Ross Hauser, MD

Costen’s syndrome is an older term for a group of jaw, ear, head, and facial symptoms historically attributed to dysfunction of the temporomandibular joint (TMJ). A patient may have jaw pain or clicking together with tinnitus, ear fullness, ear pain, dizziness, headache, facial pain, or a change in hearing. The symptoms are real, but the label can create confusion because many dental, ear, neurologic, sleep, and cervical spine disorders can produce a similar pattern.

For some patients, the primary issue is within the jaw joint or chewing muscles. For others, an ear disorder, migraine, neuralgia, sleep disorder, or another medical condition better explains the symptoms. In a carefully selected subset—particularly patients with neck pain, prior trauma, hypermobility, posture-dependent symptoms, or symptoms reproduced by neck movement—we also consider whether cervical dysfunction or instability may be contributing.

This article explains what is established, what remains uncertain, and how we evaluate the possible interaction among the jaw, ear, and neck.

What is Costen’s syndrome?

In 1934, otolaryngologist James Costen described a syndrome of ear and sinus symptoms that he believed depended on disturbed TMJ function. The historical paper helped focus attention on the possibility that jaw dysfunction can produce symptoms beyond the jaw itself. (1)

Today, clinicians more commonly use the broader term temporomandibular disorders (TMDs). TMD is not one disease. It includes more than 30 conditions affecting the TMJs, the chewing muscles, and related tissues. Modern diagnostic systems distinguish muscle-related pain from joint pain, disc displacement, degenerative joint disease, and other specific disorders.

A 2025 international standard-of-care statement emphasized that TMD is multifactorial and should be diagnosed through an appropriate history and clinical examination, with imaging used selectively. It also cautioned against simplistic explanations and irreversible bite-changing treatment without a sound indication. (2)

Symptoms commonly attributed to Costen’s syndrome

The symptom cluster may include:

• Jaw pain, tenderness, clicking, locking, or limited opening
• Pain with chewing or clenching
• Ear pain without an obvious middle-ear infection
• Ear fullness, pressure, tinnitus, or sound sensitivity
• Dizziness, disequilibrium, or vertigo-like sensations
• Headache, temple pain, occipital pain, or facial pain
• Neck pain and muscle tightness
• Burning or painful sensations involving the mouth or tongue
• Bruxism, meaning awake or sleep-related clenching or grinding

An anatomical review of Costen’s syndrome concluded that TMJ ligaments, muscles, sensory pathways, and central nervous system processing may all participate in the symptom pattern. It also highlighted the role of neuroplasticity—the nervous system’s ability to change how it processes signals—rather than reducing the syndrome to dental occlusion alone. (3)

Is dental malocclusion the cause?

Malocclusion means the upper and lower teeth do not meet in an ideal relationship. Costen originally proposed that a deep bite or altered bite mechanics could injure the TMJ and create ear and sinus symptoms. That historical model should not be presented as settled fact.

Current evidence does not support treating ordinary variations in bite as a universal cause of TMD. A 2024 systematic review found associations between some occlusal factors and TMD, but the available studies were heterogeneous and could not establish a simple causal relationship. (4)

Finding an overbite, missing teeth, wear marks, or an abnormal-looking bite does not prove that dental correction will resolve tinnitus, dizziness, headache, or neck pain. Irreversible procedures such as grinding down teeth or bite-altering orthodontic treatment should not be undertaken solely on an unproven theory.

I have personal experience with this problem. Before understanding the broader jaw-neck relationship, he underwent tooth reshaping, multiple splints, and other dental approaches. In his experience evaluating patients over many years, a subset did not improve because the bite was not the only relevant factor.

Why can a jaw disorder produce ear symptoms?

The TMJ lies immediately in front of the ear. The joint, chewing muscles, middle ear region, and upper neck also share overlapping sensory pathways. Signals from the trigeminal system—the major sensory network of the face and jaw—interact with cervical and auditory processing pathways. This helps explain why jaw movement, clenching, or pressure on chewing muscles can sometimes change tinnitus or ear discomfort.

