What is the treatment for ear sensitivity to loud noises with pain on palpation of the mandible?

Treatment for Ear Sensitivity to Loud Noises with Mandibular Pain

Temporomandibular joint (TMJ) disorder is the most likely cause of ear sensitivity to loud noises with pain on palpation of the mandible, and should be treated with cognitive behavioral therapy, manual therapy, and supervised exercises as first-line interventions.

Diagnosis

The combination of ear sensitivity to loud noises with pain on palpation of the mandible strongly suggests temporomandibular disorder (TMD). This is a common condition affecting 6-9% of adults globally 1.

Key diagnostic indicators include:

• Pain on palpation of the mandible
• Ear sensitivity to loud noises (referred otalgia)
• Possible associated symptoms:
  • Clicking/popping sounds in the TMJ
  • Limited jaw movement
  • Headaches
  • Periauricular pain

Treatment Algorithm

First-Line Treatments (Strong Recommendations)

1. Cognitive Behavioral Therapy (CBT)

   • With or without biofeedback or relaxation therapy
   • Addresses psychological factors that may contribute to TMD 1

2. Manual Therapy

   • Therapist-assisted mobilization
   • Manual trigger point therapy for masticatory muscles 1

3. Exercise Therapy

   • Supervised jaw exercises and stretching
   • Supervised postural exercises 1

4. Patient Education

   • Self-care routines including relaxing the lower jaw
   • Massaging masticatory muscles
   • Application of hot or cold packs to painful sites 2

Second-Line Treatments (Conditional Recommendations)

1. Manipulation

   • With or without postural exercise 1

2. Acupuncture

   • May provide pain relief 1

3. Pharmacotherapy

   • Acetaminophen or NSAIDs for pain management 2
   • Consider CBT with NSAIDs 1

Treatments to Avoid (Conditional or Strong Recommendations Against)

1. Occlusal Splints

   • Reversible occlusal splints are conditionally recommended against
   • Irreversible oral splints have a strong recommendation against 1

2. Invasive Procedures

   • Arthrocentesis
   • Discectomy (strong recommendation against)
   • Trigger point injections
   • Botulinum toxin injections 1, 3

3. Medications to Avoid

   • Benzodiazepines
   • NSAIDs with opioids (strong recommendation against)
   • Gabapentin
   • β-blockers 1

Important Considerations

Differential Diagnosis

It's crucial to rule out other causes of ear pain that may mimic TMD:

• Acute otitis externa
• Furunculosis of the ear canal
• Viral infections of the external ear
• Cholesteatoma
• Primary dental pathology 1

Red Flags Requiring Immediate Referral

• Progressive, unremitting pain
• Neurological symptoms
• History of trauma
• Signs of infection
• Older patients with risk factors for cancer 1

Common Pitfalls

1. Overtreatment

   • Avoid unnecessary invasive procedures or irreversible treatments
   • TMD often responds well to conservative management 1

2. Misdiagnosis

   • TMD symptoms can overlap with primary otolaryngologic disorders
   • Consider multidisciplinary evaluation when symptoms persist 4

3. Focusing Only on Occlusion

   • Specific occlusal relationships have poor sensitivity and specificity for TMD 5
   • Avoid irreversible occlusal modifications

Follow-up and Monitoring

• Reassess symptoms after 4-6 weeks of conservative treatment
• If symptoms persist or worsen, consider referral to a specialist in orofacial pain
• Monitor for changes in symptoms that might suggest alternative diagnoses

TMD is a multifactorial condition that often responds well to conservative management. The evidence strongly supports non-invasive approaches focusing on physical therapy, behavioral interventions, and patient education as first-line treatments.