Final Myofascial Pain

Myofascial Pain-Dysfunction Syndrome
Crainiomandibular Syndrome
Temporomandibular Joint Dysfunction
Patients with severe ear, face and head pain may have normal examinations of their ears,
nose and throat. To most patients, this is both unbelievable and frustrating. Earache with
a normal ear exam is a common complaint. However, in healthy adults without a history
of ear problems, ear infection and eustachain tube problems are actually uncommon and
often misdiagnosed. The most common reason for a normal exam is because the pain is
referred from another part of the head or neck. If the pain originates in a muscle or
tendon it is called Myofascial Pain. If the pain originates in the jaw joint, it is called
Temporomandibular Joint Dysfunction. Problems that are initially muscular in origin
may cause physical changes or damage to the jaw joint or teeth and are better described
as a Crainiomandibular syndrome.
Referred Pain
Referred pain is pain that originates in one part of the body, but is felt in an entirely
unrelated part of the body. It is a result of the wiring of nerves. It is especially common in
the head and neck area because during embryological development the crainial nerves
branch and grow in many directions. For example, ear pain may be caused from dental or
tonsil infections or canker sores in the throat mouth or tongue. It is possible to have the
ear pain without feeling any symptoms in the mouth or throat. Other causes of referred
ear pain include the deep jaw and throat muscles and the jaw joint itself. For many
patients it is hard to believe that the pain they are feeling is not actually coming from the
ear.
Trigger Point
A trigger point is a point within a muscle or tendon that is the focus of pain or initiates
muscle spasms. Trigger points can cause intense spreading pain as a result of neural
feedback.
Neural Feedback
This is an involuntary reflex mediated by the spinal cord, and sometimes altered by the
brain. In myofascial pain, the pain is sensed by the spinal cord, which in turn creates
muscle contraction, which may intensify the pain. Pain stimulates contraction and
contraction exacerbates pain, a vicious cycle. Factors such as stress and anxiety may
intensify the neural feedback, making problems worse and difficult to treat. Unless the
neural feedback is suppressed, the problem will not improve and may worsen, leading to
possible permanent physical damage.
Myofascial Pain
Myofascial pain can vary from very localized pain, to a diffuse headache with neck pain.
Ear pain is probably the most common initial complaint for patients seen by an ENT
physician. Sinus pain, headache, neck complaints and sore throat are also common.
Perhaps the features of Myofascial Pain Syndrome that are most difficult for a patient to
understand are the complaints of dizziness, ringing in the ears (tinnitus) and hearing loss.
As many as 60-70% of patients with Myofascial Pain Dysfunction may have one or more
of these ear complaints. Other common observations of myofascial pain include:
It may either improve or worsen with sleep.
It usually worsens with stress.
It will usually intensify in the cold.
It will usually improve with heat.
It may come and go with what may seem like a random pattern.
It may intensify with jaw manipulation, for example: popping the ears or gum
chewing.
May be associated with tooth grinding (Bruxism)
May be triggered by a change in diet, activity or lifestyle.
It may occur after injury, surgery or dental work.
In many patients with myofascial pain, a distinct cause or trigger cannot be identified.
Diagnosis
Myofascial pain is an extremely common and frustrating problem and a common reason
that adult patients seek out an Ear, Nose and Throat doctor. However, myofascial pain is
a diagnosis of exclusion, meaning that an ear nose and throat doctor will look for other
reasonable causes of pain prior to making the diagnosis. Although myofascial pain is
common, a thorough physical exam is required to rule out other causes of referred pain.
For example, ear pain can be the only symptom of a throat or voice-box cancer.
A thorough exam will include a detailed exam of the deep throat and voice box, which
may require endoscopy. Although rarely needed, other studies like CT scans or blood
work may be required. The first priority is to rule out anything serious (fortunately rare)
before initiating treatment.
Natural Course
In the majority of patients, the pain is self-limited and may even resolve without
treatment in 2-12 weeks. However, without treatment, the condition can escalate to a
level that is very hard to treat. Physical changes may occur in the jaw joint, leading to
severe pain that wont respond to medications.
Treatment
Probably the most important factor for successful treatment is acceptance. In general,
patients have a hard time accepting the diagnosis of myofascial pain. The concept of
treatment is simple, break the viscous cycle of neural feedback and the condition
improves. When a patient fails to accept the diagnosis, it is unlikely that he/she will be
able to prevent the neural feedback.
The brain can modulate neural feedback. Factors like stress and emotional reactions can
significantly amplify the feedback. Additionally, a patients response to situations, pain
or sensations may make the problem worse. For example, ear pain or fullness may cause
a patient to try to pop their ears by moving or manipulating the muscles of the jaw and
the throat. This irritates the jaw joint and strains the muscles responsible for the pain.
Other habits may include jaw clinching with stress or vigorous gum chewing with
emotion or stress.
Factors that break the viscous cycle of neural feedback:
o Heat relaxes muscles (a warm electric heating pad on the affected area
minimum 60 minutes per day)
o Massage this is a form of biofeedback, a patient can train themselves to identify
when muscles are tight and to relax a muscle or a group of muscles.
o Soft Diet avoiding foods difficult to chew like steak, carrots or any other
durable foods will help. Gentle jaw exercises may be helpful, but gum chewing is
usually harmful.
o Anti-inflammatory medications like ibuprofen or prednisone. These medications
need to be taken well beyond the termination of symptoms for maximal benefit.
For ibuprofen it is usually 800mg three times a day on a regular schedule for ten
days.
o Muscle relaxant medications may reduce neural feedback, pain and reduce
bruxism (jaw grinding usually during sleep)
o Dental appliance Dentists can make a bite guard that can reduce pressure on the
jaw joint and reduce or eliminate the effect of bruxism.
o Trigger point injections if a distinct spot can be identified a simple injection of
local anesthetic and anti-inflammatory steroid may improve or cure myofascial
pain.
o Physical Therapy
TODD A. CHILD, M.D.

Memorial Medical Center
2000 South 900 East
Salt Lake City, Utah
The sole purpose of this pamphlet is to provide patients with practical education about
referred pain in the head and neck.

Final Myofascial Pain

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Myofascial Pain-Dysfunction Syndrome

TODD A. CHILD, M.D.

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