CRANIO® The Journal of Craniomandibular & Sleep Practice
ISSN: 0886-9634 (Print) 2151-0903 (Online) Journal homepage: http://www.tandfonline.com/loi/ycra20
The Relationship Between Craniomandibular Disorders and Otitis Media in Children Stephen Youniss D.D.S. To cite this article: Stephen Youniss D.D.S. (1991) The Relationship Between Craniomandibular Disorders and Otitis Media in Children, CRANIO®, 9:2, 169-173, DOI: 10.1080/08869634.1991.11678364 To link to this article: http://dx.doi.org/10.1080/08869634.1991.11678364
Published online: 18 Feb 2016.
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Date: 27 March 2017, At: 19:17
The Relationship Between Craniomandibular Disorders and Otitis Media in Children Stephen Youniss, D.D.S. Abstract
Most of the literature written about temporomandibular joint (TMJ) or craniomandibular dysfunction has looked at the problem in adults, probably because most of the patients we see with problems are adults. This article first establishes the fact that young children also exhibit signs and symptoms of craniomandibular dysfunction, almost at the same percentage as seen in adults. A review of otitis media with effusion (OME) in children establishes that malfunction of the eustachian tube is the underlying cause of this disease process. Because of the close anatomical and embryological relationship between the TMJ and the middle ear, there exists the possibility that a dysfunctioning TMJ may initiate the bout of OME, primarily by its relationship to the tensor veli palatini muscle. This muscle controls the function of the eustachian tube. This author feels that we might be able to decrease the incidence of OME by improving the function of the eustachian tube. This could be done by altering the relationship between the TMJ and the muscles of mastication, similar to the way we treat craniomandibular (TMJ) dysfunction in adults.
Dr. Stephen Youniss graduated from Marquette School of Dentistry in 1981. He completed a general practice residency program at Baltimore City Hospital in 1982. He completed the Advanced Program in the Diagnosis and Management of Oral Facial Pain and Temporomandibular Joint Dysfunction at the University of Medicine and Dentistry of New Jersey in 1989 and is now in private practice in Baltimore, Maryland.
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0886-9634/91/0901-0169$03.00/0 THE JOURNAL OF CRANIOMANDIBULAR PRACTICE Copyright© 1991 by Williams & Wilkins
ENT ivergent opinions about the signs, symptoms, and causative factors involved with disorders of the temporomandibular joint (TMJ) are common in both the dental and medical literature. These TMJ, or craniomandibular, disorders have generally been viewed as a degenerative problem, probably because most of the patients seeking treatment are adults. This tendency to investigate the adult population is apparent in most of the epidemiologic studies concerning craniomandibular dysfunction. 1- 4 A few of these epidemiologic studies have focused on the signs and symptoms of craniomandibular disorders in children and adolescents, and it appears that the younger patient does exhibit headaches, TMJ tenderness to palpation, muscle tenderness, TMJ sounds, and deviations with opening. 5- 9 A different disorder that is common in the majority of children from 0 to 12 years of age is otitis media with effusion (OME). Like TMJ disorders, the origin of OME remains controversial, although malfunction of the eustachian tube seems to be the underlying cause in the majority of cases. 10- 12 Turner noted that the eustachian tube disorder could develop from adenoid hypertrophy or inflammation, from barotrauma, sinusitis, nasopharyngitis, nasopharyngeal tumors, allergies of the respiratory tract, or TMJ disease. 10 He also stated that malfonnation of the jaws, palate, or facial bones could predispose the patient to OME, and that is why patients with cleft palate exhibit extreme problems with OME. Several dental authors have also written on the association between TMJ disorders and children with chronic OME. 14• 15 The intent of this article is to briefly review the epidemiologic studies of TMJ disorders in children and most specifically to examine the possible relationship between OME and a dysfunctioning TMJ in the developing child.
D
Epidemiologic Studies of TMJ Disorders in Children Epidemiologic studies of TMJ disorders in adults indicate a prevalence of signs and symptoms in the range of 30 to 70%, depending on which author you might read. 1- 4 One of the reasons for this wide range of results is that there is no consistent method of examination and diagnosis criteria. Nonetheless, it is generally agreed on that many adults do suffer from disorders of the TMJ.
Presented by the University of Medicine and Dentistry of New Jersey; Center for TMJ Disorders and Orofacial Pain Management.
