Lockjaw

Lockjaw

Plan 

1. Introduction

   Definition of trismus:

   Etiological diagnosis:

1. Local causes:
   1. Inflammatory and infectious causes:

2. Traumatic causes:
3. Tumor causes:
4. ATM pathology:

  B. General causes:

  1. Infectious causes: 

• Tetanus: 

• Acute meningitis:  
• Rabies: “meningoencephalomyelitis”:   

2. Toxic and drug causes:  
3. Neurological causes:  
4. Trismus of metabolic and deficiency origin:

2. Differential diagnosis of trismus: 
3. Positive diagnosis:
   1. Circumstances of discovery:
   2. Questioning: 
   3. Clinical examination:
   4. General review: 
   5. Paraclinical examinations:
4. Evolution :
5. Treatment :

• Symptomatic treatment:
• Etiological treatment:

CONCLUSION : 

TRISMUS

6. Introduction

   Limitation of mouth opening is a common reason for consultation. It is sometimes isolated, without any accompanying signs, but often it is part of a richer and more evocative clinical picture.

  Definition of trismus:

  Trismus is a symptom characterized by temporary limitation of mouth opening due to contraction of the mandibular elevator muscles that prevent the action of the depressor muscles and related to an evolving disease or infection.

   Most often, it is a reflex contraction of defense (against pain) which is why the trismus is temporary and disappears when the infection heals.

   Etiological diagnosis:

1. Local causes:
   1. Inflammatory and infectious causes:

    These are the most common causes; the more posterior the inflammatory or infectious process, the tighter the trismus is.

• Most often the etiology is of dental origin:

-It may be a root, periradicular, periodontal or pericoronal dental infection (++) [accident of evolution of the mandibular wisdom tooth]

– It may be perimaxillary cellulitis above or below the mylohyoid or masseter.

 – More rarely, osteitis.

• Extra dental infectious causes:

-Oral: stomatitis (in intense, ulcerative or necrotizing forms), odontiatic stomatitis, gingivitis.

-Salivary: submaxillary, parotitis.

– Articular: temporomandibular arthritis found in serum sickness. This arthritis is rarely of general cause (septicemia). More often of local cause in the vicinity (otitis, parotitis, mastoiditis or soiled wound next to the joint)

-Cutaneous: in certain skin infections (boil).

– Specific infection: cervicofacial actinomycosis, syphilis (localized to the masticatory muscles), tuberculosis (tuberculous osteitis of the mandibular angle)

5. Traumatic causes:

• Fracture of the mandible: 

-High condylar or low subcondylar fracture (it is necessary to note the secondary risk of permanent constriction of the maxillae due to temporomandibular ankylosis in high condylar fractures)

-Fracture of the ascending ramus and angular region of the mandible.

• Fracture of the zygomatic or zygomato-malar arch: which can impinge the temporal muscle.
• Trauma to the masticatory muscles:

-Contusion or injury to the muscles that lift the mandible (temporal, masseter).

-Muscle hematoma, intramuscular foreign body.

• Finally, the traumatic extraction of a mandibular wisdom tooth must be mentioned.

6. Tumor causes:

• Benign tumors: they are rarely the cause of trismus which can occur during progressive inflammatory growths.
• Malignant tumors: trismus in this case is not due to a reflex contracture but to an invasion of the muscle by a tumor with a deep starting point . 
• The trismus is all the more severe as the lesion is located posteriorly:

• Oropharyngeal cancer: soft palate, tonsils, tonsillar pillars.
• Oral cavity cancer: intermaxillary commissure (+++)
• Cancer of the posterior floor of the mouth, vestibule and cheek
• Malignant tumor of the maxillary sinus with posterior extension towards the pterygomaxillary fossa.

7. ATM pathology:

  Trismus is part of the symptomatology of temporomandibular dysfunction. The latter includes muscular and articular signs.

2. General causes:

   General trismus is characterized by its intermittency with periods of relaxation followed by paroxysms ++.

