Psychoacoustic characteristics of tinnitus in temporomandibular disorders: a systematic review

Picinini, Taís de Azevedo; Moraes, Ingrid Eismann; Chaves, Karen Dantur Batista; Lessa, Alexandre Hundertmarck; Unchalo, Adriana Laybauer Silveira; Teixeira, Adriane Ribeiro

doi:10.1590/2317-1782/e20250343pt

person Taís de Azevedo Picinini

methodology · data curation · writing · original draft · writing · review · editing

schoolPrograma de Pós-graduação em Saúde da Comunicação Humana, Universidade Tuiuti do Paraná – UTP - Curitiba, PR, Brasil.

0000-0001-8524-3594

person Ingrid Eismann Moraes

conceptualization · investigation · data curation · writing · original draft · writing · review · editing

schoolCurso de Fonoaudiologia, Universidade Federal do Rio Grande do Sul – UFRGS - Porto Alegre (RS), Brasil.

0009-0000-8754-7575

person Karen Dantur Batista Chaves

methodology · writing · original draft · writing · review · editing

schoolDepartamento de Odontologia Conservadora, Faculdade de Odontologia, Universidade Federal do Rio Grande do Sul – UFRGS - Porto Alegre (RS), Brasil.

0000-0003-2658-801X

person Alexandre Hundertmarck Lessa

writing · original draft · writing · review · editing

schoolDepartamento de Saúde e Comunicação Humana, Instituto de Psicologia, Serviço Social, Saúde e Comunicação Humana, Universidade Federal do Rio Grande do Sul – UFRGS - Porto Alegre (RS), Brasil.schoolServiço de Fonoaudiologia, Hospital de Clínicas de Porto Alegre – HCPA - Porto Alegre (RS), Brasil.

0000-0002-3083-8934

person Adriana Laybauer Silveira Unchalo

methodology · data curation · writing · original draft · writing · review · editing

schoolServiço de Fonoaudiologia, Hospital de Clínicas de Porto Alegre – HCPA - Porto Alegre (RS), Brasil.

0000-0003-0713-9016

person Adriane Ribeiro Teixeira

conceptualization · investigation · data curation · writing · original draft · writing · review · editing

schoolDepartamento de Saúde e Comunicação Humana, Instituto de Psicologia, Serviço Social, Saúde e Comunicação Humana, Universidade Federal do Rio Grande do Sul – UFRGS - Porto Alegre (RS), Brasil.schoolServiço de Fonoaudiologia, Hospital de Clínicas de Porto Alegre – HCPA - Porto Alegre (RS), Brasil.

0000-0003-4242-1666

Conflict of interests:

nothing to declare.

Correspondence address: Adriane Ribeiro Teixeira Departamento de Saúde e Comunicação Humana, Instituto de Psicologia, Serviço Social e Saúde e Comunicação Humana, Universidade Federal do Rio Grande do Sul – UFRGS Rua Ramiro Barcelos, 2600, Porto Alegre (RS), Brasil, CEP: 90035-003. E-mail:
adriane.teixeira@gmail.com

Editor:

Ana Carolina Constantini.

