Causes of Tetanus

• TMJ disorders
  –Associated with unilateral or bilateral achy pain and diffuse tenderness of the masseter and temporalis muscles
  –Exaggerated by jaw use
  –Joint may be tender to palpation
  –“Clicking” sounds are often present
  –More common in females age <50

• Giant cell (temporal) arteritis
  –Unilateral pain in older patients
  –Headache, jaw claudication, and vision loss
• Mucosal lesions (buccal mucosa, hard and soft
  palate, floor of mouth, or oropharynx)
  –Aphthous ulcers
  –Herpes simplex or coxsackievirus B
  –Cancer
  –Tongue or lip lesions
• Paranasal sinus pathology
  –Most common pathology is maxillary
  sinusitis secondary to viral URI
  –Pain is often referred to the upper molars
• Salivary gland pathology, including inflammation (e.g., parotiditis), ductal stone, or neoplasm
• Headache with radiation to the jaw
• Referred pain from cardiac, cervical spine, pulmonary, or throat disease
• Neuralgias (e.g., trigeminal, glossopharyngeal)
• Neuropathies
  –Systemic neuropathies (e.g., HIV, diabetes)
  –Dental/alveolar neuropathies, usually
  subsequent to extrinsic trauma (e.g., blow to face, dental surgical intervention)
• Behavioral disorders
• Primary neoplasms of the maxilla, mandible, or major salivary gland
• Metastases to mandible, maxilla, or TMJ
• Herpes zoster or post-herpetic neuralgia
• Fibromyalgia
• Rheumatologic disease (e.g., Sjögren's syndrome)
• Systemic arthritis (e.g., rheumatoid arthritis)

» READ BOOK EXCERPT ONLINE »

Source: In a Page: Signs and Symptoms, 2004

Carpopedal spasm: Medical causes
(Handbook of Signs & Symptoms (Third Edition))

Hypocalcemia.

 Carpopedal spasm is an early sign of hypocalcemia. It's usually accompanied by paresthesia of the fingers, toes, and perioral area; muscle weakness, twitching, and cramping; hyperreflexia; chorea; fatigue; and palpitations. Positive Chvostek's and Trousseau's signs can be elicited. Laryngospasm, stridor, and seizures may appear in severe hypocalcemia.

Chronic hypocalcemia may be accompanied by mental status changes; cramps; dry, scaly skin; brittle nails; and thin, patchy hair and eyebrows.

Tetanus.

Tetanus develops when Clostridium tetani enters a wound in a nonimmunized individual. The patient develops muscle spasms and painful seizures. Difficulty swallowing and a low-grade fever are also present. If the patient isn't treated or treatment is delayed, the mortality rate is very high.

Other causes

Treatments.

Multiple blood transfusions and parathyroidectomy may cause hypocalcemia, resulting in carpopedal spasm. Surgical procedures that impair calcium absorption, such as ileostomy formation and gastric resection with gastrojejunostomy, may also cause hypocalcemia.

» READ BOOK EXCERPT ONLINE »

Source: Handbook of Signs & Symptoms (Third Edition), 2006

Jaw pain: Medical causes
(Handbook of Signs & Symptoms (Third Edition))

Angina pectoris

Angina may produce jaw pain (usually radiating from the substernal area) and left arm pain

Angina is less severe than the pain of an MI

It’s commonly triggered by exertion, emotional stress, or ingestion of a heavy meal and usually subsides with rest and the administration of nitroglycerin. Other signs and symptoms include shortness of breath, nausea and vomiting, tachycardia, dizziness, diaphoresis, belching, and palpitations.

Arthritis

With osteoarthritis, which usually affects the small joints of the hand, aching jaw pain increases with activity (talking, eating) and subsides with rest

Other features are crepitus heard and felt over the TMJ, enlarged joints with a restricted range of motion (ROM), and stiffness on awakening that improves with a few minutes of activity. Redness and warmth are usually absent.

Rheumatoid arthritiscauses symmetrical pain in all joints (commonly affecting proximal finger joints first), including the jaw. The joints display limited ROM and are tender, warm, swollen, and stiff after inactivity, especially in the morning. Myalgia is common. Systemic signs and symptoms include fatigue, weight loss, malaise, anorexia, lymphadenopathy, and a mild fever. Painless, movable rheumatoid nodules may appear on the elbows, knees, and knuckles. Progressive disease causes deformities, crepitation with joint rotation, muscle weakness and atrophy around the involved joint, and multiple systemic complications.

Gender cue

Rheumatoid arthritis usually appears in early middle age, between ages 36 and 50, and most commonly in women.

Head and neck cancer

Many types of head and neck cancer, especially of the oral cavity and nasopharynx, produce aching jaw pain of insidious onset

Other findings include a history of leukoplakia; ulcers of the mucous membranes; palpable masses in the jaw, mouth, and neck; dysphagia; bloody discharge; drooling; lymphadenopathy; and trismus.

