Swollen Glands, Hernias, and Other Lumps Under the Skin

Are you concerned about swollen glands or other lumps under the skin?

Yes

Concern about swollen glands or lumps under skin

No

Concern about swollen glands or lumps under skin

How old are you?

Less than 12 years

Less than 12 years

12 years or older

12 years or older

Are you male or female?

Why do we ask this question?

The medical assessment of symptoms is based on the body parts you have.

• If you are transgender or non-binary, choose the sex that matches the body parts (such as ovaries, testes, prostate, breasts, penis, or vagina) you now have in the area where you are having symptoms.
• If your symptoms aren’t related to those organs, you can choose the gender you identify with.
• If you have some organs of both sexes, you may need to go through this triage tool twice (once as “male” and once as “female”). This will make sure that the tool asks the right questions for you.

Can you feel a lump in the neck or throat?

Yes

Lump in throat or neck

Did the lump develop quickly (over hours)?

Yes

Lump in neck or throat developed quickly

No

Lump in neck or throat developed quickly

Are you having trouble breathing (more than a stuffy nose)?

Yes

Difficulty breathing more than a stuffy nose

No

Difficulty breathing more than a stuffy nose

Are you having trouble swallowing?

Can you swallow food or fluids at all?

Yes

Able to swallow food or fluids

No

Unable to swallow food or fluids

Is your voice hoarse for no clear reason?

Yes

Unexplained hoarseness

Do you have any symptoms of hyperthyroidism or hypothyroidism?

The thyroid gland sits in your neck in front of your windpipe. It can become swollen if it’s not working properly.

Yes

Symptoms of hyperthyroidism or hypothyroidism

No

Symptoms of hyperthyroidism or hypothyroidism

Are there red streaks leading away from the area or pus draining from it?

Do you have diabetes, a weakened immune system, peripheral arterial disease, or any surgical hardware in the area?

“Hardware” includes things like artificial joints, plates or screws, catheters, and medicine pumps.

Yes

Diabetes, immune problems, peripheral arterial disease, or surgical hardware in affected area

No

Diabetes, immune problems, peripheral arterial disease, or surgical hardware in affected area

Do you think you may have a fever?

How bad is the pain on a scale of 0 to 10, if 0 is no pain and 10 is the worst pain you can imagine?

8 to 10: Severe pain

Severe pain

5 to 7: Moderate pain

Moderate pain

1 to 4: Mild pain

Mild pain

Has the pain lasted for more than 3 days?

Yes

Pain for more than 3 days

No

Pain for more than 3 days

Is it a soft lump near the belly button, the groin, or the site of a past surgery?

This type of lump could be a hernia.

Yes

Soft lump near belly button, groin, or surgical site

No

Soft lump near belly button, groin, or surgical site

Does the pain go away when you press on the lump?

Yes

Pain goes away when lump is pressed

No

Pain goes away when lump is pressed

Have you had the lump or swollen gland for more than 2 weeks?

Yes

Swollen gland or lump for more than 2 weeks

No

Swollen gland or lump for more than 2 weeks

Many things can affect how your body responds to a symptom and what kind of care you may need. These include:

• Your age. Babies and older adults tend to get sicker quicker.
• Your overall health. If you have a condition such as diabetes, HIV, cancer, or heart disease, you may need to pay closer attention to certain symptoms and seek care sooner.
• Medicines you take. Certain medicines and natural health products can cause symptoms or make them worse.
• Recent health events, such as surgery or injury. These kinds of events can cause symptoms afterwards or make them more serious.
• Your health habits and lifestyle, such as eating and exercise habits, smoking, alcohol or drug use, sexual history, and travel.

Try Home Treatment

You have answered all the questions. Based on your answers, you may be able to take care of this problem at home.

• Try home treatment to relieve the symptoms.
• Call your doctor if symptoms get worse or you have any concerns (for example, if symptoms are not getting better as you would expect). You may need care sooner.

Pain in adults and older children

• Severe pain (8 to 10): The pain is so bad that you can’t stand it for more than a few hours, can’t sleep, and can’t do anything else except focus on the pain.
• Moderate pain (5 to 7): The pain is bad enough to disrupt your normal activities and your sleep, but you can tolerate it for hours or days. Moderate can also mean pain that comes and goes even if it’s severe when it’s there.
• Mild pain (1 to 4): You notice the pain, but it is not bad enough to disrupt your sleep or activities.

Symptoms of infection may include:

• Increased pain, swelling, warmth, or redness in or around the area.
• Red streaks leading from the area.
• Pus draining from the area.
• A fever.

Certain health conditions and medicines weaken the immune system’s ability to fight off infection and illness. Some examples in adults are:

• Diseases such as diabetes, cancer, heart disease, and HIV/AIDS.
• Long-term alcohol and drug problems.
• Steroid medicines, which may be used to treat a variety of conditions.
• Chemotherapy and radiation therapy for cancer.
• Other medicines used to treat autoimmune disease.
• Medicines taken after organ transplant.
• Not having a spleen.

Hyperthyroidism occurs when your body has too much thyroid hormone.

Symptoms of hyperthyroidism may include:

• Tiredness.
• Muscle weakness.
• Weight loss.
• Sweating and not being able to tolerate hot temperatures.
• Fast heart rate.
• Feeling edgy or anxious.
• Enlarged thyroid gland (your thyroid gland is in your neck).

Hypothyroidism occurs when the thyroid gland does not make enough thyroid hormone.

Symptoms of hypothyroidism may include:

• Tiredness and weakness.
• Weight gain.
• Depression.
• Memory problems.
• Constipation.
• Dry skin, brittle nails, and coarse, thinning hair.
• Not being able to tolerate cold temperatures.

A soft lump in one of these areas (belly button, groin, past surgical site) may be a hernia. A hernia can occur when there is a weakening in the muscle wall and part of an internal organ (often part of the bowel) pushes through.

With a hernia, the lump may go away when you press on it or lie down, and it may get worse when you cough. It may or may not be painful.

Symptoms of difficulty breathing can range from mild to severe. For example:

• You may feel a little out of breath but still be able to talk (mild difficulty breathing), or you may be so out of breath that you cannot talk at all (severe difficulty breathing).
• It may be getting hard to breathe with activity (mild difficulty breathing), or you may have to work very hard to breathe even when you’re at rest (severe difficulty breathing).

Seek Care Today

Based on your answers, you may need care soon. The problem probably will not get better without medical care.

• Call your doctor today to discuss the symptoms and arrange for care.
• If you cannot reach your doctor or you don’t have one, seek care today.
• If it is evening, watch the symptoms and seek care in the morning.
• If the symptoms get worse, seek care sooner.

Seek Care Now

Based on your answers, you may need care right away. The problem is likely to get worse without medical care.

• Call your doctor now to discuss the symptoms and arrange for care.
• If you cannot reach your doctor or you don’t have one, seek care in the next hour.
• You do not need to call an ambulance unless:
  • You cannot travel safely either by driving yourself or by having someone else drive you.
  • You are in an area where heavy traffic or other problems may slow you down.

Make an Appointment

Based on your answers, the problem may not improve without medical care.

• Make an appointment to see your doctor in the next 1 to 2 weeks.
• If appropriate, try home treatment while you are waiting for the appointment.
• If symptoms get worse or you have any concerns, call your doctor. You may need care sooner.

Call 911 Now

Based on your answers, you need emergency care.

Call 911 or other emergency services now.

Sometimes people don’t want to call 911. They may think that their symptoms aren’t serious or that they can just get someone else to drive them. But based on your answers, the safest and quickest way for you to get the care you need is to call 911 for medical transport to the hospital.

Otolaryngological aspects of orofacial pain

3.1.2. Rhinosinusitis

Rhinosinusitis is a group of disorders characterized by inflammation of the mucosa of the nose and paranasal sinuses. The term ‘rhinosinusitis’ is used instead of ‘sinusitis’ due to the fact that sinusitis is almost always accompanied by concurrent nasal airway inflammation, and in many cases, sinusitis is preceded by rhinitis. Rhinosinusitis is a leading healthcare problem which may affect up to 14% of the adult population and costs more than $2 billion in direct medical costs (^{Anand et al 1997}). Rhinosinusitis is increasing in prevalence and incidence and has been estimated to affect approximately 31 million patients in the United States each year (^{International Rhinosinusitis Advisory Board 1997}).

A common presenting symptom of acute rhinosinusitis is facial pain or headache. The pain is usually accompanied by other symptoms such as nasal congestion, anterior and posterior purulent nasal drainage and hyposmia or anosmia. The pain is a subjective complaint; however, tenderness on percussion is a function of spinal cord pain processing (hyperalgesia). People with acute rhinosinusitis have a significantly lower pain and sensory detection threshold in their sinus regions when compared to a healthy control group (^{Meltzer 2004, Benoliel 2006}). Sinus pain caused by inflammation induced by infection (bacterial or viral) or allergic rhinosinusitis occurs when exudate blocks the sinus ostium and exerts pressure which stimulates local trigeminal nerve fibres. The local release of proinflammatory and proalgesic mediators is an early mechanism (this is probably as important as the pressure).

The development of rhinosinusitis depends on a variety of environmental and host factors and is considered to be a disease with multifactorial causes. Host factors include genetic or congenital conditions (e.g. cystic fibrosis, immotile cilia syndrome), allergic rhinitis, sinonasal anatomic abnormalities and systemic diseases. Environmental factors include infectious agents, trauma, noxious chemicals and iatrogenic causes.

There are two principal systems of classification and diagnostic criteria relating headaches and sinus disease: the working definitions for acute rhinosinusitis (ARS), subacute rhinosinusitis (SRS) and chronic rhinosinusitis (CRS) recommended by the American Academy of Otolaryngology-Head and Neck Surgery (AAO-HNS), and the International Headache Society (IHS) criteria (^{Lanza 1997, Benninger 2003, Meltzer 2004, Olesen 2004}). As expected the IHS classification relates to diseases that may induce facial pain or headache whilst the AAO-HNS classification is concerned primarily with the disease process itself.

The different types of rhinosinusitis can be diagnosed clinically in most patients based on the history and physical examination. Physical examination includes otoscopy, anterior rhinoscopy, percussion over the areas of the paranasal sinuses and oropharyngeal and neck examination. Nasal endoscopy and imaging evaluation are not required for an initial diagnosis of any form of rhinosinusitis. However, these modalities may be very helpful in definitive diagnosis of rhinosinusitis. Patients with recurrent or complicated sinus disease may require imaging. Computerized tomography is superior to radiography because the latter are imprecise at determining the extent of the disease and the patency of the sinus ostium (^{Lanza 1997, Sinus and Allergy Health Partnership 2004}). CT scanning of the sinonasal region has two major roles in rhinosinusitis:

3.

1.3. Acute Rhinosinusitis

Acute rhinosinusitis is an inflammatory condition involving the paranasal sinuses and the lining of the nasal passages, where the symptoms and signs last up to 4 weeks (^{Lanza and Kennedy 1997}) (see , ). The symptoms resolve completely, and after the disease has been treated, antibiotics are no longer required.

Table 6.4

Clinical Criteria for the Diagnosis of Acute Rhinosinusitis (ARS)

	Criteria	Comments
Major factors:	Purulent anterior nasal discharge Purulent-discoloured posterior nasal drainage Nasal obstruction or blockage Facial pain/pressure/congestion/fullness Hyposmia or anosmia Fever	A diagnosis of rhinosinusitis is possible if: (a) 2 or more major symptoms or (b) 1 major symptom and 2 or more minor symptoms are present.
Minor factors:	Headache Ear pain/pressure/fullness Halitosis Dental pain Cough Fever (all non-acute) Fatigue	Nasal purulence in itself is a strong indicator of an accurate diagnosis. Headache/facial pain or pressure as sole symptoms is not indicative of ARS. Similarly fever as a sole symptom is not indicative of ARS.

Table 6.5

The IHS Criteria for the Diagnosis of Headache/Facial Pain due to Rhinosinusitis

	Diagnostic Criteria	Comment
A	Frontal headache accompanied by pain in one or more regions of the face, ears or teeth and fulfilling criteria C and D
B	Clinical, nasal endoscopy, computerized tomography and/or magnetic resonance imaging, and/or laboratory evidence of acute or acute-on-chronic rhinosinusitis	Clinical evidence includes purulent nasal discharge, nasal obstruction, hyposmia or anosmia and/or fever
C	Headache and facial pain develop simultaneously with onset or acute exacerbation of rhinosinusitis
D	Headache and/or facial pain resolve within 7 days after remission or successful treatment of acute or acute-on-chronic rhinosinusitis	Chronic sinusitis is not validated as a cause of headache or facial pain unless there is re-acutization.

