Severe Trismus Research Articles

Perioperative Airway Management in Patient with Mental Retardation and Severe Trismus Due to Buccal Mucosal Tumors

Perioperative Airway Management in Patient with Mental Retardation and Severe Trismus Due to Buccal Mucosal Tumors

Relationship between preoperative dental anxiety and short-term inflammatory response following oral surgery.

The relationship between dental anxiety and mucosal wound healing, especially the inflammatory response, has not been well studied. This study aimed to examine the relationship between anxiety prior to dental treatment and short-term inflammation following impacted mandibular third molar (IMTM) surgery. Fifty-nine patients who required IMTM surgery were recruited for this study. Sample demographics (gender, age) and surgical extent (Pederson classification, duration) were collected. Psychological stress towards surgery was assessed by the Dental Fear Survey (DFS). All surgeries were conducted according to an identical surgical protocol and all patients were given the same medical prescription. Correlations between short-term inflammation (swelling and trismus after 2days) and DFS, demographics and surgical extent were statistically analysed. The results showed that patients with a higher DFS score demonstrated more severe swelling (β=0.36, P=0.016) and trismus (β=0.37, P=0.008) 2days after surgery. In addition, more severe trismus occurred following more difficult surgery (β=0.29, P=0.016) or that with a longer duration (β=0.21, P=0.081). Neither gender nor age showed any significant relationship with swelling or trismus. Short-term inflammatory response following IMTM surgery correlated with the preoperative dental anxiety and this correlation was independent of gender and surgical extent.

Bilateral Mastoid Process Hypertrophy Associated With Severe Trismus.

The mastoid process, a pneumatized prominence of the temporal bone with air-filled air cells, grows with age. We present here a series of 4 patients with bilateral mastoid hypertrophy associated with severe trismus from different etiologies, and discuss the possible explanation of this observation.

Self-Reported Trismus: prevalence, severity and impact on quality of life in oropharyngeal cancer survivorship: a cross-sectional survey report from a comprehensive cancer center.

The purpose of this study was to estimate prevalence/severity of self-reported trismus, determine association with quality of life (QOL), and examine clinical risk factors in a large population of patients treated for oropharyngeal cancer. A cross-sectional survivorship survey was conducted among patients who completed definitive treatment for oropharyngeal carcinoma, disease-free ≥ 1-year post-treatment (median survival, 7years among 892 survivors). Associations between trismus and QOL were also analyzed using MDASI-HN, EQ-5D, and MDADI. Dietary and feeding tube status were also correlated to trismus status. Trismus was self-reported in 31%. Severity of trismus positively correlated (r = 0.29) with higher mean interference scores reflecting a moderate association with quality of life (p < 0.0001). There was a negative correlation for MDADI composite scores (r = - 0.33) indicating increased perceived dysphagia related to trismus severity (p < 0.0001). EQ-5D VAS scores were also negatively correlated with trismus severity (r = - 0.26, p < 0.0001). Larger T-stage (p ≤ 0.001), larger nodal stage (p = 0.03), tumor sub-site (p = 0.05), and concurrent chemoradiation (p = 0.01) associated with increased prevalence of trismus. Diet negatively correlated (r = - 0.27) with trismus severity (p = < 0.0001), and survivors with severe trismus were also more likely to be feeding tube-dependent. Severity of trismus appears to negatively impact quality of life and associate with various adverse functional outcomes in long-term oropharyngeal cancer survivorship. Trismus remains associated with advanced disease stages, tumor sub-site (tonsil), and addition of chemotherapy. Further investigation is merited for the dose-effect relationship to the muscles of mastication.

