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PubMed2004

False positive fluorine-18 fluorodeoxy-D-glucose positron emission tomography finding caused by osteoradionecrosis in a nasopharyngeal carcinoma patient.

Nasopharyngeal carcinoma (NPC) is treated by radiotherapy with or without chemotherapy. It is not uncommon to find the residual/recurrent lesion in the skull base area. For patients who had received radiotherapy, it is difficult to differentiate the skull base tumour from post-treatment change in the CT or MRI. (18)F-2-fluoro-2-deoxyglucose (FDG) positron emission tomography (PET) provides an alternative diagnostic choice in this situation for head and neck cancer including NPC especially when there is inconclusive CT/MRI finding. This report of an NPC patient who received radiotherapy 18 months previously, describes the misdiagnosis of tumour recurrence at the skull base found in both MRI and FDG PET scan. Histopathological studies showed osteoradionecrosis of the debrided tissue and follow-up PET showed complete regression of the skull base lesion. Therefore, a false positive result in FDG PET caused by osteoradionecrosis was confirmed. To the best of our knowledge, this is the first case report in the literature.

Adult↗

PubMed1985

Osteoradionecrosis of the maxilla and skull base.

Osteoradionecrosis of the maxilla and base of skull are rare phenomena, usually seen after combined therapy for malignancies of the maxillary sinus. While the mandible is most commonly affected by osteoradionecrosis, the maxilla and skull base may also be affected when preoperative or postoperative radiotherapy is combined with surgery. Contributing factors may be: high radiation dosage delivered to the treatment volume (greater than 6000 rads), loss of tissue protective effects due to surgery, decreased vascularity caused by surgery and radiation, and proximity of a contaminated field. Onset of symptoms may vary. One patient presented 25 years after postoperative radiotherapy. Major symptoms were pain, trismus, and purulent discharge. The best diagnostic modality remains the history and physical exam, as the area is readily accessible. CT scans may be helpful in diagnosis and treatment planning. Therapy should follow time honored principles of local wound care. Home irrigations and hyperbaric therapy have been helpful in encouraging early sequestration and rapid healing.

Bone Diseases↗

PubMed1985

Prevention of osteoradionecrosis: a randomized prospective clinical trial of hyperbaric oxygen versus penicillin.

A prospective randomized trial comparing hyperbaric oxygen and systemic antibiotics in the prevention of osteoradionecrosis was presented. The results indicated, in a high-risk population who required tooth removal in irradiated mandibles, that up-front hyperbaric oxygen produced an incidence of osteoradionecrosis of 5.4% as compared with the antibiotic group of 29.9% (P = .005). Hyperbaric oxygen should be considered a prophylactic measure when post-irradiation dental care involving trauma to tissue is necessary.

Clinical Trials as Topic↗

PubMed2005

CSF otorrhea complicating temporal bone osteoradionecrosis in a patient with nasopharyngeal carcinoma.

A 44-year-old Chinese man with a history of nasopharyngeal carcinoma that was treated with radiotherapy presented with fluid in the middle ear. We performed a myringotomy and subsequently made a diagnosis of cerebrospinal fluid (CSF) leakage secondary to osteoradionecrosis of the temporal bone. To the best of our knowledge, this is only the second reported case of an otogenic CSF leak resulting from osteoradionecrosis of the temporal bone. This case highlights the controversial role of myringotomy in the management of CSF otorrhea.

Adult↗

PubMed2006

[Diagnosis and treatment on osteoradionecrosis of temporal bone in cases with nasopharyngeal carcinoma after radiotherapy].

OBJECTIVE: To discuss the diagnosis and treatment on osteoradionecrosis of temporal bone in case with nasopharyngeal carcinoma (NPC) after radiotherapy. METHOD: The clinical data of 21 cases (22 ears) diagnosed as osteoradionecrosis of temporal bone with NPC were studied, including 17 ears of localized type and 5 ears of diffuse type. Minimally surgical debridement with otoscope was performed on 17 ears of localized type and 1 ear of diffuse type. Four ears of diffuse type underwent the modified radical mastoidectomy and obliteration with vascularized fascia flaps. RESULT: The common clinical features were foul-smelling otorrhea and otalgia. Otoscopy revealed the exposed bone and bony sequestration in the external auditory canal with impacted keratotic debris, granulation tissue and cholesteatoma accumulation. It was with erosion or/and orifice to the mastoid. CT scan demonstrated the presentations: osteomyelitis, bone destruction as the islet-appearance and soft tissue mass. Among the 17 ears of localized type, 12 ears (70.6%) showed complete epithelization of the raw surface, 4 ears (23.5%) not fully epithelized were followed up without sequestration, and 1 ear (5.9%) was developing progressively. As for the 5 ears of diffuse type, 1 ear received the minimally surgical debridement and another 3 ears treated with mastoidectomy and obliteration were healed. Only 1 ear needed secondary surgery because of re-sequestration. CONCLUSION: Both otoscopy and CT scan can offer the diagnostic value with different characteristics. The minimally surgical debridement of the sequestration by otoscopy can obtain good effects on localized type. It should be careful to select the surgery recipient on the diffuse type, and mastoid obliteration with vascularized flaps from regional tissue may be warranted after mastoidectomy. Regular follow up is needed because of possibility of the progressive development of the disease.

