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## Meet the editor

Dr. Tang-Chuan Wang is an excellent otolaryngologist—head and neck surgeon from Taiwan. He is also a research scholar at Harvard Medical School and University of Iowa hospitals. During his Fulbright experience, he worked in Hospital of the University of Pennsylvania, Boston Children's Hospital and Massachusetts Eye and Ear. Besides his great efforts in clinical and basic medicine, he is also branching out into public health

in Taiwan. In recent years, he has been devoted to innovation. He always says that "in theoretical or practical aspects, no innovation is a step backward." Due to his contribution to biomedical engineering, he was invited into executive committee of HIWIN-CMU Joint R & D Center in Taiwan.

Contents

**Section 1**

Disciplines

**Section 2**

*by Ayo Osisanya*

**Section 3**

**Section 4**

**Section 5**

*by Ismail Aytaç*

*by Tang-Chuan Wang and Yi-Chien Ho*

Temporomandibular Joint Disorders and Tinnitus

Herbal Medicine in the Management of Tinnitus

*Ali Bagherihagh and Elnaz Ahmadzadeh*

**Preface III**

Introduction **1**

**Chapter 1 3**

A Perspective of Sound Therapies for Elderly Patients with Hypertension **7**

**Chapter 2 9**

A Perspective of Temporomandibular Joint Therapies **27**

**Chapter 3 29**

A Perspective of Herbal Therapies **43**

**Chapter 4 45**

A Perspective of Complementary and Alternative Therapies **55**

**Chapter 5 57**

Introductory Chapter: Management of Tinnitus - The Views of Various

Audiological Tinnitus Management: An Essential Audiological Protocol for Elderly Patients with Comorbidity of Hypertension and Tinnitus

*by Henrique F. Pauna, Maria S.A. Amaral and Miguel Â. Hyppolito*

*by Mohammad Hossein Khosravi, Masoumeh Saeedi, Jaleh Yousefi,*

Complementary and Alternative Treatments for Tinnitus

### Contents

Preface

Tinnitus ("ringing in the ears") is a serious health condition that can negatively affect a patient's quality of life. This book provides a multidisciplinary overview on the evaluation and management of this widespread and troubling disorder. Although at present there is no perfect way to cure tinnitus, some good, wellestablished methods can significantly reduce the burden of tinnitus. Importantly, the only way to success is to take in detailed knowledge of clinicians and researchers. This book incorporates updated developments as well as future perspectives in the ever-expanding field of tinnitus treatment. Because of its organization and its extensive subject index, this book can also serve as a reference for persons who are involved in this field, whether they are clinicians, researchers, or patients. Once we integrate the views of various disciplines and treatment options, we can step

Because there is currently no clinically proven one way to fully eliminate tinnitus for most chronic cases, the ideal treatment option often depends on the various factors of each patient. Therefore, successful management of tinnitus might combine multi-levels of treatment to lessen the burden of tinnitus. In this book, organized sections offer some perspectives from various treatment options, such as sound therapies, temporomandibular joint therapies, herbal therapies, and some alternative therapies. I hope this book helps readers expand the field of tinnitus

In the section on sound therapies for elderly patients with hypertension, Dr. Ayo Osisanya discusses the efficacy of audiological tinnitus management options considered essential in the rehabilitation of individuals with comorbidity of hypertension and tinnitus. He highlights the benefits of combined therapies and concludes with some useful recommendations for effective management of the comorbid conditions. In the section on temporomandibular joint (TMJ) therapies, Dr. Henrique F. Pauna et al. presents some TMJ therapies and provides studies that have shown benefits for treating tinnitus associated with temporomandibular disorders. He suggests that TMJ therapies should employ an interdisciplinary approach in

In the section on herbal therapies, Dr. Mohammad Hossein Khosravi et al. talk about current medicinal plants for the treatment of tinnitus; they think that today's world is going toward the use of medicinal plants, and herbal medicine is now finding its place in the market. In the section on complementary and alternative therapies, Dr. Aytaç İsmail will review the complementary and alternative treatments now being used for tinnitus. Through a holistic approach combined with medical know-how, patients can sometimes gain control over their problems, decreasing or even eliminating the effects of these problems. For that reason, the prevalence and acceptance of non-traditional approaches for tinnitus have increased among both

I appreciate all those who contributed to this book. Their efforts made possible the success of this academic work. I would like to thank Manuela Gabric and

forward to manage tinnitus well.

order to extend and maximize its effect.

patients and practitioners.

management.

## Preface

 Tinnitus ("ringing in the ears") is a serious health condition that can negatively affect a patient's quality of life. This book provides a multidisciplinary overview on the evaluation and management of this widespread and troubling disorder. Although at present there is no perfect way to cure tinnitus, some good, wellestablished methods can significantly reduce the burden of tinnitus. Importantly, the only way to success is to take in detailed knowledge of clinicians and researchers. This book incorporates updated developments as well as future perspectives in the ever-expanding field of tinnitus treatment. Because of its organization and its extensive subject index, this book can also serve as a reference for persons who are involved in this field, whether they are clinicians, researchers, or patients. Once we integrate the views of various disciplines and treatment options, we can step forward to manage tinnitus well.

Because there is currently no clinically proven one way to fully eliminate tinnitus for most chronic cases, the ideal treatment option often depends on the various factors of each patient. Therefore, successful management of tinnitus might combine multi-levels of treatment to lessen the burden of tinnitus. In this book, organized sections offer some perspectives from various treatment options, such as sound therapies, temporomandibular joint therapies, herbal therapies, and some alternative therapies. I hope this book helps readers expand the field of tinnitus management.

In the section on sound therapies for elderly patients with hypertension, Dr. Ayo Osisanya discusses the efficacy of audiological tinnitus management options considered essential in the rehabilitation of individuals with comorbidity of hypertension and tinnitus. He highlights the benefits of combined therapies and concludes with some useful recommendations for effective management of the comorbid conditions. In the section on temporomandibular joint (TMJ) therapies, Dr. Henrique F. Pauna et al. presents some TMJ therapies and provides studies that have shown benefits for treating tinnitus associated with temporomandibular disorders. He suggests that TMJ therapies should employ an interdisciplinary approach in order to extend and maximize its effect.

In the section on herbal therapies, Dr. Mohammad Hossein Khosravi et al. talk about current medicinal plants for the treatment of tinnitus; they think that today's world is going toward the use of medicinal plants, and herbal medicine is now finding its place in the market. In the section on complementary and alternative therapies, Dr. Aytaç İsmail will review the complementary and alternative treatments now being used for tinnitus. Through a holistic approach combined with medical know-how, patients can sometimes gain control over their problems, decreasing or even eliminating the effects of these problems. For that reason, the prevalence and acceptance of non-traditional approaches for tinnitus have increased among both patients and practitioners.

I appreciate all those who contributed to this book. Their efforts made possible the success of this academic work. I would like to thank Manuela Gabric and

Kristina Jurdana, the author service managers; Edita Umihanic, the publishing process manager; and Mirena Calmic, the commissioning editor, for their wonderful assistance. In addition, the technical editors were indispensable to the uniform format in this book. At last, I am forever grateful to the persons who raised me well, including my family, teachers, and colleagues.

#### **Tang-Chuan Wang (Vincent Wang)**

Chairman of Otolaryngology—Head and Neck Surgery, China Medical University, Hsinchu Hospital, Taiwan

> School of Medicine, China Medical University, Taiwan

Department of Public Health, China Medical University, Taiwan

Research Scholar of Harvard Medical School, USA

Research Scholar of University of Iowa Hospitals and Clinics, USA

> Fellow of the American College of Surgeons, USA

Member of American Academy of Otolaryngology—Head and Neck Surgery, USA

Section 1 Introduction

Chapter 1

circle.

2. What is tinnitus?

high risk of tinnitus.

3

it and enhance the quality of life.

3. Tinnitus treatment in proper

Introductory Chapter:

Tang-Chuan Wang and Yi-Chien Ho

1. Why do we need to value tinnitus?

Management of Tinnitus - The

Today, tinnitus has become more common in most modern world. In this case, we assume a huge number of people suffer from tinnitus and they desire to find solutions. Furthermore, suffering from tinnitus can be also related to psychological problem in social life. This means that when tinnitus is ringing for 24 hours a day, then people cannot have a standard quality of life, including sleeping. It also affects communication skills which indicate that tinnitus is usually associated with hearing loss, in a physiological way. However, some clinicians do not realize precisely how important the tinnitus is related with their patients' life and put their life in vicious

Tinnitus is a condition where individuals are conscious of a particular sound without outside stimulation. It has been shown that tinnitus is a prevalent issue and common in most societies. More than 40 million people in the United States have experienced tinnitus and are currently suffering from it [1]. Many people experience tinnitus, and it is not only related to aging or auditory pathway but also connected with some negative impacts. It can cause psychological and physical reactions which can reduce their quality of life. Today there are more and more researches suggesting that tinnitus may be connected to aging, auditory pathway, hearing loss, psychological issues, high blood pressure, and cardiovascular diseases. Furthermore, there have been a few cases where tinnitus started after being exposed to extremely loud sounds, which means that the noise exposure also has a

Besides, in most developed countries, tinnitus is more like a "civilized disease" due to people lifestyles being more and more stressful. Stress will affect psychological health with tinnitus becoming a symptom. This matters not only to elderly groups but also youths. Therefore, it is very important to address tinnitus so that people can understand how important the issue is, in order to reduce the impact of

Recently, the treatment can come in many forms, such as sound therapy, counseling, transcranial magnetic stimulation (TMS), transcranial direct current

Views of Various Disciplines

#### Chapter 1

### Introductory Chapter: Management of Tinnitus - The Views of Various Disciplines

Tang-Chuan Wang and Yi-Chien Ho

#### 1. Why do we need to value tinnitus?

Today, tinnitus has become more common in most modern world. In this case, we assume a huge number of people suffer from tinnitus and they desire to find solutions. Furthermore, suffering from tinnitus can be also related to psychological problem in social life. This means that when tinnitus is ringing for 24 hours a day, then people cannot have a standard quality of life, including sleeping. It also affects communication skills which indicate that tinnitus is usually associated with hearing loss, in a physiological way. However, some clinicians do not realize precisely how important the tinnitus is related with their patients' life and put their life in vicious circle.

