DiagnosticTree/ThroatFrontofNeck
{
"tree_id": "throat-front-neck-pain", "region": "Throat and Front-of-Neck Pain", "start": "agg-1",
"redflags": {
"emergency": [
{
"id": "rf-e1",
"label": "Airway compromise / Ludwig's angina",
"question": "Is there rapidly progressive swelling of the floor of the mouth, submandibular or anterior neck region, with difficulty breathing, stridor, or inability to swallow saliva?",
"rationale": "Ludwig's angina and other deep space infections of the anterior neck can rapidly compromise the airway. This is a life-threatening emergency.",
"action": "Call emergency services immediately. This is a surgical emergency."
},
{
"id": "rf-e2",
"label": "Epiglottitis",
"question": "Is there sudden onset severe throat pain with drooling, muffled voice, dysphagia, and the patient sitting upright or in a tripod position?",
"rationale": "Epiglottitis produces severe throat pain and is an airway emergency, particularly in adults with diabetes or immunocompromise.",
"action": "Call emergency services immediately. Do not attempt to examine the throat with a tongue depressor."
},
{
"id": "rf-e3",
"label": "Carotid dissection",
"question": "Is there anterior neck pain on one side with new ipsilateral headache, ptosis, or neurological symptoms (facial weakness, arm weakness, speech change)?",
"rationale": "Carotid artery dissection presents as anterior neck pain — often aching — and may precede ischaemic stroke by hours to days. Horner syndrome from sympathetic chain disruption may be present.",
"action": "Emergency medical referral immediately. MRI/MRA urgently required."
}
],
"urgent": [
{
"id": "rf-u1",
"label": "Neck malignancy",
"question": "Is there a hard or fixed anterior or lateral neck mass, unexplained hoarseness persisting more than two weeks, progressive dysphagia, or unexplained weight loss?",
"rationale": "Persistent throat and anterior neck symptoms with a mass, hoarseness, or dysphagia require urgent ENT assessment to exclude laryngeal, pharyngeal, or thyroid malignancy.",
"action": "Urgent ENT referral. Do not delay for myofascial assessment."
},
{
"id": "rf-u2",
"label": "Eagle syndrome",
"question": "Is there throat or anterior neck pain provoked specifically by turning the head or swallowing, with a sensation of a foreign body in the throat and tenderness in the tonsillar fossa?",
"rationale": "Eagle syndrome (elongated styloid process) mimics digastric and medial pterygoid TrP patterns and is a recurrence trap — recalcitrant TrP-like throat pain should trigger exclusion of this condition.",
"action": "If recalcitrant to TrP treatment, refer for panoramic radiograph and oral/maxillofacial surgery assessment."
},
{
"id": "rf-u3",
"label": "Thyroiditis / thyroid pathology",
"question": "Is there anterior neck pain over the thyroid gland with tenderness to palpation, fever, or recent viral illness?",
"rationale": "Subacute (de Quervain) thyroiditis presents as anterior neck pain, sometimes severe, with tenderness over the thyroid gland. Thyroid pathology must be excluded before myofascial assessment of anterior neck pain.",
"action": "GP or endocrinology referral. TSH, free T4, ESR, and ultrasound of the thyroid."
