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Tinnitus Related to Temporomandibular Disorders

Original Editor - Ewa Jaraczewska based on the course by Micaela Weinberg

Top Contributors - Ewa Jaraczewska and Jess Bell  

Introduction

Tinnitus—the perception of sound without external auditory stimulus—can be associated with temporomandibular disorders (TMD).[1] When this connection exists, physiotherapists may be able to influence symptoms through careful assessment and targeted treatment. Successful outcomes depend on accurate identification of the type of tinnitus and contributing factors, including jaw pathology and Eustachian tube dysfunction. Physiotherapists must understand the underlying mechanisms, recognise which patients may benefit from intervention, and maintain realistic expectations about outcomes. This page discusses the basic physiology of hearing, different types of tinnitus, and the associations between tinnitus and the temporomandibular joint (TMJ).

Basic Physiology of Hearing

Sound waves travel through the external auditory canal (meatus) and cause the tympanic membrane to vibrate.[2] These vibrations transfer through the ossicles in the middle ear to the cochlea in the inner ear.[3] Within the cochlea, specialised hair cells detect the vibrations and transmit signals via the cochlear nerve to the brain for interpretation.[4] The tympanic membrane is supplied by a branch of the mandibular nerve. The Eustachian tube equalises pressure in the middle ear, allowing the tympanic membrane to vibrate optimally. The middle ear ossicles are mechanically linked to the TMJ through the discomalleolar ligament and the anterior malleolar ligament.[5][6] Movement of these ligaments may influence the malleus and affect how the tympanic membrane transmits sound energy.[6]

[7]

Types of Tinnitus

There are four types of tinnitus: subjective, somatic, objective and neurological.  

Subjective Tinnitus

"Tinnitus is in most cases subjective, meaning that the patient experiences the tinnitus in the absence of any auditory stimulus."[8]

Subjective tinnitus is typically linked to sensorineural damage or hearing loss. This damage to the auditory system often arises from age-related decline, ototoxic medications (e.g., salicylates), noise exposure, or head injuries. It can co-occur with other conditions, such as anxiety or depression, or cervical spine and TMJ dysfunction.[8]

Somatic

Somatic tinnitus is a form of subjective tinnitus. In this type of tinnitus, the frequency or intensity can increase or decrease in response to body movements or positions.[9] Movements that may influence symptoms include jaw clenching, bruxism, eye movements, or applying manual pressure to the TMJ, mastoid process, head, or neck.[10]

Objective

Objective tinnitus is a less common type of tinnitus. The sounds are generated by the ear or surrounding structures. Unlike subjective tinnitus, sounds are audible to the patient and the clinician, and are often detected with a stethoscope.[11] These sounds are typically mechanical or vascular in origin and can be classified by source, including vascular (pulsatile tinnitus), muscular or mechanical (myoclonus), or other structural issues, such as a patulous Eustachian tube.[12]

The clinician's ability to hear the sound aids diagnosis. The perceived noise can be loud, intrusive, and indicative of an underlying medical condition that requires investigation and management.

Neurological

Neurological tinnitus is associated with various neurological conditions and may be an early indicator of central nervous system disease.[13][14] In some patients with severe, disabling, subjective idiopathic tinnitus (predominantly central-type), it may represent a "soft" sign of neurodegeneration in the central nervous system.[15]

Connection Between the Temporomandibular Joint and Tinnitus

Research demonstrates a link between TMD and tinnitus.[16] Patients with severe tinnitus report higher rates of TMD than those with mild or moderate symptoms.[17] This group experiences more severe tinnitus overall and includes more women than men. They can often modify their tinnitus through somatic manipulation and more frequently describe it as pulsating and tonal.[17]

Two key mechanisms explain the influence of the TMJ on tinnitus. First, the vestibulocochlear nerve nucleus overlaps with the trigeminal nerve nucleus in the brainstem. TMJ pathology can cause excessive or atypical signalling from the trigeminal nerve. This may affect vestibulocochlear nerve function, thereby contributing to tinnitus. Reducing TMJ pathology may normalise trigeminal nerve activity and indirectly influence auditory nerve function. Second, the cranial nerve system is extensively interconnected. Modulating one cranial nerve through targeted treatment can influence other cranial nerves, providing additional pathways for TMJ intervention to affect tinnitus.

Physiotherapy Assessment

The assessment begins with open questions, allowing patients to describe their tinnitus experience before becoming more specific.

