Cochlear Nerve Section Cures Some People's Tinnitus

[Molan]

I thought this had already been posted as a stand alone thread but I was mistaken so here it is.


Cochlear nerve section for intractable tinnitus

Abstract
Tinnitus is a common and often very disturbing symptom. The majority of patients can now be successfully treated either by conservative medical treatment or by specific surgery. Intractable subjective tinnitus originating within the cochlea or cochlear nerve can frequently be successfully treated by cochlear nerve section. The cochlear nerve must be severed medial to the spiral ganglion to obtain optimum results. One hundred fifty-one cases are reported. Complete relief of tinnitus was achieved in 101 patients, worthwhile improvement was obtained in 43 patients and 7 patients obtained no improvement. The indications for this surgery will be given. Careful examination, accurate diagnosis, and proper selection of patients with intractable tinnitus for cochlear nerve section offer a good chance for success.



Although I would certainly never advocate anyone sacrificing their hearing to cure their Tinnitus it's an interesting study because it shows that at least for some people their Tinnitus is caused exclusively in their ears and not the brain.

 

[t-man]

Perpetual noise or perpetual silence.

Makes one think...

 

[Molan]

Unfortunately out of 151 cases 7 reported no improvement at all but lost their hearing as a result so it is no guarantee. In my opinion it is far too big a risk for anyone to seriously consider this procedure. I posted this study because it provides evidence that for some at least the problem is actually in the inner ear region and is not exclusively in their brains which alot of researchers seem to be focusing on more and more. It is my understanding that most people who have Tinnitus have some degree of hearing loss.

I believe repair and regeneration of damaged neurons in the inner ear should be the primary goal of Tinnitus researchers.

 

[EddyLee]

I think this is a good news! Complete relief of tinnitus was achieved in 101 patients, that means majority of patients in the report has problem in their inner ear. But what is the duration of these patients tinnitus? Isn't they said after few months our brain will start to get used to the phantom sound? If these patients actually has chronic tinnitus that means our brain will get used to phantom sound is not correct and therefore AM-101 should still be useful for chronic tinnitus patients?

 

[James White]

I think this is a good news! Complete relief of tinnitus was achieved in 101 patients, that means majority of patients in the report has problem in their inner ear. But what is the duration of these patients tinnitus? Isn't they said after few months our brain will start to get used to the phantom sound? If these patients actually has chronic tinnitus that means our brain will get used to phantom sound is not correct and therefore AM-101 should still be useful for chronic tinnitus patients?

I'm having the same reflection, but i guess these people who would want to have the auditory nerve severed must have been extremely severe cases !!

 

[frohike]

The majority of patients can now be successfully treated either by conservative medical treatment or by specific surgery.

uh uh this sounds too optimistic. This article is from 1995 by the way.

From "Tinnitus Retraining Therapy" by Pawel Jastreboff, 2004

Ablative surgery to eradicate tinnitus

The persistent requests from a patient deeply distressed by tinnitus to have the "offending ear" removed by ablative surgery are occasionally heeded by the equally desperate surgeon who does not have a solution for the patient's tinnitus. Destroying the ear in an attempt to eradicate tinnitus, or cutting the auditory nerve, is a naive approach that frequently fails and is based on lack of knowledge of the mechanisms of the neurophysiological processes involved in tinnitus. In fact, clinical data show that cutting the auditory nerve induces tinnitus in 50% of patients who previously did not experience it (Berliner et al., 1992). [ouch!] As can be predicted from the neurophysiological model, patients with the highest level of distress, most likely to seek this extreme treatment, are those least likely to benefit from altering a peripheral component of tinnitus. It is possible to expect that in these patients there are the strongest connections between the auditory system and the limbic and autonomic nervous systems, and thus the relative importance of the peripheral signal is much smaller than in other tinnitus patients.

