Ear, Nose and Throat Disorders

Temporo-Mandibular Joint Dysfunction/Syndrome (“TMJ”)

Open your jaw all the way and shut it. This simple movement would not be possible without the Temporo-Mandibular Joint (TMJ). Even though it is only a small disc of cartilage, it separates the bones so that the mandible may slide easily whenever you talk, swallow, chew, kiss, etc. Therefore, damage to this complex, triangular structure in front of your ear, can cause considerable discomfort.

Where is the Temporo-Mandibular Joint?

You can locate this joint by putting your finger on the triangular structure in front of your ear. Then move your finger just slightly forward and press firmly while you open your jaw all the way and close it. You can also feel the joint motion in your ear canal.

​How does the Temporo-Mandibular Joint work?

​When you bite down hard, you put force on the object between your teeth and on the Temporo-Mandibular Joint. In terms of physics, the jaw is the lever and the TMJ is the fulcrum. Actually, more force is applied (per square foot) to the joint surface than to whatever is between your teeth because the cartilage between the bones provides a smooth surface, over which the joint can freely slide with minimal friction.

​Therefore, the forces of chewing can be distributed over a wider surface in the joint space and minimize the risk of injury. In addition, several muscles contribute to opening and closing the jaw and aid in the function of the TMJ.

​What causes TMJ pain?

​In most patients, pain associated with the TMJ is a result of displacement of the cartilage disc that causes pressure and stretching of the associated sensory nerves. The popping or clicking occurs when the disk snaps into place when the jaw moves. In addition, the chewing muscles may spasm, not function efficiently, and cause pain and tenderness.

​Damage to the TMJ is often caused by…

  • ​Major and minor trauma to the jaw
  • Teeth grinding
  • Excessive gum chewing
  • Stress and other psychological factors
  • Improper bite or malpositioned jaws
  • Arthritis

What are the symptoms?

  • ​Ear pain
  • Sore jaw muscles
  • Temple/cheek pain
  • Jaw popping/clicking
  • Difficulty in opening the mouth fully
  • Frequent headaches
  • Neck pain

The ear pain may be sharp and searing, occurring each time you swallow, yawn, talk, or chew, or it may be dull and constant. It hurts over the joint, immediately in front of the ear, but pain can also radiate elsewhere. It often causes spasms in the adjacent muscles that are attached to the bones of the skull, face, and jaws. Then, pain can be felt at the side of the head (the temple), the cheek, the lower jaw, neck and the teeth.

​Many patients come to the ear specialist quite convinced their pain is from an ear infection. When the earache is not associated with a hearing loss and the eardrum looks normal, the doctor will consider the possibility that the pain comes from TMJ.

​There are a few other symptoms besides pain that TMJ can cause. It can make popping, clicking, or grinding sounds when the jaws are opened widely. Or the jaw locks wide open (dislocated). At the other extreme, TMJ can prevent the jaws from fully opening. Some people get ringing in their ears from TMJ.

With today’s constant computer and cell phone usage a common side effect is a TMJ disorder.

TMJ disorders can often be missed by a physician as it can often be referred to by the patient as an earache, ear ringing, sinus pressure or pain or sinus headache , and/or a fullness sensation in the throat or a post nasal drip feeling

How is TMJ pain treated?

Because TMJ symptoms often develop in the head and neck, otolaryngologists are appropriately qualified to diagnose TMJ problems. Proper diagnosis of TMJ begins with a detailed history and physical, including careful assessment of the teeth occlusion and function of the jaw joints and muscles. An early diagnosis will likely respond to simple, self-remedies:

  • Rest the muscles and joints by eating soft foods.
  • Do not chew gum or chewy foods like apples, carrots and hard breads.
  • Avoid clenching or tensing.
  • Ice over the joints
  • Relax muscles with moist heat (1/2 hour at least twice daily).
  • Anti-inflammatory medications eg. Ibuprofen, naproxen
  • Muscle relaxers

In cases of joint injury, apply ice packs soon after the injury to reduce swelling. Relaxation techniques and stress reduction, patient education, non-steroidal anti-inflammatory drugs, muscle relaxants or other medications may also offer relief.

​Other treatments for advanced cases may include fabrication of an occlusal splint to prevent wear and tear on the joint, improving the alignment of the upper and lower teeth.

​After diagnosis, your otolaryngologist may suggest further consultation with a physical therapist, your dentist and oral surgeon to facilitate further management of TMJ syndrome.

​Mouth Sores

​Oral lesions (mouth sores) make it painful to eat and talk. Two of the most common recurrent oral lesions are fever blisters (also known as cold sores) and canker sores. Though similar, fever blisters and canker sores have important differences.

