Dr. Claudia Mghazli examines how osteopathic manual therapy can aid with tinnitus, a condition that affects an estimated 10-15% of the global population.

1. Evaluation of
Osteopathic Manual Therapy
in the treatment of tinnitus
Master thesis for the degree of
Master of Science in Osteopathy
Presented to
London College of Osteopathy and Health Science,
London, Ontario
Claudia Mghazli
Winnipeg, Mai, 2020
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2. Abstract
This study investigates the role of osteopathic manual therapy in the treatment of tinnitus.
Current literature about tinnitus pathogenesis, diagnosis and treatment was reviewed and
discussed. Additionally, osteopaths who treat tinnitus patients were questioned about
their experience in regard of tinnitus characteristics, additional symptoms, underlying
diseases, previous treatments, other practitioners involved in the treatment, osteopathic
techniques being used, frequency and interval of treatment, overall improvement, and
objective and subjective changes. Osteopaths could participate by completing an online
available questionnaire. The results were afterwards analyzed and discussed.
It seems that osteopathic manual therapy has a positive effect in tinnitus patients in many
ways. Osteopathic treatment, especially craniosacral therapy, can resolve cranial
dysfunction, improve circulation, relief muscle and fascia tension, facilitate venous and
lymphatic drainage from head and neck, decrease intracranial pressure, and restore the
function of the temporomandibular joint (TMJ). All this can benefit tinnitus patients.
Because of the complexity of tinnitus, some aspects are still unknown. Most experts
agree that there will be no universal treatment for tinnitus, rather a combination of
therapies, individually for each patient, depending on causes and underlying pathology.
Osteopathic manual therapy is one modality that proved itself in numerous studies and
case reports. However, well- conducted scientific studies are necessary to establish a
validated base for the use of osteopathic manual therapy in tinnitus treatment, and raise
awareness of this treatment option.
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3. Table of contents
1. Introduction………………………………………………….………………….….…..5
1.1. Purpose of this study……………………………………………………..….5
1.2. Hypothesis……………………………………………………………….…..5
2. Pathogenesis of tinnitus…………………………………….…………………….….…5
2.1. General pathways…………………………………………………………….5
2.2. Somatosensory tinnitus………………………………………………….……8
3. Diagnosis of tinnitus………………………………………………………….….……..9
3.1. Assessment………………………………………………………….….…..10
3.1.1. History…………………………………………………….….…..…9
3.1.2. Clinical examination..........................................................................9
3.1.3. Specific tests…………………………………………….………….9
3.1.4. Psychological assessment…………………………………………10
3.2. Classification of tinnitus………………………………………….………10
3.3. Somatic tinnitus syndrome………………………………………………..12
4. Treatment options for tinnitus………………………………………………………...13
4.1. Causal therapy – locale treatable pathology………………………………...13
4.2. Symptomatic therapy………………………………………………………..13
4.2.1. Auditory stimulation………………………………………….…...13
4.2.2. Cognitive behavioral therapy……………………………………...14
4.2.3. Pharmacotherapy…………………………………………………..14
4.2.4. Electrical and magnetic stimulation…………………………….....15
4.2.5. Neurofeedback…………………………………………………….16
4.2.6. Tinnitus treatments using somatosensory-auditory interaction.......16
5. Osteopathic manual therapy and tinnitus……………………………………………...18
5.1. Osteopathic relevant structures and their relationship to tinnitus……...……18
5.1.1. Os temporale………………………………………………….…...18
5.1.2. Os sphenoidale………………………………………………….....20
5.1.3. Os occipitale…………………………………………………….....21
5.1.4. Temporomandibular joint (TMJ)……………………………….…21
5.1.5. Tuba auditiva (Eutachian tube)…………………………………....22
5.1.6. Circulation around the ear and lateral cranium……………….…...22
5.1.7. Peri- and endolymph in the inner ear.…….…………………….....23
5.2. Possible osteopathic treatment options regarding tinnitus………………..…23
5.2.1. Entrapment of nerves and blood vessels………………………..…23
5.2.2. Cervical syndrome………………………………………………...24
5.2.3. Jaw and dental problems………………………………………..…25
5.2.4. Eustachian tube…………………………………………………....25
5.2.5. Endo- and perilymphatic system………………………………..…26
5.2.6. Circulation…………………………………………………….…...26
5.2.7. Congestion…………………………….…………………..………26
5.2.8. Relation to stress……………………………….………………….26
5.3. Case report……………………………………………………………….….27
5.4. Experience of other osteopaths treating tinnitus patients……………….…..28
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4. 6. Conclusion.……………………………………………………………………….…...30
7. Acknowledgment…………………………………………………………………...…32
8. Bibliography……………………………………………………………………….….32
9. Appendix…………………………………………………………….………….…….37
List of abbreviations………………………………………………………….… 37
List of illustrations…………………………………………………………….…38
Tinnitus- study questionnaire………………………………………………….....39
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5. 1. Introduction
Tinnitus is the perception of a sound without identification of a corresponding external
source of this sound (www.health.harvard.edu ).
About 10-15 % of people worldwide suffer from some kind of tinnitus (McCormack et
al., 2016). Because many causes can lead to tinnitus, it is rather a symptom than a
disease. The perception of tinnitus can vary from single to multiple tones, with high or
low pitch, rushing, hissing, whistling or ringing in one or both ears, or within the skull. It
can be constant, fluctuant, or synchronized with the heart beat (pulsatile tinnitus).
Because of the different characteristics of tinnitus, it has been, and still is, difficult to find
a system to classify tinnitus. Attempts were made to classify tinnitus in regard to history
of origin (subjective vs. objective tinnitus), location of possible cause (ear, cochlea,
auditory nerve, CNS), progression (acute, subacute, chronic), and secondary symptoms/
influence of life quality (compensated, decompensated) (Plamberger, 2006; AWMF,
2015). Because of the different causes of tinnitus, there are different explanation models
and treatment options.
1.1. Purpose of this study
The aim of this study is to evaluate the efficacy of Osteopathic Manual Therapy in the
treatment of tinnitus by review of the current literature and compare it with the personal
experience of osteopaths who treat tinnitus patients.
1.2. Hypothesis
Manual Osteopathy, especially craniosacral therapy, is effective in treating tinnitus.
2. Pathogenesis of tinnitus
2.1. General pathways
The heterogeneity of tinnitus in etiology, pathophysiology, and clinical characteristics
makes it difficult to explain its pathogenesis. Despite the relentless efforts of various
research groups e.g. in Germany, USA, UK, Australia, New Zealand, and Brazil, tinnitus
is still not fully understood.
So far scientists agree that tinnitus can be generated not only in the peripheral auditory
system (ear, cochlea and auditory nerve (AN), but also involves the central auditory
system (neuronal network of primary and secondary sensory cortex, influence of frontal,
parietal and limbic brain regions). This is supported by the observation that profound deaf
people and people with severed auditory nerve (after surgery of a vestibular Schwannoma
– tumor of vestibulo –cochlear nerve) can also experience tinnitus (Levine et al., 2003)
Table 1 and 2 show the pathways that can lead to tinnitus.
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6. Ear
Spontaneous otoacoustical emissions
Para- auditory sounds Objective tinnitus
Cochlea
Loss of inner hair cells (IHC) through:
ENT infections (otitis media, etc.)
Noise trauma
Ototoxic drugs (salicylate, antibiotica)
Cytostatica
Head trauma (with/without fracture)
Presbyacusis
Otosclerosis
Mb. Meniere
Excessive ear wax
Disorder of tuba auditiva
Auditory nerve
Axonal degeneration
Regeneration of excitatory fibers exceed
inhibitory fibers Hyperactivation
Input
Inhibition
Table 1: Ear related causes of tinnitus (auditory generators)
If sensory afferences are diminished, there is a decreased inhibition of irrelevant external
sounds resulting in amplifying of excitatory impulses. Therefore, the increased activity of
neurons leads to misinterpretation of acoustic signals and to the perception of tinnitus.
Spontaneous otoacoustical emissions (SOE) are normal low- level sounds emitted by
the healthy normal ear (outer hair cells). SOE are at least partially responsible for tinnitus
in around 6 -12% of normal hearing people (Langguth et al., 2007).
Para-auditory sounds are sounds generated outside the auditory system e.g. cardiac
murmurs, vascular bruits (pulsatile tinnitus), or fasciculation of M. tensor tympani or M.
tensor palatini correlated with problems of jaw and/or neck.
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7. Auditory nerve
DCN, VCN
Primary auditory cortex
Secondary auditory cortex (ACII)
Non-auditory tinnitus generators
Heart vitium (blood flow murmur)
Intracran. Hypertension
Compromised blood flow (Art. Vertebr. Stenosis)
Muscle tension of neck and shoulder
Cervicale dysfunction (esp. C0-C2)
Temporo-mandibular joint dysfunction
Jaw and dental problems (malocclussion, etc.)
Somato-sensory
tinnitus
Activity of Limbic system
And Thalamus
• Stress
• Depression
• Anxiety
• Suppressed
emotions
Spontaneus firing rate (SFR)
Neuronal synchrony
Neuroplasticity
Objectiver / Subjectiver tinnitus
Hyper-
activation
Table 2: Not ear related causes of tinnitus (non- auditory generators)
DNC- dorsal cochlear nucleus
VNC- ventral cochlear nucleus
Primary auditory cortex - situated in temporal lobe, consciousness of auditory impulses
takes place without any interpretation
Secondary auditory cortex – along superior edge of lateral surface of temporal lobe
(surrounding primary auditory cortex), where auditory impulses can be interpreted and
perceived as words, melodies or noise
Neuroplasticity is the property of the nervous system (NS) that allows specific parts of
the NS to change its function and its organization. It can cause change of synaptic
efficacy by creation or elimination of synapses and new connections trough sprouting of
axons and dentrits.
Expression of neural plasticity can be a new balance between excitation and inhibition,
promotion of hyperactivity, re-organization of specific parts of the NS, or redirecting of
information to parts of the NS not normally involved in processing of sound.
