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Secondary Otalgia in an Adult Population
Seppo J. Kuttila, MD;
Marjaana H. Kuttila, DDS, PhD;
Päivi M. Niemi, PhD;
Yrsa B. Le Bell, DDS, PhD;
Pentti J. Alanen, DDS, PhD;
Jouko T. Suonpää, MD, PhD
Arch Otolaryngol Head Neck Surg. 2001;127:401-405.
ABSTRACT
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Objective To analyze the associations of secondary otalgia with general health,
stress, insomnia, bruxism, and recurrent head and neck region pains.
Design A population-based survey.
Setting General community.
Subjects A total of 391 randomly selected subjects (186 men, 205 women) aged
25, 35, 45, 55, or 65 years.
Methods Standardized interview and self-report questionnaires of general health
and stress.
Results Otalgia was statistically significantly associated with all the studied
factors. However, in the whole study group, independent predictors of otalgia
were the obvious need for temporomandibular disorder treatment, high frequency
of stress symptoms, and bruxism. When analyzed in women, the predictors of
otalgia were the obvious need for temporomandibular disorder treatment, high
frequency of stress symptoms, and age. When analyzed in men, recurrent neck
pain was a predictor of otalgia.
Conclusions We suggest that after ruling out otorhinolaryngologic infectious diseases
and temporomandibular disorder in patients with secondary otalgia, the next
step is to explore the frequency of stress symptoms, bruxism, and recurrent
neck pain. Furthermore, women and men may need a different approach in diagnostics
of secondary otalgia. By diagnosing and treating these predictors of otalgia,
it may be possible to reach a more successful outcome.
INTRODUCTION
PAIN RESULTING from a pathologic condition of the ear is called primary otalgia. It is most frequently caused by infectious
diseases in the ear, such as otitis media.1
Other causes of primary otalgia are tumor and trauma. However, according to
Paparella and Jung,1 about half or more of
the patients with otalgia have some other reason for aural pain, called secondary otalgia. Secondary otalgia may arise from diseases
in the paranasal sinuses, nose, and pharynx or, frequently, from temporomandibular
disorder (TMD). In the study by Leonetti et al,2
the most common cause of referred otalgia in patients whose chief complaint
was otalgia with a normal-appearing ear was dental (74%). Furthermore, the
cause of secondary otalgia can also be referred pain from the mouth, teeth,
larynx, or thyroid gland; neural, vascular, or lymphatic structures of the
neck; or the esophagus, heart, or lungs.
According to our previous report,3 in
a random adult population, the prevalence of otalgia without infection varied
from 12% to 16% during a 2-year follow-up. It was more prevalent in the subjects
with an obvious need for treatment of TMDs than in the others and closely
associated with palpatory tenderness of the lateral pterygoid and posterior
digastric muscles and the temporomandibular joint.
The purpose of this study was to examine, in an adult population, the
associations of secondary otalgia with general disease, stress symptoms, insomnia,
bruxism, and head and neck region pains and the power of these factors to
predict otalgia, together with age, sex, and need for TMD treatment.
SUBJECTS AND METHODS
A total of 515 subjects, 246 men and 269 women, born in the years 1927,
1937, 1947, 1957, or 1967, participated in a 2-year follow-up study (March
1992 to November 1993) of TMD and related symptoms. The sample was randomly
drawn from the records representing the population of the municipality of
Jyväskylä, Finland. The present report is based on 391 subjects
(186 men, 205 women) who participated in all 3 consecutive examinations and
interviews, completed a self-report questionnaire at 12-month intervals, and
were not treated for stomatognathic reasons. An experienced clinician (M.H.K.)
performed all the clinical examinations and interviews. Informed consent was
obtained from subjects before participation in the study. The study was approved
by the ethical committee of the Central Hospital in the Province of Middle
Finland. A more detailed description of the sample and clinical examinations
has been published previously.4
After clinical examination, subjects were interviewed using standardized
questions for symptoms related to TMD. One question was asked about whether
otalgia, defined as pain in or around the ear that was not associated with
infections or otitis, had occurred during the last month. The interview also
included 3 questions about insomnia, bruxism, and recurrent head and neck
region pains during the preceding month. Bruxism reported in the interview
was used in analyses and no clinical criteria were used. General health was
assessed with a standardized self-report formula. The severity and disability
of otalgia were not estimated.
