Symptom relief after treatment of temporomandibular and cervical spine disorders in patients with Meniere's disease: a three-year follow-up

Effectiveness of conservative approaches on otologic signs and symptoms in patients with temporomandibular disorders and Meniere's disease: A systematic review

OBJECTIVE

This systematic review aimed to evaluate the effectiveness of conservative approaches on otologic signs and symptoms in patients affected by Menière's Disease (MD) and temporomandibular disorders (TMD).

METHODS

PubMed, Scopus, and Web of Science were systematically searched to identify studies presenting participants with a diagnosis of MD associated with TMD, conservative approaches as interventions, and modification of the otological signs and symptoms as outcome.

RESULTS

Out of 627 articles assessed for eligibility, two studies were included. Both studies showed a significant reduction of Situational Vertigo Questionnaire after treatment, number of vertigo spells, Functional Level Scale, Dizziness Hearing Inventory, and Tinnitus Handicap Inventory, after occlusal splint therapy. No significant differences were found in terms of pure-tone audiometry average.

CONCLUSION

Findings of this systematic review suggested that conservative approaches might improve vertigo in patients affected by MD and TMD. However, the low number of included studies makes difficult to draw strong conclusions.

Oral splint therapy in patients with Menière's disease and temporomandibular disorder: a long-term, controlled study

PURPOSE

To assess the effect of oral splint therapy on audio-vestibular symptoms in patients with Menière's disease (MD) and temporomandibular disorder (TMD).

METHODS

Retrospective case-control study. Treatment group: 37 patients with MD and TMD who received gnatological treatment.

CONTROL GROUP

26 patients with MD and TMD who had never received gnatological treatment. The number of vertigo spells in 6 months (primary endpoint), pure-tone audiometry average (PTA), MD stage, functional level, Dizziness handicap Index (DHI), Tinnitus handicap Index (THI) and Aural Fullness Scale (AFS) were compared at baseline and after 24 months according to groups. Analysis of Covariance was used to determine the treatment effect.

RESULTS

Groups were comparable for demographic, clinical data, baseline PTAs and the number of vertigo spells. Analysis of covariance showed a significant effect of gnathological treatment on number of vertigo spells ([Formula: see text] = 0.258, p < 0.001), PTA ([Formula: see text] = 0.201, p < 0.001), MD stage ([Formula: see text] = 0.224, p < 0.001), functional level ([Formula: see text] = 0.424, p < 0.001), DHI ([Formula: see text] = 0.421, p < 0.001), THI ([Formula: see text] = 0.183, p < 0.001), but not for AFS ([Formula: see text] = 0.005, p = 0.582). The treatment group showed vertigo control of class A in 86.5% and class B in 13.5% of patients. In the control group, vertigo control was of class A in 19.2% of patients and class B in 11.5%, class C in 30.8%, class D in 11.5%, class E in 19.2% and class F in 7.7%. Classes of vertigo control differed significantly (X² test, p < 0.001).

CONCLUSIONS

Oral splint therapy could represent a viable treatment in patients with TMD and uncontrolled MD disease. The effects are maintained at least after 2 years.

Prevalence and distribution of musculoskeletal pain in patients with dizziness-A systematic review

BACKGROUND AND PURPOSE

Musculoskeletal disorders are among the leading causes of disability globally, but their role in patients with dizziness and imbalance is not well understood or explored. Such knowledge may be important as musculoskeletal pain and dizziness can mutually influence each other, leading to a complex condition requiring more comprehensive approaches to promote successful recovery. We conducted a systematic review to examine the extent and characteristic of reported musculoskeletal pain in patients with dizziness.

METHODS

A comprehensive literature search in Medline, Embase, Cochrane, Scopus, Amed, Google Scholar, SveMed+, and Web of Science was conducted in March 2021. Inclusion criteria were studies examining patients with a vestibular diagnosis, patients with cervicogenic dizziness and patients included based on having dizziness as a symptom; and reported musculoskeletal pain. Data regarding age, sex, sample size, diagnosis and musculoskeletal pain was extracted. The Crowe Critical Appraisal Tool was used for assessing methodical quality of the included studies.

