Ear pressure, plugging and pain: It could be your TMJ (Temporal Mandibular Joint)

 


If you experience pressure, plugging, pain or a “blocked” sensation in your ear or ears, and feel the need to “pop” your ears over and over again, by repeatedly opening your mouth or moving and thrusting your jaw around, here’s some advice:  for the love of God, stop!  This only perpetuates a problem related to the temporal mandibular joint, abbreviated TMJ.  Irritation, inflammation in this area can lead to ear pain, a sense of ear pressure or plugging, ear ringing (tinnitus), and pain radiating to various areas of the head, down the neck and jaw (mandible). 

I’ve covered Ear Popping and TMJ and Ear Pain before, but find some folks have a difficult time grasping (or in some cases outright refusing to accept) the relationship of the TMJ to their ear symptoms.  This post helps to explain the mechanics on this rather nebulous problem.

TMJ anatomy 

Let’s first explore some anatomy.  To avoid punishing you like an overwhelmed medical student, I simplified maters a bit.  The drawings leave out the numerous ligaments and muscles attached to and around the area of interest.  We’ll focus on the major structures and concepts.  So here we go, and don’t fall asleep.

The TMJ actually refers not to one structure, but to several interacting together in close proximity.  Located just in front of your ear is in a curved fossa in your skull, called the glenoid fossa.  Beneath this fossa is a rounded shape of bone called the mandibular condyle, which is the site of articulation (movement) where the jaw (mandible) “hinges” to your skull.  As you can see, it is not a simple hinge but more of a ball and socket relationship.

Between the fossa and the condyle is a curved articular disc, sometimes called a meniscus, similar to the ones found in the knee joint.  This allows the condyle to smoothly rotate within the fossa as the mouth opens and closes when eating or talking.  The disk serves as a smooth pad to reduce friction between the condyle and the fossa.  Otherwise. bone would rub on bone which, as you could imagine, would be rather uncomfortable.  The disk also allows the condyle to move forward when one opens the mouth really wide, say to bite into a large double bacon cheese burger.

TMJ Inflammation

Inflammation can occur within the TMJ region, where the disk becomes inflamed and swollen.  Normally the disk allows the mandibular condyle to rotate smoothly in the fossa.  Also with wider mouth opening, the condyle actually moves forward out of the fossae to allow the jaw to drop further.  Repeated chewing or wide mouth opening can irritate and inflame the disk.  Thrusting the jaw forward repeatedly also does the same.  TMJ inflammation thus can occur with:

-Bite misalignment, where the teeth are not properly aligned, leading to uneven occlusion of the teeth, which in turn can skew the condylar relationship to their respective glenoid fossae, irritating the TMJs.

-Chewing on harder, rougher foods: puts more force onto the TMJ.

-Frequent or prolonged chewing gum:  places unnecessary, repeated or prolonged  force on the TMJs

-Clenching the jaw or grinding the teeth, also called bruxism.  Bruxism often occurs during sleep or folks find themselves doing this unintentionally during the day.   Needless to say, this most often occurs under conditions of stress and anxiety.

-Arthritis of the TMJ area, where irregular bone forms on the condyle or fossa, making these structures rougher.  This gives the sensation of crackling or the rubbing of sandpaper when the mouth opens and closes, called crepitus by us medical folks.

-And the last one: popping the ear by manipulating the jaw: open mouth wide to click or pop the jaw or forcing the condyles by thrusting the jaw forward, or trying to yawn repeatedly (which causes one to open the mouth widely).

When folks try to “pop” the ears by the above methods, they are not equalizing the pressure inside their ears.  Instead, the “pop” is disk shifting in the fossa, or the condyle moving forward out of the fossa.  Done repeatedly for the mistaken belief of “clearing” the ears or equalizing pressure leads to TMJ inflammation.  This can improve symptoms briefly since the condyle moves out of the fossa, alleviating pressure on the disk.

Rarely, a patient will lock the jaw open and is unable to close the mouth.  This happens due to the condyle slipping farther out of the fossa, where it is then locked in place.  While perfect for catching flies, it is otherwise undesirable.  The muscles to and around the jaw then spasm, making the condition worse.  Oftentimes this needs a trip to the ER where muscle relaxants are given and manipulation of the mandible to replace it back in proper position.  Another reason to avoid popping the ears in this fashion.

