The Effectiveness of Surgical Methods for Trismus Release at Least 6 Months After Head and Neck Cancer Treatment: Systematic Review

Abstract

BackgroundThe objective of this systematic review was to identify the different surgical treatment modalities of severe trismus after head and neck squamous cell cancer treatment.MethodsAn electronic literature database search was conducted in Medline, Embase, Cochrane, Web of Science, and OpenGrey to determine articles published up to September 2021. Two observers independently assessed the identified papers for eligibility according to PRISMA guidelines. The inclusion criteria were trismus after head and neck squamous cell cancer with consecutive treatment, detailed description of the surgical procedure for trismus release, description of the initial treatment, at least 6 months between initial cancer treatment and trismus release surgery, a minimal follow-up (FU) of 6 months, and availability of full text. The quality was evaluated using the Newcastle-Ottawa scale. A subanalysis of the maximal mouth opening (MMO) was performed using a mixed-effect model.ResultsA total of 8,607 unique articles were screened for eligibility, 69 full texts were reviewed, and 3 studies, with a total of 46 cases, were selected based on the predetermined inclusion and exclusion criteria. Three treatment strategies were identified for trismus release (1) free flap reconstruction (FFR), (2) coronoidectomy (CN), and (3) myotomy (MT). There was a clear improvement for all treatment modalities. A quantitative analysis showed a beneficial effect of CN (mean 24.02 ± 15.02 mm) in comparison with FFR (mean 19.88 ± 13.97 mm) and MT (mean 18.38 ± 13.22 mm) (P < 0.01*). An increased gain in MMO after trismus release was found if no primary resection was performed (P = 0.014*). Two studies included in the analysis had an intermediate risk of bias and one had a low risk of bias.ConclusionCurrently available reports suggest a low threshold for performing a CN compared with FFR and MT. There is a need for high-quality randomized controlled trials with carefully selected and standardized outcome measures.

Delayed Commissuroplasty Increases Interincisal Distance in Buccogingival Cancer Patients Treated with Free Flap Reconstruction of the Oral Commissure

“…The group reported an immediate postoperative IID increase of nearly 30 mm and long-term gain of 9 mm after manifestation of postsurgical scarring. 17 Prior radiotherapy and cases requiring cutaneous excision (a patient population similar to ours) fared worse than a cohort without these treatment components. The group advocated for revision surgery if necessary to continue to improve IID, an argument which could support staged commissuroplasty's pairing with trismus release.…”

“…The group identified coronoidectomy, free flap reconstruction, and myotomy to be effective methods of trismus release, although the heterogeneity of cohorts limited direct comparison of the surgical outcomes. 17 Delayed commissuroplasty combined with scar release is likely the most successful method of establishing oral competence while maximizing IID.…”

Trismus surgery and microsurgical reconstruction after oral cancer treatment

“…Coronoidectomy could be an efficient treatment for less severe trismus, but insufficient in cases where the interincisal distance is just a few millimeters. 24 In such cases the treatment goal should be the liberation or removal of all the scar tissue and defect reconstruction with vascularized tissue to prevent secondary contraction. To our knowledge, this technique has only been described for trismus after oral cancer by Mardini et al 17 2003) and by Lee et al, 25 with our series having the largest number of patients and also the longest follow-up.…”

“…However, their initial mean IID of 16 mm was higher than in our series. Coronoidectomy could be an efficient treatment for less severe trismus, but insufficient in cases where the interincisal distance is just a few millimeters 24 . In such cases the treatment goal should be the liberation or removal of all the scar tissue and defect reconstruction with vascularized tissue to prevent secondary contraction.…”

Treatment Complications of Head and Neck Cancers and Rehabilitation Measures: A Narrative Review

“…This condition can result in progressive radiation fibrosis, which may develop five to 10 or more years after therapy [96]. Surgical removal of cancer through transoral laser or robotic resection may result in scarring, which in turn may cause trismus in the short and medium terms, leading to the possibility of permanent mouth-opening problems if aggressive therapy is not initiated [97]. Therefore, clinicians should be aware of the potential risk of trismus and carefully monitor patients who have undergone therapy to ensure appropriate management of this condition.…”