTP digital pressure on non-tender fibers of H&N muscles with MTP of H&N muscles with MTP (10 weekly sessions) (10 weekly sessions) Δ tinnitus loudness (VAS) P < 0,001 Δ pain intensity (VAS) P < 0,001 Δ handicap by THI P = 0,01 Δ number of MTP P < 0,001

Case of cure with deactivation of MTP • 51 y-o ♀, whose positive findings were: • bilateral T for 4y (R>L), VAS = 10; THI=68 • dizziness • chronic pain (upper limbs, cervical spine and head) for 4 y, VAS = 9 • Normal ENT exam and normal pure tone audiometry Tinnitus Research Group, University of São Paulo School of Medicine

Cure with deactivation of MTP Weekly sessions, manual deactivation of TP: gradual Trapezius: change in SCM: remission of LT decrease of P, T, D. Cure in right tinnitus pitch trapezius: dizziness 3m; stable at 2 and 4m. Tinnitus Research Group, University of São Paulo School of Medicine

The body talks… • …and tinnitus modulation is a “language” to be interpreted • ...an instrument for suspecting of the (hyper)activated connections between auditory and SS systems

PRESENT TREATMENT OPTIONS - somatosensory tinnitus - • Specific treatment of bony/muscular problems of TMJ / neck • Deactivation of trigger points (Rocha & Sanchez, 2007) • TENS (Herraiz & Diges, 2007) • Future options under evaluation!! • Qi Gong (Biesinger, in study) • Botox (Herraiz, in study) • Acupuncture (Zhang, in study) • Oral drugs: baclofen, pregabalin, cyclobenzaprine (Hoekstra, in study)

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Somatosensory Tinnitus (From Past To Now)

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