}
]
},
"nodes": {
"agg-1": {
"type": "choice",
"question": "Which feature best characterises the throat or front-of-neck pain?",
"clinical_rationale": "Three muscles contribute to throat and front-of-neck pain. The SCM sternal division is the essential (bold) source — it refers to the throat and produces a specific finding on the SCM Compression Test. The digastric posterior belly produces pseudo-SCM pain that mimics SCM referral so closely that it only becomes apparent after SCM treatment gives incomplete relief. The medial pterygoid produces throat and pharyngeal pain with the distinctive ear stuffiness (barohypoacusis), a compensatory swallowing pattern, and jaw restriction — making it immediately distinguishable by symptom character. This three-way choice separates the muscles by their cardinal presenting features without premature commitment.",
"options": [
{
"label": "Throat soreness or front-of-neck ache aggravated by swallowing — OR ipsilateral autonomic phenomena (tearing, rhinitis, apparent eyelid drooping)",
"sublabel": "Swallowing provokes or worsens the throat pain; OR profuse tearing, blocked nose, or palpebral narrowing on the same side",
"next": "exam-scm-sternal-1"
},
{
"label": "Throat and ear stuffiness — AND restricted jaw opening or compensatory swallowing pattern (extending neck and pushing tongue forward)",
"sublabel": "Cannot equalise ear pressure; jaw opening reduced; swallowing requires an abnormal neck or tongue movement",
"next": "exam-medial-pterygoid-1"
},
{
"label": "Throat or under-chin soreness without a clear jaw component — possibly with tongue soreness or burning",
"sublabel": "Throat discomfort under the chin or anterior to the SCM without jaw restriction; may have burning or sore tongue",
"next": "digastric-throat-split-1"
}
]
},
"exam-scm-sternal-1": {
"type": "examination",
"question": "Does the SCM Compression Test confirm the sternal division? — Firmly grip the full sternal belly while the patient swallows: does the throat pain resolve with compression? And does pincer palpation of the sternal head reproduce the throat, front-of-neck, or cheek pain?",
"exam_type": "palpation",
"landmark": "SCM Compression Test: patient supine, head rotated slightly toward the TrP side. Firmly grasp the full sternal belly in a pincer grip from mastoid to sternum. Ask the patient to swallow a small amount of saliva — resolution of pharyngeal pain or throat soreness WITH compression is pathognomonic of a sternal central TrP. This test is specific to the sternal division and cannot be positive from digastric posterior belly TrPs alone. Also confirm: pincer palpation of the full sternal belly length reproduces familiar throat or front-of-neck pain. Note palpebral fissure width — narrowing without miosis on the TrP side confirms sternal division.",
"positive_finding": "SCM Compression Test positive — throat pain resolves on gripping the sternal belly during swallowing. Pincer palpation reproduces throat or front-of-neck pain.",
"muscles_implicated": ["SCM (Sternal Division)"],
"yes": "digastric-pseudo-screen-1",
"no": "digastric-throat-split-1"
},
"digastric-pseudo-screen-1": {
"type": "symptom",
"question": "After confirming SCM sternal involvement — is there RESIDUAL throat soreness or tenderness in the upper SCM region that persists even after SCM TrP release, with diffuse moderate tenderness but no taut bands or local twitch response in the SCM belly?",
"symptom_name": "Pseudo-SCM pain — residual after SCM treatment",
"muscles_implicated": ["Digastric (Posterior Belly)"],
"clinical_rationale": "Pseudo-sternocleidomastoid pain from the posterior digastric belly is among the most clinically deceptive presentations in the throat pain group. It is so similar to SCM referral that it is routinely attributed to the SCM — until the SCM is treated and the pain persists. The critical diagnostic clue is: when the SCM is cleared of TrPs, the upper SCM region remains diffusely and moderately tender to palpation but is free of taut bands and local twitch responses. This residual pattern without taut bands is the hallmark of digastric posterior belly pseudo-SCM pain. Examine the posterior digastric belly whenever SCM treatment gives incomplete relief of throat or anterior neck pain.",