Neuroscientists are certain that neuroplasticity plays an important role in the development
of abnormalities that cause many forms of tinnitus (Langguth et al., 2007).
Objective tinnitus is the perception of sounds generated in the body through conduction,
(e.g. blood flow, muscle contraction). Objective tinnitus can sometimes be detected by
other people e.g. with the help of a stethoscope (Langguth et al., 2007)
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8. Subjective tinnitus is the perception of sounds where no external source can be
identified. It is based on abnormal coding of auditory information (Plamberger, 2006;
Kinne et al., 2019)
Table 3 shows the connections between the hearing organ and the CNS.
Table 3:
Hearing tract from dorsal, afferent tracts from the right cochlea, efferent tracts
to the hair cells of left organ of Corti
(Boenninghaus/Lenarz, 2005, p. 20, Plamberger, 2006)
2.2. Somatosensory tinnitus
Somatic or somatosensory tinnitus is the clinically observed modulation of pitch and /or
loudness of tinnitus by somatic stimulation.
About 2/3 of people with tinnitus can manipulate/modulate pitch and loudness by
voluntary or external manipulation of jaw, movement of head and upper extremities,
pressure to certain points on the head as well as shoulder and neck muscles, or eye
movement (Rubinstein et al., 1990). Studies have shown that 60% of people could induce
tinnitus trough head and neck contractions without having tinnitus or are profoundly deaf
(Levine et al., 2003). Median nerve stimulation could modulate tinnitus in 40% (Møller et
al., 1992), and jaw movement in 33% (Rubinstein, 1993).
Stimulation of dorsal column and dorsal cervical root ganglia (esp. C2 root) showed a
peak in single unit firing in the dorsal cochlear nucleus (DCN). These findings suggest a
neuronal cross-connection between auditory and somatosensory system that may play a
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9. role in generating tinnitus. It seems that somatosensoric neurons can alter the intensity
and character of tinnitus by changing the spontaneous firing rate (not driven by auditory
stimuli) or the synchrony of firing neurons in the cochlear nucleus (CN) or auditory
cortex. A change in firing rate of CN neurons could modulate loudness, and a change in
synchrony between neurons could alterate the pitch of tinnitus (Langguth et al.,2007;
Sanchez and Rocha, 2011; Ralli et al., 2017).
3. Diagnosis of tinnitus
3.1. Assessment
3.1.1 History
This involves the usually questions about onset, character, fluctuation, progression, and
associated problems. Sometimes questionnaires or checklists are a useful tool. In practice,
it could be an advantage to just let the patient talk about their tinnitus in order to obtain
more valuable information (R. Goodey, in Langguth et al., 2007, Ch.22).
3.1.2. Clinical Examination
General examination should involve
 inspection of nose, throat and ear,
 temporomandibular joint (TMJ) checked for tenderness, crepitus,
 asymmetry in mouth opening,
 palpation of jaw and neck muscles for tenderness and spasm,
 checking for trigger points on head, neck and shoulders,
 ROM of cervical spine
 checking for cervical dysfunctions (esp. C0-C1-C2),
Osteopathic (craniosacral) examination can add valuable information
 observation of the primary respiratory rhythm (PRM),
 recognizing of any restrictions in movement of cranial bones (esp. Os
temporale, synchondrosis sphenobasilaris),
 restrictions of ligaments,
 restriction of dura mater, anterior and posterior cervicothoracal fascia.
3.1.3 Specific tests
 Audiometry (pure tone air conduction, bone conduction, speech testing)
 Tympanometry with reflexes
 Test for residual inhibition
 Lidocaine test
 Test if tinnitus can be modulated by clenching or grinding teeth, traction
or compression of head, isometric contraction of neck/ jaw muscles
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10. Residual inhibition - Following offset of an appropriate masking stimulus, tinnitus may
remain suppressed for a period of time, typically less than a minute. This phenomenon is
known as ‘‘residual inhibition’’ (RI) (Langguth et al., 2007, Ch. 47)
RI-test- Exposure to noise (e.g. 18 G suction tip at center of ear canal) for 60 sec.,
immediately after exposure, the patient will be asked if the tinnitus in that ear is worse,
unchanged or improved, and to what degree (greatly, moderately or slightly), then the
other ear will be tested.
If residual inhibition in the first ear was considerable, then the patient may get a period of
complete relief from tinnitus in both ears. Patients with good residual inhibition tend to
respond well to sound therapy (R. Goodey in Langguth et al., 2007, Ch. 22).
Lidocaine test – intravenous injection of a test dose lidocaine can abandon tinnitus for a
short period of time. This test should be done with caution, because of possible side
effects of the medication. There could be also high expectations of the patient for a quick
cure that is not realistic (R. Goodey in Langguth et al., 2007, Ch.22)
3.1.4. Psychological assessment
This assessment is mostly done with questionnaires about the influence of tinnitus in
 day to day life,
 sleep disturbance,
 concentration,
 professional performance,
 Questions to emotional stress, anxiety, depression, suicidal thoughts
The most common questionnaires are - Tinnitus Handicap Inventory (THI)
(Newman et al., 1996)
- Tinnitus Handicap questionnaire (THQ)
- Tinnitus Reaction questionnaire (TRQ).
3.2. Classification of tinnitus
After gathering this information, tinnitus can be classified by:
History of origin 1. Objective tinnitus
2. Subjective tinnitus
Location 3. Conductive tinnitus (auricle, tympanum)
4. Cochlear tinnitus (inner ear)
5. Neural tinnitus (central auditory system)
Progress 6. Acute (up to 3 month)
7. Subacute (3 month to 1 year)
8. Chronic (more than 1 year)
Secondary symptomatology
9. Compensated
Stage 1- patient detects tinnitus, faded into background, no
suffering,
Stage 2- tinnitus appears mostly during silence, disturbing
factor in psycho-physical stress situations
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11. 10. Decompensated
Stage 3 - tinnitus causes constant disturbance in private and
professional situations, disturbances occur in
physical, cognitive, and emotional areas
Stage 4 - complete decompensation, tinnitus affects entire
sensorial perception and orientation, patient is
depressive, social isolated and probably at risk of
suicide
(Plamberger, 2006; AWMF, 2005)
The Tinnitus Clinic Network created a flow chart (Table 4) available online that explains
step by step the current recommendations for diagnosis and treatment of tinnitus.
Table 4: Interactive Algorithm for Diagnostic & Therapeutic Management of Tinnitus
TRI Tinnitus Clinic Network
https://www.tinnitusresearch.net/index.php/for-clinicians/diagnostic-flowchart
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12. 3.3. Somatic tinnitus syndrome
Levine et al. (in Langguth et al., 2007, Ch.17) defined a tinnitus subgroup (somatic
tinnitus syndrome) that was responsive to somatosensoric based treatment modalities.
Characteristics of the somatic tinnitus syndrome are
- begin shortly after disturbance of head or upper neck (e.g. whiplash-injury)
- tinnitus perceived ipsilateral to the event and in the ear
- onset is not associated with other/ new hearing complains, can occur in people
with or without hearing loss
They also conducted the following tests.
Somatic testing: maneuvers currently being used to test for tinnitus modulation
Jaw contractions
1. Clench teeth together
2, 3. Open mouth, with and without restorative pressure
4, 5. Protrude jaw, with and without restorative pressure
6, 7. Slide jaw to left, with and without restorative pressure
8, 9. Slide jaw to right, with and without restorative pressure
10. Retract jaw
Head and neck contractions
With the head in the neutral position, contractions were made to resist pressure
applied by the examiner to:
11. forehead
12. occiput
13. vertex
14. left temple
15. Right temple
16. with the head turned to the left, resist the tortional force on the left zygoma
17. with the head turned to the right, resist the tortional force on the right zygoma
18. with the head turned to the right and tilted to the left, resist force applied to
the left temple (left sternocleidomastoid)
19. With the head turned to the left and tilted to the right, resist force applied to
the right temple (right sternocleidomastoid)
Pressure on muscle insertions
20. right mastoid attachment of sternocleidomastoid
21. left mastoid attachment of sternocleidomastoid
22. right suboccipital attachment of splenius capitis
23. left suboccipital attachment of splenius capitis
Posterior pinna pressure
24. right pinna attachment of posterior auricular
25. Left pinna attachment of posterior auricular
Note: all maneuvers use maximal force applied by the examiner.
(Langguth et al., 2007)
Similar test were also used by Ralli et al, 2017.
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13. They developed the following criteria of this tinnitus subgroup:
1. tinnitus ipsilateral to somatic event, usually in the ear
2. tinnitus strongly lateralized to one ear
3. onset not related with any new hearing complains, associated with symmetric
hearing
If all three criteria are met and the somatic testing shows modulating of the tinnitus, the
diagnosis of somatosensoric tinnitus could be established.
This subgroup could profit from appropriate activation of the somatosensory system (see
chapter 4.2.6.). People with tinnitus in one ear and strong somatic component in its
etiology may be most responsive to treatment.
4. Treatment options for tinnitus
4.1 Causal therapy - local treatable pathology
Any underlining pathology in tinnitus patients should be treated first.
Examples are:
 Diseases of the ear (e.g. excessive ear wax, ear infection)
 Necessary surgical intervention (e.g. ear drum repair, arterio-venous
malformation (Slater, P., 2020), aneurysm, benign cerebral hypertension (Funnell,
J.P. et al.,2018), Glomus tumor, Carotid stenosis)
 Surgery on auditory nerve/ middle ear (vestibulo-cochlear Schwannoma,
Cholesteatoma)
 Management of nose, Eustachian tube and middle ear
(negative middle ear pressure)
 Conductive deafness - Cochlear implant, suppressive effect on tinnitus
in profoundly deaf patients
4.2. Symptomatic therapy
4.2.1. Auditory stimulation
 Hearing aids –help with hearing impairment and masks tinnitus noise
