DiagnosticTree/EarTMJ

{

 "tree_id": "ear-tmj",
 "region": "Ear & Temporomandibular Joint Pain",
 "start": "tmj-screen-1",

 "redflags": {
   "emergency": [
     {
       "id": "rf-e1",
       "label": "Otitis media / Mastoiditis",
       "question": "Is there fever, acute hearing loss, or purulent ear discharge?",
       "rationale": "Acute otitis media or mastoiditis requires urgent antibiotic treatment or surgical referral — not myofascial assessment",
       "action": "Call emergency services or send directly to Emergency Department"
     },
     {
       "id": "rf-e2",
       "label": "Cardiac referred pain",
       "question": "Is there jaw or ear pain with an exertional component, particularly on the left side, or associated chest tightness?",
       "rationale": "Cardiac ischaemia reliably refers to the jaw and ear — must be excluded before musculoskeletal assessment",
       "action": "Call emergency services immediately"
     },
     {
       "id": "rf-e3",
       "label": "Mandibular fracture",
       "question": "Is there a history of direct trauma to the jaw with malocclusion, inability to close the mouth, or bony crepitus on mandible palpation?",
       "rationale": "Mandibular fracture must be excluded before any intraoral examination or jaw manipulation",
       "action": "Emergency referral to oral/maxillofacial surgery or ED. Do not proceed with intraoral assessment."
     }
   ],
   "urgent": [
     {
       "id": "rf-u1",
       "label": "Temporal arteritis",
       "question": "Is the patient aged 50+ with jaw claudication (jaw pain that builds with chewing and eases with rest), temporal headache, or scalp tenderness?",
       "rationale": "Jaw claudication is pathognomonic of temporal arteritis. Can cause irreversible blindness if untreated. Same-day ESR required.",
       "action": "Same-day GP referral + ESR and CRP. Do not delay for myofascial assessment."
     },
     {
       "id": "rf-u2",
       "label": "Parotid / neck malignancy",
       "question": "Is there a hard fixed parotid or neck swelling, or any facial nerve weakness?",
       "rationale": "Possible salivary gland malignancy with nerve involvement",
       "action": "Urgent ENT or oncology referral"
     },
     {
       "id": "rf-u3",
       "label": "Cervical instability",
       "question": "Is there a history of trauma to the head or neck combined with upper cervical pain, arm symptoms, or gait disturbance?",
       "rationale": "Odontoid fracture or cervical instability can refer to the ear region. Manual therapy is contraindicated until cleared.",
       "action": "Urgent spinal assessment — no manual therapy until cleared"
     }
   ]
 },

 "nodes": {

   "tmj-screen-1": {
     "type": "rom",
     "question": "Before proceeding: is there acute TMJ pain on joint palpation — tenderness directly over the lateral pole of the condyle (anterior to the tragus) or on retrodiscal palpation (little finger in the external auditory meatus)?",
     "movement": "TMJ capsule palpation",
     "direction": "screening",
     "clinical_rationale": "Acute capsulitis or synovitis is the primary contraindication to masticatory muscle stretching. If the joint is hot, palliative care must precede myofascial treatment. Periarticular tenderness from referred TrP pain is relatively mild compared to true joint inflammation. True joint pain is characteristically periarticular and aching in quality. Palpation of the lateral pole: press firmly with the index finger anterior to the tragus — truly inflamed joints are markedly tender even with light pressure.",
     "yes": "refer-tmj-acute",
     "no": "agg-1"
   },

   "agg-1": {
     "type": "choice",
     "question": "What is the PRIMARY activity or circumstance that aggravates or reproduces the ear or TMJ pain?",
     "clinical_rationale": "This single question separates the three major muscle groups contributing to ear and TMJ pain. Jaw movement implicates the masticatory muscles (lateral pterygoid, masseter deep, medial pterygoid). Neck and postural loading implicates the SCM clavicular division. Rest pain or movement-independent ear symptoms often reflect SCM or may indicate non-myofascial pathology.",
     "options": [
       {
         "label": "Jaw movement",
         "sublabel": "Chewing, clenching, biting, or opening — jaw movement is the primary trigger",
         "next": "jaw-symptom-1"
       },
       {
         "label": "Neck movement or sustained posture",
         "sublabel": "Rotation, looking down, carrying weight on the shoulder, or prolonged forward head position",
         "next": "exam-scm-1"
       },
       {
         "label": "Neither — ear or jaw pain at rest, or with ear symptoms only",
         "sublabel": "Pain is present without clear jaw or neck aggravation; may include ear fullness, tinnitus, or muffled hearing",
         "next": "symptom-rest-1"
       }
     ]
   },

