The Journal of Craniofacial Surgery Volume 26, Number 7, October 2015 Brief Clinical Studies comprehensive neck dissection on right side, and selective neck Use of Superficial Temporal dissection on the left side without reconstruction for carcinoma oral cavity (primary: anterolateral tongue; stage: T2 N2b, Mo). Only Fascia Flap for Treatment of primary closure was carried out to close the defect. The mouth opening after surgery was limited to 2 finger breadth. Following Postradiation Trismus: An surgery, chemo and radiotherapy was used to address the adverse features noticed during histopathological examination of the Innovation excised specimen. During radiotherapy mouth opening further reduced and progressed to the present state. On examination inter- Rohit Sharma, MDS, FIBOMS, Indranil Deb Roy, MDS, FIBOMS, incisal mouth opening was 11 mm (Fig. 1). There was severe Tushar S. Deshmukh, BDS, and Amit Bhandari, BDS fibrosis of the entire oral cavity with restriction of the tongue movements. Keeping in view the clinical findings, history and Abstract: Post radiation trismus severely reduces the quality of life. medical documents produced by the patient—a diagnosis of post- Radiation causes fibrosis of muscles of mastication resulting in radiation trismus in an operated patient of carcinoma oral cavity was severe restriction of mouth opening. Treatment options are limited made. Patient was counseled regarding available surgical modal- as most of the local flaps are in the radiation zone. The present case ities and the poor prognosis of the condition. Routine preanaesthetic is the first case in existing literature where, following the release of investigations were carried out and surgery was planned under fibrosis secondary to radiation, superficial temporal fascia (STF) general anesthesia (fibre-optic intubation). Incision from the pre- was used to cover the defect with excellent results and no recurrence auricular region was extended to the temporal region and dissection after a year of follow up. was performed in the subfollicular plane to develop STF to its maximum limit (Fig. 2A). Similar incision and dissection was carried out on the opposite side (Fig. 2B). After subperiosteal Key Words: Radiation, superficial temporalfascia flap, trismus dissection over the zygomatic arch, origin of the masseter muscle was completely released till zygomatic process of the maxillary bone. This allowed partial release of the fibrosis. Intraorally, he ever-increasing incidence of oral cancer in India is apparent bilateral incisions were made to release the mucosa, buccinator T in the literature. Use of tobacco and its products can cause muscle, and pterygomandibular raphe. Through the same approach devastating effects on health. Treatment of cancer in the form of bilateral coronoidectomy along with temporalis myotomy was surgery and radiation for complete cure has resulted in a vast carried out. This procedure created a large mucomuscular defect. number of functional problems. Post radiation fibrosis of muscles Mouth opening achieved at this stage was 40 mm. STF flap was of mastication resulting in trismus is often a late complication.1 The elevated from the pericranium and the deep temporal fascia prevalence reported for trismus after head and neck cancer treat- (Fig. 2C-D). The flap was pedicled on the superficial temporal ment is in the range of 5% to 38%.2 Literature supports physiother- vessels and rotated over the zygomatic arch and brought intraorally apy and medical modalities for treatment of radiation-induced to fill in the defect. The interrupted and mattress sutures were placed fibrosis but in severe patients surgery remains the only treatment by using No. 3-0 Vicryl (Ethicon, Somerville, NJ) to secure the graft option. Trismus is unavoidable in patients with cancer of the base of (Fig. 3A-B). STF covered the entire defect, eliminating the possib- tongue wherein surgical and radiation treatment is often mandatory. ility of secondary epithelialization. Postoperatively, prophylactic The surgical treatment options for trismus include various pro- antibiotics and nasogastric feed was given for 1 week. Surgical cedures such as simple release of fibrous bands with or without suction drains were removed from the temporal region after reconstruction using various flaps, for example, skin graft,3 buccal 72 hours. Mouth-opening exercise was started within 48 hours. This pad fat,4 nasolabial flap,5 greater palatine pedicled flap,6 tongue intensive exercise was carried out daily for 3 months and with flap7 and radial artery forearm flap.8 Coronoidectomy is a known reduced frequency for next 1 year. The patient was monitored for adjunct to all these surgical procedures.9 The technique described postoperative mouth opening (interincisal distance in millimeters) here was first used for treatment of oral submucous fibrosis in and epithelialization of STF. Excellent take up and epithelialization 2005.10 To the best of the knowledge of all the authors, the present of STF was noticed in 4 