Hypocalcemic tetany

Besides painful muscle contractions of the jaw and mouth, hypocalcemic tetany — a life-threatening disorder — produces paresthesia and carpopedal spasms

The patient may complain of weakness, fatigue, and palpitations. Examination reveals hyperreflexia and positive Chvostek’s and Trousseau’s signs. Muscle twitching, choreiform movements, and muscle cramps may also occur. With severe hypocalcemia, laryngeal spasm may occur with stridor, cyanosis, seizures, and cardiac arrhythmias.

Ludwig’s angina

Ludwig’s angina is an acute streptococcal infection of the sublingual and submandibular spaces that produces severe jaw pain in the mandibular area with tongue elevation, sublingual edema, and drooling

A fever is a common sign

Progressive disease produces dysphagia, dysphonia, and stridor and dyspnea due to laryngeal edema and obstruction by an elevated tongue.

MI

Initially, MI causes intense, crushing substernal pain that’s unrelieved by rest or nitroglycerin

The pain may radiate to the lower jaw, left arm, neck, back, or shoulder blades. (Rarely, jaw pain occurs without chest pain.) Other findings include pallor, clammy skin, dyspnea, excessive diaphoresis, nausea and vomiting, anxiety, restlessness, a feeling of impending doom, a low-grade fever, decreased or increased blood pressure, arrhythmias, an atrial gallop, new murmurs (in many cases from mitral insufficiency), and crackles.

Sinusitis

Maxillary sinusitis produces intense boring pain in the maxilla and cheek that may radiate to the eye. This type of sinusitis also causes a feeling of fullness, increased pain on percussion of the first and second molars and, in those with nasal obstruction, the loss of the sense of smell. Sphenoid sinusitis causes scanty nasal discharge and chronic pain at the mandibular ramus and vertex of the head and in the temporal area. Other signs and symptoms of both types of sinusitis include a fever, halitosis, a headache, malaise, a cough, and a sore throat.

Suppurative parotitis

Bacterial infection of the parotid gland by Staphylococcus aureus tends to develop in debilitated patients with dry mouth or poor oral hygiene

Besides the abrupt onset of jaw pain, a high fever, and chills, findings include erythema and edema of the overlying skin; a tender, swollen gland; and pus at the second top molar (Stensen’s ducts). Infection may lead to disorientation; shock and death are common.

Temporal arteritis

Most common in women older than age 60, temporal arteritis produces sharp jaw pain after chewing or talking

Nonspecific signs and symptoms include a low-grade fever, generalized muscle pain, malaise, fatigue, anorexia, and weight loss

Vascular lesions produce jaw pain; a throbbing, unilateral headache in the frontotemporal region; swollen, nodular, tender and, possibly, pulseless temporal arteries; and, at times, erythema of the overlying skin.

TMJ syndrome

TMJ syndrome is a common syndrome that produces jaw pain at the TMJ; spasm and pain of the masticating muscle; clicking, popping, or crepitus of the TMJ; and restricted jaw movement

Unilateral, localized pain may radiate to other head and neck areas. The patient typically reports teeth clenching, bruxism, and emotional stress. He may also experience ear pain, a headache, deviation of the jaw to the affected side upon opening the mouth, and jaw subluxation or dislocation, especially after yawning.

Tetanus

A rare life-threatening disorder caused by a bacterial toxin, tetanus produces stiffness and pain in the jaw and difficulty opening the mouth

Early nonspecific signs and symptoms (commonly unnoticed or mistaken for influenza) include a headache, irritability, restlessness, a low-grade fever, and chills. Examination reveals tachycardia, profuse diaphoresis, and hyperreflexia. Progressive disease leads to painful, involuntary muscle spasms that spread to the abdomen, back, or face. The slightest stimulus may produce reflex spasms of any muscle group. Ultimately, laryngospasm, respiratory distress, and seizures may occur.

Trigeminal neuralgia

Trigeminal neuralgia is marked by paroxysmal attacks of intense unilateral jaw pain (stopping at the facial midline) or rapid-fire shooting sensations in one division of the trigeminal nerve (usually the mandibular or maxillary division). This superficial pain, felt mainly over the lips and chin and in the teeth, lasts from 1 to 15 minutes. Mouth and nose areas may be hypersensitive. Involvement of the ophthalmic branch of the trigeminal nerve causes a diminished or absent corneal reflex on the same side. Attacks can be triggered by mild stimulation of the nerve (for example, lightly touching the cheeks), exposure to heat or cold, or consumption of hot or cold foods or beverages.

Other causes

Drugs

Some drugs, such as phenothiazines, affect the extrapyramidal tract, causing dyskinesias; others cause tetany of the jaw secondary to hypocalcemia.

» READ BOOK EXCERPT ONLINE »

Source: Handbook of Signs & Symptoms (Third Edition), 2006

Carpopedal spasm: Medical causes
(Professional Guide to Signs & Symptoms (Fifth Edition))

Hypocalcemia

Carpopedal spasm is an early sign of hypocalcemia. It’s usually accompanied by paresthesia of the fingers, toes, and perioral area; muscle weakness, twitching, and cramping; hyperreflexia; chorea; fatigue; and palpitations. Positive Chvostek’s and Trousseau’s signs can be elicited. Laryngospasm, stridor, and seizures may appear in severe hypocalcemia.