#### 2. What is tinnitus?

Tinnitus is a condition where individuals are conscious of a particular sound without outside stimulation. It has been shown that tinnitus is a prevalent issue and common in most societies. More than 40 million people in the United States have experienced tinnitus and are currently suffering from it [1]. Many people experience tinnitus, and it is not only related to aging or auditory pathway but also connected with some negative impacts. It can cause psychological and physical reactions which can reduce their quality of life. Today there are more and more researches suggesting that tinnitus may be connected to aging, auditory pathway, hearing loss, psychological issues, high blood pressure, and cardiovascular diseases. Furthermore, there have been a few cases where tinnitus started after being exposed to extremely loud sounds, which means that the noise exposure also has a high risk of tinnitus.

Besides, in most developed countries, tinnitus is more like a "civilized disease" due to people lifestyles being more and more stressful. Stress will affect psychological health with tinnitus becoming a symptom. This matters not only to elderly groups but also youths. Therefore, it is very important to address tinnitus so that people can understand how important the issue is, in order to reduce the impact of it and enhance the quality of life.

#### 3. Tinnitus treatment in proper

Recently, the treatment can come in many forms, such as sound therapy, counseling, transcranial magnetic stimulation (TMS), transcranial direct current stimulation (tDCS) [2], temporomandibular disorder (TMD) treatment [5], acupuncture, herbal medicine, or other alternative treatments. This is why more and more data have revealed to achieve the aim, getting rid of tinnitus successfully. Typically, counseling and sound therapy can provide a significant reduction to the severity of tinnitus [3]. Those wishing to seek for this kind of treatments are suggested to have an appropriate examination and audiological evaluation before therapy. On the other hand, tinnitus is associated with hearing loss [4]. It is essential to deal with the hearing loss problem while processing the sound therapy.

Moreover, counseling plays a critical role in this process. Counseling will focus on both the psychological and physical impacts; it helps the therapist to comprehend different cases better. The purposes are: Firstly, to classify tinnitus into different groups. Secondly, to design a personal program to reduce the impact of tinnitus. Thirdly, to observe the patients' change, which may include patients' sleeping quality, social life, hearing loss level, diet preference, or exercise habit. Coincidentally, tinnitus can happen in various ways, and it is important to find the main reason first and to mark the effect to make a long-term plan to manage tinnitus. Bothersome tinnitus will cause a severe problem and reduce the quality of life if therapists could not identify it. We also believe that different treatments have their potential to be applied into the different groups of tinnitus patients. In general times, it is not possible to treat all tinnitus patients by only one way.

#### Author details

Tang-Chuan Wang1 \* and Yi-Chien Ho2

1 Department of Otolaryngology-Head and Neck Surgery, China Medical University Hsinchu Hospital, Taiwan

2 Department of Speech Language Pathology and Audiology, National Taipei University of Nursing and Health Sciences, Taiwan

\*Address all correspondence to<EMAIL_ADDRESS>
© 2019 The Author(s). Licensee IntechOpen. This chapteris distributed underthe terms oftheCreative Commons Attribution License (http://creativecommons.org/licenses/ by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Introductory Chapter: Management of Tinnitus - The Views of Various Disciplines DOI: http://dx.doi.org/10.5772/intechopen.87242

#### References

[1] Rauschecker JP, Leaver AM, Muhlau M. Tuning out the noise: Limbicauditory interactions in tinnitus. Neuron. 2010;66(6):819-826

[2] Wang TC et al. Effect of transcranial direct current stimulation in patients with tinnitus: A meta-analysis and systematic review. The Annals of Otology, Rhinology, and Laryngology. 2018;127(2):79-88

[3] Jastreboff PJ, Jastreboff MM. Tinnitus retraining therapy (TRT) as a method for treatment of tinnitus and hyperacusis patients. Journal of the American Academy of Audiology. 2000; 11(3):162-177

[4] Tan CM et al. Tinnitus and patterns of hearing loss. Journal of the Association for Research in Otolaryngology. 2013;14(2):275-282

[5] Lee CF, et al. Increased risk of tinnitus in patients with temporomandibular disorder: A retrospective population-based cohort study. European Archives of Oto-Rhino-Laryngology. 2016;273(1): 203-208

Section 2

A Perspective of Sound

Therapies for Elderly Patients

with Hypertension

7

Chapter 2

Ayo Osisanya

Abstract

condition.

9

1. Introduction

Audiological Tinnitus

Management: An Essential

Audiological Protocol for Elderly

Elderly population with comorbidity of hypertension and tinnitus is increasing across the world, and the dilemma in the management of such elderly patients across the neurology and audiology/otology clinics seems enormous due to the attendant effects of such health-related comorbid conditions and ageing. This has been observed to have negative effect on the general well-being of quite a number of the elderly patients identified with the comorbid health conditions. It has also increased the tinnitus severity and related psychosocial reactions of the elderly patients. Worse still, the situation causes undulating increase in the prevalence of the comorbid condition of advanced age both male and female irrespective of cultural differences. Due to the aforementioned, this chapter is written with the aim of highlighting the efficacy of audiological tinnitus management options considered essential in the rehabilitation of individuals with comorbidity of hypertension and tinnitus. The chapter also discusses the benefits of combined therapies in rehabilitating elderly patients with comorbidity of hypertension and tinnitus and concluded with some useful recommendations for effective management of the comorbid

Keywords: ageing, audiological rehabilitation, elderly, hypertension, tinnitus

The synchronous firing of auditory neurons, which always results in tinnitus, has been clinically observed to have a significant relationship with hypertension the age-related blood pressure (Bp) elevations as a consequence of changes in the arterial structure and physiological functions accompanying ageing. Although the rise in blood pressure (Bp) is not a normal part of ageing, it often occurs as a result of some underlying conditions such as lifestyle factors, diseases and abnormalities that can aggravate (high) blood pressure, leading to severe complications and increased risk of heart disease, stroke and death. Due to multifactorial relationship between hypertension and tinnitus, the incidence of the comorbid conditions in the elderly population is increasing across the globe, even with increased blood pressure

Patients with Comorbidity of

Hypertension and Tinnitus

#### Chapter 2

## Audiological Tinnitus Management: An Essential Audiological Protocol for Elderly Patients with Comorbidity of Hypertension and Tinnitus

Ayo Osisanya

### Abstract

Elderly population with comorbidity of hypertension and tinnitus is increasing across the world, and the dilemma in the management of such elderly patients across the neurology and audiology/otology clinics seems enormous due to the attendant effects of such health-related comorbid conditions and ageing. This has been observed to have negative effect on the general well-being of quite a number of the elderly patients identified with the comorbid health conditions. It has also increased the tinnitus severity and related psychosocial reactions of the elderly patients. Worse still, the situation causes undulating increase in the prevalence of the comorbid condition of advanced age both male and female irrespective of cultural differences. Due to the aforementioned, this chapter is written with the aim of highlighting the efficacy of audiological tinnitus management options considered essential in the rehabilitation of individuals with comorbidity of hypertension and tinnitus. The chapter also discusses the benefits of combined therapies in rehabilitating elderly patients with comorbidity of hypertension and tinnitus and concluded with some useful recommendations for effective management of the comorbid condition.

Keywords: ageing, audiological rehabilitation, elderly, hypertension, tinnitus

#### 1. Introduction

The synchronous firing of auditory neurons, which always results in tinnitus, has been clinically observed to have a significant relationship with hypertension the age-related blood pressure (Bp) elevations as a consequence of changes in the arterial structure and physiological functions accompanying ageing. Although the rise in blood pressure (Bp) is not a normal part of ageing, it often occurs as a result of some underlying conditions such as lifestyle factors, diseases and abnormalities that can aggravate (high) blood pressure, leading to severe complications and increased risk of heart disease, stroke and death. Due to multifactorial relationship between hypertension and tinnitus, the incidence of the comorbid conditions in the elderly population is increasing across the globe, even with increased blood pressure level as a consequence of damage to inner ear microcirculation, ototoxic effects of antihypertensive drugs and increased/constant perception of noise generated by the blood vessels. Hypertension is the major risk factor for cardiovascular morbidity and mortality in the elderly population [1]. Hypertension alters cognitive functions of motor and visual acuity as well as auditory performance in the elderly population. It also leads to vascular remoulding by narrowing the lumen and wall thickening. This may affect cerebral blood flow and also disturbs cerebral metabolism and structure. The negative effect of high Bp levels on intellectual performance can also be linked to alterations in the cerebral white matter [2].

Hypertension which is one of the most common clinical conditions affecting older people in this contemporary time accounts for the majority of health-related cases with evidence of increased systolic blood pressure due to advancing age. Thus, a positive association has been observed as regards to the relationship between hypertension and tinnitus. This promotes vascular changes, inner ear microcirculation and tinnitus as noticed. It in turn brings about cochlear microcirculation, resulting in hair cell damage and consequently tinnitus, a common pathophysiological scenario to many conditions such as arterial hypertension, dyslipidaemia, diabetes mellitus, smoking and caffeine abuse [3]. The association between hypertension (especially arterial type) and tinnitus is stronger in older patients and cannot be disassociated from the hearing loss, which is endemic among attendant tinnitus patients [4]. Also, the clinical and psychoacoustic characteristics of tinnitus in hypertensive and normotensive patients seem similar, as well as tinnitus-related distress [4]. The comorbidity and characteristics of the conditions in addition to advancing age can be attributed to the increased complications and attendant effects of the conditions on the elderly patients. This is evident in the galloping increase in the prevalence of elderly patients with comorbidity of hypertension and tinnitus attending neurology and audiology clinics in this contemporary time. Tinnitus has also been reported to be associated with the use of diuretics with low systolic blood pressure. Although the prevalence of tinnitus is observed higher in patients with uncontrolled Bp (≥140 ≥ 90 mmHg) than patients with adequate Bp control (<140/<90 mmHg) [5], the increased prevalence of tinnitus in elderly patients can be as a result of some factors such as hypertension, vascular disease, diabetes and autoimmune and degenerative disorders.

