Tinnitus and
Vertigo in Patients With Temporomandibular Disorder Richard A.
Chole, MD, PhD, William
The association of tinnitus and vertigo with temporomandibular disorder (TMD) has been debated for many years. The observation that patients with TMD have otologic symptoms is confounded because tinnitus and vertigo are common symptoms in the normal population. The present study was conducted to determine if tinnitus and vertigo are actually more prevalent in patients with TMD than in appropriate age-matched controls. One control group was recruited from patients seeking care for health maintenance and the other from patients seeking routine dental care. We surveyed 1032 patients: 338 had TMD and 694 served as two age-matched control groups. Tinnitus and vertigo symptoms were significantly more prevalent in the TMD group than in either of the control groups. The mechanism of the association of TMD and otologic symptoms is unknown. (Arch Otolaryngol Head Neck Surg. 1992;118:817-821) \s=b\
authors have reported that various otologie Manysymptoms, including tinnitus and vertigo, with disorder occur
frequently in patients
(TMD) (Table l).1"13 A
temporomandibular variety of mechanisms have
been
proposed to explain this apparent association.14"24 The changing understanding of this complex problem has pro¬ duced different terminology over time. Costen's syndrome,2 temporomandibular joint pain dysfunction syndrome,25 myofascial pain dysfunction syndrome,26 and craniomandibular syn¬ drome27 are just some of the terms that have been suggested, and today are included under the blanket title TMD.2S Tinnitus, dizziness, and vertigo are common complaints in the general population; therefore, the occurrence of these symptoms in patients with TMD does not necessar¬ ily imply a causal relationship. However, if the incidence of these symptoms is significantly higher than in an appropriate control population, a causal relationship could be hypothesized. Previous studies of otologie symptoms in patients with TMD have compared this group with a
Accepted From the
for
publication
November 5, 1991.
Department of Otolaryngology, University of California,
Davis, School of Medicine. Reprint requests to Department of Otolaryngology, Otology Laboratory, 1159 Surge III, University of California, Davis, CA 95616 (Dr Chole).
S.
Parker, DMD, PhD
"normal" population without regard to age, gender, or general health. In this study we selected control populations that might provide meaningful comparisons with a population of pa¬
tients with TMD. We initially included the full range of pa¬ tients being treated for TMD. The prevalence of otologie symptoms in patients with TMD appears to be greater than in the general population. Because tinnitus and vertigo are common symptoms in the general population and also in¬ crease with increasing age, we compared the group of TMD patients with two control groups of comparable age. We chose the control groups from subjects who might be similar to the test population except for the presence of TMD. The first control group (control group 1) consisted of patients seeking routine medical care for health maintenance; the ra¬ tionale for choosing this group was that patients regularly seeking medical care may be more likely to be focused on chronic somatic symptoms (as was the TMD group).29 The second control group (control group 2) was selected from a population of patients seeking routine dental care; the ratio¬ nale for choosing this group was that it represented a demographically similar group of subjects who were not experi¬ encing chronic symptoms. This study was designed to test the null hypothesis that there is no association of tinnitus or vertigo and TMD when compared with appropriate con¬ trols.
