Download relationship between somatic tinnitus and temporomandibular

CLINICAL DENTISTRY AND RESEARCH 2011; 35(1): 25-32
RELATIONSHIP BETWEEN SOMATIC TINNITUS AND
TEMPOROMANDIBULAR JOINT DYSFUNCTION
SIGNS AND SYMPTOMS
G. Kaan Beriat, MD
Assistant Professor, Department of Otorhinolaryngology
Faculty of Medicine, Ufuk University, Ankara, Turkey
ABSTRACT
Background
and
Aim:
To investigate the possible
relationship(s) between somatic tinnitus and temporomandibular
Nilüfer Çelebi Beriat, DDS, PhD
joint dysfunction symptoms.
Healtcare Services, Dental Prosthesis Program
Subjects and Methods: This study was carried out on a
Hacettepe University, Ankara, Turkey
total of 318 randomly-selected patients (mean age 44.35±
16.38), who admitted to the Department of Oral Diagnosis and
Serdar Uysal, DDS, PhD
Radiology for routine dental treatment between November
Assistant Professor, Department of Oral Diagnosis and Radiology
2005 and 2008. 151 of the patients had tinnitus complaint,
Faculty of Dentistry, Hacettepe University, Ankara, Turkey
whereas 167 of them were symptom-free. The patients were
evaluated for the use of prostheses, bruxism, otalgia, loss of
posterior teeth and findings of temporomandibular joint (TMJ)
dysfunction, as a possible cause of tinnitus. The TMJ examination
also included: TMJ sounds; TMJ pain during palpation; pain on
masticatory muscles on palpation; and deviation and limitation
on mouth opening.
Results: It was observed that tinnitus was significantly
associated with age, bruxism, otalgia, loss of posterior teeth,
pain in masticatory muscles, TMJ pain, and existence of TMJ
sounds (p<0.05). On the other hand, no significant relationship
was observed between tinnitus and the use of partial dentures,
and deviation during jaw movements (p>0.05).
Conclusion: The results of this study demonstrate that TMJ
Correspondence
G. Kaan Beriat, MD
Department of Otorhinolaryngology
Faculty of Medicine
Ufuk University, Mevlana Avenue No: 86, 06520, Balgat, Ankara
Phone: +90 312 2044175
Fax: +90 312 2044088
e-mail: [email protected]
symptoms and the complaint of somatic tinnitus should be
taken into account during differential diagnosis.
Key words: Bruxism, Otalgia, Somatic Tinnitus, Temporomandibular Joint Dysfunction
Submitted for Publication: 08.12.2010
Accepted for Publication : 01.25.2011
25
CLINICAL DENTISTRY AND RESEARCH
INTRODUCTION
Tinnitus may be defined as an auditory sensitivity which
occurs without any external stimulus. It is not considered
as a disease, but rather as a symptom that may occur
due to various causes such as; cochlear lesions, acoustic
nerve diseases, exposure to high sound volume, atoxic
medicaments, trauma arteriosclerosis, vascular diseases,
cervical pathologies, ear infections, foreign body or plug
in the helix, nasal allergy, temporomandibular joint (TMJ)
disease and depression.1-4
Despite several attempts to describe the mechanism(s)
of tinnitus through various theories, the pathophysiology
of tinnitus has yet to be elucidated.5 Through an
epidemiological search, it may be observed that 31% of the
affected adults may sometimes experience tinnitus, while
14.2% of them would experience the condition frequently,
and 2.4% of them would experience it significantly.2 It has
been demonstrated that tinnitus adversely affects the
quality of life in 20% of the patients, and 60% of them have
presented with symptoms of depression.6
The relationship between TMJ and tinnitus have been initially
defined by Costen7, who suggested that the auriculotemporal
branch of the trigeminal nerve and chorda tympani branch
of the facial nerve are compressed due to the disposition
of the mandibular condyle to the posterior. Consequently,
dysfunction of the Eustachian tube and changes in tympanic
pressure may occur, which will result in temporomandibular
joint pathologies that are accompanied with tinnitus, otalgia,
auditory insufficiency and aural fullness.7
Today, the correlation between the TMJ diseases and
tinnitus has been confirmed by many studies.2,8-10 Recent
epidemiological studies show that complaints of tinnitus, the
mastication system and cervical muscular system pain are
accompanied with TMJ diseases.3,11,12 Further, degeneration of
the TMJ disc is associated with tinnitus and masticator muscle
pain; and is indicated as the TMJ dysfunction symptom.13-15
It has also been shown that the frequency of tinnitus is high
in patients with myofacial pain.16 Different approaches have
been made to describe the correlation between the TMJ
disease and tinnitus. Some of these studies have suggested
that dysfunction of the craniomandibular system causes
hyperactivity in masticatory muscles, and the increase in
this activity, specifically in veli palatini and tensor timpani
muscles may be the cause of tinnitus. Alternatively, the
afferent somatic stimulation on the trigeminal nerve during
bruxism may cause tinnitus by creating stimulation on the
26
ventral cochlear nucleus and superior olivery complex.17 It
has also been suggested that psychological stress induces
both mechanisms.18 In light of previous studies, complaints of
tinnitus can be classified in two basic categories with respect
to its location: 1. Otic tinnitus that originates from the inner
ear or acoustic nerve pathologies; and 2. Somatic tinnitus
that originates from the head-neck pathologies other than
the ear.8 Otic tinnitus may originate as a consequence of
peripheral, central or peripheral-induced central event.
