DiagnosticTree/EarTMJ

{

 "tree_id": "ear-tmj",
 "region": "Ear & Temporomandibular Joint Pain",
 "start": "rom-1",

 "redflags": {
   "emergency": [
     {
       "id": "rf-e1",
       "label": "Otitis media / Mastoiditis",
       "question": "Is there fever, acute hearing loss, or purulent ear discharge?",
       "rationale": "Requires urgent antibiotic treatment or surgical referral",
       "action": "Call emergency services or send directly to Emergency Department"
     },
     {
       "id": "rf-e2",
       "label": "Cardiac referred pain",
       "question": "Is there jaw or ear pain with an exertional component, particularly on the left side?",
       "rationale": "Cardiac pain can refer to the jaw and ear — must be excluded immediately",
       "action": "Call emergency services immediately"
     }
   ],
   "urgent": [
     {
       "id": "rf-u1",
       "label": "Temporal arteritis",
       "question": "Is the patient aged 50+ with jaw claudication (pain building with chewing then easing), temporal headache, or scalp tenderness?",
       "rationale": "Can cause irreversible blindness if untreated. Same-day ESR required.",
       "action": "Same-day GP referral + ESR blood test"
     },
     {
       "id": "rf-u2",
       "label": "Parotid / neck malignancy",
       "question": "Is there a hard fixed parotid or neck swelling, or any facial nerve weakness?",
       "rationale": "Possible salivary gland malignancy with nerve involvement",
       "action": "Urgent ENT or oncology referral"
     },
     {
       "id": "rf-u3",
       "label": "Cervical instability",
       "question": "Is there a history of trauma to the head or neck combined with upper cervical pain and ear symptoms?",
       "rationale": "Odontoid fracture or cervical instability can refer to the ear region",
       "action": "Urgent spinal assessment — no manual therapy until cleared"
     }
   ]
 },

 "nodes": {

   "rom-1": {
     "type": "rom",
     "question": "Is jaw movement — opening, chewing, or clenching — the PRIMARY aggravator of pain?",
     "movement": "Jaw opening / chewing / clenching",
     "direction": "aggravating",
     "muscles_implicated": ["Masseter", "Medial Pterygoid", "Lateral Pterygoid"],
     "muscles_excluded": ["SCM (Clavicular head)"],
     "yes": "rom-2",
     "no": "rom-5"
   },

   "rom-2": {
     "type": "rom",
     "question": "Is maximum mouth opening restricted (less than ~40mm between upper and lower incisors) or painful at end range?",
     "movement": "Mouth opening — end range",
     "direction": "aggravating",
     "muscles_implicated": ["Medial Pterygoid", "Lateral Pterygoid"],
     "muscles_excluded": ["Masseter (superficial head)"],
     "yes": "rom-3",
     "no": "result-masseter-superficial"
   },

   "rom-3": {
     "type": "rom",
     "question": "Is there a history of facial trauma, jaw injury, or is bony crepitus palpable over the mandible?",
     "movement": "Trismus differential screen",
     "direction": "aggravating",
     "clinical_rationale": "Mandibular fracture must be excluded before proceeding with myofascial assessment of restricted opening",
     "yes": "refer-urgent-fracture",
     "no": "rom-4"
   },

   "rom-4": {
     "type": "rom",
     "question": "Is pain reproduced or worsened by closing the mouth against resistance — e.g. biting down on a tongue depressor?",
     "movement": "Resisted jaw closure",
     "direction": "aggravating",
     "muscles_implicated": ["Lateral Pterygoid"],
     "muscles_excluded": ["Medial Pterygoid"],
     "yes": "result-lateral-pterygoid",
     "no": "symptom-1"
   },