Author and Year (Country/Study Design)	Sample, Age, and Sex	Objective	Assessment	Evaluated Tinnitus Characteristics	Results	Conclusion
Author and Year (Country/Study Design)	Sample, Age, and Sex	Objective	Procedures	Evaluated Tinnitus Characteristics	Results	Conclusion
Cassol et al.(¹⁰), 2019 (Brazil) / Descriptive observational cross-sectional study	53 patients: 7 males and 46 females; ages ranging from 22 to 69 years, with a mean age of 41 years.	To investigate the auditory health of individuals with tinnitus associated with TMD during the pre-dental treatment stage.	Conventional pure-tone audiometry (PTA)	Tinnitus laterality	Tinnitus showed a strong association with the side affected by TMD, occurring on the same side in 52 out of the 53 participants analyzed (98%). When bilateral TMD was observed, tinnitus was also bilateral and more intense on the side where TMD was more severe.	All patients with TMD, regardless of the presence of tinnitus, should be referred for audiological monitoring.
			Speech audiometry	Aural fullness and otalgia	Unilateral tinnitus was reported by the majority of participants and was associated with the presence of aural fullness (77%) and absence of otalgia (53%).
			Acoustic immittance measures		Most participants presented bilateral hearing thresholds within normal limits (RE = 43%; LE = 50%), followed by moderate hearing loss (RE = 30%; LE = 25%), as well as poorer performance in high-frequency audiometry (HFA) compared with conventional pure-tone audiometry (PTA).
			High-frequency audiometry (HFA)		Fifty percent of the participants showed absence of transient evoked otoacoustic emissions (TEOAE), despite normal conventional audiometry findings.
			Otoacoustic emissions (OAE)
Kanji and Khoza-Shangase(¹³), 2013 (South Africa) / Exploratory, comparative, non-experimental pilot study	20 participants:	To identify the clinical signs and symptoms of tinnitus in patients with TMD.	Questionnaire (adapted from the tinnitus questionnaire of the Carolina Ear and Hearing Clinic [2005]) related to tinnitus perception and the impact of tinnitus on the individual’s lifestyle.	Pitch, loudness, tinnitus onset, duration, and location	In the group without TMD (Group B), the majority of participants (8 out of 10) reported tinnitus with constant frequency and duration, whereas in the group with TMD (Group A), only 3 out of 10 reported this pattern. All participants in Group A described tinnitus as a single sound, whereas three participants in Group B reported multiple sounds. The sounds most frequently reported in Group A were “ringing” and “whistling,” whereas in Group B the predominant descriptions were “ringing” and “buzzing.”	The characteristics of tinnitus in patients with TMD differed from those observed in patients without TMD.
	Group A with TMD: 10 participants (1 male and 9 females)		Conventional pure-tone audiometry (PTA)		Regarding loudness, no statistically significant difference was observed between the groups; however, the group with TMD presented lower mean loudness (25.4 dB) compared with Group B (33.5 dB). Concerning pitch, eight participants in Group A matched their tinnitus to 6 kHz (6 with pure tone and 2 with narrowband noise). In the group without TMD, half of the participants matched tinnitus to 8 kHz, three to 1 kHz, one to 3 kHz, and one to 250 Hz narrowband noise.	Tinnitus may occur in patients with TMD and may present as high-frequency tinnitus, highlighting the importance of careful evaluation in patients with tinnitus, as this may have implications for both diagnosis and clinical management.
	Group B without TMD: 10 participants (5 males and 5 females)		Speech audiometry
			Acoustic immittance measures
			Psychoacoustic tinnitus measurements
Lacerda et al.(¹²), 2016 (Brazil) / Descriptive observational cross-sectional study	19 individuals with TMD, with a predominance of females in the sample (89.47%).	To evaluate the impact of tinnitus on the quality of life of patients with TMD.	Pure-tone audiometry, acuphenometry, and the Brazilian version of the THI questionnaire.	Time since symptom onset, sound description, location, type, duration, and frequency	A total of 63.12% of participants had experienced tinnitus for less than five years, and 15.79% described tinnitus sounds resembling whistling, rain, and/or crickets.
	The mean age was 53.5 years (range: 26 to 72 years).				Regarding laterality, there was a predominance of right-ear tinnitus (42.11%), and 52.63% of participants reported continuous tinnitus.	A significant correlation was observed between THI scores, tinnitus duration, and frequency of occurrence.
					Audiometric evaluation demonstrated mean hearing thresholds above 25 dB HL at frequencies of 3000, 4000, 6000, and 8000 Hz bilaterally.	The tinnitus reported by patients with TMD caused a moderate impact on quality of life and could be perceived even in the presence of background noise, although daily activities could still be performed.
					Acuphenometry revealed a mean tinnitus loudness of 21 dB SL in the right ear and 17.85 dB SL in the left ear, whereas the mean tinnitus pitch was 3775 Hz in the right ear and 3750 Hz in the left ear.
					The total THI score was 37.8 points.