Peripheral originated otic tinnitus is associated with the
damage of the cochlear hair cell19. It has been suggested
that molecular movement and joint sound are increased upon
removal of the streocilias from the techtorial membrane and
this is perceived as tinnitus.19 According to another theory,
the interruption of the normal, regular spontaneous afferent
transmission of the cochlear nerve results in tinnitus.9
Loss of the tonic afferent input causes removal of the
inhibition in the acoustic structures of the brain stem and,
consequently, the occurrence of tinnitus.9 Other theories
describing otic tinnitus are localized on the neural sources
of the central tinnitus or central neural dysfunction.11 With
the advent of functional imaging techniques; the activation
of tinnitus has been detected in many sections of the
brain. Accordingly, central activation changes leading to
tinnitus are associated with a number of areas from inferior
colliculus to acoustic cortex, which are the other elements
of the central auditory system on higher levels.11 Persistent
and dense tinnitus, which is seen after complete incision of
the eighth cranial nerve, is a consequence of the aberrant
central neural activity. On the other hand, the tinnitus
accompanied by acoustic trauma and age related hearing
loss causes peripheral originated central damage, namely,
the damage in the periphery induces central damage.12
A search of the literature reveals that the relationship
between TMJ and somatic tinnitus has not been clarified.
Hence, the aim of the present study was to investigate
the possible relationship(s) between somatic tinnitus and
complaints of the temporomandibular joint.
SUBJECTS AND METHODS
This study was carried out on a total of 318 randomlyselected patients who were admitted to the Department of
Oral Diagnosis and Radiology for routine dental treatment
between November 2005 and 2008. The mean age of the
patients was 44.35± 16.38 (13-84 ages). The patients were
selected on a voluntary basis of having tinnitus complaints
or not. All participants were white Caucasians, with no racial
“SOMATIC TINNITUS AND TEMPOROMANDIBULAR JOINT DYSFUNCTION"
or ethnic diversity among the study population. Emergency
cases were not included, since such patients presented
with chief complaints that could interfere with the proper
diagnosis of tinnitus (i.e., trauma, acute pain and swelling).
The dental and otorhinolaryngologic examinations of each
patient were performed by a specialist in oral diagnosis
and a specialist in otorhinolaryngology and audiology,
respectively. Patients with underlying pathologies which
may cause otic tinnitus (i.e., hearing loss, the use atoxic
drugs, history otologic disease, ear surgery, and head and/or
ear trauma) and those using full removable dentures were
excluded from the study. The tinnitus complaints of 318
patients were recorded as “yes” or “no” without taking into
account its direction or intensity.
Thereafter, the TMJ of patients was examined by a
prosthodontist. The patients were evaluated for the use
of prostheses, bruxism, otalgia, loss of posterior teeth and
findings of TMJ dysfunction, as a possible cause of tinnitus.
The TMJ examination also included: TMJ sounds (being
classified as click, pop and crepitation, without the use of a
stethoscope); TMJ pain during palpation; pain on masticatory
muscles (temporal, masseter, medial and lateral pterygoid) on
palpation; and deviation and limitation on mouth opening. A
standard pressure was applied during palpation of the TMJ
and masticatory muscles. Based on above findings, the
patients with or without tinnitus complaints were further
subgrouped according to the existence or absence of
posterior teeth loss, bruxism, use of partial dentures, otalgia
and TMJ examination findings.
All data were analyzed statistically using Statistical Package
for the Social Sciences (SPSS, V.16, SPSS Inc. Chicago, IL,
U.S.A.). Cross-tabulations, t-test and chi-square test were
used for comparison of the data at significance level of p<
0.05.
