Conservative management of osteoradionecrosis

Oral Surgery and Osteoradionecrosis in Patients Undergoing Head and Neck Radiation Therapy: An Update of the Current Literature

Osteoradionecrosis (ORN) is a serious long-term complication of head and neck radiotherapy (RT), which is often triggered by dental extractions. It results from avascular aseptic necrosis due to irradiated bone damage. ORN is challenging to treat and can lead to severe complications. Furthermore, ORN causes pain and distress, significantly reducing the patient's quality of life. There is currently no established preventive strategy. This narrative review aims to provide an update for the clinicians on the risk of ORN associated with oral surgery in head and neck RT patients, with a focus on the timing suitable for the oral surgery and possible ORN preventive treatments. An electronic search of articles was performed by consulting the PubMed database. Intervention and observational studies were included. A multidisciplinary approach to the patient is highly recommended to mitigate the risk of RT complications. A dental visit before commencing RT is highly advised to minimize the need for future dental extractions after irradiation, and thus the risk of ORN. Post-RT preventive strategies, in case of dento-alveolar surgery, have been proposed and include antibiotics, hyperbaric oxygen (HBO), and the combined use of pentoxifylline and tocopherol ("PENTO protocol"), but currently there is a lack of established standards of care. Some limitations in the use of HBO involve the low availability of HBO facilities, its high costs, and specific clinical contraindications; the PENTO protocol, on the other hand, although promising, lacks clinical trials to support its efficacy. Due to the enduring risk of ORN, removable prostheses are preferable to dental implants in these patients, as there is no consensus on the appropriate timing for their safe placement. Overall, established standards of care and high-quality evidence are lacking concerning both preventive strategies for ORN as well as the timing of the dental surgery. There is an urgent need to improve research for more efficacious clinical decision making.

Evaluation of Anterolateral Thigh Fascia Lata Rescue Flap for Mandibular Osteoradionecrosis

Importance

Mandibular osteoradionecrosis (ORN) is a progressive disease that can be difficult to treat. Conservative measures often fail, while conventional definitive management requires a morbid segmental resection with osteocutaneous reconstruction. Evidence of the anterolateral thigh fascia lata (ALTFL) rescue flap technique's safety, effectiveness, and long-term outcomes is needed.

Objective

To determine the long-term outcomes of the ALTFL rescue flap procedure for treating patients with mandibular ORN.

Design, Settings, and Participants

This was a retrospective medical record review performed at a single tertiary-level academic health care institution with patients who were appropriate candidates for the ALTFL procedure to treat mandibular ORN from March 3, 2011, to December 31, 2022. Data analyses were performed from January 1 to March 26, 2023.

Main Outcomes and Measures

Patient characteristics, preoperative radiographic Notani staging, intraoperative defect size, length of stay, complication rates, and clinical and radiographic findings of progression-free intervals.

Results

The study population of 43 patients (mean [SD] age, 66.1 [47-80] years; 24 [55.8%] male individuals) included 52 cases of mandibular ORN. The preoperative Notani staging of the study population was known for 46 of the 52 total cases: 11 cases (23.9%) were stage I; 21 (45.7%), stage II; and 14 (30.4%), stage III. The mean defect area was 20.9 cm2. Successful arrest of ORN disease progression was noted in the clinical and radiographic findings of 50 of the 52 (96.2%) cases, with only 2 (3.8%) cases subsequently requiring fibular free flap reconstruction. The major complication rate was 1.9% (1 case). Clinical and radiographic progression-free intervals were assessed, and no statistically significant differences were noted between Notani staging groups (log-rank P = .43 and P = .43, respectively); ie, patients with stage III disease had no significant difference in risk of clinical (HR, 0.866; 95% CI, 0.054-13.853) or radiographic (HR, 0.959; 95% CI, 0.059-15.474) progression vs those with stage I disease. Weibull profiling revealed 96.9%, 94.6%, and 93.1% successful mandibular ORN arrest at 1, 3, and 5 years, respectively. The major complication rate was 1.9%. Mean (SD) length of stay was 2.7 (0.0-7.0) days. Mean (SD) radiographic follow-up was 29.3 (30.7) months.

Conclusions and Relevance

The findings of this large retrospective patient case series support the continued success of the ALTFL rescue flap technique, a safe and highly effective long-term treatment for mandibular ORN in carefully selected patients.

