Acupuncture Therapy in Tinnitus Using Single Needle Through Multiple Points Technique TE21-SI19-GB2 and GB3-SI19: A Case Report

Abstract

Background:

Tinnitus is defined as the perception of sounds without physical or external acoustic sources. Treatment methods for tinnitus include psychological and pharmacological therapy; some have disturbing side effects. Acupuncture is another treatment method with minimal adverse effects to return to a homeostatic state. It has been reported that acupuncture can immediately decrease both the hard and tingling quality of tinnitus, resulting in a meaningful improvement in quality of life and better sleep.

Case:

A 45-year-old male presented with complaints of ringing in both ears and diminished auditory perception in the left ear characterized by a rumbling noise. The Tinnitus Handicap Inventory (THI) score of 34 indicated mild tinnitus. An audiometry examination revealed moderate hearing loss in the left ear. The patient was diagnosed with bilateral tinnitus and moderate left ear hearing loss.

Methods:

Manual acupuncture therapy was performed twice per week for 12 sessions at the following points: TE21, SI19, GB2, GB3, TE17, LI4, and KI3 bilaterally. This case report introduces a special technique, single needle through multiple points (SNMP), which penetrates through TE21-SI19-GB2 and GB3-SI19.

Results:

After 12 sessions of acupuncture therapy, the patient’s THI score decreased from 34 to 0, and a subsequent audiometry examination showed normal hearing in both ears.

Conclusions:

This case report demonstrates that SNMP acupuncture therapy could alleviate tinnitus symptoms with no observed side effects. Furthermore, investigation into acupuncture therapy for tinnitus is warranted. Further pragmatic trials are needed to confirm the efficacy and safety of the proposed treatment.

INTRODUCTION

Tinnitus is a common complaint encountered in daily practice by both general practitioners and ENT doctors. Managing cases of tinnitus presents a challenge because of its diverse pathophysiology, which makes treatment quite complex. Tinnitus is often a symptom of an underlying condition, such as ear infections, a history of head or neck trauma, vascular disorders, tumors, hormonal disorders, jaw joint problems, and others. Broadly, these conditions fall into categories such as musculoskeletal, vascular, neurological, and sensory origins.^1,2

About 10–15% of the general population experiences tinnitus. Tinnitus is most prevalent among the elderly, although it can occur at any age. ³ Subjective tinnitus affects about more than 600 million people worldwide, with a prevalence of about 12–15% in the adult population. ⁴ Tinnitus is more common in men than in women, and its prevalence increases with age. Approximately 12% of men aged 65–74 have hearing impairment caused by tinnitus. Individuals exposed to machinery noise are more likely to experience tinnitus. ⁵

Tinnitus caused by conduction disorders typically presents as low-pitched or high-pitched sounds, and it may ring, buzz, whistle, hum, click, hiss, or squeal. If accompanied by inflammation, this phantom sound may feel pulsatile. Low-tone tinnitus associated with conduction disorders often occurs because of ear canal blockages caused by cerumen or tumors, Eustachian tube dysfunction, otitis media, otosclerosis, and other conditions. High-pitched tinnitus frequently correlates with sensorineural hearing impairment, arising from chronic noise exposure, senescence, or ototoxic drug administration, whereby intense sound waves traverse the inner ear’s fluid, resulting in the overstimulation and degeneration of auditory hair cells, thus diminishing its ability to respond to certain sound frequencies and prompting the persistent perception of high-pitched tinnitus.^1,6,7

The pathophysiological mechanism of tinnitus remains unclear, making the condition difficult to treat effectively. ⁸ Tinnitus results from endogenous electrical activity in the auditory cortex, producing sound sensations independent of external stimuli, often linked to various auditory disorders and abnormal subcortical neurological activity, with characteristic patterns tied to auditory memory and the limbic system’s emotional associations.^1,9 Stress-induced cortisol modifies hippocampal synaptic plasticity, with diminished sensory input enhancing neuronal plasticity, commonly associated with tinnitus and auditory deficits, while the limbic system, particularly the hippocampus, amygdala, and prefrontal cortex, is implicated in cortisol’s stress response; furthermore, chronic stress is proposed as a significant factor exacerbating tinnitus. ¹⁰

Treatment methods for tinnitus include acoustic desensitization, cognitive therapy, transcranial magnetic stimulation, masking, habituation therapy, stress management, and pharmacological treatments (such as sedatives and anticonvulsants). However, some of these methods have side effects, and currently no treatment has shown promising clinical outcomes for tinnitus.^7,11 Acupuncture, a relatively safe option with minimal side effects, is another approach, particularly for tinnitus with somatic triggers.

