DiagnosticTree/EarTMJ
{
"tree": {
"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."
}
}
},
"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"
}
]
},
"broad_diff": [
{
"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."
}
]
}