What is the recommended treatment for tinnitus triggered by palpation of the temporomandibular joint (TMJ) muscles?

Management of Tinnitus Triggered by TMJ Muscle Palpation

For tinnitus triggered by palpation of temporomandibular joint (TMJ) muscles, conservative management including jaw rest, soft diet, application of heat/cold therapy, and manual trigger point therapy targeting masticatory muscles is the recommended first-line approach. 1

Diagnostic Considerations

• Tinnitus associated with TMJ disorders represents a specific subtype that may respond to targeted treatments:

  • More common in younger women 2
  • Often features somatosensory modulation (ability to change tinnitus with jaw or neck movements) 2, 3
  • May be accompanied by other symptoms like headache, vertigo/dizziness, and neck pain 3

• Imaging considerations:

  • MRI is indicated when there are concerning features such as unilateral tinnitus, pulsatile tinnitus, focal neurological abnormalities, or asymmetric hearing loss 4
  • Dedicated MRI of the temporomandibular joint may be considered if TMJ pathology is suspected 4
  • Contrast-enhanced MRI is currently the best method to detect active TMJ inflammation 4

Treatment Algorithm

First-Line Interventions:

1. Conservative TMJ Management:

   • Jaw rest and behavioral modifications (avoid wide mouth opening)
   • Soft or liquid diet to minimize jaw movement
   • Application of moist heat (10-15 minutes several times daily) alternating with cold therapy (ice wrapped in towel for 10-minute periods) 1

2. Manual Therapy:

   • Manual trigger point therapy targeting masticatory muscles 1
   • Physical therapy approaches for the TMJ and surrounding muscles

3. Pharmacological Management (short-term):

   • NSAIDs at anti-inflammatory doses: ibuprofen (600-800mg every 6-8 hours) or naproxen (500mg twice daily) 1
   • Acetaminophen may be used for breakthrough pain, though evidence suggests limited efficacy when used alone 1

Second-Line Interventions:

1. Occlusal Splints/Stabilization Splints:

   • May help reduce muscle tension and protect teeth from grinding
   • Note: Irreversible oral splint interventions are strongly recommended against for acute TMJ pain management 1

2. Short-term Pharmacological Options:

   • A short course of benzodiazepines may be considered for acute management despite conditional recommendation against long-term use 1
   • Avoid long-term benzodiazepine use
   • NSAIDs combined with opioids and gabapentin are conditionally recommended against for TMJ pain management 1

For Persistent Cases:

• Consider multidisciplinary referral including oral and maxillofacial surgeons, oral medicine specialists, physiotherapists, and audiologists 1
• For severe cases unresponsive to conservative therapy, consider:
  • Arthrocentesis (77% success rate for chronic closed lock) 1
  • Arthroscopic lysis and lavage (shown to increase mouth opening) 1

Important Clinical Considerations

• The prevalence of TMJ complaints is greater in subjects with severe tinnitus (36%) compared to those with any tinnitus (19%), indicating TMJ problems contribute to tinnitus severity 3

• Patients with TMJ-related tinnitus often have:

  • Better hearing function
  • Lower subjectively perceived tinnitus loudness
  • Ability to modulate tinnitus by jaw or neck movements 2

• Stress appears to be a significant factor in the co-occurrence of TMJ problems and tinnitus, suggesting stress management should be incorporated into treatment 3

• In some patients, injection of lidocaine in jaw muscles has been shown to temporarily reduce tinnitus while the local anesthetic is active, supporting the somatosensory connection 5

Monitoring and Follow-up

• Regular reassessment of orofacial symptoms is recommended
• Longitudinal evaluation is important regardless of current TMJ disease activity 4
• Monitor for improvement in both TMJ symptoms and tinnitus characteristics

By addressing the underlying TMJ dysfunction through this systematic approach, many patients experience improvement in their associated tinnitus symptoms.