Tinnitus, cervical spine instability, and neck pain
Ross Hauser, MD, Caring Medical Florida
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 in 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
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 through 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.
Before we begin this article and research findings, if you would like to contact our medical team, please use our contact form page. We can help assess your candidacy for our treatments and answer your questions.
“Many patients are not satisfied with their doctor’s answer when they complain about tinnitus.”
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.”(1)
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.
- Patient has tinnitus and no one is sure why
- 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 (2) 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. (3) 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 the 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 was 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 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.”
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 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.(4) 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 in January 2019. This study comes from medical university doctors in Spain, and also published in the Journal of Oral Rehabilitation.(5) 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, (6) 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?
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.(7)
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 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 is 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.”
Patient had these symptoms for 3 – 4 months. It started with a fall of of a ladder. Symptoms did not develop for months
- 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 at 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 (8) 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.
Clocking tinnitus and anti-migraine treatment: Tinnitus triggered by Migraine
In February 2019, researchers wrote in the Clinical Neurology and Neurosurgery (9) 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 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 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.
Tinnitus and the Trigeminal Nerve
A paper in the May 2020 issue of the Journal of Headache and Pain (10) 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.
Tinnitus and the Vagus Nerve
If you look at the illustration above you will see where the Vagus nerve is closely related to the C1 – C2 – C3 vertebrae. While doctors usually discuss the vagus nerve in 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 urinary problems 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.
Medical research validating the use of Comprehensive Prolotherapy, from simple dextrose injections to stem cell prolotherapy injections is not new. There is 55 years of research supporting the use of Prolotherapy for problems of the neck and head.(7)
Research on cervical instability and Prolotherapy
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,(11) 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.
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 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 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.(12)
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.”
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.
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 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.
3 Colagrosso EM, Fournier P, Fitzpatrick EM, Hébert S. A Qualitative Study on Factors Modulating Tinnitus Experience. Ear and hearing. 2018 Jul. [Google Scholar]
4 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]
5 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]
6 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]
7 Yew KS. Diagnostic approach to patients with tinnitus. American family physician. 2014 Jan 15;89(2). [Google Scholar]
8 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]
9 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]
10 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]
11 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]
12 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]