Research indicates that the tinnitus-related neuronal activity may emerge as a modification of the spontaneous activity in auditory neurons in the brainstem and may be related to decreased activity coming from the cochlea, more specifically from dysfunctional OHC and imbalance of activity arising from stimulation of IHC and OHC (Chen & Jastreboff, 1995; Jastreboff & Sasaki, 1986; Kaltenbach, 2000; Kaltenbach & Afman, 2000). Moreover, this activity undergoes further enhancement in the auditory pathways and their connections with the limbic and autonomic nervous systems (Jastreboff, 1995). Therefore, section of the auditory nerve or destruction of the cochlea, which are peripheral to the brainstem, would not be expected to have any positive effect on tinnitus and could even make it worse (Jastreboff, 1990, 1995). From this perspective, it seems highly inappropriate to use ablative surgery for treating tinnitus, even if the precise anatomical localization of the centers involved in the processing of tinnitus could be identified. Nevertheless, some authorities still strongly promote this kind of surgical treatment (Pulec, 1995). [<-- this reference is "Cochlear nerve section for intractable tinnitus"]

Even in profound hearing loss and the absence of cochlear hair cells, there is a random pattern of resting discharge potentials that represents the "code for silence" (Moller, 1984). This activity is blocked by subcortical filters and, therefore, no sound is perceived. Sectioning of the auditory nerve results in scarring and sometimes in the growth of an electrically active "stump neuroma," a benign swelling on the end of the cut nerve. This can lead to increased auditory nerve discharge, together with a synchrony of firing in various auditory nerve fibers: a phenomenon which in the normal auditory system results in the perception of a sound. It is interesting that in a somewhat analogous situation where a patient is suffering from severe pain, the concept of cutting the peripheral nerve has been almost totally abandoned because of the typical lack of improvement and the frequent establishment of phantom pain after the surgical procedure (Melzack, 1992).

In the literature, there are a limited number of reports of auditory nerve section for tinnitus alone. Fisch (1970) reported that one of four patients had a positive response with respect to tinnitus. Most data on ablative surgery come from studies of the treatment of Méniere's syndrome or vestibular schwannoma (Baguley, Moffat & Hardy, 1992; Harcourt et al., 1997; Silverstein, Haberkamp & Smouha, 1986; van Leeuwen et al., 1996). In Méniere's syndrome, labyrinthectomy or vestibular nerve section often result in a rapid recovery from incapacitating vertigo, but tinnitus is typically unchanged. The elevation of a mood state may result in a dramatic improvement in general stress level, and through this mechanism alleviate tinnitus in some patients.

 

[t-man]

This article is outdated and most recent publication lean toward the brain generating a phantom single due to a lack of output from the cochlear.

The fact that the author states that tinnitus can be "successfully treated either by conservative medical treatment or by specific surgery" should set off a few warning bells.

Isn't they said after few months our brain will start to get used to the phantom sound?

Not for me and many other people.

 

[Molan]

With regard to what Jastreboff wrote I believe it's important to bear in mind he is selling a product that is Tinnitus retraining therapy which he profits from. The more people pay to have TRT through him the more money he makes it's that simple. So it's important to bear in mind what he says is unlikely to be completely objective if it shows the neurophysiological model he endorses to be flawed.

A few points from what was pasted,

clinical data show that cutting the auditory nerve induces tinnitus in 50% of patients who previously did not experience it (Berliner et al., 1992).

The study I posted was from 1995 which was 3 years after which showed complete relief in 101 patients out of 151 which is a success rate of 67%. This is a statistically significant figure in my opinion.

However Jastreboff writes,

Therefore, section of the auditory nerve or destruction of the cochlea, which are peripheral to the brainstem, would not be expected to have any positive effect on tinnitus and could even make it worse (Jastreboff, 1990, 1995)

However this is clearly shown to be incorrect because 67% of people who had their auditory nerve severed experienced complete relief from their Tinnitus. So that clearly shows Jastreboff to be wrong on this subject. In fact if even one person had their Tinnitus cured from having the nerve severed shows that in some cases at least the Tinnitus signal is produced exclusively in the inner ear region and when the connection to the brain is severed the Tinnitus noise can no longer be heard.

However this is obviously a very complex condition which vary from individual to individual. Although 101 out of 151 patients experienced complete relief it's very important to note that 43 patients only reported an improvement and crucially 7 reported no change at all. Therefore I would strongly discourage anyone from having this procedure done even if it had a 99% success rate which it clearly does not.

