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Management of trismus by masseter myotomy

Article January 2014

DOI: 10.4103/0975-2870.126366

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Case Report
Management of trismus by masseter myotomy
Sonal Bhavesh Shah, Suhas Vaze1, Kapil Kshirsagar
Department of Oral and Maxillofacial Surgery, Dr. D. Y. Patil Vidyapeeths Dr. D. Y. Patil Dental College and Hospital, Pimpri, 1Department of Oral and
Maxillofacial Surgery, Sahyadri Hospital, Pune, Maharashtra, India
ABSTRACT
Mild trismus after parotid gland surgery may be related to inflammation
and fibrosis of the masseter muscle. We present a case of long
standing trismus due to masseter muscle spasm caused by a recurrent
pleomorphic adenoma. As the patient did not agree for removal of the
pleomaorphic adenoma, owing to the risk of injuring the facial nerve,
a masseter myotomy with inter-positioning of temporalis fascia was
planned for symptomatic relief. Mouth opening showed significant
improvement even 1 year post-operatively.
Keywords: Masseter myotomy, recurrent pleomorphic adenoma,
temporalis fascia inter-positioning, trismus
Introduction
Pleomorphic adenoma is the most common of all salivary
gland tumors, constituting over 50% of all cases of tumors
and about 90% of all benign salivary gland tumors. It is
characterized by a morphologic and histologic complexity
marked by the presence of a variety of cell types. The parotid
is the most common site of pleomorphic adenoma (90%).[1] It
may cause difficulties in breathing, talking, and mastication.
Mild trismus, after parotid gland surgery may be related
to inflammation and fibrosis of the masseter muscle. This
complication is usually mild and transient and improves
with jaw-opening exercises.[2]
We present a case of long standing trismus due to masseter
muscle spasm caused by a recurrent pleomorphic adenoma.
As the patient did not agree for removal of the pleomaorphic
adenoma, owing to the risk of injuring the facial nerve, a
masseter myotomy was planned. Mouth opening showed
significant improvement post-operatively.
Case Report
A 70-year-old male patient, reported to us with the chief
complaint of inability to open the mouth completely since 2 years.
Address for correspondence:
Dr. Sonal Bhavesh Shah, Department of Oral and Maxillofacial Surgery, Dr. D. Y. Patil Vidyapeeths Dr. D. Y. Patil Dental College and Hospital, Pimpri,
Pune, India.
E-mail: sonalbshah@rediffmail.com
236 Medical Journal of Dr. D.Y. Patil University | March-April 2014 | Vol 7 | Issue 2
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DOI:
10.4103/0975-2870.126366
The patient had a history of surgical removal of right parotid
gland tumor 7 years ago, which was diagnosed as pleomorphic
adenoma. He now presented with an inter-incisal opening (IIO)
was approximately 5 mm [Figure 1] and a soft to firm, well-
defined, non-tender swelling measuring around 2 cm 2 cm
over the right parotid region [Figure 2]. Cause of the trismus was
suspected to be fibrosis and spasm of the masseter muscle due to
impingement from the recurrent tumor. Computed tomography
(CT) scan confirmed the presence of a secondary tumor.
Excision of the tumor was planned and the patient was
explained regarding the possibility of facial nerve palsy
post-operatively. Considering the above complication, the
patient did not agree for the procedure. Hence, masseter
muscle myotomy with inter-positioning of temporalis fascia
over the zygomatic arch was planned.
After thorough medical and anesthetic evaluation, the
patient was prepared for surgical inter-vention.
The procedure was carried out under general anesthesia
with naso-endotracheal intubation. A Popowich incision
was made over the right temporal and pre-auricular region
up to retromandibular area. The flap was raised over the
temporalis fascia to expose the zygomatic arch, taking
care to preserve the branches of the facial nerve. Masseter
muscle was stripped subperiosteally over the zygomatic arch
[Figure 3]. Mouth opening was verified at this juncture.
IIO of 30 mm was achieved. Temporalis fascia was raised
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Shah, et al.: Management of trismus by masseter myotomy

Figure 1: Pre-operative inter-incisal mouth opening Figure 2: Pre-operative lateral profile