The most common cause of ARS is a community-acquired viral infection leading to a self-limiting period of upper respiratory symptoms, such as nasal discharge, nasal congestion and coughing (^{Meltzer et al 2004}). Human rhinovirus is the most common cause of viral ARS. Other viruses include coronavirus, influenza A and B virus, parainfluenza virus, respiratory syncytial virus and adenovirus. Occasionally, a secondary bacterial infection of the paranasal sinuses occurs and requires specific antimicrobial therapy (^{Meltzer et al 2004}). Allergic rhinitis, nasal polyposis, foreign body in the nasal cavity, trauma, dental infection and other factors leading to inflammation of the nose and paranasal sinuses can also predispose individuals to develop ARS.

Commonly isolated bacteria in patients with ARS include S. pneumonia, non-typeable H. influenzae and M. catarrhalis (^{Sinus and Allergy Health Partnership 2004}). Streptococcus pneumonia and non-typeable H. influenzae account for more than 75% of bacterial isolates (^{Meltzer et al 2004}). Other streptococcal species, anaerobic bacteria and S. aureus are responsible for a small percentage of cases. Nosocomial rhinosinusitis often occurs in patients who require extended periods of intensive care, which involve prolonged nasotracheal intubation or a nasogastric tube. Isolates from hospitalized patients usually contain Gram-negative enterics such as P. aeruginosa, Klebsiella pneumoniae, Enterobacter spp., Proteus mirabilis, Serratia marcescens, and coagulase-negative S. aureus (^{Meltzer et al 2004}).

The diagnosis of ARS focuses on clinical history and physical examination with radiographic diagnosis playing a supportive role (^{Sinus and Allergy Health Partnership 2004}). The clinical diagnostic criteria for ARS as defined by the Task Force on Rhinosinusitis of the AAO-HNS include major and minor symptoms or signs, with a disease duration of less than 4 weeks (
). According to this classification, facial pain or pressure is regarded as a major symptom, whereas headache is considered to be a minor symptom (^{Lanza 1997, Meltzer 2004}). This classification was designed to be used by both primary care physicians and specialists. A diagnosis of rhinosinusitis is possible if two or more major symptoms or one major symptom and two or more minor symptoms are present. However, nasal purulence is a strong indicator of an accurate diagnosis. Facial pain or pressure alone does not constitute a suggestive history in the absence of another major nasal symptom or sign. Fever in itself does not constitute a strongly suggestive history in the absence of another major nasal symptom or sign. The IHS diagnostic criteria for sinusitis-related headache reiterate the requirement of clinical findings of acute sinusitis, along with a reversible ‘sinus headache’; see
(^{Olesen et al 2004}).

ARS has four basic clinical courses: resolution, development of adverse sequelae, development of a symptomatic CRS and development of a silent CRS.

In the immunocompetent person living in the general community, ARS is typically believed to be induced by viruses and does not require antibiotics for the first 10–14 days. Symptomatic relief may be obtained by the use of topical application of a nasal decongestant such as xylometazoline and oral acetaminophen. The presence of severe headache or facial pain, high fever, and brain, eye or lung complications indicate secondary bacterial infection and antibiotics are indicated (^{Meltzer et al 2004}).

In cases where no complications occur but the symptoms and signs persist for more than 10–14 days, bacteria are presumed to predominate and the patient can benefit from initiating antibiotic therapy as described below (^{Meltzer et al 2004}).

Expert recommendation is divided about the appropriate therapy for ARS and ranges from symptomatic treatment alone (^{Snow et al 2001}) to a prolonged course of antibiotic therapy effective against β-lactamase-producing organisms (^{Winther and Gwaltney 1990}). Primary care and specialty physicians demonstrate variability in treatment approaches (^{Piccirillo et al 2001}). No benefit for antibiotic therapy has been demonstrated for the treatment of ARS diagnosed by clinical criteria alone (^{Stalman et al 1997}) and one study showed no overall benefit for seven days of penicillin V compared to placebo (^{Hansen et al 2000}). However, there are indications that early antibiotics are of benefit for patients with the most severe maxillofacial pain symptoms at baseline (^{Williams et al 2003}). Success rates for amoxicillin, trimethoprim-sulfamethoxazole or erythromycin compared to newer, broader spectrum antibiotics are similar (^{Piccirillo et al 2001}). Therefore, current data do not support the use of newer, more expensive, non-penicillin antibiotics for first-line empiric therapy (^{Williams et al 2003}). Among the newer, wider-spectrum antibiotics efficacy was similar but amoxicillin-clavulanate had significantly more adverse effects than cephalosporins (^{Williams et al 2003}). Therefore, differences in adverse effects and costs should be considered when choosing a second-line antimicrobial therapy. Based on a meta-analysis, ARS should be treated with amoxicillin 500 mg three times daily for 10 days (^{Williams et al 2003}). For penicillin-allergic patients, several cephalosporins and macrolides have been shown to be equivalent to amoxicillin (^{Williams et al 2003}). Based on limited data, there is no convincing evidence that adjuvant treatment such as topical nasal decongestants or nasal corticosteroids improve clinical outcomes.

3.1.3.1. Acute Maxillary Rhinosinusitis

Acute maxillary rhinosinusitis is the most common affliction of all paranasal sinuses and the most common sinus disease causing facial pain (
). The pain is usually related to the affected maxillary antrum, but is often referred to the upper teeth (whose roots are intimately related to the floor of the maxillary sinus, see
) or to the forehead. Purulent nasal discharge in the middle nasal meatus and sensitivity to percussion over the cheek or teeth confirm the diagnosis.

• Plain film demonstrating left acute maxillary rhinosinusitis with air-fluid level in the left maxillary sinus (arrow).

• Coronal CT scan demonstrating right chronic maxillary rhinosinusitis with complete opacification of the right maxillary sinus and obstruction of the sinus ostium (arrow).

3.1.3.2. Sinonasal Toothache

Diseases in the maxillary sinus mucosa may refer pain to the upper teeth. The pain is usually felt in several teeth as dull, aching or throbbing. Occasionally, the pain is associated with pressure below the eyes. It increases when bending the head, applying pressure over the sinuses, coughing or sneezing. Tests performed on the teeth, such as applying ice, chewing and percussion, may increase pain from a sinonasal origin. A history of URI, nasal congestion or other sinus problem is suspicious of a sinus toothache. Thorough dental examination (clinical and radiographic) excludes a primary dental cause.

3.1.3.3. Acute Ethmoiditis

Acute ethmoiditis causes pain at the root of the nose or behind the eye. Seldom does ethmoiditis occur as an isolated infection. More often it is part of an acute pansinusitis involving the maxillary and frontal sinuses as well. Purulent anterior and posterior nasal discharge and tenderness over the inner canthus of the eye are characteristic. The pain may spread laterally into the orbit or radiate to the temporal region. Occasionally, an orbital complication (such as periorbital cellulitis or abscess) may occur due to spreading of the infection into the orbit through the thin lamina papyracea.

3.1.3.4. Acute Frontal Rhinosinusitis

Acute suppurative frontal rhinosinusitis is not very common, apparently because of the vertical nature of the frontal sinus and its natural advantage of a dependent drainage through the nasofrontal duct (
). Thus, the common forehead pain is seldom due to an underlying frontal rhinosinusitis.

• Coronal CT scan demonstrating right acute frontal rhinosinusitis with opacification of the right frontal sinus (arrow).

The characteristic pain is over the affected sinus and often along the upper orbital rim. The pain may radiate to the vertex and behind the eye. Tenderness is usually felt in the frontal sinus or along its floor. When frontal sinusitis is complicated by osteomyelitis of the frontal bone, the pain is prominent, diffuse and intense, often worsening at night keeping the patient awake.

3.1.3.5. Acute Sphenoiditis

Acute sphenoiditis is rare and is characterized by a wide variety of types and distributions of pain. These include severe occipital headache, retro-orbital dull and aching pain and a stabbing pain at the vertex. Definitive diagnosis is by CT scan.

3.1.3.6. Subacute Rhinosinusitis

Subacute rhinosinusitis represents a continuum of the natural progression of ARS which has not resolved. SRS is diagnosed after 4 weeks duration of symptoms or signs of rhinosinusitis, and lasts up to 12 weeks (^{Lanza and Kennedy 1997}).

3.1.4. Chronic Rhinosinusitis

Chronic rhinosinusitis is divided into two major categories, including CRS with nasal polyposis (CRSwNP) and CRS with no nasal polyposis. The clinical diagnostic criteria suggested by the AAO-HNS for CRS include major and minor symptoms or signs, with disease duration of 12 weeks or more; see
(^{Lanza 1997, Meltzer 2004}).

Table 6.6

Clinical Criteria for the Diagnosis of Chronic Rhinosinusitis (CRS)

Symptoms of CRS are generally the same as those of ARS. However, they are usually milder and include only one symptom such as postnasal drip, headache, nasal obstruction or facial pain. CRS has not been defined as a cause of headache or facial pain according to the IHS diagnostic criteria, unless relapsing into an acute stage (^{Olesen et al 2004}). The most recent otolaryngologic literature regarding CRS includes ‘facial pain and pressure’ as a major factor in CRS, with ‘headache’ as a minor factor, but suggests that facial pain and pressure or headache alone are not suggestive of CRS in the absence of other major nasal symptoms or signs (^{Lanza 2004}). Other causes of headache or facial pain should be considered in the differential diagnosis of such cases.

Bacterial infection as a causative factor in patients with CRS is controversial, but is regarded as a relatively important factor. A comparatively new hypothesis regarding the pathogenesis of CRS is related to colonization of the sinonasal mucosa with microorganisms such as superantigen-producing S. aureus, colonizing fungi, or biofilms, and the host response to their presence (^{Meltzer et al 2004}). A recent study has shown increased sensory thresholds in the skin over sinuses diagnosed with CRS, suggesting some form of peripheral nerve damage (^{Benoliel et al 2006}).

CRS has four basic clinical courses: resolution, persistence, development of adverse sequelae and progression to generalized airway reactivity.

CRS is predominantly a medical condition where surgery can relieve symptoms and sometimes bring about a reversal in the course of the disease.

3.1.4.1. Chronic Maxillary Rhinosinusitis

The most characteristic symptom of this condition is persistent purulent rhinorrhea with localization of pus in the middle meatus (). CRS in the maxillary sinus seldom gives rise to facial pain or headache, except during an episode of acute exacerbation or with progression towards maxillary pyocele or maxillary osteomyelitis.

3.1.4.2. Chronic Frontal Rhinosinusitis

Pain is seldom a symptom of CRS of the frontal sinus. This condition is usually part of chronic pansinusitis which involves the ethmoid and maxillary sinuses, the most common symptom being chronic purulent nasal discharge.

Temporomandibular Disorders (TMD or TMJ Problems) –

Disease Overview

Temporomandibular Disorders (TMD) is the accepted professional term for TMJ problems, more commonly known to the public as TMJ (Temporomandibular Joint). This constellation of problems is musculoskeletal in origin. It involves either the jaw joints located just in front of the ears and/or the muscles that move the jaw, which are located on the sides of the head. (See Anatomical Illustration on the right.)Although this is a reasonable means of conceptualizing the problem, the disorder is much more complex, involving nervous system and cognitive modifications. This “biopsychosocial complexity” is not unique to TMD. It exists in all medical disorders.