RESULTS

Out of 1507 screened studies, 16 studies met the inclusion criteria. The total sample consisted of 1144 individuals with dizziness. The frequency of patients reporting pain ranged between 43% and 100% in the included studies. Pain intensity were scored between 5 and 7 on a 0-10 scale. Pain in the neck and shoulder girdle was most often reported, but musculoskeletal pain in other parts of the body was also evident.

DISCUSSION

In the included studies, musculoskeletal pain was highly prevalent in patients with dizziness, with pain intensity that may have a moderate to severe interference with daily functioning. Pain in the neck and shoulder is well documented, but there are few studies addressing musculoskeletal pain in additional parts of the body. More research is needed to understand the relations between dizziness and musculoskeletal pain.

Occlusal splint therapy in patients with Ménière's disease and temporomandibular joint disorder

Objective

This retrospective study aimed to verify the outcomes of stabilising occlusal splint therapy prescribed to 22 patients with unilateral definite Ménière’s disease and comorbid temporomandibular joint disorder.

Methods

The results of a battery of audiometric and vestibular tests were recorded before and after 6 months of treatment, as well as the scores of disease-specific questionnaires.

Results

The average hearing threshold in the affected ear and the acoustic immittance were unchanged. No spontaneous and positional nystagmus were recorded. Caloric hypo-responsiveness and vestibular myogenic evoked responses did not vary. No changes of stabilometric body sway parameters in eyes opened condition and with optokinetic stimulation delivered to the unaffected labyrinth were observed. A significant reduction was recorded in eyes closed condition and with the optokinetic stimulation toward the affected ear. The Tinnitus Handicap Inventory, the Situational Vertigo Questionnaire and the Numeric Pain Rating Scale scores improved. The number of vertigo attacks was reduced.

Conclusions

Occlusal splint therapy is a favourable option to reduce aural symptoms of Ménière’s disease and comorbid temporomandibular joint disorder, even if its pathophysiological mechanism remains elusive.

Ear symptoms in patients with orofacial pain and dysfunction - An explorative study on different TMD symptoms, occlusion and habits

Objectives

Ear symptoms coincident with TMD symptoms have been noticed for a long time. The aim was to investigate the relationship between reported ear symptoms in TMD patients and different TMD symptoms, dental occlusion, oral parafunction and habits.

Material and methods

Consecutive patients, ≥18 years of age and referred to a specialist clinic for orofacial pain and dysfunction during a three‐month period, were considered for the study. Patients with poor general or psychiatric health were excluded. One hundred thirty‐two patients were included and studied with regard to reported ear symptoms in relation to clinical dysfunction, occlusion, habits and subjective rating of their symptoms. A clinical examination was performed according to RDC/TMD and extended with occlusal factors, parafunctions and habits.

Results

Ear symptoms were reported by 72% of the TMD patients, with ear fullness in 49% as the most frequent symptom. The patients with ear symptoms were significantly older and proportionally more often females. Ear symptoms were significantly correlated to the subjective index, to myalgia (p = 0.003), decreased opening capacity (p = 0.01), TMJ pain (p = 0.02), parafunctions (p = 0.007), and some occlusal factor (p = 0.018–0.003). Muscle pain on palpation was significantly associated with ear fullness, and changed hearing and sensitivity to sound, on the same side (p < 0.005).

Conclusions

Ear symptoms are frequently reported by TMD patients. Concomitant ear symptoms are associated with oral parafunction and muscle pain on palpation on the same side as the ear symptoms.

Revisiting "Meniere's Disease" as "Cervicogenic Endolymphatic Hydrops" and Other Vestibular and Cervicogenic Vertigo as "Spectrum of Same Disease": A Novel Concept

Vertigo and dizziness are one of the commonest and least understood symptom. Vestibular vertigo of Meniere's disease and Benign Paroxysmal positional vertigo (BPPV) and cervicogenic dizziness are classified as separate entities. Cervicogenic dizziness is not considered the domain of Otolaryngologists, as it is mainly related to neck proprioceptors. Headache and neck pain, have been found to be associated with both Meniere's disease and BPPV, so is cervicogenic dizziness. The present study was undertaken to study the association between cervical signs and symptoms in patients with Vestibular Vertigo of Meniere's disease, Benign Paroxysmal Positional Vertigo and cervicogenic dizziness. 132 patients complaining of vertigo and diagnosed with Meniere's disease, BPPV or cervicogenic dizziness were examined for symptoms and signs related to neck, shoulder and muscle tightness and asymmetry. Most of the patients of Meniere's Disease (80% for unilateral and 88.23% for bilateral), Benign Paroxysmal Positional Vertigo (75%for right sided BPPV, 66.67% for left sided BPPV) and cervicogenic dizziness (90%) had associated symptoms of neck pain or headache, and were found to be positive for neck tightness and/or asymmetry of shoulder. Headache was more common in patients with Meniere's Disease. Vestibular Dizziness of Meniere's Disease, Benign Paroxysmal Positional Vertigo and Cervicogenic Dizziness may be spectrum of the same disease with underlying myofascial problems. Meniere's Disease of Idiopathic or primary type needs to be revisited as Cervicogenic Hydrops.

