CRANIO® The Journal of Craniomandibular & Sleep Practice

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Tinnitus of TMJ Origin: A Preliminary Report Douglas H. Morgan D.D.S. To cite this article: Douglas H. Morgan D.D.S. (1992) Tinnitus of TMJ Origin: A Preliminary Report, CRANIO®, 10:2, 124-129, DOI: 10.1080/08869634.1992.11677900 To link to this article: http://dx.doi.org/10.1080/08869634.1992.11677900

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Date: 13 March 2017, At: 19:57

• ENT

TINNITUS OF TMJ ORIGIN: A PRELIMINARY REPORT Douglas H. Morgan, D.D.S.

0886-9634192/1 0020124$03.00/0, THE JOURNAL OF CRANIOMANDIBULAR PRACTICE, Copyrigh1 © 1992 by Williams & Wilkins Manuscript received July 2, 1991; revised manuscript received September 17, 1991; accepted September 17,

1991 This work was supported by the American Tinnitus Association, Portland, Oregon. Address for reprint requests: Douglas H. Morgan, D.D.S. Suije 8 3043 Foothill Boulevard La Crescenta, California 91214

ABSTRACT: Twenty patients whose chief complaint was tinnitus were examined. They were not known to have temporomandibular disorders. They did not have pain or dysfunction. They were examined by physicians for ear disorders and the results were considered negative. Each of these patients had a complete history and clinical temporomandibular joint examination. The clinical examination included muscle and joint palpation and stethoscopic examination of the joint. This examination also included selected computerized mandibular scans and electromyographic studies of selected facial muscles. Each subject had eight views of transcranial lateral oblique x-rays taken. It was determined that 19 of these individuals had one or more clinical, electromyographic, and radiographic indications of a temporomandibular disorder. From this study, it appears that individuals who have tinnitus with no apparent otologic basis for this symptom should have a careful evaluation of the temporomandibular apparatus. A temporomandibular disorder may be one of the primary causes of this symptom.

C

osten' in 1936 wrote of a syndrome in which ear and sinus symptoms were related to disturbed function of the temporomandibular joint (TMJ). Goodfriend2 in 1936 also wrote concerning ear symptoms related to dental factors. Bernstein et al. 3 wrote in 1969 of TMJ dysfunction masquerading as ENT disease. Morgan4 in 1971 wrote of results of joint surgery correcting pain, dysfunction, tinnitus, and vertigo. House et al. 5 wrote in 1984 concerning results of TMJ surgery over a 14-year period using a vitallium articular eminence device. There was an elimination or improvement in over 80% of the pain symptoms (Table 1). In the symptoms other than pain, including tinnitus, there was an elimination or improvement of the tinnitus in 39% (Table 2). These cases involved individuals who had osteoarthritis of the TMJ that did not respond to non-surgical treatment. Their chief complaints were pain and dysfunction. However, a significant percentage also had tinnitus, vertigo, subjective hearing loss, nausea, and other otologic symptoms. One patient had no pain and/or dysfunction, only severe vertigo and moderate tinnitus. X-rays and a clinical examination revealed he had severe osteoarthritis in the right TMJ. It was explained to him that surgery was usually accomplished for pain and/or dysfunction. He had been to a center specializing in problems of the ear, but no otologic basis for his Meniere's disease-like symptoms could be found. He was referred to the author. He agreed to the surgery on an experimental basis. An arthroplasty was performed with placement of a vitallium articular eminence device. After surgery the vertigo was eliminated

Dr. Douglas H. Morgan obtained his dental degree from the University of Southern California School of Dentistry and his oral surgery training at the University of Southern California-Los Angeles County Medical Center. He is a fellow of the American College of Oral and Maxillofacial Surgeons and a member of the Western Association of Oral and Maxillofacial Surgeons. He is a founding fellow of the International College of Craniomandibular Onhopedics and was a founding fellow of the American College of Craniomandibular Disorders. He is president of the TMJ Research Foundation, a non-profit foundation dedicated to teaching education and research in the field of the TMJ and related structures.

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Table 1

Table 2

Subjective Overall Assessment of Surgical Results Patient Rating in Percent No No. of Year of Joints Response Excellent Good Fair Poor Surgery

Ratings of Symptoms Other Than Pain After TMJ Surgery 1965-1977 Patient Rating in Percent Not No Eliminated Improved Change Worse Applicable Pain Location 10.0 29.2 10.0 11.5 Grating sound in 39.2 joint 14.8 4.4 23.7 31.1 Partial inability to 25.9 open mouth 17.6 6.4 12.0 31.2 Clicking sound in 32.8 joint 19.9 8.4 11.5 22.1 Snapping sound in 38.2 joint 22.9 7.6 6.1 25.2 Popping sound in 38.2 joint 0.7 27.9 10.0 30.0 31.4 Vertigo 35.3 8.1 Fullness, pressure, 19.1 29.4 8.1 blockage in ear 6.2 35.7 21.7 17.1 19.4 Ringing in ears 0.8 52.3 12.9 7.6 Nausea 26.5 54.6 12.4 3.3 Subjective hearing 19.0 10.7 loss 2.8 69.4 Total inability to 21.3 4.6 1.9 open mouth

