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Year : 2022  |  Volume : 28  |  Issue : 3  |  Page : 235-238

The anterior wall sign: A new tool in the diagnosis of temporomandibular disorders

Division of Otolaryngology, Hospital General Universitario Rafael Mendez, Lorca, Murcia, Spain

Date of Submission29-Mar-2022
Date of Decision22-Jul-2022
Date of Acceptance11-Aug-2022
Date of Web Publication21-Nov-2022

Correspondence Address:
Dr. Esteban Merino-Galvez
Hospital General Universitario Rafael Méndez, Ctra.N-340, 30813 Lorca, Murcia
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/indianjotol.indianjotol_57_22

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Diagnosis of temporomandibular disorder (TMD) in patients with otalgia is based on the medical history and physical examination, which is based on deep palpation of the joint area, however, palpation will often cause discomfort in healthy patients. Ninety-nine patients with otological symptoms in relationship with TMD were studied. We palpated with a blunt curette, the skin lining the anterior wall of the bony auditory canal located above the temporomandibular joint. We only consider a positive sign if palpation unequivocally evokes pain or discomfort identical to what the patient feels or has felt before. The positivity of the anterior wall sign was 99% in the TMD group. We found a significant difference between the control and TMD groups regarding the sign of the anterior wall (P < 0.005). The anterior wall sign could be an effective tool to detect temporomandibular dysfunction.

Keywords: Attrition, pain, reflex otalgia, temporomandibular dysfunction

How to cite this article:
Merino-Galvez E, Merino-Coy G, Gomez-Hervas J. The anterior wall sign: A new tool in the diagnosis of temporomandibular disorders. Indian J Otol 2022;28:235-8

How to cite this URL:
Merino-Galvez E, Merino-Coy G, Gomez-Hervas J. The anterior wall sign: A new tool in the diagnosis of temporomandibular disorders. Indian J Otol [serial online] 2022 [cited 2023 Feb 5];28:235-8. Available from: https://www.indianjotol.org/text.asp?2022/28/3/235/361642

  Introduction Top

Reflex otalgia is a challenge for otorhinolaryngologists because its differential diagnosis includes multiple clinical entities, some of them potentially serious. These involve tumors throughout the entire length of the pharynx and larynx, from the nasopharynx to the pyriform sinuses, diverse types of neuralgia, and pathology of the temporomandibular joint (TMJ).

Signs and symptoms related to temporomandibular disorder (TMD) may appear in 5% of the general population,[1] which stands for a high incidence rate. Hilton's principle assumes that nerve fibers which innervate a given joint are also responsible for the innervation of the muscles that allow the movement in that joint and the skin above the joint.[2] Consequently, there are patients who report earache without inflammatory signs in the outer ear and with normal otoscopy as well. Frequent symptoms from these patients include vague hemifacial discomforts, such as numbness, tingling, paresthesia, or feeling of plugging in their ears, but with the normal audiological study. It has been suggested that overactive chewing muscles can contract both the tensor tympani muscle and tympanic membrane, thus causing a dysfunction of the auditory system with symptoms such as fullness in the ear. Finally, some patients request our attention for tinnitus, even though otoscopy and audiometry are normal.

The diagnosis of TMD in patients with otalgia is based primarily on the medical history and physical examination findings.[3] We lead the diagnosis of this pathology when we find disorders such as malocclusion or bruxism, recent manipulation of the oral cavity by the dentist or the dental technician, as well as pain with chewing movements in the preauricular masseter.[3] The examination of referred otalgia caused by TMD is based on deep palpation in the face over the TMJ. Pressure sensitivity suggests an intra-articular disorder. However, this area by itself has a high nociceptive sensitivity, therefore deep palpation could cause discomfort in healthy patients.

The aim of this study is to verify the efficacy of a simple method that we use to diagnose TMD in patients who have or have had earache with normal otoscopy as well as pharyngeal and laryngeal endoscopy without significant findings. Based on Hilton's law,[4] we set out to study the existence of TMD by gently mechanically stimulating the skin that covers the articulation of the anterior wall of the ear canal.

