“Tinnitus” is defined as the perception of sound without a corresponding external acoustic stimulus.  There is a difference between subjective tinnitus and objective tinnitus.
- Subjective (somatic) tinnitus is a hallucinatory phenomenon that can only be heard by the sufferer.
- Objective tinnitus can be described as a condition in which sounds are generated in the body and transmitted to the ear, eg, tinnitus. Spasm of the tensor tympani muscle.  Another person can hear the sound coming from the ear canal. 
Severe tinnitus is associated with depression, anxiety and insomnia. 
Clinically Relevant Anatomy
Neural connections between the somatosensory and auditory systems may be important in tinnitus. Anatomical and physiological evidence supports this claim. The trigeminal and dorsal root ganglia relay incoming somatosensory information from the periphery to secondary sensory neurons in the brain brainstem. These structures send excitatory projections to the cochlear nucleus. In addition, the cochlear nucleus innervates part of the ophthalmic and mandibular nuclei of the trigeminal nerve. Signals from the trigeminal nerve supply the auditory system in the cochlear nucleus superior and inferior olivary nuclei hill 
Patients with chronic tinnitus show changes in brain regions responsible for affect regulation (amygdala-hippocampus, etc.) and frontoparietal regions associated with attention regulation and conscious perception. 
Between 5% and 15% of the general population report tinnitus, which has a major negative impact on the quality of life of 1% of these specific tinnitus populations. 
Tinnitus is multifaceted and has multiple causes: Otology Neurometabolic Pharmacology Vascular Musculoskeletal and Psychological. 
Although tinnitus is often associated with hearing impairment, not all patients have hearing impairment.  Subjective tinnitus is a hallucinatory phenomenon. An example of auditory hallucinations is auditory hallucinations, especially in people with schizophrenia or after  Somatic (subjective) tinnitus is also associated with neck musculature and arthropathy (eg, facet joint disease ) and temporomandibular joint disease.  
Latifpour DH et al 2009 described the relationship between head and neck somatosensory disturbance/dysfunction and tinnitus. Exacerbated tinnitus can be caused by disturbances in the somatosensory systems of the upper neck and head. Head and upper neck dysfunction The area can cause tinnitus by activating the somatosensory system. Intense muscle contractions of the head and neck mediate tinnitus perception in 80% of tinnitus sufferers and induce sound perception in 50% of people without tinnitus. These somatic images are evenly distributed in the population People with or without cochlear disease. There was also a clear link between jaw disease, neck pain, headaches and tinnitus. There may also be a connection between nerve impulses from the back of the neck and the head via polysynaptic connections in the brainstem and cochlea. A The main finding of a 2006 study by Reisshauer et al. was that the overall range of motion of the cervical spine was impaired, which was due to several factors. These include dysfunction of the head segmental joints and cervicothoracic junction and imbalances of the shoulder and neck muscles Muscles (descendor of sternocleidomastoid trapezius levator and masseter of scapula) 
People with tinnitus hear noises without corresponding external acoustic stimuli. Tinnitus consists of various unorganized auditory impressions. Ear noises may be perceived as unilateral, bilateral, or cephalad. 
In objective tinnitus, the sound can be heard by another person. On the other hand, somatic tinnitus associated with head and neck disease, the sound is exclusively located in the ear ipsilateral to the physical dysfunction, no vestibular discomfort, and no abnormalities Regarding neurological examination.  In the case of subjective tinnitus, patients may experience auditory hallucinations and often involve the perception of organized forms of sound, such as music or speech.  It is also possible to distinguish between pulsatile and nonpulsatile tinnitus. Pulsatile tinnitus is synchronous Related to heartbeat, may be symptom of vascular malformation. Tinnitus may also manifest as widespread fluctuating tinnitus.  In this case, the noise in the ear can be adjusted by movement of the jaw or cervical spine. 
Flowchart Chronic tinnitus
In every case of tinnitus, the following features must be identified:
- Duration of tinnitus (acute vs chronic)
- Modulation of the tinnitus
- Concomitant symptoms, such as sleep disturbance and concentration problems
If the ear noise can be accommodated by jaw or cervical spine movement, physical therapy or a check-up by an orthopedic surgeon/orthodontist should be considered. In patients with unilateral tinnitus and significant tinnitus, magnetic resonance imaging is recommended to rule out vestibular schwannoma Hearing left and right differences. Pulsating tinnitus synchronized with the heartbeat may be a symptom of a vascular malformation. These patients should be referred to a physician for neuroradiological examination. 
For patients with body-related tinnitus, it is advisable to check: 1) The range of motion of neck flexion and extension, lateral flexion, and left-right rotation, using an inclinometer to perform left-right rotation. Measurements are made in a sitting position and the best of the three is recorded. 2) Posture By using a kyphometer. Measurements are performed in a standing position. Thoracic kyphosis is measured from C7-T12 and lumbar lordosis is measured from T12-L5. 
In a 2006 study by Reisshauer et al, the examination protocol included global and segmental joint range of motion of the craniomandibular muscles of the first rib at the cervical cervicothoracic junction and the trigger point of the sternocleidomastoid muscle, the sternocleidomastoid descending part of muscle Levator and masseter muscles of the trapezius scapula. 
