Positive response of advanced oropharyngeal cancer with trismus to chemoradiation. (Letters to the Editor).

To the Editor: Patients with head and neck cancer (HNC) and trismus can be managed with surgery. (1) However, a poor outcome may result because of the difficulty in obtaining clear margins of resection. The resection involving the pterygoid (muscles) space is bloody because of the presence of large pterygoid veins. (1) However, the effects of nonoperative treatment of patients with HNC with trismus are not well documented in the literature. In this letter, we describe a case of a patient with HNC and trismus in which we achieved a significant response with the use of chemoradiation, which is an infrequently reported outcome of treatment.

A 50-year-old man presented at our university hospital in July 1977 with a 3-week history of odinodysphagia and neck pain. He also experienced increased difficulty in opening his mouth for a period of 3 months. His medical history was unremarkable. He smoked and consumed alcohol to a moderate degree. The physical examination showed a large tumor occupying the left tonsil, soft palate, the base of the tongue, and the nasopharynx. The maximum interincisal (II) opening was 20 mm. A 6.5 X 6-cm mass was present in the left side of the neck. Axial computed tomographic scans revealed an extensive tumor involving the left parapharyngeal space, invasion of the pterygold muscle, and erosion of the posterior wall of the ipsilateral maxillary sinus (Fig. 1A). A biopsy proved the lesion to be Grade 2 squamous cell carcinoma of the oropharynx. A chest x-ray was normal. The tumor was staged as T4N3M0.

We treated the patient by administering induction chemotherapy (using a three-drug regimen of cisplatin, 5-fluorouracil, and etoposide) followed by concomitant chemoradiation. At the time of completion of the second chemotherapy cycle, the maximum II opening was 35 mm. Significant resolution of the primary tumor (Fig. 1B) and regional disease was observed after the conclusion of irradiation (60 Gy delivered in 30 fractions) in October 1997. Panendoscopy performed 3 months later disclosed only dry oropharyngeal mucosa, and biopsies revealed no evidence of cancer. At the time of the last follow-up examination in January 2001 (43 months from the time of oropharyngeal carcinoma diagnosis), the patient was well, free of tumor recurrence, and without severe restriction in opening his mouth.

The muscles of mouth closure--the masticatory muscles: temporalis, masseter, and medial pterygoid--exert a power 10 times greater than the power of the mouth-opening muscles (lateral pterygoid, digastric, mylohyoid, and geniohyoid muscles). (2) The severity of trismus can be classified into three grades, depending on the II distance: Grade 1, distance between 40 and 25 mm; Grade 2, distance between 25 and 10 mm; and Grade 3, distance less than 10 mm. (3)

The parapharyngeal space (which was invaded by tumor in our case) is a "potential space, shaped like an inverted pyramid, with its base at the cranial base and its apex at the greater cornu of the hyoid bone. It is defined superiorly by the temporal bone, posteriorly by the vertebrae and prevertebral muscles including their fasciae, and laterally by the mandible, the posterior belly of the digastric muscle and the medial pterygoid muscle. These boundaries are bony and. . . rigid." (4) Thus, it is not surprising that the growth of tumors arising in this space is toward the path of least resistance--anteriorly, inferiorly, and medially (explaining destruction of the posterior portion of the maxillary sinus seen on imaging scan in our patient).

Trismus in HNC patients is not often encountered. In an 18-year experience with 212 patients with malignant neoplasms in the head and neck region, 9 (4%) had restricted opening of their mouths in which difficulty in opening the mouth was caused by tumor infiltrating the muscles of mastication or by reflex spasm. (5) Cases of trismus attributed to locally extensive oropharyngeal or oral cavity cancer reported in the literature have been managed with radiotherapy alone, definitive surgery alone, or chemotherapy and irradiation. Unfortunately, patient outcomes are not mentioned. Reported here is an apparent significant response to chemoradiation, a finding that, to the best of our knowledge, has not been described previously.

The prognosis of Stage IV HNC has commonly been regarded to be poor. We suggest that induction chemotherapy followed by concomitant chemoradiation should be considered in patients who present with trismus from HNC who are not in a near-terminal state, because it offers the prospect of having profound beneficial effects.

Federico L. Ampil, MD

Department of Radiology

Glenn M. Mills, MD

Department of Medicine

Cherie Ann O. Nathan, MD

Department of Otolaryngology--Head and

Neck Surgery

Gary V. Burton, MD

Richard Mansour, MD

Department of Medicine

Mardjohan Hardjasudarma, MD

Department of Radiology

Health Sciences Center

Louisiana State University 

Shreveport, LA

References

(1.) DeSanto LW, Thawlcy SE, Genden EM. Treatment of tumors of the oropharynx: Surgical therapy, in Thawley SE, Panje WR, Batsakis JG, Lindberg RD (eds): Comprehensive Management of Head and Neck Tumors. Philadelphia, W.B. Saunders Co., 1999, vol 1, ed 2, pp 806-860.

(2.) Tveteras K, Kristensen S. The aetiology and pathogenesis of trismus. Clin Otolaryngol 1986;l1:383-387.

(3.) Becker W, Naumann HH, Pfaltz CR, Buckingham RA. Ear, Nose, and Throat Diseases: A Pocket Reference. New York, Thieme Medical Publishers, 1989, pp 320-371.

(4.) Myers EN, Johnson JT, Curtin HD. Tumors of the parapharyngeal space, in Myers EN, Suen JY (eds): Cancer of the Head and Neck. Philadelphia, W.B. Saunders Co., 1996, ed 3, pp 562-585.

(5.) Ichimura K, Tanaka T. Trismus in patients with malignant tumours in the head and neck. J Laryngol Otol 1993;107:1017-1020.