RADIATION INDUCED TRISMUS

Kara G. Cullins

What is Trismus?

Traditional Definition “Tonic contraction of the muscles ofmastication ” –Taber’s s Cyclopedic Medical Dictionary

any limitation or restriction of opening the mouth

Criteria for Trismus?

Three finger test for screening

Inconsistency as to what degree of opening or restriction is classified as trismus in the literature.

Dijkstra et al. proposed that an opening of 35mm or less be used to classify trismus in head and neck cancer patients

Criteria continued

Some researchers that define trismus variously as a mouth opening less than 20 mm and less than 40mm (Dijkstra, Huisman, & Roodenburg, 2006

A measurement of less than 15mm of opening is classified as severe (Thomas et. al., 1998)

An opening of less than 18-20mm makes oral feeding difficult

Incidence

Found in 2% of patients at time of diagnosis for head and neck cancer. (Scott, Butterworth, Lowe, & Rogers, 2008)

Incidence rates vary greatly according to research

5-38% of patients who undergo treatment for head and neck cancer will develop trismus

Causes of Trismus

May be caused by radiation, trauma, infection, surgery, or due to tumor growth (oncology) (Dijkstra, Huisman, & Roodenburg, 2006)

Neurologic Craniofacial/ Dental Congenital/ Developmental Iatrogenic

Radiation induced Trismus

Temporal mandibular joint, masseter muscle, and pterygoid muscles involved in radiation therapy

www.parkchambersdental.co.uk/images/tmj.jpg

Radiation induced Trismus

“The direct effect of radiation on muscles ultimately results in fibrosis and contracture”

(Sciubba and Goldenberg, 2006)

Muscle fibers shorten, degeneration occurs, inflammation, pain, and atrophy

Radiation induced Trismus

Goldstein, Maxymiw, Cummings, and Wood (1999) found that as radiation dosage to the area of the TMJ and muscles of mastication increased there was a decrease in the maximal vertical dimension between the incisors

If radiation affected the pterygoid muscles that radiation to this area alone was enough to cause trismus in 31% of those in their study.

Onset

Begins roughly 9 weeks after completion of treatment

Rapid for the first 9 months post therapy (Wang et al., 2005) and progresses at a rate of 2-4% loss of opening per month (Kent, et al., 2008)

Loss in opening progresses at a slower rate in later years

Wang et al. found that 4 years after radiation therapy there was a mean reduction in initial interincisal distance of 32% of patients

Quality of Life

Eating- oral or percutaneous gastrostomy tube

Swallowing Weight maintenance Speech Oral hygiene Medical procedures

Traditional therapies

Physical therapy- active ROM, stretching , hold relax, heat, massage

Botulinum toxin (Botox) injection

Coronoidectomy, TMJ Total Joint Replacement

TheraBite and Dynasplint- passive ROM devices

Traditional therapies

TheraBite

www.platonmedical.co.uk

Dynasplint

www.slceroderma.org

Case Study

J.C. 59-year-old male Until recently was a college

professor teaching at a local university

Tonsillar cancer for which he was treated with maximum radiation treatment

Case Study

Medical history continued: - heart surgery- Acute Respiratory Distress Syndrome- tracheotomy to allow ventilation- coma- percutaneous endoscopic gastrostomy tube - developed trismus during coma - unable to swallow and remained npo, including water, until he was seen at this clinic in 2007 - Guillain-Barre’ Syndrome - sensory impairment to the right side

Previous Therapy

Mercy Health- VitalStim- Swallowing exercises- Referred for myotomy

resulted in loss of voice improvement

Swallow studies showed- lack of tongue base movement, stasis, aspiration before & after swallow

U of A Clinic

Spring 2007 assessed

Pitch Level Habitual

Frequency 73 cps

Jitter 1.9%

Shimmer .32 dB

NHR .11

Therapy: Lee Silverman Voice Technique (LSVT) to increase vocal loudness, quality, and intelligibility

Demonstrated audible, intelligible speech and was able to continue this for over one year

U of A Clinic

Swallowing therapy: The Frazier Water Protocol Began to drink small amounts of fluids, swallow

honey consistency foods, and canned peaches. Against recommendations, he ate chicken and

drank beer. FEES examination indicated he was closing the

vocal cords and initiating a pharyngeal swallow, however, the PE segment did not allow a solid or large bolus to enter the esophagus.

