Trismus in patients with head and neck cancer and 5-year overall survival

Amplification, Resistance, and Kinetics of the Jaw Stretching Device (ARK-JSD): analysis of the force variation and implications for trismus therapy

PURPOSE

Jaw-stretching devices, including the Amplification, Resistance, and Kinetics of the Jaw (ARK-JSD), are an effective option for treating trismus after head and neck cancer (HNC) treatment. The force, however, that is applied to the patient's jaw is unknown.

METHODS

Ten ARK-JSD devices were constructed for each of the levels of resistance (total of 30 samples). Each sample was tested using a Universal Testing Machine (UTM).

RESULTS

The easy, medium, and hard ARK-JSD had a mean maximum force of 12.3, 21.0, and 32.7 Newtons (N) at a mean interincisal distance (IID) of 8.0 mm, 13.0 mm, and 16.0 mm, respectively. The force varied by 6.9 N for the easy and 24.1 N for the hard ARK-JSD. Fatigue analysis demonstrated up to 5.5 N loss of force over 10 weeks.

CONCLUSION

The ARK-JSD is a low-cost trismus device that can force between 12.3 and 32.7 N. The variation in resistance may impact efficacy. Understanding this variation will assist clinicians and patients using the ARK-JSD for trismus therapy.

Restorabite™: Phase II trial of jaw stretching exercises using a novel device for patients with trismus following head and neck cancer

Patients treated for oral cancer, may experience restricted mouth opening (trismus). Barriers such as cost have limited the utilization of traditional jaw stretching devices, and consequently, patients experience problems with swallowing, oral care, communication, and cancer surveillance. The safety and efficacy of Restorabite™, a new device designed to overcome these barriers, is evaluated prospectively over 12 months. This phase II investigator-led trial included patients with chronic trismus underwent 10-weeks of trismus therapy using Restorabite™. Safety, adherence, changes in mouth opening, and patient-reported outcomes are presented. 114/120 participants with trismus completed the intervention, and 104 had their progress monitored for 12 months. Thirteen participants withdrew due to tumour recurrence. At the completion of the intervention, mouth opening improved by 10.4 mm (p < .001). This increased to 13.7 mm at 12 months (p < .001). Patient reported outcome all significantly improved and 47 participants were no longer classified as having trismus. There were no serious treatment related adverse events. In patients with trismus following head and neck cancer treatment, a 10-week programme of jaw stretching exercises using Restorbite™ safely improves mouth opening and associated quality of life outcomes with high adherence and the benefits are maintained for 12-months.

Rehabilitation strategies for trismus post oral cancer treatment: Progress in the study of mouth opening exercises

Oral cancer is a significant public health issue worldwide. Although its treatment methods effectively control tumor growth, they can lead to complications, including Trismus, severely affecting patients' quality of life. The practice standards for mouth opening exercises, a rehabilitative method to prevent and treat Trismus, are not yet clear. Therefore, this article aims to review the research progress of mouth opening exercises in the rehabilitation of Trismus post oral cancer treatment, providing a scientific and effective rehabilitation plan for oral cancer patients to improve their quality of life.

A pilot study of intensive intervention using a novel trismus device

PURPOSE

Trismus secondary to head and neck neoplasm treatment impacts upon quality of life, nutrition, oral hygiene, and dentition. Current treatment options for trismus apply unquantified force to the jaw, and in many cases, the device costs are prohibitive. This study aimed to prospectively evaluate the impact of a novel trismus device.

METHOD

This single arm cohort study prospectively evaluated the impact of a novel trismus device on maximal incisal opening (MIO), trismus-related function and quality of life scores. Seventeen patients diagnosed with trismus were recruited to undergo a 10-week program using a novel device. The effect of the intervention was assessed by comparing pre- vs post-intervention validated measures.

RESULT

A significant improvement in MIO was observed post the 10-week intervention period (12.6 mm). This was associated with an improvement in patient reported trismus symptomology including quality of life, swallowing, speech, and jaw pain.

CONCLUSIONS

This pilot study demonstrates the feasibility of a novel device in the treatment of trismus. Further evaluation of this device is warranted to assess efficacy, safety, and cost-effectiveness in a larger cohort with appropriate controls.

Evaluation of the Effects of Radiation Therapy on Muscle Contractibility and Skin Healing: An Experimental Study of the Cancer Treatment Implications

BACKGROUND

Radiotherapy can affect healthy cells, resulting in side effects. This study aimed to assess the impact of radiotherapy on soft tissue in surgical wounds in rats.