Age-dependent hypertension, with the prolongation of life expectancy, remains one of the major factors causing cardiovascular morbidity, mortality and pulsatile tinnitus. This always affects older people, with the prevalence of 60% among the elderly [5]. Therefore, blood pressure has been observed as an important risk factor in the development of cerebrovascular disease, congestive heart failure and coronary heart disease [6] which is the major cause of continuous ringing in the ear/ head of the elderly population. Often, the associated tinnitus, which is not generated by external stimulus, can be classified as auditory and para-auditory tinnitus. The former represents the majority of cases, and the latter is subdivided into muscular tinnitus somatosounds [3]. With the impact of high Bp and the immense amount of blood flowing in and out of the head, tinnitus becomes evident in the humans, causing hearing loss of different degrees and severity, depending on the severity of the blood pressure. This comorbid conditions always make the elderly to experience vascular abnormality, blurred vision, chest pain, reduced anxiety, irritability, reduced cognitive functions, reduced quality of life, depression, poor communication, fatigue, reduced social functions, mood swing, withdrawal syndrome, poor emotional state or health, regular hospital visit and continued use of antidepressants [7]. Therefore, comprehensive management strategy, involving audiological rehabilitation and blood pressure control mechanisms, might be holistically employed, for it will aid the reduction of hearing-loss-induced deficits of function, activity, participation, quality of life through a combination of sensory

management, perceptual training, counselling [8], as well as drug management, psychotherapy and physical exercises to regulate the blood pressure and its flow in and out of the brain.

#### 2. Tinnitus: meaning and effects on the elderly population

#### 2.1 Tinnitus: a health-related condition

Tinnitus is an observed condition in which people experience different kinds of auditory sensation without any external stimulation. Tinnitus, as a health-related condition, can be described as an evidence of perception of noise or ringing in the ear/head without external influence or generation (propagation) of sound signal(s). Tinnitus is regarded as the sensation of hearing kind(s) such as ringing, buzzing, hissing, chirping, whistling or other sounds without external sound signal; it is rather a symptom of underlying condition(s) such as age-related hearing loss, drugrelated conditions, high blood pressure, ear injury, evidence of accumulated ear wax, cardiovascular disorders or metabolic disorder and/or a circulatory system disorder [7].

Tinnitus is derived from the Latin word tinnire which means to ring, and as a condition it is being described as a conscious perception of an auditory sensation in the absence of a corresponding external stimulus. Tinnitus can be subjective, when the experience is of the individual alone, or less commonly, and it can be objective, when an observer can hear the tinnitus. The sensation is generally of an elementary nature as descriptions of hissing, sizzling and ringing are common, although, in some cases, more complex sounds such as voices or music are perceived [9].

Scientifically, tinnitus is regarded as a kind of sensation of sound in the absence of overt acoustic stimulation, and it can be classified according to whether the perceived noise has an identifiable source, for example myoclonic contractions of tensor tympani muscle [10]. Tinnitus is a deafferentation-induced phantom phenomenon characterised by abnormal cerebral synchrony and connectivity, as the reduced or absent afferent cochlear input causes a reorganisation of tonotopic cortical maps, where representations of those frequency regions neighbouring the deafferented part become expanded [11]. Also, tinnitus can be described as a constant ringing, buzzing noise or a high-frequency whistling sound affecting all age groups. Tinnitus may be present all the time, or it may be an occasional phenomenon. This deafferentation-induced phantom phenomenon may vary in pitch from low sound to a very high sequel, with attendant capacity towards interfering in one's ability to concentrate or perceive the actual (intended) sounds or messages.

Tinnitus has been identified as a common symptom associated with ageing health-related conditions. Tinnitus is a continuous ringing in the ear or head without any external corresponding sound signal, which features noise in one ear or both ears or in the middle of the head. At times, it is difficult to pinpoint the site of lesion, but it is a manifestation of malfunction in the processing of auditory signals involving perceptual and psychological components. It is the sensation of any sound perceived in the head or in the ears without an evident of external stimulus. Currently, there is no universal agreeable definition of tinnitus; but some definitions state that it is a phantom auditory sensation [12–14].

Tinnitus ranges from high pitch to low pitch with multiple tones or sounds without tonal quality, but it may be perceived as pulsed, intermittent or continuous noise. This debilitating condition may begin suddenly or gradually, as well as being sensed in one ear (or both ears) or in the head. This health-related condition has been observed to affect 10–33% of the aged population, and it is mostly associated with some psychosocial and health conditions such as anxiety, irritation,

annoyance, concentration and insomnia, stroke, rhinosinusitis, diabetes, head injury, hypertension [15] and reduced quality of life [16]. Also, it has been observed that a number of health conditions are capable of causing or worsening tinnitus. The causes include inner ear cell damage, which always affect the random electrical impulses to the brain loading to tinnitus, chronic health conditions/injuries affecting the auditory nerves, exposure to loud noise, age-related hearing loss, head/neck injuries, auditory canal blockage, Meniere's disease, atherosclerosis, malfunction of capillaries (a kind of abnormal connections between arteries and veins) and hypertension as well as other related conditions that can increase blood pressure [7].

Tinnitus noise may be low pitched, mid pitched or high pitched; it may also be one or more components perceived by the patient. Therefore, diagnosis and treatment are majorly based on self-report. It is important to note that tinnitus is neither a disease nor an illness but a symptom to many treatable health conditions. At one time or the other, people may experience ringing in the ears as a result of the usage of certain drugs (antibiotics or aspirin) and/or being exposed to loud noise of 85 dB and above for 8 hours daily and without adequate ear protection and traumatic brain injury, as part of normal ageing process (presbycusis). It can also coexist with some ear problems such as impacted wax, inner ear abnormality, etc. Tinnitus is a prevalent problem and common in all groups, although in the past, it had been considered as a problem of youths, but now it has been discovered that it is more common among the aged [17]. It is estimated that tinnitus affects approximately 50 million people in the United States of America. A similar ratio has been reported in the United Kingdom [18]. In Nigeria, it is mostly associated with treatable health conditions such as otitis media, stroke, rhinosinusitis, diabetes, head injury and hypertension, which affect 10–33% of the population. The association between tinnitus with functional impairment and reduced quality of life highlights the need for its inclusion in any comprehensive medical programme for the elderly, but it cannot be overemphasised [15]. Therefore, people have to be educated on how to take care of their health to prevent any health hazard which can lead to tinnitus and to avoid suffering from ringing in the ear in their old age. People suffering from tinnitus go through tough time as a result of associated psychosocial [emotional and behavioural] problems which include severe headache, negative thoughts, dizziness, hearing problem, anxiety, irritation, annoyance, concentration problem, sleep difficulties, depression and poor attention focus [7]. Studies have shown that the quality of life is reduced in patients suffering from the aforementioned problems [16, 19]. Meanwhile, it is noteworthy that psychoacoustical characterisation of tinnitus cannot fully determine the level of discomfort evoked by this condition. Thus, it has been observed that a person suffering from tinnitus may not be aware of it and may not feel any discomfort occasioned by the affliction, while another person suffering from tinnitus is constantly aware of the difficulty in attention focus, falling asleep, and enjoying life; this is because tinnitus is perceived differently and allows the individual to react to it differently [20].

#### 2.2 Classifications and symptoms of tinnitus

Tinnitus can be classified into four different groups based on its nature and characteristics. Each of these classifications has different characteristics but with similar nature and symptoms. The four classifications would be discussed as follows:

i. Subjective tinnitus: This is a kind of tinnitus that can only be perceived or heard by the affected person. Scientifically, subjective tinnitus can be defined as an acoustic phantom phenomenon of a perception of sound in the absence of external-physical generated sound signal(s) [7], which is typically Audiological Tinnitus Management: An Essential Audiological Protocol for Elderly Patients… DOI: http://dx.doi.org/10.5772/intechopen.81854

initiated by damage to the peripheral hearing system leading to a sequence of structural and functional changes in the central hearing system [21, 22].

Subjective tinnitus is the most common type of tinnitus, and it always occurs as a result of exposure to excessive noise. Most of the times, this type of tinnitus appears and disappears suddenly and may last for a period of time before it disappears. There are two types of subjective tinnitus, which are:

This rhythmic tinnitus can be caused by several health conditions such as anaemia or an overactive thyroid gland making the blood to flow rapidly and loudly, hardening of the arteries (atherosclerosis), high blood pressure or irregular blood flow in the brain and around the ear leading to pressure or internal noise generation within the central nervous system. Apart from the common signs and symptoms of tinnitus, inflicted individuals with this type of tinnitus will manifest a health condition referred to as idiopathic intracranial hypertension.

#### 3. Hypertension: meaning and effects on the elderly

#### 3.1 What is hypertension?

Hypertension is a condition characterised as an abnormality of high blood pressure (HBp), with an evidence of exerted force by the blood against the walls of the blood vessels. Thus, hypertension as a health-related condition is referred to as high blood pressure that can lead to severe-to-profound complications and increased risk of coronary artery diseases, cardiovascular diseases, atherosclerosis and dementia [23]. This high blood pressure (Bp) has been observed affecting 25% of the world's population, and it is the largest single contributor to global mortality [24]. It has also been found to be a significant economic burden to public healthcare providers in most countries of the world, even with improved pharmacological and counselling treatment.

Hypertension is an age-dependent health-related condition, as it is common in people aged 65 and older, and a clinical diagnosis is established by demonstrating a systolic Bp of greater than or equal to 140 mmHg and/or diastolic Bp of greater than or equal to 90 mmHg on at least three different Bp measurements [24, 25]. Hypertension can be confirmed with a repeated blood pressure checkups, based on the manifestation of consistently high blood pressure with a force of the blood flowing against the walls of the blood vessels. At this junction, it is medically defined as a blood pressure higher than 130 over 80 millimetres of mercury (mmHg) [26]. Also, it has been determined by the volume of the blood the heart pumps and the amount of resistance to blood flow in the arteries. For instance, the more blood the heart pumps, the narrower the arteries, and then, the higher the blood pressure will be experienced. Therefore, the long the force of the blood exerted on the arteries, this will automatically lead to high blood pressure, which will eventually cause some health problems if the condition is not controlled early. Once the condition is not adequately controlled, it will lead to serious health challenges including heart attacks, stroke and a state of psychological stress. In determining blood pressure, two (2) numbers have been recorded which are the upper and lower numbers. The upper number is referred to as the systolic pressure that is the pressure exerted during the heartbeat, while the lower number is the diastolic pressure—a kind of pressure evident when the heart is relaxing after the heartbeats. This reading is important and encouraged to be taken repeatedly for appropriate decision and management. Hypertension is the major risk factor for some health-related conditions. Most of the times, it allows cognitive functions, motor and visual sensitivity and auditory performance of the elderly populations who experience the condition.

