Keywords
Trigger points
Facial pain
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Abstract
Objective: To report a clinical case of craniocervicomandibular dysfunction associated with cochlear alterations in an 18-year-old female patient with intense pain in the mandibular angle. Case details: During the anamnesis, the patient reported a sensation of ear fullness (aural fullness), bilateral tinnitus, nocturnal teeth clenching, and clicking sounds on the right side of the ear. Physical examination revealed bilateral trigger points in the masticatory and cervical muscles, especially in the descending trapezius, sternocleidomastoid, and masseter muscles. Loss of cervical lordosis was also observed, leading to anterior head posture and shoulder misalignment. A diagnosis of ascending craniocervicomandibular dysfunction was established. The proposed treatment consisted of fabrication of a 2 mm lower interocclusal device and daily physiotherapy exercises. After one year of treatment, the patient reported relief from painful symptoms, improved shoulder alignment, and complete resolution of aural fullness and tinnitus. Final considerations: Diagnostic accuracy, an appropriate therapeutic plan, and patient adherence were essential for achieving a favorable prognosis.
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