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52 y/o female with ear pain. [O] [P] [Q] [R] [S] [T] [A]. Onset one week prior Worsened with chewing Throbbing Left ear Almost disabling Intensifies over 3-4 minutes Associated jaw “clicking” and “popping” Also with nasal congestion, headache. Pertinent negatives.

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52 y o female with ear pain
52 y/o female with ear pain

[O]

[P]

[Q]

[R]

[S]

[T]

[A]

  • Onset one week prior
  • Worsened with chewing
  • Throbbing
  • Left ear
  • Almost disabling
  • Intensifies over 3-4 minutes
  • Associated jaw “clicking” and “popping”
  • Also with nasal congestion, headache
pertinent negatives
Pertinent negatives
  • No vision change or eye pain
  • No tooth or throat pain
  • No jaw claudication
  • No fever or chills
  • No otorrhea
history
PMHx:

HTN

Hyperlipidemia

H.pylori

?Pre-diabetes

All:

PCN - rash

Meds:

Zestoretic

Atorvastatin

Omeprazole

Clarithromycin

Metronidazole

History
slide4
Exam
  • BP 125/74 Wt 88 kg
  • Gen: NAD
  • HEENT:
    • PERRL, EOMI, anicteric, non-injected
    • TMs translucent, no pre-/post-auricular tenderness
    • Clear-white rhinorrhea with minimal turbinate erythema, no sinus tenderness
    • Subluxation/crepitus of left jaw
  • Neck: supple, no LAD/masses, no bruits
otalgia

Otalgia

Thank you, eMedicine.

agenda
Agenda
  • What is otalgia?
  • What is TMJ?
  • Where can I eat for free today?
otalgia the pathogenesis
Otalgia: the pathogenesis
  • Sensory nerves of the ear
    • CN V - auriculotemporal branch
    • CN VII - Ramsey-Hunt branch
    • CN IX - Jacobson branch
    • CN X - Arnold branch
    • C1, C2
  • Neuroanatomic otalgia
    • Spinal tract nucleus of CN V
      • CN V, VII, IX, X, C1, C2, C3
otalgia the differential
Primary

Otitis media

Otitis externa

Mastoiditis

TM perforation

Foreign body

Referred

Dental

TMJ

Dental abscess

Poorly-fitting denture

Oral cavity

Tongue

Sinuses

Throat

Tonsillitis/pharyngitis

Eustachian dysfunction

Neck

Musculoskeletal

Other

Neuralgias

Tumors

Angina

Temporal arteritis

Zoster

Otalgia: the differential
otalgia the h p
Otalgia: the H&P
  • History
    • Otologic symptomatology
    • Dental problems
    • Sinus problems
    • Swallowing disorders
    • Cervicofacial pain syndromes
    • Recent trauma
    • Cardiopulmonary history
  • Physical
otalgia the exam
Otalgia: the exam

Ear normal?

No

Yes

Thorough head and neck exam

Done

tmj names
TMJ: Names
  • Costen disease
  • TMJ
  • TMJ syndrome
  • TMJ disease
  • TMD
  • TMJD
tmj causes
TMJ: Causes
  • Myogenous
    • Bruxism
    • Daytime jaw clenching
  • Arthrogenous
    • Disk displacement disorder
    • DJD
    • Systemic arthritic conditions
    • Ankylosis
    • Infections
    • Neoplasia
tmj demographics
TMJ: Demographics
  • Male:female - 1 : 4
  • Caucasian > African-American
  • Age - 20-40 years
  • Lifetime prevalance - 5-10%
tmj history
TMJ: History
  • Pain
  • Sounds
  • Jaw opening/locking
  • Headaches
  • Other
tmj exam
TMJ: Exam
  • Asymmetry
  • Malocclusion
  • Jaw opening (between incisors): 5 cm
  • Protrusive/lateral jaw movement: 1 cm
  • Muscle spasm
  • Joint sounds
tmj associations
TMJ: Associations
  • TNF-alpha
  • IL-1ra
  • sIL-1rII
  • COMT
tmj treatment
TMJ: Treatment
  • Meds
    • NSAIDs
    • Opiates
    • Muscle relaxants
    • Tricyclic antidepressants
  • Occlusal splints
  • Physical therapy
  • Surgery
slide24
Plan
  • Cyclobenzaprine 5mg TID PRN
  • Jaw exercises
  • Dental follow up, if needed
recap
Recap
  • All ears that ache aren’t earaches
  • Normal ear = more exam
  • Treat the cause of TMJ, although most cases resolve spontaneously