Temporal Tendonitis explained by Dr. Wesley Shankland

Temporal tendonitis (or, tendinitis) is perhaps one of the most common craniofacial pain disorders seen in clinical practice. Unfortunately, this widespread problem is frequently confused and misdiagnosed as an intra-articular temporomandibular joint disorder, tension-type headaches, or even maxillary sinusitis. The reason for this misdiagnosis is two-fold. First, temporal tendonitis is not well known or understood by the dental profession, and its existence is virtually unknown within the medical profession. Second, the symptoms of temporal tendonitis are similar to these other common disorders and therefore, dentists, physicians and chiropractors alike immediately make a diagnosis based primarily upon their training and background without further investigation.

Simply defined, temporal tendonitis is inflammation of the temporal tendon as it inserts into the coronoid process of the mandible. Dr. Edwin Ernest, Dr. Shankland’s mentor, demonstrated that microscopically, there is evidence of degeneration and temporalis muscle tissue cellular loss, as well as loss of the appearance of the tendon. This degeneration occurs in Sharpey’s fibers, which insert the temporalis muscle into the coronoid process.

The diagnosis of temporal tendonitis is relatively simple. Three criteria of the following four should be fulfilled in order to establish the diagnosis and to differentiate it from other disorders, particularly displacement of the ipsilateral temporomandibular joint disk.

First, historical reporting by the patient is important. Usually, the patient will recall an incident where his or her mouth had been opened for a long period of time. Gaining access for an endodontic procedure, a restorative procedure, oral surgery or intubation is quite commonly reported. Also, the patient may mention a recent increase in stress, which correlates with the onset of symptoms.

Further, he or she may report mandibular trauma from a fall or injury, which also correlates with the first recollection of symptoms.

Second, tenderness upon palpation of the temporal tendon is characteristic of temporal tendinitis. Often, when students and residents are taught to perform a muscle palpation test of the muscles of mastication, they are fooled when they believe they are palpating the lateral pterygoid as they are actually palpating the temporal tendon.

Third is radiographic evaluation. Those suffering from temporal tendonitis, especially of a chronic nature, may exhibit elongation of the coronoid process in comparison with the ipsilateral condylar process, but also with the opposite coronoid process.

Lastly, the most accurate and definitive diagnostic test is a local anesthetic block of the deep temporal nerves, which provide the somatosensory innervation of the temporalis muscle and its tendon. The temporal tendon is actually comprised of two tendinous attachments, a long medial head and a shorter lateral head. Blocking the deep temporal nerves will greatly serve to reduce or eliminate all of the patient’s symptoms if the correct diagnosis is temporal tendinitis. Probably the most dramatic effect of this injection will be the elimination of the patient’s complaint of ear pressure.

One note of caution concerning the establishment of a diagnosis of temporal tendonitis: this disorder often presents concurrently with other craniofacial disorders, such as anterior dislocation of the ipsilateral articular disk of the temporomandibular joint, Ernest syndrome, myofascial pain dysfunction, or even maxillary sinusitis. So, if one diagnosis is an internal derangement of the joint, one should not overlook the possibility that temporal tendonitis is also present.

Treatment for temporal tendinitis is simple and straightforward. As with other inflammatory disorders, the real culprit is the inflammation itself. Treatment needs to be aimed at elimination of this natural, but destructive process. Treatment is either conservative or surgical. Conservative therapy consists of several steps. After anesthetic confirmation of the disorder a combination of an anti-inflammatory medication and a long acting anesthetic are injected into the temporal tendon. Sarapin is preferable to avoid the possible effects of steroid injections (viz, tissue necrosis, stimulation of osteonecrosis, and degenerative arthritis). An anti-inflammatory medication is usually prescribed as well. A soft diet is recommended and if the patients clenches or grinds when sleeping, an NTI appliance is usually used as well.

Temporal headaches and associated symptoms relating to the styloid process and its attachments

. 1995 Jan;24(1):124-8.