 Tinnitus retraining therapy (TRT)
Tinnitus retraining therapy (TRT) is a specific clinical method based on the
neurophysiological model of tinnitus. The method is aimed at habituation of
reactions evoked by tinnitus, and subsequently habituation of the tinnitus. TRT
consist of 2 components (1) counseling, aimed at reclassification of tinnitus to a
category of a neutral signals and (2) sound therapy, aimed at weakening tinnitus-
related neuronal activity. (Jastreboff et al., 2004; Jastreboff, 2007)
 Auditory discrimination therapy (ADT )
Auditory discrimination training (ADT) designs a procedure to increase cortical
areas responding to trained frequencies (damaged cochlear areas with cortical
misrepresentation) and to shrink the neighboring over-represented ones (tinnitus
pitch) (Herraiz, C. et al., in Langguth et al, 2007, Ch 45).
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14. 4.2.2. Cognitive behavioral therapy (CBT)
Cognitive behavioral therapy in tinnitus (tCBT) aims at treating a person’s reaction to
tinnitus, and consists of cognitive restructuring. It is based on identifying and modifying
negative thoughts concerning tinnitus, and the behavioral modification promoting
habituation to tinnitus by positive images, attention control and relaxation (Martinez-
Devesa, 2010). The method is especially efficient in cases when tinnitus is correlated to
severe stress, anxiety or depression.
4.2.3. Pharmacotherapy
A wide variety of substances have been tested for their ability to treat tinnitus. As of
today, there is no specific medication that can claim to heal tinnitus. Most of the existing
studies are not satisfactory to the scientific standards. For a high evidence rate only well-
structured and high-quality studies conducted in a randomized, controlled, double-blind,
and placebo-controlled way with sufficiently high numbers of patients should be
considered (Coyle, 2007). Only a few studies meet these criteria (Garduno- Anaya et al.,
2005). Because of lack of evidence and scientific support, the FDA (Food and Drug
Administration) or EMA (European Medicine Agency) have not yet approved any drug
for tinnitus (Dziuganowska, 2016).
The following drugs and substances have been used more or less successful in tinnitus
treatment. Prescription and use are empirical and supported by several studies, but they
are not official recommended.
Intratympanic injection of Gentamycine (Diamond, 2003), Dexamethason (Garduno-
Anaya, 2005), or Lidocaine (Sanchez et al., 1999) have shown an average reduction of
tinnitus symptoms in 50% of patients.
Intravenous injection of Lidocaine leads to a short term disappearance of tinnitus in
70% of cases, but is not clinically used, because of the application form and possible side
effects (Dziuganowska, 2016).
Benzodiazepine (Clonacepam), anticonvulsants (Carbamazepine (Melding and Goodey,
1979)) and antidepressiva are often prescribed to treat the psychological aspects of
tinnitus (Langguth et al., 2007; Sanchez et al., 1999).
Gabapentin Gamma-amino butyric acid (GABA) is a generally inhibitory
neurotransmitter found in appreciable amounts at many levels of the central auditory
pathway. Chronic tinnitus might be linked to down-regulation of GABA activity. The
results of a single-blind, placebo-controlled clinical trial of Gabapentin demonstrated
drug efficacy in reducing tinnitus annoyance in the trauma group (acoustic trauma) and
reducing tinnitus loudness in a subpopulation of the trauma participants (Bauer et al.,
2006; Langguth, 2007, ch. 27).
Acamprosate, a drug used to treat alcohol dependence, was first reported as a potential
treatment for tinnitus in 2005. By acting as a glutamate antagonist and GABA agonist,
the drug may improve tinnitus by a dual mechanism of action on both the ear and the
nervous system (de Azevedo, in Langguth et al., 2007, Ch. 25).
Zinc is an essential trace element present in all organs, tissues, fluids, and secretions of
the body. The brain has the highest zinc content in the body, estimated to 150 mmol/L,
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15. 10 times higher than the serum zinc level (Takeda, 2000). Zinc is widely distributed in
the central nervous system, including the auditory pathway, in synapses of the vestibulo-
cochlear nerve and in the cochlea.
Several studies support the effectiveness of Zinc supplement, especially in the elderly
with zinc deficiency (Coelho et al. in Langguth et al., 2007, Ch.26)
Antioxidantien, minerals, vitamins, and herbal remedies
Despite the popularity of these alternative products, the evidence regarding their efficacy
for tinnitus is in general scarce and their potential toxic effects are often underestimated
or even neglected. Most represented substances are vitamin A, B1, B3, B6, B9, B12, C,
E, magnesium, calcium, potassium, manganese, selenium, and zinc.
Herbal remedies like Gingko biloba extracts have been proposed as cognitive enhancers
and for the treatment of a large number of pathologies of the central nervous system,
including tinnitus. Other herbal concoctions, mostly found in Chinese traditional
medicine, contain Cimicifuga racemosa, Cornus officinalis, Verbascum densiflorum, and
Yoku-kan-san (Okamoto et al., 2005). Reports of efficacy of Rhodhiola rosea, Hydrastis
canadensis, Sesamum indicum (seeds), and Heliantus annus (seeds) for tinnitus are
anecdotal (Enrico et al., in Langguth et al., 2007, Ch. 29).
Melatonin is a neurohormone that is secreted by the pineal gland and regarded to be a
safe and natural sleep aid. A review of the literature suggests that melatonin has a
beneficial effect on tinnitus, especially for patients with sleep disturbance, but it does not
seem to modify the strength or frequency of the tinnitus (Piccirillo in Langguth et al.,
2007, Ch. 30).
Botulinum toxin has been used to reduce peripheral inputs from cervical, temporal,
frontal, and periauricular muscles. This mechanism can produce a reduction of the
activation of the medullary-somatosensory nucleus (MSN) to the dorsal cochlear
nucleus (DCN) pathway that is effective in the management of chronic headache, and
therefore it could also explain tinnitus relief.
4.2.4. Electrical and magnetic stimulation
Repetitive transcranial magnetic stimulation (rTMS) is a non-invasive method.
Electrical currents are induced in the brain through impulses of strong magnetic fields
applied externally. It could relieve tinnitus by modulating the excitability of neurons in
the auditory cortex, and therefore decrease hyperexcitability that causes some forms of
tinnitus (Kleinjung et al., in Langguth et al., 2007, Ch. 34).
Electrical stimulation of the auditory cortex using extradural implanted electrodes for
treatment of tinnitus was studied in 12 patients suffering tinnitus, and 5 patients suffering
neuropathic pain. 97% of patients with pure tone tinnitus experienced significant relief.
From this study it can be concluded that electrical stimulation of sensory cortices can be
an effective treatment of severe unilateral tinnitus and unilateral neuropathic pain in
selected patients. The results suggest that similar pathophysiological mechanisms
underlie some forms of tinnitus and neuropathic pain (phantom sensations), and
therefore, similar treatment such as electrical stimulation of the respective sensory
cortices can suppress tinnitus and pain (de Ridder et.al., in Langguth et al., 2007, Ch 36).
Transcutaneous Electrical Nervous Stimulation (TENS) is a clinical form of electrical
stimulation of the somatosensory system applied to the skin by electrodes.
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16. TENS of areas of skin close to the ear increases the activation of the dorsal cochlear
nucleus (DCN) through the somatosensory pathway and may augment the inhibitory role
of this nucleus on the CNS and thereby ameliorate tinnitus (esp. somatosensory tinnitus).
TENS is also effective when treating painful trigger points around the head, neck and
upper back. (Bonaconsa et al., 2010; Herraiz et al., in Langguth et al., 2007, Ch. 37)
4.2.5. Neurofeedback
EEG and MEG studies have found that many individuals with tinnitus have abnormal
oscillatory brain activity (elevated delta-waves, reduced tau-activity within the alpha
frequence range). Dohrmann et al., (2007) have developed a way to normalize such
pathological activity by neurofeedback techniques. This activity is recorded from
electrodes placed on the frontal scalp. It can be concluded from the study that
modification of the tau-to-delta ratio significantly reduces tinnitus intensity (Langguth et
al., 2007, Ch. 46).
4.2.6. Tinnitus treatments using somatosensory-auditory interactions
These varieties of treatments are mediated through central somatosensory- auditory
interactions and could be beneficial to the somatosensoric tinnitus subgroup (see chapter
2.2 and 3.2.).
Treatments that target the somatosensory system are:
 Acupuncture (Hansen et al., 1982; Axelson et al., 1994)
Studies show a definitive pattern in regard of benefit in tinnitus. People with
strongly lateralized tinnitus and symmetric hearing threshold are most likely to
get relief. Examples of dramatic response to acupuncture after one session have
been reported (Langguth et al., 2007).
 Electrical stimulation of scalp and auricle (Dobie et al., 1986) is only beneficial
in patients with unilateral tinnitus and symmetric hearing.
 Cervical manipulation/ Chiropractice (Alcantra et al., 2002; Cherian et al.,
2013; Kaute, 1998)
Successful treatments have been reported (mostly case reports). The
characteristics of patients responding to this treatment are largely unknown.
 Craniosacral therapy/Osteopathy/Manual therapy (Bjorne, 1993; Arab et al.,
2014; Goyal et al., 2017 ; Hill J.C. ; Kinne et al., 2019 ; Oostendorp et al., 2016 ;
Wilson, 1999; Plamberger, 2006; Duesberg, 2009) – see chapter 5
 TMJ therapy (Attanasio et al., 2015; Buergers et al., 2011, 2013, Wright and
Bifano, 1997)
50 % of moderate and severe cases of tinnitus, and 65% of less severe cases were
resolved or improved. People with normal hearing and tinnitus ipsilateral to TMJ
disorder benefited most. The study suggests a significant association between
somatic modulation testing and improvement of tinnitus with TMJ treatment
(Wright and Bifano, 1997).
 Triggerpoint therapy (Rocha, Sanchez, 2012; Injection- Estola-Partanen, 2000)
Injection of Lidocaine in triggerpoints in jaw and neck muscles can transiently
abolish tinnitus. The symptom disappeared in 15% of patients (total 178 patients)
16

