Tinnitus, cervical spine instability, and neck pain
Ross Hauser, MD
People with tinnitus can find benefit in many treatments. In this article, we will suggest one aspect of tinnitus treatment, the connection of tinnitus symptoms to cervical neck instability and treatments that strengthen the cervical spine neck ligaments. Repairing cervical spine neck ligaments can lead to an alleviation of tinnitus symptoms. Tinnitus can be a very complex condition to treat. Not all cases of tinnitus are caused by cervical neck ligament damage. In this article, however, we will discuss when cervical neck ligament damage is suspected as the cause of hearing issues and as a possible reason why you have been unresponsive to other treatments.
Tinnitus is a symptom of cervical spine instability
One person’s story:
I had three ear tests and went to a well known hearing specialists. The doctor looked in my ears and said ears are healthy. Reviewed hearing tests and said I didn’t need hearing aids. He was a very nice doctor, but no help. I would like to be rid of or have tinnitus ringing sound.
It is very likely that if you are reading this page, you or a loved one have been struggling with tinnitus or “ringing in the ears.” You have been subjected to multiple testings, have researched the condition extensively, have had more people look into your ears than you can count. You have had all sorts of treatments, sound therapies, behavioral therapies, drug therapies, and coping therapies to help you manage your day. There are many treatments to help manage tinnitus, but there are no validated treatments that will cure tinnitus.
Many people that reach out to our offices say they are confused and scared because there does not seem to be a direction that they can go to have this problem taken care of. This is why they are reaching out, we are presenting a different option.
Tinnitus is my primary concern
As you will see in this article, tinnitus as it is related to cervical spine instability and connected to neck pain can be one of many symptoms. For some people tinnitus may get lost among this myriad. For others however the tinnitus is the primary concern. For these people tinnitus has expanded into something more. Typically they have these tinnitis / neck instability related symptoms:
- Tinnitus is only in one ear
- They have numbness in the face on that side.
- Touching their face can produce a twitching or “nervous reaction” that worsens the tinnitus symptoms
- They have post-stroke like symptoms that makes a full smile difficult or they have a droopy eye-lid.
- When they eat, their up and down jaw movement creates a louder / softer fluctuation of the ringing in their ear.
- Mouth closing and jaw positioning is used to lower the ringing sensation.
Tinnitus is part of many problems and treatments that did not help
I have been to several specialists. The ENTs say that tinnitus is not treatable. The chiropractor and the acupuncturist thought they could “fix” it but neither did anything useful.
My dentist is certain my tinnitus is from my night teeth grinding and that a night guard will cure me. It did not.
Ross Hauser, MD discusses the neurology behind why many people with cervical instability complain of tinnitus.
Explanatory notes and supportive research are below.
About half of the patients that I see have tinnitus or ringing in the ears. There are many different types and designations of tinnitus. Some tinnitus is the high pitch type, some are the low pitch type, some are pulsatile, they have a beat. Then there is the humming type. I am going to explain in this video and the notes below, the neurology of tinnitus.
There are many different ways that cervical instability causes tinnitus. The most common way that cervical neck instability causes tinnitus or ringing in the ears is because it disrupts eustachian tube function or if it causes compression of the carotid sheath or carotid artery. Then you get a pulsatile tinnitus, a rhythmic beating that corresponds to the heart beat.
What are we seeing in this image? The most common ways cervical instability causes tinnitus
This image is described below.
There are many types of tinnitus. There is:
- Head pressure tinnitus
- Venous hum tinnitus. Venous hum tinnitus is a Pulsatile tinnitus.
The fact that Venous hum tinnitus treatment remains elusive is attested to in this description published 40 years ago in 1983 in the journal Laryngoscope (1). “Sounds arising from abnormalities of or abnormal communications between blood vessels in the neck or cranial cavity may result in objective tinnitus. It is audible to patient and examiner alike. Contrary to the usual subjective tinnitus of non-vascular origin (subjective tinnitus are sounds heard only by the patient), it is low pitched and pulsatile (there is a beat, like a heart beat) in character. That tinnitus which arises from and within the internal jugular vein is particularly important, as it may be loud enough to interfere with sleep, and result in some loss of hearing. Diagnosis is important as it can be cured by simple ligation of the internal jugular vein.”