   "rom-5": {
     "type": "rom",
     "question": "Is pain aggravated by neck rotation, sustained postures, or carrying weight on the shoulder?",
     "movement": "Neck rotation / ipsilateral head tilt",
     "direction": "aggravating",
     "muscles_implicated": ["SCM (Clavicular head)"],
     "muscles_excluded": ["Masseter", "Medial Pterygoid", "Lateral Pterygoid"],
     "clinical_rationale": "If neck rotation is also stiff or restricted, additional TrPs in levator scapulae, splenius cervicis, or posterior cervical muscles may be co-active alongside SCM.",
     "yes": "exam-scm-1",
     "no": "result-overlap"
   },

   "symptom-1": {
     "type": "symptom",
     "question": "Does the patient report difficulty swallowing (dysphagia) or a sensation of throat tightness or foreign body in the throat?",
     "symptom_name": "Dysphagia / throat tightness",
     "muscles_implicated": ["Medial Pterygoid"],
     "muscles_excluded": ["Lateral Pterygoid"],
     "yes": "exam-medial-1",
     "no": "exam-masseter-deep-1"
   },

   "exam-scm-1": {
     "type": "examination",
     "question": "Does palpation of the SCM — both sternal and clavicular heads — reproduce the patient's familiar ear pain or facial symptoms?",
     "exam_type": "palpation",
     "landmark": "Sternal head: pincer palpation along muscle belly from mastoid to sternum. Clavicular head: flat palpation of posterior/deep head from medial clavicle upward.",
     "positive_finding": "Reproduces deep ear pain, facial pain, or familiar symptoms",
     "clinical_rationale": "Note which head is more reactive — sternal vs clavicular determines the dominant symptom cluster. Full clinical detail on the muscle landing page.",
     "muscles_implicated": ["SCM (Sternal head)", "SCM (Clavicular head)"],
     "yes": "result-scm",
     "no": "result-overlap"
   },

   "exam-medial-1": {
     "type": "examination",
     "question": "Does intraoral palpation of the medial pterygoid reproduce the ear or throat pain?",
     "exam_type": "palpation",
     "landmark": "Intraoral: gloved finger along medial surface of posterior mandible behind last molar. Extraoral: just anterior to the angle of the mandible.",
     "positive_finding": "Reproduces deep ear pain, throat tightness, or jaw ache",
     "muscles_implicated": ["Medial Pterygoid"],
     "yes": "result-medial-pterygoid",
     "no": "result-overlap"
   },

   "exam-masseter-deep-1": {
     "type": "examination",
     "question": "Does palpation of the deep masseter just anterior to the tragus of the ear reproduce ear pain or tinnitus?",
     "exam_type": "palpation",
     "landmark": "Deep masseter: just anterior to the tragus at TMJ level; press medially toward the condyle",
     "positive_finding": "Reproduces ear pain or tinnitus",
     "muscles_implicated": ["Masseter (deep head)"],
     "yes": "result-masseter-deep",
     "no": "result-overlap"
   },

