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IMMUNOTHERAPY IN HEAD AND NECK CANCERS
Table 73.3 Palliative use of tyrosine kinase inhibitors (TKI)
Treatment/Trial Study info Summary
Geftinib
(Stewart 2009)
Afatinib in LUX-Head and
Neck-1 trial
(Machiels 2015)
Recurrent or metastatic HNSCC
treated with getinib (250 or
500 mg/day) or single-agent
methotrexate
Methotrexate or afatininb for
relapsed/metastatic HNSCC
The data do not support the
use of getinib as a palliative
therapy in relapsed/metastatic
HNSCC
Afatinib improved progression-
free survival, but it did not
improve OS. It also caused
deterioration of global health
status, pain, and dysphagia
Palliative TKI
Currently, there is no evidence that supports the use of TKI in the palliative setting (see
Table 73.3), but there is continued research that may change this in the future.
Radiosensitisers
Radiotherapy is an extremely eective therapy for HNSCC. In tandem with the development
of advanced radiotherapy techniques, a parallel track of studies has evaluated combinations
of radiotherapy with cytotoxic drugs, in an attempt to enhance radiation-induced (RI) cytotoxicity. Large meta-analyses demonstrate radiotherapy delivered with concomitant platin
monotherapy as the standard-of-care for locally advanced HNSCC (Pignon 2009).
Cell Cycle
Cell division is an essential component of development, growth, and tissue repair. It is
tightly regulated, and failure to copy the cellular DNA faithfully confers a risk of inheriting
mutations.
Cells can also slow down or stop in the cell cycle when they experience DNA damage. ere
are four main cell cycle phases (Figure 73.2). Potentially the most lethal DNA lesions induced
by ionizing radiation are double-strand breaks (DSB). erapies that can prevent the repair
of DSB are potentially profoundly radiosensitising.
M
G2
M
G2
G1
S
G1
Cell Cycle Phases:
G1
Growth
DNA Synthesis
S
G2
Growth & mitosis preparation
M
Mitosis
Cell Cycle Checkpoints:
G1
Restriction checkpoint
G2
DNA Damage checkpoint
M
Metaphase/spindle checkpoint
Figure 73.2 The cell cycle.
378 Head and Neck
IMMUNOTHERAPY IN HEAD AND NECK CANCERS
apoptosis occurs when cells attempt to divide with damaged DNA. e cell is unable to complete mitosis and dies, in a process known as mitotic catastrophe. e majority of HNSCC
lack normal p53-mediated G1/S checkpoint and are dependent on S and G2/M arrest to allow
repair of DNA damage aer irradiation. Hence, G2/M checkpoint control is a particularly
appealing target for cancer-specic radiosensitisation.
Radiosensitiser Drugs
e protein kinase ATR is involved in identifying DNA damage. ATR inhibitors can radiosensitise cancer cells through disruption of intra-S and G2 checkpoints. Inhibitors of ATR
have been tested in pre-clinical studies. us far, there have been no publications on ATR
inhibitors in cancer patients, but clinical trials have begun.
Chk1 is directly downstream of ATR in the DNA damage response signalling cascade. Chk1
inhibitors that have been tested include UCN-01, AZD7762, and SAR-020106, but all of them
had severe toxicities and lacked clinical ecacy.
e Wee1 kinase regulates entry into mitosis, by negatively controlling CDK1 and Chk2.
AZD-1775 is an agent shown to potentiate DNA-damaging agents in vitro and in vivo, and it
is currently undergoing phase I trials.
Enhancing Antitumor Immune Responses
Recently, aer decades of negative studies, immunotherapy has emerged as a major new
modality for cancer treatment. Identication of immune checkpoints integral to normal
immune responses has been pivotal in this progress. Checkpoints normally inhibit T-cells,
preventing them from becoming chronically or aberrantly activated. is system functions
as a negative regulator or ‘the brakes’ on the immune response. Many cancers subvert these
inhibitory pathways in order to evade immunosurveillance and thereby escape immune
detection and attack.
