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Auriculo-vestibular symptoms related to structural and functional

disorders of stomatognatic system

Article  in  Journal of physiology and pharmacology: an official journal of the Polish Physiological Society · April 2011
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 JOURNAL OF PHYSIOLOGY AND PHARMACOLOGY 2011, 62, 2, 251-256
www.jpp.krakow.pl

Short communication

M. PIHUT1, P. MAJEWSKI1, G. WISNIEWSKA1, E. RERON2

AURICULO-VESTIBULAR SYMPTOMS RELATED TO STRUCTURAL

AND FUNCTIONAL DISORDERS OF STOMATOGNATIC SYSTEM

1Chair and Department of Dental Prosthetics of the Institute of Dentistry, Jagiellonian University Medical College, Cracow, Poland;
2Chair and Department of Otolaryngology, Jagiellonian University Medical College, Cracow, Poland

Auriculo-vestibular symptoms are otolaryngological complaints which frequently co-occur with functional disorders of
masticatory organ. These symptoms include: earache, plugged ears sensation, sudden hearing impairment, burning pain
of the throat, tinnitus, and dizziness. The aim of the study was assessment of co-occurrence of functional disorders of
masticatory organ and auriculo-vestibular symptoms, in patients referred for otolaryngological treatment. Forty-two
patients aged 24-46 years of both sexes referred for otolaryngological treatment, because of auriculo-vestibular
symptoms, were qualified to our study within the framework of research project. After otolaryngological diagnostics
(Department of Otolaryngology), these patients were referred for prosthetic consultation to the Department of Dental
Prosthetics of Jagiellonian University Medical College. In Otolaryngology Clinic the following specialist examinations
were carried out: basic clinical examinations, including otoscopy, tuning fork trials, tonal and verbal audiometry, and
tympanometry. These examinations were supplemented with electronystagmometry. On prosthetic consultation,
specialist functional investigations of masticatory organ, and electromyographic assessment of the activity of masseter
muscles and the anterior part of the temporal muscle, were carried out. Results of the investigation revealed
otolarygological causes of the reported symptoms in 30 patients, whereas in 12 patients (out of 42 patients referred for
prosthetic consultation), numerous functional disorders of the stomatognathic system were observed. The investigation
confirmed the occurrence of functional disorders in patients with auriculo-vestibular symptoms and appropriateness of
treatment by a multi-specialist team.

K e y w o r d s : auriculo-vestibular symptoms, functional disorders, stomatognatic system, tinnitus, dizziness

