#192 TMD and Ear Infections

Ear Pain is one of the most common symptoms of Temporomandibular Joint Disorder (TMD).  I have listened to patients describe it a thousand times.  It’s described as a sharp or dull constant pain originating from the area of the external auditory canal.  Patients point to the ear canal and say that it feels like it is coming from inside their head, deep inside the ear canal.  Many of them share a history of going to a convenient care clinic because the pain is intense and arrived without any warning.  When arriving at the convenient care clinic, they are examined by a physician’s assistant or nurse practitioner who looks in their ear with an otoscope and proclaims they have an ear infection They are then given a prescription for antibiotic, usually Amoxicillin, unless they have an allergy to Penicillin at which point they are given a prescription for Cephalexin.   

They go home and take the Amoxicillin for 3 days and the pain continues, so they go back to the convenient care clinic, at which time one of two things happens.  1. The PA or NP looks in the ear again and prescribes another type of antibiotic, or 2. The PA or NP tells them they need to see an ENT, (Otolaryngologist) who specializes in treating ear pain and ear infection.  If the patient takes the second round of antibiotics, they get no relief and sometimes go to a different convenient care clinic or sometimes decide on their own to seek out the help of an ENT doctor.  If they go to a different convenient care clinic, they are examined and told they have an ear infection and given another round of antibiotics.  If they go to an ENT doctor, referred or self-referred, they are usually examined by the doctor or his NP/PA who is used to examining the ear canal and can discriminate between an ear infection and no infection.  At that point, 1. the ENT doctor or his NP/PA tell the patient they do not see any evidence of an ear infection and don’t know why they should be having pain in the ear and tell the patient they have no further recommendations.  Or more likely, 2. begin a very expensive Otolaryngology work up including blood test, MRIs, and various other hearing and balance/motion examinations ending with a bill for thousands of dollars. 

One thing a patient can count on for sure is if they go to a convenient care clinic with symptoms of ear pain, they will walk out with a prescription for antibiotics, 100 % of the time.   That has been my experience listening to thousands of patients sharing what happens when they go to a walk-in clinic with ear pain. 

No health care provider in this scenario ever thinks that the ear pain may be originating from the Temporomandibular Joint, (TMJ) unless the ENT practice is somewhere in Middle Tennessee and has already been made aware, by the educational efforts of our practice, that at least half of the adult patients who present with a history of ear pain is generated by inflammation within the TMJ, not infection within the ear. 

Ear pain originating from inflammation within the TMJ is simple to explain and easy to understand if you know a little bit about the anatomy of the area.   

The socket of the TMJ (Glenoid Fossa) and the External Auditory Canal abut each other, both side by side, with the Glenoid Fossa in front of the External Auditory Canal.  The wall between them is a sometimes-paper-thin sheet of bone about as thick as an eggshell.  Inflammation and its cellular and exudative components within the TMJ, due to damage caused by bruxism, acurate traumatic events, or functional malocclusion, can penetrate the wall separating the TMJ from the ear canal and stimulate the very sensitive services of the canal eliciting pain.  This inflammatory effect of TMD will not be apparent by looking into the ear with an otoscope.  The effect of the inflammation stimulates the surfaces of the bone and deeper layers of the canal cover.  This cannot be seen on the surface of the canal like you would see with an actual ear infection. 

Fortunately, in Middle Tennessee, many ENT practices can now recognize TMD when present, but we have a long way to go in making our educational efforts heard throughout the rest of the country.