Magnetic and electrical stimulation of the auditory cortex for intractable tinnitus

Case report

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✓ Tinnitus is a distressing symptom that affects up to 15% of the population for whom no satisfactory treatment exists. The authors present a novel surgical approach for the treatment of intractable tinnitus, based on cortical stimulation of the auditory cortex.

Tinnitus can be considered an auditory phantom phenomenon similar to deafferentation pain, which is observed in the somatosensory system. Tinnitus is accompanied by a change in the tonotopic map of the auditory cortex. Furthermore, there is a highly positive association between the subjective intensity of the tinnitus and the amount of shift in tinnitus frequency in the auditory cortex, that is, the amount of cortical reorganization. This cortical reorganization can be demonstrated by functional magnetic resonance (fMR) imaging.

Transcranial magnetic stimulation (TMS) is a noninvasive method of activating or deactivating focal areas of the human brain. Linked to a navigation system that is guided by fMR images of the auditory system, TMS can suppress areas of cortical plasticity. If it is successful in suppressing a patient's tinnitus, this focal and temporary effect can be perpetualized by implanting a cortical electrode.

A neuronavigation-based auditory fMR imaging-guided TMS session was performed in a patient who suffered from tinnitus due to a cochlear nerve lesion. Complete suppression of the tinnitus was obtained. At a later time an extradural electrode was implanted with the guidance of auditory fMR imaging navigation. Postoperatively, the patient's tinnitus disappeared and remains absent 10 months later.

Focal extradural electrical stimulation of the primary auditory cortex at the area of cortical plasticity is capable of suppressing contralateral tinnitus completely. Transcranial magnetic stimulation may be an ideal method for noninvasive studies of surgical candidates in whom stimulating electrodes might be implanted for tinnitus suppression.

Article Information

Address reprint requests to: Dirk De Ridder, M.D., Department of Neurosurgery, University Hospital Antwerp, Wilrijkstraat 10, 2650 Edegem, Belgium. email: dirk.de.ridder@uza.be.

© AANS, except where prohibited by US copyright law.

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Figures

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    Functional MR images demonstrating patient brain activity when listening to music compared with activity during a rest period (p < 0.05, corrected for multiple comparisons). The fMR images are overlaid on structural images in the transversal, coronal, and sagittal planes and on a three-dimensional surface reconstruction of the patient's brain. Note the asymmetry in activation strength and the size of area A1 (left side > right side); this indicates cortical reorganization because sudden unilateral deafness results in an initial absence of contralateral auditory cortex activity.

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    Bar graphs showing the results of TMS on tinnitus suppression as it relates to different stimulation parameters. Upper: Tinnitus suppression as influenced by stimulation frequency and intensity. Lower: Tinnitus suppression as influenced by the stimulation site and by sham stimulation. Note that stimulation 1 cm away from the target has no effect on subjective tinnitus.

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    Postoperative x-ray films demonstrating the site of the electrode (left) and the IPG (right). The stimulation settings are 80 Hz, 2 mA with a 390-µsec pulse width. The stimulator is set for a cycle of on 10 seconds on, 10 seconds off.

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