What are the possible causes of left temporal pain above the ear associated with reading?

Left Temporal Pain Above Ear When Reading: Differential Diagnosis

The most likely causes of left temporal pain above the ear triggered by reading are temporomandibular disorders (TMD), temporal tendinosis, or nerve entrapment (zygomaticotemporal or auriculotemporal nerve), with giant cell arteritis being a critical consideration if the patient is over 50 years old.

Primary Diagnostic Considerations

Temporomandibular Disorders (TMD)

• TMD is the most prevalent cause of chronic orofacial pain and commonly presents with pain in the jaw, face, neck, and temporal region, often accompanied by headaches and earache 1
• Reading involves sustained jaw positioning and facial muscle tension that can exacerbate TMD symptoms 1
• Women are disproportionately affected, and psychological comorbidities are common 1
• The temporal region pain may be referred from masticatory muscle dysfunction or joint pathology 1

Temporal Tendinosis

• This is a significantly under-recognized cause of unilateral temporal pain that presents with or without temporal headache 2
• The temporalis muscle is heavily engaged during reading due to sustained jaw positioning and facial tension 2
• Pain typically radiates from the distal temporalis tendon to the temporalis muscle belly 2
• Diagnosis requires focused palpation of the temporalis tendon with reproduction of symptoms, ideally confirmed with ultrasound imaging (MRI as alternative) 2, 3
• Local anesthetic injection adjacent to the tendon should eliminate pain if this is the source 3

Nerve Entrapment Syndromes

• Zygomaticotemporal nerve (ZTN) entrapment causes pain anterior to the ear in the temple region, precisely where reading-related pain often localizes 4
• Auriculotemporal nerve (ATN) dysfunction presents as strictly unilateral temporal and preauricular pain with nerve tenderness 5
• Pain is triggered by pressing the preauricular area and may include burning exacerbations lasting seconds to 30 minutes 5
• The sustained facial positioning during reading can compress these nerves 4

Critical Red Flag: Giant Cell Arteritis

• In any patient over age 50 with new-onset temporal pain, giant cell arteritis must be urgently excluded as it can cause irreversible blindness 6
• Check ESR and C-reactive protein immediately; if elevated, refer urgently for temporal artery biopsy 6
• Treatment with systemic steroids should be commenced rapidly once diagnosis is suspected 6

Diagnostic Approach

Physical Examination Findings to Elicit:

• Palpate the temporalis muscle and tendon for focal tenderness and reproduction of symptoms 2, 3
• Press the preauricular area to assess for nerve tenderness (ATN) 5
• Examine the temporal fossa anterior to the ear for ZTN entrapment 4
• Assess temporomandibular joint for clicking, crepitus, and range of motion limitations 1, 3
• Check for trigger points in masticatory muscles 1

Diagnostic Testing:

• Diagnostic local anesthetic injection at the site of maximal tenderness provides both diagnostic confirmation and therapeutic benefit 3, 4, 5
• Ultrasound imaging of the temporalis tendon is preferred for temporal tendinosis; MRI is an alternative 2
• ESR and C-reactive protein if patient is over 50 years old 6

Management Algorithm

First-Line Conservative Management:

• For TMD: Conservative therapy including patient education, self-care instructions, and reversible oral splints are recommended over invasive interventions 1
• For temporal tendinosis: Education on the condition, self-care instructions, and activity modification typically result in resolution 3
• For nerve entrapment: Gabapentin (effective in multiple case series) or anesthetic nerve blocks 5

Interventional Options:

• Anesthetic blockade is highly effective for both temporal tendinosis and nerve entrapment syndromes 3, 4, 5
• For ATN specifically, complete relief was achieved with gabapentin in three of eight patients and anesthetic blockade in three of eight patients 5
• Additional options include cryoneuroablation, chemical neurolysis, neuromodulation, and surgical decompression for refractory nerve entrapment 4

Treatments to Avoid:

• Avoid irreversible interventions such as discectomy, irreversible oral splints, and combined NSAIDs with opioids for TMD 1
• These carry important harms without proven benefit 1

Common Pitfalls

• Temporal tendinosis remains under-diagnosed due to anatomical complexity and inadequate description in medical textbooks, leading to extensive unnecessary workups 2
• Many healthcare providers are unfamiliar with temporal tendinosis and nerve entrapment syndromes, resulting in diagnostic confusion and iatrogenic harm 2, 3
• Failing to consider giant cell arteritis in patients over 50 can result in preventable blindness 6
• The diagnostic criteria for TMD subtypes are largely subjective, and patients commonly satisfy criteria for multiple subtypes simultaneously 1