Clinical case presentation on palliative care in subjects with trismus grade III due to moderately differentiated squamous cell carcinoma of mentum....

1. Presented by – Suparna Bandyopadhyay,
MPT (Neurology), 1st year

2. Name: Mr. XYZ
Age: 62Y
Sex: M
Occupation: Daily laborer
Address: Pingla, Medinipur
Date and place of assessment: 17th June
2023 at ABC pain OPD.
20XX 2

3. Persistent pain and ulcerated swelling
in the lower lip region lead to
Difficulty taking foods and opening
the mouth. Generalized body pain and
weakness for 6 months results in
limitations in performing self-care.
20XX 3

4. ONSET GRADUAL
PROVOKING FACTOR OPENING MOUTH
QUALITY OF PAIN SHARP SHOOTING PAIN
REGION MENTUM
SEVERITY NPRS SCORE IS 7 OUT OF 1O
TIME MOST OF THE TIME OF A DAY
O
P
Q
R
S
T

5. 20XX 5
Difficulty
in
Opening
mouth and
Chewing,
foods
History
of
anorexi
a for
the last
2
months
Limitations
in
performing
activities of
daily living
History
of
unexplain
ed fatigue
that does
not
improve
with rest
History of weight loss over the
past 5-6 months. 3kg weight was
lost since February 2023
Swelling of
locoregion
al neck
node
History
of
bleeding
from the
ulcerated
wound
Disturbe
d sleep

6. The patient
reported there
was a non-
healing ulcer
over the lower
jaw for 6 months
First 2-3 months
he took some
homeopathy and
ayurvedic
treatment from
local Doctors
He reported to
the subdivisional
hospital when
there was
bleeding from the
painful ulcer
He was referred
to the CNCI
hospital for
further treatment
and evaluation
6

7. No history
of T2DM,
HTN,
Thyroid
No
history
of
trauma
History
of
constipat
ion
On
metronomic
chemothera
py and pain
medication
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No relevant surgical
history

8. Regular tobacco smoker
for 40 years. On an
average 1 pack a day
Occasionally alcoholic
for 40 years
Used to took khaini
regularly for 40 years
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Personal history

9.  No relevant family history of cancer
 According to BG Prasad’s Socioeconomic status scale patient belongs to
the lower class family
9
Per capita income =
Total monthly income of the family
Total number of members in the family

10. Body build and nutrition:
Endomorphic and poor
Ambulation: required
some assistance
Posture: Normal
10
General examination
Oral examination:

11. 11
Three finger test:
Trismus grade
was III
Maximal interincisal opening (MIO)
Tongue ROM:
Tongue protrusion: Restricted
Tongue elevation depression: Could not be elicited
Tongue fasciculation and wasting : Absent

12. 20XX 12
Sensory examination
The oral cavity is hyper-sensitive to any hot and cold stimulus
The score is 3- 50% in bed. Capable of only limited self-care
confined to bed or chair 50% or more of waking hours

13. SAMPLE FOOTER TEXT 20XX 13

14. Fine-needle aspiration cytology (FNAC) of the lymph node on April 2022:
 Showed clusters of atypical squamous cells with pleomorphism and hyperchromasia.
 No evidence of malignancy was found in the accompanying lymph node aspirate.
Histopathological examination (HPE) on April 2022:
Moderately differentiated squamous cell carcinoma
Computed tomography (CT) scan of the head and neck on April 2022:
5 cm x 5 cm soft tissue mass involving the right & left lower jaw, with the destruction
of the mandible at the angle of the jaw.
No evidence of distant metastasis was seen.
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Investigation

15.  C T4aN2cMx
T4a- CT scan finding states that the size of the tumor is 5x5 cm
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16. SAMPLE FOOTER TEXT 16
N2c- Bilateral rt. Level Ia 1x1 cm and level Ib 2x2 cm
Mx- Distal metastasis cannot be assessed.

