Making the case for cervical instability as a cause of Tinnitus
Ross Hauser, MD | Caring Medical Regenerative Medicine Clinics, Fort Myers, Florida
David N. Woznica, MD | Caring Medical Regenerative Medicine Clinics, Oak Park, Illinois
Danielle R. Steilen-Matias, MMS, PA-C | Caring Medical Regenerative Medicine Clinics, Oak Park, Illinois
Making the case for cervical instability as a cause of Tinnitus
People with tinnitus can find benefit in many treatments. In this article we will suggest one aspect of tinnitus treatment, the connection of tinnitus to cervical neck instability and treatment to strengthen the cervical neck ligaments. Not all cases of tinnitus is caused by cervical neck ligament damage, in this article we discuss when cervical neck ligament damage is suspected in causing hearing issues.
“Many patients are not satisfied with their doctor’s answer when they complain about tinnitus.”
“Tinnitus: A Stepchild in Our Specialty.” October 2018, Otolaryngology-Head and Neck Surgery: official journal of American Academy of Otolaryngology-Head and Neck Surgery. (1)
If you are reading this article you are likely not satisfied with your doctor’s answers to the problem of your tinnitus. There are many causes of tinnitus or “ringing in the ears,” as we will see below. There are many treatments to help manage tinnitus, but there are no validated treatments that will cure tinnitus. If you are reading this article you have likely tried many sound therapies, behavioral therapies, drug therapies, and coping therapies to help you manage through your day.
“The full experience of living with tinnitus from a patient’s perspective has been under-investigated.”
Here is another statement you may be in full agreement with:
“The full experience of living with tinnitus from a patient’s perspective has been under investigated”
This is from a new May/June 2019 study in the journal Ear and hearing. (2) Here we find Canadian researchers from the University of Montreal and the University of Ottawa suggesting that Tinnitus is a challenge that needs to be addressed on an individual basis. They point to these observations:
- The impact of tinnitus on sleep, concentration abilities, social activities, and mood may vary greatly from one individual to another, with some being severely affected and others only experiencing a slight handicap. WHY?
- The researchers suggest that the full experience of living with tinnitus from a patient’s perspective has been under-investigated. The answers may lie in something hidden.
The answers may lie in something hidden
In this article, we are going to make a case for something hidden, the “untreatment,” or “lack of treatment,” of cervical neck instability as a cause of tinnitus in some people. We will present the evidence for Prolotherapy injections as a treatment for cervical neck instability and a treatment for a symptom of cervical neck instability, tinnitus.
- The focus on this article is that for many sufferers, tinnitus is a mechanical disorder of the cervical spine as borne out by TMJ-TMD involvement and new research below on a migraine trigger called “Clocking Tinnitus.”
Results in this patient may not be typical. Not all patients benefit from treatment.
Throughout our website, we have demonstrated that problems of the head and neck, including sensory issues of sight and sound, are more than an isolated problem of a single diagnosis. TMJ needs to be treated with a focus on cervical neck instability. Cervical neck instability needs to be treated as a problem of itself and the cause of a vast myriad of symptoms including TMJ and Tinnitus, among others.
The patients that we see in our clinics, maybe just like yourself, have been on long journeys looking for help for their problems. They often spend a lot of time on trial and error medications and treatments looking for that correct combination that will provide relief.
The United States National Library of Medicine has a web page dedicated to Tinnitus.(MedlinePlus)
On this page, is listed common causes of tinnitus. This list is as follows:
- Tinnitus often accompanies hearing loss in older people
- Tinnitus can be triggered by loud noises
- Tinnitus can be triggered by ear and sinus infections
- Tinnitus can be triggered by heart disease or blood vessel problems
- Meniere’s disease causes Tinnitus
- Brain tumors can cause Tinnitus
- Tinnitus can be triggered by hormonal changes in women
- Tinnitus can be triggered by thyroid problems
- Tinnitus can be triggered by certain medicines
What is missing on this list is what we are going to cover in this article? Tinnitus can be triggered by cervical neck instability
Tinnitus can be triggered by cervical neck instability, TMJ-TMD can be triggered by cervical neck instability. The evidence for a missing diagnosis and treatment.
