TRAUMATIC CERVICO-GENIC TINNITUS

TRAUMATIC CERVICO-GENIC TINNITUS

 (Hissing in the ears) January 12, 2021

 By: Akbar Poorshafiee, D.C., Q.M.E.

ABSTRACT

Tinnitus is perception of sound (buzzing, hissing, ringing in the ears), without an outside auditory stimulus. It is a complicated and complex symptom. Furthermore, it has been studied and observed that acute tinnitus could be modulated by stimulation arising from somatosensory system activated by the mechanoreceptors. Acute and subacute cervicogenic tinnitus is underdiagnosed and poorly understood. It is necessary to establish protocols for diagnoses and conservative treatments focusing on the cervical spine subluxations and auditory pathways.

INTRODUCTION

 Cervicognic and somatosensory tinnitus is ringing

(Hissing sound in the ears) and it could arise out of many sources. Depression, anxiety, high or low blood pressure, blunt sound trauma, drug interaction, cervical spine disorders, and TMJ disorders just to name a few. It is often very complicated to pin-point a definitive reason for the complication. Most often, a detailed history and examination could provide a clue. 

Frequently, a trauma to the head and neck could be a reason for the beast. It is not to say that the trauma to the cervical spine itself causes the sound in the ears, but it is the impact on the neck that modulates the cervical sympathetic chain ganglion that can trigger the brainstem structures and that input can modulate the neural pathway that participate in sound generation. In our practice based on over thirty years of experience and the cases that we have encountered as well as continuous studies, we believe it to exist. Cervical tinnitus is not rare but it is often misdiagnosed (Montazem etal, 2000). However, in 2018 following review of 24 papers on the subject (Bousema et al) concluded that “There is weak evidence for an association between subjective tinnitus and Cervical Spine Disorders “CSD”, but our protocols for diagnosis and treatment of acute and subacute tinnitus have documented otherwise. 

For chronic tinnitus cases, there is no definitive treatment and many doctors still tell their patients that management of the symptoms is the way to go. 

DIAGNOSIS

More often than not, diagnosis of acute and subacute tinnitus is based on the history and often by the process of elimination. 

In the past, it was impossible for the examiner to hear the sound and they had to conceptualize what was subjectively relayed to them by the patient. Thanks for the advancement of the technology, today the audiologist can actually record the sound electronically.

Although it is reported that the diagnosis of Cervicogenic and Somatic Tinnitus (CST) is made when the predominant feature is the simultaneous appearance or increase of both neck pain and tinnitus(Michaels et al, 2015). We have found that the coincidence of neck pain and tinnitus is not necessarily always the case and more often than not neck pain may or may not be associated with tinnitus. We have documented tinnitus cases that were purely secondary to a blow to the cervical spine or head, or simply following a manipulation, massage or manual therapy or simply a visit to the barber shop. 

In our practice, we make the diagnosis of cervical tinnitus with the process of elimination. We request that the patient be evaluated by a neurologist, an ear, nose, and throat specialist and if necessary and audiologist. Absent of diagnosis of CSD, TMD, and other head and neck pathology, we then rely on the history as it is relayed to us by the patient regarding the trauma to the head or neck. 

Extensive experience and knowledge of the cervical spine range of motion and spinal anatomy together with clear understanding of plane of segmental motion is required as well as ability to analytical interpretation of diagnostic imaging. Lateral inclination, lateral shifting, and rotation of the C1-C2 in relationship with the occiput should be carefully examined. 

Only with the following conditions, neuromuscular release, manipulation, and specific nonforce chiropractic adjustment techniques may be considered.

The physical examination includes not just the ear but also the entire head, neck, and torso for signs of the origin of tinnitus. Include complete auscultation of the neck for bruits, which can be transmitted along the carotid artery, and for venous hums, which can be transmitted along the jugular vein 

  1. 1.Unilateral facet subluxation with intact transverse 

ligament where dens acts as a pivot for C1.

  1. 1.Unilateral facet subluxation with ADI 3-5 mm associated with mild transverse ligament injury.
  2. 2.Considering cases 1 and 2 the following subluxations (misalignments have been documented by chiropractic physicians as observed on CT scans and radiographs of the upper cervical spine.

Anterior right or left. Using Cartesian coordinate system of X-Y-Z axes. 

The following subluxations (misalignments) have been recognized and documented

Atlas Right or Left lateral subluxation

Atlas Anterior Superior Right or Left 

Atlas Posterior Inferior Right or Left

Axis Anterior Right or Left Superior

Axis Posterior Right or left inferior 

There is a possibility for a combination of all the above subluxations which is beyond The scope of this paper. 

MECHANISM 

Mechanical irritation following a trauma or blow to the head and neck would impact the vertebral artery along its course resulting in neuritis. The Sympathetic vertebral nerve runs along the vertebral artery traveling through the arterial foramen of the transverse processes in cervical spine. Subluxation of the vertebra especially at C1-C2 may impact the cervical nerve fibers on its way to the brain stem.  

Briefly stated, Neuronal networks in tinnitus:

The stimulation of the auditory system could have an impact on areas of the brain responsible for Affect Regulation such as Amygdala and Hippocampus as well as frontoparietal region which stimulates attention and conscious perception.

