ORIGINAL ARTICLE

Application of Mouth Gag and Temporomandibular Joint

Pain and Trismus in Tonsillectomy
ABSTRACT

Nasir Akram Kundi1, Talat Mehmood2 and Omair Abid1

Objective: To determine the effect of duration of application of mouth gag on Temporomandibular (TM) joint pain and
trismus after tonsillectomy.
Study Design: Descriptive study.
Place and Duration of Study: Department of ENT and Head and Neck Surgery, Combined Military Hospital, Nowshera,
from February to July 2012.
Methodology: A total of 40 patients undergoing tonsillectomy, in mouth opening prior to surgery was measured as inter
incisor distance in cms. A stop watch was used to calculate the time of application of mouth gag. Mouth opening was again
measured 06 hours after the surgery. Difference between the two readings was considered as trismus score and
categorized as mild (1 cm), moderate (2 cm) and severe (3 cm). Patient was asked to score pain on a visual analogue
scale (0 - 9). Score 0 was categorized as no pain; 1 - 3 as mild pain; 4 - 6 as moderate pain; 7 - 9 as severe pain. Spearmans
rank correlation was used for finding correlation between time of mouth gag application and study outcome (pain and
trismus).
Results: Trismus as observed by difference in inter incisor distance was mild in 11 patients; moderate in 15 patients and
severe in 14 patients 06 hours after the surgery. Eleven (27.5%) had mild pain over temporomandibular joint, 15 (37.5%)
had moderate and 14 (35%) had severe pain 06 hours after the surgery. Direct relationship was observed between
duration of application of mouth gag with postoperative pain and trismus. Significant strong correlation was observed
between length of mouth opening to severity of pain and trismus (rs = 0.738; p < 0.001).
Conclusion: Duration of mouth gag application should be reduced to cause less TM joint pain and trismus in early postoperative period in tonsillectomy.
Key Words: Boyles Davis mouth gag. Tonsillectomy. Trismus. Temporomandibular joint pain.

INTRODUCTION

Tonsillectomy is one of the commonest procedures in

ENT practice.1 It is defined as removal of pharyngeal
tonsils alongwith its fibrous capsule.2 It is performed to
alleviate the recurrent tonsillar infections leading to
recurrent ear and sinus infections.3

The procedure is performed under general anaesthesia.

It consists of application of mouth gag (Boyle's Davis) for
exposure of pharyngeal tonsils. There are various
methods for tonsillectomy. Dissection method, diathermy
method,4 KTP laser and use of harmonic scalpel.5
Postoperative trismus and pain in TM joint at rest and on
chewing is mainly attributed to prolonged application of
mouth gag. But there is no evidence available to know
the relationship between the duration of application and
degree of trismus and severity of pain felt by the patient.
During application of mouth gag all the muscles of
mastication that maintain jaw opening are under tonic
Department of ENT1 / Emergency2, Combined Military Hospital,
Nowshera, Peshawar.
Correspondence: Dr. Nasir Akram Kundi, Classified ENT
Specialist, PAF Hospital, E-9 PAF Complex, Islamabad.
E-mail: nasir1926@hotmail.com
Received: April 18, 2013; Accepted: February 09, 2015.
268

contraction.6 It leads to accumulation of lactic acid in the

muscles leading to feeling of pain and trismus.
Prolonged mouth opening also has stretch effect on joint
capsule which causes pain. Moreover, subluxation of TM
joint is a known complication of tonsillectomy. Although
effective analgesia is administered during anaesthesia.
But postoperative pain and trismus is an indicator of
prolonged application of mouth gag.
The objective of this study was to determine the effect of
duration of application of mouth gag on Temporomandibular (TM) joint pain and trismus after tonsillectomy.

METHODOLOGY

A total of 40 patients were selected from February to

July 2012, by random sampling. Sample size was
selected on the basis of patient turnover in ENT
Department of Combined Military Hospital, Nowshera,
undergoing tonsillectomy in the pre-defined period of
study. This was calculated from statistical records of the
hospitals. Informed consent was taken from the patients
for participation in the study and permission was
obtained from hospital's ethical committee. All the
patients were healthy individuals with no pre-existing
developmental orofacial deformity.7 None of the patients
was suffering from myopathy, mandibular bone and joint
disorder.8 Patients below 10 years of age were excluded

Journal of the College of Physicians and Surgeons Pakistan 2015, Vol. 25 (4): 268-270

Application of mouth gag and temporomandibular joint pain and trismus in tonsillectomy

due to difficulty in recording the pain severity. All the

patients underwent tonsillectomy by dissection method.9
Patients were given tablet Acetaminophen 2 tablets
thrice daily or its suspension 5 ml thrice daily or given to
patients under 12 years of age for pain relief.