What it does show however is that severing the cochlear nerve has been shown to cure some people's Tinnitus and therefore highlights the flaws in the Neurophysiological model and the theory that Tinnitus is a brain only disorder. Therefore it's important to approach any potential treatment from multiple angles not just one. My personal belief is that neuron damage is responsible for most cases of Tinnitus but even then there are people who are completly deaf who do not have it and others with hearing loss but no tinnitus.

 

[frohike]

Below I'm pasting content from the recent overview article of The Lancet. It suggests that some conditions may be treatable with ablation of the cochlear nerve. It also says that more data is needed.

Surgery for tinnitus

Surgery has a small but definite role in tinnitus management. Its place with regard to pulsatile tinnitus and that associated with specific conditions such as otosclerosis or Ménière's disease is beyond the scope of this Seminar. Initial theories of tinnitus pathogenesis focused very much on the ear; consequently, the working hypothesis was that ablation of the cochlea or section of the cochlear nerve would eradicate tinnitus, albeit at the expense of causing total deafness in the affected ear. Few studies of this treatment option have been done, and none that meet stringent scientific standards. The available data show tinnitus improvement in 45%85 to 95% of patients,86 but complete destruction of the hearing will always limit the applicability of this procedure.

The suggestion that some cases of tinnitus could be caused by blood vessels pressing against the auditory nerve arose from work on facial neuralgia. Surgery to decompress these neurovascular conflicts could therefore offer a resolution of the symptoms in these cases; however, the evidence so far is conflicting. Although some researchers have reported positive results,87 these are based on small numbers of patients. This type of surgery is best thought of as a preliminary experimental technique.

Cochlear implantation is one type of tinnitus research in which good evidence supports the effect of the intervention.88 More than 80% of patients with bilateral profound sensorineural hearing loss have tinnitus. Cochlear implantation improves or eliminates tinnitus in up to 86% of these patients, although 9% report worse postoperative tinnitus. Of patients who do not have tinnitus initially, up to 4% develop it after surgery. Cochlear implantation is also being investigated as treatment for patients with single-sided profound sensorineural hearing loss and normal or near-normal hearing in the other ear. Although this approach will probably be appropriate for only a tiny proportion of patients with tinnitus, initial reports suggest that it is very successful in this subgroup.89

85 Wazen JJ, Foyt D, Sisti M. Selective cochlear neurectomy for debilitating tinnitus. Ann Otol Rhinol Laryngol 1997; 106: 568-570. PubMed
86 Pulec JL. Cochlear nerve section for intractable tinnitus. Ear Nose Throat J 1995; 74: 468-476. PubMed
87 De Ridder D, Møller A. Microvascular compression of the vestibulocochlear nerve. In: Møller AR, Langguth B, DeRidder D, Kleinjung T, eds. Textbook of tinnitus. New York: Springer, 2011: 327-336.
88 Baguley DM, Atlas MD. Cochlear implants and tinnitus. Prog Brain Res 2007; 166: 347-355. CrossRef | PubMed
89 Punte AK, Meeus O, van der Heyning P. Cochlear implants and tinnitus. In: Møller AR, Langguth B, DeRidder D, Kleinjung T, eds. Textbook of tinnitus. New York: Springer, 2011: 619-624.

Jastreboff suggests that "decreased activity coming from the cochlea" could result in "tinnitus-related neuronal activity" after the initial relief. I don't know if this was the case.

My impression is that surgery may help on some cases, that there is a risk that deafness causes tinnitus, and that more data is needed. Caveat: I'm just trying to form an opinion from what I read. I'm no scientist, and even for them it's hard work to evaluate this stuff.

 

[EddyLee]

The most important findings for me is that since many tinnitus patients still can eliminate their tinnitus by surgery or other methods after some long time means our brain most likely will not get used to tinnitus and regenerate the phantom sound by itself and this gives hope that chronic tinnitus still can be eliminated by treatment that target inner ear aka AM-101.

