Evaluation of new treatment in patients suffering from trismus following radiotherapy

Caterina Finizia, Prof, MD, PhD Division of ENT Sahlgrenska University Hospital Gothenburg Sweden

INTRODUCTION DISCUSSION RESULTS

Figure 3. MIO before, 6 and 12 months after exercise intervention in the study group

Figure 1. TheraBite device ®

Figure 2. Engström’s wooden blades

ABSTRACT

METHODS AND MATERIALS

CONCLUSIONS

REFERENCES

CONTACT

Objectives Trismus (maximum interincisal opening ≤35 mm) impacts on activities of daily living and adversely affects patient quality of life (QoL). This study aims to investigate the effectiveness of mouth-opening tools in the rehabilitation of trismus in patients with head and neck (H&N) cancer as well as any improvement in patients’ health-realted quality of life (HRQL) . Methods Thirteen study patients suffering from trismus following radiotherapy treatment for H&N cancer were identified at Sahlgrenska University Hospital, Gothenburg, Sweden. An additional 13 patients constituted a control group. The study patients were enrolled in a mouth opening training programme in contrast to the control patients who did not receive any systematic training. All patients reported HRQL and trismus related problems via validated questionnaires including Gothenburg Trismus Questionnaire (GTQ) and EORTC C30, EORTC H&N35. Results Twelve months after completion of radiotherapy treatment, none of the study patients demonstrated trismus, whereas 62% of patients in the control group suffered from trismus 12 months post-treatment. The study cohort reported a clinically significant improvement after mouth opening exercises with regard to social function and global QoL. No clinically significant change was observed with regard to these scales in the control group. Conclusion This study indicates a positive relationship between systematic mouth-opening training, reduction of trismus and improved QoL. Systematic mouth opening exercises could be implemented as standard treatment for cancer patients demonstrating trismus once larger trials have confirmed the results from this study.

Twelve months after completion of radiotherapy treatment, none of the study patients demonstrated trismus, whereas 62% of patients in the control group suffered from trismus 12 months post-treatment. During the study follow-up year the control patients reported statistically significant more symptoms/trimsus problems according to all three GTQ domains, compared to the study group (intervention group). The intervention group also reported a clinically significant improvement after mouth opening exercises with regard to the EORTC QLQ-C30 domains social function and global QoL. No clinically significant change was observed with regard to these scales in the control group.

This prospective intervention study investigated the impact of structured exercise on trismus. We found that structured jaw exercise program with the TheraBite ® or Engström´s wooden blades device were effective and significantly improved patients´ mouth opening capacity. The objective effect on trismus (MIO) was also reflected in the PRO questionnaires where the patients who underwent a structured exercise program after cancer treatment also reported improvements in HRQL and less trismus related symptoms according to GTQ compared to the control group. All patients in the study group (100%) improved their jaw opening capacity during the 12 month follow-up compared to only 7 patients in the control group (54%). Although jaw opening capacity does improve spontaneously to some extent, systematic exercise training appears to be of great importance following trismus development as the study group did in fact report better mouth opening capability as well as completely recovering from the trismus diagnosis when compared to the control group, where 62% of patients still suffered from trismus after 12 months.

Thirteen study patients suffering from trismus following radiotherapy treatment for H&N cancer were identified during one year at Sahlgrenska University Hospital, Gothenburg, Sweden. An additional 13 patients constituted a control group. The study patients were enrolled in a structured mouth opening training programme in contrast to the control patients who did not receive any systematic training. Tumorlocalization in each group were tonsils (n=7), base of tongue (n=4) and tumor colli (n=2). The definition of trismus as proposed by Dijsktra, i.e. maximal interincisal opening (MIO) ≤35 mm (2) was used and measured as the maximum distance between the upper and lower incisors. Measurements were done using a ruler with the patient in a supine position. All patients reported HRQL via validated Patient Report Outcomes (PRO) questionnaires including Gothenburg Trismus Questionnaire (GTQ) (3) and the European Organisation for Research and Treatment of Cancer Quality of Life; EORTC QLQ Core 30 and the EORTC QLQ H&N35.

The study demonstrates that jaw exercise training is an effective treatment for trismus arising secondary to radiotherapy treatment of H&N tumors. In clinical practice, this training could be introduced as a treatment option for patients who develop trismus or even as a preventative measure. Although trismus is a common complication, there is currently no established treatment approach and further trials with larger study populations are required to investigate how the training protocol itself should be designed to produce maximum training benefit. .

Reduced ability to open the mouth (trismus) is a common symptom in head and neck (H&N) cancer patients with an incidence of 38% (1). Trismus affects many aspects of daily life such as eating, chewing, swallowing, dental hygiene and impairs necessary dental or surgical management. As a consequence, trismus can lead to malnutrition and weight loss. Patients with trismus and H&N cancer also report pain, depressive symptoms and an overall impaired health related quality of life (HRQL) (1). This study aims to further investigate the effectiveness of mouth-opening tools in the rehabilitation of trismus in patients with H&N cancer as well as any improvement in patients’ HRQL.

1.  Pauli N, Johnson J, Finizia C, Andrell P. The incidence of trismus and long-term impact on health-related quality of life in patients with head and neck cancer. Acta Oncol. 2012.

2.  Dijkstra PU, Huisman PM, Roodenburg JL. Criteria for trismus in head and neck oncology. Int J Oral Maxillofac Surg. 2006; 35(4): 337-42.

3.  Johnson J, Carlsson S, Johansson M, Pauli N, Ryden A, Fagerberg-Mohlin B, et al. Development and validation of the Gothenburg Trismus Questionnaire (GTQ). Oral Oncol. 2012; 48(8): 730-6.

Prof, MD, PhD Caterina Finizia Department of Otolaryngology Sahlgrenska University Hospital Gothenburg, Sweden caterina.finizia@gu.se

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