Neglected conditionsproducingpreauricular referred pain · 1068 cians, using the termstemporomandibularjointdys-function8 or craniomandibular syndrome,9 believe that malocclusions

Journal ofNeurology, Neurosurgery, and Psychiatry 1983 ;46:1067-1072

Occasional Review

Neglected conditions producing preauricular andreferred painMARK H FRIEDMAN, BERTRAND AGUS, JOSEPH WEISBERG

From the New York University School ofMedicine, The New York Infirmary, Beekman Downtown Hospital,and Downstate Medical Center, Brooklyn, NY, USA

SUMMARY Various theories regarding temporomandibular joint symptoms are reviewed. Twohundred and forty six patients suffering from head, neck, or facial pain, or masticatory dysfunc-tion were studied. In 108 of these patients, the diagnosis of temporomandibular joint synovitis,lateral pterygoid muscle dysfunction, or tenomyositis of the masseter muscle was made. Examina-tion procedures, diagnosis, frequency of occurrence, and initial treatment of these conditions aredescribed.

Certain conditions described extensively in the liter-ature (maxillary sinusitis, otitis media, trigeminalneuralgia, and parotid gland disease) often producepreauricular pain. However, a few musculo-skeletaldisorders of this region (temporomandibular jointsynovitis, lateral pterygoid muscle dysfunctions, andtenomyositis of the masseter muscle at its attach-ment to the zygomatic arch) produce similar symp-toms to these conditions,' and are sometimes over-looked. These disorders centering about the ear, arepart of a larger group involving other derangementsof the temporomandibular joint and all the mas-ticatory muscles.

Since 1934, when Costen's syndrome was intro-duced into the medical literature,2 and especiallysince 1937 when it reached the dental literature,3clinicians began to classify many pains about the earand face as "temporomandibular joint pains". Cos-ten observed this syndrome of ear and sinus pains ina series of iI cases. These patients had loss ofposterior teeth or were completely edentulous, withresultant "collapsed bite" and mandibular overclos-ure. They were "cured" or "improved" by prosthe-tic dental bite opening techniques. Costen ascribed

Address for reprint requests: Mark H Friedman, DDS, 660 Grama-tan Ave, Mt Vernon, NY 10552, USA.

Received 27 December 1982 and in revised form 28 June 1983.Accepted 17 July 1983

the symptoms to condylar pressure on underlyingstructures-such as the auriculotemporal andchorda tympani nerves. Over the next 10 to 15yeats, many investigators, such as Sichert and Zim-merman,5 disagreed with Costen on anatomicalgrounds.The concept of facial pain and dysfunction was

introduced by Schwartz in the 1950s, who investi-gated 500 patients with temporomandibular jointpain. The temporomandibular pain-dysfunction syn-drome that he described included the entire mas-ticatory system and the patient's psychological statusas well.6 Malocclusion was believed to be merely acontributing factor. The work started by Schwartzwas expanded by Laskin, who in 1969 introducedthe term myofascialpain dysfunction syndrome. Thispsychophysiologic theory relates muscle fatigue topsychologically motivated, persistent, tension reliev-ing oral habits, as the prime factor in the aetiology ofthe signs and symptoms of this disorder. Diagnosisof the myofascial pain dysfunction syndromerequires the presence of one or more of the follow-ing signs: pain (unilateral, usually in the ear orpreauricular area), masticatory muscle tenderness,clicking of the temporomandibular joint, limitedopening or mandibular deviation during opening.7Laskin attempted to rule out intrinsic joint disordersby requiring the absence of radiologic evidence ofjoint damage and lack of posterior joint tenderness.At the opposite end of the spectrum, many clini-

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cians, using the terms temporomandibular joint dys-function8 or craniomandibular syndrome,9 believethat malocclusions are responsible for these disor-ders. This concept may have been introduced byHippocrates, who described "a group of patientswhose teeth are disposed irregularly, crowding oneon the otfier and they are molested by headache andotorrhea". 'The various theories so far described have one

common denominator-temporomandibular jointcomplaints are viewed as a clinical entity describedas an all-inclusive syndrome. This approach differsfrom that used to examine other synovial joints andassociated musculature, and often leads to imprecisediagnosis and treatment. The fact that health profes-sionals who treat synovial joints (those concemedwith orthopedics, rheumatology, physiatrists, physi-cal therapy) usually avoid the temporomandibularjoint may explain the use of this different approach.

