Trismus-pseudocamptodactyly syndrome: case report ten years after

BACKGROUND

In 1969, Hecht and Beals described for the first time a rare dominant autosomal syndrome characterised by reduced mouth opening, pseudocamptodactyly, short stature, and foot deformities. Recent studies have confirmed that TPS is caused by a mutation of MYH8 that is common to another disease called Carney syndrome.

CASE REPORT

The authors describe the long term follow-up of a case presented in 2003, ten years after the first surgical procedure: a 14-year-old girl, affected by this rare syndrome, had underwent an early (at 4 years) surgical treatment of bilateral coronoidotomies to ensure safe airway management to allow subsequent surgical treatment to correct foot deformities. After six years, a complete relapse of the trismus occurred. Three years later, the patient underwent a second surgery of bilateral coronoidotomies to definitely solve trismus. At the 18 months follow-up, the mouth opening was stable.

Orofacial pain and neurosensory disorders and dysfunction in cancer patients

Orofacial pain and altered nerve sensation may be the initial sign of oropharyngeal or nasopharyngeal cancer. This article focuses on the most common orofacial pain conditions and neurosensory alterations that affect cancer patients, such as neuropathic pain, muscle spasm or contractures, mucositis, and increased or decreased sensory discrimination in the affected area. The various pharmacotherapeutic modalities for cancer pain management ranging from non steroidal anti-inflammatory drugs (NSAIDs) for mild pain to opioids for severe pain are discussed in detail.

Migration of aluminum silicate from the oral cavity to the submandibular region, with foreign body granuloma formation: report of a case

We present the first case of foreign body granuloma in the cervical (submandibular) region as a result of migration of noninjected aluminium silicate particles from the oral mucosa. This migration can be explained by macrophage phagocytosis and transport through the local lymphatic network and surgical disruption of fascial layers. The appearance of foreign body granulomas in distant sites may appear several weeks after the local event in a specific disposition according with the migration route. This entity must be born in mind in differential diagnosis of multiple nodules, pigmentation, or persistent swelling in the cervical-orofacial region.

Trismus: An unconventional approach to treatment

A 63 year-old man who had had an operation for adenocarcinoma of the left parotid gland presented with worsening trismus after the completion of radiotherapy. None of the treatments given were successful so he resorted to a "home-made" approach, and succeeded in improving his mouth-opening by 18 mm.

Aspiration of peritonsillar abscess in severe trismus

We present a novel method of aspirating a peritonsillar abscess in a patient with severe trismus. In our experience, this method is efficient, allows good access to the peritonsillar area and facilitates rapid resolution of the trismus before definitive drainage can be performed.

Oral complications of radiotherapy

Radiotherapy-induced damage in the oral mucosa is the result of the deleterious effects of radiation, not only on the oral mucosa itself but also on the adjacent salivary glands, bone, dentition, and masticatory musculature and apparatus. Biological response modifiers, cytoprotective drugs, salivary-sparing radiation techniques, and surgery have been introduced to combat and, more importantly, to prevent, the development of these complications. Radiotherapy-induced oral complications are complex, dynamic pathobiological processes that lower the quality of life and predispose patients to serious clinical disorders. Here, we focus on these oral complications of radiotherapy, highlight preventive and therapeutic developments, and review the current treatment options available for these disorders.

Diagnosing and treating the patient with restricted mandibular opening: a new approach

Patients with a restricted mandibular opening and related pain require a systematic process for differential diagnosis and treatment planning. This article considers the differential diagnostic process, treatment planning, and treatment delivery for a patient seeking a second opinion before surgery for a closed lock. A closed lock occurs when the disc in the joint has been pulled off the head of the condyle and forward, blocking the condyle from translating forward.