Proteins expressed on activated T-cells allow cancers to evade anti-tumour immunity by
interfering with activation or eector phases of immune responses. CTLA4 is an important control mechanism that inuences the immune response’s activation phase, and it can
switch o T-cells. MAbs that target CTLA4 are able to block this interaction and enhance
T-cell activation against tumour cells. T-cells can be prevented from engaging with and/or
killing a tumour cell if the tumour cell expresses PD-L1 on its surface. is negative interaction between T-cell and tumour cell can be interrupted by administration of specic MAbs
that block PD-1.
Clinical Experience with Checkpoint Inhibitors
MAbs have demonstrated signicant activity in a range of tumour types. It appears that the
likelihood of a patient’s beneting from immunotherapy may correlate with the mutational
burden and, hence, the neoantigenic load carried by their tumour. Head and neck cancers,
especially human papillomavirus negative (HPV–) tumours, are also associated with a signicant number of mutations.
ere have been initial reports of single-agent activity in patients with relapsed/metastatic
disease. For example, trials have used pembrolizumab (an anti-PD1 MAb). In the
KEYN0TE-012 trial, patients with PD-L1-positive tumours were divided into HPV+ and
HPV− cohorts and were treated with pembrolizumab. Overall, 26 of 51 patients had a reduction in tumour burden. ere are several ongoing randomised phase II/III clinical trials with
anti-PD1 agents (pembrolizumab, nivolumab, and durvalumab) in patients with relapsed/
metastatic disease, and the results are likely to be reported in the next few years. e side
eects of immune checkpoint inhibitors are autoimmune adverse reactions, such as skin
rash, colitis, hepatitis, and endocrinopathy. In all instances, these treatments require specialist management because they can evolve into serious, even life-threatening, conditions.
ere is evolving work (both pre-clinical and clinical data) to demonstrate that immune
checkpoint inhibition may enhance the eect of, and lead to systemic activity of, a local
Head and Neck 379
QUALITY OF LIFE, SURVIVORSHIP, AND OUTCOMES IN HEAD AND NECK CANCER
therapy, such as radiation. ese observations, combined with the excitement over the ecacy of single-agent immune checkpoint inhibition, have led to a number of clinical studies
that are combining immune checkpoint inhibitors with ionizing radiation.
KEY POINTS
• Understanding of fundamental biological processes involved in cancer cell formation
has resulted in drug strategies to treat HNSCC.
• EGFR inhibitors, TKI, drugs which arrest the cell cycle, and radiosensitisers have been
used in various treatment regimens.
• Knowledge about use of checkpoint inhibitors for treatment is evolving.
Further Reading
Bauml JM, Aggarwal C, Cohen B. Immunotherapy for head and neck cancer: where are we
now and where are we going? Ann Transl Med 2019; 7(Suppl 3): S75.
Paleri V, Rollands NJ. (Eds.) Head and Neck Cancer United Kingdom National Multi-
disciplinary Guidelines, 5th edition, 2016.
Sim F, Leidner R, Bell RB. Immunotherapy for head and neck cancer. Haematology/Oncology
Clin 2019; 36(2): 301–321.
74. QUALITY OF LIFE, SURVIVORSHIP, AND OUTCOMES
IN HEAD AND NECK CANCER
Introduction
ere are two million people living with or beyond cancer in the United Kingdom. It is a
cause for celebration that more people than ever are surviving aer diagnosis, but we know
the impact of cancer does not suddenly stop when treatment is over. Survivorship focuses on
the health and life of a person with cancer from the completion of treatment until the end of
life. It covers the physical, psychosocial, and economic issues of cancer, beyond the diagnosis
and treatment phases (Fig ure 74.1). It is recognised that family members, friends, and caregivers are also part of the survivorship experience.
Measurement of Treatment Outcomes
Survival Outcomes
Undoubtedly, survival is the cornerstone of outcome assessment for head and neck cancer
(HNC). Analysis of survival has the advantages that there can only be two categories, alive
or dead, and that this outcome cannot be misrepresented.
A ‘time-to-event’ analysis, such as the Kaplan-Meier survival curve, is commonly used, where
a log-rank test is used to compare two or more survival curves. is is only appropriate where
relative mortality does not change over time (proportional hazards assumption). Another
limitation is that patients may not experience the outcome within the analysis time frame,
so it can be insensitive for certain diseases. Other parameters besides overall survival are
disease-free survival, progression-free survival, disease-specic survival rate, and median
survival; therefore, it is important to clarify which parameter is being reported.
