ENT Pain Causes and TMJ

Differentiating ENT pain and TMJ pain can be difficult for doctors and patients

ENT Pain Causes and TMJ

By Dr. Bradley Eli, DMD, MS

Differentiating ear, nose, and throat (ENT) and TMJ pain can be difficult for doctors and patients alike. Learn how to tell the difference, especially when it concerns your ears.

The task of differentiating between ENT pain and TMJ pain is often complicated. This is because of the intricate connection between the various structures of the head and neck. This article explores the connection between ENT pain and TMJ issues, shedding light on the potential causes, symptoms, and solutions. We will look closely at three common ear disorders, tinnitus, aural fullness, and otalgia, and see how these might relate to TMJ pain.

Table of Contents

Why does TMJ cause severe ear pain?

The primary reason why the TMJ causes severe ear pain is the shared nerve supply. There is one nerve in particular that is responsible, called the trigeminal nerve. This is one of the 12 paired “cranial nerves”, which are nerves in the face and neck that extend directly from the brainstem. The trigeminal nerve provides sensory innervation to both the TMJ and ear areas, so pain from the TMJ structures can result in a perceived severe pain in the ear.

Common causes of TMJ pain include jaw joint sprain/strain injuries (JAMSS), joint misalignment, inflammation or degeneration, and prolonged muscle tension from clenching habits (called “bruxism“).

Do I have ear pain or TMJ pain?

It’s often difficult to tell if your pain is coming from the region of the ear or from the TMJ, even for doctors. Collaboration between providers and across disciplines is often necessary to figure out where pain is coming from. “TMJ problems are mistaken for ENT issues quite frequently. This often delays appropriate treatment for months or even years”, according to Sachi Mehrotra, DMD, MS, a Southern California Orofacial Pain Specialist. Orofacial Pain Specialists are dental professionals with advanced training in diagnosing and treating disorders related to pain in the face, jaw, and oral region.

What are common symptoms of referred TMJ pain?

The primary referred TMJ pain symptom patterns to specific ENT regions:

  1. Temple Pain: TMJ problems in the joint itself, or from chronic masticatory muscle tension, can refer to pain in the temple region. This is most often experienced as headaches.
  2. Ear Pain: TMJ dysfunction may cause earaches, tinnitus (ringing in the ears), or a feeling of fullness in the ear.
  3. Facial Pain: Pain originating from the TMJ can radiate to the face, manifesting as facial discomfort, headaches, or even toothaches.
  4. Sinus Symptoms: TMJ problems can mimic sinusitis, causing a sensation of deep sinus pain.

These symptoms typically surface during chewing food or pain on opening or closing the jaws.

Shared Anatomy in the ENT RegionAnatomical proximity of th ear canal and a person's jaw

Dysfunction or inflammation in the TMJ complex are referred to as temporomandibular disorders (TMDs). The sensory output from this dysfunction or inflammation can often feel like it’s coming from the ENT region. This is because the anatomy in the jaw/ear region is overlapping and often shared.

  • Nerves: The TMJ and ENT structures share overlapping nerve networks. The trigeminal nerve, the main cranial nerve responsible for facial sensation and motor control of the jaw, has branches that also supply sensory information to the ear, nose, and throat.
  • Bones: The temporal bone forms the bottom of the ear canal, but it also forms the top of the TMJ joint space. In fact, a strong upward blow to the jaw can cause an ear canal fracture. Additionally, cheek bone pain is often referred TMJ pain.
  • Muscles: The jaw muscles, also known as the muscles of mastication, can contribute to facial tension pain or headaches. The temporalis muscle, the fan shaped muscle that raises the jaw up and down, passes just in front of the ear canal and extends all the way up to the forehead. Around 50% of the time, what people experience as tension headaches are related to clenching of the this muscle.

Referred ENT Pain vs. Co-Localized Pain

Because of shared anatomy, pain may be perceived to be originating in one region when it’s originating from another. This can occur due to referred pain and co-localized pain, which are two distinct processes.

What is referred ENT pain?

