CLINICS 2011;66(6):1089-1094 ratio or receiver operator curves for any of the maneuvers described. Management of somatosensory tinnitus Somatosensory tinnitus patients need an evaluation of their temporomandibular joint and neck before the best treatment option can be selected. Otolaryngologists and neurologists are usually the first physicians to be sought by patients with tinnitus, but unfortunately little attention is given to the somatosensory influence on tinnitus.28 Many patients with tinnitus would benefit from the complemen- tary opinion of a dentist or a physiotherapist (depending on their availability in each country). If a patient with tinnitus has muscular problems, such as tension in the temporo- mandibular joint or in the neck, these problems should be addressed. Various approaches for the treatment of tinnitus have been modified to include patients with somatosensory tinnitus. Relaxing muscle tension in the jaw and neck Because patients with temporomandibular disorder often present with muscular tension in both the jaw and neck – as well as tinnitus, vertigo/dizziness and aural fullness – the first aim of treatment for somatosensory tinnitus is the reduction of such muscular tension.29 Many patients with such problems also benefit from performing regular stretching exercises of their suboccipital muscles at home, as well as rotation movements in the atlanto-occipital joint – especially to the restricted side – and relaxing exercises involving breathing with the diaphragm. Such treatment of muscle tension in the jaw and neck can reduce tension-related symptoms such as tinnitus, vertigo, aural fullness and pain in the jaw, neck or headache. Indeed, the intensity of all such symptoms was significantly reduced (p,0.001) after a 3-year follow-up examination for patients who used this type of treatment.29 Focal administration of lidocaine into jaw muscles (mainly the lateral pterygoid or the masseter) or into neck muscles (mainly the trapezius and the sternocleidomastoid) may temporarily reduce tension and, consequently, the tinnitus, while the local anesthetic is active.29 This means that relieving temporomandibular disorder and other forms of muscular tension may also relieve tinnitus. Fel´ıcio et al.30 observed that patients with temporomandibular disorder and auditory symptoms improved after using bite splints for eight weeks. Moreover, Wright and Bifano31 reported an 82.5% improve- ment of tinnitus in patients whose temporomandibular disorders improved with the use of cognitive therapy, bite splints and home exercises. Manual therapies (cervical manipulation) Chiropractic care is a popular and successful management option for reversible functional disorders of the cervical spine and other body structures. Some studies have demonstrated that such manipulation can relieve tinnitus.32–36 Alcantara et al.34 described how chiropractic treatment could reduce tinnitus, vertigo and hearing loss in a patient with cervical subluxation and temporomandibular disorder. Symptoms eventually ceased after nine sessions. Kessinger et al.32 documented clinical changes after chiropractic sessions in a geriatric patient with tinnitus, vertigo, hearing loss and cervical alterations from C3 to C7. Throughout the sessions, the patient’s symptoms were alleviated and 1091 Review of somatosensory tinnitus Sanchez TG and Rocha CB structural/functional improvements were also evident through radiographic examination. In contrast to classical chiropractic treatment, Arlen’s atlas therapy is performed without traction, rotation or extension of the cervical spine.37 By means of irritation and tension of the posterior cervical muscle, one might increase the afferent input to the vestibular nuclei in the brain stem, which might give rise to tinnitus.37 Thus, reduction of the tension via atlas therapy seems to lower the proprioception and nociception output, leading to normalization of the flow of information to the brain stem, and, as a consequence, tinnitus improvement. It seems that some somatosensory tinnitus could be alleviated by correcting the misalignment of the cervical spine through manual therapy (chiropractic or osteopathy), especially in the upper cervical region. Such readjustment might allow the entire spine to reposition itself and possibly readjust the input of the region through the somatosensory pathway on the auditory system. According to Kaute,37 many other methods are used to relax the neck muscles, with some success in treating tinnitus: the Alexander method, autogenous training, the Br u¨gger method, craniosacral treatment and Feldenkrais. All act on the same point – the posterior neck muscle. Nevertheless, as much as this topic has been receiving more attention in the current literature, it still needs further clarification. Myofascial trigger point deactivation The relationship between myofascial trigger point (MTP) deactivation and tinnitus relief was initially demonstrated by injecting local anesthetic into these painful spots. In 1960, Travell38 related tinnitus to MTPs located in the deep portion of the masseter muscle, because local injection of lidocaine on the ipsilateral masseter’s myalgic spots relieved one patient’s tinnitus. In this study, injections were repeated eight times and the relief lasted from several days up to four weeks. Wyant39 described two patients in whom tinnitus was relieved after injections with steroid and lidocaine into MTPs in the cervical region. In this study, both tinnitus and pain relief occurred for four months. In an unpublished study of 178 patients who were compared with 39 subjects in a control group, tinnitus completely disappeared in 15% of the cases after cervical MTP injection of lidocaine 1%. In a six-month follow-up after the last injection, tinnitus improved in more than 30% of the cases, as opposed to 15% from a control group.40 In 2005, Eriksson et al.41 showed that some tinnitus patients benefited from stretching and massage. Rocha and Sanchez42 reported the case of a female patient who experienced improvement in her tinnitus, dizziness and chronic facial and cervical pain after having her MTP deactivated by pressure release and after having followed a home exercise program (muscle stretching, postural gui- dance and hot pack). In a double-blind placebo-control randomized clinical trial, we have shown a significant decrease in tinnitus loudness (p,0.001), and in pain intensity (p,0.001), a decrease in tinnitus handicap inven- tory scores (p = 0.01) and a decrease in the number of MTPs (p,0.001) from MTP inactivation by pressure release.43 We consider pressure release as a gradual and sustained digital pressure on the MTP until the patient no longer perceives any sensory abnormality, referred pain or discomfort at the spot where such pressure is applied.