Fix for Sound Induced Pain — Stellate Ganglion Block?

[Johan_L]

https://www.themonthly.com.au/issue/2018/may/1525096800/kate-cole-adams/when-sound-becomes-pain

Read the last bit about the nerve block.
I think this was mentioned in Norenas recent article. Anybody tried or discussed with their doctor?

 

[lapidus]

Some further reading:

https://www.ncbi.nlm.nih.gov/pubmed/22035147
A study from 2012 on stellate ganglion block for sudden hearing loss

http://medicalrepublic.com.au/sound-affects-diagnosing-managing-intolerances/15366
This article about hyperacusis and TTTS says that "A stellate ganglion block has been effective for temporary pain relief in one ASD patient, confirming sympathetic nervous system involvement, and further trials are being carried out." I'm guessing the patient is Charlotte from Johan_L's link but is there any more info about these trials that are supposedly being carried out?

 

[Contrast]

very interesting.

 

[gorzakus]

They have very good results with this on people suffering from PTSD, depression, anxiety.
Dr Lipov in chicago uses this procedure and helped lots of people.

 

[Johan_L]

"http://www.hunterpainclinic.com.au/stellate-ganglion

• This procedure is used for conditions such as:
  • Complex regional pain syndrome (CRPS);
  • Ménière's disease (an inner ear condition);
  • Postherpetic neuralgia (pain after Herpes Zoster / shingles) affecting the face, head, or arms;
  • Facial pain."

Why is this new information to us? Why is it not yet trialled? It fixed her pain! I want one tomorrow.

@1000 You mentioned a trigeminal nerve block earlier. Did you do it? Maybe your doc can offer you this instead?

 

[lapidus]

The only oher thread about stellate ganglion blocking on TT is this old one from 2015 with barely any replies.
https://www.tinnitustalk.com/threads/stellate-ganglion-nerve-block.7893/

 

[Johan_L]

http://medicalrepublic.com.au/sound-affects-diagnosing-managing-intolerances/15366

"– A stellate ganglion block has been effective for temporary pain relief in one ASD patient, confirming sympathetic nervous system involvement, and further trials are being carried out."

The good: "Trials are being carried out". Hopefully we can see more about this.
The bad: "Temporary pain relief" I thought that the relief was permanent after several injections.

 

[lapidus]

http://medicalrepublic.com.au/sound-affects-diagnosing-managing-intolerances/15366

"– A stellate ganglion block has been effective for temporary pain relief in one ASD patient, confirming sympathetic nervous system involvement, and further trials are being carried out."

The good: "Trials are being carried out". Hopefully we can see more about this.
The bad: "Temporary pain relief" I thought that the relief was permanent after several injections.

It was stated already in the first article you posted about this that it was temporary but that it worked for a longer time period after several injections:

"For five days after the first stellate ganglion block, the stabbing sensation disappeared. "That night, I noticed people were clanging things and I wasn't having pain," says Charlotte. "It was amazing." It surged back when the block wore off, but when the procedure was repeated the relief lasted longer. The third time it was 25 days. Same for the fourth, fifth and sixth times. In January this year, her doctor tried a different kind of block that would act more slowly but hopefully for longer and not require her to go under general anaesthesia to administer."

 

[Johan_L]

It was stated already in the first article you posted about this that it was temporary but that it worked for a longer time period after several injections:"

The 2nd article is newer and for the medical community. Just thought that its a bit strange that she did not mention the permanent effects in this article in this piece. At least it seems that the trials are underway. Hope to hear more about that soon....

 

[Johan_L]

So, I emailed Myriam and received a lengthy and prompt reply (!). Some interesting info here though we can expect more details from the case study when she has completed it.

The new information is that Botox provided longer effect than the nerve block. Also interesting is her view on nerve damage.

Excerpt:"I am currently finishing off the paper about the stellate ganglion block – it is a case study involving one hyperacusis patient with very severe sound-induced pain. Her pain was successfully and immediately treated by a series of stellate ganglion blocks for progressively longer periods. Adding botox has provided the most long lasting effect. However this is one patient only and a trail involving more patients is currently underway and will take time to complete. Please wait for the case study paper for more details re the treatment, I am writing it in conjunction with the pain specialist who provided the treatment.