380 Head and Neck
QUALITY OF LIFE, SURVIVORSHIP, AND OUTCOMES IN HEAD AND NECK CANCER
100
Cumulative survival
60
80
60
40
Toxicity
20
Complications
Cancer deaths
0
01224
Figure 74.1 Transition from early post-treatment to longer-term survivorship after head and neck
cancer.
Survivorship
Late eects
Population deaths
36 48
Months from operation
All causesDisease specic
Functional Outcomes
Currently, there are no outcome reporting standards for clinical practice or trials in HNC.
e World Health Organisation (WHO) recommended as early as 1981 that, as a minimum
standard, oncology clinical trials should measure tumour and metastasis response, duration
of response, and adverse eects. Treatment for HNC aects speech, social interaction, swallowing, and breathing, with speech and eating having the most impact on well-being in a
disease-specic quality of life (QoL) survey.
Measures of Voice, Speech, and Swallow Outcome
Voice and speech represent dierent ends of the same spectrum. e larynx serves as the
source of phonation, thereby producing voice, while the vocal tract (oral cavity, oropharynx,
nasopharynx, nasal cavity, and paranasal sinuses) act as a lter, altering the voice and shaping speech. Speech is the nal outcome of voiced sound. Cancers or treatments involving
the vocal tract sites will aect speech and not the voice. Voice is predominantly aected by
laryngeal cancers or treatments aecting the larynx, directly or indirectly. Numerous tools
are used for the evaluation of voice and speech (Box 74.1), but there is no widely accepted
outcome measure.
Dysphagia assessments require a multimodality approach (Box 74.1b) and fall broadly into
two categories: those that assess the severity of the swallowing disorder and those that try to
establish its cause.
Adult Comorbidity Evaluation
Adult Comorbidity Evaluation-27 (ACE-27) is a modication of the Kaplan-Feinstein Index
(KFI), validated and especially designed for patients with cancer. An overall score of 1, 2, or 3
is assigned according to the highest ranked single condition, except where two or more grade
2 illnesses occur in dierent organ systems, in which case a score of 3 is given. Other comorbidity indexes are available, but the National Cancer Intelligence Network in the United
Kingdom recommends the use of ACE-27 for all cancer patients.
What is Health-Related QoL (HRQoL) and How is it Measured?
HRQoL involves four areas: physical functioning, psychological functioning, social functioning, and symptoms from the disease and treatment.
HRQoL has a major role in treatment decisions in several situations. For example, when different treatments have a good chance of cure, their HRQoL outcomes w ill inuence treatment
Head and Neck 381
QUALITY OF LIFE, SURVIVORSHIP, AND OUTCOMES IN HEAD AND NECK CANCER
BOX 74.1 ASSESSMENT TOOLS FOR MEASURING VOICE, SPEECH,
AND SWALLOW IN HNC PATIENTS
a) Assessment of Outcome of Voice
Questionnaire-Based Measures
• Voice Handicap Index (VHI)
• Voice Symptom Scale (VoiSS)
• Voice Activity and Participation Prole
(VAPP)
• Voice Prosthesis Questionnaire
• Vocal Handicap Index-10
• Vocal Performance Questionnaire
(VPQ)
Perceptual Measures
• GRBAS rating scheme
• Perceptual evaluation of alaryngeal
speech
Instrument-Based Measures
• Stroboscopy
• Acoustic analysis of voice using inverse
ltering and linear predictive coding
• Electroglottography (EGG)
• Electromyographanalysis
c) Tools Available for the Assessment of Outcome of Speech
Questionnaire-Based Measures
• Speech Handicap Index (SHI)
Perceptual Measures
• The London Speech Evaluation (LSE) scale
Instrument-Based Measures
• Assessment of Intelligibility of Dysarthric Speech (ASSIDS)
• Acoustic analysis of speech signal using linear predictive coding
b) Assessment of Outcome of Swallow
Questionnaire-Based Measures
• Sydney Swallow Questionnaire (SSQ)
• SWAL-QOL and SWAL-CARE
• MD Anderson Dysphagia Inventory (MDADI)
Perceptual Measures
• Blue dye test
• Water swallow test
Instrument-Based Measures
• Videouoroscopy
• Functional endoscopic evaluation of
swallowing (FEES)–score on the
penetration-aspiration scale
• Flexible endoscopic evaluation of
swallowing with sensory testing (FEESST)
• Electromyography
Performance Scales
• Performance Status Scale for Head and Neck
• The Functional Intraoral Glasgow Scale
selection. e priority given to the best chance of cure oen outweighs HRQoL outcomes for
individual patients, treatment protocols, and trial designs. Patients set cure and survival as
priorities. When cancer treatment is very unlikely to be curative or the intention of treatment
is palliative, there is a strong focus on treatments that maintain HRQoL.
