Persistent face and eye pain after facial-neuralgia treatment, with assessment around the hyoid bone

This de-identified case involved a man in his fifties whose eye pressure sensation and pain in the temples, cheekbones, ears, TMJs, neck, and shoulders continued after MRI showed no clear abnormality and he received treatment for facial neuralgia.

The earlier diagnosis was not simply rejected. Teeth and occlusion, the TMJs and masticatory muscles, and the muscles and ligaments around the hyoid bone were assessed as parts of a broader differential evaluation.

Over about 11 months, the patient had 52 TMJ-care visits, including a custom jaw appliance, physical therapy, medication, and one injection treatment. Dental prosthetic and implant visits were separate and are not included in 52.

At the final visit he reported living comfortably without a particular problem and felt ready to finish care. This course does not prove that all face, eye, ear, or neck symptoms began in the TMJ or hyoid region, nor does it predict another person's outcome.

Case record

Case 000027: a man in his fifties treated during 2023–2024 for TMJ pain, eye pressure, temple, cheekbone, ear, neck and shoulder pain, headache, and dizziness after prior MRI, injections, and medication for facial neuralgia.

This record shows the patient's reported symptom sequence and the evaluation and care documented in this case. It does not demonstrate the efficacy of a particular treatment or imply that everyone needs the same number of visits.

Pain continued despite a normal MRI and neuralgia treatment

The patient said that an anesthesiology pain clinic found no clear MRI abnormality and diagnosed facial neuralgia. Weekly injections and prescribed medication continued until the week before his visit, without improvement in face, eye, head, and neck pain.

A normal MRI is important information, but it does not mean pain is absent or exclude every dental, TMJ, muscular, headache, or neuropathic pain condition.

The differential included teeth and gums, TMJs and masticatory muscles, migraine and other headaches, neuropathic facial pain, eye and ear disease, sinus and cervical disorders, pain around hyoid muscles and ligaments, and neck-shoulder musculoskeletal problems.

Failure to respond to earlier treatment was not used to declare the earlier diagnosis wrong. Other explanations for the current symptoms were assessed in parallel.

Symptoms reported at the first visit

He described right TMJ pain and a closing click present for about five months. After three days of burning pain in the left cheek and cheekbone, pulling and tightening developed at the outer and upper eye.

Other symptoms included forehead and temple pressure, electric pain rising from the back of the neck to the occiput, scalp numbness, ear and cheekbone pain, posterior neck and shoulder pain, headache, dizziness, limb tingling, and a bone-like sound at the back of the neck when closing the mouth.

When symptoms span many areas and are described in different ways, it is especially important not to force them into a single cause.

Morning symptom pattern

On waking, he sometimes felt pressure in the left eye followed by pain at the back of the neck and left side of the head. Symptoms began around 5 a.m.; washing his face after rising around 6 a.m. was the most uncomfortable time.

On some days, tingling in the left cheekbone after waking was followed by an occipital headache. The sequence was not identical every day.

Recording onset time, location, and sequence helps distinguish overlapping pain patterns; it does not by itself establish a cause.

Feeling eye pressure is not the same as measured high intraocular pressure

A subjective feeling that the eye is pressured or tightening is not the same as elevated intraocular pressure measured in an ophthalmic examination.

Sudden visual loss or field change, severe redness, halos, double vision, severe eye pain with vomiting, marked pain on eye movement, or accompanying neurologic symptoms require ophthalmic or emergency assessment before TMJ care.

Persistent eye pain or pressure still warrants ophthalmic evaluation even without those warning signs. TMJ and muscle assessment cannot substitute for examination of eye disease.

When no actual pressure elevation is found, some people may still perceive pressure while temple and periocular referred pain varies with TMJ or masticatory-muscle discomfort. This sensation cannot diagnose jaw-related pain or establish normal eye pressure.

Can TMJ or muscle pain be felt around the eye?

TMJ and masticatory-muscle discomfort can occur with temple and periocular pain. In this case, pulling above the eye, eye tightness, temple and cheekbone pain, and neck-shoulder pain recurred with jaw symptoms.

The temporalis muscle moves the jaw, and pain from the TMJ or masticatory muscles may be perceived more broadly in nearby facial areas. Eye pressure alone, however, cannot diagnose referred pain.