Referred pain is the perception of pain in a region that is distant from the actual source of the pain. It occurs when sensory nerve fibers from different regions converge on the same nerve pathways in the spinal cord. This shared routing on nerve fibers leads to a misinterpretation of the origin of the pain. A classic example is when the chest pain of a heart attack can be felt as discomfort in the left arm.

Secondary or referred otalgia is ear pain that occurs from pathology located outside the ear. A complex neural network innervates the ear as a result of complex embryologic development. The ear shares this neural network with other organs, which leads to numerous potential causes of referred ear pain.” – NIH: Otalgia ear pain [1]

An orofacial pain specialist is trained to identify and treat referral ENT pain in TMJ patients. It’s fascinating to learn how TMJ Disorders relate to orofacial pain.

A National Institute of Health (NIH) 2022 Sep 12 report found that 60% of people with TMJ problems have referred pain to other parts of the head and neck. We learn that “referred pain was recorded most commonly in the temporal area (45.2%) followed by the ear (42.1%) then the neck (19.0%)”.

Author Nawal Alketbi further explains in the Prevalence and characteristics of referred pain in patients diagnosed with temporomandibular disorders according to the Diagnostic Criteria for Temporomandibular Disordersstudy that referred pain in the ENT region is due to the shared nerve connections in the trigeminal nerve. This cranial nerve supplies sensation throughout the face and neck, as well as the covering of the brain.

How are referred ENT pain and co-localized pain different?

Co-localized pain refers to the experience of pain originating from the same location as the actual source. In this case, the pain is accurately localized to the area where the underlying condition or injury exists. For instance, if there is inflammation of the TMJ joint, the pain will be felt precisely around that joint, which by virtue of shared anatomy, would also involve the surrounding ear structures.

The main difference between referred ENT pain and co-localized ENT pain lies in the perception and localization of the pain. Referred pain can often be misleading, as it may be perceived in a different area from where the problem truly exists. In contrast, co-localized pain accurately indicates the source of the pain, allowing for a more targeted approach to diagnosis and treatment.

Understanding the origin of TMJ pain pathology has benefited from multiple complex studies by NIH and other researchers.

Our results showed a correlation between the clinical diagnosis of the pathological TMJ, biomarkers and the fMRI study. The fMRI study of TMD patients showed an abnormal hyper-connected salience network and a diminished blood flow to the anterior frontal lobes when they did not wear their customized dental orthotics.” – NIH: Translational research of temporomandibular joint pathology

Co-Occurrence of TMJ and ENT Disorders

Aside from referred pain and co-localized pain, there is often significant co-occurrence of TMJ and ENT disorders. When this happens, they are known as “comorbid” disorders. For instance, chronic sinusitis, otitis media, eustachian tube dysfunction, and even certain types of vertigo have a significant association with the presence of TMJ dysfunction.

Compounding efforts, TMJ issues can exacerbate the symptoms of these ENT disorders, making both problems worse. A classic example of this is that when headaches and TMJ symptoms occur together, the headaches are typically more frequent and more severe.

Common ENT conditions that are often comorbid with TMDs:

  • Tinnitus.
  • Aural fullness.
  • Otalgia.
  • Eustachian tube dysfunction.
  • Vertigo.
  • Hyperacusis.
  • Sinusitis.
  • Allergic rhinitis.
  • Headaches.
  • Chronic facial pain.
  • Sleep disorders.
  • Pharyngitis.
  • Dysphagia.

Ear Conditions and TMDs

Now, let’s explore some specific common ear disorders and their relationship to TMDs. We’ll specifically focus on tinnitus, aural fullness, and otalgia, as these complaints are frequently encountered at general practitioners’ offices. Given that they are ear-related concerns, it is natural that the initial treatment approach is to address the ear, with consideration of TMJ involvement a secondary or overlooked consideration.

Thankfully, this is changing as more doctors learn the degree of interconnection between ear complaints and TMDs.