INTRODUCTION MATERIAL AND METHODS

Functional disorders of the stomatognathic system constitute
a wide spectrum of pathologies including dysfunctions affecting
temporo-mandibular joints and masseter muscles which are
responsible for proper mobility of mandible and occlusion.
These dysfunctions are manifested by pain in the ear region,
impairment of the course of abduction and adduction of the
mandible, lack of symmetry of its lateral movements and
excessive tension of stomatognathic system’s muscles.
Among functional complaints reported by patients, auriculo-
vestibular symptoms such as earache, plugged ears sensation,
sudden hearing impairment, tinnitus, dizziness and burning pain
of the throat can be observed (1-3).
One of the main aims of prosthetic therapy of masticatory
organ functional disorders’ syndrome is the eradication of
articular and muscular pain, and restoration of normal
functioning of the stomatognathic system, including symmetric
and physiological function of the masseter muscles. Consecutive
rehabilitation plays an adjuvant role in the therapy (4, 5).
The aim of the present study is the assessment of co-
occurrence of functional disorders of the masticatory organ in
patients referred for otolaryngological treatment because of
auriculo-vestibular symptoms.
Forty-two patients aged 24-46 years of both sexes (with
prevalence of females), who were presented for
otolaryngological treatment, were qualified for our study within
the framework of the research project. The auriculo-vestibular
symptoms reported by the patients included earache, tinnitus,
hypoacusia, sudden hearing impairment and dizziness.
Specialist diagnostic examinations were carried out in the
Otolaryngological Department and the Chair of Dental
Prosthetics of the Jagiellonian University Medical College in
Cracow. The laryngological investigation contains tests such as
basic clinical assessment, including otoscopy, tuning fork trials,
tonal and verbal audiometry, tympanometric measurements
(assessment of stapes reflex) and electronystagmography.
In otolaryngological examination, the following symptoms
were assessed: occurrence of inflammation (reddening,
oedema), ulceration of the auricle, presence of nodules,
anatomical deformities, fistulas and cicatrization. Instrumental
examination included otoscopy, tuning fork trials, tonal
audiometry, tympanometry and electronystagmography.
Otoscopy was performed with the use of an electric otoscope
with inbuilt low-voltage light and a magnifying system. During
this examination, the condition of the external auditory canal and
252
the tympanic membrane were evaluated with special attention
paid to its colour, tone, transparency, mobility and presence of
post-inflammatory cicatrization. Tuning fork trials allowed to
assess conduction of both ears with Weber and Rinne test (using
a 512 Hz tuning fork type C). Tonal audiomerty was carried out
to determine the hearing threshold for clear tons, that is,
deprived of harmonic vibrations, and to determine the threshold
for normal hearing; the aim of verbal audiometry was to assess
the ability of speech discrimination. In tympanometric
examination, the acoustic resistance of the tympanic membrane
was registered during the change of pressure in the external and
internal ear. Electronystagmography was used for the
diagnostics of spontaneous and induced nystagmus on the basis
of the changes of the corneal and retinal potential and amplitude,
frequency and nystagmus speed.
After otolaryngological examinations, the patients were
referred to the Department of Dental Prosthetics of the
Jagiellonian University Medical College for specialist functional
tests of the masticatory organ.
Dental diagnostics included patients’ history and specialist
functional tests carried out in accordance with stomatognatic
system functional analysis form, used in Department of
Prosthetic Dentistry.
Information concerning the general patients’ condition, as
well as drugs used on pain occurrence or other symptoms or
dysfunctions within head and face region, interfering with
physiological activity of masticatory organ (food mastication,
long-term speech) were recorded on patients’ history. In case of
muscle pain or/and temporo-mandibular joints pain, the most
important was its location, intensity, irradiation, duration,
circumstances accompanying pain intensification or remission,
and tension headache. In patients that reported appearance of
acoustic symptoms, time of occurrence was crucial, as well as, if
the symptoms lasted uninterrupted to the moment of dental
examination. Taking into consideration etiological factors,
information concerning the occurrence of parafunctions,
especially in dental articulation (proceeding with opposing teeth
contact), including bruxism, was crucial. Patients were also
asked to make self-assessment of their psycho-emotional
condition, frequency of stress situations’ occurrence, and
methods of stress management. While conducting masticatory
organ functional examination, condition and pathologies present
within dentition (pathological teeth attrition, malocclusions) and
extent of dental defects were estimated. The significant part of
the examination was assessment of path and range, as well as
adduction and abduction jaw movements and lateral mandibular
movements’ symmetry. Position of static occlusion was
examined (with occlusal tracing paper) and dynamic occlusion
(visual examination of contact configuration of the opposing
teeth) in laterotrusive and mediotrusive side.
On palpation of masticatory organ muscles (masseter,
temporal muscle, lateral pterygoid, medial pterygoid as well as
biventer muscle, and floor of mouth) the level of muscle tone in
comparison to physiological norm was examined, and the
occurrence of provoked pain was estimated. On examination of
temporo-mandibular joints close attention was paid to the
occurrence of acoustic symptoms during mandible vertical
movements and their character (e.g. crepitus, grating sounds),
and pain ailments on palpation and mandible motion.
The specialist examination was supplemented with the close
analysis of functional temporo-auricular radiograms of temporo-
mandibular joints, taken in Schuller projection in mandible
central occlusion and maximum mandible adduction. These
examinations allow for direct assessment of the joint osseous
structure, position of articular heads in glenoid cavity being
crucial for diagnostics, indirect assessment of articular discs and
the range of articular heads mobility in joints (e.g. joint
subluxation). Examinations were carried out and the results
prepared in Chair of Radiology JU MC. For functional
examination results, analysis of mandible articular heads
location in central occlusion was significant, assessed indirectly
based on the dimension of articular fossa (frontal dimension- in
front of the articular head, upper dimension- above articular
head, back dimension- behind the articular head) and the
location of articular heads in the maximum mandible adduction.
Dental and functional examinations of the stomatognathic
system were supplemented with electromyography of the
masseter muscles’ tone and the anterior part of the temporal
muscles at central occlusion, simultaneously for the right and
left side, using an eight-channel device BIO EMG II. Superficial
bipolar electrodes were used with constant distance between the
measuring poles, which were placed along the course of
muscular fibres. Surface electrode was located in the medial line
of the forehead. During EMG examination the patient was in a
sitting position with no back support, his hands resting on the
knees.
Electromyography was repeated three times at each
examination session. Average values were analyzed in order to
assess objectively the patients’ muscular tone, and to compare
their electric potentials with the normal potential levels for the
masseter and anterior part of temporalis muscles. The
asymmetry between the activities of left and right-side muscles
was quantified by the asymmetry index Naeije i Maccarolla (6).
RMS right – RMS left
asymmetry index = —————————————
RMS right + RMS left
RMS – root mean square value
A positive index indicates a right – side dominance and
negative index a left – side dominance of muscle´s activity.
The results obtained underwent statistical analysis based on
the calculation of mean values, mean standard deviations,
minimal and maximal values, analysis of variance test for
dependent random variables, and Tukey’s post-hoc test.
RESULTS
Results of otolaryngological examinations
Specialist otolaryngological examinations among 12 patients
(out of 42) showed no otolaryngological cause of the reported
auriculo-vestibular symptoms such as sudden occurrence of low-
intensity tinnitus, otalgia lasting 2-3 weeks, plugged ears
sensation, burning pain of the throat and dizziness at various
times of the day. Otolaryngological treatment of auriculo-
vestibular symptoms in the group of remaining 30 patients was
effective.
Results of functional examinations of the masticatory organ
Functional examinations of the masticatory organ carried out
among 42 patients revealed no disorders in 30 patients, and
numerous dysfunctions in 12 patients (8 females and 4 men).
Out of 12 patients, only 10 fully dentulous patients (7 females
and 3 males), 7 were qualified for further dental examinations; 2
partially edentulous patients were excluded from the study
because of numerous missing teeth in both jaws with no
prosthetic restoration, which could prevent correct interpretation
of the results.
The history elicited from the patients revealed self-induced
pain in the peri-auricular region lasting about 1-12 weeks,
located in one or both sides of the face. The pain appeared during