   "jaw-symptom-1": {
     "type": "choice",
     "question": "Which of these features best describes the dominant associated symptom alongside the ear or TMJ pain?",
     "clinical_rationale": "Within the jaw-aggravated group, the associated symptom character is the most efficient separator. Tinnitus (low roaring, set off or interrupted by wide jaw opening) points to the deep masseter. Restricted opening with pain specifically on CLOSING or clenching, or TMJ clicking, points to the lateral pterygoid. Ear stuffiness with throat or palate pain on wide opening points to the medial pterygoid. These three patterns are clinically distinct enough to function as a choice node.",
     "options": [
       {
         "label": "Tinnitus — a low roaring or buzzing in the same ear",
         "sublabel": "Ear noise that may be activated or interrupted by opening the jaw wide; not associated with hearing loss or vertigo",
         "next": "exam-masseter-deep-1"
       },
       {
         "label": "TMJ clicking, locking, or pain specifically when CLOSING the jaw or biting down",
         "sublabel": "Click or pop during opening or closing; OR pain that is worse on clenching or biting, not on opening",
         "next": "jaw-closing-screen-1"
       },
       {
         "label": "Ear stuffiness or muffled hearing, throat soreness, or difficulty swallowing",
         "sublabel": "Sensation of blocked ear without infection; OR throat pain and difficulty swallowing when chewing",
         "next": "exam-medial-1"
       }
     ]
   },

   "jaw-closing-screen-1": {
     "type": "rom",
     "question": "Is jaw opening significantly restricted — less than approximately 36 mm (two knuckles between the incisor teeth) — and does the jaw deflect to one side without returning to midline on full opening?",
     "movement": "Interincisal opening measurement",
     "direction": "restriction",
     "clinical_rationale": "Significantly restricted opening (less than 36 mm) with non-correcting deflection and a hard end feel may indicate TMJ ankylosis or anteriorly displaced disc without reduction — this situation requires specialist referral before myofascial treatment. Muscular restriction from TrPs produces a soft end feel and is improved by spray and stretch. True internal derangement without reduction produces a hard end feel.",
     "yes": "rom-endfeel-1",
     "no": "exam-lateral-pterygoid-1"
   },

   "rom-endfeel-1": {
     "type": "rom",
     "question": "On gentle passive overpressure — thumb on upper incisors, middle finger on lower incisors, gently prising apart — is the end feel SOFT (gives with gentle pressure, possibly with patient discomfort) or HARD (rigid, no give)?",
     "movement": "Passive end feel assessment",
     "direction": "restriction",
     "clinical_rationale": "A soft end feel with increased range on passive overpressure indicates muscular restriction (TrPs or splinting) — proceed with TrP examination. A hard end feel with little or no increase in range indicates articular pathology (ankylosis or anteriorly displaced disc without reduction) — refer to specialist. Muscular restriction may also cause tremor and reflex contraction against the opening pressure.",
     "yes": "exam-lateral-pterygoid-1",
     "no": "refer-tmj-specialist"
   },

   "exam-masseter-deep-1": {
     "type": "examination",
     "question": "Does firm flat palpation of the deep masseter — against the posterior ramus of the mandible and along the base of the zygomatic buttress — reproduce the ear pain or activate the tinnitus? With jaws separated 3 cm, also palpate through the mandibular notch toward the condylar neck.",
     "exam_type": "palpation",
     "landmark": "Deep masseter TrP: with jaws slightly open, palpate along the posterior ramus of the mandible from the angle upward to the zygomatic buttress with firm flat pressure. For the upper posterior TrP specifically: press anterior to the tragus at the level of the TMJ, pressing medially — this is the tinnitus TrP. Tinnitus provocation test: sustained pressure on the upper posterior TrP may activate or reproduce the ipsilateral tinnitus, confirming deep masseter involvement.",
     "positive_finding": "Reproduces deep ear pain, TMJ area pain, or activates/reproduces the tinnitus",
     "muscles_implicated": ["Masseter (Deep Layer)"],
     "yes": "result-masseter-deep",
     "no": "exam-lateral-pterygoid-1"
   },