​What are fever blisters?

​Fever blisters are fluid-filled blisters that commonly occur on the lips. They also can occur on the gums and roof of the mouth (hard palate), but this is rare. Fever blisters are usually painful; pain may precede the appearance of the lesion by a few days. The blisters rupture within hours, then crust over. They last about seven to ten days.

Why do fever blisters reoccur?

Fever blisters result from a herpes simplex virus that becomes active. This virus is latent (dormant) in afflicted people, but can be activated by conditions such as stress, fever, trauma, hormonal changes and exposure to sunlight. When lesions reappear, they tend to form in the same location.

Are fever blisters contagious?

Yes, the time from blister rupture until the sore is completely healed is the time of greatest risk for spread of infection. The virus can spread to the afflicted person’s eyes and genitalia, as well as to other people.

How are fever blisters treated?

Treatment consists of coating the lesions with a protective barrier ointment containing an antiviral agent, for example 5% acyclovir ointment. While there is no cure now, scientists are trying to develop one, so hopefully fever blisters will be a curable disorder in the future.

Tips to prevent spreading fever blisters

  • Avoid mucous membrane contact when a lesion is present.
  • Do not squeeze, pinch or pick the blisters.
  • Wash hands carefully before touching eyes, genital area or another person.

NOTE: Despite all caution, it is possible to transmit herpes virus even when no blisters are present.

What are canker sores?

Canker sores (also called aphthous ulcers) are different than fever blisters. They are small, red or white shallow ulcers occurring on the tongue, soft palate or inside the lips and cheeks; they do not occur in the roof of the mouth or the gums. They are quite painful, and usually last 5-10 days.

Who is most likely to get canker sores, and what causes them?

Eighty percent of the U.S.population between the ages of 10 to 20, most often women, get canker sores. The best available evidence suggests that canker sores result from an altered local immune response associated with stress, trauma or irritation. Acidic foods (e.g., tomatoes, citrus fruits and some nuts) are known to cause irritation in some patients.

Are canker sores contagious? How are they treated?

Because they are not caused by bacteria or viral agents, they are not contagious and cannot be spread locally or to anyone else. Treatment is directed toward relieving discomfort and guarding against infection. A topical corticosteroid preparation such as triamcinolone dental paste (Kenalog in Orabase 0.1%®) is helpful. Chemical cautery of the lesion can speed healing.

When should a physician be consulted?

Consider consulting a physician if a mouth sore has not healed within two weeks. Mouth sores offer an easy way for germs and viruses to get into the body, so it is easy for infections to develop.

People who consume alcohol, smokers, smokeless tobacco users, chemotherapy or radiation patients, bone marrow or stem cell recipients, or patients with weak immune systems should also consider having regular oral screenings by a physician. The first sign of oral cancer is a mouth sore that does not heal.

What kind of screenings are performed?

The physician will most likely examine the head, face, neck, lips, gums and high-risk areas inside the mouth, such as the floor of the mouth, the area under the tongue, the front and sides of the tongue, and the roof of the mouth or soft palate. If a suspicious lesion is found, the physician may recommend collecting and testing soft tissue from the oral cavity.

Tips to prevent mouth sores

  • Stop smoking.
  • Reduce stress.
  • Avoid injury to the mouth caused by hard tooth brushing, hard foods, braces or dentures.
  • Chew slowly.
  • Practice good dental hygiene, including regular visits to the dentist.
  • Eat a well-balanced diet.
  • Identify and eliminate food sensitivities.
  • Drink plenty of water.
  • Avoid very hot food or beverages.
  • Follow nutritional guidelines for multivitamin supplements.

What are other types of oral lesions to be concerned about?

​Leukoplakia

​A thick, whitish-color patch that forms on the inside of the cheeks, gums or tongue. These patches are caused by excess cell growth and are common among tobacco users. They can result from irritations such as ill-fitting dentures or the habit of chewing on the inside of the cheek. Leukoplakia can progress to cancer.

​Candidiasis

​A fungal infection (also called moniliasis or oral thrush) that occurs when yeast reproduce in large numbers. It is common among denture wearers and most often occurs in people who are very young, elderly, debilitated by disease, or who have a problem with their immune system. People who have dry mouth syndrome are very susceptible to candidiasis. Candida may flourish after antibiotic treatment, which can decrease normal bacteria in the mouth.

​Hairy Tongue

​A relatively rare condition caused by the elongation of the taste buds. It can be caused by poor oral hygiene, chronic oral irritation or smoking.