The frequency of physical, behavioral, and psychological stress symptoms
was assessed with the Symptoms of Stress Inventory, which is derived from
the Cornell Medical Index.5 The reliability
and validity of the Symptoms of Stress Inventory and its use as a screening
instrument have been shown in both American and Finnish studies.6, 7, 8
For treatment need analyses of TMDs, the classification system by Kuttila
et al4 was used. The classification was based
on anamnestic data, clinical and radiologic findings, and clinician's judgment.
Subjects in the active treatment need subgroup had moderate or severe signs
and subjective symptoms of TMDs, prompting them to seek help or designating
them as needing care independently of other possible oral health problems
(ie, TMDs alone require treatment). Subjects in the passive treatment subgroup
showed some minor signs or symptoms of TMDs, but were assessed as needing
no stomatognathic treatment if no other dental care was considered necessary.
Subjects were classified into the no treatment need subgroup if TMD problems
did not require treatment in any circumstances.
The  2 test was used in analyses of associations of otalgia
with general disease, sleep problems, bruxism, and head and neck region pain.
The Student t test was used in comparing means of
age, number of general diseases, and total stress scores between subjects
with otalgia and those without. Stepwise binomial logistic regression analysis
(SPSS 10.0, SPSS Inc, Chicago, Ill) was used to find independent predictors
of otalgia. The differences in the occurrence of the studied variables were
considered as statistically not significant if P>.05,
almost significant if .05>P>.01, significant if .01>P>.001, and highly significant if .001>P.
RESULTS
The prevalences of the studied variables in the study population are
as follows:
The mean age of subjects with otalgia was 45.4 years, and the mean age
of those without otalgia was 47.4 years. The prevalence of otalgia increased
with age from 10.6% in the 25-year-old age group to 19.7% in the 55-year-old
age group and thereafter decreased to 8.9% in the 65-year-old age group. Women
reported otalgia almost twice as often as did men (16.0% vs 8.6%; 2 = 4.8, P = .03). The same sex difference
in prevalence of otalgia was present in all age groups, but no statistical
significance was revealed, probably because of the small sample sizes.
The prevalence of general disease in the whole study group was 43.7%.
It was 1.4 times more prevalent in the subjects with otalgia than in those
without otalgia (57.1% vs 42.9%; 2 = 4.1, P = .04). The mean number of general diseases was almost 2-fold in
subjects with otalgia compared with those without otalgia (1.0 vs 0.6; F =
12.0, P = .001). However, among subjects with otalgia,
only 1 in 4 had more than 1 general disease. The subjects with otalgia in
general did not have more specified diseases than those without, with the
exception of general arthrosis and cardiovascular disease (Table 1).
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Table 1. Distribution of Subjects With Specified General Disease in
Subjects With and Without Otalgia (N = 391)
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In the whole study group, the mean total score of stress symptoms was
75.7 (men, 71.0; women, 80.1; F = 5.0; P = .03).
The subjects with otalgia had higher mean stress scores than those without
otalgia (100.1 vs 72.3; F = 20.9, P<.001), and
38.8% of them had a total stress score higher than 120 compared with 10.5%
of subjects without otalgia (2 = 28.3, P<.001).
The subjects with secondary otalgia more often had sleep problems than
those without otalgia. Not falling asleep was reported 1.3 times, waking up
more often than once a night was reported 1.9 times, and waking up in pain
was reported 3.2 times as often in subjects with otalgia as in those without
otalgia (Figure 1). The difference
was highly significant in waking up more often than once a night (2 = 13.4, P<.001) and almost significant
in not falling asleep (2 = 5.8, P
= .02) and waking up in pain (2 = 6.6, P = .01).