   "exam-lateral-pterygoid-1": {
     "type": "examination",
     "question": "Ask the patient to protrude the jaw forward against resistance applied at the chin — is this painful? And does placing a tongue blade between the molar teeth on the painful side eliminate pain on vigorous clenching?",
     "exam_type": "provocation",
     "landmark": "Resisted protrusion test: patient seated, examiner applies firm resistance at the chin while the patient protrudes — pain on resisted protrusion is specific to lateral pterygoid TrPs (0% of asymptomatic controls find this painful). Tongue blade test: insert a tongue blade between the molar teeth on the painful side and ask the patient to clench vigorously — elimination of pain strongly implicates the inferior division of the lateral pterygoid on that side.",
     "positive_finding": "Pain on resisted jaw protrusion AND/OR pain eliminated by tongue blade interposition on clenching",
     "muscles_implicated": ["Lateral Pterygoid"],
     "clinical_note": "Intraoral palpation alone has a 27.6% false positive rate in asymptomatic subjects — always use resisted protrusion as the confirmatory test.",
     "yes": "result-lateral-pterygoid",
     "no": "exam-medial-1"
   },

   "exam-medial-1": {
     "type": "examination",
     "question": "Does intraoral palpation of the medial pterygoid — gloved finger behind the last molar, pressing posteriorly against the belly of the muscle on the medial surface of the ramus — reproduce the ear pain, throat pain, or ear stuffiness? Confirm by asking the patient to alternately clench and relax against a block — tissue tension changes should identify the muscle.",
     "exam_type": "palpation",
     "landmark": "Intraoral central TrP: patient supine, jaw drops open as far as comfortable. Gloved index finger pad facing outward, slides over the molar teeth to the bony anterior edge of the ramus. The belly of the medial pterygoid lies immediately posterior to this edge. Palpate for taut bands and exquisite spot tenderness. Gag reflex management: ask patient to exhale fully, or tap the ipsilateral temporalis as sensory distraction. Extraoral attachment TrP: press upward at the angle of the mandible along its inner medial surface.",
     "positive_finding": "Exquisite tenderness with referral to throat, palate, ear, or jaw. Ear stuffiness (barohypoacusis) present.",
     "muscles_implicated": ["Medial Pterygoid"],
     "yes": "result-medial-pterygoid",
     "no": "result-overlap"
   },

   "exam-scm-1": {
     "type": "examination",
     "question": "Does pincer palpation of the SCM — encircling the full muscle belly between thumb and forefinger from mastoid to sternum — reproduce the patient's familiar ear pain or associated symptoms? Note which head is more reactive: sternal (facial/autonomic) versus clavicular (dizziness/frontal headache).",
     "exam_type": "palpation",
     "landmark": "Sternal head: pincer palpation with the full muscle belly between thumb and forefinger from the mastoid process downward to the sternal attachment. Clavicular head: lies deep and posterior to the sternal head — flat palpation from the medial clavicle upward toward the mastoid. SCM Compression Test: grasp the SCM in a firm pincer grip and ask the patient to swallow — positive if pharyngeal pain resolves with compression (pathognomonic of sternal division central TrP).",
     "positive_finding": "Reproduces deep ear pain, facial pain, dizziness, or frontal headache. SCM Compression Test may relieve concurrent sore throat.",
     "muscles_implicated": ["SCM (Clavicular division)", "SCM (Sternal division)"],
     "yes": "result-scm",
     "no": "symptom-rest-1"
   },

   "symptom-rest-1": {
     "type": "choice",
     "question": "In the absence of clear jaw or neck aggravation, which feature best describes the ear or jaw symptoms?",
     "clinical_rationale": "Rest pain or ear symptoms without mechanical aggravation can still be myofascial — SCM deep head tinnitus, deep masseter tinnitus at rest, or medial pterygoid ear stuffiness at rest. However, this presentation also warrants consideration of non-myofascial ear pathology. This node guides to examination rather than result.",
     "options": [
       {
         "label": "Tinnitus — ear ringing or roaring at rest",
         "sublabel": "Continuous or intermittent ear noise; not clearly triggered by jaw or neck movement",
         "next": "exam-masseter-deep-1"
       },
       {
         "label": "Ear fullness or muffled hearing without infection signs",
         "sublabel": "Sensation of blocked ear; may feel like pressure equalisation failure",
         "next": "exam-medial-1"
       },
       {
         "label": "Diffuse jaw or preauricular ache with no clear trigger",
         "sublabel": "Constant background ache in the jaw angle or in front of the ear",
         "next": "exam-scm-1"
       }
     ]
   },

