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Auriculo-vestibular symptoms related to structural and functional


disorders of stomatognatic system

Article  in  Journal of physiology and pharmacology: an official journal of the Polish Physiological Society · April 2011
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JOURNAL OF PHYSIOLOGY AND PHARMACOLOGY 2011, 62, 2, 251-256
www.jpp.krakow.pl

Short communication

M. PIHUT1, P. MAJEWSKI1, G. WISNIEWSKA1, E. RERON2

AURICULO-VESTIBULAR SYMPTOMS RELATED TO STRUCTURAL


AND FUNCTIONAL DISORDERS OF STOMATOGNATIC SYSTEM

1Chair and Department of Dental Prosthetics of the Institute of Dentistry, Jagiellonian University Medical College, Cracow, Poland;
2Chair and Department of Otolaryngology, Jagiellonian University Medical College, Cracow, Poland

Auriculo-vestibular symptoms are otolaryngological complaints which frequently co-occur with functional disorders of
masticatory organ. These symptoms include: earache, plugged ears sensation, sudden hearing impairment, burning pain
of the throat, tinnitus, and dizziness. The aim of the study was assessment of co-occurrence of functional disorders of
masticatory organ and auriculo-vestibular symptoms, in patients referred for otolaryngological treatment. Forty-two
patients aged 24-46 years of both sexes referred for otolaryngological treatment, because of auriculo-vestibular
symptoms, were qualified to our study within the framework of research project. After otolaryngological diagnostics
(Department of Otolaryngology), these patients were referred for prosthetic consultation to the Department of Dental
Prosthetics of Jagiellonian University Medical College. In Otolaryngology Clinic the following specialist examinations
were carried out: basic clinical examinations, including otoscopy, tuning fork trials, tonal and verbal audiometry, and
tympanometry. These examinations were supplemented with electronystagmometry. On prosthetic consultation,
specialist functional investigations of masticatory organ, and electromyographic assessment of the activity of masseter
muscles and the anterior part of the temporal muscle, were carried out. Results of the investigation revealed
otolarygological causes of the reported symptoms in 30 patients, whereas in 12 patients (out of 42 patients referred for
prosthetic consultation), numerous functional disorders of the stomatognathic system were observed. The investigation
confirmed the occurrence of functional disorders in patients with auriculo-vestibular symptoms and appropriateness of
treatment by a multi-specialist team.

K e y w o r d s : auriculo-vestibular symptoms, functional disorders, stomatognatic system, tinnitus, dizziness

INTRODUCTION MATERIAL AND METHODS

Functional disorders of the stomatognathic system constitute Forty-two patients aged 24-46 years of both sexes (with
a wide spectrum of pathologies including dysfunctions affecting prevalence of females), who were presented for
temporo-mandibular joints and masseter muscles which are otolaryngological treatment, were qualified for our study within
responsible for proper mobility of mandible and occlusion. the framework of the research project. The auriculo-vestibular
These dysfunctions are manifested by pain in the ear region, symptoms reported by the patients included earache, tinnitus,
impairment of the course of abduction and adduction of the hypoacusia, sudden hearing impairment and dizziness.
mandible, lack of symmetry of its lateral movements and Specialist diagnostic examinations were carried out in the
excessive tension of stomatognathic system’s muscles. Otolaryngological Department and the Chair of Dental
Among functional complaints reported by patients, auriculo- Prosthetics of the Jagiellonian University Medical College in
vestibular symptoms such as earache, plugged ears sensation, Cracow. The laryngological investigation contains tests such as
sudden hearing impairment, tinnitus, dizziness and burning pain basic clinical assessment, including otoscopy, tuning fork trials,
of the throat can be observed (1-3). tonal and verbal audiometry, tympanometric measurements
One of the main aims of prosthetic therapy of masticatory (assessment of stapes reflex) and electronystagmography.
organ functional disorders’ syndrome is the eradication of In otolaryngological examination, the following symptoms
articular and muscular pain, and restoration of normal were assessed: occurrence of inflammation (reddening,
functioning of the stomatognathic system, including symmetric oedema), ulceration of the auricle, presence of nodules,
and physiological function of the masseter muscles. Consecutive anatomical deformities, fistulas and cicatrization. Instrumental
rehabilitation plays an adjuvant role in the therapy (4, 5). examination included otoscopy, tuning fork trials, tonal
The aim of the present study is the assessment of co- audiometry, tympanometry and electronystagmography.
occurrence of functional disorders of the masticatory organ in Otoscopy was performed with the use of an electric otoscope
patients referred for otolaryngological treatment because of with inbuilt low-voltage light and a magnifying system. During
auriculo-vestibular symptoms. this examination, the condition of the external auditory canal and
252