   "result-scm": {
     "type": "result",
     "diagnosis": "SCM Trigger Point — Myofascial Pain",
     "confidence": "high",
     "wiki_page": "Muscle:Sternocleidomastoid",
     "chapter_ref": "Travell & Simons Vol.1 — Ch.7 Sternocleidomastoid",
     "division": "both",
     "notes": "Soreness may be misattributed to lymphadenopathy. Patient prefers to lie on the sore side with pillow supporting the head so the sore face does not bear weight.",
     "treatment_hint": "Spray and stretch (superior to inferior), ischemic compression, correct forward head posture. Treating SCM often improves satellite TrPs.",
     "also_consider": ["Scalene muscles", "Splenius cervicis", "Levator scapulae"],
     "less_likely": [
       { "muscle": "Masseter — Deep Head", "reason": "No jaw movement aggravation identified" },
       { "muscle": "Medial Pterygoid", "reason": "No restriction of mouth opening or dysphagia" },
       { "muscle": "Lateral Pterygoid", "reason": "No resisted jaw closure pain or clicking" }
     ],
     "confirmatory": [
       "Horner's excluded — pupils equal and reactive, no miosis, ciliospinal reflex present",
       "Spasmodic torticollis excluded — no jaw-pressure inhibition of head rotation; dystonic movement ceases in sleep",
       "Note which head is more reactive: sternal (facial/autonomic symptoms) vs clavicular (dizziness/frontal headache)"
     ],
     "satellite_trps": ["Scalene muscles", "Sternalis", "Pectoralis major", "Pectoralis minor", "Masseter", "Temporalis", "Orbicularis oculi", "Frontalis"],
     "landing_page_topics": [
       "Sternal vs clavicular division — full symptom profiles",
       "Dizziness — vestibular vs non-vestibular differentiation",
       "Neurological screen: Romberg, nystagmus, postural BP, carotid bruit",
       "Autonomic features — tearing, rhinitis, palpebral fissure narrowing",
       "Horner syndrome — full exclusion protocol",
       "CN XI entrapment — examination and monitoring",
       "Visual symptoms — venetian blinds phenomenon",
       "Patient posture and sleep advice",
       "Satellite TrP activation and treatment sequence"
     ],
     "related_pages": [
       { "label": "Scalene TrPs →", "page": "Muscle:Scalene" },
       { "label": "Sternalis TrP →", "page": "Muscle:Sternalis" }
     ]
   },

   "result-masseter-superficial": {
     "type": "result",
     "diagnosis": "Masseter — Superficial Head Trigger Point",
     "confidence": "high",
     "wiki_page": "Muscle:Masseter/Superficial",
     "chapter_ref": "Travell & Simons Vol.1 — Ch.8 Masseter",
     "notes": "Refers to cheek, lower jaw, upper and lower molar teeth, maxilla (often described as sinusitis), eyebrow, and temple. Tooth hypersensitivity to pressure, percussion, heat, and cold is a common associated feature. Chewing pain without significant restriction of opening.",
     "treatment_hint": "Pincer palpation with one digit inside mouth and one outside. Spray and stretch, intraoral massage, correct parafunctional habits (clenching, bruxism). Check SCM and upper trapezius as key TrPs first.",
     "confirmatory": [
       "Tooth hypersensitivity to all stimuli (pressure, percussion, heat, cold) without dental pathology — confirms myofascial referral",
       "Sinusitis-like maxillary pain without fever, discharge, or radiographic changes — confirms anterior-superior TrP referral",
       "Gonial angle tenderness on flat palpation — associated with bruxism (enthesopathy, not primary TrP)",
       "Observe for mandibular deviation toward affected side on slow opening — more apparent than with deep head TrPs"
     ],
     "less_likely": [
       { "muscle": "Masseter — Deep Head", "reason": "Opening not restricted — deep head more associated with end-range restriction and tinnitus" },
       { "muscle": "Medial Pterygoid", "reason": "No restriction of mouth opening or dysphagia" },
       { "muscle": "Lateral Pterygoid", "reason": "No resisted jaw closure pain" },
       { "muscle": "SCM", "reason": "Jaw movement is the primary aggravator, not neck rotation" }
     ]
   },