mastication or in border left and right lateral jaw position that is
in the maximal mandible depression or mandible adduction as
well as during lateral mandibular movements. Pain irradiation in
temporal and occipital region was recorded in 4 cases. Acoustic
symptoms, heard by patients at least 2 months before the
prosthetic consultation, were reported by 3 patients. Earlier,
sudden maximal dimension of mandible depression limitation
was noted in 2 patients. Difficulties with mastication and
intensified masseter muscle and temporalis muscle tone, were
recorded in 4 patients. Auriculo-vestibular symptoms (plugged
ears sensation, hearing impairment, burning in the throat) were
recorded in all patients’ histories. The results of the subjective
examination are presented in Table 1.
The functional analysis disclosed deviation from the norm in
maximal dimension of mandible depression (up to 18 mm), and
mandible lateral movements (up to 5 mm). Abnormal jaw path and
disturbances in vertical movements were recorded in 7 patients.
Rest position distance was smaller in 2 patients. Configuration of
occlusal contacts in central and eccentric occlusion was abnormal
in 8 patients. In 5 cases pain on palpation was noted and in 7 cases
pain in temporo-mandibular joints, provoked by palpation, was
recorded. Increased muscle tone on palpation was present in all
patients. Masseter muscle hypertrophy was noted in 1 case and the
symptoms of parafunctions occurrence in oral cavity region were
Table 1. The results of the subjective examination.
Reported ailments
Self-induced One joint
pain Both joints
Joint pain present during food mastication
Pain irradiation
Crepitus in temporo-mandibular joint reported
by patients
Feeling of tension in joints
Previous limitation of mouth opening
Self-induced pain of masseter or temporalis muscles
Difficulties in food mastication
Occlusal and non-occlusal parafunctions incidence
Auriculo-vestibular symptoms
 
253
detected in 7 patients. Occurrence of acoustic symptoms such as
crepitus in temporo-mandibular joints was confirmed in 3 patients
(Table 2).
Radiographic analysis of functional temporo-auricular
radiograms of temporo-mandibular joints taken in Schuller
projection revealed asymmetry in the position of the mandibular
heads in the temporal fossa in the position of central occlusion in
2 cases and excessive dimension of mandible depression in 1
case (Fig. 1).
Electromyographic examination of the masseter muscles and
anterior temporal muscles confirmed clinically manifested
increased tone of these muscles in the central occlusion (Table 3
and 4). Lack of symmetry in the muscular tone was noted, which
was proved by the difference in the potentials of the right and left
sides of the same muscle ranging between 4.7 µV and 42.5 µV.
Muscle tone asymmetry index was positive for masseter muscles
(2.641), which indicates the right-side muscle activity
dominance, and negative for temporal muscles (-2.944), which
shows left-side muscle activity dominance (Table 5).
Excess of the physiological level of muscular tone, the norm
of which is within 10-15 µV (5), ranged from about 30 µV to 120
µV for the masseter muscles, and from 10 µV to 105 µV for the
temporal muscles. It indicated that in patients with no
otolaryngological causes of auriculo-vestibular symptoms, the
Females Males
4 2
2 1
4 2
3 1
2 1
3 2
1 1
3 1
4 2
5 2
7 3
Fig. 1. Asymmetry in the position
of the mandibular heads in the
temporal fossa in the position of
central occlusion in radiographic
investigation.
254

Table 2. Results of functional stomatognatic system examinations.