E Wong 
¹
, G Lee, D T Mason

Affiliations

Affiliation

• ¹ Head and Neck Pain Center, Honolulu, Hawaii, USA.

• PMID:

  7605081

E Wong et al.

Ann Acad Med Singap.

1995 Jan.

. 1995 Jan;24(1):124-8.

Authors

E Wong 
¹
, G Lee, D T Mason

Affiliation

• ¹ Head and Neck Pain Center, Honolulu, Hawaii, USA.

• PMID:

  7605081

Abstract

The styloid process is a slender spike-like bony process that is attached to the base of the skull that has been of interest to physicians for centuries. From this process is the attachment for five structures–three muscles and two ligaments are attached to it. Any of these soft tissues of the styloid process are prone to be torn due to trauma by way of detachment of the periosteum from the bone. These lesions may occur from auto accidents, falls, sports injuries, to prolonged medical or dental procedures requiring excessive mouth opening. The detachment of Sharpey’s fibres results in the release of noxious chemicals such as kinins, histamines, prostaglandins, etc, which can produce a withdrawal reflex, causing muscle tension, ischaemia, spasm and pain. Pain transmission via C fibres may induce a host of autonomic responses as well. We have observed 11 common pains and symptoms that are associated with soft tissue lesions of the styloid process and stylomandibular ligament. They are (1) headaches localised in the anterior temporal fossa, (2) sore throat and difficulty swallowing in the absence of inflammation, (3) pain radiating to the temporomandibular joint and ear, (4) voice alteration, (5) dry, non-productive cough, (6) pain in the masseter muscle, (7) restricted mandibular opening or the “closed lock”, (8) development of the “open lock”, (9) sinusitis, congested stuffy nose or post nasal drip, (10) tinnitus, and (11) excessive lacrimation and bloodshot eyes. A few drops of local anesthetic into the styloid process and stylomandibular ligament attachment can temporarily relieve the pain and symptoms.(ABSTRACT TRUNCATED AT 250 WORDS)

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causes, symptoms, diagnosis and treatment

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• Mastoiditis is an inflammation of the mucous membrane of the mastoid process of the temporal bone. It is located behind the auricle, has a cellular structure and is normally filled with air. The disease is most often secondary, with the exception of injuries.

  Causes

  The most common route of infection is from the middle ear during suppurative otitis media. Pathogens can be different:
  – streptococcus;
  – staphylococcus aureus;
  – moraxella;
  – hemophilic or Pseudomonas aeruginosa;
  – mycobacteria.

  Rare is the spread of infection through the bloodstream in the presence of a primary focus of tuberculosis, syphilis or sepsis.

  Primary infection develops in case of various injuries (traumatic brain injury, gunshot wound, fall, blow, etc.). A decrease in local and / or general immunity increases the likelihood of developing mastoiditis. Risk factors include:
  – rheumatoid arthritis;
  – bronchitis;
  – diabetes mellitus;
  – hepatitis;
  – pyelonephritis.

  Violation of the anatomical integrity of the middle ear may be a trigger factor for the development of the disease.

  Symptoms

  The first signs of illness appear approximately seven days after the onset of the primary illness or injury. These symptoms are not specific:

  • Deterioration of general condition.
  • Headache.
  • Febrile body temperature.
  • Sleep problems.

  After some time, patients begin to complain of tinnitus, a feeling of blood pulsation, pain in the behind the ear area, spreading to the face (eyes, upper jaw). Objectively, the skin over the mastoid process is edematous, hot to the touch, red, sharply painful when touched. In severe cases, discharge of pus from the ear is observed.

  Diagnostics

  Otorhinolaryngologists, in addition to collecting anamnesis and complaints, use the following research methods:

  • Otoscopy. The upper and posterior walls of the ear canal are edematous, the tympanic membrane swells, and pus is visualized.
  • Microotoscopy.
  • Audiometry and tuning fork tests (mastoiditis may cause hearing loss).
  • Ear culture to detect bacteria and determine their susceptibility to antibiotics.
  • X-ray of the temporal bone.
  • CT or MRI of the skull.
  • Clinical blood test (increased white blood cell count, elevated ESR).