Hypertension has been observed to always aggravate pre-existent tinnitus through two principal mechanisms: damage to the cochlear microcirculation and to ototoxicity caused by diverse antihypertensive drugs, such as furosemide and betablockers, as an electron microscope study revealed that the primary site of cochlear involvements in patients with hypertensive is the stria vascularis, followed by the Corti organ [27]. It has also been observed that there is an increase of extracellular volume generally associated with high sodium retention in hypertension [28, 29]. The prevalence of hypertension and its related condition(s) is increasing. Thus, patients who experience tinnitus often report significant associated morbidities, hypertension, lifestyle detriment, emotional difficulties, sleep deprivation, work hindrance, interference with social interaction, depression, anxiety, insomnia and decreased overall health have been attributed to tinnitus, although causative relations are yet unknown. Patients with tinnitus can have risk of depression, anxiety, and insomnia [30].

#### 3.2 Types, symptoms and causes of hypertension

There are two major types of hypertension. These types will be discussed based on the observable symptoms and causes:

1. Primary hypertension: Primary hypertension is a kind of high blood pressure characterised by a pressure that is not associated with any identifiable

Audiological Tinnitus Management: An Essential Audiological Protocol for Elderly Patients… DOI: http://dx.doi.org/10.5772/intechopen.81854

pathological cause. It is the most common type of hypertension, as it accounts for about 95% of the hypertensive cases, and it is more common among the elderly [31]. This primary type of hypertension has non-universally established or agreed known cause(s) but is observed to occur as a result of various factors including obesity, stress, negative lifestyle and other negative psychosocialrelated factors and heredity. The observable symptoms include frequent experience and feeling of headaches, tiredness, dizziness and/or nose bleeds and insomnia.

2. Secondary hypertension: This is a kind of high blood pressure that is less common among the aged population. It accounts for about 5% of the hypertensive cases. Secondary hypertension is an abnormality in the arteries supplying blood to the kidney due to an elevation of blood pressure resulting from the underlying cause(s) such as cardiovascular disorder, uncontrolled primary hypertension, loss of elasticity in the arteries, airway obstruction during sleep, hormone abnormalities, tumour of the adrenal glands and drugrelated factors [31]. The symptoms of this secondary type of hypertension include very high blood pressure, systolic blood pressure that is over 180 millimetres of mercury (mmHg) or diastolic blood pressure over 120 mmHg, resistant hypertension, central obesity and palpitation.

Other minor types of hypertension are:

### 4. Effects of comorbidity of hypertension and tinnitus on elderly

#### 5. Signs and symptoms of comorbidity of hypertension and tinnitus

Audiological Tinnitus Management: An Essential Audiological Protocol for Elderly Patients… DOI: http://dx.doi.org/10.5772/intechopen.81854

#### 6. Audiological tinnitus management

#### 6.1 Different audiological tinnitus management (ATM) options for the elderly patients with comorbidity of hypertension and tinnitus

There are several audiological tinnitus management options available towards the rehabilitation of the elderly patients with comorbidity of hypertension and tinnitus. The different ATM options are discussed as follows:

i. Tinnitus retraining therapy (TRT)

Tinnitus retraining therapy is a form of habitual therapy designed to help people who are suffering from tinnitus. TRT is a kind of therapeutic mechanism which is used as a noise generator towards rehabilitating individuals with tinnitus by exposing them to a kind of background noise level towards reducing the negative effect of unwanted sound perception and to also overshadow the perception of the ringing in the ear/head.

Tinnitus retraining therapy is designed to alter the mechanism that transfers the signal from the auditory mechanisms to the limbic and autonomous nervous systems, thereby removing tinnitus-induced reactions [14, 32]. This TRT is a therapeutic mechanism, which always helps an individual with tinnitus to gradually ignore the sound and the associative effects of the tinnitus condition. TRT is used as habitual therapy to give hope to individuals with tinnitus as well as a mechanism of relief to those who are willing to be rehabilitated or adjusted with the condition [33]. Structurally, TRT is designed to help individuals with tinnitus to understand and learn how to stop thinking about the perceived ear/head noise.  It is a training or a process of learning how to cope with the perception of the negative sound consciously or subconsciously. As well, TRT is designed to achieve complete habituation of the noise (ringing) perceived in the ear/head practically done through:

#### ii. Tinnitus masking therapy (TMT)

Tinnitus masking therapy (TMT) is designed to promote the reduction of audibility of tinnitus by introducing another sound signal through an instrument known as tinnitus masker. The tinnitus masker is used to generate masking noise which can either be applied to the ipsilateral or contralateral ear. The tinnitus masker can also be placed on a bed side for a patient with tinnitus who is experiencing sleeping difficulty [34]. TMT is referred to as sound therapies designed to minimise the contrast between the tinnitus and the surrounding sound, thereby promoting a shift of the patient's focus away from the tinnitus, and to reduce the fatigue and stress occasioned by the tinnitus. TMT involves the use of several devices to produce masking sounds that will interfere with the ringing in the ear. It also means to offer an expected relief to the individuals with severe tinnitus and associated psychosocial reactions.

iii. Cognitive behavioural therapy (CBT)

Cognitive behavioural therapy is another type of audiological rehabilitative mechanism designed to minimise the negative thoughts flowing in the mind of an individual with tinnitus while at the same time changing the person's behaviour towards the tinnitus. CBT is a therapeutic measure to rehabilitate and reduce the effect of tinnitus and its attendant psychosocial reactions by reducing the distress caused by tinnitus. This audiological tinnitus management mechanism makes use of relaxation strategies, cognitive restructuring mechanism of thoughts, reasoning and modified situations to repattern the thoughts and feelings of an individual with tinnitus to acquire essential skills to respond positively to tinnitus and live welladjusted life, even with the tinnitus condition.

iv. Tinnitus desensitisation therapy (TDT)

Tinnitus desensitisation therapy is a kind of tinnitus therapeutic strategy to desensitise the abnormal processing of negative sound perceived. This is achieved by redirecting the attention (cognitive processing) of the individuals with tinnitus away from the tinnitus-induced signal and enabling the brain to naturally habituate the perceived tinnitus signal.

TDT makes use of directional (specific) counselling signal therapy and relaxation exercises to enable the natural habituation processing of the tinnitus-induced signal.

#### v. Biofeedback therapy

This is a kind of therapeutic programme structurally designed to rehabilitate individuals with pulse-synchronous tinnitus. Biofeedback therapy is a nondrugbased treatment employed to rehabilitate individual with stress and pain healthrelated conditions towards alleviating the negative feelings and psychosocial effects of the condition on such individual. Biofeedback therapy is designed to rehabilitate stress-induced health conditions through relaxation methods. The therapy is structured to help individuals with tinnitus to control his/her breathing system, heart rate and involuntary functions so as to reduce the effect of hypertension-related conditions. With this therapy, the elderly with comorbidity of hypertension and tinnitus will be remediated towards the control of all the bodily processes, such as heart rate, breathing system and blood pressure. Also, it will help to aid the rehabilitation reduction of elevated blood pressure, increased body temperature and disruption of brain functions through the promotion of mental and

#### Audiological Tinnitus Management: An Essential Audiological Protocol for Elderly Patients… DOI: http://dx.doi.org/10.5772/intechopen.81854

physical-functional activity to even cope with any occasioned stress due to combined effect of hypertension and tinnitus.

vi. Acoustic coordinated reset neuromodulation

The acoustic CR neuromodulation is a well-structured rehabilitative programme based on noninvasive desynchronising stimulation aimed at counteracting a neural synchrony in the individual with pulsatile subjective tinnitus. Acoustic coordinated reset neuromodulation is a kind of rehabilitative mechanism to bring about significant relief of tinnitus symptoms along with a significant decrease of pathological oscillatory activity in a network comprising auditory and nonauditory brain areas which is often accompanied with a significant tinnitus pitch change [34]. The acoustic coordinated reset neuromodulation is used as a therapeutic mechanism towards the reduction in neural synchrony which is considered as a cause of the decrease in the connectivity across the brain areas involved in the larger salience network [35–37]. In essence, this acoustic CR neuromodulation is an essential rehabilitative mechanism for the elderly patients with comorbidity of hypertensive and tinnitus.

#### vii. Sleep therapy

This is a kind of therapeutic programme which is structured to rehabilitate individuals with sleep disorder. In most cases, tinnitus patients always experience sleep disorder as a result of attendant effect of the health condition on their physical, mental and emotional functioning. The condition may lead to persistent disturbances, depression, anxiety, trauma and sleeplessness.

Sleep disorder often leads to cognitive changes, mental health conditions and daytime distress. As well, tinnitus patient with high blood pressure often experiences poor quality of sleep due to the negative impact of the health condition. This is occasioned by the perception of tinnitus, especially in a quiet environment, and this always affects the sleep patterns and the development of physical discomfort and other related illness. Most of the times, the attendant difficulty often prevents the tinnitus patients from falling asleep. Thus, it is necessary to resolve the sleep difficulty through the development of skills towards the modification of unwanted sleep patterns.

Sleep therapy is a planned psychological treatment to help patients with tinnitus condition to reflect on their beliefs about sleep and negative feeling, as a result of tinnitus and comorbidity of hypertension. Sleep therapy is an effective strategy to resolve sleeping difficulty and attendant anxiety. It is also effective in modifying the emotional responses of patients with tinnitus and comorbidity of hypertension to the health challenges.

#### viii. Environmental sound enrichment

This is another type of therapeutic programme well structured to rehabilitate individual with tinnitus-related conditions. Environmental sound enrichment is based on the principle of distraction of one sound for the intended sound (message) to be heard or received. This tinnitus management strategy is commonly referred to as sound therapy in the audiology parlance. The sound therapy, which was introduced by Jastreboff and McKinney in 1993, has been an effective mechanism to habituate any disordered auditory system through the use of low-level sounds (sound enrichment) to regulate the auditory functions of any individual with experience of tinnitus. The most effective way for sound therapy is the usage of a kind of sound enrichment suitable (pleasant and well tolerated) to the patient(s) with tinnitus, although some natural background sounds such as recorded traffic noise or music playing functions (instrumental sounds) and sound generators are well encouraged or advised for effective and prompt result.

ix. Relaxation therapeutic exercise

Relaxation therapy is a kind of stress management mechanism to consciously relax the body and mind of any individual with health-related conditions and stress either directly or through guided assistance by initiating calmness into the lives of those who are exposed to it. This therapeutic exercise is aimed at reducing stress symptoms and enables the elderly patients with comorbidity of hypertension and tinnitus enjoy better quality of life and, at the same time, reduce the effect of tinnitus and hypertension.