"yes": "exam-digastric-posterior-1",
"no": "result-scm-sternal"
},
"digastric-throat-split-1": {
"type": "symptom",
"question": "Is there TONGUE soreness, burning tongue (glossodynia), or tenderness under the chin in the submental region — alongside or instead of the throat pain?",
"symptom_name": "Tongue soreness / glossodynia / submental tenderness",
"muscles_implicated": ["Digastric (Anterior Belly)"],
"muscles_excluded": ["Digastric (Posterior Belly)"],
"clinical_rationale": "The anterior belly of the digastric refers pain to the four lower incisor teeth and the tongue, and can cause glossodynia (burning tongue) — a pattern distinct from the posterior belly which refers to the upper SCM region and throat in front of the SCM. Burning tongue with submental tenderness argues for anterior belly involvement. The absence of tongue or submental involvement routes to the posterior belly. Both bellies are part of the same clinical examination — always examine both.",
"yes": "exam-digastric-anterior-1",
"no": "exam-digastric-posterior-1"
},
"exam-digastric-posterior-1": {
"type": "examination",
"question": "Does palpation of the posterior digastric belly — along the course from the mastoid notch downward and forward to the hyoid, passing anterior to the SCM — reproduce the throat or anterior neck pain? Does the Swallowing Test (palpating the belly during swallowing) produce pain or increased tension?",
"exam_type": "palpation",
"landmark": "Posterior belly course: from the mastoid notch, passing deep to the lower SCM toward the hyoid bone. Palpate along this diagonal line with firm flat pressure. The jaw must be completely relaxed — any jaw tension tightens the digastric and obscures the examination. Swallowing Test: maintain palpation contact on the posterior belly and ask the patient to swallow a small amount of saliva — increased pain or tension confirms posterior belly involvement. Distinguish from SCM by location: the digastric belly lies anterior to the SCM at the level of the hyoid. Mandibular Deviation Sign: ask the patient to open the jaw slowly — deviation toward the TrP side confirms digastric involvement. Hyoid mobility: press the hyoid bone gently laterally — restricted lateral shift indicates suprahyoid muscle tension.",
"positive_finding": "Tenderness along the posterior belly from mastoid notch toward the hyoid, anterior to the SCM. Swallowing Test positive. Hyoid mobility restricted.",
"muscles_implicated": ["Digastric (Posterior Belly)"],
"yes": "result-digastric-posterior",
"no": "exam-digastric-anterior-1"
},
"exam-digastric-anterior-1": {
"type": "examination",
"question": "Does palpation of the anterior digastric belly — at the floor of the mouth along the inferior border of the mandible near the symphysis — reproduce submental pain, tongue soreness, or lower incisor referral? Is the Anterior Digastric Test positive (pain on resisted jaw opening)?",
"exam_type": "palpation",
"landmark": "Anterior belly: palpate along the inferior border of the mandible from the midline symphysis posteriorly toward the hyoid. The patient must keep the jaw fully relaxed. Anterior Digastric Test: place a finger on the lower incisors and ask the patient to open the jaw against mild resistance — reproduction of submental or lower incisor pain confirms anterior belly involvement. Glossodynia: ask specifically about burning tongue — glossodynia from anterior digastric TrPs is relieved by TrP inactivation. Hyoid mobility: the hyoid should shift laterally with gentle side pressure — restriction indicates suprahyoid muscle tension from both bellies.",
"positive_finding": "Anterior belly palpation reproduces submental pain or lower incisor referral. Anterior Digastric Test positive. Glossodynia present.",
"muscles_implicated": ["Digastric (Anterior Belly)"],
"yes": "result-digastric-anterior",
"no": "exam-medial-pterygoid-1"
},
"exam-medial-pterygoid-1": {
"type": "examination",
