It is fairly common condition. sudden hearing loss with or without giddiness and tinnitus (ringing) in any age group. Most of the time in children hearing loss will not be known. It is usually detected by chance when some body talks in the affected ear or does not hear the telephone voice. It is caused mostly by viral infection and occasionally with severe attack of typhoid. No treatment if the hearing loss is total. They should be careful about the other ear. If there is any middle ear infection it should be treated immediately. In cases of bilateral total loss which is rare, requires cochlear implantation.

In adults and aged people it is usually due to vascular spasm or embolism (blood clot) in the cochleovestibular end artery which supply blood to cochlea (hearing) and vestibular (balance) organ and occasionally may be due to viral infection.

Recognition and treatment within 48 hours would help to regain total hearing in majority of cases and partially in others.

Some unfortunate patients even if they go within 48 hrs to the doctor who is ignorant about the seriousness of this conditions may think that the ear blocking may be due to Eustachian tube obstruction, secondary to cold. Even if patient has no cold or nasal obstruction and get treatment for the same.

History, clinical examination and audiometric evaluation confirm the diagnosis.

Since the condition is sudden onset in a normal individual we should think first as a vascular accident. So vasodilators, systemic steroid, plasma expanders and intratympanic dexamethasone are given to improve blood circulation to the hearing and balance organ (labyrinth) and to reduce inflammation and prevention of clot formation in the blood vessels. And in addition Vit. B complex with zinc and Methylcobalamine (B 12) are also given, with this we can see dramatic improvement in hearing in majority of patients and in some total recovery. In elderly patients with arterial disease the result may not be so dramatic or it may not improve at all.

Intratympanic dexamethosone if given within 48 hours dramatic improvement of hearing will be noticed on the next day itself. Usually 1ml of dexamethasone(4mg) is injected into the middle ear piercing the TM just inferior to the level of round window under microscope. After filling the entire middle ear patient is asked to lie down on the table in the same position for one hour to help permiation of the drug through the round window membrane into the inner ear. If necessary another injection may be given after 3 days.

And in patients who came after one month to about 1 ½ months some improvement of hearing and diminition of tinnitus is noticed..

Patients come with episodic vertigo,fluctuating hearing loss, tinnitus and occasional pressure in the affected ear. The cause of this disease is not known. Several theories have been mentioned in the literature. In my experience this disease occurs mostly in urbanites who have lot of anxiety and stressful life at work place and home. And as a matter of fact I have not seen meniere’s disease in people who lead contented and tension free life, and also people who live in deep villages without any distraction or difficulties in day to day life style.

In 95% of cases, diagnosis is made by history and clinical examination. The classical tried of symptoms as we see in Meniere’s disease are not seen in any other conditions. Audiological investigation and if necessary CT scan and MRI are required to confirm the final diagnosis.

The medical treatment with vasodilators and vestibular sedatives like cinnarizine hydrochloride, Betahistine dihydrochloride and tranquilizers will help to relieve symptoms, but not cure. Meniere’s disease is slowly progressive disease with periods of remission and excerbation.

For medical treatment failure cases earlier we were performing surgery to relieve vertigo.

Surgical Procedures:
• Hearing preservation procedures
  - Endolymphaitic sac decompression – in this procedure only 50-60% have relief of vertigo.
  - Selective vestibular nerve section – it is major surgical procedure with known complications.
  - Destruction of labyrinth (both vesticular and cochlear)

Now we can control vertigo (giddiness) in all most all cases without surgery by simply injecting Gentamycin in to the middle ear as out patient procedure. Surgery for meniere’s disease has been discontinued through out the world. And so far I have treated more than 750 patients since 1997 with excellent results.

TMJ syndrome is a very common condition seen in every day practice and I consider this is no. 1 cause of headache in humanity. Every day I see 8 to 10 patients in OPD and I have recognized the seriousness of this condition way back in 1973 when patients were coming to me with earache and headache after few months of ear surgery without any problem in the ear related to surgical intervention. And to my surprise, I found that they were all chewing all the time in the unoperated ear with fear of pain in the operated side.

This condition is not well recognized by many physicians because TMJ syndrome is casually mentioned as one of the causes of head ache and earache in medical text books and not emphasized during clinical training in MBBS course and ENT post graduate training programme. So most of the doctors do not know this condition is one of the major causes of headache.

The TMJ syndrome is usually caused by improper occlusion of the jaws and chewing one side for a long time mainly due to the teeth problems. During the life of every human being all most all people will have some kind of teeth problems. occasionally it can be caused by habitual clenching or grinding of teeth and abnormal movement of the jaws. As a result the joint under stress gets inflamed and swollen. In long standing cases the articular cartilaginous disc may be damaged along with condyle.