Examination of the temporomandibular joint andpreauricular area frequently revealed specificmusculo-skeletal disorders (temporomandibularjoint synovitis, lateral pterygoid muscle dysfunction,and tenomyositis of the masseter muscle at itsattachment to the zygomatic arch). The patient may,in these cases, complain of pain or soreness relatingto masticatory function. Sometimes, however, thepain may be referred as headache or earache.' Sincethese symptoms may simulate or be produced byother pathological conditions, misdiagnosis mayoccur. The examination procedures, diagnosis, fre-quency of occurrence, and initial treatment of theseconditions will be described in the present review.

Materials and methods

During the past 3 years, 246 patients complaining of head,neck, or facial pain, or jaw dysfunction (restricted open-openings, masticatory discomfort, or clicking of the tem-poromandibular joint) were studied; of these, 49 weremale and 197 were female. The age ranged from 14 to 79years. Forty of these patients had originally consulted aneurologist and 44 had initially consulted an otolaryn-gologist. The conditions to be described were diagnosed byposterior and lateral temporomandibular joint palpation,application of resistance to the lateral pterygoid muscles,and palpation and application of resistance to the massetermuscles.We have found radiographs to be of limited use in evalu-

ation of these disorders, or in correlating them with thepatient's symptoms. These disorders involve radiotranslu-cent tissues-joint capsule, muscles, and tendinous inser-tions." 12 The radiograph can be misleading even whenhard tissues are involved. Since cartilage is radiolucent,osteoarthritis of the temporomandibular joint, affectingthe cartilage and disc, can exist for many years before bonychanges are evident;" by this time extensive damage to thejoint may have occurred.

Friedman, Agus, Weisberg

Observations and description

TEMPOROMANDIBULAR JOINT SYNOVITISInflammation of the joint lining occurs in the tem-poromandibular joint, as it does in any synovial jointin the body. When temporomandibular jointsynovitis occurs, pain or tenderness can be elicitedby the examiner during lateral or posterior jointpalpation, or both. The aetiology can be systemicinflammatory disease, osteoarthritis, infection, or avirus.'3 Often, a localised synovitis of the posterioraspect of the joint, with effusion of fluid, occurs.This condition is called retrodiscitis'4 or posteriorcapsulitis'5 and often causes mandibular deviation,usually directly proportional to the amount Qfintracapsular oedema. To observe this deviation, therelation of the midlines of the upper and lower cen-tral incisors to each other with the teeth together(maximum intercuspation) is noted and compared tothat when the mouth is opened. In posterior cap-sulitis, the mandible will deviate toward the affectedside close to, or at, maximal opening.'5 This occursas the range of motion (forward translation) of theaffected condyle is limited by the inflammation. Inextreme cases, the mandible may also deviatetoward the opposite side with the jaws at rest (sep-aration between upper and lower teeth from 1-4mm) as the intracapsular oedema prevents posteriorcondylar movement on the affected side.'5'

Examination proceduresInspection: A visible swelling would indicate arather severe pathology of this joint, often with sys-temic involvement. An acute infection of systemicinflammatory disease such as rheumatoid arthritisand its variants, particularly psoriatic arthritis, mightbe severe enough to cause significant swelling.'3Lateral palpation: The area overlying the tem-poromandibular joint can be felt as a depression justanterior to the tragus of the ear-as the patientopens widely. If inflammation is present, the areawill feel tender to palpation.'6Posterior palpation: The examiner places the tips ofhis little fingers in the patient's external auditorycanals, bilaterally; the patient's head should beerect. Pressure is exerted anteriorly by theexaminer, as the patient opens and closes his jawseveral times. If the posterior aspect of the joint isinflammed, pain will be elicited when tissue is com-pressed against the examiner's finger with the post-erior movement of the condyle during closure.3 Inaddition to inflammation, this phase of the examina-tion may disclose a posteriorly positioned condyle'7or reciprocal clicking, a common type of disc dys-function. Condylar malposition or reciprocal click-ing, or both, commonly cause retrodiscal synovitis