17. after 5-10 days, and 30% felt an improvement after 6 month (compared to 15% in
the control group). The most cervical tension was found on the side of the
tinnitus, and women responded better than men (Estola-Partanen, 2000).
In another study, a strong correlation between tinnitus and the presence of
myofascial triggerpoints (MTP) in head, neck, and shoulder girdle has been
shown. Pressure on MTP (esp. M. masseter) could modulate tinnitus in 56% of
cases. Compression of MTP on the same side as the tinnitus and in patients with
previous chronic pain in this area was more effective (Rocha and Sanchez, in
Langguth et al., 2007, Ch. 18).
 Physical therapy (Bonaconsa et al., 2010; Michiels et al., 2016, 2017)
Physical therapy can consist of different modalities e.g. electrotherapy (TENS),
manual therapy, massage, stretching of muscles, relaxing exercises, correction of
bad posture etc. Specific exercises or physical treatments can be effective in
tinnitus at least in some cases. Many of the manipulative treatments used for
musculoskeletal disorders (chiropractic manipulations, osteopathy, and massage)
may be considered in tinnitus treatment. They can be used in responsive tinnitus
subjects such as those with painful trigger points (somatic tinnitus), as well as in
subjects presenting other associated symptoms (sleep disturbance, irritability etc.)
since these therapies may elicit somatovisceral reflexes which have effects on
non-musculoskeletal symptoms (Bonaconsa et al., 2010).
Nearly all tinnitus treatments have been reported to produce some degree of improvement
for some patients. Measurement of tinnitus treatment outcome and assessment of tinnitus
are not uniform and make it difficult to evaluate different treatment options. Despite the
existence of a wide range of assessment techniques, there is no consensus how to
measure features of tinnitus and effects of tinnitus treatment.
An American study group (Meikle et al., in Langguth et al., 2007, Ch. 49) aimed to
develop relevant criteria to evaluate the effectiveness of a questionnaire for diagnostic
purposes vs. for treatment evaluation purposes. The ideal questionnaire should satisfy
various clinical and research needs, e.g. high reliability, ease of use, high validity for
measuring the severity and negative impact of tinnitus, as well as treatment related
changes in tinnitus. They applied the various criteria in a new developed questionnaire.
Because there are various causes of tinnitus associated with multiple other symptoms and
underlying diseases, there will be probably not a single treatment, but a combination of
several treatment modalities.
The choice of treatment is largely influenced by country specific training routes and
practices, differences in the availability of hearing services, requirements for
reimbursement from medical insurance, limitation of local resources and patient’s
preference (Baguley et al., 2013).
Proposing a therapy should be based on detailed examination and individual approach.
It seems that different causes of tinnitus require different treatments. However, as the
mechanism of tinnitus is still not fully understood, more well- controlled clinical studies
to investigate the efficacy of different treatments should be performed (Dziuganowska,
2016).
17

