Chapter 14 Head and neck pain, part 2

Case 14.1

History

Fatima is a 22-year-old homemaker and mother of two children under the age of 5. She immigrated as a refugee with her husband 3 years ago from a war torn country. She has a history of anxiety and depression, suffers from occasional headaches, palpitations and stomach upsets — all attributed by her doctor to the effects of stress. She has been taking antidepressants and stomach antacids continuously for the last 2 years.

Her dentist has referred her to you requesting some physical therapy of her painful right-sided jaw muscles, which he felt was due do a reactive spasm following root canal therapy of her 2nd right mandibular molar. Her history revealed that several days after the dental treatment she began to complain of constant jaw pain on the same side. Dental history also revealed that she had her 2nd left molar crowned 2 months before. She reported previous episodes of varying intensity and duration over the last 2 years. She states that this episode appears to be worse in the morning. Biting down or clenching makes the pain worse, while a warm pack applied to the side of her jaw seems to relieve her symptoms. She reports a long list of health complaints including uterine fibroids, recurrent urinary tract infections, paraesthesia in both hands, general malaise and thalassaemia minor.

Questions

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

2. Why was Fatima asked about:

a previous episodes

b previous dental procedures

c other health complaints?

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

Physical examination

Vitals	•Pulse rate/min	86
	•Respiratory rate/min	22, shallow
	•Blood pressure mm Hg	122/80
	•Height (cm)	160
	•Weight (kg)	47
	•BMI	18.35
	•Temperature (degrees C)	37
HEENT	• Pallor of conjunctiva, otherwise normal • Mild incisal tooth wearing suggestive of chronic grinding • Gums and pharyngeal structures clear mild pallor, no sign of pus or smell of putrefaction • Small 5 mm abscess along mesial side of the coronoid process adjacent to maxillary third molar (wisdom tooth) on the right side • Tonsils appear normal
	• Pterygoids, temporalis and masseter muscles very tender to palpation • Upon opening jaw, deviates to right, range of 25 mm interincisal opening range. No click. Jaw opening end-feel stretch tender but not locked • Facial sensory findings normal • While clenching caused pain in the right jaw region, biting down on a tongue depressor placed onto the individual cusps of the molars reveal no likelihood of cusp fracture or nerve sensitivity
Neurological	Grossly intact

Questions

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

5. Explain the significance of the following signs, in context of your differential diagnosis:

a abscess of the coronoid process

b pallor of gums and conjunctiva

c jaw range of motion (ROM) findings.

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?

Investigations

Orthopantograph (OPG)

TMJs appear symmetrical, well formed condyles, articular eminences smooth and symmetrical. No sign of alveolar or abscess in mandible or periodontal disease. Some crowding and angulation of 2nd and 3rd mandibular molars. Coronoid processes appear normal.

Full blood count

Questions

7. What is the most likely diagnosis, based on these results? Justify your answer.

8. Explain the significance of each of the following investigation results, in context of your differential diagnosis:

a crowding of 2nd and 3rd molars

b blood test results

c symmetry of TMJs.

9. Are any further investigations required?

Case 14.2

History

Helen is a 50-year-old woman complaining of intermittent, almost daily, headaches occurring over the past several months. The headaches are usually worse in the morning and get better as the day progresses. The pain is moderate in intensity and is located throughout the suboccipital and frontal areas of the head bilaterally. The headaches are described as dull and achy with a feeling of pressure and pain, greater in the left side of the face, and are worse with activities such as bending forward.

Helen also complains of itchy ears bilaterally, red itchy eyes, nasal congestion, post nasal drip with a cough that is worse at night, nasal congestion with secretions that are purulent at times, decrease in sense of smell, and frequent episodes of sneezing. The headaches are frequently associated with upper neck pain. No associated visual disturbances, photophobia, phonophobia, nausea, or vomiting is reported. When questioned, Helen notes that she has multiple allergies. She had allergy testing done many years ago and recalls sensitivity to ragweed, dust and mould among others. Helen denies any other significant health history, trauma, or musculoskeletal injuries. She also denies taking medications other than occasional Benadryl and Advil for her symptoms. While Helen does not smoke herself, she has been spending a great deal of time with her elderly father who is a chain smoker.

The distribution of her pain is shown in Figure 14.1.

Figure 14.1 Pain distribution

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