DiagnosticTree/EarTMJ

{

 "tree_id": "ear-tmj",
 "region": "Ear & Temporomandibular Joint Pain",
 "start": "rom-1",
 "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"
   },
   "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"
   },
   "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-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 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"
     ],
     "satellite_trps": [
       "Scalene muscles",
       "Sternalis",
       "Pectoralis major",
       "Pectoralis minor",
       "Masseter",
       "Temporalis",
       "Orbicularis oculi",
       "Frontalis"
     ],
     "confirmatory": [
       "Horner's excluded — pupils equal and reactive, no miosis, ciliospinal reflex present",
       "Spasmodic torticollis excluded — no jaw-pressure inhibition of head rotation; any dystonic movement ceases in sleep",
       "Note which head is more reactive: sternal (facial/autonomic symptoms) vs clavicular (dizziness/frontal headache)"
     ],
     "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": "Trigger_point:Masseter_superficial",
     "chapter_ref": "Travell & Simons Vol.1 — Ch.8",
     "notes": "Refers to cheek, lower jaw, upper and lower molar teeth, and eyebrow. Chewing pain without restriction.",
     "treatment_hint": "Spray and stretch, intraoral massage, correct parafunctional habits (clenching, bruxism)",
     "also_consider": [
       "Temporalis",
       "Medial Pterygoid"
     ]
   },
   "result-masseter-deep": {
     "type": "result",
     "diagnosis": "Masseter — Deep Head Trigger Point",
     "confidence": "high",
     "wiki_page": "Trigger_point:Masseter_deep",
     "chapter_ref": "Travell & Simons Vol.1 — Ch.8",
     "notes": "Refers deep into the ear and TMJ area. Tinnitus is a strongly associated feature of deep head involvement.",
     "treatment_hint": "Deep pressure release, spray and stretch over TMJ, address bruxism",
     "also_consider": [
       "Lateral Pterygoid",
       "SCM clavicular head"
     ]
   },
   "result-medial-pterygoid": {
     "type": "result",
     "diagnosis": "Medial Pterygoid Trigger Point",
     "confidence": "high",
     "wiki_page": "Trigger_point:Medial_pterygoid",
     "chapter_ref": "Travell & Simons Vol.1 — Ch.9",
     "notes": "Refers to inside the mouth, hard palate, throat, posterior TMJ, and ear. Dysphagia is key distinguishing feature. Intraoral palpation required.",
     "treatment_hint": "Intraoral spray and stretch, ischemic compression. Refer to dental/oral medicine if needed.",
     "also_consider": [
       "Lateral Pterygoid",
       "Digastric (posterior belly)"
     ]
   },
   "result-lateral-pterygoid": {
     "type": "result",
     "diagnosis": "Lateral Pterygoid Trigger Point",
     "confidence": "high",
     "wiki_page": "Trigger_point:Lateral_pterygoid",
     "chapter_ref": "Travell & Simons Vol.1 — Ch.9",
     "notes": "Refers to TMJ area and maxillary sinus. Pain on resisted jaw CLOSING is pathognomonic. Associated with jaw deviation and clicking.",
     "treatment_hint": "Intraoral spray and stretch, address jaw deviation. Refer to dental/oral medicine for occlusal assessment.",
     "also_consider": [
       "Masseter deep head",
       "Medial Pterygoid"
     ]
   },
   "result-overlap": {
     "type": "overlap",
     "text": "Findings are inconclusive. Multi-muscle involvement or atypical presentation likely. Perform a full palpation screen of all four muscles.",
     "screen_these": [
       "SCM — Clavicular head",
       "Masseter — superficial and deep heads",
       "Medial Pterygoid (intraoral)",
       "Lateral Pterygoid (intraoral)"
     ],
     "wiki_page": "Differential:Ear_TMJ_pain"
   },
   "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."
   }
 }

}