METHODS

The animals were divided into four groups: control (S) group without irradiation, immediate irradiation (S-IIr) group receiving irradiation right after surgery, late irradiation (S-LIr) group receiving irradiation four weeks after surgery, and early irradiation (Ir-S) group receiving irradiation before surgery. The irradiated groups underwent two fractional stages of 15 Gy. Muscle contractibility (EMG) was evaluated at two different time points, and after 2 and 7 weeks, the animals were euthanized for histological analysis of the muscles and skin.

RESULTS

There was no significant difference between the EMG1 and EMG2 values of the S and S-LIr groups, but both S-IIr and Ir-S groups exhibited a statistically significant difference. The S group demonstrated a larger diameter of muscle fiber compared to other groups, showing a significant difference. In terms of skin analysis, the S-IIr group had the least inflammatory infiltrate and the highest amount of red fibers, differing significantly from the other groups.

CONCLUSIONS

Regardless of the duration, radiotherapy was found to have effects on the surrounding soft tissues, as concluded by this study.

Assessment of mouth opening before and after head and neck radiotherapy in patients with intraoral stents

Background

We evaluated the evolution of mouth opening before and after radiotherapy of the head and neck in patients using intraoral stents.

Materials and methods

Twenty-one patients with head and neck cancer who were indicated for radiotherapy participated in this study. Maximum interincisal opening measurements were performed before and after radiotherapy. Paired analyses of the pre- and post-radiotherapy groups were performed using paired samples t-tests and correlation analyses using Spearman's correlation test, with p < 0.05 considered statistically significant.

Results

Paired analyses of the pre- and post-radiotherapy groups revealed a statistically significant reduction in post-radiotherapy maximum interincisal opening (p < 0.001). However, only four individuals were diagnosed with trismus after radiotherapy. Regarding the correlation tests, no statistically significant differences were observed between the differences in pre- and post-radiotherapy maximum interincisal opening values and the study variables.

Conclusion

The use of prosthetic devices during head and neck radiotherapy can reduce radiation doses in areas of no interest, thereby preventing the acute and late toxicities associated with cancer therapy.

Trismus after partial maxillectomy and radiotherapy: Free flap reconstruction versus prosthetic obturation

OBJECTIVE

Partial maxillectomy and postoperative radiotherapy are both risk factors associated with trismus. This retrospective study aimed to evaluate the incidence and severity of trismus in patients following partial maxillectomy with or without postoperative radiotherapy and to compare free flap reconstruction and prosthetic obturation.

METHODS

A retrospective review of 40 oral cancer patients who underwent partial maxillectomy with or without postoperative radiotherapy was performed. Maximum interincisal distance recorded at least 6 months after surgery was classified according to a revised subjective-objective management-analytical (SOMA) scale and compared between the free flap reconstruction group (n = 12) and the prosthetic obturation group (n = 28).

RESULTS

Trismus was observed in 16/40 (40%) patients, and severe trismus was observed in 4/40 (10%) patients. Although no significant difference in trismus grade was observed between the free flap reconstruction and prosthetic obturation groups, both severe trismus and radiation-induced osteonecrosis were only seen in the prosthetic obturation group with postoperative radiotherapy.

CONCLUSION

Free flap reconstruction was preferable to prosthetic obturation to avoid severe trismus and radiation-induced osteonecrosis in patients who underwent both partial maxillectomy and postoperative radiotherapy.

Addressing symptoms that affect patients' eating according to the Head and Neck Patient Symptom Checklist©

PURPOSE

The purpose of this prospective study was to assess which nutritional impact symptoms (NIS) interfere with oral intake in patients with head and neck cancer (HNC) and how the symptoms interfere with body weight loss, up to 1 year after treatment.

METHODS

This was a prospective study of 197 patients with HNC planned for treatment with curative intention. Body weight was measured before the start of treatment, at 7 weeks after the start of treatment, and at 6 and 12 months after completion of treatment. NIS and NIS interfering with oral intake at each follow-up were examined with the Head and Neck Patient Symptom Checklist^© (HNSC^©).

RESULTS

At 7 weeks of follow-up, patients experienced the greatest symptom and interference burden, and 12 months after treatment the NIS scorings had not returned to baseline. One year after treatment, the highest scored NIS to interfere with oral intake was swallowing problems, chewing difficulties, and loss of appetite. At all 3 follow-ups, the total cumulative NIS and NIS interfering with oral intake were associated with body weight loss. Factors increasing the risk for a body weight loss of ≥ 10% at 12 months after treatment were pain, loss of appetite, feeling full, sore mouth, difficulty swallowing, taste changes, and dry mouth. Women scored higher than men in NIS and NIS interfering with oral intake. Furthermore, during the study period about half of the population had a body weight loss > 5%.