SUBJECTS
AND METHODS
A total of 1032 subjects were included in this study: 338 under¬ going treatment for TMD, 326 in control group 1 (selected from patients seeking routine medical care for health maintenance), and 368 in control group 2 (selected from a population of patients seeking routine dental care). Patients in the TMD group were being treated in the private practices of individuals specializing in the treatment of patients with TMD. Subjects in control group 1 were individuals present¬ ing to private medical offices for routine health maintenance or to the University of California at Davis Student Health Center for various reasons. No otolaryngological practices were included. Control group 2 consisted of patients presenting for dental hygiene only in private dental offices and the Sacramento (Calif) City College School of Dental Hygiene. Data were collected by means of self-administered question¬ naires consisting of 11 questions (Table 2). The reliability of ques¬ tionnaires used in this manner has been verified.30"32 The following
Downloaded From: http://archotol.jamanetwork.com/ by a New York University User on 05/12/2015
Reporting Otologie Symptoms
Table 1.—Authors
in Patients With
Temporomandibular Disorder % I
No. of Patients
Source, y
Goodfriend,' 1933 Costen,' 1934 Myrhaug et al,4 1964 Dolowitz et al,5 1964 Gelbetal/· 1967 Bernstein et al,7 1968 Principato and Barwell,8 1978 Koskinen et al,9 1980 Brookes et al,'0 1980 Gelb and Bernstein," 1983 Cooper et al,'2 1986 Wedel and Carlsson," 1986 Table
Otalgia
Hearing Loss
91
3
14
5
26
38
13
12
13
Fullness in Ear
1391
21
32
28
32
64
100
43
5
38
742
36
40
20
15
86
93
42
14
33
62
25
100
44
47
47
20
26
24
26
45
82
76
33
80
62
36
40
25
48
36
40
38
14
15
14
200 476
50
148
Table
2.—Questionnaire
Question
48
3.—Age Distribution of Study Groups*
Answer -1
Age Range,
Age
3. Sex 4. Do you
Vertigo
400
1. Name 2.
Tinnitus
experience pain
in
or
around
your ears? 5. Do you experience head noise? 6. Would you ever consider the noises in your ears severe? 7. Does the noise interfere with your
sleep?
8. Do you ever any sort? 9. Do you ever
experience dizziness of
experience spinning
dizziness? 10. Is it ever severe?
11. Do you have any clicking or sounds in your jaw joints?
grinding
Yes/no Yes/no Yes/no
Yes/no Yes/no Yes/no Yes/no Yes/no
information was obtained: name, age, sex, and history of arthritis, diabetes, heart disease, high blood pressure, surgery within the last year, ear pain (unilateral and bilateral), tinnitus (unilateral or bilat¬ eral), severity of tinnitus, tinnitus that interferes with sleep, dizzi¬ ness, spinning vertigo, severity of dizziness, and temporomandib¬ ular joint noises (unilateral or bilateral). The principal outcome vari¬ ables of this study were tinnitus and vertigo. For the purposes of analysis, we retained patients in the TMD group only if they experienced both clicking in the joint and pain in the region of the ear (the joint). Thus, in the TMD group only those individuals with evidence of dysfunction or derangement of structures within the joint itself were included, resulting in a net of 200 subjects. Likewise, patients in the control group were excluded if they had both joint pain and joint clicking; 302 sub¬ jects were retained in control group 1 and 347 in control group 2. Statistical analyses were run on two levels to examine the fac¬ tors associated with the TMD group: likelihood ratio 2 tests to examine the marginal associations and a more sophisticated method fitting several log-linear models to the data to assess the partial associations while adjusting for the other predictive factors. A progressive Bonferroni adjustment was made for mul¬ tiple comparisons when differences appeared significant.33
TMD
Group
y
Control
Control
Group
Group
1
11-20
15.0
11.3
8.6
21-30
25.5
24.8
15.3
31-40
30.5
16.9
29.1
41-50
16.0
13.2
17.9
51-60
8.0
10.2
10.1
61-70
4.5
13.2
11.8
71-80
0.5
8.3
5.8
81-90
0.0
2.0
1.4
*TMD indicates
2
temporomandibular disorder. RESULTS
Subjects randomly chosen as outlined above. The age distribution in the study group (TMD) and the two con¬ trol groups was roughly comparable (Table 3). The principal outcome variables of this study were tin¬ nitus and vertigo. Since both symptoms vary in severity, and tinnitus varies in laterality, several comparisons were made in each group (Table 4). were
Tinnitus The patients in the TMD group had significantly more tinnitus than those in control group 1 or 2 (P=.001). As can be seen in Table 4, tinnitus is a very common symptom in the control population (13.8% in control group 1 and 32.5% in control group 2). Nevertheless, 59.0% of the patients with TMD experienced tinnitus. When questioned about "severe" vertigo, 28.0% of the TMD group responded af¬ firmatively, compared with only 6.0% and 8.3% in the control groups. About half of the subjects in each of the three groups had unilateral tinnitus and half had bilateral tinnitus. An even more striking difference was noted when patients were asked if the tinnitus interfered with sleep: 17.1% of the TMD group had this complaint. Only 3.2% and 5.0% of the control groups had tinnitus of this magnitude. This difference was significant (P=.001) (Fig 1 and
Table 5).
