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Muscular Tension and Tinnitus MARJA ESTOLA-PARTANEN Muscular Tension and Tinnitus An Experimental Trial of Trigger Point Injections on Tinnitus University of Tampere Tampere 2000 ACADEMIC DISSERTATION University of Tampere, Medical School Tampere University Hospital, Department of Otorhinolaryngology Finland Supervised by Reviewed by Docent Tapani Rahko Professor Kalevi Jokinen University of Tampere University of Oulu Professor Ilmari Pyykkö Karolinska Institutet Distribution University of Tampere Tel. +358 3 215 6055 Sales Office Fax +358 3 215 7150 P. O. B o x 617 [email protected] 33101 Tampere http://granum.uta.fi Finland Cover design by Juha Siro Illustration Hannu Tapiovaara Printed dissertation Electronic dissertation Acta Universitatis Tamperensis 782 Acta Electronica Universitatis Tamperensis 75 ISBN 951-44-4965-7 ISBN 951-44-4972-X ISSN 1455-1616 ISSN 1456-954X http://acta.uta.fi Vammalan Kirjapaino Oy Vammala 2000 MARJA ESTOLA-PARTANEN Muscular Tension and Tinnitus An Experimental Trial of Trigger Point Injections on Tinnitus ACADEMIC DISSERTATION To be presented, with the permission of the Faculty of Medicine of the University of Tampere, for public discussion in the main auditorium of Building K, Medical School of the University of Tampere, Teiskontie 35, Tampere, on December 8th, 2000, at 12 o’clock. University of Tampere Tampere 2000 INDEX A. ABBREVIATIONS B. INTRODUCTION C. REVIEW OF LITERATURE 1. DEFINITION OF TINNITUS 2. CHARACTERIZATION OF TINNITUS 2.1. Characterization by patient description 2.2. Characterization with audiometer 2.2.1. Pitch 2.2.2. Loudness 2.2.3. Masking abilities 2.3. Characterization with VAS-scale 2.4. Inconvenience caused by tinnitus 2.5. Objective measurements of tinnitus 3. EPIDEMIOLOGY OF TINNITUS 3.1. Prevalence of tinnitus in population studies 3.2. Prevalence among children 3.3. Prevalence among aged 3.4. Factors affecting the prevalence of tinnitus 3.5. Site of tinnitus 3.6. Course of tinnitus 3.7. Tinnitus-related disorders 4. POSSIBLE ETIOLOGIES OF TINNITUS 4.1. General diseases 4.2. Ear diseases 4.3. Possible role of craniomandibular disorders 4.4. Cervical disorders 4.5. Drugs 5. AUDITORY PATHWAYS AND TINNITUS 5.1. Normal functions of the auditory pathways 5.1.1. Anatomical considerations 5.1.2. Neurotransmitters in the auditory pathways 5.2. Pathology in the auditory pathways and cochlea in tinnitus 5.2.1. The possible cochlear mechanisms 5.2.2. The OHC- efferent innervation theories 5 5.2.3. The neurotransmitter imbalance 5.2.4. Vascular compressions and central nervous system disorders 5.2.5. Extralemniscal theories 5.2.6. Spontaneous otoacoustic emissions (SOAEs) 5.3. Animal studies 6. TREATMENT OF TINNITUS 6.1. Examination and counselling 6.2. Drugs 6.2.1. Lidocain 6.2.2. Oral anticonvulsant drugs 6.2.3. Psychopharmacas 6.2.4. Other drugs 6.3. Masking 6.3.1. Hearing aids 6.3.2. Maskers 6.3.3. Comparing hearing aids to maskers 6.3.4. Cochlear implants 6.4.Treatment by stimulation 6.4.1. Transcutaneous nerve stimulation (TNS) 6.4.2. Other electrical stimulations 6.5. Relaxation 6.6. Acupuncture 6.7. Biofeedback 6.8. Hypnosis 6.9. Treatment of the external ear canal 6.10. Surgery 