Chronic hypocalcemia may be accompanied by mental status changes; cramps; dry, scaly skin; brittle nails; and thin, patchy hair and eyebrows.

Tetanus

Tetanus is an infectious disease that develops when Clostridium tetani enters a wound in a nonimmunized individual. The patient develops muscle spasms, painful seizures, difficulty swallowing, and a low-grade fever. Without prompt treatment, mortality is very high.

Other causes

Treatments

Multiple blood transfusions and parathyroidectomy may cause hypocalcemia, resulting in carpopedal spasm. Surgical procedures that impair calcium absorption, such as ileostomy formation and gastric resection with gastrojejunostomy, may also cause hypocalcemia.

» READ BOOK EXCERPT ONLINE »

Source: Professional Guide to Signs & Symptoms (Fifth Edition), 2006

Jaw pain: Medical causes
(Professional Guide to Signs & Symptoms (Fifth Edition))

Angina pectoris

Angina may produce jaw pain (usually radiating from the substernal area) and left arm pain. Angina is less severe than the pain of an MI. It’s commonly triggered by exertion, emotional stress, or ingestion of a heavy meal and usually subsides with rest and the administration of nitroglycerin. Other signs and symptoms include shortness of breath, nausea and vomiting, tachycardia, dizziness, diaphoresis, belching, and palpitations.

Arthritis

With osteoarthritis, which usually affects the small joints of the hand, aching jaw pain increases with activity (talking, eating) and subsides with rest. Other features are crepitus heard and felt over the TMJ, enlarged joints with a restricted range of motion, and stiffness on awakening that improves with a few minutes of activity. Redness and warmth are usually absent.

Rheumatoid arthritis causes symmetrical pain in all joints (commonly affecting proximal finger joints first), including the jaw. The joints display limited range of motion and are tender, warm, swollen, and stiff after inactivity, especially in the morning. Myalgia is common. Systemic signs and symptoms include fatigue, weight loss, malaise, anorexia, lymphadenopathy, and mild fever. Painless, movable rheumatoid nodules may appear on the elbows, knees, and knuckles. Progressive disease causes deformities, crepitation with joint rotation, muscle weakness and atrophy around the involved joint, and multiple systemic complications.

Gender Cue: Rheumatoid arthritis usually appears in early middle age, between ages 36 and 50, and most commonly in women.

Head and neck cancer

Many types of head and neck cancer, especially of the oral cavity and nasopharynx, produce aching jaw pain of insidious onset. Other findings include a history of leukoplakia ulcers of the mucous membranes; palpable masses in the jaw, mouth, and neck; dysphagia; bloody discharge; drooling; lymphadenopathy; and trismus.

Hypocalcemic tetany

Besides painful muscle contractions of the jaw and mouth, this life-threatening disorder produces paresthesia and carpopedal spasms. The patient may complain of weakness, fatigue, and palpitations. Examination reveals hyperreflexia and positive Chvostek’s and Trousseau’s signs. Muscle twitching, choreiform movements, and muscle cramps may also occur. With severe hypocalcemia, laryngeal spasm may occur with stridor, cyanosis, seizures, and cardiac arrhythmias.

Ludwig’s angina

An acute streptococcal infection of the sublingual and submandibular spaces that produces severe jaw pain in the mandibular area with tongue elevation, sublingual edema, and drooling. Fever is a common sign. Progressive disease produces dysphagia, dysphonia, and stridor and dyspnea due to laryngeal edema and obstruction by an elevated tongue.

Myocardial infarction

Initially, this life-threatening disorder causes intense, crushing substernal pain that’s unrelieved by rest or nitroglycerin. The pain may radiate to the lower jaw, left arm, neck, back, or shoulder blades. (Rarely, jaw pain occurs without chest pain.) Other findings include pallor, clammy skin, dyspnea, excessive diaphoresis, nausea and vomiting, anxiety, restlessness, a feeling of impending doom, low-grade fever, decreased or increased blood pressure, arrhythmias, an atrial gallop, new murmurs (in many cases from mitral insufficiency), and crackles.

Osteomyelitis

Bone infection after trauma, sinus infection, dental injury, or surgery (dental or facial) may produce diffuse, aching jaw pain along with warmth, swelling, tenderness, erythema, and restricted jaw movement. Acute osteomyelitis may also cause tachycardia, sudden fever, nausea, and malaise. Chronic osteomyelitis may recur after minor trauma.

Sialolithiasis

With this disorder, stones form in the salivary glands, causing painful swelling that makes chewing uncomfortable. Jaw pain occurs in the lower jaw, floor of the mouth, and TMJ. It may also radiate to the ear or neck.

Sinusitis

Maxillary sinusitis produces intense boring pain in the maxilla and cheek that may radiate to the eye. This type of sinusitis also causes a feeling of fullness, increased pain on percussion of the first and second molars and, in those with nasal obstruction, the loss of the sense of smell. Sphenoid sinusitis causes scanty nasal discharge and chronic pain at the mandibular ramus and vertex of the head and in the temporal area. Other signs and symptoms of both types of sinusitis include fever, halitosis, headache, malaise, cough, sore throat, and fever.

