Can Temporomandibular Joint (TMJ) disorders cause tinnitus?

Can TMJ Disorders Cause Tinnitus?

Yes, temporomandibular joint (TMJ) disorders can cause tinnitus, with patients experiencing TMJ dysfunction having a significantly increased prevalence of tinnitus (3.7-70%, median 42.3%) compared to those without TMJ disorders (1.7-26%, median 12%), making tinnitus a recognized comorbidity of TMD. 1, 2

Evidence Supporting the TMJ-Tinnitus Connection

Epidemiological Association

• Patients with TMJ derangement have increased incidence of tinnitus, though the underlying mechanism remains unclear 1
• The prevalence of tinnitus in TMD patients is substantially higher than in control populations without TMD across multiple studies involving 13,358 patients and 33,876 controls 2
• In patients with unilateral tinnitus and arthographically confirmed disc displacement, 100% had ipsilateral TMJ involvement, with 94.3% having an asymptomatic contralateral joint 3

Clinical Characteristics Distinguishing TMJ-Related Tinnitus

Patients with TMJ-related tinnitus present with a distinct clinical profile compared to other tinnitus patients 4:

• Younger age at presentation and tinnitus onset (P = .001 and P = .002 respectively) 4
• Better hearing function (P < .0005), indicating tinnitus occurs independent of typical age-related hearing loss 4
• Female predominance (P = .003) 4
• Lower subjectively perceived tinnitus loudness (P = .01) 4
• Ability to modulate tinnitus with jaw or neck movements (P = .001), characteristic of somatosensory tinnitus 4, 5

Clinical Presentation of TMJ Disorders with Tinnitus

The American Academy of Otolaryngology-Head and Neck Surgery identifies TMJ syndrome as a common cause of referred otalgia with the following features 1, 6:

• Sharp pain in the TMJ area worsening with chewing and swallowing 6
• Pain upon opening the mouth 6
• Tenderness on palpation to the back of jaw and ear 6
• Pain radiating down behind the ear (referred otalgia) 1, 6
• History of gum chewing, bruxism, or recent dental procedures with malocclusion 1
• Tenderness over the affected TMJ with possible crepitus 1

Diagnostic Approach

Key Clinical Findings

• Normal otoscopic examination (normal ear canal and tympanic membrane) rules out primary otologic pathology and strongly suggests referred pain from TMD 6
• Bilateral examination is essential as TMD may be unilateral or bilateral 6
• Somatosensory tinnitus (sound modulations with neck or mandible movements) is frequently associated with TMJ dysfunction, though not pathognomonic 5

Important Differential Considerations

A complete head and neck examination is mandatory in older patients with tobacco/alcohol use history or human papillomavirus risk factors to rule out upper aerodigestive tract cancer presenting as referred otalgia 6

Imaging Considerations

• MRI of the TMJ shows disc displacement as the most common finding in TMD patients with tinnitus (80% vs 65% without tinnitus, P = 0.043), particularly disc displacement with reduction 7
• However, imaging should be guided by the ACR Appropriateness Criteria for tinnitus, which notes that patients with temporomandibular joint derangement have increased incidence of tinnitus, but the underlying mechanism is unclear 1

Treatment Approach

First-Line Conservative Management

The American Academy of Otolaryngology-Head and Neck Surgery and American College of Physicians recommend the following evidence-based interventions 6:

• Cognitive behavioral therapy (CBT) with biofeedback/relaxation therapy (provides pain relief approximately 1.5-2 times the minimally important difference compared to placebo) 6
• Therapist-assisted jaw mobilization (substantial pain reduction with moderate certainty evidence) 6
• Manual trigger point therapy (significant pain relief with moderate certainty evidence) 6
• Supervised postural exercise (important pain relief with moderate certainty evidence) 6
• Supervised jaw exercise and stretching (important pain relief with moderate certainty evidence) 6
• Usual care including home exercises, stretching, reassurance, and education 6

Effect on Tinnitus Symptoms

• Eight treatment studies involving 536 patients indicated that treatment of TMD symptoms may have a beneficial effect on severity of tinnitus, though only one included a control group, resulting in low overall evidence quality 2
• TMJ functional therapy should be part of multidisciplinary rehabilitation in patients with somatosensory tinnitus and TMJ dysfunction 5

Interventions to Avoid

The following treatments are not recommended for TMJ-related symptoms 6:

• Occlusal splints alone 6
• Gabapentin 6
• Benzodiazepines 6
• NSAIDs with opioids (risk of GI bleeding, addiction, and overdose) 6

Second-Line Options

If first-line treatments fail after 4-6 weeks, consider 6:

• CBT combined with NSAIDs 6
• Acupuncture 6
• Manipulation with postural exercise 6

Clinical Significance and Mechanism

Causal Relationship

Classical risk factors for tinnitus (age, male gender, hearing loss) are less relevant in tinnitus patients with TMJ disorder, suggesting a causal role of TMJ pathology in the generation and maintenance of tinnitus 4

Prognostic Factors

• Depression and catastrophizing reduce treatment success 6
• Lack of patient self-efficacy reduces success 6
• Improved self-efficacy through education leads to fewer symptoms 6
• Up to 30% of acute TMD cases may progress to chronic pain, highlighting the importance of early intervention 6

Common Pitfalls

• Do not dismiss tinnitus as unrelated to TMJ simply because hearing loss is absent—TMJ-related tinnitus characteristically occurs with better hearing function 4
• Do not overlook the ability to modulate tinnitus with jaw movements—this is a key distinguishing feature (P = .001) 4
• Do not assume bilateral tinnitus excludes a unilateral TMJ problem—patients with unilateral TMJ internal derangement can present with bilateral symptoms 3
• Reassess patients after 4-6 weeks of conservative management, with specialist referral if symptoms persist 6