• Pain and dysfunction are the hallmarks of this disease, akin to other musculoskeletal disorders.
• The signs and symptoms can involve just one side (unilateral) or both sides (bilateral) of the head and neck and may include:
  • Headaches
  • Jaw and/or ear pain
  • Teeth pain
  • Ear ringing and/or clogged ears
  • Neck and/or shoulder pain
  • Jaw locking in the open and/or closed positions
  • Limited mouth opening (trismus)
  • Jaw noises, such as clicking, popping, grinding, or sandpaper sounds
  • Teeth clenching or grinding (bruxism)
  • Insomnia and dietary restrictions
  • Less common symptoms include dizziness, pain in the cheeks and around the eyes, and swallowing pain or difficulty
• Headaches and ear symptoms are frequently misdiagnosed as non-TMD in origin, attributed to sinus problems, ear problems, and migraine headaches.
• Patients commonly attribute their headaches and ear symptoms to sinus problems. They erroneously assume the problem originates in the ears because the jaw joints are located directly in front of the ears, which are affected in most TMD problems. The ear canal forms the back of the TMJs, hence this close anatomical relationship is the reason for this misconception.
• The diagnosis is further complicated by the fact that patients with TMD problems can have most symptoms or a very limited presentation, i.e. just headaches, tooth pain, or ear ringing or stuffiness.
• TMD is a self-limiting problem for most patients. It is generally neither progressive nor degenerative, and patients are uncommonly faced with a lifetime of treatment. If this were not the case, TMD would be endemic in the elderly population. In fact, TMD problems are less common in the elderly and tend to occur at a steady 10% prevalence per decade of life between the age of 20 and 70 years.
• The “gold standard” for TMD diagnosis is a history, clinical examination, and a screening TMJ image.
• Other diagnostic adjuncts, such as electromyography, jaw tracking, sonography, TENS, and sophisticated TMJ imaging, do not improve diagnostic accuracy, and hence, are not recommended.
• Treatment for the average patient includes education, medications, flat plane full coverage occlusal orthotic therapy, and at times, exercises. This treatment regimen is time tested and highly successful, improving or eliminating pain and dysfunction in greater than 95% of patients.
• TMJ surgery is a treatment option indicated for less than 5% of patients. Likewise, orthodontics, bite adjustments, and crowns are not needed for the vast majority of patients.

Problems (Pathologies)

• Most TMD problems are inflammatory and not structural in nature. Inflammatory problems involve either inflammation of the joints, termed capsulitis, and/or of the muscles that move your jaws, especially the muscles that close your mouth, termed myositis.
• Patients with inflammatory problems commonly have bilateral symptoms and do not require invasive therapies, i.e. joint injections, arthrocentesis, TMJ surgery, etc. These problems are generally not structural in nature.
• The most common structural problems include disk displacements and TMJ arthritis. Generally, there are two forms of disk displacement.
  • A reducing disk displacement is where the disk is recaptured with mouth opening. Patients with this problem manifest a popping or clicking jaw noise with opening and can generally open fully.
  • A non-reducing disk displacement is distinguished by limited opening, deviation of the jaw upon opening to the affected side and pain in the affected joint. Patients with this problem usually had a popping jaw in the past that suddenly stopped popping, accompanied by an inability to open fully (trismus).
  • TMJ disk displacements exist in approximately 40% of the general population, are usually well tolerated, and frequently do not result in progression of the disease. Most patients undergo an adaptive intra-articular response after disk displacement, obviating the need to treat the disk displacement.
  • Surgical attempts to permanently reposition the disk have high failure rates. Commonly, the disk displaces again and significant side-effects (morbidity) can occur. For a small percentage of patients, the disk displacement is the primary reason for their TMD, associated with frequent closed locking, trismus and/or persisting pain. In such cases, therapies aimed at improving mouth opening and pain are needed. However, even in such cases, TMJ surgery is not commonly needed.
  • The third structural problem is arthritic degeneration, usually osteoarthritis accompanied by pain and frequently limited opening. It commonly produces a grinding or sandpaper sound in the joints (crepitus). TMJ arthritis is usually preceded by a non-reducing disk displacement. Because arthritis is commonly a manifestation of host susceptibility, TMD patients with intra-articular arthritis usually have arthritic pain in other bodily joints.
  • Other less common TMD pathologies are developmental problems with asymmetrical jaw growth, jaw fractures, and tumors. Benign and malignant tumors are extremely rare causes of TMD.

Causes (Etiologies)

Science has been unable to clearly elucidate a cause for the majority of TMD. Suggested causes include:

• Malocclusions, or bad bites.
• External trauma, i.e. car accidents; blows to the head/neck; etc

Occlusion and external trauma have been shown to be etiologic factors in a very small percentage of TMD patient.
Consistent with the minimal role occlusion plays in TMD, orthodontic care has been shown to neither cause nor cure TMD in large population comparisons. Most malocclusions that correlate with the presence of TMD problems are caused by the TMD problem, as opposed to being the cause of the TMD problems. One’s ability to occlude their teeth is determined by jaw joint and masticatory muscle health. For example, TMJ effusions and arthritic changes, along with muscle inflammation or spasms alter the way one’s teeth come together. With the exception of boney arthritic changes, these bite changes are transitory and are generally alleviated by successful TMD treatment. The resultant bite changes that occur following significant hard tissue changes in the joints (arthritis) are usually permanent and the most common bite change is the inability to occlude the front teeth.

Bruxism, stress/anxiety, and insomnia. Bruxism is a subconscious clenching or grinding behavior occurring while asleep or clenching during the daytime. Bruxism can be promoted by stress/anxiety and insomnia (co-morbidities).

Of the potential causes, bruxism and stress/anxiety have enjoyed the best scientific support.

• Sleep bruxism is generally of greater consequence than daytime clenching because one can generate greater forces during sleep (up to twice the force generated during eating).
• Sleep partners are generally poor witnesses to the behavior because the period of true observation is usually limited and because clenching is silent, making its more difficult to attest to.
• Diurnal bruxism can be modified by patient awareness, however, nocturnal bruxism is beyond patient control.
• Stress/anxiety is an important risk factor in TMD. Patients commonly recognize that their symptoms occur or worsen during periods of heightened stress.

At times, patients develop TMD problems after a TMD stress that is normally well tolerated, such as routine dental therapies, yawning, eating, etc. It is important to understand that the onset of TMD problems is determined by the relationship of the musculoskeletal insult to stress and bruxism in combination with the patient’s ability to accommodate to these insults (host tolerance). Host tolerance is a confluence of factors, such as TMJ remodeling capacity, muscle injury/fatigue tolerance, the ability of the teeth to balance and deflect loading, pain reaction thresholds, etc. When patients are subconsciously loading their muscles and joints, additional musculoskeletal stressors can exceed their tolerance and patients become symptomatic. Hence, the assumed lone initiating factor is simply the final insult, which would not have produced symptoms without the underlying musculoskeletal loading. The role of host tolerance is important to understand in musculoskeletal disorders because this obscure contributor helps explain the quixotic nature of the rheumatologic disease.

Musculoskeletal loading is much greater in one’s youth and declines as one ages. However, musculoskeletal pain throughout the body increases with age, even though loading is in decline. The decline in host tolerance factors described previously is the likely reason.

Who Is Affected? (Epidemiology)

TMD affects 5-10% of the population.

• For reasons not clearly understood, women are predominately affected by a 9:1 ratio. The best research to date suggests women are physiologically predisposed, secondary to hormonal influences. The female predisposition also exists in most other rheumatologic/musculoskeletal disorders, i.e. systemic arthritis, lupus, fibromyalgia, etc.
• TMD is uncommon in the very young and very old. Otherwise, the prevalence remains steady for each decade of life. This statistic underscores why TMD is transitory in nature for most patients. It is neither a progressive nor a degenerative condition for most.

Musculoskeletal healing or adaptation is probable for most patients, irrespective of treatment. However, the slow pace of musculoskeletal healing and the persistence of uncontrollable perpetuating factors (stress and bruxism) are reasons why most patients seek care.

Signs and Symptoms

Because TMD is a musculoskeletal problem, signs, and symptoms are defined by pain and dysfunction. As such, patient self-report data plays a large role in diagnosis. Both the presence of disease and the need for treatment is essentially defined by the patient.

Pain

• Qualitatively, it is usually a dull ache, but can be more acute. Also commonly described as feelings of tension, tightness, or fatigue.
• The location is commonly on the sides of the head, either unilaterally (on one side) or bilateral (on both sides).
• The frequency can be episodic or constant with varying intensity throughout the day.
• The pain typically worsens with jaw movement or functions, i.e. eating, talking, yawning, and opening wide.
• The presence of pain is determined by patient self-report (historical), palpation findings during a clinical examination (pain with palpation pressure), and pain elicited with jaw movement during the clinical exam.
• The pain can be inflammation and muscle fatigue secondary to bruxism or be the result of intra-articular degenerative changes.

Types of Pain

• Headaches: They are usually tension-type, but TMD can be an initiator for vascular or migraine headaches. The location is commonly on sides of the head but can occur in any location and be generalized. Headaches that are worse during sleep or upon awakening are usually TMD related. The term “tension-type” is a misnomer, as all headaches are probably vascular in origin.
• Facial Pain: Usually in the jaw joints (located in front of ears) and in the masticatory muscles (sides of face). Pain in cheeks and lower jaw are also common. See the illustration below.
• Ear Pain: This is usually referred pain from the TMJs and is secondary to the close anatomical relationship of the jaw joints and ear canals (The ear canals form the back of the jaw joints). Other common ear symptoms include ringing or tinnitus and a stuffy or clogged sensation. Hearing loss and vertigo are sometimes reported, but are uncommon. Patients commonly mistake these ear symptoms as indications of sinus problems, but for most adults, the symptoms are manifestations of TMD.
• Neck/Shoulder Pain: This commonly represents a separate neck problem, i.e. cervical degenerative disease, but can be related to either the TMJ problem contributing to the neck pain or vice versa.
• Toothaches: When associated with TMD, the tooth pain/soreness is usually generalized, variable, and can change locations in the mouth.

Dysfunction

• Joint Sounds: Clicking or popping sounds usually indicate the presence of a reducing displaced disk, though it can indicate a change in the shape of intra-articular tissues. Crepitus or grinding/grating/sandpaper sounds is highly correlated with the presence of TMJ arthritis. Joint sounds in the absence of pain or dysfunction are insufficient to allow the diagnosis of TMD. However, new onset joint sounds or a sudden change in joint sounds can be meaningful and justify treatment.
  • Reducing disk displacements do not usually become non-reducing. When the closed locking occurs, it can be episodic and gradual or sudden and permanent.
  • An increased frequency of closed locking episodes usually implies that a permanently closed lock is imminent and unavoidable. With a permanent closed lock, patients notice that they suddenly have limited opening, accompanied by pain in the locked joint with the opening. The lower jaw deviates or swings towards the locked joint with the opening.

• Jaw Locking refers to jaws getting stuck in either the open or closed position.
  • Open Locking usually results from a combination of TMJ hypermobility in conjunction with contraction of the jaw-closing muscles. In some people, with maximal opening the end of their lower jaw extends beyond a confining bump of bone called the articular eminence. If muscle contraction occurs when the jaw is in this position, it will get stuck open. To spontaneously unlock and re-close requires patients to relax the jaw muscles with massage and/or moist heat. Open locking can be very disquieting causing patients to engage in behaviors to avoid this problem at all cost. They limit opening by stifling yawns and avoiding foods that require wider mouth opening. Sometimes, reduction by a health care professional may be required. This is generally accomplished manually in a dental chair without the need for injections or sedation. The procedure is simple and well tolerated by patients.
  • Closed locking usually results from a TMJ disk displacement that the condyle can no longer recapture. Closed locking is usually preceded by jaw popping, i.e. a reducing disk displacement. The popping can continue for months or years before jaw locking occurs. Closed locking usually begins to occur episodically and the patient is able to unlock and resume popping. However, if the locking frequency increases and/or the locking becomes more difficult to resolve, it is probable that the closed locking will become permanent.

• Trismus or limited jaw opening is usually indicative of an intra-articular problem, as opposed to a muscular disorder and can be caused by non-reducing disk displacements or arthritis. The responsible intra-articular pathology can involve an impairment of tissue mobility that exists secondary to reduced joint pressure, diminished joint lubrication, or the formation of fibrous or scar tissue adhesions. Normal opening for most people is 40-50 mm, with a small number of people opening to 50-70 mm. Opening less than 40 mm is considered limited, however, people can generally function normally (eat a normal diet) with an opening above 35 mm. The pain and/or trismus usually causes restrictions in diet and patients commonly avoid eating difficult foods, such as:
  • Hard foods, i.e. meat, uncooked vegetables, and chips
  • Chewy foods, i.e. gum, candies, jerky, etc.
  • Foods that require wide opening, i.e. apples or burgers.

• Bite Changes. Most alterations in patient’s occlusion are perceived, but not clinically detectable. These bite changes are transient because they are secondary to muscle and/or joint inflammation or muscle tension. The perceived bite changes generally resolve with resolution of the TMD problem. Bite changes can be secondary to arthritic changes in the TMJs, generally small amounts of condylar bone loss. These bite changes are permanent and remain after other TMD symptoms have been resolved. In these specific cases, occlusal adjustment, evening the bite by adjusting the surfaces of the teeth, is the most cost-effective treatment. Orthodontic care, such as braces and crowning the teeth, are additional solutions with more limited application.

