Middle Ear, Eustachian Tube, and Otomandibular/Craniofacial Pain

This case report found that a unique monomodal treatment protocol—utilizing a passive intra-oral appliance—both verified the diagnosis and provided immediate relief to sympathetically-mediated pain suffered by the patient over the previous 10 years.
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Dr. Kloefler’s article is an important perspective of pain from the viewpoint of the maxillofacial prosthodontist. The consequences of tumors and cancer in the oral and facial region are best managed by a team approach, though the dentist is not always thought of to be included in the team managing oral and craniofacial pain. His article is stimulating and thought-provoking.

Edwin A. Ernest, III, DMD, FAANaOS

Today’s TMD specialist must think and act beyond the inadequate biomechanical aspects, explanations, and theories of TM pain and dysfunction which was anchored in the mechanical model of pain. He/she must enter the field of neurophysiology and acknowledge the interrelationship of the physical and psychological dimensions of craniofacial pain and join with the medical specialists who are now recognizing neuromuscular and musculoskeletal pain contained in the stomatognathic system. It has been noted that common symptomatology is frequently observed in the otic symptoms and TMD during daily clinical practice and should be understood by each discipline from the broad anatomical and clinical perspective as described in this article. It is incumbent on clinicians treating pain in the head, neck and facial areas to become familiar with the less common pain disorders to assist in the differential review. An early intervention in these conjugated anatomical areas of pain can be provided by a unique monomodal treatment protocol utilizing a passive intra-oral device (maxillary anterior passive appliance; MAPA).1

When we consider the amount of anatomical structures included in the cranial-maxillofacial area and the complexity of the pathophysiologies, it can be concluded that only a multi-disciplinary approach to orofacial pain symptoms is effective. Four less-common pain disorders were described and ruled out in the case report described in this article. Reciprocity among the disciplines of ENT and the orofacial pain doctor should be brought together by the TMD and otic-referred mutual symptomathology. These type of cases should promote the principles of successful team effort.

Developing good communication skills and establishing therapeutic relationships with patients is a priority for physicians and dentists involved in head, neck and facial pain. The diagnostic background of the case study—as well as the patient’s observations—may demonstrate that an inadequate team effort may have occurred resulting in a lack of trust by the patient as well as indecision by the doctors. The lessons learned from this case study should hopefully contribute to a stronger proactive relationship between the TMD and ENT specialists.

Background

Although otomandibular syndrome is seldom described in the literature, it exists in many patients that are seen every day in ENT offices as well as dental offices. “Patients suffering from otomandibular syndrome present one or more symptoms without ear, nose, or throat pathology but have one or more masticatory muscles in a state of constant spasm.”2

Ear pain (otalgia) is found in many pains of the craniofacial mandibular area, and is one of the most frequently encountered in TMD pain. It is often associated with hearing loss, tinnitus, fullness in the ear and disorders of balance. Pain arising from the external ear structures is usually not difficult to recognize. Often there is history of trauma, or manipulation of the ear (e.g., from the use of Q-tips, blunt trauma or water exposure). Scuba divers will easily understand and appreciate the anatomy and physiology of this article. The most common problem in their first dive can be ear damage as a result of the inability of the diver to equalize pressure between the middle and the outer ear. ENT doctors frequently see these divers since as much as 80% of divers show observable tympanic membrane damage during the first few dives. Hyperbaric oxygen is sometimes used because the equalization process (“clearing ears” in the ascent from the depths) was not mastered. If the clearing of the ears does not occur, the water pressure pushing against the eardrum may cause it to rupture.

A more dramatic illustration of this equalization process occurred in World War II, when German Stuka bomber pilots needed an instant opening of the eustachian tube the moment they completed a successful dive on their target. The Stuka bomber attacks were the most precise form of bombing. The pilots, having both hands on the stick, would put their plane into a steep dive aimed directly at their target. Just before crashing into their target they would release their bomb and pull out of the dive. The bomb followed the launch trajectory and fell into the target. There were no computer adjusted hydraulics available and so the pilot needed to instantly balance the eustachian/middle ear connection or face possible deafness. It was imperative that a hands-free, rapid, effective and safe method of clearing ears was used. The technique they used was developed in 1938 by a German physician named Herman Frenzel.

Head and neck pain patients are often suspected of having sinusitis, dental disease symptoms or both since they may, at least in part, mimic an underlying neurologic disorder. Invasive surgical procedures should be avoided in cases of less than fully conclusive evidence. Detailed advanced diagnosis based on new knowledge and experience may also avoid excessive opioid medication for previously undiagnosed conditions. Another, perhaps most important reason for this differentiation, is proper identification and diagnosis so that definitive therapy can be given.

Both ENT and dental specialties have often observed that the eustachian tube and the palatine muscles display a fascinating array of cranial interneuron connections, and that these connections reveal an often-overlooked neurological pain and dysfunction genesis. As we discuss this fascinating array of interneuron connections, the rationale leads one to believe that this very common objective finding in temporomandibular joint dysfunction is spasm of the internal pterygoid muscle. Embryologically, the same nerve that innervates the internal pterygoid muscle directly innervates the tensor timpani muscle. It is therefore stands to reason that if a stimulation along the nerve that innervates the internal pterygoid muscle places that much stress and reactivity in the jaw muscles then it can affect the adjacent network of nerve and muscle response in the middle ear and the pharyngotympanic tube.

The interaction of the craniomandibular posture and gravity is demonstrated by the patients who complain of ear pain, jaw pain, or both. Muscle or nerve dysfunction in the maxillofacial area, especially around the palatal vault and the temporomandibular area, is responsible for many resulting signs and symptoms easily misdiagnosed as Menieare’s disease, positional vertigo, or other otologic maladies.

The following case report will present a critical review of the craniofacial anatomy and the neuromuscular anatomy, as well as the central nervous system connections involved in vertigo, temporomandibular disorders and co-morbid otologic disease. This author’s intraoral exam of head, neck or facial pain patients routinely includes a close look at the palatine muscles, uvula, the posterior border of the maxillae, and the hamular notch.

First published on: November 1, 2009