  Treatment

  For therapy:

  • Broad-spectrum antibiotics.
  • Non-steroidal anti-inflammatory drugs.
  • Immunomodulators (interferon stimulators).
  • Disinfectants.
  • Antiallergics.

  As a surgical aid, the mastoid process is drained, opened and the damaged cells are removed, and, if necessary, a complete resection of the bone.

  The most common complications are:
  – neuritis of the facial nerve;
  – thrombophlebitis and phlebitis;
  – labyrinthitis;
  – encephalitis, meningitis, brain abscesses;
  – sepsis.

  There is no specific prophylaxis. It is recommended to treat inflammation of the middle ear in a timely and complete manner, to prevent hypothermia and injuries.

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Mastoiditis: symptoms, diagnosis and treatment

Otolaryngologist for adults and children

Synebogov

Stanislav Vladimirovich

Experience 27 years

Otorhinolaryngologist of the highest category, candidate of medical sciences, member of the European Rhinologic Society (European Rhinologic Society)

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An infection that enters the body can manifest itself in the most unexpected way. So, with acute otitis media, the patient sometimes develops a concomitant disease – mastoiditis of the ear. This is the name of the inflammation of the mastoid process of the temporal bone, which has an infectious etiology. The symptoms noted during the development of the inflammatory process are characteristic of any type of infectious diseases: soreness and hyperemia of the skin behind the ear, painful pulsation, fever, swelling of tissues and hearing loss resulting from swelling. It is possible to make a diagnosis on the basis of a visual examination: on palpation, a seal in the region of the temporal bone, caused by suppuration, is clearly felt. You can cope with the disease conservatively or surgically, blocking the development of purulent foci and destroying pathogenic microorganisms with antibiotics.

Disease etiology

The mastoid process of the temporal bone is located behind the auricle. Its internal structure is a set of communicating cells with dense partitions. The features of the bone structure of the process are considered the norm:

• with pneumatic construction – many large air cells;
• with a diploetic structure – small cells filled with bone marrow;
• with a sclerotic structure – an almost complete absence of cells.

The development of left-sided or right-sided mastoiditis largely depends on the structure of the mastoid process. The smaller the cells, the lower the likelihood of inflammation and its spread throughout the structure of the bone tissue. More often, mastoiditis with inflammation is noted in patients with a pneumatic bone structure. Its development is due to the spread of infection from the tympanic cavity in acute otitis media or chronic suppurative otitis media. It is dangerous to start pathology due to the possible spread of suppuration to neighboring tissues and complete hearing loss.

Causes

Depending on the causes that caused otitis media and its complications, the following types of mastoiditis are distinguished:

• otogenic – due to the spread of infection to the parotid tissues in the absence of timely treatment of acute otitis media. The causative agents are staphylococci, pneumococci, streptococci or influenza bacillus. The development of the inflammatory process is facilitated by a small opening of the eardrum, a violation of the outflow of pus and its accumulation, closing the ear opening with granulation tissue;
• hematogenous – a type of disease that develops as a secondary infection with syphilis, tuberculosis and other infectious diseases;
• traumatic form of mastoiditis – is the cause of damage to the mastoid process upon impact, injury or traumatic brain injury. The accumulation of blood in the area of ​​damage and the violation of the process of its drainage serves as a favorable environment for the development of infection.

Activation of the inflammatory process is facilitated by:

• weakening of the body’s immune defenses;
• pathology of the nasopharynx, the presence in the patient’s history of chronic diseases;
• changes in the structure of the auricle after previous diseases;
• high virulence (degree of pathogenicity) of an infection that has entered the body.