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Figure 1. Percentage distribution of subjects
with and without otalgia experiencing sleeping problems (n = 391). Subjects
with otalgia more often reported not falling asleep, waking up more often
than once a night, and waking up in pain.
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The prevalence of nocturnal bruxism was 20%; diurnal bruxism, 7%; and
both bruxisms, 4%. Bruxism was reported 1.8 times as often by subjects with
otalgia as those without otalgia (Table
2). Compared with men, women more often reported any symptom of
bruxism, a finding that was statistically significant (37.9% vs 22.7%; 2 = 10.5, P = .001).
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Table 2. Distribution of Subjects With Diurnal, Nocturnal, or Both
Bruxisms Among the Subjects With Secondary Otalgia
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In subjects with otalgia, the prevalence of head and neck region pains
recurring twice a month or more often were higher in subjects with otalgia
than those without: headache was 2.7 times, neck pain 1.7 times, and shoulder
pain 1.6 times as prevalent as in subjects without otalgia (Figure 2). The differences were statistically significant (headache, 2 = 18.7, P<.001; neck pain, 2 = 13.9, P<.001; and shoulder pain, 2 = 11.3, P = .001).
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Figure 2. Percentage distribution of subjects
with and without otalgia experiencing headache, shoulder pain, or neck pain
occurring twice a month or more often (n = 391). Subjects with otalgia more
often reported these symptoms than subjects without otalgia.
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When the studied variables were analyzed together by binomial stepwise
logistic regression analysis, the independent predictors of secondary otalgia
were active need for TMD treatment, total stress symptom score of more than
120, and bruxism (Table 3). The
final model correctly classified 88.2% of subjects overall. However, when
the regression analysis was carried out separately for men and women, the
final model differed. In men, the final model included recurrent neck pain,
and in women, it included active need for TMD treatment, total stress symptom
score of more than 120, and the 55-year-old age group. In men, the final model
correctly classified 91.9% of subjects, and in women, 85.0% of subjects.
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Table 3. Final Models of Binomial Variables Predicting Secondary Otalgia
by Stepwise Logistic Regression Analysis in the Whole Study Group, Men, and
Women*
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COMMENT
Our previous report analyzed the associations of otalgia with signs
and symptoms of TMD and visits to a physician due to otalgia in a random adult
population.3 It was based on a 2-year longitudinal
study of 411 subjects and the first study to report the prevalence of otalgia
without infection in an adult population (12%-16%). The present study is based
on the same study group, but the subjects who did not complete the stress
questionnaire (n = 20) were excluded from the analysis. The subjects and participation
of the study group have been discussed in detail previously.4
The study population was as healthy as Finns in general. The reported
prevalences of general disease and recurrent neck pain were in line with the
studies by Aromaa et al,9 Mäkelä
et al,10 and Takala et al.11
The prevalence of recurrent headache in our study was lower than that reported
by Honkasalo et al12 and Sillanpää,13 and the prevalence of recurrent shoulder pain in
our study was higher than reported by Takala et al11
and Mäkelä et al.14 However, in Swedish
studies by Ekberg et al15 and Westerling and
Jonsson,16 prevalences of shoulder symptoms
were much more in line with our study. The total prevalence of bruxism in
our study is almost the same as in the study by Goulet et al,17
31% and 26%, respectively. However, daytime and nighttime prevalences were
just the opposite between the studies: our figures were 11% and 24% compared
with 20% and 6%, respectively, in the study by Goulet et al. In summary, our
prevalence figures of general disease, recurrent pain in the head and neck
region, and bruxism may not be overestimates but rather the result of different
methods and criteria.
In the present study, 58% of subjects reported some sleeping problem.
This is higher than the 35% in the study by the National Institute of Mental
Health,18 but in line with the figures of TMD
patient studies by Fricton et al19 and Harness
et al.20 In our study, the subjects with otalgia
without infection reported sleep problems more often than those without otalgia.