Tinnitus can be caused by temporomandibular disorders. Temporomandibular disorders can be caused by cervical neck instability. Shouldn’t we then explore the source? Cervical neck instability?
Listen to this research, published in January 2019, it comes from medical university doctors in Sweden, published in the Journal of Oral Rehabilitation.(3) In this study, the doctors evaluated the prevalence of tinnitus in patients with temporomandibular disorders and the possible effects of TMJ/TMD treatment on tinnitus symptoms.
Here is what they discovered: “The finding that tinnitus is more common in patients with TMD means that it can be regarded as a comorbidity to TMD. However, in view of the lack of evidence currently available, further well-designed and randomised studies with control groups are needed to investigate whether possible mechanisms common to tinnitus and TMD do exist and whether TMD treatment can be justified to try to alleviate tinnitus in patients with TMD and comorbidity of tinnitus.”
- Listen again: The study says there is a connection between temporomandibular disorders and tinnitus. The researchers cannot make a definitive connection because available research on treatment does not allow them to suggest a treatment that would appear to be beneficial to BOTH problems.
- Something is missing in this puzzle. In our opinion at Caring Medical, it is a diagnosis of cervical instability.
The missing diagnosis of cervical instability appears to have influenced supportive findings that were also published in print January 2019. This study comes from from medical university doctors in Spain, and also published in the Journal of Oral Rehabilitation.(4) After reviewing the medical literature that spanned from 1992 to 2018, this research team was able to demonstrate that the prevalence of tinnitus in TMD patients is significantly higher than that in patients without TMD.
- So there is a connection between temporomandibular disorders and tinnitus, but there seems to be a missing link.
- Something is missing in this puzzle. In our opinion at Caring Medical, it is a diagnosis of cervical instability.
Doctors find “something is missing,” in a tinnitus examination. It is a look at the neck
In December 2018, Israeli doctors summed up a big problem in tinnitus examinations in one simple sentence. In their study published in the The journal of international advanced otology, (5) this is what they said:
- “Physicians routinely perform an otoscopic examination, whereas other relevant possible physical findings, such as temporomandibular joint disorders or neck trauma, are less frequently examined.”
For many people with tinnitus, a simple look in the ear for ear wax buildup or infection can be an effective way to handle problems of tinnitus by handling the problems of ear wax and ear infection. But what about persistent tinnitus? How many times can we look inside a patient’s ear looking for an answer that may not be in the ear?
Doctors do look at the neck, but what they may be looking for is a neck mass or a neck tumor, an obvious anatomical deformity which may lead them towards neurological disorders. But what if there is an anatomical deformity that is not so obvious? Cervical neck ligament damage that causes hypermobility in the cervical spine and pressure on the nerves that run through the vertebrae and the nearby circulatory system into the neck and head?
In 2014, Dr Kenneth Yew wrote a comprehensive paper on the many causes of tinnitus and how to examine for them. The paper appeared in the journal American Family Physician.(6)
As our article focuses on cervical neck instability, we will focus on the musculoskeletal examination portion of Dr. Yew’s paper.
Physical Examination Findings for Evaluating Tinnitus
- Examination observation: Change in perception of tinnitus during teeth grinding, side-to-side or resisted head twisting
- What does this mean? Diminished or enhanced tinnitus perception with these maneuvers suggests a somatosensory component. That is pressure, pain, or influence on the somatosensory system.
- Examination observation: Neck tenderness or limited range of motion, Temporomandibular joint tenderness, pain, or crepitus with motion, Tenderness of mastication muscles
- What does this mean? Tenderness in these areas may suggest a somatosensory component and need for dental or otolaryngology referral.
- OUR COMMENT: this denotes an anatomical problem. The recommendation to a dentist could implicate TMJ – TMD, the recommendation to otolaryngology referral or an ENT surgeon could suggest that the doctor should be looking for tumor or derangement. Below we will discuss a non-surgical application if a tumor is ruled out.