Most hyperacusis patients I see have developed their hyperacusis secondary to tinnitus or acoustic shock. In those cases I consider the hyperacusis to be an involuntary threat/"protective" response which triggers TTTS, a very real involuntary physiological phenomenon leading a cluster of symptoms which can include severe sound-induced pain.

If you didn't have a head injury triggering your TTTS, it is most unlikely that you have had neurological damage."

On this topic...
Norena wrote in the article "Exiting the loop" that "The present model is testable: In particular, Tensor Tympani Muscle overload may be revealed by middle ear impedancemetry and middle ear inflammation by otoscopy or tympanocentesis, for instance.""

If there is no evidence of inflammation, can we then disregard the possibility that I have TTM overload? I have no inflammation what my ENT can see, and I don't think others with TTTS symptoms have it either.

@Contrast @lapidus @Greg Sacramento Any thoughts?

 

[EDogg]

@Johan_L

Thanks for sharing! In what way(s) did your ENT evaluate your middle ear for inflammation? Was he looking for erythema ? Dilated vessels? How can he look into your middle ear space and not perforate the ear drum? How can he look at your tensor tympani and judge whether it is inflamed due to overuse? Certainly he could look for myoclonus. So did he? Just because you may not have redness on your eardrum (assuming that's what they look for) at the time of evaluation doesn't mean you don't have inflammation. It can come and go. Since these blocks can be done very temporarily, and if pain is very severe, might be worth looking into. If the temporary block helps, you can consider a longer term solution. Who cares exactly why? Figure that out later when you are living a life free of otalgia.

Btw- I get really red and hot ears with my severe ear pain, as well as flushed cheeks. This might be very helpful for me to investigate as well. I appreciate you sharing this.

Best,
EDogg

 

[Johan_L]

@Johan_L

Thanks for sharing! In what way(s) did your ENT evaluate your middle ear for inflammation? Was he looking for erythema ? Dilated vessels? How can he look into your middle ear space and not perforate the ear drum? How can he look at your tensor tympani and judge whether it is inflamed due to overuse? Certainly he could look for myoclonus. So did he? Just because you may not have redness on your eardrum (assuming that's what they look for) at the time of evaluation doesn't mean you don't have inflammation. It can come and go. Since these blocks can be done very temporarily, and if pain is very severe, might be worth looking into. If the temporary block helps, you can consider a longer term solution. Who cares exactly why? Figure that out later when you are living a life free of otalgia.

Btw- I get really red and hot ears with my severe ear pain, as well as flushed cheeks. This might be very helpful for me to investigate as well. I appreciate you sharing this.

Best,
EDogg

He only looked with otoscope. I guess it's a bit more invasive if he perforates the eardrum but will discuss with him. Need to find somebody who will do these blocks. Most doctor don't really care or show interest as they are not familiar with H and pain.

Also, Myriam and Norena has different focus (or disagrees) on the inflammation part.
Expert from Myriam: "My TTTS patients have normal tympanometry results – but then I don't have the old-fashioned manual tympanometry equipment. In hyperacusis patients, I diagnose TTTS through a detailed history looking at the pattern of development over time and by sound-induced symptom development/escalation, not by clinical observation or measurement – for 2 reasons: the action of the tensor tympani is often too subtle to measure easily. Additionally, the tensor tympani may not always be in spasm so it may not manifest during a clinical encounter.

There is still a lot to discover about TTTS. From my clinical experience, I don't agree that TTTS either causes or is the result of an inflammatory response.

The botox was injected into the stellate ganglion – but please wait until the paper is published for further details."

Interesting that the Botox was injected in the stellate ganglion (not head/ear/cheek). Really looking forward to her article.

 

[EDogg]

@Johan_L

Again, thank you very much for sharing this compelling information. I entirely agree with her on her TTTS points. These periods of myoclonus are episodic and, given such a small muscle, can be difficult to measure.

Stellate ganglion blocks are fairly routine outpatient procedures for interventional pain specialists. They are more commonly performed for other symptoms, such as trigeminal neuralgia and CRPS, amongst others. I would just look for someone who can do the injection for trigeminal neuralgia. Will help to be in the midst of a pain flare when you have it performed, as the effects for the initial block can wear off fairly quickly.

