What causes cracking and pain near the ear and in the jaw when opening the mouth wide, and how can it be treated?

Temporomandibular Disorder (TMD)

Your symptoms of cracking and pain near the ear and jaw when opening your mouth wide are most consistent with temporomandibular disorder (TMD), specifically a musculoskeletal type involving the jaw joint and muscles of mastication. 1

What This Condition Is

TMD is the most common cause of referred ear pain (otalgia) in the absence of ear canal swelling or middle ear disease. 1 The condition involves:

• Pain radiating to the periauricular area (near the ear), temple, or neck 1
• Clicking, popping, or crepitus (cracking sounds) in the temporomandibular joint 1, 2
• Tenderness over the affected TMJ on examination 1
• History often includes gum chewing, bruxism (teeth grinding), or recent dental procedures 1

TMD affects up to 15% of adults with peak incidence between ages 20-40, and is more common in women. 2, 3

Diagnostic Approach

The diagnosis is primarily clinical based on specific findings:

• Jaw pain or dysfunction with earache and facial pain 3
• Limitations in jaw movement 2
• Joint sounds (clicking, popping, cracking) during jaw movements 2
• Tenderness to palpation over the TMJ 1
• Pain aggravated by prolonged chewing, eating, or stress 1

Important red flags to exclude:

• Giant cell arteritis in patients over 50 years old (requires urgent ESR/CRP and possible biopsy) 1
• Cancer in patients with tobacco/alcohol use or age >50 (requires complete head and neck examination) 1
• Dental pathology (caries, impacted molars) 1

Imaging is generally not needed initially unless malocclusion or intra-articular abnormalities are suspected. 3

Treatment Algorithm

First-Line Management (Start Here)

Most patients improve with noninvasive therapies initiated early: 1, 3

1. Patient education and reassurance - Early diagnosis and explanation is often effective in those with good coping strategies 1

2. NSAIDs - Nonsteroidal anti-inflammatory drugs are recommended as initial pharmacotherapy 1, 3

3. Physical therapy - Simple physiotherapy exercises for the jaw 1

4. Occlusal splints - Dentists often make splints to wear at night to prevent bruxism 1

5. Self-care modifications:

   • Avoid prolonged chewing and hard foods 1
   • Stress management 1
   • Jaw rest 3

Second-Line Options (If First-Line Inadequate)

• Muscle relaxants for acute cases 3
• Cognitive behavioral therapy for chronic cases 1, 3
• Benzodiazepines or antidepressants may be added for chronic, refractory cases 3

When to Refer

Refer to oral and maxillofacial surgeon for: 3

• Refractory cases not responding to conservative management
• Suspected intra-articular pathology
• Severe functional impairment

Multidisciplinary team management is recommended for chronic facial pain patients. 1

Important Caveats

• Avoid invasive or irreversible treatments initially - Conservative management should be exhausted first 1
• TMD can coexist with other chronic pain conditions including headaches, migraines, and fibromyalgia 1
• Psychological comorbidities are common and should be addressed as part of comprehensive care 2, 3
• Sustained mouth opening (such as during prolonged dental procedures) can worsen or trigger TMD symptoms 4

The prognosis is generally favorable with early conservative management, though up to 30% of acute TMD may become chronic. 1