What is the most likely diagnosis for a 72‑year‑old woman with chronic left mandibular pain and trismus after a tooth extraction, no oral pathology, no fever, a several‑month cough, impacted earwax, and anterior ear pain radiating to the left cheek?

Chronic Post-Extraction Jaw Pain with Trismus and Ear Involvement

This 72-year-old woman most likely has temporomandibular disorder (TMD) with myofascial pain, possibly complicated by post-traumatic trigeminal neuropathic pain from the prior tooth extraction. The combination of chronic unilateral jaw pain, trismus (inability to open mouth), anterior ear pain radiating to the cheek, normal dental examination, and absence of infection strongly points to TMD as the primary diagnosis. 1, 2

Key Diagnostic Features Supporting TMD

The clinical presentation matches classic TMD with referred otalgia:

• Sharp pain in the TMJ area worsening with jaw movement and eating is characteristic of TMD, which commonly causes referred pain to the ear in the absence of primary ear pathology 2
• Pain upon opening the mouth and tenderness anterior to the ear (at the TMJ) are hallmark findings of TMD 2
• Normal ear canal and tympanic membrane (aside from impacted wax) rules out primary otologic disease and strongly suggests referred pain from TMD 2
• Trismus (restricted mouth opening due to pain) indicates masticatory muscle dysfunction, which accounts for approximately 85-90% of TMD cases 2

Post-Traumatic Neuropathic Component

The history of pain starting after tooth extraction raises concern for superimposed trigeminal neuropathic pain:

• Dental procedures including extractions can cause trigeminal nerve injury leading to neuropathic pain that begins within 3-6 months of the trauma 1, 3
• The continuous burning or sharp quality of pain, if present, would support a neuropathic component 1
• Post-traumatic trigeminal pain often presents with allodynia or altered sensation in the affected area 1

Critical Red Flags to Exclude First

Before confirming TMD, you must rule out more serious conditions:

Giant Cell Arteritis (GCA)

• At age 72, jaw claudication (pain with chewing) could represent GCA, which requires urgent treatment to prevent blindness 4
• Check for: temporal artery tenderness, visual symptoms, fever, malaise, elevated ESR/CRP 4
• If any suspicion exists, obtain ESR and CRP immediately and start high-dose corticosteroids (minimum 40 mg prednisone daily) within 2 weeks 4

Osteomyelitis

• The chronic cough raises concern for possible aspiration or systemic infection 5
• Check for: fever, swelling, progressive worsening, diabetes history 2, 5
• Absence of fever and swelling makes this less likely, but diabetes would increase risk 5

Malignancy

• Any ulcer or pain persisting >2 weeks without clear diagnosis warrants biopsy consideration 6
• The chronic cough could represent metastatic disease, though lack of constitutional symptoms makes this less likely 1

Recommended Diagnostic Workup

Perform the following systematic evaluation:

1. Palpate the TMJ bilaterally (just anterior to the ear tragus) during jaw opening/closing to assess for tenderness, clicking, or crepitus 2
2. Palpate masticatory muscles (masseter, temporalis) for tenderness and trigger points 2
3. Assess for dental wear facets indicating chronic bruxism/clenching 2
4. Check ESR and CRP given age >50 years to exclude GCA 4
5. Perform qualitative sensory testing in the left trigeminal distribution to identify neuropathic features (allodynia, hyperalgesia) 1
6. Remove impacted earwax to fully visualize the tympanic membrane and exclude otologic pathology 2

Evidence-Based Treatment Algorithm

Start with conservative, non-invasive management that has the strongest evidence:

First-Line Treatments (Moderate to High Certainty Evidence)

These interventions provide pain relief approximately 1.5-2 times the minimally important difference compared to placebo: 2

• Cognitive behavioral therapy (CBT) with relaxation therapy or biofeedback - most effective intervention 2
• Supervised jaw exercises and stretching - important pain relief 2
• Manual trigger point therapy - substantial pain reduction 2
• Supervised postural exercises - important pain relief 2
• Patient education and reassurance - improves self-efficacy and reduces symptoms 2

Specific Instructions for Jaw Exercises

• Gentle stretching within pain tolerance
• Avoid hard/chewy foods temporarily
• Apply moist heat to jaw muscles before exercises 2

Second-Line Options (If First-Line Insufficient After 4-6 Weeks)

• Acupuncture - moderate evidence 2
• NSAIDs combined with CBT - moderate evidence 2
• Avoid: occlusal splints, benzodiazepines, opioids, corticosteroid injections 2

Management of Neuropathic Component (If Present)

If sensory testing confirms neuropathic features:

• Neuropathic pain medications (gabapentin, pregabalin, tricyclic antidepressants) are indicated for post-traumatic trigeminal neuropathic pain 1
• This represents a separate but potentially overlapping condition requiring concurrent management 1, 3

Common Pitfalls to Avoid

1. Do not assume clicking sounds indicate structural joint damage requiring invasive treatment - clicking is not linked to pain development and most patients have muscular TMD amenable to conservative therapy 2
2. Do not rush to splint therapy - evidence shows education may be more beneficial long-term, and poorly fitted splints can cause malocclusion 1
3. Do not overlook GCA in elderly patients with jaw pain - this is a medical emergency requiring immediate corticosteroids 4
4. Do not ignore the chronic cough - investigate this separately as it may indicate systemic disease or aspiration risk 5

Prognosis and Follow-Up

• Up to 30% of acute TMD cases progress to chronic pain, making early intervention critical 2
• Reassess after 4-6 weeks of conservative management 2
• Depression and catastrophizing reduce treatment success - address psychological factors early 2
• Refer to oral/maxillofacial surgery or pain medicine if symptoms persist despite appropriate first-line treatment 2