A 32-year-old man comes to the office due to right ear pain for the past month. The pain often awakens the patient and increases in severity when he chews food. He does not have ear discharge, dizziness, sinus tenderness, or rash. Medical history is significant for generalized anxiety disorder, for which he takes sertraline. The patient does not use tobacco or alcohol. Vital signs are within normal limits. On examination, the ears are normal with a small amount of wax. Mobility of the tympanic membrane is normal, and results of the Weber and Rinne tests are normal. There are no lesions in the oral cavity, the tonsils are normal, and the teeth appear worn and smooth with no evidence of dental cavities or periodontal disease. Which of the following is the most likely diagnosis?

Question

A 32-year-old man comes to the office due to right ear pain for the past month.  The pain often awakens the patient and increases in severity when he chews food.  He does not have ear discharge, dizziness, sinus tenderness, or rash.  Medical history is significant for generalized anxiety disorder, for which he takes sertraline.  The patient does not use tobacco or alcohol.  Vital signs are within normal limits.  On examination, the ears are normal with a small amount of wax.  Mobility of the tympanic membrane is normal, and results of the Weber and Rinne tests are normal.  There are no lesions in the oral cavity, the tonsils are normal, and the teeth appear worn and smooth with no evidence of dental cavities or periodontal disease.  Which of the following is the most likely diagnosis?

Quizplus · Accepted Answer

11ec25c8_d399_c692_bc81_7d53168301ec_MD0003_00 This patient with otalgia during chewing, signs of bruxism (worn and smooth teeth), and a normal ear examination likely has temporomandibular joint disorder (TMD). Otalgia in the setting of a normal ear examination is likely referred pain (pain perceived at a different site than its true origin). The most common causes of referred otalgia are dental disease and TMD. Although the most recognizable symptoms of TMD are pain exacerbated by jaw motion and tenderness of the temporomandibular joint, headache, neck stiffness, and ear pain are quite common. Nocturnal teeth grinding (bruxism) can occur but may go unnoticed; it should be suspected if teeth are worn. Patients with psychiatric illnesses may be at increased risk. The diagnosis of TMD is typically clinical. Palpation of the temporomandibular joint during jaw opening and closing often elicits pain, crepitus, and/or audible clicks, but sensitivity can be low. Initial management should consist of education, a soft diet, warm compresses, and avoidance of triggers. Referral for dental treatment and a nighttime bite guard are often recommended if bruxism is a contributing factor. Nonsteroidal anti-inflammatory drugs are the first-line medication. Muscle relaxants (eg, cyclobenzaprine) can be added for patients with associated muscle spasm. (Choice A) Eustachian tube dysfunction may present with ear pain accompanied by popping sounds. However, it typically results in hearing loss and changes to the tympanic membrane (eg, retraction, middle ear effusion). (Choice B) Giant cell arteritis can present with pain while chewing (ie, jaw claudication), but patients generally report pain in the jaw rather than referred otalgia. In addition, it very rarely occurs in patients age <50. (Choice C) Glossopharyngeal neuralgia presents with intermittent, severe, stabbing pain in areas innervated by the glossopharyngeal and vagus nerves (CN IX and CN X), which include the ear. However, this patient's history of worsening pain with chewing and likely nocturnal bruxism makes TMD more likely. (Choice D) Referred otalgia can be the presenting symptom of mucosal head and neck squamous cell carcinoma, but it is much less likely in this young patient with no other suggestive signs (eg, neck mass) or risk factors (eg, smoking). Educational objective: Temporomandibular joint disorder can result in referred pain to the ear that is worse with chewing. Patients typically have a history of nocturnal teeth grinding. References: Diagnosis and treatment of temporomandibular disorders. (http://www.ncbi.nlm.nih.gov/pubmed/25822556)

A 32-Year-Old Man Comes to the Office Due to Right