weeks (Fig. 4). Mouth opening 1 year case is the first case in the existing literature wherein following the postoperatively is about 35 mm (Fig. 5). release of fibrosis secondary to radiation, STF was used to cover the defect with excellent results and no recurrence after a year of follow-up. DISCUSSION When the radiation field involves the muscles of mastication CLINICAL REPORT postradiation, fibrosis leading to trismus often takes place. Ischemia and fibrosis is thought to be due to endarteritis obliterans. Post- A 46-year-old male reported to our center with a chief complaint of radiation trismus often leads to poor quality of life. It compromises inability to open mouth since 1 year. History of present illness the dental hygiene and results in poor calorie intake.1 The aim of revealed that the individual had undergone hemiglossectomy, this procedure was to release the postradiation fibrosis and provide long-term adequate mouth opening. From the Department of Oral and Maxillofacial Surgery, Armed Forces Conservative treatment options are not recommended in the Medical College, Pune, India. advanced stage as surgery is the only effective treatment modality. Received March 29, 2015. The release of fibrous bands and use of skin grafts often result in Accepted for publication June 28, 2015. Address correspondence and reprint requests to Rohit Sharma, MDS, FIBOMS, Armed Forces Medical College, Pune, India 411040; E-mail: [email protected] The authors report no conflicts of interest. Copyright # 2015 by Mutaz B. Habal, MD ISSN: 1049-2275 DOI: 10.1097/SCS.0000000000002044 FIGURE 1. Reduced preoperative mouth opening. # 2015 Mutaz B. Habal, MD e591 Copyright © 2015 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited. Brief Clinical Studies The Journal of Craniofacial Surgery Volume 26, Number 7, October 2015 absolutely no donor site morbidity with this flap. The scar gets covered by the hair bearing area. Facial nerve is underneath STF, so there are minimal chances of damage to the temporal branch. Looking at the poor prognosis of radiation trismus, the authors have combined transection of the fibrous bands, temporalis myot- FIGURE 2. A, STF developed through preauricular approach on right side. B, STF developed through preauricular approach on right side. C, STF raised on omy, cornoidectomy, and interpositioning with STF as an inno- right side. D, STF raised on left side. vative technique and found it to be safe and effective. REFERENCES 1. Wang CJ, Huang EY, Hsu HC, et al. The degree and time-course assessment of radiation-induced trismus occurring after radiotherapy for nasopharyngeal cancer. Laryngoscope 2005;115:1458–1460 2. Dijkstra PU, Kalk WW, Roodenburg JL. Trismus in head and neck FIGURE 3. A, STF secured intraorally on the right side. B, STF secured intraorally oncology: a systematic review. Oral Oncol 2004;40:879–889 on the left side. 3. Borle RM, Borle SR. Management of oral submucous fibrosis: a conservative approach. J Oral Maxillofac Surg 1991;49:788–791 4. Sharma R, Thapliyal GK, Sinha R, et al. Use of buccal fat pad for treatment of oral submucous fibrosis. J Oral Maxillofac Surg 2012;70:228–232 5. Kavarana NM, Bhathena HM. Surgery for severe trismus in submucous fibrosis. Br J Plast Surg 1987;40:407–409 6. Khanna JN, Andrade NN. Oral submucous fibrosis: a new concept in FIGURE 4. Take up and epithelialization of STF. surgical management: report of 100 cases. Int J Oral Maxillofac Surg 1995;24:433–439 7. Domarus HV. The double-door tongue flap for total cheek mucosa defects. Plast Reconstr Surg 1988;80:351–356 8. Wei FC, Chang YM, Kildal M, et al. Bilateral small radial forearm flaps for the reconstruction of buccal mucosa after surgical release of submucosal fibrosis: a new reliable approach. Plast Reconstr Surg FIGURE 5. Adequate mouth opening postoperatively. 2001;107:1679–1683 9. Bhrany AD, Izzard M, Wood AJ, et al. Coroindectomy for the treatment of trismus in head and neck cancer patients. Laryngoscope recurrences due to graft contraction and scarring. Only release of 2007;117:1952–1956 fibrous bands and coronoidectomy will not provide adequate mouth 10. Mokal NJ, Raje RS, Ranade SV, et al. Release of oral submucous opening as some form of interpositional barrier is required so as to fibrosis and reconstruction using superficial temporal fascia flap and achieve and maintain adequate mouth opening. Buccinator and split skin graft: a new technique. Br J Plast Reconstr Surg masseter muscle flaps could not be used due to extensive fibrosis. 2005;58:1055–1060 Buccal pad fat is generally the first choice in oral submucous 11. Sharma R. Prevention of Frey syndrome with superficial temporal fascia fibrosis. This option was not available as it gets fibrosed following interpositioning: a retrospective study. Int J Oral Maxillofac Surg 2014;43:413–417 radiotherapy. Nasolabial flaps were not used because of impaired blood supply as the facial artery is ligated at level I B during neck dissections. Moreover, it is inadequate to cover large mucomuscular defect.