the tympanic membrane were evaluated with special attention subluxation). Examinations were carried out and the results
paid to its colour, tone, transparency, mobility and presence of prepared in Chair of Radiology JU MC. For functional
post-inflammatory cicatrization. Tuning fork trials allowed to examination results, analysis of mandible articular heads
assess conduction of both ears with Weber and Rinne test (using location in central occlusion was significant, assessed indirectly
a 512 Hz tuning fork type C). Tonal audiomerty was carried out based on the dimension of articular fossa (frontal dimension- in
to determine the hearing threshold for clear tons, that is, front of the articular head, upper dimension- above articular
deprived of harmonic vibrations, and to determine the threshold head, back dimension- behind the articular head) and the
for normal hearing; the aim of verbal audiometry was to assess location of articular heads in the maximum mandible adduction.
the ability of speech discrimination. In tympanometric Dental and functional examinations of the stomatognathic
examination, the acoustic resistance of the tympanic membrane system were supplemented with electromyography of the
was registered during the change of pressure in the external and masseter muscles’ tone and the anterior part of the temporal
internal ear. Electronystagmography was used for the muscles at central occlusion, simultaneously for the right and
diagnostics of spontaneous and induced nystagmus on the basis left side, using an eight-channel device BIO EMG II. Superficial
of the changes of the corneal and retinal potential and amplitude, bipolar electrodes were used with constant distance between the
frequency and nystagmus speed. measuring poles, which were placed along the course of
After otolaryngological examinations, the patients were muscular fibres. Surface electrode was located in the medial line
referred to the Department of Dental Prosthetics of the of the forehead. During EMG examination the patient was in a
Jagiellonian University Medical College for specialist functional sitting position with no back support, his hands resting on the
tests of the masticatory organ. knees.
Dental diagnostics included patients’ history and specialist Electromyography was repeated three times at each
functional tests carried out in accordance with stomatognatic examination session. Average values were analyzed in order to
system functional analysis form, used in Department of assess objectively the patients’ muscular tone, and to compare
Prosthetic Dentistry. their electric potentials with the normal potential levels for the
Information concerning the general patients’ condition, as masseter and anterior part of temporalis muscles. The
well as drugs used on pain occurrence or other symptoms or asymmetry between the activities of left and right-side muscles
dysfunctions within head and face region, interfering with was quantified by the asymmetry index Naeije i Maccarolla (6).
physiological activity of masticatory organ (food mastication,
long-term speech) were recorded on patients’ history. In case of RMS right – RMS left
muscle pain or/and temporo-mandibular joints pain, the most asymmetry index = —————————————
important was its location, intensity, irradiation, duration, RMS right + RMS left
circumstances accompanying pain intensification or remission,
and tension headache. In patients that reported appearance of RMS – root mean square value
acoustic symptoms, time of occurrence was crucial, as well as, if A positive index indicates a right – side dominance and
the symptoms lasted uninterrupted to the moment of dental negative index a left – side dominance of muscle´s activity.
examination. Taking into consideration etiological factors, The results obtained underwent statistical analysis based on
information concerning the occurrence of parafunctions, the calculation of mean values, mean standard deviations,
especially in dental articulation (proceeding with opposing teeth minimal and maximal values, analysis of variance test for
contact), including bruxism, was crucial. Patients were also dependent random variables, and Tukey’s post-hoc test.
asked to make self-assessment of their psycho-emotional
condition, frequency of stress situations’ occurrence, and
methods of stress management. While conducting masticatory RESULTS
organ functional examination, condition and pathologies present
within dentition (pathological teeth attrition, malocclusions) and Results of otolaryngological examinations
extent of dental defects were estimated. The significant part of
the examination was assessment of path and range, as well as Specialist otolaryngological examinations among 12 patients
adduction and abduction jaw movements and lateral mandibular (out of 42) showed no otolaryngological cause of the reported
movements’ symmetry. Position of static occlusion was auriculo-vestibular symptoms such as sudden occurrence of low-
examined (with occlusal tracing paper) and dynamic occlusion intensity tinnitus, otalgia lasting 2-3 weeks, plugged ears
(visual examination of contact configuration of the opposing sensation, burning pain of the throat and dizziness at various
teeth) in laterotrusive and mediotrusive side. times of the day. Otolaryngological treatment of auriculo-
On palpation of masticatory organ muscles (masseter, vestibular symptoms in the group of remaining 30 patients was
temporal muscle, lateral pterygoid, medial pterygoid as well as effective.
biventer muscle, and floor of mouth) the level of muscle tone in
comparison to physiological norm was examined, and the Results of functional examinations of the masticatory organ
occurrence of provoked pain was estimated. On examination of
temporo-mandibular joints close attention was paid to the Functional examinations of the masticatory organ carried out
occurrence of acoustic symptoms during mandible vertical among 42 patients revealed no disorders in 30 patients, and
movements and their character (e.g. crepitus, grating sounds), numerous dysfunctions in 12 patients (8 females and 4 men).
and pain ailments on palpation and mandible motion. Out of 12 patients, only 10 fully dentulous patients (7 females
The specialist examination was supplemented with the close and 3 males), 7 were qualified for further dental examinations; 2
analysis of functional temporo-auricular radiograms of temporo- partially edentulous patients were excluded from the study
mandibular joints, taken in Schuller projection in mandible because of numerous missing teeth in both jaws with no
central occlusion and maximum mandible adduction. These prosthetic restoration, which could prevent correct interpretation
examinations allow for direct assessment of the joint osseous of the results.
structure, position of articular heads in glenoid cavity being The history elicited from the patients revealed self-induced
crucial for diagnostics, indirect assessment of articular discs and pain in the peri-auricular region lasting about 1-12 weeks,
the range of articular heads mobility in joints (e.g. joint located in one or both sides of the face. The pain appeared during
253

