Tonic Tensor Tympani Syndrome (TTTS)

Tonic Tensor Tympani Syndrome (TTTS)

In the middle ear, the tensor tympani muscle contracts as part of our startle reflex while the stapedial muscle contracts in response to loud sounds, tightening the ossicles (the tiny bones of the middle ear) and limiting transmission of these sounds to the inner ear. This provides some protection to potentially damaging sounds.

In many people with tinnitus and almost all people with significant hyperacusis, an involuntary myoclonus (spasm) appears to develop in the tensor tympani muscle as an involuntary ‘protective’ response to sounds (or other stimuli) subconsciously evaluated as potentially painful, potentially threatening or damaging to the ears/hearing or likely to stir up their tinnitus.  This is known as tonic tensor tympani syndrome (TTTS).

TTTS typically does not develop in people with misophonia.


Following exposure to these difficult to tolerate sounds (or stimuli), this heightened contraction of the tensor tympani muscle can:

  • affect the opening of the Eustachian tube, which ventilates the middle ear cavity, and is normally closed but opens when we yawn or swallow
  • tighten the ear drum
  • stiffen the middle ear bones (ossicles)
  • lead to irritability and inflammation of the trigeminal nerve 

As a result, TTTS can cause a range of symptoms in and around the ear(s).  These include: a sensation of blockage, fullness or frequent “popping” in the ear; pain, numbness and burning sensations in and around the ear; the development of tinnitus or an increase in pre-existing tinnitus; pain in the jaw joint and down the neck; a clicking/fluttering sensation in the ear; mild vertigo/unsteadiness; muffled/distorted hearing.

For those affected, some/many/all of these symptoms may develop or be aggravated by exposure to intolerable sounds.  For others, some/many/all of these symptoms may be more intermittent, occurring randomly. 

It does not harm the ear to experience TTTS.

Even though TTTS symptoms can seem as if the ear is being significantly affected or even damaged by sounds, this is not the case.  Moderate, everyday sounds are safe and do not harm the ear or cause a hearing loss.

How to deal with TTTS

As TTTS develops from an involuntary ‘protective’ response to sounds (or other stimuli deemed as threatening), understanding TTTS, effective pain management, managing stress and anxiety, and achieving tinnitus habituation/hyperacusis desensitisation will reduce TTTS symptoms. 

Individual guidance from a skilled musculo-skeletal physiotherapist to provide neural desensitisation strategies including neural tapping, relaxation of the facial muscles in and around the ear, identification and massage of muscular trigger points in the shoulder and neck, will be of benefit. 

Effective pain management is a priority for hyperacusis patients with severe sound-induced neuropathic pain.  Consulting a Pain Physician is recommended, where the treatment should be as for trigeminal neuralgia using nerve pain medication, such as Endep, Lyrica (Pregabalin, anticonvulsant).  This approach, combined with neural tapping from a skilled physiotherapist and our hyperacusis therapy program, has been uniquely effective in these patients at our clinic.

TTTS-like symptoms may be due to middle or inner ear pathology.  TMJ (jaw joint) dysfunction from jaw clenching and tooth grinding can cause secondary symptoms in and around the ear which have been attributed to TTTS.  As a result, TTTS symptoms can be mistakenly diagnosed as due to middle/inner ear pathology or TMJ dysfunction.  Consulting an Ear, Nose and Throat Specialist/TMJ Specialist should be carried out to exclude these possibilities.  When TTTS is solely a secondary consequence of TMJ dysfunction, the symptoms are not triggered/aggravated by sounds.  With TTTS associated with tinnitus/hyperacusis, the primary cause is related to the way sound is perceived in the brain. 

TTTS symptom desensitisation

Refocussing strategies

The ‘protective’ mechanism of TTTS causes symptoms in the ears which are uncomfortable and cause anxiety.  This can lead the brain to fear these symptoms, and consider the ears need to be ‘protected’ from further discomfort/anxiety by subconsciously triggering ongoing TTTS, which causes discomfort/anxiety ……  Unfortunately, not at all an efficient mechanism.   

Once TTTS has been diagnosed, there is no medical reason why the symptoms should be monitored.  Overly anticipating and monitoring the symptoms will perpetuate this cycle and reinforce the brain’s need to ‘protect’ the ears.  Additionally, over-monitoring will keep the symptoms prominent and reinforce awareness of them.  

The best way to deal with TTTS symptoms is to train your brain not to monitor them – briefly acknowledge them when you notice them, then use refocussing strategies to reduce your symptom awareness.  


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