Frequencies were calculated for gender of the patients

included in the study. Mean was calculated for age of the
patient and time of application of mouth gag.
Time from start of application of mouth gag (Boyles
Davis) to its removal was recorded with the help of a
stop watch. Time above 30 seconds was rounded off to
full minute.

Distance between upper and lower incisor teeth was set

as yardstick for measurement of degree of trismus. Two
readings were recorded one before and one 06 hours
after tonsillectomy. Their difference was calculated.
Severity of trismus was graded as mild (1 cm), moderate
(2 cm) and severe (3 cm), reading more than 0.5 was
rounded off to full.

All the patients were interviewed 06 hours after surgery.

They were asked to provide feedback on degree of pain
felt by scoring on a visual analogue scale (0 - 9).
Patients with score 1 - 3 were grouped as having mild
pain; 4 - 6 as moderate pain and 7 - 9 as severe pain.
Data analysis was done with the help of SPSS
version 20. P-value less than 0.05 was taken as
significant. Variables like time of application of mouth
gag was compared to the outcome (pain and trismus).
Spearman's rank correlation was used for finding
correlation between time of mouth gag application and
study outcome.

RESULTS

Out of 40 patients, 18 (45%) were males and 22 (55%)

were females. Mean age of the patients undergoing
tonsillectomy was 21 9 years. Mean time of application
of Boyles Davis mouth gag was 47 12 minutes.

Figure 1: Showing relation of time to degree of pain and trismus.

Degree of trismus out of 40 patients 06 hours after the

surgery was shown in Figure 1. Frequency of patients
who had mild pain over temporomandibular joint was 11
(27.5%). Fifteen (37.5%) had moderate and 14 (35%)
had severe pain 06 hours after the surgery. Significant
strong correlation between duration of application of
mouth gag with postoperative pain and trismus was
observed (rs = 0.738; p < 0.001). It was also evident that
trismus and pain over TM joint were also related to each
other. In patients with duration of application of mouth
gag more than 55 minutes, the degree of trismus and
pain was severe in all the cases postoperatively.

DISCUSSION

Tonsillectomy is performed frequently in our set up. In

expert hands, it is thought to be day-care procedure with
patient going home in the evening.10 Patients frequently
complain of severe pain in temporomandibular joint (TM
joint) after tonsillectomy on mouth opening. The reason
for this is prolonged mouth opening during the surgery
and use of mouth gag.11,12 It is well established fact that
prolonged mouth opening causes stress on the muscles
involved in mastication and the TM joint.13 After surgery,
patient feels pain in the pharyngeal region due to
removal of tonsillar tissue which is aggravated by the
pain in temporal region and TM joint.14 However, no data
was available about the severity of pain and trismus
after tonsillectomy.15

In this study, 40 patients above 10 years of age were

selected randomly and time duration of application of
mouth gag was compared with postoperative pain and
trismus. The result showed that severity of postoperative pain and trismus was higher with longer time
of application of mouth gag and vice versa. Furthermore,
it was observed that there was relationshiop between
duration of mouth gag with pain and trismus. Those
patients who complained of pain after prolonged
application of mouth gag also complained of trismus.
The analgesics used were the same for same period of
time. Patients below 10 years of age were not included
due to problems in obtaining results regarding pain
perception.16,17 These results may vary in different age
groups, gender and races due to variation in
development of muscles of mastication.18-19 Those with
different eating habits and type of diet may also
influence the development of muscles of mastication
and TM joint.21 Hydri tried to find out the long-term
effects of tonsillectomy on mouth opening in children,
which showed transient trismus in immediate
postoperative period with no permanent effects on
mouth opening.20 This study result is consistent with it.
At the end of surgery postoperative throat pain is the
most important concern for surgeon but sometimes pain
and trismus due to use of mouth gag is the biggest issue
faced by the patient. Hence the expertise evolved for

Journal of the College of Physicians and Surgeons Pakistan 2015, Vol. 25 (4): 268-270

269

Nasir Akram Kundi, Talat Mehmood and Omair Abid

minimizing the duration of mouth gag application is

essential to minimize the postoperative trismus and pain.

CONCLUSION

Duration of mouth gag application should be reduced to

cause less TM joint pain and trismus in early postoperative period in tonsillectomy.

REFERENCES

1. Hydri AS, Malik SM Post-tonsillectomy pain and bupivacaine,

an intra individual design study. J Coll Physicians Surg Pak
2010; 20:538-41.

2. Omrani M, Barati B, Omidifar N, Okhovvat AR, Hashemi SA.

Coblation versus traditional tonsillectomy: a double blind
randomized controlled trial. J Res Med Sci 2012; 17:45-50.