CONCLUSION

Because both nutritional and clinical factors may affect body weight, this study highlights the importance of a holistic approach when addressing the patients' nutritional issues.

TRIAL REGISTRATION

ClinicalTrials.gov NCT03343236, date of registration: November 17, 2017.

Identifying Patient-Reported Outcome Measures (PROMs) for Routine Surveillance of Physical and Emotional Symptoms in Head and Neck Cancer Populations: A Systematic Review

The aims of this review were to identify symptoms experienced by head and neck cancer (HNC) patients and their prevalence, as well as to compare symptom coverage identified in HNC specific patient-reported outcome measures (PROMs). Searches of Ovid Medline, Embase, PsychInfo, and CINAHL were conducted to identify studies. The search revealed 4569 unique articles and identified 115 eligible studies. The prevalence of reported symptoms was highly variable among included studies. Variability in sample size, timing of the assessments, and the use of different measures was noted across studies. Content mapping of commonly used PROMs showed variability and poor capture of prevalent symptoms, even though validation studies confirmed satisfactory reliability and validity. This suggests limitations of some of the tools in providing an accurate and comprehensive picture of the patient's symptoms and problems.

Association of Trismus With Quality of Life and Swallowing in Survivors of Head and Neck Cancer

OBJECTIVE

We aim to (1) determine the prevalence and predictors of trismus and (2) examine the relationship of trismus, swallowing dysfunction, and quality of life (QOL) in survivors of head and neck cancer (HNC).

STUDY DESIGN

Case series with chart review.

SETTING

Multidisciplinary HNC survivorship clinic.

METHODS

Data on trismus and patient-reported outcomes were obtained from survivors of HNC between December 2016 and October 2019. Trismus was defined as a maximum interincisal opening ≤35 mm. QOL and swallowing dysfunction were measured with the University of Washington Quality of Life questionnaire and EAT-10 (Eating Assessment Tool-10), respectively. Linear regressions were applied to investigate the relationship of trismus with QOL and swallowing dysfunction.

RESULTS

Of the 237 survivors, 22.78% (n = 54) had trismus. Advanced stage of cancer (stage III/IV vs Tis-II, P = .002) and treatment (nonsurgical and surgery + adjuvant treatment vs surgery only, P = .006) were correlated with a higher prevalence of trismus. After controlling for cancer stage and treatment type, EAT-10 scores for survivors with trismus were 9.342 (95% CI, 6.262-12.423; P < .0001) higher than those without trismus. The University of Washington Quality of Life Physical and Social-Emotional subscales for patients with trismus were 14.088 (95% CI, 9.042-19.134; P < .0001) and 10.470 (95% CI, 4.793-16.147; P = .0003) lower than those without trismus, respectively.

CONCLUSION

Trismus is a common, treatment-related consequence and is associated with increased symptoms of dysphagia and decreased QOL. Early detection and management of trismus in survivors of HNC are essential to optimize QOL and reduce morbidity.

Dysphagia, trismus and speech impairment following radiation-based treatment for advanced stage oropharyngeal carcinoma: a one-year prospective evaluation

OBJECTIVE

The objective was to assess swallowing, mouth opening and speech function during the first year after radiation-based treatment (RT(+)) after introduction of a dedicated preventive rehabilitation program for stage III-IV oropharyngeal carcinoma (OPC).

METHODS

Swallowing, mouth opening and speech function were collected before and at six- and twelve-month follow-up after RT(+) for OPC as part of ongoing prospective assessments by speech-language pathologists .

RESULTS

Objective and patient-perceived function deteriorated until 6 months and improved until 12 months after treatment, but did not return to baseline levels with 25%, 20% and 58% of the patients with objective dysphagia, trismus and speech problems, respectively. Feeding tube dependency and pneumonia prevalence was low.

CONCLUSION

Despite successful implementation, a substantial proportion of patients still experience functional limitations after RT(+) for OPC, suggesting room for improvement of the current rehabilitation program. Pretreatment sarcopenia seems associated with worse functional outcomes and might be a relevant new target for rehabilitation strategies.