​Oral Cancer

​It may appear as a white or red patch of tissue in the mouth, or a small ulcer that looks like a common canker sore. Other than the lips, the most common areas for oral cancer to develop are on the tongue and the floor of the mouth. Other symptoms include a lump or mass that can be felt inside the mouth or neck, pain or difficulty in swallowing, speaking or chewing, any wart-like mass, hoarseness that lasts for more than two weeks, or any numbness in the oral/facial region.

​Voice Disorders

​Laryngitis

​Is an inflammation of the voice box (larynx). Symptoms are an unnatural change of voice, such as hoarseness, or even loss of voice that develops within hours to a day or so. The throat may tickle or feel raw, and a person may have a constant urge to clear the throat. Symptoms vary with the severity of the inflammation

​Vocal cord nodules/polyps

​Vocal cord nodules are small growths on both vocal folds that are caused by vocal abuse. Polyps can appear on either one or both vocal cords. Their appearance varies from a swelling or bump (like a nodule) to a stalk-like growth or a blister-like lesion.

​Vocal cord paralysis

​Everyone has two vocal cords in his or her larynx. The vocal cords vibrate during speech to produce voice. If one or both vocal cords are paralyzed, and are unable to move, then the person will experience voice problems and possibly breathing and swallowing problems.

​How Are Vocal Disorders Treated?

​The treatment of hoarseness depends on the cause. Most hoarseness can be treated by simply resting the voice or modifying how it is used.

​What can I do to prevent and treat mild hoarseness?

  • ​If you smoke, quit.
  • Avoid agents which dehydrate the body, such as alcohol and caffeine.
  • Avoid secondhand smoke.
  • Drink plenty of water.
  • Humidify your home.
  • Watch your diet: Avoid spicy foods.
  • Try not to use your voice too long or too loudly.
  • Use a microphone in situations where you need to protect your voice.
  • Seek professional voice training. Avoid speaking or singing when your voice is injured or hoarse. Don’t sing when you are sick.

When Should I See an Otolaryngologist (ENT doctor)?

  • ​Hoarseness lasting longer than two weeks, especially if you smoke.
  • Pain not from a cold or flu.
  • Coughing up blood.
  • Difficulty swallowing.
  • Lump in the neck.
  • Loss or severe change in voice lasting longer than

Dizzyness

​Feeling unsteady or dizzy can happen due to poor circulation, vertigo, injury, infection, allergies, or neurological disease. Dizziness is treatable but it is important for your doctor to help you determine the cause so that the correct treatment is used.

What is dizziness?

Dizziness can be described in many ways, such as feeling lightheaded, unsteady, or giddy. Vertigo is a type of dizziness experienced as an illusion of movement of self or the environment and is usually unpleasant. Others experience dizziness associated with motion sickness, a nauseating feeling brought on by the motion of riding in an airplane, on a roller coaster, or aboard a boat. Dizziness, vertigo, and motion sickness all relate to the sense of balance and equilibrium. Your sense of balance is maintained by a complex interaction of the following parts of the nervous system:

What causes dizziness?

Circulation: If your brain does not get enough blood flow, you feel lightheaded. Almost everyone has experienced this on occasion when standing up quickly from a lying down position. But some people have light-headedness from poor circulation on a frequent or chronic basis. This could be caused by arteriosclerosis or hardening of the arteries, and it is commonly seen in patients who have high blood pressure, diabetes, or high levels of blood fats (cholesterol). It is sometimes seen in patients with inadequate cardiac function, low blood sugar, or anemia.

Certain drugs also decrease the blood flow to the brain, especially stimulants such as nicotine and caffeine. Excess salt in the diet also leads to poor circulation. Sometimes circulation is impaired by spasms in the arteries caused by emotional stress, anxiety, and tension.

If the inner ear fails to receive enough blood flow, the more specific type of dizziness occurs, that is, vertigo. The inner ear is very sensitive to minor alterations of blood flow and all of the causes mentioned for poor circulation to the brain also apply specifically to the inner ear.

Vertigo: Benign paroxysmal positional vertigo (BPPV), labyrinthitis, Ménière’s syndrome (fluctuating hearing usually in one ear, pressure in the ear, ringing in one ear, and attacks of spinning), and some forms of migraine are all causes of vertigo. BPPV occurs when you change the position of your head (typically lying down or sitting up), while inner ear infections can cause labyrinthitis.

A skull fracture: that damages the inner ear produces a profound and incapacitating vertigo with nausea and hearing loss. The dizziness will last for several weeks, and then slowly improve as the normal (other) side takes over.