Downloaded From: http://archotol.jamanetwork.com/ by a New York University User on 05/12/2015
highly
4.—Symptom Summary for All Subject Groups*
Table
% Incidence TMD
Group
Factor
Control
Control
Group
Group
1
Gender (female)
87.0
62.5
58.9
Arthritis
15.0
15.0
18.5
Hypertension
2.0
4.0
19.9
Prior surgery
17.5
6.6
Vertigo Any dizziness Vertigo Severe vertigo
70.0 40.7 20.0
30.1 11.0 3.5
44.0 18.5 7.3
50.0 50.0
5.2 4.3
9.3 5.0
59.0 22.5 36.5 28.0 13.0 15.0 17.1
13.8 3.2 10.6 6.0 2.0 4.0 3.2
32.5 13.3 19.2 8.3 4.0 4.3 5.0
Otalgia
Unilateral Bilateral
Tinnitus
Unilateral Bilateral Severe tinnitus
Unilateral Bilateral
Disrupts sleep *TMD indicates
2
8.61
temporomandibular disorder.
Fig 2.—Incidence of vertigo in temporomandibular (TMD) group com¬
pared with
two
control groups.
Vertigo Dizziness and vertigo were significantly more com¬ monly reported in the TMD group than in the other two groups (Table 4 and Fig 2). Significantly more patients in the TMD group (70.0%) reported dizziness than in the control groups (30.1% and 44.0%) (P=.001). When patients were asked specifically about the symptom of spinning
vertigo and severe spinning vertigo, significantly more patients in the TMD group reported this symptom than in the control groups (P
Vertigo in Patients With Temporomandibular Disorder Richard A.
Chole, MD, PhD, William
The association of tinnitus and vertigo with temporomandibular disorder (TMD) has been debated for many years. The observation that patients with TMD have otologic symptoms is confounded because tinnitus and vertigo are common symptoms in the normal population. The present study was conducted to determine if tinnitus and vertigo are actually more prevalent in patients with TMD than in appropriate age-matched controls. One control group was recruited from patients seeking care for health maintenance and the other from patients seeking routine dental care. We surveyed 1032 patients: 338 had TMD and 694 served as two age-matched control groups. Tinnitus and vertigo symptoms were significantly more prevalent in the TMD group than in either of the control groups. The mechanism of the association of TMD and otologic symptoms is unknown. (Arch Otolaryngol Head Neck Surg. 1992;118:817-821) \s=b\
authors have reported that various otologie Manysymptoms, including tinnitus and vertigo, with disorder occur
frequently in patients
(TMD) (Table l).1"13 A
temporomandibular variety of mechanisms have
been
proposed to explain this apparent association.14"24 The changing understanding of this complex problem has pro¬ duced different terminology over time. Costen's syndrome,2 temporomandibular joint pain dysfunction syndrome,25 myofascial pain dysfunction syndrome,26 and craniomandibular syn¬ drome27 are just some of the terms that have been suggested, and today are included under the blanket title TMD.2S Tinnitus, dizziness, and vertigo are common complaints in the general population; therefore, the occurrence of these symptoms in patients with TMD does not necessar¬ ily imply a causal relationship. However, if the incidence of these symptoms is significantly higher than in an appropriate control population, a causal relationship could be hypothesized. Previous studies of otologie symptoms in patients with TMD have compared this group with a
Accepted From the
for
publication
November 5, 1991.
Department of Otolaryngology, University of California,
Davis, School of Medicine. Reprint requests to Department of Otolaryngology, Otology Laboratory, 1159 Surge III, University of California, Davis, CA 95616 (Dr Chole).