Mandibular Nerve Blocks for the Removal of Dentures During Trismus Caused by Tetanus

We report a case of trismus caused by tetanus in an 80-yr-old woman who developed severe and painful masseter spasms during which she violently bit the tip of her tongue with her dentures. Bilateral mandibular blocks were performed to remove the dentures. The patient fully recovered. We suggest that mandibular blocks are a useful tool in the management of oral events during trismus in conscious patients.

Comparative study of the therapeutic effect of a systemic analgesic and transcutaneous electrical nerve stimulation (TENS) on post-IMF trismus and pain in Nigerian patients

OBJECTIVES

To compare the therapeutic effect of paracetamol and Transcutaneous Electrical Nerve Stimulation (TENS), on post-Intermaxillary Fixation (IMF) trismus, and pain in some Nigerian patients.

PATIENTS AND METHODS

Twenty patients treated for mandibular fractures with IMF were randomly selected into two groups of ten patients each. After the release of IMF, they were started on jaw exercises with the aid of wooden spatulae to overcome trismus due to muscle spasm. Patients in Group I underwent jaw exercises before and after TENS therapy which lasted for 30 minutes while those in Group II had jaw exercises before and 30 minutes after ingestion of 100 mg of paracetamol. Their inter-incisal distances were recorded pre and post intervention.

RESULTS

Analysis of the data showed that for both therapeutic interventions, there was an appreciable gain in mouth-opening which was more prominent for patients with unusual difficulty in mouth-opening initially. However, a comparison between the mean improvements produced by TENS and analgesic revealed no significant difference between the two groups.

CONCLUSION

Both the TENS therapy and paracetamol provided similarly appreciable differences in inter-incisal distances (mouth-opening) after their applications.

The influence of cryotherapy on reduction of swelling, pain and trismus after third-molar extraction

BACKGROUND

Swelling, pain and trismus are undesirable consequences of impacted mandibular third-molar extraction. The authors conducted a study to evaluate the effectiveness of cryotherapy, the therapeutic use of cold, in reducing undesirable consequences after surgery.

METHODS

Fourteen patients aged 20 to 28 years comprised the sample. The authors extracted two impacted mandibular third molars at different times from each patient. Immediately after surgery, the patient underwent cryotherapy on one side for 30 minutes every one and one-half hours for 48 hours when he or she was awake. The patient did not receive cryotherapy on the other side. The authors performed clinical examinations to measure trismus and swelling before surgery, immediately after surgery and 24 and 48 hours after surgery.

RESULTS

The authors compared both sides for differences in swelling, pain and trismus in each patient. The results showed significant statistical differences in two of the five points that were used to measure the swelling (Wilcoxon nonparametric signed rank test of linear distances between the angle of the mandible to the pogonion and to the tragus). They found statistical differences between the two sides in relation to the pain; however, they found no significant differences in relation to trismus.

CONCLUSIONS

Cryotherapy was effective in reducing swelling and pain in this sample. Despite playing no role in the reduction of trismus, cryotherapy was effective in reducing swelling and pain in this sample, and the authors still recommend it be used.

CLINICAL IMPLICATIONS

Cryotherapy is helpful after third-molar extraction. Further studies need to be conducted that use larger samples of patients and other types of therapy, such as low-level laser therapy.

Trismus in head and neck oncology: a systematic review

The aim of this review was to identify systematically, criteria for trismus in head and neck cancer, the evidence for risk factors for trismus and the interventions to treat trismus. Three databases were searched (time period 1966 to June 2003) for the text "trismus" or "restricted mouth opening". Included in the review were clinical studies (> or = 10 patients). Two observers independently assessed the papers identified. In 12 studies nine different criteria for trismus were found without justifying these criteria. Radiotherapy (follow-up: 6-12 months) involving the structures of the temporomandibular joint and or pterygoid muscles reduces mouth opening with 18% (sd: 17%). Exercises using a therabite device or tongue blades increase mouth opening significantly (no follow-up), effect sizes (ES) 2.6 and 1.5 respectively. Microcurrent electrotherapy (follow-up 3 months) and pentoxifylline (no follow-up) increases mouth opening significantly (ES for both: 0.3).

