Ross Hauser, MD
When balance is off, a person often complains of dizziness or lightheadedness. Dizziness or lightheadedness is a common symptom for those who have TMD or cervical instability.
Otolaryngologists fail to connect TMD and dizziness
A November 2023 paper in the medical journal BMC Oral Health (2) wrote: “Symptoms of temporomandibular disorders (TMD) could be present as otologic symptoms like earache and dizziness in some patients. In most cases, these symptoms are not recognized because otolaryngologists fail to diagnose TMD as a source of the problem.”
In this study, patients who were complaining of otalgia, ear fullness, tinnitus, hearing loss, and dizziness were evaluated and forty patients who had no known otologic or other primary causes to explain their symptoms were referred to the orofacial pain clinic with a possible diagnosis of TMD. If the diagnosis was confirmed by an orofacial pain specialist, a combination of TMD treatments was administered.
According to the researchers, “All patients received standard treatment protocol instructions, including a soft diet, stretching exercises, moist heat, and ice pack, correcting neck posture, and eliminating parafunctional habits.” The results showed that more than 50% of the patients reported complete or partial recovery in the second follow-up.
The study’s authors recommended that in cases with unexplained otologic symptoms, otolaryngologists should explore neck trigger points (TP) and ask about the patient’s parafunctional habits (habits related to the mouth such as bruxism or nail biting) as poor neck posture, cervical trigger points, or these parafunctional habits may be contributing to their TMJ symptoms.
One of the easiest ways to understand how TMD and upper cervical instability affect balance and various symptoms is to consider the Eustachian tube and the vagus nerve
What are we seeing in this image? Proper eustachian tube function vs. dysfunction. The proper opening of the eustachian tube requires the action of the levator veli palatine and tensor veli palatine muscles innervated by the vagus and trigeminal nerves respectively. When these muscles don’t operate optimally, fluid builds up in the middle ear potentially causing ear discomfort, fullness, pressure, pain, dizziness, and even partial or complete hearing loss.
One of the eustachian tube’s functions is the ventilation of the middle ear to equilibrate air pressure in the middle ear with atmospheric pressure and drainage and clearance into the nasopharynx of secretions from within the middle ear. This eustachian tube is innervated by the vagus nerve and mandibular branch of the trigeminal nerve, both of which are affected by TMJ and upper cervical dysfunction or instability.
One of the easiest ways to understand how TMD and upper cervical instability affect balance and various symptoms is to consider the Eustachian tube. The Eustachian tube is a canal that connects the middle ear to the nasopharynx. Its job is to create equal pressure between the outside world and the middle ear. When Eustachian tube dysfunction occurs, there is a disturbing middle ear pressure to inner ear pressure relationship, causing dizziness, vertigo, and imbalance. TMD has been found to affect Eustachian tube function. The structures involved in the vestibular system are responsible for:
- maintaining balance, posture, and the body’s orientation in space
- regulating locomotion and other movements
- keeping objects in visual focus as the body moves
- controlling muscles and joints, sensation in fingertips, palms of the hand, and soles of the feet
- adjusting heart rate and blood pressure
The vestibular system shows the interconnectivity of body functions. Sensory input from the inner ear, sight, and proprioception (from the neck primarily but can be from other parts of the body) go to the cerebellum, which coordinates and regulates posture, movement, and balance. Some of the sensory information also goes to the brainstem and, together with the cerebellum, they figure out what to do with all this information. In order to have balance, we must have the right motor impulses and the right eye movements to make postural adjustments. There is evidence that suggests that upper cervical sensory nerves interact directly with vestibular nuclei in the midbrain to keep us upright and stable. Balance issues, especially after a neck injury point toward the missing diagnosis, cervical instability as being the cause.
Eustachian tube dysfunction is one of several mechanisms by which upper cervical instability can cause lightheadedness, dizziness, imbalance, tinnitus, and vertigo. Upper cervical instability can also produce these symptoms through compression of the vertebrobasilar artery, resistance to cerebrospinal fluid flow, dysautonomia, as well as altered proprioceptive input through mechanoreceptors.
The last is perhaps most important because the brain can only give the right instructions to the rest of the body if it gets the right sensory information. For the body to have the head perfectly balanced on the neck and for the rest of the body to balance on planet Earth, you need exact sensory information coming from the mechanoreceptors to the central nervous system. They have to function at an optimum level at all times. When there is upper cervical instability, this does not occur. Another point that needs to be made is that the upper cervical instability also makes much of the body unable to carry out the commands of the brain even if the commands are correct. So one can see again that upper cervical instability has whole body-damaging effects!
