Some features of the mandibular articulation as it pertains to otolaryngology

Abstract

Summary Review of a large group of cases in which headache and ear symptoms were shown to be partially or altogether due to disturbed function of the mandibular joint, suggests the frequency of this factor. The descriptions of pain and ear involvement are similar in every respect to some commonly known eye, sinus and ear disorders. Eighty-five cases fall into the pain group, and these include the ones with burning and sensory disturbance about the tongue and pharynx. Only since the return of saliva in the tenth of the group with glossodynia, has this point been obtained in the histories. There are twenty-two cases of glossodynia to date, and among the last twelve, four patients have described constant dryness of the mouth. In each the saliva has returned abundantly during the test treatment. Another in the glossodynia group, with unbearable pain, had excessive saliva, which became normal after relief of pain. Another, not in the painful class, had been diagnosed parotid tumor for twenty-three years. The gland remained enlarged and hard regularly, and at intervals softened, with discharge of a large amount of saliva into the mouth. Increase of vertical dimension of the jaw 3 mm. on the affected side in this case was followed by return of the gland to normal in four months. These various phenomena may be accounted for by records of some earlier experimentation as follows: Heidenhain showed (1878) that stimulation by weak induction shocks of the chorda tympani in dogs caused the submaxillary and sublingual glands to secrete promptly. Further experiment showed that stimulation of sympathetic as well as parasympathetic fibers augments salivary secretion, especially if done simultaneously. However, Czermak (1857) had shown that sympathetic stimulation with strong stimulus to the chorda tympani inhibited with the secretory activity of the submaxillary, and Mislawsky and Smirnow (1893) observed a similar inhibitory effect on the parotid gland by stimulation of the auriculotemporal nerve. A direct parallel seems to be shown between the above classic experiments and the clinical cases reported herewith. Thirty-five cases had varying grades of catarrhal deafness, due either to compression from overclosure or to chronic nasal infection. Four of the ear cases had shortened bone conduction and were not improved by repositioning the jaw; these may be regarded either as VIII nerve deafness, or as examples of microfractures of regions near the otic capsule interfering with transmission of sound waves to the inner ear, as observed by Guild. The dizziness is not typical of toxic labyrinthitis. Analysis indicates that ear symptoms predominate in edentulous mouths whose symptoms develop slowly; this is the pressure effect on eustachian tubes as explained; and that pain symptoms, with or without herpes of the external canal and buccal mucosa, predominate in the cases of natural malocclusion or malocclusion from loss of molar support on one side only. The correction of the jaws and replacement of dentures were done by various dentists, within the patients' acquaintance. The results were generally good except in the few cases of malocclusion of natural teeth presenting great difficulty. It was noted, however, that the cases showing the best results were corrected in several stages, slowly increasing the vertical dimension of the jaw. The prognosis in a given case depends on these factors: (a) the accuracy with which refitted dentures relieve abnormal pressure on the joint, the increase of vertical dimension keeping the moving condyles out of range of dura, chorda tympani and auriculotemporal nerves; (b) the extent of injury to the tube and to the condyle, the meniscus and the joint capsule. Twenty-six patients of the series showed mild herpes of the buccal mucosa, angle of the mouth and external ear canal, all preceded by pain and improving with the disappearance of the other symptoms. Some form of herpes occurs in 20 per cent of mandibular joint cases. The complete relief of eighteen cases of burning tongue is important evidence that the cases of glossodynia without local lesion on the tongue and pharynx are due to irritation from the uncontrolled movement of the condyle. Approximate testing to prove the presence or absence of these factors is done by the use of 2 mm. cork discs, which are placed within the patient's jaw for a short test at the time of the examination, and when not conclusive the patient is given the discs and instructed to carry them within the jaws for a few days, several hours a day. Changes in the nature of the symptoms are reported on his return.