Radiation-induced middle ear and mastoid opacification in skull base tumors treated with radiotherapy

Post-radiation middle ear effusion in NPC patients: Analysis of patient, tumour, and radiation factors

OBJECTIVE

The purpose of this study was to investigate whether patient, tumour and radiation therapy factors are associated with development of middle ear effusion (MEE) in nasopharyngeal carcinoma (NPC) patients.

DEIGN, SETTINGS, AND PARTICIPANTS

A retrospective review of NPC patients treated between January 2000 and June 2018 at Rabin Medical Center. Patient factors, tumour factors, radiation doses, and radiation fields were collected and outlined if needed (middle ear, eustachian tube [ET], tensor veli palatini [TVP], and levator palatini [LVP] muscles), then analysed and compared between patients with MEE and those without and between sides in patients with unilateral MEE.

MAIN OUTCOME MEASURES AND RESULTS

Seventy-three patients were enrolled. Most were males (71.2%) with advanced-stage diseases (78%). At the time of diagnosis 14 patients (19.2%) presented with MEE. Following radiation, 18 patients, with no evidence of MEE at presentation, developed MEE. Tumour stage, histology, and laterality were not associated with development of MEE. Comparison of mean radiation field dosages including-gross target volume, clinical target volume, and patient target volume showed no association with post-radiation MEE. In addition, no difference was found in the radiation doses to the middle ear, ET or the LVP nor the TVP between ears with and without MEE.

CONCLUSIONS

Post-irradiation MEE remains a common adverse effect in NPC patients. Surprisingly, tumour stage, tumour laterality, and histology were not associated with MEE. Similar findings were observed for total radiation doses and specific doses to the middle ear, ET, and ET muscles.

Cochlear Implantation in Radiation-Induced Hearing Loss: A Systematic Review

OBJECTIVE

Cochlear implantation (CI) has been reported as a treatment modality for radiation-induced sensorineural hearing loss (SNHL). However, its efficacy is based on individual reports with no cumulative supporting evidence. Therefore, we conducted the current systematic review to provide cumulative evidence regarding the feasibility and safety of CI in this context.

DATABASES REVIEWED

An online bibliographic search was conducted in PubMed, ProQuest, Scopus, Google Scholar, and Web of Science using MeSH-based terms.

METHODS

A systematic review was conducted to retrieve both observational and interventional studies that reported the outcomes of CI for patients suffering from radiation-induced SNHL.

RESULTS

We included 12 studies that recruited 88 patients who underwent CI because of radiation-induced SNHL. All included studies reported satisfactory hearing/speech perception outcomes. No serious complications were reported, whereas some manageable adverse events were reported, such as paroxysmal facial spams (n = 1), postauricular wound dehiscence with mastoid cutaneous fistula (n = 1), dehiscence in blind sac closure (n = 1), and electrode exposure (n = 1). Four studies assessed the postoperative quality of life/patient satisfaction, showing improved outcomes.

CONCLUSION

CI could be considered to be feasible and safe in patients with irradiation-induced SNHL. The adverse events of CI in such cases are manageable. Future studies are needed to be strengthened this context.

Hearing Loss Risk in Pediatric Patients Treated with Cranial Irradiation and Cisplatin-Based Chemotherapy

PURPOSE

Cranial radiation therapy (RT) and cisplatin-based chemotherapy are essential to treating many pediatric cancers but cause significant ototoxicity. The objective of this study is to determine the relationship between the RT dose and the risk of subsequent hearing loss in pediatric patients treated with cisplatin.

METHODS AND MATERIALS

This retrospective study of cisplatin-treated pediatric patients examined ototoxicity from cranial RT. Ototoxicity was graded for each ear according to the International Society of Pediatric Oncology (SIOP) consensus ototoxicity scale. The RT dose to the cochlea was calculated using the mean, median, maximum, and minimum dose received to determine the most predictive parameter for hearing loss. Multivariable logistic regression models then examined risk factors for hearing loss.