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The corresponding epidemiologic studies of TMJ disorders in children surprisingly reveal similar results. Riolo et al. 9 in a study of 6- to 17-year-old children found that up to 25% of his subjects exhibited clicking or crepitation, 21% exhibited TMJ tenderness, and up to 33% showed signs of muscle tenderness. Williamson 5 found that out of a total of 304 children ranging in age from 6 to 16 years old, 107 or 35.2% were symptomatic. Grosfeld and Czamecka 6 found that 56.4% of 6- to 8-year-old children and 67.6% of 13- to 15-year-old children did show signs and symptoms of the TMJ dysfunction. From a study of 440 children aged 7 to 14, Nilver and Lassing 7 found that 36% revealed symptoms of TMJ dysfunction in a pretreatment interview ( 15% with recurrent headaches and 13% with clicking sounds from the TMJ), 64% of his group claimed pain on palpation of the muscles associated with the TMJ, and 39% claimed pain on palpation of the joint. Wanman and Agerberg 13 found that 23% of his subjects aged 6 to 12 years of age reported joint sounds; 18% reported headaches; and 20% reported either pain, locking, or difficulty with opening wide. On that same group of adolescents, the author found that 20% exhibited TMJ sounds, and that 50% of the group exhibited either joint pain, muscle pain, or impaired mandibular mobility. 13 It is obvious from the above studies that the signs and symptoms of TMJ dysfunction are common in adolescents and children, although generally they are of mild characteristics.
Background and Natural History of Otitis Media with Effusion Having concluded that TMJ signs and symptoms do exist in children, the author would like to discuss another very common disorder found in children-otitis media with effusion (OME). OME is probably one of the most prevalent illnesses in the developing child. Destalozza et al. 11 reported that 3.3% of all nonnal newborns are born with OME. When he looked at newborns from the Neonatal Intensive Care Unit (NICU), that percentage rose to 21%. These babies exhibited irritability, lethargy, and prolonged crying. In children from 1 to 12 months old, the incidence of OME increased to 57 to 67%. The author found that the child was asymptomatic in at least 50% of these cases, even though the effusion was present upon examination of the ear. Between ages 1 and 6 years, the indication of OME fell to 40%, with the disease falling gradually from 62% at age 2 years down to 17% at age 5 years. By the time the child
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was 7 to 8 years old, the indication of OME was down to 4.2%. The diagnosis for OME is derived from a number of factors. First of all, the patient usually complains about ear pain, ear fullness, tinnitus, along with slight hearing loss. Upon examination of the ear, the physician will observe inflammation, fluid, distortion, or discoloration of the eardrum. There often is an associated phacyngitis or rhinitis. Acute cases of OME often present themselves with prominent blood vessels running along a red, bulging tympanic membrane. Sometimes actual bubbles inside the fluid collection can be observed along with a very prominent appearance of the malleus on the eardrum. Various forms of otitis media exist and coexist with possible progression from one form to another. The International Meeting on Recent Advances in Middle Ear Effusions in 1976 recommended the following classifications 16 : POM SOM MOM COM
Purulent Otitis Media Serous Otitis Media Mucoid or Secretory Otitis Media Chronic Supperative Otitis Media
Acute, subacute, and chronic types of otitis media can be seen in each of the classifications. Acute inflammation lasts less than one week, subacute otitis media lasts from two weeks to two months, and chronic lasts beyond two months. An accurate history and ear exam is required to properly diagnose otitis media. The clinical literature is not l 00% in agreement on the natural cause of otitis media. 16- 18 Generally it is felt that the patient develops an upper respiratory infection or rhinitis that when treated with antibiotics will leave a residual sterile fluid. This now becomes the serous otitis media or mucoid or secretory otitis media type or more commonly referred to as OME. It is not clear whether the eustachian tube, which normally aerates and drains fluid from the middle ear, closes down or malfunctions as a result of this infection, or on the other hand, if the infection and accumulation of fluids results from the malfunction or obstruction of the tube. Oftentimes, the fluid accumulated behind the closed eustachian tube is void of bacteria, while in other cases, there is bacterial and white blood cell infiltration. The literature does mention this problem of eustachian tube disorders and how these disorders can lead to OME. 16• 17 As mentioned earlier, these disorders may result from adenoid hypertrophy, barotrauma, sinusitis, nasopharyngitis, tumor, or even TMJ disease. Complications can result from prolonged retention
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of fluid and malfunctioning of the eustachian tube, including hearing loss, more acute infection, and structural changes such as pockets, adhesions, or membrane perforations. 19 To prevent these complications of OME, medical treatment is attempted at first. This treatment includes antibiotics, nasal decongestants, and eustachian tube decongestants such as phenylmetazoline or pseudoephedrine. 16 After three months of persistent fluid accumulation behind the eardrum, it is recommended that the tympanic membranes be incised (myringotomy) and ventilation tubes (PE or METS) placed to act as an artificial eustachian tube. The current medical literature on OME seems to conclude two things. First, OME is one of the most prevalent reasons for a child to visit his or her pediatrician or family physician. Secondly, the literature concludes that the underlying cause of all inflammatory ear diseases is eustachian tube malfunction. It is not so clear, though, whether the inflammation encourages the eustachian tube malfunction, or whether malfunction of the eustachian tube begins first, and this in turn results in the sequence of fluid accumulation, inflammation, and even infection of the middle ear system. In light of the fact that a fair number of children presenting with OME exhibit sterile environments upon culture of their effusion, it does seem reasonable that at least some of these children do develop the eustachian tube malfunction problem before the inflammation problem.