1. Infectious causes: 

• Tetanus: 

   This is the first general etiology to be considered when faced with trismus;

According to LORRAIN “all trismus that is not proven must be considered as tetanus”

   It is a toxic infection caused by a strict anaerobic gram(+) bacillus; Clostridium tetani, which enters the body most often through a wound, develops locally and acts by releasing a toxin.  

  The incubation period is 3-15 days, this phase is silent until the occurrence of the first sign which is usually trismus.

Contractures are exaggerated by paroxysm. We look for other clinical signs that appear rapidly in acute tetanus:

• Dysphagia
• Contraction of the neck muscles, 
• Sardonic laughter
• In 2-3 days, the contractures become generalized and permanent.  

NB: The questioning reveals the absence of vaccination and booster, the existence during questioning and/or examination of a wound dating back 3 days or more.

• Acute meningitis: 

   Trismus is often drowned in the midst of other general signs: fever, headache, vomiting, cutaneous hyperesthesia, meningeal syndrome and neck stiffness. Lumbar puncture establishes the diagnosis. 

• Rabies: “meningoencephalomyelitis”:

   Currently exceptional, trismus is only part of the clinical picture (paresthesia at the level of the bite wound, convulsions, sometimes generalized contractures, hypersalivation, laryngeal spasms, etc.).

2. Toxic and medicinal causes: they are rare

• Neuroleptics: the products most frequently involved are so-called “incisive” neuroleptics (Haldol ®, Majeptil ®, Terfluzine®).
• Antihistamines: Diphenhydramine, Doxylamine.
• Strychnine poisoning: toxic dose of 20mg in adults.  

3. Neurological causes:

  These uncommon conditions are only exceptionally complicated by trismus;

• Vaccine encephalitis or epidemic encephalitis in young people.
• Brain lesions of the bulboprotuberant region.
• Some forms of Parkinson’s disease. 

4. Trismus of metabolic and deficiency origin:

• It can be part of the clinical picture of hypoglycemia.  
• It occurs most often in alcoholics.
• In case of encephalopathy due to a deficiency of vit B1.q

7. Differential diagnosis of trismus: it is necessary to eliminate:

• Permanent constriction of the jaws: it is the exact opposite of trismus because it is: 

• Resulting from an abnormal consolidation process.
• Due to a lesion of bone, muscle, mucosa or skin origin.
• It is painless and chronic.
• She does not give in under general anesthesia.
• It is permanent.
• Posterior temporomandibular dislocation with associated tympanic membrane fracture:

  It is rare; causes a blockage of the joint in the closed mouth with laterodeviation on the side opposite the lesion and on examination we find a void in the dislocated condylar region.

• Pithiatism or the false trismus of simulators: 

  To differentiate true trismus from pithiatism, it is sufficient to stimulate the gag reflex by placing a tongue depressor in contact with the veil and the uvula. 

• Blockage of mandibular kinetics by a submandibular or subangulo-maxillary tumor:

• Benign or malignant salivary tumor of the submandibular gland.
• Adenopathy. 

8. Positive diagnosis:
   1. Circumstances of discovery:

  Most often, the patient consults for difficulty opening the mouth; sometimes a practitioner discovers this limitation during a general examination.

  Sometimes trismus is sought systematically, as an integral part of a symptomatic complex.

2. Questioning: 

• It specifies the installation methods (sudden, gradual).
• The date of onset and development of trismus.
• Circumstances of occurrence: trauma, wound, recent surgery, etc.
• Associated functional signs (pain and its characteristics, dysphagia, and possible general signs; hyperthermia).
• Finally, he specifies the family, personal and medical history (tetanus vaccination) and current drug treatment.

3. Clinical examination:

• Oral exo examination: 

 – Assesses the limitation of the mouth opening by measuring it / to the normal which is 47 +/- 7mm. The mouth opening is measured using a caliper taking two antagonist teeth as a constant reference.