RESULTS
The statistical relationship among the studied parameters
is presented in Table 1. Statistical analysis of the data
showed that the frequency of somatic tinnitus significantly
increased as the age of the patient increased (p<0.05). 151
of the patients had tinnitus complaint, whereas 167 of them
were symptom-free. 58% of the patients were female, and
51.9% of them had tinnitus complaints. Among the male
patients (42%), 40.6% had the complaint of tinnitus. The
frequency of tinnitus were significantly in women than in
men (cross-tabulation and chi-square test, p<0.05). 71.4%
of the patients with otalgia had the complaint of tinnitus,
while 28.6 % of them were symptom-free, leading to a
significant relationship otalgia and tinnitus (p<0.05).
62.1% of the patients with posterior teeth loss had symptoms
of tinnitus, yielding a significant relationship between the
loss of posterior teeth and complaint of tinnitus (p<0.05).
However, 37.6% of the patients without posterior teeth loss
also presented with the same complaint. Likewise, 65.6% of
the patients with TMJ sounds had tinnitus complaints, and
thus, a significant relationship was observed between the
existence of TMJ sounds and tinnitus (p<0.05). On the other
hand, 39.9% of the patients without TMJ sounds also had
tinnitus complaints. Within the study population, limited
mouth opening was not observed.
Among 18.6% of the patients with deviation on mouth
opening, 50.8% had the complaint of tinnitus; while 46.3% of
the patients without deviation had also tinnitus complaints.
No significant relationship was observed between the
deviation and tinnitus (p>0.05). 51.1% of the patients
using partial dentures had the complaint of tinnitus, while
44.1% of those not using partial prosthesis also presented
with the same complaint. No significant relationship was
observed between the use of partial prostheses and tinnitus
complaints (p>0.05).
57.1% of the patients with bruxism had the complaint of
tinnitus, yielding a significant relationship between both
conditions (p<0.05). Similarly, a significant relationship
between masticatory muscle pain during palpation and
tinnitus complaints was observed (p<0.05). 89.7% of
patients with pain on TMJ during palpation had tinnitus
complaints. A significant relationship was detected between
TMJ pain and tinnitus complaint (p<0.05).
When all the data were pooled together, it was observed that
tinnitus was significantly associated with bruxism, otalgia,
loss of posterior teeth, pain in masticatory muscles, TMJ pain,
and existence of TMJ sounds (p<0.05). On the other hand,
no significant relationship was observed between tinnitus
and the use of partial dentures, and deviation during jaw
movements (Figures 1 and 2, p>0.05).
DISCUSSION
Attempts to describe the origin of somatic tinnitus have been
made through neural, vascular and craniocervical theories.
Initially, Moller et al.12 suggested that the lemniscal or nonauditory neural stimulations can induce tinnitus. Lockwood
et al.20 utilized positron emission computerized tomography
27
CLINICAL DENTISTRY AND RESEARCH
Table 1. A summary of parameters investigated in the present study.
TINNITUS
Yes
No
p value
40.29+ 15.83
48.85+ 15.85
0.0001
Male
36 %
47 %
0.030
Female
64 %
53 %
Use
51.1 %
48.9 %
No use
55.9 %
44.1 %
Yes
57.1 %
42.9 %
No
43.6 %
56.4 %
Yes
71.4 %
28.6 %
No
41.2 %
58.8 %
Yes
62.9 %
37.1 %
No
37.6 %
62.4 %
Yes
87 %
13 %
No
44.4 %
55.6 %
Yes
89.7 %
10.3 %
No
41.6 %
58.4 %
Yes
73.1 %
26.9 %
No
45.2 %
54.8 %
Yes
75 %
25 %
No
44.4 %
55.6 %
Yes
89.7 %
10.3 %
No
41.6 %
58.4 %
Yes
52.5 %
47.5 %
No
46.3 %
53.7 %
Yes
65.6 %
34.4 %
No
39.9 %
60.1 %
Age
Gender
Partial prosthesis
Bruxism
Otalgia
Posterior tooth loss
Masseter muscle pain during palpation
Temporal muscle pain during palpation
Medial pterygoid muscle pain during palpation
Lateral pterygoid muscle pain during palpation
TMJ pain during palpation
Deviation during jaw movements
TMJ sounds
28
0.130
0.022
0.0001
0.0001
0.0001
0.0001
0.005
0.001
0.0001
0.314
0.0001
“SOMATIC TINNITUS AND TEMPOROMANDIBULAR JOINT DYSFUNCTION"
Figure 1. Patients with tinnitus and pain during palpation
Figure 2. Patients with tinnitus and other parameters investigated
(PECT) in order to describe the mechanism of somatic
tinnitus, and observed a positive correlation between the
orofacial movements, the blood flow in the temporal lobe
and hypocampus. Levine21 proved the increased frequency
of tinnitus following trauma of the head and neck.
