What is the likely diagnosis and treatment for a female patient with sinus congestion, ear pain, and left-sided jaw pain, who experiences pain upon clenching her teeth, and has not taken any medication for her symptoms over the last 2 days?

Likely Diagnosis and Treatment Approach

This patient most likely has acute bacterial sinusitis with referred pain to the jaw, and should be treated with amoxicillin-clavulanate 875 mg/125 mg twice daily for 5-10 days, combined with intranasal corticosteroids and NSAIDs for pain relief. 1

Understanding the Clinical Presentation

The constellation of sinus congestion, ear pain, and jaw pain with teeth clenching over 2 days strongly suggests acute sinusitis with referred pain rather than a primary temporomandibular disorder (TMD). 1

• Jaw pain with mastication is a well-documented symptom of acute maxillary sinusitis because the maxillary sinus sits directly above the upper jaw and molar teeth, causing referred pain to these structures. 1
• The short 2-day duration makes this more consistent with acute sinusitis rather than TMD, which typically presents with chronic or recurrent symptoms. 2, 3
• The presence of sinus congestion and ear pain alongside jaw symptoms points toward a sinus origin rather than isolated TMJ pathology. 4, 1

Diagnostic Confirmation

Before initiating treatment, confirm the diagnosis clinically:

• Persistent upper respiratory symptoms for ≥10 days without improvement, OR severe symptoms for ≥3 consecutive days are the key diagnostic criteria for bacterial sinusitis. 1, 5
• Since this patient has only 2 days of symptoms, assess severity: purulent nasal discharge, facial pain/tenderness, and fever indicate severe acute bacterial sinusitis warranting immediate antibiotic therapy. 4, 1
• On physical examination, look for sinus tenderness on palpation, mucosal erythema with purulent nasal secretions, and purulent material in the posterior pharynx. 5

First-Line Treatment Protocol

Antibiotic therapy:

• Amoxicillin-clavulanate 875 mg/125 mg twice daily for 5-10 days is the preferred first-line antibiotic for acute bacterial sinusitis with jaw pain, providing coverage against β-lactamase-producing organisms. 1
• This is superior to plain amoxicillin when jaw pain is present, as it suggests more significant maxillary sinus involvement. 1, 5

Essential adjunctive therapies to address both sinus inflammation and jaw pain:

• Intranasal corticosteroids (mometasone or fluticasone) should be prescribed to reduce mucosal inflammation and improve sinus drainage, with strong evidence from multiple trials. 1, 5
• NSAIDs or acetaminophen should be used to directly address jaw pain and facial discomfort. 1
• Saline nasal irrigation provides symptomatic relief and mechanical removal of infectious debris. 1

When to Reassess and Escalate

• If no improvement occurs after 3-5 days of treatment, switch to high-dose amoxicillin-clavulanate, a respiratory fluoroquinolone, or a third-generation cephalosporin. 1, 5
• If symptoms persist beyond 7 days of appropriate second-line therapy, refer to an otolaryngologist or allergist-immunologist to evaluate for complications, anatomic abnormalities, or underlying conditions. 1

Critical Differential Consideration: TMD

While less likely given the acute presentation with sinus symptoms, temporomandibular disorder (TMD) should be considered if:

• Jaw pain persists after sinus symptoms resolve. 4
• Pain is specifically triggered by jaw movement, prolonged chewing, or clenching/bruxing habits rather than sinus pressure. 4
• There is clicking, locking, or limitation of jaw movement. 4, 2
• The patient has chronic widespread pain, headaches, or fibromyalgia. 4

TMD affects up to 15% of adults and commonly presents with regional face/preauricular pain, jaw movement limitations, and TMJ noise. 2, 3 However, TMD typically does not present with acute sinus congestion and ear pain simultaneously, making it a less likely primary diagnosis in this case. 2, 3

Common Pitfalls to Avoid

• Never assume jaw pain is purely dental or TMD-related when sinus symptoms are present—the maxillary sinus-jaw connection creates frequent referred pain. 1
• Do not delay antibiotic therapy if severe symptoms are present (fever, purulent discharge, significant facial pain), even if duration is <10 days. 4, 1
• Do not prescribe antibiotics for viral upper respiratory infections—only use when bacterial sinusitis criteria are met to avoid unnecessary antibiotic exposure. 4, 5
• If unilateral symptoms develop or worsen, consider dental infection as a cause of maxillary sinusitis and evaluate for periapical tooth infections. 1