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Neglected conditions producing preauricular and referred painTable Aetiology oftemporomandibular joint synovitis

Disease Mechanism

Degenerative joint disease Microtrauma, malocclusion,disc dysfunction, retrodiscalsynovitis, constitutional factors

Retrodiscal synovitis Posteriorly positioned condyle,prolonged opening, discdysfunction, trauma

Inflammatory joint disease Systemic inflammation orrheumatoid arthritis, autoimnmunityjuvenile rheumatoid arthritis,psoriatic arthritis, ankylosingspondylitis, lupuserythymatosis

Infections, bacterial Local extension fromchronic otitis, directpenetration or septicaemia

Infections, viral Viraemiameasles, mumps, infectiousmononucleosis

Condensed from Friedman MH, Weisberg J, Agus B. Diagnosisand treatment of inflammation of the temporomandibular joint.Arthritis and Rheum 1982;12:44-51.

(table). Reciprocal clicking can be felt (and oftenheard) during mandibular movements. It is theresult of abrupt condylar shifting as the articular discslips on and off the condyle with the movements.'8Once the examiner has determined that synovitis

exists, a search should be made for systemic disease(table). Degenerative joint disease is the most com-mon primary joint disease of the temporomandibu-lar joint and predisposes to temporomandibularjoint synovitis-occurring as a secondary phenome-non of this disease. Degenerative joint disease isusually unilateral, occurring more frequently (by aratio of 2 to 1) in women.'3

If systemic disease or an infection is present, theESR, alpha-2-globulin, and the serum fibrinogenare frequently elevated. If infection, with fluid in thejoint, is suspected, arthrocentesis should be per-formed. The skin over the joint is cleansed andanaesthetised (1-2% xylocaine without epineph-rine). The patient's mouth is fully opened, and a 20gauge needle is inserted and directed slightly post-eriorly superiorly until fluid can be aspirated. Aspi-ration of the fluid is accomplished by gentle suction.Fluid obtained should be Gram stained and cul-tured.'3

If synovitis is present, and physical and laboratoryfindings do not indicate systemic involvement, localcauses should be considered. Condylar encroach-ment of the highly vascular retrodiscal tissurs is acommon cause of synovitis in this area. An exces-sively posterior condylar position will be evident ifthe joint is correctly palpated. The loose joint cap-sule, non-limiting bony configuration, and constantuse of the temporomandibular joint make it particu-larly vulnerable to shifts in condylar position. Aposteriorly positioned condyle during maximum

closure can be caused by any factor (posterior toothor alveolar bone loss, caries, excessive tooth wear)causing a loss of vertical dimension between thejaws (bite collapse). In addition, interceptive toothcontacts during vertical closure or lateral move-ments may force the mandible posteriorly, as willcertain orthodontic malocclusions. Another localcause of temporomandibular joint synovitis istrauma induced by prolonged stretching of the joint,as might occur during tonsillectomy or lengthy den-tal procedures in areas of difficult accessibility of themouth. In these cases, the posterior attachment ofthe disc may be stretched or torn.

Initial treatmentThe initial treatment of temporomandibular jointsynovitis is similar to that prescribed for anyinflamed joint. If the inflammation is severe, a softdiet, limited movement, and use of mild heat or coldwill make the patient more comfortable. Aspirin ornon-steroidal anti-inflammatory medications can bevery effective in many cases. If the patient is allergic,intolerant, or unresponsive to these drugs, intra-articular instillation or corticosteroids may be indi-cated, provided the joint is not infected.'9 After thepatient is made comfortable, if the aetiology of thesynovitis is judged to be an excessively posteriorlypositioned condyle, dental treatment to repositionthe condyle anteriorly may be required. In the caseof a severe infection, the patient may require hos-pitalisation and the use of intra-venous antibioticsand surgical drainage.

