2. medical and dental history, history of the TMD
problems, and evaluation of clinical signs or symp-
toms. The patients were also questioned about oto-
logic complaints, including tinnitus, vertigo, otalgia,
and hearing loss. Temporomandibular magnetic res-
onance images were taken of all patients in sagittal
and coronal sections; the same protocol was strictly
followed for all patients who had TMD signs or
symptoms.
The patients were divided into 3 groups. Group 1
consisted of 22 (11%) who were diagnosed with
MPD.16
Group 2 consisted of 154 patients (77%)
diagnosed with internal derangement of the TMJ; this
group included internal derangement types I, II, and
III.16
Group 3 consisted of 24 patients with either
myalgia or MPD and internal derangement signs and
symptoms. The groups were based on research diag-
nostic criteria described by Dworkin and LeResche.16
All patients who described having at least 1 oto-
logic complaint were sent to the ear, nose, and throat
and the audiology departments of Ankara University
for clinical consultation and audiologic tests that in-
cluded pure tone audiometry, impedance test, and reflex
tympanometry.
A control group of 50 asymptomatic, normal sub-
jects (group 4) was randomly selected from the patients
referred to the department of oral and maxillofacial
surgery for minor dentoalveolar surgery. All were fit
and healthy (American Society of Anesthesiology,
status I or II patients), with no current (or history of)
TMD problems.
The collected data and comparison of the groups
having the otologic complaints were evaluated with
chi-square test for independent samples.
RESULTS
Of the 200 patients, 165 were female and 35 were
male; they were aged 13 to 67 years (mean 29.6 years).
Forty-five patients (22.5%) said that they had no
otologic complaints; 155 (77.5%) reported at least 1
complaint; 100 (50%) reported earache, and 91 (45.5%)
reported tinnitus. Vertigo and loss of hearing were
noted in 72 (36%) and 47 (23.5%) patients, respec-
tively.
Group 1 comprised 22 patients (17 females, 5
males) with a mean age of 32.5 years. Otalgia was
reported in 14 (63.6%), tinnitus in 13 (59.1%), and
vertigo in 11 (50%); hearing loss was noted in 5
(36.4%) patients.
Group 2 comprised 154 patients (127 females, 27
males) with a mean age of 29.2 years. The prevalence
of otologic complaints was 71 (46.1%) for otalgia, 68
(44.2%) for tinnitus, 50 (32.5%) for vertigo, and 34
(22%) for hearing loss.
Group 3 comprised 24 patients (21 females, 3
males) with a mean age of 29.5 years. Otalgia, vertigo,
tinnitus, and difficulty in hearing were reported in 11
(45.8%), 10 (41.6%), 15 (62.5%), and 8 (30.0%)
patients, respectively.
Among the 155 TMD patients with at least 1 of the
4 otologic complaints, only 3 (1.9%) also had objective
coincidence (hearing loss) related to their subjective
complaints after specialist consultation. The causes of
hearing loss in these patients included deafness related
to otitis media in 1 patient and otosclerosis in 2
patients, with 15% and 20% diminished hearing.
Group 4 comprised 50 control subjects (27 females,
23 males), aged 15 to 66 years (mean 37.2 years).
Fig. Schematic view of relationship of nerves, TMJ, and ear structures.
American Journal of Orthodontics and Dentofacial Orthopedics
Volume 123, Number 6
Tuz, Onder, and Kisnisci 621
3. Otalgia was reported in 4 patients (8%), tinnitus in 13
(26%), vertigo in 7 (14%), and hearing loss in 7 (14%).
Statistically, no significant difference was found for
the prevalence of otalgia, tinnitus, vertigo, and hearing
loss among the 3 study groups. However, otalgia in
TMD patients was higher than in the control group; this
difference was statistically significant. Tinnitus and
vertigo were significantly higher in the symptomatic
patients than in the control group. Hearing loss was also
higher in the study groups than in the control group, but
this difference was not statistically significant (Table).
DISCUSSION
In this study, the TMD patients were divided into
groups with a diagnosis of either MPD (group 1) or
internal derangement of the types I, II, or III (group 2)
according to research diagnostic criteria for TMD.16
A
third group was also created to include patients having
both myogenic and internal derangement signs or
symptoms at the early pretreatment stage. This group
was formed with no attempt to elucidate the primary
cause, which could have been either internal derange-
ment or myalgia/MPD. The TMD groups were de-
signed to delineate the effects of different mechanisms
that might produce aural symptoms, because several
hypotheses in the literature describe various mecha-
nisms and structures, as well as functional and behav-
ioral patterns.1,2,8,17
In groups 1 and 3, the ratios of the
patients with otalgia, vertigo, and tinnitus were higher
than in the internal derangement group alone. However,
this difference was not statistically significant. Simi-
larly, no statistically significant difference was found
between group 3 and the other 2 groups.