Acupuncture has been shown to modify neurotransmitter levels such as serotonin, oxytocin, and endorphins, potentially influencing tinnitus by regulating the autonomic nervous system and alleviating hyperactivity and distress. ⁷ Abnormal cerebral blood flow, notably increased in regions such as the bilateral primary auditory cortex and the right superior temporal gyrus, superior frontal gyrus, fusiform gyrus, and parahippocampal gyrus, has been strongly associated with tinnitus severity. Acupuncture may help normalize these irregularities by modulating blood flow and fostering neuroplasticity. ¹² In addition, functional magnetic resonance imaging studies revealed that acupuncture may correct abnormal connectivity in regions such as the posterior cingulate gyrus, supplementary motor area, and superior frontal gyrus, potentially addressing the auditory and emotional dysfunctions associated with tinnitus. These findings provide a neurophysiological basis for acupuncture’s role in tinnitus management.^13,14

Several clinical trials have been conducted to evaluate the efficacy of acupuncture for tinnitus, with varying methodologies and outcomes, such as improved recurrence frequency, intensity, and quality of life. Despite these promising results, none of the studies specifically investigated techniques such as the single-needle through multiple points method, suggesting that innovative approaches, such as this case, could add significant value to the field.^15–18

CASE

A 45-year-old male presented with complaints of ringing in both ears, along with diminished auditory perception in the left ear characterized by a rumbling noise, with the onset of these symptoms occurring abruptly, devoid of preceding hearing impairment, persisting for 1 year, and exacerbating in crowded environments or periods of fatigue. There was no history of flu and nasal congestion, otitis media, acoustic trauma, significant stress at that time, foreign objects inserted into the ear, manipulation, or removal of the earwax. The patient had previously been treated at an ENT clinic in a private hospital, where he was suspected of having sudden deafness and received treatment for a few days. Upon hospital discharge, symptoms recurred without any therapy for a year before initiating acupuncture.

The examination revealed cerumen accumulation in both auditory canals, an intact tympanic membrane devoid of inflammatory signs, normal laboratory results, a Tinnitus Handicap Inventory (THI) score of 34 denoting mild tinnitus (class 2), and moderate hearing loss in the left ear. The patient was diagnosed with bilateral tinnitus and moderate left ear hearing loss.

After the patient provided informed consent for the acupuncture procedure, the patient was treated with acupuncture therapy using filiform needle sizes 0.25 × 25 mm and 0.25 × 40 mm, targeting acupuncture points TE21, SI19, GB2, GB3, TE17, LI4, and KI3 (Fig. 1), bilaterally. ¹⁹ The technique used was single needle through multiple points (SNMP), using a single needle on TE21, SI19, and GB2, and another needle on GB3 toward SI19. The needles were inserted at a 15–30-degree angle into a depth of 3–4 mm. The remaining points were treated using a single needle at each acupuncture point, which was inserted perpendicularly to a standardized depth of 15 mm. The acupuncture needles were stimulated using the rotating technique until the de qi sensation, after which the needles were retained at the acupoints for 20 min. Manual acupuncture was performed in 12 sessions twice per week. The patient was also advised to maintain regular acupuncture sessions, get adequate rest, and avoid stress.

FIG. 1.

Acupuncture points locations of TE21, SI19, GB2, GB3, TE17, LI4, and KI3 used in the 45 years old man with tinnitus. GB, gallbladder; KI, kidney; LI, large intestine; SI, small intestine; TE, triple energizer.

The patient had been experiencing this condition for 1 year, and his recovery occurred gradually over a period of 6 weeks during acupuncture therapy. This suggests that recovery was unlikely to be spontaneous and that acupuncture therapy played a significant role. In addition, during the acupuncture treatment, the patient did not receive any other therapeutic interventions from the ENT clinic.

RESULT

After 12 sessions of acupuncture therapy and a 2-month follow-up, the patient no longer experienced tinnitus, his THI score reduced to 0 (Fig. 2), and his audiometric test results returned to normal.