Establish when symptoms began. This helps determine chronicity—patients with recent onset tinnitus typically respond better to treatment than those with long-standing tinnitus, where neural patterns are more established.[2]

Ask patients how their tinnitus started. While patients frequently report a sudden onset of tinnitus without an obvious cause, common triggers include stressful periods, loud noise exposure (e.g., at a concert), air travel, or scuba diving. Barometric pressure changes during flying may reveal underlying Eustachian tube dysfunction. Many patients do not connect their tinnitus with these events unless specifically asked.[2]

Investigate the type of sound and determine whether tinnitus affects one or both ears.[18] If tinnitus affects only one ear, look for TMJ symptoms on the same side. Ask specifically about jaw clicking, pain, fatigue, or headaches, as patients might not link these symptoms with their tinnitus.

Explore the impact of tinnitus on daily life and sleep quality. Document previous treatments to understand what has been tried, the patient's expectations and their coping strategies.[2]

Outcome Measures

Several validated tools assess different aspects of the impact of tinnitus.

Multidisciplinary Approach

Effective tinnitus management requires collaboration across multiple disciplines.[19] Audiologists can quantify hearing loss and identify patients who would benefit from hearing aids. Ear, nose, and throat (ENT) specialists can exclude any structural pathology, including impacted earwax, infections, acoustic neuroma, and Ménière's disease. Psychological support helps address the emotional impact of tinnitus. Tinnitus is associated with depression and anxiety, and referrals for mental health should be prioritised when indicated. General practitioners investigate systemic contributors to tinnitus, including diabetes, anaemia, thyroid disorders, and hyperlipidaemia.[19][2]

Within this multidisciplinary framework, physiotherapy addresses TMD that may contribute to tinnitus. Assessment findings guide treatment selection, which may target muscle hypertonicity, joint dysfunction, and movement restrictions. However, outcomes depend on addressing all contributing factors.[2]

Management Strategies

Beyond direct TMJ treatment, several strategies support tinnitus management. Stress reduction techniques, including exercise, meditation, and deep breathing, can help downregulate the nervous system.[20] [21] [22] [23] Sleep hygiene is important, as persistent attention to tinnitus can reinforce neural pathways.[24] Pink noise can help mask tinnitus during sleep. Patients unable to sleep due to tinnitus should avoid remaining in bed. Instead, they should get up and engage in quiet activities until drowsiness returns, preserving the bed as a place of sleep.[2]

[25]

Dietary considerations include reducing caffeine intake, as stimulants may exacerbate symptoms.[26] Managing blood sugar levels may also be beneficial. Patient education about these lifestyle factors is a key part of treatment.[2][19]

Summary

When treating tinnitus associated with TMD, physiotherapists should maintain realistic expectations with patients. Success depends on accurate identification of contributing factors, appropriate multidisciplinary collaboration, and patient engagement with both direct treatment and self-management strategies.

