Trismus in head and neck cancer: translation and validation of the Chinese version of the Gothenburg Trismus Questionnaire-2 (C-GTQ-2).

OBJECTIVES: Trismus, marked by restricted mouth opening, significantly affects patients with temporomandibular disorder (TMD) and head and neck cancer (HNC). Despite its prevalence, specialized questionnaires for trismus assessment are scarce. This study aims to fill this gap by translating and validating the Gothenburg Trismus Questionnaire version 2 (GTQ-2) into Chinese (C-GTQ-2), enhancing the evaluation of trismus in HNC and TMD patients. MATERIALS AND METHODS: The study involved 78 HNC patients, 75 TMD patients, and a control group of 150 individuals without trismus symptoms. Participants were asked to complete the C-GTQ-2 and other health-related quality of life (HRQL) instruments. A subset of 30 individuals retook the questionnaire within two weeks to assess test-retest reliability. RESULTS: The C-GTQ-2 demonstrated remarkable reliability, with Cronbach's alpha values exceeding 0.70 in three of the four domains, indicating high internal consistency. The instrument also showcased high intra-class correlations in the test-retest, affirming its reliability. Furthermore, it exhibited strong convergent validity, aligning well with other HRQL instruments, and effectively discriminated between patients with and without trismus, establishing its discriminant validity. CONCLUSIONS: The C-GTQ-2 emerges as a valid and reliable tool for assessing trismus in HNC and TMD patients, promising to significantly enhance both clinical and research approaches to managing trismus-related complications in the Chinese-speaking demographic. CLINICAL RELEVANCE: C-GTQ-2 proves effective for trismus assessment in head and neck cancer and temporomandibular disorder patients, offering enhanced clinical and research utility.

American Cancer Society Head and Neck Cancer Survivorship Care Guideline.

Answer questions and earn CME/CNE The American Cancer Society Head and Neck Cancer Survivorship Care Guideline was developed to assist primary care clinicians and other health practitioners with the care of head and neck cancer survivors, including monitoring for recurrence, screening for second primary cancers, assessment and management of long-term and late effects, health promotion, and care coordination. A systematic review of the literature was conducted using PubMed through April 2015, and a multidisciplinary expert workgroup with expertise in primary care, dentistry, surgical oncology, medical oncology, radiation oncology, clinical psychology, speech-language pathology, physical medicine and rehabilitation, the patient perspective, and nursing was assembled. While the guideline is based on a systematic review of the current literature, most evidence is not sufficient to warrant a strong recommendation. Therefore, recommendations should be viewed as consensus-based management strategies for assisting patients with physical and psychosocial effects of head and neck cancer and its treatment. CA Cancer J Clin 2016;66:203-239. © 2016 American Cancer Society.

Trismus, health-related quality of life, and trismus-related symptoms up to 5 years post-radiotherapy for head and neck cancer treated between 2007 and 2012.

PURPOSE: Radiotherapy-induced trismus is present in up to 40% of patients treated radiotherapeutically for head and neck cancer (HNC) and impacts health-related quality of life (HRQL) negatively. This prospective study aimed to investigate the development of trismus and its influence on HRQL and trismus-related symptoms in HNC patients for up to 5 years post-radiotherapy completion as no such follow-up studies exist. METHODS: Patients (n = 211) were followed prospectively from pre-radiotherapy to 12 and 60 months post-radiotherapy. At each follow-up, maximum interincisal opening (MIO) was measured, and patients filled in the European Organization for Treatment of Cancer Quality-of-Life Questionnaire Core-30 (EORTC QLQ-C30), Head and Neck-35 (EORTC QLQ-HN35), and Gothenburg Trismus Questionnaire (GTQ). Trismus was defined as an MIO ≤ 35 mm. RESULTS: At 1 year post-radiotherapy, a total of 27% met the trismus criterion, and at 5 years post-radiotherapy, the corresponding figure was 28%. Patients in the trismus group scored significantly worse compared to the patients without trismus on 8/15 domains at 1 year post-radiotherapy on EORTC QLQ-C30, further worsening in 11/15 domains at 5 years post-radiotherapy. Similar results were found for EORTC QLQ-HN35. Patients with trismus reported more trismus-related symptoms according to the GTQ at both timepoints compared to those without trismus. CONCLUSION: This study highlights that HNC patients suffering from radiotherapy-induced trismus report poorer HRQL and more trismus-specific symptoms compared to patients without trismus. These differences persist and increase up to at least 5 years following treatment completion. Hence, our results highlight that radiotherapy-induced trismus affects long-term HRQL, jaw symptoms, and pain, further stressing the need for early and structured intervention.