Therapeutic effect of TENS on post-IMF trismus and pain

The study set out to investigate the therapeutic effect of Transcutaneous Electrical Nerve Stimulation (TENS) in the alleviation of pain and post-IMF trismus, in patients undergoing jaw exercises to hasten mouth opening after being treated for fractures of the mandible. Two groups of patients, with 10 patients in each group, were used for the study. The groups were the experimental and the control groups. They were all treated for mandibular fractures, and had their jaws immobilized for 6 weeks, immediately after which they were started on jaw exercises. The Inter-incisal distances and number of acceptable wooden spatulae that the jaws could accommodate were noted and recorded. The experimental group was then placed on the TENS therapy for 20 minutes, after which the new inter-incisal distances and the number of acceptable wooden spatulae were recorded. The control group had no TENS therapy; the patients only waited for 20 minutes without any stimulation, before the new inter-incisal distances and the number of acceptable wooden spatulae were measured and recorded. It was observed that the inter-incisal distance and the number of acceptable wooden spatulae significantly increased in patients in the experimental group compared to the control group. It was concluded that TENS could be useful in relieving the pain associated with forced mouth-opening exercises aimed at overcoming trismus caused by muscle spasm, which is associated with prolonged immobilization of the jaws for the treatment of facial fractures.

Oral complications in radiation therapy

The dentist is integral to managing care for patients with head and neck cancer. Oral complications may manifest during and/or following radiation therapy and can last for the lifetime of the individual. This article reviews a number of these complications as well as the resources available to dentists for managing care of radiation oncology patients and improving their quality of life.

Trismus-pseudocamptodactyly syndrome: a case report

BACKGROUND

Hecht and Beals in 1969 described an autosomal dominant syndrome characterised by severe restriction of mouth opening, camptodactyly, shortness of leg muscles and, as a direct consequence, foot deformities.

CASE REPORT

A case of a 4-year-old girl affected by this unusual syndrome is described. The patient underwent bilateral resection of coronoid processes by intraoral approach. An intraoral device was used in the immediate postoperative period in order to maintain mouth opening. Once at home, the patient has had, for six months, phisiokinesic therapy by means of a modified Darcissac device.

Cephalic tetanus as a result of rooster pecking: an unusual case

In this paper, a case of cephalic tetanus caused by rooster pecking to the face is presented. Cephalic tetanus is a rare type of tetanus defined by trismus and paralysis of 1 or more cranial nerves. On admission to hospital the patient had facial palsy and trismus. With proper medical management she recovered without any relapse.

[Initial results using extracorporeal low energy shockwave therapy ESWT in muscle reflex-induced lock jaw]

BACKGROUND

Post-traumatic reflex-mediated temporomandibular joint (TMJ) locking is one of the complications frequently observed after sophisticated and long dentoalveolar operations. Its severity can be up to 90%. Usually, therapy consists of mouth-opening exercises using tongue depressors. In difficult cases, the treatment regularly extends for weeks, often with only moderate improvement of this painful limitation.

USE OF ESWT

In three cases, it was shown that supportive treatment utilizing low-energy shock waves (ESWT) is significantly effective in the therapy of limited opening of the mouth. The patients reported relief of their complaints, especially over the mandibular angle region, through the daily application of ESWT and felt their condition improved after the fifth therapy course.

DISCUSSION

This in particular improved the patient's ability to eat, speak, and maintain good oral hygiene. Great physiotherapeutic benefit is imparted by the use of ESWT in the clinical management of these and other cases of dentomaxillofacial practice.

Mandibular nerve block treatment for trismus associated with hypoxic-ischemic encephalopathy

BACKGROUND AND OBJECTIVES

We describe the use of mandibular nerve block for the management of bilateral trismus associated with hypoxic-ischemic encephalopathy.