   "result-masseter-deep": {
     "type": "result",
     "diagnosis": "Masseter — Deep Head Trigger Point",
     "confidence": "high",
     "wiki_page": "Muscle:Masseter/Deep",
     "chapter_ref": "Travell & Simons Vol.1 — Ch.8 Masseter",
     "notes": "Refers deep into the ear, TMJ area, and diffuse midcheek. Tinnitus (low roaring quality, not associated with hearing loss or vertigo) is a strongly associated feature. Puffiness beneath the eye on the affected side and narrowing of the palpebral fissure may result from venous entrapment of the maxillary vein.",
     "treatment_hint": "External flat palpation against posterior ramus and zygomatic buttress. Spray and stretch over TMJ, deep pressure release, address bruxism. Check SCM and upper trapezius as key TrPs first.",
     "confirmatory": [
       "Tinnitus provocation test — pressure on TrP in upper posterior deep layer may activate or reproduce ipsilateral tinnitus",
       "Tinnitus is low roaring quality, not associated with hearing loss or vertigo — distinguishes from vestibular tinnitus",
       "Infraorbital puffiness and palpebral fissure narrowing on affected side — venous entrapment of maxillary vein",
       "Bilateral tinnitus suggests systemic cause rather than myofascial — however bilateral deep masseter involvement can produce bilateral tinnitus with unilateral fluctuation"
     ],
     "less_likely": [
       { "muscle": "Lateral Pterygoid", "reason": "No resisted jaw closure pain or jaw deviation identified" },
       { "muscle": "Medial Pterygoid", "reason": "No dysphagia or throat tightness" },
       { "muscle": "SCM — Clavicular head", "reason": "Jaw movement is primary aggravator, not neck rotation" }
     ]
   },

   "result-medial-pterygoid": {
     "type": "result",
     "diagnosis": "Medial Pterygoid Trigger Point",
     "confidence": "high",
     "wiki_page": "Muscle:Medial_Pterygoid",
     "chapter_ref": "Travell & Simons Vol.1 — Ch.9 Pterygoids",
     "notes": "Refers diffusely to the tongue, pharynx, hard palate, below and behind the TMJ, and deep in the ear. Pain is NOT referred to the teeth — this distinguishes it from masseter and temporalis. Ear stuffiness (barohypoacusis) may be present due to TrP bands blocking the tensor veli palatini from opening the eustachian tube. Dysphagia with characteristic compensatory pattern: patient extends neck and pushes tongue forward when swallowing.",
     "treatment_hint": "Intraoral ischemic compression and spray and stretch. Resisted jaw opening for reciprocal inhibition of all elevator muscles. Address lateral pterygoid and masseter concurrently — medial pterygoid rarely has TrPs in isolation.",
     "confirmatory": [
       "Pain is NOT referred to teeth — absence of tooth hypersensitivity distinguishes from masseter and temporalis",
       "Ear stuffiness (barohypoacusis) — tensor veli palatini blocked by tense TrP bands from opening eustachian tube",
       "Compensatory swallowing pattern — patient extends neck and pushes tongue forward when swallowing",
       "Mandibular deviation on opening is most marked to the contralateral side at maximum opening",
       "Chorda tympani entrapment — bitter metallic taste may indicate lingual nerve compression between medial pterygoid and mandible"
     ],
     "less_likely": [
       { "muscle": "Lateral Pterygoid", "reason": "Dysphagia and throat tightness present — more consistent with medial pterygoid" },
       { "muscle": "Masseter — Deep Head", "reason": "Throat pain and ear stuffiness argue for medial pterygoid; no tooth hypersensitivity" },
       { "muscle": "SCM", "reason": "Jaw movement and restricted opening present, not neck rotation" }
     ]
   },