An Integrative Model Accounting for the Symptom Cluster Triggered After an Acoustic Shock

Acoustic shocks and traumas sometimes result in a cluster of debilitating symptoms, including tinnitus, hyperacusis, ear fullness and tension, dizziness, and pain in and outside the ear. The mechanisms underlying this large variety of symptoms remain elusive. In this article, we elaborate on the hypothesis that the tensor tympani muscle (TTM), the trigeminal nerve (TGN), and the trigeminal cervical complex (TCC) play a central role in generating these symptoms. We argue that TTM overuse (due to the acoustic shock), TTM overload (due to muscle tension), and ultimately, TTM injury (due to hypoxia and "energy crisis") lead to inflammation, thereby activating the TGN, TCC, and cortex. The TCC is a crossroad structure integrating sensory inputs coming from the head-neck complex (including the middle ear) and projecting back to it. The multimodal integration of the TCC may then account for referred pain outside the ear when the middle ear is inflamed and activates the TGN. We believe that our model proposes a synthetic and explanatory framework to explain the phenomena occurring postacoustic shock and potentially also after other nonauditory causes. Indeed, due to the bidirectional properties of the TCC, musculoskeletal disorders in the region of the head-neck complex, including neck injury due to whiplash or temporomandibular disorders, may impact the middle ear, thereby leading to otic symptoms. This previously unavailable model type is experimentally testable and must be taken as a starting point for identifying the mechanisms responsible for this particular subtype of tinnitus and its associated symptoms.

The occlusal imaging and analysis system by T-scan III in tinnitus patients

Background

Several studies have demonstrated that the prevalence of temporomandibular disorders (TMDs) in tinnitus patients ranges from 7% to 95%, and it is reported in literature that idiopathic tinnitus patients should be referred to a dentist to define whether or not the tinnitus is associated with TMD. However, the possible pathophysiological relation between TMDs and tinnitus is not generally investigated in clinical practice.

Methods

The patterns and forces of occlusal contacts have been studied by means of T-scan III in 47 tinnitus patients (23 suffering from idiopathic tinnitus and 24 affected by Ménière disease [MD]) and 13 healthy subjects.

Results

The center of force target was offset in the opposite direction in 15/23 idiopathic tinnitus and in 7/24 MD patients (p = 0.026). No significant variation was found in the occlusal force.

Conclusions

Our data suggest that a diagnostic screening method for occlusal stability in the intercuspidal position might be clinically useful in idiopathic tinnitus patients.

Comparison of mulligan sustained natural apophyseal glides and maitland mobilizations for treatment of cervicogenic dizziness: a randomized controlled trial

BACKGROUND

There is short-term evidence for treatment of cervicogenic dizziness with Mulligan sustained natural apophyseal glides (SNAGs) but no evidence for treatment with Maitland mobilizations.

OBJECTIVE

The purpose of this study was to compare the effectiveness of SNAGs and Maitland mobilizations for cervicogenic dizziness.

DESIGN

A double-blind, parallel-arm randomized controlled trial was conducted.

SETTING

The study was conducted at a university in Newcastle, Australia.

PARTICIPANTS

Eighty-six people with cervicogenic dizziness were the study participants.

INTERVENTIONS

Included participants were randomly allocated to receive 1 of 3 interventions: Mulligan SNAGs (including self-administered SNAGs), Maitland mobilizations plus range-of-motion exercises, or placebo.

MEASUREMENTS

The primary outcome measure was intensity of dizziness. Other outcome measures were: frequency of dizziness, the Dizziness Handicap Inventory (DHI), intensity of pain, and global perceived effect (GPE).

