Programme for management of Tinnitus and Hyperacusis

Tinnitus and Hyperacusis cause considerable distress to patients. Patients with hyperacusis consider sounds are a threat to them.

Myriam Westcott, audiologist states that: “Hyperacusis is defined as an abnormal sensitivity or intolerance, a heightened sense of volume, and physical discomfort towards certain sounds, which other people can comfortably tolerate. Sounds that are typically difficult to tolerate are loud/impact sounds. Hyperacusis is the consequence of a subconscious threat response from those sounds, often due to anxiety they may exacerbate pre-existing aural symptoms such as tinnitus. Recent large-scale prevalence research has identified the development of secondary hyperacusis in about 50% of help-seeking tinnitus patients.” 1 ,2

Hyperacusis and acoustic shock disorder is considered to involve the Tensor tympani muscle (TTM) in the middle ear causing Tonic Tensor Tympani Syndrome. 3 This muscle has innervation from the trigeminal nerve in addition to the Vestibulocochlear nerve. Hence influencing the pathway of the trigeminal and the trigemino-cervical nucleus (TCN) can assist patients.

Myriam Westcott further states that: “Tonic tensor tympani syndrome (TTTS) has been proposed as the physiological mechanism underlying the persistent symptoms of acoustic shock disorder and these symptoms are also frequently seen in patients with tinnitus, particularly if they have developed hyperacusis.2,4

With TTTS an involuntary myoclonus develops in the tensor tympani muscle in the middle ear from a central nociceptive “protective” response to sounds or other stimuli subconsciously perceived as potentially threatening to the ear/hearing. TTTS can trigger a series of physiological reactions in and around the ear from tympanic membrane tension, alterations in middle ear ventilation and, in some cases, trigeminal nerve irritability.3

In addition, research work on tinnitus indicates that the central nervous system (CNS) becomes activated causing central neural sensitisation. This phenomenon can be described like an orchestra playing a symphony leading to considerable anguish.

The following recommendations are based on evidence informed medicine from patients presenting with tinnitus, hyperacusis, orofacial, temperomandibular joint (TMJ) dysfunction and cervico-thoracic involvement. They have been formulated in conjunction with patients presenting from Audiologists, Myriam Westcott, Kaush Troy, Dr Siobhan McGinnity and Susan Tegg-Quinn. These approaches are not exhaustive and will vary from patient to patient. The treating practitioner will be in the best position to make the clinical decision making following a comprehensive assessment.

Audiologist and ENT Specialists:

It is important to consult your medical practitioner, audiologist and ENT Specialist to rule out any potential balance dysfunction related to the tinnitus. Audiologists play a very important role in the assessment of tinnitus and hyperacusis and recommending suitable management strategies.

Physical Therapy/Physiotherapy

Specialist Musculoskeletal Physiotherapists involved in tinnitus and hyperacusis treatment and management and those trained by them have a holistic approach to management of these conditions. Habituation strategies, self-management strategies and dealing with the anxiety caused by tinnitus and hyperacusis are important in managing these conditions

Neural de-sensitisation strategies

Neural tapping influences the neural and muscular system. Neural tapping was initially performed on stroke patients to activate their brain and improve limb function. Neural tapping was progressed by me later in patients with sciatica, brachialgia, facial pain and headaches in the distribution of the nerves in that region. Functional MRI studies have also been conducted in patients craving for food and the effect of neural tapping to reduce craving.

Neural tapping is performed by patients with tinnitus, hyperacusis, orofacial conditions, temperomandibular disorders (TMDs), headache and migraine to modulate the nervous system and the homunculus (somatosensory cortex). In the homunculus, the head and hand points are adjacent to each other and thereby neural tapping the hand points can influence the head region. https://www.bing.com/images/search?view=detailV2&ccid=bxFSAYTo&id=13EBD00AC91B945F306CDBC4D3E4F3FDFCE41782&thid=OIP.bxFSAYToz-9yiZvEwZLOygHaCv&mediaurl=https%3a%2f%2fi0.wp.com%2fwww.liveconsciouslyconnected.com%2fwp-content%2fuploads%2f2016%2f11%2fCortical-Homunculus-Image.jpg&exph=1154&expw=3115&q=homunculus+brain&simid=607997163128162553&selectedIndex=0&ajaxhist=0

Functional MRI studies on needling hand points have demonstrated the effect on the homunculus. Functional MRI research studies on patients with complex regional pain syndrome by Prof Lorimer Mosley demonstrated the changes in the homunculus in the brain in these patients. Prof Mosley demonstrated that performing mirror therapy exercises and the Recognise programme can change the effect on the homunculus and and improve the patient’s function and thereby reduce their pain.

Neural tapping can be performed at home with the index fingers. Neural tapping can be performed initially on hand points at the first dorsal interosseous muscle region (between the thumb and index finger) for 30 seconds on both hands. Neural tapping can then be progressed to the back of both hands for 30 seconds. Neural tapping can be performed twice per day, when one experiences symptoms and before one visits a noisy place.

