Ear pain. Sometimes it’s mild, sometimes it’s excruciating. For a relatively small organ of the body, the ear can be a source of tremendous displeasure, not from the things it hears but from the whopping degree of pain it can cause. Oftentimes a diagnosis is readily made—such as otitis media (an infection involving the ear drum and the middle ear space behind it) or otitis externa (a.k.a. “swimmer’s ear” where the ear canal is inflamed and swollen)—and treatment is straightforward and successful.
But sometimes the diagnosis is more elusive and treatment is then empiric, based upon an educated assumption of its cause. Before you call the person treating you a “quack”, keep in mind this is an accepted practice for many situations, as far too frequently medicine is not clear-cut.
Let’s say you’ve been to a doctor or a number of different doctors or providers, have visited the urgent care several times, and they’ve treated you with an assortment of nifty stuff such as antibiotics, ear drops, decongestants, antihistamines, or did procedures like flushing your ear or took a hammer and chisel to your head or made the sign of the cross over your pained ear, you’re no doubt fed up since nothing is working. So what gives? “Why does my frickin’ ear still hurt?” you ask yourself and everyone within ear-shot.
Tired of your repeated complaints, your family, friends, coworkers, complete strangers, even your pet dog demand you see an ENT doc. You make an appointment reluctantly, since you’ve heard rumors these docs are an odd breed, who wear strange mirrors on their heads and nonsensically babble at times, not much unlike this current post.
After examining your ear and finding there is nothing wrong with the ear itself, your ENT may do one of two things: 1. Throw her/his hands up in air and walk out the room but only after he/she gives you the billing sheet to take to the front desk, or 2. discover you have a problem with your Temporal Mandibular Joint (TMJ for short).
The TMJ is comprised of a ball-and-socket joint located right in front of the ear canal (external auditory canal), that small dark hole leading deeper towards the eardrum (tympanic membrane) and all those little organs necessary for hearing and balance. This ball-and-socket joint allows for the rotation of the mandible (lower jaw) in order to open and close the mouth. The “ball” part is the condyle of the mandible, the “socket” is the mandibular fossa, and in between the two is an articular disc. This disc serves as a cushion and allows the condyle to smoothly rotate in the fossa when opening the mouth (note, the mandible lowers during mouth opening, and the upper jaw (the maxilla) actually remains stationary). As the mandible drops lower to open the mouth really wide--for instance, when you’re about to chomp into a thick, triple-bacon-cheeseburger with lettuce, tomatoes and onions with perhaps a fried egg wedged between the patties (forgive me—I’m salivating on the keyboard)—the condyle slips a bit forward out of the fossa to partially disarticulate. This often causes the crack or pop you may notice when you’re opening your mouth.
However, some people tend to manipulate the condyle by jutting the mandible forward and/or opening their mouth. They feel “popping” the ear in this manner is ventilating the air space behind the eardrum (the middle ear). They feel this is opening the eustachian tube (the tube that leads from the middle ear to the back of the nose). This IS NOT THE CASE, however. Some people clench their jaws and teeth or grind their teeth. This can occur consciously or unconsciously, particularly during sleep, and often associated with stress or anxiety. This forces the condyle up further into the fossa and compresses the articular disc. Some people chew gum regularly, doing the same thing. All of these maneuvers must be avoided since the end-result is inflammation of the TMJ and tissues around it. This leads to variety of problems including:
1. Ear pain, which is a common symptom of a TMJ problem. As you can see from the attached drawing, the TMJ sits right in front of the ear canal and eardrum. Thus, people often feel pain deep inside the ear canal itself and start digging at it with a variety of things like Q-tips, bobby pins and bamboo skewers. This practice must be avoided, for as you can imagine, serious damage is possible, such as skewering your brain through-and-through with a long sharp instrument, which I’ve heard is a very freaky experience.
2. Pain down the jaw and sometimes down the neck from the muscles that attach to the jaw and around the ear (i.e., the masseter muscle, the sternocleidomastoid muscle)
3. Pain upwards towards the temple and face, causing headaches and facial pain. There’s a large muscle called the temporalis that fans out from the mandible and inserts onto the side of the skull as a broad, tough sheet of tissue called fascia. The temporalis muscle and fascia tighten, spasms and becomes painful. In turn this can aggravate adjacent muscles in the forehead, the back of the head and other muscles around the face, triggering more diffuse headaches and facial pain.
4. Wearing down of the teeth, sometimes cracking a tooth or several teeth in the process.
5. Trismus or difficulty opening the mouth due to inflammation in the TMJ area. If severe spasming of muscles occur, the jaw can sometimes lock shut.
6. Locking the mandible open. This unusual phenomenon occurs when the mouth is opened too widely, and some people tend to do this repeatedly out of habit. This causes immediate inflammation of the TMJ and also spasms of the muscles of the mandible, making closing the mouth difficult. Often a trip to the ER is needed, where muscle relaxants, pain meds and manipulation of the jaw into proper alignment (usually by an oral surgeon) is required.
Treatment is often conservative but requires a diligence upon the part of the patient to follow it thoroughly. The recommendations listed below were gleaned from discussions from various oral surgeons with whom I’ve worked in the past:
1. Soft diet for two weeks. Avoid any chewy food (ie, raw vegetables, crunchy food, rare meat). The goal is gentle chewing and avoid biting hard into a piece of food.
2. No gum chewing. That means absolutely NO gum--zilch, zero.
3. Avoid tensing the jaws or grinding the teeth. Avoid “popping” the ear by manipulating the jaw; don’t “pop” the ears by opening and closing your mouth or jutting your jaw forward. This does not equalize ear pressure. The pop is actually that part of the jaw moving inside the TMJ area. People often argue with me about this and how it “clears” the ear. But again, they’re doing it over and over again, multiple times a day and with no long-term benefit. It then becomes habitual. So please stop this--you’re only making things worse.
4. Warm compress or a heating pack to the TMJ area just in front of the ear. Also you can apply this to the upper neck and side of the head to relax muscles in those areas.
5. Massage the TMJ area (area just in front of the ear) with your fingers. Better yet, get someone to do this for you like a sympathetic spouse or significant other. Nothing is more relaxing as a facial massage. Dim the lights, play soft, romantic music, light an aromatic candle or two and make this enjoyable for your partner as well. You never know—you might get lucky afterwards.
6. Anti-inflammatory medication such as ibuprofen (ie, Motrin, Advil) or naproxen (ie, Aleve) as needed for pain or discomfort. These are anti-inflammatory as well as pain medications which will alleviate any inflammation around the TMJ. Make sure you have no contraindications or are taking other medications that might interact before taking these medications.
7. Make an appointment with you DENTIST to check for any wear-facets on your teeth. If problems are noticed, then your dentist may need to create a mouth appliance to cover your teeth to prevent teeth grinding. This also helps to alleviate problems with the TMJ and prevent future dental problems as well.
8. Lastly, try to reduce stress. I know this is easier said than done, but honestly, it seems that in this day and age there seems to be a higher incidence of stress and the anxiety that typically accompanies it. I’ve seen more and more patients on anti-anxiety and antidepressant meds and at younger ages. Stress also causes or aggravates a variety of other medical problems. I believe we worry about things we oughtn’t worry too much about, and if we can only take one day at a time and be mindful of the present moment, then much of this will wash away. An entirely different topic altogether, but my two cents. And yet your ear pain might go away.
So, there you have it, the down-and-dirty little mystery behind the TMJ and elusive ear pain, and a host of other troubles it causes.
©Randall S. Fong, M.D.