RESULTS

Both manual therapy groups had reduced dizziness intensity and frequency posttreatment and at 12 weeks compared with baseline. There was no change in the placebo group. Both manual therapy groups had less dizziness intensity posttreatment (SNAGs: mean difference=-20.7, 95% confidence interval [95% CI]=-33.6, -7.7; mobilizations: mean difference=-15.2, 95% CI=-27.9, -2.4) and at 12 weeks (SNAGs: mean difference=-18.4, 95% CI=-31.3, -5.4; mobilizations: mean difference=-14.4, 95% CI=-27.4, -1.5) compared with the placebo group. Compared with the placebo group, both the SNAG and Maitland mobilization groups had less frequency of dizziness at 12 weeks. There were no differences between the 2 manual therapy interventions for these dizziness measures. For DHI and pain, all 3 groups improved posttreatment and at 12 weeks. Both manual therapy groups reported a higher GPE compared with the placebo group. There were no treatment-related adverse effects lasting longer than 24 hours.

LIMITATIONS

The therapist performing the interventions was not blind to group allocation.

CONCLUSIONS

Both SNAGs and Maitland mobilizations provide comparable immediate and sustained (12 weeks) reductions in intensity and frequency of chronic cervicogenic dizziness.

Signs and symptoms of temporomandibular disorders and the incidence of tinnitus

In a cross-sectional analysis of data from the Study of Health in Pomerania (SHIP 0), temporomandibular disorders (TMD) were the strongest predictors for tinnitus beside headache. The aim of this study was to investigate whether signs and symptoms of TMD can be identified as risk factors for developing tinnitus. The SHIP 1 is a population-based 5-year longitudinal study intended to systematically describe the prevalence of and risk factors for diseases common in the population of Pomerania in northern Germany. A total of 3300 subjects (76% response) were reevaluated after 5 years for tinnitus and signs and symptoms of TMD using the same questionnaires and examination tools as baseline. To estimate the relative risk (RR) appropriately, a modified Poisson regression was used. After exclusion of prevalent cases with diagnosed tinnitus, 3134 subjects were analysed. Among the 191 exposed subjects with palpation pain in the temporomandibular joint (TMJ), 24 subjects (12·6%) received diagnosed tinnitus after 5 years, whereas among the 2643 unexposed subjects 142 subjects (5·8%) received tinnitus yielding a risk difference of 7·7% (95% confidence interval [CI]: 3·0%-12·5%) and a risk ratio of 2·60 (95% CI: 1·7-3·9). The risk ratio was 2·4 (95% CI: 1·6-3·7) after adjustment for gender, age, school education and frequent headache. Pain on palpation of the TMJ, however, did not worsen the prognosis for tinnitus in prevalent tinnitus cases (RR = 0·8, P = 0·288). Signs of TMD are a risk factor for the development of tinnitus.

Pharmacological interventions for pain in patients with temporomandibular disorders

BACKGROUND

Temporomandibular disorders (TMD) are a group of disorders affecting the temporomandibular joints and the muscles of mastication. TMDs are treated with a wide range of drugs. The extent to which the use of these drugs is based upon evidence is unknown.

OBJECTIVES

To assess the effectiveness of pharmacological interventions both alone and in combination with non-pharmacological therapy in relieving pain in patients with chronic TMD.

SEARCH STRATEGY

Electronic searches of the Cochrane Oral Health Group's Trials Register (2 August 2010), CENTRAL (The Cochrane Library 2010, Issue 3), MEDLINE via OVID (1950 to 2 August 2010), EMBASE via OVID (1980 to 2 August 2010) and CINAHL via EBSCO (1981 to 2 August 2010) were conducted. Reference lists of articles and previous reviews were scanned for relevant articles and authors were contacted for further information where appropriate.

SELECTION CRITERIA

Randomised controlled trials (RCTs) in which a pharmacological agent was compared with placebo for the management of pain in patients with TMD. Parenteral routes of administration were excluded.

DATA COLLECTION AND ANALYSIS

Duplicate data extraction and assessment of risk of bias in included studies was performed.