CLINICAL AND RADIOGRAPHIC MANIFESTATIONS WITH 3-DIMENSIONAL PRINTED MODEL OF TRUE BONY ANKYLOSIS OF THE TEMPOROMANDIBULAR JOINT: A CASE REPORT

<h3>Clinical Presentation</h3> We present a case of a 20-year-old male who presented with facial asymmetry, severe trismus since early childhood, generalized physical weakness, and other skeletal deformities, including pigeon chest and kyphoscoliosis. No clear history of trauma was elicited. However, early childhood trauma was considered a possibility. <h3>Differential Diagnosis</h3> Severe trismus can be caused by various etiologies, including trauma, temporomandibular joint (TMJ) disorders, benign and malignant neoplasia, infections, and iatrogenic causes. However, with the history and clinical presentation, a TMJ condition, including bony and fibrous ankyloses, was considered. <h3>Diagnosis and Management</h3> Multidetector computed tomography (MDCT) was performed. Radiographic features were consistent with stage IV bony ankyloses of the left TMJ, according to the classification system of Sawhney et al. A 3-dimensional (3-D) printed medical model of the skull and the mandible was used for surgical simulation. Gap arthroplasty with interpositional temporalis muscle flap was performed, followed by vigorous physiotherapy. After surgery, mouth opening increased significantly from 0 to 35 mm. One year clinical follow-up was done. <h3>Discussion</h3> TMJ ankylosis is a pathologic condition in which the mandible is fused to the glenoid fossa by bony or fibrotic tissues, interfering with mastication, speech, oral hygiene, and nutrition. Multiple factors, including trauma, arthritis, infection, congenital deformities, or iatrogenic causes, can result in ankylosis, but trauma remains the most common etiology. In growing individuals, it can result in very severe craniomaxillofacial deformities and can also affect the airway. This case report discusses the clinical and radiographic features affecting the craniomaxillofacial structures associated with TMJ ankylosis and the applicability of 3-D printing in treatment planning. Because TMJ ankylosis can affect multiple aspects of the patient's life, an interdisciplinary management approach is required.

Resident Contribution—Temporomandibular Joint Ankylosis Resection and Reconstruction With Rib Grafts in a Young Adult With a History of Panfacial Trauma

Temporomandibular joint (TMJ) ankylosis is a debilitating condition, which has implications for jaw function, mastication, overall quality of life, and psychosocial well-being.1 The objectives of treating TMJ ankylosis include restoring mouth opening and posterior mandibular ramus height and facial symmetry and preventing future recurrences. We have highlighted the case of a young adult with a remote history of repaired panfacial fractures who had presented with severe trismus and evidence of bilateral mandibular ankylosis on imaging studies.

Traumatic myositis ossificans: multifocal lesions suggesting malignancy on FDG-PET/CT\u2014a case report

Myositis ossificans (MO) is a benign soft-tissue lesion characterized by the heterotopic formation of the bone in skeletal muscles, usually due to trauma. MO is occasionally difficult to diagnose because of its clinical and radiological similarities with malignancy. We report a case of traumatic MO (TMO) in the masseter and brachial muscles of a 37-year-old man who presented with painless swelling in the left cheek and severe trismus. Due to the absence of a traumatic history at the first consultation and identification of a tumorous lesion in the left masseter muscle by magnetic resonance imaging (MRI), the lesion was suspected to be a malignant tumor. Subsequently, 18F-fluorodeoxyglucose positron-emission tomography/computed tomography (FDG-PET/CT) showed multiple regions of high FDG uptake across the whole body, suggestive of multiple metastases or other systemic diseases. However, intramuscular calcifications were also observed in the left masseter and brachial muscles, overlapping the areas with high FDG uptake. Moreover, multiple fractures were seen in the rib and lumbar spine, also overlapping the areas with high FDG uptake. Based on these imaging findings, along with a history of jet-ski trauma, TMO was suspected. The left cheek mass was surgically excised and histologically diagnosed as TMO. In this case report, FDG-PET/CT could detect multiple TMOs across the whole body. To the best of our knowledge, cases of multiple TMOs located far apart in different muscles are rare, and this may be the first report.

