DiagnosticTree/EarTMJ

/* ══════════════════════════════════════════════════════

  TREE DATA
  ══════════════════════════════════════════════════════ */

var TREE_DATA = {

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

   /* ── JAW MOVEMENT BRANCH ── */
   "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"
   },

   /* ── NECK / SCM BRANCH ── */
   "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"
   },

   /* ── SCM EXAMINATION ── */
   "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"
   },

   /* ── CN XI ENTRAPMENT — on landing page, not algorithm ── */

   /* ── PTERYGOID / MASSETER SYMPTOMS ── */
   "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"
   },

   /* ── EXAMINATIONS ── */
   "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"
   },

   /* ══════════════════════════════════
      RESULTS
      ══════════════════════════════════ */
   "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"
   },

   /* ══════════════════════════════════
      REFERRAL ENDPOINTS
      ══════════════════════════════════ */
   "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."
   }
 }

};

/* ══════════════════════════════════════════════════════

  RED FLAGS
  ══════════════════════════════════════════════════════ */

var REDFLAG_DATA = {

 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" }
 ]

};

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  BROAD DIFFERENTIAL
  ══════════════════════════════════════════════════════ */

var BROAD_DIFF_DATA = [

{ 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 is unimpaired. Trigger zones on face. Ceases between attacks completely.",
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 of >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 (≥20mmHg systolic drop on standing). Generalised fatigue, skin hyperpigmentation, salt craving. Dizziness on rising or postural change.",
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." }

];

/* ══════════════════════════════════════════════════════

  NODE META
  ══════════════════════════════════════════════════════ */

var NODE_META = {

 rom:              { color:'#1d4ed8', icon:'🔄', label:'Movement Screen' },
 nerve_entrapment: { color:'#6d28d9', icon:'⚡', label:'Nerve Screen' },
 symptom:          { color:'#0f766e', icon:'💬', label:'Patient Symptom' },
 examination:      { color:'#15803d', icon:'🩺', label:'Examination' },
 result:           { color:'#15803d', icon:'✅', label:'Diagnosis' },
 overlap:          { color:'#78716c', icon:'🔍', label:'Inconclusive' },
 neuro_referral:   { color:'#b91c1c', icon:'🧠', label:'Neurological Referral' }

};

DiagnosticTree/EarTMJ

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