"question": "Does intraoral palpation of the medial pterygoid — gloved finger behind the last molar on the medial surface of the mandibular ramus — reproduce the throat, pharyngeal, or palate pain? Is ear stuffiness (barohypoacusis) present and is jaw opening restricted?",
"exam_type": "palpation",
"landmark": "Intraoral central TrP: patient supine, jaw drops open as far as comfortable. Gloved index finger slides over the molar teeth to the bony anterior edge of the ramus — the medial pterygoid belly lies immediately posterior to this edge. Palpate for exquisite tenderness with referral to throat, palate, ear, or jaw. Gag reflex management: ask patient to exhale fully, or tap the ipsilateral temporalis as sensory distraction. Extraoral: press upward at the angle of the mandible along its inner medial surface. Barohypoacusis screen: ask specifically whether the ear feels blocked or whether the patient cannot equalise ear pressure — this is caused by TrP bands blocking the tensor veli palatini from opening the eustachian tube. Swallowing compensation: does the patient extend their neck and push their tongue forward when swallowing?",
"positive_finding": "Intraoral palpation reproduces throat, pharyngeal, or palate pain. Barohypoacusis confirmed. Compensatory swallowing pattern observed.",
"muscles_implicated": ["Medial Pterygoid"],
"yes": "result-medial-pterygoid",
"no": "result-overlap"
},
"result-scm-sternal": {
"type": "result",
"diagnosis": "SCM Trigger Point — Sternal Division",
"confidence": "high",
"wiki_page": "Muscle:Sternocleidomastoid",
"chapter_ref": "Travell & Simons Vol.1 — Ch.7 Sternocleidomastoid",
"notes": "The sternal division of the SCM is the essential (bold) source of throat and front-of-neck pain in the Travell and Simons taxonomy. Its throat referral is clinically important because the soreness along the anterior neck is commonly misattributed to lymphadenopathy — the patient is examined for enlarged lymph nodes and the muscle is never palpated. The SCM Compression Test is pathognomonic for the sternal central TrP: pharyngeal pain on swallowing resolves when the sternal belly is firmly gripped. A cough TrP near the sternal attachment may produce a dry tingling cough. Autonomic phenomena — tearing, rhinitis, palpebral fissure narrowing — may accompany the throat referral and are specific to the sternal division. Treating the sternal SCM frequently resolves satellite TrPs in the digastric, zygomaticus major, and facial muscles without direct treatment of those satellites.",
"treatment_hint": "Pincer palpation and spray and stretch, superior to inferior. SCM Compression Test confirms sternal central TrP. Correct forward head posture. Always examine the posterior digastric belly — residual throat pain after SCM treatment that persists without taut bands in the SCM indicates pseudo-SCM pain from the posterior digastric.",
"also_consider": ["Digastric Posterior Belly (satellite — always examine)", "Upper Trapezius", "Zygomaticus Major (satellite)"],
"less_likely": [
{ "muscle": "Digastric Posterior", "reason": "SCM Compression Test positive — specific to the sternal division; but examine digastric posterior for residual pain after SCM treatment" },
{ "muscle": "Medial Pterygoid", "reason": "No ear stuffiness or compensatory swallowing; SCM Compression Test is specific to the sternal division" }
],
"confirmatory": [
"SCM Compression Test positive — pharyngeal pain resolves on gripping the sternal belly during swallowing; pathognomonic",
"Soreness along anterior neck misattributed to lymphadenopathy — nodes non-tender, SCM belly reproduces the ache",
"Profuse ipsilateral tearing and rhinitis if autonomic phenomena present — specific to sternal division",
"Palpebral fissure narrowing without miosis — exclude true Horner syndrome",
"Head tilts toward TrP side",
"ALWAYS examine digastric posterior — residual throat soreness without SCM taut bands after treatment = pseudo-SCM pain"
],
"satellite_trps": ["Digastric (Posterior Belly)", "Zygomaticus Major", "Orbicularis Oculi", "Frontalis", "Masseter"],
"landing_page_topics": [