18. 5. Osteopathic manual therapy and tinnitus
5.1. Osteopathic relevant structures and their relationship to tinnitus
5.1.1. Os temporale - “Home of the hearing organ”
The temporal bone plays a central role in the osteopathic understanding of tinnitus.
Situated on both sides of the cranium (paired bones), it connects the front and back part
of the skull.
A B C D
The Os temporale consist of four
parts:
 Pars squamosa
 Pars mastoidea
 Pars petrosa
 Pars tympanica
Important connections to
neighboring parts of the cranium
A. Sutura occipitomastoidea
B. Sutura parietosquamosa
C. Sutura sphenosquamosa
D. Sutura zygomaticotemporale
Picture 1: By Anatomography -
https://commons.wikimedia.org/w/index.php?
curid=24031021
The temporal bone has several openings and processus.
The meatus acusticus externus leads to the structures of the middle and inner ear that lie
within the pars petrosa, also called petrous pyramid, because of its shape.
Noticeable are also:
Processus zygomaticus – originates from the lower region of the squamous part
and articulates with the zygomatic bone
Processus mastoideus – point of important muscle insertions from neck and head
Processus styloideus – see picture 2
18

19. Pict.2 Attachments of Processus styloideus
Processus styloideus – attachement of
Lig. stylohyoideum,
Lig. stylomandibulare
M. stylohyoideus,
M. styloglossus
M. stylopharyngeus
important connection to hyoid bone and
deep cervical fascia
Muscle attachments of the temporal bone are shown in picture 3 and 4.
Muscles attached to temporal bone:
Squama – M. temporalis
Zygomatic arch – M. masseter
Pars mastoidea/ Mastoid processus–
M. auricularis post.
M. sternocleidomastoideus
M. splenius capitis
M. capitis longus
M. digastricus (venter post.)
M. occipitalis
Pars petrosa – M. tensor tympany
Styloid processus –
M. stylohyoideus
M. styloglossus
M. stylopharyngeus
Picture 3 and 4: By Henry Vandyke Carter -
Gray's Anatomy, Plate 187, Public Domain
https://commons.wikimedia.org/w/index.php?
curid=564607
By Henry Vandyke Carter - Gray's
Anatomy, Plate 137, Public Domain,
https://en.m.wikipedia.org/wiki/File:
Gray137.png
19

20. 5.1.2. Os shenoidale
The Os sphenoidale is an unpaired bone that forms the central base of the skull and the
anterior walls and floor of the middle cranial fossa. It articulates with the frontal, parietal,
ethmoid, temporal, zygomatic, palatine, vomer, and occipital bones and helps to connect
the neurocranium to the facial skeleton.
The median portion (body of sphenoid bone) contains the paired paranasal sinuses
(sphenoidal sinuses), as well as the sella turcica that forms the hypophyseal fossa, which
houses the pituitary gland.
The anterior side is formed by two lesser wings, and the lateral side by two greater wings.
Directed downwards from the junction of the body and the greater wings are the
pterygoid processus of the sphenoid.
The sphenoid has multiple openings for the passage of nerves and blood vessels.
Because of its central location and close proximity to important nerves and vessels, it is
also a crucial structure in craniosacral therapy.
Pict. 5 Sphenoid bone
https://opentextbc.ca/anatomyandphysiology/wp-content/uploads/sites/142/2016/03/709
Muscle attachments : M. pterygoideus lateralis and medialis
M. tensor veli palatini
M. levator veli palatini
The pituitary gland in the sella turcica is enclosed by a fold of the dura mater.
Therefore, tension of the dura mater can influence the function of this gland.
The middle cranial fossa is formed by the lesser wings of the sphenoid bone anteriorly,
and the petrous ridges (petrous portion of the temporal bones) posteriorly.
Openings of the middle cranial fossa and their passing through structures are:
(see picture 5)
 Optic canal - provides for passage of the optic nerve (N.II) into the orbit.
 Superior orbital fissure - N. occulomotorius (N.III), N. trochlearis (N.IV), N.
ophtalmicus( N.V1), N. abducens( N.VI) and associated muscles to the
forehead/eye pass through this opening.
 Foramen rotundum - is the exit point for N. maxillaris (N.V2) that supplies the
cheek, nose, and upper teeth.
20

21.  Foramen ovale - provides passage for N. mandibularis (N.V3) to the lateral head,
cheek, chin, and lower teeth.
 Foramen spinosum - entry point for Art. and V. meningea media, that supplies
the covering layers surrounding the brain, and meningeal branch of mandibular
nerve.
 Carotid canal - is the passageway through which the internal carotid artery enters
the skull.
 Foramen lacerum- This opening is an artifact of the dry skull, because in life it is
completely filled with connective tissue.
5.1.3. Os occipitale
The occipital bone is a single bone that forms the posterior skull and posterior base of the
cranial cavity. It is connected to the temporal and sphenoid bone.
Muscle attachments are: (see picture 3)
M. rectus capitis lateralis
M. rectus capitis posterior major et minor
M. rectus capitis anterior
M. capitis longus
M. obliquus superior
M. semispinalis capitis
M. splenius
M. sternocleidomastoideus
M. occipitalis
M. trapezius
Tension in these muscles can alter the position of the occipital bone in relation to other
bones of the skull (esp. temporal bone) and lead to cranial dysfunction.
Important openings of the occipital bone are:
Foramen magnum - Medulla oblongata, Art. vertebralis, Art.
spinalis ant. et post., N. accessorius entry)
Meatus acusticus internus - N. facialis – N.II, and
N. vestibulocochlearis – N.VIII
Foramen jugulare - N. glossopharyngeus – N. IX,
N. vagus – N.X, and
N. accessorius – N.XI, exit
Canalis hypoglossus - N. hypoglossus – N.XII)
5.1.4. Temporomandibular joint
The temporomandibular joints (TMJ) are a bilateral articulation between the mandibular
fossa of the temporal bone and the mandible. Between the two bones of the joint lies the
articular disc, a fibrous extension of the capsule. The temporomandibular joints can be
felt in front of or within the external acoustic meatus during movements of the mandible.
This joint is unique, because the right and left joints must function together as a unit and
therefore are not independent of each other. There are several ligaments associated with
the temporomandibular joint that connect to other structures of the skull.
21

22. Ligamentum temporomandibulare – strongest ligament between temporal bone and
mandible. The base of this triangular ligament is attached to the zygomatic process of the
temporal bone and the articular tubercle, its apex is fixed to the lateral side of the neck of
the mandible.
Ligamentum stylomandibulare – from the styloid process to the angle of the mandible
Ligamentum sphenomandibulare – from the sphenoid bone to the lingula of mandible
Ligamentum malleomandibularis anterior – from mandible to malleolus (middle ear)
Dysfunctions of the TMJ are often associated with tinnitus.
Osteopathic treatments of the TMJ, esp. myofascial release of tense jaw muscle (M.
masseter, M. temporalis, M. pterygoideus med. et lat.) have shown a beneficial influence
on tinnitus.
5.1.5 Tuba auditiva (Eustachian tube)
The auditory tube (Eustachian tube) is a tube that consists of a bony part (within the pars
petrosa of the temporal bone) and a cartilaginous part. It connects the middle ear to the
nasopharynx and equalizes the pressure of the middle ear to that of the external auditory
meatus. Mm. tensor and levator veli palatini aid in opening the tube primarily through
swallowing, and allow the pressure compensation. The narrowing (Isthmus) where the
osseous part meets the cartilaginous part can become dysfunctional. It can compromise
the equalization of pressure, and therefore the transmission of sound waves through the
middle ear.
5.1.6. Circulation around the ear and lateral cranium
Picture 6: Arteries and veins of the head and neck
https://www.slideshare.net/rineekhanna/blood-vessels-of-head-and-neck
22

23. Arterial blood supply and venous drainage of the cranium as shown in the pictures above
illustrate the proximity of the vessels to the base of the skull formed by occipital,
temporal and sphenoidal bone and the hearing organ. Shifting of bones can compromise
vessels in various ways (pinching in foramina, channels and fissures) and lead to reduced
flow and congestion.
5.1.7. Peri- and Endolymph in the inner ear (cochlea)
The cochlea has three fluid-filled sections (scala media, scala tympani and scala
vestibuli), and supports pressure waves that are transferred through the perilymphatic
space onto the endolymphatic space. The cochlear duct or scala media, contains
endolymph, whereas the scala tympani and scala vestibuli contain perilymph.
Endolymph is a fluid similar in composition to the intracellular fluid and rich on
potassium ions. Perilymph is rich on sodium and calcium ions and similar in composition
to cerebrospinal fluid (Plamberger, 2006). The chemical difference between the
endolymphatic and perilymphatic fluids is important for the function of the inner ear due
to differences in the electrical potential between potassium and calcium ions. Dysfunction
of the ion milieu of the endolymph can lead to a malfunction of the sensory epithelium.
Furthermore it can lead to deafness from incorrect sound impressions (Draeger, 2000).
Structures that contain endolymph (light pink)
are the arcades, sacculus, utriculus, scala media,
and saccus endolymphaticus.
The endolymphatic sac assists in pressure
balance in the membranous labyrinth and act as
a reservoir. Located subdurally on the inside of
the pars petrosa, it is exposed to pressure
changes of the liquor.
The perilymphatic space (blue) is connected to
the subarachnoidal space through the cochlear
aqueduct (ductus perilymphaticus).
Picture 7
Endo- and perilymphatic spaces (Boenninghaus/Lenarz, 2005)
5.2. Possible osteopathic treatment options regarding tinnitus
5.2.1. Entrapment of nerves and blood vessels
Pathological findings in tinnitus patients can involve
 Dysfunction of synchondrosis sphenobasilaris (SSB)
 Os temporale in external or internal rotation fixed
23