Esophageal dilation on November 6, 2007

U of A Clinic

Fall 2008- pneumonia- unable to attend therapy for weeks- regression in speech intelligibility and swallowing - demonstrated a loss in the ability to move his tongue and paresis of the right side of the lips- trismus

U of A Clinic

J.C. utilizes TheraBite at home

Will chewing exercises maintain or increase his mouth opening over the course of 1 hour?

- manage his secretions & tongue movement

Goals for therapy: maintain vocal loudness and vocal quality and was to improve swallowing function

Chewing Exercises

Filter bag

Beef jerky, peaches, mandarin oranges

He was asked to chew the items, move them using his tongue, and if applicable attempt to group and form a bolus

Mouth Opening

Measured at beginning of session and again at the end

Used TheraBite Range of Motion Scale

J.C.’s mouth opening increased consistently by at least 2mm www.craniorehab.com

Tongue Movement

Computerized Speech Lab Model 4150

Measure was taken at the beginning of each therapy session

“Joe took father’s shoe bench out”

Measure again taken at the conclusion of therapy session

Tongue Movement

Formant 1 was analyzed for “Joe”

Trend noted on the 10 dates analyzed indicated an increase in F1 frequency from the first to the second measure - indicated the pharynx size was smaller due to the contact point of the back of the tongue being farther back

- indicated movement of the base of the tongue Base of his tongue movement is extremely problematic for

JC -would suggest that he showed improved position for being able to control a bolus, effect on the ability to

produce the phonemes /k/ and /g/

Tongue Movement

Formant frequency changes were then analyzed for the word “out”

There was an increase in the range of F1 from the initial to the second measure taken on 5 of the samples

- would indicate that there was more movement of the back and base of the tongue for the second measure

Tongue Movement

“out” continued: range of F2 was analyzed from the first to second measure

the range in the second measure increased in 4 of the samples

- consistent with change of position and movement of the oral tongue

Swallow Function

Varying consistency of the bolus presented, timing of bolus presentations, and bolus manipulation exercises

Consistencies presented included thin liquid, nectar, and thin puree

Most consistent swallow responses were obtained with thin liquid and nectar consistency boluses

Boluses of thin puree consistency were retained in the oral cavity

Swallow Function

Residue at level of cricopharyngeus

Saliva swallows

Conclusion

Trismus has a profound effect on a person’s quality of life

Prevention and therapy Resisted chewing exercises to assist

with maintaining or increasing mouth opening over a period of one hour, managing his secretions, and exercising his tongue

References

Bensadoun, R., Riesenbeck, D., Lockhart, P., Elting, L., Spijkervet, F., & Brennan, M. (2010). A systematic review of trismus induced by cancer therapies in head and neck cancer patients. Support Care in Cancer. doi: 10.1007/s00520-010-0847-7

Bhatia, K., King, A., Paunipagar, B., Abrigo, J., Vlantis, A., Leung, S., et al. (2009). MRI findings in patients with severe trismus following radiotherapy for nasopharyngeal carcinoma. European Radiology , 19 (11), 2586-2593.

Bhrany, A. D., Izzard, M., Wood, A. J., & Futran, N. D. (2007). Coronoidectomy for the Treatment of Trismus in Head and Neck Cancer Patients. The Laryngoscope , 117 (11), 1952-1956.

Dijkstra, P., Huisman, P., & Roodenburg, J. (2006). Criteria for trismus in head and neck oncology. International Journal of Oral & Maxillofacial Surgery , 35 (4), 337-342.

Dijkstra, P., Kalk, W., & Roodenburg, J. (2004). Trismus in head and neck oncology: a systematic review. Oral Oncology , 40 (9), 879-889.