  Materials and Methods Top

We performed a prospective study with a controlled single-blind group. We focused the investigation on those patients who came to the Ear, Nose and Throat (ENT) consultation for pain, in one or both ears, with suspected TMJ pathology between 2009 and 2021. Candidates had to have no history of ear pathology, as well as normal pharyngeal and laryngeal endoscopy. Similarly, they must not have had an active ear or aerodigestive tract infection. Once these etiologies had been ruled out, a medical history was taken on habits or circumstances related to temporomandibular dysfunction, such as a recent visit to the dentist or orthodontist for prosthesis adjustment, having been chewing gum excessively, or similar situations. Next, the degree of tooth wear was explored following the Gerasimov scheme simplified by Bardsley.[5] [Table 1].
Table 1: Grade of tooth wear was explored following the Gerasimov scheme simplified by Bardsley

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Finally, when the patients were selected, the anterior wall maneuver that we were going to perform was explained to them. The action is simple and should be performed under microscopic vision [Figure 1] and [Video 1]. The patients were asked to confirm if they felt pain, its intensity on a Visual Analog Scale (VAS) and if it corresponded to the same area and characteristics that they had suffered before. We only consider a positive sign of the anterior wall if palpation of the anterior wall unequivocally evokes pain or discomfort identical to what the patient feels or had felt before. Once the suspicion of TMD was set up, we prescribed some indications, leading to reduce ear discomfort. The treatment consisted of wearing an occlusal splint, applying local heat to the joint, and keeping chewing hygiene habits (do not chew gum, eat soft foods.). After 2 months, we evaluate the result, in terms of persistence, improvement, or disappearance of pain.
Figure 1: To evoke the anterior wall sign, we expose the transition zone between the cartilaginous and the bony part of the auditory canal on its anterior face. Then, we palpated with a blunt curette, without pressing so as not to cause pain, the skin lining the anterior wall of the bony auditory canal located above the temporomandibular joint

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In addition, a control sample group was made up of patients randomly selected among whom consulted for otorhinolaryngological problems unrelated to direct or referred otalgia. We assessed, using a VAS, the pain sensation produced by palpation on the anterior wall, which was done by a single investigator

Statistical analysis was performed using the Chi-square test to assess the relationships between qualitative factors, and Student's t-test or ANOVA to the quantitative, both with 95% confidence intervals. The software SPSS for Windows (SPSS, Inc., Chicago, Illinois, USA) was used for the analysis. A P < 0.05 was considered statistically significant. The researchers have obtained approval from the hospital's independent ethics committee to conduct the study, as well as permission to use the information in databases.

  Results Top

Ninety-nine patients with otological symptoms in relationship with TMD were studied. The distribution was 35.4% men and 64.6% women with a mean age of 49.76 ± 18.5 years. The incidence of TMD peaks between 50 and 60 years of age and is twice as high in women. Concerning the side, 46.5% of the otalgia was referred to the right ear, 35.4% to the left ear and in the rest of the patients, it was bilateral. The period with symptoms of earache was 4.78 ± 10.7 months with a mode of 1 month.

Regarding personal history, 11% had sleep bruxism, 6% recognized abuse in chewing gum, and 4% there was a recent history of visiting the dentist. The attrition grade is shown in [Figure 2].
Figure 2: Degree of dental attrition in our sample

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In our sample, the number of consultations was higher in cold months than in hot ones, especially in women, but without statistical significance (P = 0.54) [Figure 3].
Figure 3: Earache in cold/warm months

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The control sample was made up of 110 patients. The composition was 45.5% men and 54.5% women with a mean age of 50.35 ± 17.83 years. Attrition is shown in [Figure 4]. Regarding the painful sensation caused, it was <3 in 91.8%, between 3 and 7 in 5.5%, and >7 in 2.7% (3 patients who consulted for tinnitus, with a degree of attrition 1 in two cases and 0 in the remaining). When we studied both groups in relation to the pain manifested in the VAS after palpation and we found a significant difference with a direct relationship between the sign of the anterior wall and the TMD group (P < 0.0001).
Figure 4: Degree of dental attrition in the control sample

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The positivity of the anterior wall sign was 99% in the study group and 4.5% (More than 5 points with VAS score) in the control group (P > 0.0001). In all patients with a positive anterior wall sign, symptomatic improvement was seen in <3 weeks with treatment consisting of occlusal splint therapy, chewing hygiene measures, and local heat.

