Tongue crushing trismus following brainstem stroke

• Trismus as a sequel of brainstem strokes can lead to severe oromandibular dysfunction posing challenges with oral care and tongue injuries. • Focal chemo denervation with Botulinum Toxin could be preferred pharmacological option for trismus. • Early identification of lock jaw and prompt treatment with Botulinum toxin can prevent trismus related complications. 38-year-old female presented to emergency with history of dizziness followed by loss of consciousness. She was intubated in ED due to low GCS E3 M4 V1 and admitted to neuro intensive care unit. MRI Brain showed left and right pontine paramedian and right cerebellar infarcts. On day 7 after tracheostomy tube placement, trial of weaning was started and tongue bites were noted with difficulty to open the mouth due to masseter tightness. The tongue is crushed between the upper and lower teeth. She had a swollen left side of the tongue with a large laceration and slough formation suggestive of a severe tongue injury. Oral baclofen trial failed, and she needed sedation for muscle relaxation and prevention of tongue injury. Botulinum toxin was injected in the masseter (50 units per side) and temporalis (25 units per side) bilaterally. There was minimal improvement (5 mm) at two weeks, with intermittent tongue bites requiring a mouth gag and sedation. Due to intermittent severe trismus persisting into the 3rd week, she underwent dental extraction of the upper incisors to prevent further tongue damage. At about 60 days, interincisal distance improved satisfactory, she was then able to open and close her mouth voluntarily, allowing adequate oral care. Trismus resulting in functional impairment should receive prompt treatment with Botulinum toxin to the oromandibular muscles for prevention of complications.