1965 1967 1968 1970 1971 1972 1973 1974 1975 1976 1977 Group results

1 2 1 4 17 20 18 29 30 25 20 167

2 2 4

100.0 100.0 100.0 50.0 70.6 25.0 33.3 34.5 50.0 39.1 30.0 41.7

50.0 11.8 45.0 44.4 24.1 21.4 13.0 50.0 28.8

11.8 5.9 30.0 5.6 16.7 41.4 21.4 7.1 43.5 4.4 20.0 14.1 15.3

Table is reproduced from House L, Morgan D: Temporomandibular joint surgery: Results of a 14-year joint implant study, Laryngoscope 1984; 94(4).

and the tinnitus was reduced in volume. Individuals may have ear symptoms that are related primarily to a temporomandibular disorder. However, since there may be little or no apparent symptoms pointing to a TMJ problem, this area is not usually considered or examined. In 1962, Pinto6 wrote concerning a tiny ligament that seemed to connect the malleous in the middle ear to the capsule and disk of the TMJ. He noticed that when the ligament was moved, the chain of ossicles and the tympanic membrane also moved. This was one possible explanation for the TMJ-ear connection. In 1986 KomorF confirmed this by his dissections. However, he determined that the anterior malleolar ligament was actually two ligaments, the diskomalleolar ligament and the sphenomandibular ligament. In his specimens he was unable to show movement of the middle ear bones and tympanic membrane when the disk and capsular ligament were moved. However, this non-movement may be due to the physical condition of the specimens and how they were prepared according to Pinto. 8 Arlen9 wrote in 1977 about the ''Otomandibular Syndrome.'' In 1987 Frurnker and Kyle 10 wrote about tinnitus as a symptom ofTMJ dysfunction. Also in 1987 Morgan 11 wrote about TMJ, tinnitus, and related symptoms. Williamson12 in 1990 wrote about the inner-relationship of internal derangements of the TMJ and headaches, vertigo, and tinnitus. He postulated various bases for this connection but did not cite the diskomalleolar/sphenomandibular ligaments as a possible cause of ear symptoms. In 1990 Rubinstein et al. 13 wrote of the symptoms of craniomandibular disorders in patients with tinnitus. In January 1991 Eckerdal 14 wrote about the petrotympanic fissure as APRIL 1992, VOL 10, NO.2

Table is reproduced from House L, Morgan D: Temporomandibular joint surgery: Results of a 14-year joint implant study. Laryngoscope 1984; 94(4).

being the connecting link between the tympanic cavity and the TMJ. Also in 1991 Ash and Pinto 15 postulated a relationship of the middle ear to the TMJ as hypothetically due in part to a "tiny ligament," the sphenomandibular ligament, or the diskomalleolar ligament. Examination of the joints were also accomplished. Measurements of certain jaw and teeth movements were made. This was an update on Pinto's earlier article.

Materials and Methods A computerized mandibular scan and electromyographic studies were done on each subject.* This involved 13 separate scans including the electromyographic studies. For this study only four of the scans were used. The study was simplified by focusing on only two of the "jaw tracking" scans: the sagittal-frontal views and the velocity trace view. Only the temporalis anterior and the medial masseter muscles were studied. All the other scans and electromyographic studies would make another interesting paper. Scan No. 1 involved sagittal and frontal measurements of maximum jaw opening (Figure 1). These scans showed deviations of the mandible on open*Myotronic, Seattle, Washington.

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TINNITUS OF TMJ ORIGIN

Figure 1

Figure 3

Craniomandibular scan showing normal sagittal and frontal opening of the mandible.

Craniomandibular scan showing normal velocity trace and normal frontal scan (magnified five times).

Figure 2

Figure 4

Craniomandibular scan showing abnormal sagittal (crossover) and frontal opening (deviation to right and/or left).

Craniomandibular scan showing abnormal or aberrant velocity trace and frontal scan.

ing and closing maneuvers (Figure 2). Scan No. 2 was a velocity trace and magnified frontal scan of the mouth opening and closing (Figure 3). This velocity trace, can depict such conditions as dyskinesia, bradykinesia, disk popping on opening and/or on closing movements (Figure 4). These scans can also give information relating to abnormal bony structure in the joints. The electromyographic studies, scans No. 9 and No. 10, register the right and left temporalis anterior and medial masseter muscle activity. This is measured in microvolts at rest and after a transcutaneous electrical

nerve stimulation unit had electronically relaxed the muscles (Figures 5 and 6). t These measurements gave us information relating to fatigued muscles and muscle ''trigger points.' ' This information helps in making a diagnosis of myofascial pain dysfunction syndrome, which is usually a secondary adaptive condition relating to an internal derangement of the disk, an osteoarthritis,

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tLine drawing and electromyographic studies from Jankelson RP: Neuromuscular Dental Diagnosis and Treatment. St. Louis-Tokyo: 1990, Ishiyaku EuroAmerica, Inc.

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Tinnitus of TMJ origin: a preliminary report.

Twenty patients whose chief complaint was tinnitus were examined. They were not known to have temporomandibular disorders. They did not have pain or d...
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