Suppurative parotitis

Bacterial infection of the parotid gland by Staphylococcus aureus tends to develop in debilitated patients with dry mouth or poor oral hygiene. Besides the abrupt onset of jaw pain, high fever, and chills, findings include erythema and edema of the overlying skin; a tender, swollen gland; and pus at the second top molar (Stensen’s ducts). Infection may lead to disorientation; shock and death are common.

Temporal arteritis

Most common in women older than age 60, this disorder produces sharp jaw pain after chewing or talking. Nonspecific signs and symptoms include low-grade fever, generalized muscle pain, malaise, fatigue, anorexia, and weight loss. Vascular lesions produce jaw pain; throbbing, unilateral headache in the frontotemporal region; swollen, nodular, tender and, possibly, pulseless temporal arteries; and, at times, erythema of the overlying skin.

Temporomandibular joint syndrome

This common syndrome produces jaw pain at the TMJ; spasm and pain of the masticating muscle; clicking, popping, or crepitus of the TMJ; and restricted jaw movement. Unilateral, localized pain may radiate to other head and neck areas. The patient typically reports teeth clenching, bruxism, and emotional stress. He may also experience ear pain, headache, deviation of the jaw to the affected side upon opening the mouth, and jaw subluxation or dislocation, especially after yawning.

Tetanus

A rare life-threatening disorder caused by a bacterial toxin, tetanus produces stiffness and pain in the jaw and difficulty opening the mouth. Early nonspecific signs and symptoms (commonly unnoticed or mistaken for influenza) include headache, irritability, restlessness, low-grade fever, and chills. Examination reveals tachycardia, profuse diaphoresis, and hyperreflexia. Progressive disease leads to painful, involuntary muscle spasms that spread to the abdomen, back, or face. The slightest stimulus may produce reflex spasms of any muscle group. Ultimately, laryngospasm, respiratory distress, and seizures may occur.

Trauma

Injury to the face, head, or neck—particularly fracture of the maxilla or mandible—may produce jaw pain and swelling and decreased jaw mobility. Associated findings include hypotension and tachycardia (indicating shock), lacerations, ecchymoses, and hematomas. Rhinorrhea or otorrhea indicates the leakage of cerebrospinal fluid; blurred vision indicates orbital involvement.

Trigeminal neuralgia

This disorder is marked by paroxysmal attacks of intense unilateral jaw pain (stopping at the facial midline) or rapid-fire shooting sensations in one division of the trigeminal nerve (usually the mandibular or maxillary division). This superficial pain, felt mainly over the lips and chin and in the teeth, lasts from 1 to 15 minutes. Mouth and nose areas may be hypersensitive. Involvement of the ophthalmic branch of the trigeminal nerve causes a diminished or absent corneal reflex on the same side. Attacks can be triggered by mild stimulation of the nerve (for example, lightly touching the cheeks), exposure to heat or cold, or consumption of hot or cold foods or beverages.

Other causes

Drugs

Some drugs, such as phenothiazines, affect the extrapyramidal tract, causing dyskinesias; others cause tetany of the jaw secondary to hypocalcemia.

» READ BOOK EXCERPT ONLINE »

Source: Professional Guide to Signs & Symptoms (Fifth Edition), 2006

Tetanus: Causes
(Handbook of Diseases)

Normally, transmission is through a puncture wound that is contaminated by soil, dust, or animal excreta containing C. tetani, or by way of burns and minor wounds. After C. tetani enters the body, it causes local infection and tissue necrosis. It also produces toxins that then enter the bloodstream and lymphatics and eventually spread to central nervous system tissue.

Tetanus occurs worldwide, but it’s more prevalent in agricultural regions and developing countries that lack mass immunization programs. It’s one of the most common causes of neonatal deaths in developing countries, where neonates of unimmunized mothers are delivered under unsterile conditions. In such neonates, the unhealed umbilical cord is the portal of entry.

In America, about 75% of all cases occur between April and September.

» READ BOOK EXCERPT ONLINE »

Source: Handbook of Diseases, 2003

Carpopedal spasm: Medical causes
(Alarming Signs and Symptoms: Lippincott Manual of Nursing Practice Series)

Hypocalcemia.

Chronic hypocalcemia may be accompanied by mental status changes; cramps; dry, scaly skin; brittle nails; and thin, patchy hair and eyebrows. Tetanus is an infectious disease that develops when Clostridium tetani enters a wound in a nonimmunized individual. The patient develops muscle spasms and painful seizures. Difficulty swallowing and low-grade fever are also present. If the patient isn’t treated or treatment is delayed, the mortality rate is very high.