A novel method for the remote measurement of trismus in clinical trials using mobile phone cameras.

OBJECTIVE: To evaluate the reliability and validity of a novel method for remotely measuring trismus. MATERIALS AND METHODS: We recruited 60 volunteers who took three types of photographs at a fixed restricted jaw position mimicking limited mouth opening, including one selfie and one portrait with or without a reference frame. Additionally, the interincisal distance and the width of the upper central incisors were measured with a ruler, as per common practice. Measurements of trismus were made using image analysis software comparing different types of photos and calibration methods. Intraclass correlation coefficient (ICC) and 95% limits of agreement (LoA) with 95% confidence interval were calculated to evaluate reliability and validity. RESULTS: The proposed method demonstrated high reliability (ICC 0.998; 95% CI 0.997, 0.999). Calibration of photographs using at least a baseline photograph with an external reference frame yielded unbiased measurements and minimised variability. The use of selfies compared to portrait photos also increased variability. CONCLUSION: The measurement of trismus can be performed using images taken remotely by patients using their mobile phone cameras. The proposed method is highly accurate, with best results obtained by using a reference frame for calibration of portrait photographs. CLINICAL RELEVANCE: We propose an easy, cheap, and accurate method that allows for remote and frequent monitoring of trismus in clinical studies using patients' mobile phones.

Tetanus presenting as painful muscle spasms, dysphagia and delirium in an older adult.

While tetanus is now a rare disease in the UK, it remains an important differential diagnosis for trismus and muscle spasms. Even more so in older adults, as this population is less likely to have received full vaccination. Hence, the highest incidence of tetanus in England is seen in older adults. Written informed consent for publication of their clinical details was obtained from the patient proxy.

Adenoid cystic carcinoma with dedifferentiation/expansion of the luminal cell component and preserved biphasic morphology - Early high-grade transformation.

We present two patients (29 and 67 years) with histomorphologic and immunohistochemical evidence of early high-grade transformation of adenoid cystic carcinoma in the nasal cavity and floor of mouth, respectively. The component of early high-grade transformation was characterized by 1) selective expansion of the luminal (CK7+, c-kit+, p63-) cell component with severe cytologic atypia and significantly increased Ki-67 proliferation index, and 2) retained albeit attenuated abluminal (CK7-, c-kit-, p63+) cells, surrounding nests of high-grade luminal cells.

Crisponi/cold-induced sweating syndrome: Differential diagnosis, pathogenesis and treatment concepts.

Crisponi/cold-induced sweating syndrome (CS/CISS) is an autosomal recessive disease characterized by hyperthermia, camptodactyly, feeding and respiratory difficulties often leading to sudden death in the neonatal period. The affected individuals who survived the first critical years of life, develop cold-induced sweating and scoliosis in early childhood. The disease is caused by variants in the CRLF1 or in the CLCF1 gene. Both proteins form a heterodimeric complex that acts on cells expressing the ciliary neurotrophic factor receptor (CNTFR). CS/CISS belongs to the family of "CNTFR-related disorders" showing a similar clinical phenotype. Recently, variants in other genes, including KLHL7, NALCN, MAGEL2 and SCN2A, previously linked to other diseases, have been associated with a CS/CISS-like phenotype. Therefore, retinitis pigmentosa and Bohring-Optiz syndrome-like (KLHL7), Congenital contractures of the limbs and face, hypotonia, and developmental delay syndrome (NALCN), Chitayat-Hall/Schaaf-Yang syndrome (MAGEL2), and early infantile epileptic encephalopathy-11 syndrome (SCN2A) all share an overlapping phenotype with CS/CISS, especially in the neonatal period. This review aims to summarize the existing literature on CS/CISS, focusing on the current state of differential diagnosis, pathogenesis and treatment concepts in order to achieve an accurate and rapid diagnosis. This will improve patient management and enable specific treatments for the affected individuals.

