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

2. Let’s see “strange”
cases of tinnitus…

3. 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

4. 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

5. 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

6. 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…

7. 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

8. 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

9. 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

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

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

12. 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…

13. 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

14. 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)

15. 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

16. 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…

17. 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

18. 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

19. 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

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

21. 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

22. 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

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

24. 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?

25. 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).

26. 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

27. 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…

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

29. 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…

30. 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)

31. 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

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

33. 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

34. 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!!

35. 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

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

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

38. 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

39. 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)

40. 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

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

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

43. 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

44. 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

45. 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

46. 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

47. 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)