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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_5184_Библиотеки_им_академика_М_И_Перельмана.pdf
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3 Case 2
3.1 Conductive Hearing Loss
Resulting fromEustachian
Tube Dysfunction Initiated by
TMJ Disorders. When
Measuring Makes
theDierence
Symptoms of mild hearing loss occurring in
childhood may go unnoticed. The early detection
of this disability is vital. Various physical and
psychological activities of children and adolescents may be affected due to hearing impairment.
The conductive hearing loss resulting from
Eustachian tube dysfunction initiated by TMJ
disorders is often not considered; however, it is
essential to think about this etiologic origin.
There are two general types of hearing loss,
conductive and sensorineural. Conductive hearing loss results from a disruption in the passage
of sound from the external ear to the oval window.
Anatomically, this pathway includes the ear
canal, tympanic membrane, and ossicles (middle
ear). Such loss may be due to cerumen impaction,
tympanic membrane perforation, otitis media/
middle ear effusion, otosclerosis, intra-aural
muscle dysfunction, or displacement of the ossicles by the malleolar ligament.
Sensorineural hearing loss results from otologic abnormalities within the cochlea and auditory nerve (CN VIII). Such abnormalities may
affect the sensory cells of the cochlea or the
neural bers of the eighth cranial nerve. Hearing
loss from loud noise exposure or from advanced
age (presbycusis) is an example of sensorineural
hearing loss. Cerebellopontine angle tumors
rarely lead to such hearing loss.
3.2 Case Report
An 11-year-old male patient arrived at the clinic
for consultation complaining of headache, pain
on the back of the head, shoulder pain, neck
pain, hand numbness, tingling in hands, and
limited mouth opening. The patient also reported
pain in the left ear, a sensation of ear blockage
on the left, as well as tinnitus and diminished
hearing in both ears. An antecedent of trauma on
the chin in early childhood is relevant to the
patient’s medical history. It is also important to
consider a history of recurrent ear and throat
infections and severe pneumonia that required
hospitalization when he was 8 months old. A
signicant overbite and lack of space for the
correct positioning of the left maxillary canine
can be seen (Fig. 17). One can observe in
Figs. 18 and 19 (1) the superior and posterior
position of the left condylar process in the articular cavity when the jaw is in the position of
maximum intercuspation. Rectication of the
cervical spine is observed in this radiograph
(Fig.20).
The disc is slightly anteriorly dislocated
(Fig.21a) in the right TMJ; Fig. 21b the same
Fig. 17 Patient’s habitual occlusion (above). Upper and lower occlusal view (below)
TMJ Pathology Treatment
Fig. 18 Patient’s panoramic radiograph
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Fig. 19 Patient temporomandibular joint laminography, open and closed mouth
image is given with a color highlight. The anterior dislocation is more evident in the left TMJ
Fig. 21c, where the head of the mandible is
backed on the retrodiscal zone; Fig. 21d the
same image is given with a color highlight. We
can also observe anterior facets on both the right
and left mandibular heads. Both mandibular
condyles cannot translate, limiting mouth opening (Fig.22). Anterior right and left temporalis
muscles, right and left masseter muscles, right
and left digastric muscles, and right and left
superior trapezius muscles are recorded in
dynamic surface electromyography (Fig.23) (2)
in habitual occlusion, open mouth, close mouth,
bite clenching, and to swallowing in this order
for this exam.
One can see the activation of the digastric
muscles when the patient closes the mouth. These
muscles should be active when opening but not
closing. During the examination, there was an
activation of the right and left upper trapezius
muscles, even when the patient was instructed to
lower his shoulders. He had activated both trapezii throughout the examination. Because of the
patient’s reported hearing symptoms, we
requested an audiogram, which can be seen in
Fig.24 from the patient’s otorhinolaryngologist.
An audiogram is produced by using a relative
measurement of the patient’s hearing as compared
with an established “normal” value. It is a graphic
representation of auditory threshold responses
that are obtained from testing a patient’s hearing
with pure-tone stimuli. The parameters of the
audiogram are frequency, as measured in cycles
per second (Hz), and intensity, as measured in
decibels (dB). The rst audiometry of the patient
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Fig. 20 Patient’s lateral radiograph
revealed a mild hearing loss in his left ear and
moderate hearing loss in his right ear. Hearing
loss is classied as mild when the ear is unable to
detect sounds below 40 dB, which makes it difcult to understand human speech. In the moderate
loss, sounds below 70 dB are not heard.
The mandibular rest position was recorded
after electronic deprogramming, together with
the information from the MRI to orient decisions
regarding bite registration, for the threedimensional construction of the orthotic (Figs.25
and 26). The patient had a pathological free space
of 8.6mm and 8mm of mandibular retro- position.