MAIN RESULTS

Eleven studies were included with a total of 496 participants. The primary outcome of most of the studies was pain. The risk of bias in the included studies was variable. Whilst four studies showed significant pain relief for the active treatment, three were of poor quality. Most adverse effects were mild to moderate in severity. Four studies reported withdrawals due to severe adverse reactions, but insufficient information was provided regarding the trial groups from which the withdrawals occurred. No meta-analysis was conducted due to lack of similarities across the included studies.

AUTHORS' CONCLUSIONS

There is insufficient evidence to support or not support the effectiveness of the reported drugs for the management of pain due to TMD. There is a need for high quality RCTs to derive evidence of the effectiveness of pharmacological interventions to treat pain associated with TMD.

Chiropractic management of a 40-year-old female patient with Ménière disease

OBJECTIVE

The purpose of this case report is to describe the chiropractic management of a patient with Ménière disease.

CLINICAL FEATURES

A 40-year-old woman presented with a diagnosis of Ménière disease including a 2-month history of vertigo and a 16-month history of left-sided tinnitus, low-frequency hearing loss, and aural fullness. The patient's other symptoms included left-sided neck pain, temporomandibular joint pain, and headaches. Examination revealed left-sided upper cervical joint dysfunction along with myofascial trigger points in the middle and upper trapezius muscle.

INTERVENTION AND OUTCOME

Treatment included primarily high-velocity, low-amplitude spinal manipulation to the upper cervical and thoracic spine, along with soft-tissue trigger-point therapy, and stretching exercises. Within 2 weeks of treatment, the patient's tinnitus had resolved; and all other symptoms (including vertigo) were improved. The patient's headaches, neck pain, and vertigo were subsequently resolved within 3 months of treatment. The patient experienced only 2 minor episodes of self-resolving "light-headedness" over that time. After 2½ years of follow-up, any occasional episodes of mild aural fullness and/or light-headedness are either self-resolving or relieved with cervical spinal manipulation and soft-tissue treatment.

CONCLUSION

This case report suggests that chiropractic care, including upper cervical spinal manipulation and soft-tissue therapy, may be beneficial in treating some patients with Ménière disease.

Electromyographic activity of sternocleidomastoid and masticatory muscles in patients with vestibular lesions

This study evaluated the electromyographic characteristics of masticatory and neck muscles in subjects with vestibular lesions. Surface electromyography of the masseter, temporalis and sternocleidomastoid muscles was performed in 19 patients with Ménière's disease, 12 patients with an acute peripheral vestibular lesion, and 19 control subjects matched for sex and age. During maximum voluntary clenching, patients with peripheral vestibular lesions had the highest co-contraction of the sternocleidomastoid muscle (analysis of covariance, p=0.02), the control subjects had the smallest values, and the patients with Ménière's disease had intermediate values. The control subjects had larger standardized muscle activities than the other patient groups (p=0.001). In conclusion, during maximum voluntary tooth clenching, patients with vestibular alterations have both more active neck muscles, and less active masticatory muscles than normal controls. Results underline the importance of a more inclusive craniocervical assessment of patients with vestibular lesions.

Cervical Vertigo—Cervical Pain: An Alternative and Efficient Treatment

OBJECTIVES

Cervical vertigo (CV) is commonly attributed to a disturbed cervical proprioception and is associated with cervical pain (CP). It is assumed to respond to a treatment that improves CP. In a prospective observational study, we examined whether a treatment originally devised for patients with CP could improve CV also in cases without CP.

DESIGN

During a period of 3 years, a total of 238 consecutive patients, 41 patients with CV only, 43 patients with CV and CP, 154 patients with CP only, received the same treatment, which consisted of local anaesthetics applied on average in 8 sessions to a fixed set of epidermal, epithelial, and periosteal locations. Outcome was relief of symptoms measured by a verbal-analogue scale at the end of therapy and on average a year later.

RESULTS

At the end of therapy, 58% of patients with CV responded with complete remissions compared to 41% of patients with CP. At follow-up a year later, there were complete remissions in more than 50% in CV as well as in CP.

CONCLUSIONS

The applied therapy led to complete remissions of long duration in a high percentage of patients with CV even when symptoms of CP were missing. This therapy produced good effects for CP as well. Its neurophysiological basis is discussed and may offer a new approach not only to the treatment of CV and CP but in a general sense also to that of acute, chronic, and neuropathic pain. It needs to be emphasized, however, that this study was not a randomized controlled trial and its encouraging results have to be proved by further research.