Low level laser therapy of
tinnitus - a case for the dentist?
Jan Tunér DDS, Swedish Laser-Medical Society
Is the tinnitus always in the ear?
The following is an edited version of a chapter from the book “Laser
therapy, clinical practice and scientific background” (Prima Books
of Sweden, 2002, www.prima-books.com)
A new and promising indication for laser therapy is tinnitus. This
inner ear disease is a growing problem in noisy modern society and the
number of persons suffering from tinnitus is increasing. Traditional
treatment for tinnitus is psychological support or various masking procedures.
Acupuncture and ginko extracts have been tried with limited success.
Laser therapy alone offers a new and promising treatment modality. Irradiation
is given partly through the meatus, partly behind the ear, provided
the problem really is located in the inner ear. Since the bone behind
the ear is very compact, high power densities and prolonged treatment
times are necessary to reach a sufficient dose in the inner ear when
irradiating through bone.
Witt  is one of the pioneers in this field, but to the knowledge
of the authors his results have not been published in any peer-review
journal. Witt combines infusion of Gingko biloba (Egb 761, 17.5 mg dry
extract per 5 ml ampoule) and laser. This may be a favorable combination
but an evaluation of the contribution of the laser is not possible.
More than 500 patients have been treated since 1989 and Witt claims
that more than 60% of the patients have reached a considerable or total
relief. The laser used is a combination of a HeNe laser with 12 mW output
and a GaAs laser with 5 laser diodes each with 15 mW average power and
output was used. Treatment technique is not stated.
Swoboda  did not find any significant effect of Gingko/laser.
However, the ginkgo infusion used was at a homeopathic level (D3 = 1:1000
dilution), according to Witt.
Partheniadis-Stumpf  also failed to find any effect from the combined
ginkgo (6 ml Tebonin) infusion and laser. However, the laser was applied
at a distance of one cm above the mastoid. The non-contact mode reduces
penetration considerably and the mastoid is not ideal for reaching the
Plath  treated 40 tinnitus patients with 50 mg Ginkgo biloba. 20
patients received sham laser irradiation, 20 real laser. A HeNe laser
with 12 mW output and a GaAs laser with 5 laser diodes each with 15
mW average power and output was used, irradiation procedure approximately
the same as for Partheniadis-Stumpf. In this study, however, 50% of
the patients reported a reduction of the tinnitus of more than 10 dB,
as compared with 5% in the control group, in both self-assessment and
A similar study has been performed by von Wedel . 155 patients
were treated with Ginkgo infusion (5 ml Syxyl D3) and laser. The outcome
was negative. No information about the type of laser, treatment technique
or dosage is given, making evaluation impossible.
Shiomi  has investigated the effect of infrared laser applied directly
into the meatus acousticus, 21 J, once a week for 10 weeks. The result
of this non-controlled study is as follows: 26% of the patients reported
improved duration, 58% reduced loudness and 55% reported a general reduc¬tion
The same author  has also examined the effect of light on the cochlea
using guinea pigs. Direct laser irradiation was administered to the
cochlea through the round window. The amplitude of CAP was reduced to
53-83% immediately after the onset of irradiation. The amplitude then
returned to the original level. The results of this investigation suggest
that laser therapy might lessen tinnitus by suppressing the abnormal
excitation of the eighth nerve of the organ of Corti.
More or less the same parameters were used in a controlled study by
Mirtz  but in this case there was no significant effect.
Nakashima  treated 68 ears in 68 patients with tinnitus. A 60
mW laser was applied for 6 minutes (21.6 J), once a week for 4 weeks
in a double blind study. There was no significant difference between
the two groups, which is not surprising considering the few sessions
and the low energy applied. No differential diagnosis between somatosensory
and other causes for tinnitus was performed.
Wilden [474, 1089] uses a different method with a considerably increased
dose. A set consisting of one visible laser and three powerful GaAlAs
lasers is used, covering a large area over and around the ear in the
non-contact mode. Doses between 3,000 and 5,000 J are given each session.
Laser is applied as a monotherapy. More than 800 patients have been
treated with this concept and positive effects are reported even for
vertigo. Recent injuries in “the disco generation” are more
easily treated than long-term chronic conditions. In a separate study
 Wilden reports improvement of the hearing capacity of these patients,
as evaluated by audiometry. An advantage of the Wilden method is that
several muscles with a possible somatosensory background will be affected
by the large area of irradiation used.
