Can Tmj Jaw Change The Structure Of The Ear Canal
Korean J Audiol. 2013 Sep; 17(2): 90–93.
A Case of Spontaneous Temporomandibular Joint Herniation into the External Auditory Canal with Clicking Audio
Tae Hyun Kim
Department of Otorhinolaryngology-Head and Neck Surgery, Kyung Hee University Hospital at Gangdong, Seoul, Korea.
Sun Kyu Lee
Department of Otorhinolaryngology-Caput and Neck Surgery, Kyung Hee University Hospital at Gangdong, Seoul, Korea.
Su Jin Kim
Department of Otorhinolaryngology-Head and Neck Surgery, Kyung Hee University Hospital at Gangdong, Seoul, Korea.
Jae Yong Byun
Department of Otorhinolaryngology-Head and Cervix Surgery, Kyung Hee Academy Hospital at Gangdong, Seoul, Korea.
Received 2013 Mar 27; Revised 2013 Apr 11; Accustomed 2013 May 12.
Abstract
A bony defect of the external auditory canal (EAC) and herniation of the temporomandibular articulation (TMJ) tin can be caused past tumorous atmospheric condition, inflammation, trauma, and otologic procedures. Spontaneous TMJ herniation into the EAC can be acquired by a congenital bony defect known as patent Huschke'south foramen, which is a very rare condition. In our case, an objective clicking sound was produced when the patient opened his mouth. A protruding mass was found in the anterior wall of the EAC during oral fissure endmost, and herniation of the TMJ was confirmed with computed tomography. Therefore, nosotros idea the clicking audio of our instance could have resulted from spontaneous TMJ herniation through the patent foramen of Huschke.
Keywords: Huschke'due south foramen, Temporomandibular joint, Tinnitus
Introduction
The external auditory culvert (EAC) is intimately related to the temporomandibular articulation (TMJ), separated only by its bony anterior wall, which is of variable thickness. The herniation of the TMJ which is protruded into the EAC is by and large known to occur from tumor, injury, and inflammation. On the other mitt, spontaneous TMJ herniation resulting from the congenital bony defect is a very rare status, and it is assumed this is caused by a persistent foramen of Huschke.
During the osseous development of the tympanic os, the initial osseous EAC was constructed past the fusing of two prominences that arose from the anterior and posterior portions of the tympanic band. The anterior and posterior processes are growing in a 'U' shape. This fusion divides the primordial annulus into the superior EAC and inferior Huschke's foramen. The Huschke's foramen is becomes smaller every bit the tympanic plate grows through a membranous ossification procedure and usually closes before the age of 5 years.i) But persistent foramen of Huschke is occasionally generated past an imperfect series fusion procedure.2)
Recently, the authors report a example of a persistent foramen of Huschke and subsequent protrusion of temporomandibular joint tissue into the EAC in a patient who visited our infirmary for the chief complaint of clicking tinnitus.
Example Report
A 53-twelvemonth-old human came to the Otorhinolaryngology department every bit an outpatient in September 2011 for the chief complaint of clicking tinnitus on the left. The patient had a by medical history of arrhythmia and heart valve disease but at that place was no history of trauma or surgery which could accept led to tinnitus. Since July 2008, he had received rehabilitation handling due to cerebral infarction in the eye cerebral artery zone. The clicking tinnitus started suddenly 3 weeks before he visited the infirmary, by and large during mastication and when opening and closing his mouth. During the three weeks, the clicking tinnitus happened without forcefulness modify and without other otologic symptoms such every bit otalgia and otorrhea. In the otoscopic test, the tympanic membrane was normal but there was slight protrusion of the soft tissue, originating from the inductive wall of the left EAC. This protrusion was observed when the mouth was closed and if it was open, the protrusion retracted (Fig. ane). The clicking sound that was heard in the left ear of the patient was also heard by the observer when he put a stethoscope on the EAC of the patient when the oral fissure was opened and airtight.
A: Otoendoscopic finding shows protruding lesion (white arrow) on anterior wall of left external auditory canal during closing rima oris. B: This lesion was reduced with mouth opening (black arrow).