Clocking tinnitus and anti-migraine treatment: Tinnitus triggered by Migraine
In February 2019, researchers wrote in the Clinical neurology and neurosurgery (7) of tinnitus being a symptom or manifestation of migraine headache. The treatment option they offered was an anti-migraine treatments to alleviate the audible ringing. Here is a brief review of the research.
- The researchers agree that tinnitus is no longer thought of as only an otologic disorder. Current evidence supports it as a phantom sensory phenomenon of vestibulocochlear damage with cortical reorganization. (Pressure on the vestibulocochlear nerve is causing the problem).
- It is a common problem worldwide, but the treatment response is always unsatisfactory.
Ten patients in this study were examined who described a “ticking sound” of a “pendulum or quartz clock (or termed clocking tinnitus)”.
- Clocking tinnitus was experienced in one side in three patients
- Both sides in one patient
- and at midline in another six patients.
- It usually subsided within 15 min.
Neither patient experienced vertigo, hemifacial spasm, focal neurological deficit or otic disorder in association with tinnitus. Pre-existing migraine was present in seven patients.
- During tinnitus attack, a few migraine symptoms concurrently occurred in six patients.
CONCLUSION: Clocking tinnitus may be an audiology manifestation of migraine in some individuals. Anti-migraine treatment can be considered in this specific group of staccato tinnitus.
So what is happening here: The researchers believed that a migraine caused the ticking sounds of the tinnitus.
The interconnection between tinnitus and other symptoms and manifestations again shows that these problems are not problems in isolation but problems that can be traced, in many patients, to problems of cervical instability.
Prolotherapy injections and Cervical Realignment Therapy for cervical neck instability and a possible answer for tinnitus
As we stated above, tinnitus can be caused by many physical challenges. We will not suggest that every incidence of tinnitus can be treated by addressing chronic neck pain and chronic neck instability. The purpose of this article was to offer a “missing diagnosis” for people who have had extended medical care and seemingly no answers. We are trying to help people who are on medications and other cope management techniques by looking at something they may not have had explored, an examination of the stability of their cervical spine.
Research on cervical instability and Prolotherapy
Caring Medical Regenerative Medicine Clinics have published dozens of papers on Prolotherapy injections as a treatment in difficult to treat musculoskeletal disorders. We are going to refer to two of these studies as they relate to cervical instability and a myriad of related symptoms including the problem of tinnitus. It should be pointed out that we suggest in our research that “Additional randomized clinical trials and more research into its (Prolotherapy) use will be needed to verify its potential to reverse ligament laxity and correct the attendant cervical instability.” Our research documents our experience with our patients.
In 2014, we published a comprehensive review of the problems related to weakened damaged cervical neck ligaments in The Open Orthopaedics Journal.(8) We are honored that this research has been used in at least 6 other medical research papers by different authors exploring our treatments and findings and cited, according to Google Scholar, in more than 40 articles.
What we demonstrated in this study is that the cervical neck ligaments are the main stabilizing structures of the cervical facet joints in the cervical spine and have been implicated as a major source of chronic neck pain. Chronic neck pain often reflects a state of instability in the cervical spine and is a symptom common to a number of conditions, including disc herniation, cervical spondylosis, whiplash injury and whiplash associated disorder, post-concussion syndrome, vertebrobasilar insufficiency, and Barré-Liéou syndrome.
In the upper cervical spine (C0-C2), this can cause a number of other symptoms including, but not limited to:
- nerve irritation and vertebrobasilar insufficiency with associated:
- facial pain,
- and migraine headaches.
We often see patients with all these symptoms, yet they do not have a coordinated effort to address them all.
We often see patients with all these symptoms, yet they do not have a coordinated effort to address them all. They may be getting medications for all of these problems, they may be getting physical therapy or other treatments to help them cope with these issues but rarely do they get a unified treatment to address them all. We suggest that Prolotherapy injections to strengthen the cervical ligaments gets at the root cause of these disorders at the cervical level. We are treating the cause not the symptoms.
