Research Article

Manual Therapy on Quality of Life and Symptom of Tinnitus

Thatiane Aline Cunha1, Bruna Mastroldi dos Santos2 and Paulo Roberto Rocha Júnior2,3,4*

1Department of Physiotherapy, Paulista University of Assis, São Paulo, Brazil

2Department of Physical Therapy, Paulista University of Assis, São Paulo, Brazil

3Departments of Medicine and Physical Therapy, University Center of Adamantina, São Paulo, Brazil

4Master's Program in Health Education, Medical School of Marília, São Paulo, Brazil

*Corresponding author: Paulo Roberto Rocha Júnior, Department of Physical Therapy, Paulista University of Assis, São Paulo, Brazil, Tel: +5514981460418; E-mail:

Citation: Cunha TA, dos Santos BM, Rocha Júnior PR (2019) Manual Therapy on Quality of Life and Symptom of Tinnitus. Curr Adv Otorhinolaryngol Dis Ther 2019: 4-7

Received: 17 June, 2019; Accepted: 02 August, 2019; Published: 07 August, 2019


Objective: to analyze the effect of a manual therapy protocol on the symptom and quality of life of individuals with non-specific tinnitus. Method: during the evaluation, the subjects were submitted to the Tinnitus Handicap Inventory (THI), to identify the quantification of tinnitus impact on quality of life, and the Visual Analogue Scale (VAS) to identify intensity of tinnitus. A manual therapy protocol was developed based on the manipulation of the sternocleidomastoid and masseter muscles, circumferential movement of the temporal bones and the technique of the "pull of the ear". Results: the sample consisted of 11 patients, 63.6% female and 36.3% male. The mean age of participants was 71.6 years. Significant improvement of the overall quality of life (p=0.0002) and intensity of the tinnitus (p=0.0001) was observed. Conclusion: the manual therapy improved the tinnitus symptom and quality of life of the participants.

Keywords: Tinnitus; Musculoskeletal manipulations; Physiotherapy; Quality of life


The human ear has the function of perceiving the balance and transforming the sound waves into electrical signals, transmitting this information to the brain, through the auditory nerve. The ear is in the temporal bone, positioned at the base and lateral wall of the skull [1].

Regarding biomechanics, the temporal bone rotates on axes located externally near the external auditory canals. These axes move diagonally and anteriorly, causing oscillating rotation of the temporal squama. The widening of the transverse distance between the upper margins, along with the anterior movement is referred to as an external rotation of the temporal bones. In internal rotation, the movements are reversed: the transverse distance between the upper margins of the temporal bones decreases as these margins move posteriorly (Figure 1) [2].


Figure 1: Temporal rotation of external rotation and internal rotation [2].


For Upledger [2], movement restrictions of temporal bones can result in clinical problems related to hearing, balance, pain and vagotonia.

Tinnitus (sensation of noise inside the ear) can be caused by an injury, infection or a disorder of the auditory system and, in many cases, it is related to the vestibular system [3-5].

The presence of tinnitus has the negative consequence of insomnia, irritability, making it difficult for social life, emotional balance, loss of daily activities, resulting in anxiety and depression crises, including health disorders, behavioral disturbances and interpersonal relationships [5-8].

According to Liem [9], manual therapy has musculoskeletal techniques and manipulations that can relieve the tinnitus symptom. In this sense, cranial osteopathy aims to release the restrictions of bones and cranial sutures, in order to promote structural mobility and fluctuation of cerebrospinal fluid [9].

Person et al. [4] emphasize that there is no "ready recipe" to treat tinnitus. Successes and failures occur with any professional, but the experience and encouraging way in which the problem is dealt with will reflect on therapeutic success [10].

Thus, knowing that temporal bone contains relevant connective, vascular and nerve structures for the ear, and that possible biomechanical dysfunctions can trigger auditory and vestibular symptoms, a study to analyze the efficacy of a manual therapy protocol with emphasis on temporal bone synchronization in the tinnitus symptom was proposed [2,4,5].


To analyze the effect of manual therapy on quality of life and nonspecific tinnitus symptom.


Kind of study

Field study, quantitative of experimental character.

Data collection and ethical aspects

This research was approved by the Committee of Ethics in Research with human beings, based on the resolution n° 466/12 of the National Council of Health (CAAE - 62604916.8.0000.5413).


Participants in the study were users of a Family Health Strategy, aged 18 years or older, of both sexes, with tinnitus. We included those who agreed to the study and signed the Informed Consent Term. Individuals with neurological and oncological diseases, cognitive and intellectual disorders, as well as non-participating individuals were excluded.