A Philosophical Discussion on the Relationship between Craniomandibular Dysfunction and OME in Children In the preceding paragraph, the author has attempted to present evidence from the medical and dental literature that establishes a number of findings: I. TMJ dysfunction does exist in children. 2. OME does exist in children. 3. Eustachian tube malfunction is somehow involved in either the onset or the progression of OME. These three facts are followed by the following three big questions: I . Are the three facts stated above somehow related to each other, or are they entirely independent? 2. Specifically, could TMJ dysfunc-
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tion be a causative factor in the onset of OME? 3. Could eustachian tube malfunction be related to TMJ dysfunction? The author's interest in the above questions first began in 1984 when he attended a seminar given by Dr. Merle Bean, a practicing pediatric dentist for over 25 years. 15 Dr. Bean said he found dramatic improvement in OME symptomatology upon placing stainless steel crowns over the primary molars in young children. He intentionally opened the vertical dimension of these young children by placing the stainless steel crowns over unprepared primary molars, and found that the children had an improvement in hearing, and a decrease in the need for PE tubes and antibiotics. He provided no solid scientific explanation for his clinical findings, but he did say he had found this improvement in OME in many cases. There seems to be no questiqn that many young children are having recurring bouts of OME, with repeated doses of antibiotics and eventual PE or MET tube placement. If, in fact, there was a craniomandibular component to this problem, it would be a most enlightening fact to ear, nose, and throat physicians because it could affect so many patients. There also is no question that there is a very close embryologic and anatomic relationship between the TMJ, the muscles of mastication, the middle ear, and also the tensor veli palatini muscle which opens and closes the eustachian tube. These muscles of mastication as well as the tensor veli palatini are all derived from the mesoderm of the first branchial arch, and thus share common innervation by the fifth cranial nerve. 19 •20 The nerve that supplies the tensor veli palatini muscle is a direct branch of the nerve that supplies the medial pterygoid muscle. When the tensor veli palatini muscle is relaxed, the eustachian tube remains closed, allowing no fluid to escape. Upon normal function of the mandible and muscles of mastication (such as swallowing, yawning, or sneezing), the tensor veli palatini muscle will allow the tube to open and allow the escape of any fluid accumulation in the middle ear. The same bud cell that gives off the internal pterygoid muscle also gives off the tensor tympani muscle which is a very important muscle in the function of the middle ear. 21 More recently, it is thought that the tensor tympani muscle may be an extensio::t of the tensor veli palatini muscle, thus having the same innervation. Several dental authors have also examined the re-
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lationship between the TMJ complex and otitis media with effusion. Marasa and Ham 15 review five patients between the ages of 4 and 7 years. Their average overjet was 7 mm and they all presented with an overbite of 90 to 100%. Four out of the five exhibited narrow dental arches and all were classified as retrognathic. All five of the patients had experienced multiple bouts of OME, starting as early as 5 months old. Because of their frequent bouts with OME, all of the patients had multiple attempts of antibiotic therapy and several had ventilation tubes placed in their tympanic membrane to allow for drainage. The author of the article placed composite material on the occlusal surfaces of the lower deciduous molars, which immediately reduced the vertical overbite to lO to 20%. On one of the patients, the author also used an upper expansion device to widen the arch and increase the vertical dimension. The author found that four out of the five patients had a significant and dramatic decrease in the occurrence of their OME bouts after altering the maxillary-mandible relationship. The one patient that did continue to have bouts with OME was noncompliant with his therapy, and treatment had to be discontinued. In conclusion, this author noted the same thing that Dr. Bean had noted earlier, specifically that alteration of the vertical dimension dramatically decreases the incidence of OME in young children. Marasa and Ham noted several explanations for the patients' improvement after treatment. 14
Malfunction of the Tensor Veli Palatini Muscle Due to Neurotransmission Because of the shared innervation of the trigeminal nerve, if the muscles of mastication are in a hypertonic state, so the tensor veli palatini muscle will be. If the tensor veli palatini muscle is hypertonic for a long time, the eustachian tube will not be able to open and fluid will not be able to escape from the middle ear. By restoring the vertical dimension to the patients with a loss of vertical dimension, the muscles will be able to function because they no longer will be in spasm.