   "result-masseter-deep": {
     "type": "result",
     "diagnosis": "Masseter — Deep Layer Trigger Point",
     "confidence": "high",
     "wiki_page": "Muscle:Masseter",
     "chapter_ref": "Travell & Simons Vol.1 — Ch.8 Masseter",
     "notes": "Deep layer TrPs refer pain deep into the ear, to the TMJ region, and to the diffuse midcheek. The upper posterior TrP is the tinnitus TrP — it produces a low roaring unilateral tinnitus that may be activated or interrupted by wide jaw opening. Tinnitus is not associated with hearing loss or vertigo, distinguishing it from vestibular or neurological causes. Active TrPs in the deep layer can closely mimic the pain of TMJ rheumatic disease — the joint itself is non-tender on palpation. Infraorbital puffiness and narrowing of the palpebral fissure on the affected side may result from venous entrapment of the maxillary vein by deep masseter taut bands.",
     "treatment_hint": "External flat palpation against the posterior ramus and zygomatic buttress. Spray and stretch with contralateral lateral excursion and jaw opening. Deep pressure release. Address SCM and upper trapezius as key TrPs first — masseter TrPs are frequently satellites. Tinnitus provocation test confirms involvement.",
     "also_consider": ["Lateral Pterygoid", "Medial Pterygoid", "SCM Sternal Division"],
     "less_likely": [
       { "muscle": "Lateral Pterygoid", "reason": "Tinnitus pattern and ear pain reproduced at deep masseter — no resisted protrusion pain identified" },
       { "muscle": "Medial Pterygoid", "reason": "No ear stuffiness or throat referral identified; tinnitus is the cardinal feature here" },
       { "muscle": "SCM Clavicular", "reason": "Jaw movement is the primary aggravator, not neck posture or rotation" }
     ],
     "confirmatory": [
       "Tinnitus provocation test positive — sustained pressure on upper posterior deep TrP activates or reproduces ipsilateral tinnitus",
       "Tinnitus is low roaring quality — not associated with hearing loss or vertigo (distinguishes from vestibular cause; bilateral tinnitus suggests systemic cause)",
       "Tinnitus may be activated or interrupted by stretching the jaw wide open — a pathognomonic feature",
       "Infraorbital puffiness and palpebral fissure narrowing on affected side — venous entrapment of maxillary vein",
       "Joint palpation negative — TMJ itself is non-tender; periarticular tenderness is from referred TrP pain, not joint inflammation"
     ],
     "satellite_trps": ["Temporalis", "Medial Pterygoid", "SCM", "Upper Trapezius"],
     "landing_page_topics": [
       "Tinnitus mechanism — stapedius and tensor tympani motor unit activity",
       "Deep vs superficial layer — palpation technique distinction",
       "Venous entrapment — infraorbital puffiness mechanism",
       "Bilateral tinnitus — systemic vs myofascial considerations",
       "Drug-induced tinnitus exclusion (salicylates — bilateral, dose-dependent)"
     ],
     "related_pages": [
       { "label": "Lateral Pterygoid TrP →", "page": "Muscle:Lateral_Pterygoid" },
       { "label": "TMJ Screening →", "page": "Pain:TMJ_Screening_Examination" }
     ]
   },