Infection: Viruses can attack the inner ear and its nerve connections to the brain. This can result in severe vertigo, but hearing is usually spared. However, a bacterial infection such as mastoiditis that extends into the inner ear will completely destroy both the hearing and the equilibrium function of that ear. The severity of dizziness and recovery time will be similar to that of a skull fracture.

Allergy: Some people experience dizziness and/or vertigo attacks when they are exposed to foods or airborne particles (such as dust, molds, pollens, dander, etc.) to which they are allergic.

Neurological diseases: A number of diseases of the nerves can affect balance, such as multiple sclerosis, syphilis, tumors, etc. These are uncommon causes, but your doctor will think about them during the examination.

When should I seek medical attention?

Call 911 or go to an emergency room if you experience:

  • A head injury
  • Fever over 101°F, headache, or very stiff neck
  • Convulsions or ongoing vomiting
  • Chest pain, heart palpitations, shortness of breath, weakness, a severe headache, inability to move an arm or leg, or change in vision or speech, or
  • Fainting and loss of consciousness for more than a few minutes.

Consult your doctor if you:

  • ​have never experienced dizziness before,
  • experience a difference in symptoms you have had in the past,
  • suspect that medication is causing your symptoms, or
  • experience hearing loss.

How will my dizziness be treated?

​The doctor will ask you to describe your dizziness and answer questions about your general health. Along with these questions, your doctor will examine your ears, nose, and throat. Some routine tests will be performed to check your blood pressure, nerve and balance function, and hearing.

​Possible additional tests may include a CT or MRI scan of your head, special tests of eye motion - ENG—electronystagmography or VNG—videonystagmography and in some cases, blood tests or a cardiology evaluation. Your doctor will determine the best treatment based on your symptoms and the cause of them

​Prevention tips:

  • ​Avoid rapid changes in position.
  • Avoid rapid head motion (especially turning or twisting).
  • Eliminate or decrease use of products that impair circulation, e.g., tobacco, alcohol, caffeine, and salt.
  • Minimize stress and avoid substances to which you are allergic.
  • Get enough fluids• Treat infections, including ear infections, colds, flu, sinus congestion, and other respiratory infections

If you are subject to motion sickness:

  • ​Do not read while traveling.
  • Do not sit in a seat facing backward.
  • Do not watch or talk to another traveler who is having motion sickness.
  • Avoid strong odors and spicy or greasy foods immediately before and during your travel.
  • Talk to your doctor about medications.

Remember: Most cases of dizziness and motion sickness are mild and self-treatable. But, severe cases and those that become progressively worse deserve the attention of a doctor with specialized skills in diseases of the ear, nose, throat, equilibrium, and neurological systems.

​Tinnitis (Ear ringing)

​Nearly 36 million Americans suffer from tinnitus or head noises. It may be an intermittent sound or an annoying continuous sound in one or both ears. Its pitch can go from a low roar to a high squeal or whine. Prior to any treatment, it is important to undergo a thorough examination and evaluation by your otolaryngologist. An essential part of the treatment will be your understanding of tinnitus and its causes.

​What causes tinnitus?

​Most tinnitus comes from damage to the microscopic endings of the hearing nerve in the inner ear. The health of these nerve endings is important for acute hearing, and injury to them brings on hearing loss and often tinnitus. If you are older, advancing age is generally accompanied by a certain amount of hearing nerve impairment and tinnitus. If you are younger, exposure to loud noise is probably the leading cause of tinnitus, and often damages hearing as well.

​There are many causes for “subjective tinnitus,” the noise only you can hear. Some causes are not serious (a small plug of wax in the ear canal might cause temporary tinnitus). Tinnitus can also be a symptom of stiffening of the middle ear bones (otosclerosis).

​Tinnitus may also be caused by TMJ (jaw joint) problems, allergy, high or low blood pressure, a tumor, diabetes, thyroid problems, injury to the head or neck, and a variety of other causes including medications such as anti-inflammatories, antibiotics, sedatives, antidepressants, and aspirin. If you take aspirin and your ears ring, talk to your doctor about dosage in relation to your size.

​Treatment will be quite different in each case of tinnitus. It is important to see an otolaryngologist to investigate the cause of your tinnitus so that the best treatment can be determined.

How is tinnitus treated?

In most cases, there is no specific treatment for ear and head noise. If your otolaryngologist finds a specific cause of your tinnitus, he or she may be able to eliminate the noise. But, this determination may require extensive testing including X-rays, balance tests, and laboratory work. However, most causes cannot be identified. Occasionally, medicine may help the noise. The medications used are varied, and several may be tried to see if they help.

What are some other tinnitus treatment options?

