Often ear symptoms, including tinnitus, ear fullness and pain, are the result of infection or structural dysfunction of the ear anatomy. If these common causes are ruled out, typically by an ENT, TMD is commonly considered as the main contributing factor. Because of the proximity of the ear and the temporomandibular joint, adjacent structure often interact, sometimes negatively. As shown in clinical research by Travell and Simons, both muscles of mastication and muscles in the neck region can produce ear symptoms. More specifically, trigger points in the sternocleidomastoid (SCM) and masseter (the main muscle used in chewing) muscles can directly refer pain to the ears. Similarly, deep chewing muscles in the jaw attach in areas close to the very small muscles of the ear. Dysfunction of these muscles which move the jaw can subsequently impede the muscles which dilate the eustachian tubes, resulting in ear fullness.
The Basis of TMD Rehabilitation
Addressing TMD often results in a resolution of ear symptoms. The initial goal of physical therapy treatment is identifying irritating factors which may contribute to tinnitus, ear fullness and ache in the ears. A TMD physical therapist educates patients on the causes of symptoms and methods to reduce these aggravating factors. Cessation of parafunction, such as nail biting, excessive gum chewing and snacking on hard foods, is instructed. These basic steps allow patients to actively assist in the reduction of their symptoms with minor modifications to normal daily activities.
Similarly, education of proper posture and breathing techniques are vital component in the rehabilitation process. Strain on the muscles of the neck and face can directly result in ear symptoms. Ergonomic workstations, sleeping positions and cell phone use are reviewed to minimize muscle and joint stress. Diaphragmatic breathing is also taught, which not only reduces stress, but eliminates strain of accessory breathing muscles. Abnormal use of these muscles can place pressure on structure not designed to accommodate this force, and result in ear pain.
Decreasing Acute TMD Inflammation
Although the ear may be the sole area of pain for some patients, addressing the entire neck and facial region is necessary to resolve symptoms. At the beginning of most treatments, moist heat and electrical stimulation are utilized to reduce muscle tightness. These modalities increase blood flow to oxygen deprived tissues. In addition to promoting relaxation, they reduce inflammation and the body’s pain response on the cellular level. Both cervical and facial structures are addressed with interventions designed to passively reduce pain. Modalities are not the permanent solution to ear pain, but they can reduce symptoms and prepare problematic areas for more advance interventions.
Cold laser application, which utilizes non-thermal light energy, can further reduce localized inflammation. Cold laser technology is well supported by clinical research as a pain-free method to reduce cellular inflammation. This modality is applied directly to the TMJ region without strain to the area. It is frequently recommended with persistent pain and severe tenderness to palpation.
Remodeling Soft Tissue
A skilled TMD physical therapist is often the first healthcare provider who thoroughly assesses and addresses the soft tissue in the TMJ and cervical regions. This includes the muscles of mastication, which are responsible for both opening/closing the mouth and chewing. These muscles are of additional importance as some are located deep in the skull, adjacent to the ear. Research has consistently shown that trigger points in the deep masseter muscle specifically can result in ear pain. Cervical structures are often a critical component in the production of ear symptoms and dysfunction in these areas can directly refer to the ear.
From a physical therapy standpoint, muscle knots and adhesions are tissues fibers that no longer align correctly. On diagnostic ultrasound, they appear disheveled instead of uniformly symmetrical. Utilizing soft tissue mobilization and myofascial release techniques, muscle adhesions are broken down and dispersed. This assists the body in removing cellular waste and beginning the remolding process. Normal movement patterns of the neck and jaw then return. The neck and jaw muscles are comprehensively manipulated both superficially and intraorally. The temporomandibular joint is also mobilized to stretch the joint capsule and surrounding ligaments, which often tighten with the onset of pain. Cranial distraction and stretching of the cervical paraspinals is often utilized to reduce compression and tightness.
An Advanced Treatment
Dry needling is a minimally invasive procedure in which a solid filament needle is inserted into the muscle directly at a persistent trigger point. While the needle used is similar to acupuncture needle, the technique and methodology varies greatly. The sole purpose of dry needling aims to decrease contraction knots, which are related to the production and maintenance of the pain cycle. These very thin needles and inserted through the skin and can affect deep layers of muscle tissue. Dry needling in the orofacial region also allows TMD physical therapists to address muscles unreachable by the fingers. Specific to patients with ear ringing, fullness and pain, this technique allows TMD physical therapists to affect the sternocleidomastoid, medial pterygoid and deep masseter muscles, which can all cause ear symptoms. Well supported in the clinic literature, dry needling is an excellent way to reduce ear issues without jeopardizing the delicate inner ear structures.