The patient did non feel uncomfortable in his daily life from the clicking tinnitus, and the Tinnitus Handicap Inventory (THI) score was 18. According to the pure tone audiometry, the air conduction boilerplate threshold value (4 division method) was 23 dB on the right and 22 dB on the left while the average threshold value from bone conduction audiometry was 21 dB and 20 dB respectively. On the impedance test, both sides were A type. We conducted a tinnitogram merely the patient complained of merely clicking and we failed to detect the verbal strength and frequency.
According to his otologic history, he had clicking at the time of mastication. Pure tone audiometry also failed to detect sensorineural or conductive hearing loss while the otoscopy institute an anterior wall protrusion at the left EAC, and so TMJ herniation was suspected. Therefore, we conducted TMJ Ten-ray and temporal computed tomography. From the TMJ X-ray, nosotros could see a left temporomandibular joint herniation at the time of mastication (Fig. 2), and the temporal os computed tomography detected a 6 mm bony defect in the left EAC anterior wall and subsequent soft tissue herniation (Fig. iii). At the right EAC, there was no bony defect or other unusual findings. The left clicking tinnitus complained by the patient was revealed to occur from TMJ tissue herniation into the EAC at the time of mastication. Therefore, nosotros considered surgical treatment for the left EAC anterior wall defect but the patient refused surgery because he felt uncomfortable with surgical treatment as he was receiving rehabilitation for cerebral infarction, and furthermore, he did not suffer much inconvenience from the clicking tinnitus. Thus, the authors treated him with an anxiolytic and muscle relaxant for 2 weeks, after which we could non see any change in loudness of the tinnitus (according to the patient) and emotional reaction. Now, the authors are observing the progress of the clicking tinnitus.
Temporomandibular joint scalograms. A: Airtight mouth view. B: Open mouth view. Annotation that the mandibular condyle (black pointer) is outside of the glenoid fossa (white arrow).
Temporal bone computed tomography browse showing defect (white arrow) in the anterior bony wall of left external auditory canal. A: Centric view. B: Coronal view.
Discussion
Tinnitus is an auditory stimulus that is heard without external sound sources, and information technology can be roughly divided into subjective tinnitus or sensorineural tinnitus, and objective tinnitus or somatosound. Somatosound tin be subdivided into muscular origin tinnitus, vascular tinnitus, and patent Eustachian tube origin tinnitus.iii) This tinnitus has a lower prevalence charge per unit than sensorineural tinnitus simply its cause and occurrence mechanism has been studied well, and the fact that tinnitus can exist completely treated with drugs or surgical treatment is important.
The clicking tinnitus in this case was an objective tinnitus that could be detected by the observer by putting a stethoscope on the EAC, equally well as by the patient. When nosotros integrated the EAC findings and the radiologic findings, the tinnitus was causeless to be caused by the TMJ herniation. Though the patient was under rehabilitation treatment for cognitive infarction, he had neither a medical history of head and neck surgery or injury nor a medical history of caput and neck radiation treatment. Besides, no inflammation was discovered in the EAC on otoscopy, so the cause was more likely to exist spontaneous TMJ herniation than secondary TMJ herniation.