Exome sequencing in Crisponi/cold-induced sweating syndrome-like individuals reveals unpredicted alternative diagnoses.

Crisponi/cold-induced sweating syndrome (CS/CISS) is a rare autosomal recessive disorder characterized by a complex phenotype (hyperthermia and feeding difficulties in the neonatal period, followed by scoliosis and paradoxical sweating induced by cold since early childhood) and a high neonatal lethality. CS/CISS is a genetically heterogeneous disorder caused by mutations in CRLF1 (CS/CISS1), CLCF1 (CS/CISS2) and KLHL7 (CS/CISS-like). Here, a whole exome sequencing approach in individuals with CS/CISS-like phenotype with unknown molecular defect revealed unpredicted alternative diagnoses. This approach identified putative pathogenic variations in NALCN, MAGEL2 and SCN2A. They were already found implicated in the pathogenesis of other syndromes, respectively the congenital contractures of the limbs and face, hypotonia, and developmental delay syndrome, the Schaaf-Yang syndrome, and the early infantile epileptic encephalopathy-11 syndrome. These results suggest a high neonatal phenotypic overlap among these disorders and will be very helpful for clinicians. Genetic analysis of these genes should be considered for those cases with a suspected CS/CISS during neonatal period who were tested as mutation negative in the known CS/CISS genes, because an expedited and corrected diagnosis can improve patient management and can provide a specific clinical follow-up.

Criterion for trismus in head and neck cancer patients: a verification study.

PURPOSE: Several cut-off points for trismus in head and neck cancer patients have been used. A mouth opening of 35 mm or less is most frequently used as cut-off point. Due to the variation in cut-off points, prevalence, risk factors and treatment outcomes of trismus cannot be studied in a uniform manner. To provide uniformity, we aimed to verify the cut-off point of 35 mm or less. Additionally, we aimed to determine associated covariates with reported difficulties when opening the mouth. METHODS: In a cross-sectional design, we measured the mouth opening in 671 head and neck cancer patients at the Department of Oral and Maxillofacial Surgery, at the University Medical Center Groningen. The cut-off point was determined using the receiver operating characteristic curve and Youden index, with reported difficulties when opening the mouth as criterion for trismus. Cut-off points for significant covariates were also determined. RESULTS: The Youden index was highest at 35 mm, with a sensitivity of 0.71 and a specificity of 0.86. Of the covariates analysed, type of treatment modality was significantly associated with reported difficulties when opening the mouth. The highest Youden index for patients treated with surgery alone was 37 mm and for patients treated with radiotherapy alone 33 mm. CONCLUSIONS: The cut-off point of 35 mm or less for trismus was confirmed in a head and neck cancer population and is recommended to be used in future studies. Patients receiving different treatment modalities experience difficulty when opening the mouth differently.

Effects of Leukocyte- and Platelet-Rich Fibrin Alone and Combined With Hyaluronic Acid on Pain, Edema, and Trismus After Surgical Extraction of Impacted Mandibular Third Molars.