 

[James White]

@EddyLee I agree with you and if AM101 goes to the market, we'll probably see a lot of experiments on people with chronic tinnitus that may work. Maybe the number 67% would correlate, making it a pretty good treatment.

 

[Molan]

My impression is that surgery may help on some cases, that there is a risk that deafness causes tinnitus, and that more data is needed. Caveat: I'm just trying to form an opinion from what I read. I'm no scientist, and even for them it's hard work to evaluate this stuff.

Thank you for posting that article from the lancet.

Yes Tinnitus is a very strange condition. Just when you think you might have deciphered some pattern to it more evidence emerges to contradict it. It's not suprising that the medical professionals have had a hard time figuring it out. However given all the availible data so far I think a multiple approach is needed to take into account all the angles. The neurophysiological method endorsed by Jastreboff has been proven to be limted and flawed.

I found another study on Pubmed which I was not previously aware of. It's got alot of technical words in it but from what I can understand,

In a case review of patients who had the surgical procedure done on their cochlear nerve In a long-term follow-up, 53.3% (8 cases) of our tinnitus cases improved and 20% (3 cases) of them were completely cured. This is further evidence of Tinnitus residing in the inner ear exclusively in some people at least. See the abstract below,



Microvascular decompression of cochlear nerve for tinnitus incapacity: pre-surgical data, surgical analyses and long-term follow-up of 15 patients.

Abstract
The level of success of neurovascular decompression in ponto-cerebellar angle for hemifacial spasm and trigeminal neuralgia has already established the reality of the pathology to explain such symptoms. However, cochlear nerve compression syndrome by vascular loop is still a controversial topic. We have performed a retrospective cases review with long-term follow-up (5-7 years) concerning the results of microvascular decompression surgery of the cochlear nerve via an endoscopy assisted retrosigmoid approach on 15 patients suffering from unilateral incapacitating tinnitus with abnormal auditory brainstem response and an offending vessel on magnetic resonance imaging. During the surgery, a vascular compression was found on every patient. In a long-term follow-up, 53.3% (8 cases) of our tinnitus cases improved and 20% (3 cases) of them were completely cured. The ABR returned to normal in all patients who had good clinical results (diminished or disappeared tinnitus). When a vertebral artery loop (5 cases) was concerned we obtained 80% of good clinical results. No one showed amelioration or sudden aggravation of their hearing. Three cases required surgical correction of cerebrospinal fluid leak and one case developed spontaneously regressive swallowing problems. Such microvascular decompression surgery of the cochlear nerve appears to be successful in treating incapaciting tinnitus in particular when a vertebral artery loop is observed. Therefore, in such a case, one might recommend neurovascular decompression surgery, keeping in mind that the complications of this surgery should be minimized by a careful closure of the retrosigmoid approach. In order to ensure a better selection of patient more accurate cochlear nerve monitoring and functional MRI should be a promising assessment.



Again though this procedure did not have a 100% success rate further highlighting the complexity of the condition.

 

[Molan]

Here is another study showing some people's Tinnitus being cured through surgery.

Seventy-four patients were operated on within a period of 10 years to treat incapacitating tinnitus; 72 underwent microvascular decompression (MVD) of the intracranial portion of the auditory nerve, and 2 underwent section of the eighth nerve close to the brain stem. Of those who underwent MVD, 2 had no change in symptoms and later also underwent section of the eighth nerve near the brain stem. Two patients did not return for follow-up. Of the 72 remaining patients, 13 (18.1%) experienced total relief from tinnitus,



Vascular decompression surgery for severe tinnitus: selection criteria and results.