As we documented in this research, There is considerable overlap in chronic symptomology between atlanto-axial instability, whiplash associated disorder, post-concussion syndrome, vertebrobasilar insufficiency, and Barré-Liéou syndrome. Possibly because they all appear to be due to cervical instability.
To date, there is no consensus on the diagnosis of cervical spine instability or on traditional treatments that relieve chronic neck pain. In such cases, patients often seek out alternative treatments for pain and symptom relief. Prolotherapy is one such treatment which is intended for acute and chronic musculoskeletal injuries, including those causing chronic neck pain related to underlying joint instability and ligament laxity.
Prolotherapy is referred to as a regenerative injection technique (RIT) because it is based on the premise that the regenerative/reparative healing process can rebuild and repair damaged soft tissue structures.
In 2015 we followed up this research with our study, “Cervical Instability as a Cause of Barré-Liéou Syndrome and Definitive Treatment with Prolotherapy: A Case Series”, published in the European Journal of Preventive Medicine.(9)
Again here we are making a connection to cervical neck instability and a myriad of problems that includes, for many patients, tinnitus. We wrote:
“Barré-Liéou syndrome, or posterior cervical sympathetic syndrome, has symptomatology related to underlying cervical instability. While classified as a rare disease, Barré-Liéou syndrome is likely underdiagnosed. Vertebral instability, occurring after neck ligament injury, affects the function of cervical sympathetic ganglia (located anterior to vertebral bodies). Symptomatology includes neck pain, migraines/headache, vertigo, tinnitus, dizziness, visual/auditory disturbances, and other symptoms of the head/neck region.”
The video below presents the treatment:
Prolotherapy can be of benefit for many people. It will not benefit every patient.
If you have questions about Tinnitus, you can get help and information from our Caring Medical Staff
1 Lee KJ, Liu K. Tinnitus: A Stepchild in Our Specialty. Otolaryngology–Head and Neck Surgery. 2018 Oct;159(4):599-600. [Google Scholar]
2 Colagrosso EM, Fournier P, Fitzpatrick EM, Hébert S. A Qualitative Study on Factors Modulating Tinnitus Experience. Ear and hearing. 2018 Jul. [Google Scholar]
3 Skog C, Fjellner J, Ekberg E, Häggman‐Henrikson B. Tinnitus as a comorbidity to temporomandibular disorders—A systematic review. Journal of oral rehabilitation. 2018 Aug 20. [Google Scholar]
4 Mottaghi A, Menéndez‐Díaz I, Cobo JL, González‐Serrano J, Cobo T. Is there a higher prevalence of tinnitus in patients with temporomandibular disorders? A systematic review and meta‐analysis. Journal of oral rehabilitation. 2018 Aug 20. [Google Scholar]
5 Tamir SO, Marom T, Shushan S, Goldfarb A, Cinamon U, Handzel O, Gluck O, Oron Y. Tinnitus Perspectives among Israeli Ear, Nose and Throat Physicians: A Nationwide Survey. The journal of international advanced otology. 2018 Dec 12. [Google Scholar]
6 Yew KS. Diagnostic approach to patients with tinnitus. American family physician. 2014 Jan 15;89(2). [Google Scholar]
7 Steilen D, Hauser R, Woldin B, Sawyer S. Chronic neck pain: making the connection between capsular ligament laxity and cervical instability. The open orthopaedics journal. 2014;8:326. [Google Scholar]
8 Chen WH, Hsu YL, Chen YS, Yin HL. Clocking tinnitus: An audiology symptom of migraine. Clinical neurology and neurosurgery. 2019 Feb 1;177:73-6. [Google Scholar]
9 Hauser RA, Steilen D, Sprague IS. Cervical Instability as a Cause of Barré-Liéou Syndrome and Definitive Treatment with Prolotherapy: A Case Series. European Journal of Preventive Medicine. 2015;3(5):155-66. [Google Scholar]