DTAR Journal

Introduction

Tinnitus is usually described as a ringing sound, but some people hear other types of sounds, such as rustling leaves, rumbling like a pressure cooker, or buzzing. Tinnitus is common, and surveys estimate that 10-25% of adults have it. The causes of tinnitus are unclear, but most people who are affected by this symptom have some degree of hearing loss. For adults, tinnitus can improve or even go away over time, but in some cases, it gets worse, and when it lasts over three months or more, special attention should be paid as it can become chronic [1].

Some individuals with tinnitus problems are affected by their inability to sleep or concentrate. In more severe cases tinnitus can lead to anxiety or depression. Currently, there is no cure for tinnitus, but there are ways to reduce its symptoms. Common approaches include the use of sound therapy devices (including hearing aids), cognitive and behavioral therapies, and the use of medications. Studies from the contemporary literature during the previous years were focused on the treatment and alleviation of otologic symptoms and were limited to randomized clinical trials, case-managed case study reports, and prospective studies.

 Tinnitus symptoms can vary significantly from person to person. Usually, patients can hear unfamiliar sounds (noises) in one ear and almost every hour in both ears. The sounds can mainly be in the form of ringing, buzzing, roaring or screeching. Sounds can be soft or high-pitched. It may come and go or be present all the time in a continuous manner [2]. Most cases of tinnitus are subjective, meaning that only the individual in question can hear those sounds.

In the case of disorders of the TM articulation, the crackling in that area is heard by the individual himself, by the doctor, but also from a distance [3]. In the case of ear pathologies, the sound can pulsate rhythmically and often at the time of the patient’s heartbeat. In these cases, a doctor may be able to hear the sounds with a stethoscope, and if so, then it is considered to be objective noise in the ears, and this type of noise is clinically treatable since the sound, in this case, is related to hypertension and is eliminated with its stabilization.

The most important symptoms of disorders in the TMJ are stuttering, pain in the joint, and difficulty in moving and opening the mouth. From the pronounced pain in the joint, we also have atypical movement of the mandible [3]. These changes that are observed in the kinematics of the movement of the mandible, as well as the presence of pain around the articulation and crepitations make the diagnosis difficult and often lead to the application of non-rational and wrong treatment methods [3]. This often causes patients with various pathologies of TMJ disorders to be accompanied by neuralgic pain, otology, facial pain, noise in the ear (tinnitus), dizziness, etc., to which they turn to doctors of different profiles, who are not always familiar with the specifics of dental diseases and especially TMJ pathology. The most frequent pathology encountered in dental practice is the non-functional disorder of this joint. Today, in contemporary literature, the term: “Intra-articular disorders of the Temporomandibular joint” [4] is widely used for these pathologies with different names spread over time.

To identify the nature, and origin of pain and common pathologies that have otorhinolaryngological diseases such as Tinnitus, Delirium, etc., with intra-articular disorders of the TM articulation, it is necessary to undertake some additional diagnostics, specifically:

For TM articulation disorders:

X-ray panoramic-cephalometry radiographic images, Computed Tomography (CT)-Scanner radiographic images, as well as Magnetic Resonance Imaging (MRI), which together can reveal structural anomalies of the TM joint such as: arthritis or displacement of the condyle disc, subluxations and damage to the condyle disc.

For Tinnitus and other ORL symptoms

Magnetic Resonance Imaging (MRI), Computed Tomography (CT) of the head/ear/neck, etc., which can confirm whether there are changes for structural abnormalities, such as acoustic neuroma or vascular problems, etc. [5].

Today in contemporary literature there are several methods for the treatment of ORL disease which can be divided into two categories:

a) methods aimed at directly reducing the intensity of noise in the ears, and b) methods aimed at alleviating the annoyance associated with the noises in the ears. The first methods include pharmacotherapy compression and electrical stimulation, and the second methods include pharmaco-therapy, cognitive and behavioral therapies, voice therapy, habit therapy, massages, and the use of hearing aids [6,7].

When Tinnitus has an underlying physiological cause and symptoms can persist for months or even years, then some of the treatments your doctor may recommend are:

1) Sound therapies, which are based in part on the view that ringing in the ears stems from changes in the neural circuits of the brain that have caused the hearing loss. Some evidence suggests that exposure to sound can reverse some of these neural changes and help silence tinnitus. Also, this method can be called functional by masking the sounds of tinnitus and helping the individual to get used to them, or in more special cases by distracting the individual from the irritations of the noise in the ears.

