ABBA sang “Ring, ring, why don’t you give me a call?” Yet, unlike the singularity of a phone call, for those living with the challenge that is somatic tinnitus the “ring” becomes a “thing” that can impact many aspects of life’s beauty.
Indeed, for many suffering with somatic tinnitus it’s more a case of “dial 000” than “give me a call”.
So how can this common and frustrating condition be treated?
From a musculoskeletal perspective the answer may lie in understanding the neurological, functional and embryological connections that exist between muscles of the middle ear, jaw, palate and neck.
Anecdotally, incorporating manual therapy approaches with an interdisciplinary approach may be best practice to achieve a positive patient outcome. The following provides a recently offered perspective:
In 2022 a team of otolaryngologists from Brazil, the United States and Colombia assessed a novel approach to tinnitus treatment by undertaking a preliminary study of 22 participants. 1 A manual therapy approach was applied to mobilize tissue associated with a soft palate muscle, the tensor veli palatini (TVP). In a single session a gentle 15-second digital pressure was applied. This approach was performed three (3) times (total time = 45 seconds) to the left and right regions of the palatal aponeurosis. Results published in the HSOA Journal of Otolaryngology Head & Neck Surgery were very encouraging. 1
‘The massage reduced tinnitus loudness immediately after being performed. It also reduced associated otological complaints such as ear pressure and muffled hearing.’1
‘The outcome measurement was based on a tinnitus loudness rating scale of 0-100. The mean tinnitus loudness score before treatment was 54.77 (confidence interval-CI 45.8 to 65.47) and after treatment 25.2 (CI 19.59-to 32.61) (p < 0.001). The magnitude effect mean ratio was 0.46 (95% CI .0.39 to 0.54.), p < 0,001.’1
Denoting both a statistically and clinically meaningful result, this preliminary study by otolaryngologist, Claudia Barros Coelho et al. together with related studies by otolaryngologist, Luis Miguel Ramirez Aristeguieta, combined with works by esteemed peers Myriam Westcott and Dr. Peter Selvaratnam and 28 years of my own clinical experience, the following realisation emerged. 2
Several other pathways for new treatment options exist for patient populations experiencing somatic tinnitus, aural fullness, tensor tympani syndrome (TTS) and hyperacusis.
The first of these pathways is through the shared innervation of the trigeminal nerve. What does that mean? Well, it means that the TVP muscle and a very important middle ear muscle, tensor tympani (TT) along with numerous chewing muscles of the jaw including the medial pterygoid and masseter muscles share the same nerve supply.2 Hence muscles that contribute to tinnitus can be influenced through specific examination of the soft palate muscle and/or the masticatory muscles of the jaw.
Figure 1 (see appendix for description)
Additionally, TVP, medial pterygoid and lateral pterygoid (bilaterally) are three of a group of six (6) muscles whose actions affect the eustachian tube.8 In the medical literature they are infrequently termed ‘paratubal muscles’.
Further to that, the medial pterygoid and two other local structures are believed to support the functional integrity of the TVP muscle. Each is used as a hypomochlion (fulcrum) to enable the TVP muscle to contract with optimal force.6 Therefore, ensuring correct medial pterygoid function provides the second pathway to restore middle ear function.
Figure 2 (see appendix for description)
From an embryological perspective it is also worth noting that structures including the jaw, soft palate, middle ear, eustachian tube and the masticatory muscles all develop from the first pharyngeal arch.3 The relevance of this becomes apparent when TVP and TT muscle functioning is better understood.
Working as synergists, the TVP soft palate muscle and the TT middle ear muscle not only assist in various auditory processes but also act during reflex actions. These actions include swallowing,4 chewing, speaking, laughing, coughing and breathing.5 Assessing and addressing the motor pattern of tongue movements when swallowing whilst also considering any associated impact on temperomandibular joint (TMJ) mobility provides the third pathway to restore function through the association of these tissues.