Varied Presentations of Non-Hodgkin Lymphoma in Head and Neck Region

Introduction&#x0D; Majority of lymphomas involving the head and neck are Non-Hodgkin lymphoma (NHL). Most of them present as cervical lymphadenopathy. The objectives of this study are to present the problems encountered in the diagnosis of extra-nodal NHL in head and neck region and show the importance of thorough clinical examination and proper investigation.&#x0D; Materials and Methods&#x0D; A prospective study was done in the department of ENT in a tertiary care hospital of West Bengal from July 2015 to June 2018. Patients diagnosed as NHL on the basis of histopathology and immunohistochemistry were included in this study. Patients who were lost in follow up were excluded from the study. Patients were treated with chemotherapy and radiotherapy by Oncologist. All patients were followed up routinely both by Otorhinolaryngologist and Oncologist. &#x0D; Results&#x0D; There were 26 male and 11 female patients in this study. Patients were between 22 years to 76 years of age with highest incidence in 6th decade of life. Patients presented with only cervical lymphadenopathy; asymmetrical tonsillar enlargement with cervical lymphadenopathy; unilateral tonsillar enlargement only; huge inta-oral mass with stridor; parotid gland swelling; thyroid swelling with multiple cervical lymphadenopathy; epistaxis, palatal ulcer and cheek swelling; severe trismus with inconspicuous retro-mandibular mass. Majority of patients did well with chemoradiotherapy. Two patients succumbed to death, one with huge intra-oral NHL and another with nasal T/NK-cell lymphoma. &#x0D; Conclusion&#x0D; Good knowledge of the clinical characteristics of extra-nodal NHL and the methods to establish the diagnosis are essential for a correct and timely therapy of the disease.

Medial Pterygoid Myositis Complicated by Numbness of the Tongue and Nonodontogenic Toothache: A Case Report

A 34-year-old woman visited our clinic with complaints of trismus, numbness in the left half of the tongue, and pain in tooth 34. At the patient’s initial visit to our clinic, the maximum assisted jaw opening movement was 20 mm, pointing to severe trismus. The patient complained of spontaneous pain in tooth 34 but did not evince percussion pain. Her pain remained unchanged even under local anesthesia. Radiography showed no pathological findings. A tenderness test of masticatory muscles failed to induce pain. The presence of severe trismus argued against temporomandibular disorders, resulting in suspicion of other inflammatory disease. In view of numbness of the tongue, other diseases such as inflammation or neoplastic disease in the head and neck region were considered. The patient was referred to the departments of neurosurgery and otolaryngology for examination. The results of MRI and CT diagnosis led to the identification of acute myositis of the left medial pterygoid muscle requiring the prescription of nonsteroidal anti-inflammatory drugs, and relaxation of mandibular muscles. With time, maximum unassisted jaw opening improved and pain in tooth 34 ceased, but tongue numbness persisted. The condition was attributed to compression of lingual nerve (LN) and mandibular nerve (MN) resulting from medial pterygoid muscle inflammation.

Looking Beyond a Rare Presentation of Betel Nut Use in a North American Patient- an Opportunity for Lessons and Intervention in Global Health and Gender Equity

Betel nut is estimated to be the fourth most common psychoactive substance used globally behind caffeine, alcohol, and nicotine with 600 million global users. Betel nut use has a strong association with oral cancer and many other systemic effects including oral submucosal fibrosis. Although North American use is rare, its enduring effects may surface long after use posing a diagnostic challenge to practitioners caring for an increasingly global diaspora. Herein, we present a patient with severe trismus due to advanced oral submucosal fibrosis who was unexpectedly found to be importing and using Betel nut for over thirty years after immigrating. The prevalence of use in North America is unknown due to a paucity of current epidemiologic data. Betel nut side effects include a strong association with oral squamous cell carcinoma, hepatocellular carcinoma, cirrhosis, and cardiovascular disease, among others. However, there remains widespread lack of attributable risk awareness and entrenched social norms that permit betel nut use in early childhood in endemic areas. Importantly, women often bear a higher proportion of betel nut-related disease not only due to limited means of healthcare access but also due to cultural norms that often discourage women from smoking tobacco and instead encourage betel nut use. Here, standard tobacco and cancer screening had the potential to overlook a silent but significant driver of poor health. This case demonstrates a need for awareness of betel nut availability and its effects in the North American context. Moreover, it underscores the judicious care warranted for migrant patients who may have a history of exposure to betel nut and other imported cultural habits of clinical importance; these considerations are relevant to the individualized provision of culturally informed, gender equitable care.