Relaxation therapy is a designed process to reduce the effects of noise in the ears/head and psychosocial reactions occasioned by the comorbidity of hypertension and tinnitus-related patient cope with everyday stress. For this therapy would help to boost the confidence level of the patients to handle the condition, maintaining normal blood sugar levels and increasing blood flow to the muscles, reducing tension and chronic pain, slowing down the heart rate and breathing rate and lowering the blood pressure, as well as reducing anger and frustration. Relaxation therapy can be achieved through regular deep breathing exercises, relaxing music, mediation and mindfulness exercises.

#### 7. Recommendations

Due to the attendant effects of comorbidity of hypertension and tinnitus on the elderly population, it is noteworthy to make the following recommendations in order to holistically rehabilitate elderly patients with such comorbid health-related condition:

Audiological Tinnitus Management: An Essential Audiological Protocol for Elderly Patients… DOI: http://dx.doi.org/10.5772/intechopen.81854

#### 8. Conclusion

Audiological tinnitus management with the aim of providing appropriate treatment and adjustment for the individual with hearing loss and other conditions occasioned due to the attendant effects of such condition or associated health challenges remains the essential audiological management protocol for the elderly patients with comorbidity of hypertension and tinnitus. Also, it has been established that there is no single therapeutic programme capable of resolving attendant effects occasioned due to comorbidity of hypertension and tinnitus. Therefore, this chapter recommends combined audiological therapies, several psychological measures and regular physical activity in addition to behavioural modification and changes in life styles among the elderly patients with comorbidity of hypertension and tinnitus. Prompt attention must be paid to health conditions relating to unresolved hypertensive condition and its attendant effect on the general well-being of the elderly.  The mechanism of aural rehabilitation must also be integrated into the audiological tinnitus management for the elderly patients with comorbidity of hypertension and tinnitus. This will promote sensory management towards enhancing auditory functions as well as increase the probability of positive outcomes, which will enable the elderly patients enjoy good quality of life even with the comorbid health-related conditions.

#### Acknowledgements

The author is grateful to God for the available wisdom and strength. At the same time, I gratefully acknowledge the influence of several audiological rehabilitative and management training programmes cum exposure over the years and the effort of Adenike E. Adesokan towards the arrangement of the manuscript.

### Conflict of interest

The author declares no conflict of interest.

### Author details

Ayo Osisanya Audiology and Speech Pathology Unit, Department of Special Education, University of Ibadan, Ibadan, Nigeria

\*Address all correspondence to<EMAIL_ADDRESS>
© 2019 The Author(s). Licensee IntechOpen. This chapteris distributed underthe terms oftheCreative Commons Attribution License (http://creativecommons.org/licenses/ by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Audiological Tinnitus Management: An Essential Audiological Protocol for Elderly Patients… DOI: http://dx.doi.org/10.5772/intechopen.81854

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**27**

Section 3

A Perspective of

Temporomandibular Joint

Terapies

Section 3

## A Perspective of Temporomandibular Joint Terapies

**29**

**Chapter 3**

**Abstract**

*Miguel Â. Hyppolito*

Temporomandibular Joint

Disorders and Tinnitus

*Henrique F. Pauna, Maria S.A. Amaral and*

components, specifically the mandibular condyle and TMJ disc.

multidisciplinary approach, hypersensitivity

**1. Introduction**

**Keywords:** tinnitus, temporomandibular joint, anatomical interactions,

Tinnitus is a sensation of sound perceived by the individual regardless of external sound stimulus. It is a symptom present or considered as a manifestation of different diseases. It can be manifested as a simple noise with no clinical complaining, or intense enough to prohibit the social activities of the individual. Up to 50% of cases are tinnitus, the etiology of which is unknown, but often tinnitus is associated with hearing loss, trauma, or ototoxic medication leading to cochlear damage, with sustained neural changes in the central auditory system causing such lesions [1, 2]. The global prevalence of tinnitus reaches 14–32%. It occurs at all ages and increases with aging, which can affect both men and women alike. Approximately 4% of the North American population suffers from a severe form of tinnitus [3, 4]. In a more recent meta-analysis, McCormack et al. found a prevalence of tinnitus ranging from 5.1 to 42.7%. They also found that tinnitus is commonly observed among elderly population (8–20% in individuals above the age of 60 years) [5].

Tinnitus is defined as a sound a person hears that is generated by the body, rather than by outside source. The word tinnitus is derived from the Latin "*tinnire*" meaning "to ring" and is perceived as ringing, buzzing, or hissing in or around the ear(s). Approximately 50 million Americans are affected, while there is a prevalence of 10% in the United Kingdom among adult population. It has multiple etiologies and is sometimes idiopathic. Tinnitus may vary widely to pitch, loudness, description of sound, special localization, and temporal pattern. Most often, tinnitus is associated with other aural symptoms, such as hearing loss and hyperacusis. Tinnitus may result in sleep disturbances, work impairments, distress. Males are more likely to suffer from tinnitus. In the mechanically demanding and biochemically active environment of the temporomandibular joint (TMJ), therapeutic approaches are capable of restoring joint functionality. TMJ treatments including splints, occlusal adjustments, and jaw exercises have been shown to be more effective than no treatment. The following chapter presents a synopsis of etiology, current treatment methods, and the future of tissue engineering for repairing and/or replacing diseased joint

#### **Chapter 3**

## Temporomandibular Joint Disorders and Tinnitus

*Henrique F. Pauna, Maria S.A. Amaral and Miguel Â. Hyppolito*

#### **Abstract**

 Tinnitus is defined as a sound a person hears that is generated by the body, rather than by outside source. The word tinnitus is derived from the Latin "*tinnire*" meaning "to ring" and is perceived as ringing, buzzing, or hissing in or around the ear(s). Approximately 50 million Americans are affected, while there is a prevalence of 10% in the United Kingdom among adult population. It has multiple etiologies and is sometimes idiopathic. Tinnitus may vary widely to pitch, loudness, description of sound, special localization, and temporal pattern. Most often, tinnitus is associated with other aural symptoms, such as hearing loss and hyperacusis. Tinnitus may result in sleep disturbances, work impairments, distress. Males are more likely to suffer from tinnitus. In the mechanically demanding and biochemically active environment of the temporomandibular joint (TMJ), therapeutic approaches are capable of restoring joint functionality. TMJ treatments including splints, occlusal adjustments, and jaw exercises have been shown to be more effective than no treatment. The following chapter presents a synopsis of etiology, current treatment methods, and the future of tissue engineering for repairing and/or replacing diseased joint components, specifically the mandibular condyle and TMJ disc.

**Keywords:** tinnitus, temporomandibular joint, anatomical interactions, multidisciplinary approach, hypersensitivity

#### **1. Introduction**

Tinnitus is a sensation of sound perceived by the individual regardless of external sound stimulus. It is a symptom present or considered as a manifestation of different diseases. It can be manifested as a simple noise with no clinical complaining, or intense enough to prohibit the social activities of the individual. Up to 50% of cases are tinnitus, the etiology of which is unknown, but often tinnitus is associated with hearing loss, trauma, or ototoxic medication leading to cochlear damage, with sustained neural changes in the central auditory system causing such lesions [1, 2].

The global prevalence of tinnitus reaches 14–32%. It occurs at all ages and increases with aging, which can affect both men and women alike. Approximately 4% of the North American population suffers from a severe form of tinnitus [3, 4]. In a more recent meta-analysis, McCormack et al. found a prevalence of tinnitus ranging from 5.1 to 42.7%. They also found that tinnitus is commonly observed among elderly population (8–20% in individuals above the age of 60 years) [5].

Disabling tinnitus was considered by the "Public Health Agency of America" in 1984 and 1985 to be the third worst condition a person can have [6].

One of the most known classifications to address tinnitus is the one that address to its source of origin. Tinnitus can originate from the sensorineural hearing system and para-auditory system. Tinnitus classified as sensorineural origin occurs due to injury and/or functional breakdown in the sensorineural hearing system, whether in the inner ear or the central auditory pathways. Tinnitus originated from the paraauditory system can be caused by vascular or muscular structures [7].

Tinnitus originated from the sensorineural hearing system is more frequent than the tinnitus originated from the para-auditory system and may be accompanied by a hearing loss (more frequently) or not [8].

#### **2. Physiopathology of tinnitus**

The pathophysiology of tinnitus of sensorineural origin has not yet been fully established, although some authors believe that tinnitus would be the result of an exacerbated neuronal activity in the auditory pathways, usually of an excitatory nature, which would be interpreted as sound by the auditory cortex [9].

Both expression and intensity of tinnitus are difficult to quantify, leading to diagnostic, prognostic, and therapeutic difficulties. Several methods of examination, such as clinical and laboratory tests, scales and questionnaires, have been proposed to measure the intensity of tinnitus [10, 11]. However, the internal contradictions of each of these methods, such as the imprecision of the tests, limit the possibility of establishing a safety application tool focused on the manifestation of these symptoms.

 In 1995, Zenner and Ernst hypothesized that tinnitus generation was due to cochlear disorders caused by mechanical trauma or altered blood supply, leading to changes in the properties of inner ear hair cells, increasing spontaneous neurotransmission, increasing the activity of the auditory nerve fibers, and, consequently, tinnitus [12]. Henry et al. described that central neuronal activity would be the basis of tinnitus. Deafferentation of the resulting VIII cranial nerve leads to a central increase of upward regulation, thus increasing spontaneous activity, burst activity, and neural synchrony of the central auditory system [13].

Connections between the dorsal column and trigeminal systems, where the projections end in the cochlear nucleus (CN), have been demonstrated [14, 15]. Excitation of the ventral CN (VCN) neurons in the absence of sound upon stimulation of the trigeminal ganglion has also been documented, and others have shown both excitation and inhibition in dorsal CN (DCN) neurons [16, 17].

According to the animal theory proposed by Shore et al., cochlear damage triggers tinnitus by inducing aberrant stimulus to central auditory structures and increasing the spontaneous activity in the DCN and VCN neurons [15, 18]. The study also shows an increased activity in DCN fusiform cells as a result of upregulation of the glutamatergic somatosensory innervation or changes in glycine receptors [19].

Tinnitus can be a manifestation of a turbulent blood flow near to the auditory pathways, caused by a vascular pathology (such as fistulas or aneurysms) [8]. Tinnitus can also be caused by myoclonic activity of the muscles of the middle ear or the palate, or by functional alterations of the stomatognathic system (such as dental problems, alteration of the condyle position, or loss of the dental support). Individuals with temporomandibular disorders (TMDs) may complain of tinnitus in 33–46% of cases [3, 4]. TMD is related to occlusal, emotional, and

*Temporomandibular Joint Disorders and Tinnitus DOI: htp://dx.doi.org/10.5772/intechopen.79453*

neuromuscular (in the mastication muscles). TMD pain may be a contributing factor in the generation of tinnitus, with great interest among many areas [4, 20, 21].