Best,
EDogg

 

[Johan_L]

@Johan_L

Again, thank you very much for sharing this compelling information. I entirely agree with her on her TTTS points. These periods of myoclonus are episodic and, given such a small muscle, can be difficult to measure.

Stellate ganglion blocks are fairly routine outpatient procedures for interventional pain specialists. They are more commonly performed for other symptoms, such as trigeminal neuralgia and CRPS, amongst others. I would just look for someone who can do the injection for trigeminal neuralgia. Will help to be in the midst of a pain flare when you have it performed, as the effects for the initial block can wear off fairly quickly.

Best,
EDogg

I definitely think the trigeminal nerve is involved now. When I put in earplugs I get pain in my cheecks and the ear. Will start looking for somebody who can do this procedure

 

[lapidus]

So, I emailed Myriam and received a lengthy and prompt reply (!). Some interesting info here though we can expect more details from the case study when she has completed it.

The new information is that Botox provided longer effect than the nerve block. Also interesting is her view on nerve damage.

Excerpt:"I am currently finishing off the paper about the stellate ganglion block – it is a case study involving one hyperacusis patient with very severe sound-induced pain. Her pain was successfully and immediately treated by a series of stellate ganglion blocks for progressively longer periods. Adding botox has provided the most long lasting effect. However this is one patient only and a trail involving more patients is currently underway and will take time to complete. Please wait for the case study paper for more details re the treatment, I am writing it in conjunction with the pain specialist who provided the treatment.

Most hyperacusis patients I see have developed their hyperacusis secondary to tinnitus or acoustic shock. In those cases I consider the hyperacusis to be an involuntary threat/"protective" response which triggers TTTS, a very real involuntary physiological phenomenon leading a cluster of symptoms which can include severe sound-induced pain.

If you didn't have a head injury triggering your TTTS, it is most unlikely that you have had neurological damage."

On this topic...
Norena wrote in the article "Exiting the loop" that "The present model is testable: In particular, Tensor Tympani Muscle overload may be revealed by middle ear impedancemetry and middle ear inflammation by otoscopy or tympanocentesis, for instance.""

If there is no evidence of inflammation, can we then disregard the possibility that I have TTM overload? I have no inflammation what my ENT can see, and I don't think others with TTTS symptoms have it either.

@Contrast @lapidus @Greg Sacramento Any thoughts?

Sorry for a late reply but my thoughts are that we simply have to wait for this case study and the upcoming bigger study I guess. One thing that I do wonder though is which type of pain this has effect on. Is it just for the lingering pain one can get after too much noise or will it also help the acute pain that happens directly upon hearing a noise above one's LDL? Also, botox isn't exactly risk free from what I understand, so would be interested in learning about potential side effects from this procedure.

@lymebite, you know Bryan Pollard of Hyperacusis Research. Do you know if this is on their radar? I haven't seen them posting anything about this case study.

 

[lymebite]

Do you know if this is on their radar? I haven't seen them posting anything about this case study.

This is an old article (1993) about the cochlea and the stellate ganglion but maybe it connects?

https://www.researchgate.net/public...sympathetic_regulation_of_cochlear_blood_flow

The functional properties of the sympathetic fibers innervating the cochlea are not well understood. Adrenergic fibers supplying lateral wall structures of the cochlea have been observed terminating on radiating arterioles and collecting venules. Adrenergic fibers also terminate as 'free' endings in the spiral osseous lamina. Stimulation or transection of sympathetic fibers originating from superior cervical chain and supplying the cochlea have yielded mixed results concerning many aspects of cochlea physiology. In order to clarify the origin of sympathetic fibers and their role in control of cochlear blood flow (CBF), we examined the effect of electrical stimulation of the stellate ganglion (ESS) and transection of postganglionic fibers from the stellate on CBF measured by laser Doppler flowmetry and on systemic blood pressure (BP) in the guinea pig. ESS produced a 20-35% increase in BP and 10-15% decrease in CBF. The decrease in CBF presumably reflects the net result of increased perfusion pressure, local autoregulatory mechanisms, and a direct sympathetic-induced vasoconstriction. Section of the immediate postganglionic sympathetic trunk had little or no effect on the ESS-related change in BP; however, it eliminated the CBF reduction. Intravenously infused beta 1-blocker diminished the BP increase due to ESS, while the electrically-evoked reduction in CBF remained. Local application of an alpha-blocker on the round window blocked ESS evoked CBF reductions without altering the BP increase. These data confirm the functional role of sympathetic projections from the stellate ganglion in CBF regulation in guinea pig.