RESULTS

In 96 children (161 ears) treated with RT + cisplatin, the minimum cochlear RT dose was most predictive of hearing loss. A higher cochlear RT dose was associated with increased hearing loss (odds ratio per 10 Gy dose increase = 1.64; P = .043), with an added risk in those receiving an autologous bone marrow transplantation (hazard ratio = 10.47; P < .001).

CONCLUSIONS

This research supports further testing of the minimum cochlear RT dose as a more predictive dose parameter for risk of ototoxicity. The cochlear RT dose was additive to the risk of hearing loss from underlying cisplatin-based chemotherapy. Exposure to autologous bone marrow transplantation was the strongest predictor of developing hearing loss, placing these children at particularly high risk for hearing loss across all cochlear doses. Future prospective studies are crucial to further inform RT dose thresholds and minimize the risk of hearing loss in childhood cancer survivors.

Hearing and Other Neurologic Problems

Ototoxicity and other neurologic toxicities are potential consequences of exposure to common therapeutic agents used during treatment of childhood cancer, including platinum and vinca alkaloid chemotherapy, cranial radiation, surgery involving structures critical to cochlear and neurologic function, and supportive care medications such as aminoglycoside antibiotics and loop diuretics. This article provides an overview of ototoxicity and other neurologic toxicities related to childhood cancer treatment, discusses the challenges that these toxicities may pose for survivors, and presents an overview of current recommendations for surveillance and clinical management of these potentially life-altering toxicities in survivors of childhood cancers.

Adverse Events of Concurrent Radiotherapy and ALK Inhibitors for Brain Metastases of ALK-Rearranged Lung Adenocarcinoma

BACKGROUND

We investigated acute adverse events in patients with brain metastases (BMs) of anaplastic lymphoma kinase-rearranged (ALKr) non-small cell lung cancer (NSCLC) treated with both cranial radiotherapy and tyrosine kinase inhibitors (TKIs) of ALK.

PATIENTS AND METHODS

Acute AEs were retrospectively investigated in patients with BMs of ALKr-NSCLC who received both whole-brain radiotherapy (WBRT) and ALK-TKI. For comparison, they were also assessed in patients with epidermal growth factor receptor (EGFR)-mutated NSCLC and wild-type with neither ALK rearrangement nor EGFR mutation treated with WBRT.

RESULTS

Two ALKr cases were consequently eligible. Grade 3 otitis media unexpectedly occurred in both cases, while there was one case out of 11 and one case out of 18 of grade 2 otitis media among the EGFR-mutated cases and wild-type cases (p=0.013), respectively.

CONCLUSION

Concurrent treatment with WBRT and ALK-TKI may be associated with acute severe ear toxicity in patients with BMs of ALKr-NSCLC.

The prevalence of pneumatized articular eminence in the temporal bone. Do we need a high resolution computed tomography-based novel risk classification for eminectomy?

INTRODUCTION

Besides mastoid air filled cells, pneumatizations (PN) occasionally occur in the articular eminence (AE) of the temporomandibular joint (TMJ). These findings represent no pathological character but may increase the risk of perforating the AE during eminectomy with potential harming the skull base. Various classifications catagorize the degree of temporal PN without focussing solely on the AE. Panoramic radiograph (PR) and computed tomographie (CT) are both described as suitable for diagnosing PNs. Are the common ways of imaging capable for precise diagnosis and do we need a risk pattern for eminectomy?

METHODS

A 4-year retrospective study evaluated high resolution computed tomographie (HRCTs) of 300 patients. We screened digitalized skull images for PN of the AE. The frankfort horizontal was determined as the reference mark for measurements. Images were assessed by a craniomaxillofacial surgeon and a radiologist.

RESULTS

300 patients (600 AEs) were investigated. We detected 60 PNs (10% of all AEs) in 44 patients (14.7%). We subdevided the findings according to the extent of PN. 10 AEs showed PNs of less than 20% (type 1); n=18: 21-40% (type 2); n=18: 41-70% (type 3). n=14: 71 to 100% (type 4). In 32 cases (72.7%) with 42 PNs a PR existed. Of the 42 AEs, corresponding PN could be detected in 21 cases (50%).