mastication or in border left and right lateral jaw position that is detected in 7 patients. Occurrence of acoustic symptoms such as
in the maximal mandible depression or mandible adduction as crepitus in temporo-mandibular joints was confirmed in 3 patients
well as during lateral mandibular movements. Pain irradiation in (Table 2).
temporal and occipital region was recorded in 4 cases. Acoustic Radiographic analysis of functional temporo-auricular
symptoms, heard by patients at least 2 months before the radiograms of temporo-mandibular joints taken in Schuller
prosthetic consultation, were reported by 3 patients. Earlier, projection revealed asymmetry in the position of the mandibular
sudden maximal dimension of mandible depression limitation heads in the temporal fossa in the position of central occlusion in
was noted in 2 patients. Difficulties with mastication and 2 cases and excessive dimension of mandible depression in 1
intensified masseter muscle and temporalis muscle tone, were case (Fig. 1).
recorded in 4 patients. Auriculo-vestibular symptoms (plugged Electromyographic examination of the masseter muscles and
ears sensation, hearing impairment, burning in the throat) were anterior temporal muscles confirmed clinically manifested
recorded in all patients’ histories. The results of the subjective increased tone of these muscles in the central occlusion (Table 3
examination are presented in Table 1. and 4). Lack of symmetry in the muscular tone was noted, which
The functional analysis disclosed deviation from the norm in was proved by the difference in the potentials of the right and left
maximal dimension of mandible depression (up to 18 mm), and sides of the same muscle ranging between 4.7 µV and 42.5 µV.
mandible lateral movements (up to 5 mm). Abnormal jaw path and Muscle tone asymmetry index was positive for masseter muscles
disturbances in vertical movements were recorded in 7 patients. (2.641), which indicates the right-side muscle activity
Rest position distance was smaller in 2 patients. Configuration of dominance, and negative for temporal muscles (-2.944), which
occlusal contacts in central and eccentric occlusion was abnormal shows left-side muscle activity dominance (Table 5).
in 8 patients. In 5 cases pain on palpation was noted and in 7 cases Excess of the physiological level of muscular tone, the norm
pain in temporo-mandibular joints, provoked by palpation, was of which is within 10-15 µV (5), ranged from about 30 µV to 120
recorded. Increased muscle tone on palpation was present in all µV for the masseter muscles, and from 10 µV to 105 µV for the
patients. Masseter muscle hypertrophy was noted in 1 case and the temporal muscles. It indicated that in patients with no
symptoms of parafunctions occurrence in oral cavity region were otolaryngological causes of auriculo-vestibular symptoms, the

Table 1. The results of the subjective examination.


Reported ailments Females Males
Self-induced One joint 4 2
pain Both joints 2 1
Joint pain present during food mastication 4 2
Pain irradiation 3 1
Crepitus in temporo-mandibular joint reported
2 1
by patients
Feeling of tension in joints 3 2
Previous limitation of mouth opening 1 1
Self-induced pain of masseter or temporalis muscles 3 1
Difficulties in food mastication 4 2
Occlusal and non-occlusal parafunctions incidence 5 2
Auriculo-vestibular symptoms 7 3

 

Fig. 1. Asymmetry in the position


of the mandibular heads in the
temporal fossa in the position of
central occlusion in radiographic
investigation.
254

Table 2. Results of functional stomatognatic system examinations.