Pathogenesis. Stages of disease progression

The initial stage of the disease is called exudative. The development of chronic mastoiditis begins with inflammation of the mucous cells of the mastoid process with the simultaneous development of periostitis (inflammation of the periosteum) and the accumulation of exudate in the bone cavity. Puffiness of the tissues, together with the accumulation of fluid, blocks the communication between the cells and the passage between the tympanic cavity and the mastoid process, thereby “clogging” the infectious process. Due to a violation of ventilation in the cells, the air pressure in them drops, and under the influence of internal pressure, transudative fluid from the blood vessels begins to flow into the affected area. Mixed with pus, it quickly fills all the cells of the mastoid process. The first stage of the disease lasts about 10 days, in children – up to 6 days.

The second stage is profilative-alternative. Purulent inflammation passes to the bone walls and partitions, contributing to the development of osteomyelitis. The partitions are destroyed, and one cavity is formed inside the bone tissue, filled with purulent contents. The disease acquires a typical or atypical form. The second is characterized by a sluggish course and a weak symptom.

Symptoms in adults

The appearance of signs of mastoiditis can be observed simultaneously with signs of otitis media, but more often it is noted after 7-10 days from the moment the underlying disease manifests itself. In adults, the complication makes itself felt by fever, headache, sleep disturbance, and a state of general intoxication. In the complaints of patients, indications of pulsation and noise in the ear, hearing impairment, and sharp pain when trying to touch the skin near the auricle prevail. Pain radiates along the nerve fibers to the upper jaw and temporal region of the head. At the same time, there is an abundant outflow of purulent contents from the auditory canal, redness of the behind-the-ear region, protrusion of the auricle caused by swelling of nearby tissues. The breakthrough of the purulent cavity is accompanied by severe pain, thrombosis of the vessels and the development of periosteal necrosis with the formation of a percutaneous fistula.

Complications

In advanced cases, in the absence of timely medical care, the acute development of unilateral or bilateral mastoiditis can lead to:

• neuritis of the facial nerve;
• thrombophlebitis;
• purulent mediastinitis, when pus penetrates into the space of the cervical spine;
• brain abscess, encephalitis;
• damage to the eyeball, development of phlegmon or endophthalmitis;
• sepsis, pharyngeal process.

When to see a doctor

The first signs of otitis media or mastoiditis require timely examination by a specialist, qualified treatment and constant monitoring. You should abandon attempts at self-treatment and contact an otolaryngologist for additional diagnosis and development of a treatment course.

Diagnostics

It is possible to make an accurate diagnosis already with a visual examination of the behind-the-ear region of the patient’s head. Difficulties in diagnosis can only be caused by atypical mastoiditis, when the symptoms are either completely absent, or are rather weakly expressed, or are similar to the manifestations of a number of infectious diseases. Additional studies of instrumental and laboratory diagnostics include otoscopy, microotoscopy, bacteriological culture of ear discharge, radiography and computed tomography. In the picture of the temporal region, veiled cells, “clogged” with purulent contents, and barely visible septa are clearly visualized. If necessary, a neurosurgeon, dentist, ophthalmologist and other highly specialized doctors are involved in the diagnosis.

Adult treatment

The treatment course is developed taking into account the etiology of the disease and its complexity, the age of the patient and the general condition of the body. As a drug therapy, a course of antibiotics is prescribed to stop inflammation and destroy the causative agents of mastoiditis. To remove the painful symptoms and traces of edema in acute purulent mastoiditis, antihistamines, formulations for stimulating the immune system, and anti-inflammatory drugs allow. To remove purulent contents with mastoiditis, a sanitizing or general cavity operation is used in the behind-the-ear region of the head. Surgical opening of the process allows you to clean the cells from pus and perform drainage to restore the bone structure. Through the opening of the middle ear, purulent exudate is removed by washing.

How to make an appointment with the specialists of JSC “Medicina”

You can make an appointment with the specialists of JSC “Medicine” (clinic of academician Roitberg) on ​​the website – an interactive form allows you to choose a doctor by specialization or search for an employee of any department by name and surname. The schedule of each doctor contains information about visiting days and hours available for patient visits.