Eye disease, migraine, and neurologic causes should be separated first, then clinicians can assess whether symptoms vary with jaw movement and masticatory-muscle findings.

Facial neuralgia and jaw-related referred pain

Facial neuralgia and TMJ or masticatory-muscle pain are not the same diagnosis, although more than one pain mechanism can coexist in one person.

Neuropathic facial pain assessment considers electric-shock quality, brief severe attacks, triggers such as washing, brushing, or talking, sensory change, and whether pain follows a nerve distribution.

Jaw-related assessment considers change with chewing, opening, closing, or clenching; reproduction of familiar pain on joint or muscle palpation; joint sounds or catching; and changes in opening range or path.

Neither lack of response to neuralgia treatment nor later improvement during TMJ care was used to prove a single diagnosis or origin.

What is hyoid bone syndrome?

Hyoid bone syndrome is a rare differential diagnosis for neck and facial pain arising around the hyoid region. Brown first described a pain syndrome characterized by tenderness at the greater cornu of the hyoid in 1954.

The hyoid lies in the front of the neck and connects through muscles and ligaments with the tongue, pharynx, mandible, and surrounding neck structures.

Published descriptions report localized pain and tenderness at the greater cornu radiating toward the throat, ear, face, mandible, submandibular area, and sometimes the shoulder or upper chest. Talking, swallowing, yawning, or turning the head may aggravate it.

Pain across several face and neck areas alone is not enough to diagnose hyoid bone syndrome.

Findings considered in suspected hyoid bone syndrome

Relevant findings can include localized tenderness near the greater cornu, deep anterior-neck or throat pain, worsening with swallowing, discomfort with talking or yawning, change with head rotation, radiation toward the ear, jaw, or face, and reproduction of familiar pain on palpation.

ENT disease, thyroid and cervical disorders, infection, salivary-gland disease, dental and TMJ problems, neuralgia, and other anterior-neck pain syndromes must also be distinguished.

Was this a typical case of hyoid bone syndrome?

The patient had ear, cheekbone, TMJ, neck, posterior shoulder, temple, and periocular pain. He did not report clear throat pain, pain on swallowing, non-dental molar-area pain, clavicular pain, or chest pain.

He was therefore not labeled as having typical hyoid bone syndrome. Because jaw, ear, neck, and shoulder pain was widespread, possible functional involvement of muscles and ligaments around the hyoid was included in the differential.

This is a case in which pain around the hyoid, including hyoid bone syndrome, was considered—not a case that confirmed the syndrome.

Where should hyoid-region pain be evaluated?

When ENT assessment comes first

Throat-centered pain, difficult or painful swallowing, persistent hoarseness, neck swelling or fever, breathing difficulty, or a palpable neck mass should first be assessed for pharyngeal, laryngeal, thyroid, infectious, and other cervical disease.

When dental and oral-maxillofacial assessment can contribute

Dental assessment may contribute when jaw and ear pain occur together; symptoms vary with chewing, yawning, talking, or neck movement; joint sounds or opening changes are present; or teeth, TMJs, masticatory muscles, and the hyoid region need to be distinguished.

No single test diagnoses hyoid bone syndrome.

Assessment can include onset location, greater-cornu tenderness, reproduction on palpation, relation to swallowing, talking, yawning or head rotation, dental and TMJ status, pharynx, larynx and thyroid, imaging such as CT when indicated, infection, and neuropathic pain.

Does a sore feeling near the hyoid prove the syndrome?

A sore or wounded feeling in the throat or hyoid area is not diagnostic.

Pharyngeal or laryngeal inflammation, tonsillar, thyroid or cervical disease, neck infection, salivary-gland disease, neuralgia, TMJ and muscle pain, and other anterior-neck syndromes must be considered first.

If these causes are not found, familiar pain is reproduced by palpating the greater cornu, and symptoms vary with swallowing, talking, yawning, or neck rotation, hyoid bone syndrome may be included in the differential diagnosis.

How the 1991 JPD paper described hyoid bone syndrome

Ernest and Salter described degenerative injury at the attachment of the middle pharyngeal constrictor to the greater cornu, with histologic evidence of insertion tendinosis.

The paper is important for understanding the diagnostic concept and localized attachment-site pain, but it does not justify diagnosing everyone with widespread face and neck pain as having hyoid bone syndrome.