Figure 3 (see appendix for description)
Many patients’ experiencing somatic tinnitus can also present with an overactive sympathetic nervous system (SNS) and/or a resting hypertonic muscle state that adds to the complexity of their condition.7 Specific breath work, visualization approaches and tongue exercises can benefit these patients. In addition, down-regulation of the SNS along the thoracic spine via gentle mobilization can be helpful in encouraging an up-regulation of the parasympathetic nervous system (PNS) enabling the experience of calmness.
These principles have been applied to somatic tinnitus patients since 2022 with very encouraging outcomes.
Treated with an otic neuromuscular (ONM) myotherapy approach, patients have reported a reduction in the intensity and/or frequency of their symptoms. Treatment generally follows specialist audiology assessment and diagnosis of somatic tinnitus. Additionally, it is worth noting tinnitus emanating from other pathways has also been treated with an ONM approach. Initial consultations can take up to 1.5 hours. Patients are then reviewed weekly or fortnightly over a 4-to-6-week period. Follow-up consultations generally take between 45 minutes to 1 hour.
If required further consultations are made in accordance with individual responses
The following are a few case studies –
Case study 1 A patient with long term tinnitus due to neural sensitivity reported 3 days of complete resolution of their tinnitus symptoms following the initial ONM consultation. This transient resolution provided a patient belief that recovery was possible.
Case study 2
A patient reported that at the 12-week mark a 95% reduction in tinnitus symptoms was experienced following an ONM approach. The patient then observed their tinnitus was exacerbated in association with food intolerances.
Case study 3
A patient presenting with bilateral tinnitus reported complete resolution of tinnitus symptoms during an ONM treatment and for a further 2 days post treatment. When paired with learned management tools they began to understand how to self-habituate when stressed and when tinnitus symptoms were heightened.
Improvement in all stated examples is driven by an interdisciplinary approach to patient care. Specialist audiology followed with specialist musculoskeletal tinnitus physiotherapy input initially is important to assess whether the patient’s tinnitus is driven by the central nervous system. An ONM myotherapy approach then follows this providing the somatic tinnitus patient population an opportunity to habituate their condition. 5
Colleagues, Dr. Peter Selvaratnam and our audiology peers are highly skilled, experienced and well placed to offer exemplary care in supporting somatic tinnitus patients. Each target specific aspects of the disorder. In fact, their work is so complex that to outline their approach individually would require another blog!
The emerging research and medical literature clarify that the muscles of the middle ear and the trigeminal nerve play a role in somatic tinnitus.9 Applying this knowledge with clinical expertise can influence functional outcomes.
Stay young at heart,
Kerrie
Kerrie Bor is a Senior Consultant Myotherapist, ONM pioneer and TMJD, somatic tinnitus, aural fullness, TTS and hyperacusis practitioner.
Kerrie co-authored a book chapter: Myofascial trigger point treatment for headache and TMD. In: Headaches Orofacial Pain and Bruxism: Diagnosis and multidisciplinary approaches to management. Editors: Dr Peter Selvaratnam, Dr Ken Niere and Maria Zuluaga, 2009. Publisher Elsevier, UK.
NOTE- Our practitioners consult throughout the week, Monday to Thursday. Telehealth consultations are available with Kerrie on request. If you would like to communicate your tinnitus concerns with us, we can be contacted via info@mssm.com.au6
Appendix
Figure 1.
Nurci Efrilia Safitri. (2023). Trigeminal Neuralgia: A Brief Review. European Journal of Medical and Health Sciences, 5(3), 8–11. https://doi.org/10.24018/ejmed.2023.5.3.1733
Figure 2.
Lau, B. (2015). The Masseter and Pterygoids and their Channel Relationships. Sinewchannels.com. https://www.sinewchannels.com/2015/11/the-masseter-and-pterygoids-and-their.html
Figure 3.