In 53 of these patients (21 %), temporomandibu-lar joint synovitis was found. In 25 of these patients(10-2%), both temporomandibular joint synovitisand lateral pterygoid muscle dysfunction werefound.

LATERAL PTERYGOID MUSCLE PATHOLOGYThe inferior heads of the lateral pterygoid, the mainopening jaw muscles, insert on the neck of the man-dibular condyle, close to the external ear. Pathologyin these muscles usually results from a poor accom-modation by the patient to a faulty occlusion andmay produce symptoms similar to temporomandibu-lar joint synovitis. These muscles are physicallyinaccessible for direct examination. When palpationis attempted, the tissue posterolaterally to the maxil-lary tuberosity is compressed against the lateralpterygoid plate, and pain, often mistaken for evi-dence of pathology, can be elicited, even in a normalindividual.20 On the other hand, when a pathologi-cal condition exists in these muscles, the absence ofpain on active contraction may prove misleadinglynegative. However, in these cases, pain will beexperienced when the muscle is forced to contract

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Fig 1 Application ofcontraction against resistance toopening masticatory muscles. Patient's occiput is supportedduring testing to prevent backward head movement.

against maximum resistance. Therefore, the exami-nation must include muscle testing against resis-tance. I

The distinction between muscle dysfunction andtemporomandibular joint synovitis is important forits treatment; synovitis requires anti-inflammatorytreatment, while lateral pterygoid muscle dysfunc-tion does not. Dental management (repositioning ofthe mandible) or muscle relaxant techniques orboth, are indicated for this condition. Since exces-sive tension may cause or exaggerate this condition,psychiatric counselling may be indicated.To test the lateral pterygoid muscles, the patient

opens his mouth 1-2 cm and resists a strong closingforce directed upward against the patient's chin (fig1). The force is gradually applied, in order to allowthe patient time to recruit the maximum number ofmuscle fibres. If pathology exists, pain or othersymptoms will be elicited during this test." 22

This condition often causes an opening deviationaway from the affected side. This deviation usually

Friedman, Agus, Weisberg

occurs early in the opening cycle as muscular spasmcauses premature condylar translation. A deviationoccurring later in the opening cycle may be causedby a muscular imbalance of the lateral pterygoidmuscles. In this case, the stronger lateral ptergoidmuscle would encourage earlier condylar transla-tion, often causing a mid-opening cycle deviationtoward the weaker side.

In 30 of these patients (12%), lateral pterygoidmuscle dysfunction was found. As previously discus-sed, both lateral ptergoid muscle dysfunction andtemporomandibular joint synovitis were found in 25of these patients (10-2%).

TENOMYOSITIS OF THE MASSETER MUSCLEThe masseter muscle arises from the lower border ofthe zygomatic arch. Its attachment here is somewhatunusual-muscle fibres and layers of tendon alter-nate. Therefore, we describe inflammation in thisarea as tenomyositis. Symptoms of this disorder,masticatory pain and tenderness to palpation in thearea of the zygomatic arch, tend to be more localisedthan in the previously described disorders.The aetiology of the masseter muscle

tenomyositis, affecting the proximal attachment ofthis muscle, can be either occlusomuscular in nature,or traumatic. In this latter case, a sudden overwideyawn or unexpected bite on a hard object can be thecause. The tendon or muscle can maintain aninflammation, originally traumatic, for long periodsof time."I

Contraction against resistance is applied to testthis muscle (fig 2). The examiner applies a strongdownward force to the biting surfaces of the loweranterior teeth as the patient resists. Pain or othersymptoms indicates closing masticatory muscle dys-function (masseter, medial pterygoid, temporalis).Palpation is used to corroborate the results of thismuscle test; a positive response and tenderness topalpation in the region of the zygomatic arch indi-cates tenomyositis of the masseter muscle. The resis-tive closing muscle test just described will also aid indistinguishing between a pathologic condition of themasseter muscle and involvement of the parotidgland. The entire area may be tender to palpation.In the latter case, however, no increase in symptomswould be noted during contraction against resis-tance.Muscle physiology is not affected whether the

patient resists an applied force against the jaw, orattempts to move the jaw as the examiner resists.Practically, however, the force applied by theexaminer can be better controlled, and the resultsevaluated more effectively.22