Tauber  has performed an ex-vivo laser penetration study. Based
on these findings it was possible to calculate the energy needed to
obtain a dose of 4 J/cm2 in the cochlea itself. Irradiation via the
mastoid showed values 103 to 105 times smaller (depending on wavelength)
than irradiation through the tympanic membrane. 30 patients were treated
five times within 2 weeks . One group was irradiated with 635
nm diode laser, the other with 830 nm diode laser. By self-assessment
around 40% of the patients reported a slight to significant attenuation
of the tinnitus loudness of the irradiated ear.
Prochazka  has evaluated the effect of combined Egb 761 Ginkgo
infusion and laser in a blind study. 37 patients were divided into three
groups. One group had Egb 761 only, one Egb761 and placebo laser, one
Egb761 and real laser, 830 nm. The results in the three groups were
as follows: no effect 29/26/19, less than 50% relief 44/48/29, more
than 50% relief 18/26/36, no more tinnitus 9/0/26. Irradiation was performed
over the mastoid and over the meatus acousticus, twice a week, 8-10
sessions, total 175 J.
In an extended study over 3 years Prochazka  evaluated the effect
of laser in a group of 200 patients. These patients were taking gingko
biloba preparations (73%) or Betahistadine (39%) and also had physical
therapy, mainly directed at the neck vertebrae. Laser therapy was performed
with a 300 mW GaAlAs laser, 75 J/cm2 into the ear and 135 J/cm2 behind
the ear. The outcome was: no more tinnitus 26%, more than 50% relief
43%, less than 50% relief 15%, no effect 16%. In addition a group of
31 patients were selected for a double blind study where the same therapy
as above was performed, but one group received placebo laser. At 6 months
the outcome was as follows, with laser/no laser: no more tinnitus 25.8%/0.0%,
more than 50% relief 35.5%/25.8%, less than 50% relief 19.4%/48.4%,
no effect 19.4%/25.8%.
Hahn  examined 120 patients with an average duration of tinnitus
of 10 years. The patients underwent pure-tone audiometry, speech audiometry
and objective audiometry tests. The intensity and frequency of tinnitus
was also determined. EGb 761 was administered 3 weeks before the start
of laser therapy. The patients underwent 10 sessions of laser therapy,
each lasting 10 minutes. An improvement in tinnitus was audiometrically
confirmed in 50.8% of the patients; 10 dB in 18, 20 dB in 22, 30 dB
in 10, 40 dB in 6 and 50 dB in 5 patients.
Rogowski  divided a group of 32 tinnitus patients into one group
receiving laser therapy and one receiving a placebo procedure. Dose,
wavelength and treatment technique are not stated in the available English
abstract. The effect was evaluated through VAS. Within the patient group,
transiently evoked otoacoustic emissions (TEOAE) were measured before,
during and after therapy. No significant difference between laser and
placebo was found in annoyance or loudness of the tinnitus and in changes
of TEOAE amplitude. These results indicate that there is no relationship
between the effect of low-power laser and changes in cochlear micromechanics.
All the above studies assume that tinnitus and vertigo are always
inner ear problems. However, these conditions frequently have a muscular
origin (“somatosensory tinnitus”).
The percentage of patients with a muscular origin for their tinnitus/
vertigo is not known but seems to be large. A differential diagnosis
is therefore very important before any therapy is applied, laser or
traditional thera¬pies. If this is not done, studies of the effect
of transmeatal laser therapy become a gamble. The outcome would rather
be related to the type of tinnitus dominating in the verum group than
the actual effect of the therapy. An interdisciplinary co-operation
between the ENT physician and a dentist is recommended.
Meniere´s disease is a condition first described by the French
physician Ménière in 1861. It is a clinical entity consisting
of vertigo, fluctuating hearing loss and tinnitus. Few medical conditions
have been so thoroughly studied and described, yet lacking an effective
therapy. Tinnitus, however, is not necessarily associated with Meniere;
it is often an isolated condition. But the treatment of somatosensory
Meniere and somatosensory tinnitus is very similar and in the following
we make a simplification and speak only about "tinnitus".
