Ann Rehabil Med.  2012 Feb;36(1):154-158. 10.5535/arm.2012.36.1.154.

Severe Spastic Trismus without Generalized Spasticity after Unilateral Brain Stem Stroke

• Seo JH
• Kim DK
• Kang SH
• Seo KM
• Seok JW

• KMID: 2266795
• DOI: http://doi.org/10.5535/arm.2012.36.1.154

Abstract

A 62-year-old female patient diagnosed with left brain stem stroke 2 months ago was admitted to our clinic for rehabilitation. She had no generalized spasticity on both extremities, but could open her mouth only approximately 2 mm between her upper and lower teeth due to severe trismus. On needle electromyography, the left masseter muscle showed paradoxically increased muscle activity during mouth opening. We injected 50 units of type A botulinum toxin (Botox(R)) into the left masseter muscle, and 20 units into the left temporalis muscle with guidance of ultrasonography. The interincisal distance increased to 8 mm on the 3rd day after injection, and 9 mm on the 4th day. One month later, the interincisal distance increased to 14 mm. The increased interincisal distance was maintained for 13 months after injection, and the quality of hygienic care and compliance of oral stimulation therapy also improved.

Keyword

Trismus; Botulinum toxin; Brain stem stroke

MeSH Terms

Botulinum Toxins
Brain
Brain Stem
Compliance
Electromyography
Extremities
Female
Humans
Masseter Muscle
Middle Aged
Mouth
Muscle Spasticity
Muscles
Needles
Stroke
Tooth
Trismus
Botulinum Toxins

Figure

• 

  Fig. 1 On follow-up magnetic resonance imaging on the day of admission, cerebromalacia on the left middle cerebral peduncle was observed (A), lateral medulla oblongata (B), and lower cerebellum (C). Positron emission tomography (PET) findings were checked to find another brain lesion that can cause the severe trismus. Areas with decreased activities were found on the same areas with abnormalities which were found on MRI such as cerebellum (D), but there were no additional focuses in other areas of the brain (E).

• 

  Fig. 2 Before treatment with Botulinum toxin A, the patient had left facial palsy (A), and her interincisal distance was about 2 mm (B). After treatment, the interincisal distance increased from 2 mm to 8 mm on 3rd day after injection (C), and 9 mm on 4th day (D), and one month after, the interincisal distance increased to 12 mm and this interincisal distance continued after 3 months of injection (E).

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