6.10.1. Middle ear surgery 6.10.2. Inner ear surgery 6.10.3. Surgery for vascular abnormalities and central nervous system disorders 7. TRIGGER POINTS 7.1. The character of trigger points 7.2. The prevalence of trigger points 7.3. The pathogenesis of trigger points 7.4. Fibromyalgia and myofascial pain syndrome 7.5. The laboratory findings of the trigger points 7.5.1. Blood tests 7.5.2. Biopsies 7.5.3. Electromyographic studies 7.6. The supposed neural connections of the trigger points 7.7. Treatment of trigger points 7.8. Tinnitus and trigger points 6 D. THE AIM OF THE STUDY E. MATERIAL AND METHODS 1. TIME OF THE RESEARCH AND THE SELECTION OF THE GROUP 2. THE PARTICIPANTS OF THE STUDY 3. THE CHARACTER OF THE GROUPS 3.1.Age 3.2 Diseases 3.2.1. General diseases and operations 3.2.2. Degenerative and traumatic disorders 3.2.3. Ear diseases 3.3. Working history 3.4. General medication and tinnitus treatments 3.5. Status 4. THE EXAMINATION SCHEDULE 4.1. Medical examination 4.2. Tinnitus measurements 4.2.1. The measurement technique 4.2.2. The number of tinnitus measurements 4.2.3. The classification of the measurements 5. THE TREATMENT SCHEDULE 5.1. The undertaking of the treatment 5.2. The series of treatments 6. THE STATISTICS F. RESULTS 1. TINNITUS HISTORY 1.1. Duration of tinnitus 1.2. The site of tinnitus and the number of sounds 1.3. Description of tinnitus sounds 1.4. The tinnitus sounds listed according to loudness 1.5. The behavior of tinnitus 1.5.1. Natural changes 1.5.2. The influence of head position 1.5.3. The influence of stress 1.5.4. The temperature changes 1.6. Drugs and tinnitus 1.7. The potential etiology of tinnitus 1.7.1.Ear disorders 1.7.2. General disorder 1.7.3. Local disorders 7 2. TINNITUS RELATED ANNOYANCE 2.1. Subjective hypacusis 2.2. Headache 2.3. Vertigo 2.4. Sensations of the ear (pressure and fullness) 2.5. Distortions of hearing 3. THE MUSCULAR STATUS 3.1. The neck muscles 3.2. The shoulder muscles 3.3. The scapular muscles 4. HEARING MEASUREMENTS 5. TINNITUS MEASUREMENTS 5.1. Audiometrically 5.2. VAS-scale 6.THE EFFECT ON TINNITUS DURING THE TREATMENT PERIOD 6.1. The subjective effects 6.1.1. The subjective effect of the treatment on the feeling of tinnitus 6.1.2. The effect of the treatment on the character of tinnitus 6.1.3. The effect of the treatment on the site of tinnitus 6.2. The objective measurements of tinnitus during the treatment period 6.2.1. The changes in loudness 6.2.2. The changes in frequency 6.3. The time interval between the treatment and result 6.4.The duration of the tinnitus changes 6.5. The characters of reappearing tinnitus 7. THE RESULTS AFTER THE TREATMENT PERIOD 7.1. The results after the last treatment 7.1.1. The volume of changes 7.1.2. The comparisons of tinnitus changes among the treated and control groups 7.2. The results 6 months after the end of the treatment period 7.2.1. The overall rating of the change of the tinnitus sounds 7.2.2. The duration of the tinnitus change 8. THE RESULTS FOR THE TINNITUS-RELATED DISORDERS 9. COMPLICATIONS OF THE THERAPY 10.THE COMPARISONS BETWEEN RESPONDERS, NON-RESPONDERS AND CONTROLS 10.1. The division into groups 10.2. The age and sex distribution of the groups 10.3. The comparison of ear