Patients usually come with history of one sided headache (half head) and earache which increases on exposure to cold breeze while traveling in a vehicle, sitting under the fan or in the air condition room, after head bath, when eating cold food, long use of cell phone, at the time of descent of Aero plane, exposure to loud noises and sleeping on the affected side. And some people come with unilateral throat pain without any problem of swallowing and some with giddiness or falling sensation to one side. In long standing cases they may complain of clicking (myoclonus) or tic –tic noise in the ear (objective tinnitus). Many patients come with all possible investigations which are usually normal and after taking treatment by specialists of all specialities for sinus head ache or migraine or other problem. If people come by saying that they have sinus head ache without any problem in the nose (obstruction, cold or discharge) it is not a sinus disease. If a patient goes to an Opthalmologist even he finds 6/6 vision still prescribes headache glasses which is of no use. And a neurologist after clinical examination, EEG, MRI or CT Scan finds no evidence of any disease and still he treats for migraine or tension headache. So doctors without knowing TMJ syndrome treat the patients with many courses of different types of antibiotics and other drugs without any help.

On the examination we can see and feel the swelling of the particular joint. Tenderness will be there over the joint, retromandibular and sub mandibular areas. Any stimulation of the joint by cold, pressure and sound causes severe spasm of the powerful muscles attached to mandible and results in earache, headache and other associated symptoms.

The definitive diagnosis is usually made by good history taking and physical examination. ENT and other examination will be normal. It is mostly a clinical diagnosis. Radiological examination in early cases (up to 2 years) no changes will be seen however in long standing cases we may see degenerative changes in the articular disc and condyle with dislocation.

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Ask the patient not to open his mouth too wide, not to eat hard food for few months and then to put cotton in the ears when sitting under the fan or going out in cold breeze and traveling..

Local application of anti-inflammatory gel over the joint area and systemtic anti inflammatory drugs would help to relive pain and swelling of the joint.

In long standing case, suffering from head ache more than one year, in addition to we have to give intrarticular injection of Hydrocartisone ½ ml mixed with xylocaine once in 3 weeks, 3 to 5 injections depending on severity of the condition.

The most important thing to prevent recurrence of headache and other symptoms is continuation of equal jaw movements that is bitting equally on both sides while eating at all the times.

It is a long established fact that a reader will be distracted by the readable content of a page when looking at its layout. The point of using Lorem Ipsum is that it has a more-or-less normal distribution of letters

Ask the patient not to open his mouth too wide, not to eat hard food for few months and then to put cotton in the ears when sitting under the fan or going out in cold breeze and traveling..

Local application of anti-inflammatory gel over the joint area and systemtic anti inflammatory drugs would help to relive pain and swelling of the joint.

In long standing case, suffering from head ache more than one year, in addition to we have to give intrarticular injection of Hydrocartisone ½ ml mixed with xylocaine once in 3 weeks, 3 to 5 injections depending on severity of the condition.

The most important thing to prevent recurrence of headache and other symptoms is continuation of equal jaw movements that is bitting equally on both sides while eating at all the times.

It is a long established fact that a reader will be distracted by the readable content of a page when looking at its layout. The point of using Lorem Ipsum is that it has a more-or-less normal distribution of letters

Ask the patient not to open his mouth too wide, not to eat hard food for few months and then to put cotton in the ears when sitting under the fan or going out in cold breeze and traveling..

Local application of anti-inflammatory gel over the joint area and systemtic anti inflammatory drugs would help to relive pain and swelling of the joint.

In long standing case, suffering from head ache more than one year, in addition to we have to give intrarticular injection of Hydrocartisone ½ ml mixed with xylocaine once in 3 weeks, 3 to 5 injections depending on severity of the condition.

The most important thing to prevent recurrence of headache and other symptoms is continuation of equal jaw movements that is bitting equally on both sides while eating at all the times.

Oral hygiene is very important, patients are advised to brush the teeth before going to bed at night and morning after breakfast.

They are asked to chew (bite) the food equally on both sides jaw at the same time.
If the patient has any teeth problem, they should be treated by the dentist.

Ask the patient not to open his mouth too wide, not to eat hard food for few months and then to put cotton in the ears when sitting under the fan or going out in cold breeze and traveling..

Local application of anti-inflammatory gel over the joint area and systemtic anti inflammatory drugs would help to relive pain and swelling of the joint.

In long standing case, suffering from head ache more than one year, in addition to we have to give intrarticular injection of Hydrocartisone ½ ml mixed with xylocaine once in 3 weeks, 3 to 5 injections depending on severity of the condition.

The most important thing to prevent recurrence of headache and other symptoms is continuation of equal jaw movements that is bitting equally on both sides while eating at all the times.

Surgical Management:
• Surgery is indicated in cases when the conservative and injection therapy which fail to relieve pain and other symptoms .
• When there is X-ray evidence of damage to the disc & condyle is present.

Surgical procedure:
1. Removal of damaged articular disc and interposition of autogenous free graft (conchal cartilage) or alloplastic implant (silastic sheet or Goretex).
2. Mandibular high condylectomy (rarely).

Conclusion:
T.M.J syndrome is number one cause for headache in humanity. Headache and unilateral throat pain with normal ENT examination findings we should always suspect TMJ syndrome. Headache in children when they come from school, in the absence of any ENT or any other problems is always due to TMJ syndrome. Headache, heaviness in the head, ear ache and giddiness after exposure to cold breeze while driving bike or car, walking in a cold breeze and after head bath is always due to TMJ syndrome.