   "result-lateral-pterygoid": {
     "type": "result",
     "diagnosis": "Lateral Pterygoid Trigger Point",
     "confidence": "high",
     "wiki_page": "Muscle:Lateral_Pterygoid",
     "chapter_ref": "Travell & Simons Vol.1 — Ch.11 Lateral Pterygoid",
     "notes": "The lateral pterygoid is the chief myofascial source of referred pain felt in the TMJ area. Inferior division TrPs displace the mandibular condyle anteriorly, producing premature anterior tooth contact on the opposite side and altered posterior occlusion on the same side — pain is worst on jaw closing to this displaced position. Clicking in the TMJ may result from lateral pterygoid dysfunction. Severe pain to the maxillary sinus region (described as sinusitis) with autonomic secretion is a characteristic pattern. Pain is NOT referred to the teeth — this distinguishes lateral pterygoid from masseter and temporalis.",
     "treatment_hint": "Treat masseter and temporalis TrPs first — they may be preventing adequate mouth opening for examination. Spray and stretch over the TMJ region during jaw opening and lateral excursion. Intraoral ischemic compression via the intraoral approach. Address forward head posture and parafunctional habits. Consider vitamin B1, B6, B12, and folic acid if recalcitrant.",
     "also_consider": ["Masseter (Deep)", "Medial Pterygoid", "SCM"],
     "less_likely": [
       { "muscle": "Masseter Deep", "reason": "Resisted protrusion pain and tongue blade test are specific to lateral pterygoid — masseter does not produce this pattern" },
       { "muscle": "Medial Pterygoid", "reason": "Closing/clenching aggravation and condylar displacement argue for lateral pterygoid; medial pterygoid is worsened by wide opening" },
       { "muscle": "SCM Clavicular", "reason": "Jaw movement is the primary aggravator; no dizziness or postural component" }
     ],
     "confirmatory": [
       "Resisted jaw protrusion pain — 0% of asymptomatic controls find this painful; highly specific for lateral pterygoid TrPs",
       "Tongue blade test: blade between molars on painful side eliminates pain on clenching — strongly implicates inferior division on that side",
       "Tongue-tip-to-palate test: incisal path straightens when tongue tip is slid to the posterior hard palate — confirms lateral pterygoid as chief cause of muscular imbalance",
       "Lateral excursion reduced toward the SAME side as the involved muscle",
       "Pain NOT referred to the teeth — distinguishes from masseter and temporalis",
       "Buccal nerve entrapment: weird tingling or numbness of the cheek + buccinator weakness indicates lateral pterygoid compressing the buccal nerve",
       "CAUTION: 27.6% of asymptomatic individuals are tender to intraoral palpation alone — always use resisted protrusion as the confirmatory test"
     ],
     "satellite_trps": ["Medial Pterygoid", "Masseter (Deep)", "Temporalis (posterior fibres)", "Contralateral lateral pterygoid"],
     "landing_page_topics": [
       "Tongue position test — full technique and interpretation",
       "Tongue blade test — inferior division confirmation",
       "Condylar displacement and occlusal changes",
       "Buccal nerve entrapment — cheek tingling and buccinator weakness",
       "Intraoral palpation technique and false positive rate (27.6%)"
     ],
     "related_pages": [
       { "label": "Medial Pterygoid TrP →", "page": "Muscle:Medial_Pterygoid" },
       { "label": "Masseter TrP →", "page": "Muscle:Masseter" },
       { "label": "TMJ Screening →", "page": "Pain:TMJ_Screening_Examination" }
     ]
   },

   "result-medial-pterygoid": {
     "type": "result",
     "diagnosis": "Medial Pterygoid Trigger Point",
     "confidence": "high",
     "wiki_page": "Muscle:Medial_Pterygoid",
     "chapter_ref": "Travell & Simons Vol.1 — Ch.9 Medial Pterygoid",
     "notes": "Medial pterygoid TrPs refer diffusely to the tongue, pharynx, hard palate, below and behind the TMJ, and deep into the ear. Pain is NOT referred to the teeth — distinguishes from masseter and temporalis. Barohypoacusis (ear stuffiness, inability to equalise pressure) is characteristic — tense TrP bands block the tensor veli palatini from opening the eustachian tube. The characteristic swallowing compensation is pathognomonic: patient extends the neck and pushes the tongue forward when swallowing. Bitter metallic taste may indicate chorda tympani entrapment between the medial pterygoid and the mandible.",
     "treatment_hint": "Intraoral ischemic compression and resisted jaw opening (reciprocal inhibition technique). Intraoral spray and stretch during jaw opening. Treat lateral pterygoid and masseter concurrently — medial pterygoid rarely occurs in isolation. Gag reflex management: full exhale, tap ipsilateral temporalis, tongue backward-and-down on opposite side.",
     "also_consider": ["Lateral Pterygoid", "Masseter", "SCM", "Digastric"],
     "less_likely": [
       { "muscle": "Lateral Pterygoid", "reason": "Ear stuffiness and throat/palate referral are specific to medial pterygoid; lateral pterygoid does not produce barohypoacusis" },
       { "muscle": "Masseter Deep", "reason": "No tinnitus; ear stuffiness and throat pain argue strongly for medial pterygoid" },
       { "muscle": "SCM Clavicular", "reason": "Jaw movement worsens the pain; no dizziness or postural component" }
     ],
     "confirmatory": [
       "Ear stuffiness (barohypoacusis) on the same side — inability to equalise ear pressure; specific to medial pterygoid blocking eustachian tube opening",
       "Compensatory swallowing pattern: patient extends neck and pushes tongue forward when swallowing — pathognomonic",
       "Pain NOT referred to teeth — distinguishes from masseter and temporalis",
       "Chorda tympani entrapment: extremely bitter metallic taste — lingual nerve compressed between medial pterygoid and mandible",
       "Mandibular deviation most marked toward the contralateral side at maximum opening",
       "Jaw opening restricted — less than 36 mm in many active cases; soft end feel distinguishes from articular restriction"
     ],
     "satellite_trps": ["Lateral Pterygoid", "Masseter", "Temporalis", "Digastric"],
     "landing_page_topics": [
       "Intraoral palpation technique and gag reflex management",
       "Barohypoacusis — eustachian tube mechanism",
       "Chorda tympani entrapment — metallic taste",
       "Compensatory swallowing pattern",
       "Resisted jaw opening technique for reciprocal inhibition"
     ],
     "related_pages": [
       { "label": "Lateral Pterygoid TrP →", "page": "Muscle:Lateral_Pterygoid" },
       { "label": "TMJ Screening →", "page": "Pain:TMJ_Screening_Examination" }
     ]
   },

