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Temporomandibular Disorder
and New Aural Symptoms
Kent W. Cox, MD, PhD
Objectives: To report the prevalence and demographics Results: Ten percent of all new otolaryngology clinic pa-
of temporomandibular disorder (TMD) within a popula- tients were diagnosed as having TMD. Of the 78 pa-
tion of clinic patients and to describe the prevalence of re- tients, 27 (35%) listed the ear as one of their sites of pain.
visited and new, previously unstudied, aural symptoms de- The prevalence of each of the 8 aural symptoms as-
scribed by a sample of these patients with TMD (hereinafter sessed was significantly higher in TMD patients com-
“TMD patients”). pared with controls (P⬍.001). A warm and/or fluid sen-
sation in the ear and a stuffed cotton sensation in the ear
Design: A retrospective evaluation of patient records was were the most indicative symptoms of TMD because they
completed to determine the percentage and the demo- had the highest relative risk ratios in TMD patients. Au-
graphics of TMD patients in a clinical setting. A prospec- ral symptoms of loud noise sensitivity and cold air/wind
tive analysis was done on the self-reported prevalence of sensitivity are also relevant and were approximately 5
previously studied and new aural symptoms of 78 TMD times more frequent in TMD subjects than in controls.
study patients compared with 78 control patients with-
out TMD. Conclusions: Patients with TMD are a significant com-
ponent of otolaryngology practice. There are previously
Setting: A private otolaryngology practice in a rural Ari- uninvestigated aural symptoms that occur much more
zona town. frequently in TMD patients than in patients without TMD.
Patients: Patients with TMD and aural symptoms. Arch Otolaryngol Head Neck Surg. 2008;134(4):389-393
T
EMPOROMANDIBULAR DISOR- the clinical evaluation is the history.1 In ad-
der (TMD) is classified as a dition to TMJ dysfunction and cephalgia,
subset of primary headache otalgia, tinnitus, and aural fullness have be-
disorders by the Interna- come recognized as characteristic compo-
tional Headache Society. nents of TMD.2
There is no simple and standard definition In several decades of practice, it be-
of TMD. In the medicodental literature, came clear that nonpediatric patients re-
TMD is frequently defined as a collective ferred with a diagnosis of ear infections or
term describing a complex and broad group sinus infections frequently had neither, and
of conditions involving the temporoman- the origin of the patients’ symptoms was de-
dibular joint (TMJ), muscles of mastica- termined to be TMD. The seemingly high
tion, and associated structures. The scope number of these cases led to this study that
of the phrase “collective term” can be ap- analyzes the demographics and the preva-
preciated by the number of conditions lence of aural symptoms of patients with
TMD (hereinafter “TMD patients”) in a pri-
considered to constitute TMD.1 These con-
vate clinical practice. The prevalence of otal-
ditions, listed in decreasing rates of occur-
gia, tinnitus, vertigo, and hearing loss is ana-
rence, are as follows: (1) myofascial pain
lyzed. More important, new aural symptoms
dysfunction; (2) internal derangement;
described by TMD patients but not previ-
(3) arthritides (osteoarthritis, inflamma- ously evaluated are reported.
tory, infectious, and metabolic); (4) hyper-
mobility (subluxation and dislocation);
(5) acute trauma (contusions and frac- METHODS
tures); (6) ankylosis (true or false); (7) de-
velopmental abnormalities (genetic or ac- RETROSPECTIVE
quired); and (8) neoplasia (benign or DEMOGRAPHIC STUDY
Author Affiliation: Summit malignant). The 3 cardinal features of TMD The setting of this study was in my private oto-
Health Care Regional Medical are pain, joint noise, and restricted jaw mo- laryngology practice in a retirement town in ru-
Center, Show Low, Arizona. tion. However, the most important part of ral Arizona, with a population base of approxi-
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sites of pain in the head and neck commonly described by TMD
Table 1. Demographics of All Patients With TMD, patients were presented as choices on the questionnaire. Be-
the Study Group, and the Control Group cause TMD cephalgia is multisited, the patients were asked to
select their 3 sites of worst pain.