Recent evidence supports an association, not a single proven mechanism. A 2024 systematic review of randomized trials reported that rehabilitative treatments may improve secondary ear pain and tinnitus in patients with TMD, but the number and quality of studies limited certainty. (5)

A second systematic review, published in 2025, found that combined manual therapy and exercises directed at the jaw and neck may reduce tinnitus severity, earache, and ear fullness in some patients. However, the authors rated the overall certainty of evidence as very low. (6)

Therefore, improvement after TMD rehabilitation can support a somatic component to ear symptoms, but it does not rule out hearing loss, vestibular disease, migraine, or another diagnosis. Patients can read more about the proposed ligament and sensory connections in our discussion of TMJ dysfunction and tinnitus and our overview of tinnitus and cervical spine instability.

The jaw-neck connection

The jaw and neck work as a coordinated mechanical and neurologic system. Chewing, swallowing, speaking, head position, and eye-head coordination require activity across both regions. Neck pain may alter muscle recruitment around the jaw; jaw pain may increase protective tension in the neck. Sensory signals from the upper cervical spine and trigeminal system also converge within the brainstem.

Observational research supports a relationship. A 2020 systematic review and meta-analysis found that patients with TMD had more neck disability and impairment in several cervical measures than people without TMD. The authors did not establish that cervical dysfunction caused TMD or that TMD caused the cervical findings. (7)

Treatment research provides another clue. A 2024 systematic review found short-term improvement in pain outcomes when cervical rehabilitation—particularly upper-cervical manual therapy with or without neck exercise—was used for adults with muscle-related TMD. Heterogeneity was high, and long-term benefit remains uncertain. (8)

Caring Medical’s clinical perspective

In our clinical experience, the neck deserves closer evaluation when a patient has a combination such as:

• Jaw and ear symptoms accompanied by persistent neck pain
• Symptoms that began after whiplash, concussion, or another head-neck injury
• Dizziness, headache, tinnitus, or facial pain that changes with neck position
• Generalized joint hypermobility or Ehlers-Danlos syndrome
• Recurrent jaw subluxation or a feeling that the jaw and neck are both unstable
• Failure of reasonable dental and orofacial treatment to provide durable improvement

These findings do not diagnose cervical instability by themselves. They identify patients in whom a focused cervical history, neurologic examination, and appropriate imaging may be reasonable.

Could cervical instability contribute to Costen-like symptoms?

Cervical instability refers to excessive or poorly controlled motion between neck vertebrae. Clinically significant instability may follow trauma, connective-tissue laxity, degeneration, or surgery. Severe instability can threaten neural structures and requires conventional spine or neurosurgical evaluation.

Ross Hauser, MD, and colleagues have published a narrative review proposing that cervical capsular ligament laxity may be an overlooked source of chronic neck pain and, in some patients, associated headaches, dizziness, tinnitus, or facial pain. Because this was a review containing proposed mechanisms and clinical experience—not a randomized trial—it should not be interpreted as proof that ligament treatment resolves Costen’s syndrome. (9)

In a 2024 Frontiers in Neurology article, we proposed that loss of normal cervical alignment and ligamentous instability could, in selected patients, affect structures traveling through the neck, including veins and nerves. The article included a retrospective cohort and proposed pathophysiologic models, but it did not study Costen’s syndrome directly and cannot establish that cervical instability causes TMJ-related ear symptoms. (10)

Our 2025 cervicovagopathy paper further proposed that cervical dysstructure and instability may influence vagus nerve function. This is a developing hypothesis relevant to patients with broader autonomic symptoms, not established evidence that vagus nerve compression is a routine cause of TMD, tinnitus, or vertigo. (11)

We understand that a cervical contribution is considered one possible coexisting factor in a subset of patients. Our broader clinical model is explained in our articles on cervical instability and dysautonomia and cervicogenic dizziness.

A clinical observation involving a mouth guard

One patient with Ehlers-Danlos syndrome experienced a sudden decline in balance and coordination whenever she inserted a newly made oral appliance. Removing it reversed the immediate change. This was an individual clinical observation, not a controlled experiment. It suggested that altering mandibular position affected her sensorimotor function, but it did not prove that the appliance reduced cerebral blood flow or that the same mechanism occurs in other patients.Depending on the symptoms, that may involve the treating dentist, an orofacial pain specialist, an ear, nose, and throat physician, a neurologist, a vestibular clinician, or a cervical spine specialist.

