Download Trismus: Diagnosis and Management Considerations for the Speech

Trismus:
Diagnosis and Management
Considerations for the
Speech Pathologist
Melissa Walker, M.S. CCC-SLP
Katie Burns, M.S. CCC-SLP
ASHA
November 16, 2006
Definition
From the Greek trismos; grating, grinding
Traditional Definition
– “Tonic contraction of the muscles of
mastication” – Taber’s Cyclopedic Medical Dictionary
Current Definition
– Any restriction in mouth opening, including
restriction caused by infection, trauma,
surgery, or radiation
Congenital or acquired
Definition
Uniform criteria is lacking!
Various criteria for presence of trismus…
– Mouth opening <20mm (Jen et. al., 2002)
– Mouth opening <40mm (Nguyen et. al., 1988)
– Severity Scales
Mild, >30mm; Moderate, 15-30mm; Severe,
<15mm (Thomas et. al., 1998)
Generally, opening of <35-40mm a functional
guideline
Less than 18-20mm, oral alimentation is difficult
Incidence
Reported incidence varies greatly,
anywhere from 5% to 38%
Incidence increases in irradiated patients
Incidence increases with head and neck
cancer diagnosis
– 36%, Nasopharyngeal tumors
– 55%, Parapharyngeal tumors
– Parotid gland
Complications of Trismus
Poor oral hygiene
Complications of
conditions associated
with head and neck
cancer treatments
Reduced access for
oral examination and
dental procedures
Dysphagia
Aspiration and related
complications
Malnutrition
Decreased access for
medical procedures,
including intubation
Inability to use
dentures or oral/
pharyngeal
prosthetics
Speech deficits
Airway compromise
Pain
Anatomy Review
Bones: The Mandible
Only moveable bone
in skull
Capable of rapid
movement
Moves in multiple
planes
Function:
http://zemlin.shs.uiuc.edu/Skull/defult.htm
– Mastication
– House teeth
– Modify dimensions of
vocal tract
Ligaments
Lateral Ligament
– Limits & guides movement
– Stabilizes
Sphenomandibular Ligament
– Limits protrusive and
mediotrusive movements
– Limits passive jaw opening
Stylomandibular Ligament
– Relaxes with jaw opening
Courtesy N. Capra
Muscles
Bumann & Lotzmann 2002
www.nidcr.nih.gov
Muscle Movement
Elevation
– Masseter
– Temporalis
– Medial Pterygoid
Depression
–
–
–
–
Digastric
Mylohyoid
Geniohyoid
Lateral Pterygoid
Protrusion
– External pterygoid
– Internal pterygoid
Retraction
–
–
–
–
Temporalis
Mylohyoid
Geniohyoid
Anterior digastric
Lateral
– External pterygoid
– Temporalis
Vascular and Neural Supply
Vascular
Neural
Temporomandibular Joint
Most active joint in
the body
Controls mandibular
movement
Complex and easily
damaged joint
www.Dr.Spiller.com
Easily evaluated
TMJ Movement
Translation
– Upper part of the joint
capsule
– Bilateral movement
– Condyle slips forward
and downward over
the articular eminence
– Suprahyoid muscles
Rotation
– Lower part of the joint
capsule
– Condyle rotates within
the glenoid fossa
– Lateral pterygoids
Jaw Opening
Initial Phase
– Condyle rotates
Intermediate Phase
– Condyle translates
Terminal Phase
– Condyle reaches
maximum rotation and
translation
Bumann & Lotzman
Jaw Closing
Initial Phase
Intermediate Phase
Terminal Phase
The Masticatory System is a
Biologic System
(Bumann Model)
A healthy system adapts and compensates in
response to influences
–
–
–
–
Malocclusion
Dysfunction
Parafunctional activities
Trauma
Symptoms arise when the adaptive mechanisms
of connective tissue and the compensatory
mechanisms of muscles have been exhausted
Differential Diagnosis
Trismus: Differential Diagnosis