Ligation of the jugular is a procedure that ties the jugular vein in a way to prevent pooling of blockage of the blood exiting the brain. What this research above suggests is that Venous hum tinnitus is a drainage problem of blood out of the brain that in many cases allows the patient and health care provider hear the patients heart beat coming from the ear. I have an extensive article on the compression of the internal jugular vein and how it may be treated conservatively without stenting of other surgical interventions. Please see Symptoms and conditions of cervical spine compression causing internal jugular vein stenosis.
- Pulsatile tinnitus
- Ear fullness tinnitus
- Sensory tinnitus
These different types of tinnitus can be caused by:
- Increased intracranial pressure
- Internal jugular vein compression
- Carotid artery compression
- Vestibular neuritis
- Blocked cerebrospinal fluid
- Eustachian tube dysfunction
- Please see my companion article: Neck pain Chronic Sinusitis and Eustachian Tube Dysfunction
- Vestibular nerve swelling
- Vestibulocochlear nerve injury
- Meniere’s disease.
- Please see my related article: Meniere’s Disease and Chronic cerebrospinal venous insufficiency
Researchers from the University of Antwerp published findings in the Interactive journal of medical research (2) investigated the presence of physical symptoms in a large group of participants with tinnitus and if these physical symptoms are more frequently present in a subgroup of participants with somatosensory tinnitus (neck and TMJ pain).
Here are the learning points of this research:
Many patients indicate that the perception (severity of symptoms) of their tinnitus is not constant and can vary from moment to moment. This tinnitus fluctuation is one of the diagnostic criteria for somatosensory tinnitus, a tinnitus subtype that is influenced by cervical spine or temporomandibular dysfunctions, although various factors have been reported to cause fluctuations in tinnitus, such as stress, anxiety, and physical activity.
The aim of this study was twofold: (1) to investigate the presence of physical symptoms in a large group of participants with tinnitus and (2) to investigate if these physical symptoms are more frequently present in a subgroup of participants with somatosensory tinnitus (neck and TMJ pain).
- In total, 6115 participants average age 54, physical symptoms were frequently present:
- 4221 participants (69.02%) reported some form of neck pain,
- 429 (7.01%) were diagnosed with temporomandibular disorders,
- 2730 (44.64%) indicated they have bruxism, and
- between 858 and 1419 (14.03%-23.20%) participants were able to modulate their tinnitus by voluntary movements.
- Somatosensory tinnitus was diagnosed in 154 out of 1262 (12.20%) participants whose tinnitus cause was diagnosed by a physician.
- Symptoms referring to the known diagnostic criteria were evidently more present in the somatosensory tinnitus group than in the non-somatosensory tinnitus group. Additionally, participants with somatosensory tinnitus more often indicated a negative effect of a bad night’s sleep and light intensity exercise.
Conclusions: Physical activity and movement (disorders) frequently affect tinnitus severity. Head-neck related symptoms are more frequently reported in the somatosensory tinnitus group, as is the ability to modulate the tinnitus by head or jaw movements. Additionally, participants with somatosensory tinnitus more often report fluctuations of their tinnitus and reaction to sleeping difficulties and low intensity exercise.
“Treating cervical spine disorders can result in a reduction of tinnitus.”
The idea that treating cervical spine instability as a method of treating tinnitus, is an idea that we, as well as many researchers and clinicians, have had for a long time. Yet recent research still has to present this idea as “novel” or new. Henk M Koning, MD, Ph.D., whose research is presented in this article published a paper in The International Tinnitus Journal (3) in November 2020 where he stated at the very onset “Treating cervical spine disorders can result in a reduction of tinnitus.”
Here are the summary learning points:
- The object of the study was to determine the benefit of (painkiller injection) therapy of the third and fourth cervical nerves in reducing tinnitus
- There were 37 tinnitus patients who were treated with injection into the third and fourth cervical nerves
- In a group of tinnitus patients, 19% of the patients reported less tinnitus after therapy of the third and fourth cervical nerves. Most of the patients had a moderate reduction of 25% to 50%.