24.  Vertical strain on sphenoid bone (up or down)
 Dysfunction of tentorium cerebelli and falx cerebri
Important structures like the cranial nerves (see chapter 5.1.2 and 5.1.3.), arteries and
veins (see picture 6) enter or exit the cranium trough multiple foramina, fissures and
canals. Misalignment and restricted movement of cranial bones can lead to narrowing of
the openings and pinching or irritating these structures. The following example will
illustrate this statement.
Relevant for the treatment of tinnitus could be the entrapment of the vestibulo-cochlear
nerve (VIII) in the facial canal on its way to the meatus acusticus internus. Damage or
mechanical injury in the canal can cause biochemical and bioelectrical changes of the
nerve, alteration of the firing pattern and finally contribute to the perception of tinnitus.
Elevated pressure on the nerve is also possibly due to atherosclerotic changes of the Art.
cerebellaris ant., or abnormal tension of the dura mater.
Surgical intervention, known as microvascular decompression (MVD), can solve the
problem by moving a blood vessel off the intracranial portion of the auditory nerve
(Møller, A.R. in Langguth et al., 2007, ch. 38). In a study with 72 patients, 13 (18,2%)
had total relief, and 16 patients (22,2%) had marked improvement of their tinnitus.
Because osteopathic treatment can take off the pressure of the nerve by resolving the
cranial dysfunction, it could be an alternative, gentle way to relief tinnitus compared to
the invasive surgical procedure.
5.2.2. Cervical syndrome
Pathological findings in the head and neck area of tinnitus patients can involve:
 Dysfunction of cervical spine (flex. –ext., rotation, side bending)
 Dysfunction of upper thoracal spine
 Hypertone muscles of head and neck with trigger points
 Traumatic or compensatory dysfunctions as a result of
dysfunctions in other segments of the spine or the pelvis
As shown in chapter 2.2. afferent impulses of the cervical spine (esp. C2 root) can cause
hyperactivation of the DCN and the entire auditory system leading to auditory
misperception and tinnitus.
Resolving the spinal dysfunction (e.g. through Atlas therapy) and relief of muscle tension
could have a positive influence on tinnitus symptoms.
Arlen’s Atlas therapy has been proven to relax posterior small cervical muscles and
normalize afferent proprioceptive input to the brainstem (Kaute, B., 1998).
Several other examples of tinnitus relief through osteopathy/ manual therapy of the
cervical spine can be found in the literature (Arab et al., 2014; Hill J.C.; Kinne et al.,
2019; Oostendorp et al., 2016; Wilson, 1999; Plamberger, 2006; Draeger, K. 2000).
24

25. 5.2.3. Jaw and dental problems
Common findings in tinnitus patients in regard to TMJ and dental problems:
 TMJ dysfunction (e.g. forerun on one side, asymmetry of mouth opening, disc
dislocation)
 Tension/ trigger points of jaw muscles (M. pterygoideus lat., M. masseter, M.
temporalis)
 Overuse/strain of muscles on one side of the jaw due to dental problems
(infection, surgery, implants, dentures) on the other side
The temporal bone forms a part of the TMJ (fossa mandibularis), therefore dysfunctions
of the TMJ can influence the os temporale and vice versa. The TMJ is also very close to
the auditory canal. Because of the interrelationship between structure and function,
osteopathic treatment of the TMJ and/or Os temporale can be beneficial for tinnitus
patients. Examples can be found in the literature:
The relationship between tinnitus and temporomandibular disorder (TMD),
Wright, E.F. and Bifano, S.L. (1997)
Chiropractic care of a patient with temporomandibular disorder and atlas
subluxation, Alcantara, J. et al. (2002)
Tinnitus aureum as an effect of increased tension in the lateral pterygoid muscle.
Bjorne, A. (1993).
Treatment strategies of temporomandibular joint and masticatory muscle
disorders in patients with tinnitus, in Textbook of Tinnitus
Bürgers, R., Behr, M., and Gosau, M. (2011).
Improving tinnitus with mechanical treatment of the cervical spine and jaw
Cherian K, et al. (2013)
Ligamentous connections between mandible and middle ear (ear ossicle), as described by
Liem (2004), could influence the transmission of sound waves in the middle ear directly.
The ligamentum malleomandibularis anterior runs from the processus anterius of the
malleolus through the fissure petrotympanica to the spina shenoidalis, joints fibers with
the ligamentum sphenomandibulare and inserts on the ramus of the mandible.
Examination and treatment of TMJ problems are an essential part of osteopathic
treatment in tinnitus patients (Draeger, 2000).
5.2.4. Eustachian tube
Opening and closing of the Eustachian tube can be influenced by internal and external
rotation of the temporal bone. In external rotation, the tuba auditiva is more open, the
pressure balance between the middle ear and the pharynx is disturbed and a low-pitch
drone is generated. Whereas internal rotation of the temporal bone leads to narrowing or
closing of the tuba auditiva, and is associated with a high-pitch humming or hauling
sound (Magoun, 1976; Plamberger, 2006).
Treatment of the Eustachian tube is regularly integrated in the osteopathic treatment of
tinnitus (Draeger, 2000).
25

26. 5.2.5. Endo- and perilymphatic system
As shown in picture 7 (chapter 5.1.7.), the endolymphatic sac is located subdural and
exposed to the liquor system. Changes in intracranial pressure could influence the flow in
the endolymphatic system and have an impact on the auditory system.
The ductus perilymphaticus (aquaeductus cochlea) has a direct connection to the
subarachnoidal space. The perilymphatic system could also be influenced by elevated
pressure e.g. in the ventricles.
The aim of osteopathic treatment is to release tension in the membranes around the brain,
restore the motility of cranial bones and promote unrestricted circulation of cerebrospinal
fluid, endo- and perilymph (Plamberger, 2006).
5.2.6. Circulation
Misalignment of cranial bones and restricted movement can lead to compromised
circulation in the area of the middle and inner ear and the entire cranium.
The arterial bloodstream to the inner ear is supplied by the Art. labyrinthi, a branch of the
Art. cerebellaris ant. inf., or the Art. basilaris, and can be compromised by rotation
dysfunction of the temporal bone. A reduced flow to the cochlea is suspected to cause
hearing loss and tinnitus. The rotation of the os temporale can also influence the
circulation of the Art. carotis interna within the canalis caroticus ( pars petrosa of os
temporale). Deformation and compression of the foramen magnum caused by a
dysfunction of the occipital bone could lead to reduced blood flow in the Art. vertebralis,
Art. spinalis post., and Truncus basilaris and contribute to vertigo and tinnitus.
Osteopathic relief on blood vessels could be a solution.
5.2.7. Congestion
Ca. 95% of venous blood exits the cranium via the V. jugularis interna through the
foramen jugulare (Plamberger, 2006). Dysfunction of the petrojugular area
(synchondrosis petrojugularis) can lead to compression of the foramen, compromised
drainage, and backflow in cerebral sinuses with increased tension of the dura mater
(Plamberger, 2006).
Osteopathic release of the cervicothoracal and thoracal diaphragm can benefit venous and
lymphatic drainage from the head, reduce intracranial pressure, and could relief tinnitus.
5.2.8. Relation to stress
Several studies and articles mention stress as a major trigger for tinnitus (e.g. Plamberger,
2006). Physical stress, emotional strain, and psychological stress are named as subjective
causes of tinnitus, as well as an aggravating factor.
Stress also leads to contraction of head, neck, and jaw muscles. Proprioceptive impulses
from the muscles are conducted to the spinal column and upper root ganglia. These
ganglia (esp. C2 root) have a connection to the dorsal cochlear nucleus (DCN) that is also
involved in the auditory pathway (Ralli et al., 2017). Stimulation of root ganglia can
26