S.
Parker, DMD, PhD
"normal" population without regard to age, gender, or general health. In this study we selected control populations that might provide meaningful comparisons with a population of pa¬
tients with TMD. We initially included the full range of pa¬ tients being treated for TMD. The prevalence of otologie symptoms in patients with TMD appears to be greater than in the general population. Because tinnitus and vertigo are common symptoms in the general population and also in¬ crease with increasing age, we compared the group of TMD patients with two control groups of comparable age. We chose the control groups from subjects who might be similar to the test population except for the presence of TMD. The first control group (control group 1) consisted of patients seeking routine medical care for health maintenance; the ra¬ tionale for choosing this group was that patients regularly seeking medical care may be more likely to be focused on chronic somatic symptoms (as was the TMD group).29 The second control group (control group 2) was selected from a population of patients seeking routine dental care; the ratio¬ nale for choosing this group was that it represented a demographically similar group of subjects who were not experi¬ encing chronic symptoms. This study was designed to test the null hypothesis that there is no association of tinnitus or vertigo and TMD when compared with appropriate con¬ trols.
SUBJECTS
AND METHODS
A total of 1032 subjects were included in this study: 338 under¬ going treatment for TMD, 326 in control group 1 (selected from patients seeking routine medical care for health maintenance), and 368 in control group 2 (selected from a population of patients seeking routine dental care). Patients in the TMD group were being treated in the private practices of individuals specializing in the treatment of patients with TMD. Subjects in control group 1 were individuals present¬ ing to private medical offices for routine health maintenance or to the University of California at Davis Student Health Center for various reasons. No otolaryngological practices were included. Control group 2 consisted of patients presenting for dental hygiene only in private dental offices and the Sacramento (Calif) City College School of Dental Hygiene. Data were collected by means of self-administered question¬ naires consisting of 11 questions (Table 2). The reliability of ques¬ tionnaires used in this manner has been verified.30"32 The following
Downloaded From: http://archotol.jamanetwork.com/ by a New York University User on 05/12/2015
Reporting Otologie Symptoms
Table 1.—Authors
in Patients With
Temporomandibular Disorder % I
No. of Patients
Source, y
Goodfriend,' 1933 Costen,' 1934 Myrhaug et al,4 1964 Dolowitz et al,5 1964 Gelbetal/· 1967 Bernstein et al,7 1968 Principato and Barwell,8 1978 Koskinen et al,9 1980 Brookes et al,'0 1980 Gelb and Bernstein," 1983 Cooper et al,'2 1986 Wedel and Carlsson," 1986 Table
Otalgia
Hearing Loss
91
3
14
5
26
38
13
12
13
Fullness in Ear
1391
21
32
28
32
64
100
43
5
38
742
36
40
20
15
86
93
42
14
33
62
25
100
44
47
47
20
26
24
26
45
82
76
33
80
62
36
40
25
48
36
40
38
14
15
14
200 476
50
148
Table
2.—Questionnaire
Question
48
3.—Age Distribution of Study Groups*
Answer -1
Age Range,
Age
3. Sex 4. Do you
Vertigo
400
1. Name 2.
Tinnitus
experience pain
in
or
around
your ears? 5. Do you experience head noise? 6. Would you ever consider the noises in your ears severe? 7. Does the noise interfere with your
sleep?
8. Do you ever any sort? 9. Do you ever
experience dizziness of
experience spinning
dizziness? 10. Is it ever severe?