• Sleep disruption (insomnia) can be an important risk factor to TMD because of the relationship between sleep quality and bruxism. Science has shown that when people lighten their sleep, it is accompanied by an “arousal reaction”. This is characterized by increases in motor activity (muscular activity), heart rate, blood pressure, and galvanic skin response. The increase in motor activity may involve bodily movement and teeth grinding. People who sleep poorly, i.e. sleep lightly or awaken frequently during the night, grind their teeth more commonly. Patients mistakenly think that sleep disruption is only relevant to TMD if the disruption is because of facial pain. However, the reason for insomnia is immaterial to the facilitation of bruxism. Hence, it does not matter why one sleeps poorly. The important relationship is that poor sleep behavior, no matter the cause, can cause nocturnal bruxism.
  • Besides the relationship with bruxism, insomnia can have a negative impact on one’s mood, performance, energy levels, etc., hence, sleeping well can have a significant impact on the quality of patients’ lives.
  • Frequently, and especially in older patients, it is assumed that insomnia is secondary to the need for urination. However, it is probable that these patients awaken for other reasons, and they urinate because the opportunity is there. Patients erroneously form this causative association between the need to urinate and nocturnal awakening because of the obvious temporal relationship, however, such patients are simply unaware of why they awoke. When these patients are pharmacologically allowed to sleep through the night, bedwetting is not an issue, hence the association between urination and awakening is untrue for most patients.
  • A very important “take away” message is that insomnia can be caused by many things, such as stress, noise, a partner’s snoring, sleeping with pets, trying to listen for children, etc. One reason for insomnia that is very popular today is sleep apnea, which should be ruled out in the presence of other sleep apnea signs and symptoms (gasping for breath during sleep, snoring, and diurnal fatigue). However, it should be understood that most insomnia is not secondary to sleep apnea, and likewise, it is a mistake to indescriminately ascribe the presence of nocturnal bruxism to sleep apnea.

• Obstructive Sleep Apnea (OSA) is a relatively newly recognized disorder. As such, its diagnosis and relevance are presently poorly understood. This is true for the diagnosis and treatment of most “new” disorders. The relevance of most newly discovered problems are usually overstated in the beginning, and it is only with the findings of longitudinal and comparative research that the disorder’s diagnosis or treatment can be put in proper perspective. So today, it is fair to say that the relationship of OSA to TMD is likely being overstated.

Diagnosis

The gold standard for TMD diagnosis today is a thorough history, a clinical examination, and a screening radiograph. Expensive, though superiorly detailed, TMJ imaging, such as MRIs and CTs, are neither needed nor recommended for most patients because the information gained has little impact on treatment.

• Patients should avoid extraneous diagnostic efforts, such as TMJ Doppler, TMJ Sonography, EMG (Electromyography), Kinesiography (Jaw Tracking), etc. The test results do not improve diagnostic accuracy and commonly lead to iatrogenic outcomes and unnecessary invasive therapies, such as braces, crowns, occlusal adjustments, and TMJ surgery.
• Caution is advised if you are being told that your jaw is in the wrong place, as determined by jaw imaging, EMG data, analysis of your bite, eccentricities in jaw movement, and/or disk displacements. These assertions are scientifically invalid and commonly lead to prolonged invasive and expensive care, ultimately resulting in iatrogenic injury (unnecessary bite changes).
• Although advances in technology commonly afford more accurate and detailed information, such advances are only meaningful if their therapeutic impact is significant.

Types of TMD Problems (Disease Classification)

Inflammatory Problems

• This is the most common disorder.
• Inflammation of the muscles that move the lower jaw (myositis) and/or the jaw joints (capsulitis) are the common maladies.
• Limitations in jaw movement and jaw locking are uncommon, although disk displacements can be present. If jaws make popping noises for most patients, the disk displacement is unrelated to the pain and dysfunction.
• Pain is present with palpation, jaw movement, and functions, such as yawning, eating, talking, etc.

Disk Displacements

• TMJ disk displacements are generally caused by the stretching or tearing of disk attachments, hence, the displacement is generally permanent and the disk is incapable of returning to its original position. Diminished joint lubrication, adherence of the disk to the hard tissue, and increased joint pressures have also been implicated in the pathophysiology.
• TMJ disk displacements occur in 30-40% of the normal population. They are commonly well tolerated and are not usually associated with pain or dysfunction. For a small percentage of patients, the disk displacement is at the center of the TMJ problem and is responsible for pain, locking, trismus, etc. To be classified as a TMJ problem, the disk displacement must be the cause of pain or dysfunction, i.e. jaw locking, limited opening, dietary limitations, etc.
• Joints with disk displacements may or may not make a popping noise and the presence of popping/clicking generally means the disk is displaced and recaptures with the opening. In this scenario, jaw movement is generally normal. This problem is termed a reducing disk displacement. A non-reducing disk displacement occurs if the end of the jaw (condyle) cannot recapture a displaced disk. In this scenario, joint noise is absent, jaw opening is restricted, and the jaw deviates with the opening towards the joint with the disk displacement.
• Closed locking refers to situations where a reducing disk displacement intermittently becomes a non-reducing disk displacement. In these situations, a patient’s jaw clicks and opens normally most of the time, but at times the disk does not reduce, and the patient is unable to open fully. If the locking increases in frequency and/or becomes harder to unlock, it is probable that the reducing disk displacement will become a permanent non-reducing disk displacement (a permanently closed lock).

TMJ Arthritis
Arthritis refers to breakdown or degeneration of the disk and bone tissues in the joint. Such changes can include thinning of the disk, wearing down of the condyle, and articular eminence hard tissues.

• Arthritis can be isolated to the TMJ, but can also be a manifestation of a systemic joint disease, such as osteoarthritis, fibromyalgia, lupus, polymyositis, etc. Patients, especially young patients, with multi-joint pains (neck, back, knees, hips, shoulders, etc.) should consider an evaluation by a rheumatologist.
• Osteoarthritis is the most common type of TMJ arthritis. Sandpaper-like sounds, grinding, or grating sounds, called crepitus in the jaw joints, generally means that arthritic changes have occurred.
• The significance is age-related, hence some degenerative changes are expected with aging and are normal. Symptomatic TMJ arthritis generally denotes a host susceptibility to articular degeneration, and as such, arthritis commonly exists in other joints (neck, knee, hips, shoulders, hands, and back).
• TMJ osteoarthritis can be asymptomatic, but symptoms include pain, crepitus, and trismus.
• Osteoarthritic changes are commonly preceded by a non-reducing disk displacement. Bite changes can occur when the bone loss in the TMJs is significant. Generally, the associated bite changes include either the inability to occlude one side (if the bone loss is unilateral) or the inability to occlude your front teeth (if the bone loss is bilateral). Such bite changes are permanent and require permanent changes to the teeth in order to correct. These treatments can include bite adjustments, crowns, braces, or TMJ surgery.

TMJ Tumors
They are uncommon and most are benign.

Treatments

For most TMD patients, successful treatment involves a combination of medications, occlusal orthotic therapy, i.e. splint or night guard, and exercises. Medications commonly entail some combination of anti-inflammatory agents (NSAIDs, such as ibuprofen and naproxen and a short course of steroids, i.e. Medrol Dosepak) and hypnotic agents for insomnia.

• These therapies each address different aspects of the disease and are most effective if used conjointly.
• The anti-inflammatory agents (NSAIDs) diminish joint and muscle inflammation, however, the effects are transient as these medicines “chase the problem” and are not preventative. These agents are fine if taken routinely, however, extended routine use should be avoided. Their primary side-effect is gastritis. Meloxicam and celecoxib are the least likely to produce this side-effect.
• The orthotic and the hypnotic agents attack the cause of most people’s problems. As such, both are preventative and therapeutic. Regarding orthotics:
  • Constant orthotic wear and orthotics that do not cover all of your teeth should be avoided as unneeded bite changes are likely.
  • The problems with over the counter nightguards is that they are made of a soft material which can promote bruxism and do not afford the distribution of loading. The desired orthotic is hard, covers all of your teeth and allows all of the opposing teeth to contact the appliance at the same time.
  • Orthotics that fit over the upper and lower teeth are equally effective, however, upper orthotics are preferred because this orthotic best allows the maximum distribution of load (due to the occlusion). The only advantage of lower orthotics is that they are less visible and have less impact on speech, hence are preferred if patients plan to wear the appliance while interacting in public (an unlikely scenario).
  • Most patients only need to wear the orthotic at night, but some patients benefit from also wearing the appliance during stressful periods of the day.
  • The orthotics that we make are exceptionally durable and can last a lifetime. The appliances can be adjusted and material added to them ad infinitum. (See photographs below.)
  • For many patients, their need for the orthotics is long-term, as their bruxism or intra-articular pathology is persistent. However, if one’s need for the orthotic is infrequent and predictable, then episodic use is appropriate.

• Regarding hypnotic agents, they can be essential for many patients because poor sleep behavior is a significant risk factor for bruxism. Because the medication is taken at bedtime, addiction is very unlikely. Patients commonly confuse the therapeutic impact of the medication with addiction. For example, the medication will improve your sleep, and if you stop the medication, you will return to sleeping poorly. This is not a manifestation of addiction, but the absence of the medication. It is likened to stopping an anti-hypertensive medication and having your blood pressure increase. Addiction is when one takes a medication for non-medical purposes or unnecessarily escalates the dosing of the medicine. Both of these outcomes are unlikely with taking a medication at bedtime for sleep. With all treatments, patients’ compliance depends on their risk-benefit assessment. If the risks are low and the benefits significant, compliance is sensical.
• Generally irreversible and invasive TMD treatments should be avoided, such as occlusal adjustments, braces, crowns, and surgery. Bite adjustments, full mouth rehabilitation, and braces are not recommended for most patients because one’s bite (occlusion) and the position of one’s teeth are unrelated to most TMD problems.
• TMJ corticosteroid injections and arthrocentesis (rinsing out the joint) can benefit a subset of patients with intra-articular disorders whose pain/dysfunction are not sufficiently improved with medications, orthotics, and exercise. The indication for a joint injection is a persistent pain with normal ranges of joint movement. The steroid injection is well-tolerated and involves a pressure sensation. We precede the injection with a local anesthetic injection to minimize discomfort. A maximum of three injections is recommended separated by one month each. As with any joint, the benefits of TMJ injections are variable, ranging from complete relief to no long-term improvement. Arthrocentesis only differs from a joint injection by the introduction of a second need to allow the joint to be rinsed out (lavage). This affords the removable of intra-articular inflammatory mediators and helps alleviate negative intra-articular pressure. This procedure is indicated for persistent pain in the presence of limited joint movement.
• TMJ surgery is also rarely needed as a TMJ treatment. For example, our practice evaluates two to four new patients a day and refers fewer than five patients a year for surgery. Most people with structural TMJ problems (arthritis and disk displacements) do not need surgery as an adaptive response is likely with time. Because TMJ surgery has significant failure rates and significant morbidity (side effects), it should only be considered for patients who fail a comprehensive effort at conservative therapy, have untenable pain, and suffer from the dysfunction that is intra-articular in origin. The surgeries include arthrocentesis, arthroscopy, open joint, and joint replacement (artificial joint).

Prognosis

• Most TMD problems are self-limiting and spontaneously resolve over time.
• The vast majority of TMD patients respond to nonsurgical therapies.
• Fewer than 5% of TMD patients require surgery.
• TMD problems can recur. Recurrences depend on environmental factors, such as bruxism activity and external trauma, which are difficult to predict. Recurring problems normally respond to re-instituting nonsurgical therapy.
• A very small percentage of patients suffer from a progressive or debilitating disease.

Insurance Coverage

Medical insurance provides the best coverage for most patients. Few dentists can or do bill medical insurance. TMD providers do not need to be in-network providers for the insurer to pay for care. For a more detailed discussion, see our Insurance Coverage page.

Temporomandibular Joint Dysfunction – Causes, Symptoms, Treatment, Diagnosis

The Facts

The temporomandibular joint (TMJ) is one of the most complicated joints in your body. You have one on each side of your face, just in front of your ears, where the temporal bone of the skull connects to the lower jaw (mandible). Your TMJs open and close like a hinge and slide forward, backward, and from side to side. When you bite and chew, they sustain an enormous amount of pressure.