27. cause hyperexcitation of neurons in the auditory system (somatosensory cross-
connection) and misinterpretation as tinnitus (see chapter 2.2.)
As stress can contribute to tinnitus, tinnitus can also cause stress that can amplify tinnitus.
This happens by hyperactivating of neurons in the auditory cortex through impulses from
the limbic system and thalamus, and result in a self- running process causing
neuroplasticity (see chapter 2.1., table 2).
Osteopathy can relief stress through various techniques. Most patients feel a deep
relaxation after osteopathic treatment (Draeger, 2000).
5.3. Case report
I would like to share my own experience treating a tinnitus patient and the treatment
outcome.
A 74-y old woman suffers from tinnitus in her right ear since 15 year.
Tinnitus started in 2005 after dental work (2 implants in upper left jaw). Due to repeated
inflammation in the left upper jaw, she chewed mostly on the right side. Over time she
developed tinnitus in her right ear. The tinnitus becomes worse with loud music (concert
music), and chewing (e.g. nuts). She describes mainly a high pitched tone that is pulse
synchronic (pulsatile tinnitus). MRI from 6/2018 showed blocked artery in the neck, she
doesn’t remember exactly where, most likely Art. vertebralis. MRI control 1 year later
could not confirm this diagnosis. Intracranial structures were unremarkable. Years ago,
she was diagnosed with osteoarthritis of the cervical spine. As a retired science and music
teacher, she tries to stay positive, sings and speaks to the tinnitus (“good morning my
dear, why you are bothering me again….”). She also had some “bad” days, where the
tinnitus annoyance level was high, and she had the feeling like her head “explodes”.
On clinical examination, she showed decreased ROM of the cervical spine in all
directions with painful tension at the end of the movement. Trigger points are palpable in
M. trapezius, M. splenius cap., M. levator scapulae, M. rhomboideus, M. masseter, and
M. pterygoideus lat., on the right side more than left. Examination of the TMJ produced a
“click” on the right joint when opening the mouth, as well as deviation of the mandible to
the left.
Additional findings are a painful right shoulder by known osteoarthritis and rotator cuff
lesion, a valgus gonarthritis on the right side with scheduled knee replacement surgery in
a couple of month, and flat feet with a painful clavus over the head of metatarsal V bone
on the sole of the left foot.
The patient came primarily for acupuncture treatment of her tinnitus, so osteopathic
examination was not complete. In the course of the acupuncture treatment (no change of
the tinnitus was noticed after the third acupuncture session), osteopathic techniques were
integrated e.g. trigger point release (MFR) of neck and jaw muscles, occipital cradle,
mastoid wobble, normalization of the falx cerebri, and temporal rocking.
During the treatment, the breathing became deeper and more regular, muscles soften and
the body felt relaxed. After the treatment the patient felt some relief, she experienced the
therapy as “relaxing”, and the tinnitus was about 10% reduced. With following
treatments, the tinnitus became less prominent, and she could “blend it out” for a while.
Unfortunately these promising effects could not be sustained, because of worsening of
27

28. the knee and shoulder arthritis (independent of the tinnitus) with very painful restriction
of movement. Ultimately the treatment shifted to knee and shoulder.
Because of the beneficial effects of craniosacral therapy on her tinnitus, the patient might
continue the treatment, if the acute problems are solved.
5.4. Experience of other osteopaths treating tinnitus patients
Because of my own positive experience of treating tinnitus with craniosacral therapy, I
was curious to know, if other osteopaths have similar or maybe contrary experiences.
I created a tinnitus questionnaire (see appendix) that is accessible online (www.tinnitus-
study.weebly.com) and sent the link via email to 42 osteopaths around the world (24 in
Canada, 10 in Germany, 4 in UK, 4 other countries). I got a response from 10 osteopaths
(7 from Canada, 3 from Germany). 2 stated that they have never treated tinnitus, and
therefore have no experience. The remaining 8 are a very small group and probably not
representative, but I would like to share the results.
The questions are constructed as multiple choice questions with multiple answers
allowed. For the evaluation, the total number of entries was counted. Each question could
have a maximum of 8 entries. The percentage in brackets is only for illustration. It is not
representative, because of the low numbers.
Graph 1: number of patients treated
The fact that only 10 out of 42 osteopaths responded could mean that 32 (+2 who stated
no experience with tinnitus) have never treated tinnitus. That implicates that tinnitus
sufferers may not be aware of the osteopathic treatment option, or there are not enough
osteopaths who would treat tinnitus.
If 4 (50%) out of 8 osteopaths treated 10-50 patients, the latter is more likely.
The kind of tinnitus treated was mostly constant tinnitus (50%) and pulsatile tinnitus
(37%). Associated symptoms were vertigo and headache (50%), somatosensoric
modulation (37%), psychological problems (37%), and posttraumatic occurrence (25%).
As underlying problems were identified cervical dysfunction (100%), Stress (87%), tense
muscles/fascia (62%), and hypertension (37%).
28

29. Trigger points are almost always present. The most trigger points were found in M.
trapezius and M. temporalis (75%), M. masseter and M. pterygoideus (62%), M.
rhomboideus and M. sternocleidomastoideus (50%), M. levator scapulae and M. splenius
capitis (37%), and Mm. scalenii (25%).
Medication for tinnitus involved most likely antidepressants (50%), followed by NSAR
(37%), and Chinese herbs and homeopathic remedies (25%).
Only 1 entry (12%) counted for opioids.
Interestingly, under “others” were mentioned CBD (Cannabis- oil) and myorelaxans.
It can be assumed that all tinnitus patients tried other therapies first, or in combination
with osteopathy. Previous treatment was most often acupuncture and massage (87%),
followed by chiropractic and physiotherapy (62%).
Only 1entry were found for psychotherapy.
Medical doctors/ therapists who were involved are GPs (87%), ENT specialists (62%),
audiologist (25%), orthopaedic surgeon (25%- in Germany), and psychologists (12%).
Graph 2: osteopathic techniques used in treatment
MET – muscle energy technique
SCS – strain counter strain
HVLA – high velocity low amplitude thrust
CST – craniosacral therapy
MFR – myofascial release
It is not surprising that craniosacral and myofascial techniques are more frequently used
in treating tinnitus. This may suggest that they are more successful and efficient.
29

30. The frequency of treatments is usually 3-5 times (37%), or as needed (25%), and the most
common interval is once per week (25%), or as needed (25%).
One osteopath reported a tinnitus overall improvement of 70%, 2 of 50%, 2 of 10% and
one stated no improvement. This shows the heterogeneity of the subject. The different
causes of tinnitus, its pathways (peripheral or central), the reaction of the patient
(can/cannot relax), or even the different personalities of the patients could be a factor for
this inhomogeneous outcome. In agreement with the literature and my own experience,
patients with somatosensoric tinnitus, in one ear, without (or only minimal) hearing loss,
are the best candidates for osteopathic treatment. Women tend to be more receptive than
men, and more acute tinnitus is easier to treat than chronic.
The osteopaths reported objective changes like dysfunction resolved (75%), muscle and
fascia tension released (37%), and better ROM (37%).
Subjective changes involved diminished tinnitus awareness (75%), lower intensity and
frequency (37%), psychological improvement (37%), pitch has changed (25%), and pain
relief (25%).
In 12% there was no subjective and objective change, and 12% showed an increased
intensity of tinnitus.
6. Conclusion
This study shows that osteopathic treatment can intervene at several points of the tinnitus
pathways, and at several levels corresponding to the principles of osteopathy.
In osteopathy, the body is always treated as a whole.
Pathology of tinnitus can involve dysfunction not only of the auditory system, but also
dysfunction in the movement of cranial bones, TMJ, membranous and muscle tension,
and cervical dysfunction. All dysfunctions should be treated in connection to each other
for maximal results.
The interrelationship between structure and function is fundamental in osteopathy.
Restoring the structure (e.g. TMJ) leads to improved function (less tension on muscles,
ligaments, and fascias), and normalization of body systems (e.g. the auditory system).
The rule of artery is supreme. Unimpeded flow of bodily fluids is essential in good
health. Restoration of the unrestricted flow in arteries, veins, and the lymphatic system
(endo- and perilymph) are another osteopathic way to treat tinnitus.
The body is a self-regulating and self-healing system.
In correcting the dysfunctions that can lead to tinnitus, the body gets a chance to heal
itself. Osteopathic treatment is just the inducement to the self-regulating capabilities of
the individual.
30