 

[lapidus]

This is an old article (1993) about the cochlea and the stellate ganglion but maybe it connects?

https://www.researchgate.net/public...sympathetic_regulation_of_cochlear_blood_flow

The functional properties of the sympathetic fibers innervating the cochlea are not well understood. Adrenergic fibers supplying lateral wall structures of the cochlea have been observed terminating on radiating arterioles and collecting venules. Adrenergic fibers also terminate as 'free' endings in the spiral osseous lamina. Stimulation or transection of sympathetic fibers originating from superior cervical chain and supplying the cochlea have yielded mixed results concerning many aspects of cochlea physiology. In order to clarify the origin of sympathetic fibers and their role in control of cochlear blood flow (CBF), we examined the effect of electrical stimulation of the stellate ganglion (ESS) and transection of postganglionic fibers from the stellate on CBF measured by laser Doppler flowmetry and on systemic blood pressure (BP) in the guinea pig. ESS produced a 20-35% increase in BP and 10-15% decrease in CBF. The decrease in CBF presumably reflects the net result of increased perfusion pressure, local autoregulatory mechanisms, and a direct sympathetic-induced vasoconstriction. Section of the immediate postganglionic sympathetic trunk had little or no effect on the ESS-related change in BP; however, it eliminated the CBF reduction. Intravenously infused beta 1-blocker diminished the BP increase due to ESS, while the electrically-evoked reduction in CBF remained. Local application of an alpha-blocker on the round window blocked ESS evoked CBF reductions without altering the BP increase. These data confirm the functional role of sympathetic projections from the stellate ganglion in CBF regulation in guinea pig.

There might be a connection but I'm not able to see it since that whole piece was basically greek to me as a layperson (spoiler: I don't speak greek ). Good find though, thanks!

 

[Johan_L]

Sorry for a late reply but my thoughts are that we simply have to wait for this case study and the upcoming bigger study I guess. One thing that I do wonder though is which type of pain this has effect on. Is it just for the lingering pain one can get after too much noise or will it also help the acute pain that happens directly upon hearing a noise above one's LDL? Also, botox isn't exactly risk free from what I understand, so would be interested in learning about potential side effects from this procedure.

@lymebite, you know Bryan Pollard of Hyperacusis Research. Do you know if this is on their radar? I haven't seen them posting anything about this case study.

Seems to work for acute pain:
"For five days after the first stellate ganglion block, the stabbing sensation disappeared. "That night, I noticed people were clanging things and I wasn't having pain," says Charlotte. "It was amazing." "

But maybe not for the lingering pain if thats what is meant by "incessant throbbing".
"Although the treatment has resolved the stabbing pain (at least for a while), it has had limited impact on the incessant throbbing. But for the first time in years there is at least the possibility of hope."

 

[lapidus]

Seems to work for acute pain:
"For five days after the first stellate ganglion block, the stabbing sensation disappeared. "That night, I noticed people were clanging things and I wasn't having pain," says Charlotte. "It was amazing." "

That does indeed sound amazing but it leads me to another thought. What if this effect is just a numbing of your sense of pain and the ears are actually just as vulnerable for damage as before? Say you get 5 days without any pain from noise and you spend those days living a normal life but you're actually doing further damage?

 

[Johan_L]

That does indeed sound amazing but it leads me to another thought. What if this effect is just a numbing of your sense of pain and the ears are actually just as vulnerable for damage as before? Say you get 5 days without any pain from noise and you spend those days living a normal life but you're actually doing further damage?

I had the same thought... We don't want to suddenly experience the setback of our life after the nerve block wears off...

On the other hand, if that was the case I think it would have been mentioned. I hope so at least.

 

[Rojo]

I had the same thought... We don't want to suddenly experience the setback of our life after the nerve block wears off...

On the other hand, if that was the case I think it would have been mentioned. I hope so at least.

I don't know, I often feel like this is the case when I'm "feeling good" or when my ativan is really kicked into gear, I feel like my sound tolerance is better than usual but if I do a lot with it, it seems to catch up with me later.