Studies show that long-term survivors of advanced HNC accept major surgical procedures,
with over 90% of 273 patients stating that ‘I would undergo the same treatment’. ere is
also strong agreement among patients, their companions, and members of the multidisciplinary team (MDT) about priorities in HNC outcomes, and there is low post-treatment
regret among patients and their companions.
HRQoL is usually measured by a patient’s self-completed questionnaire. Questionnaires can
be complemented by objective measures of swallowing, speech, and shoulder movement.
ere is no gold standard questionnaire that is best. e British Associat ion of Head and Neck
Oncologists and the British Association of Otorhinolaryngologists Head Neck Surgeons both
recommend that HRQoL should be longitudinally recorded. e most commonly used questionnaires are the European Organization for Research and Treatment for Cancer (EORTC)
and the University of Washington Quality of Life (UW-QoL) questionnaires.
382 Head and Neck
QUalIty of lIfe, SUrvIvorShIp, anD oUtcomeS In heaD anD neck cancer
Treatment Decisions and Outcomes in the Context of HRQoL and Survivorship
e epidemiology of HNC in the United Kingdom is changing. e oral cavity is now the
subsite most oen involved, and there was a 51% increase in human papillomavirus (HPV)related oropharyngeal cancers between 1989 and 2006. e HPV-related cancers appear
to aect younger people and may respond better to chemoradiotherapy with or without
surgery.
Shared decision-making improves patients’ satisfaction with the consultation, leading to better QoL. Information supplied to the patient needs to be tailored to the individual patient.
Giving patients too much information can result in anxiety and reduced recall, while too
little information makes it unlikely that patients will fully understand.
Outcomes used in clinical trials of HNC treatment frequently focus on objective measures of
function and survival rates. Mortality may not be the most important outcome to the patient,
nor is it necessarily a good proxy for other outcomes. A range of outcome predictors should
be considered, including the social and healthcare environment, psychosocial factors, and
health behaviours, as well as biological factors.
HRQoL and Survivorship
e risk factors for poor HRQoL outcomes are given in Table 74.1. Poor HRQoL has been
identied as an independent predictor of survival.
Total Laryngectomy (TL)
Aer laryngectomy, patients are more accepting of anticipated sequelae (such as sensory
impairments, cough, and dyspnoea), than they are accepting of more general side eects
(such as constipation and nausea/vomiting). Surprisingly, many patients who have undergone total laryngectomy (TL) maintain a good overall QoL, although they face potential
diculties in returning to work aer TL. ere is also evidence that both primary and secondary trachea-oesophageal puncture (TEP) aect HRQoL. Primary TEP provides almost
immediate and satisfactory voice rehabilitation.
Treatment
In general, single-modality treatment (e.g. radiotherapy or surgery alone) confers much better HRQoL. Transoral robotic surgery oers a way to preserve functional anatomy without
compromising surgical resection margins and could have a positive impact on HRQoL. e
advantage of less-invasive surgery for HRQoL (e.g. transoral resection versus open resection
and free ap reconstruction) is lost if primary surgery has to be followed by adjuvant radiotherapy. Avoiding radiotherapy aer primary surgery has substantial benets for HRQoL as
long as optimal survival is maintained. ere is also evidence that reducing the dosage of
radiotherapy can make a substantial dierence. In addition, IMRT has much better HRQoL
outcomes than 3D-conformal radiotherapy (3D-CRT) has.