FIG. 2.

THI score during treatment. THI, Tinnitus Handicap Inventory.

DISCUSSION

In this case, the diagnosis of tinnitus was based on the patient’s chief complaint of a ringing sound similar to a rumble. Henry defined tinnitus as the perception of sound without any external acoustic stimulus. ²⁰ This case was not classified as auditory hallucination, as the sound did not have any specific meaning, unlike those experienced in auditory hallucinations. The audiometry results indicate the presence of hearing impairment, which confirms the diagnosis of subjective tinnitus.

The principle of acupuncture treatment for tinnitus is to improve the pathological condition within the ear through nerve stimulation, providing both local and central effects. ²¹ Acupuncture points in the ear region are selected to stimulate the innervation of the ear, as well as distal points that are clinically indicated for ear disorders. The selected local points are TE21, SI19, GB2, GB3, and TE17, while the selected distal points are LI4 and KI3. The local points used in this case were located in front of the tragus, an area traversed by various neurovascular branches, including branches of the superficial temporal artery and vein, the great auricular nerve, the auriculotemporal nerve, and the facial nerve. ²² Stimulation of these acupuncture points triggers the neurovascular complex, which can affect the inner ear cells in the cochlea, improve local microcirculation, facilitate blood diffusion and perfusion, and aid in the recovery of hearing function caused by reversible functional disorders.^22,23 Based on functional near-infrared spectroscopy examinations, needling at these acupuncture points can increase the concentration of oxygenated hemoglobin in the temporal lobe and activate the auditory cortex in patients with tinnitus. ²⁴ The use of distal acupuncture points has been proven to influence auditory area activity in the cerebral cortex and provides central stimulation through the hypothalamus-pituitary complex, leading to the release of neurotransmitters such as serotonin, oxytocin, and endorphin, which induce physiological and psychological effects, thereby alleviating tinnitus symptoms.^25–27

Research by Neri et al. ²⁸ explored the role of nitric oxide and L-ornithine in patients with tinnitus, revealing reduced levels of both substances alongside elevated oxidative markers in acute cases, which may contribute to cerebrovascular endothelial and microcirculatory dysfunction in the inner ear, while acupuncture is noted to enhance nitric oxide levels. ²⁹ A theoretical framework for tinnitus, akin to chronic pain, ³ posits that it arises from spontaneous neuronal discharges generally elicited by glutamate. ³⁰ Acupuncture demonstrates efficacy in mitigating excitatory amino acids such as glutamate, thus paralleling its effectiveness in chronic pain. Meanwhile, high-frequency electroacupuncture may enhance GABA levels, which counteract glutamate. ³¹

The method used is the penetrating needle technique, using a single needle on TE21, SI19, GB2, and GB3 towards SI19. Penetrating needle insertion (SNMP) is a technique that uses one acupuncture needle to stimulate multiple acupuncture points simultaneously. The advantage of this technique is that it reduces the number of needles and insertions, thereby minimizing the pain caused by needle insertion. This method can stimulate more tissue sensory receptors, resulting in better therapeutic outcomes. ³²

In this case, the patient experienced significant improvement and reported that it was easier to communicate in crowded places. In addition, a notable reduction in the THI score was observed from 34 to 0. During the fifth session, a slight increase in the THI score was noted following the patient’s recent airplane trip, illustrating that tinnitus symptoms may exacerbate with exposure to loud sounds; however, audiometric evaluations demonstrated significant improvement from initial moderate left ear hearing loss to normal hearing in both ears after 12 therapy sessions.

CONCLUSION

This case study demonstrated the efficacy of SNMP acupuncture therapy for a tinnitus patient, suggesting it may serve as an alternative for those unresponsive to conventional treatments or hindered by adverse effects; however, further pragmatic trials comparing this method to standard care are essential to assess optimal dosing parameters, including the timing, frequency, and duration of treatment, and mitigate bias in determining acupuncture’s true impact.

AUTHORS’ CONTRIBUTIONS

R.E.: Writing—original draft, methodology, conceptualization, data curation, investigation. H.M.: Writing—original draft, methodology, supervision. C.L.: Writing—review and editing, Methodology. D.L.: Writing—review and editing, validation. E.B.: Writing—review and editing, validation. N.N.H.: Writing—review and editing, visualization. O.R.A.: Writing—review and editing, visualization.