 The pathophysiology of tinnitus caused by TMD, as well as the pathophysiology of sensorineural tinnitus, is also a controversial subject. Some authors believe that tinnitus caused by TMD could be explained by many craniofacial nociceptive receptors (such as the ones present under the skin, fascia, periosteum, fibrous capsule, and temporomandibular joint (TMJ) ligaments). These receptors would be stimulated by mechanical forces that deform or alter the surrounding tissues resulting from the inflammatory process and ischemia [22, 23]. In addition, it was proposed that innervation plays a role in the vascular tone of cochlear blood vessels and may also provide a pathophysiological explanation for ear manifestations that occur in trigeminal nerve irritation as in TMD and may lead to tinnitus sensation [24, 25, 26].

#### **3. Anatomical relationship of the ear and temporomandibular joint**

 Temporomandibular joint is a ginglymoarthrodial joint (meaning hinge joint which permits a gliding motion of the surfaces) that allows the movement in one plane—backward and forward. The TMJ forms a bicondylar articulation with an elliptical shape, and its articular surface is covered by a fibrocartilage (**Figure 1**) [27]. Movement is guided by the shape of the bones, muscles, ligaments and also by the occlusion of the teeth.

#### **3.1 Mandibular component**

It consists of an ovoid condylar process seated atop a narrow mandibular neck. It is 15–20 mm side to side and 8–10 mm from front to back. Thus, if the long axes of two condyles are extended medially, they meet at approximately the basion on the anterior limit of the foramen magnum, forming an angle that opens toward the front ranging from 145 to 160°. The articular surface lies on its anterosuperior aspect, thus facing the posterior slope of the articular eminence of the temporal bone [27, 28].

#### **Figure 1.**

*Lef: General picture of the relationship of TMJ and other cranial structures. Right: A closer image of the components of the TMJ.*

 The mandibular condyle varies greatly among different ages and individuals. Morphologic changes occur based on each individual's development as well as remodeling secondary to malocclusion, trauma, and other developmental abnormalities [28].

#### **3.2 Articular disc**

The articular disc is a biconcave fibrocartilaginous structure located between the mandibular condyle and the temporal bone. The articular disc—the most important structure of the TMJ—is an oval fibrous plate. The superior surface of the disc is saddle-shaped to fit into the cranial contour, and the inferior surface is concave to fit against the mandibular condyle.

The disc is attached all around the joint capsule except for the medial and lateral condylar poles, which ensure that it moves in protraction and retraction [29].

 Functionally, the condyle and the disc are seated more anteriorly. When the jaw is opened, the condyle moves down and forward (translates). The upper part of the retrodiscal attachment has a rather prominent vascular shunt, and this vascular network is contained within loosely organized fat, collagen, and elastin [30].

#### **3.3 Fibrous capsule**

This is a thin tissue completely surrounding the joint. On the lateral part of the joint, the capsule functionally limits the condyle to move forward. This capsule is reinforced more laterally by an external TMJ ligament, which also limits the posterior movement of the condyle.

The synovial membrane covers all the intra-articular surfaces except the pressure-bearing fibrocartilage. The lower and upper compartments form fluid-filled sulci in the joint. These sulci change shape during translatory movements, which requires the synovial membrane to be flexible [31].

#### **3.4 Muscular component**

The masticatory muscles surrounding the joint are groups of muscles that contract and relax in harmony so that the jaws function properly. Different muscles are required for the opposite movements of the mandible. These muscles are abductors (jaw openers) and adductors (jaw closers). The temporalis, masseter, and medial pterygoids muscles are adductors, while the lateral pterygoids muscles are the primary abductors of the jaw.

#### **4. Physiopathology of temporomandibular joint disorder**

 A large percentage of individuals with tinnitus report tinnitus modulation by TMJ and head and neck maneuvers. Up to half the patients who have TMJ dysfunction have tinnitus as one of their symptoms, and in these patients, success rates in eliminating these sounds approach 90%. This suggests that the auditory pathway inputs from the cranial nerves and upper cervical region of the spinal cord are more important in modulating tinnitus than the inputs from the caudal spinal cord [15].

 It has been established that, while progressive and regressive, mechanically induced remodeling is a normal process early on. When the capacity for the joint to remodel has been exceeded, remodeling merges into osteoarthritis. Characteristic osteoarthritic changes observed in the TMJ include alterations in shape and overall size of joint components. Degenerative remodeling present in pathologic TMJs

#### *Temporomandibular Joint Disorders and Tinnitus DOI: htp://dx.doi.org/10.5772/intechopen.79453*

may result from either decreased adaptive capacity in the articulating structures or from excessive or sustained physical stress to the articulating structures [32]. Microtrauma of the TMJ (which is caused by bruxism or jaw tightening) or macrotrauma of the TMJ (punch to the jaw or impact in an accident) can lead to muscle inflammation, dislocation of the TMJ, or damage to the cartilaginous disc. Other inflammatory diseases, such as osteoarthritis, may cause degeneration of the cartilage and increased blood flow that may lead to a greater number of inflammatory cells close to the TMJ and the ear. This increase in blood flow may be suggestive of tinnitus perception.

The TMD has as signs and symptoms the limitation of mouth opening, the presence of articular noises during its opening and/or closing, and pain in the musculature of the face and in the TMJ to chew, both uni- and bilaterally. TMD may be presented with chronic pain in the head and neck region, in the cervical region, and the TMJ itself [33].

 There are three main theories behind why problems with the TMJ may cause tinnitus or make it worse. Firstly, the chewing muscles are near to some of the muscles that insert into the middle ear (tensor tympani muscle) and so may have an effect on hearing and so may promote tinnitus. Secondly, there can be a direct connection between the ligaments that attach to the jaw and one of the hearing bones that sits in the middle ear. Thirdly, the nerve supply from the TMJ has been shown to have connections with the parts of the brain that are involved with both hearing and the interpretation of sound. The general discomfort associated with TMJ problems can also aggravate any preexisting tinnitus.

 Patients with tinnitus and TMD often have excessive somatic concern syndrome with complaints disproportionate to the severity of physical and clinical findings exacerbated by emotional disturbances and are often diagnosed as depression and anxiety. Studies indicate that patients with TMD report their auditory and vestibular symptoms exacerbated, being alleviated by drug treatment and emotional control [34]. These patients demonstrate emotional imbalance, depression, and anxiety. They manifest periods of control of their symptoms. They present physical and cognitive limitations, and the intensity of the symptoms and signs oscillates in an uneven way, suffering the distinct influence of personal, family, professional, and social problems in their daily life [34].

#### **5. TMD diagnosis and complementary tests**

The diagnosis of TMD is clinical, being performed through the clinical history and complete physical examination of the joint with palpation, measurement of mouth opening movements, functional tests, and evaluation of joint noises. TMD patients were defined as those who had experience of TMJ symptoms over the previous year as indicated by the presence of one or more of the following symptoms:

a.clicking sounds in the auricular area during the past year,

b.pressure or pain in the auricular area during the past year, or

c. discomfort opening the mouth during the past year [35].

Functional disorders of the masticatory organs are often manifested by acute or chronic pain in and around the TMJ and/or masseter muscles. Impaired dynamics of mandibular movements is manifested as restricted or enhanced range of jaw openings, deviations in the course of abduction and adduction of the mandible,

 and lack of symmetry of mandibular lateral movements. Acoustic symptoms within the joints, manifested as popping and cracking sounds, are an evidence of the lack of coordination between the articular head TMJ articular discs during mandible movements [2]. Patients with TMD characterize their tinnitus as acute, continuous, sporadic, of short duration, moderate intensity, and that generally did not interfere with their daily activities [36]. Otolaryngological symptoms are a less common group of dysfunction symptoms, including sudden hearing impairment or loss, ear plugging sensation and earache, sore and burning throat, difficulties in swallowing, and vertigo [3, 4, 6].

Due to the latter symptom, patients may experience fear when moving around. Tinnitus may be experienced as squeaks, whistles, chirps, bubbling sounds, pulsations, howls, paper rustle, or sea humming [7]. Facial pain and headache are one of the symptoms of the painful form of the functional dysfunction of the masticatory organ, commonly misdiagnosed and treated as pain of some other etiology [8–10]. The impact of the emotional factors in the development of TMD and common concomitance of otolaryngological symptoms should also be noted. Tinnitus, chronic facial pains, and dysfunctions were commonly reported in depressive patients [10, 12, 13, 37].

Imaging examinations can be performed to confirm the clinical diagnosis, as well as to verify the degree of impairment and integrity of the structures involved. In addition, imaging may also confirm the extent of TMD and assists to document the effects of the treatment already initiated [38, 39].

The imaging tests that may be requested are simple or panoramic X-ray of TMJ, CT, and MRI scans. Both simple radiography and panoramic jaw radiography have low-cost and low-radiation dose but have low sensitivity rates. They are indicated for initial evaluations of less complex symptoms and in the differential diagnosis between TMD and maxillofacial inflammatory conditions [38, 39].

CT scan is considered the "gold standard" for the evaluation of bone structures. This examination is necessary for evaluation in cases of sudden trauma, occlusal changes and limitation of mouth opening, the presence of joint noises, joint systemic diseases, infection, and failure in conservative treatments. Cone-beam computed tomography (CBCT) currently presents an increased indication during the evaluation of TMD [32, 38, 39].

MRI scan has been the method of choice for the study of TMJ pathologic processes involving soft tissues such as discs, ligaments, retrodiscal tissues, intracapsular synovial contents, adjacent masticatory musculature, as well as the cortical and medullary integrity of the bone components, respectively, in the axial, coronal, and sagittal planes, and is highly sensitive for intra-articular degenerative changes [32, 38, 39].

#### **5.1 Electromyography**

Electromyography is the study of muscle function, obtained from electrodes placed on the surface of the skin around the muscle, and connected to an equipment for amplification and recording of signals and, therefore, an examination that is capable to verify the action potentials of the muscle fibers of patients. It is considered a safety, easy, and noninvasive method that objectively allows quantification of energy within the studied muscle. It can be useful to assess TMD changes and to follow-up after the established therapy [32, 38, 39].