Adult↗

PubMed1979

[Recent advances in the therapy of osteoradionecrosis of the maxillomandibular bones (author's transl)].

In spite of the considerable technical progress made over the last few years, no type of irradiation used at the present time for treating malignant tumors in the maxillofacial region can protect the patient from the always dreaded appearance of a secondary osteoradionecrosis of the maxillomandibular bones. Extablished osteoradionecrosis is not a "true" necrosis of these bones but a particularly severe osteitis which evolves in bone, which is pathological because it has been irradiated, and is surrounded by tissues which are also pathological for the same reason. Very high doses of antibiotics, comparable to those used in the treatment of osteomyelitis, mandibular resection by the endobuccal route, and the possibility of treating perimaxillomandibular tissues by reconstructive surgery, have completely transformed the prognosis of this dreaded affection, which is being increasingly prevented by daily fluoride applications applied locally.

Anti-Bacterial Agents↗

PubMed1987

[Limited mandibular osteoradionecrosis. Early conservative surgical treatment].

Nine patients with early phase mandibular osteoradionecrosis received conservative treatment involving closure with mucosal and periosteal graft. Early intervention and the limited nature of the osteoradionecrosis are the two fundamental elements for a successful outcome to this conservative therapy, thus avoiding progression to an extensive form requiring interruption mandibulectomy.

Adult↗

PubMed1979

[Bone reconstruction after resection of the mandible for osteoradionecrosis (author's transl)].

Resection of the sections of the mandibular affected by osteoradionecrosis has completely modified the progression and prognosis of this affection by ensuring that the patient does not have to suffer long periods of pain and suppuration, constantly observed when medical treatment is used alone. Unfortunately, these resections are usually extensive and are themselves responsible for functional and esthetic sequelae supported with difficulty by some patients, especially in the case of bilateral or mandibular arch resections. All efforts must be made, therefore, to limit the consequences, and with this in mind it is possible: -- to perform an uninterrupted resection limited to the alveolar area involved, in early cases of mandibular osteoradionecrosis; -- to reconstitute mandibular continuity with a bone graft in more advanced stages; -- to improve the esthetic appearance with skin and subcutaneous grafts whenever this is necessary. Good results can only be obtained if certain anatomical conditions exist and if surgical precautions are adapted to each case.

Adult↗

PubMed1979

Osteoradionecrosis of the temporal bone.

Six cases of osteoradionecrosis of the temporal bone are described. Persistent symptoms of otitis externa refractory to local treatment measures should alert the physician to the possibility of underlying osteoradionecrosis. Treatment of superficial parotidectomy and partial temporal bone resection with preservation of the facial nerve is indicated if local aggressive conservative measures fail to control the disease. Benign mixed tumors of the parotid gland should be treated surgically with avoidance of radiotherapy.

Adult↗

PubMed1984

[Osteoradionecrosis in adults].

Osteoradionecrosis (ORN) is not exceptional, despite advances in irradiation techniques. Six cases are reported, involving the pelvis, coxofemoral joint, mandible and vertebrae; in this last case, the semiologic value of the lucent intrasomatic image seen on plain films and tomographies of the vertebrae is underscored. The irradiation dose (above 3 000 rad) is the chief factor in osteoradionecrosis, which may be precipitated by adjuvant factors and potentiating events such as trauma and infection. Pathologic study shows several lesions whose association is suggestive: cell lesions, osteoporosis, vascular lesions, and foci of necrosis. The pathogenic significance of lesions of bone cells is demonstrated, while the part played by vascular lesions is controversial. Involvement of the pelvis and hips following irradiation of pelvic carcinoma is the most common. The scapular girdle and ribs may be involved in irradiation for breast cancer. In involvement of the mandible, remarkable features are its frequency following irradiation of carcinoma of the mouth, the significant part played by potentiating factors, i.e. infection and trauma, severity of complications, i.e. fistulae and hemorrhage, and lastly difficulties of management. Among infrequent sites, involvement of the vertebrae is of interest as it may mimic collapse due to osteoporosis or metastasis. Diagnosis rests on an association of criteria, and fortunately bone biopsy is usually unnecessary. The clinical features, topographical characteristics and course of the disease allow differentiation from bone metastasis; it may be more difficult to distinguish postirradiation sarcoma, which is exceptional, or a number of benign conditions, such as aseptic necrosis, infectious osteoarthritis, and destructive coxarthrosis.