Functional examination Normal Abnormal
Range of mandible depression 8 2
Vertical jaw Middle 4
movements Stage Final 2
path S-shaped 1
Rest position distance 8 2
Central occlusion 2 8
Occlusal Lack of occlusion in
conditions Eccentric 6
canine teeth line
occlusion Occlusal contacts in
4
mediotrusive side
Temporo-mandibular pain present on examination 5
On palpation muscle pain 7
Increased muscle tone 10
Muscle hypertrophy 1
Symptoms of parafunction incidence 7
In one joint 2
Acustic effects
In both joint 1 3
Positive clenching test 5
Positive grinding test 6
Abnormal radiogram 4

Table 3. Electric potentials of masseter and temporalis muscle and more attention in literature. This co-existence can be
expressed in micro voltage-µV. associated with the common filogenetic and ontogenetic
Temporal muscles- development of the muscles: medial pterygoid, soft palate tensor
Patients Masseter muscles
anterior part and tympanic tensor, which originate from the first branchial
arch (6-8). Moreover, anatomical adjacency of the temporo-
R L R L
mandibular joints and the middle ear can promote transmission
1. 157.72 128.23 179.24 187.33 of excessive mechanical forces originating from the region of the
2. 124.8 112.6 145.7 112.6 TM joints to the ear via the disc-malleus ligament or as a result
3. 32.5 56.7 65.4 45.7 of direct pressure and irritation of the auriculo-temporal nerve by
4. 67.8 45.8 98.6 118.8 the mandibular head in the region of the petro-tympanic fissure.
This creates an impulse for reflex contraction of the tympanic
5. 27.8 15.7 45.7 64.8 tensor muscle. Posterior translocation of the mandibular heads
6. 51.6 36.8 75.2 99.5 can cause pressure on the tympanic artery and vein, leading to
7. 21.1 43.5 54.6 87.4 the blood supply impairment and functions of the middle ear,
8. 15.7 34.66 75.5 87.3 contraction of the stapes muscle and, in consequence,
immobilization of the stapes. In these reciprocal relations, the
9. 44.5 87.4 76.9 83.9
innervation of the tympanic tensor, soft palate tensor and
10. 16.8 21.5 22.7 33.4 masseter muscles by the mandibular branch of the trigeminal
nerve seems to play a significant role. The increase in the tone of
one group of muscles is frequently accompanied by excessive
tension in the muscles of the other group (9-15). Functional
predominant problem was functional disorder of the masticatory disorders of the masticatory organ are frequently reported by
organ accompanied by the increase in muscular tone markedly patients seeking prosthetic treatment. Co-ocurence of auriculo-
exceeding the physiological norm. vestibular symptoms such as: hearing impairment, dizziness,
In the group of 12 patients referred to the Otolaryngological tinnitus, diagnosed in the control group, have been noticed by
Department, successive prosthetic treatment was performed with many authors treating patients with functional dysfunctions of
the use of occlusive splints and reconstructive procedures, masticatory organ (16-24).
aiming at restoration of correct relation between the jaws, Tinnitus and dizziness analyzed by Chole R. (25) appeared
combined with physiotherapy and psychological support. In significantly more often in patients with functional disorders
follow-up examinations carried out after 6 and 9 months of the than in control group formed with patients searching general
prosthetic treatment beginning, the auriculo-vestibular medical treatment.
symptoms were excluded in all patients. Among patients referred to Department of Otolaryngology
females predominated (7 females and 3 men), which was also
noticed by Lam et al. (26), as from among 344 examined
DISCUSSION patients with functional disorders, women significantly
outnumbered men. Alarmingly high percentage of patients in
Common occurrence of auriculo-vestibular symptoms with this study constituted patients with auriculo-vestibular
functional disorders of the masticatory organ is receiving more symptoms (59%).
 255

Table 4. Assessemet of the level of significance for electric potentials of examined muscles.

