This is a 35-year-old male patient today with a dual activity: a lonely button in a synphonic orchestra and teaching in two companies as a tumbling teacher.
Apparently it begins with symptoms, lip discomfort, difficulty issuing high notes and early fatigue at the end of 2009.
It extends part of AT 24.08.2010 as a lonely orchestra with the following description: "there has been lip contracture".
It is unclear whether at that date there was an acute event in relation to their work in the orchestra or a worsening of something previous, nor is it clear why the share of OA extends in this particular company.
Establishment of a period of sick leave of 24.8.10 to 2.8.11 for "other specific muscle disorders", apparently discharge went to the situation of exceedance in the orchestrategy for teaching and learning
He was treated by many specialists both in Spain and abroad, and especially in the Instituto de Fisiología y Medicina del Arte de Tarrasa, a curious institution dedicated to the treatment of specific lesions of the skin.
The first available report of this institute arrives at the diagnosis of "elongation of the orbicularis oris muscle" and recommends rest of the instrument, physical reconditioning, electrostimulation and progressive increments of the practice.
Successive reports show improvement, in March 2011 it is said that it has reached 120 minutes a day.
In July 2011 it is said that he still has discomfort, perceives a fibrous cord on the lip that by ultrasound corresponds to thickening with slight thickening to the orbicularis.
In any case it was high and exceeded.
During it she has several activities, mostly teaching.
1.9.13 is reincorporated to the orchestra and 3.9.13 extends a new part of TA and starts a new loss.
On day 4.10.13 is discharged by Report Proposal and his Mutua proposes Total IP.
A new report by the Instituto del Arte is available, stating that ultrasound still shows a 4 mm scar on the upper lip and that its situation is incompatible with its work and that "we do not know" other possible treatments that can be applied.
He had been seen by a maxillofacial surgeon who prescribed discharge splint for bruxism.
He was also seen by an eminent and mediatic plastic surgeon who advised against the surgical option.
His Mutua understands that the process is completed and that it is impossible for him to keep the button bulging for more than 1 hour and proposes IP, which can be reviewed in 18 months because he says that the pathology rest is susceptible to improvement.
1.
Description of the syndrome
The syndrome was first described in a communication by Dr. Planas in 19821.
Although it is not an uncommon condition in the musicians who play metal wind instruments, to date the anatomical substrate of the pathology had not been described, nor had it been named.
In 1935, Louis Amstromg, who was told that he suffered an injury, right to stop.
In spite of the relative frequency of the pathology, there is little search in literature, a search in PudMed or databases of the terms: rupture orbicularis oris oris or similar results, barely gives rise to:
Probably because it affects a small group, I would say special, so the lack of knowledge of the pathology is great even in specialists in the specific area: ENT, maxillofacial.
In fact, Dr. Planas is a plastic surgeon.
I'll start with a brief functional anatomical memory.
Within wind instruments, a special subgroup is metal instruments.
In these, the sound occurs after the musician adapts his lips to the shape of the instrument's mouthpiece hermetically amplified and vibrating the same inside the mouthpiece itself is then produced.
In others, such as wood, the sound produces the vibration produced in a wooden tongue that is in the mouthpiece when blowing through it, but in the metal encounters it is the vibration of the lips.
This process of adaptation of the mouth to the mouthpiece of the instrument is known as wrapping and critical in these instruments.
It affects both the lips, their shape, the ability to contract the orbicularis, and the teeth behind and produce support.
The pressure exerted on one side by the column of air generated against the lips that should only fail to pass a minimum amount, while vibrating and pressing with force against the metal long mouthpiece notes is very important.
And in addition, these combined forces should not only end up producing a sound (this may be within reach of all), but must produce a fine sound of different tones and nuances as well as intensities.
The key to the whole process (nothing better said) is a muscle called that its thickness at rest is 1 mm and 3 contracted and that has no bone insertions.
As in any other muscle that breaks, the area is repaired by a scar, i.e. a non-muscle tissue. This, in addition to discomfort (the edge of the mouthpiece, some small galling muscles are supported).