11. Do you have any clicking or sounds in your jaw joints?
grinding
Yes/no Yes/no Yes/no
Yes/no Yes/no Yes/no Yes/no Yes/no
information was obtained: name, age, sex, and history of arthritis, diabetes, heart disease, high blood pressure, surgery within the last year, ear pain (unilateral and bilateral), tinnitus (unilateral or bilat¬ eral), severity of tinnitus, tinnitus that interferes with sleep, dizzi¬ ness, spinning vertigo, severity of dizziness, and temporomandib¬ ular joint noises (unilateral or bilateral). The principal outcome vari¬ ables of this study were tinnitus and vertigo. For the purposes of analysis, we retained patients in the TMD group only if they experienced both clicking in the joint and pain in the region of the ear (the joint). Thus, in the TMD group only those individuals with evidence of dysfunction or derangement of structures within the joint itself were included, resulting in a net of 200 subjects. Likewise, patients in the control group were excluded if they had both joint pain and joint clicking; 302 sub¬ jects were retained in control group 1 and 347 in control group 2. Statistical analyses were run on two levels to examine the fac¬ tors associated with the TMD group: likelihood ratio 2 tests to examine the marginal associations and a more sophisticated method fitting several log-linear models to the data to assess the partial associations while adjusting for the other predictive factors. A progressive Bonferroni adjustment was made for mul¬ tiple comparisons when differences appeared significant.33
TMD
Group
y
Control
Control
Group
Group
1
11-20
15.0
11.3
8.6
21-30
25.5
24.8
15.3
31-40
30.5
16.9
29.1
41-50
16.0
13.2
17.9
51-60
8.0
10.2
10.1
61-70
4.5
13.2
11.8
71-80
0.5
8.3
5.8
81-90
0.0
2.0
1.4
*TMD indicates
2
temporomandibular disorder. RESULTS
Subjects randomly chosen as outlined above. The age distribution in the study group (TMD) and the two con¬ trol groups was roughly comparable (Table 3). The principal outcome variables of this study were tin¬ nitus and vertigo. Since both symptoms vary in severity, and tinnitus varies in laterality, several comparisons were made in each group (Table 4). were
Tinnitus The patients in the TMD group had significantly more tinnitus than those in control group 1 or 2 (P=.001). As can be seen in Table 4, tinnitus is a very common symptom in the control population (13.8% in control group 1 and 32.5% in control group 2). Nevertheless, 59.0% of the patients with TMD experienced tinnitus. When questioned about "severe" vertigo, 28.0% of the TMD group responded af¬ firmatively, compared with only 6.0% and 8.3% in the control groups. About half of the subjects in each of the three groups had unilateral tinnitus and half had bilateral tinnitus. An even more striking difference was noted when patients were asked if the tinnitus interfered with sleep: 17.1% of the TMD group had this complaint. Only 3.2% and 5.0% of the control groups had tinnitus of this magnitude. This difference was significant (P=.001) (Fig 1 and
Table 5).
Downloaded From: http://archotol.jamanetwork.com/ by a New York University User on 05/12/2015
highly
4.—Symptom Summary for All Subject Groups*
Table
% Incidence TMD
Group
Factor
Control
Control
Group
Group
1
Gender (female)
87.0
62.5
58.9
Arthritis
15.0
15.0
18.5
Hypertension
2.0
4.0
19.9
Prior surgery
17.5
6.6
Vertigo Any dizziness Vertigo Severe vertigo
70.0 40.7 20.0
30.1 11.0 3.5
44.0 18.5 7.3
50.0 50.0
5.2 4.3
9.3 5.0
59.0 22.5 36.5 28.0 13.0 15.0 17.1
13.8 3.2 10.6 6.0 2.0 4.0 3.2
32.5 13.3 19.2 8.3 4.0 4.3 5.0
Otalgia
Unilateral Bilateral
Tinnitus
Unilateral Bilateral Severe tinnitus
Unilateral Bilateral
Disrupts sleep *TMD indicates
2
8.61
temporomandibular disorder.
Fig 2.—Incidence of vertigo in temporomandibular (TMD) group com¬
pared with
two
control groups.
Vertigo Dizziness and vertigo were significantly more com¬ monly reported in the TMD group than in the other two groups (Table 4 and Fig 2). Significantly more patients in the TMD group (70.0%) reported dizziness than in the control groups (30.1% and 44.0%) (P=.001). When patients were asked specifically about the symptom of spinning
vertigo and severe spinning vertigo, significantly more patients in the TMD group reported this symptom than in the control groups (P