Table: Standardized examination protocol for the management of patients with tinnitus 
No pharmaceutical approach can yet be considered an established treatment option. Consequently, there are no drugs approved for the treatment of tinnitus, neither in Europe nor in the United States. Therefore, the indications for drug therapy are limited to the treatment of comorbidities, such as anxiety disorders Sleep disorders and depression.  Gritsenko et al. A 2014 case report of a 65-year-old man diagnosed with C2-C3 facet joint disease described successful treatment by applying a C2-C3 medical branch block combined with C2-C3 medial radiofrequency ablation branches. 
Physical Therapy Management
So far, 5 methods have been found to be effective in treating tinnitus.
Cervical Spine Movement and Muscle Contraction
Performing a series of repetitive cervical motions and neck muscle contractions has been shown to be successful in treating cervical tinnitus.  The exercise chosen should be aimed at restoring cervical mobility.  There is evidence that performing cervical exercises and Muscle contractions modulate tinnitus more often than produce or aggravate tinnitus.  Cherian K et al. who underwent a similar treatment found that the tinnitus was completely reversed after 25 months of exercise and noted a significant improvement in cervical spine movement.  Sanchez TG et al. It was also noted that the action of head and neck muscle contraction induced tinnitus modulation in a frequent and reliable manner after two months. Tinnitus exacerbations decreased and improvements increased, although day-to-day perceptions remained the same. 
Stretching Poses and Acupuncture
Stretching posture training and ear acupuncture also significantly reduced tinnitus up to 3 months after treatment. It is recommended to stretch tense muscles in the neck and shoulders like a m. Sternocleidomastoid m. Trapezius m. Levator scapula m. Suboccipital muscle  This method Based on somatosensory stimulation, it can be used as an alternative therapy.
TENS may also be effective when applied to the skin area near the ear or to the upper cervical nerve C2, but this depends on the patient.  Vanneste S. et al. A 4292% improvement in symptoms was found in 6 cases, with complete relief of symptoms, but only 179% of 42 cases responded to C2 ten
Finally Qigong has been shown to be an effective method of treating ear infections. No adverse effects have been reported with a significant improvement in somatic tinnitus severity and effects remain fairly stable for at least 3 months after the last session.
Cognitive behavioral therapy
Cognitive behavioral therapy (CBT) is the most well-established treatment option for chronic tinnitus. The primary goal of CBT in patients with tinnitus is to improve cognition and facilitate changes in maladaptive patterns of cognition and behavior.
- Further research could help the millions who suffer from ‘ringing in the ears’.
- Why Is There No Cure for Tinnitus?
- Multidisciplinary Tinnitus Research
Practical Diagnosis and Treatment of Cervicogenic Headache
- Kreuzer PM, Vielsmeier V, Langguth B. Chronic tinnitus: an interdisciplinary challenge. Dtsch Arztebl Int. 2013 Apr;110(16):278-84 (Level of evidence 2A)
- Gritsenko K, Caldwell W, Shaparin N, Vydyanathan A, Kosharskyy B. Resolution of long standing tinnitus following radiofrequency ablation of C2-C3 medial branches–a case report. Pain Physician. 2014 Jan-Feb;17(1):E95-8 (Level of evidence 3B)
- Biesinger E, Kipman U, Schätz S, Langguth B. Qigong for the treatment of tinnitus: a prospective randomized controlled study. J Psychosom Res. 2010 Sep;69(3):299-304 (Level of evidence 1B)
- Latifpour DH, Grenner J, Sjödahl C. The effect of a new treatment based on somatosensory stimulation in a group of patients with somatically related tinnitus. Int Tinnitus J. 2009;15(1):94-9 (Level of evidence 1B)
- Cherian K, Cherian N, Cook C, Kaltenbach JA. Improving tinnitus with mechanical treatment of the cervical spine and jaw, J Am Acad Audiol, 2013 Jul-Aug;24(7):544-55, (Level of evidence 3B)
- TMJ Anatomy, Physiopedia. [last accessed 11/2/2022]
- Reisshauer A, Mathiske-Schmidt K, Küchler I, Umland G, Klapp BF, Mazurek B. Functional disturbances of the cervical spine in tinnitus. HNO. 2006 Feb;54(2):125-31 (level of evidence 2C)
- Sanchez TG, da Silva Lima A, Brandão AL, Lorenzi MC, Bento RF. Somatic modulation of tinnitus: test reliability and results after repetitive muscle contraction training, Ann Otol Rhinol Laryngol, 2007 Jan;116(1):30-5, (level of evidence 1B)
- Sanchez TG, Guerra GC, Lorenzi MC, Brandão AL, Bento RF. The influence of voluntary muscle contractions upon the onset and modulation of tinnitus, Audiol Neurootol, 2002 Nov-Dec;7(6):370-5, (level of evidence 2B)
- Herraiz C, Toledano A, Diges I. Trans-electrical nerve stimulation (TENS) for somatic tinnitus. Prog Brain Res. 2007;166:389-94. (Level of evidence 1B)
- Vanneste S, Plazier M, Van de Heyning P, De Ridder D. Transcutaneous electrical nerve stimulation (TENS) of upper cervical nerve (C2) for the treatment of somatic tinnitus. Exp Brain Res. 2010 Jul;204(2):283-7. (Level of evidence 1B)