- At 3.8 months, 50% of the successfully treated patients still had a positive effect. No adverse events of the procedure were observed.
Conclusions: “Treating cervical spine disorders can reduce tinnitus.”
Dr. Koning’s further research is presented throughout this article.
“Many patients are not satisfied with their doctor’s answer when they complain about tinnitus.”
As mentioned, treating cervical spine disorders is typically not the first line of treatment for tinnitus. Extensive hearing tests are. This is why a portion of tinnitus sufferers may find fault with their treatment programs. It is probably of little comfort to know that you are not alone in thinking this way, but you may take solace in that doctors are trying to figure out how to help you. Unfortunately, if you are reading this article you are likely not satisfied with your doctor’s answers to the problem of your tinnitus.
In October 2018, researchers at Hofstra, Yale, and Columbia Universities published a paper titled: ‘”Tinnitus: A Stepchild in Our Specialty.”(4)
They wrote: “Many patients are not satisfied with their doctor’s answer when they complain about tinnitus,” and called for a new classification system to be used to communicate with patients as well as guide future research.
- Type A itemizes the treatable causes of tinnitus.
- Type B itemizes tinnitus with a lack of medical explanation.
- Type C tinnitus is caused by diagnosable and treatable conditions, as listed in tinnitus type A, but the tinnitus persists after the successful treatment of the other symptoms.
The patient types we see are mostly from the B and C types.
- The patient has tinnitus and no one is sure why
- The patient has tinnitus, it was thought to be caused by something treatable, i.e, too much ear wax, hypertension, vascular disease, or medications that are causing tinnitus as a side-effect and the Tinnitus remains after the ear wax or hypertension was managed.
The Tinnitus Handicap Inventory survey, “Does your tinnitus make you angry?”
In January 2020, researchers (5) at the Institute of Physiology and Pathology of Hearing in Poland re-examined the Tinnitus Handicap Inventory (THI), this is a survey that many of you reading this article may have taken. It is, according to the researchers, “one of the world’s most commonly used tools to assess tinnitus severity.”
Using the questions of the inventory’s survey which included the sample below, to which most people would probably answer yes. The researchers sought to further divide the sufferers by gender, and those with normal hearing and those with hearing loss as responses from women differed significantly than men and those with normal hearing and those with hearing loss differed significantly. This would help guide decisions about appropriate intervention options or evaluate treatment outcomes.
- Does your tinnitus make you angry?
- Does your tinnitus make you feel confused?
- Because of your tinnitus, do you feel desperate?
- Do you feel as though you cannot escape your tinnitus?
- Because of your tinnitus, do you feel that you have a terrible disease?
- Does your tinnitus interfere with your job or household responsibilities?
- Does your tinnitus make you upset?
- Do you feel that your tinnitus problem has placed stress on your relationships with members of your family and friends?
“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. (6) 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.
Before we continue on with the research, here is a video from Dr. Ross Hauser that describes the patient conditions and what we look for in treatment possibilities.
In this video Ross Hauser, MD discusses general problems of ear pain, ear fullness, sound sensitivity, and hearing problems.
Here is a transcript summary:
- Dr. Hauser makes a connection between cervical spine/neck instability and cause problems related to the ear and hearing
- Many patients we see have ear pain, ear fullness, or sensitivity to sound.
- Some of these people have a long medical history that may include visits to the ENT and other specialists and doctors. Some may get a diagnosis of Meniere’s disease.
- In many of these patients, their problems of tinnitus, Meniere’s disease, dizziness, ear fullness, decreased hearing, or sensitivity to sound may be traced to problems of cervical spine/neck instability.
- Eustachian Tube Dysfunction
- The eustachian tube is the canal that connects the inner ear and the upper throat. It regulates the pressure within the inner ear.