"SCM Compression Test — technique and interpretation",
"Lymphadenopathy misattribution — anterior neck soreness",
"Cough TrP near sternal attachment",
"Horner syndrome exclusion",
"Satellite TrP treatment sequence",
"Pseudo-SCM pain from posterior digastric — when to examine digastric after SCM treatment"
],
"related_pages": [
{ "label": "Digastric TrP →", "page": "Muscle:Digastric" },
{ "label": "Medial Pterygoid TrP →", "page": "Muscle:Medial_Pterygoid" }
]
},
"result-digastric-posterior": {
"type": "result",
"diagnosis": "Digastric — Posterior Belly Trigger Point (Pseudo-SCM Pain)",
"confidence": "high",
"wiki_page": "Muscle:Digastric",
"chapter_ref": "Travell & Simons Vol.1 — Ch.12 Digastric",
"notes": "The posterior belly of the digastric refers pain to the upper SCM region, the throat in front of the SCM, under the chin, and occasionally to the occiput. This is pseudo-sternocleidomastoid pain — so convincingly similar to SCM TrP referral that it is routinely attributed to the SCM. The critical diagnostic clue is that residual throat soreness persists after SCM treatment, with the upper SCM region remaining diffusely and moderately tender but free of taut bands and local twitch responses. The digastric nearly always develops TrPs secondary to masseter TrPs rather than in isolation. Eagle syndrome (elongated styloid process) must be excluded if TrPs are recalcitrant. The mutual satellite relationship between the digastric and SCM means both must be examined when either is involved.",
"treatment_hint": "Treat masseter TrPs first — digastric posterior is frequently their satellite. Spray and stretch of the posterior belly. Swallowing Test and hyoid mobility assessment confirm. Eagle syndrome exclusion: intraoral palpation in the tonsillar fossa if recalcitrant. Always treat SCM concurrently.",
"also_consider": ["Masseter (key TrP)", "SCM Sternal Division", "Medial Pterygoid", "Stylohyoid"],
"less_likely": [
{ "muscle": "SCM Sternal Division", "reason": "Pseudo-SCM pain is the hallmark — the SCM has been cleared but upper SCM soreness persists without taut bands" },
{ "muscle": "Medial Pterygoid", "reason": "No ear stuffiness or compensatory swallowing; pseudo-SCM pattern without jaw restriction argues for posterior digastric" }
],
"confirmatory": [
"Residual upper SCM region soreness after SCM treatment — diffuse moderate tenderness without taut bands or local twitch response in the SCM belly",
"Posterior belly palpation from mastoid notch to hyoid reproduces throat or upper SCM pain",
"Swallowing Test positive — pain or increased tension in posterior belly during swallowing",
"Mandibular Deviation Sign — deviation toward TrP side on slow jaw opening",
"Hyoid mobility restricted — lateral shift reduced",
"Masseter TrPs also active — posterior digastric is almost always their satellite",
"Eagle syndrome excluded — no tonsillar fossa pain on intraoral palpation"
],
"satellite_trps": ["Masseter (key TrP)", "SCM Sternal Division", "Occipitalis", "Medial Pterygoid"],
"landing_page_topics": [
"Pseudo-SCM pain — when the SCM is cleared but upper SCM soreness persists",
"Swallowing Test and hyoid mobility assessment technique",
"Eagle syndrome exclusion — intraoral palpation and panoramic radiograph",
"Mandibular Deviation Sign",
"Satellite relationship with masseter and SCM"
],
"related_pages": [
{ "label": "SCM TrP →", "page": "Muscle:Sternocleidomastoid" },
{ "label": "Masseter TrP →", "page": "Muscle:Masseter" },
{ "label": "Medial Pterygoid TrP →", "page": "Muscle:Medial_Pterygoid" }
]
},
"result-digastric-anterior": {
"type": "result",
"diagnosis": "Digastric — Anterior Belly Trigger Point",
"confidence": "moderate",
"wiki_page": "Muscle:Digastric",
"chapter_ref": "Travell & Simons Vol.1 — Ch.12 Digastric",
"notes": "The anterior belly of the digastric refers pain to the four lower incisor teeth, the alveolar ridge below them, and the tongue — and can cause glossodynia (burning tongue). In the throat and front-of-neck context, the anterior belly's contribution is submental soreness and tongue pain rather than classical throat pain. Glossodynia from anterior digastric TrPs resolves with TrP inactivation, distinguishing it from idiopathic burning mouth syndrome. The responsible TrP is located just under the tip of the chin and can be on either side of the midline. Anterior belly TrPs develop secondary to masseter TrPs — always examine and treat masseter first.",