Clinical interpretation still requires localized greater-cornu tenderness, reproduction of familiar pain, change with swallowing or talking, and exclusion of other dental, ENT, and neurologic causes.

Teeth, occlusion, and TMJs were assessed together

Obok Dental Clinic does not routinely perform occlusal adjustment or prosthetic treatment merely because TMJ symptoms are present. In this case, missing teeth reduced occlusal support and dental restoration needs coexisted with TMJ and muscle symptoms.

Implant and prosthetic care and TMJ care were therefore coordinated within one overall plan. This does not mean that missing teeth caused the face and eye pain or that implant restorations directly treated TMJ pain.

Appliance planning considered remaining teeth, existing prostheses and implants, current occlusion, structures available for support, opening and jaw movement, joint and muscle pain, and the treatment goal.

Dental and TMJ care occurred during the same period, but the recorded 52 visits count only TMJ care; prosthetic and implant visits are excluded.

Custom jaw-appliance workflow

The teeth and occlusion were recorded with a digital intraoral scanner, and the custom appliance was produced through a digital workflow that included 3D printing.

Making the appliance was not the end of care. Fit and retention, occlusal contacts, jaw movement, pain and opening changes, masticatory fatigue, and adaptation during sleep and daily life were repeatedly checked and adjusted.

Digital fabrication is a production method; clinical value depends on post-delivery adjustment and follow-up of function and symptoms.

TMJ care over 11 months

The 52 TMJ visits included custom-appliance care, TMJ physical therapy, medication, care informed by jaw function and occlusion, one injection treatment, appliance-fit and occlusal adjustment, and repeated assessment of symptoms and mouth opening.

The count is not a standard number of visits. This was a complex case with chronic multi-site pain that required long-term observation of symptom changes and appliance adaptation.

It should not be used to estimate another patient's duration or visit count.

Why was follow-up so long?

The course involved persistent pain after neuralgia treatment; symptoms across the eye, temple, cheekbone, ear, neck, and shoulder; TMJ pain and sound; morning variation; appliance fabrication and repeated adjustment; simultaneous dental restoration; and observation of hyoid-region and neck function.

A high visit count does not mean that all TMJ treatment is difficult or prolonged. It documents follow-up chosen for this patient's symptom range and circumstances.

Change at the final visit

The patient said, “I have been comfortable without anything unusual. I think I can finish treatment.” After confirming his current condition, the approximately 11-month TMJ course was ended.

Improvement at the end does not establish that every original symptom was caused by the TMJ, that hyoid bone syndrome caused everything, that one appliance resolved all symptoms, or that another patient will improve after 52 visits.

Treatment response is clinically useful information, but it does not prove the cause in reverse.

Symptoms that require other care urgently

Do not assume TMJ or hyoid bone syndrome when there is sudden visual loss, double vision, severe red-eye pain, facial weakness, sudden slurred speech, weakness in one arm or leg, a new very severe headache, altered consciousness, repeated vomiting, chest pain or breathing difficulty, cold sweating or fainting, rapid neck swelling, difficult swallowing or breathing, or fever with severe throat pain.

Ophthalmic, neurologic, ENT, or emergency evaluation may take priority in these situations.

Four points to retain from this case

1. A normal MRI does not end pain evaluation

MRI findings must be considered with onset, duration, triggers, examination, and function; they do not exclude all dental, jaw, muscular, headache, or neuropathic pain.

2. Other possibilities were assessed without rejecting the earlier diagnosis

TMJ pain, neuropathic pain, headache, and neck pain may coexist. Nonresponse to one treatment alone does not settle the diagnosis.

3. Hyoid bone syndrome remained a differential diagnosis

The hyoid region was considered because ear, jaw, neck, and shoulder pain was widespread, but typical throat and swallowing pain was absent, so the syndrome was not confirmed.

4. Fifty-two visits counted TMJ care only

Prosthetic and implant care was separate. The number documents this individual's long course and is not a standard visit count.

Summary

After no clear MRI finding and treatment for facial neuralgia, the patient continued to have eye pressure and pain involving the temples, cheekbones, ears, TMJs, neck, and posterior shoulders.