THE MULTIDISCIPLINARY TEAM (MDT) IN THE TREATMENT OF HEAD AND NECK CANCER - A SINGLE-INSTITUTION EXPERIENCE

Head and neck cancers are associated with significant morbidity and mortality despite advancements in treatment in recent decades. A multidisciplinary approach to the treatment of these diseases is thus of essential importance and is becoming the gold standard. Head and neck tumors also endanger relevant structures of the upper aerodigestive tracts, including bodily functions such as voice, speech, swallowing, and breathing. Damage to these functions can significantly influence quality of life. Thus, our study examined not only the roles of head and neck surgeons, oncologists and radiotherapists, but also the importance of the participation of different scientific professions such as anesthesiologists, psychologists, nutritionists, stomatologists, and speech therapists in the work of a multidisciplinary team (MDT). Their participation results in a significant improvement of patient quality of life. We also present our experiences in the organization and work of the MDT as part of the Center for Head and Neck Tumors of the Zagreb Clinical Hospital Center.

Utilization of a Chimeric Medial Femoral Condyle Free Flap for Mandibular Osteoradionecrosis

BACKGROUND

Primary options for oromandibular reconstruction with osteocutaneous free flaps are the vascularized fibula and iliac crest. Complications of mandible reconstruction are not uncommon and include osteomyelitis, malunion, and osteoradionecrosis (ORN) after radiation therapy. The medial femoral condyle (MFC) free flap is an established salvage option for carpal reconstruction in hand surgery, frequently used for scaphoid nonunion and avascular necrosis. We hypothesize that the MFC flap can be utilized to restore blood supply and reverse the negative effects of radiotherapy in patients who require mandibular reconstruction due to ORN.

METHODS

A retrospective chart review was conducted at Beaumont Health System, Royal Oak, for patients who underwent MFC free flap reconstruction for mandibular ORN between the years 2012 and 2018. Demographic data, operative details, complications, medical comorbidities, and patient outcomes were retrospectively gathered.

RESULTS

A total of four patients were isolated. Four patients developed ORN after resection of squamous cell carcinoma and adjuvant radiotherapy. No patients experienced donor site deficits. Revisions after MFC reconstruction were dependent on individual aesthetics and involvement of neighboring tissue. All four patients continue to be followed with no current issues to the osseous component of the MFC flap.

CONCLUSION

Utilization of the MFC periosteal flap is a viable option in selected patients to salvage nonunion/resorption of mandible reconstruction and ORN of the mandible. Our experience found that the MFC is able to provide pain resolution and healing of intraoral soft tissue defects, and may halt the progression of ORN of the mandible.

Dental Evaluation Prior to Cancer Therapy

A comprehensive oral examination and dental care prior to the start of cancer therapy is the standard of care in many cancer centers. This is because good oral health will likely minimize the undesirable complications such as opportunistic infections during cancer therapy. As the considerations differ between anti-neoplastic regimens, this chapter discusses the indications and rationale when planning and executing a treatment plan for patients undergoing various cancer therapies.

Bacterial spectrum analysis and antimicrobial susceptibility study of osteoradionecrosis of the jaw in Southern China

OBJECTIVE

Osteoradionecrosis of the jaw (ORNJ) is one of the most common and serious complications after radiotherapy of head and neck malignancies due to the high incidence of nasopharyngeal cancer in Southern China. Clinicians lack understanding and consensus on anti-infective treatment in ORNJ lesions. This research aims to provide evidence for rational use of antibiotics by reviewing the bacterial spectrums and antimicrobial susceptibility test of ORNJ patients.

METHODS

We collected patient who was diagnosed with ORNJ from November 2012 to June 2019 in our hospital. Exudate or bone unexposed wound surface sampling, agar plates culturing, and susceptibility testing were analyzed. Descriptive statistics were used for data presentation.

RESULTS

A total of 219 samples were collected in our retrospective study. The most common cultured bacteria were Klebsiella pneumoniae (15.10%), Pseudomonas aeruginosa (13.54%), and Staphylococcus aureus (10.94%). Methicillin-resistant Staphylococcus aureus (MRSA) accounted for 5.21% in the whole positive samples. Ticarcillin, Ofloxacin, Vancomycin, Tigecycline, and Meropenem were more susceptible than other antibiotics to treat uncontrollable infection.

CONCLUSIONS

Our research provided objective evidence for understanding the types of local bacterial flora and drug susceptibility in ORNJ lesions and gave a guiding reference for empirical antibiotics medication.

Radiation ulcer treatment with hyperbaric oxygen therapy and haemoglobin spray: case report and literature review

OBJECTIVE

To explore the effectiveness of a combination of hyperbaric oxygen therapy and haemoglobin spray in radiation ulcer treatment.

METHOD

We reviewed the available literature and present a case report in which radiation ulcer was treated with a combination of hyperbaric oxygen therapy and haemoglobin spray.

RESULTS

After 30 sessions of hyperbaric oxygen therapy (2.4 ATA; 90 minutes each session) and administration of haemoglobin spray, the wounds showed gradual progress towards healing and a good granulating base was achieved. The wounds were closed after two months using a small split thickness skin graft.