  Discussion Top

TMD is a global term for some clinical problems that may involve both the masticatory muscles and temporomandibular articulation. This pathology has a multifactor etiology, although sleep bruxism is considered a causal agent involved in the initiation and/or perpetuation.[6]

Usually, the diagnosis of TMD is based on gathered clinical information: anamnesis and examination, including signs such as pain with chewing movements, joint noises, or signs of bruxism such as attrition,[3] although 50% of the patients are asymptomatic.[7] The most used examination for clinical diagnosis is compression of the TMJ, just on the preauricular area. We consider positive if pain appears.[3] From our point of view, this sign is nonspecific because patients only report pain, but not the specific sensation that led them to consult. Therefore, this test could lend itself to false positives since some patients could report pain caused by the compression itself and be interpreted as TMD-positive cases.

Our work is based on evoking, with minimal discomfort (just a touch on the skin of the ear canal that covers the joint), exclusively the same sensation that the patient says to have felt or to feel at that moment. Following Hilton's law, this sign, along with the presence of dropouts, is highly suggestive of TMD to us. In the patients of the control sample, pain above 5 points on the VAS was only evoked in five patients, three of whom presented tinnitus as a consultation symptom, so they could be considered cases with TMD.

The distribution of cases by sex coincides with Gauer,[3] although our age peak is slightly older than that of this author, found between 40 and 50 years. We coincide totally with the data provided by Magalhaes,[6] which shows a strong association between TMD and both otological symptoms and bruxism.

In our sample, the number of consultations was higher in cold months than in hot ones, but without statistical significance. We have the impression that patients with a large bony protrusion of the anterior wall of the canal, above the TMJ, are candidates to present this type of symptoms more easily, although we have not carried out a detailed study.

We believe that it is an issue in which more structured studies could be carried out with case controls and with a greater number of participants. We encourage our colleagues to use this exploration in their daily practice.

  Conclusions Top

The results of this study show that the anterior wall sign is a useful tool to approach the diagnosis of patients with temporomandibular dysfunction.

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Conflicts of interest

There are no conflicts of interest.

  References Top

National Academies of Sciences, Engineering, and Medicine; Health and Medicine Division, Board on Health Care Services; Board on Health Sciences Policy, Committee on Temporomandibular Disorders (TMDs): From Research Discoveries to Clinical Treatment, Yost O, Liverman CT, English R, et al., editors. Temporomandibular Disorders: Priorities for Research and Care. Washington, (DC): National Academies Press (US); 2020. Appendix C, Prevalence, Impact, and Costs of Treatment for Temporomandibular Disorders. Available from: https://www.ncbi.nlm.nih.gov/books/NBK557996/. [Last accessed on 2021 Apr 14].  Back to cited text no. 1
Hébert-Blouin MN, Tubbs RS, Carmichael SW, Spinner RJ. Hilton's law revisited. Clin Anat 2014;27:548-55.  Back to cited text no. 2
Gauer RL, Semidey MJ. Diagnosis and treatment of temporomandibular disorders. Am Fam Physician 2015;91:378-86.  Back to cited text no. 3
Kang O. Hilton's Law. Reference Article, Radiopaedia.org. Available from: https://doi.org/10.53347/rID-50338. [Last accessed on 2021 Mar 15].  Back to cited text no. 4
Bardsley PF, Taylor S, Milosevic A. Epidemiological studies of tooth wear and dental erosion in 14-year-old children in North West England. Part 1: The relationship with water fluoridation and social deprivation. Br Dent J 2004;197:413-6.  Back to cited text no. 5
Magalhães BG, Freitas JL, Barbosa AC, Gueiros MC, Gomes SG, Rosenblatt A, et al. Temporomandibular disorder: Otologic implications and its relationship to sleep bruxism. Braz J Otorhinolaryngol 2018;84:614-9.  Back to cited text no. 6
Scrivani SJ, Keith DA, Kaban LB. Temporomandibular disorders. N Engl J Med 2008;359:2693-705.  Back to cited text no. 7


  [Figure 1], [Figure 2], [Figure 3], [Figure 4]

  [Table 1]


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