Unexplained Left-Sided Facial Pain: A Case for Clinical Discussion

Subtitle: Specialist examination and MRI findings without significant TMJ internal derangement — an invitation for independent clinical discussion

Clinical Case Discussion

Case Presentation

A 43-year-old man was referred for oral and maxillofacial assessment because of left-sided jaw and facial pain.

He described a dull, poorly localised pain on the left side of his face, sometimes perceived in the temporal or forehead region.

The pain was generally mild, rated approximately 2–3/10. He reported brief episodes occurring with swallowing on a daily basis, each lasting several seconds.

There was no associated jaw clicking, locking, restricted mouth opening or other significant mechanical temporomandibular joint (TMJ) symptoms.

He had commenced a short trial of amitriptyline 20 mg, subsequently reduced to 10 mg.

Relevant Medical History

His medical history included hypertension, dyslipidaemia, pelvic pain and medical anxiety.

He was a non-smoker, reported no relevant oral habits and had no known drug allergies.

Two longstanding, asymptomatic white lesions had also been identified on the palate. There was no reported ulceration, bleeding or other concerning oral symptoms.

1. Oral and Maxillofacial Examination

Temporomandibular Joint Examination

The specialist documented:

  • No tenderness over either TMJ.
  • No mandibular deviation on opening.
  • Maximum mouth opening greater than 50 mm.
  • Normal protrusive and lateral mandibular movements.
  • No joint clicking.
  • Class I occlusion.

Masticatory Muscle Examination

  • Mild tenderness of the left masseter.
  • Mild tenderness of the left temporalis.

Intraoral and Neck Examination

Two discrete areas of leukoplakic change were identified on the palatal mucosa adjacent to teeth 17 and 27.

Each lesion measured approximately 5 × 4 mm.

There was no associated ulceration or induration.

The neck was soft, with no palpable cervical lymphadenopathy.

2. MRI Findings

Temporomandibular Joints

MRI demonstrated:

  • Normal morphology and position of both TMJ discs.
  • Normal translation of the discs and condyles on opening.
  • No evidence of internal derangement.
  • No significant joint effusion.
  • No degenerative osseous changes.

The radiological Wilkes classification was considered not applicable bilaterally.

Paranasal Sinuses and Mastoid Region

Additional MRI findings included:

  • Partial opacification of the left ethmoid air cells.
  • Mild mucosal thickening of both maxillary sinuses.
  • A trace, non-specific left mastoid effusion.
  • No nasopharyngeal mass identified.

The frontal sinuses were outside the imaging field.

3. Specialist Impression

The oral and maxillofacial specialist documented three principal findings.

1. Left-Sided Facial Pain with Mild Masseter and Temporalis Myalgia

Clinical examination identified mild tenderness of the left masseter and temporalis muscles.

MRI showed no significant TMJ internal derangement or structural joint abnormality sufficient to account for the reported symptoms.

2. Bilateral Palatal Leukoplakic Lesions

The two palatal lesions were longstanding and asymptomatic.

Histopathological assessment was recommended to establish a definitive diagnosis.

3. Paranasal Sinus Disease

MRI identified partial left ethmoid opacification and bilateral maxillary sinus mucosal thickening.

An ENT assessment was recommended to evaluate the significance of these findings, particularly in relation to the left-sided facial symptoms.

4. Specialist Management Plan

The specialist recommended:

  1. A 3–6 month trial of non-surgical, conservative management for the suspected TMJ-related muscular symptoms.
  2. Referral for physiotherapy and appropriate conservative management.
  3. An occlusal bite splint.
  4. Intermittent soft diet, warm compresses and topical NSAID therapy.
  5. Biopsy of both palatal lesions under IV sedation for definitive histopathological diagnosis.
  6. ENT referral for assessment of the paranasal sinus abnormalities identified on MRI.
  7. Specialist review following biopsy, with further management guided by the histopathological findings.

5. Invitation for Clinical Discussion

The information above represents the history, specialist examination, MRI findings and management recommendations currently available.

The precise source of this patient’s left-sided facial pain has not yet been established.

We invite colleagues in general practice, oral and maxillofacial medicine, neurology, otolaryngology, pain medicine, physiotherapy and acupuncture to review the case independently.

Questions for discussion:

  1. Based on the available information, what differential diagnoses would you consider?
  2. Which clinical and imaging findings do you consider most relevant?
  3. What additional history or physical examinations would you prioritise?
  4. How would you approach further assessment and management before establishing a definitive pain diagnosis?

We welcome clinical perspectives, alternative interpretations and constructive professional discussion.

No additional clinical examination findings or personal diagnostic conclusions have been included in this presentation.

Source Note

This case has been prepared from an existing oral and maxillofacial specialist assessment and MRI report for professional discussion. The documented findings and recommendations are those of the referring specialist and have not been independently verified through a new clinical examination for this article.

Disclaimer

This article is intended for professional clinical discussion and education only. It does not provide an individual diagnosis or treatment recommendation for other patients. Patient-identifying details have been omitted, and appropriate publication consent is required before public release.

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