#### **6. Tinnitus diagnosis and complementary tests**

Tinnitus should be evaluated according to a clinical questionnaire, characterizing the type of tinnitus, laterality, continuity, whether there is modulation or not,

#### *Temporomandibular Joint Disorders and Tinnitus DOI: htp://dx.doi.org/10.5772/intechopen.79453*

if there are associated symptoms (hearing loss, vertigo, previous exposure to noisy environments), improvement and worsening, and eating habits, in order to quantify the limitations caused by tinnitus.

 The prevalence of TMD was higher in patients with tinnitus and hearing difficulty symptoms than in patients without tinnitus or hearing difficulty, which is consistent with previous TMD studies where reports of auditory complaints are common [35]. Moreover, patients with TMDs were at a greater risk of developing tinnitus and symptoms of a greater severity than patients without TMDs [40]. Excessive mechanical irritation of the disco-mallear ligament is suspected to play a definitive role in the development of tinnitus in TMD patients [41]. Tinnitus has also been linked with pressure and strain from mastication and jaw movement [42]. In an audiological evaluation of aural symptoms in TMD, hearing loss was observed in up to 15–32% of TMD patients [35, 43]. A previous study by Riga et al. attributed the hearing difficulty in TMD cases to increase in resonant frequency in the tympanum ipsilateral to the TMD [44]. The association between tinnitus, hearing difficulty, and TMDs has thus been ascribed to a bidirectional delivery of mechanical stimulation and stress due to anatomical proximity.

 TMD prevalence was found to be higher in patients with dizziness/balance disorder than in those without. Otologic complaints most frequently cited with TMDs in the study are dizziness, tinnitus, ear pain, ear fullness, and hearing loss [35]. de Moraes Marchiori et al. reported that patients with TMDs are 2.38 times more likely to present with dizziness, and Chole et al. conducted a case–control study to determine whether dizziness is more common in TMD patients compared to age-matched controls, finding dizziness to be significantly more prevalent in TMD group [3, 45].

The otolaryngological examination should be performed with flexible fibroscopy, verifying the palatal myoclonus. Laboratory tests should be performed with glucose and insulin curves, thyroid function tests, blood count, lipidogram, and audiometric tests (audiometry, impedanciometry, and acuphenometry), electrophysiological examinations (auditory brainstem response, otoacoustic emissions, and eletrocochleography). Cervical spine X-ray, CT of ears, and carotid Doppler can be performed [46].

#### **7. Integrated therapeutic approach**

The difficulty of associating tinnitus and TMD is very much associated with the unilateral view of the professionals involved in patient care over the integrated multiprofessional approach [46].

In addition, another difficulty in managing such pathologies is that there is a high number of drugs for the treatment and control of symptoms related to tinnitus and TMD and that have as their side effects the very triggering of these, making diagnosis related to side effects or caused by congenital or acquired disease.

Patients with tinnitus and TMD complaints require careful attention and should be assisted by a multidisciplinary team of dentists, nurses, speech pathologists, ENT doctors, and psychologists. This approach is more effective in diagnosis, therapeutic plan, and prognosis by hierarchizing specific procedures of each professional to approach this patient [15, 46].

#### **8. Results of multidisciplinary approach**

 Studies have shown benefits for treating tinnitus associated with TMD. Wright and Bifano, in 1997, studied tinnitus in patients with TMD and reported that 56%

were cured and 30% showed significant improvement with cognitive therapy and modulation through maneuvers [47]. Sherman et al. in 2001 found that TMD treatment resulted in greater improvement when combined with psychological and dental treatment, showing improved outcomes when combined with conventional dental therapy alone, implying that psychological factors should be taken into account in the treatment of TMD [48].

Stomatognathic treatment includes therapy of myorelaxant plaques, therapeutic exercises for lower jaw, and occlusal adjustment. Occlusal plaques, considered as reversible and noninvasive devices for the treatment of TMD, can regulate the vertical dimension of occlusion and eliminate malocclusion. They contribute to muscle relaxation, pain relief, and promote neuromuscular stability [49].

Referral to dentists or orthodontists, referral to audiologists, utilization of hearing aids or tinnitus-dampening devices, tinnitus-retaining therapy, music therapy, behavioral therapy related to reducing factors that lead to jaw clenching and bruxism, and osteopathic-manipulative treatment are all therapeutic options that can be considered. In addition, therapeutic options with less of an evidence basis such as acupuncture, tinnitus therapy, hyperbaric oxygen, and others may also be considered for patients who have not responded to other modalities [32, 49, 50].

 Treatment through muscle relaxation, through massage and stretching exercises, is reported by some authors. Other authors have shown good results with drug treatment (vasodilators, hemorrhages, calcium-channel blockers, anxiolytics, antiplatelet agents, anticonvulsants, and vitamins) [50]. Okeson et al., comparing muscle relaxation therapies with the use of occlusal plaques, concluded that occlusal plaque therapy was more effective than muscle relaxation therapy in the treatment of temporomandibular disorders [51].

Somatic modulation therapy (treatment aimed at modulating the intensity of a particular symptom, by motion) and electrical stimulation in the treatment of tinnitus have recently been cited. The electrical stimulation of the skin areas near the ear could increase the activation of the dorsal cochlear nucleus through the somatosensory pathway, increasing the inhibitory role of this nucleus in the central nervous system and thus improving tinnitus [52]. For the most debilitating and severe tinnitus, the transcranial stimulation by magnetic stimulation has been studied [53].

#### **9. Prognostic**

The increased prevalence of TMD with increased modulation of tinnitus by somatic maneuvers highlights the role of somatosensory afferents, depicting somatosensory tinnitus. However, many questions remain regarding the clinical approach to patients with tinnitus.

*Temporomandibular Joint Disorders and Tinnitus DOI: htp://dx.doi.org/10.5772/intechopen.79453*

> a characteristic that seems more closely related to somatic components such as the presence of musculoskeletal disorders than to specific demographic profiles.

 Current evidence supports a link, mainly for TMD, between the presence of a somatic disorder and higher modulation of tinnitus, especially in patients with a normal hearing threshold.

Identification of specific individual demographic or tinnitus-related factors that increase the chance of tinnitus modulation can be helpful in the management of patients with somatosensory tinnitus. Although some of these treatments may have a positive effect on tinnitus, their effect depends on the correct identification of the underlying somatic disorder, when present.

#### **10. Conclusion**

Somatosensory tinnitus is certainly a widespread condition, and further animal studies are required to better understand its pathophysiologic basis. New studies are necessary to investigate whether the correct diagnosis and treatment of a possible underlying somatic disorder could contribute to the management of tinnitus.

 Accurate screening for somatosensory modulation of tinnitus is imperative to correctly select patients who would benefit from a multidisciplinary somatic approach. Chronic diseases were associated with a higher TMD prevalence. These findings suggest that TMD treatment should employ an interdisciplinary approach in an effort to extend and maximize its effect.

#### **Conflicts of interest**

None to declare.

#### **Author details**

Henrique F. Pauna\*, Maria S.A. Amaral and Miguel Â. Hyppolito Department of Ophthalmology, Otolaryngology, Head and Neck Surgery, Ribeirão Preto Medical School, University of São Paulo (FMRP-USP), Ribeirão Preto, São Paulo, Brazil

\*Address all correspondence to<EMAIL_ADDRESS>
© 2018 Te Author(s). Licensee IntechOpen. Tis chapter is distributed under the terms of the Creative Commons Atribution License (htp://creativecommons.org/licenses/ by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

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**43**

Section 4

A Perspective of Herbal

Therapies

Section 4

## A Perspective of Herbal Therapies

**45**

**Chapter 4**

**Abstract**

Herbal Medicine in the

herbal medications of Tinnitus from all over the world.

**1. Tinnitus: definition, etiology, and epidemiology**

lems in 3–5% of patients [1–5].

**Keywords:** tinnitus, herbal medicine, treatment, epidemiology, *Ginkgo biloba*

Tinnitus, which is commonly defined as "ringing in the ears" by the patients, is a perception of an auditory sensation without any accompanying external stimulation [1, 2]. It accounts for a notable part of visit in otolaryngology clinics and has been estimated to involve about 5–15% of adult population making serious prob-

Tinnitus causes a lot of problems for patients, their family, and guardians and significantly decreases quality of life of patients. Most of the patients have complaints with sleep disorders, depression, decreased self-confidence, and altered

Tinnitus is generally categorized into two types: subjective and objective. A majority of patients suffer from a subjective tinnitus, which means perception of an auditory sensation without any evident stimulus. In some patients, a kind of organic measurable stimulus such as glomus tumor, by making turbulence of blood flow, is the cause for tinnitus, which is called objective tinnitus [1, 2]. This type of tinnitus can be found by examiner using an ear-canal microphone or stethoscope [6].

A variety of risk factors have been reported for subjective tinnitus so far; hearing loss, depression, head trauma, and medication-related ototoxicity [7–9]. Some other conditions may have a role in predisposing patients to tinnitus such as acoustic trauma and presbycusis, and it may be associated with temporomandibular joint (TMJ) or cervical spine dysfunctions (somatic tinnitus) as well as depression and anxiety [10–14].

social communications as well as difficulties in quotidian activities [2].

Management of Tinnitus

*Mohammad Hossein Khosravi, Masoumeh Saeedi,*

*Jaleh Yousefi, Ali Bagherihagh and Elnaz Ahmadzadeh*

Tinnitus, which is commonly defined as "ringing in the ears" by the patients, is a perception of an auditory sensation without any accompanying external stimulation. It accounts for a notable part of visits in otolaryngology clinics and has been estimated to involve about 5–15% of adult population making serious problems in 3–5% of patients. Tinnitus causes a lot of problems for patients, their family, and guardians and significantly decreases quality of life of patients. Many treatment methods have been proposed and presented for Tinnitus since the first year of diagnosis. These methods range from conservative management and chemical medications to surgical methods. As the other diseases and conditions, herbal medicine has been trying to treat Tinnitus and a variety of medications have been proposed. In this chapter, we aimed to have a comprehensive review on the current

#### **Chapter 4**

### Herbal Medicine in the Management of Tinnitus

*Mohammad Hossein Khosravi, Masoumeh Saeedi, Jaleh Yousefi, Ali Bagherihagh and Elnaz Ahmadzadeh*

#### **Abstract**

 Tinnitus, which is commonly defined as "ringing in the ears" by the patients, is a perception of an auditory sensation without any accompanying external stimulation. It accounts for a notable part of visits in otolaryngology clinics and has been estimated to involve about 5–15% of adult population making serious problems in 3–5% of patients. Tinnitus causes a lot of problems for patients, their family, and guardians and significantly decreases quality of life of patients. Many treatment methods have been proposed and presented for Tinnitus since the first year of diagnosis. These methods range from conservative management and chemical medications to surgical methods. As the other diseases and conditions, herbal medicine has been trying to treat Tinnitus and a variety of medications have been proposed. In this chapter, we aimed to have a comprehensive review on the current herbal medications of Tinnitus from all over the world.