Group Value a In addition, the TMD study patients were asked about the
All TMD patients (n =230) b
presence or absence of 8 aural symptoms, which have been noted
Gender to occur frequently in TMD. From past experience, TMD pa-
Female 180 (78) tients usually described their episodes of vertigo as short in du-
Male 50 (22) ration and entailing more of a sense of unsteadiness than ro-
Age, y tary motion. In the questionnaire, 1 of the 8 symptoms was
Range 10-83 collectively presented as “dizziness, spinning, or loss of equi-
Mean 46.9 librium” and the study patients were asked to respond yes or
Median 50 no if 1 or more of these symptoms lasted less than 5 minutes.
Study group patients (n = 78) Prevalences of other symptoms, such as tinnitus and fullness,
Gender have been studied elsewhere but were included in this study
Female 65 (83) as a comparison to lend credibility to the prevalences of new
Male 13 (17) aural symptoms reported herein. These new aural symptoms
Age, y c on the questionnaire include loud noise sensitivity, cold air/
Range 10-83 wind sensitivity in the ear, and warm and/or fluid sensation in
Mean 49.1 the ear and are new because they have not been previously evalu-
Median 47 ated. The questionnaire was given sequentially over a 10-
Control group patients (n = 78)
month period to all new clinical patients diagnosed as having
Gender
TMD who had a normal ear examination result (ie, there was
Female 65 (83)
Male 13 (17)
no pathological feature in the middle ear, tympanic mem-
Age, y
brane, or ear canal). Seventy-eight patients returned their ques-
Range 10-89 tionnaires and comprised the TMD study patients.
Mean 52.8 To evaluate aural symptom prevalence in non-TMD patients,
Median 57 the aural symptoms section of the questionnaire was presented
consecutively to prospective clinic patients who also had normal
Abbreviation: TMD, temporomandibular disorder. ear examination results and no history of chronic headaches, mi-
a Data are given as number (percentage) of each group unless otherwise graines, or TMD. These patients also had no recent history of ear
indicated. infections or rhinosinusitis. The first 78 questionnaires from non-
b The TMD was diagnosed in 230 of 2319 consecutive patients (10%).
c The mean age of onset of TMD was 36.5 years, and the mean age of first
TMD patients who cross matched for gender formed the control
group and then their demographics were also tabulated.
seeking medical help was 42.8 years.
The frequency of each of the 8 aural symptoms in TMD and
control patients was compared using the Fisher exact test.
Statistical calculations were performed using the JMP ver-
mately 30 000. In this retrospective study, the 2319 medical records
sion 5.1.1 statistical software package (SAS Institute Inc, Cary,
from all new clinic patients seen from late 1998 and the subse-
North Carolina).
quent 30 months were reviewed retrospectively. The age and gen-
der of all new patients diagnosed as having TMD were recorded.
The diagnosis of TMD was based on the patient history and RESULTS
results of physical examination. The patients were asked about
the presence of signs and symptoms strongly associated with
TMD. In the TMD patients, at least 70% reported painful knots
DEMOGRAPHICS
in the head and neck; cephalgia increased by chewing gum, ba-
gels, and jerky; grinding of their teeth under stress; and pain In a 30-month period, 230 of 2319 new patients were di-
migrating between the head and neck. Palpation of the TMJ and agnosed as having TMD. The demographics of all 230
the lateral pterygoid, temporalis, trapezius, and sternocleido- TMD patients seen in the 30-month period are shown
mastoid muscles was done bilaterally to determine the pres- in Table 1. The demographics of the 78 TMD study group
ence of pain or tenderness. It is not clear if one can actually patients and the 78 control group patients are also found
palpate the lateral pterygoid muscles themselves, but an at- in Table 1. The Figure compares all 3 groups, and it seems
tempt to palpate these muscles for tenderness was performed, that the 78 patients in the TMD study group were rep-
as described by Cooper.3 Pterygoid pain on finger pressure be- resentative of all 230 TMD patients seen in the clinic dur-
hind the maxillary dental arch into the condyle, palpable hy-
percontractions of the temporalis and/or trapezius muscle(s),
ing the 30-month period because the demographics of
lateral deviation of the mandible on excursion, and TMJ pain both groups are similar. The control group age distribu-
and crepitus (clicking, popping, or grating) were the most com- tion is skewed because the median age is 10 years older
mon signs of TMD; at least 2 of these signs were present in each than that of the TMD study group. The age range of the
of the TMD patients. This retrospective review of all patients 230 TMD patients is 10 to 83 years. The median age is
seen in the 30-month period was done after the prospective study 50 years. The female to male ratio is 3.6:1.
and included the study sample patients.