Malfunction of the Tensor Veli Palatini Muscle Due to Malposition or Hypertonicity of the Medial Pterygoid Muscle When the tensor veli palatini pulls on the eustachian tube to open it, it must first push the medial pterygoid muscle aside. If this muscle is in spasm, it would be hard for the tensor veli palatini to open the eustachian
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tube. Alteration of the function of the medial pterygoid muscle by changing its length through restoration of the vertical dimension might allow for better eustachian tube function.
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Reprint requests to: Stephen Youniss. D.D.S. 19 Fontana Lane Suite 202 Baltimore. Maryland 21237
References I. Helkimo, M: Epidemiological surveys of dysfunctions of the masticatory system. Oral Sci Rev 1976; 1:54-69 2. Heliie B. Heliie LA: Frequency and distribution of myofascial pain dysfunction syndrome in a population. Community Dent Oral Ep· idemio/1979: 7:357-360 3. Ingervall B. Mohlin B. Thilander B: Prevalence of symptoms of functional disturbances of the masticatory system in Swedish. Am J Rehabi/1980; 7:185-197 4. Solberg WK. Woo M. Houston J: Prevalence of mandibular dysfunctions in young adults. JADA 1979; 98:25-34 5. Williamson EH: Temporomandibular dysfunction in pretreatment adolescent patients. A J Orthod 1977; 72:429-433 6. Grosfeld 0. Czamecka B: Musculo-articular disorders of the stomatognathic system in school children examined according to clinical criteria. J Oral Rehabil 1977; 4:193-200 7. Nilver M. Lassing SA: Prevalence of functional disturbances and diseases of the stomatognathic system in 7-14 year olds. Swed Dent J 1981; 5:173-187 8. Stack BC. Funt LA: Temporomandibular joint dysfunction in children. J Pedod 1977; 1:240--247 9. Riolo M. Brandt D. Tenhaven T: Associations between occlusal characteristics and signs and symptoms of TMJ dysfunction in children and young adults. Am J Onhod Dentofacial Orthop 1987; 92:467477 10. TurnerS: Medicine for the Practicing Physician. Moburn: Butterworth Publishers. 1983; 1712-1716 , II. Destalozza G. et al.: Incidence of OME. Adv Otorhino/aryngo/1988; 40:47-56 12. Lim D. et al.: Otitis media with effusion. Arch Otolarvnco/ Head Neck Surg 1979; 105:404-12 · · 13. Wanman A. Agerberg G: Two year longitudal study of signs of mandibular dysfunction in adolescents. Acta Odontal Scand 1986; 44:333342 14. Marasa F. Ham B: Case reports involving the treatment of children with chronic otitis media with effusion via craniomandibular methods. J Craniomandib Pract 1988; 6:256--270 15. Dean M: Part of a lecture on temporomandibular dysfunction. Baltimore. MD. Oct 1984 16. TurnerS: Medicine for the Practicing Physician. Moburn. Butterworth Publishers. 1983 17. Davidson T: Otolaryngology. New York: Grune and Stratton. Inc. 1984; 19-27 18. Dayal V: Clinical Otolaryngology. Philadelphia: JB Lippincott Co. 1981; 41-43 19. Paradise J: OME in children. Adv Otorhinolaryngol 1988; 40:47-56 20. Penny HT. et al.: The embryology of the temporomandibular joint. J Craniomandib Pract 1985; 3:125-132 21. Arlen H: The Otomandibular Syndrome: A New Concept.
Communication through the Petrotympanic Fissure The tympanic orifice of the eustachian tube is present on the anterior wall of the middle ear. In a patient with a loss of vertical dimension, the mandibular condyles may be forced distally and pushed into the petrotympanic fissure. This distal position may cause some blockage of the eustachian tube orifice. Likewise, if the retrodiskal tissue of the TMJ becomes inflamed, this inflammation could spread through the petrotympanic fissure and into the middle ear. This again could account for the blockage of the eustachian tube.
Conclusion Even though the medical literature does not fully appreciate the relationship between craniomandibular dysfunction and OME in children, there does exist the possibility that the two may be directly related. This is supported by the success of the small group of patients presented by Dr. Marasa, especially after the failure of the more traditional mode of OME treatment. Without question, more research must be provided in this area, especially with well controlled clinical studies. Hopefully one day, children with OME can be treated via craniomandibular methods rather than surgical intervention.