Temporomandibular joint dysfunction (TMD) is a term
comprising two groups of disorders; actual TMJ anomalies
and primer involvement of the masticatory muscles
(myofacial pain syndrome). Since it is difficult to discriminate
between the latter two groups, it is hard to diagnose.7 TMD
can occur due to trauma, bruxism, and loss of teeth, one
sided mastication, degenerative joint diseases, ankylosis,
developmental anomalies, myofacial pain syndrome and
psychological reasons. Temporomandibular joint symptoms
present with joint sounds, pain during TMJ and muscle
palpations, limitation on mouth opening, deviation, chronic
facial pain and head ache; or auditory symptoms.7
TMJ pathologies may present with tinnitus, otalgia, auditory
insufficiency and aural fullness; as the Eustachian tube
dysfunction and tympanic pressure changes occur.7,22
Following the Eustachian tube hypothesis of Costen7,
many researchers have tried to describe the relationship
between tinnitus and TMD. According to the tensor tympani
hypothesis, masticatory muscles and tensor tympani muscle
29
CLINICAL DENTISTRY AND RESEARCH
are innervated by the trigeminal nerve; and the hyperactivity
of these muscles causes tinnitus.23
Previous studies have indicated the relationship between
tinnitus and TMJ symptoms without any ear diseases.24,25
In this study, none of the patients had ear disease which
might be the actual cause of tinnitus. Our results revealed a
significant relationship between TMJ findings and somatic
tinnitus.
The vagal and glossopharyngeal nerves directly innervate
the inner, medial and external ear canal, while the trigeminal
nerve accomplished this through the greater auricular nerve.26
The greater auricular nerve and the facial nerve also
innervate the TMJ directly. The close anatomic connection
shows the relationship between the neural structures,
and the pathologies concerning the entire head and neck
complex may cause symptoms on the ear.26
Johansson et al.27 compared tinnitus and disk displacement
in the TMJ, and observed that frequency of the symptoms
in the areas innervated by the trigeminal nerve was higher
in patients with tinnitus than those without it. In the same
study, it was found that the complaint of tinnitus is associated
with pain complaints of the temporal zone and posterior
eye.27 It was also demonstrated that displacement of the
disk causes mechanical irritation of the auriculotemporal,
lingual and, inferior alveolar nerves or motor nerve branches
such as the masseter and deep posterior temporal nerve.27
Phylogenetic and embryogenic approaches suggest that
there is a complex neuromuscular relationship between
the masticatory muscles and the auditory system.23 This
hypothesis has been generated on the theory that the
tensor tympani and tensor veli palatine muscles, which
function on the opening and closing of the Eustachian
tube ostium, are in close relationship with the masticatory
muscles during embryonic development. Both muscle groups
are innervated by the motor branches of the trigeminal
nerve. Consequently, the occurrence of the Eustachian tube
dysfunction causes tinnitus.23
Reflex disorders of the tensor tympani and veli palatini
muscles and the otomandibular ligaments (disco-malleolar
and tympanomandibular) cause ear symptoms.24 Because of
the otomandibular ligament, the ear symptoms concerning
the temporomandibular joint occur due to the direct
stimulation of malleus through the malleolar ligament.28 The
present study clearly demonstrates the relationship between
the TMJ, peripheral musculature, otalgia and bruxism.
30
According to the excessive somatic concern (polysymptomatic
somatization syndrome) approach, TMJ dysfunction and
tinnitus are associated with emotional disorders. Previous
studies have shown that emotional stress may cause
such complaints by means of somatization.28-30 Our study
indicated that the pain on TMJ and masticatory muscles and
symptoms of bruxism are associated with emotional stress,
and thus tinnitus.
Lasisi et al.31 observed that the frequency of tinnitus
increases with age and that persistent and chronic tinnitus
is frequently experienced above the age of 60. Consistent
with their findings, our results confirmed the influence
of age on tinnitus, and further establish a significant
relationship in an increasing trend.
The present results indicate a relationship between the TMJ,
peripheral muscular structures, otalgia and bruxism. This
relationship also suggests that the sensation of tinnitus
and TMJ pain uses inter-related neural paths.
The results of this study demonstrate that TMJ symptoms
and the complaint of somatic tinnitus should be taken
into account during differential diagnosis. Nonetheless,
the parameters used in the present study are subjective
in nature, as with many other studies conducted so far.
Further studies are required to elucidate the possible
direct and indirect causes of TMJ symptoms and somatic
tinnitus.
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