PURPOSE: In this prospective, randomized, double-blind controlled study, we evaluated the effects of leukocyte- and platelet-rich fibrin (L-PRF) alone and combined with a hyaluronic acid (HA) sponge on pain, edema, and trismus after mandibular third molar surgery. PATIENTS AND METHODS: In total, 60 patients were included in this study. The patients were randomly divided into 3 groups: L-PRF group (L-PRF was applied to the socket), L-PRF-plus-HA group (L-PRF combined with HA was applied to the socket), and control group (nothing was applied). The primary outcome variables were edema (tragus to pogonion, tragus to labial commissure, and angulus mandibulae to lateral canthus), trismus on postoperative days 2 and 7, and postoperative pain scores on a visual analog scale from hour 6 to day 7. RESULTS: After extraction, the tragus-to-pogonion values were significantly higher in the control group both on day 2 (higher than L-PRF-plus-HA group) and on day 7 (higher than both groups). The mean increase in tragus-to-labial commissure values on day 2 was significantly higher in the control group than in the L-PRF-plus-HA group. The mean increase in angulus mandibulae-to-lateral canthus values on days 2 and 7 was significantly higher in the control group than in the L-PRF and L-PRF-plus-HA groups. There was no significant difference among groups in trismus and visual analog scale pain scores. Analgesic intake on the day of surgery in the L-PRF-plus-HA group was significantly lower. CONCLUSIONS: Our results imply that L-PRF, particularly when combined with HA, can be used to minimize postoperative edema after mandibular third molar surgery. However, further studies with larger samples are required.

Temporal patterns of patient-reported trismus and associated mouth-opening distances in radiotherapy for head and neck cancer: A prospective cohort study.

OBJECTIVES: To identify temporal patterns of patient-reported trismus during the first year post-radiotherapy, and to study their associations with maximal interincisal opening distances (MIOs). DESIGN: Single institution case series. SETTING: University hospital ENT clinic. PARTICIPANTS: One hundred and ninety-six subjects who received radiotherapy (RT) for head and neck cancer (HNC) with or without chemotherapy in 2007-2012 to a total dose of 64.6/68 Gy in 38/34 fractions, respectively. All subjects were prospectively assessed for mouth-opening ability (Gothenburg Trismus Questionnaire (GTQ), European Organization for Research and Treatment of Cancer quality of life Questionnaire (EORTC QLQ-H&N35), and MIO) pre-RT and at 3, 6 and 12 months after RT. MAIN OUTCOME MEASURES: Correlations between temporally robust GTQ symptoms and MIO as given by Pearson's correlation coefficients (Pr ); temporally robust GTQ-symptom domains as given by factor analysis; rates of trismus with respect to baseline by risk ratios (RRs). RESULTS: Four temporally robust domains were identified: Eating (3-7 symptoms), Jaw (3-7), Pain (2-5) and Quality of Life (QoL, 2-5), and included 2-3 persistent symptoms across all post-RT assessments. The median RR for a moderate/severe (>2/>3) cut-off was the highest for Jaw (3.7/3.6) and QoL (3.2/2.9). The median Pr between temporally robust symptoms and MIO post-radiotherapy was 0.25-0.35/0.34-0.43/0.24-0.31/0.34-0.50 for Eating/Jaw/Pain/QoL, respectively. CONCLUSIONS: Mouth-opening distances in patients with HNC post-RT can be understood in terms of associated patient-reported outcomes on trismus-related difficulties. Our data suggest that a reduction in MIO can be expected as patients communicate their mouth-opening status to interfere with private/social life, a clinical warning signal for emerging or worsening trismus as patients are being followed after RT.

Masseter and temporalis muscle electromyography findings after lower third molar extraction.