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ISSN: 0886-9634 (Print) 2151-0903 (Online) Journal homepage: http://www.tandfonline.com/loi/ycra20
The Relationship Between Craniomandibular Disorders and Otitis Media in Children Stephen Youniss D.D.S. To cite this article: Stephen Youniss D.D.S. (1991) The Relationship Between Craniomandibular Disorders and Otitis Media in Children, CRANIO®, 9:2, 169-173, DOI: 10.1080/08869634.1991.11678364 To link to this article: http://dx.doi.org/10.1080/08869634.1991.11678364
Published online: 18 Feb 2016.
Submit your article to this journal
View related articles
Citing articles: 3 View citing articles
Full Terms & Conditions of access and use can be found at http://www.tandfonline.com/action/journalInformation?journalCode=ycra20 Download by: [NUS National University of Singapore]
Date: 27 March 2017, At: 19:17
The Relationship Between Craniomandibular Disorders and Otitis Media in Children Stephen Youniss, D.D.S. Abstract
Most of the literature written about temporomandibular joint (TMJ) or craniomandibular dysfunction has looked at the problem in adults, probably because most of the patients we see with problems are adults. This article first establishes the fact that young children also exhibit signs and symptoms of craniomandibular dysfunction, almost at the same percentage as seen in adults. A review of otitis media with effusion (OME) in children establishes that malfunction of the eustachian tube is the underlying cause of this disease process. Because of the close anatomical and embryological relationship between the TMJ and the middle ear, there exists the possibility that a dysfunctioning TMJ may initiate the bout of OME, primarily by its relationship to the tensor veli palatini muscle. This muscle controls the function of the eustachian tube. This author feels that we might be able to decrease the incidence of OME by improving the function of the eustachian tube. This could be done by altering the relationship between the TMJ and the muscles of mastication, similar to the way we treat craniomandibular (TMJ) dysfunction in adults.
Dr. Stephen Youniss graduated from Marquette School of Dentistry in 1981. He completed a general practice residency program at Baltimore City Hospital in 1982. He completed the Advanced Program in the Diagnosis and Management of Oral Facial Pain and Temporomandibular Joint Dysfunction at the University of Medicine and Dentistry of New Jersey in 1989 and is now in private practice in Baltimore, Maryland.
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0886-9634/91/0901-0169$03.00/0 THE JOURNAL OF CRANIOMANDIBULAR PRACTICE Copyright© 1991 by Williams & Wilkins
ENT ivergent opinions about the signs, symptoms, and causative factors involved with disorders of the temporomandibular joint (TMJ) are common in both the dental and medical literature. These TMJ, or craniomandibular, disorders have generally been viewed as a degenerative problem, probably because most of the patients seeking treatment are adults. This tendency to investigate the adult population is apparent in most of the epidemiologic studies concerning craniomandibular dysfunction. 1- 4 A few of these epidemiologic studies have focused on the signs and symptoms of craniomandibular disorders in children and adolescents, and it appears that the younger patient does exhibit headaches, TMJ tenderness to palpation, muscle tenderness, TMJ sounds, and deviations with opening. 5- 9 A different disorder that is common in the majority of children from 0 to 12 years of age is otitis media with effusion (OME). Like TMJ disorders, the origin of OME remains controversial, although malfunction of the eustachian tube seems to be the underlying cause in the majority of cases. 10- 12 Turner noted that the eustachian tube disorder could develop from adenoid hypertrophy or inflammation, from barotrauma, sinusitis, nasopharyngitis, nasopharyngeal tumors, allergies of the respiratory tract, or TMJ disease. 10 He also stated that malfonnation of the jaws, palate, or facial bones could predispose the patient to OME, and that is why patients with cleft palate exhibit extreme problems with OME. Several dental authors have also written on the association between TMJ disorders and children with chronic OME. 14• 15 The intent of this article is to briefly review the epidemiologic studies of TMJ disorders in children and most specifically to examine the possible relationship between OME and a dysfunctioning TMJ in the developing child.
D
Epidemiologic Studies of TMJ Disorders in Children Epidemiologic studies of TMJ disorders in adults indicate a prevalence of signs and symptoms in the range of 30 to 70%, depending on which author you might read. 1- 4 One of the reasons for this wide range of results is that there is no consistent method of examination and diagnosis criteria. Nonetheless, it is generally agreed on that many adults do suffer from disorders of the TMJ.
Presented by the University of Medicine and Dentistry of New Jersey; Center for TMJ Disorders and Orofacial Pain Management.