Figure 3: Masseter striped Figure 4: Temporalis fascia inter-positioning

and sutured to the exposed zygomatic arch to prevent
reattachment of the masseter [Figure 4]. The flap was sutured
back in position [Figure 5].
Mouth opening remained satisfactory throughout the
recovery period. Active physiotherapy was initiated from
the third post-operative day. All sutures were removed on
the eighth post-operative day. Although, recurrence of
trismus can occur after masseter muscle reattachment after
4 weeks our patient was followed-up at regular intervals and
an inter-incisal mouth opening of 30 mm was retained even
at the end of 1 year [Figure 6].
Discussion
It is known that trismus can occur due to diseases of the
muscles of mastication. This may include fibrosis, masticator
space infection, degenerative changes, inflammation, and
muscle spasm. Nishimura et al.[3] reported a case of a 62-year-
old patient with a chronic organized abscess of the right
masseter muscle that developed following parotidectomy.
The patients chronic abscess originated from an infection
in the masticator space from the second molar. Cases of
repeated parotitis should lead one to suspect a masticator
space infection. In this case, the cicatricical masseter muscle
produced severe trismus. Total eradication of the abscess and
myotomy of the masseter resolved the problem completely.
Cooper[4] described division of muscle fibres as a method of
relieving myo-fascial pain in the masseter and temporalis.
Its use is suggested when non-surgical measures have failed
and where the pain is mainly confined to either the masseter
or temporalis. It is further suggested that muscle section
might be used experimentally to throw some light on
pain located in the joint region. Pomatto et al.[5] reported
a unique case of fatty replacement of the masticatory
muscles, causing progressive limitation of mouth opening.
Both CT and magnetic resonance imaging revealed an
almost total substitution of the masticatory muscles with
fatty tissue, confirmed by the histopathology after surgery.
Myotomy of the masseter and internal pterygoid muscles
and coronoidotomy improved the symptoms. There is no
known cause of fibroadipose replacement of muscle fibres.

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Shah, et al.: Management of trismus by masseter myotomy

Figure 5: Closure of wound Figure 6: Post-operative inter-incisal opening

Thus, we can conclude that in cases of trismus due to
muscle spasm occurring secondary to any other pathology,
muscle myotomy can be considered as a mode of treatment
for getting symptomatic relief if due to any reason the
surgical management of the primary lesion is deferred or
contraindicated.
References
1. Leonetti JP, Marzo SJ, Petruzzelli GJ, Herr B. Recurrent
pleomorphic adenoma of the parotid gland. Otolaryngol Head
Neck Surg 2005;133:319-22.
2. Marchese-Ragona R, De Filippis C, Marioni G, Staffieri A.
Treatment of complications of parotid gland surgery. Acta
Otorhinolaryngol Ital 2005;25:174-8.
3. Nishimura T, Okabe Y, Furukawa M. A chronic organized
masseter abscess causing trismus resolved by hemi-masseter
myotomy. Auris Nasus Larynx 1996;23:140-2.
4. Cooper EH. Partial myotomy in temporomandibular pain
dysfunction: A preliminary communication. Br J Oral Surg
1972;10:154-7.
5. Pomatto E, Castellano S, Bianchi SD. Unilateral fibroadipose
degeneration of the masticatory muscles. Dentomaxillofac
Radiol 2001;30:346-8.
How to cite this article: Shah SB, Vaze S, Kshirsagar K.
Management of trismus by masseter myotomy. Med J DY Patil Univ
2014;7:236-8.
Source of Support: Nil. Conflict of Interest: None declared.

Commentary

Masseter muscle myotomy as an effective

surgical method for managing trismus
The publishing of the article Management of trismus Access this article online
by masseter myotomy brings into focus several factors Quick Response Code:
like proper diagnosis and management which result
from primary surgical procedures in the orofacial region. Website:
Trismus is a pathological condition involving the muscles of www.mjdrdypu.org

mastication, and commonly affects the patients undergoing

dental procedures, facio-maxillary surgery, and radiation
therapy for managing head and neck tumours. Trismus is a
result of sustained contraction of one or more of the muscles muscles which can yield contracture of the connective tissue
of mastication: the masseter, temporalis, or pterygoid resulting in restriction of mouth opening.[1,2]

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