At this point though I would be happy without taking enough of the discomfort and pain edge off to be able to attempt sound therapy.

 

[grate_biff]

So, this happened in 2016 and they talk about trials then. But still no info on this?
I'm up for botox soon. I'll be sure to ask if they can inject my stellate ganglion for sure.

 

[Johan_L]

So, this happened in 2016 and they talk about trials then. But still no info on this?
I'm up for botox soon. I'll be sure to ask if they can inject my stellate ganglion for sure.

I think it went on from 2016 to 2018 as there were several inections. She is soon finished with the case study paper. No info on the trial. Might be ongoing, might not have started.

I would go for a nerve block first. If it has good effect I might ask for botox in the stellate ganglion. I think a nerve block has lower risk. Doing nerve blocks does not seem to be popular in Sweden though. I have found 1 clinic, and they have 7 months waiting list... Hope you have better luck in Norway.

Keep us posted on the Botox effect!

 

[grate_biff]

I have found 1 clinic, and they have 7 months waiting list... Hope you have better luck in Norway.

Think I can promise you it will be a long wait here as well. My scheduled botox appointment is in June. But I´ll look for someone who does the SG block injection as well and we´ll keep each other posted. What kind of place did you find? Who did the procedure? A neurologist I reckon?

 

[Johan_L]

Pain Doctors https://www.smartkliniken.eu/om-oss/personal/läkare-3321285

 

[Juan]

View attachment 26201
very interesting.

But this procedure is aimed at the symptoms and does not fix the underlying cause of hyperacusis. It is just injections to block pain, and may have side effects:

https://www.rcoa.ac.uk/sites/default/files/images/FPM-stellate ganglion block.pdf

In a sense, it would be like resorting to corticoids or steroids for everything. It is a risky approach to fixing things as this can produce really bad side effects in the long run.

A phisiotherapist told me about "ozone injections" but I have not researched that yet. Really, if H and T could be fixed just injecting stuff there wouldnt be forums like tinnitustalk, all hospitals would perform these treatments on the spot, as a normal routine.

 

[R. David Case]

https://www.themonthly.com.au/issue/2018/may/1525096800/kate-cole-adams/when-sound-becomes-pain

Read the last bit about the nerve block.
I think this was mentioned in Norenas recent article. Anybody tried or discussed with their doctor?

I stopped my tinnitus and 440 other people's tinnitus with the Tinnitus Mix. It is free to download if you wish to try it. Go to https://TinnitusMix.com to download it and put on loop. Play it on very LOW volume at first for 3 weeks every night all night. It works best on sound induced and sudden unexplained tinnitus.

 

[grate_biff]

@Johan_L

I´m happy to say I´m up for SGB next week.
I´ve had no luck trying to get it through our fucked up health system, but my dad got to talk to an anesthesia doctor through a "trip-walk-group". He is 72 years old and very experienced.
He told me there was a 30% success rate with this procedure, so here is hoping.
I´ll be back with info on how it went. It´s not a one time injection as I understood him.

 

[Juan]

@Johan_L

I´m happy to say I´m up for SGB next week.
I´ve had no luck trying to get it through our fucked up health system, but my dad got to talk to an anesthesia doctor through a "trip-walk-group". He is 72 years old and very experienced.
He told me there was a 30% success rate with this procedure, so here is hoping.
I´ll be back with info on how it went. It´s not a one time injection as I understood him.

Best of luck! Keep us posted! Tell us how it goes!

 

[grate_biff]

Best of luck! Keep us posted! Tell us how it goes!

So, what I thought was gonna be a SGNB procedure turned out to be something else. The doctor only communicated through my dad so there was some miscommunication there.

Instead he gave me, at his house, 400ml of lidocaine intravenously. His thinking was that this would affect my voltage gated sodium channels and that this worked for up to 30% of chronic pain sufferers.

Through administration I felt really dizzy and numb all over my body. I could feel all the senses numbing, thus I had some immediate relief from my Noxacusis (and tinnitus) and bursted into tears.

Sadly, it was very short lived, indeed. Just about an hour later my Noxacusis was actually much worse and still is as I am writing. My blood pressure and heart rate skyrocketed because of the dizziness and triggered my everlasting benzo withdrawal. I´m not gonna do that again.

I´m still scheduled for SGNB in the fall, but you never know with these doctors