DiagnosticTree/EarTMJ

{

 "tree_id": "ear-tmj",
 "region": "Ear & Temporomandibular Joint Pain",
 "muscles_in_differential": [
   "SCM (Clavicular head)", "Masseter", "Medial Pterygoid", "Lateral Pterygoid"
 ],
 "start": "emergency-1",
 "nodes": {

   "emergency-1": {
     "type": "emergency",
     "question": "Is there fever, acute hearing loss, or purulent ear discharge?",
     "clinical_rationale": "Acute otitis media or mastoiditis — requires urgent antibiotic treatment or surgical referral",
     "flag_label": "Possible otitis media / mastoiditis",
     "yes": "refer-emergency",
     "no": "emergency-2"
   },
   "emergency-2": {
     "type": "emergency",
     "question": "Is there jaw or ear pain with an exertional component, particularly on the left side?",
     "clinical_rationale": "Cardiac referred pain can present as jaw or ear pain — must be excluded before proceeding",
     "flag_label": "Possible cardiac referral",
     "yes": "refer-emergency",
     "no": "urgent-1"
   },

   "urgent-1": {
     "type": "urgent",
     "question": "Is the patient aged 50+ with jaw claudication (pain that builds with chewing then eases), temporal headache, or scalp tenderness?",
     "clinical_rationale": "Temporal arteritis — can cause irreversible blindness if untreated. Same-day ESR required.",
     "flag_label": "Possible temporal arteritis",
     "yes": "refer-urgent",
     "no": "urgent-2"
   },
   "urgent-2": {
     "type": "urgent",
     "question": "Is there a hard, fixed swelling of the parotid gland or neck, or any facial nerve weakness?",
     "clinical_rationale": "Possible parotid or salivary gland malignancy with nerve involvement",
     "flag_label": "Possible malignancy",
     "yes": "refer-urgent",
     "no": "urgent-3"
   },
   "urgent-3": {
     "type": "urgent",
     "question": "Is there a history of trauma to the head or neck combined with upper cervical pain and ear symptoms?",
     "clinical_rationale": "Cervical instability or odontoid fracture can refer to the ear region",
     "flag_label": "Possible cervical instability",
     "yes": "refer-urgent",
     "no": "rom-1"
   },

   "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 pain reproduced or worsened by closing the mouth against resistance (e.g. biting down on a 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 neck 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"],
     "yes": "symptom-scm-1",
     "no": "symptom-scm-2"
   },

   "symptom-1": {
     "type": "symptom",
     "question": "Does the patient report difficulty swallowing (dysphagia) or a sensation of throat tightness?",
     "symptom_name": "Dysphagia / throat tightness",
     "patient_reported": true,
     "muscles_implicated": ["Medial Pterygoid"],
     "muscles_excluded": ["Lateral Pterygoid"],
     "yes": "exam-medial-1",
     "no": "exam-masseter-deep-1"
   },
   "symptom-scm-1": {
     "type": "symptom",
     "question": "Does the patient report dizziness, spatial disorientation, or a feeling of imbalance — without obvious inner ear diagnosis?",
     "symptom_name": "Dizziness / spatial disorientation",
     "patient_reported": true,
     "muscles_implicated": ["SCM (Clavicular head)"],
     "yes": "exam-scm-1",
     "no": "exam-scm-1"
   },
   "symptom-scm-2": {
     "type": "symptom",
     "question": "Does the patient report ipsilateral tearing, nasal congestion, or conjunctival redness without allergic cause?",
     "symptom_name": "Autonomic signs — tearing, congestion, conjunctival redness",
     "patient_reported": true,
     "muscles_implicated": ["SCM (Clavicular head)"],
     "yes": "exam-scm-1",
     "no": "result-overlap"
   },

   "exam-scm-1": {
     "type": "examination",
     "question": "Does palpation along the posterior border of the sternocleidomastoid — particularly the clavicular head — reproduce the patient's deep ear pain or dizziness?",
     "exam_type": "palpation",
     "landmark": "Clavicular head of SCM: palpate the medial clavicle attachment, follow the muscle belly superiorly toward the mastoid",
     "positive_finding": "Reproduces deep ear pain, dizziness, or spatial symptoms",
     "muscles_implicated": ["SCM (Clavicular head)"],
     "yes": "result-scm",
     "no": "result-overlap"
   },
   "exam-medial-1": {
     "type": "examination",
     "question": "Does intraoral palpation of the medial pterygoid (along the medial aspect of the mandible, posterior to the last molar) reproduce the ear or throat pain?",
     "exam_type": "palpation",
     "landmark": "Intraoral: gloved finger along medial surface of posterior mandible. 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, at the TMJ level) reproduce ear pain or tinnitus?",
     "exam_type": "palpation",
     "landmark": "Deep masseter: palpate just anterior to the tragus, at the level of the TMJ; 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 — Clavicular Head Trigger Point",
     "confidence": "high",
     "wiki_page": "Trigger_point:Sternocleidomastoid_clavicular",
     "chapter_ref": "Travell & Simons Vol.1 — Ch.7 Sternocleidomastoid",
     "notes": "The clavicular head refers deep into the ear canal and can cause dizziness, spatial disorientation, and autonomic signs. Often misdiagnosed as inner ear disorder.",
     "treatment_hint": "Spray and stretch (superior to inferior), ischemic compression, correct forward head posture",
     "also_consider": ["Splenius capitis", "Suboccipitals"]
   },
   "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 Masseter",
     "notes": "Refers to cheek, lower jaw, upper and lower molar teeth, and the 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 Masseter",
     "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 Pterygoids",
     "notes": "Refers to inside the mouth, hard palate, throat, posterior TMJ, and ear. Dysphagia is a key distinguishing feature. Intraoral palpation required.",
     "treatment_hint": "Intraoral spray and stretch, intraoral 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 Pterygoids",
     "notes": "Refers to TMJ area and maxillary sinus. Pain on resisted jaw CLOSING is pathognomonic. Often 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"]
   },

   "refer-emergency": {
     "type": "referral",
     "urgency": "emergency",
     "text": "Do not proceed with musculoskeletal assessment.",
     "action": "Call emergency services or send directly to Emergency Department",
     "flag_label": "Serious pathology must be excluded before any manual therapy"
   },
   "refer-urgent": {
     "type": "referral",
     "urgency": "urgent",
     "text": "Refer to appropriate specialist today. Do not proceed with myofascial assessment until serious pathology is excluded.",
     "action": "Contact GP / specialist for same-day or next-day assessment",
     "flag_label": "Urgent referral — serious pathology suspected"
   },

   "result-overlap": {
     "type": "overlap",
     "text": "Findings are inconclusive. Multi-muscle involvement or an atypical presentation is 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"
   }

 }

}