05 Feb

【Learn Clinical Reasoning with Dr. Win Huang】“TMJ Discomfort” with a Cervical Origin: A Reverse Diagnosis Involving the Great Auricular Nerve

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“TMJ Discomfort” with a Cervical Origin: A Reverse Diagnosis Involving the Great Auricular Nerve

This type of patient can easily lead a clinician off track.
He arrives with a “diagnosis” already formed — temporomandibular joint disorder (TMJ).

But in clinical reality, the diagnosis brought by the patient is often unreliable.
The clinician’s job is not to follow the patient’s conclusion, but to return to objective findings and logic.

The core misunderstanding in this case can be summarized in one sentence:

The location of discomfort is not equal to the location of the lesion.

1 | Case Background: Long-standing “ear-front discomfort” that recently became constant

The patient reported many years of discomfort — not sharp pain, but a vague aching, fullness, and odd sensation — mainly around:

  • The pre-auricular region

  • The angle of the mandible

  • The parotid / peri-auricular region

Previously, it was mild. Moving the jaw or resting would relieve it, so he ignored it.
But in recent months, the discomfort became constant throughout the day. He repeatedly opened his mouth wide, moved the jaw, and rubbed the ear-front area to seek relief.

He came with a clear request: treat my TMJ disorder.

2 | First step: Does this actually look like a true TMJ problem? (It did not)

Key examination findings:

  • Mouth opening was symmetrical, no deviation

  • No limitation of opening

  • No significant occlusal complaint

  • No tenderness over the TMJ itself

True joint pathology usually presents with clearer signs: deviation, clicking, restriction, or joint tenderness. None were present.

At this point, it was clear:

His self-diagnosed “TMJ disorder” did not match the objective findings.

3 | A change in direction: Could a nerve be “mimicking” a joint problem?

Discomfort in the ear-front, mandibular angle, and parotid region without TMJ signs suggests a frequently overlooked participant:

Great auricular nerve (C2–C3) irritation or sensitization

Two key checks were performed:

  • Sensory comparison: the ear lobule, mandibular angle, and parotid skin were more sensitive on the right side

  • Provocation point: pressure applied near the C2–C3 transverse process region reproduced pain radiating to the ear front and temple

A diagnostic moment occurred:

After pressure was applied, the patient immediately said,
“That uncomfortable TMJ feeling is gone.”

4 | The turning point: Not “joint movement helps,” but “nerve tension released”

The patient believed:

“Opening the mouth makes it better → therefore it must be TMJ.”

But the new evidence showed:

When the upstream C2–C3 / great auricular nerve pathway was addressed, the discomfort disappeared immediately.

This suggests that the relief was not due to joint correction, but due to:

  • Change in cervical tension

  • Temporary reduction of cutaneous nerve sensitization

  • Release of local traction sensation

In other words:

The sensation felt like TMJ discomfort, but the source was not the TMJ.

5 | The likely source: Great auricular nerve involvement with cervical contribution

The evidence was consistent:

  • Lack of classic TMJ signs

  • Increased cutaneous sensitivity in the ear lobule / mandibular angle region

  • Strong tenderness at C2–C3 with radiation to the ear front and temple

  • Immediate relief after pressure (therapeutic confirmation)

Thus, the conclusion favored:

Great auricular nerve involvement with cervical origin, rather than TMJ pathology.

6 | Therapeutic diagnosis: Treating Tianyou (SJ16) and the C2 region

Treatment was applied at:

  • Tianyou (SJ16) with superficial bloodletting

  • C2 transverse process region with cupping

After treatment, the patient reported:

  • Disappearance of the ear-front and mandibular angle discomfort

  • A clear sense of lightness

  • The vague “odd sensation” was gone

This reinforced the conclusion:

The problem lay in the cervical–great auricular nerve pathway, not in the joint.

Tianyou (SJ16) is located just below the mastoid process, at the posterior border of the sternocleidomastoid muscle.
This depression is exactly where the great auricular nerve emerges from C2–C3 and ascends superficially along the muscle.

Tianyou is not merely near the great auricular nerve — it lies directly on its pathway.

7 | What This Case Truly Teaches

(1) The “diagnosis” brought by the patient is often the greatest source of misdirection
He came in convinced that he had “TMJ disorder,” and had believed this for many years. Once this label enters the clinician’s mind, it is very easy to unconsciously follow the “TMJ pathway” in an attempt to confirm it, rather than observing what the objective findings are actually saying.
In clinical practice, patients provide symptom clues, not diagnostic conclusions. If the clinician accepts the patient’s belief as a conclusion, the thinking process is already placed inside the wrong framework.

(2) The more anatomically “reasonable” the pain location appears, the easier it is to form a false judgment
The pre-auricular region, mandibular angle, and parotid area perfectly match the typical TMJ region. Precisely because it looks so convincing, it becomes easier to overlook other possibilities. Discomfort in this area easily traps the clinician into thinking about teeth, parotid gland, masseter muscle, trigeminal nerve, or ear canal problems.
Anatomical location may be correct, but the pathological level may not be.

(3) Vague symptoms make clinicians more likely to fall into local thinking
This was not severe pain, but a vague aching, fullness, and discomfort that was difficult to describe. Such unclear sensations push the clinician toward searching for local structural problems, while deeper neural involvement and cervical contribution are easily ignored.

(4) “Moving the jaw makes it feel better” is a highly misleading clue
This reinforces a false cause-and-effect relationship:
“If moving the joint makes it better, the joint must be the problem.”
In reality, this only temporarily changes tension patterns; it does not correct any joint pathology.

(5) Clinicians get ‘lost’ not because the case is difficult, but because they are led by the patient’s narrative
When the clinician keeps searching for answers within the framework provided by the patient, everything appears logical, yet nothing truly explains the condition. The real breakthrough comes from stepping outside that framework.

(6) The more cases you have seen, the longer your ‘suspicion list’ becomes
Without prior experience treating great auricular nerve–related cases, it would be very difficult to think in this direction. The essence of clinical experience is continuously expanding the range of possibilities you are able to consider.

8 | A practical clinical conclusion

When a patient reports “TMJ discomfort,” but:

  • Mouth opening is symmetrical

  • No joint tenderness

  • No limitation of motion

  • Skin around the ear lobule / mandibular angle is hypersensitive

  • C2–C3 pressure reproduces symptoms radiating to the ear front and temple

Consider great auricular nerve involvement of cervical origin before blaming the TMJ.

And always remember:

Patients provide symptom clues, not diagnostic conclusions.

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