BACKGROUND: The main clinical application of electromyography is to detect abnormalities in muscle function, to assess muscle activity for purposes of recruitment, and in the biomechanics of movement. OBJECTIVES: To analyze electromyography (EMG) findings for masticatory muscles during chewing following surgical extraction of lower third molars, and to determine any correlation between pain, inflammation, trismus, and the EMG data registered. MATERIAL AND METHODS: This prospective study included 31 patients. Surface EMG was used to study masseter and temporalis muscle function before lower third molar extraction and 72 hours and seven days after surgery. Clinical variables, pain, inflammation, and trismus were registered before and after surgery. RESULTS: Studying the area and size of the masticatory muscles, higher values were found for temporalis than masseter muscles, regardless of the surgical side, which points to the greater involvement of the temporalis muscle in mastication. Comparing the side where surgery had been performed with the non-surgical side, a sharp and statistically significant reduction in amplitude and area were noted on the surgical side reflecting major functional affectation. One week after surgery, amplitude and area had almost returned to base-line values, indicating almost complete recovery. While pain decreased progressively after surgery, inflammation peaked at 72 hours, while mouth opening reached a minimum at this time, returning to normality within the week. CONCLUSIONS: Surgical extraction of lower third molars produces changes to electromyography activity that are more evident during the first hours after surgery and closely related to the intensity of pain suffered and the patient's inflammatory responses, although they are not related to mouth opening capacity.

Neonatal Coronoid Hyperplasia: A Report of a Case and Concepts to Promote Early Diagnosis and Treatment.

Limited mouth opening in the neonatal patient is primarily caused by either soft tissue or hard tissue pathologic features. Differentiation between the two can usually be elicited by physical examination with the patient under anesthesia. Limited opening from soft tissue pathologic features can be increased with stretching. In contrast, osseous pathologic features will produce an anatomic stop. Syndromic cases with hard tissue pathologic features are primarily due to coronoid hyperplasia. Our aims are to help clinicians evaluate and identify mandibular hypomobility in the pediatric patient resulting from coronoid hyperplasia and to promote early treatment to improve long-term oral function. We present the case of a 2-month-old male who was born premature at 30 weeks by emergency cesarean section. Examination revealed multiple anomalies, including significant trismus with a maximal opening of 4 mm. A computed tomography scan revealed significant bilateral coronoid hyperplasia. At the age of 90 days, the patient underwent bilateral coronoidectomies with endoscopic guidance under general anesthesia. After resection, the patient was able to open his mouth to 25 mm. This opening was maintained with postoperative physiotherapy. Clinical problems can arise from the potential sequelae of neonatal trismus. Acutely, these problems can range from feeding difficulty and potential malnutrition to aspiration and emergent airway compromise. Long-term consequences include growth restrictions because of malnutrition, speech delay, muscle contracture and atrophy, facial asymmetry, and the risk of infection owing to poor oral hygiene. Information is limited about neonatal treatment of condylar hyperplasia in the published data. Treatment tends to be delayed owing to a late diagnosis and referral, and patients are prone to developing relapse. Postoperative physical therapy will help to prevent relapse and allows for maintenance of the improved jaw range of motion.

Trismus in patients with head and neck cancer: etiopathogenesis, diagnosis and management.

BACKGROUND: Trismus indicates severely restricted mouth opening of any aetiology. A mouth opening of 35 mm or less should be regarded as trismus. Aim of this study was to review the etiopathogenesis, incidence, treatment and prevention of trismus in patients with head and neck cancer. OBJECTIVE OF REVIEW: Trismus is frequently seen in patients suffering from malignant tumours of the head and neck. The reported prevalence of trismus in those patients varies considerably in the literature and ranges from 0 to 100% depending on the tumour site and extension. Trismus may worsen or remain the same over time, or the symptoms may reduce, even in the absence of treatment. When a patient presents with trismus after tumour treatment, it is important to determine whether the trismus is the result of the treatment, or is the first sign of a recurrence. Restricted mouth opening may impede inspection of the oral cavity as needed for dental care, and particularly for oncologic follow-up. CONCLUSIONS: Mouth opening after radiotherapy (RT) decreases on average by approximately 20% compared to mouth opening prior to RT. The prevalence of trismus increases with increasing doses of RT to mastication structures. The use of intensity-modulated RT seems to lower the percentage and severity of RT-induced trismus. Treatment of trismus can be conservative (with either medical or physical therapy) or surgical. Exercise therapy is the mainstay of treatment and exercise should start as soon as possible after treatment. The prevention of trismus, rather than its treatment, is the most important objective.

Trismus-pseudocamptodactyly syndrome: a 20 year follow-up.