Masseter muscles Temporal muscles – anterior part

Difference Difference
R L (absolute values) R L (absolute values)

X=56.0 X=58.0 X=20.4 X=83.95 X-92.1 X=18.7

SD=48.4 SD=38.4 SD=10.7 SD=46.8 SD=43.1 SD=9.4
Min. 15.7 Min. 15.7 Min. 4.7 Min. 22.7 Min. 33.4 Min. 7.0
Max. 157.7 Max. 128.2 Max. 42.9 Max. 179.2 Max. 187.3 Max. 33.1
Physiological muscle tone about 10 µV Physiological muscle tone about 15 µV
P=0.0418 P=0.0233 P=0.0097 P=0.0079 P=0.0020 P=0.0000

Table 5. The asymmetry index of the masseter and anterior part of temporalis muscles.
Masseter Masseter Temporalis Temporalis
Muscle R L R L
square 24875.6 16442.93 32126.98 35092.53
15575.04 12678.76 21228.49 12678.76
1056.25 3214.89 4277.16 2088.49
4596.84 2097.64 9721.96 14113.44
772.84 246.49 2088.49 4199.04
2662.56 1354.24 5655.04 9900.25
445.21 1892.25 2981.16 7638.76
246.49 1201.316 5700.25 7621.29
1980.25 7638.76 5913.61 7039.21
282.24 462.25 515.29 1115.56
Mean value 5249.332 4722.953 9020.843 10148.73
RMS 72.45227 68.72374 94.97812 100.7409
A .index 2.641050489 -2.944426083

The results of the examinations that were carried out,
indicate necessity of functional dysfunctions’ verification within
the stomatognatic system in case of lack of otolaryngological
causes of auriculo-vestibular symptoms, according to Turp and
Ramirez (18, 24). In Tuz H. et al. study the incidence of
auriculo-vestibular symptoms’ occurrence in a group of patients
with functional disorders was estimated and it was demonstrated
that in a group of 200 examined patients 77.5%, that is 155
persons, were diagnosed with at least one of the symptoms
regarded as auriculo-vestibular group (29). The similar
incidence was stated by Manni et al., as in 53 patients treated
due to functional disorders, 67.9% of patients were diagnosed
with at least one functional disorder (10).
Results of electric potentials of masseter and anterior part of
temporal muscles’ estimation, analyzed in activity, in central
mandibular occlusion, indicate much higher electric potentials in
comparison to physiological norm. Similar results were achieved
by numerous authors who compared the tension level of
masseter and temporal muscles in patients with stomatognatic
system functional disorder and healthy controls (16, 18, 19, 24,
27-29). Different results can be found in Manni et al. study
because higher electric potentials were observed in control group
than in patients treated due to functional disorders (10).
In case of 10 patients examined in a study (referred from
Department of Otolaryngology) application of specialist
prosthetic treatment caused permanent disappearance of
auriculo-vestibular symptoms. The same result is described by
Cooper et al. and Kuttila M et al. who conducted orthopedic
treatment with occlusal splints used to reposition the jaw in
patients with functional disorders having symptoms such as:
earache, hearing impairment, tinnitus. This caused the
significant reduction or disaapearance of auriculo-vestibular
symptoms (30, 31). Peloz in his study emphasizes that in 37% of
221 treated patients with functional disorders, there were some
auricular symptoms that were eliminated by the use of
stabilization splint, commonly used in prosthetic treatment.
Moreover, correlation between the incidence of auriculo-
vestibular symptoms and clinically diagnosed disc dislocation
without blocking was found by the author (32).
The accompanying otolaryngological symptoms impede the
patients’ everyday life, their professional work as well as correct
diagnosis of this disorder. Tinnitus can interfere with speech
understanding and hinder sleep, dizziness is a frequent cause of
the fear of free mobility. Because of otolaryngological
symptoms caused by this disorder, the patients are frequently
referred for specialist treatment which is not related to
stomatognathic system (16-20). The coexistence of auriculo-
vestibular symptoms and otolaryngological disorders within the
masticatory organs is due to the activation of the brain-auriculo-
ventricular axis, mediated mostly via trigeminal nerves. The
treatment of masticatory organ disorders requires multi-
specialistic and therapeutic approach.
CONCLUSIONS
Results of dental examinations revealed numerous
abnormalities of the function and biomechanics in the
masticatory organ which can coexist with otolaryngological
symptoms of auriculo-vestibular type.
Functional disorders of the masticatory organ and auriculo-
vestibular symptoms, observed in our study, require preparation
 256
and introduction of common otolaryngological and dental
management for diagnostics and therapy of patients with this
kind of disorder.
Acknowledgements: We are very grateful to Professor
Stanislaw Konturek for his assistance and kindness.
Conflict of interests: None declared.
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R e c e i v e d : October 25, 2010
A c c e p t e d : April 12, 2011
Author’s address: Dr. Malgorzata Pihut, Chair and
Department of Dental Prosthetics of the Institute of Dentistry,
31-155 Cracow, 4 Montelupich Street, Cracow, Poland; E-mail:
pihut_m@poczta.onet.pl