The tympanic ring composes a function of the tympanic bone which is undergoing evolution at the time of nativity. During the starting time year of life, both the inductive procedure and the posterior process grow toward each other in the tympanic band for ane year. At the age of well-nigh 1 year, two processes fuse together and a foramen persists medial to the betoken of fusion. This foramen is called the foramen of Huschke. The foramen of Huschke is occluded slowly as the tympanic plate grows through the membranous ossification procedure and information technology is usually considered to be closed fully by 5 years of age. But it occasionally persists, and this is called a persistent foramen of Huschke.4) Lately, the persistent foramen of Huschke is considered a normal variant in temporal bone anatomy, and it is located at the anteroinferior aspect of the EAC, posteromedial to the mandibular caput, causing a bony defect of the EAC anterior wall.5)
According to previous study, the incidence of persistent foramen of Huschke ranged from three% to 24%, and most of the sizes ranged from 1 mm to 8 mm. A cadaver written report reported that the incidence of persistent foramen of Huschke was 7.ii% and the size averaged 2.7 mm on coronal images and averaged 3.0 mm on sagittal images.6) The study of Park, et al.7) reported that persistent foramen of Huschke was in 1.5% of all cases and the TMJ soft tissue herniation was observed in only 26% of persistent foramen of Huschke cases in spite of the EAC anterior wall defect. In add-on, TMJ soft tissue herniation was found to have shut a relationship with the size of the defect. In some cases, the initial opening in the Huschke's foreman was probably sufficiently pocket-sized for no herniation of the TMJ or any other soft tissue into the EAC to have occurred. However, years of mastication could have softened the intervening tissue or enlarged the opening, leading to the observed soft tissue herniation.8)
The traumatic influence of masticatory movements may result in enlargement of the defect and the symptoms become more prominent. In symptomatic patients the foramen of Huschke usually reveals itself with otalgia, mandibular joint pain, recurrent infections of the EAC, tinnitus, conductive hearing loss and salivary belch from the EAC.viii) It is known that the condyle itself is not herniated through the foramen of Huschke but retrodiskal tissue or diskal tissue around the TMJ is protruded into the EAC.i,ii) The clicking tinnitus in this example occured from the EAC anterior wall move initiated by the temporomandibular tissue that is herniated by masticatory movements.eight,9) In this case, nosotros could also see the EAC anterior wall protruding and retracting whenever the patient opened and closed his mouth respectively, and according to the temporal computed tomography, the soft tissue herniated into the EAC.
Handling of foramen Huschke in symptomatic cases requires closure of the defect in order to foreclose the prolapsus of the periarticular tissue into the EAC. There are two kinds of surgical approaches, one is the preauricular approach based on TMJ exposure and the other i is the endaural approach based on anterior exposure of the tympanic bone.8,10) The tragal cartilage for autologous cartilage transplantation is preferable. There have been cases in which tragal cartilage and temporal fascia were used for the repair of the bony defect. Anand, et al.10) reported the method of covering the defect by using a polypropylene (Medpore) implant in the case when the defect was big (sized over 5 mm). Park, et al.vii) used titanium mesh for the repair of the bony defect and confirmed that the TMJ tissue did not herniate into the EAC regardless of jaw movement at the postsurgical state. When in that location is a salivary fistula formation through foramen of Huschke, ligation and then dividing of the fistula tract may be sufficient for handling of salivary otorrhea from the EAC.11) Co-ordinate to the assay of Moriyama, et al.8) in which fourteen published cases were collected, in 7 cases out of all the surgical treatments, they could find symptom improvement, and they confirmed that they could achieve satisfactory results without postsurgical complications. However, there is insufficient data on complications of surgical treatment of persistent foramen of Huschke and on longterm progress. Possible postsurgical complications are inserted cartilage movement, TMJ damage, eye ear impairment, and rima oris opening limitation.10)
In this case, because the patient had no intention of being treated surgically due to his weak physical status from the cognitive infarction, and because the THI score was xviii, indicating he was non suffering too much from the clicking tinnitus, nosotros chose conservative treatment. We prescribed an anxiolytic (clonazepam) and a muscle relaxant (eperisone HCl) for 2 weeks, and during the follow-up, we could find neither change in the tinnitus on measurement with a stethoscope nor change in the subjective tinnitus loudness. Therefore, this case is now under progress observation.
Nosotros diagnosed objective tinnitus occurring in clan with persistent foramen of Huschke. We think this example was very meaningful as a example of objective tinnitus originating clinically very rare cause. Though nosotros failed to obtain full recovery from the tinnitus using conservative treatment, we were able to find a crusade of the tinnitus which will be helpful for improving our understanding of tinnitus patients. According to the literature, tinnitus can be successfully treated by surgery. Therefore, we want to emphasize the importance of taking a careful history and performing a physical examination that are appropriate for checking the masticatory movements, likewise equally describe the related EAC findings, and the symptom occurrence in this disorder, to find out the crusade of the objective clicking tinnitus.
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Source: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3936545/
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