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A case of trismus treated by manipulation
A CASE O F T R I S M U S T R E A T E D
BY M A N I P U L A T I O N
By B. S. C_AtAWl:OI~, M.B., F.R.C.S.
From the Plastic and Jaw Department, The United Sheffield Hospitals THV. value o f manipulative treatment in cases o f chronic capsular shortening o f the temporo-mandibular joint was described by Hynes (195o). This m e t h o d o f treatment was recently applied successfully to a case o f painful trismus which had followed an injury to the temporalis muscle. CASE HISTORY
History.--A 38-year-old shunter was admitted under the care o f Mr W. Hynes on 23rd January 1952, complaining of localised pain in the left temporal region, which was felt each time the mouth was opened beyond a limited range. The pain and trismus, which were causing progressive difficulty in eating, came on three days after an injury which had occurred two months previously when he had fallen, striking the left temporal region against a railway waggon. He did not lose consciousness or notice any damage to the skin after the accident.
FIG. 2 Photograph taken the day after
FIG. I Illustrating the painful trismus before manipulation.
manipulation to illustrate dramatic recovery.
the
Examination.--There was a visible swelling about 3 cm. in diameter in the centre of the left temporal region ; on palpation the swelling, which was finn, ill-defined, and slightly tender, was considered to be situated in the temporalis muscle as it became firmer when that muscle was made to contract. The mouth could be opened with difficulty to establish a gap Of 2 cm. between the upper and lower incisors ; further opening was prevented by pain in the left temporal region (Fig. x). Apart from tobacco staining and a heavy deposit of tartar, the teeth were in good condition. X-ray examination did not reveal a fracture either of the skull or in the left malar-maxiUary region. 203
204
BRITISh JOURNAL OF PLASTIC SURGERY
It was considered that the painful trismus was due to a tear in the left temporalis muscle together with associated h~emorrhage, as a result of which scar tissue had subsequently developed in and around the muscle during the healing process, interfering with its free action owing to contraction and adhesion between it and the surrounding tissues. Treatment.--On 24th January I952 a general anazsthetic was administered, induction being carried out with ~ g. (IO ml.) of intravenous sodium thiopentone, followed by z'75 ml. (87"5 mg.) of intravenous Scoline (succinyl-choline chloride) to produce muscular relaxation which lasted about four minutes. The mandible was manipulated using the method described by Hynes (z95o), particular care being paid to the production of a full range of opening. Post-operative Course.--The patient made a dramatic recovery in that within two hours of the manipulation he was able to open the jaw fully and almost painlessly. He was instructed to practise this movement frequently, and returned to work the next day apparefitly cured (Fig. 2). One week later the movements of the mandible were normal, he was able to masticate normally and painlessly, and the swelling in the left temporal region was much smaller and ill-defined. Three months later he was examined for follow-up purposes, when it was found that the swelling had disappeared and there was a full, painless range of movement of the mandible. SUMMARY AND CONCLUSIONS A case o f painful trismus following a tear o f the temporalis muscle is described. T h e dramatic recovery which followed manipulation o f the jaw suggests that this method o f treatment, which has hitherto been employed in cases o f chronic capsular shortening, might be applied with benefit to selected cases o f trismus in which the underlying lesion is extra-articular. T h e use o f Scoline to produce muscular relaxation for a short period enables manipulation to be performed satisfactorily without the necessity for deep anazsthesia, and in many cases makes admission to hospital unnecessary. I wish to thank M r IV. Hynesfor permission to publish this case, attd Dr ffz. j . Patterson zc'ho suggested the use of Scoline.
REFERENCE ttYN~, W. (z95o). Brit. J. Plastic Surg., 3, 141.
BY M A N I P U L A T I O N
By B. S. C_AtAWl:OI~, M.B., F.R.C.S.
From the Plastic and Jaw Department, The United Sheffield Hospitals THV. value o f manipulative treatment in cases o f chronic capsular shortening o f the temporo-mandibular joint was described by Hynes (195o). This m e t h o d o f treatment was recently applied successfully to a case o f painful trismus which had followed an injury to the temporalis muscle. CASE HISTORY
History.--A 38-year-old shunter was admitted under the care o f Mr W. Hynes on 23rd January 1952, complaining of localised pain in the left temporal region, which was felt each time the mouth was opened beyond a limited range. The pain and trismus, which were causing progressive difficulty in eating, came on three days after an injury which had occurred two months previously when he had fallen, striking the left temporal region against a railway waggon. He did not lose consciousness or notice any damage to the skin after the accident.
FIG. 2 Photograph taken the day after
FIG. I Illustrating the painful trismus before manipulation.
manipulation to illustrate dramatic recovery.
the
Examination.--There was a visible swelling about 3 cm. in diameter in the centre of the left temporal region ; on palpation the swelling, which was finn, ill-defined, and slightly tender, was considered to be situated in the temporalis muscle as it became firmer when that muscle was made to contract. The mouth could be opened with difficulty to establish a gap Of 2 cm. between the upper and lower incisors ; further opening was prevented by pain in the left temporal region (Fig. x). Apart from tobacco staining and a heavy deposit of tartar, the teeth were in good condition. X-ray examination did not reveal a fracture either of the skull or in the left malar-maxiUary region. 203
204
BRITISh JOURNAL OF PLASTIC SURGERY
It was considered that the painful trismus was due to a tear in the left temporalis muscle together with associated h~emorrhage, as a result of which scar tissue had subsequently developed in and around the muscle during the healing process, interfering with its free action owing to contraction and adhesion between it and the surrounding tissues. Treatment.--On 24th January I952 a general anazsthetic was administered, induction being carried out with ~ g. (IO ml.) of intravenous sodium thiopentone, followed by z'75 ml. (87"5 mg.) of intravenous Scoline (succinyl-choline chloride) to produce muscular relaxation which lasted about four minutes. The mandible was manipulated using the method described by Hynes (z95o), particular care being paid to the production of a full range of opening. Post-operative Course.--The patient made a dramatic recovery in that within two hours of the manipulation he was able to open the jaw fully and almost painlessly. He was instructed to practise this movement frequently, and returned to work the next day apparefitly cured (Fig. 2). One week later the movements of the mandible were normal, he was able to masticate normally and painlessly, and the swelling in the left temporal region was much smaller and ill-defined. Three months later he was examined for follow-up purposes, when it was found that the swelling had disappeared and there was a full, painless range of movement of the mandible. SUMMARY AND CONCLUSIONS A case o f painful trismus following a tear o f the temporalis muscle is described. T h e dramatic recovery which followed manipulation o f the jaw suggests that this method o f treatment, which has hitherto been employed in cases o f chronic capsular shortening, might be applied with benefit to selected cases o f trismus in which the underlying lesion is extra-articular. T h e use o f Scoline to produce muscular relaxation for a short period enables manipulation to be performed satisfactorily without the necessity for deep anazsthesia, and in many cases makes admission to hospital unnecessary. I wish to thank M r IV. Hynesfor permission to publish this case, attd Dr ffz. j . Patterson zc'ho suggested the use of Scoline.
REFERENCE ttYN~, W. (z95o). Brit. J. Plastic Surg., 3, 141.