Use of Bilateral Nasolabial Flaps with Coronoidectomy as a Novel Approach to a Case of Oral Cancer with Severe Trismus.

Patients with oral malignancy often have associated trismus. Trismus is a debilitating condition that needs to be treated adequately with the release of fibrosis and interposition of vascularized tissue to provide long-term improvement in the mouth opening. Treatment of oral cancer in patients with severe trismus becomes challenging because of difficult access and further deterioration of mouth opening following treatment of the malignancy. Herein, the planning of access to oral cancer and management of trismus in 9 oral cancer patients with severe trismus using nasolabial flaps and coronoidectomy are described. Bilateral nasolabial flaps and coronoidectomy were used successfully as an approach in these 9 patients with oral carcinoma with severe trismus. The advantages of this procedure are described.

PREVENTION PROTOCOL OF OSTEORADIONECROSIS AFTER RADIOTHERAPY OF THE HEAD AND NECK: BIMODAL TREATMENT

Although osteoradionecrosis is considered a late sequela of radiotherapy in the head and neck region, it is the most severe. Dental examination should be performed in advance to eliminate all odontogenic foci, decreasing the chance of developing osteoradionecrosis. A white female patient, 50 years of age, was treated with adjuvant radiotherapy for undetected primary tumor with cervical metastasis. After 6 months, extensive caries in the lower left second molar were noticed, which were removed and a glass ionomer restoration and indirect pulp-capping with calcium hydroxide were performed. Dental pulp vitality test along with periapical radiography to follow the treatment's progress were also done. After 10 months, a periapical radiolucent lesion was observed. Pulp vitality testing turned out negative. As a sequela of radiotherapy, the patient presented with severe trismus, making endodontic treatment impossible. Exodontic procedure with antibiotic and laser therapy for the prevention of osteoradionecrosis was recommended, and the patient remains without any complications.

A comprehensive, multidisciplinary, precision medicine approach to discover effective therapy for an undiagnosed, progressive, fibroinflammatory disease

Precision medicine has generated diagnoses for many patients with challenging undiagnosed disorders. Some individuals remain without a diagnosis despite comprehensive testing, and this impedes their treatment. This report addresses the role of personalized medicine in identifying effective therapy for an undiagnosed disease. A 22-year-old woman presented with chronic severe recurrent trismus, facial pain, progressive multicentric inflammatory and fibrotic masses, and high C-reactive protein. Sites of disease included the pterygomaxillary region, masseter muscles, mandible, lung, pericardium, intrabdominal cavity, and retroperitoneum. A diagnosis was not established after an extensive assessment, including multiple biopsies. The patient was subsequently evaluated under the Undiagnosed Diseases Program at the National Institutes of Health. Large scale genotyping, proteomic studies, and in vitro and gene expression analyses of fibroblasts obtained from a major disease locus were performed. Germline genetic testing did not identify strong candidate genes; proteomic studies of the patient's serum and bronchoalveolar lavage fluid and gene expression analyses of her cells were consistent with dysregulation of the tumor necrosis factor-alpha pathway. The patient's cultured fibroblasts were incubated with selected drugs, and cell proliferation was inhibited by hydroxychloroquine. Treatment of the patient with hydroxychloroquine conferred prolonged beneficial clinical effects, including stabilization of trismus and reduction of corticosteroid dose, C-reactive protein, and size of masses. This case represents an example of precision medicine applied to discover effective treatments for individuals with enigmatic undiagnosed disorders.