   "result-lateral-pterygoid": {
     "type": "result",
     "diagnosis": "Lateral Pterygoid Trigger Point",
     "confidence": "high",
     "wiki_page": "Muscle:Lateral_Pterygoid",
     "chapter_ref": "Travell & Simons Vol.1 — Ch.11 Pterygoids",
     "notes": "Chief myofascial source of TMJ area pain. Refers deep into the TMJ and to the maxillary sinus region (may be described as sinusitis). Pain is NOT referred to the teeth. Tinnitus may be present. Clicking in the TMJ area may result from lateral pterygoid dysfunction. Inferior division shortening displaces condyle anteriorly causing altered occlusion — premature anterior tooth contact on opposite side.",
     "treatment_hint": "Tongue-tip-to-palate test to isolate lateral pterygoid. Tongue blade test on painful side confirms inferior division. Spray and stretch, intraoral ischemic compression. Treat masseter and temporalis TrPs first to allow adequate mouth opening for examination. Address forward head posture and parafunctional habits. Consider vitamin B1, B6, B12, folic acid if recalcitrant.",
     "confirmatory": [
       "Tongue-tip-to-palate test — slide tongue tip to posterior border of hard palate and observe if incisal path straightens on opening; if yes, lateral pterygoid is chief cause",
       "Tongue blade test — insert between molars on painful side; pain eliminated on vigorous clenching strongly implicates inferior division on that side",
       "Resisted jaw protrusion — pain on resisted protrusion is a specific confirmatory test; more reliable than palpation alone",
       "Lateral excursion reduced toward the SAME side as involved muscle",
       "Pain NOT referred to teeth — distinguishes from masseter and temporalis",
       "Buccal nerve entrapment — weird tingling or numbness of the cheek with buccinator weakness indicates lateral pterygoid compressing the buccal nerve"
     ],
     "less_likely": [
       { "muscle": "Medial Pterygoid", "reason": "Resisted jaw closure pain is more specific to lateral pterygoid; medial pterygoid pain is more diffuse involving throat and palate" },
       { "muscle": "Masseter — Deep Head", "reason": "Resisted jaw closure and condylar displacement pattern argues against masseter" },
       { "muscle": "SCM", "reason": "Jaw movement is primary aggravator, not neck rotation" }
     ]
   },

   "result-overlap": {
     "type": "overlap",
     "text": "Findings are inconclusive. Multi-muscle involvement or atypical presentation is likely. Perform a full palpation screen of all four muscles.",
     "screen_these": [
       "SCM — Sternal and Clavicular heads",
       "Masseter — Superficial and Deep heads",
       "Medial Pterygoid (intraoral palpation required)",
       "Lateral Pterygoid (intraoral palpation required)"
     ],
     "wiki_page": "Differential:Ear_TMJ"
   },

   "refer-emergency-neuro": {
     "type": "neuro_referral",
     "urgency": "emergency",
     "title": "Neurological Emergency — Do Not Proceed",
     "body": "Impaired or lost consciousness with dizziness or head symptoms indicates serious neurological pathology. Differential includes: pontine haemorrhage, intracranial vascular lesion, cerebellopontine angle tumour, or petit mal epilepsy.",
     "action": "Call emergency services or send directly to Emergency Department. Do not perform manual therapy."
   },

   "refer-urgent-fracture": {
     "type": "neuro_referral",
     "urgency": "emergency",
     "title": "Possible Mandibular Fracture",
     "body": "History of facial trauma with restricted mouth opening and/or bony crepitus on palpation of the mandible must be treated as a fracture until proven otherwise.",
     "action": "Refer to oral/maxillofacial surgery or Emergency Department. Do not proceed with intraoral assessment."
   }

