http://www.medscape.com/viewarticle/505738
What Are the Differential Diagnoses for Chronic Ear Pain?
Question
I often see adult patients with acute ear pain but without infection,
effusion, or inflammation. What other etiologies could explain this
phenomenon? Could it be TMJ?
Expert Response from Judith Shannon Lynch, MS, MA, APRN-BC, FAANP
Assistant Clinical Professor, Yale School of Nursing, New Haven,
Connecticut; Nurse Practitioner, ENT Associates, Waterbury, Connecticut
Chronic otalgia (earache) is a common occurrence for many adults. Although
acute otitis media, otitis media with effusion, and chronic eustachian
tube dysfunction may be causal, another less accurately diagnosed disorder
in adult patients is temporomandibular joint (TMJ) dysfunction.
TMJ dysfunction is a collective term used to describe a group of medical
disorders estimated to affect 10.8 million Americans at any given time,
with 90% of those seeking treatment being women in childbearing years.[1]
Inflammation of, or around, the joint connecting the temporal bones to the
mandible often leads to masticatory muscle fatigue and resultant spasm.
Extracapsular etiologies include mechanical injuries that originate in the
musculature and often produce secondary myofascial pain.
* Chronic bruxism -- nocturnal jaw clenching and/or teeth grinding
* Missing teeth/ill-fitting dentures causing the patient to chew
unequally
* Current orthodontia
* Frequent gum chewing
* Stress and other psychological factors
1. Anxiety
2. Depression
3. Posttraumatic stress disorder [2]
Less common etiologies are intracapsular , originating in the joint itself
and causing true articular disease resulting in joint deterioration:
* Connective tissue diseases -- rheumatoid arthritis, osteoarthritis,
systemic lupus erythematosus, and Lyme disease may induce synovitis within
the capsule
* Displacement of the cartilage disc
* Tumors of the joint[3]
* Cervical injuries (whiplash)
* Direct trauma to the joint
Symptoms of TMJ Dysfunction
The hallmark symptom of TMJ dysfunction is chronic, unilateral dull,
aching jaw, or facial pain exacerbated by joint movement (chewing,
talking, or yawning).
Other symptoms include:
* Surrounding muscle tenderness
* Pain radiating into temple, cervical area, cheek, or shoulder
* Clicking or popping of the jaw
* Jaw locking (dislocation)
* Trismus -- inability to open the mouth fully
* Frequent headache, especially temporal
* Dental pain
* Otalgia[4]
Connection Between Otalgia and TMJ Dysfunction
Misalignment of the temporomandibular joint can affect ear structures due
to pressure on the petrotympanic fissure and tympanic bone that separates
the jaw joint from the external auditory canal. Because the chorda tympani
nerve (which passes through a fissure in the TMJ capsule) innervates pain
sensation to the tongue, there may also be sensitivity in certain areas of
that organ. There is some evidence that these pressures may cause certain
types of tinnitus, subjective hearing loss, and an increased sensitivity
to sound (hyperacusis).[5]
Patient Evaluation
History Clues
1. Subjective data are often confusing as patient is convinced that the
problem is in the ear and otalgia may be the only symptom.
2. Traditional symptoms of infection (fever, lymphadenopathy,
associated nasal symptoms) are lacking.
3. Look for the following:
* Recent dental work including root canal, tooth extraction, and
braces
* Positive psychiatric history including trauma
* Presence of connective tissue disease
* History of MVA (motor vehicle accident), especially with
cervical injury
* Recent smoking cessation (patients tend to replace cigarettes
with gum chewing)
* Positive history of tooth grinding or clenching, which may be
sequelae of increased stress
Physical Examination
The following assessment should be performed. Evaluate:
* Head and face for signs of trauma or structural abnormalities of the
temporomandibular joint
* Ears for signs of acute or chronic inflammation
* Cranial nerve assessment, especially if there is comorbid headache
* Oropharynx for acute tonsillar enlargement and/or inflammation;
peritonsillar and retropharyngeal abscesses may radiate pain to the ear
* Cervical area to rule out lymphadenopathy and myalgias from cervical
disease
* Direct manipulation of the joint; full range of motion will often
reveal clicking, crepitus, or incomplete dislocation with or without pain.
Diagnosis
Confirmation of internal derangement of the TMJ requires an MRI (magnetic
resonance imaging) only of the joint itself. MRI is more sensitive than CT
scanning for bony and soft tissue visualization. Usually testing is
deferred until conservative measures have failed. If underlying connective
tissue disease is suspected, appropriate testing is mandatory.
Management Strategies
A conservative treatment regimen may be 75% successful, especially if the
etiology is extracapsular. Strategies include:
* Dental consultation. This is essential for all patients to rule out
malocclusion and bruxism. Many times a mouthguard can be used at night
that completely resolves the problem.
* Soft diet that minimizes hard repetitive chewing of crunchy foods
(bagels, steak).
* Analgesia -- a 2-week course of an anti-inflammatory medication such
as
ibuprofen or
aspirin. Patients should take the medication on a regular
basis unless comorbid conditions preclude use.
* Warm compresses to the affected area twice daily for 10 minutes to
decrease pain and increase joint movement.
* Stop all gum chewing and avoid tooth clenching.
* Relaxation exercises that emphasize gentle range of motion of the
affected joint.
If symptoms persist, a course of physical therapy is often recommended.
Patients who are refractory to a comprehensive regimen must be referred to
an oral surgeon for possible surgical modalities.
Conclusion
Otalgia is commonly encountered in primary care settings. The clinician
who searches beyond the ear itself when there is no inflammation or
infection will provide the patient with more accurate diagnosis and
treatment of other etiologies. The common problem of TMJ dysfunction will
also be discovered in its early stages -- before there is permanent damage
to the joint.
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