Other causes

» READ BOOK EXCERPT ONLINE »

Source: Alarming Signs and Symptoms: Lippincott Manual of Nursing Practice Series, 2007

Jaw pain: Medical causes
(Alarming Signs and Symptoms: Lippincott Manual of Nursing Practice Series)

Angina pectoris

Arthritis

Rheumatoid arthritis causes symmetrical pain in all joints (commonly affecting proximal finger joints first), including the jaw. The joints display limited range of motion and are tender, warm, swollen, and stiff after inactivity, especially in the morning. Myalgia is common. Systemic signs and symptoms include fatigue, weight loss, malaise, anorexia, lymphadenopathy, and mild fever. Painless, movable rheumatoid nodules may appear on the elbows, knees, and knuckles. Progressive disease causes deformities, crepitation with joint rotation, muscle weakness and atrophy around the involved joint, and multiple systemic complications.

Head and neck cancer

Many types of head and neck cancer, especially of the oral cavity and nasopharynx, produce aching jaw pain of insidious onset. Other findings include a history of leukoplakia ulcers of the mucous membranes; palpable masses in the jaw, mouth, and neck; dysphagia; bloody discharge; drooling; lymphadenopathy; and trismus.

Hypocalcemic tetany

Ludwig’s angina

An acute streptococcal infection of the sublingual and submandibular spaces that produces severe jaw pain in the mandibular area with tongue elevation, sublingual edema, and drooling. Fever is a common sign. Progressive disease produces dysphagia, dysphonia, and stridor and dyspnea due to laryngeal edema and obstruction by an elevated tongue.

Myocardial infarction

Osteomyelitis

Bone infection after trauma, sinus infection, dental injury, or surgery (dental or facial) may produce diffuse, aching jaw pain along with warmth, swelling, tenderness, erythema, and restricted jaw movement. Acute osteomyelitis may also cause tachycardia, sudden fever, nausea, and malaise. Chronic osteomyelitis may recur after minor trauma.

Sialolithiasis

Sinusitis

Maxillary sinusitis produces intense boring pain in the maxilla and cheek that may radiate to the eye. This type of sinusitis also causes a feeling of fullness, increased pain on percussion of the first and second molars and, in those with nasal obstruction, the loss of the sense of smell. Sphenoid sinusitis causes scanty nasal discharge and chronic pain at the mandibular ramus and vertex of the head and in the temporal area. Other signs and symptoms of both types of sinusitis include fever, halitosis, headache, malaise, cough, sore throat, and fever.

Suppurative parotitis

Temporal arteritis

Temporomandibular joint syndrome

Tetanus

A rare, acute life-threatening disorder caused by a bacterial toxin, tetanus produces stiffness and pain in the jaw and difficulty opening the mouth. Early nonspecific signs and symptoms (commonly unnoticed or mistaken for influenza) include headache, irritability, restlessness, low-grade fever, and chills. Examination reveals tachycardia, profuse diaphoresis, and hyperreflexia. Progressive disease leads to painful, involuntary muscle spasms that spread to the abdomen, back, or face. The slightest stimulus may produce reflex spasms of any muscle group. Ultimately, laryngospasm, respiratory distress, and seizures may occur.

Trauma

Trigeminal neuralgia

Other causes

Drugs

» READ BOOK EXCERPT ONLINE »

Source: Alarming Signs and Symptoms: Lippincott Manual of Nursing Practice Series, 2007

Carpopedal spasm: Medical causes
(Signs & Symptoms: A 2-in-1 Reference for Nurses)

Hypocalcemia

Carpopedal spasm is an early sign of hypocalcemia. It’s usually accompanied by paresthesia of the fingers, toes, and perioral area; muscle weakness, twitching, and cramping; hyperreflexia; chorea; fatigue; and palpitations. Positive Chvostek’s and Trousseau’s signs can be elicited. Laryngospasm, stridor, and seizures may appear in severe hypocalcemia.

Chronic hypocalcemia may be accompanied by mental status changes; cramps; dry, scaly skin; brittle nails; and thin, patchy hair and eyebrows.

Tetanus

With tetanus, an infectious disease caused by Clostridium tetani, the patient develops muscle spasms and painful seizures. Difficulty swallowing and a low-grade fever are also present. If the patient isn’t treated or treatment is delayed, the mortality rate is very high.

Other causes

Treatments

Multiple blood transfusions and parathyroidectomy may cause hypocalcemia, resulting in carpopedal spasm.

Surgical procedures

Surgical procedures that impair calcium absorption, such as ileostomy formation and gastric resection with gastrojejunostomy, may also cause hypocalcemia.

» READ BOOK EXCERPT ONLINE »

Source: Signs & Symptoms: A 2-in-1 Reference for Nurses, 2007

Jaw pain: Medical causes
(Signs & Symptoms: A 2-in-1 Reference for Nurses)

Angina pectoris

Angina may produce jaw pain (usually radiating from the substernal area) and left arm pain. Angina is less severe than the pain of an MI. It’s commonly triggered by exertion, emotional stress, or ingestion of a heavy meal and usually subsides with rest and the administration of nitroglycerin. Other signs and symptoms include shortness of breath, nausea and vomiting, tachycardia, dizziness, diaphoresis, belching, and palpitations.

Arthritis

With osteoarthritis, aching jaw pain increases with activity (talking, eating) and subsides with rest. Other features are crepitus heard and felt over the TMJ, enlarged joints with a restricted range of motion, and stiffness on awakening that improves with a few minutes of activity. Redness and warmth are usually absent.

