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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


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    1. 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

    2. Pertinent negatives • No vision change or eye pain • No tooth or throat pain • No jaw claudication • No fever or chills • No otorrhea

    3. PMHx: HTN Hyperlipidemia H.pylori ?Pre-diabetes All: PCN - rash Meds: Zestoretic Atorvastatin Omeprazole Clarithromycin Metronidazole History

    4. 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

    5. Otalgia Thank you, eMedicine.

    6. Agenda • What is otalgia? • What is TMJ? • Where can I eat for free today?

    7. 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

    8. Trigeminal nerve

    9. Facial nerve (VII)

    10. Glossopharyngeal and Vagus

    11. 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

    12. Otalgia: the H&P • History • Otologic symptomatology • Dental problems • Sinus problems • Swallowing disorders • Cervicofacial pain syndromes • Recent trauma • Cardiopulmonary history • Physical

    13. Otalgia: the exam Ear normal? No Yes Thorough head and neck exam Done

    14. Temporomandibular Joint Syndrome

    15. TMJ: Names • Costen disease • TMJ • TMJ syndrome • TMJ disease • TMD • TMJD

    16. TMJ: Causes • Myogenous • Bruxism • Daytime jaw clenching • Arthrogenous • Disk displacement disorder • DJD • Systemic arthritic conditions • Ankylosis • Infections • Neoplasia

    17. TMJ: Demographics • Male:female - 1 : 4 • Caucasian > African-American • Age - 20-40 years • Lifetime prevalance - 5-10%

    18. TMJ: History • Pain • Sounds • Jaw opening/locking • Headaches • Other

    19. TMJ: Exam • Asymmetry • Malocclusion • Jaw opening (between incisors): 5 cm • Protrusive/lateral jaw movement: 1 cm • Muscle spasm • Joint sounds

    20. TMJ: Associations • TNF-alpha • IL-1ra • sIL-1rII • COMT

    21. TMJ: Imaging • Panorex

    22. TMJ: Treatment • Meds • NSAIDs • Opiates • Muscle relaxants • Tricyclic antidepressants • Occlusal splints • Physical therapy • Surgery

    23. Back to our patient…

    24. Plan • Cyclobenzaprine 5mg TID PRN • Jaw exercises • Dental follow up, if needed

    25. Recap • All ears that ache aren’t earaches • Normal ear = more exam • Treat the cause of TMJ, although most cases resolve spontaneously

    26. The End?