AURAL SYMPTOMS IN TMD
PROSPECTIVE STUDY
OF AURAL SYMPTOMS
Of the 78 TMD study patients, 27 (35%) listed the ear as
A questionnaire was designed regarding gender, age, and the one of the sites of their TMD pain. However, the jaw, the
site of TMD pain. Any TMD patients reporting ear infections, back of the head into the neck, the temple, and behind the
sinusitis, and jaw trauma or jaw surgery were excluded. Nine eyes are more often chosen as sites of pain (Table 2). In
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35.0
All TMD patients (n = 230)
Study patients (n = 78)
30.0 Control patients (n = 78)
25.0
% of Patients
20.0
15.0
10.0
5.0
0.0
10-19 20-29 30-39 40-49 50-59 60-69 70-79 80-89
Age, y
Figure. The age distribution of the study patients, the control patients, and all patients with temporomandibular disorder (TMD).
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Table 3. Prevalence of Ear Symptoms
study group (mean age, 49.1 years) will have more aural
Table 4. Relative Risk Ratio of Aural Symptoms symptoms and fewer pain symptoms than their younger
in Patients With TMD
study group (mean age, 29.6 years). However, using the
study and control prevalence numbers of Tuz et al to cal-
Relative Risk Ratio
Symptom in culate the risk ratios of aural symptoms, we find there is
Present Study by the Study good agreement in the relative risk ratios of tinnitus, ver-
Symptom Study Tuz et al4 by Tuz et al4 tigo, and hearing loss between the 2 studies. The relative
Warm and/or fluid sensation ⬎38 a NA NA risk ratios of both studies are reported in Table 4 and lend
Stuffed cotton sensation in the ear 14.0 NA NA credence to the relative risk ratios of the new aural symp-
Loud noise sensitivity 6.2 NA NA
toms evaluated herein.
Pressure or fullness in the ear 6.2 NA NA
Cold air/wind sensitivity 4.4 NA NA
Tinnitus, hearing changes (such as a muffled quality or
Brief (⬍5-min) dysequilibrium 3.5 3.3 Vertigo perception of hearing loss), and dysequilibrium or vertigo
Ringing or other noises in the ear 2.8 2.3 Tinnitus are 3 aural symptoms that occur in more than half of the
Muffled hearing 2.4 2.2 Hearing loss study patients with TMD but are not as useful for recog-
nizing TMD because they are also frequent in the non-
Abbreviations: NA, data not applicable; TMD, temporomandibular disorder. TMD population. As examples, tinnitus is the most preva-
a Because relative risk ratio is the prevalence in the study group divided by
the prevalence in the control group, this calculates here to 38/0, or a value of lent ear symptom (76%) in the TMD study patients but has
infinity. a low relative risk ratio of 2.8 and more than half of the
study patients reported muffled hearing, which is only 2.4
times the rate found in the control group.
Ramirez et al,8 the prevalences of aural symptoms from Several components of aural symptoms distinct from
40 different studies completed between 1933 and 2004 hearing change, tinnitus, and vertigo were found in the TMD
were compiled. The occurrence of reported values for otal- study patients and are much more useful in recognizing
gia, tinnitus, vertigo, hearing loss, and ear fullness each TMD. The new aural symptoms of this study include a warm
ranged from approximately 10% to 90%. However, in their and/or fluid sensation in the ear, a stuffed cotton in the ear
review article, Ramirez et al made the following gener- sensation, loud noise sensitivity in the ear, and cold air/
alizations. The reported prevalence of otic pain and other wind sensitivity in the ear. The sensations of cotton, warmth,
otic symptoms of nonotologic origin in patients with TMD and/or fluid in the ear are present in TMD patients at least
varies from 3.5% to 42%. The frequency of tinnitus in 14 times more frequently than in control patients. These
patients with TMD varies from 33% to 76%. Dizziness symptoms are probably specific descriptors of aural full-
in patients with TMD ranges from 40% to 70%, and ver- ness, which itself was present in 74% of TMD patients. Al-
tigo ranges from 5% to 40%. The prevalence of tinnitus though warmth and/or fluid sensation in the ear was se-
in the healthy adult population is between 14% and 32%,2 lected by only 38% of the study group patients, it was the
and this compares favorably with the 27% prevalence in only aural symptom not present in the control patients.