Rheumatoid arthritis causes symmetrical pain in all joints, including the jaw. The joints display limited range of motion and are tender, warm, swollen, and stiff after inactivity, especially in the morning. Myalgia is common. Systemic signs and symptoms include fatigue, weight loss, malaise, anorexia, lymphadenopathy, and mild fever. Painless, movable rheumatoid nodules may appear on the elbows, knees, and knuckles. Progressive disease causes deformities, crepitation with joint rotation, muscle weakness and atrophy around the involved joint, and multiple systemic complications.

Head and neck cancer

Many types of head and neck cancer, especially those of the oral cavity and nasopharynx, produce aching jaw pain of insidious onset. Other findings include a history of leukoplakia ulcers of the mucous membranes; palpable masses in the jaw, mouth, and neck; dysphagia; bloody discharge; drooling; lymphadenopathy; and trismus.

Hypocalcemic tetany

Besides painful muscle contractions of the jaw and mouth, this life-threatening disorder produces paresthesia and carpopedal spasms. The patient may complain of weakness, fatigue, and palpitations. Examination reveals hyperreflexia and positive Chvostek’s and Trousseau’s signs. Muscle twitching, choreiform movements, and muscle cramps may also occur. With severe hypocalcemia, laryngeal spasm may occur with stridor, cyanosis, seizures, and cardiac arrhythmias.

Ludwig’s angina

Ludwig’s angina is an acute streptococcal infection of the sublingual and submandibular spaces that produces severe jaw pain in the mandibular area with tongue elevation, sublingual edema, and drooling. Fever is a common sign. Progressive disease produces dysphagia, dysphonia, and stridor and dyspnea due to laryngeal edema and obstruction by an elevated tongue.

Myocardial infarction

Initially, this life-threatening disorder causes intense, crushing substernal pain that’s unrelieved by rest or nitroglycerin. The pain may radiate to the lower jaw, left arm, neck, back, or shoulder blades. (Rarely, jaw pain occurs without chest pain.) Other findings in MI include pallor, clammy skin, dyspnea, excessive diaphoresis, nausea and vomiting, anxiety, restlessness, a feeling of impending doom, low-grade fever, decreased or increased blood pressure, arrhythmias, an atrial gallop, new murmurs (in many cases from mitral insufficiency), and crackles.

Osteomyelitis

Bone infection after trauma, sinus infection, dental injury, or surgery (dental or facial) may produce diffuse, aching jaw pain along with warmth, swelling, tenderness, erythema, and restricted jaw movement. Acute osteomyelitis may also cause tachycardia, sudden fever, nausea, and malaise. Chronic osteomyelitis may recur after minor trauma.

Sinusitis

Maxillary sinusitis produces intense boring pain in the maxilla and cheek that may radiate to the eye. This type of sinusitis also causes a feeling of fullness, increased pain on percussion of the first and second molars and, in those with nasal obstruction, the loss of the sense of smell. Sphenoid sinusitis causes scanty nasal discharge and chronic pain at the mandibular ramus and vertex of the head and in the temporal area. Other signs and symptoms of both types of sinusitis include fever, halitosis, headache, malaise, cough, sore throat, and fever.

Suppurative parotitis

With suppurative parotitis, bacterial infection of the parotid gland by Staphylococcus aureus produces abrupt onset of jaw pain, high fever, and chills. Other findings include erythema and edema of the overlying skin; a tender, swollen gland; and pus at the second top molar (Stensen’s ducts). Infection may lead to disorientation; shock and death are common.

Temporal arteritis

Temporal arteritis produces sharp jaw pain after chewing or talking. Nonspecific signs and symptoms include low-grade fever, generalized muscle pain, malaise, fatigue, anorexia, and weight loss. Vascular lesions produce jaw pain; throbbing, unilateral headache in the frontotemporal region; swollen, nodular, tender and, possibly, pulseless temporal arteries; and, at times, erythema of the overlying skin.

Temporomandibular joint disorders

TMJ disorders produce jaw pain at the TMJ; spasm and pain of the masticating muscle; clicking, popping, or crepitus of the TMJ; and restricted jaw movement. Unilateral, localized pain may radiate to other head and neck areas. The patient typically reports teeth clenching, bruxism, and emotional stress. He may also experience ear pain, headache, deviation of the jaw to the affected side upon opening the mouth, and jaw subluxation or dislocation, especially after yawning.

Trauma

Injury to the face, head, or neck — particularly fracture of the maxilla or mandi-
ble — may produce jaw pain and swelling and decreased jaw mobility. Associated findings include hypotension and tachycardia (indicating shock), lacerations, ecchymoses, and hematomas. Rhinorrhea or otorrhea indicates the leakage of cerebrospinal fluid; blurred vision indicates orbital involvement.

