TMJ and Tinnitus: Should we explore the ligament chain from the cervical spine through the neck to the jaw to the ear?

Ross Hauser, MD

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 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.”

In June 2020 university researchers in Switzerland and France published their intent to find evidence suggesting an association between TMJ and cervical spine signs and symptoms in adults. Their study paper was published in the journal JBI Evidence Synthesis (2) What the researchers hoped was that they could “lend credence to mechanisms supporting the association (between cervical spine disorders and TMJ) in order to improve care strategies for this condition. They wrote: “The association of cervical spine impairments (in relation to neck posture, cervical spine mobility, muscle tenderness, muscle activity, and neck disability) with TMD has been widely discussed in the literature. Clarification of this relationship is important for health professionals to better assess and treat TMD.”

What are we seeing in this image? The close relationship between TMJ, cervical instability, and ultimately a cause of tinnitus

The close anatomical association between the temporomandibular joint and the upper cervical vertebrae is demonstrated in the image below. As stated in the caption, the close relationship between the structures can be used to illustrate to sufferers how injury to the cervical spine ligaments supporting the proper position and movement of the C1 (atlas) and C2 (axis) could cause pain that would travel throughout the head, face, and TMJ area. Additionally, the same concept can apply to the TMJ joint. The TMJ can cause problems of cervical spine instability and pain. As this article points out, TMJ impacting the cervical spine and cervical instability impacting the TMJ can both lead to issues of tinnitus.

The symptoms of TMJ and Tinnitus vary from patient to patient.

When patients suffer from a myriad of confusing and often conflicting diagnoses, they search for others like themselves to see what their experiences were how they may have come to terms, or a resolution of their tinnitus and TMJ challenges. What many people find is that the severity of TMJ and Tinnitus vary greatly, while there are many similar characteristics, there are many variables. Sometimes there is hearing loss, some times there is no hearing loss.

This will lead to discussions that jaw pain is not that significant as tinnitus and neck pain are. Conversely, jaw pain is significant, tinnitus is not that significant and neck pain comes and goes. It is these variations in pain, severity, and function that often confuses doctors and patients alike in trying to determine a proper treatment path. In many patients we see we focus on the possible underlying common problem, the problem of cervical instability.

The incidence of tinnitus was found to be 11.46% among patients with temporomandibular disorders. Tinnitus and tinnitus severity levels were found to have significant differences in patients with temporomandibular disorders.

In this October 2020 study in the medical journal Cranio, (3) Dr. Ahmet Taylan Cebi from the Faculty of Dentistry, Department of Oral and Maxillofacial Surgery, Karabük University in Turkey Turkey offered these observations in patients with temporomandibular joint and tinnitus complaints.

The conclusion of this research is that there is a relationship between aural symptoms, tinnitus, and temporomandibular disorders. A brief note here: The most commonly reported aural symptoms in TMJ/TMD patients are otalgia (earache), tinnitus, vertigo, and hearing loss.

These are the same observations we have seen in 28 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.

Dr. Cebi’s work was cited by a team of Brazilian researchers publishing in the American Journal of Audiology (4). In this study, the doctors found that patients with somatosensory tinnitus (tinnitus caused by impact, spasm, or movement to or in the jaw, who also have temporomandibular disorders, do not seem to have a hearing impairment. Also, they do not have a higher quality of life handicap when compared to those without tinnitus and temporomandibular disorder.

Somatosensory tinnitus and TMJ

At this point of our discussion, we will focus on the diagnosis of somatosensory tinnitus. Let’s have a paper from Antwerp University Hospital and lead researcher Dr. Sarah Michiels explain. This research is from July 2021 in the medical journal Ear and Hearing. (5) We added some explanatory notes.

“Tinnitus can be influenced by changes in somatosensory afference from the cervical spine or temporomandibular area, then called somatosensory or somatic tinnitus.” (Afference is the way the brain sends and receives signals from the body. When these signals are distorted or interfered with by compression, impingement, or herniation in the cervical spine, symptoms, such as tinnitus can develop).

The problem Dr. Michiels and her team sought to answer was trying to help doctors treating patients with somatosensory or somatic tinnitus understand the problem better. How? By expanding on the 2018 criteria for diagnosing somatosensory or somatic tinnitus that Dr. Michiels was the lead author on. These criteria were published in the journal Trends in Hearing. (6) Below are the summary findings of that criteria.

In this 2018 Criteria, doctors are advised that a person presenting with tinnitus has the following symptoms and characteristics, doctors should strongly suspect Somatosensory (problems in the cervical spine).

Let’s stop here for a moment to help put a human face on all this.

Let’s stop here for a moment to help put a human face on all this. Perhaps your human face. We often get emails from people looking for help and they describe a medical history similar to that which I have just described but more so. For them, it is not just a problem on tinnitus, neck pain, and jaw pain. The problems of many conditions are described.