Table 74.1 Common factors associated with worse HRQoL outcomes
Alcoholism: Pre-existing comorbidity and poor coping mechanisms
Age: Young patients have much more to lose in terms of life expectancy and nances
Combined treatments: Surgery and radiotherapy, chemoradiotherapy
Deprivation: Lower socioeconomic background
Personality: Negative, nihilistic
Pre-existing distress: Anxiety-related conditions, mental health problems
Single: Lack of support
Site: Oropharynx and hypopharynx
Stage: Advanced disease
Unknown: Clinicians clinical experience
Head and Neck 383
QUALITY OF LIFE, SURVIVORSHIP, AND OUTCOMES IN HEAD AND NECK CANCER
Although the short-term side eects of treatment may dier, long-term QoL is remarkably
similar with either primary chemoradiation or surgery with post-operative radiation.
Osteoradionecrosis (ORN) of the mandible is a severe complication of radiation therapy and
has a detrimental impact on HRQoL. Surgery for ORN can result in an improved HRQoL;
however, lack of improvement despite the restoration of an intact mandible is related to the
persistent eects of chemoradiotherapy.
Clinical Trials
In the literature, the evidence is limited concerning HRQoL with respect to clinical trials.
HRQoL is oen included as a secondar y outcome of a clinical trial and is not explicitly driven
by hypothesis. In the future, an increasing number of trials and interventions will specically aim at evaluating HRQoL dierences (such as a study to assess the eect of low-level
laser therapy on oral mucositis and QoL in HNC patients receiving chemoradiotherapy).
IMRT will also continue to be the subject of trials for until it becomes a standard of care.
HRQoL Issues
A diverse range of patient and carer needs and concerns arise aer completion of HNC treatment. Signicant HRQoL issues are reected in Table 74.2. e issue that patients raise most
frequently is fear of recurrence (FoR).
Carer Support
e benet of carer support is a key issue in terms of patients’ HRQoL. During the treatment
phase and in the early period aer interventions, a wide range of supportive care is needed,
including dental hygienists, physical therapists, specialist dietitians, and speech therapists.
Long-term supportive care focuses on dental hygiene, speech therapy, and physical therapy.
Increased social isolation may be a risk factor for poorer physical recovery from, or adjustment to, treatment-related side eects. Carers see patients as they are, ‘day to day’, and not
Table 74.2 A summary of HRQoL issues after HNC treatment
Issues, in alphabetical order
Carer: Positive carer support is important
Coping: Seeking social support is good, avoidance is bad
Dental status: Eating, social interaction, and coping are affected by dental issues
Disgurement: Appearance, body image, and intimacy are adversely affected
Emotion: Anxiety is common pre-treatment, and depression and mood disorders require treatment
Fatigue: Common in rst year and is associated with poor sleep and low energy
Fear of recurrence: Does not lessen over time
Financial/work: Employment, benets, and retirement are all affected by illness
Information: various amounts, in various ways, at various times
Nutrition: Weight loss, poor diet, and percutaneous endoscopic gastrostomy (PEG) feeding are concerns
Oral rehabilitation: Chewing/eating are subject to expectations vs trade-off with actual function
Pain: Causes need for opiates, poor sleep, and depression
Personality: optimism and HRQoL + survival, high neuroticism
Self-esteem: Low self-esteem is associated with poor QOL
Sociodemographic: children, social support, ethanol abuse
Speech: Laryngeal speech and isolation affect QOL
Swallowing: Presence of a feeding tube is most signicant
Shoulder: Shoulder discomfort and neck tightness
Trismus: Difculty with mouth opening affects diet, social life, and intimacy
Xerostomia: Profound impact on social function, intensity modulated radiotherapy (IMRT)
Unknown: clinical art of the individual not a precise science
384 Head and Neck
TEMPOROMANDIBULAR JOINT DISORDERS
just at the review clinic visit. Carers are oen more able to identify needs than the patient
themselves. Family caregivers also report signicant stress and needs, including the need for
more information and for healthcare services. ere is merit in developing a tool to identify
carer needs and caregiving training programs.