  Trismus is thus described as mild when the mouth opening range remains >20mm, moderate if it is 10-20mm or severe if it is <10mm. 

 – The straightness of the opening path or any laterodeviation is assessed. Propulsion and lateral movements are also assessed.   

 – Look for signs of trauma (bruise, hematoma, wound).

 – Assess facial symmetry, the existence of possible swelling, hypertrophy of one or more masticatory muscles (temporal, masseter).  

• Intraoral examination: Performed if necessary, under general anesthesia in the event of severe trismus. Assess under good lighting:

• The appearance of the bucco-pharyngeal mucosa.
• Dental condition (++) and occlusion.
• The salivary glands.

4. General review: 

 Including a neurological examination to look for the classic cause of trismus: tetanus. 

5. Paraclinical examinations:

  In a traumatic context, radiological examinations are requested based on clinical findings.

  Apart from trauma, a panoramic or a bite allows us to have an initial idea of ​​the dental , joint and bone condition.

  As a second intention, the following are carried out:

• A CT scan focused on the pterygomandibular region, subtemporal, and the sinuses of the face.
• Nasal fibroscopy to look for a temporal cause.
•  In case of joint pathology of supposed dysfunctional origin, a magnetic resonance imaging (MRI) examination.

9. Evolution :

• Healing is complete when the cause is treated.
• If left untreated, it progresses to permanent constriction.
• The prognosis remains favorable when the etiology is local, it will be reserved when the etiology is general.  

10. Treatment :

     Trismus is only a symptom; the treatment of which involves treating the etiology.

• Symptomatic treatment:
• Infiltrations:

• Locoregional anesthesia of the temporomasseter nerve with xylocaine or novocaine, via the subzygomatic route;
• Anesthesia of the sphenopalatine ganglion by endonasal route with 10% cocaine or more often with Xylocaine;
• Extraoral anesthesia of the inferior alveolar nerve according to the Ciezynski technique.

  General anesthesia which always causes trismus to subside unlike permanent constriction of the jaws.  

• Medical treatments:

• Muscle relaxants that act at different levels: muscle fibers or nervous system.
• Injection of botulinum toxin into a spasmed muscle (particularly the lateral pterygoid) in the context of dysfunctional TMJ disorders related to a dental articulation disorder.

1. Etiological treatment:
2. In trismus of local cause:

• Traumatic trismus:

• Analgesic, ATB.
• Treatment of different mandibular fracture sites by intermaxillary blocking or osteosynthesis using screwed microplates or steel wire.
• Reduction of a zygomatic arch fracture.
• Trismus of infectious cause:

• Medical treatment; ATB
• Local treatment of the cause:

• Dental cause: dental extraction or treatment, extraction of a DDS in case of pericoronitis or application of trichloroacetic acid, drainage of cellulitis or an abscess of dental origin
• Non-dental cause: incision of a peritonsillar phlegmon and drainage. Tonsillectomy will be performed a few weeks later.

-Mouthwash in case of stomatitis.

– Evacuation of salivary lithiasis at the level of Wharton’s canal.

• Trismus of tumoral cause: treatment varies depending on the tumor, but in all cases, it is essential to administer antibiotic therapy combined with NSAIDs, or even corticosteroids for a transitional period.
• Acute suppurative arthritis of the TMJ requires short-term rest of the joint followed by reduction as soon as the infectious syndrome is controlled.

2. In trismus of general cause:

  We simply recall the importance of tetanus seroprophylaxis and mandatory preventive measures in the event of an animal bite.

CONCLUSION : 

   Trismus remains a fairly revealing symptom for many pathologies. It is first and foremost important to take it into account and look for the etiology, but it is also important to prevent its onset through early and adequate treatment. 

Good oral hygiene  Regular scaling at the dentist  Dental implant placement Dental x-rays  Teeth whitening  A visit to the dentist  The dentist uses local anesthesia to minimize pain  

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