When you have TMJ and Tinnitus look for cervical spine instability as a cause
Ross Hauser, MD, Caring Medical Florida
For most of the patients that we see with problems linked to the cervical spine, we rarely see a patient who suffers from the symptoms of one diagnosis. Such is the case with people with tinnitus and TMJ and TMJ and tinnitus. This is not a play on words. Some people have the primary diagnosis of TMJ (Temporomandibular joint dysfunction) or a diagnosis of temporomandibular disorders (TMD) with secondary tinnitus. Some people have tinnitus and among other secondary disorders, problems of the TMJ. These people with diagnosed correctly with TMJ and tinnitus are fortunate that their problems have been identified accurately as an accurate diagnosis is not always easy to come by.
This relationship and diagnosis problem between TMJ and tinnitus was discussed in an August 2019 study by researchers publishing in The Annals of Otology, Rhinology, and Laryngology. (1) They wrote: “There was a strong relationship between tinnitus occurrence and temporomandibular disorders. The findings implied the significance of exploring the signs of temporomandibular disorders in patients with tinnitus as well as tinnitus in those who complain from temporomandibular disorders.”
These are the same observations we have seen in 27 plus years of clinical experience. Many people with tinnitus have TMJ and many people with TMJ and tinnitus. One more thing, many of these people have cervical spine instability as the origin of their problems.
How this cervical spine instability developed can be helpful in understanding the overall experiences that this patient is feeling or suffering from. If tinnitus and TMJ resulted from a neck injury, such as a whiplash injury, then we can face tinnitus and TMJ with an eye towards other symptoms as they relate to Whiplash Associated Disorders. If the problems of tinnitus and TMJ stem from degenerative wear and tear and osteoarthritis, we can also anticipate the various problems associated with cervical spine instability and cervical and vagus nerve compression.
Patient frustrations, the long wait to see if treatment was effective or not, and seeing what may or may not help.
In our article tinnitus treatment when there are symptoms of cervical spine instability, we noted two recent research studies that took the time to ask patients what their feelings were in how they were being treated for their tinnitus. In the first study from October 2018, (2) researchers at Hofstra, Yale, and Columbia Universities wrote: “Many patients are not satisfied with their doctor’s answer when they complain about tinnitus.” Why? A May/June 2019 study in the journal Ear and Hearing. (3) may offer us the clue as this paper suggested that the full experience of living with tinnitus from a patient’s perspective has been under-investigated.” This under-investigation may miss the true cause of the patient’s problems.
What these two studies suggest is reflected in the stories that we hear from our patients. They sound like this:
I have TMJ only on my right side, and that is the side I have tinnitus. I wear a neuromuscular orthodic at night. My surgeon told me that we have to wait a few months to see if this helps before we can move onto surgery. I have been wearing it, it is not helping, but I have to wait some more. I need help today.
My doctor asked me if I moved my jaw around, could I lessen or worsen the sound in my ears and the clicking in my jaw. I said no, but if I ice my jaw or take anti-inflammatories my tinnitus gets better. I also need drugs to sleep well. My doctor said to continue on with the pain medications and sleep medications. I want treatment not medications
Insufficient knowledge in diagnosis and treatment
A September 2019 study in The International Tinnitus Journal (4) found that when 37 Primary Health Care Dentists were sent a questionnaire to verify the dentist’s knowledge on the interrelationship between temporomandibular dysfunction and tinnitus after continuing education, the collected data indicated insufficient dentist knowledge. The researchers concluded: “It is important to emphasize the importance of instructing and strengthening the knowledge of the Primary Health Care Dentists professional on the interrelationship between temporomandibular dysfunction and tinnitus.”
The prevalence of tinnitus is higher in individuals with a temporomandibular joint disorder but is it a TMJ disc problem?
One problem that you and your doctors may be chasing is the TMJ disc problem. In our article The evidence and comparisons of TMJ injection treatments, we wrote: “Someone who has been suffering from long-term TMJ problems, at some point, starts to realize that their challenges are challenges far beyond a disc or a TMJ appliance problem. When this person then has a failed TMJ surgery, these challenges they face become that much greater and their jaw problem that started out as an annoyance has turned into years of searching for anything that will help them with the new cascade of symptoms they suffer from beyond opening their mouths without pain.”
TMJ surgery and appliances do help people. But these are not the patients we see in our clinics. We see the people TMJ surgery and appliances did not help. These are people, perhaps like yourself, whose TMJ has turned into a problem of tinnitus, headaches, neck pain, difficulty swallowing, and dizziness.
A January 2020 study in the journal International Archives of Otorhinolaryngology (5) offered these insights:
- The study included 53 adult patients with bilateral or unilateral TMD (30 with and 23 without tinnitus).
- The association between tinnitus and morphological aspects of TMD (changes in condylar morphology (bone changes or spurring at the TMJ)), articular eminence morphology (displacement of the bone), and disc morphology), disc displacement (with/without reduction), condylar translation (the movement of the bone – this would be classic TMJ instability), and intra-articular effusion (swelling) was analyzed on MRI images.
The average patient age was about 46 years old. Disc displacement was the most common finding in both groups (24 patients with tinnitus versus 15 without. Only the frequency of disc displacement with reduction was significantly different between groups.
