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

Abstract

Background: The objective of this systematic review was to identify the different surgical treatment modalities of severe trismus after head and neck squamous cell cancer treatment.

Methods: An 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.

Results: A 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.

Conclusion: Currently 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.

Keywords: coronoidectomy; free flap; myotomy; oral cancer; trismus; trismus release.

Figure 1

Prisma flow chart.

Figure 2

Estimated marginal means preoperative, perioperative and at the end of FU described for each surgical intervention strategy, when performed alone or in combination with one of the two strategies. Solid line, CN; dotted line, MT; striped line, FFR. *, P-value < 0.05 was set as statistically significant.