After a week, the patient can progress to gentle neural tapping of the arms, upper shoulders, the back of the neck. The following week the neural tapping can progress to the mastoid bone in the back of the skull, to the top of the head (in the region of the homunculus), temples, the orofacial region for a total of 1 minute and later progress to 2 minutes. Neural tapping to the upper cervical region, sternocleidomastoid (SCM) and trapezius, can influence the afferent input to the TCN and thereby the trigeminal nerve and its influence on the TTM. Neural tapping the orofacial region can influence the trigeminal nerve. Neural tapping can later be progressed to influence the sympathetic nerves in the upper thoracic region and the stellate ganglion that supply the head and orofacial region.

Myofascial Trigger Point Therapy

At a subsequent consultation, the patient can progress to gentle myofascial trigger point therapy to the masseters, temporalis, SCM, upper cervical muscles and the upper trapezius. The myofascial trigger point therapy provides afferent input via to the trigeminal nerve and the TCN.

Low Level Laser Therapy and Dry Needling Acupuncture:

Low Level Laser Therapy may be beneficial in some patients. Researchers have demonstrated that the combined treatment approaches of Low Level Laser Therapy, occlusal splint and an isometric cervical programme can assist 42% of tinnitus patients.6

Thor Laser (830 nm) can be applied to the vertex and either side to the vertex to influence the somatosensory cortex.7 Laser can be applied to above-mentioned regions where neural tapping is recommended. Application of Laser to the posterior aspect of the Mastoid is also beneficial.

In clinical practice, many patients report that gentle insitu Dry Needling / Acupuncture7 to the orofacial region and head beneficial due to the neuromodulatory effects of needling and reduction in anxiety.

Biomechanical approaches

A biomechanical approach of the spine, shoulder girdle, pelvis and limbs is important in the holistic approach of patients with headache,7 migraine, orofacial condition such TMJ, tinnitus and hyperacusis. Neuro-biomechanical approaches have benefited patients with headache, migraine and orofacial condition. Tinnitus and hyperacusis patients report that changing their biomechanics assist their function.

Psychology

Counselling and cognitive behavioural therapy is important in the holistic management of headaches, tinnitus and hyperacusis.

Radical Exposure Tapping (RET)

RET- Radical Exposure Tapping has great benefits in reducing the affect/emotion due PTSD. This was first put forward by Dr Laurie McKinnon who runs programmes in Sydney. There are Psychologists who are specifically trained in RET. http://www.radicalexposure.com/

Grounding strategies

  • Visualise 5 objects in front of you (for example: the wall, ceiling, floor, picture on the wall, the window, the sky or grass to name a few)
  • Tactile-feel where your feet contact, your hips, low back, arms and hands contact
  • Hearing- listen to 5 sounds around you

Visualisation strategies

Visualise activities that you enjoy most or what you enjoy performing with your hands. Identify the different tinnitus sounds that you hear. Then for each sound, associate the activity you enjoy most for 60 seconds. Repeat this process during the day. (Tegg-Quinn, person al communication) 5

Medication

Appropriate medication management from your general practitioner, and input from a pain management specialist can benefit patients.

Patients can benefit from stellate ganglion blocks or cervical blocks. In Melbourne these are performed by a Pain Management Specialist, Dr Nick Christelis or Dr Paul Verrills.

Dr Peter Selvaratnam AM

Editor and author Headache Orofacial Bruxism: multidisciplinary approaches to diagnosis and management

References

  1. Schecklmann M, Landgrebe M, Langguth B, the TRI Database Study Group (2014) Phenotypic Characteristics of Hyperacusis in Tinnitus. PLoS ONE 9(1): e86944. https://doi.org/10.1371/journal.pone.0086944
  2. Westcott M et al. Tonic Tensor Tympani Syndrome (TTTS) in Tinnitus and Hyperacusis Patients: A Multi-Clinic Prevalence Study. Noise and Health Journal, Mar-Apr 2013, Volume 15, Issue 63 pp117-128.
  3. Myriam Westcott, Audiologist, personal communication
  4. Noreña AJ, Fournier P, Londero A, Ponsot D, Charpentier N. An Integrative Model Accounting for the Symptom Cluster Triggered After an Acoustic Shock. Trends Hearing 2018 Jan-Dec; 22: 2331216518801725
  5. Susan Tegg- Quinn, audiologist, personal communication
  6. Marie Tullberg and Malin Ernberg. 2006. Long-term effect on tinnitus by treatment of temporomandibular disorders: a two-year follow-up by questionnaire Acta Odontologica Scandinavica,; 64: 89-96
  7. Peter Selvaratnam, Ken Niere and Maria Zuluaga. 2009. Headache, Orofacial Pain and Bruxism; Multidisciplinary Approach to Diagnosis and Management. Elsevier, UK and USA.AM