DISCUSSION

PNs are a potential threat when performing TMJ surgery. Sufficient preoperative imaging is required to avoid severe endangerment for the patient. CT imaging is most suitable detecting PNs. PR seem to fail in diagnosing PNs of different degree. Our novel HRCT-based classification shows the distribution of PNs and provides a risk pattern.

CONCLUSION

HRCT exceeds the diagnostic accuracy of PR in detecting pneumatized AEs. PR is not capable for detecting PNs of different degree. A novel classification may increase the prediction of perforation risk. Restricting eminectomy to reduce height only to a certain amount reduces the risk of complications.

Chemoradiation-induced hearing loss remains a major concern for head and neck cancer patients

OBJECTIVE

Review of the literature regarding hearing loss in patients with head and neck cancer treated with chemoradiation.

DESIGN

Studies in the literature are reviewed that pertain to hearing loss sustained in head and neck cancer patients receiving cisplatin-based chemoradiation. Personal observations noted while treating these patients are also detailed.

STUDY SAMPLE

PubMed was searched for pertinent articles regarding hearing loss in head and neck cancer patients receiving cisplatin chemotherapy and/or radiation.

RESULTS

Studies on the incidence and severity of hearing loss in head and neck cancer patients are limited, but those studies suggest that the risk of hearing loss is greater with higher-dose regimens.

CONCLUSIONS

Newer cisplatin chemotherapy regimens using lower, weekly doses may be associated with a lower incidence and severity of hearing loss; however, large prospective studies are needed. Such information will be paramount to effective pre-treatment counselling of head and neck cancer patients.

Effects of radiation on the temporal bone in patients with head and neck cancer

Radiotherapy is a key component in the treatment of many head and neck cancers, and its potential to cause long-term adverse effects has become increasingly recognized. In this review, we describe the short-term and long-term sequelae of radiation-associated changes in and injury to the temporal bone and its related structures. The pathophysiology of radiation-induced injury and its clinical entities, including sensorineural hearing loss, chronic otitis media, osteoradionecrosis, and radiation-associated malignancies, are described. We also discuss radiation dose to the head and neck as it relates to these conditions. An improved understanding of radiation's effects on the temporal bone will enable physicians and researchers to continue efforts to reduce radiotherapy-related sequelae and guide clinicians in diagnosing and treating the various otologic conditions that can arise in patients with head and neck cancer who have received radiotherapy. © 2016 Wiley Periodicals, Inc. Head Neck 38: 1428-1435, 2016.

Predictors of Mastoiditis after Intensity-Modulated Radiotherapy in Nasopharyngeal Carcinoma: A Dose-Volume Analysis

Background: To identify predictors for development of mastoiditis after intensity-modulated radiation therapy (IMRT) in nasopharyngeal carcinoma (NPC).

Methods: Data for 146 NPC patients treated with IMRT was retrospectively reviewed under institutional ethics committee approval. Clinical factors associated with mastoiditis were analyzed. Dose-volume histogram analysis was performed for the Eustachian tube, tympanic cavity, mastoid air cells, cochlea, internal auditory canal and vestibular apparatus to relate doses to radiographic changes in the mastoid. Mastoiditis was assessed using magnetic resonance imaging and was classified as Grade 0 (none), 1 (mild), 2 (moderate) or 3 (severe); Grade 3 mastoiditis was the study end-point.

Results: Eighty-eight ears (36%) had radiation-induced mastoiditis: 38/244 (15.6%) mastoid complexes had Grade 1-2 mastoiditis and 50/244 (20.5%) mastoid complexes had Grade 3 mastoiditis. Multivariate analysis revealed a mastoid mean dose > 35.93 Gy (odds ratio [OR]=4.22, P=.003), Eustachian tube mean dose > 53.43 Gy (OR=2.16, P=.034) and advanced T category (T3 and T4; OR=10.33, P=.032) were negative prognostic factors for Grade 3 mastoiditis.

Conclusions: Radiation-induced mastoiditis remains a common late toxicity in NPC after radiotherapy. The mean dose to the mastoid air cells and Eustachian tube should be limited to reduce the risk of radiation-induced mastoiditis.

