Red flags and serious pathology

First consider MSK physiotherapy red flags and serious pathology guidance.

Specific concerns for orofacial area:

• Age <19 or >51: new or unfamiliar symptoms/dysfunction (Cancer, growth disturbance)
• Progressive pain/dysfunction despite treatment; non-mechanical, constant (Cancer)
• Paroxysmal unilateral lancinating pain; autonomic signs (eye watering/redness or drooping eyelids) (Trigeminal neuralgia)
• Unilateral headache/scalp tenderness; age>50; jaw claudication; visual symptoms; general malaise; polymyalgia (temporal arteritis)
• Pain precipitated by exertion, coughing, sneezing; or abrupt in onset; severe; or interrupts sleep (intracranial pathology, cardiac ischaemia)
• Severe night pain (cancer, infection, inflammation)
• Occlusal changes; new (cancer, bone growth around TMJ), inflammatory arthritis; trauma)
• Trismus: mouth opening less than 15 mm; Progressively worsening; no history of clicking; pain of myofascial origin (e.g. neuralgia); swollen lymph glands; suspicious intra-oral soft tissue lesion; painless limitation in young (cancer; growth disturbance)
• Pulsating tinnitus; unilateral (vascular pathology)
• Persistent loss of smell; purulent discharge; nasal blockage; recurrent bleeds (nasopharyngeal tumour; chronic sinusitis)
• Hoarseness; sudden onset (cancer)
• Globus sensation; with pain (cancer)
• Neurological signs and symptom changes in: facial sensation/power, vision, smell, taste, swallow; or muscle atrophy, dizziness, cognitive changes, gait disturbance, reduced hand dexterity, long tract signs (intracranial pathology e.g. cancer, MS); or ipsilateral hearing loss (acoustic neuroma; nasopharyngeal tumour)
• Trauma to head/neck; osteoporosis (fracture)
• Weight loss (cancer)
• Fever (septic arthritis, osteomyelitis, intracranial abscess, tooth abscess, mastoiditis)
• History of cancer (new cancer; recurrence; metastases)
• HIV/AIDS/injection drug abuse (infection; immunosuppression)
• Facial asymmetry; deformity; mass; nodule; swelling of TMJ, mandible, parotid gland (trauma; cancer; infection, inflammatory arthropathy, lymphadenopathy, growth disturbance)
• Neck mass/persistent cervical lymphadenopathy (cancer; infection)
• Skin lesions; growing, pigmented - e.g. face, mouth, neck (cancer)

NICE Clinical Knowledge Summaries (CKS).  Temporomandibular disorders (TMDs). 2021