As with other joints, the surfaces of your TMJs are covered with cartilage. Like the knee joint, the two parts of the joint are separated by a small disc, or meniscus, that prevents the bones from rubbing against each other. Muscles that enable you to open and close your mouth also serve to stabilize these joints, which are located about ½ inch (1.25 cm) in front of each ear canal.

A range of problems can affect the TMJs and the muscles surrounding them. These problems usually occur between the ages of 20 and 50. Most often, the cause of TMJ is a combination of muscle tension, anatomical problems, and injury. Sometimes, there may be a psychological component as well.

Like all of your joints, your TMJ may develop osteoarthritis, rheumatoid arthritis, and other inflammatory conditions. In rare instances, tumours may develop in this area. But for most people, pain in the area of the TMJ isn’t serious. Discomfort and pain may be temporary or chronic and sometimes goes away with little or no treatment.

Causes

In order for you to open your mouth and operate your jaw in the way that it should, your left and right TMJs must work in unison. If the movement of both of these joints isn’t coordinated, the disc that separates your lower jaw from your skull can slip out of position, and problems will result. Dislocation of your TMJ may take place if your mouth is forced to open rapidly or too widely.

In addition, muscle pain and tightness around the jaw can often come from muscle overuse as a result of clenching or grinding the teeth (bruxism) brought on by psychological stress or overuse. Extreme jaw clenching can also lead to pain over the temples. This occurs because the muscles that control jaw movement are also attached to a nearby bone of your skull. Excessive gum chewing or forceful biting, such as cracking nuts in your teeth, may also strain the TMJs and cause pain.

Some additional and less common ways of developing TMJ problems include:

• sports-related injury
• auto accident injury
• ankylosis, which is loss of joint movement resulting from a fusion of bones within the joint or calcification of the ligaments around it
• arthritis
• certain inherited facial characteristics that produce misalignments
• congenital abnormalities where the top of the jawbone doesn’t form or is smaller than normal
• dental conditions such as a high filling, a tipped tooth, or teeth displaced due to earlier loss of other teeth
• developmental abnormalities such as in some children where the top of the jawbone may grow faster or for a longer time than normal (congenital and developmental abnormalities are rare, but can cause facial deformities and misalignment of the upper and lower sets of teeth)
• hypermobility (looseness of the jaw), when the ligaments that hold the joint together become stretched
• internal derangement, where the disc inside the joint lies in front of its normal position
• structural abnormalities of the temporal joint









Symptoms and Complications




There is an easy test you can do yourself to check whether you’re able to open your jaw as much as you should. Most people can place the tips of their index, middle, and ring fingers held vertically in the space between the upper and lower front teeth without forcing. If your space is smaller, or if you experience pain or a clicking or grinding noise when you try to open your mouth this far, you probably have TMJ problems.

Common symptoms of TMJ problems include:

• a clicking sound or grating sensation on opening the mouth or chewing
• dull aching pain in front of the ear
• headaches that don’t respond to the usual medical treatment
• locking of the joint, making it difficult to open
• tenderness of the jaw muscles
• pain made worse by pushing on the TMJ when the mouth is open

The pain will often occur only on one side of the face, and sometimes the pain may seem to occur near the joint rather than in it. Pain and muscle tightness may be present after waking up in the morning or during and after stressful periods. These symptoms result from muscle spasms brought on by repeated muscle or tooth clenching and tooth grinding. Many people grind their teeth during their sleep and aren’t even aware of it, and clenching and grinding is more forceful when a person is asleep than when they are awake.










Making the Diagnosis




If you experience any of the above symptoms, you should speak to your doctor or, better yet, to your dentist. Dentists commonly diagnose and prescribe treatment for TMJ problems. In order to make the diagnosis, he or she will take your medical history and perform a physical examination of your jaw and face. The dentist may push on the side of your face or place a finger by your ear and gently press forward while you open and close your jaw. Also, in order to detect pain or tenderness, your dentist may gently feel the muscles you use to chew. He or she will also check to see whether your jaw slides when you bite, and can tell if you’re grinding your teeth by looking for excessive wear on the biting surfaces of your teeth.

Special X-ray techniques may be used to help make the diagnosis. If your dentist suspects that the disc lies in front of its normal position (a condition called internal derangement), he or she may order an X-ray in which a dye is injected into your joint (an arthrogram). Computed tomography (CT) or magnetic resonance imaging (MRI) may be used in rare cases to find out why a person isn’t responding to treatment.

Laboratory tests for TMJ problems aren’t often done, as they’re rarely useful. Dentists occasionally use electromyography, which analyzes muscle activity, to monitor treatment and occasionally to make a diagnosis.












Treatment and Prevention




Many people with temporomandibular joint problems (TMJ ) recover without any treatment. TMJ disorders that may require treatment are those that include:

• arthritis
• damage to the inside of the joint
• developmental or congenital abnormalities
• injury
• muscle pain and tightness
• reduced or excessive mobility of the joint

If the TMJ disorder is caused by inflammation within the joint, physical therapy and medications such as acetylsalicylic acid* (ASA), other nonsteroidal anti-inflammatory drugs (NSAIDs), or muscle relaxants work quite well. If a person is experiencing severe pain and inflammation, the doctor or dentist may recommend that a corticosteroid or a local anesthetic medication be injected into the joint to reduce discomfort. Acupuncture, acupressure, massage, and hypnosis are other techniques used by some dentists to decrease pain and to relax muscles.

A soft diet may be recommended to reduce the strain on the TMJ caused by biting and chewing.

If you’re aware that you clench or grind your teeth, you can take steps to break the habit. Splint therapy is the most popular and least invasive treatment. A thin plastic night guard is specially made to fit over either your upper or lower set of teeth and is then adjusted to provide you with an even bite. Most night guards are worn at night to reduce grinding, although they can also be used during the day. They can also prevent damage to your teeth. In addition, biofeedback or relaxation therapy, physical therapy, other behaviour modification techniques, and therapeutic jaw exercises can help.

If you have abnormalities in the alignment of your teeth that are causing TMJ problems, your dentist may correct this by balancing biting surfaces, replacing missing teeth, or replacing uneven or defective fillings or crowns.

Misalignment of the TMJ is usually treated with a plastic bite plate or splint that helps promote better alignment of your jawbones. This corrective device is also worn over your teeth and will help to re-establish proper alignment. As with the night guard used to prevent grinding, you should bring this device with you when you visit your dentist, as it may need to be adjusted occasionally.

Your dentist may also recommend changes in your chewing habits such as limiting gum chewing or avoiding firm foods such as caramels, non-tender meats, raw carrots, and celery. You may also be asked to try to limit opening your mouth wide when you yawn.

If your symptoms continue despite treatment, you may be referred to a specialist in oral and maxillofacial surgery to repair or to remove the disc that separates the adjacent bony surfaces of the TMJ or to realign the bones.

All material copyright MediResource Inc. 1996 – 2021. Terms and conditions of use. The contents herein are for informational purposes only. Always seek the advice of your physician or other qualified health provider with any questions you may have regarding a medical condition. Source: www.medbroadcast.com/condition/getcondition/Temporomandibular-Joint-Dysfunction

Atypical Earache Otomandibular Symptoms

With a basic understanding of ear pain-related pathologies and referral patterns, a physician can provide a quick screening examination for atypical earache by palpating the jaw joint, muscles of mastication, and cervical muscles.

By Keith A. Yount, DDS, MAGD, FAGD

There is a close relationship between disorders of the jaw/neck and symptoms of the ear. In one study of 344 patients, 60% of the patients with temporomandibular joint disorder (TMD) had ear symptoms.¹ In another study of 400 patients, 42% had ear symptoms.² Twenty-one of 28 patients had relief of tinnitus following orofacial pain therapy.³ The prevalence of non-otologic aural symptoms or referred otalgia in TMD patients varies from 3.5 to 42%.⁴ The prevalence of tinnitus is 15% in the general population. With TMD patients, this percentage escalates from 33% to 76%.⁵ The prevalence of vertigo in the general population is 5% and in the TMD population this percentage escalates from 40% to 70%⁶. The fullness in the ear and minor hearing loss have not have been adequately studied. Referred otalgia may account for as much as 50% of all ear pain complaints.⁷ Disc displacement was found to be present in the ipsilateral joint in all 53 patients with unilateral tinnitus.⁸ In a clinical case report, a 38-year old female with confirmed TMD underwent an arthroscopic procedure; upon awakening she had ear pain, saline in her middle ear, and hearing loss without ear canal perforation.⁹

An understanding of the relationship between the jaw/neck pathologies and ear requires reviewing today’s anatomical, neuromuscular, and central sensitization science. The anatomical concepts relate the direct connection of the jaw joint and trigeminal structures to the ear. The neuromuscular concept relates referral patterns of specific muscles of the trigeminal and cervical systems to the ear. Central sensitization incorporates how several different sources of pain (undiagnosed pain, ‘piggy-back’ pains, frequent recurrent pains, and chronic pains) induce anatomical, neurochemical, and physiological changes to the nervous system. The chronic pain that evolves from these mechanisms changes the visual diagnostic world of acute pain to the “bio-detective” world of orofacial pain and may confound diagnoses.

Differential Diagnosis

The atypical earache patient’s differential diagnostic list should include articular disc disorders (TMJ/TMD), myofascial pain dysfunction (chewing muscle pain), cervical muscle dysfunction, or cancer. Even though the ear is the source of most ear pain, the atypical earache is a fairly common adult occurrence in medical practices. Atypical earaches commonly are in the chronic pain arena with multiple causes and often involve central sensitization. If the physician had some way of knowing it was only a muscle problem the patient could be referred to a dentist for therapy. If the diagnosis is unknown at the time of referral, it may be a better choice to refer to an orofacial pain specialist trained in all the atypical ear pains. The atypical earache poses a management problem. All too often, after ruling out the ear as the source of the pain — an important step in the diagnostic journey — the patient is given no direction on the next step to complete the diagnosis. Some patients report that they have been told that they are “just a stressed-out female” since the pain is aggravated by stress. Occasionally, a physician might just pass it off as TMD without an exam due to the statistics of occurrence. Some refer the patient to an ENT for a second opinion on the ear as the source of the pain. In a busy practice where the typical doctor has about 12.5 minutes with the patient, it is difficult to correctly diagnose or refer the patient to the appropriate specialist.

The following clinical case illustrates the risks in not pursuing a differential diagnosis for an atypical earache:

A patient complained of moderate, deep aching pain in her left ear with one or more of following symptoms: tinnitus, vertigo, fullness in the ear, or minor hearing loss. The patient had little or no inflammation of the tympanic membrane. She complained that chewing, yawning, opening wide, and stress aggravated the pain. Since the pain seemed not to be associated with the ear, the attending physician made a casual comment that it might be TMD. However, a referral to an orofacial pain specialist was not made. The patient, feeling that her complaint was a benign problem, went home instead of seeking the appropriate consultation. The left ear pain worsened and she finally went to an orofacial pain specialist. Months later, this pain was diagnosed as a cancer in the pterygoid fossa.

Figure 1. Pterotympanic fissure: anterior Malleolar artery and vein, chorda tympana nerve, and anterior Malleolar and disco Malleolar ligament run through this fissure. (Photo by Keith A. Yount, DDS, GD) Figure 2. Anterior Malleolar Ligament attaching to head of Malleolus. (From Loughner BA, Larkin LH, & Mahan PE.14 Reprinted with permission.)

Pathophysiology

The anatomical relationship between the jaw/neck and ear is seen by examining the skull and reviewing the close proximity of the two adjacent structures. The “wiring of the skull” is much more complex and convoluted than in the rest of the body, which makes it difficult for the brain to discriminate between the ear and jaw joint. The jaw joint is separated by a thin window of bone to the mid-brain and a thick bone to the adjacent ear canal.¹⁰ The retrodiscal tissues of the jaw joint attach up and down the ear bone with the blood and nervous tissues in the lower and middle tissues. The upper compartment of retrodiscal tissue attaches elastin from the tympanic plate bone to the meniscus (disc) of the superior head of the lateral pterygoid. The elastin retracts the disc from the 2 o’clock position on opening back to the 11 o’clock position on closure. Also, the elastin resists condylar dislocation or excessive translation. This elastin opposes the eccentric pull of the superior head of the lateral pterygoid in front of the disc to continually keep the disc directly interposed between the two convex surfaces of bone at maximum vector of force. In 1983, Dr. Parker Mahan found that the Superior lateral pterygoid muscle contracts on closing¹¹ as the condyle moves posteriorly. The disc sits in between the convex surfaces in a bow tie configuration when anatomically correct. The disc is connected to the condyle by two-bucket handle ligaments on the lateral and medial sides of the joint. The medial aspect of the joint is associated with the medial disc ligament, the anterior malleolar ligament, and the sphenomandibular ligament. The medial aspect of the condyle has no capsule, but is a blending of different tissues.¹²

The second way the jaw joint and ear are connected is through a common nerve distribution, the auriculotemporal nerve. This nerve supplies both the lateral surface of the meatus of the ear and all the innervation of the jaw joint.10 This wiring commonality is one of the ways pain from the joint may be referred to the ear. In the world of acute pain, the site of the pain is the source of the pain, but in the chronic pain world this is not always true. Whether it is known exactly how this referral happens scientifically, it does happen clinically — especially with chronic pain pathologies.