Aged↗

PubMed1993

[The pathogenesis of osteoradionecrosis].

The microradiographic analysis of thick sections of fragments removed from irradiated patients suffering from osteoradionecrosis has made it possible to bring to the fore two types of bone resorption caused by cells: an osteoclastic one not followed by a relevant osteogenesis, and another, pathognomonic of postradic complications, linked with an altered activity of the osteocytes. Those cells, which have been affected, because of a progressive infection, are responsible for an irreversible widening of the osteoplasts, set in the properly vascularized bone regions, in particular in the wall of haversian canals. The coalescence of widened osteoplats causes polycylic cavities which is a typical feature of osteoradionecrosis. A third type of bone postradic damage consists in a massive demineralization, related to the presence of saliva or pus.

Adult↗

PubMed1993

Osteoradionecrosis of the temporal bone: treatment with hyperbaric oxygen therapy.

Radiation necrosis is a major complication of surgery or trauma in a previously irradiated field. Although it may occur in any location, the most common region affected is the head and neck. Osteoradionecrosis (ORN), the involvement of bone with radiation necrosis, occurs most frequently in the mandible, and has been well described. Involvement of the temporal bone, although less frequent, is nonetheless a difficult problem in management. Described herein is a case of ORN of the temporal bone treated with adjunctive hyperbaric oxygen therapy with complete resolution. This is followed by a discussion of the pathophysiology, presentation, and management of osteoradionecrosis of the temporal bone, including the role of adjunctive hyperbaric oxygen in the treatment regimen.

Adult↗

PubMed1997

Imaging of maxillary osteoradionecrosis.

Over a 3-year period, four cases of maxillary osteoradionecrosis were diagnosed in patients undergoing radiotherapy for nasopharyngeal carcinoma at the Queen Mary Hospital, Hong Kong, giving an estimated incidence of 0.8%. Patients with this complication presented after a mean period of 34 months post-radiotherapy. Risk factors that were identified were dental problems, and more than one full course of radical radiotherapy. Serial CT scans in the axial and coronal planes were useful in demonstrating the development, extent and features of maxillary osteoradionecrosis such as bony sclerosis, the destruction of maxillary antral walls and adjacent bony structures, and in excluding recurrent tumour.

Adult↗

PubMed1996

Risk factors and dose-effect relationship for osteoradionecrosis after hyperfractionated and conventionally fractionated radiotherapy for oral cancer.

A high frequency of osteoradionecrosis after hyperfractionated radiotherapy (RT) of head and neck tumours led to a detailed analysis of risk factors in the dental, surgical, and radiotherapeutic areas. 168 patients with oral cancer were analysed retrospectively. 19% of them had been irradiated primarily and 81% postoperatively. 116 patients received a total dose mostly ranging from 60 Gy to 70 Gy to the ICRU 29 reference point (daily single dose 2 Gy). 52 patients were treated hyperfractionally with two daily fractions of 1.2 Gy per day, 4 h minimum apart and a total dose 82.8 Gy. Dental findings could be evaluated in 126 patients. Factors were checked for prognostic significance for osteoradionecrosis (ORN). Dose dependency was computed using a PROBIT analysis. Dental status before radiotherapy was generally poor (mean 11/32 teeth present, of these 1 was dead, 2.4 carious, 2.4 loose, 0.3 destroyed). On average, six teeth (range 0-27 teeth) had to be extracted. In one-third of the patients bone surgery was necessary. ORN occurred in 8.6% of the patients treated conventionally but in 22.9% of those treated hyperfractionally (p = 0.029). Biologically effective dose (p = 0.032) and deep paradontitis (p = 0.034) proved to be significant risk factors for ORN. PROBIT analysis showed a steadily rising dose dependency of the ORN frequency after conventional radiotherapy. Using total doses up to 70 Gy the frequency of ORN was 8.6%. Dose escalation using hyperfractionation led to an intolerable ORN frequency (22.9%) where a short interfraction interval was a significant factor. The use of this dose fractionation was therefore discontinued in 1992.

Dose-Response Relationship, Radiation↗

PubMed2000

Radiation effects on osteoblasts in vitro: a potential role in osteoradionecrosis.