EFFICACY OF INTRA-MASSETERIC AND SUBMUCOSAL DEXAMETHASONE INJECTION IN SURGICAL EXTRACTION OF IMPACTED LOWER THIRD MOLAR.

Objectives: To determine the efficacy of intra-masseteric and submucosal dexamethasone injection to minimize the postoperative discomfort after the surgical extraction of impacted lower third molar. Study Design: Cross sectional study (Comparative). Setting: Department of Oral &amp; Maxillofacial Surgery, Institute of Dentistry, Liaquat University of Medical &amp; Health Sciences Jamshoro / Hyderabad. Period: January 2017 to June 2017. Subjects and Methods: All surgical extractions were done under local anaesthesia by giving conventional inferior alveolar nerve block. An envelope mucoperiosteal flap was raised to expose the third molar. Then tooth was extracted. After the removal of tooth any sharp bone was smoothened by bone filer and the socket was washed and sutured. The severity of pain was recorded by using Visual Analogue Scale from 0 (no pain) to 10 (worst pain) described as mild, moderate or severe. Degree of swelling was measured by facial size through Amin and laskin criteria which was measured in millimeters. Mouth opening was measured by interincisal distance through ruler (35-45mm normal value). Results: From sixty four patients it was observed that the minimum age was 28.03+6.12 years. There were 35 male patients and 29 female patients. When Chi square test was applied, there was a significant association found between Groups (A and B). By using independent sample t-test, it was observed that there was a significant association found in both groups concerning facial swelling (Facial size in mm) having p-value 0.00. When the independent t-test was applied on the data, there was a significant association found in Group A and B regarding mouth opening (in mm) having p-value 0.001. Conclusions: Dexamethasone has a good efficacy for reducing the postoperative symptoms including severe pain, facial swelling and trismus after the surgical extraction of impacted lower third molar. The better outcomes perceived when it was administered submucosally.

A case of medial pterygoid muscle metastasis of lung cancer presenting with trismus.

A man in his 60s with severe trismus was referred to our hospital. Based on computed tomography (CT), positron emission tomography/computed tomography (PET/CT), and biopsy, his initial diagnosis at another hospital was oropharyngeal cancer with cervical lymph node and distant metastases. After the review of the contrast-enhanced CT and reevaluated PET/CT images, we updated his diagnosis to left primary lung cancer that had metastasized to the cervical lymph nodes, bones, and skeletal muscles including the right medial pterygoid muscle. Since metastasis from primary lung cancer to the contralateral cervical lymph node is relatively rare, cervical lymph node metastases were thought to have originated from the metastatic lesion in the right medial pterygoid muscle. As metastases in the masticator muscles from lung cancer are rare, it is sometimes necessary to differentiate from primary head and neck lesions. Here, we report a rare case of lung cancer with the onset of trismus due to metastasis to the masticator muscle and perineural spread along the mandibular nerve.

Dentomaxillofacial sequelae resulting from a chemoradiotherapy against rhabdomyosarcoma: 6-year follow-up

Introduction: Rhabdomyosarcoma is an aggressive malignant soft tissue neoplasm of immature mesenchymal cells treated with surgery and chemoradiotherapy. The effects of chemoradiotherapy in head induce a series of sequelae on oral cavity and growth development. Objectives: Report the case of a child undergoing treatment for rhabdomyosarcoma whose effects on the dento-maxillofacial development were cared for in order to safe guard the patient’s quality of life. Case report: Describes a case of severe dento-maxillofacial defects resulting from chemoradiation therapy for embryonal rhabdomyosarcoma in a child aswell as the dental management performed. Clinically, the patient had gingivitis, severe mobility of permanent teeth, hyposalivation, mucositis and severe trismus. The radiologic exams showed interruption of root formation of all permanent teeth and over-retention of primary teeth. Cephalometric analyses revealedmandibular and maxillary hypoplasia. Results: Was made extraction of the overretained primary teeth associated with a prophylactic program and use of artificial saliva due to hyposalivation in order to improve the quality of life of the patient. After 6 years of dental and phonoaudiologic follow-up her oral opening hasincreased and chewing and swallowing difficulties have decreased, there is no gingivitis or mucositis and she has remained free of recurrent or metastatic diseases 11 years after the initial diagnosis. Conclusion: Our report emphasizes the importance of dental treatment with a program of prevention and follow-upfor patients undergoing anticancer therapies.

