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 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.”

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.

In this October 2020 study in the medical journal Cranio, (2) 288 patients with temporomandibular joint complaints as well as 33 patients with both temporomandibular and tinnitus complaints were evaluated.

  • 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.
  • No significant relationships were found between right and left ear pure tone audiometry test results in patients.
    • For those of you, if not all of you reading this article, pure tone audiometry test seeks to measure hearing loss. In some patients, there is hearing loss and in some no hearing loss, yet another compounding factor in tinnitus and TMJ.

The conclusion of this research is that there 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 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(3), 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. (4) 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 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.

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 on 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 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 (5) 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 (6) 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.

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 (7) 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 Journal of cranio-maxillo-facial surgery (8) compared the effectiveness of  dextrose prolotherapy and occlusal (mouth) splints in treating internal derangement of the temporomandibular joint.

  • A total of 34 patients with temporomandibular joint internal derangement classed as Wilkes stages II or III were recruited for the study, and were randomly divided into study and control groups with 17 patients each.
    • Wilkes stages for TMJ assessment
      • Wilkes stage II is typically characterized by normal or seemingly normal range of jaw motion with intermittent episodes of pain, jaw locking and clicking.
      • Wilkes stage II is typically characterized by more pain, frequent headaches, loss of range of motion, onset or development of TMJ disc damage and deformity.
  • The patients in these control and study groups were treated with splints and prolotherapy, respectively. Outcome parameters, such as pain, mouth opening, clicking and deviation, were assessed for a review period of 1 year.

Results: Nine patients in the (Prolotherapy) study group had 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 (p = 0.862).

Conclusion: Prolotherapy was found to be superior in providing long-term clinical relief, with 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 (9) 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.(10) 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.

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 which 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,(11) a 1989 study examined structural damage to the middle ear caused by TMJ surgery. Two structures that they looked at was the 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 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:

  • It is possible that there is an interaction between TMJ ligaments instability and inner ear ligament instability

To test this hypothesis the researchers applied tension to the 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?

  • Tension/stress applied directly to the sphenomandibular ligament resulted in movement of the malleus.
  • When the mandibular condyle was manipulated, tension was demonstrated in the sphenomandibular ligament. The results indicate that the anterior malleolar ligament via the anterior malleolar ligament has the potential to cause middle ear damage.
  • Damage to the ligaments can cause middle ear damage through the connecting ligament chain from jaw to middle ear.

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 (12) 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:

  • When tension/stress was applied to the  but when the AML was overstretched, significant movement was observed in 5 cadavers; little movement in 6 cadavers, and no movement in 4 cadavers. This study suggests that extreme stretching of the condyle in conjunction with the ligaments between the ossicles of the inner ear and the TMJ could be the reason for unexplained otological problems.

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 (13) examined that now decades long investigation of “several anatomic relationships between the ear and the temporo-mandibular joint (that) have been proposed to account for the presence of tinnitus during temporo-mandibular 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 temporo-mandibular joint and the malleus may play a role in the otologic symptoms during temporo-mandibular 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,(14) 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.(15)

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.

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

1 Omidvar S, Jafari Z. Association Between Tinnitus and Temporomandibular Disorders: A Systematic Review and Meta-Analysis. Annals of Otology, Rhinology & Laryngology. 2019 Jul;128(7):662-75. [Google Scholar]
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8 Priyadarshini S, Gnanam A, Sasikala B, Panneerselvam E, Cheeman SR, Mrunalini R, Raja VK. Evaluation of prolotherapy in comparison with occlusal splints in treating internal derangement of the temporomandibular joint–a randomized controlled trial. Journal of Cranio-Maxillofacial Surgery. 2020 Nov 17.  [Google Scholar]
9 Skog C, Fjellner J, Ekberg E, Häggman‐Henrikson B. Tinnitus as a comorbidity to temporomandibular disorders—A systematic review. Journal of oral rehabilitation. 2018 Aug 20. [Google Scholar]
10 Mottaghi A, Menéndez‐Díaz I, Cobo JL, González‐Serrano J, Cobo T. Is there a higher prevalence of tinnitus in patients with temporomandibular disorders? A systematic review and meta‐analysis. Journal of oral rehabilitation. 2018 Aug 20. [Google Scholar]
11 Loughner BA, Larkin LH, Mahan PE. Discomalleolar and anterior malleolar ligaments: possible causes of middle ear damage during temporomandibular joint surgery. Oral surgery, oral medicine, oral pathology. 1989 Jul 1;68(1):14-22. [Google Scholar]
12 Şencimen M, Yalçin B, Doğan N, Varol A, Okçu KM, Ozan H, Aydintuğ YS. Anatomical and functional aspects of ligaments between the malleus and the temporomandibular joint. International journal of oral and maxillofacial surgery. 2008 Oct 1;37(10):943-7. [Google Scholar]
13 Anastasi MR, Macchi V, Vellone V, Siniscalchi EN, Anastasi G, Morra A, Porzionato A, De Caro R, De Ponte FS, Cascone P. The discomallear ligament: anatomical, microscopical, and radiologic analysis. Surgical and Radiologic Anatomy. 2020 Jan 25:1-7. [Google Scholar]
14 Steilen D, Hauser R, Woldin B, Sawyer S. Chronic neck pain: making the connection between capsular ligament laxity and cervical instability. The open orthopaedics journal. 2014;8:326.  [Google Scholar]
15 Hauser RA, Steilen D, Sprague IS. Cervical Instability as a Cause of Barré-Liéou Syndrome and Definitive Treatment with Prolotherapy: A Case Series. European Journal of Preventive Medicine. 2015;3(5):155-66. [Google Scholar]

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