- Department of Ear Nose and Throat/Head and Neck Surgery, Maastricht University Medical Center, P. Debyelaan 25, 6229 HX Maastricht, The Netherlands
- Department of Neurosurgery, Maastricht University Medical Center, P. Debyelaan 25, 6229 HX Maastricht, The Netherlands
Gusta van Zwieten
Department of Ear Nose and Throat/Head and Neck Surgery, Maastricht University Medical Center, P. Debyelaan 25, 6229 HX Maastricht, The Netherlands
DOI:10.4103/2152-7806.176134Copyright: © 2016 Surgical Neurology International This is an open access article distributed under the terms of the Creative Commons Attribution-NonCommercial-ShareAlike 3.0 License, which allows others to remix, tweak, and build upon the work non-commercially, as long as the author is credited and the new creations are licensed under the identical terms.
How to cite this article: Zwieten Gv, Smit JV, Jahanshahi A, Temel Y, Stokroos RJ. Tinnitus: Is there a place for brain stimulation?. Surg Neurol Int 10-Feb-2016;7:
How to cite this URL: Zwieten Gv, Smit JV, Jahanshahi A, Temel Y, Stokroos RJ. Tinnitus: Is there a place for brain stimulation?. Surg Neurol Int 10-Feb-2016;7:. Available from: http://surgicalneurologyint.com/surgicalint_articles/tinnitus-is-there-a-place-for-brain-stimulation/
Tinnitus is the perception of a “phantom sound” and has a high prevalence. Although many therapies have been investigated within the last decades, there is still no effective standard therapy. Animal studies and human functional imaging studies revealed that tinnitus perception is associated with many complex changes in multiple brain structures. There is growing evidence that brain stimulation might be able to interrupt the local altered neuronal activity and hereby inhibit tinnitus perception. In this editorial review, an update is given on the most promising targets for brain stimulation. Promising structures for stimulation are the dorsal cochlear nucleus, the inferior colliculus and the medial geniculate body of the thalamus. For cortical stimulation, the auditory cortex is considered as a target. Nevertheless, the field is waiting for evidence from well-designed clinical trials, based on supporting evidence from experimental/mechanistic research, to support or discourage the application of brain stimulation in tinnitus.
Keywords: Deep brain stimulation, electric stimulation, neuromodulation, tinnitus, treatment
Currently, up to 15% of the general population suffers chronically from the perception of a “phantom sound”, also known as tinnitus.[
Animal studies and human functional imaging studies revealed that tinnitus perception is associated with many complex changes in several different brain structures. The generally accepted hypothesis is that neuronal changes occur in both auditory and nonauditory brain structures, most often as a compensating mechanism on reduced input from the auditory nerve caused by cochlear hair cell damage, which is associated with hearing loss. These central neuronal changes include an increase in spontaneous firing rate, synchronized activity, bursting activity, and tonotopic reorganization.[
Complex interactions within and between auditory and nonauditory brain structures are present in tinnitus. Every change in neuronal activity causes a cascade of changes in direct and indirect connected brain areas. An important role of the limbic system has been implied, as studies have shown that attention and emotions can influence tinnitus perception.[
Multiple targets can be proposed in which DBS might have an advantageous effect on tinnitus perception, as shown in
A schematic representation of a sagittal view of a human brain showing possible targets for brain stimulation to treat tinnitus. Auditory structures include the dorsal cochlear nucleus, inferior colliculus, medial geniculate body of the thalamus, and auditory cortex. Nonauditory structures are the nucleus accumbens, locus of caudate neurons (area LC), and ventral intermediate nucleus of the thalamus
Coincidental findings in patients with movement disorders who were treated with DBS, taught us that stimulation of nonauditory targets can attenuate tinnitus. Stimulation of the ventral intermediate nucleus of the thalamus (VIM) in Parkinson's disease patients who also suffered from tinnitus improved tinnitus in three out of seven patients.[
Other neuromodulation-based approaches have also been suggested. In this respect, modulating the activity of relevant cortical structures has been performed. Transcranial magnetic stimulation (TMS) is a noninvasive technique in which strong magnetic field impulses can alter neuronal activity not only in cortical but also in areas connected to the cortex. Repetitive TMS can induce residual inhibition and suppress tinnitus loudness temporarily.[
Besides DBS and cortical neuromodulation approaches, some other concepts have been described. Intracochlear stimulation via cochlear implantation is a viable treatment option in patients with tinnitus and unilateral of bilateral severe or profound hearing loss.[
In conclusion, developments in the field of neuromodulation are promising for patients with severe tinnitus. Several types of neuromodulation-based approaches are being investigated. The general mechanism of action is that neuromodulation interferes with pathological neuronal activity and thereby can attenuate distress or perception of tinnitus. In this respect, increased neuronal activity is found in the DCN, IC, MGB, and auditory cortex. These regions are, therefore, potential targets for brain stimulation. It is impossible to reach these regions selectively and precisely with noninvasive stimulation methods. When surgery is considered, then the MGB is a more accessible target. Furthermore, the MGB is an important relay station where the auditory and limbic structures interact. Tinnitus perception can be influenced by superficial stimulation techniques, which attenuate abnormal auditory cortex activity. Up to date, only a subgroup of tinnitus patients responded to auditory cortex stimulation. From the nonauditory structures, stimulation of the VIM, caudate nucleus (area LC), and NAc have potential to interfere with tinnitus. Using a bottom-up approach with cochlear stimulation or TENS of somatosensory inputs of the DCN, tinnitus percept can be modified in some cases.
Although much is happening at the moment, the field is waiting for evidence from well-designed clinical trials, based on supporting evidence from experimental/mechanistic research, to support or discourage the application of brain stimulation in tinnitus.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
The authors wish to thank Geertjan van Zonneveld for the three-dimensional reconstruction of the potential brain stimulation targets for tinnitus.
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