Dissection research by Rees, Pintos, and Loughner discovered the direct connection from the ear to the jaw joint by revealing an embryonic ligament that in approximately 6% of individuals is large and mobile enough to put tension on the middle ear structures. In 1954, Dr. Rees described the discomalleolar ligament (DML) that arises from the tendon of the lateral pterygoid and passes superiorly through the petrotympanic fissure and attaches to the malleus. In two additional studies, the DML was not observed to be a viable ligament in these dissections. Some studies show it attaches to the wall of the petrotympanic fissure or dissipates with development; and therefore is not a viable link. Pintos’ dissection¹³ in 1962, suggests the anterior malleolar ligament (AML) is a viable ligament that could explain the inter-connected symptoms of the ear and jaw joint. He reported that this ligament (AML) attaches to the anterior process and neck malleus and passes inferiorly through the petrotympanic fissure to join the retrodiscal tissues of the medial aspect of the joint joining the sphenomandibular ligament. Since that time, the ligament existence has been confirmed by additional researchers. In 1989, Loughner, Larkin, and Mahan expanded Pintos’ dissection research findings.¹⁴ In seventeen of the specimens in the Loughner dissection, the DML joined the AML attaching to the neck of the malleus. In three of the specimens, even pulling on the SML caused movement on both the AML and malleus. This is a concern for any surgical procedure that requires mandibular distraction in the jaw joint allowing tension on the SML, AML, and then on the malleus, causing potential hearing loss. The mandible is lowered up to 10 mm for jaw joint surgery. This movement would be enough to rip the malleus from the tympanic membrane. This helps explain the significant statistical relationship between tinnitus and displaced discs (articular disc disorder). The disc of the jaw joint assembly displaces at the medial pole in an anterior and medial direction, putting tension on the medial and retrodiscal tissues, including the medial ligament and the AML as it enters the pterotympanic fissure. If the AML were mobile enough, it would put enough tension on the malleus to cause the tinnitus or vertigo. Figures 1 and 2 illustrate the pterotympanic fissue and the malleolar ligament interconnections.

Trigger Points

Muscular problems of the head and neck may refer pain to distant sites under certain conditions. To understand this phenomenon, research must be reviewed that has been conducted over the past 25 years. The muscle spindle is innervated by the sympathetic system.¹⁵ In a series of physiologic studies in 1985, Passatore & Gassi placed an EMG electrode into the muscle spindle, showing a significant increase in activity when sympathetic stimulation is provided. This response is not blocked by curare (skeletal neuromuscular blocker), but is blocked by phentolyamine (sympathetic alpha blocker).¹⁶ Hubbard used an EMG guided needle into a muscle spindle to record spontaneous activity in trigger points, but even at a distance of 1 mm there was no activity.¹⁷ It is now a known fact that the sympathetic system does exert control over the muscle spindle and accounts for tension in muscles when over-stimulated by stress, anxiety, or emotional upset. Over time, and with repeated over-stimulation, the spindle swells, becomes tender, damaged, and a source of ectopic electrical activity¹⁸ This hidden source of recurrent, persistent, and ectopic pain signal threatens to add confusion to any physician’s diagnostic differentiation. These muscle spindles have a tendency to refer pain to distant sites, making the diagnosis more difficult. Surprisingly, most patients are rarely aware of the existence of these trigger points in the muscles until they are pointed out by a physical therapist, an orofacial pain specialist,18 or even during a massage. During a massage, the woman may accuse the masseuse of too much pressure, but in reality a tender spot was touched in the muscle with the same pressure. Trigger points are established from an array of predisposing and precipitating factors including poor sleep, poor nutrition, lack of cardiovascular conditioning, bad posture, cervical parafunction, clenching/grinding teeth, poor bite, stimulants, muscle tension, an up-regulated sympathetic system, and an array of many other factors.¹⁹

“The jaw joint refers to the ear more often than any other structure. The TMJ is separated from the ear by millimeters of bone. It is so close to the ear it is easy to understand how pain from the joint is confused with ear pain by the brain, especially with all its head and neck wiring.”

Because there are multiple causes, trigger points are impossible to manage without using a multi-disciplinary approach. The presence of a trigger point in one part of the muscle makes the muscle prone to additional trigger points in other areas of the muscle.¹⁸ Trigger points lower pain thresholds, intensify muscle pain, increase muscle fatigue, fatigue the muscle faster, functionally shorten the muscle, and increase muscle weakness.¹⁸ One of the most effective techniques in locating a trigger point is to find the taut band (it feels like a banjo string) and palpate the length of the band until finding the trigger point.¹⁸ The trigger point location will be confirmed by the patient’s jump sign. These damaged muscle spindles seem to be the key to the referred pain from a muscle to a distant site. Muscle referral patterns have been worked out by Dr. Janet Travell in her book, MPD and Trigger Point Manual, Volume 1.¹⁸ The basis for this referral mechanism is the damaged area of muscle, commonly called the trigger point, and it’s interconnection with the sympathetic and skeletal system.

Pain Referral Patterns

The jaw joint refers to the ear more often than any other structure. The TMJ is separated from the ear by millimeters of bone. It is so close to the ear it is easy to understand how pain from the joint is confused with ear pain by the brain especially with all its head and neck wiring. The second way the jaw joint can refer pain to the ear is through the common nerve distribution of the auriculotemporal nerve that supplies the eardrum and all of the jaw joint structures. The third way is the direct connection from the medial ligament to the AML to the malleus. This helps explain the strong tinnitus and vertigo component common to patients with articular disc disorders. If one finds no inflammation in the eardrum, screening for jaw joint problems should be considered.

These structures may be checked out like any orthopedic problem. Any painful joint or muscle tissue is easily identified by palpating or functionally moving the jaw structures. The lateral pole of the jaw will be significantly tender to palpation, especially when disc displacements and arthritic changes affect the jaw joint.²⁰ When the patient reports that the ear pain is aggravated by chewing, yawning, or opening wide, it provides clues as to the source of the pain. A further clue is that the dull moderate ache is episodic and does not intensify with time. The pain will be episodic for the TMJ and not progressive, as it would be with an ear infection. Additional clues to a TMJ problem, is a history of restricted opening or deviation on movement. Also there may be a presence or history of jaw clicking on function.

Figure 3. Deep masseter: fibers run at a 45 degree angle to vertical as compared to superficial masseter fibers which are more vertical. (From Travell JG and Simons DG.¹⁸ Reprinted with permission.) Figure 4. Referral pattern: deep masseter. The source of pain is deep masseter and the site of pain is the ear. (From Travell JG and Simons DG.¹⁸ Reprinted with permission.) Figure 5. The source of the pain is the sternocleidomastoid with the perceived site of the pain posterior to the ear. (From Travell JG and Simons DG.¹⁸ Reprinted with permission.)

There are many ways to differentiate the jaw joint from the ear, but one should choose a set of tests that can be performed in 5 minutes to be able to refer with confidence to an orofacial pain specialist. In the diagnostic world, pathologies rarely present with this much diagnostic data. The presentations of a real earache and the atypical earache may be so similar that a clinical trial of antibiotics may be necessary to differentiate between the two. If the earache is not responsive to the antibiotic, then a referral to an orofacial pain specialist may be the right choice. On the other hand, if all indications continue to point to the ear itself, then a referral to ENT may be the best next step.

The referral of pain from a muscle to the ear can be from any one of four muscles, two trigeminal and two cervical. The trigeminal muscles are the deep masseter and the Lateral Pterygoid. The cervical muscles are the SCM and the deep posterior cervical muscles (little devils of the atlas/axis complex). Of all the muscles, the deep masseter is the most likely structure to refer pain to the ear18 from a muscle group.

Figure 6. Suboccipital muscles at the base of the skull (after illustration by Netter, Ciba-Geigy, 1989). These muscles are also known by names such as little devils, atlas and axis muscles, deep cervical muscles, and 3 layer posterior neck muscles. Specific names are rectus capitis superior and inferior, superior oblique and inferior oblique. Figure 7. True source of the pain is suboccipitals with the perceived site of pain at the ear. (From Travell JG and Simons DG.18 Reprinted with permission.)

Deep Masseter Muscle

The deep masseter is part of the power closing muscles and assists at retruding the mandible. It lies at a 45-degree angle to the vertical plane from the zygomatic arch to the posterior border of mandible. The Superficial Masseter is in the vertical plane over the deep masseter from the zygomatic arch to the lower border of mandible. Over-stimulation of this muscle occurs in patients that tooth brace, clench, object bite, avoid a high posterior crown or filling, or have a Class II bite. The muscle can be palpated just below the jaw joint, along the border of the posterior mandible. To palpate the deep masseter, the physician has the patient clench and relax, feeling the bulging superficial masseter with a finger. The deep masseter lies in the lower part of the triangle between the bulge of superficial masseter on clench, the posterior border of the mandible, and the lateral pole of the jaw joint. In a patient with a significantly tender deep masseter, it increases the suspicion that the differential diagnosis for the atypical earache should include deep masseter referral of pain. The aggravators to this type of pain will be chewing, talking, yawning, stress, opening wide, and clenching. The pain descriptors are dull, ache, and moderate. The pain does not respond to antibiotics or any ear therapy, but does partially respond to muscle relaxants and NSAIDs. The pain is episodic in nature. An ear pain would not be challenged by chewing gum. In this case, the ear cartilage may be tender for either joint or deep masseter pathology due to diffusion of inflammatory chemicals to the surrounding area. See Figures 3 and 4 for illustration of deep masseter fibers and referral pattern.

lateral pterygoid Muscles

The lateral pterygoid muscles manage the position of the disc or meniscus between the condyle and eminence during function. It will refer pain to the ear,18 the maxillary sinus, or retro-orbital. The lateral pterygoid is comprised of an upper belly and a lower belly. The lower belly contracts on opening, protrusion, or movement to the opposite side. The upper belly contracts on closing to stabilize the disc against the posterior pull of the elastin and to keep the disc in place between the convex bones at the major force zone. When clenching, both bellies contract at the same time along with the power closure muscles and is not the muscles’ normal mode of operation nor function. This results in isometric contraction of muscles, excessive lactic acid production with no lymphatic pump, and inflammation. The excessive pull on the joint structures can cause microtearing of ligaments and connective tissue and the inflammation can create pain in tissues adjacent to the ear bone.

Sternocleidomastoid (SCM) Muscle

The cervical muscles are less likely to refer pain to the ear, but they can. In the absence of tender jaw muscles or a tender lateral condylar pole and jaw function not aggravating the pain, the physician might consider the possibility that cervical muscle referral might be part of the differential diagnosis for the atypical earache. One of the cervical muscles Janet Travell found to refer pain to the ear¹⁸ is the sternocleidomastoid (SCM). As compared to the deep cervical muscle of the altas/axis complex, the sternocleidomastoid, or SCM, is easy to palpate.¹² It lies just below the skin at the anterior lateral border of the neck. It attaches to the Mastoid process just behind the ear and to the sternum and clavicle as two different bodies. This attachment to the bone behind the ear structure may be one of its mechanisms for referral to the ear. It is a major muscle for head function and balance. If the SCM is tender to palpation and the pain is aggravated by head and neck movement, SCM may be considered as a component of the differential diagnosis. The pain may be described as a moderate, dull, or ache. Referred pain from the SCM occurs with poor posture, carrying a heavy backpack, heavy computer bags, tension in the cervical muscles, up-regulation of the sympathetic system, holding the phone on the shoulder, poor work station layout, arthritis of the cervical facet joints, and injury. The SCM has been associated with dizziness and is responsible for balance. In the absence of tender jaw muscles and lateral pole of joint and pain not aggravated by jaw function, cervical muscles are considered a possibility for a cause of the ear pain. In the presence of a tender SCM and head function aggravating the pain, the SCM muscle would be suspect as the source of the ear pain. Figure 5 illustrates the referral pattern of the sternocleidomastoid neck positioning muscle which is used in forward head posture and balance.