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Provisional diagnosis
Trismus due to squamous cell carcinoma in
mentum

18. SAMPLE FOOTER TEXT 18
Short term
goal
• Maintain oral hygiene
• Pain management
• Improving TMJ range of motion
• Maintain respiratory capacity
• Prevent DVT, edema, pressure ulcer
• Improve and maintain the strength of core muscles
and strength of upper and lower extremities
• Psychological counseling of prognosis
Long
term goal
• Improve ADL and QOL

19. TMJ range of motion
 Active facilitation of TMJ ROM 5 Sec hold 10 rep for 3 times a day
SAMPLE FOOTER TEXT 20XX 19
Mechanical mouth opening tool

20. Respiratory care:
Deep breathing exercise
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Incentive spirometry
Prevent DVT and edema Positioning

21. SAMPLE FOOTER TEXT 20XX 21
Active aerobic exercise:
 Regular walking at a comfortable speed at least for 10-15 minutes
 Core strengthening exercise
 Bed mobility exercises
Give liquid food
Maintain oral hygiene
Regular dressing of
the ulcerated wound
Use water or air bed
Do the regular
physical activity
Don’t leave the
ulcerated uncovered
Don’t lie over a
single side for a long
time
Avoid tobacco

22.  S. Senthilkumar in 2020 conducted an RCT with 30 cancer patients in India. They
were divided into two groups. Group-A (Control group) has restricted mouth opening
due to trismus and was given jaw mobilization exercises. Group B (Experimental
group) also have restricted mouth openings and were subjected to therabite exercises
and they were also given jaw mobilization exercises. Both groups were given
treatment for 2 weeks. Post-test NPRS and functional outcomes were taken.
 Two weeks of practicing jaw mobilization exercises and therabite exercises there was
an appreciable increase in their mouth opening and relief of pain.1
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Evidence-based practice

23.  Anna Pyszora in 2017 conducted a RCT with 60 patients diagnosed with advanced
cancer receiving palliative care. They were randomized into two groups: the treatment
group (n = 30) and the control group (n = 30). The therapy took place three times a
week for 2 weeks. The 30-min physiotherapy session included active exercises,
myofascial release and proprioceptive neuromuscular facilitation (PNF) techniques.
The control group did not receive any exercise
 The physiotherapy program, which included active exercises, myofascial release and
PNF techniques, had beneficial effects on CRF and other symptoms in patients with
advanced cancer who received palliative care. The results of the study suggest that
physiotherapy is a safe and effective method of CRF management.2
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24. 20XX 24
Recent advancements in palliative care
Shuzhen Chee in 2021 conducted a systemic review involving 11 RCTs which includes total
of 685 head-neck cancer patients. Six RCTs evaluated the effectiveness of a jaw mobilization
device with exercises; there was no significant benefit of an exercise regime with a jaw
mobilization device either initiated before, during or after treatment compared to no exercise.
Two RCTs compared 2 intervention groups that involved exercises only, with 1 study
assessing the benefit of weekly supervised physical therapy with gum chewing and another
evaluating the benefit of immediate (1-2days) versus delayed (7-10 days) initiation of exercise
post-surgery; there was no significant difference between groups in either study. One RCT that
recruited only patients with trismus demonstrated that an exercise regime in combination with
low-level laser therapy or low-intensity ultrasound had superior results in mouth opening
measurements compared to exercise alone. Two RCTs compared intervention groups with and
without follow-up reminders; both studies showed a significant improvement in mouth
opening measurements in groups with follow-up reminders.

25.  This systematic review did not convey a clear consensus as to optimal intervention for
trismus in HNC patients. A variety of exercise regimens and jaw rehabilitation devices
appear to have comparable effectiveness. Also, low-level laser therapy and low-
intensity ultrasound coupled with exercise may be beneficial for patients with
trismus.3
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26.  1. Senthilkumar S, Tarun S. A study on the effectiveness of therabite exercises to
improve the jaw range of motion in trismus among oral cancer patients. Research
Journal of Pharmacy and Technology. 2020;13(2):519-22.
 2. Pyszora A, Budzyński J, Wójcik A, Prokop A, Krajnik M. Physiotherapy
programme reduces fatigue in patients with advanced cancer receiving palliative care:
randomized controlled trial. Supportive care in cancer. 2017 Sep;25:2899-908.
 3. Chee S, Byrnes YM, Chorath KT, Rajasekaran K, Deng J. Interventions for trismus
in head and neck cancer patients: a systematic review of randomized controlled trials.
Integrative Cancer Therapies. 2021 May;20:15347354211006474.
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Reference

27. Suparnamoom9.6@gmail.com