3. Subramanyam R, Varughese A, Willging JP, Sadhasivam S.

Future of pediatric tonsillectomy and perioperative outcomes.
Int J Pediatr Otorhinolaryngol 2013; 77:194-9.

4. Muninnobpamasa T, Khamproh K, Moungthong G. Prevalence

of tonsillectomy and adenoidectomy complication at
Phramongkutklao Hospital. J Med Assoc Thai 2012;
95:S69-74.

5. Tweedie DJ, Bajaj Y, Ifeacho SN, Jonas NE, Jephson CG,

Cochrane LA, et al. Peri-operative complications after
adenotonsillectomy in a UK paediatric tertiary referral centre.
Int J Pediatr Otorhinolaryngol 2012; 76:809-15. Epub 2012 Apr 1.

6. Maini S, Osborne JE, Fadl HM, Spyridakou C, Ogunyemi L, Hill

P.
Temporomandibular
joint
dysfunction
following
tonsillectomy. Clin Otolaryngol Allied Sci 2002; 27:57-60.

7. Fennessy BG, O'Connor R, Cronin M, Fenton JE, Hughes JP.

Safety implications of the Boyle-Davis mouth gag and tracheal
tube position in tonsillectomy. Br J Anaesth 2010; 105:863-6.
Epub 2010 Oct 6.

8. Shirley PJ, Kulkarni V, Frost N. A problem with the Boyle-Davis

gag following difficult intubation. Anaesthesia 1994; 49:551-2.

9. Heiba MH, Atef A, Mosleh M, Mohamed R, El-Hamamsy M.

Comparison of peritonsillar infiltration of tramadol and
lidocaine for the relief of post-tonsillectomy pain. J Laryngol
Otol 2012; 126:1138-41.

270

10. Paquette J, Le May S, Lachance Fiola J, Villeneuve E,

Lapointe A, Bourgault P. A randomized clinical trial of a nurse
telephone follow-up on paediatric tonsillectomy pain management and complications. J Adv Nurs 2013; 69:2054-65.

11. Vaiman M, Krakovski D, Haitov Z. Oxycodone and

dexamethasone for pain management after tonsillectomy: a
placebo-controlled EMG assessed clinical trial. Med Sci Monit
2011; 17:PI25-31.

12. Chacra ZA, Manoukian JJ, Al-Qahtani K, Al-Eisa M, Balys R,

Hagr A, et al. Hydrogen peroxide mouth rinse: an analgesic
post-tonsillectomy. J Otolaryngol 2005; 34:178-82.

13. Norinkavich KM, Howie G, Cariofiles P. Quality improvement

study of day surgery for tonsillectomy and adenoidectomy
patients. Pediatr Nurs 1995; 21:341-4.

14. Sutters KA, Levine JD, Dibble S, Savedra M, Miaskowski C.

Analgesic efficacy and safety of single-dose intramuscular
ketorolac for postoperative pain management in children
following tonsillectomy. Pain 1995; 61:145-53.

15. Subramanyam R, Varughese A, Willging JP, Sadhasivam S.

Future of pediatric tonsillectomy and perioperative outcomes.
Int J Pediatr Otorhinolaryngol 2013; 77:194-9.
16. Kocum AI, Sener M, Caliskan E, Bozdogan N, Micozkadioglu
D, Yilmaz I, et al. Intravenous paracetamol and dipyrone for
postoperative analgesia after day-case tonsillectomy in
children: a prospective, randomized, double blind, placebo
controlled study. Braz J Otorhinolaryngol 2013; 79:89-94.

17. Knuf M. Tonsillectomy and tonsillotomy: ENT surgeon and

pediatric viewpoints. HNO 2013; 61:173-86.

18. Khalili G, Sajedi P, Shafa A, Hosseini B, Seyyedyousefi H.

A randomized evaluation of intravenous dexamethasone
versus oral acetaminophen codeine in pediatric adenotonsillectomy: emergence agitation and analgesia. Middle East
J Anesthesiol 2012; 21:499-504.

19. Lescanne E, Chiron B, Constant I, Couloigner V, Fauroux B,

Hassani Y, et al. Pediatric tonsillectomy: clinical practice
guidelines. Eur Ann Otorhinolaryngol Head Neck Dis 2012;
129:264-71.

20. Hydri AS, Malik SM. Reduced mouth opening following

tonsillectomy in children: myth or reality. J Coll Physicians Surg
Pak 2010; 20:781-4.

Journal of the College of Physicians and Surgeons Pakistan 2015, Vol. 25 (4): 268-270