CASE REPORT

The patient was a 65-year-old man with bilateral trismus due to hypoxic-ischemic encephalopathy. Despite his impaired consciousness, we performed fluoroscopically guided bilateral mandibular nerve block. The bilateral symptoms were sufficiently improved, without obvious side effects, by injecting a local anesthetic near the right mandibular nerve and a neurolytic near the left mandibular nerve.

CONCLUSIONS

Mandibular nerve block may be an effective treatment for patients with bilateral trismus due to ischemic-encephalopathy, even when consciousness is impaired.

Trismus: aetiology, differential diagnosis and treatment

Trismus is a problem commonly encountered by the dental practitioner. It has a number of potential causes, and its treatment will depend on the cause. This article discusses the primary causes of this condition and the various treatments available.

Oral administration of milk from cows immunized with human intestinal bacteria leads to significant improvements of symptoms and signs in patients with oral submucous fibrosis

BACKGROUND

Previous studies have shown that the local and systemic upregulation of fibrogenic cytokines and downregulation of antifibrotic cytokine are central to the pathogenesis of oral submucous fibrosis (OSF). The milk from cows immunized with human intestinal bacteria (immune milk) contains an anti-inflammatory component that may suppress the inflammatory reaction and modulate cytokine production. Therefore, it was decided to test whether immune milk may have some beneficial effects on controlling the symptoms and signs in OSF patients.

METHODS

In this preliminary study, 26 OSF patients who received immune milk treatment (45 g of immune milk powder twice a day) for 3 months and oral habit intervention were included in the experimental group. Another 20 OSF patients who received only oral habit intervention served as the control group.

RESULTS

We found that the interincisor distance was significantly improved (> or =3 mm of the baseline measurement) in 18 of the 26 (69.2%) OSF patients in the experimental group at exit. However, in the control group none of the OSF patients had an increase in interincisor distance greater than 2 mm. In addition, disappearance or significant improvement of symptoms at exit was observed in 80% (16/20) of the patients with intolerance to spicy foods (P < 0.001) and 72.2% (13/18) of the patients with xerostomia (P < 0.005) in the experimental group, compared with 17.6% (3/17) of the patients with improvement of intolerance to spicy foods and 15.4% (2/13) of the patients with improvement of xerostomia in the control group. Partial regression of concomitant oral leukoplakia or erythroplakia (judged from the size reduction of the lesions) at exit was noted in 71.4% (5/7) of the patients in the experimental group (P < 0.05), compared with none (0/5) of the patients with improvement in the control group.

CONCLUSION

We conclude that oral administration of immune milk leads to significant improvements of symptoms and signs in OSF patients.

[A case of cephalic tetanus presenting with opisthotonus]

We report a case of cephalic tetanus presenting with opisthotonus. A 49-year-old man was admitted because of repeated convulsions. The patient was a garbage truck driver known to be alcoholic, who fell down to suffer an injury of the left face two days before the onset of convulsion. Intravenous administration of diazepam and phenytoin partially relieved the convulsions. Anti-tetanus human immuno-globulin was also administered despite absence of typical clinical sign. Six hours later, however, the patient became unable to open the mouth, i.e. lockjaw developed, and the diagnosis of tetanus was made. Additional anti-tetanus human immunoglobulin of 3,000 units and 4,500 units on the next day rapidly relieved the lockjaw, convulsion, and general muscle rigidity without sequalae. The patient showed transient bilateral facial palsy and rotatory nystagmus during the course. Cephalic tetaus is characterized by a history of an injury of the head and a short latency before developing generalized tonic convulsion or opisthotonus. While a typical case presents with lockjaw, our case presented with opisthotonus, presumably because of early systemic lymphatic spreading of tetanus toxin. Early diagnosis and treatment is important to prevent generalized convulsions which are more frequent and sometimes lethal in cephalic tetanus than the common form.