The mechanical pressure on the pathway of the sympathetic nerves send impulses through afferent nerves fibers to the brain stem, amygdala, hippocampus, etc. and frontoparietal regions relevant for regulation of attentions and for conscious perception.

White and Panjabi have reported that stimulation of the cervical sympathetic truck can cause alteration of the cerebral circulation and its regulatory mechanism. It has been documented that irritating lesions involving the cervical region and its articulations may in turn irritate the sympathetic never plexus ascending into the head via the vertebral and carotid arteries which in turn affect the neural pathways into the brainstem. 

Case study: 

The most recent case in our facility belongs to a 32 years old female patient. She is 167 cm tall and 62 kg. She denies use of medicine on regular basis. She walks one hour daily and had two pregnancies and has two children. She is generally healthy and had not prior history of Migraine headaches or persistent neck problems. She reported that six month ago, she was in the basketball court playing with her son who is 8 years of age. He throws the basketball at her and the ball hit her on the right side of the head and neck. She had some pain and discomfort following the blow to her head but did not take it seriously. A couple of hours later she started hearing a hissing sound in her ears.  And mild neck pain and headaches. Later on, the headaches and neck pain subsided but the tinnitus continued. A couple of days later, she went to a local clinic where she was given diuretic medicine. With the persistent tinnitus, she went to see a neurologist. Radiographs of the cervical spine were obtained which was reported normal.  She was later sent in for an MRI of head and neck and was referred to an ear, nose and throat specialist and an audiologist. The symptoms persisted for six month and a CT scan of the head and neck was obtained which was reported as normal. Her neurologist just suggested for her to see a doctor of chiropractic.

Following a detailed history and examination, review of CT scan and a report of examination by her doctor of audiology and based on observation of lateral inclination and posterior rotation of the C1 on C2 and restriction of motion on right lateral flexion and left rotation diagnosis of cervical subluxation was made. 

It is imperative to watch for possible instability and micro instabilities of the cervical spine for any and all interventions. 

TREATMENTS

Thorough range of motion examination of the cervical spine and palpation of the spine and its surrounding musculature was performed with signs of muscle hypertonicity, muscle spasm and palpable subluxations.

Auscultation of the carotid arteries revealed normal. 

Orthopedic and neurological examination of the head, neck and upper extremities were within normal limits. 

Myofascial release techniques in order to reduce muscle resistance. Triger point therapy for the muscles of SCM, Suboccipitalis, and trapezius muscles particularly at the origins and insertions was performed. 

Specific chiropractic adjustments in accordance with the findings of axial CT scan finding of C1-C2 were performed and the patient was instructed to monitor any changes in tinnitus pattern, its intensity, duration, or its location of perception. 

The patient was again visited in two days and she reported that the buzzing sound in her left ear was noticeably reduced. The mentioned treatment protocol continued.  

On the third visit, she reported complete relief in her left ear and mild tinnitus in the right ear.  Again the same treatment protocol was performed.  

She was visited after a week. She reported that her tinnitus was no longer present. Her range of motion of the head and neck was normal with no pain or restrictions. She was discharged. 

CONCLUSION

Tinnitus is perception of sound (buzzing, hissing, ringing in the ears), without an outside auditory stimulus. It is a complicated and complex symptom. Furthermore, it has been studied and observed that acute tinnitus could be modulated by stimulation arising from somatosensory system activated by the mechanoreceptors.

This study does not include medical treatment approach to chronic or acute and subacute tinnitus. It simply investigates conservative diagnosis and treatment approaches to cervicogenic tinnitus and to be more specific, traumatic cervicogenic tinnitus. 

History as relayed by the patent comprises the most  important aspect of the diagnosis. It is imperative to consult which other specialists and to obtain diagnostic imaging to rule in/out other pathologies. It is of outmost importance for the practitioner to have extensive knowledge and experience of working with the spine and more specifically working with the occiput upper cervical spine. The patient should be carefully evaluated for possible instability or micro instability of cervical spine before any muscle work, manipulation or even specific corrective chiropractic Adjustments. 

Epidemiology/Etiology

Different sources have documented the prevalence of 5% and 15% of the general population to suffer from tinnitus during their lifetime. About 1% of those with tinnitus report that it has major negative impact on quality of their life. 

R:EFERENCES

Bousema, E. J., et al. (2018). “Association Between Subjective Tinnitus and Cervical Spine or Temporomandibular Disorders: A Systematic Review.” 

Cherian, K., et al. (2013). “Improving tinnitus with mechanical treatment of the cervical spine and jaw.” J Am Acad Audiol 24(7)

Mielczarek, M., et al. (2013). “The application of direct current electrical stimulation of the ear and cervical spine kinesitherapy in tinnitus treatment.” Auris Nasus Larynx 40(1): 61-65. 

White and Panjabi Cervical Spine Instability (clinical biomechanics of the spine 1978

Michiels, S., et al. (2015). “Diagnostic Value of Clinical Cervical Spine Tests in Patients With Cervicogenic Somatic Tinnitus.”

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