**Keywords:** tinnitus, herbal medicine, treatment, epidemiology, *Ginkgo biloba*

#### **1. Tinnitus: definition, etiology, and epidemiology**

Tinnitus, which is commonly defined as "ringing in the ears" by the patients, is a perception of an auditory sensation without any accompanying external stimulation [1, 2]. It accounts for a notable part of visit in otolaryngology clinics and has been estimated to involve about 5–15% of adult population making serious problems in 3–5% of patients [1–5].

Tinnitus causes a lot of problems for patients, their family, and guardians and significantly decreases quality of life of patients. Most of the patients have complaints with sleep disorders, depression, decreased self-confidence, and altered social communications as well as difficulties in quotidian activities [2].

Tinnitus is generally categorized into two types: subjective and objective. A majority of patients suffer from a subjective tinnitus, which means perception of an auditory sensation without any evident stimulus. In some patients, a kind of organic measurable stimulus such as glomus tumor, by making turbulence of blood flow, is the cause for tinnitus, which is called objective tinnitus [1, 2]. This type of tinnitus can be found by examiner using an ear-canal microphone or stethoscope [6].

A variety of risk factors have been reported for subjective tinnitus so far; hearing loss, depression, head trauma, and medication-related ototoxicity [7–9]. Some other conditions may have a role in predisposing patients to tinnitus such as acoustic trauma and presbycusis, and it may be associated with temporomandibular joint (TMJ) or cervical spine dysfunctions (somatic tinnitus) as well as depression and anxiety [10–14].

#### **2. Current treatments**

 Currently, United States Food and Drug Administration (FDA) or the European Medicine Agency has not approved any drug for the treatment of tinnitus [15]. The complex mechanism and innate diversity in etiology of tinnitus have made its treatment a dilemma for physicians and specially otolaryngologists. Despite considerable number of researches, none of the so far presented medications and treatments has resulted in a sustained reduction in perception of tinnitus [16]. No appropriately controlled clinical trials have been successful to prove efficacy of a single drug. Thus, pharmacological treatment of tinnitus seems to be ineffective [17, 18]. Antidepressants are more frequently prescribed for tinnitus and seem to be effective but with a notable number of side effects. Anticonvulsants, benzodiazepines, lidocaine, and antispasmodics are also among commonly prescribed medications [19]. Voice therapy, using hearing aids, adjuvant therapies as well as environmental sound enrichment are the most common nonmedical approaches to Tinnitus [20].

Regarding the abovementioned issues, there are varieties of complementary and alternative medicine (CAM) treatments, which have been experimented in clinical stage for tinnitus. Herbal medicine or acupuncture, as the most popular types of CAMs therapy among people, have been shown to be effective in management of tinnitus when prescribed solely or in combination [21, 22]. Most of the CAM studies have a small sample size and few methodological pitfalls make it difficult to decide firmly about these treatments.

Some of medicinal herbs and their derivates have been evaluated in various phases of studies: in vitro, in vivo, and even in small to large scale clinical trials [23–30]. In fact, people in different regions of the world have different approaches to medicinal plants and use a variety of herbal medications for treating different diseases and conditions, which have not yet been scientifically assessed [31, 32]. In this chapter, we will discuss and review current traditional and herbal medicine treatments with approved or possible effects on management of Tinnitus.

#### **3.** *Ginkgo biloba* **(Jinko)**

 *Ginkgo biloba* from the Ginkgoaceae family is a Chinese traditional medicine herb, which is being used for the treatment of asthma and bronchitis for a long time [22, 33]. It has gotten popular also in western countries as well as in Asian ones [34]. *Ginkgo biloba* is widely available as easily accessible, inexpensive, and relatively safe leaf extracts with various reported therapeutic benefits such as improved cognition and memory as well as sexual function [35, 36]. These improvements beside other biological effects of Jinko extracts such as improvement of microcirculation and neuroprotection are attributable to flavonoid glycosides and terpene lactones, active pharmacologic gradients of *Ginkgo biloba*. It should be pointed that seeds play a remarkable role in Chinese traditional medicine and they are the most commonly used parts of plants for herbal medications, while *Ginkgo biloba* is processed from the plants' leaves.

Jinko has been proposed for management of various central nervous system pathologies including tinnitus; however, some previous researches have reported no beneficial effects for *Ginkgo biloba* in treatment of tinnitus [36–41]. Nevertheless, no certain decide can be made regarding effects of *Ginkgo biloba* on management of tinnitus according to its complex pharmacological profile, which shows need for further accurate researches [42].

#### **4. Bojungikgitang and banhabaekchulchonmatang (traditional Korean medicine)**

Bojungikgitang and banhabaekchulchonmatang have been approved by Korea Food and Drug Administration and are being widely used in Korea for treatment of Tinnitus because of their very low rate of adverse effects [16]. These two herbal medications have found their places among Korean people and physicians. Traditional Korean medicine (TKM) believes that Tinnitus is mainly caused from irregularities in bowel and visceral (zang-fu) functioning [16]. According to TKM, gallbladder deficiency associated with tinnitus is managed by banhabaekchulchonmatang, and bojungikgitang is used to manage the pattern of qi-deficiency [21]. Both of these drugs are now fully covered by Korean National Health Insurance (KNHI).

#### **5. Gushen Pianas**

*Gushen Pianas* is a novel Chinese medicinal herb, which is being used in the treatment of sensorineural hearing loss and Tinnitus. Phlegm-accumulation stasis and splenonephric hypofunction are the two main proposed mechanisms of action for *Gushen Pianas* in treatment of Tinnitus [43]. This medication has been developed by Institute of Otorhinolaryngology of Chinese PLA General Hospital and Wuhan Kexing Biomedical Development Co.

 Effectiveness of the drug was evaluated in a phase 2 double-blind randomized clinical trial on 120 patients with sensorineural deafness associated with tinnitus. Patients received five tablets of Gushen Pianas every 8 hours and the effect was assessed after 4 weeks. The findings suggested Gushen Pianas as a suitable treatment for hearing loss with no evident adverse effects [43].

#### **6.** *Panax ginseng* **(Jinseng)**

 Root of the *Panax ginseng*, with local name of Jinseng, a Chinese medicinal plant from the Araliaceae family has been being used for treatment of Tinnitus since dawn of traditional medicine [44]. Korean red ginseng (KRG) is a traditional Korean herbal medication, which has been used for more than 2000 years, believed to have several benefits for human body [45]. It is considered that oxidative stress is the cause for idiopathic tinnitus and patients may take benefits from oral antioxidant therapy [46, 47]. So, KRG has been proposed for treatment of tinnitus as it inhibits production of reactive oxygen species (ROS) and also attenuates hydrogen peroxide-induced oxidative stress in human neuroblastoma cells [48, 49]. The effect of KRG (3000 mg/day) was evaluated in a randomized clinical trial in which the patients showed a significant reduction in tinnitus handicap inventory (THI) score and increased quality of life. Also some adverse effects have been reported for Jinseng and specially KRG in literature. Deficiency of vital energy (DE), known as qi-deficiency, is a traditional Chinese medicine syndrome, which indicates the disease emerging identity. Some studies believe that Ginseng, especially Korean Red Ginseng, might cause some adverse effects if the patient's body constitution does not match the qi-deficiency. However, others have reported the Ginseng as the treatment of qi-deficiency caused by any reasons [50].

Further researches are needed to assess beneficial and adverse effects of KRG more accurately.

#### **7. Garlic**

Previous conducted researches have reported a lipid-lowering effect for garlic and some others have counted fibrinolytic activity and lowering blood pressure as therapeutic roles of garlic. Few studies have also reported garlic to be beneficial for treatment of tinnitus [6]. Garlic's effect on tinnitus is attributable to improve blood flow of cochlea as a result of its antiplaque formation ability, stabilizing blood pressure, and augmentation in antioxidant capability of the blood. No scientific studies have been conducted for approving these effects and all of them are theoretical [51].

#### **8. Yoku-kan-san**

There are more than 120 plants approved by Japanese ministry of health, labor, and welfare, which are now being used in practice as traditional medications [52]. *Yoku-kan-san*, a traditional Japanese herbal medication, is one of these approved herbal medications composed from seven plants (Angelicae Radix, Atractylodis Lanceae Rhizoma, Bupleuri Radix, Poria, Glycyrrhizae Radix, Cnidii Rhizoma, and Uncariae Uncis Cum Ramlus). This combination is more frequently used as treatment of psychological conditions such as irritability, insomnia, night terrors, and hypnic myoclonia, especially in infant patients [53]. Although, there are not enough clinical investigation and convincing data for beneficial effect of *Yoku-kan-san* on tinnitus, but it has been shown to be effective for tinnitus resulted from undifferentiated somatoform disorder in a 44-year-old woman [54]. There is an obvious need for more clinical researches to support such kind of case reports.

Today's world is going toward the use of medicinal plants and herbal medicines, which are now finding their place among people. Conditions with no precise pharmacologic treatment, such as tinnitus, are more probable to be resolved by herbal medications. In this chapter, we tried to review current medicinal plants for treatment of tinnitus; however, currently, there is a lack of clinical research in this issue. The effect of herbal medications on tinnitus should be investigated in more future clinical researches. *Herbal Medicine in the Management of Tinnitus DOI: http://dx.doi.org/10.5772/intechopen.81320*

#### **Author details**

Mohammad Hossein Khosravi1,2,3\*, Masoumeh Saeedi1,3, Jaleh Yousefi3 , Ali Bagherihagh3 and Elnaz Ahmadzadeh1,4

1 International Otorhinolaryngology Research Association (IORA), Universal Scientific Education and Research Network (USERN), Tehran, Iran

2 Student Research Committee, Baqiyatallah University of Medical Sciences, Tehran, Iran

3 Department of Otorhinolaryngology-Head and Neck Surgery, Faculty of Medicine, Baqiyatallah University of Medical Sciences, Tehran, Iran

4 Department of Audiology, School of Rehabilitation, Shahid Beheshti University of Medical Sciences, Tehran, Iran

\*Address all correspondence to<EMAIL_ADDRESS>
© 2018 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/ by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

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