I suffer from Chronic Migraine, chronic trigeminal nerve pain, cervical spine pain. Dizziness, loss of balance, tinnitus, hearing loss, eye pain, dryness, blurry vision, macular degeneration, glaucoma, TMJ, shoulder pain, wrist and finger pain, diarrhea/constipation (irritable bowel), stroke, anxiety, depression, PTSD, muscle spasms in the lower leg, nerve pain in toes, thinning of pubic bones, high blood pressure, allergies to fruits, body rash, profuse sweating of head and neck, etc.

As I often say to patients. Is it easier to understand that these problems are coming from one possible source, cervical spine instability than that they all developed simultaneously and independently of each other? The patient we see with TMJ, tinnitus, and cervical spine and neck pain, typically can run off dozens of symptoms and treatments that have been going on for years.

Returning to the work of Dr. Michiels and her colleagues. The 2018 diagnostic criteria for somatosensory tinnitus agreed upon by a large group of somatosensory tinnitus experts still requires extensive and specific expertise to diagnose somatosensory tinnitus correctly. Helping doctors do that would be the next step by the development of easily applicable diagnostic criteria is to assess the diagnostic value of each individual criterion. Therefore, to quote the new paper: “The aim of this study was, therefore, to further investigate the diagnostic value of these criteria, validate them empirically, and identify their sensitivity and specificity.”

How did they do this and what were the results?

The doctors presented an online survey to tinnitus patients. The results of this survey allowed the researchers to divide the participants into three groups.

In total, 8221 participants filled out the online survey.

“The researchers noted that as expected, the diagnostic criteria for somatosensory tinnitus are more prevalent in the groups with somatic (nervous system problems) influence, but the criterium of tinnitus modulation also often occurs in the group with no somatic influence.”

People with suspected somatic problems and people without suspected somatic problems were having the same issues.

The simultaneous onset or increase and decrease of both tinnitus and pain complaints have the highest positive likelihood ratios, next to the influence of certain postures on the tinnitus. To rule out somatosensory tinnitus, the absence of neck pain or tension in the neck extensor muscles is most suited.

In other words, if the patient has no neck pain or chronic muscle spasm extending from the neck, Somatosensory tinnitus can be ruled out. Our program is based on problems of the cervical spine. If we cannot realistically assess a problem of tinnitus or TMJ as having degenerative spine origins, we have to help the patient understand that they may not be a good candidate for our treatments and that other specialties may be able to help them.

How did this paper wrap up?

“Conclusion: The simultaneous onset or increase and decrease of tinnitus and neck or jaw pain and the influence of certain postures are most suited to use as a single criterion for identifying patients with a somatic influence on their tinnitus. On the other hand, the absence of neck pain or tension in the neck extensor muscles is a valid criterion to rule out a somatic influence. Additional analysis is needed to identify clusters of symptoms and criteria to further aid somatosensory tinnitus diagnosis.”

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 (7), 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. (8) 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 have TMJ only on my right side, and that is the side I have tinnitus. I wear a neuromuscular orthotic 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.

If I ice my jaw or take anti-inflammatories my tinnitus gets better

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 with the pain medications and sleep medications. I want treatment, not medications

I have TMJ, Tinnitus, and many other problems 

I have TMJ, tinnitus, digestive problems, and a list of other symptoms. I was one of the people who got SSRIs for anxiety and later it was found out they were making my tinnitus worse. Now my doctors are looking at the low vagal tone. I have a heart rate variable monitor to check my vagus nerve function.

Note: Heart Rate Variability (HRV) is one of the ways you can measure your vagal tone and can be a great indicator of overall health and ability to heal. We use it frequently to help some of our more complex neck patients who are being treated for disabling conditions.

Insufficient knowledge in diagnosis and treatment

A September 2019 study in The International Tinnitus Journal (9) 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 comparison 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 clinic. 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 (10) offered these insights:

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 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.

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 (11) 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.”

Dextrose Prolotherapy injections

Researchers compared the effectiveness of dextrose Prolotherapy and occlusal (mouth) splints in treating internal derangement of the temporomandibular joint.

A November 2020 study published in the Journal of Cranio-Maxillo-Facial Surgery (12) compared the effectiveness of dextrose Prolotherapy and occlusal (mouth) splints in treating internal derangement of the temporomandibular joint.

Results: Nine patients in the (Prolotherapy) study group had a complete absence of pain, compared with only one (splint group) patient in the control group. The results showed that patients who received Prolotherapy demonstrated improvement in pain, mouth opening, and clicking, but no significant difference in deviation was observed between the groups after 1 year.

Conclusion: Prolotherapy was found to be superior in providing long-term clinical relief, with a reduction in pain and clicking along with improved mouth opening.