- Eustachian Tube Dysfunction can occur when the muscles of the eustachian tube, the tensor veli palatini, the levator veli palatini, the salpingopharyngeus, and the tensor tympani, do not perform their job of opening and closing the tube. This can cause fluid build-up in one ear as opposed to the other. This can cause problems of inner ear fullness, ear pain, and loss of sense of balance. Cervical spine instability can cause muscle disruption.
- Case history at 1:44
- A recent patient had been given hearing aids and had used them for much of the last ten years
- After three Prolotherapy sessions (dextrose injections described below) the patient has significant hearing improvement.
- NOTE: The patient was treated for cervical spine instability, of which hearing problems were one symptom. This treatment can help improve hearing in many people, it does not improve hearing in every patient. A careful evaluation of each person is needed to give a realistic assessment of possible outcomes.
- At 2:23 Explaining cervical spine instability relationship to hearing dysfunction
- When there is cervical spine instability, the vagus nerve which controls levator veli palatini muscle, and the trigeminal nerve which controls the tensor veli palatini muscle, can be compressed causing dysfunction of these muscles. For many people, restoring cervical spine stability restores the proper function of these muscles and alleviates problems of Eustachian Tube Dysfunction.
- Of note, the tensor veli palatini helps dampen sound. If there is tensor veli palatini dysfunction, problems of sound sensitivity may occur.
In this next video, a patient discusses how she no longer required hearing aids. Again, this treatment can help improve hearing in many people, it does not improve hearing in every patient. A careful evaluation of each person is needed to give a realistic assessment of possible outcomes.
The answers to Tinnitus may lie in something hidden
In this article, we are going to make a case for something hidden, the “non-treatment,” 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 treatment for a symptom of cervical neck instability, tinnitus.
- The focus of 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.”
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)
The common causes of tinnitus:
- 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
I have extreme tinnitus, which gets better or worse when I rotate my neck. When I move my head from side to side, it gets better. When I move my head up and down it gets worse. Then my jaw hurts
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. (7) 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 randomized 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 in January 2019. This study comes from medical university doctors in Spain, and also published in the Journal of Oral Rehabilitation. (8) 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.
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.
- 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 Journal of International Advanced Otology, (9) 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 that may lead them towards neurological disorders. But what if there is an anatomical deformity that is not so obvious? Cervical neck ligament damage 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?
What are we seeing in this image?
In problems of tinnitus, we frequently see co-existing problems, some of which are detailed in this article. This includes migraine headaches, TMJ pain, ear fullness, hearing loss, and Meniere’s disease. One thing all these syndromes and diagnoses have in common is that their origins can be found in cervical spine instability caused by weakened and damaged neck ligaments.
In 2014, Dr. Kenneth Yew wrote a comprehensive paper on the many causes of tinnitus and how to examine them. The paper appeared in the journal American Family Physician. (10)
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.
Brain fog, breathing and swallowing difficulty, dizziness, tinnitus
Brad’s story will resonate with many of you. He will describe the same symptoms and combination of symptoms that many of our patients suffer with when they first see us.
Brad’s story is unique, it may not be typical of the patients we see. Brad with treated with Prolotherapy injections and neck curve correction techniques. Not everyone will achieve these results as the results of treatment will vary.
We specifically want to highlight his case because he has some unusual strange sensations in his ear and breathing difficulties because of his problem with his contracting diaphragm.
Patient symptom list:
- Ringing in the ears and a sensation in his ears of hot wax. He also reported it was as if spiders were crawling in his ears.
- Severe dizziness. The patient describes that he would be in a car and then out of nowhere he would get dizziness and it would feel like the car was flipping end over end.
- Brain fog
- Contracting diaphragm
- Patient’s description at 1:32: “I would just be sitting or standing there, doesn’t matter which, and all of a sudden I couldn’t breathe. Finally, I would take a big gasp of air, and finally, I would be able to breathe.
- Swallowing difficulties: The saliva in his mouth would build up and it was as if he was drowning. This would cause panic attacks.
- The patient also reported when he turned his head to the right, he would lose control of all his muscles and he would “drop.”