 },

 "broad_differential": [
   {
     "id": "bd-1",
     "condition": "Ménière's Disease",
     "confidence": "uncommon",
     "mimics": "Episodic deep ear fullness, tinnitus, and dizziness — overlaps strongly with SCM clavicular and masseter deep head patterns",
     "distinguishing_feature": "Triad of fluctuating unilateral sensorineural hearing loss, episodic rotational vertigo (minutes to hours), and low-frequency tinnitus. Nystagmus during attacks.",
     "action": "Refer to ENT / audiovestibular medicine. Audiometry and caloric testing."
   },
   {
     "id": "bd-2",
     "condition": "Ramsay Hunt Syndrome",
     "confidence": "rare",
     "mimics": "Deep ear pain indistinguishable from SCM clavicular referral at onset",
     "distinguishing_feature": "Vesicular eruption in the ear canal or on the pinna — may appear days after pain onset. Facial nerve palsy may follow.",
     "action": "Examine the ear canal at every visit. If vesicles present refer urgently — antiviral window is 72 hours."
   },
   {
     "id": "bd-3",
     "condition": "Eagle Syndrome",
     "confidence": "rare",
     "mimics": "Throat, ear, and TMJ pain overlapping with medial pterygoid and SCM patterns",
     "distinguishing_feature": "Pain provoked by turning the head or swallowing. Elongated styloid process may be palpable in the tonsillar fossa on intraoral examination.",
     "action": "Panoramic radiograph to assess styloid length. Refer to oral/maxillofacial surgery."
   },
   {
     "id": "bd-4",
     "condition": "Glossopharyngeal Neuralgia",
     "confidence": "rare",
     "mimics": "Severe episodic ear and throat pain overlapping with SCM and medial pterygoid referral",
     "distinguishing_feature": "Lancinating, electric shock quality — seconds to minutes duration. Triggered by swallowing, talking, or yawning.",
     "action": "Refer to neurology. Carbamazepine is first-line."
   },
   {
     "id": "bd-5",
     "condition": "Tic Douloureux (Trigeminal Neuralgia)",
     "confidence": "rare",
     "mimics": "Facial and jaw pain overlapping with masseter, temporalis, and SCM sternal patterns",
     "distinguishing_feature": "Lancinating electric shock quality with characteristic facial grimace. Consciousness unimpaired. Trigger zones on face. Ceases completely between attacks.",
     "action": "Refer to neurology. MRI to exclude vascular compression. Carbamazepine first-line."
   },
   {
     "id": "bd-6",
     "condition": "Cerebellopontine Angle Tumour",
     "confidence": "rare",
     "mimics": "Unilateral ear symptoms, dizziness, and tinnitus overlapping with SCM clavicular and masseter deep patterns",
     "distinguishing_feature": "Progressive unilateral sensorineural hearing loss, tinnitus, facial numbness (V), and facial weakness (VII) develop over months. Positive Romberg.",
     "action": "Refer to neurology / ENT. MRI internal auditory meatus urgently."
   },
   {
     "id": "bd-7",
     "condition": "Subclavian Steal Syndrome",
     "confidence": "rare",
     "mimics": "Postural dizziness and neck-related symptoms overlapping with SCM clavicular TrP pattern",
     "distinguishing_feature": "Reversed vertebral artery flow from subclavian stenosis. BP difference >15mmHg between arms. Bruit in supraclavicular fossa. Symptoms provoked by arm exercise.",
     "action": "Check BP in both arms. Refer to vascular surgery. Carotid/subclavian Doppler."
   },
   {
     "id": "bd-8",
     "condition": "Adrenocortical Insufficiency",
     "confidence": "rare",
     "mimics": "Postural dizziness identical to SCM clavicular division pattern",
     "distinguishing_feature": "Orthostatic hypotension (drop ≥20mmHg systolic on standing). Generalised fatigue, skin hyperpigmentation, salt craving.",
     "action": "Refer to GP / endocrinology for serum cortisol and ACTH stimulation test."
   },
   {
     "id": "bd-9",
     "condition": "Spasmodic Torticollis",
     "confidence": "uncommon",
     "mimics": "Neck pain and head posture changes resembling SCM TrP-driven posture",
     "distinguishing_feature": "Involuntary head rotation inhibited by gentle pressure on jaw ipsilateral to rotation (geste antagoniste). Dystonic movement ceases completely during sleep.",
     "action": "Refer to neurology. Botulinum toxin injection is first-line treatment."
   },
   {
     "id": "bd-10",
     "condition": "Sialolithiasis (Parotid duct calculus)",
     "confidence": "uncommon",
     "mimics": "Pre-auricular and TMJ area pain resembling masseter deep head TrP",
     "distinguishing_feature": "Pain peaks predictably during or before meals. Visible or palpable parotid swelling that partially resolves after eating.",
     "action": "Palpate parotid duct. Ultrasound first-line. Refer to oral surgery."
   }
 ]

}