Tinnitus (Ringing in the Ears) – the Great Quandary

Tinnitus is a spontaneous, internally generated noise which is usually heard in one ear but can be heard in both ears.  It is primarily a subjective complain, and the severity is dependent primarily on the patient’s description.  Almost any condition that causes malfunction of the auditory end-organ might cause tinnitus, but the most common cause is age degeneration (presbycusis).  Other causes are biochemical changes, e.g., from aspirin, Meniere’s disease, trauma (acoustic or chemical), and labyrinthitis.  It may occur alone or in concert with other symptoms such as head, neck and back pain: dizziness (vertigo); otalgia; impaired hearing; stuffy sensations in the ears; double and blurred vision; various TM joint noises during chewing; maximum voluntary clenching; maximum jaw protrusion; mouth opening against resistance; and pressure applied to the ipsilateral temporomandibular joint.

Tinnitus is present in approximately one-third of patients who present with ear pain, fullness, hearing loss, etc.  The patient may also complain of high hissing sound, not the roaring type.  In older patients exhibiting a high frquency sensorineural hearing loss, tinnitus could be attributed to a degenerative process in the cochlea of the ear.

Patients with temporomandibular disorders report a higher prevalence of tinnitus than do age matched control groups.  Also TMD has been implicated as a cause of tinnitus.  As many as one-third (32%) of all Americans experience tinnitus sometimes in their lives.  These data are supported sometime in their lives.  These data are supported by similar studies performed in Europe.  It is estimated that approximately 18 million Americans seek medical attention for their tinnitus.  Nine million report being seriously  affected by their condition, and two million are disabled because of elusive sounds.

There are two historical classifications for tinnitus.

  1. Objective tinnitus refers to a noise that can be heard by both the patient and physician. This formation of tinnitus is usually derived from one of two sources: the vascular system or from the muscle contraction.
  2. Vascular tinnitus is usually pulsatile and synchronous with the pulse.  Glomus tumors, aneurysms along the carotid system, and other vascular malformations cause a pulsatile tinnitus that can be heard with a stethoscope and that abates when pressure is applied to the feeding vessels. The tinnitus of muscle contraction is usually a most annoying ringing sound caused by clonic activity of the tensor veli palatini (palatal myoclonus).

Treatment

Treatment has been frustrating for the treating physician who often prescribes tranquilizers and muscle relaxants in an effort to control muscle contraction.  Although there is no specific medical or surgical therapy for tinnitus, many patients find relief by playing background music to mask the tinnitus.  A hearing aid for the associated hearing loss often results in suppression of the tinnitus. Some patients benefit from use of a tinnitus masker, a device worn like a hearing aid that presents a noise more pleasant than tinnitus.

Current Medical Theory

Current medical theory is that the majority of cases of tinnitus have no detectable acoustic basis, but instead arise from anomalies in one or more of the elements of the neural chain that constitutes the auditory nervous system.  In the past few years, experts treating patients from a stomatognathic approach have had success in alleviating tinnitus.  However, since tinnitus can be a symptom of serious ear disease, it is recommended that an ENT or neurological evaluation be performed prior to initiating dental treatment.

For more than half a century, investigators have attempted to explain the association between TMJ and tinnitus in the dental otologic literature.  One of the first was Costen, who speculated that pressure from the condyle could cause eustachian tube blockage, thereby producing tinnnitus.  A second hypothesis, which is implicated with eustachian tube, was based on the common nerve supply to the masticatory muscles and tensor veli palatini muscle.  These researchers speculated that hyperactivity of the masticatory muscles could induce a secondary reflex contraction of the tensor veli palatini muscle, congestion of the middle ear, and consequently tinnitus.

Others have proposed the concept that the middle and inner ears receive input from the trigeminal nerve and sympathetic nerves of the middle ear through the tympanic plexus, thus speculating these combined inputs might be responsible for tinnitus.  Chan and Read speculated that a masseter muscle trigger point may cause tinnitus and referred pain at distant locations.  Other investigators speculated that inflammation within the TMJ could be a source of tinnitus.

It has been reported that palpation of the deep masseter, medial pterygoid, lateral pterygoid, and sternocleidomastoid muscles can reproduce or intensify a patient’s tinnitus.

After proper dental therapy tinnitus, has been known to generally relieve.  It has been reported that TMD therapy improves tinnitus in 46-96% of patients who have TMD and coexisting tinnitus.  The neuromuscular dentist has the ability to measure masticatory muscle activity at rest and in function, thereby obtaining quantitative objective data from which therapy can be instituted.  It has been the author’s clinical experience that when masticatory and associated muscle activity are optimally at rest and in function, TMD complaints of tinnitus usually resolves.  When the only complain is tinnitus with no TMD complaints, resolution of tinnitus is usually limited/poor.

Which TMD patients have the greatest likelihood of experiencing tinnitus improvement? 

  1. The age range is 18-76 years.
  2. Occurs less frequently on a monthly basis rather than on a constant basis.
  3. Lasts for a short period of time, seconds rather than continuous.
  4. Hearing is normal.
  5. They have pain in their ipsilateral ear.
  6. Tinnitus began approximately when TMD symtptoms began.
  7. More intense when the TMD symptoms increase.
  8. Appears to be related to stress.
  9. They experience changes in tinnitus (such as intensity) when they move their jaw.
  10. Tinnitus is reproduced or intensified when thy clench their posterior teeth as hard as possible.

It is unfortunate that the medical and dental profession has a very limited knowledge or understanding in the arena of gneuromuscular (GNM) craniomandibular orthopedics.  Literature is sparse and most health care providers have little to no understanding of the necessity for a multidisciplinary approach to the treatment of patients suffering from eustachian tube dysfunction, otalgia, and/or tinnitus.

After medical treatment options have been exhausted, it is essential that gneuromuscular (GNM craniomandibular) orthopedics be considered.

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