Dijkstra, P., Sterken, M., Pater, R., Spijkervet, F., & Roodenburg, J. (2007). Exercise therapy for trismus in head and neck cancer. Oral Oncology , 2007 (4), 389-394.

Goldstein, M., Maxymiw, W., Cummings, B., & Wood, R. (1999). The effects of antitumor irradiation on mandibular opening and mobility. Oral Surgery, Oral Medicine, Oral Pathology, Oral Radiology and Endodontology , 88 (3), 365-373.

Graner, D., Foote, R., Kasperbauer, J., Stoeckel, R., Okuno, S., Olsen, K. et al. (2003). Swallow function in patients before and after intra-arterial chemoradiotherapy. The Laryngoscope, 113, 573-579.

Hartl, D. M., Cohen, M., Julieron, M., Maranda, P., Janot, F., & Bourhis, J. (2008). Botulinum toxin for radiation-induced facial pain and trismus. Otolaryngology-Head and Neck Surgery , 138 (4), 459-463.

Kent, L., Brennan, M., Noll, J., Fox, P., Burri, S., Hunter, J., et al. (2008). Radiation-Induced trismus in head and neck cancer patients. Support Care Cancer , 16 (3), 305-309.

References

Logemann, J., Rademaker, A., Pauloski, B., Lazarus, C., Mittal, B., Brockstein, B. et al. (2006). Site of disease and treatment protocol as correlates of swallowing function in patients with head and neck cancer treated with chemoradiotherapy. Head & Neck, 28, 64-73.

Melchers, L., Van Weert, E., Beurskens, C., Reinstema, H., Slagter, A., Roodenburg, J., et al. (2009). Exercise adherence in patients with trismus due to head and neck oncology: a qualitative study into the use of the Therabite. International Journal of Oral & Maxillofacial Surgery , 38 (9), 947-954.

Nguyen, N., Moltz, C., Frank, C., Karlsson, U., Nguyen, P. Vos, P., et al. (2006) Dysphagia severity following chemoradiotherapy and postoperative radiotherapy for head and neck cancer. European Journal of Radiology, 59, 453-459.

References Sciubba, J., & Goldenberg, D. (2006). Oral complications of radiotherapy. The Lancet Oncology, 7 (2), 175-183. Scott, B., Butterworth, C., Lowe, D., & Rogers, S. (2008). Factors associated with restricted mouth opening and

its relationship to health-related quality of life in patients attending a Maxillofacial Oncology clinic. Oral Oncology , 44 (5), 430-438.

Teguh, D., Levendag, P., Voet, P., van der Est, H., Noever, I., de Kruijf, W., et al. (2008). Trismus in patients with oropharyngeal cancer: relationship with dose in structures of mastication apparatus. Head & Neck , 30 (5), 622-630.

Thomas, F., Ozanne, F., Mamelle, G., Wibault, P., & Eschwege, F. (1998). Radiotherapy alone for oropharyngeal carcinomas: the role of fraction size (2 Gy vs. 2.5 Gy) on local control and early and late complications. International Journal of Radiation Oncology Biology Physics, 15, 1097-1102.

van der Molen, L., van Rossum, M., Burkhead, L., Smeele, L., & Hilgers, F. (2009). Functional outcomes and rehabilitation strategies in patients treated with chemoradiotherapy for advanced head and neck cancer: a systematic review. European Archives of Oto-Rhino-Laryngology , 266 (6), 889-900.

Walker, M., & Burns, K. (2006). Trismus: Diagnosis and Management Considerations for the Speech Language Pathologist [PDF document]. Retrieved from http://www.eshow2000.com/asha/2006/handouts.cfm

Wang, C., Huang, E., Hsu, H., Chen, H., Fang, F., & Hsiung, C. (2005). The Degree and Time-Course Assessment of Radiation-Induced Trsimus Occurring After Radiotherapy for Nasopharyngeal Cancer. The Laryngoscop , 115 (8), 1458-1460.