Tinnitus

Tinnitus is the perception of sound in the absence of an external source, most classically described as “ringing in the ears”. This was believed to be exclusively due to the loss of hair cells in the cochlea. However, researchers are now establishing that there are connections in the brain stem that permit TMJ structures to influence the occurrence of tinnitus. This is sometimes referred to as “somatic tinnitus”.

From a clinical perspective, there is a well-established and statistically significant bidirectional link between tinnitus and TMJ issues. For instance, it’s estimated that 65% of patients with tinnitus have a comorbid TMD. Another study found that patients with TMDs are 8x more likely to suffer from tinnitus [2].

Individuals with TMDs often exhibit hypersensitivity to stimuli from various regions, which is evident in the high comorbidity between TMDs and other chronic pain disorders. Additionally, the amygdala, the fear center of the brain, is activated in TMDs, and this activation may contribute to the perception of tinnitus.

Preliminary studies are now exploring the notion that managing TMJ issues can lead to a reduction or alleviation of tinnitus symptoms. One study on patients with comorbid TMD and tinnitus examined what would happen to the tinnitus if the TMD was addressed with standard therapy. They found a statistically significant reduction in measures of tinnitus severity, estimating that 35% of the observed reduction in tinnitus severity could be attributed to the reduction in TMD pain from treatment [3].

Aural Fullness and TMDs

Aural fullness is the medical term for the sensation of ear fullness or pressure. People describe it as being like having the ears plugged or blocked. Aural fullness can occur in one or both ears and can present with other associated ear symptoms, such as muffled hearing, ear pain, tinnitus, or dizziness.

Aural fullness can have various underlying causes, one of which is TMDs. One study found that Ear fullness was the most commonly reported symptoms, affecting almost 50% of the TMD patients. [4]

Other causes of aural fullness include:

  • Eustachian tube dysfunction.
  • Middle ear infections.
  • Fluid accumulation in the middle ear.
  • Meniere’s disease.
  • Sinus congestion.
  • Excessive earwax buildup.

The Temporomandibular Joint Disorders as a Cause of Aural Fullness study reports the impact of treating an underlying TMD condition had on the sensation of aural fullness. An astounding 90% showed either disappearance or significant improvement in aural fullness [5]. This level of responsiveness to treatment physicians should consider screening for and treating TMDs in patients with the complaint of aural fullness.

Otalgia and TMDs

Otalgia is the medical term for ear pain. It can be felt as a sharp or dull ache, a stabbing sensation, or a constant throbbing in the ear. The pain may be localized to the ear itself or radiate to nearby areas, such as the jaw, neck, or head. Otalgia is broken down into primary causes (i.e. from the ear) and secondary causes. Interestingly, secondary causes account for around 50% of otalgia cases [6], and should always be suspected when otalgia is present with a normal ear exam.

Differences Between the Two Types of Otalgia
Primary Otalgia Secondary Otalgia
Middle and outer ear infections TMJ pain
Eustachian tube dysfunction neck pain
Wax impaction Dental pain
  Sinusitis
  Neuropathic pain
  Head and neck tumors

The good news is that if an underlying TMD is the cause of otalgia, there is an excellent chance that with treatment, the ear pain will go away.

The presence of TMDs is one of the most common causes of secondary otalgia. Likewise, for patients with TMDs, around 55% experience recurring otalgia [7]. The likely connection between the two is shared neurological pathways (and therefore referred pain) and shared regional anatomy (causing colocalized pain).

Consider this quote from ENT Health:

A common focus of pain is in the ear. Many patients see an ENT (ear, nose, and throat) specialist, or otolaryngologist, convinced that their pain is from an ear infection. When the earache is not associated with a hearing loss and the eardrum looks normal, the ENT specialist will consider the possibility that the pain comes from TMJ.” – Temporo-Mandibular Joint (TMJ) Pain

Which muscles may cause referred ear pain?

Muscles in the ear can spasm due to dysfunction of your jaw joint. The muscles most associated with ear pain include the masseter and the temporalis muscles, which are located above (temporalis) and below (masseter) of the ear canal.