"treatment_hint": "Treat masseter TrPs first. Anterior Digastric Test (resisted jaw opening) confirms. Hyoid mobility assessment — restricted lateral shift indicates suprahyoid tension. Inactivating the TrP resolves glossodynia and lower incisor hypersensitivity.",
"also_consider": ["Masseter (key TrP)", "Mylohyoid", "Medial Pterygoid"],
"less_likely": [
{ "muscle": "Digastric Posterior", "reason": "Tongue referral and submental location are specific to the anterior belly; posterior belly refers to the upper SCM region and throat anterior to the SCM" },
{ "muscle": "SCM Sternal Division", "reason": "Tongue soreness and submental tenderness argue for anterior digastric; SCM does not refer to the tongue" }
],
"confirmatory": [
"Anterior belly palpation at the floor of the mouth reproduces submental pain or lower incisor referral",
"Glossodynia — burning tongue resolves with anterior belly TrP inactivation",
"Anterior Digastric Test positive — resisted jaw opening reproduces submental pain",
"Lower incisor tooth hypersensitivity may accompany the tongue and submental pain",
"Masseter TrPs identified on the same side — anterior digastric is almost always their satellite"
],
"satellite_trps": ["Masseter (key TrP)", "Medial Pterygoid", "Mylohyoid"],
"landing_page_topics": [
"Glossodynia (burning tongue) — resolution with TrP inactivation",
"Lower incisor tooth referral — preventing unnecessary dental treatment",
"Anterior Digastric Test technique",
"Hyoid mobility assessment",
"Satellite relationship with masseter"
],
"related_pages": [
{ "label": "Digastric full page →", "page": "Muscle:Digastric" },
{ "label": "Masseter TrP →", "page": "Muscle:Masseter" }
]
},
"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 Medial Pterygoid",
"notes": "Medial pterygoid TrPs refer diffusely to the tongue, pharynx, hard palate, below and behind the TMJ, and deep into the ear. In the throat and front-of-neck context, the pharyngeal and palatal referral is the presenting complaint. Barohypoacusis (ear stuffiness, inability to equalise ear pressure) is characteristic — tense TrP bands block the tensor veli palatini from opening the eustachian tube. The compensatory swallowing pattern is pathognomonic: the patient extends the neck and pushes the tongue forward when swallowing to open the pharyngeal space. Pain is NOT referred to the teeth — this single feature distinguishes medial pterygoid from masseter and temporalis. Bitter metallic taste indicates chorda tympani entrapment between the medial pterygoid and the mandible. Wide mouth opening is restricted and painful.",
"treatment_hint": "Intraoral ischemic compression and spray and stretch. Resisted jaw opening for reciprocal inhibition of all elevator muscles. Treat lateral pterygoid and masseter concurrently — medial pterygoid rarely has TrPs in isolation. Gag reflex management: full exhale, tap ipsilateral temporalis as sensory distraction.",
"also_consider": ["Lateral Pterygoid", "Masseter", "SCM"],
"less_likely": [
{ "muscle": "SCM Sternal Division", "reason": "Barohypoacusis and compensatory swallowing are specific to medial pterygoid; SCM Compression Test was not positive" },
{ "muscle": "Digastric Posterior", "reason": "Ear stuffiness, compensatory swallowing, and jaw restriction argue for medial pterygoid; digastric produces pseudo-SCM pain without these features" }
],
"confirmatory": [
"Barohypoacusis — ear stuffiness, inability to equalise ear pressure; specific to medial pterygoid blocking the eustachian tube",
"Compensatory swallowing pattern — extends neck and pushes tongue forward when swallowing; pathognomonic",
"Jaw opening restricted — less than 36–40mm; soft end-feel distinguishes from articular restriction",
"Pain NOT referred to teeth — distinguishes from masseter and temporalis",