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The corresponding epidemiologic studies of TMJ disorders in children surprisingly reveal similar results. Riolo et al. 9 in a study of 6- to 17-year-old children found that up to 25% of his subjects exhibited clicking or crepitation, 21% exhibited TMJ tenderness, and up to 33% showed signs of muscle tenderness. Williamson 5 found that out of a total of 304 children ranging in age from 6 to 16 years old, 107 or 35.2% were symptomatic. Grosfeld and Czamecka 6 found that 56.4% of 6- to 8-year-old children and 67.6% of 13- to 15-year-old children did show signs and symptoms of the TMJ dysfunction. From a study of 440 children aged 7 to 14, Nilver and Lassing 7 found that 36% revealed symptoms of TMJ dysfunction in a pretreatment interview ( 15% with recurrent headaches and 13% with clicking sounds from the TMJ), 64% of his group claimed pain on palpation of the muscles associated with the TMJ, and 39% claimed pain on palpation of the joint. Wanman and Agerberg 13 found that 23% of his subjects aged 6 to 12 years of age reported joint sounds; 18% reported headaches; and 20% reported either pain, locking, or difficulty with opening wide. On that same group of adolescents, the author found that 20% exhibited TMJ sounds, and that 50% of the group exhibited either joint pain, muscle pain, or impaired mandibular mobility. 13 It is obvious from the above studies that the signs and symptoms of TMJ dysfunction are common in adolescents and children, although generally they are of mild characteristics.
Background and Natural History of Otitis Media with Effusion Having concluded that TMJ signs and symptoms do exist in children, the author would like to discuss another very common disorder found in children-otitis media with effusion (OME). OME is probably one of the most prevalent illnesses in the developing child. Destalozza et al. 11 reported that 3.3% of all nonnal newborns are born with OME. When he looked at newborns from the Neonatal Intensive Care Unit (NICU), that percentage rose to 21%. These babies exhibited irritability, lethargy, and prolonged crying. In children from 1 to 12 months old, the incidence of OME increased to 57 to 67%. The author found that the child was asymptomatic in at least 50% of these cases, even though the effusion was present upon examination of the ear. Between ages 1 and 6 years, the indication of OME fell to 40%, with the disease falling gradually from 62% at age 2 years down to 17% at age 5 years. By the time the child
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was 7 to 8 years old, the indication of OME was down to 4.2%. The diagnosis for OME is derived from a number of factors. First of all, the patient usually complains about ear pain, ear fullness, tinnitus, along with slight hearing loss. Upon examination of the ear, the physician will observe inflammation, fluid, distortion, or discoloration of the eardrum. There often is an associated phacyngitis or rhinitis. Acute cases of OME often present themselves with prominent blood vessels running along a red, bulging tympanic membrane. Sometimes actual bubbles inside the fluid collection can be observed along with a very prominent appearance of the malleus on the eardrum. Various forms of otitis media exist and coexist with possible progression from one form to another. The International Meeting on Recent Advances in Middle Ear Effusions in 1976 recommended the following classifications 16 : POM SOM MOM COM
Purulent Otitis Media Serous Otitis Media Mucoid or Secretory Otitis Media Chronic Supperative Otitis Media
Acute, subacute, and chronic types of otitis media can be seen in each of the classifications. Acute inflammation lasts less than one week, subacute otitis media lasts from two weeks to two months, and chronic lasts beyond two months. An accurate history and ear exam is required to properly diagnose otitis media. The clinical literature is not l 00% in agreement on the natural cause of otitis media. 16- 18 Generally it is felt that the patient develops an upper respiratory infection or rhinitis that when treated with antibiotics will leave a residual sterile fluid. This now becomes the serous otitis media or mucoid or secretory otitis media type or more commonly referred to as OME. It is not clear whether the eustachian tube, which normally aerates and drains fluid from the middle ear, closes down or malfunctions as a result of this infection, or on the other hand, if the infection and accumulation of fluids results from the malfunction or obstruction of the tube. Oftentimes, the fluid accumulated behind the closed eustachian tube is void of bacteria, while in other cases, there is bacterial and white blood cell infiltration. The literature does mention this problem of eustachian tube disorders and how these disorders can lead to OME. 16• 17 As mentioned earlier, these disorders may result from adenoid hypertrophy, barotrauma, sinusitis, nasopharyngitis, tumor, or even TMJ disease. Complications can result from prolonged retention
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of fluid and malfunctioning of the eustachian tube, including hearing loss, more acute infection, and structural changes such as pockets, adhesions, or membrane perforations. 19 To prevent these complications of OME, medical treatment is attempted at first. This treatment includes antibiotics, nasal decongestants, and eustachian tube decongestants such as phenylmetazoline or pseudoephedrine. 16 After three months of persistent fluid accumulation behind the eardrum, it is recommended that the tympanic membranes be incised (myringotomy) and ventilation tubes (PE or METS) placed to act as an artificial eustachian tube. The current medical literature on OME seems to conclude two things. First, OME is one of the most prevalent reasons for a child to visit his or her pediatrician or family physician. Secondly, the literature concludes that the underlying cause of all inflammatory ear diseases is eustachian tube malfunction. It is not so clear, though, whether the inflammation encourages the eustachian tube malfunction, or whether malfunction of the eustachian tube begins first, and this in turn results in the sequence of fluid accumulation, inflammation, and even infection of the middle ear system. In light of the fact that a fair number of children presenting with OME exhibit sterile environments upon culture of their effusion, it does seem reasonable that at least some of these children do develop the eustachian tube malfunction problem before the inflammation problem.