The patient had these symptoms for 3 – 4 months. It started with a fall of a ladder. Symptoms did not develop for months
- The patient fell off a ladder from a height of 12 feet. He hit a sink and his head snapped backed
- His symptoms started to develop four months after the fall
Because of the nature of his injury and ligament damage in his cervical spine, the patient underwent eight prolotherapy treatment sessions. Here is his description:
- After the eight sessions, the patient reports “almost everything is gone.” A slight ringing in the ears remains but is diminishing.
- The patient did not realize how bad his brain fog was. On his first visit, he had difficulty filling out paperwork. On his last visit he realized filling out the paperwork was “super easy.” It was then he realized the extent of his brain fog.
- The diaphragm problems went away after the 4th or 5th visit along with the swallowing difficulties.
Something at C2 – the Dorsal Root Ganglion
That researchers and clinicians are making a connection between what is happening in the cervical spine in tinnitus patients is expressed by a study concerning Pulsed Radiofrequency Treatment. This is a treatment that we do not use. We have been offering cervical spine therapies for almost three decades and based on our experiences and that of our patients, we have not found these treatments to be more effective than our current treatments of regenerative medicine injections. So let’s look at this research, it is not so much about the treatment but an observation of the C2 vertebrae.
Many of you may have already tried or are at least familiar with Pulsed Radiofrequency Treatment. An electrode is applied to the impacted nerves and electrical stimulation is offered. The hope is that the treatment will provide pain relief by altering the nerve’s currents and transmissions.
In this September 2019 study in The International Tinnitus Journal (11) researchers wrote:
“The second cervical nerve ganglion bar appears to be beneficial in patients with treatment safe tinnitus… The point of this investigation was to decide the adequacy of beat radiofrequency of C2 dorsal root ganglion for treating patients with tinnitus, and all the more explicitly, to survey the parameters related to a long haul advantage so as to improve understanding determination.
- Sixty-one back-to-back patients were treated with beat radiofrequency of C2 dorsal root ganglion.
- 25% of the patients had a decrease in their tinnitus after a beat radiofrequency of C2 dorsal root ganglion.
- At 13.5 months, half of at first effective treated patients still encountered an advantage.
- Pulsed radiofrequency of C2 dorsal root ganglion can lessen the power of tinnitus extensively and for the long haul in 25% of the patients with tinnitus without genuine antagonistic impacts. We prescribe this treatment in patients with an age under 43 years at the time tinnitus began.
To summarize, the clinicians in this study suggested that if you focus on C2 dorsal root ganglion, you can achieve good results (25% of patients) with beat radiofrequency.
“Therapy of C6 and C7 caused less tinnitus for 18% of the tinnitus patients.”
A January 2021 study in The International Tinnitus Journal (12) intended to estimate the outcome of (steroid injection) treatment of C6 and C7 to lessen tinnitus intensity and to find criteria for long-term success.
- In this study, 78 tinnitus patients were treated with (steroid injections) of the sixth and seventh cervical nerves.
- 18% of these patients had less tinnitus after the treatment of C6 and C7.
- The majority of the patients announced a moderate easing of their tinnitus.
- At two months and at five months, half of the patients with a positive response still had benefits.
- Conclusions: Treating afferent cervical nerves can lessen tinnitus. Therapy of C6 and C7 caused less tinnitus for 18% of the tinnitus patients. Especially patients with no hearing loss at 8 kHz and no disc degeneration at C4-C5.
In this study, the steroid was offered. Below we will demonstrate the benefits of dextrose Prolotherapy as an alternative.
Clocking tinnitus and anti-migraine treatment: Tinnitus triggered by Migraine
In February 2019, researchers wrote in the Clinical Neurology and Neurosurgery (13) of tinnitus being a symptom or manifestation of migraine headaches. The treatment option they offered was an anti-migraine treatment 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 the 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 on one side in three patients
- Both sides in one patient
- and at the 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 the tinnitus attack, a few migraine symptoms concurrently occurred in six patients.
CONCLUSION: Clocking tinnitus may be an audiology manifestation of migraines 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 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.