Resources

References

  1. ↑ Dipalma G, Inchingolo AD, Pezzolla C, Sardano R, Trilli I, Di Venere D, Inchingolo F, Palermo A, Inchingolo AM. The Association Between Temporomandibular Disorders and Tinnitus: Evidence and Therapeutic Perspectives from a Systematic Review. J Clin Med. 2025 Jan 29;14(3):881.
  2. ↑ 2.0 2.1 2.2 2.3 2.4 2.5 2.6 2.7 Weinberg M. Tinnitus Related to Temporomandibular Disorders Course. Physiopedia Plus, 2026.
  3. ↑ Boedts MJO. Tympanic Resonance Hypothesis. Front Neurol. 2020 Jan 30;11:14.
  4. ↑ Hayes SH, Ding D, Salvi RJ, Allman BL. Anatomy and physiology of the external, middle and inner ear. InHandbook of Clinical Neurophysiology, 2013 Jan 1 (Vol. 10, pp. 3-23). Elsevier.
  5. ↑ Rowicki T, Zakrzewska J. A study of the discomalleolar ligament in the adult human. Folia Morphologica. 2006;65(2):121-5.
  6. ↑ 6.0 6.1 Aristeguieta LM, Acuña LE, Ortiz GP, Ramirez L, Ballesteros A, Sandoval O. A direct anatomical study of the morphology and functionality of disco-malleolar and anterior malleolar ligaments. Int J Morphol. 2009 Jun 1;27(2):367-79.
  7. ↑ National Institutes of Health (NIH). Journey of Sound to the Brain. Available from: https://www.youtube.com/watch?eQEaiZ2j9oc [last accessed 4/2/2026]
  8. ↑ 8.0 8.1 Michiels S, Naessens S, Van de Heyning P, Braem M, Visscher CM, Gilles A, De Hertogh W. The effect of physical therapy treatment in patients with subjective tinnitus: a systematic review. Frontiers in neuroscience. 2016 Nov 29;10:545.
  9. ↑ Han BI, Lee HW, Kim TY, Lim JS, Shin KS. Tinnitus: characteristics, causes, mechanisms, and treatments. Journal of Clinical Neurology (Seoul, Korea). 2009 Mar 31;5(1):11.
  10. ↑ Haider HF, Bojić T, Ribeiro SF, Paço J, Hall DA, Szczepek AJ. Pathophysiology of subjective tinnitus: triggers and maintenance. Frontiers in Neuroscience. 2018 Nov 27;12:866.
  11. ↑ Park SN. Objective tinnitus. Hanyang Med Rev. 2016 May 1;36(2):99-108.
  12. ↑ Salehi PP, Kasle D, Torabi SJ, Michaelides E, Hildrew DM. The aetiology, pathogenesis, and treatment of objective tinnitus: unique case series and literature review. American Journal of Otolaryngology. 2019 Jul 1;40(4):594-7.
  13. ↑ Chu HT, Liang CS, Yeh TC, Hu LY, Yang AC, Tsai SJ, Shen CC. Tinnitus and risk of Alzheimer’s and Parkinson’s disease: a retrospective nationwide population-based cohort study. Scientific reports. 2020 Jul 22;10(1):12134.
  14. ↑ Lechtenberg R, Shulman A. The neurologic implications of tinnitus. Archives of Neurology. 1984 Jul 1;41(7):718-21.
  15. ↑ Shulman A, Goldstein B, Strashun AM. Central nervous system neurodegeneration and tinnitus: a clinical experience. Part I: Diagnosis. Int Tinnitus J. 2007;13(2):118-31.
  16. ↑ Inchingolo AM, Inchingolo AD, Settanni V, De Leonardis N, Campanelli M, Garofoli G, Benagiano S, Malcangi G, Minetti E, Palermo A, Inchingolo F. Correlation between temporomandibular disorders and tinnitus and possible treatment strategies: comprehensive review. Applied Sciences. 2023 Aug 5;13(15):8997.
  17. ↑ 17.0 17.1 Edvall NK, Gunan E, Genitsaridi E, Lazar A, Mehraei G, Billing M, Tullberg M, Bulla J, Whitton J, Canlon B, Hall DA. Impact of temporomandibular joint complaints on tinnitus-related distress. Frontiers in neuroscience. 2019 Aug 22;13:879.
  18. ↑ Shoushtarian M, Esmaelpoor J, Bravo MM, Fallon JB. Objective assessment of tinnitus laterality. PLoS One. 2025 Jun 16;20(6):e0325903.
  19. ↑ 19.0 19.1 19.2 Fabrizia DA, Giuseppe M, Martina C, Patricia RR, Vincenzo G, Ludovica N. Treatment approaches, outcomes and prognostic indicators in patients with tinnitus and temporomandibular disorders evaluated with DC/TMD: A systematic review and Meta‐analysis. Journal of Oral Rehabilitation. 2025 Feb;52(2):230-42.
  20. ↑ Gans J. Mindfulness based tinnitus stress reduction: Unraveling the Gordian Knot of tinnitus. Canadian Audiologist. 2016;3(1).
  21. ↑ Buizza C, Franco E, Ghilardi A, Cela H. A Brief Biofeedback Training, Integrated with Breathing and Relaxation Exercises, in Treating Tinnitus Disorders within Routine Medical Care. Applied Psychophysiology and Biofeedback. 2025 Feb 6:1-2.
  22. ↑ Gunjawate DR, Ravi R. Effect of yoga and meditation on tinnitus: a systematic review. The Journal of Laryngology & Otology. 2021 Apr;135(4):284-7.
  23. ↑ Arif M, Sadlier M, Rajenderkumar D, James J, Tahir T. A randomised controlled study of mindfulness meditation versus relaxation therapy in the management of tinnitus. The Journal of Laryngology & Otology. 2017 Jun;131(6):501-7.
  24. ↑ Unchalo AL, Santos CD, Weingaertner LW, Selaimen FA, Sartor NC, Teixeira AR. Sleep Quality in Patients with Tinnitus. Sleep Science. 2025 Dec;18(04):e372-8.
  25. ↑ Treble Health. 3 BEST Breathing Exercises to Calm Tinnitus Today! Available from: https://www.youtube.com/watch?mq6kEtMHGag [last accessed 4/2/2026]
  26. ↑ Dawes P, Cruickshanks KJ, Marsden A, Moore DR, Munro KJ. Relationship Between Diet, Tinnitus, and Hearing Difficulties. Ear Hear. 2020 Mar/Apr;41(2):289-299.
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