Abstract
Seventy-four patients were operated on within a period of 10 years to treat incapacitating tinnitus; 72 underwent microvascular decompression (MVD) of the intracranial portion of the auditory nerve, and 2 underwent section of the eighth nerve close to the brain stem. Of those who underwent MVD, 2 had no change in symptoms and later also underwent section of the eighth nerve near the brain stem. Two patients did not return for follow-up. Of the 72 remaining patients, 13 (18.1%) experienced total relief from tinnitus, 16 (22.2%) showed marked improvement, 8 (11.1%) showed slight improvement, 33 (45.8%) had no improvement, and 2 (2.8%) became worse. The patients who experienced total relief and those who showed marked improvement had experienced their tinnitus for an average of 2.9 years and 2.7 years, respectively; those who showed slight improvement and those who had no improvement had experienced their tinnitus for a longer time before the operation (mean, 5.2 and 7.9 years, respectively). Of the 72 patients who were operated on and followed, 32 were women. Of these, 54.8% experienced total relief from tinnitus or marked improvement, while only 29.3% of the men showed such relief or improvement. Selection of the patients for operation was mainly based on patient history and, to some extent, on auditory test results (brainstem auditory evoked potentials [BAEP], acoustic middle ear reflexes, and audiometric data).

 

[EddyLee]

@EddyLee I agree with you and if AM101 goes to the market, we'll probably see a lot of experiments on people with chronic tinnitus that may work. Maybe the number 67% would correlate, making it a pretty good treatment.

I guess the effective rate of AM101 won't be as high but as long as it is proven to be effective for chronic tinnitus that will be wonderful as it means our brain won't be remembering the sound causing inner ear treatment uneffective. And then one day a more potent inner ear drug in the future will surely be effective for most patients!

 

[Per]

However this is obviously a very complex condition which vary from individual to individual. Although 101 out of 151 patients experienced complete relief it's very important to note that 43 patients only reported an improvement and crucially 7 reported no change at all. Therefore I would strongly discourage anyone from having this procedure done even if it had a 99% success rate which it clearly does not.

If this procedure had a 99% success rate I would definitely have it. I would still have it if the 1% outcome was death.

 

[Andrew Monger]

My T is incredibly constant in both frequency and amplitude, and this has led me to think of my T as though an audio oscillator is running in my head. I've studied the principles of the cochlear amplifier and the tonotopic structure of both the cochlea and the auditory cortex which, along with the regulatory action of the efferent feedback system, seems to support regenerative feedback between the cochlea and the auditory cortex. If this is the case, then it would appear that this procedure would be successful. I hope to soon see the results of the T survey that will show how many people have the same constancy of T that I have as this will further support the feedback theory.

 

[Erlend]

If such amazing results have been achieved, how come people still say "there might be a treatment in 10 years"

Sounds like were pretty fucking close if these results are true?

On an unrelated note:
I was "myself" for the first time since i got T while falling a sleep last night. I suddenly noticed that I wasn't thinking about the T at all, I was doing what I used to do trying to fall asleep; Playing out what a dialogue would be if I met Louis CK, Steve Jobs, Vince Gilligan and other people I admire (I find this to be extremely an effective way to fall asleep lol)

Was a "milestone" or whatever you wanna call it for me!

 

[Molan]

If such amazing results have been achieved, how come people still say "there might be a treatment in 10 years"

Sounds like were pretty fucking close if these results are true?

I think they are referring to treatments which will cure Tinnitus but won't cost you your hearing. If you have your Cochlear nerve severed like in these studies then you will obviously be completely deaf.

 

[LadyDi]

Apparently, vascular decompression of the eighth cranial nerve has been tried in various cases, on and off, for some time. And it has been successful in some cases. Here is one:

http://www.tinnitusjournal.com/detalhe_artigo.asp?id=371

Unlike a nerve section, it does not cost you your hearing.

I have heard nothing of this procedure and plan to look for more info. Apparently, it works in those cases where the tinnitus is caused by a pressure on a certain portion of the nerve. Vertigo often is involved.

 

[Molan]

Thanks very much for that study LadyDi I had not seen it before. It was very interesting to read.

Yes I too have never heard of this particular procedure before yet it was done almost 20 years ago? Looks like it has potential so I wonder why it isn't more well known?

 

[LadyDi]

Hey Molan... I fear it probably is not more well know because it is effective only when very specific circumstances are involved. I saw on initial look no large studies. But I will look more and let u all know.

 

[gary]

Apparently, vascular decompression of the eighth cranial nerve has been tried in various cases, on and off, for some time. And it has been successful in some cases. Here is one:

http://www.tinnitusjournal.com/detalhe_artigo.asp?id=371

Unlike a nerve section, it does not cost you your hearing.