Evaluation tools

The Tinnitus Handicap Inventory was developed by Craig Newman to assess and diagnose the intensity and quantification of the impact of tinnitus on quality of life. This questionnaire is composed of 25 questions, adapted to the Portuguese language. A score of zero to 100 points is obtained, classifying the impact of tinnitus on quality of life in soft (0-16), mild (18-36), moderate (38-56), severe (58-76) and catastrophic (78-100) [11-13].

Tinnitus intensity was assessed by a Visual Analogue Scale (EVA) in a quiet environment. There was a line about ten centimeters long on the evaluation form. At the beginning of the line was marked "absence of tinnitus" and at the end of the line, "unbearable buzz". The patient will graduate with a pen the intensity of his tinnitus on that line. Then the examiner will check the score with a ruler [14].

Intervention strategies

Ten manual therapy sessions were held within five weeks. These sessions were held in the physiotherapy laboratory by a research physiotherapist duly trained to perform the techniques. The patients lay on the stretcher in a quiet room.

The procedures followed the following sequence:

  1. Observation of the craniosacral movement, forward and backward, with hands on the patient's ears, seeking movement observation [2];
  2. Transversal mobilization of the sternocleidoocciptotoid muscles, to obtain the facilitation of movement of the temporal bone [2];
  3. Digital pressure on the masseter muscles, because, when hypertonic, they restrict the movement of the temporal bones [2];
  4. Synchronization of temporal bone movement and Still Point are performed. During the Still Point, our body's natural corrective forces promote a deep structural reorganization in the environment where the brain and spinal cord work. The auscultation of the movement to have if there is still the restriction of the craniosacral movement is realized later (Figure 2) [2].

    Figure 2: Circumferential motion technique [2].

  5. In the technique of "ear tugging" the therapist performs traction of the ear lobes for posterior and lateral ear (Figure 3) [2].


Figure 3: "Ear Pull" Technique [2].


The technique is indicated for medial compression and dysfunction of the temporal bones, when the movement of the skull becomes abnormal. The movement of the technique will reach the petrous part of the temporal bone, releasing the compressed movement [2].

Data analysis

The paired Student T test was used to compare pre and post-evaluation data. A significance level of p<0.05 was used for all the results.


The study sample was 11 patients, 63.6% female and 36.3% male. The mean age of participants was 71.6.

It was observed that the manual therapy protocol contributed significantly (p=0.0002) to the quality of life of the studied sample, as shown in figure 4.


​​​​​Figure 4: Total quality of life measured by Tinnitus Handicap Inventory
before and after manual therapy interventions.


As for the manual therapy protocol on tinnitus intensity, a very significant improvement (p = 0.0001) was identified (Figure 5).


Figure 5: Tinnitus intensity measured by visual analog scale before and
after manual therapy interventions.



Temporal bone dysfunction in internal rotation leads to narrowing of the cartilaginous part of the auditory tube, resulting in an acute noise. In external rotation, the tube is kept open, presenting a low noise. This sound can be produced by the blood flow to the internal carotid artery in its curve in the petrous portion of the temporal bone, as the artery is separated only by a thin bone layer [15].

The most common symptoms involving temporal bone dysfunction are deafness, tinnitus, dizziness, earache, otitis media, neuralgia, migraine, headache, temporomandibular joint problems and facial nerve palsy [9].

Nonspecific tinnitus in the ear may be related to pain, pain radiating to the neck, joint pain with muscle spasm, ear fullness and involvement of the masticatory muscles. There are case reports that confirm the association of non-specific tinnitus with myofascial trigger points. Myofascial pain syndrome can be relieved by the digital pressure technique for the deactivation of myofascial trigger points and the relief of non-specific tinnitus. People who have the symptom of nonspecific tinnitus, are three times more likely to present myofascial pain [16-18].

Manual therapy techniques may contribute to the relief of non-specific tinnitus by mobilizing temporal bones and myofascial release of the masseter muscles [2,17].

Cranial osteopathy and manual therapy are aimed at reestablishing temporal bone mobility, craniosacral motion and the release of trigger points from the mastigatory muscle. Cranial osteopathy releases restrictions on cranial bones and sutures. It promotes the fluctuation of cerebrospinal fluid and, thus, improves the tinnitus symptom [19,20].


Manual therapy promoted improvement in the nonspecific tinnitus symptom and quality of life of the study population.

It is worth mentioning that this is a small and convenient sample. Therefore, studies with random allocation of individuals in different treatment groups and with greater representation are suggested.


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