Infectious
Neurologic
Craniofacial/ Dental
Oncology – Tumor, Treatment
Congenital/ Developmental
Trauma
Iatrogenic
Differential Diagnosis:
Infection
Odontogenic Infection
–
–
–
–
Pupal
Periodontal
Most frequently third molar
Secondary to injection
Non-odontogenic Infection
–
–
–
–
Tetanus
Tonsillitis
Meningitis
Encephalitis
Differential Diagnosis:
Drug Toxicity
Medications capable of causing trismus
– Neuroleptic agents
– Phenothiazines
– Tricyclic antidepressants
– Metaclopromide
– Halothane (general anesthetic)
Differential Diagnosis:
Trauma
Most commonly due to MVA, sport accidents,
assault/ battery
Most common mandibular fractures
– Condylar (30%)
– Angle (25%)
– Body (20%)
Trismus secondary to fracture often exacerbated
by prolonged immobility
Bony Ankylosis
– Hematoma formation within joint space and
subsequent fibrosis and calcification
Differential Diagnosis:
Neurologic Etiologies
CVA and TBI
– May result in severe trismus secondary to masseter
spasticity
– EMG will show abnormal tonic hyperactivity at rest
ALS
– Mazzini et. al. (1995), 9% of patients unable to
undergo PEG placement secondary to severe
masseter spasticity
Restivo et. al. (2005) found masseter botulinum
toxin denervation effective in reducing trismus
caused by neurogenic spasticity
Temperomandibular Disorder
(TMJ Syndrome)
TMJ pain and reflex spasm of muscles of
mastication secondary to…
– Excessive tension or anxiety, jaw clenching
– Habits, including excessive gum chewing
– Disc displacement
– Malocclusion
– Bruxism
Symptoms may resolve on their own
Differential Diagnosis:
Arthritis
True ankylosis unlikely
TMJ Arthritis
– 50% of those with rheumatoid arthritis have
some involvement
– Traumatic
– Degenerative joint disease
Differential Diagnosis:
Congenital / Developmental
Coronoid Hyperplasia
– Abnormal bony elongation of normal coronoid
process
– Treatment is surgical
Hecht Syndrome (Trismus
Pseudocamptodactyly Syndrome )
Trotter's Syndrome
Differential Diagnosis:
Central Nervous System
Conditions affecting the CNS may result in
trismus, including
– Multiple Sclerosis
– Meningitis
– Parkinson’s Disease
– Epilepsy
– Bulbar paralysis
– Brain tumor
– Scleroderma
Post-Surgical Effects
Dental injections – hematoma formation
and infection
Nerve damage
Misalignment
Damage to muscles
Hyperextension of joint
Scarring
Radiation Therapy
Trismus most likely when RT to TMJ,
pterygoids, or masseter
RT for tumors in the nasopharynx, base of
tongue, salivary gland, maxilla/ mandible
RT in excess of 6000 grays
Patients being treated for recurrence
Patients treated concurrently surgery and RT
Chemotherapy agents may exacerbate the
condition
Time of Onset
Most often a gradual onset, 8 – 12 weeks
after completion of treatment
May develop at any time following
treatment
Damage progresses at a rate of
approximately 2.4% loss per month
Without intervention, mean reduction of
32% opening at 4 years post treatment
– Sciubba & Goldenberg, 2006, The Lancet
Trismus Secondary to RT
Radiation results in rapid formation of collagen
– Progression often slow, may not notice until opening
is <20mm
– Patients may not be eating and not notice slow
changes
– Patients may think reduced jaw opening is normal
Radiation results in on muscle results in fibrosis and
contracture
When muscles of mastication are in the field of
radiation, edema, cell destruction, and fibrosis
may result
Trismus: Physiologic Effects
Joint immobilization results in…