CONCLUSION

A combination of hyperbaric oxygen therapy and haemoglobin spray was effective as a short course of treatment for radiation ulcers.

Surgical Management of Skull Base Osteoradionecrosis in the Cancer Population - Treatment Outcomes and Predictors of Recurrence: A Case Series

BACKGROUND

Skull base osteoradionecrosis (ORN) is a challenging treatment-related complication sometimes seen in patients with cancer. Although ORN management strategies for other anatomic sites have been reported, there is a paucity of data guiding the management of skull base ORN.

OBJECTIVE

To report a single-center tertiary care series of skull base ORN and to better understand the factors affecting ORN recurrence after surgical management.

METHODS

We conducted a retrospective cohort study of patients with skull base ORN treated at our center between 2003 and 2017. Univariate and multivariate binary logistic regressions were performed to identify predictors of recurrence.

RESULTS

A total of 31 patients were included in this study. The median age at ORN diagnosis was 61.1 yr (range, 32.8-84.9 yr). Of these 31 patients, 15 (48.4%) patients were initially treated medically. All 31 patients underwent surgery. Three (14.3%) of 21 patients treated with a free flap and 4 (50.0%) of 8 patients who underwent primary closure experienced recurrence. Cox regression analysis revealed that reconstruction with local tissue closure (P = .044) and ongoing treatment for active primary cancer (P = .022) were significant predictors of recurrence. The median overall survival from index surgery for ORN treatment was 83.9 mo. At 12-mo follow-up, 78.5% of patients were alive.

CONCLUSION

In this study, we assess the outcomes of our treatment approach, surgical debridement with vascularized reconstruction, on recurrence-free survival in patients with skull base ORN. Further studies with larger cohorts are needed to assess current treatment paradigms.

[Predictive factors for mandibular osteoradionecrosis after irradiation of head and neck cancers]

The identification of the different risk factors for mandibular osteoradionecrosis (ORN) must be done before and after the management of patients with head and neck cancer. Various clinical criteria for this severe radiation-induced complication are related to the patient (intrinsic radiosensitivity, malnutrition associated with thin weight loss, active smoking intoxication, microcapillary involvement, precarious oral status, hyposalivation) and/or related to the disease (oral cavity, large tumor size, tumor mandibular invasion). Therapeutic risk factors are also associated with a higher risk of ORN (primary tumor surgery, concomitant radio-chemotherapy, post-irradiation dental avulsion, preventive non-observance with the absence of stomatological follow-up and daily installation of gutters fluoride and, non-observance curative healing treatments). Finally, various dosimetric studies have specified the parameters in order to target the dose values distributed in the mandible, which increases the risk of ORN. An mean mandibular dose greater than 48-54Gy and high percentages of mandibular volume receiving 40 to 60Gy appear to be discriminating in the risk of developing an ORN.

A Novel Treatment Concept for Advanced Stage Mandibular Osteoradionecrosis Combining Isodose Curve Visualization and Nerve Preservation: A Prospective Pilot Study

Background

Osteoradionecrosis (ORN) of the mandible is a severe complication of radiation therapy in head and neck cancer patients. Treatment of advanced stage mandibular osteoradionecrosis may consist of segmental resection and osseous reconstruction, often sacrificing the inferior alveolar nerve (IAN). New computer-assisted surgery (CAS) techniques can be used for guided IAN preservation and 3D radiotherapy isodose curve visualization for patient specific mandibular resection margins. This study introduces a novel treatment concept combining these CAS techniques for treatment of advanced stage ORN.

Methods

Our advanced stage ORN treatment concept includes consecutively: 1) determination of the mandibular resection margins using a 3D 50 Gy isodose curve visualization, 2) segmental mandibular resection with preservation of the IAN with a two-step cutting guide, and 3) 3D planned mandibular reconstruction using a hand-bent patient specific reconstruction plate. Postoperative accuracy of the mandibular reconstruction was evaluated using a guideline. Objective and subjective IAN sensory function was tested for a period of 12 months postoperatively.

Results

Five patients with advanced stage ORN were treated with our ORN treatment concept using the fibula free flap. A total of seven IANs were salvaged in two men and three women. No complications occurred and all reconstructions healed properly. Neither non-union nor recurrence of ORN was observed. Sensory function of all IANs recovered after resection up to 100 percent, including the patients with a pathologic fracture due to ORN. The accuracy evaluation showed angle deviations limited to 3.78 degrees. Two deviations of 6.42° and 7.47° were found. After an average of 11,6 months all patients received dental implants to complete oral rehabilitation.

Conclusions

Our novel ORN treatment concept shows promising results for implementation of 3D radiotherapy isodose curve visualization and IAN preservation. Sensory function of all IANs recovered after segmental mandibular resection.