S. Schröder, Lehmann, M., Ebmeyer, J., T. Upile, & Sudhoff, H. (2015). Balloon Eustachian tuboplasty: a retrospective cohort study. Clinical Otolaryngology, 40(6), 629–638. https://doi.org/10.1111/coa.12429
References
1. Barros Coelho, C, Tyler, R, Miguel Ramirez Aristeguieta, L & Assis Dos Santos, M 2022, Palatal Aponeurosis Massage: a Diagnostic and Treatment Tool to Tinnitus and Otological Symptoms, Heraldopenaccess.us, viewed 8 January 2024, <https://www.heraldopenaccess.us/openaccess/palatal-aponeurosis-massage-a-diagnostic-and-treatment-tool-to-tinnitus-and-otological-symptoms>.
2. Huff, T, Weisbrod, LJ & Daly, DT 2022, Neuroanatomy, Cranial Nerve 5 (Trigeminal), Nih.gov, StatPearls Publishing, viewed 29 January 2024, <https://www.ncbi.nlm.nih.gov/books/NBK482283/>.
3. Toro-Tobon, S, Manrique, M, Paredes-Gutierrez, J, Mantilla-Rivas, E, Oh, H, Ahmad, L, Oh, AK & Rogers, GF 2023, ‘Pharyngeal Arches, Chapter 1: Normal Development and Derivatives’, Journal of Craniofacial Surgery, vol. 34, Lippincott Williams & Wilkins, no. 7, pp. 2237–2241, viewed 13 February 2024, <https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10521768/>.
4. Miguel, L, Ernesto, L & Sandoval, P 2010, ‘Tensores del velo del paladar y del martillo: vínculos anatómicos, funcionales y sintomáticos’, Acta Otorrinolaringológica Española, vol. 61, Elsevier BV, no. 1, pp. 26–33, viewed 13 February 2024, <https://pubmed.ncbi.nlm.nih.gov/19850273/>.
5. Ramírez, L, Ernestos Ballesteros, L, Sandoval, G & Luis, M 2018, E96 Tensor tympani muscle: strange chewing muscle, viewed 13 February 2024, <https://scielo.isciii.es/pdf/medicorpa/v12n2/03.pdf>.
6. Georgakopoulos, B & Borger, J 2023, ‘Anatomy, Head and Neck, Tensor Veli Palatini Muscle’, StatPearls, viewed 13 February 2024, <https://pubmed.ncbi.nlm.nih.gov/31335022/#:~:text=Control%20of%20the%20Eustachian%20tube’s,from%20the%20Eustachian%20tube%20itself.>.
7. Hackenberg, B, Döge, J, O’Brien, K, Bohnert, A, Lackner, KJ, Beutel, ME, Michal, M, Münzel, T, Wild, PS, Pfeiffer, N, Schulz, A, Schmidtmann, I, Matthias, C & Bahr, K 2023, ‘Tinnitus and Its Relation to Depression, Anxiety, and Stress—A Population-Based Cohort Study’, Journal of Clinical Medicine, vol. 12, Multidisciplinary Digital Publishing Institute, no. 3, pp. 1169–1169, viewed 13 February 2024, <https://pubmed.ncbi.nlm.nih.gov/36769823/#:~:text=The%20prevalence%20of%20depression%2Fanxiety,p%2Dvalue%20%3C%200.0001).>.
8. Szymanski, A & Agarwal, A 2023, Anatomy, Head and Neck, Ear Eustachian Tube, Nih.gov, StatPearls Publishing, viewed 29 January 2024, <https://www.ncbi.nlm.nih.gov/books/NBK482338/#:~:text=Structure%20and%20Function&text=The%20Eustachian%20tube%20is%20located,of%20the%20medial%20pterygoid%20plate.>.
9. Westcott, M, Ganz Sanchez, T, Diges, I, Saba, C, Dineen, R, McNeill, C, Chiam, A, O’Keefe, M & Sharples, T 2013, ‘Tonic tensor tympani syndrome in tinnitus and hyperacusis patients: A multi‐clinic prevalence study’, Noise Health, vol. 15, no. 63.
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