- School of Medicine, University of California at Irvine, Irvine, CA, USA
- Loyola Marymount University, Los Angeles, USA
- Department of Neurosurgery, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
- Department of Neurology, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
- Department of Radiation Oncology, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
Antonio A.F. De Salles
Department of Neurosurgery, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
Department of Radiation Oncology, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
DOI:10.4103/2152-7806.86834Copyright: © 2011 Soleymani T. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
How to cite this article: Soleymani T, Pieton D, Pezeshkian P, Miller P, Gorgulho AA, Pouratian N, De Salles AA. Surgical approaches to tinnitus treatment: A review and novel approaches. Surg Neurol Int 29-Oct-2011;2:154
How to cite this URL: Soleymani T, Pieton D, Pezeshkian P, Miller P, Gorgulho AA, Pouratian N, De Salles AA. Surgical approaches to tinnitus treatment: A review and novel approaches. Surg Neurol Int 29-Oct-2011;2:154. Available from: http://sni.wpengine.com/surgicalint_articles/surgical-approaches-to-tinnitus-treatment-a-review-and-novel-approaches/
Background:Tinnitus, a profoundly widespread auditory disorder, is characterized by the perception of sound in the absence of external stimulation. The aim of this work is to review the various surgical treatment options for tinnitus, targeting the various disruption sites along the auditory pathway, as well as to indicate novel neuromodulatory techniques as a mode of tinnitus control.
Methods:A comprehensive analysis was conducted on published clinical and basic neuroscience research examining the pathophysiology and treatment options of tinnitus.
Results:Stereotactic radiosurgery methods and microvascular decompressions are indicated for tinnitus caused by underlying pathologies such as vestibular schwannomas or neurovascular conflicts of the vestibulocochlear nerve at the level of the brainstem. However, subsequent hearing loss and secondary tinnitus may occur. In patients with subjective tinnitus and concomitant sensorineural hearing loss, cochlear implantation is indicated. Surgical ablation of the cochlea, vestibulocochlear nerve, or dorsal cochlear nucleus, though previously suggested in earlier literature as viable treatment options for tinnitus, has been shown to be ineffective and contraindicated. Recently, emerging research has shown the neuromodulatory capacity of the somatosensory system at the level of the trigeminal nerve on the auditory pathway through its inputs at various nuclei in the central auditory pathway.
Conclusion:Tinnitus remains to be a difficult disorder to treat despite the many surgical interventions aimed at eliminating the aberrant neuronal activity in the auditory system. A promising novel neuromodulatory approach using the trigeminal system to control such a bothersome and difficult-to-treat disorder deserves further investigation and controlled clinical trials.
Keywords: Cochlear implant, microvascular decompression, neuromodulation, stereotactic radiosurgery/stereotactic radiotherapy, Tinnitus, trigeminal nerve stimulation, trigeminal nerve
Definition and incidence
Tinnitus, commonly known as “ringing in the ear,” is an auditory disorder characterized by perception of internally generated “phantom auditory sensations” without the trigger of an external stimulus.[
Tinnitus can be divided into the following two categories: objective and subjective [
(A-H): Photomicrographs of rat mossy fibers showing mossy fibers from the spinal trigeminal nucleus are found restricted to the Granule Cell Domain (GCD). Tracings from the Spinal Trigeminal Nucleus projections to Ventral and Dorsal Cochlear Nuclei – Figure 2 illustrates the somatosensory inputs of the trigeminal nerve at the level of the Spinal Trigeminal Nucleus on the cochlear nuclei. This illustration shows the nuclei communication, offering the anatomical and physiological basis for stimulation of the trigeminal system as a possible therapeutic option for tinnitus. Each tick mark represents a trigeminal neuronal terminal ending
Currently, there exists a wide variety of surgical treatment modalities aimed at resolving the phantom auditory sensations that underlie tinnitus[
It is accepted that the onset of subjective tinnitus is preceded by damage to peripheral auditory systems (e.g., cochlear hair cells), which in turn sets the stage for neuronal hyperactivity and cortical replasticity.[
Tinnitus is a common symptom in patients with vestibular schwannomas, with an average incidence rate of 63% in symptomatic tumors.[
As previously alluded to, DCN hyperactivity is one of the hallmarks in the pathophysiology of subjective tinnitus.[
Microvascular compression of the vestibulocochlear nerve in the cerebellopontine angle has also been shown to be an underlying cause of tinnitus.[
In recent studies, patients with movement disorders and concomitant tinnitus who underwent Deep Brain Stimulation (DBS) reported a reduction in tinnitus loudness (amplitude) when stimulation was initiated.[
Additionally, extradural electrical stimulation of the auditory cortices with implanted electrodes in the primary and/or overlying the secondary auditory cortices has been shown to be successful in suppressing severe refractory tinnitus.[
These results suggest that DBS as well as extradural electrical stimulation of the auditory cortices can modulate tinnitus with reductive or suppressive effects, warranting further investigation as a potential surgical treatment option for patients suffering from severe tinnitus.
Electrical stimulation of the trigeminal nerve produces neuronal excitation in the VCN, and evokes a complex mixture of excitation and inhibition in the DCN.[
Tinnitus remains to be a difficult disorder to treat despite the many surgical interventions aimed at eliminating aberrant neuronal activity in the auditory system. Tinnitus caused by underlying pathologies such as vestibular schwannomas or neurovascular conflicts of the vestibulocochlear nerve at the level of the brainstem may be treated successfully through SRS methods and microvascular decompressions, respectively. Care must be taken to prevent hearing loss and subsequent refractory tinnitus as a result of damage to the cochlea and inner ear structures, explaining the mixed results of stereotactic radiation on tinnitus when treating acoustic neuromas.
For tinnitus whose pathophysiological etiology is preceded by noise-induced, drug-induced, or other forms of damage to peripheral auditory structures, surgical control remains more elusive. At present, the most accepted treatment modality for tinnitus is cochlear implants, which mask the patient's tinnitus, though on rare occasions, cochlear implantation itself may run the adverse risk of postoperative or secondary tinnitus development. Attempts to resolve tinnitus through surgical ablation of the cochlea, vestibulocochlear nerve, or DCN have been ineffective with potential worsening of tinnitus symptoms, likely due to further increased deafferentation-induced neuronal hyperactivity in central auditory pathways. Emerging research shows the ability to modulate neuronal output at various nuclei in the central auditory pathway through somatosensory stimulation at the level of the trigeminal nerve. This promising and noninvasive neuromodulatory approach using the trigeminal system to control such a bothersome and difficult-to-treat disorder deserves further investigation and controlled clinical trials.
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