Bruxism, sleep, stress, and TMD

Bruxism is repetitive jaw-muscle activity involving clenching, grinding, or bracing of the jaw. Awake bruxism and sleep bruxism are related but distinct behaviors. Stress, pain, sleep arousals, medications, substances, and sleep disorders may influence them. Tooth wear alone cannot determine whether someone currently has sleep bruxism.

The relationship between bruxism and obstructive sleep apnea is more complicated than older reports suggested. A 2024 systematic review and meta-analysis did not find a clear overall association between sleep bruxism and obstructive sleep apnea, but it also judged the quality of the underlying studies to be low. (12)

In practice, loud snoring, witnessed breathing pauses, gasping, marked daytime sleepiness, morning headaches, resistant high blood pressure, or obesity should prompt formal sleep evaluation. Treating sleep apnea is important for overall health, whether or not it changes bruxism.

We also discuss stress reduction, sleep habits, and daytime jaw awareness with our patients. These measures may reduce muscle overactivity and pain, but psychological factors should never be used to dismiss physical symptoms. TMD is often best understood through a biopsychosocial model in which tissue sensitivity, sleep, stress, behavior, and nervous-system processing can interact.

Costen’s syndrome and overlapping symptoms evaluation

A careful evaluation begins by identifying the dominant symptom and asking what triggers or changes it. Important components may include:

1. Dental and orofacial evaluation: jaw range of motion, joint noises, muscle tenderness, bite history, oral disease, tooth fracture, infection, and signs of inflammatory or degenerative TMJ disease.
2. Ear and hearing evaluation: otoscopy, hearing testing, and vestibular assessment when tinnitus, hearing change, true spinning vertigo, or persistent ear fullness is prominent.
3. Neurologic and headache assessment: particularly for migraine, cranial neuralgia, new sensory loss, weakness, or atypical headache.
4. Cervical assessment: neck range of motion, neurologic findings, trauma history, hypermobility, symptom response to position, and imaging when clinically indicated.
5. Sleep and behavioral assessment: bruxism, sleep apnea risk, medication effects, stress, and parafunctional habits such as prolonged clenching.

Imaging is chosen to answer a specific question. Dental panoramic imaging, cone-beam CT, TMJ MRI, cervical radiographs, CT, MRI, or dynamic studies are not interchangeable, and not every patient needs each test.

Treatment

Most uncomplicated TMD care begins conservatively. Education, avoiding excessive jaw loading, temporary dietary modification, heat or cold, jaw exercises, physical therapy, sleep and stress management, and appropriate medication may be considered according to the diagnosis and the patient’s medical history.

A 2023 clinical practice guideline for chronic TMD pain strongly favored several conservative physical and behavioral approaches, including supervised jaw exercise, mobilization, trigger-point therapy, postural exercise, and usual self-management. Recommendations differed by intervention and certainty of evidence. (13)

Occlusal splints and mouth guards

Splints can protect teeth and may help selected patients, but they are not a universal correction for TMD or ear symptoms. A 2024 Cochrane review of 57 randomized trials found the evidence for occlusal interventions inconclusive and of very low certainty. Full-coverage stabilization splints may reduce some muscle pain when chewing, but reliable superiority over other approaches was not established. (14)

Our practical position is individualized: an appliance that reduces pain and protects teeth without worsening jaw function may be useful. An appliance that produces new pain, altered bite, increasing locking, disequilibrium, or neurologic symptoms should be reassessed. This does not justify the blanket claim that mouth guards cause TMJ or cervical instability.

Botulinum toxin

Botulinum toxin injections may temporarily reduce activity in overactive chewing muscles, but results are inconsistent and the treatment does not repair a displaced disc or lax ligament. A 2024 systematic review and meta-analysis did not find botulinum toxin clearly superior to placebo for TMD pain and reported no consistent advantage for mouth opening or other outcomes. (15)

Repeated injections also require discussion of muscle weakness, changes in chewing, facial asymmetry, dose, cost, and uncertainty about effects on mandibular bone. Botox should be viewed as a selective symptom-management option, not a proven cure for Costen’s syndrome.