Tinnitus and the Trigeminal Nerve
A paper in the May 2020 issue of the Journal of Headache and Pain (14) suggested, as we have seen in many patients, that trigeminal neuralgia patients have a significantly increased risk of tinnitus within 1 year of trigeminal neuralgia diagnosis compared to those without the diagnosis. Trigeminal neuralgia centers on what is happening to the trigeminal nerve which carries pain, feeling, and sensation from the brain to the skin of the face. In the case of trigeminal neuralgia, most medical professionals cannot find the cause of why this pain started. This is borne out by the definition of trigeminal neuralgia. Trigeminal neuralgia means that there is nerve pain in the nerve distribution of the trigeminal nerve. It actually does not tell a person what is causing the condition.
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.
In the May 2020 study, the researchers added: “While tinnitus has been traditionally associated with otologic conditions such as noise-induced hearing loss, a growing body of evidence has shown that convergence of auditory and somatosensory pathways in the brain stem also plays an important role in the pathogenesis of tinnitus.” In our experience, impacts on the brain stem can be caused by cervical spine instability.
Pulsatile Tinnitus and Cervical Instability
Improving tinnitus with the treatment of the cervical spine and jaw
A case study published in the Journal of the American Academy of Audiology (15) wrote: “Musculature and joint pathologies of the head and neck are frequently associated with tinnitus and have been hypothesized to play a contributing role in its etiology.”
To demonstrate the role of muscles and cervical spine pathology, the doctors of this case study offered the case of a 42-yr-old male experiencing intermittent bilateral tinnitus, headaches, blurred vision, and neck tightness. His occupation required long-term positioning into neck protraction. The examination found limitations in cervical extension, bilateral rotation, and side bending. Asymmetry was also noted with temporomandibular joint (TMJ) movements. Upon initial evaluation, the patient demonstrated functional, physical, and emotional deficits per neck, headache, and dizziness self-report scales and a score on the Tinnitus Handicap Inventory (THI) of 62 (severe tinnitus). Resisted muscle contractions of the cervical spine in flexion, extension, and rotation increased his tinnitus.
- Treatment focused on normalizing cervical spine mobility through repetitive movements, joint mobilization, and soft tissue massage.
Results: “At 2.5 months, the patient demonstrated a complete reversal of his tinnitus after 10 physical therapy sessions as noted by his score of 0 on the Tinnitus Handicap Inventory upon discharge. He also demonstrated objective improvements in his cervical motion. This case reflected treatment targeted at cervical and TMJ impairments and notable improvements to tinnitus. Future studies should further explore the direct and indirect treatment of tinnitus by physical therapists through clinical trials.”
Exercise and postural correction of Cervicogenic somatic tinnitus
A May 2020 study in the Journal of Manual and Manipulative Therapy (16) examined a case of Cervicogenic somatic tinnitus in which symptoms are modulated by maneuvers of the neck. The evidence for effective diagnosis and treatment of Cervicogenic somatic tinnitus is limited.
- A 67-year-old female with a 5-year history of left-sided subjective tinnitus, neck pain, and headache was referred for physiotherapy. Outcome measures included the Visual Analogue Scale (VAS), Tinnitus Handicap Inventory (THI), and Neck Disability Index (NDI).
She was evaluated and treated according to Mechanical Diagnosis and Therapy principles with management consisting of individualized directional preference exercises and postural correction.
- Results: Significant improvements in symptoms, cervical range of motion, function, and psychosocial status were observed over the long term.
- At 6 months, Tinnitus Handicap Inventory scores dropped from 62 (severe)/100 to 18 (mild)/100 and NDI scores dropped from 18 (moderate)/50 to 3 (none)/50.
” It seems that the combination of tinnitus and postural instability begins as a cervical pain syndrome”
In January 2021, publishing in The International Tinnitus Journal, (17) Henk M Koning, MD, Ph.D., also noted that:
“In patients with tinnitus as the main complaint, 64% of the patients have also cervical pain, and in patients with cervical pain as the main complaint, 44% of the patients have tinnitus. Both groups of patients have in common a high prevalence of postural instability and dizziness, degeneration of the intervertebral disc between the fifth and seventh cervical vertebrae, and a large anterior spur in front of the fifth cervical vertebrae. Patients with cervical pain as the main complaint have more degeneration of the intervertebral disc between the third and fourth cervical vertebrae, a larger anterior spur in front of the third cervical vertebrae, and more loss of cervical lordosis.