diseases and hearing disorders between the groups 10.4. The duration and type of noisy work in the groups 10.5. The comparison of the tinnitus character between the groups 10.5.1. The description of tinnitus 10.5.2. The site of tinnitus 10.6 The natural behavior of tinnitus 10.6.1. The natural fluctuations 8 10.6.2. The reactions to stress and to head and body movements 10.7. The measurements of tinnitus 10.8. The earlier treatments of tinnitus 10.9. The comparison of status between the groups 10.9.1.The ORL- status and audiometric measurements 10.9.2. The muscular status 10.10. The objective loudness changes of tinnitus after the last treatment 10.11. The results after 6 months 10.11.1. The percentage of tinnitus free periods 10.11.2. The subjective judgement about tinnitus 10.12. Tinnitus-related disorders 11. OTHER CONSIDERATIONS BASED ON THE RESULTS 11.1. The side of tinnitus compared to the muscular status 11.2. The most important correlations with good results G. DISCUSSION 1. COMPARISON OF THE PATIENTS IN THE PRESENT STUDY TO OTHER STUDIES 1.1. Age 1.2. Other diseases 1.3. Hearing and ear diseases 2. COMPARISONS OF TINNITUS MEASUREMENTS AND CHARACTER 2.1. Tinnitus presentation in the present study 2.2. The duration of tinnitus 2.3. The site of tinnitus 2.4. The pitch of tinnitus 2.4.1. The description of the sound 2.4.2. The measured pitch frequency 2.4.3 The measured loudness of tinnitus 2.5. The fluctuations of tinnitus 2.5.1. The character of fluctuations 2.5.2. The factors causing fluctuations 3. OTHER TREATMENTS IN THE STUDY GROUP 4. THE SUBJECTIVE POTENTIAL ETIOLOGY OF TINNITUS 5. TINNITUS-RELATED DISORDERS 6. TREATMENT 9 7. RESULTS 7.1. The effect on tinnitus 7.2. Why the effect is not from lidocain alone 7.3. The results for other disorders 8. PSYCHOLOGICAL ASPECTS IN TREATING TINNITUS 9. THE CONNECTION OF TINNITUS AND MUSCULAR TENSION 10. THEORETICAL EXPLANATION MODEL OF THE TREATMENT H. SUMMARY AND CONCLUSIONS 10 A. LIST OF ABBREVIATIONS ABI = Auditory Brainstem Implant ABR = Auditory Brainstem Response ADP = Adenosine-Di-Phosphate AICA = Anterior Inferior Cerebellar Artery AMPA = α-Amino-3-Hydroxy-5-Methyl-4-Isoxazone-Proprionic Acid ATP = Adenosine-Tri-Phosphate AVCN = Antero-Ventral Cochlear Nucleus BAEP = Brainstem Auditory Evoked Responses BERA = Brainstem Evoked Response Audiometry BIH = Benign Intracranial Hypertension BSER = Brainstem Evoked Responses CAP = Compoud Action Potentials CBF = Cochlear Blood Flow CGRP = Calcitonin Gene-Related Peptide CEOAE = Click Evoked Otoacoustic Emissions CMD = Craniomandibular Disorders CN = Cochlear Nucleus CNS = Central Nervous System CNV = Contingent Negative Variation CT = Computer Tomography DCN = Dorsal Cochlear Nucleus 2DG = 2-Deoxyglucose DPOAE = Distortion-Product Otoacoustic Emissions EMG = Electromyography ENG = Electroneuronography ENT = Ear, Nose and Throat GABA = Gamma Amino Butyric Acid HL = Hearing Level IC = Inferior Colliculus IHC = Inner Hair Cells LSO = Lateral Superior Olive MGB = Medial Geniculate Body MML = Minimum Masking Level MOC = Medial Olive-Cochlear MRI = Magnetic Resonance Imaging MSN = Medullary Somatosensory Nuclei MSO = Medial Superior Olive MVEP =
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