Radiation Induced Trismus

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

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 www.platonmedical.co.uk • Dynasplint www.slceroderma.org

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 • 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

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 www.craniorehab.com

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: 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.

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, 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.