Postural instability is an important discriminant factor in patients with cervical pain and in patients with tinnitus as the main complaint. In patients with cervical pain postural instability was associated with the occurrence of tinnitus. In patients with tinnitus, there is evidence for two profiles of somatic tinnitus, discriminated by the occurrence of postural instability and low-frequency hearing loss. It seems that the combination of tinnitus and postural instability begins as a cervical pain syndrome and that the tinnitus aggravates in time. . . “
Research on cervical instability and Prolotherapy. A mechanical approach to tinnitus
In the research above, a case is laid out for the treatment of cervical spine instability in patients with tinnitus. As pointed out, not every case of tinnitus can be attributed to tinnitus but it may be likely that more cases than are reported of tinnitus induced cervical spine instability exist. Certainly, at our center, we see many people with this connection because this is what we treat.
Above you read about cervical manipulation, physical therapy, and exercise programs for the treatment of tinnitus. In this section, I will explain our Prolotherapy program.
Medical research validating the use of Comprehensive Prolotherapy, from simple dextrose injections to stem cell prolotherapy injections is not new. There are decades years of research supporting the use of Prolotherapy for problems of the neck and head. (18)
Caring Medical has published dozens of papers on Prolotherapy injections as a treatment in difficult-to-treat musculoskeletal disorders. Prolotherapy is an injection technique utilizing simple sugar or dextrose. 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, (19) 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 (craniocervical 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.
Please see my article: Symptoms and conditions of Craniocervical Instability for a more comprehensive review and discussion of treatments.
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 strengthen the cervical ligaments get 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 atlantoaxial 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 that 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. (20)
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 a 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.”
What are we seeing in this image? How does cervical instability create symptoms of tinnitus?
Prolotherapy by addressing the cervical ligaments can help stabilizes the bones of the neck. Once stabilized they no longer are on the move or hypermobile.
If you look at the illustration below you will see where the Vagus nerve is closely related to the C1 – C2 – C3 vertebrae. While doctors usually discuss the vagus nerve in the singular sense, there are two vagus nerves, one on each side of the neck and in combination, they are referred to as the vagal nerves. This means that the degenerative damage in your neck can significantly impact the function of one or both vagus nerves.
Vagus nerve compression has been implicated in many problems. In our clinical and research observations, we have documented that Prolotherapy can offer answers for sufferers of cervical instability, as it treats the problem at its source. Prolotherapy to the various structures of the neck eliminates the instability and the sympathetic symptoms such as tinnitus and related disorders without many of the short-term and long-term risks of cervical fusion. We concluded that in many cases of chronic neck pain, the cause may be underlying joint instability and capsular ligament laxity. Furthermore, we contend that the use of comprehensive Prolotherapy appears to be an effective treatment for chronic neck pain and cervical instability, especially when due to ligament laxity. The technique is safe and relatively non-invasive as well as efficacious in relieving chronic neck pain and its associated symptoms.
What are we seeing in this image?
A Digital Motion X-Ray or DMX is a tool we use to help understand a patient’s neck instability and how we may be able to help the patients with our treatments. In the illustration below a patient who suffered from upper cervical instability demonstrated hypermobility of the C1-C2. This hypermobility can result in common symptoms of neck pain, headaches, dizziness, vertigo, tinnitus, concentration difficulties, anxiety, TMJ, and other symptoms.
The curvatures of the neck -What are we seeing in this image?
In our practice, we see problems of cervical spine instability caused by damaged or weakened cervical spine ligaments. With ligament weakness or laxity, the cervical vertebrae move out of place and progress into problems of chronic pain and neurological symptoms by distorting the natural curve of the spine. This illustration demonstrates the progression from Lordotic to Military to Kyphotic to “S” shape curve.