"Chorda tympani entrapment: bitter metallic taste on the same side",
"Intraoral palpation behind the last molar reproduces pharyngeal or palatal pain"
],
"satellite_trps": ["Lateral Pterygoid", "Masseter", "Temporalis", "Digastric"],
"landing_page_topics": [
"Barohypoacusis — eustachian tube mechanism and clinical recognition",
"Compensatory swallowing pattern — description and observation",
"Chorda tympani entrapment — bitter metallic taste",
"Intraoral palpation technique and gag reflex management",
"Resisted jaw opening for reciprocal inhibition",
"Pain NOT referred to teeth — distinguishing from masseter and temporalis"
],
"related_pages": [
{ "label": "Lateral Pterygoid TrP →", "page": "Muscle:Lateral_Pterygoid" },
{ "label": "Masseter TrP →", "page": "Muscle:Masseter" },
{ "label": "TMJ Screening →", "page": "Pain:TMJ_Screening_Examination" }
]
},
"result-overlap": {
"type": "overlap",
"text": "Findings are inconclusive. In the throat and front-of-neck group, multi-muscle involvement is common — SCM sternal and posterior digastric frequently coexist, and medial pterygoid rarely presents in isolation without masseter involvement. Perform a systematic screen in clinical priority order.",
"screen_these": [
"SCM sternal head — full pincer palpation; SCM Compression Test (pathognomonic if positive); autonomic phenomena; cough TrP near sternal attachment",
"Digastric posterior belly — palpation from mastoid notch to hyoid; Swallowing Test; Mandibular Deviation Sign; hyoid mobility; check masseter as key TrP",
"Digastric anterior belly — floor of mouth palpation; Anterior Digastric Test; glossodynia assessment; lower incisor hypersensitivity",
"Medial pterygoid — intraoral palpation behind last molar; barohypoacusis; compensatory swallowing pattern; jaw opening measurement"
],
"wiki_page": "Differential:Throat_Front_Neck_Pain"
}
},
"broad_differential": [
{
"id": "bd-1",
"condition": "Pharyngitis / Tonsillitis",
"confidence": "common",
"mimics": "Throat pain — overlaps with SCM sternal and posterior digastric patterns",
"distinguishing_feature": "True pharyngitis: fever, erythematous pharynx on inspection, tonsillar exudate, tender anterior cervical lymph nodes that are truly enlarged (not just the SCM belly). Myofascial throat pain: normal pharyngeal appearance, non-enlarged lymph nodes, SCM belly tender and reproduces the throat pain, SCM Compression Test positive.",
"action": "Inspect the pharynx before any myofascial assessment of throat pain. If erythema, exudate, or fever present, treat the infection before myofascial treatment."
},
{
"id": "bd-2",
"condition": "Lymphadenopathy",
"confidence": "uncommon",
"mimics": "Anterior neck soreness — SCM sternal TrP pain is commonly misattributed to lymphadenopathy",
"distinguishing_feature": "True lymphadenopathy: discrete, palpable, enlarged lymph nodes distinct from the SCM muscle belly. Myofascial: the SCM muscle belly itself is tender and reproduces the anterior neck soreness — there are no discrete enlarged nodes. SCM Compression Test is positive. The distinction is made by careful palpation and confirmation that the tender structure is the muscle belly, not lymph nodes.",
"action": "Palpate the SCM belly systematically. If the SCM belly (not discrete nodes) reproduces the anterior neck ache, perform the SCM Compression Test before lymph node investigation."
},
{
"id": "bd-3",
"condition": "Eagle Syndrome (Elongated Styloid Process)",
"confidence": "rare",
"mimics": "Throat, anterior neck, and TMJ pain — overlaps closely with posterior digastric and medial pterygoid patterns",
"distinguishing_feature": "Pain provoked by turning the head or swallowing. Elongated styloid process may be palpable in the tonsillar fossa on intraoral examination. Recalcitrant to TrP treatment — this is the key clinical indicator. Panoramic radiograph confirms the diagnosis.",
"action": "This is a red flag covered in the checklist. If TrP treatment gives partial but incomplete and recurring relief, perform intraoral palpation in the tonsillar fossa and request panoramic radiograph."