If the aetiology of the tenomyositis was traumatic,anti-inflammatory treatment, similar to that for

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Neglected conditions producing preauricular and referred pain

Fig 2 Application ofcontraction against resistance toclosing masticatory muscles. Patient's forehead is supportedduring testing to prevent head flexion.

temporomandibular synovitis, is indicated. If thepathology was caused by occlusal factors, occlusaltreatment simultaneously with anti-inflammatorymedication will give optimum results.

In six of these cases (2.4%), tenomyositis of themasseter muscle was found.

Discussion and conclusions

The systemic inflammatory joint diseases (table 1)that may be responsible for temporomandibularjoint synovitis require medical management. How-ever, synovitis due to local causes, and the otherconditions described in this paper often require den-tal evaluation and management by a suitably traineddental surgeon, often with assistance by the physi-cian.

Dental treatment of these conditions oftenrequires mandibular repositioning to correct a faultytooth, jaw or condylar position. This is accomplishedby selectively grinding interfering tooth surfaces orby building up the teeth by removable dental pros-thesis (appliance therapy). This type of treatment ismost often required in cases of masticatory muscle

dysfunction, and sometimes required when tem-poromandibular joint synovitis is present. If theaetiology of the synovitis is ascribed to a posteriorlypositioned condyle, appliance therapy can correctthe situation after acute symptoms are relieved byanti-inflammatory treatment. Masseterictenomyositis responds to anti-inflammatory treat-ment, as opposed to dysfunctions of the belly of themuscle, which do not. Dysfunctions of the lateralpterygoid muscle are often due to occlusal factors;dental removable appliances are commonly used tocorrect the situation. Some of these patients mayrequire long-term dental treatment such asorthodontics or permanent restorative procedures,afterwards.

Standard techniques of muscle tests and joint andmuscle palpation have been described and used toseparate and distinguish certain musculo-skeletaldisorders of the temporomandibular joint and adja-cent musculature from the more general diagnosis oftemporomandibular joint dysfunction.We suggest that in those cases of preauricular

pain, headache or earache, where the aetiology can-not be clearly ascribed to classical conditions likeotitis media, maxillary sinusitis, parotid gland dis-eases, and trigeminal neuralgia, that the diagnosis oftemporomandibular joint synovitis, lateral pterygoidmuscle dysfunction, and masseteric tenomyositis beconsidered.

We express our sincere thanks to Professor HilelNathan, Sackler School of Medicine Tel AvivUniversity Israel, for his constructive criticism.

References

'Possult U. Physiology of Occlusion and Rehabilitation.Oxford and Edinburgh: Blackwell, 1969:94-102.

2 Costen JB. Syndrome of ear and sinus symptoms depen-dent upon disturbed function of the temporomandibu-lar joint. Ann Otol Rhinol Laryngol 1934;43:1-15.

3 Costen JB. Some features of the mandibular articulationas it pertains to medical diagnosis, especially inotolaryngology. J Am Dent Assoc 1937;24:1507-1 1.

4 Sicher H. Temporomandibular articulation in mandibu-lar overclosure. J Am Dent Assoc 1948;36:131-9.

5Zimmennan AA. An evaluation of Costen's syndromefrom an anatomic point of view. In: Sarnat BG, ed.The Temporomandibular Joint. Springfield: Charles CThomas, 1951.

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8 Shore NA. Occlusal Equilibration and Temporoman-dibular Joint Dysfunction. Philadelphia: Lippincott,1959.

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21 Johnstone DR, Templeton M. The feasibility of palpat-ing the lateral pterygoid muscle. J Prosthet Dent1980;44:318-21.

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