In this video, a demonstration of treatment is given
Prolotherapy is referred to as a regenerative injection technique (RIT) because it is based on the premise that the regenerative healing process can rebuild and repair damaged soft tissue structures. It is a simple injection treatment that addresses very complex issues.
This video jumps to 1:05 where the actual treatment begins.
This patient is having C1-C2 areas treated. Ross Hauser, MD, is giving the injections.
Summary and contact us. Can we help you? How do I know if I’m a good candidate?
We hope you found this article informative and it helped answer many of the questions you may have surrounding cervical spine instability and tinnitus. Just like you, we want to make sure you are a good fit for our clinic prior to accepting your case. While our mission is to help as many people with chronic pain as we can, sadly, we cannot accept all cases. We have a multi-step process so our team can really get to know you and your case to ensure that it sounds like you are a good fit for the unique testing and treatments that we offer here.
1 Chandler JR. Diagnosis and cure of venous hum tinnitus. The Laryngoscope. 1983 Jul;93(7):892-5. [Google Scholar]
2 Michiels S, Harrison S, Vesala M, Schlee W. The presence of physical symptoms in patients with tinnitus: international web-based survey. Interactive journal of medical research. 2019 Jul 30;8(3):e14519.
3 Koning HM. Upper Cervical Nerves Can Induce Tinnitus. The International Tinnitus Journal. 2020 May 12;24(1):26-30. [Google Scholar]
4 Lee KJ, Liu K. Tinnitus: A Stepchild in Our Specialty. Otolaryngology–Head and Neck Surgery. 2018 Oct;159(4):599-600. [Google Scholar]
5 Skarżyński PH, Rajchel JJ, Gos E, Dziendziel B, Kutyba J, Bieńkowska K, Świerniak W, Gocel M, Raj-Koziak D, Włodarczyk EA, Skarżyński H. A revised grading system for the Tinnitus Handicap Inventory based on a large clinical population. International journal of audiology. 2019 Oct 11:1-7.
6 Colagrosso EM, Fournier P, Fitzpatrick EM, Hébert S. A Qualitative Study on Factors Modulating Tinnitus Experience. Ear and hearing. 2018 Jul. [Google Scholar]
7 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]
8 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]
9 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]
10 Yew KS. Diagnostic approach to patients with tinnitus. American family physician. 2014 Jan 15;89(2). [Google Scholar]
11 Koning HM, Meulen BCT. Pulsed radiofrequency of C2 dorsal root ganglion in patients with tinnitus. Int Tinnitus J. 2019;23(2):91‐96. Published 2019 Sep 4. doi:10.5935/0946-5448.20190016 [Google Scholar]
12 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]
13 Cheng YF, Xirasagar S, Yang TH, Wu CS, Kao YW, Shia BC, Lin HC. Increased risk of tinnitus following a trigeminal neuralgia diagnosis: a one-year follow-up study. J Headache Pain. 2020 May 6;21(1):46. doi: 10.1186/s10194-020-01121-6. PMID: 32375642; PMCID: PMC7203585. [Google Scholar]
14 Cherian K, Cherian N, Cook C, Kaltenbach JA. Improving tinnitus with mechanical treatment of the cervical spine and jaw. Journal of the American Academy of Audiology. 2013 Jul 1;24(7):544-55. [Google Scholar]
15 Wu D, Ham D, Rosedale R. Physiotherapy assessment and treatment of chronic subjective tinnitus using mechanical diagnosis and therapy: a case report. Journal of Manual & Manipulative Therapy. 2020 Mar 14;28(2):119-26. [Google Scholar]
16 Koning HM. Proprioception: the missing link in the pathogenesis of tinnitus?. The International Tinnitus Journal. 2020 Dec 26;24(2):102-7. [Google Scholar]
17 GS, HACKETT, and HUANG TC. “Prolotherapy for headache. Pain in the head and neck, and neuritis.” Headache 2 (1962): 20-28. [Google Scholar]
18 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]
19 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]
This article was updated March 31, 2021