In the first description of Dr. Planas, he was a professional musician who, after an acute episode, had pain, fatigue and difficulty with high notes.
His father also had to leave the profession for similar symptoms.
Dr. Planas conducts a surgical exploration of the lip, in this superior case, and finds an orbicular rupture whose ends were joined by fibrous material and posterior fibers were elongated.
He removed the fibrous area and joined it with stitches, and after some time with them the musician continued to touch as before.
The publication in the form of a letter to the director provoked an answer from a US surgeon who would felicit him, but, above all, raised his value, because making an incision in the lip of a trompetist would never have made.
Dr. Planas published a second case in 1988, also operated and successful3.
This produced two responses from one professional physician4 and one from the same previous American surgeon.
In principle, it may seem surprising that an answer from a professional, non-medical musician is published in a medical journal of Plastic Surgery. However, the most extensive and perhaps the main web page, including the Luuch Rehabilitation.
In addition, it is not only about writing on the subject, but it seems that it diagnoses and places rehabilitation treatment guidelines, as well as provides special adaptors to the mouthwash.
It is possible that it is the world's top authority in the pathology of windmills.
There is also a 1996 publication of a series of 10 ruptures of the orbicularis muscle, 9 successfully operated.
As we can see, almost all publications are related to surgical correction of the syndrome.
Despite this and bearing in mind that there is little published in scientific journals, it seems that specific specialists (including Lucinda Lewis), in lighter publications, do not consider removing a more conservative electrosurgical bougie for longer periods).
It is also said that if the situation of the musician advocates leaving the career, surgery could be the only way out.
The publications do not mention diagnostic criteria more than the presentation of symptoms in a mass of this type and two possible complementary tests: electromyogram (EMG) to rule out nerve injury and rupture or ultrasound to try an objective area.
The photos of the two cases of Dr. Planas, before and after the surgery, (and the articles) are available on the website: www.clinicaplanas.com The simple contemplation of the photospecialization).
1.
Discussion and Assessment
It is a classic in evaluative medicine, which when you want to put an example of the balance between limitations and professional requirements, in such a way as to place a lower level of work in the left hand that can lead to a very specific handicap.
However, this case, which fits almost the millimeter with the classic example, is real.
As an example, it also allows us to reflect on many of the conflicting points of any evaluation, in some way, I think it leads the evaluation process to its limits.
1.
Diagnosis
With respect to the pathology itself, it is not well known, or of course frequent, as it occurs with many specific pathologies of professional musicians.
As I said before, I have not found a description of the requirements for diagnosis beyond typical symptoms.
Regarding complementary tests, EMG is cited to rule out neurological involvement and ultrasound would identify the rupture zone (if there is a significant rupture, it is not clear whether an ultrasound in this muscle can detect a micro-longation).
This is not very different from other muscle diseases in very demanding physical activities such as athletes.
It is a common experience in the sports press, especially soccer, that a soccer player has symptoms of increased local irritation of the hematoma. It does not seem to have a long muscle and, above all, there is a decrease in the number of contractions.
In any case the treatment is similar: rest, anti-inflammatory measures, correction of the technique and mouthpiece and physical therapy or physical therapy with better prognosis if no break is identified.
The ruptures that are very fragile in a sport repair with a scar that is not tissue with quality of the muscle and ruptures or repeated or large can greatly deteriorate the muscle and limit or prevent its intense use, for example.
Sitting. something similar should occur in the orbicularis oris of the lips in windmusics, with the particularity that the muscle is a few centimeters and that more than power (e.g.
In this case it worsens or hinders the diagnosis that the injury of this small muscle is not frequent in the usual clinical settings and requires even specific specialists.
1.
Corresponding address: Francisco Maneiro Hiera Calle Luis Hoyo Sainz n.o 4 4.o 39001 Santander.
Spain E-mail: francisco.maneiro@seg-social.es
Recall: 21-10-14 Accepted: 03-11-14
