To the Editor.
—We read with interest the excellent synopsis of otorhinolaryngologic causes of persistent ear discomfort and neck pain by Leliever.1 In our experience, in addition to eustachian tube dysfunction, an often overlooked cause of the symptoms described is activation of myofascial trigger points in the clavicular division of the sternocleidomastoid muscle (although some have questioned the basic concept2,3).As characterized by Travell and Simons,4 when activated sternocleidomastoid trigger points are present and produce characteristic referred ear and neck pain on one side in the pattern described in the question posed to LeLiever,1 such points are usually found on the opposite side as well. This would account for the bilateral distribution of the patient's pain, as well as her increased pain on flexion of her neck. Travell and Simons note that persons with such trigger points also often experience referred frontal headaches and referred autonomic
Conwill DE, Cook BH. Persistent Ear Discomfort and Neck Pain. JAMA. 1993;270(3):323. doi:10.1001/jama.1993.03510030047027