Interventions
As our understanding of the HRQoL outcomes of patients has increased, it has led to a focus
on intervention, but evidence for interventions is limited by the small number of studies,
methodological problems, and poor comparability. Even so, some interventions can be
suggested. A nurse-led intervention around the time of discharge from hospital, based on
informational needs, has potential benets for HRQoL. Early provision of psychotherapy
may reduce patients’ post-traumatic stress disorder, anxiety, and depressive symptoms.
Interviewing patients to allow them to express their concerns has merit. Acupuncture has
been used in the prevention and treatment of radiation-induced xerostomia. ere is scope
for other interventions (e.g. interventions addressing secondary lymphoedema) to help in
the management of associated symptom burden, functional loss, and psychosocial impact.
Conclusions and Future
HNC is biologically heterogeneous; therefore, tumour behaviour and response to treatment
vary as well. Furthermore, the incidence and severity of adverse eects of treatments are
also variable among patients. Consequently, the identication, selection, and reporting of
disease-specic and appropriate endpoints have become a research priority. Advances in
information technology and patients’ familiarity with computers and the internet allow for a
much more integrated approach to HRQoL assessment and intervention.
HRQoL is now an integral part of the management of the HNC patients and their carers.
Also, as our understanding of the patient’s perspective on outcome increases, treatment
selection will become more rened and aercare will be determined by the patient’s needs.
KEY POINTS
• Outcome measures are integral to the management of patients with HNC and can
relate to survival or function. Choice of appropriate outcome measures is essential.
• HRQoL is an essential component of outcomes after HNC.
• HRQoL is usually measured by questionnaires. The choice of questionnaire is an important
consideration and depends on the reason for collecting the patient-reported outcomes.
• The many factors that affect HRQoL relate to the physical/functional, social, and
emotional consequences of treatments.
• Advances in computer technology will make a substantial difference in collecting HRQoL
outcomes and will allow the insights gained to be applied on an individual patient basis.
75. TEMPOROMANDIBULAR JOINT DISORDERS
Introduction
Temporomandibular joint (TMJ) problems are common and may aect around 30% of the
population at some stage during their life. Dierential diagnosis can be confusing, and
patients are oen referred to ENT services with ‘earache’. TMJ disorders are a spectrum of
disorders ranging from internal derangement (disc-related disorder) to masticatory myofascial pain (purely muscle disorder).
Head and Neck 385
TEMPOROMANDIBULAR JOINT DISORDERS
Epidemiology
Although TMJ disorders can present at any age, patients less than 40 years old are unlikely to
have degenerative joint disease. In people over age 40, there is increased remodelling of the
joint, with possible osteoarthritic changes.
Women are aected more commonly than men, and reported sex ratios range from 2:1 to 10:1.
Predisposing factors include previous trauma, history of clicking joint, and clenching or grinding of teeth (nocturnal parafunction).
HISTORY
Clinical Examination
Palpation of the joint for tenderness and noises/crepitus laterally and posteriorly with
•
the mouth both open and closed.
Palpation of the masseter and temporalis muscles for tenderness and areas of muscle
•
tightness.
Use of tongue spatula to assess bite between teeth on both sides.
•
Measurement of interincisal opening in millimetres.
•
Observation of the opening path of the mandible in relation to maxillary centreline.
•
Interdigitation of teeth (dental occlusion).
•
Investigations
Orthopantogram (OPG) plain radiograph is useful in screening for other pathology
•
and dental causes.
Computed tomography (CT) del ineates bony anatomy of joint and su rrounding st ructures .
•
Magnetic resonance imaging (MRI) can highlight so tissue but is dicult to inter-
•
pret even for experienced radiologists.
Isotope bone scanning (
•
hyperplasia).
99m
Tc) is useful to show increased bone turnover (e.g. condylar
Table 75.1 Primary symptoms of temporomandibular joint disorders
Pain • In joint itself (TMJ pain), usually localised in front of tragus.
Worsens on function
• In muscles of mastication (myofascial pain), usually aching,
poorly localized but often over ramus of mandible and temple.
