Head and neck pain, part 2

Chapter 14 Head and neck pain, part 2



Case 14.1



1. Using only this information, list possible causes of Fatima’s presenting symptom(s). Justify your answer.
























Possible cause Justification
DDx 1: post treatment reactive spasm of jaw muscles
• Pain is localised

• Prolonged opening posture during dental treatment
DDx 2: post treatment temporomandibular joint (TMJ) sprain
• Prolonged opening posture during dental treatment

• pain is localised
DDx 3: pain referral from an incompletely denervated tooth
• History of preceding dental treatment
DDx 4: bruxism muscle fatigue
• Yellow flags noted from past history, previous episodes
DDx 5: infection of gum or other head and/or neck structure
• Invasive dental work on same side

• Latency of onset
DDx 6: post treatment neuralgia
• Injections (often multiple) into mandibular soft tissues

2. Why was Fatima asked about:
a previous episodes

A history of pain in the area may indicate a chronic relationship to stress, clenching and grinding. It may also highlight a relationship to previous dental procedures (below), or a degenerative condition of the TMJ.


b previous dental procedures

Muscle reaction to prolonged extreme mouth opening or tooth contact changes; alveolar cavitational osteopathosis (which can present as an unusual or acute manifestation of a chronic pain condition from previous extractions or infections) are reasonable grounds for questioning.


c other health complaints

Headaches and migraines have been documented to occasionally involve the TMJ region, as have the inflammatory effects of upper respiratory tract infections such as middle ear infection or sinusitis. Anxiety and stress can also play a major role in the pathogenesis of TMJ pain as a precursor or perpetuating factor.


3. What do you need to examine in this patient?





















Examination Justification
Intra-oral exam
• Observe for swellings, signs of infection, ulcers etc

• Assess odour

• Tooth quality

• Signs of bruxism

• Palpate muscles

• Sensory tests
Palpation of masticatory muscles
• Check for tenderness or spasm
Jaw range of motion exam
• TMJ or muscle condition may restrict normal range
Take temperature
• A febrile state suggests infection (respiratory, dental)
Conjunctiva, pulse, breathing
• Assess for anaemia

4. What information can you obtain from these findings? Can you narrow your differential diagnosis?

Most significant and of particular interest is the abscess along the mesial edge of the coronoid process. The pallor of gums and conjunctiva suggest anaemia, possibly related to thalassemia, though it is unlikely to be relevant to the symptoms in this case. The most likely diagnosis is DDx 1, although DDx 4 is probably a strong underlying factor.


5. Explain the significance of the following signs, in context of your differential diagnosis:
a abscess of the coronoid process

Extreme mandibular excursion to the right during bruxism has probably caused an impact of the 3rd maxillary molar into the coronoid process, traumatising the insertions of the temporalis tendon and medial pterygoid. It is possible however, that such an abscess was the result of iatrogenesis (a lesion by an instrument during dental work). The history of previous episodes tends to support the former.


b pallor of gums and conjunctiva

While mild forms of thalassaemia may display signs of anaemia, it is usually mild. There may be some increased susceptibility to infection and prolonged healing, but otherwise symptoms such as those reported by the patient do not necessarily indicate a result of thalassaemia.


c jaw range of motion findings

Interincisal opening range restriction usually suggests either muscle spasm or TMJ sprain. The lack of clicking and the end-feel quality support the likelihood of a muscular condition particularly in light of the abscess. The jaw will usually deviate toward the more restricted side, which may be represented by the muscles in spasm. The clenching pain that could not be localised to a particular tooth or cusp suggests pain not related to a tooth condition.


6. Fatima is referred to a medical practitioner and a dentist. What investigations are required? Why? What would you expect, based on the physical examination findings?

















Investigation Justification Expectations based on differential diagnosis
Orthopantograph (OPG) •To observe TMJs, alveolar bone condition and tooth roots •Possible asymmetry of TMJ positions, condylar changes
Full blood count •To confirm a heterozygous ß thalassemia minor •Microcytic, hypochromic morphology
•Decreased Hb, normal or slightly decreased indices

7. What is the most likely diagnosis based on these results?

Acute strain of mandibular elevators predisposed by a chronic history of bruxism.


8. Explain the significance of each of the following investigation results, in context of your differential diagnosis:
a crowding of 2nd and 3rd molars

Crowding is more common in retrognathic profiles and can be associated with a greater incidence of impaction of teeth and subsequent damage to enamel and dentine structures. They can also contribute to inflammatory conditions of the gingiva, resulting in activation reflexes into the trigeminal system that may alter normal resting tone and responsiveness of masticatory muscles.


b blood test results

Blood test results indicative of thalassaemia show a decreased haemoglobin, small cell size and normal or slightly lowered indices (MCV, MCH, MCHC). The RCC tends to be normal since the marrow can still produce cells but cannot fill them with sufficient haemoglobin. Hence the cells occupy less space (lowering the Hct/PCV relative to the erythrocyte count). While thalassaemia minor is often considered to have no symptomatic effects, in some individuals with an anaemic tendency there may be secondary signs such as a weakened immune response, chronic fatigue and poorer coping with stress. In a patient with bruxism (and a strong history of yellow flags), the anaemia can magnify an existing health problem.


c symmetry of TMJs

Symmetrical and normal TMJs tend to imply that if the patient is diagnosed with a TMD (temporomandibular disorder), it is most likely to be a myogenous form. TMDs that involve disc displacement or arthrogenous elements tend to show asymmetric displacement of condylar heads along their respective articular eminences and more chronic ones may show flattening of the condylar heads or even osteophytic lipping of the head. In cases where clicking sounds or joint locking occur, MRI studies will more clearly show the extent of articular involvement, but such an examination would be unjustified in this case.


9. Are any further investigations required?

This patient may benefit from psychological counselling, which might be considered useful in the long-term management of her condition. Additionally, the long-term use of antidepressants may be associated with some of the symptomatic findings reported in the general health section of her history (malaise, paraesthesias, fatigue, stomach upsets and dizzy spells). Reviewing and adjusting her medication may be of additional value. While the patient did not report any signs of urinary tract infection, a urine analysis may be necessary if she develops fever, nausea, dysuria or frequency of urination.



Case 14.2



1. Using only this information, list the possible primary and secondary causes of Helen’s headaches. Justify your answer.



















Primary differential diagnosis Supporting factors in history
DDx 1: chronic sinusitis
• Duration of sinus related symptoms > 8 weeks

• Nasal congestion and frequent purulent secretions, post nasal drip, night cough

• Exposure to cigarette smoke

• Pain over frontal and maxillary sinuses

• Allergies
DDx 2: headache of rhinogenic origin — ‘sinus’ headache
• Bilateral, dull, achy, pressure-like pain

• Location of pain over frontal and maxillary sinuses

• Association with allergies

• No history of trauma

• Related symptoms of itchy ears, stuffy nose, post nasal drip, night cough, nasal congestion, purulent nasal secretions, sneezing

• Increase in pain with forward flexion

• Exposure to cigarette smoke
DDx 3: migraine headache
• Recurring

• Gender (more common in females)

• Aggravated by activity

• Moderate intensity
DDx 4: tension headache
• Pain in upper part of neck

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Dec 26, 2016 | Posted by in MANUAL THERAPIST | Comments Off on Head and neck pain, part 2

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