1. health and fitness
2. disease
3. cancer

Kara G. Cullins
RADIATION INDUCED TRISMUS
What is Trismus?
 Traditional Definition
“Tonic contraction of the muscles of
mastication ” –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)
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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



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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/s00520010-0847-7

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), 365373.

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 radiationinduced 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.
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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.
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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.
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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 healthrelated quality of life in patients attending a Maxillofacial Oncology clinic. Oral Oncology , 44 (5), 430-438.
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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.
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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.
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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-RhinoLaryngology , 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
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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.