Evaluation included teeth and occlusion, TMJs and masticatory muscles, opening and jaw movement, hyoid-region muscles and ligaments, periocular and ear symptoms, neck and shoulder pain, and the timing and sequence of symptoms.

The patient completed 52 TMJ visits over about 11 months with a custom appliance, physical therapy, medication, and one injection treatment. Dental prosthetic and implant visits were not included.

He reported being comfortable at the final visit and chose to end care after review. This individual response does not prove that the TMJ or hyoid region caused every symptom.

Frequently asked questions

What is hyoid bone syndrome?

It is a rare pain condition characterized by localized greater-cornu tenderness and neck or throat pain that may radiate to the ear, face, and mandible. Diagnosis requires reproduction of familiar pain and exclusion of other conditions, not a symptom checklist alone.

Which department evaluates suspected hyoid bone syndrome?

ENT assessment comes first for throat pain, swallowing difficulty, hoarseness, swelling, or fever. Dental oral-maxillofacial assessment can help when jaw and ear symptoms vary with chewing, yawning, talking, or neck movement.

Was hyoid bone syndrome confirmed in this patient?

No. Hyoid-region function was included in the differential because ear, jaw, neck, and shoulder pain coexisted, but typical throat and swallowing pain was absent.

Does tenderness over the hyoid prove the diagnosis?

No. Clinicians compare reproduction of familiar pain and change with swallowing, talking, yawning, or neck rotation while excluding ENT, thyroid, infectious, dental, TMJ, and neuropathic causes.

Can face and eye pain continue despite a normal MRI?

Yes. A normal MRI is important but does not exclude every dental, jaw, muscular, headache, or neuropathic pain condition. Symptom pattern, neurologic examination, and dental, ophthalmic, and ENT assessment must be compared.

How are facial neuralgia and jaw-related pain distinguished?

Clinicians compare brief electric attacks and sensory or trigger patterns with change during chewing, opening, closing, clenching, and palpation. More than one mechanism may coexist.

Why were there 52 TMJ visits?

Chronic pain affected several regions, and appliance fabrication and repeated adjustment, physical therapy, medication, jaw function, and symptom change were followed for about 11 months. The number excludes dental restoration and is not a general recommendation.

Research cited with this case

Brown, 1954: original description

Brown LA. Hyoid bone syndrome. Southern Medical Journal. 1954;47(11):1088–1091. DOI: 10.1097/00007611-195411000-00013. This early report described tenderness at the greater cornu; current diagnosis still requires broader differential assessment.

Ernest and Salter, 1991: attachment-site degeneration

Ernest EA III, Salter EG. Journal of Prosthetic Dentistry. 1991;66(1):78–83. DOI: 10.1016/0022-3913(91)90357-3. Histology supported insertion tendinosis at the middle pharyngeal constrictor attachment, but widespread pain alone remains insufficient for diagnosis.

Robinson and colleagues, 1994: radiating pain

Robinson PJ, Davis JP, Fraser JG. Journal of Laryngology & Otology. 1994;108(10):855–858. DOI: 10.1017/S0022215100128324. The report described pain worsened by swallowing and radiating to the ear, face, and mandible; this patient lacked the typical throat and swallowing pain.

Li and colleagues, 2023: case series and diagnostic process

Li CX, Hu L, Gong ZC. Journal of Stomatology, Oral and Maxillofacial Surgery. 2023;124(1):101263. DOI: 10.1016/j.jormas.2022.08.006.

The series included greater-cornu palpation and CT in patients whose deep throat and neck pain varied with talking, swallowing, yawning, or head turning.

Nir and colleagues, 1998: conservative treatment study

Nir D, Hefer T, Joachims HZ. American Journal of Otolaryngology. 1998;19(5):296–300. DOI: 10.1016/S0196-0709(98)90001-1. The study reported symptom change after NSAIDs in suspected hyoid bone syndrome; it does not mean that this treatment was used in this case.

Siccoli and colleagues, 2006: differential diagnosis of facial pain

Siccoli MM, Bassetti CL, Sándor PS. Lancet Neurology. 2006;5(3):257–267. DOI: 10.1016/S1474-4422(06)70375-1. This review supports separating neuralgic, dental, masticatory, sinus, and other causes rather than deciding from a normal MRI or response to one treatment.