Functional examination Normal Abnormal
Range of mandible depression 8 2
Vertical jaw Middle 4
movements Stage Final 2
path S-shaped 1
Rest position distance 8 2
Central occlusion 2 8
Occlusal Lack of occlusion in
conditions Eccentric 6
canine teeth line
occlusion Occlusal contacts in
4
mediotrusive side
Temporo-mandibular pain present on examination 5
On palpation muscle pain 7
Increased muscle tone 10
Muscle hypertrophy 1
Symptoms of parafunction incidence 7
In one joint 2
Acustic effects
In both joint 1 3
Positive clenching test 5
Positive grinding test 6
Abnormal radiogram 4

Table 3. Electric potentials of masseter and temporalis muscle and more attention in literature. This co-existence can be
expressed in micro voltage-µV. associated with the common filogenetic and ontogenetic
Temporal muscles- development of the muscles: medial pterygoid, soft palate tensor
Patients Masseter muscles
anterior part and tympanic tensor, which originate from the first branchial
arch (6-8). Moreover, anatomical adjacency of the temporo-
R L R L
mandibular joints and the middle ear can promote transmission
1. 157.72 128.23 179.24 187.33 of excessive mechanical forces originating from the region of the
2. 124.8 112.6 145.7 112.6 TM joints to the ear via the disc-malleus ligament or as a result
3. 32.5 56.7 65.4 45.7 of direct pressure and irritation of the auriculo-temporal nerve by
4. 67.8 45.8 98.6 118.8 the mandibular head in the region of the petro-tympanic fissure.
This creates an impulse for reflex contraction of the tympanic
5. 27.8 15.7 45.7 64.8 tensor muscle. Posterior translocation of the mandibular heads
6. 51.6 36.8 75.2 99.5 can cause pressure on the tympanic artery and vein, leading to
7. 21.1 43.5 54.6 87.4 the blood supply impairment and functions of the middle ear,
8. 15.7 34.66 75.5 87.3 contraction of the stapes muscle and, in consequence,
immobilization of the stapes. In these reciprocal relations, the
9. 44.5 87.4 76.9 83.9
innervation of the tympanic tensor, soft palate tensor and
10. 16.8 21.5 22.7 33.4 masseter muscles by the mandibular branch of the trigeminal
nerve seems to play a significant role. The increase in the tone of
one group of muscles is frequently accompanied by excessive
tension in the muscles of the other group (9-15). Functional
predominant problem was functional disorder of the masticatory disorders of the masticatory organ are frequently reported by
organ accompanied by the increase in muscular tone markedly patients seeking prosthetic treatment. Co-ocurence of auriculo-
exceeding the physiological norm. vestibular symptoms such as: hearing impairment, dizziness,
In the group of 12 patients referred to the Otolaryngological tinnitus, diagnosed in the control group, have been noticed by
Department, successive prosthetic treatment was performed with many authors treating patients with functional dysfunctions of
the use of occlusive splints and reconstructive procedures, masticatory organ (16-24).
aiming at restoration of correct relation between the jaws, Tinnitus and dizziness analyzed by Chole R. (25) appeared
combined with physiotherapy and psychological support. In significantly more often in patients with functional disorders
follow-up examinations carried out after 6 and 9 months of the than in control group formed with patients searching general
prosthetic treatment beginning, the auriculo-vestibular medical treatment.
symptoms were excluded in all patients. Among patients referred to Department of Otolaryngology
females predominated (7 females and 3 men), which was also
noticed by Lam et al. (26), as from among 344 examined
DISCUSSION patients with functional disorders, women significantly
outnumbered men. Alarmingly high percentage of patients in
Common occurrence of auriculo-vestibular symptoms with this study constituted patients with auriculo-vestibular
functional disorders of the masticatory organ is receiving more symptoms (59%).
255

Table 4. Assessemet of the level of significance for electric potentials of examined muscles.

