1. Radiation Induced Trismus
Kara G. Cullins
Radiation Induced Trismus

2. 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

3. 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

4. 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

5. 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

6. 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

7. Radiation induced Trismus
Temporal mandibular joint, masseter muscle, and pterygoid muscles involved in radiation therapy

8. 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

9. 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.

10. 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

11. Quality of Life Eating- oral or percutaneous gastrostomy tube
Swallowing
Weight maintenance
Speech
Oral hygiene
Medical procedures

12. 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

13. Traditional therapies
TheraBite
Dynasplint

14. 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

15. 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

16. 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

17. U of A Clinic Pitch Level Habitual Spring 2007 assessed
Frequency 73 cps
Jitter %
Shimmer dB
NHR
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

18. 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

19. 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

20. 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

21. 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

22. 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

23. 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

24. 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/

25. 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

26. 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

27. 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

28. Swallow Function
Residue at level of cricopharyngeus
Saliva swallows

29. 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

30. 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: /s
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),
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),
Dijkstra, P., Huisman, P., & Roodenburg, J. (2006). Criteria for trismus in head and neck oncology. International Journal of Oral & Maxillofacial Surgery , 35 (4),
Dijkstra, P., Kalk, W., & Roodenburg, J. (2004). Trismus in head and neck oncology: a systematic review. Oral Oncology , 40 (9),
Dijkstra, P., Sterken, M., Pater, R., Spijkervet, F., & Roodenburg, J. (2007). Exercise therapy for trismus in head and neck cancer. Oral Oncology , 2007 (4),
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),
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,
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),
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),

31. 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,
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),
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,
References
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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),
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),
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Walker, M., & Burns, K. (2006). Trismus: Diagnosis and Management Considerations for the Speech Language Pathologist [PDF document]. Retrieved from
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),