OBJECTIVE: To evaluate the factors involved in bone remodeling and wound healing that may be altered by radiation therapy. DESIGN: A prospective, controlled study of biochemical activity in vitro. SUBJECTS: MC3T3-E1 mouse osteoblasts. INTERVENTIONS: Cells were irradiated at 0, 2, 4, or 6 Gy. Specimens were harvested at 1, 7, 14, 28, and 42 days following irradiation for immunohistochemical analysis of transforming growth factor beta(1) expression and transforming growth factor beta(1) type I and II receptor expression. Collagen production was measured at 1, 7, 28, 35, and 49 days after irradiation. The effects of dexamethasone on collagen production and cell proliferation were also examined. RESULTS: Irradiated cells demonstrated decreased cell proliferation and a dose-dependent, sustained reduction in collagen production when compared with control cells. An increase in transforming growth factor beta(1) type I and II receptor expression was noted in irradiated cells when compared with controls. CONCLUSION: Radiation-induced alterations of factors related to bone remodeling and wound healing have a potential role in the pathogenesis of osteoradionecrosis.

Animals↗

PubMed2003

Influence of prior hyperbaric oxygen therapy in complications following microvascular reconstruction for advanced osteoradionecrosis.

OBJECTIVE: To review surgical outcomes in the management of advanced mandibular osteoradionecrosis (ORN) with aggressive debridement and microvascular reconstruction. DESIGN: Retrospective cohort study. SETTING: Tertiary care referral center. PATIENTS: Thirty patients with Marx stage III ORN of the mandible who underwent debridement with microvascular reconstruction. Two types of patients with stage III disease were included: those who had not received prior hyperbaric oxygen (HBO) therapy but who presented with a pathologic fracture, orocutaneous fistula, or bony resorption of the inferior border of the mandible (group 1, n = 9), and those who were classified as having stage III disease as a result of failure of previous debridement and HBO therapy (group 2, n = 21). MAIN OUTCOME MEASURE: Clinical resolution of ORN as well as surgical perioperative complications. INTERVENTIONS: Debridement and primary free flap reconstruction in all patients; Perioperative HBO therapy in 3 patients. RESULTS: The overall complication rate was 43%, but 29 (97%) of 30 patients had clinical resolution of their ORN. There were no flap failures. After smoking status and use of perioperative HBO were adjusted for, patients with Marx stage III disease who had received prior HBO therapy (group 2) were significantly more likely to have postoperative wound infection (P =.01) and overall surgical complications (P =.04) than were patients with stage III disease who had never been treated with HBO (group 1). Perioperative HBO therapy was provided too infrequently to comment on its effectiveness. CONCLUSIONS: Microvascular reconstruction is effective in the treatment of patients with mandibular ORN. Management of mandibular ORN can be successfully achieved without the use of perioperative HBO therapy. Because only 3 patients received perioperative HBO therapy, we are unable to comment on its potential benefit. Patients in whom prior HBO therapy has failed are significantly more likely to have surgical complications than are other patients with Marx stage III disease, and further study is required to improve outcomes in this subgroup of patients.

Aged↗

PubMed1975

Osteoradionecrosis of the mandible. Treatment with hyperbaric oxygen.

Hyperbaric oxygen used in the treatment of 14 patients with intractable osteonecrosis of the mandible produced a favorable response in relief of pain, elimination of extraoral draining sinus tracts, the return of osseous union in areas of the abnormal fracture, and the rapid dissolution of sequestrum without suppuration, so that further loss of hard and soft tissue was minimized. This treatment is a more conservative approach in the management of osteoradionecrosis.

Adult↗

PubMed1998

A modified protocol for early treatment of osteomyelitis and osteoradionecrosis of the mandible.

BACKGROUND: The treatment of osteoradionecrosis (ORN) and early chronic osteomyelitis (COM) of the mandible and maxilla is controversial. Hyperbaric oxygen (HBO) at two to three times the atmospheric pressure at sea level can result in tissue oxygen tension of almost 400 mmHg. Herewith HBO increases oxygen supply in hypoxic tissue, thus inducing fibroblastic proliferation and capillary formation. METHODS: From 1981 to 1991, we used a monoplace chamber and since 1992, we have also had a multiplace chamber for HBO treatment. Hyperbaric oxygen was given at 2.5-2.8 atmosphere absolute pressure (ATA) for 90-120 minutes, once per day. The patients had five to 10 preoperative and five to seven postoperative sessions. Surgical therapy consisted of decortication of the affected bone, subsequently covered with a free periosteal transplant from the tibia. RESULTS: Thirty-six patients with ORN and 33 with COM of the mandible and maxilla was treated with this protocol. The median follow-up time in this material is 34 months, with a minimum of 10 months. Thirty-six ORN patients (92%) and 26 COM patients (79%) have remained symptom-free after the first treatment period. Three failed ORN patients were successfully treated with a free microvascular flap. The seven failed COM patients have been retreated, and five of them have occasional clinical symptoms. CONCLUSIONS: Hyperbaric oxygen is a promising adjunct to surgery in the treatment of mandibular and maxillary ORN and COM. Using this protocol, the necessary HBO treatment sessions have been reduced from earlier protocols, without adverse effect on the outcome.

Adolescent↗