Prolotherapy and regenerative injections

At Caring Medical, we may consider Prolotherapy when examination and imaging support symptomatic ligament or capsular injury involving the TMJ or cervical spine. The goal is to treat a suspected structural pain generator, not the diagnostic label “Costen’s syndrome.” Our review of TMJ injection treatment options discusses the available approaches.

Evidence for Prolotherapy specifically for Costen’s syndrome, tinnitus, vertigo, or other otologic symptoms is not established by controlled trials. A patient who improves after treatment represents a clinical outcome, not proof of a universal mechanism. Decisions should be individualized after alternative diagnoses and appropriate conventional care have been considered.

The Caring Medical perspective

Costen’s syndrome remains useful as a historical description of overlapping jaw and ear symptoms, but it should not become a shortcut diagnosis. The strongest current model is that TMD is multifactorial. Ear symptoms can accompany TMD, and neck dysfunction commonly coexists, yet no single finding proves causation.

For patients with persistent jaw, ear, head, and neck symptoms, we look for the dominant pain generator and the factors that keep it active. In a subset with trauma, hypermobility, mechanical neck pain, or position-dependent symptoms, cervical dysfunction or instability may contribute and deserves appropriate evaluation. Our goal is a diagnosis-led plan that remains honest about the level of evidence and coordinates dental, otologic, neurologic, sleep, rehabilitation, and spine care when needed.

Costen’s syndrome

In the video below, Ross Hauser, MD  discusses Costen’s syndrome and his experience treating patients with the various symptoms associated with mandibular joint neuralgia. This article will expand on this video and present explanatory notes.

Transcript Summary: Costen’s Syndrome, TMJ Instability, and the Cervical Spine

Ross Hauser, MD, discusses Costen’s syndrome, a collection of symptoms historically attributed to dental malocclusion, or an uneven bite. These symptoms may include tinnitus, ear fullness, unusual ear sounds, reduced hearing, dizziness, balance problems, migraines, tongue sensations, and TMJ clicking or grinding.

Dr. Hauser explains that dental appliances and bite correction may help some patients, but they do not address the underlying problem in every case. In some patients—particularly those with joint hypermobility or Ehlers-Danlos syndrome—a mouthguard may worsen symptoms.

His clinical perspective is that many cases attributed to malocclusion may instead involve TMJ ligament laxity, cervical instability, forward head posture, or abnormal muscular tension involving the jaw, neck, and hyoid bone. Bruxism, or nighttime clenching, may further stress an already unstable TMJ.

The TMJ is anatomically connected to the middle ear through the discomalleolar, or Pinto’s, ligament. Dr. Hauser proposes that excessive TMJ motion may place abnormal tension on this connection and contribute to tinnitus, ear pressure, or other auditory symptoms.

He also describes the close relationships among the jaw, hyoid bone, styloid process, upper cervical spine, internal jugular vein, vagus nerve, and surrounding muscles. Forward head posture may increase mechanical strain throughout this region. In selected patients, possible positional jugular vein compression may be investigated with dynamic Doppler ultrasound or CT venography.

At Caring Medical, the evaluation may therefore include both the TMJs and cervical spine rather than focusing solely on the patient’s bite. When instability is identified, treatment may include Prolotherapy, cervical curve correction, postural rehabilitation, and strengthening exercises.

Dr. Hauser also emphasizes reducing prolonged downward viewing of phones, improving posture, strengthening the back of the neck, managing stress, addressing nighttime clenching, and developing a calming bedtime routine.

The central message is that Costen’s syndrome symptoms may not originate from dental malocclusion alone. TMJ instability, cervical instability, posture, muscular tension, and the anatomical connections among the jaw, neck, hyoid, and ear may also deserve consideration.

These proposed cervical and ligamentous mechanisms reflect Dr. Hauser’s clinical perspective and have not been established as causes in every patient. Treatment outcomes vary.

Medical disclaimer

This article is for educational purposes only and is not a diagnosis or a substitute for individualized medical or dental care. Symptoms attributed to Costen’s syndrome may arise from conditions requiring dental, otolaryngologic, neurologic, cardiovascular, sleep-medicine, or spine evaluation. Treatment suitability and risks must be assessed by a qualified clinician who has examined the patient.

References

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