The trigeminal nerve is the largest cranial nerve; it has both a sensory and a motor division. The motor division of the trigeminal nerve innervates the muscles involved in mastication and also the tensor muscle of the tympanic membranes of the ear.

According to the same NIH study mentioned above, the TMD-referred pain was diagnosed at the masseter muscle in 14.3% of cases studied. The report also found the temporalis muscle was affected 9.6% of the time, and the mandibular area (8.6%), whereas the joint area was involved in only 7.5%.

The Michigan Head and Neck Institute offers a helpful explanation of how the inner ear and jaw muscle inflammation are interconnected.

Ear pain that stems from TMJ is caused by inflammation in the jaw joint. Muscle swelling pushes and pulls on tendons and ligaments that help connect your jaw to your skull and keep the bones of your inner ear in place. – Ear Pain Caused By TMJ Is More Than Just An Ear Ache

“Pain from the TMJ and muscles of mastication is a common symptom. It can be a constant or periodic dull ache over the joint, the ear, and the temporal fossa. It is more commonly observed during mandibular movement or palpating the affected regions. The pain can be myogenic, caused by mechanical trauma and muscle fatigue. Articular pain arises from overloading, trauma, or degenerative changes of articular and periarticular tissues”, according to Kushagra Maini’s Temporomandibular Syndrome article. [8]

Conclusion: ENT Pain and TMJ Have a Strong Connection

ENT pain and TMJ issues share a strong connection due to the close anatomical relationship and shared nerve supply between the temporomandibular joint and structures of the ear, nose, and throat. This is especially true of the ear, where tinnitus, aural fullness, and otalgia have a high correlation to an underlying TMJ condition.

Understanding this relationship is essential for accurate diagnosis and effective management of patients experiencing ENT symptoms that may originate from TMJ dysfunction. By fostering interdisciplinary collaboration, TMJ healthcare professionals can provide comprehensive care, addressing both the underlying TMJ issues and associated ENT symptoms.

Learn More About TMD Disorders

Author bio

Author Dr. Brad EliDr. Brad Eli, DMD, MS is a graduate of UCLA’s post-doctoral Orofacial Pain program. His clinical practice of over 30 years specializes in orofacial pain and coordination of care with Ear Nose and Throat and Neurology specialists, TMJ dentists, Endodontist and Oral Surgeons. Dr. Eli’s service on educational staff at university hospitals, pain centers, and the clinical staff of Southern California hospitals contribute to his expertise in neuropathic pain, neurological pathways, and TMD.

 

References

[1] Jessica Coulter & Edward Kwon, Otalgia, https://www.ncbi.nlm.nih.gov/books/NBK549830/, August 2022

[2] Sarah Michiels, et al., “Conservative therapy for the treatment of patients with somatic tinnitus attributed to temporomandibular dysfunction: study protocol of a randomised controlled trial”, https://pubmed.ncbi.nlm.nih.gov/30314506/, 2018

[3] Annemarie van der Wal, et al., “Reduction of Somatic Tinnitus Severity is Mediated by Improvement of Temporomandibular Disorders”, https://pubmed.ncbi.nlm.nih.gov/35020685/, March 2022

[4] Christina Mejers & Nina Pauli, “Ear symptoms in patients with orofacial pain and dysfunction ‐ An explorative study on different TMD symptoms, occlusion and habits”, https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8638311/, December 2021

[5] Yongxin Peng, “Temporomandibular Joint Disorders as a Cause of Aural Fullness”, https://www.e-ceo.org/m/journal/view.php?number=530, Sep. 2017

[6] Jessica Coulter & Edward Kwon, “Otalgia”, http://www.ncbi.nlm.nih.gov/books/NBK549830/, July 2023

[7] Porto De Toledo et al., “Prevalence of otologic signs and symptoms in adult patients with temporomandibular disorders: a systematic review and meta-analysis”, Mar. 2017, https://link.springer.com/article/10.1007/s00784-016-1926-9.

[8] Kushagra Maini & Anterpreet Dua, “Temporomandibular Syndrome”, https://www.ncbi.nlm.nih.gov/books/NBK551612/, Jan 2023