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Revista Española de Cirugía Oral y Maxilofacial

On-line version ISSN 2173-9161Print version ISSN 1130-0558

Rev Esp Cirug Oral y Maxilofac vol.31 n.6 Madrid Nov./Dec. 2009




Functional Alteration of the temporomandibular joint: Infrequent clinical Presentation for external otitis

Alteración funcional de la ATM: Otitis externa de presentación atípica



J.L. Cebrián Carretero3, G. Demaría Martínez2, S. Rivas Vila3

1 Medico Adjunto de Cirugía Oral y Maxilofacial. Hospital Universitario La Paz. Madrid, España
2 Medico Residente de Cirugía Oral y Maxilofacial. Hospital Universitario La Paz. Madrid, España
3 Médica adjunta de Cirugía Pediátrica. Hospital General Universitario Gregorio Marañón. Madrid, España





Introduction: Infectious pathology of the external ear is quite frequent in small children and sometimes appears as an alteration of the temporomandibular joint function. However, acute pathology of this joint is quite rare in this age group and is nearly always preceded by trauma. A complete history and thorough clinical exploration allows for good diagnosis without the need for additional studies.
Patients and Methods: We present three clinical cases that were referred to the Paediatric Maxilofacial Surgery Service of the La Paz Hospital with diagnoses of acute temporomandibular joint (TMJ) pathology. The final diagnosis in all three was acute external otitis (AEO).
Discussion: AEO is the second most frequent cause of otalgia after acute medial otitis. Humidity, repeated traumas and glandular obstruction can promote infection. The clinical symptoms are characterised by pain, itchiness, suppuration and, occasionally, hearing loss. Sometimes mandible movement without malocclusion is painful. The last symptom can cause confusion and lead to an erroneous diagnosis of TMJ pathology, something that is quite rare in children. Childhood TMJ pathology is characterised by painful mouth opening and dental disocclusion. An otoscopy will allow a differential diagnosis of the two clinical entities and avoid an unnecessary radiological exploration.
Conclusion: Given the rarity of TMJ pathology in small children, AEO must be ruled out before subjecting the patient to radiological examination.

Key words: Acute external Otitis; Children; Temporomandibular joint.


Introducción: La Patología infecciosa del oído externo es relativamente frecuente en niños pequeños y en algunas ocasiones presentándose como una alteración de la articulación temporomandibular. Sin embargo, la patología aguda de esta articulación es muy poco frecuente en esta edad de la vida. Si existe, habitualmente es precedida por un episodio de traumatismo. Una adecuada anamnesis y exploración física suele resultar en un diagnostico acertado sin realizar pruebas complementarias adicionales.
Materiales y métodos: Presentamos tres casos clínicos derivados al Servicio Pediátrico de Cirugía Oral y Maxilofacial del Hospital Universitario La Paz con el diagnóstico de patología ATM aguda. El diagnóstico final en los tres casos fue otitis externa aguda (OEA).
Discusión: La OEA es la segunda causa mas frecuente de otalgia después de la otitis media aguda. La humedad, los traumas repetidos y la obstrucción glandular pueden promover la infección. Los síntomas incluyen dolor, prurito, supuración y en ocasiones pérdida auditiva. En ocasiones el movimiento mandibular sin maloclusión es doloroso. Este síntoma puede causar confusión e inducir a un diagnóstico erróneo de patología articular, lo cual es muy poco frecuente en niños. La patología de ATM en niños se caracteriza por dolor durante la apertura oral asociando disoclusión. Una correcta otoscopia permitirá realizar el diagnostico diferencial entre ambas entidades y evitar exploraciones radiológicas innecesarias.
Conclusión: Debido a la poco frecuente presentación de patología ATM en niños pequeños, la OEA debe ser descartada antes de someter al paciente a exámenes radiológicos complementarios.

Palabras clave: Otitis externa aguda; Niños; ATM.



An acute infection of the external ear, which is frequent in small children, basically involves pain that is occasionally accompanied by other symptoms such as irritability and rejection of food.1 Children express pain in many different ways, and occasionally external otitis may simulate other clinical conditions.

Contrary to acute external otitis (AEO), acute pathology of the TMJ is very uncommon in children, and is almost always related to mandible trauma that has affected the condylar region.2 In these cases the clinical manifestations are pain upon mandible movement and altered dental occlusion. Inability to close the mouth is relatively rare and usually indicates luxation of the temporomandibular joint.

This paper reviews the clinical history of three patients who came to our hospital emergency room with pain in the TMJ region and were unable to close their mouth. They had been falsely diagnosed with temporomandibular joint luxation. The otolaryngologeal examination definitively diagnosed their AEO.


Case 1

A three year old girl came to the maxillofacial surgery because repeated episodes of TMJ luxation during the previous month. The episodes were attacks lasting a few minutes during which she could not close her mouth and were resolved once the girl fell asleep after the administration of analgesics. The only pertinent antecedent was chronic juvenile arthritis of the knees that was being controlled with low corticoid doses. Suspecting a possible arthritic affectation of the temporomandibular joint, the paediatrician had requested x-rays of both TMJ and sent the girl to our Department. The physical exploration found no signs of joint affectation; her dental occlusion was good and mandible mobility acceptable. Although, it was mildly painful when opening and closure were forced/stressed. The otoscopic examination revealed flaking and erythema of the external auditory duct and pain when placing the otoscope into the canal. The x-ray was normal. Once the diagnosis of external otitis was made the patient was sent to the otolaryngology service, where symptoms were relieved with appropriate treatment.