   "result-scm": {
     "type": "result",
     "diagnosis": "SCM Trigger Point — Clavicular or Sternal Division",
     "confidence": "high",
     "wiki_page": "Muscle:Sternocleidomastoid",
     "chapter_ref": "Travell & Simons Vol.1 — Ch.7 Sternocleidomastoid",
     "division": "both",
     "notes": "The clavicular division refers deep ear pain and produces postural dizziness — the patient veers toward the TrP side on straight-line walking without nystagmus (non-vestibular). The sternal division refers to the cheek, orbit, occiput, and vertex, with autonomic phenomena (tearing, rhinitis, palpebral fissure narrowing). Soreness from SCM TrPs may be misattributed to lymphadenopathy. Either division can contribute to ear symptoms — note which head is more reactive as this determines the dominant clinical picture.",
     "treatment_hint": "Spray and stretch superior to inferior. Ischemic compression. Correct forward head posture — the single most important perpetuating factor. Treating SCM often resolves satellite TrPs in the masticatory muscles and face without direct treatment of those muscles.",
     "also_consider": ["Scalene muscles", "Splenius cervicis", "Levator scapulae"],
     "less_likely": [
       { "muscle": "Masseter Deep", "reason": "Neck posture is the primary aggravator, not jaw movement; no jaw-movement-specific tinnitus" },
       { "muscle": "Medial Pterygoid", "reason": "No jaw movement aggravation; no ear stuffiness or throat referral from neck posture" },
       { "muscle": "Lateral Pterygoid", "reason": "No jaw movement as primary aggravator; no resisted protrusion pain" }
     ],
     "confirmatory": [
       "SCM Compression Test positive — pharyngeal pain on swallowing resolves when the sternal head is firmly gripped (sternal division)",
       "Straight-line walking test: patient veers toward the side of the active clavicular TrP while walking toward a fixed point — confirms clavicular division",
       "Romberg's sign NEGATIVE — distinguishes from vestibular pathology; nystagmus absent",
       "Apparent ptosis (palpebral fissure narrowing) WITHOUT miosis — exclude true Horner syndrome by confirming normal pupillary reactivity",
       "Autonomic phenomena ipsilateral: tearing, rhinitis, conjunctival redness (sternal division)",
       "Dry tingling cough triggered by palpation near the sternal attachment — cough TrP"
     ],
     "satellite_trps": ["Scalene muscles", "Sternalis", "Masseter", "Temporalis", "Orbicularis oculi", "Frontalis"],
     "landing_page_topics": [
       "Sternal vs clavicular division — full symptom profiles and examination technique",
       "Dizziness differentiation — vestibular vs non-vestibular: Romberg, nystagmus, straight-line walk",
       "Hearing restoration manoeuvre — rotate head toward affected side and tilt chin down",
       "Horner syndrome exclusion protocol",
       "CN XI entrapment and trapezius weakness monitoring",
       "Forward head posture correction — axial extension exercise",
       "Sleep posture, workstation setup, and driving advice"
     ],
     "related_pages": [
       { "label": "Scalene TrPs →", "page": "Muscle:Scalene" },
       { "label": "Masseter TrP →", "page": "Muscle:Masseter" }
     ]
   },