Piezo-electric surgery for re-ankylosis of temporomandibular joints on the Mercy Ships in West Africa

Introduction: Extensive ankylosis of the temporomandibular joints (TMJ) in West Africa is often caused by childhood infection or trauma. The majority of these patients do not have access to health care which leads to hypoplastic mandible with severe trismus and retrognathic chin. We report a case of TMJ re-ankylosis with the use of Piezosurgery.

PRIMARY INTROASSEAOUS DEDIFFERENTIATED ADENOID CYSTIC CARCINOMA IN MANDIBLE: A CASE REPORT AND REVIEW

Adenoid cystic carcinoma (ACC) is a malignant glandular neoplasm, representing 10% of all epithelial salivary neoplasms with a survival rate of 10 to 15 years. Bone involvement is uncommon with thirty-five reported cases. Here, a 65-year-old male patient presented with a swelling in the anterior mandible, with facial asymmetry and severe mandibular trismus. Radiographic examination demonstrated an extensive radiolucent lesion involving the body and ramus of mandible with root resorption of involved teeth. CT scans revealed an osteolytic lesion with zones of degeneration located in the anterior mandible. Incisional biopsy showed a biphasic salivary gland tumor with peripheral hyperchromatic and basaloid cells with scanty cytoplasm. Tumor cells were distributed in islets and strands with areas of comedonecrosis. It was also observed dental pulp invasion. Because of the tumor size, patient referred for chemotherapy treatment and radiotherapy palliative 3 years with medical and dental care.

Severe trismus due to bilateral elongated mandibular coronoid process in an infantile-onset Pompe disease patient: A case report

Abstract Pompe disease is a rare neuromuscular disorder characterized by orofacial muscle weakness with consequent dysphagia and poor weight gain. We report the first case of severe trismus due to abnormal elongation of the coronoid process of the mandible in a child with infantile-onset Pompe disease. Bilaterally elongated mandibular coronoid processes cause abnormal impingement between the coronoid process and the zygomatic process, which in this patient, resulted in a maximal interincisal opening of only 6 mm. Although rare, clinicians should be aware of the development of coronoid process elongation in neuromuscular disorders with hypotonia, specifically those involving hypotonic orofacial muscles.

痂皮より破傷風菌が分離できた破傷風の1例

A 69-year-old woman was referred to our department because of trismus. Physical examination showed a normal temporomandibular disorder, and she was prescribed a muscle relaxant and analgesic and went home. However, her symptoms became worse, and she was re-examined 2 days later and had severe trismus, stiffness of the masseter muscles, neck pain, and backache. She had a scab from a minor injury on the left knee. Tetanus was diagnosed on the basis of the clinical course and symptoms. The patient was immediately admitted to the intensive care unit. She was given anti-tetanus human immunoglobulin, tetanus toxoid, and antibiotics. The patient recovered without tracheotomy or tracheal intubation. We isolated Clostridium tetani from the scab on her knee, and tetanus was clinically and biologically diagnosed. Isolation of Clostridium tetani is very rare, and to our knowledge this is a rare case in which Clostridium tetani was isolated from a scab. Even if the wound shows signs of healing, tetanic symptoms do not improve, and such wounds should always be débrided for therapeutic purposes.