I have heard nothing of this procedure and plan to look for more info. Apparently, it works in those cases where the tinnitus is caused by a pressure on a certain portion of the nerve. Vertigo often is involved.

Thank you for the link, I am going to see my ENT next week. He has been working with me very closely regarding T I will bring this to his attention and get his thoughts...

 

[LadyDi]

Thanks Gary. This study is from 1995... But are they looking into this at all anymore? We know more neuologist are getting involved in T research. Be interested I u or anyone hears anything.

 

[Rog]

@Molan Found this one from 2012


http://www.neurologyindia.com/artic...e=60;issue=5;spage=495;epage=497;aulast=Zhang

 

[vasil]

Hello everybody. This is my first post here, so excuse me if I i put this tread in the wrong section of the site. I have tinnitus in my right ear for almost two mounts now. The audiogram in the right ear was pretty good, while the left one was not so pink. I am tired of ENTs and otoneurologist who cant find a reason for my tinnitus and just prescribe me a handfull of useless drugs. I tried to enter the AM-101 test but Auris just said me that there was no clinical trials in my country, so f*ck you and kind regards, was pretty much the e-mail I received from them. I read that after the third month the the tinnitus goes from the ear to the brain and from that point it becomes chronic. And threatment from chronic tinnitus is lightyears away, so I am thinking of killing the right ears somehow. I have read about severingthe 8th nerve, but it was too much for my not so good english and I didnt manage to understand, is it possible to just to cut the nerves in the right ear or I have to go the full way and become completely deaf?

 

[Sen]

There is a very good chance that severing part or all of the auditory nerve will do nothing for your tinnitus.

There is also a very high chance that over time you will habituate to your tinnitus and find that it no longer bothers you. Two months is hardly anything in the grand time-scale of tinnitus, and I strongly suggest that you work on habituating for a good length of time before making any rash decisions.

 

[HighDesertSage]

I've read that it will cause deafness, but the tinnitus will still be there. Certainly not worth it, but I understand your frustration. We've sent a spacecraft practically out of the solar system and we can't find a cure for tinnitus? Come on science!

 

[vasil]

There is a very good chance that severing part or all of the auditory nerve will do nothing for your tinnitus.

There is also a very high chance that over time you will habituate to your tinnitus and find that it no longer bothers you. Two months is hardly anything in the grand time-scale of tinnitus, and I strongly suggest that you work on habituating for a good length of time before making any rash decisions.

Yep its i wild chance, but still better than the other options. And I am not good at habitating so my options are pretty limited. I have read about TRT, emotions understanding and other stuff, but my bullshit detector is pretty sensitive and sounds the alarm, when it detects some "beleive in yourself and everything will be fine" nonsence.
So still is there an option just to cut the nerve in the right ear. Going completely deaf is kind of too harsh, but if this sound continues i can consider even that.

 

[Sen]

Habituation is a very real and natural physiological phenomenon that happens on its own over time. TRT didn't invent the concept, and you don't have to do any particular therapy in order to habituate. Habituation also has nothing to do with "believing in yourself." Time is easily the most important factor in habituation, and two months is hardly a blip on the radar.

I suggest being a little more open minded and putting some degree of trust in people who have a much greater degree of experience in living with tinnitus than you do. The vast majority of people with tinnitus are eventually able to move on with their lives and stop caring that they have it. There is good evidence to support this.

 

[vasil]

I just cant. The ENT said to me on the second visit, that nothing can be done and i have to "live with it". TRT and habituation sound like live with it. And I don't want to. Considering the fact that I am a little bit more lucky than the people having it in the both ears I have a chance to be normal again if I kill the damaged ear. The above comments give pretty good chance for completely curing or tunning down the sound. But is it possible to be done just on the damaged side? Its too much of a risk if it makes you deaf and doesnt even give 100% chance of eliminating the sound. I can take the chance if the left ear remain, even if the right is completely gone, but tinnitus remains. It will be not very different from my current condition, but atlest I will know that i tried.