   "result-overlap": {
     "type": "overlap",
     "text": "Findings are inconclusive or atypical. Multi-muscle involvement is likely. Perform a systematic full palpation screen of all four muscles, addressing the most frequently implicated first.",
     "screen_these": [
       "Lateral pterygoid — resisted protrusion test; tongue blade test; tongue-tip-to-palate test; intraoral palpation (treat masseter first if restricted opening prevents access)",
       "Masseter deep — flat palpation against posterior ramus and zygomatic buttress; tinnitus provocation test with pressure anterior to tragus",
       "SCM — pincer palpation full length, both heads; SCM Compression Test; straight-line walking test if dizziness present",
       "Medial pterygoid — intraoral palpation behind the last molar; clench-relax confirmation test; assess for ear stuffiness and compensatory swallowing"
     ],
     "wiki_page": "Differential:Ear_TMJ"
   },

   "refer-tmj-acute": {
     "type": "neuro_referral",
     "urgency": "urgent",
     "title": "Acute TMJ Inflammation — Refer Before Myofascial Treatment",
     "body": "Acute capsulitis or synovitis of the TMJ is present. This is a contraindication to masticatory muscle stretching until the acute inflammation resolves. The pain from a hot joint will restrict any masticatory muscle stretching and TrPs will recur secondary to the central excitatory effects from the nociceptive source. Palliative care must be instituted first. Basic myofascial TrP strategies (posture correction, cervical stretching, elimination of oral habits) may be started in parallel.",
     "action": "Refer to a dentist trained in orofacial pain and TM disorders. Palliative care: soft diet, eliminate abusive oral habits, 7–10 days anti-inflammatory medication, cold pack over joint 10 minutes on/off 2–3 times per day. Return for myofascial assessment once acute symptoms subside."
   },

   "refer-tmj-specialist": {
     "type": "neuro_referral",
     "urgency": "urgent",
     "title": "Possible Articular TMJ Pathology — Specialist Assessment Required",
     "body": "Significantly restricted jaw opening with a hard end feel and deflection to one side that does not respond to spray and stretch or passive mobilisation may indicate TMJ ankylosis or anteriorly displaced disc without reduction. Basic myofascial TrP pain management strategies — good posture, body mechanics, cervical stretching — may be started while awaiting specialist review.",
     "action": "Refer to a dentist specialising in orofacial pain and temporomandibular disorders for imaging and specialist assessment. Do not attempt forcible jaw opening."
   }