  • Alternative treatments
  • Amplification (hearing aids)
  • Cochlear implants or electrical stimulation•
  • Cognitive therapy
  • Drug therapy
  • Sound therapy
  • TMJ treatment

Can other people hear the noise in my ears?

​Not usually, but sometimes they are able to hear a certain type of tinnitus. This is called “objective tinnitus,” and it caused either by abnormalities in blood vessels around the outside of the ear or by muscle spasms, which may sound like clicks or crackling inside the middle ear.

​Can children be at risk for tinnitus?

​Yes, children are at risk too. However, it is not a common complaint. Like people of all ages, children who are exposed to loud noises are at a higher risk for tinnitus. High-decibel recreational events, like car races, music concerts, or sports games, can damage children’s ears. Hearing protection devices should always be worn.

​Tips to lessen the severity of tinnitus

  • ​Avoid exposure to loud sounds and noises.
  • Get your blood pressure checked. If it is high, get your doctor’s help to control it.
  • Decrease your intake of salt. Salt impairs blood circulation
  • Avoid stimulants such as coffee, tea, cola, and tobacco
  • Exercise daily to improve your circulation
  • Get adequate rest and avoid fatigue.
  • Stop worrying about the noise. Recognize your head noise as an annoyance and learn to ignore it as much as possible.

What can help me cope?

​Concentration and relaxation exercises can help to control muscle groups and circulation throughout the body. The increased relaxation and circulation achieved by these exercises can reduce the intensity of tinnitus in some patients.

​Masking out the head noise with a competing sound at a constant low level, such as a ticking clock or radio static (white noise), may make it less noticeable. Tinnitus is usually more bothersome in quiet surroundings. Products that generate white noise are available through catalogs and specialty stores.

​Hearing aids may reduce head noise while you are wearing them and sometimes cause the noise to go away temporarily, if you have a hearing loss It is important not to set the hearing aid at excessively loud levels, as this can worsen the tinnitus in some cases. However, a thorough trial before purchase of a hearing aid is advisable if your primary purpose is the relief of tinnitus.

​Tinnitus maskers can be combined within hearing aids. They emit a competitive but pleasant sound that can distract you from head noise. Some people find that a tinnitus masker may even suppress the head noise for several hours after it is used, but this is not true for all users.

​Hearing Loss

​Loss of hearing is described by varying degrees, not percentages. Hearing loss may be mild, moderate, moderately-severe, severe or profound and vary across pitches. It is determined by a simple hearing test as the amount of volume loss you experience compared to an average of many other adult listeners with normal auditory systems. The volume, or intensity, of sounds you hear is measured in decibels (dB), 0 dB being the softest whisper and 120 dB being a jet engine. The softest sounds one can hear are called thresholds. Normal hearing thresholds for adults are considered 0 to 25 dB.

​Conductive Hearing Loss

​Occurs when there is a problem with the way sound is conducted to the inner ear or cochlea. The problem may lie in the outer ear (lobe or ear canal), eardrum (tympanic membrane), or the middle ear (ossicles and eustachian tube). The inner ear remains unaffected in this type of hearing loss.

​Some causes of conductive hearing loss can include outer or middle ear infections, complete earwax blockage, deterioration of the middle ear bones (ossicles), fixation of the ossicles (otosclerosis), a hole in the tympanic membrane, or absence of the outer ear or middle ear structures.

​Conductive hearing losses may be temporary or permanent, depending on the source of the problem. Medical management can correct some cases of conductive hearing loss, while amplification may be a recommended treatment option in more long-standing or permanent cases.

​Individuals with conductive hearing loss may report that sounds are muffled or quiet. Generally, when sounds are made louder, these individuals can hear well again.

​Sensorineural Hearing Loss

​Occurs when there is a problem with the sensory receptors, in the cochlea of the inner ear. The majority of sensorineural hearing loss occurs as a result of an abnormality or damage to the hair cells in the cochlea. This abnormality prevents sound from being transmitted to the brain normally, resulting in a hearing loss.

​The hair cells may have been abnormal since birth (congenital), damaged as a result of genetics, infection, drugs, trauma or over-exposure to noise, or damaged as a result of the aging process, a kind of hearing loss known as presbycusis (pres-be-cue-sis).

​Sensorineural hearing losses are generally permanent and may stay stable or worsen over time. Routine hearing tests are needed to monitor the hearing loss. Amplification, including hearing aids or cochlear implants in the most severe cases, is a common treatment recommendation.

​Individuals with sensorineural hearing loss may report muffled speech, ringing in the ears (tinnitus), difficulty hearing in background noise or that others do not speak clearly.