What about the “blocked” sensation? 

Patients often feel the ear is plugged or blocked, or they feel pressure needs to be released.  I’ve had some folks ask me to “just poke a hole” in the ear drum to alleviate the pressure.   Many times a microscope exam is needed to check for any unusual findings in the ear canal or the TM.

Problems with the eustachian tube can cause negative air pressure (relative to the pressure outside the ear drum) in the middle ear, which can lead to a retracted TM or fluid to accumulate in the middle ear behind the ear drum (see The Eustachian Tube Part 1).   To measure middle ear pressure tympanograms (that measure pressure behind the TM) to eval for hearing loss.

Sometimes hearing loss in the setting of normal middle ear pressure can also cause a blocked or pressure sensation.  The reduction of sound perception can give a sense of a hollow or plugged felling in the ear.  People with sudden onset hearing loss (ie, when exposed to unexpected loud noise) also experience this feeling when their hearing is reduced.  I’ve experienced this myself (e.g., as a kid, when exposed to deafening noise from a concert or thousands of firecrackers exploding during Chinese New Year celebrations—my ears felt plugged for days but cleared when my hearing returned).  An audiogram is done to determine the whether hearing loss exists and to what degree.

If no Eustachian tube problem or hearing loss is noted, and no other ear findings are noted on exam or under the microscope, then often the source is the TMJ.   Inflammation of the TMJ meniscus or disk can cause a sensation.  This is the lesser of the evils, so to speak, since it is better than ear pain.  Thus poking a hole in the ear drum and placing a tube will not help, since this is not a problem of actual air pressure.

Treatment

Treatment for TMJ problems centers on reducing inflammation and preventing its recurrence.  Below is a list of instructions:

1.  Soft diet for two weeks.  Avoid any chewy food (i.e., raw vegetables, rare meat).  Avoid wide mouth opening (ie, avoid that double bacon cheese burger temporarily). 

2.  No gum chewing

3.  Avoid tensing jaws or grinding on teeth.  Avoid “popping: the ear by manipulating (opening and closing) the jaw; this is actually causing TMJ popping and not clearing the eustachian tubes, and thus may be trading one problem for another.  This can lead to ear fullness, sometimes ear pain, sometimes distorted hearing. 

4.  Warm compress to the TMJ area just in front of the ear.

5.  Massage the TMJ area (area just in front of the ear).

6.  Anti-inflammatory medication such as ibuprofen (i.e., Motrin, Advil) or naproxen (i.e., Aleve) as needed for pain or discomfort (if these medications are not contraindicated for you).  Alternatively, you may take these daily for 1-2 weeks to alleviate any inflammation around the TMJ.

7.  See your DENTIST to check for any wear-facets on your teeth or for teeth misalignment.  If problems are noticed, then he or she may need to create a mouth appliance to cover your teeth to prevent teeth grinding, or dental procedures may be needed to help realign the teeth or jaw.  This also helps to alleviate problems with the TMJ and prevent future dental problems as well.

8.  Last but not least: stress reduction.  Stress often is associated with bruxism and TMJ problems.

I suffer from this problem from time to time.  I’ll occasionally grind my teeth when sleeping, usually if I’m turning something over in my head prior to bedtime or when there’s more stress (beyond the usual stress that comes with the job), such as being on call.  I’ve woken up at times with terrible ear pain, sometimes with a headache and jaw pain on the same side.  I’ve even woken myself up when I’ve forcefully clicked my teeth together.   My wife has never noticed or heard me grind my teeth (though she’s complained about my snoring and loud breathing), but I’ve cracked a tooth and a 2 crowns in the past, which bears this truth.  I used to clench my jaw during more difficult surgeries, but I consciously try to relax my mouth by keeping it open, which is another benefit of wearing a surgical mask!

©Randall S. Fong, M.D.

www.randallfong.com


For more topics on medicine, health and the weirdness of life in general, check out the rest of the blog site at  randallfong.blogspot.com


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