},
{
"id": "bd-4",
"condition": "Globus Pharyngeus (Lump in the Throat)",
"confidence": "uncommon",
"mimics": "Persistent sensation of a foreign body in the throat — overlaps with medial pterygoid and longus colli TrP patterns",
"distinguishing_feature": "Globus pharyngeus: persistent sensation of a lump in the throat, worse between meals, without true dysphagia. Myofascial: TrPs in the longus colli and longus capitis (deep anterior vertebral muscles) cause lump-in-throat sensation alongside difficulty swallowing. Medial pterygoid and posterior digastric TrPs contribute to this pattern. All should be examined before assigning an idiopathic diagnosis.",
"action": "Systematic TrP examination including longus colli, medial pterygoid, and posterior digastric. Refer for ENT assessment to exclude structural causes before myofascial diagnosis."
},
{
"id": "bd-5",
"condition": "Thyroiditis (Subacute / de Quervain)",
"confidence": "uncommon",
"mimics": "Anterior neck pain — overlaps with SCM sternal referral to the front of the neck",
"distinguishing_feature": "Subacute thyroiditis: anterior neck pain specifically over the thyroid gland, tender to palpation over the gland itself, associated with recent viral illness and fever. Elevated ESR and thyroid function changes. Myofascial anterior neck pain: the SCM belly is the source, not the thyroid gland; thyroid gland palpation is non-tender.",
"action": "This is a red flag covered in the checklist. Palpate the thyroid gland specifically alongside the SCM belly."
},
{
"id": "bd-6",
"condition": "Burning Mouth Syndrome (Idiopathic)",
"confidence": "uncommon",
"mimics": "Burning tongue (glossodynia) — overlaps with anterior digastric referral",
"distinguishing_feature": "True burning mouth syndrome: persistent bilateral burning of the oral mucosa without identifiable cause, often postmenopausal women, associated with dysgeusia and dry mouth. Myofascial glossodynia: unilateral or follows the anterior digastric territory, resolves immediately on TrP inactivation — this resolution distinguishes myofascial glossodynia from idiopathic burning mouth syndrome.",
"action": "Palpate anterior digastric belly before assigning an idiopathic burning mouth diagnosis. TrP inactivation resolves myofascial glossodynia; idiopathic burning mouth syndrome does not respond."
},
{
"id": "bd-7",
"condition": "Gastro-oesophageal Reflux (GORD)",
"confidence": "uncommon",
"mimics": "Throat soreness and front-of-neck discomfort — 'silent reflux' or laryngopharyngeal reflux can produce chronic throat irritation",
"distinguishing_feature": "GORD throat: burning or irritation worse after meals, bending forward, or at night; associated with cough, hoarseness, or taste of acid. SCM and digastric throat pain: worsened by neck posture and jaw use, not meals or position. SCM Compression Test positive for myofascial source.",
"action": "Distinguish by symptom relationship to meals and posture vs neck posture. SCM Compression Test helps — positive test confirms myofascial throat pain. Refer to gastroenterology if GORD features are present."
},
{
"id": "bd-8",
"condition": "Carotid Artery Dissection",
"confidence": "rare — critical",
"mimics": "Unilateral anterior neck pain — may be confused with SCM sternal or posterior digastric patterns",
"distinguishing_feature": "Anterior neck pain with ipsilateral headache, Horner syndrome (ptosis AND miosis — not just palpebral narrowing), or stroke symptoms (facial weakness, arm weakness, speech change). SCM TrP palpebral narrowing does NOT cause miosis. Any anterior neck pain with miosis is carotid dissection until proven otherwise.",
"action": "This is a red flag covered in the checklist. Emergency MRI/MRA if suspected."
}
]
}