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, and eyebrow. Chewing pain without restriction of opening.",
     "treatment_hint": "Spray and stretch, intraoral massage, correct parafunctional habits (clenching, bruxism)",
     "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 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",
     "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 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, ischemic compression. Refer to dental/oral medicine if needed.",
     "less_likely": [
       { "muscle": "Lateral Pterygoid", "reason": "Dysphagia present — more consistent with medial pterygoid" },
       { "muscle": "Masseter — Deep Head", "reason": "Throat tightness argues for medial pterygoid" },
       { "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.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.",
     "less_likely": [
       { "muscle": "Medial Pterygoid", "reason": "Resisted jaw closure pain is more specific to lateral pterygoid" },
       { "muscle": "Masseter — Deep Head", "reason": "Resisted jaw closure 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."
   }
 ]

}