What are we seeing in this image?

A Digital Motion X-Ray or DMX is a tool we use to help understand a patient’s neck instability and how we may be able to help the patients with our treatments. In the illustration below a patient who suffered from upper cervical instability demonstrated hypermobility of the C1-C2. This hypermobility can result in common symptoms of neck pain, headaches, dizziness, vertigo, tinnitus, concentration difficulties, anxiety, and other symptoms common in TMJ/TMD patients.

A Digital Motion X-Ray or DMX is a tool we use to help understand a patient' neck instability and how we may be able to help the patients with our treatments. In the illustration below a patient who suffered from upper cervical instability demonstrated hypermobility of the C1-C2. This hypermobility can result in common symptoms of neck pain, headaches, dizziness, vertigo, tinnitus, concentration difficulties, anxiety and other symptoms common in TMJ/TMD patients.

 

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 (13) 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 randomized 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.”

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. (14) 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.

From cervical ligaments to TMJ ligaments to middle ear ligaments. The long connection.

Investigating the ligaments further. First, we are going to connecting the middle ear to the TMJ via the ligaments. Then the connection will be made to the cervical spine.

In your many tests and examinations, you have probably been described the function of the malleus. If you have not, that is the small bone in the middle ear that transmits vibrations along the line of other small vibrating bones in your ear.

There is a long journey of medical research which suggests ligament damage may be the cause for strange sound sensations in the ear. We are going to briefly travel this journey to help support our suggestion that ligament problems can be the cause of your TMJ and tinnitus.

Research in 1989: It could be the ligaments causing the problems

In the journal Oral Surgery, Oral Medicine, and Oral Pathology, (15) a 1989 study examined structural damage to the middle ear caused by TMJ surgery. Two structures that they looked at was the discomalleolar ligament (DML), which passes from the malleus to the medial retrodiscal tissue (simply the connective tissue at the mandibular fossa that helps holes jaw to the skull) of the TMJ, and the anterior malleolar ligament (AML), which connects the malleus with the lingula (a bony portion in the jaw in which nerves including the trigeminal nerve pass) of the mandible via the sphenomandibular ligament (SML).

Learning points:

To test this hypothesis the researchers applied tension to the discomalleolar ligament and/or anterior malleolar ligament in cadaver studies to see if this caused the malleus to move (out of place.) What did they find?

Research in 2008: It could be the ligaments causing the problems of unexplained otological problems

In 2008, surgeons wrote in the International Journal of Oral and Maxillofacial Surgery (16) of their investigations into the relationship between the ligaments, malleus, and temporomandibular joint (TMJ) and to determine the role of these ligaments on the movement of the malleus.

Here 15 cadaver specimens were examined: Here are the findings:

Research in 2020: It could be the discomallear ligament causing the problems of unexplained otologic symptoms in TMJ disorders

In May 2020 researchers publishing in the Journal of Clinical Anatomy (17) examined that now the decades-long investigation of “several anatomic relationships between the ear and the temporomandibular joint (that) have been proposed to account for the presence of tinnitus during temporomandibular disorders. In this study, the discomallear ligament role in TMJ and tinnitus-like symptoms was explored.

Again, using cadavers, the researchers found damage in the ligaments that could be the result of a ripple effect between the TMJ ligaments and the middle ear ligaments. They concluded.

The discomallear ligament could represent an anatomical structure that joining the temporomandibular joint and the malleus may play a role in the otologic symptoms during temporomandibular disorders.

Everything appears to be connected.

Research on cervical instability and cervical spine ligaments

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,(18) 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. (19)

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

Prolotherapy is referred to as a regenerative injection technique (RIT) because it is based on the premise that the regenerative healing process can rebuild and repair damaged soft tissue structures. It is a simple injection treatment that addresses very complex issues.

This video jumps to 1:05 where the actual treatment begins.

This patient is having C1-C2 areas treated. Ross Hauser, MD, is giving the injections.

Summary and contact us. Can we help you? How do I know if I’m a good candidate?

We hope you found this article informative and it helped answer many of the questions you may have surrounding the problems of cervical spine instability, cervical dystonia, and spasmodic torticollis treatment. Just like you, we want to make sure you are a good fit for our clinic prior to accepting your case. While our mission is to help as many people with chronic pain as we can, sadly, we cannot accept all cases. We have a multi-step process so our team can really get to know you and your case to ensure that it sounds like you are a good fit for the unique testing and treatments that we offer here.

Please visit the Hauser Neck Center Patient Candidate Form

 

This is a picture of Ross Hauser, MD, Danielle Steilen-Matias, PA-C, Brian Hutcheson, DC.

Brian Hutcheson, DC | Ross Hauser, MD | Danielle Steilen-Matias, PA-C

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References for this article:

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This article was updated September 16, 2021

 

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