Deep Posterior Cervical Muscles

The little devils or sub-occipital muscles are the other cervical muscles that refer pain to the ear.¹⁸ The suboccipital muscles attach to the atlas/axis complex (C1 and C2) in the deep, third level of neck muscles. The names of these muscles are rectus capitis superior, rectus capitis inferior, inferior oblique, and superior oblique. Patients with this type of pain referral usually have a history of motor vehicle collisions (MVCs) or cervical traumas associated with the onset of ear pain. These patients also report that head and neck movements or posturing can aggravate the ear pain. The pain can be provoked by poor head and neck posture and by provoking the deep muscles, creating ear pain or significant other pain. The report that the pain worsens as the day progresses can be a clue indicating that cervical muscles may be a strong candidate for the source of this pain. These cervical muscles cannot be directly palpated and must be provoked to create the tension on the muscle that may indicate its involvement. Unlike acute pain where the source and site of pain are the same, when it comes to chronic pain, there is no rule that limits the number of structures that can refer pain to same site. In fact, it is not unusual for the jaw joint and the deep masseter to refer pain to the ear at same time. Fig 6 and 7 illustrate the location of potential pain sources in the suboccipitals and the subsequent referred pain sites.

Another mechanism for referred pain is the elastin tension on the ear bone from the pull of the superior head of the lateral pterygoid against the disc to which the elastin attaches. An additional way the lateral pterygoid can create pain in the ear is by its attachment to an embryonic ligament, the AML, putting tension on the malleus. In this case, the ear pain is usually associated with dizziness or tinnitis. The lateral pterygoid muscle cannot be palpated; thus, the only way to test this muscle is by provoking the muscle to work. If the muscle is inflamed and is provoked, it will feel tightness, tension, pulling, or discomfort. However, provocation of a muscle is never as accurate as direct palpation. In this case, the ear pain will be non-progressive, dull, and moderate compared to acute ear pain.

Chronic Pain Progression

The more difficult a problem is to diagnose — with mulitple causes or aggravators or weaker referral connections and communications — the more chance it has of remaining for many months or even years. The longer the duration and the more severe the pain levels, the greater the chance that the pain will alter the biochemistry, anatomy, and function of the pain reporting system. The greater the severity and the longer duration of pain, and the more emotionally distressed the patient, the greater the impact will be on hormonal function.²¹ It has been observed that the intensity of pain from a physical injury relates to the attention given at the time.²² Chronic pain has lasting effects on the pain sensing and reporting systems. Constant or recurrent pain induces a lowering of the threshold for pain by the pain receptors.²³ The pain system also activates the silent nociceptors by initiating “wind up.”²⁴ These receptors do not normally react to pain stimulation, but when activated by long term pain, they are brought into action. The pain system reacts to smaller and less intense stimuli. Under normal conditions the pain reporting fibers (C-fibers) report a pain stimulus from a pain receptor. Over time, the pain reporting fibers (C-fibers) begin to develop alpha adrenergic receptors²⁵ which respond to adrenalin, the stress molecule. The pain also induces mass cells to enhance production of NGF²⁶ enhancing the sprouting and growth of nerves. This in turn stimulates the sympathetic nerves to sprout in lamina 3 of the dorsal horn and attach to the pain reporting fibers in lamina 1.²⁷ A stressor can now initiate the same pain response that a pain stimulus can elicit. The purpose of the adaptive response to pain is to limit activity to allow healing, but when the pain system is over-stimulated, the pain is ignored, the pain is undiagnosed, the pain has significant meaning, or the pain is so severe the adaptive response in not as effective. A compounding aspect is the difficulty in limiting activity in the head region due to its importance. The nervous system adapts to multiple, constant, or recurrent pain impulses, becoming part of the pain syndrome. The longer a pain is present and the more severe the pain, the more changes manifest in the pain reporting system.

“The atypical ear pain patient presents a chronic pain in which the pain impulse may be coming from one or multiple sources and is enhanced by the pain reporting system, but is referring to the ear.”

Conclusion

The majority of earaches are associated with ear structures; yet one may find ear pain with a tympanic membrane that is normal, or one in which antibiotics do not reduce the pain. The physician may refer the patient for an ENT evaluation and find that the patient returns after no inflammation is found in the tympanic membrane. The usual medical practice sees mostly acute ear pain in which the site and the source are same. The atypical ear pain patient presents a chronic pain in which the pain impulse may be coming from one or multiple sources and is enhanced by the pain reporting system, but is referring to the ear. When there is no inflammation in the eardrum, one is tempted to dismiss the patient’s concerns. When lack of time limits the number of diagnostic tests, the physician may provide a diagnosis of exclusion (if it’s not the ear, it must be TMJ or psychosomatic/stress-induced), or take the pharmaceutical route. Such misdiagnosis may lead to a hyper-active pain reporting system, a dependence on drugs, patient frustration, or perhaps even legal implications for one’s practice.

Expanding the differential list of pathologies to include these sources of atypical earaches can help the practitioner determine the best course of diagnostics to define the problem. By referring for an orofacial consultation, the practitioner can rule out these sources of ear pain and help the patient finally get to the root of the problem — yet, because there is misconception and confusion involving the connection of ear pain to the jaw and neck structures, an orofacial pain specialist is typically the fifth to seventh doctor seen for atypical earaches. With an understanding of these ear pain-related pathologies, a physician can provide a quick screening examination by palpating the jaw joint, muscles of mastication, and cervical muscles and then referring as needed. One of these referral sources is an orofacial pain or trigeminal orthopedic specialist. It is important to note that “TMD patients” respond well to conservative treatment.2 and TMD is significantly correlated to aural health.1 n

Last updated on: January 5, 2012

Jaw and Ear Pain

Patients often ask us ‘why do I have jaw & ear pain’. It’s a good question. Often you know why you have a pain in the back or neck – too much gardening or driving etc. But the jaw – that seems to be a bit of mystery.

So this article will explain the causes of jaw & ear pain, but will also go further & explain how it can be treated. After all it’s nice to know why you have a pain, but it’s much nicer to get rid of that pain!

Neck and Jaw Pain

But use this link if it is neck and jaw pain rather than jaw and ear pain then you have.

What Causes Jaw & Ear Pain

As with all pain there can be a number of causes and without taking a full case history for your particular case the information below can only be taken as a guide.

First off lets rule out heart problems – so skip to the next paragraph if you know this isn’t the cause of the pain. If you are still with me on this paragraph then you need to know that heart problems can cause jaw & ear pain this is known as referred pain. If you also have tightness or gripping in the chest or shortness of breath or pain down into the arm then please see a doctor or present yourself to hospital straight away.

OK here we are post heart discussion – so what else can cause jaw & ear pain – well musculo-skeletal problems are the most common, that’s muscles, bones ligaments etc and I will cover these in detail below.

As well as this teeth problems (cavities, abscesses, infections etc) and ear & sinus infections can cause jaw & ear pain. So it maybe worth seeing your dentist, but read on first as only yesterday I saved a patient her dental fee – she was booked in with me for neck pain but asked me about the jaw pain she was having. After 30 minutes of treatment she left pain free & cancelled her dentist appointment, she had a strain in one of the ligaments of the jaw. So we will explore below how you will know whether its your teeth or your jaw.

Musculo-skeletal Causes of Jaw & Ear Pain

The jaw is made up of 2 bones – the temporal bone and the mandible bone. These 2 bones then come together to make a joint – this gives us

T   for temporal

M  for Mandiblle

and J for Joint

– the TMJ, you may have heard of the TMJ or TMJ Syndrome, this is label for longstanding pain in the jaw.

Anytime the temporal bone or mandible bone move into a position that causes strain on the ligaments or muscles then that can lead to pain. 

Think about when you are at the dentist and you have to keep your move open for a long time. You will feel a strain or pull in the muscles. 

So anything that influences the bones will influence the muscles and ligaments that are attached to those bones.

It’s just like any other joint you lift something heavy and you feel a strain in your low back. the only difference with the jaw is that you don’t need a heavy weight as the muscles and ligaments in your jaw are much smaller than in your back.

So just like with back pain trauma can cause jaw pain, so any kind of blow or force to that area. Which of course would include a dental extraction or root canal.

But even without injury we can have jaw pain – and again its a bit like back pain where you can just sit at the computer for hours and you will ‘strain’ the back muscles. And sometimes sitting at the computer will give you the back and the jaw pain – how – well we end up gritting or clenching our teeth or even just really tightening up in the neck and all of that is going to put a strong force into the jaw and annoy the jaw ligaments and muscles.

If you continually do that then often it will only surface months or years later as the problem builds up.

This can also happen if you combine an old injury that has caused s small problem with the TMJ which led to wear & tear on the joint over time as the jaw worked in way that it shouldn’t.

The jaw – A Complex Joint

What makes the TMJ complex as a joint is that it has lots of influences on it from above and below.

Influences on the Jaw from Below

From below anterior neck & throat tightness can be causing a pull on the jaw – if you feel up under your jaw often you can feel its easier to press into the tissue on on side or the other, this would indicate imbalance. This could cause one side of the jaw to open easier than the other which can cause wear & tear and lead to jaw pain.

Influences on the Jaw from Above

If we look above the jaw the area becomes even more complex, all of the bones in the head work as a unit so if one moves all the others will move. The bones in the head have little gaps between them called sutures that allow for this movement. So problems in one part of the skull can have a knock on effect causing jaw & ear pain or headaches, sinus problems, tinnitus etc. So any previous head trauma could over time cause jaw & ear pain.

Dentistry as a cause of Jaw & Ear Pain

First up this is not going to be criticism of dentistry. However due to the large forces that are sometimes needed to extract teeth dentistry can cause problems for the jaw. Often just having your mouth open for long periods at the dentists can cause problems, again not a criticism of dentistry just something that can happen. Anyone who has had wisdom or other teeth extracted will remember the event so can understand how that could strain the jaw structures. So what about just having your mouth open. Well if you do this now for more than a minute (& don’t if you have jaw pain already) then it will feel uncomfortable. Do this for a lot longer and the jaw ligaments will often spasm, this contraction will draw the mandible up on that side often & it can stay that way for months & years & cause problems for the jaw.

Ear Pain

This article is getting long so I will write a separate one on ear pain, so here I will just say that the ear bone, “the temporal” is so closely linked to the jaw, that any jaw issue can cause ear pain.

Treatment For Jaw & Ear Pain

If after reading this article you think the jaw & ear pain is coming from muscle, bones or ligaments then hands on treatment can be very effective at resolving the pain. There is a branch of osteopathy called ‘Cranial” that works very well for jaw & ear issues as it specializes in the treatment of the cranial bones & the face. Treatment is gentle, as you would expect, as the face & cranial bones are delicate structures.

A cranial osteopath will first identify the tissues that are causing the problem. This maybe ligaments, muscles, or the alignment of the bones or all of these. Then with their hands they will use gentle pressure to release or move the problem tissues in order to correct the anatomy that is out of balance. This may include work on the skull bones or work on neck muscles & ligaments. It may also include specialized releases within the mouth. For these techniques the practitioner will first put on a latex or synthetic glove & then place one finger alongside the back of your teeth in order to press on & release the ligaments & muscles around the inside of the jaw. It is an extremely effective way to treat jaw problems. The pressure used should be gentle and not cause pain.

All cranial osteopaths need first to be registered osteopaths (4 or 5 year university training) & then they can choose to undergo further post graduate training in this area. Training includes courses such as the SCTF ‘Face’ course which is a 5 day course which concentrates purely on the treatment of the face & the jaw. If you would like more information on the SCTF click here

If you would like more information on this topic

Jaw & Post Dental Pain

Article Title : Jaw & Ear Pain

Author : Dr Jonathan Evans

About the author : Dr Evans is a registered osteopath with post graduate training in cranial osteopathy. He is a faculty member of the SCTF – which is the largest worldwide foundation for the post graduate training of cranial osteopaths. As such he has taught on cranial courses including the 5 day Face course. He practices in Tweed Heads, Gold Coast, Australia.

Gold Coast Osteopath Gold Coast

My Ear Hurts and I Have Eye Pain: What Do I Do?

My Ear Hurts! What Does This Mean?