the control group of this study. The higher rates of aural fullness in this study com-
The most relevant article to this work is a comparably pared with prior investigations could reflect a selection bias
controlled study of otic symptoms in TMD by Tuz et al.4 because ear symptoms in the subjects were often the main
In 155 study patients with TMD who reported having au- reason for referral to the otolaryngology clinic. Also, there
ral symptoms, the frequency of their aural symptoms vs likely was more extensive questioning regarding the na-
those of the control group was as follows: tinnitus, 59% vs ture of their ear symptoms than in other studies, particu-
26%; vertigo, 46% vs 14%; and hearing loss, 30% vs 14%. larly in research originating from a dental population.
Compared with this study, those prevalence rates are ap- Cold air/wind sensitivity in the ear is 4.4 times more
proximately 2 times higher for otalgia and half of the val- common in the TMD patients than in the control group.
ues for tinnitus, vertigo, and hearing loss. This might be Sensitivity of the ear canal to cold air/wind is a telling
accounted for by the fact that the older population of our symptom of TMD. These patients are so aware of this dis-
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comfort that they describe carrying cotton or ear covers cally middle aged and female. They complain of pain in the
to protect their ears from cold air or wind. Brief dysequi- jaw, temple, and lateral side of the head, with radiation of
librium is reported 3.5 times more often in the study pa- the pain to the neck. Despite a normal ear examination re-
tients than in control patients. sult, one-third may have otalgia. Warmth, fluid, or a stuffed
Tinnitus, aural fullness, hyperacusis, and hearing loss cotton sensation in the ear, ear sensitivity to loud noise or
have been reported in patients with migrainous vertigo; cold air/wind, or a feeling of aural fullness, especially in
however, migrainous vertigo is distinguished by spon- the presence of a normal ears, nose, and throat examina-
taneous rotational vertigo, recurrent vestibular symp- tion result, strongly suggests an underlying TMD. The oto-
toms of at least moderate severity that last for hours, a laryngologist’s familiarity and knowledge of the ear, and
current or previous history of migraine, and at least 1 mi- the awareness of these aural symptoms, should contrib-
graine symptom during at least 2 vertiginous attacks (ie, ute to the recognition and diagnosis of TMD.
migrainous headache, photophobia, phonophobia, or vi-
sual auras).9 Migrainous vertigo should be distinguish-
able from TMD in most cases. Submitted for Publication: April 30, 2007; final revi-
Aural symptoms are a consistent and provocative fea- sion received July 21, 2007; accepted August 16, 2007.
ture of TMD. Otalgia is often considered to be a referred Correspondence: Kent W. Cox, MD, PhD, Summit Health
pain of orofacial origin, but it could also be speculated Care Regional Medical Center, 2200 Show Low Lake Rd,
that otalgia and the sensitivity of the ear canal are influ- Show Low, AZ 85901 (kcox714@yahoo.com).
enced by chemical mediators of inflammation10,11 asso- Financial Disclosure: None reported.
ciated with the contiguous TMJ. Temporomandibular joint Additional Contributions: Robert Dobie, MD, and
inflammation and arthralgia are related to hypercontrac- Leslie Bernstein, DDS, MD, provided critical review and
tive dystonia of the muscles of mastication and likewise suggestions for improvement of this study; Robert Klein,
may cause stapedial muscle contractions. Perturbations Department of Pathology, University of Arizona, per-
of ossicular function could be linked to the attenuation formed statistical analysis of the data; and Adrienne Cox,
of the acoustic reflex and the hyperacusis apparently de- RN, patiently and supportively helped collect data and
scribed by these patients with loud noise sensitivity. Wa- prepare the manuscript.
tanabe et al12 previously associated tinnitus with hyper-
contractility of the stapedial muscle. They demonstrated REFERENCES
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