Is it eustachian tube dysfunction or TMJ dysfunction
There is a controversy surrounding the understanding of eustachian tube dysfunction and TMJ dysfunction. Doctors from the Cedars-Sinai Medical Center in Los Angeles, the University of Louisville, and Indiana University wrote in April 2020 in the medical journal Laryngoscope (3) “Symptoms of eustachian tube dysfunction (fullness, pressure and/or pain in the ears) are highly prevalent among patients with TMJD determined by patient-reported outcome measures. It is not clear if these symptoms reflect true derangement of eustachian tube function in these patients or whether there is only clinical similarity between Eustachian tube dysfunction and TMJ dysfunction. However, future research efforts may resolve this dilemma.”
Ocular Stabilization Reflexes
In discussing dizziness related to the cervical spine or TMJ, several reflexes should be addressed that give balance to the body so we don’t fall over or get symptoms such as dizziness or vertigo when upright or changing positions. Balance is provided by automatic reflexes for stabilization of the visual field (vestibulocochlear reflex, VOR) as well as for erect standing (vestibulospinal reflex, VSR) and head position (vestibulocollic reflex, VCR) so that we can have correct posture. All of these reflexes are called ocular stabilization reflexes serve to stabilize the visual image on the retina during head movements. These help us have the proper posture so we can balance and see what we are doing without falling over. When the vestibular system is not working properly, even small head movements can be accompanied by gaze instability and postural imbalance results. The vestibular system is crucial in controlling gaze, balance, and posture, and an imbalance can manifest as a dramatic, sudden onset of vertigo. The vestibulocochlear reflex (VOR) functions to stabilize gaze and ensure clear vision during everyday activities. Vestibular signals from the inner ear go to the vestibular nuclei in the medulla (brainstem), which connect to the cranial nerves that control eye movements. During head movement, the eye movement is equal and opposite to that of head movement. The vestibulospinal (VSR) reflex stabilizes the head and upright posture in relation to gravity.
The vestibulocollic reflex (VCR) serves to stabilize the head position in space. Muscles of the neck respond to input from the vestibular system to provide reflexive head movement. For example, when the head is rotated in relation to the neck, the VCR stabilizes the head position thereby stabilizing gaze direction in space. When the head moves, the vestibulocochlear reflex (VOR) tends to stabilize the image of an object in space on the retina by producing eye movement compensatory to head movement.
In all probability, you have experienced a bout of dizziness at least once in your life, but you may not have analyzed how this phenomenon occurred. Our balance is maintained thanks to the interaction between the visual, vestibular, and spinal systems. The visual system makes us aware of the position of our bodies in relation to our environment; the vestibular system detects various motions such as walking, stopping, turning, or head movements; and the spinal system makes these movements happen. When we move our heads, the fluid within the vestibular system (inner ear) is set in motion, generating an electrical impulse that is carried to our brain for interpretation. When the brain recognizes the impulse as a head movement, it signals our eyes to move in a way that will maintain clear vision during the motion. The brain also signals our muscles to ensure good balance, regardless of whether we are sitting, standing, lying down, or moving.
The vestibular systems in both inner ears must work equally well sending uninterrupted signals to the brain because otherwise one’s sense of balance will be disrupted. When this happens, a person experiences dizziness, lightheadedness, or vertigo with symptoms such as unsteadiness on their feet, feeling woozy, or having a sensation of spinning or floating. Often the person is said to have Meniere’s disease, resulting from an abnormality in the way fluid of the inner ear is regulated; however, no basis for this is ever found. Perhaps the true missing diagnosis is TMJ instability.
Our published research
The association between mandibular position to cervical spine and internal jugular vein diameters in upright position. Have we been ignoring critical generators of head and neck pathology? Lockerman LZ, Hauser R. The association between mandibular position to cervical spine and internal jugular vein diameters in upright position. Have we been ignoring critical generators of head and neck pathology? Cranio. 2023 Sep;41(5):403-406. [Google Scholar]
Dextrose Prolotherapy and Pain of Chronic TMJ Dysfunction Hauser R., Hauser H, Blakemore KA. Dextrose Prolotherapy and Pain of Chronic TMJ Dysfunction. (2007) [Google Scholar]
References
2 García-de la-Banda-García R, Cortés-Pérez I, Ibancos-Losada MD, López-Ruiz MD, Obrero-Gaitán E, Osuna-Pérez MC. Effectiveness of Dry Needling versus Manual Therapy in Myofascial Temporomandibular Disorders: A Single-Blind Randomized Controlled Trial. Journal of Personalized Medicine. 2023 Sep 21;13(9):1415. [Google Scholar]
3 Naderi Y, Karami E, Chamani G, Amizadeh M, Rad M, Shabani M. Temporomandibular treatments are significantly efficient in improving otologic symptoms. BMC Oral Health. 2023 Nov 23;23(1):913. [Google Scholar]
4 Newman AC, Omrani K, Higgins TS, Ting JY, Walgama ES, Wu AW. The prevalence of eustachian tube dysfunction symptoms in temporomandibular joint disorder patients. The Laryngoscope. 2020 Apr;130(4):E233-6. [Google Scholar]