Stimulated by Zha et al 2024.[1]
EA – electroacupuncture
ENT – ears nose and throat (refers to a medical specialty)
TrP – trigger point
NMDA – N-methyl-D-aspartate (glutamate receptor)
TS – subjective tinnitus
THI – tinnitus handicap inventory
rs-fMRI – resting state functional magnetic resonance imaging
FC – functional connectivity
INS – insula
Treatment of tinnitus with acupuncture has been a thorny issue for me from my earliest days in the BMAS. I came across acupuncture for the first time in 1989, shortly after my first ENT job, and just after starting on a short service commission in the Royal Air Force (RAF). After training with the BMAS and subsequently retiring from the RAF, I had a portfolio of jobs for a few years in the Plymouth area. One of those jobs was as a clinical assistant in ENT at Derriford Hospital. The department principally wanted me to do on calls, but I negotiated for a weekly session of acupuncture as well as.
I treated a lot of different presentations, but I never tried treating tinnitus. I guess I was influenced by my senior colleagues in the BMAS, who mostly considered it to be a condition that did not respond along with sensory neural deafness.
Having heard that the TrP gurus, Travell and Simons,[2–4] made a link between TrPs in deep masseter and SCM and ipsilateral tinnitus, I kept an eye and an ear out for such cases. Over the years I have come across a handful of young patients with normal hearing and unilateral tinnitus, but I have never seen a dramatic cure in this group. I have only heard of a single case of a TrP in SCM from a vet colleague (Sam) on a Western veterinary acupuncture course. The vets on the course did some practice on each other, and in one case, needling a TrP in SCM exacerbated existing unilateral tinnitus. I am unsure of how long the exacerbation lasted.
I avoided the patients with deafness and bilateral symptoms but would occasionally come across reports submitted to Acupuncture in Medicine or published in other journals, which claimed to have some success in treating the condition.
Controlled trials in the west are mostly small and negative. I learned of a large sham controlled trial (n=300) from a colleague in Sweden, which was essentially negative or neutral, but the results of this trial have never been published.
Since the discovery of NMDA receptors and their potential for amplification of sensory signals, I have wondered whether or not the influence of acupuncture via descending inhibition could turn down the volume on sensory symptoms other than pain. It seems conceivable mechanistically, so I kept open to the possibility, even though it was just a chink open.
This paper is the first to provide some objective measure of change in patients with tinnitus – a condition that is notoriously hard to evaluate objectively. 34 patients with subjective tinnitus (ST) were recruited and matched with 34 healthy controls by age and sex. The ST group were treated with acupuncture and EA 3 times a week for a total of 10 sessions. Points were needled on the midline (GV14, GV15, GV20), locally on the ipsilateral side (SI19, TE17, GB11), and a distant point on the ipsilateral side was also used (TE3). After manual needling, the points SI19 and GB11 were connected to EA at 2/50Hz for 30 minutes.
The outcomes used were the THI, pure tone audiometry (mean auditory threshold), and rs-fMRI FC between INS and relevant brain structures identified at baseline.
THI improved significantly from baseline after the course of acupuncture (this is a within group comparison over time ie uncontrolled). Pure tone mean threshold reduced (ie improved) from baseline.
Baseline measures in rs-fMRI FC between INS and the left superior temporal gyrus and the right hippocampus were significantly reduced compared with healthy controls. The reduction in FC between INS and the left superior temporal gyrus was negatively correlated with THI.
This result is rather less dramatic than I was expecting from the title of the paper, and my attitude to treating patients with tinnitus is still somewhat reserved. There was a rather upbeat review published recently in the American Journal of Otolaryngology from a different group in China, which was also in my ‘recent’ folder.[5] I checked some of the references from this paper but I was still less than convinced.
Finally, I searched for recent systematic reviews on PubMed. I found two reasonable ones.[6,7] The majority of the trials were from China and the results were generally positive although considerable methodological flaws were noted from the Chinese research.
References
1 Zha B, Zhang Y, Shi F, et al. Modulations of resting-static functional connectivity on insular by electroacupuncture in subjective tinnitus. Front Neurol. 2024;15:1373390.
2 Travell JG, Simons DG. Myofascial Pain & Dysfunction. The Trigger Point Manual. Volume 1. The Upper Extremities. 1st ed. Baltimore: Williams & Wilkins 1983.
3 Simons DG, Travell JG, Simons PT. Travell & Simons’ Myofascial Pain & Dysfunction. The Trigger Point Manual. Volume 1. Upper Half of Body. 2nd ed. Baltimore: Williams & Wilkins 1999.
4 Donnelly JM, Fernandez de las Peñas C, Finnegan M, et al., editors. Travell, Simons & Simons’ myofascial pain and dysfunction: the trigger point manual. 3rd ed. Philadelphia: Wolters Kluwer Health 2019.
5 Yu S, Wu J, Sun Y, et al. Advances in acupuncture treatment for tinnitus. Am J Otolaryngol. 2024;45:104215.
6 Wu Q, Wang J, Han D, et al. Efficacy and safety of acupuncture and moxibustion for primary tinnitus: A systematic review and meta-analysis. Am J Otolaryngol. 2023;44:103821.
7 Liu F, Han X, Li Y, et al. Acupuncture in the treatment of tinnitus: a systematic review and meta-analysis. Eur Arch Otorhinolaryngol. 2016;273:285–94.
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