Muscular tension is a key element in somatosensory tinnitus. The role
of the laser is to create an immediate reduction of pain in the muscle
with a consecutive relaxation. Thus, this intervention will make all
the following therapy faster and more successful. Somatosensory tinnitus
has been difficult to treat and often passes without a diagnosis. The
combination of laser ther¬apy in the traditional therapy of temporomandibular
disorders and cervical spine disorders (CSD) has been proven to be a
more successful way of helping these patients, compared to traditional
therapies. However, it is not to be expected that all symptoms will
subdue rapidly. The skill of the dentist, the co-operation of the patient
and concomitant physiotherapy are important factors. Many patients will
not be completely relieved of symp¬toms but the majority will experience
a great reduction of their problems. According to Bjorne  and
Estola-Partanen  the treatment of somatosensory tinnitus reduces
the severity of tinnitus more than the inci¬dence. The 3-year follow
up study by Bjorne  showed simultaneous decreases in the intensities
of vertigo, nonwhirling dizziness, tinnitus, feeling of fullness in
the ear, pain in the face and jaws, pain in the neck and shoul¬ders,
and headache that were both longitudinal and highly significant. Signif¬icant
reductions in the frequency of vertigo, nonwhirling dizziness, and headache
were also reported by the patients as well as complete disappear¬ance
of pain located in the vertex area. A significant relief of TMD symptoms
and decrease in nervousness was also achieved. It must be underlined
that the success in the study  reflects the outcome of the therapy
before the author started to use laser therapy as an additional method.
The addition of laser therapy has then further improved the progress
in this category of patients. Frequently these patients can notice a
change in the character of their tinnitus when the lateral pterygoid
muscle is irradiated.
The suboccipital muscles should also be palpated, since these muscles
and the masticatory muscles are closely functionally connected. In fact,
the mandible and the upper cervical joint (C0/C1) constitute an integrated
The therapy outlined below brings new hope to a large group of "intractable"
patients. It outlines the traditional therapy created by Bjorne, with
the recent (2000) successful addition of laser therapy.
Somatosensory tinnitus examination and therapy acc. to Bjorne/Tunér
Does the patient experience a feeling of fatigue in the jaws, difficulties
in mouth opening, sensations of tension in the jaws/neck, hypersensitive
or tender teeth, clenching of tongue/jaws, tendency for general stress,
wakes up at night due to tinnitus?
Can the patient manipulate his/her tinnitus through movements of the
jaw and neck? Usual movements evoking this phenomenon are: opening the
mouth wide, protrusion and side movements of the mandible, flexion/
extension and side rotation of the upper cervical joints.
Can the patient manipulate his/her tinnitus by putting pressure/ stimulation
in the areas of the sensory innvervation of the trigeminal nerve of
the trigeminal nerve? Usual areas evoking this phenomenon are putting
pressure on tragus, over the cheek, jaw or temple, the stylomandibular
ligament but also gazing with the eyes.
Are there other symptoms related to tension: pain in the jaws, face,
neck, and headache?
Observation of hypertrophic masticatory muscles and possible abnormal
posture of the head/neck.
Palpation of the masticatory muscles (the lateral pterygoid muscle in
particular), the TMJ, and the suboccipital muscles.
Range of movement of the mandible and neck.
Active shining bruxing facets as signs of active bruxism.
Laser treatment of tender areas in the jaw and neck muscles, 5-15 J
per point depending on size and location of muscle. 2-3 sessions per
week acc. to the evolution of improvement, preferably with GaAlAs or
Training in how to normalise abnormal head/neck posture, and training
how to relax masticatory, neck and shoulder muscles.
Training of autostretching of the suboccipital muscles (the rectus capitis
posterior minor and major muscles and the obliquus capitis superior
muscles), the upper and middle trapezius muscles and the levator scapulae
muscles. Laser therapy of tender areas in these muscles is also recommended.
Minute examination of occlusal function and presence of active interferences,
followed by adjustment through grinding.
Information about the necessity of adjusting style of life.
Bite splint in selected cases
Most common dental occlusal backgrounds:
The patient is clenching/bruxing on active shining facets of the front
teeth, forcing the TMJ:s to slide forwards, due to activation/tension
of the lateral pterygoid muscles.
Cross bite (sliding areas preventing central occlusion and balanced
Elongated teeth, forcing the TMJ into an unbalanced position.
Also see old article Low
level laser therapy of tinnitus - a case for the dentist?