A Philosophical Discussion on the Relationship between Craniomandibular Dysfunction and OME in Children In the preceding paragraph, the author has attempted to present evidence from the medical and dental literature that establishes a number of findings: I. TMJ dysfunction does exist in children. 2. OME does exist in children. 3. Eustachian tube malfunction is somehow involved in either the onset or the progression of OME. These three facts are followed by the following three big questions: I . Are the three facts stated above somehow related to each other, or are they entirely independent? 2. Specifically, could TMJ dysfunc-
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tion be a causative factor in the onset of OME? 3. Could eustachian tube malfunction be related to TMJ dysfunction? The author's interest in the above questions first began in 1984 when he attended a seminar given by Dr. Merle Bean, a practicing pediatric dentist for over 25 years. 15 Dr. Bean said he found dramatic improvement in OME symptomatology upon placing stainless steel crowns over the primary molars in young children. He intentionally opened the vertical dimension of these young children by placing the stainless steel crowns over unprepared primary molars, and found that the children had an improvement in hearing, and a decrease in the need for PE tubes and antibiotics. He provided no solid scientific explanation for his clinical findings, but he did say he had found this improvement in OME in many cases. There seems to be no questiqn that many young children are having recurring bouts of OME, with repeated doses of antibiotics and eventual PE or MET tube placement. If, in fact, there was a craniomandibular component to this problem, it would be a most enlightening fact to ear, nose, and throat physicians because it could affect so many patients. There also is no question that there is a very close embryologic and anatomic relationship between the TMJ, the muscles of mastication, the middle ear, and also the tensor veli palatini muscle which opens and closes the eustachian tube. These muscles of mastication as well as the tensor veli palatini are all derived from the mesoderm of the first branchial arch, and thus share common innervation by the fifth cranial nerve. 19 •20 The nerve that supplies the tensor veli palatini muscle is a direct branch of the nerve that supplies the medial pterygoid muscle. When the tensor veli palatini muscle is relaxed, the eustachian tube remains closed, allowing no fluid to escape. Upon normal function of the mandible and muscles of mastication (such as swallowing, yawning, or sneezing), the tensor veli palatini muscle will allow the tube to open and allow the escape of any fluid accumulation in the middle ear. The same bud cell that gives off the internal pterygoid muscle also gives off the tensor tympani muscle which is a very important muscle in the function of the middle ear. 21 More recently, it is thought that the tensor tympani muscle may be an extensio::t of the tensor veli palatini muscle, thus having the same innervation. Several dental authors have also examined the re-
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lationship between the TMJ complex and otitis media with effusion. Marasa and Ham 15 review five patients between the ages of 4 and 7 years. Their average overjet was 7 mm and they all presented with an overbite of 90 to 100%. Four out of the five exhibited narrow dental arches and all were classified as retrognathic. All five of the patients had experienced multiple bouts of OME, starting as early as 5 months old. Because of their frequent bouts with OME, all of the patients had multiple attempts of antibiotic therapy and several had ventilation tubes placed in their tympanic membrane to allow for drainage. The author of the article placed composite material on the occlusal surfaces of the lower deciduous molars, which immediately reduced the vertical overbite to lO to 20%. On one of the patients, the author also used an upper expansion device to widen the arch and increase the vertical dimension. The author found that four out of the five patients had a significant and dramatic decrease in the occurrence of their OME bouts after altering the maxillary-mandible relationship. The one patient that did continue to have bouts with OME was noncompliant with his therapy, and treatment had to be discontinued. In conclusion, this author noted the same thing that Dr. Bean had noted earlier, specifically that alteration of the vertical dimension dramatically decreases the incidence of OME in young children. Marasa and Ham noted several explanations for the patients' improvement after treatment. 14
Malfunction of the Tensor Veli Palatini Muscle Due to Neurotransmission Because of the shared innervation of the trigeminal nerve, if the muscles of mastication are in a hypertonic state, so the tensor veli palatini muscle will be. If the tensor veli palatini muscle is hypertonic for a long time, the eustachian tube will not be able to open and fluid will not be able to escape from the middle ear. By restoring the vertical dimension to the patients with a loss of vertical dimension, the muscles will be able to function because they no longer will be in spasm.