Some investigators have hypothesized that eusta-
chian tube dysfunction, masticatory muscle dysfunc-
tion, or reflex-sympathetic vasospasm of labyrinthine
vessels occurs secondary to abnormal stimulation of
autonomic nerves of the TMJ.17-19
Hypotheses empha-
sizing structural effects inducing aural symptoms in-
clude mandibular overclosure and posterior displace-
ment of the condyle that secondarily puts pressure on
the auriculotemporal nerve and chorda tympani, as well
as the eustachian tube, which might produce erosion of
the tympanic plate.2,20
Moreover, reflex disturbances of
the tensor tympani and veli palatini muscles, as well as
the otomandibular (eg, diskomalleolar and tympano-
mandibular) ligaments are among the structural causes
for aural symptoms.1
Otalgia, vertigo, and tinnitus as subjective com-
plaints were noted significantly more frequently in the
experimental groups than in the control group. In
contrast, the difference in the incidence of hearing loss
was not found to be statistically significant. The inci-
dence of patients with hearing loss complaints was
23.5%, although the audiometric documentation
showed true hearing loss in only 3 patients (1.5%).
Thus, the ear, nose, and throat consultants failed to find
any objective pathologic condition to explain the ear
symptoms. Rubinstein21
suggested that subjective com-
plaints are not correlated with the objectively assessed
level of hearing loss. Williamson,22
to validate otologic
symptoms in patients with TMD, reported that none of
them had an otologic disorder when examined by
specialists. In another study, no significant difference of
pretreatment audiometric findings was found between
12 internal derangement and 9 MPD patients, and, more
interestingly, no difference was found between pre-
treatment and posttreatment audiometric measure-
ments. That study also concluded that a correlation was
not found between reduced hearing sensitivity and
audiometric results.23
Toller and Juniper24
reported
results from audiograms, tympanograms, and eusta-
chian tube function tests on 57 TMD patients and
showed no statistically significant differences when
compared with 57 control subjects.
The reported prevalence of otologic complaints in
TMD patients varies in the literature. However, only
few complaints are supported by audiometric documen-
tation.18,24
The frequency of otalgia, tinnitus, hearing
loss, and vertigo are reported with ranges of 20% to
100%, 31% to 59%, 15% to 32%, and up to 70%,
respectively.8,9,17,25-29
Nevertheless, it is well docu-
Table. Distribution of patients
Group Otalgia Tinnitus Vertigo
Loss of
hearing
Difference
between control
and groups 1–3*
1 (MPD) (n ⫽ 22)* 14 (63.6) 13 (59.1) 11 (50.0) 5 (36.4) P ⬍ .05
2 (ID) (n ⫽ 154)* 71 (46.1) 68 (44.2) 50 (32.5) 34 (22) P ⬍ .01
3 (MPD-ID) (n ⫽ 24)* 15 (62.5) 10 (41.6) 11 (45.8) 8 (30.0) P ⬍ .002
4 (Control) (n ⫽ 50)* 4 (8) 13 (26) 7 (14) 7 (14) P ⬍ .14
Data presented as n (%). MPD, myofascial pain syndrome; ID, internal derangement.
*Total number of patients in each group does not equal sum of each row because most patients have more than 1 complaint.
American Journal of Orthodontics and Dentofacial Orthopedics
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622 Tuz, Onder, and Kisnisci
4. mented that TMD patients with otalgia or tinnitus have
higher pain and dysfunction scores than do TMD
patients without otologic symptoms.29,30
The differ-
ences in the occurrence rates of subjective otologic
symptoms could be due to the lack of constant or
persistent ear symptoms, the failure to use audiometric
tests, the lack of asymptomatic control subjects, and the
inclusion of especially elderly patients.
Our working hypothesis was mainly based on
whether arthrogenic/anatomic causes due to internal
derangement or myogenic disorders alone or combined
can influence the rank order, incidence, and occurrence
of otologic complaints. Our findings are nonsupportive,
with no statistically significant results. Otalgia was the
most frequently encountered complaint, followed by
tinnitus, vertigo, and subjective deafness.
CONCLUSIONS
Several factors play a role in the occurrence of
otologic symptoms in patients with TMD, with no
predilection of the otologic symptoms between TMD
subgroups. Patients with signs and symptoms of inter-
nal derangement and MPD or a combination of internal
derangement and myalgia/MPD were equally affected
by these disturbances.
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