M2 ANATOMY

You are a second-year Family Medicine resident, seeing a 39-year-old small business owner concerned with aching pain around her left ear, temple, eye, and jaw. She feels fullness in her left ear, general sinus pain on the left side of her face, intermittent tinnitus, and frequent headaches. With the feelings of sinus pain, she has tried using decongestants and did not see any improvement of her symptoms. Her pain is constant but changes in intensity throughout the day with the most intense pain in the morning. Her pain has been bothering her for over a year, but has become more intense on average with recent economic difficulties. On her medical history, you note that she had her upper and lower 3rd molars extracted 15 years ago without complication. Her current medications include fluoxetine and bupropion to manage depression. She is physically active and does not drink or smoke.

Physical examination reveals some facial asymmetry in the area of the ramus of the mandible on the left, and in palpation a distinct fullness on this side is noted. Her facial sensation on the forehead, cheek, and chin is normal and equal on both sides. When you ask her to close her eyes tightly, her closed eyes appear symmetrical. Her otologic examination is normal. When she opens and closes her mouth for the exam, you palpate and hear crepitis (clicking) of the temporomandibular joint. Her palate and oral cavity appear healthy, except for some wearing of the teeth especially the left premolars and molars. You measure her temporomandibular joint range of motion as 20 mm (normal is 35-55 mm). You place a cotton ball between the maxillary and mandibular canines, on first the right and then left side sequentially, and she bites down. She notes pain more in the left TMJ when biting the cotton ball on the right side.

While you normally would not order imaging for her condition, she had asked her dentist to share a recent panoramic radiograph. In review of the radiograph, her teeth appear normal with no evidence of dental abscesses, caries, or periodontal bone loss. Her maxilla and mandible are clear of tumors. The TMJs bilaterally are not clearly demonstrated on the radiograph. However, based on your physical exam and these findings, you feel confident in a differential diagnosis. You speak with the patient about taking steps to improve her sleep hygiene, posture, and habits including stress reduction. In addition, you recommend that she speaks to her dentist about an occlusal splint. In the short term, you suggest NSAIDs to help with the pain.