–
–
–
–
–
Reduced strength
Fatiguability
Rapid joint and muscle degeneration
Inflammation, pain
Flexion contractures (common in muscles acting
across a damaged joint)
– Shortening of muscle fibers
– Disuse atrophy
(Booth, F., 1987, Clin Orthop Relat Res, v219)
Pathophysiology of Trismus
www.atosmedical.com
Evaluation
The Trismus Team
Patient
Speech-Language Pathologist
Physical Therapist
Dentist/ Orthodontist
Oral Hygienist
Oral Surgeon
Physician
Radiation Oncologist
Nurse
Social Worker
SLP Evaluation
History and Interview
Questionnaire
Measure
–
–
–
–
Interincisal opening
Lateral movement
Protrusion
Retraction
Palpation
History and Interview
Medical/ Surgical/ Trauma History
Medications
Quality of life measurements
Pain history
–
–
–
Headaches
Jaw
Neck
Dental status and history
Speech and swallowing history
Mandibular Function Impairment
Questionnaire (MFIQ)
(Stegenga et. al., 1993)
11 items assessing
perceived difficulties
–
–
–
–
–
–
–
–
–
Social activities
Speaking
Taking a large bite
Chewing hard, soft, and
resistant foods
Work and/ or daily activities
Drinking
Laughing
Kissing
Yawning
(Stegenga et. al., 1993)
Measurement
Screening
– “Three finger test”
Measurement Tools
– Boley Gauge
– Manufacturer’s scales
Dynasplint
Therabite
Influencing Factors
–
–
–
–
–
Dental alignment
Age
Gender
Ramus length
Gonial angle
www.atosmedical.com
Measurement
Reliability
Norms (Bumann & Lotzman, 2002)
–
–
–
–
Jaw opening
Laterotrusion
Protrusion
Retrusion
49-56mm
10-11mm
10-11mm
0-1mm
Hypomobility
– <40mm (Bitler et. al., 1991)
– <35 (Dijkstra et.al..
et.al.. (2006)
www.atosmedical.com
Measurement Technique
Active Opening
Passive Opening
Lateral Movement
Retraction
Protrusion
Manual Functional Analysis
Screen neck mbility
At rest and with
movement
–
–
–
Look
Listen
Palpate
Joint
Muscles of mastication
Instrumental Evaluation
General dental exam
Panorex
– Confirms degenerative joint
changes
– Quantify level of
asymmetry
CT
MRI
Casting
Axiography
– Evaluates trajectory
Traditional Treatments
None/ Compensation
– Diet modification
Clothespins
Screws
“Open your mouth”
Manual pressure
Chewing gum
Tongue depressors
Dental Treatments
Elimination of
behaviors that
strengthen
antagonists
Intraoral orthotics
Distraction
osteogenesis
Physical Therapy
Icing/ Heat
Massage
Manipulation/ Traction
Compression
TENS
EMG biofeedback
Ultrasound
Manual lymph drainage
Exercise
Facial-Flex
Two minutes/ 2x a day
Isometric/ Isokinetic
Reduces scar formation
and lip contraction
Open to maximum
comfort, close and hold
for two seconds
Treatment: Passive ROM
Passive
– External force is applied
– Joint moves
– Surrounding muscles inactive
Benefits
–
–
–
–
–
Improved circulation
Reduces inflammation
Elongates muscle fibers
Mobilizes joint
Increases flexibility of connective tissue
Buchbinder & Currivan (1991)
Passive ROM Devices
Dynasplint
– Passive
– Low load prolongedduration stretch
– Spring-loaded
– Hands-free option
– Adjustable
– Customized
mouthpiece
– 3x/ day for 30 minutes
– Rented to patient
www.dynasplint.com
Therabite
Therabite
www.atosmedical.com
– Efficacy is
documented
– Dental pads
– Passive range of
motion
– Patient controlled
– 7-7-7 protocol
– 5-5-30 protocol
Therapacer CPM
Programmable
18-61 mm
100% passive
Motorized
Continuous
4-6 hours/day for 4-6
weeks
Lateral and protrusive
attachments
The Final Word
Abdel-Galil et.al.
References
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