Masseter muscles Temporal muscles – anterior part


Difference Difference
R L (absolute values) R L (absolute values)

X=56.0 X=58.0 X=20.4 X=83.95 X-92.1 X=18.7


SD=48.4 SD=38.4 SD=10.7 SD=46.8 SD=43.1 SD=9.4
Min. 15.7 Min. 15.7 Min. 4.7 Min. 22.7 Min. 33.4 Min. 7.0
Max. 157.7 Max. 128.2 Max. 42.9 Max. 179.2 Max. 187.3 Max. 33.1
Physiological muscle tone about 10 µV Physiological muscle tone about 15 µV
P=0.0418 P=0.0233 P=0.0097 P=0.0079 P=0.0020 P=0.0000

Table 5. The asymmetry index of the masseter and anterior part of temporalis muscles.
Masseter Masseter Temporalis Temporalis
Muscle R L R L
square 24875.6 16442.93 32126.98 35092.53
15575.04 12678.76 21228.49 12678.76
1056.25 3214.89 4277.16 2088.49
4596.84 2097.64 9721.96 14113.44
772.84 246.49 2088.49 4199.04
2662.56 1354.24 5655.04 9900.25
445.21 1892.25 2981.16 7638.76
246.49 1201.316 5700.25 7621.29
1980.25 7638.76 5913.61 7039.21
282.24 462.25 515.29 1115.56
Mean value 5249.332 4722.953 9020.843 10148.73
RMS 72.45227 68.72374 94.97812 100.7409
A .index 2.641050489 -2.944426083

The results of the examinations that were carried out, significant reduction or disaapearance of auriculo-vestibular
indicate necessity of functional dysfunctions’ verification within symptoms (30, 31). Peloz in his study emphasizes that in 37% of
the stomatognatic system in case of lack of otolaryngological 221 treated patients with functional disorders, there were some
causes of auriculo-vestibular symptoms, according to Turp and auricular symptoms that were eliminated by the use of
Ramirez (18, 24). In Tuz H. et al. study the incidence of stabilization splint, commonly used in prosthetic treatment.
auriculo-vestibular symptoms’ occurrence in a group of patients Moreover, correlation between the incidence of auriculo-
with functional disorders was estimated and it was demonstrated vestibular symptoms and clinically diagnosed disc dislocation
that in a group of 200 examined patients 77.5%, that is 155 without blocking was found by the author (32).
persons, were diagnosed with at least one of the symptoms The accompanying otolaryngological symptoms impede the
regarded as auriculo-vestibular group (29). The similar patients’ everyday life, their professional work as well as correct
incidence was stated by Manni et al., as in 53 patients treated diagnosis of this disorder. Tinnitus can interfere with speech
due to functional disorders, 67.9% of patients were diagnosed understanding and hinder sleep, dizziness is a frequent cause of
with at least one functional disorder (10). the fear of free mobility. Because of otolaryngological
Results of electric potentials of masseter and anterior part of symptoms caused by this disorder, the patients are frequently
temporal muscles’ estimation, analyzed in activity, in central referred for specialist treatment which is not related to
mandibular occlusion, indicate much higher electric potentials in stomatognathic system (16-20). The coexistence of auriculo-
comparison to physiological norm. Similar results were achieved vestibular symptoms and otolaryngological disorders within the
by numerous authors who compared the tension level of masticatory organs is due to the activation of the brain-auriculo-
masseter and temporal muscles in patients with stomatognatic ventricular axis, mediated mostly via trigeminal nerves. The
system functional disorder and healthy controls (16, 18, 19, 24, treatment of masticatory organ disorders requires multi-
27-29). Different results can be found in Manni et al. study specialistic and therapeutic approach.
because higher electric potentials were observed in control group
than in patients treated due to functional disorders (10).
In case of 10 patients examined in a study (referred from CONCLUSIONS
Department of Otolaryngology) application of specialist
prosthetic treatment caused permanent disappearance of Results of dental examinations revealed numerous
auriculo-vestibular symptoms. The same result is described by abnormalities of the function and biomechanics in the
Cooper et al. and Kuttila M et al. who conducted orthopedic masticatory organ which can coexist with otolaryngological
treatment with occlusal splints used to reposition the jaw in symptoms of auriculo-vestibular type.
patients with functional disorders having symptoms such as: Functional disorders of the masticatory organ and auriculo-
earache, hearing impairment, tinnitus. This caused the vestibular symptoms, observed in our study, require preparation
256

and introduction of common otolaryngological and dental 17. Fanali S, Cerri A. The otoneurological and dental picture of
management for diagnostics and therapy of patients with this Costen’s pain- dysfunction syndrome. Minerva Stomatol
kind of disorder. 1993; 42: 37-43.
18. Turp JC. Correlation between myoarthropatlies of the
Acknowledgements: We are very grateful to Professor masticatory system and ear symptoms (otalgia, tinnitus).
Stanislaw Konturek for his assistance and kindness. HNO 1998; 46: 303-310.
19. Toller M, Juniper R. Audiological evaluation of the aural
Conflict of interests: None declared. symptoms in temporomandibulon joint dysfunction. J
Craniomaxillofac Surg 1993; 21: 2-8.
20. Salvinelli F, Casale M, Paparo F, Persico A, Zini C.
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