The retrusion of the mandible, whether iatrogenically induced or because of malocclusion, often
results in otalgia due to excessive compression of
the neurovascular retrodiscal tissues. The patient
can feel ear pain. The degree of compression
determines the degree of pain for the patient.
The parents of the patient were informed that
the priority at this stage was the patient’s health,
focusing on improving function, controlling
L. Yavi ch
symptoms, and observing the response of conductive hearing loss to the treatment. Hearing
loss resulting from Eustachian tube dysfunction,
initiated by craniomandibular disorders, is usually subjective; for this reason, there is a need for
objective control by audiometry. It was decided
to stage corrective orthodontics.
The installed orthotic is controlled through
surface electromyography (SEMG) to evaluate
its function (Fig.27). A signicant reduction in
digastric muscle activity was realized, the
trapezius muscles were not activated during
clenching, and the masseter muscles increased
their activity. Controlling the orthotic with SEMG
is important to check the improvement of motor
unit recruitment and the requirement for recalibration or orthotic substitution. It takes time and
effort to stabilize the muscles and the TMJ, when
possible, during treatment; this time and effort
vary with different patients, different ages, and
different pathologies. Even a decompressed joint
takes time to recover. Some structural lesions can
be recovered, while others cannot.
The patient’s third audiogram shows normal
thresholds in the left and in the right ear (Fig.28).
With the normalization of the conductive hearing
loss, the remission of symptoms, and the improvement of images from the exams, second phase of
the TMJ treatment commenced. This includes
three-dimensional orthodontics, neuromuscular
physiological rehabilitation, or a combination of
both, to remove the orthotic used during the rst
phase of the treatment (Fig. 29). In the second
phase, the use of the orthotic during the active
eruption of the teeth must be continued, and the
mandible should maintain the best position possible to that which was achieved with the rst
orthotic. This means equilibrium with the muscular planes and the temporomandibular joint.
In tridimensional orthodontics, during the
active eruption of the teeth in the second phase of
TMJ treatment, the orthotic is changed and/or
recalibrated, as required (Fig.30). Not every case
will allow the implementation of a second phase
of treatment. There are cases where the TMJ is
severely damaged and/or patients with active
autoimmune diseases will have an affected joint
(Fig.31). There was no recovery of the physio-
ab
cd
TMJ Pathology Treatment
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Fig. 21 MRI T1: Left and right TMJ sagittal slice, closed mouth before treatment
logical lordosis apparent in the patient’s cervical
spine image; however, an improvement can be
seen (Fig.32). The mouth opening of the patient
improved from 32.9 to 38.9mm and also reached
an optimum speed regarding mouth opening and
closing (Figs.33 and 34).
The SEMG after the two phases of treatment
demonstrates the symmetry between the anterior
temporal muscles and between the masseter muscles. There is very low digastric muscle activity
(Fig.35a). The habitual trajectory is not coincident with the neuromuscular trajectory seen
before the treatment Fig. 35b. The habitual trajectory is tridimensionally coincident with the
neuromuscular trajectory after treatment.
Tridimensional orthodontics needs to maintain
the tridimensional position of the mandible in
balance with its osseous and muscular planes as
close as possible to the result obtained in the rst
phase. The conductive hearing loss resulting
from Eustachian tube dysfunction initiated by
temporomandibular disorders is often not considered (Fig. 36). The early detection of this deciency is vital.
230
ab
cd
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Fig. 22 MRI T1: Sagittal slice, left and right TMJ open mouth before treatment
TMJ Pathology Treatment
a
b
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Fig. 23 (a) Initial kinesiographic and (b) initial electro-
myographic record. In the kinesiographic record (a), there
is a reduced speed when the patient opens and closes his
mouth, and limited mouth opening to only 32.9 mm.
There is no coincidence between the opening and closing
trajectories in the sagittal view of the record
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Fig. 24 Threshold tonal audiometry
TMJ Pathology Treatment
Fig. 25 Graphic for mandible tridimensional position after electronic deprogramming together with the MRI image of
the left TMJ, which was more compromised
233
a
b
Fig. 26 Patient’s comparative occlusions (a) with the orthotic and (b) habitual occlusion
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a
b
Fig. 27 Comparative electromyographic recordings, (a) orthotic in place and (b) in habitual occlusion
Fig. 28 Comparison of patient’s rst, second, and third audiometry during treatment
TMJ Pathology Treatment
235
Fig. 29 From top to bottom, a sequence of three-dimensional orthodontics in the second phase of the treatment of TMJ
disorders