In TMD patients, according to the study by Fricton et al,19
sleep problems are associated with myofascial pain, and so one could expect
that sleep problems also increase the intensity, duration, or handicap of
secondary otalgia. To summarize, in patients with secondary otalgia, the amount
and quality of sleep should also be evaluated and treated along with other
symptoms.
Beaton et al6 have used a cutoff point
of 100 points of the total stress score to determine which American patients
with TMD would benefit from further psychological consultation. The screening
point of 120 has been suggested for Finnish patients and subjects with TMD.7, 21 In the follow-up study of an adult
population by Kuttila,21 32% to 49% of the
subjects with obvious need for treatment of TMD had a total stress symptom
score of 120 points or more. In the present study, 39% of subjects with otalgia
had a total stress symptom score of 120 or higher, suggesting that these subjects
might also benefit from psychological assessment and consultation.
Many theories suggest that stress is one of the factors making occasional
bruxism occur more frequently and overload the temporomandibular joint and
masticatory muscles, causing pain that can be referred to the ear. This could
explain why individuals with an elevated level of stress symptoms experience
otalgia more often than those with a lower stress level. The findings of our
earlier report support these theories: subjects with an active need for TMD
treatment had higher stress levels and more secondary otalgia than those without.3 In the present study, the prevalence figures for bruxism
were based on interview and not on clinical examination. Therefore, our figures
may underestimate the prevalence of bruxism. This underestimation does not,
however, necessarily affect the revealed association between secondary otalgia
and bruxism.
Concerning sex, regression analysis revealed that women with otalgia
seem to have elevated frequency of stress symptoms, have an obvious need for
TMD treatment, and belong in the 55-year-old age group. In men with otalgia,
recurrent neck pain was the only independent predictor of otalgia. Consequently,
diagnosing and treating otalgia may require a different approach in men than
women. Further investigations are required to identify what kind of stress
symptoms best predict otalgia: is secondary otalgia associated with the occurrence
of multiple symptoms in different organ systems or is otalgia the result of
few but frequently occurring symptoms specifically located in the head and
neck region?
In our earlier report, the association of otalgia with TMD was explained
as referred pain from the lateral pterygoid, deep masseter muscle, or temporomandibular
joint. We concluded that it is important to first rule out infectious otologic
and nasopharyngeal diseases in patients with otalgia and thereafter refer
the patient to a stomatognathically experienced dentist to rule out stomatognathic
causes of aural pain.3 According to this study,
the next step is to explore the frequency of stress symptoms, bruxism, and
recurrent neck pain.
CONCLUSIONS
When analyzed separately, the results showed an association between
otalgia and all the studied factors. However, the independent predictors of
otalgia were an active need for TMD treatment, an elevated level of stress
symptoms, and bruxism. The final models of the predictors of otalgia for men
and women differed. Women and men may, hence, need a different approach in
diagnostics and treatment of secondary otalgia. We suggest that in patients
with otalgia, it is important to first rule out infectious otologic and nasopharyngeal
diseases that may cause aural pain.3 Thereafter,
the patient should be referred to a stomatognathically experienced dentist
to rule out stomatognathic causes of otalgia. If no stomatognathic cause of
otalgia can be found, the next step is to explore the frequency of stress
symptoms, bruxism, and recurrent neck pain. By diagnosing and treating the
predictors of otalgia, it may be possible to achieve a more successful outcome
in secondary otalgia.
AUTHOR INFORMATION
Accepted for publication September 5, 2000.
From the Departments of Otorhinolaryngology (Dr S. J. Kuttila) and
Clinical Dentistry (Dr M. H. Kuttila), Otonhammas, Jyväskylä; Department
of Psychiatry (Dr Niemi), Postgraduate Program in Clinical Dentistry, Institute
of Dentistry (Dr Bell), and Department of Community Dentistry, Institute of
Dentistry (Dr Alanen), University of Turku; and Department of Otorhinolaryngology,
Turku University Central Hospital (Dr Suonpää), Turku, Finland.
Corresponding author and reprints: Seppo J. Kuttila, MD, Otonhammas
Oy, PO Box 612, FIN 40101 Jyväskylä, Finland.
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