Oral Surgery ISSN 1752-2471
CASE REPORT
Trismus: an unusual cause and its implications
A. Greenstein1, C. Mistry2, R. Lees2 & T. Lowe3
1
Oral and Maxillofacial Surgery, Department of Oral and Maxillofacial Surgery, Queen Elizabeth University Hospital, Govan, UK
2
Oral and Maxillofacial Surgery, Queen Elizabeth University Hospital, Govan, UK
3
Oral and Maxillofacial Surgery, Aberdeen Royal Infirmary, Aberdeen, UK
Key words:
benign, biopsy, facial pain, imaging,
malignant, MRI, radiograph, radiology
Correspondence to
C Mistry
Dental Core Trainee in Oral and Maxillofacial
Surgery
Queen Elizabeth University Hospital, Govan
UK
Tel.: +447740838913
email: Chetan.mistry2@nhs.net
Accepted: 17 August 2020
doi:10.1111/ors.12555
Introduction
Systemic diseases can manifest in many ways and
subtle clues to these processes can often declare
themselves in the maxillofacial region. This report
highlights one usual and rare presentation of such
case.
A 64-year-old woman, from a small island com-
munity, presented to her general practitioner with
worsening right-sided jaw pain and trismus. She
found, that over the preceding months leading up to
her consultation, it had become more difficult to
chew or use her dentures due to restriction in
mouth opening. Her weight up until that point was
stable. She was a non-smoker and teetotal but suf-
fered from rheumatoid arthritis, ulcerative colitis,
diverticulitis, asthma and hypertension. Her reliance
on analgesia had increased and found that it was no
longer effective. She was referred to the local max-
illofacial services and her mouth opening was mea-
sured at 1cm at presentation. An orthopantomogram
(OPG) (Fig. 1) taken was unremarkable. She
Oral Surgery  (2020) –.
© 2020 The British Association of Oral Surgeons and John Wiley & Sons Ltd
Abstract
Systemic diseases can manifest in many ways and subtle clues to these
processes can often declare themselves in the maxillofacial region. This
report highlights one usual and rare presentation of such case. A 64-
year-old woman, presented to her general practitioner with worsening
right-sided jaw pain and trismus. She was referred to the local
maxillofacial services and her mouth opening was measured at 1cm at
presentation. An orthopantomogram (OPG) taken was unremarkable.
She underwent an MRI of the head and neck that showed a soft tissue
mass invading the right lateral and medial pterygoid muscles and plate
with involvement of the ramus of the mandible. A staging CT was
performed that revealed a mass of the proximal sigmoid colon. A
colonoscopy performed with biopsy revealed a poorly differentiated
squamous cell carcinoma with extensive metastasis, including the right
masticatory space. She was presented at the multi-disciplinary meeting
where it was decided to treat her palliatively and she died 6 weeks after
her diagnosis.
underwent an MRI (Fig. 2) of the head and neck
and she found that it was a soft tissue mass invading
the right lateral and medial pterygoid muscles,
together with the pterygoid plate, and involvement
of the ramus of the mandible. Initially, a sarcoma
was suspected so a staging CT was performed that
revealed a mass of the proximal sigmoid colon
(Fig. 3). A colonoscopy performed with biopsy
revealed a poorly differentiated squamous cell carci-
noma with extensive metastasis, including the right
masticatory space. This correlated with a biopsy of
the tumour mass in the right masticatory space that
showed this to be a deposit of the primary colorectal
carcinoma. She was presented at the multi-disci-
plinary meeting where it was decided to treat her
palliatively and she died 6 weeks after her diagnosis.
Discussion
Trismus is defined as a limitation of mouth opening
by any cause. Normal values range between 35 and
60 mm of inter-incisal distance (distance between
1
Trismus: an unusual cause and its implications Greenstein et al.

Figure 1 A full orthopantomogram including the condyles that is unremarkable.

Figure 2 A slice of the MRI showing a soft tissue mass invading the
right lateral and medial pterygoid muscles including the ramus of the
mandible. The green arrow highlighting the mass. Figure 3 A slice of the CT at the level of the colon revealing a mass
of the proximal sigmoid colon, highlighted by the blue arrow.

upper and lower incisors).1 This makes between two Trismus can be divided into either intra-articular
to three fingers breadth the normal width of mouth or extra-articular when establishing aetiology.3 The
opening.2 intra-articular causes are those which occur within

2 Oral Surgery  (2020) –.

© 2020 The British Association of Oral Surgeons and John Wiley & Sons Ltd
Greenstein et al.
the joint space and are commonly associated with
joint pathology such as arthritis, ankylosis or menis-
cal pathology.4 Extra-articular causes occur outside
the joint space and are most are the common mech-
anism by which trismus presents.5
It is important to categorize trismus into subhead-
ings when establishing a cause, such as:
• Infection: this is the most common cause6
• Trauma
• Iatrogenic: dental treatments, local anaesthetics,
haematoma
• Joint pathology
• Tumours: primary or secondary tumours of the
maxillofacial region or breast and prostate or other
organs
• Radiotherapy and Chemotherapy: radiation induced
fibrosis
• Developmental
• Drugs: there are a number of drugs that have
extrapyramidal side effects such as, SSRI, metoclo-
pramide and phenothiazine
• Other: Submucosis fibrosis, myofascial pain syn-
dromes such as TMD.
It must be remembered that odontogenic infec-
tions, especially associated with a partially erupted
lower third molar, are the most common cause of
trismus.6 However, infections involving the orophar-
ynx, such peritonsillar abscess, tetanus and infections
within the parotid gland can also cause trismus.
Orthopantomograms (OPGs) are good screening
tools to assess common causes of orofacial pathology
that may contribute to trismus, such as odontogenic
infections. However, this is not reliable in establish-
ing soft tissue masses as observed in this case. Mag-
netic resonance imaging (MRI) is the gold standard
in delineating joint pathology and anatomy and
would be recommended if after the elimination of
common causes more rare differentials persist7. The
symptoms the patient presented heralded a more
suspicious cause as to her trismus and raised red
flags earlier on in her presentation. It is important
that all members of the oral team can recognize
atypical presentations of TMD and the red flag sig-
nals should be on the forefront of practitioners
minds when diagnosing TMD. Any red flag signs
necessitate urgent onward referral. Red flags include;
worsening trismus, absence history of clicking, suspi-
cious intra-oral lesion, swollen lymph nodes, pain of
non-myofascial origin, nasal stuffiness and epistaxis8.
Oral Surgery  (2020) –.
© 2020 The British Association of Oral Surgeons and John Wiley & Sons Ltd
Trismus: an unusual cause and its implications
It must be remembered, that colorectal tumours
metastasizing to the masticatory space is thankfully
very rare9,10 but other maxillofacial tumours do and
can cause trismus if the masticatory mechanism is
impeded.
Conclusion
Trismus represents a spectrum of oral manifestation
of systemic conditions and diseases and infections
are usually the main cause. Patients will usually pre-
sent to their primary care practitioner when this
impedes normal function. However, recognizing red
flags as in this case can lead to prompt action and
appropriate management in a timely manner.
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