Case 2

A thirty-month boy was brought to the emergency room because of intense pain when he closed his mouth. The paediatric service evaluated the patient and diagnosed TMJ luxation and referred him to the emergency maxillofacial surgeon. During our examination the boy was restless with a semi-open mouth, which however had good occlusion despite the pain when we forced his mouth shut. He had no fever or ear suppuration. A panoramic x-ray of the maxilla and mandible was performed without revealing any pathology. When we questioned the mother, she reported that several children had oto-laryngeal infections in the child's nursery school. The definitive diagnosis was made after the otoscopic examination revealed signs of acute external otitis. The clinical symptoms remitted with appropriate treatment.


Case 3

A Twenty-five month old boy who was referred to the emergency maxillofacial surgery unit by his paediatrician because of inability to close the mouth, salivation and rejection of his bottles. The day before he had fallen and hit his nose while playing at the pool, and therefore had some scraping at the base of the nose. Based on the clinical symptoms and prior incident, the child was diagnosed with traumatic luxation of the TPM joint. The clinical exploration observed pain in the preauricular region of both sides that worsened when the mouth was closed; the "swallow sign" was positive. Nevertheless it was possible to completely close the mouth with reduction manoeuvres and his dental occlusion was good. The otoscopy was very painful and the external auditory canal was inflamed with mild scaling and suppuration. An x-ray of both TMJ showed no abnormalities and the patient was referred to the Head and Neck Department, where the appropriate treatment relieved the symptoms.



External ear infectious pathology in childhood causes between 5 and 20% of all paediatric otolaryngeal consultations3 and is considered to be the second most frequent cause after acute middle otitis of otalgia in childhood.2

Whether localised or diffuse, external ear inflammation is associated with several predisposing factors such as repeated trauma- which provokes scaling - epidermal maceration from water and/or humidity and glandular obstruction. The incidence peaks in the summer, the most frequent season for middle otitis5,6 the typical clinical symptoms are characterised by otalgia, itching, suppuration and hearing loss that may be more or less intense. Around 40% of cases have a micro organic aetiology,3 most frequently P.aeruginosa or S. aureus.4

Differential diagnosis of otalgia in children requires the proper use of an otoscope. Pain can only be considered referred when the otoscopic observations are normal. Any pathology of the TMJ is rare in childhood and normally is related with trauma to the mandible and chin that provoke alterations in the condylar region. It is characterised by painful mouth opening and dental malocclusion.7 Other pathologies like dysfunction pain syndrome and luxation are caused by joint wear and appear at later ages.8,9

Mandible luxation disconnects the chondyle from the glenoid fossa and therefore from the joint cavity; the condyle remains above and lateral to the cavity. Closing the mouth when there is anterior luxation is impossible. It is possible when there is a lateral luxation although there will be very bad dental occlusion.

The erroneous diagnoses of the three cases presented here were brought about by two factors: relatively uncharacteristic clinical symptoms and inadequate exploration.

All of the case histories contained data that were ignored but that would have ruled out the possibility of joint pathology. The three children maintained good mandible mobility and the dental occlusion were not altered. Regarding the possibility of otitis, the first case was the most complicated because of the preexisting joint pathology; even though the torpid clinical symptoms and the improvement with analgesics could have given us some indication of TMJ pathology. Nevertheless, the other two cases had antecedents that suggested infectious otical aetiology, to wit: the small out break in the nursery school and the humidity that should have been associated with the visit to the pool.

The cause of the inability to close the mouth in external otitis is easily understood in light of the anatomy of the temporomandibular joint (Fig. 1). If we remember that in some areas of the external ear, the external auditory duct is separated from the mandible condyle only by a very thin osseous lamina, we will realize that once this structure reaches its resting position - in the most posterosuperior of the glenoidal cavity - it may press against the conduct. Which, if the conduct is inflamed it will be quite painful (Fig. 2). On the contrary, when the mouth is open, the condyle moves forward relieving the compressive symptoms. For a child with external otitis, open mouth is an antialgic position but closing the mouth doesn't involve any physical limitation although it is painful, the mouth can be closed.


The treatment of external otitis requires appropriate hygiene, topical antibiotics and antiseptics and non steroid systemic anti-inflammatories. Systemic antibiotherapy is not generally recommended in children although some authors do suggest it.1



Given the rarity of acute TMJ pathology in small children, when the clinical symptoms are not totally characteristic, the existence of external otitis should be ruled out before subjecting the patient to radiological examination.



Dr. Gastón Demaría Martínez
Avda. Juan Carlos I, 23 1oE
28220 Majadahonda, Madrid. España

Recibido: 15.11.2006
Aceptado: 30.11.2009




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