31. Points in the pathological pathways of tinnitus and possible osteopathic response:
Neural level
 Neural entrapment can alter the conductivity of the nerve. Restoring the
physiological movement of cranial bones allows the nerve to function properly.
 Hyperexcitation of neurons in the auditory cortex through decreased inhibition of
neural impulses in the hearing organ and other neuronal structures (DCN, auditory
nerve – see chapter 2.1.) can be seen in cervical syndrome, musculoskeletal
injuries to the head and neck, and overwhelming stress. Relaxing tense muscles
on head, neck, and jaw, as well as stress relief are most effective.
Circulatory level
 Reduced or restricted blood supply to the hearing organ through cranial
dysfunction leads to deficit in oxygen and nutrients, and elevated intracranial
pressure.
Osteopathic treatment can enhance circulation, and normalize blood pressure.
 Venous stasis through compression in the foramen magnum can lead to
hyperaemia, oedema, and retention of metabolic waste products that can change
electrochemical properties of the surrounding tissue. The results could be false
axonal conduction and synaptic transmission. Osteopathic (craniosacral) therapy
can aid in venous and lymphatic drainage from the head and neck (lymphatic
pump, release of cervicothoracal and thoracal diaphragm).
 Disturbance of free flow of endolymphatic and perilymphatic fluids through
tension on the cranial membranes and elevated intracranial pressure can
contribute to tinnitus. By releasing the tension of the membranes and normalizing
the intracranial pressure, tinnitus could be influenced.
Musculoskeletal level
 Proprioceptive impulses from tense muscles and fascias lead to hyperexcitation in
the DCN and hyperactivation of the auditory system. Osteopathic treatment could
reduce the afferent signals by relaxing muscles and fascias, and relief stress.
There are many examples in the literature that show a positive effect of osteopathic
manual therapy in the treatment of tinnitus. The experience from other osteopaths and my
own experience also support the efficacy of osteopathy, and especially craniosacral
treatment. However, there are still a lot of questions that need to be answered.
Osteopathic manual therapy as an option in tinnitus treatment must by verified by well-
controlled scientific studies with sufficient numbers of participants. Uniform criteria for
assessment of tinnitus, diagnostic, and treatment evaluation should be established in order
to compare studies with each other and within different facilities (see chapter 4). It is also
not clear what kind of tinnitus can be treated successfully. There is a tendency towards
somatosensoric tinnitus, but more research has to be done to recommend osteopathic
manual therapy in the treatment of somatosensoric tinnitus.
In summary, osteopathic manual therapy can be a valuable treatment option for tinnitus
patients. It has shown its efficacy in numerous studies and case reports, and also in the
experiences of osteopaths. Our goal must be to proof the effectiveness in clinical studies
and raise awareness to this gentle, holistic therapy.
31

32. 7. Acknowledgment
I would like to thank the 10 osteopaths who contributed to this study by completing the
tinnitus questionnaire.
 Florian Lassnig, MPh, RMT, DOMP, BSc, DO (Spain), RMO
 Alicia Dyck, www.aliciadyck.com
 Dr. Ivo Breitenbacher, Konrad –Zuse –Str.12, 71034 Böblingen, Germany
www.breitenbacher.de, praxis@breitenbacher.de
 Michal Andrzejczyk, michalandrzejczyk@onet.eu
The other 6 would like to remain anonymous.
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36

37. 9. Appendix
List of abbreviation
ADT – auditory discrimination therapy
AN – auditory nerve
ant. – Anterior
Art. – Artery
CBD – Cannabidiol (oil)
(t)CBT – cognitive behavioral therapy in tinnitus
Ch. – Chapter
CNS – central nervous system
CN – cochlear nucleus
CST – craniosacral therapy
DCN – dorsal cochlear nucleus
EEG – electroencephalogram
EMA – European Medicine agency
ENT – ear, nose, throat
FDA – food and drug administration
GABA – Gamma-amino butyric acid
HVLA – high velocity low amplitude thrust
IHC – inner hair cells
inf. – Inferior
M. – muscle
Mm. – muscles
med. – medial
MEG – Magnetic encephalogram
MET – muscle energy technique
MFR – myofascial release
MRI – Magnetic resonance imaging
MSN – medullary-somatosensory nucleus
MTP – myofascial trigger points
MVD – microvascular decompression
N. – nerve
N. II-XII – cranial nerves II to XII
N.V1, V2, V3 – 3 branches of trigeminus nerve
NS – nerve system
NSAR – non-steroid antirheumatica
post. – Posterior
PRM – primary respiratory rhythm
RI – residual inhibition
ROM – range of motion
SCS – strain- counterstrain
37

38. sec. – Second
SSB – synchondrosis sphenobasilaris
TENS – transcutanous electrical nervous stimulation
THI – tinnitus handicap inventory
THQ – tinnitus handicap questionnaire
TMJ – temporomandibular joint
rTMS – repetitive transcranial magnetic stimulation
TRQ – tinnitus reaction questionnaire
TRT – tinnitus retraining therapy
V. – vein
VCN – ventral cochlear nucleus
List of illustrations
Table 1 – ear related causes of tinnitus
Table 2 – not ear related causes of tinnitus
Table 3 – hearing tract from dorsal, afferent tracts from the right cochlea, efferent tracts
to the hair cells of left organ of Corti, (Boenninghaus/Lenarz, 2005, p. 20,
Plamberger, 2006)
Table 4 – Interactive Algorithm for the Diagnostic & Therapeutic Management of
Tinnitus, TRI Tinnitus Clinic Network
https://www.tinnitusresearch.net/index.php/for-clinicians/diagnostic-flowchart
Picture 1 – By Anatomography - en:Anatomography, CC BY-SA 2.1 jp,
https://commons.wikimedia.org/w/index.php?curid=24031021
https://en.wikipedia.org/wiki/File:Occipitimastoid_sutur.png
https://en.wikipedia.org/wiki/File:SchaedelSeitlichSutur3.png
https://en.wikipedia.org/wiki/File:SchaedelSeitlichSutur10.png
https://en.wikipedia.org/wiki/File:SchaedelSeitlichSutur4.png
Picture 2 – https://en.m.wikipedia.org/wiki/File:Hypoglossus.png
Picture 3 – By Henry Vandyke Carter - Henry Gray (1918) Anatomy of the Human Body
Bartleby.com: Gray's Anatomy, Plate 187, Public Domain,
https://commons.wikimedia.org/w/index.php?curid=564607
Picture 4 – By Henry Vandyke Carter - Henry Gray (1918) Anatomy of the Human Body
Bartleby.com: Gray's Anatomy, Plate 137, Public Domain,
https://en.m.wikipedia.org/wiki/File:Gray137.png
Picture 5 – https://opentextbc.ca/anatomyandphysiology/wp-content/uploads/sites/
142/2016/03/709_sphenoid_bone
Picture 6 – Arteries and veins of the head and neck
https://www.slideshare.net/rineekhanna/blood-vessels-of-head-and-neck
Picture 7 – Endo- and perilymphatic spaces (Boenninghaus/Lenarz, 2005)
Graph 1 – number of patients treated
Graph 2 – osteopathic techniques used in treatment
38

39. Tinnitus-Study Questionnaire
1. How many patients with tinnitus did you treat?
<5
5- 10
10- 50
>50
2. What was the most common kind/cause of tinnitus?
Pulsatile
Non-pulsatile
Acute (acute tinnitus, sudden hearing loss)
Paroxysmal
Constant
with hearing loss
Vertigo
Headache
Psych. Symptoms (depression, anxiety, PTSD, suicidal)
Somato-sensoric (Neck, TMJ)
Posttraumatic (Neck trauma (whiplash), Barotraumas, Fracture)
Other (medication, surgery)
3. What other symptoms/ illnesses were present?
Hypertension
Diabetes
Stress
Tense fascias/ muscles at the base of the skull
Cervical dysfunction C0-C1, C1- C2
Other
Trigger points present
M. trapezius
M. levator scapulae
Mm. rhomboidei
M. splenius cap./cerv.
M. sternocleidomastoideus
Mm. scaleni
M. masseter
M. temporalis
M. pterygoideus med./lat.
Other
39

40. 4. Did or does the patient take any medication?
Hypertensiva
Antidiabetica
Antidepressiva
Pain medication (NSAR)
Opioids
Zinc
Chinese herbs
Homeopathic remedies
Other
5. Had the patient any previous treatment/ therapy before seeing an osteopath?
Chiropractic
Massage
Physiotherapy
Psychotherapy
Acupuncture
6. Was or is the patient treated by a medical doctor/therapist?
GP
ENT specialist
Audiologist
Psychologist
Psychiatrist
Surgeon/ orthopaedic surgeon
7. What kind of OMT treatment did you use?
Soft tissue/ MFR
MET
FPR
Strain-Counterstrain
HVLA thrust
Craniosacral
Other
8. Please specify your techniques?
9. How often do you usually perform treatments?
Only once
At least 3 times
3- 5 times
5- 10 times
>10 times
As needed
40

41. 10. In what intervals?
3 / week
2 / week
1 / week
1 in 2 weeks
1 / month
As needed
Other comments to treatment options (e.g. combination with other
modalities – Massage, PT, Chiropractic, Acupuncture)
11. Felt patient improvement?
Not at all
10%
20%
50%
70%
100%
other
12. Objective changes
Dysfunction resolved
Muscle/ fascia tension improved
ROM improved
13. Subjective changes
Tinnitus awareness decreased
Tinnitus pitch changed
Loudness/ intensity decreased
Loudness/ intensity increased
Frequency decreased
Frequency increased
Pain decreased
Sleep improved
Psych. Symptoms improved
Overall energy level increased
Other
For some questions, multiple answers are possible.
41