BACKGROUND: Trismus-Pseudocamptodactyly Syndrome (TPS) is a rare autosomal syndrome characterised by the inability to open the mouth fully, pseudocamptodactyly, short stature and foot deformities. The maxillofacial feature entails hyperplasia of the coronoid processes which mechanically interfere with the zygomatic processes during mouth opening. CASE REPORT: A 22-year- old girl affected by a severe form of TPS was followed from the age of three years. Bone reossification was observed after two coronoidotomies of both hyperplasic coronoid processes. After the decision to perform a coronoidectomy, the four-year follow-up showed a favourable outcome. Meanwhile the patient developed an anterior open bite which was treated with a fourth orthognathic surgery. The follow-up underscores how the correction of malformation leads to the generation of EMG activity of the masticatory muscles after many years of passiveness.

A case of conversion disorder presenting as chronic trismus.

Trismus can be the symptom of several diseases. For the most part, the inability to open the mouth is due to an articular disorder but occasionally, the cause may be extra-articular. In this case, being reported, non-articular hysterical trismus caused the jaw to lock in an 11-year-old boy for 3 months. During this period the jaw was completely locked and the locking was associated with moderate to severe pain. After three sessions of therapy the patient was able to open his mouth 33 mm and his eating was back to normal. Conversion disorders often present with dramatic physical presentation including trismus and jaw lock. This report highlights the importance of complete history taking and a thorough clinical examination to make a correct diagnosis in a patient with trismus.

Rare mandibular condition presenting as trismus: an exploration of IgG4-related disease.

A woman in her 30s presented with a 12-month history of reduced mouth opening and swelling on the right side of her mandible. The swelling was non-tender and firm on palpation. The swelling began to increase in size after the extraction of her carious wisdom tooth. Histopathological and serological examinations confirmed the diagnosis of IgG4-related disease, manifested as a mass in the mandible. The patient was prescribed oral corticosteroids at a tapering dosage over 8 weeks. After 3 months, there was an improvement in the patient's mouth opening and a reduction in the size of the swelling. The patient remains in follow-up care. Including IgG4-related disease in the list of potential diagnoses for oral soft tissue masses is crucial, given their positive response to medical treatment, highlighting the significance of an accurate diagnosis to prevent unnecessary surgery, with oral lesions potentially serving as early indicators before multiorgan complications arise.

Myositis ossificans of the temporalis muscle: case report and review of the literature.

Myositis ossificans, also known as traumatic myositis ossificans or myositis ossificans circumscripta, is the product of an unusual reactive process of mesenchymal stem cells within the muscle produced secondary to a traumatic insult or inflammatory process. In approximately 75% of cases, the process has a direct correlation with a single or repetitive, traumatic, penetrating, or crushing injury to the muscle. However, in up to 25% of cases, there is no recollection of a traumatic event. The most commonly accepted mechanism of traumatic etiology includes the embedment and lysis of bone fragments within the soft tissue causing subsequent exposure of bone morphogenic proteins to extraosseous cells. This environment stimulates osteoblasts to form true bone, dystrophic calcifications, or a calcified chondroid matrix. A concomitant mechanism that occurs involves the overproduction of bone morphogenic protein-4 produced by the muscle cells or the muscle fascia.

[A case of tetanus originating from ulcerated breast cancer].

We report herein on a rare case of tetanus originating from ulcerated breast cancer. A 60-year-old homeless woman was admitted to our hospital because of lockjaw. On admission, a physical examination revealed tachypnea, trismus, opisthotonus and an ulcerated right breast. There was no other skin soft tissue damage. A diagnosis of tetanus was entertained from the lockjaw and opisthotonus. Tetanus globulin, tetanus toxoid, penicillin and respiratory support were initiated. Later, a right total mastectomy was performed, and the diagnosis of breast cancer was made, however, gram positive bacilli were not detected and Clostridiuum tetani (C. tetani) was not cultured. It is conceivable that the ulcerated breast was contaminated with C. tetani due to the patients living conditions.