Mapping Health-Related Quality of Life, Anxiety, and Depression in Patients with Head and Neck Cancer Diagnosed with Malnutrition Defined by GLIM

Patients with cancer deal with problems related to physical, psychological, social, and emotional functions. The aim was to investigate malnutrition defined by the Global Leadership Initiative on Malnutrition (GLIM) criteria in relation to health-related quality of life, anxiety, and depression in patients with head and neck cancer. This was a prospective observational research study with 273 patients followed at the start of treatment, seven weeks, and one year. Data collection included nutritional status and support, and the questionnaires: European Organization for Research and Treatment of Cancer Head and neck cancer module (EORTC QLQ-H&N35) and the Hospital Anxiety and Depression Scale (HADS). Malnutrition was defined using the GLIM criteria. The study showed that patients with malnutrition had significantly greater deterioration in their health-related quality of life at seven weeks. On a group level, health-related quality of life was most severe at this time point and some scores still implied problems at one year. Significantly, more patients reported anxiety at the start of treatment whereas significantly more patients reported depression at seven weeks. Over the trajectory of care, the need for support often varies. Psychosocial support is imperative and at the end of treatment extra focus should be put on nutritional interventions and managing treatment-related symptoms to improve nutritional status and health-related quality of life. In the long-term, head and neck cancer survivors need help to find strategies to cope with the remaining sequel.

Oral and ocular late effects in head and neck cancer patients treated with radiotherapy

A broader understanding of oral and ocular late effects in head and neck cancer (HNC) patients who underwent intensity-modulated radiotherapy (IMRT) may provide valuable information in follow-up and improve quality of life. Twenty-nine HNC patients treated at least 6 months earlier and 30 age-matched controls were recruited. After completing several questionnaires: Oral Health Impact Profile-14 (OHIP-14), Shortened Xerostomia Inventory (SXI), Ocular Surface Disease Index (OSDI) and McMonnies Dry Eye questionnaire (MDEQ), participants underwent oral and ocular examinations. Oral examination included clinical oral dryness score (CODS) and secretion rates of unstimulated and stimulated saliva (UWS, SWS). Ocular examination included tear film break-up time, Schirmer test and ocular surface staining. The patients had more problems related to dry mouth than controls based on CODS and SXI, and more complaints of dry eye disease based on OSDI and MDEQ. UWS and SWS rates and oral health related quality of life were significantly lower in the patient group. Subjective oral dryness (SXI) correlated significantly with subjective ocular dryness (OSDI and MDEQ). Our study demonstrates that HNC patients treated with IMRT experience late effects in terms of xerostomia and ocular dryness underlining the importance of interdisciplinary approach in the evaluation and follow-up of HNC patients.

Evaluation of Carbon Ion Radiation-Induced Trismus in Head and Neck Tumors Using Dose-Volume Histograms

Simple Summary

Patients who receive carbon ion radiotherapy (C-ion RT) for tumors near the temporomandibular joint are likely to experience trismus, a condition characterized by reduced jaw opening. However, the relationship between the dose of carbon ion and the onset of trismus remains unclear. Therefore, we conducted a subgroup analysis of a prospective observational study to understand the relationship between the dose of carbon ion and the occurrence of trismus. Of 35 patients included in the study, six developed grade 2 trismus, and the median onset time was 12 months. The affected muscles included masticatory muscles and the coronoid process. Our findings suggest better treatment planning, such as dose optimization, to minimize the occurrence of muscle-related adverse effects associated with C-ion RT.

Abstract

Carbon ion radiotherapy (C-ion RT) provides a highly localized deposition of energy that can increase radiation doses to tumors while minimizing irradiation of adjacent normal tissues. For tumors located near the temporomandibular joint, C-ion RT-induced trismus may occur. However, the relationship between the carbon ion dose and the onset of trismus is unclear. In this prospective observational study, we assessed the trismus/carbon ion dose relationship using dose−volume histograms in 35 patients who received C-ion RT in their head and neck regions between 2010 and 2014. Trismus was evaluated in patients according to the Common Terminology Criteria for Adverse Events, version 4.0. All patients were treated with 57.6 or 64.0 Gy (relative biological effectiveness (RBE)) in 16 fractions, and the median follow-up time was 57 months. Grade 2 trismus was observed in six patients. The median onset time was 12 months. At maximum radiation doses, all masticatory muscles and coronoid processes, particularly the masseter muscle, were significantly different (p = 0.003). The contouring of the masseter muscle and coronoid process requires different treatment planning. The maximum radiation doses of the coronoid process can be proposed as a guideline for treatment planning, considering the ease of contouring in C-ion RT.