Ototoxicity and cancer therapy

Ototoxicity is a well-established toxicity associated with a subgroup of antineoplastic therapies that includes platinum chemotherapy, radiation or surgery involving the ear and auditory nerve, and supportive care agents such as aminoglycoside antibiotics and loop diuretics. The reported prevalence of ototoxicity in patients who have received potentially ototoxic therapy ranges from 4% to 90% depending on factors such as age of the patient population, agent(s) used, cumulative dose, and administration techniques. The impact of ototoxicity on subsequent health-related and psychosocial outcomes in these patients can be substantial, and the burden of morbidity related to ototoxic agents is particularly high in very young children. Considerable interindividual variability in the prevalence and severity of ototoxicity has been observed among patients receiving similar treatment, suggesting genetic susceptibility as a risk factor. The development and testing of otoprotective agents is ongoing; however, to the author's knowledge, no US Food and Drug Administration-approved otoprotectants are currently available. Prospective monitoring for ototoxicity allows for comparison of auditory outcomes across clinical trials, as well as for early detection, potential alterations in therapy, and auditory intervention and rehabilitation to ameliorate the adverse consequences of hearing loss. Cancer 2016;122:1647-58. © 2016 American Cancer Society.

Dose-volume factors associated with ear disorders following intensity modulated radiotherapy in nasopharyngeal carcinoma

This study is to identify significant dosimetric parameters for ear disorders in nasopharyngeal carcinoma (NPC) patients treated with intensity modulated therapy only. Ninety-seven patients with NPC were retrospectively reviewed. Organs at risk (OARs) in the auditory apparatus were contoured. Dose-volume histogram parameters were generated for the Eustachian tube (ET), tympanic cavity (TC), mastoid air cells, vestibular apparatus, cochlea and internal auditory canal (IAC). Ear disorders were rated 0 (none), 1 (mild) or 2 (severe) by a clinician blinded to radiation doses; Grade 2 ear disorders was the study end-point. Multivariate analysis revealed ET.D30 (dose to 30% of ET volume) >52.75 Gy and M.D0.5CC (dose to 0.5 ml of mastoid volume) >41.04 Gy (OR = 3.77, P = 0.012 and OR = 1.27, P = 0.033, respectively) were associated with Grade 2 ear disorders. Our results demonstrated that post-irradiation ear disorders remain a common late toxicity in NPC after IMRT. ET.D30 and M.D0.5CC should be considered during IMRT treatment plan optimization, review and approval.

Incidence of and Risk Factors for Mastoiditis after Intensity Modulated Radiotherapy in Nasopharyngeal Carcinoma

PURPOSE

To report the incidence of and risk factors for mastoiditis after intensity-modulated radiotherapy (IMRT) in nasopharyngeal carcinoma (NPC).

PATIENTS AND METHODS

Retrospective analysis of pretreatment and follow-up magnetic resonance imaging (MRI) data for 451 patients with NPC treated with IMRT at a single institution. The diagnosis of mastoiditis was based on MRI; otomastoid opacification was rated as Grade 0 (none), 1 (mild), 2 (moderate) or 3 (severe) by radiologists blinded to clinical outcome. This study mainly focused on severe mastoiditis; patients were divided into three groups: the G0M (Grade 0 mastoiditis before treatment) group, G1-2M (Grade 1 to 2 mastoiditis before treatment) group and G3M (Grade 3 mastoiditis before treatment) group. The software SAS9.3 program was used to analyze the data.

RESULTS

For the entire cohort, the incidence of Grade 3 mastoiditis was 20% before treatment and 31%, 19% and 17% at 3, 12 and 24 months after radiotherapy, respectively. In the G0M group, the incidence of severe mastoiditis was 0% before treatment and 23%, 15% and 13% at 3, 12 and 24 months after radiotherapy, respectively. Multivariate analysis revealed T category (OR=0.68, 95% CI = 0.469 to 0.984), time (OR=0.668, 95% CI = 0.59 to 0.757) and chemotherapy (OR=0.598, 95% CI = 0.343 to 0.934) were independent factors associated with severe mastoiditis in the G0M group after treatment.

CONCLUSIONS

Mastoiditis, as diagnosed by MRI, occurs as a progressive process that regresses and resolves over time in patients with NPC treated using IMRT.