 },

 "broad_differential": [
   {
     "id": "bd-1",
     "condition": "Ménière's Disease",
     "confidence": "uncommon",
     "mimics": "Episodic deep ear fullness, tinnitus, and dizziness — overlaps strongly with SCM clavicular and masseter deep head patterns",
     "distinguishing_feature": "Triad of fluctuating unilateral sensorineural hearing loss, episodic rotational vertigo (minutes to hours), and low-frequency tinnitus. Nystagmus during attacks. Romberg positive. Myofascial tinnitus is unilateral low roaring without hearing loss or vertigo.",
     "action": "Refer to ENT or audiovestibular medicine. Audiometry and caloric testing required."
   },
   {
     "id": "bd-2",
     "condition": "Ramsay Hunt Syndrome",
     "confidence": "rare",
     "mimics": "Deep ear pain indistinguishable from SCM clavicular referral at onset",
     "distinguishing_feature": "Vesicular eruption in the ear canal or on the pinna — may appear days after onset of pain. Facial nerve palsy may follow. Antiviral window is 72 hours.",
     "action": "Examine the ear canal at every visit in any patient with new ear pain. If vesicles present refer urgently."
   },
   {
     "id": "bd-3",
     "condition": "Eagle Syndrome",
     "confidence": "rare",
     "mimics": "Throat, ear, and TMJ pain overlapping with medial pterygoid and posterior digastric patterns",
     "distinguishing_feature": "Pain provoked by turning the head or swallowing. Elongated styloid process may be palpable in the tonsillar fossa on intraoral examination.",
     "action": "Panoramic radiograph to assess styloid length. Refer to oral/maxillofacial surgery."
   },
   {
     "id": "bd-4",
     "condition": "Glossopharyngeal Neuralgia",
     "confidence": "rare",
     "mimics": "Severe episodic ear and throat pain overlapping with SCM and medial pterygoid referral",
     "distinguishing_feature": "Lancinating, electric shock quality — seconds to minutes duration. Triggered by swallowing, talking, or yawning. Ceases completely between attacks.",
     "action": "Refer to neurology. Carbamazepine is first-line."
   },
   {
     "id": "bd-5",
     "condition": "TMJ Internal Derangement (disc displacement with reduction)",
     "confidence": "common",
     "mimics": "Lateral pterygoid TrP presentation — clicking, restricted opening, jaw deviation",
     "distinguishing_feature": "Reciprocal click on opening and closing (loud opening click, softer closing click) at consistent positions in the range of motion. Tongue-tip-to-palate test: if the incisal path STILL zigzags after tongue positioning, articular derangement is contributing alongside or instead of lateral pterygoid TrPs. Painful clicking or increasing locking frequency requires specialist evaluation.",
     "action": "Myofascial TrPs and disc derangement commonly coexist. Treat TrPs first. Refer to orofacial pain specialist if clicking is painful or locking is frequent."
   },
   {
     "id": "bd-6",
     "condition": "Sialolithiasis (Parotid duct calculus)",
     "confidence": "uncommon",
     "mimics": "Pre-auricular and TMJ area pain resembling masseter deep head TrP",
     "distinguishing_feature": "Pain peaks predictably during or before meals. Visible or palpable parotid swelling that partially resolves after eating. Stensen's duct palpable.",
     "action": "Palpate parotid duct. Ultrasound first-line. Refer to oral surgery."
   },
   {
     "id": "bd-7",
     "condition": "Temporal Arteritis (Giant Cell Arteritis)",
     "confidence": "uncommon — critical in over-50s",
     "mimics": "Jaw pain and temporal headache from masseter and temporalis TrPs",
     "distinguishing_feature": "Jaw claudication — pain that builds with chewing and eases with rest — is pathognomonic. Age >50; non-pulsatile tender temporal artery; ESR typically >50 mm/hr, often >100.",
     "action": "Same-day GP referral + ESR and CRP in any patient over 50 with jaw pain and chewing aggravation. Do not delay."
   },
   {
     "id": "bd-8",
     "condition": "Trigeminal Neuralgia (Tic Douloureux)",
     "confidence": "rare",
     "mimics": "Facial and jaw pain overlapping with masseter, temporalis, and SCM sternal patterns",
     "distinguishing_feature": "Lancinating, electric shock quality with characteristic facial grimace. Trigger zones on face. Ceases completely between attacks. Consciousness unimpaired.",
     "action": "Refer to neurology. MRI to exclude vascular compression. Carbamazepine first-line."
   },
   {
     "id": "bd-9",
     "condition": "Spasmodic Torticollis",
     "confidence": "uncommon",
     "mimics": "Neck pain and abnormal head posture resembling SCM TrP-driven posture",
     "distinguishing_feature": "Involuntary head rotation inhibited by gentle jaw pressure ipsilateral to the rotation direction (geste antagoniste). Dystonic movement ceases completely during sleep — distinguishes from myofascial TrP-driven posture which does not cease in sleep.",
     "action": "Refer to neurology. Botulinum toxin injection is first-line treatment."
   },
   {
     "id": "bd-10",
     "condition": "Myofascial Pain Mimicking TMJ Disorder — Persisting After TMJ Treatment",
     "confidence": "common",
     "mimics": "Residual or persistent jaw and ear pain after TMJ anti-inflammatory treatment — clinician may continue treating the joint",
     "distinguishing_feature": "After acute TMJ inflammation resolves, persistent pain is commonly from myofascial TrPs (masseter, pterygoids, SCM) which developed during the period of joint-related reflex muscle splinting. The key clinical indicator: pain is no longer over the joint but is inferior and anterior — over the muscle belly. Range of motion has improved but TrP palpation reproduces the current symptoms.",
     "action": "Re-examine muscles systematically after joint inflammation resolves. Do not continue treating the joint when TrPs are the active pain source."
   }
 ]

}