2) Hearing aid placement is one of the main treatment options for patients with tinnitus or those with hearing loss. The devices amplify external noises allowing the individual to be better engaged with the world around them and making tinnitus less bothersome.

Disorders in the TM system can appear with completely different symptoms than those related to the ears and hearing system since in these cases hearing is not affected and there is no noise in the ear. Pain in the case of disorders of the TM joint occurs only during the movement of the mandible. In the case of the sensation of blocked ears accompanied by pain, it can be attributed to the dysfunction of the Eustachian tube and tensor muscles. In addition, both tensor muscles such as Veli Palatine and Tympanic Nerve are innervated by the trigeminal nerve, causing otological symptoms due to stimulation of the brain [3,9]. Disorders of the TM joint can cause pain in the jaw joint and the muscles that control jaw movement (Figure 1) [3].

Figure 1: Symptoms of reflected pain near the ear area caused by Tinnitus or TMJ disorder.

The pain can be caused by several factors, among which we can mention habits such as bruxism (grinding the teeth), chewing gum for a long time, and non-occlusal parafunctions such as biting the nails, lips, and cheeks, which lead to muscle spasms that are accompanied by pain and TM joint disorders associated with fibromyalgia phenomena, osteoarthritis and injury to jaws. In most cases, the pain and discomfort associated with disorders of the TM joint last only for a limited time, i.e. only in cases when the individual moves the mandible. The combined treatment of this therapeutic prosthetic pathology using relaxing splints is very effective in treating the symptoms of TMJ dysfunction. Surgical treatment is usually the last resort since conservative methods have not given the right result [3,10,11].

Patient treatment plan and study objectives

After long-term consultations between otolaryngologists and dentist-gnathologist specialists regarding the presence of pain in the area around the ear, the specialist doctors have decided on how to treat this symptom, which determines the objective of the following study:

A differential diagnosis between the pathology of the ear and the dysfunctional disorder of theTMJ should be determined in the case of the reported study, and which was the main objective of the study, which should be carried out by a complete analysis:

1) We had to explain and determine whether there is any relationship between the severity of tinnitus symptoms that distinguish ear diseases from dysfunctional disorders of the TMJ.

2) The methods used to treat each of the above pathologies realized are those appropriate methods for the treatment and for recovering of the patient?

Material and Method

The female patient G. R., 22 years old from the rural areas of Tirana, presented to the Otorhinolaryngological Department, near the University Hospital Center of Tirana (UHCT) for constant pain in both ears, which in this case was considered chronic. This condition started almost a year ago and, referring to the current situation, the noises and pains increased mostly in moments of daily stress. She explained to both doctors that the sounds were constantly elevated and pulsating with a progressive loss of hearing in both ears. This fact hurt her quality of life, disrupting her sleep and mood.

The noises in the ears have affected both the physical condition and the psychological condition of the patient, who reported that the noises in the ears were boring, accompanied by insomnia, decreased concentration, and mood. Tinnitus is a symptom of patients with vestibular pathology, Meniere’s syndrome, etc. Pain, which is the most frequent symptom, was also referred to by the patient as an irritating condition, which distinguishes it from jaw joint pain. What distinguishes wrist pain from ear pain is that it occurs during the movement of the lower jaw-mandible. During the movement of the mandible, the pain in the articulation increased and the noise in the left ear decreased continuously.

The ORL doctor recommended the patient be examined by audiological tests and blood tests (checkup), which showed that there were no essential changes and presented below.

Table 1: Blood analysis (check-up) for patient G.R. with Tinnitus.

Tinnitus often represents a symptom of a disease process closely related to various otological causes, but not least TM articulation disorders.

Scientific studies in this field have used the latest technology to measure and examine noise in the ears of the auditory nerve and auditory tracts of the brain. Tinnitus is a symptom that is commonly associated with a wide range of medical problems such as middle and inner ear problems, blood circulation, metabolic disorders, and side effects of medications [12].

Tinnitus is a widespread phenomenon that has affected at least 14% of the European population, 14% of men and 15% of women. This symptom causes high costs in health care, especially when the disturbance of noise in the ears is present as severe tinnitus and in Europe fluctuates in the values  of 1-2%. Tinnitus as a severe symptom fluctuates in values  of 1.0% in men and 1.4% in women, and the prevalence of tinnitus increases significantly with age and the deterioration of a person’s hearing condition. The severity of tinnitus symptoms is positively related to the use of healthcare resources [13].