Vielsmeier et al.(¹⁴), 2011 (Germany) / Case-control study	30 patients with a confirmed diagnosis of TMD and tinnitus compared with a group of 61 patients with tinnitus but without subjective complaints of TMD.	To investigate differences in clinical and demographic characteristics between the groups.	Otorhinolaryngological evaluation, including otoscopy and pure-tone audiometry.	Age at onset, type of onset (gradual or abrupt), type of tinnitus (pulsatile or non-pulsatile), loudness, tinnitus awareness/perception, masking, somatosensory modulation, hyperacusis, and tinnitus-related handicap assessed through the THI	Patients with tinnitus and TMD presented better auditory function (P < 0.0005), lower age (P = 0.001), and earlier tinnitus onset age (P = 0.002), in addition to being more frequently female (P = 0.003). These patients also reported lower subjective tinnitus loudness (P = 0.01) and greater ability to modulate tinnitus through jaw or neck movements (P = 0.001).	Classical risk factors for tinnitus (age, male sex, and hearing loss) appear to be less relevant in patients with tinnitus and TMD, suggesting a causal role of TMJ pathology in the generation and maintenance of tinnitus. Based on this finding, treatment of TMD may represent a causally oriented therapeutic strategy for tinnitus.
	Mean age of the total sample: 49.1 years.		Tinnitus Sample Case History Questionnaire and the German version of the Tinnitus Handicap Inventory (THI).		Furthermore, perceived tinnitus loudness was higher among patients without TMD (P = 0.01; mean difference: 13.1; 95% CI: 3.1–23.1).
	56 males (61.5%) and 35 females (38.5%).				The remaining evaluated variables did not demonstrate significant differences between groups.

Morais and Gil(¹¹), 2012 (Brazil) / Descriptive observational cross-sectional study	To characterize tinnitus in individuals with normal hearing and investigate its relationship with TMD.	20 adults of both sexes (70% female) with complaints of tinnitus and hearing thresholds within normal limits.	Audiological and otological history, acuphenometry, and application of a checklist of TMD signs and symptoms, developed by the researcher based on data from the literature, consultation with professionals in the field, and the Tinnitus Handicap Inventory (THI) questionnaire.	Investigation of tinnitus laterality, type, and duration, as well as identification of pitch and loudness.	Most participants reported high-pitched (75%), continuous (90%), and bilateral (60%) tinnitus. Acuphenometry revealed a mean pitch of 8.6 kHz and a mean loudness of 14.1 dB SL. Tinnitus-related distress was classified as mild, with a mean THI score of 25 points.	The most frequent tinnitus profile was characterized as high-pitched, continuous, and bilateral; 90% of participants presented at least one sign or symptom of TMD, and no correlation was observed between tinnitus and acuphenometry, THI scores, or the TMD checklist.
					Regarding TMD, 90% of participants presented at least one sign or symptom, with asymmetric mouth-opening movement being the most frequent finding (70%).
		The age of the sample ranged from 20 to 55 years, with a mean age of 32.1 years.			A statistically significant correlation was observed between tinnitus pitch and loudness (the higher the pitch, the lower the loudness – P = 0.002), as well as between pitch and THI score (P = 0.002; the higher the pitch, the higher the THI score). No significant correlations were observed between findings from the TMD checklist and the psychoacoustic tinnitus parameters or THI scores, suggesting that, despite the high prevalence of TMD signs and symptoms in the sample, no direct relationship was identified between tinnitus characteristics and TMD.

JBI Domain	Morais and Gil(¹¹)	Lacerda et al.(¹²)	Cassol et al.(¹⁰)	Kanji and Khoza-Shangase(¹³)
D1 – Clearly defined inclusion criteria	Yes	Yes	Yes	Yes
D2 – Adequacy of the recruitment process	Yes	Unclear	Yes	Yes
D3 – Adequate sample size	No	No	Yes	Yes
D4 – Detailed description of participants and setting	No	No	Yes	Yes
D5 – Adequate sample coverage	Yes	Yes	Yes	Yes
D6 – Validity of the methods used to identify the condition	Yes	Yes	Yes	Yes
D7 – Valid and reliable outcome measurement	Yes	Yes	Yes	Yes
D8 – Appropriate statistical analysis	Yes	Yes	Yes	Yes
Overall Judgment	Moderate	Moderate-to-High	Low	Low

JBI Domain	Vielsmeier et al.(¹⁴)
D1 – Clearly defined case criteria	Yes
D2 – Representativeness of cases	Yes
D3 – Appropriate selection of controls	Yes
D4 – Comparability between cases and controls	Yes
D5 – Valid identification of the condition (cases)	Yes
D6 – Valid identification of the condition (controls)	Yes
D7 – Standardized outcome measurement	Yes
D8 – Management of confounding factors	unclear
D9 – Appropriate statistical analysis	Yes
Overall Judgment	low

[1] Caption: dB HL = decibels hearing level; dB SL = decibels sensation level; TMD = Temporomandibular Disorder; RE = Right Ear; LE = Left Ear; THI = Tinnitus Handicap Inventory