“My ear hurts but I have gone to the doctor several times begging for an antibiotic and he keeps telling me that my ear looks fine!”
This is more common than you may think.  Many of my patients have complained about this.  They present with severe ear pain and pressure, some eye pain or pressure, pain around the temple area, and sometimes sensitive upper teeth.  How could this not be an infection of some sort….right?  Well the truth is, you may be suffering from temporal tendonitis.

What is Temporal Tendonitis?

Temporal tendonitis is a craniofacial pain disorder which results in the inflammation of the temporal tendon which connects the temporalis muscle on the side of the head to the mandible, or lower jaw, on the coronoid process.

Temporalis Muscle attaches to the lower jaw (mandible) on the Coronoid Process by the Temporal Tendon

After our examination, I usually discover signs of occlusal wear on a patient’s teeth, possible arthritis occurring in a patients joint, or a history of clenching.  All of these, and other predisposed conditions, can contribute to temporal tendon inflammation.

If a patient has an irritated temporal tendon prior to a dental procedure (or any of the other reasons listed above), it is more likely that they will develop a tendonitis after the procedure is completed (or after taxing the tendon through normal function: yawning, eating, etc).

What Causes Temporal Tendonitis?

You may develop temporal tendonitis from:

• Trauma to the side of your face/head
• Being opened really wide for a long period of time for a dental procedure
• Yawning really wide
• Eating very hard foods
• Loss of vertical dimension of occlusion (the distance between your nose and chin is shorter than it was when you were younger – you are becoming over-closed)
• Chronic parafunction (your bite is off and your teeth do not come together appropriately)
• Hypertrophy of the coronoid process (your coronoid process, a part of your lower jaw, becomes larger than it once was)

Temporal Tendonitis Symptoms

If you have one or more of the causes of temporal tendonitis listed above and experience one or more of these symptoms, it’s time to give us a call:

• TMJ pain
• Eye pain
• Ear pain and pressure or congestion
• Limitation in opening the mouth
• Pain/pressure behind the eye
• Temporal head pain that can radiate to the forehead
• Pain and/or swelling in the cheek
• Sensitivity of the teeth, particularly the upper maxillary teeth

How Do You Treat Temporal Tendonitis?

Treatment of temporal tendonitis can involve multiple processes such as:

• Anti-inflammatories like ibuprofen
• Muscle relaxants
• A soft diet
• Splints/orthotics
• Physical therapy
• Biofeedback if clenching related
• Injection therapy with a long lasting local anesthetic and a steroid, sarapin, or prolotherapy

Temporal tendonitis is harder to treat through medication alone.  We have several ways that we treat this condition successfully in our practice every day.  Proper diagnosing is crucial and allows us to create your ideal treatment plan.

If you believe that you may be suffering from Temporal Tendonitis, we can help you! Call us today for an evaluation and treatment and be done with that ear pain once and for all!

Dr. Tracy Davidian

Fellow of the American Academy of Craniofacial Pain

Fellow of the Las Vegas Institute of Neuromuscular Dentistry

919-366-PAIN (7246)

Jaw hurts and clicks

The upper jaw is motionless, it is part of the skull, the lower jaw is attached to the upper one with the help of muscles, ligaments and moves due to a joint called the temporomandibular joint. Its movement can be felt if you put your hand under the ear and open-close your mouth. The joint has a hinge structure, such as the humeral and hip joints.

Normally, the joint moves silently and painlessly . When the mouth opens wide, the articular head (condyle) moves forward from the glenoid fossa, when the mouth closes, the condyle returns to its place.Muscles and ligaments help and set in motion.

If suddenly you feel pain under the ear and the lower jaw is “jammed”, then most likely there was a dislocation of the temporomandibular joint. More often, muscle spasm occurs, which complicates the return of the articular head to its place. This condition requires immediate medical intervention, it is necessary to relax the muscle and return the condyle to its place – to correct the dislocation. Usually, the doctor sets the joint without surgery, in difficult cases or with constantly repeated dislocation, surgery may be required.

After the dislocation of the temporomandibular joint has been reduced, it is necessary to limit the use of coarse food for several weeks in order to reduce the pressure when chewing on the lower jaw, not to open the mouth wide, while yawning to prop the lower jaw with a fist.

If during the work of the temporomandibular joint you hear a crunch, clicking or pain, this may indicate damage to the joint, stretching of muscles and ligaments. Often the reason that the jaw clicks can be a malocclusion, the absence of some teeth, which serve as a support and provoke an increase in the load on the joint.If left untreated, pain can spread to the face, ear and neck, and the joint can collapse, affecting the reshaping of the face.

If you experience discomfort when chewing, crunching or clicking your jaw, see a specialist to determine the cause and prescribe treatment.

For professional help in our Clinic, call: 28-12-12.

Be healthy!

Tumor (lump) under the ear reasons, what to do

Swelling under the ear: treatment, causes

The appearance of a tumor under the ear may not cause serious harm to health, but in order to avoid possible complications, it is necessary to diagnose the type of this tumor with a doctor.

Tumors often develop due to failures in the immune system, due to a lack of trace elements, vitamins in the human body, due to violations of hygiene rules. Also, tumors above the ear can develop due to viral infections and injuries.

A tumor under the ear can occur due to various diseases: lymph nodes, lipomas, neoplasms, boils, nevi, papillomas, cysts, lyphangiomas and hemangiomas, cancer. Therefore, it is necessary to go to a specialist who will diagnose and select a treatment.

Usually, treatment in these cases is with medications or with the help of surgery.

Pain remaining after treatment and hearing loss should alert.

Lymphadenitis

Due to the fact that the lymph nodes are enlarged, a swelling may appear under the ear. Symptoms will be as follows: edema, severe pain of a pulsating nature, localized to the left or right under the lower jaw when pressed.

Boil

This tumor is a purulent severe inflammation, it differs in color and is easily palpable, the pain on palpation is very strong.

The boil is in the form of a cone, in the center is a purulent area. Pus comes out on its own, you do not need to press on the boil and bring the infection.

Zhirovik

The swelling occurs due to a blockage of the sebaceous glands. With swelling and growth, the formation becomes painful on palpation. It can grow up to several centimeters. Requires timely treatment.

Edema of the auricle

Edema, or perichondritis, is a swelling in the auricle and in the center of the ear that causes the cartilage to become inflamed.The disease is contagious. It usually causes swelling of the entire ear, severe pain and pus.

Lipoma

This type of tumor under the ear is harmless and benign. Its growth is slow, the lipoma does not cause pain, its composition is soft. Often does not require treatment.

Cancer

The most common cancer under the ear is a sarcoma. It is formed from connective tissue. It looks like a dark pineal lump. Usually painful.May promote pus and fistula formation.

Symptoms for visiting a doctor may include:

• Severe pain;
• Throbbing pain;
• Swollen lymph nodes;
• Increase in size of the tumor;
• Inflammatory processes;
• Presence of pus;
• Discoloration of the tumor.

First you need to come for an examination to a therapist or dentist.A knowledgeable specialist is needed to diagnose the cause of the swelling under the ear.

In order to make a diagnosis, you need:

• Undergo an ultrasound examination;
• Make an X-ray.

If you have lymphadenitis, you need to eliminate the infection or fight the virus that caused the inflammation. The patient is prescribed antiviral and immunomodulatory drugs.

If the lymph nodes are inflamed, then the treatment will be medication.

If there is a purulent process, then the doctor prescribes antifungal drugs and antibiotics. For hygiene of the sore spot, you need to use antiseptic drugs.

If the patient has a wen and needs to be removed, then first an injection of cortisol is given. The operation will be performed with local anesthetics.

Small lipoma is eliminated without surgery.

If cancer is suspected, an oncologist will be involved in treatment.

Tumor formations can be removed both by surgery and by laser. When the tumor becomes malignant, surgical removal is usually done.

Timely treatment is needed to avoid complications. If the seal is small, then, as a rule, after its elimination, complications do not arise.

But even with a normal boil, severe inflammation can occur, and the boil must be removed by the surgeon.

Complications can be as follows:

• Inflammatory tissue processes;
• Suppuration of tissues;
• Infectious diseases;
• Diseases of the oral cavity and ears;
• Inflammatory processes in nerve tissues;
• The appearance of malignant neoplasms.

To avoid complications, you need not to overcool or heat the affected area, not to press on pus and fat formation, not to physically affect them.

To avoid the appearance of a tumor over the ear, you need to adhere to the following rules:

• Dress appropriately for the weather;
• Do not overcool;
• Avoid drafts;
• Treat viral infections on time;
• Try to stress less;
• To harden the body;
• Massage the face;
• Eat right.

If a small tumor appears above the ear, you should not start the disease, not heal yourself, but contact a specialist at the Onco.Rehab clinic to make the correct diagnosis and select the necessary treatment program.

90,022 90,000 Doctors told who is at risk of facial nerve palsy after vaccination

One of the most serious consequences of vaccination against coronavirus can be paralysis of the facial nerve – such a consequence has already been experienced by some patients who received the first dose of Pfizer.The doctors explained that such a reaction of the body is allergic. It can affect different groups of patients and requires strict medical supervision in order to avoid distortion of facial features in the future.

After being vaccinated against coronavirus, there is a chance of getting facial nerve paralysis – partial numbness of the muscles, which subsequently leads to a distortion of the face. Such consequences of the vaccine have already been recorded in 13 Israelis who received the first dose of Pfizer, the country’s Ministry of Health reported.

Individual cases have been identified in other countries, said Anch Baranova, professor at the School of Systems Biology at George Mason University.

“Paresis of the facial nerve, by the way, was noted not only in Israel, there were cases in Canada and the United States. Yes, they are related to vaccinations. I must say that this effect is unpleasant for a person, it passes. Of course, maybe not so fast, but in principle, on the same horizon as, say, a tic of the eye, ”said the medic, speaking on Channel One.

As the neurologist, head of the rehabilitation center “Overcoming” Alexander Komarov, explained to Gazeta.Ru, every vaccine has an allergenic potential – it is he who causes the body’s reaction to the introduction of an antigen, which can manifest itself in the form of paralysis of the facial nerve.

“There are people who are susceptible to such reactions: they have hypersensitivity or tense immunity, which can provoke an excessive reaction in the form of allergies, Quincke’s edema, rashes. People with autoimmune diseases can have severe consequences.For example, neuropathy of the facial nerve, which appeared in some vaccinated people, is precisely an allergic autoimmune damage to the facial nerve. There is no direct connection between the vaccine and the facial nerve – this is a reaction through immunity, ”the doctor said.

A similar reaction of the body can also occur with the introduction of an antibiotic or other drug, the neurologist emphasized. According to Professor Anchi Baranova, ordinary medical procedures can also affect this.

“Such effects are observed not only after vaccination, say, Pfizer or Moderna, but also after other medical procedures.People can come to have a fibrogastroscopy for gastritis and also get facial paralysis, ”she said.

At the same time, not a single patient can consider himself protected from such consequences of vaccination, says neurologist Alexei Kudryashov. According to him, such manifestations can be associated with serious diseases, which only a doctor will help to deal with:

“There are no clinical signs of a lesion of the facial nerve – this is an anatomical feature that can be predicted only after a specialized examination.There are several types of damage to the facial nerve – these are central and peripheral. Central occurs when the central nervous system is damaged – stroke, heart attack, for example. In the case of the vaccine, peripheral damage occurs, and it is most often associated with hypothermia or other serious diseases of the face and neck. ”

The first symptom of facial nerve palsy is pain behind the ear, doctors warn. After it comes the weakness of the facial muscles – this symptom manifests itself within a few hours, and then increases within 48-72 hours.In this case, the defeat extends only to half of the face.

“Paresis of the facial nerve is the same situation as stroke and appendicitis. In such cases, you need to get urgent medical attention. Why it matters: The nerve that runs in the facial canal is very delicate. If he is in allergic edema for more than five hours, the damage can be very serious. For example, the function of the facial muscles will be disrupted, which will lead to a distortion of the face, which will subsequently harm psychologically, ”said Alexander Komarov.

When treating patients with such a problem, doctors usually use corticosteroids – when administered in the very first hours after the onset of paralysis, they reduce nerve swelling and help people restore facial muscle movement a little faster, infectious disease specialist Lilia Baranova explained to Gazeta.Ru.

“I would like to note that in this case, regardless of whether specialized treatment is carried out, most patients themselves cope with the problem within a few days or months, depending on the capabilities of the body,” the doctor concluded.

Ear hurts when you move your jaw – Question to Laura

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