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"
}
}