Trigeminal neuralgia

Trigeminal neuralgia is marked by paroxysmal attacks of intense unilateral jaw pain (stopping at the facial midline) or rapid-fire shooting sensations in one division of the trigeminal nerve (usually the mandibular or maxillary division). This superficial pain, felt mainly over the lips and chin and in the teeth, lasts from 1 to 15 minutes. Mouth and nose areas may be hypersensitive. Involvement of the ophthalmic branch of the trigeminal nerve causes a diminished or absent corneal reflex on the same side. Attacks can be triggered by mild stimulation of the nerve (for example, lightly touching the cheeks), exposure to heat or cold, or consumption of hot or cold foods or beverages.

Other causes

Drugs

Some drugs, such as phenothiazines, affect the extrapyramidal tract, causing dyskinesias; others cause tetany of the jaw secondary to hypocalcemia.

» READ BOOK EXCERPT ONLINE »

Source: Signs & Symptoms: A 2-in-1 Reference for Nurses, 2007

Carpopedal spasm: Medical causes
(Nursing: Interpreting Signs and Symptoms)

Hypocalcemia.Carpopedal spasm is an early sign of hypocalcemia. It's usually accompanied by paresthesia of the fingers, toes, and perioral area; muscle weakness, twitching, and cramping; hyperreflexia; chorea; fatigue; and palpitations. Positive Chvostek's and Trousseau's signs can be elicited. Laryngospasm, stridor, and seizures may appear in severe hypocalcemia.

Chronic hypocalcemia may be accompanied by mental status changes; cramps; dry, scaly skin; brittle nails; and thin, patchy hair and eyebrows.

Tetanus.With tetanus, the patient develops muscle spasms and painful seizures. Difficulty swallowing and a low-grade fever are also present. If the patient isn't treated or treatment is delayed, the mortality rate is very high.

Other causes

Treatments.Multiple blood transfusions and parathyroidectomy may cause hypocalcemia, resulting in carpopedal spasm. Surgical procedures that impair calcium absorption, such as ileostomy formation and gastric resection with gastrojejunostomy, may also cause hypocalcemia.

» READ BOOK EXCERPT ONLINE »

Source: Nursing: Interpreting Signs and Symptoms, 2007

Jaw pain: Medical causes
(Nursing: Interpreting Signs and Symptoms)

Angina pectoris.Angina may produce jaw pain (usually radiating from the substernal area) and left arm pain. Angina is less severe than the pain of an MI. It's commonly triggered by exertion, emotional stress, or ingestion of a heavy meal and usually subsides with rest and the administration of nitroglycerin. Other signs and symptoms include shortness of breath, nausea and vomiting, tachycardia, dizziness, diaphoresis, belching, and palpitations.

Arthritis.With osteoarthritis, which usually affects the small joints of the hand, aching jaw pain increases with activity (talking, eating) and subsides with rest. Other features are crepitus heard and felt over the TMJ, enlarged joints with a restricted range of motion (ROM), and stiffness on awakening that improves with a few minutes of activity. Redness and warmth are usually absent.

Rheumatoid arthritis causes symmetrical pain in all joints (commonly affecting proximal finger joints first), including the jaw. The joints display limited ROM and are tender, warm, swollen, and stiff after inactivity, especially in the morning. Myalgia is common. Systemic signs and symptoms include fatigue, weight loss, malaise, anorexia, lymphadenopathy, and a mild fever. Painless, movable rheumatoid nodules may appear on the elbows, knees, and knuckles. Progressive disease causes deformities, crepitation with joint rotation, muscle weakness and atrophy around the involved joint, and multiple systemic complications.

Head and neck cancer.Many types of head and neck cancer, especially of the oral cavity and nasopharynx, produce aching jaw pain of insidious onset. Other findings include a history of leukoplakia; ulcers of the mucous membranes; palpable masses in the jaw, mouth, and neck; dysphagia; bloody discharge; drooling; lymphadenopathy; and trismus.

Hypocalcemic tetany.Besides painful muscle contractions of the jaw and mouth, hypocalcemic tetany—a life-threatening disorder—produces paresthesia and carpopedal spasms. The patient may complain of weakness, fatigue, and palpitations. Examination reveals hyperreflexia and positive Chvostek's and Trousseau's signs. Muscle twitching, choreiform movements, and muscle cramps may also occur. With severe hypocalcemia, laryngeal spasm may occur with stridor, cyanosis, seizures, and cardiac arrhythmias.

Ludwig's angina.Ludwig's angina is an acute streptococcal infection of the sublingual and submandibular spaces that produces severe jaw pain in the mandibular area with tongue elevation, sublingual edema, and drooling. A fever is a common sign. Progressive disease produces dysphagia, dysphonia, and stridor and dyspnea due to laryngeal edema and obstruction by an elevated tongue.

MI.Initially, MI causes intense, crushing substernal pain that's unrelieved by rest or nitroglycerin. The pain may radiate to the lower jaw, left arm, neck, back, or shoulder blades. (Rarely, jaw pain occurs without chest pain.) Other findings include pallor, clammy skin, dyspnea, excessive diaphoresis, nausea and vomiting, anxiety, restlessness, a feeling of impending doom, a low-grade fever, decreased or increased blood pressure, arrhythmias, an atrial gallop, new murmurs (in many cases from mitral insufficiency), and crackles.

