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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 l.jpg
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


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Pertinent negatives

  • No vision change or eye pain

  • No tooth or throat pain

  • No jaw claudication

  • No fever or chills

  • No otorrhea


History l.jpg

PMHx:

HTN

Hyperlipidemia

H.pylori

?Pre-diabetes

All:

PCN - rash

Meds:

Zestoretic

Atorvastatin

Omeprazole

Clarithromycin

Metronidazole

History


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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


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Otalgia

Thank you, eMedicine.


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Agenda

  • What is otalgia?

  • What is TMJ?

  • Where can I eat for free today?


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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





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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


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Otalgia: the H&P

  • History

    • Otologic symptomatology

    • Dental problems

    • Sinus problems

    • Swallowing disorders

    • Cervicofacial pain syndromes

    • Recent trauma

    • Cardiopulmonary history

  • Physical


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Otalgia: the exam

Ear normal?

No

Yes

Thorough head and neck exam

Done



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TMJ: Names

  • Costen disease

  • TMJ

  • TMJ syndrome

  • TMJ disease

  • TMD

  • TMJD


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TMJ: Causes

  • Myogenous

    • Bruxism

    • Daytime jaw clenching

  • Arthrogenous

    • Disk displacement disorder

    • DJD

    • Systemic arthritic conditions

    • Ankylosis

    • Infections

    • Neoplasia


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TMJ: Demographics

  • Male:female - 1 : 4

  • Caucasian > African-American

  • Age - 20-40 years

  • Lifetime prevalance - 5-10%


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TMJ: History

  • Pain

  • Sounds

  • Jaw opening/locking

  • Headaches

  • Other


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TMJ: Exam

  • Asymmetry

  • Malocclusion

  • Jaw opening (between incisors): 5 cm

  • Protrusive/lateral jaw movement: 1 cm

  • Muscle spasm

  • Joint sounds


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TMJ: Associations

  • TNF-alpha

  • IL-1ra

  • sIL-1rII

  • COMT


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TMJ: Imaging

  • Panorex


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TMJ: Treatment

  • Meds

    • NSAIDs

    • Opiates

    • Muscle relaxants

    • Tricyclic antidepressants

  • Occlusal splints

  • Physical therapy

  • Surgery



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Plan

  • Cyclobenzaprine 5mg TID PRN

  • Jaw exercises

  • Dental follow up, if needed


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Recap

  • All ears that ache aren’t earaches

  • Normal ear = more exam

  • Treat the cause of TMJ, although most cases resolve spontaneously