In our case study reported during the search, we evaluated the relationship between blood parameters and the dominant influence of stress in the blood sample of patient G.R with tinnitus also presented in the discussions. Tinnitus matching by audiological examination was used to approximate psychoacoustic tinnitus parameters, a test which was performed by the ENT specialist by adjusting the sounds presented to the patient through headphones in such a way that the sounds were as close as possible to the type and frequency of the sound and the subjectively perceived level of ringing in her ears.

For the tinnitus and other ORL symptoms for patient G.R, a diagnostic procedure with Magnetic Resonance Imaging (MRI) performed for the head//ears/neck was recommended to ensure that there are changes with structural abnormalities, such as acoustic neuroma, vascular problems, or disc displacement that reflect in the ear pain identified with tinnitus, etc. MR imaging of the TM joint was one of the methods of choice for examining TMJ disorders. In our case, we hypothesized to detect comorbid TMJ disorders of any acceptable relationship using MR images. Thus, in the present study, we aimed to comparatively describe the associations of MR images of patients with TM articulation disorders with tinnitus, identifying the most common TM articulation changes and to find the existence of a relationship between the severity of TMJ disorders with Tinnitus [3,5].

The examination according to the MR images showed that in our patient, a displacement of the disc with reduction was found, which was the main cause of the crackling and noise in the TM articulation. However, an important distinction had to be made between the symptoms caused by the displacement of the disc with the reduction in tinnitus, as this would affect the correct treatment of the patient G.R.

To reach the proper objective of the patient’s treatment, the doctors recommended the patient perform a panoramic-cephalometric 3D X-ray image, as well as a radiographic image using a Computed Tomography (CT) scanner to further explore the relationship between Tinnitus and TMJ disorder [14,15].

Non-specialist doctors are not so familiar with the characteristic signs of TMJ dysfunctional syndrome, etc., and therefore rarely recommend radiological examinations to patients. A specialist dentist-gnathologist of the TMJ asks for those images when the patient shows symptoms or visible signs of disorders in the TM. The TMJ can be in varying degrees of arthritic damage that may not be fully seen on standard panoramic dental radiographs. Experienced specialists can detect TMJ disorders on standard panoramic imaging, however, X-ray and cone beam imaging can be considered a “standard of care” for TMJ diagnosis and treatment [16].

Panoramic-cephalometric images fail to reveal the functional status of the TMJ, as these images have a higher specificity, and relatively low sensitivity, compared to Computed Tomography (CT) images. While some other authors consider clinical data of greater importance than panoramic images for patients with TMJ disorders. However, several other authors have suggested panoramiccephalometric radiography as a good imaging modality for visualizing TM articulation [17].

Figure 3: Panoramic-cephalometric view (jaw-skull) of patient G.R with the relevant equipment.

Today, Computed Tomography (CT) in the diagnosis of TMJ disorders and Tinnitus symptoms has emerged as a valuable imaging modality in the diagnosis and management of TMJ disorders and Tinnitus symptoms.

Disorders in the articulation of the TM often include functional damage in the jaw joint such as the disc is displaced anteriorly (in front of the noon position) in the position of the closed mouth, an image that is visible in the sagittal plane [3].

In our study, we recommended patient G.R. perform a head/neck/ear scan with the Computed Tomography (CT) imaging technique, which method provides high-resolution and detailed images of hard tissues such as bones and joints with the advantage of high spatial resolution for detailed bone structures, etc., the purpose of which is to finalize the nature and origin of the pain she was complaining about.

Figure 4: CT Scanner device in the German Hospital in Tirana, where the G.R patient carried out scanner diagnosis.

The CT images device, the Scanner was manufactured by the German Company Siemens Som Atom. Model: Medical X-Ray System, Serial Number: 5533620/10200306, and consists of 128 slices. The methodology followed to perform a head/neck/ears examination, the voltage applied to the device is 120 kV with a bunch index Tb=2 cm and a cut of 5mm, with an average scan length L. head=20 cm with a current of 300mA. The 4D workflow practiced on these images eliminates manual reconstruction steps for 3D reconstructions at speeds up to 20 images/sec. With these data it turned out that we would have a head radiation dose index CDTI=0.223 milli Gray/milliamperes a body dose index, and CTDI=0.138 milli Gray/milliamperes, which contribute to obtaining images of a fairly high quality, from which we claimed to find a link between TM articulation disorders and tinnitus symptoms.