Sinusitis.Maxillary sinusitis produces intense boring pain in the maxilla and cheek that may radiate to the eye. This type of sinusitis also causes a feeling of fullness, increased pain on percussion of the first and second molars and, in those with nasal obstruction, the loss of the sense of smell. Sphenoid sinusitis causes scanty nasal discharge and chronic pain at the mandibular ramus and vertex of the head and in the temporal area. Other signs and symptoms of both types of sinusitis include a fever, halitosis, a headache, malaise, a cough, and a sore throat.

Suppurative parotitis.Bacterial infection of the parotid gland by Staphylococcus aureus tends to develop in debilitated patients with dry mouth or poor oral hygiene. Besides the abrupt onset of jaw pain, a high fever, and chills, findings include erythema and edema of the overlying skin; a tender, swollen gland; and pus at the second top molar (Stensen's ducts). Infection may lead to disorientation; shock and death are common.

Temporal arteritis.Most common in women older than age 60, temporal arteritis produces sharp jaw pain after chewing or talking. Nonspecific signs and symptoms include a low-grade fever, generalized muscle pain, malaise, fatigue, anorexia, and weight loss. Vascular lesions produce jaw pain; a throbbing, unilateral headache in the frontotemporal region; swollen, nodular, tender and, possibly, pulseless temporal arteries; and, at times, erythema of the overlying skin.

TMJ syndrome.TMJ syndrome is a common syndrome that produces jaw pain at the TMJ; spasm and pain of the masticating muscle; clicking, popping, or crepitus of the TMJ; and restricted jaw movement. Unilateral, localized pain may radiate to other head and neck areas. The patient typically reports teeth clenching, bruxism, and emotional stress. He may also experience ear pain, a headache, deviation of the jaw to the affected side upon opening the mouth, and jaw subluxation or dislocation, especially after yawning.

Tetanus.A rare life-threatening disorder caused by a bacterial toxin, tetanus produces stiffness and pain in the jaw and difficulty opening the mouth. Early nonspecific signs and symptoms (commonly unnoticed or mistaken for influenza) include a headache, irritability, restlessness, a low-grade fever, and chills. Examination reveals tachycardia, profuse diaphoresis, and hyperreflexia. Progressive disease leads to painful, involuntary muscle spasms that spread to the abdomen, back, or face. The slightest stimulus may produce reflex spasms of any muscle group. Ultimately, laryngospasm, respiratory distress, and seizures may occur.

Trigeminal neuralgia.Trigeminal neuralgia is marked by paroxysmal attacks of intense unilateral jaw pain (stopping at the facial midline) or rapid-fire shooting sensations in one division of the trigeminal nerve (usually the mandibular or maxillary division). This superficial pain, felt mainly over the lips and chin and in the teeth, lasts from 1 to 15 minutes. Mouth and nose areas may be hypersensitive. Involvement of the ophthalmic branch of the trigeminal nerve causes a diminished or absent corneal reflex on the same side. Attacks can be triggered by mild stimulation of the nerve (for example, lightly touching the cheeks), exposure to heat or cold, or consumption of hot or cold foods or beverages.

Other causes

Drugs.Some drugs, such as phenothiazines, affect the extrapyramidal tract, causing dyskinesias; others cause tetany of the jaw secondary to hypocalcemia.

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Source: Nursing: Interpreting Signs and Symptoms, 2007

Tetanus: Tetanus - risk factors
(The 5-Minute Pediatric Consult)

• Inadequate immunization
• Neonate born to unimmunized mother
• Elderly with declining immune status
• Injection drug use
• Chronic wounds
• Acute traumatic injury
• Nonsterile delivery conditions and practice of applying mud or feces to umbilical cord

Tetanus - pathophysiology

• C. tetani produces tetanospasmin, a powerful neurotoxin, which binds irreversibly to neurons.
• Tetanospasmin can be absorbed directly into skeletal muscles adjacent to the injury.
• Tetanospasmin can travel to the CNS through peripheral nerves or via lymphocytes.
• Tetanospasmin affects the peripheral nervous system, CNS, and autonomic nervous system:
  • At the neuromuscular junction:
    • Blocks the release of acetylcholine, preventing the inhibition of sustained excitatory nervous impulses
  • In the CNS neuronal membranes:
  • Binds to gangliosides and blocks inhibitory signals (γ-aminobutyric acid and glycine) to motor neurons.
  • In the autonomic nervous system:
    • Mechanism by which tetanospasmin causes autonomic instability and respiratory failure is not well understood.
• Tetanospasmin does not directly affect cognitive processes.

Tetanus - etiology

• Tetanus is caused by C. tetani, a spore forming, anaerobic, Gram-positive bacillus.
• C. tetani is found in soil, animal and human feces, house dust, salt and fresh water.
• Under anaerobic conditions inoculated spores become vegetative and produce tetanospasmin.
• Anaerobic conditions in wounds are promoted by large amounts of necrosis, foreign bodies and other ongoing infections with suppuration.

» READ BOOK EXCERPT ONLINE »

Source: The 5-Minute Pediatric Consult, 2008

 » Next page: Risk Factors for Tetanus

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