Malfunction of the Tensor Veli Palatini Muscle Due to Malposition or Hypertonicity of the Medial Pterygoid Muscle When the tensor veli palatini pulls on the eustachian tube to open it, it must first push the medial pterygoid muscle aside. If this muscle is in spasm, it would be hard for the tensor veli palatini to open the eustachian
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tube. Alteration of the function of the medial pterygoid muscle by changing its length through restoration of the vertical dimension might allow for better eustachian tube function.
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Reprint requests to: Stephen Youniss. D.D.S. 19 Fontana Lane Suite 202 Baltimore. Maryland 21237
References I. Helkimo, M: Epidemiological surveys of dysfunctions of the masticatory system. Oral Sci Rev 1976; 1:54-69 2. Heliie B. Heliie LA: Frequency and distribution of myofascial pain dysfunction syndrome in a population. Community Dent Oral Ep· idemio/1979: 7:357-360 3. Ingervall B. Mohlin B. Thilander B: Prevalence of symptoms of functional disturbances of the masticatory system in Swedish. Am J Rehabi/1980; 7:185-197 4. Solberg WK. Woo M. Houston J: Prevalence of mandibular dysfunctions in young adults. JADA 1979; 98:25-34 5. Williamson EH: Temporomandibular dysfunction in pretreatment adolescent patients. A J Orthod 1977; 72:429-433 6. Grosfeld 0. Czamecka B: Musculo-articular disorders of the stomatognathic system in school children examined according to clinical criteria. J Oral Rehabil 1977; 4:193-200 7. Nilver M. Lassing SA: Prevalence of functional disturbances and diseases of the stomatognathic system in 7-14 year olds. Swed Dent J 1981; 5:173-187 8. Stack BC. Funt LA: Temporomandibular joint dysfunction in children. J Pedod 1977; 1:240--247 9. Riolo M. Brandt D. Tenhaven T: Associations between occlusal characteristics and signs and symptoms of TMJ dysfunction in children and young adults. Am J Onhod Dentofacial Orthop 1987; 92:467477 10. TurnerS: Medicine for the Practicing Physician. Moburn: Butterworth Publishers. 1983; 1712-1716 , II. Destalozza G. et al.: Incidence of OME. Adv Otorhino/aryngo/1988; 40:47-56 12. Lim D. et al.: Otitis media with effusion. Arch Otolarvnco/ Head Neck Surg 1979; 105:404-12 · · 13. Wanman A. Agerberg G: Two year longitudal study of signs of mandibular dysfunction in adolescents. Acta Odontal Scand 1986; 44:333342 14. Marasa F. Ham B: Case reports involving the treatment of children with chronic otitis media with effusion via craniomandibular methods. J Craniomandib Pract 1988; 6:256--270 15. Dean M: Part of a lecture on temporomandibular dysfunction. Baltimore. MD. Oct 1984 16. TurnerS: Medicine for the Practicing Physician. Moburn. Butterworth Publishers. 1983 17. Davidson T: Otolaryngology. New York: Grune and Stratton. Inc. 1984; 19-27 18. Dayal V: Clinical Otolaryngology. Philadelphia: JB Lippincott Co. 1981; 41-43 19. Paradise J: OME in children. Adv Otorhinolaryngol 1988; 40:47-56 20. Penny HT. et al.: The embryology of the temporomandibular joint. J Craniomandib Pract 1985; 3:125-132 21. Arlen H: The Otomandibular Syndrome: A New Concept.
Communication through the Petrotympanic Fissure The tympanic orifice of the eustachian tube is present on the anterior wall of the middle ear. In a patient with a loss of vertical dimension, the mandibular condyles may be forced distally and pushed into the petrotympanic fissure. This distal position may cause some blockage of the eustachian tube orifice. Likewise, if the retrodiskal tissue of the TMJ becomes inflamed, this inflammation could spread through the petrotympanic fissure and into the middle ear. This again could account for the blockage of the eustachian tube.
Conclusion Even though the medical literature does not fully appreciate the relationship between craniomandibular dysfunction and OME in children, there does exist the possibility that the two may be directly related. This is supported by the success of the small group of patients presented by Dr. Marasa, especially after the failure of the more traditional mode of OME treatment. Without question, more research must be provided in this area, especially with well controlled clinical studies. Hopefully one day, children with OME can be treated via craniomandibular methods rather than surgical intervention.
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