Not a disc problem but a problem with alignment
In this section, we will explore how doctors are beginning to recognize that physical therapy and exercise may benefit the patient with concurrent TMJ and tinnitus symptoms.
Some people do very well with physical therapy for their symptoms. These are usually not the people who we see. While the benefits of physical therapy and exercise below are explored as being beneficial, for many patients these treatments will not have long-lasting or even short-term success. The problem is physical therapy and exercise cannot alleviate a problem caused by damaged and weakened cervical spine ligaments and damaged tendon attachments to the bone. For physical therapy and exercise to be successful, these soft tissue supporting structures must be strong enough to create the resistance needed for the muscles to strengthen. If you are having difficulties holding your head up, if you suffer from neurological problems beyond tinnitus such as vision problems, heart rate variation, difficulty swallowing, etc, it may be likely that you are suffering from significant cervical spine instability. I will address this below.
In problems of Tinnitus and TMJ we frequently many more co-existing problems. These includes Migraine headaches, Ear fullness, hearing loss, and Meniere’s disease. One thing all these syndromes and diagnosis have in common is that their origins can be found in cervical spine instability caused by weakened and damaged neck ligaments.
Doctors suggest if you do treat TMJ with a splint and exercise program you can reduce tinnitus symptoms
An April 2019 study in the Journal of Oral & Facial Pain and Headache (6) wanted to suggest that treating TMJ would help tinnitus so they did so cautiously: “There is low-quality evidence for a positive effect of conservative temporomandibular disorders treatment on tinnitus complaints. The combination of splint therapy and exercise treatment is currently the best-investigated treatment approach, showing a decrease in tinnitus severity and intensity. Despite the low level of evidence and the methodologic issues in the included studies, it is noteworthy that all included studies show positive treatment effects.”
Tinnitus can be triggered by cervical neck instability, TMJ-TMD can be triggered by cervical neck instability.
Tinnitus can be caused by temporomandibular disorders. Temporomandibular disorders can be caused by cervical neck instability. Shouldn’t we then explore the source? Cervical neck instability?
A January 2019 study (7) evaluated the prevalence of tinnitus in patients with temporomandibular disorders and the possible effects of TMJ/TMD treatment on tinnitus symptoms.
Here is what they discovered: “The finding that tinnitus is more common in patients with TMD means that it can be regarded as a comorbidity to TMD. However, in view of the lack of evidence currently available, further well-designed and randomised studies with control groups are needed to investigate whether possible mechanisms common to tinnitus and TMD do exist and whether TMD treatment can be justified to try to alleviate tinnitus in patients with TMD and comorbidity of tinnitus.”
- Listen again: The study says there is a connection between temporomandibular disorders and tinnitus. The researchers cannot make a definitive connection because available research on treatment does not allow them to suggest a treatment that would appear to be beneficial to BOTH problems.
- Something is missing in this puzzle. In our opinion at Caring Medical, it is a diagnosis of cervical instability.
The missing diagnosis of cervical instability appears to have influenced supportive findings that were also published in January 2019 in the Journal of Oral Rehabilitation.(8) After reviewing the medical literature that spanned from 1992 to 2018, this research team was able to demonstrate that the prevalence of tinnitus in TMD patients is significantly higher than that in patients without TMD.
- So there is a connection between temporomandibular disorders and tinnitus, but there seems to be a missing link.
- Something is missing in this puzzle. In our opinion at Caring Medical, it is a diagnosis of cervical instability.
Research on cervical instability
Caring Medical has published dozens of papers on Prolotherapy injections as a treatment in difficult to treat musculoskeletal disorders. Prolotherapy is an injection technique utilizing simple sugar or dextrose. In 2014, we published a comprehensive review of the problems related to weakened damaged cervical neck ligaments in The Open Orthopaedics Journal,(9) What we demonstrated in this study is that the cervical neck ligaments are the main stabilizing structures of the cervical facet joints in the cervical spine and have been implicated as a major source of symptoms to include tinnitus and TMJ.
We often see patients with tinnitus and TMJ, yet they do not have a coordinated effort to address both. We suggest that Prolotherapy injections strengthen the cervical ligaments get at the root cause of these disorders at the cervical level. We are treating the cause, not the symptoms.
In 2015 we followed up this research with our study, “Cervical Instability as a Cause of Barré-Liéou Syndrome and Definitive Treatment with Prolotherapy: A Case Series”, published in the European Journal of Preventive Medicine.(10)
Again here we are making a connection to cervical neck instability and a myriad of problems that includes, for many patients, tinnitus. We wrote:
“Barré-Liéou syndrome, or posterior cervical sympathetic syndrome, has symptomatology related to underlying cervical instability. While classified as a rare disease, Barré-Liéou syndrome is likely underdiagnosed. Vertebral instability, occurring after a neck ligament injury, affects the function of cervical sympathetic ganglia (located anterior to vertebral bodies). Symptomatology includes neck pain, migraines/headache, vertigo, tinnitus, dizziness, visual/auditory disturbances, and other symptoms of the head/neck region.”
In this video, a demonstration of treatment is given
This video jumps to 1:05 where the actual treatment begins.
For further discussion on cervical spine instability please see An overview of upper cervical instability and symptoms treatment with Ross Hauser, MD
If this article has helped you understand the problems of TMJ and tinnitus and you would like to explore Prolotherapy as a possible remedy, ask for help and information from our specialists
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