Worse in mornings
Joint noises • Clenching usually relates to anteromedial displacement of the
disc, repositioning it over the joint. No active intervention is
required
• Cracking or crepitus suggests degeneration within or around
the joint. No active treatment required in isolation
Locking • Inability to fully open (closed lock) or fully close
• Related to disc displacement, muscle spasm, or trauma
Restriction of opening • Normal interincisal opening between 35 and 55 mm
• Can be caused by muscle spasm, disc displacement, ankylosis,
trauma, infection, or spasm
Disturbance of bite • Unilateral collapse of the joint will lead to premature contact
and centreline deviation towards side of problem
• Bilateral collapse will move chin back and cause anterior open bite
Alteration in facial appearance • Collapse of the joint will cause retrusion or rotation of the chin
Other joint disorders • Rheumatoid disease can lead to joint collapse or ankylosis
• Ankylosing spondylitis may lead to restriction and ankylosis
• Hypermobility may lead to dislocations
386 Head and Neck
TEMPOROMANDIBULAR JOINT DISORDERS
Differential Diagnosis
Internal Derangement
‘Clicking joint’ is common, and it is now accepted as a variation of normal. Clinical examination may elicit muscle tenderness or direct joint tenderness and reduction of interincisal
opening. Physical limitation and lack of joint glide can indicate occlusion of the upper joint
space. Muscle tenderness will guide to a diagnosis of myofascial pain.
Degenerative Disease of the TMJ (Osteoarthrosis)
Degenerative joint disease occurs when the reparative process is overtaken by wear and tear
on the joint. It is much less common in the TMJ than in other major joints due to reduced
load on the TMJ. Symptoms include pain, swelling, and restriction of movement. Clinical
examination reveals tenderness of joint with palpable crepitus and restriction of movement
with intermittent swelling. CT ndings include sclerosis, loss of joint space, osteophytes, and
erosions or cyst formation.
Inammatory Disease of the TMJ
Rheumatoid disease can occur in the child, adolescent, or adult. It usually presents with
signs and symptoms of synovitis, namely pain, swelling, heat, and restriction of movement.
Progression can lead to joint collapse, resulting in malocclusion with anterior open bite and
retrusive contact. Diagnosis is made in coordination with the rheumatology team and is
guided by the presence of other aected joints.
Psoriatic arthropathy can lead to acute synovitis, joint collapse, or ankylosis. Classical skin
changes can be dicult to identify in up to 50% of patients, but larger joint arthropathy is
usually apparent. Patients who are HLA-B27 positive have a tendency to progress to ankylosis rather than a synovitis disease pattern.
Trauma
Unilateral or bilateral condylar fractures account for approximately 30% of mandibular
fractures. Interpersonal violence is the most common cause. Occasionally, the fracture can
involve the temporal bone, leading to hemotympanum or perforation of the external auditory canal. Symptoms and signs include pain at site of injury, swelling, malocclusion, and
possible lateral open bite.
Fractures in children tend to occur within the joint capsule and are dicult to treat operatively. Initial management is oen early mobilization and analgesia, but a short period of
intermaxillary xation with elastics and wires is sometimes required to reduce a malocclusion. Long-term follow-up is required to screen for growth abnormalities.
Adult fractures are more likely to be extracapsular and can be managed nonoperatively with
so diet and mobilization if there is no change in occlusion. Early surgical management is
becoming more common practice but should only be performed in experienced hands. Early
referral to oral and maxillofacial teams is advised for complex fractures.
Hemifacial Microsomia
Some TMJ ndings are due to the failure of the condyle to develop, possibly secondary to
inadequate blood supply in utero. is causes associated undergrowth of the ear, ear canal,
joint, and fossa to varying degrees. Hemifacial microsomia is a complex craniofacial disorder and management should involve supraregional craniofacial centres.
Condylar Hyperplasia
Condylar hyperplasia is due to either overgrowth of the condyle centre on one side before
or during puberty, or continued growth aer completion of puberty but with cessation of
growth on the aected side. Patients present with progressive malocclusion, usually with
centreline deviation and associated chin point deviation (hemimandibular hyperplasia).
ey may also present with bowing of the mandible and downward cant of dental occlusion
(hemimandibular hypertrophy).
Head and Neck 387
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