Osteoradionecrosis: Exposing the Evidence Not the Bone

Osteoradionecrosis is a relatively rare but potentially morbid and costly complication of radiation therapy for head and neck cancer. Multidisciplinary diagnosis and treatment are essential. Despite evidence guiding individual aspects of care for osteoradionecrosis, there is a lack of broad consensus on the overall diagnosis and management of this condition. This study comprehensively reviews the literature, with a focus on the past 10 years, to guide evaluation and treatment.

Recognizing Radiation-induced Changes in the Central Nervous System: Where to Look and What to Look For

Radiation therapy (RT) continues to play a central role as an effective therapeutic modality for a variety of tumors and vascular malformations in the central nervous system. Although the planning and delivery techniques of RT have evolved substantially during the past few decades, the structures surrounding the target lesion are inevitably exposed to radiation. A wide variety of radiation-induced changes may be observed at posttreatment imaging, which may be confusing when interpreting images. Histopathologically, radiation can have deleterious effects on the vascular endothelial cells as well as on neuroglial cells and their precursors. In addition, radiation induces oxidative stress and inflammation, leading to a cycle of further cellular toxic effects and tissue damage. On the basis of the time of expression, radiation-induced injury can be divided into three phases: acute, early delayed, and late delayed. Acute and early delayed injuries are usually transient and reversible, whereas late delayed injuries are generally irreversible. The authors provide a comprehensive review of the timeline and expected imaging appearances after RT, including the characteristic imaging features after RT with concomitant chemotherapy. Specific topics discussed are imaging features that help distinguish expected posttreatment changes from recurrent disease, followed by a discussion on the role of advanced imaging techniques. Knowledge of the RT plan, the amount of normal structures included, the location of the target lesion, and the amount of time elapsed since RT is highly important at follow-up imaging, and the reporting radiologist should be able to recognize the characteristic imaging features after RT and differentiate these findings from tumor recurrence. ^©RSNA, 2020.

Three-dimensional virtual surgical planning in the oncologic treatment of the mandible

OBJECTIVES

In case of surgical removal of oral squamous cell carcinomas, a resection of mandibular bone is frequently part of the treatment. Nowadays, such resections frequently include the application of 3D virtual surgical planning (VSP) and guided surgery techniques. In this paper, current methods for 3D VSP leads for optimisation of the workflow, and patient-specific application of guides and implants are reviewed.

RECENT FINDINGS

Current methods for 3D VSP enable multi-modality fusion of images. This fusion of images is not restricted to a specific software package or workflow. New strategies for 3D VSP in Oral and Maxillofacial Surgery include finite element analysis, deep learning and advanced augmented reality techniques. These strategies aim to improve the treatment in terms of accuracy, predictability and safety.

CONCLUSIONS

Application of the discussed novel technologies and strategies will improve the accuracy and safety of mandibular resection and reconstruction planning. Accurate, easy-to-use, safe and efficient three-dimensional VSP can be applied for every patient with malignancies needing resection of the mandible.

Low-Intensity Pulsed Ultrasound Modulates RhoA/ROCK Signaling of Rat Mandibular Bone Marrow Mesenchymal Stem Cells to Rescue Their Damaged Cytoskeletal Organization and Cell Biological Function Induced by Radiation

Osteoradionecrosis of the jaw (ORNJ) is an infrequent yet potentially devastating complication of head and neck radiation therapy. Low-intensity pulsed ultrasound (LIPUS) has been widely accepted as a promising method for the successful management of ORNJ, but the mechanism remains unclear. In this study, the effects of LIPUS on cytoskeletal reorganization, cell viability, and osteogenic differentiation capacity of rat mandible-derived bone marrow mesenchymal stem cells (M-BMMSCs) induced by radiation were determined by immunofluorescence staining, CCK-8 cell proliferation assay, quantification of alkaline phosphatase (ALP) activity, alizarin red staining, and real-time RT-PCR, respectively. Moreover, the involvement of the RhoA/ROCK signaling pathway underlying this process was investigated via western blot analysis. We found that radiation induced significant damage to the cytoskeleton, cell viability, and osteogenic differentiation capacity of M-BMMSCs and downregulated their expression of RhoA, ROCK, and vinculin while increasing FAK expression. LIPUS treatment effectively rescued the disordered cytoskeleton and redistributed vinculin. Furthermore, the cell viability and osteogenic differentiation capacity were also significantly recovered. More importantly, it could reverse the aberrant expression of the key molecules induced by radiation. Inhibition of RhoA/ROCK signaling remarkably aggravated the inhibitory effect of radiation and attenuated the therapeutic effect of LIPUS. In the light of these findings, the RhoA/ROCK signaling pathway might be a promising target for modifying the therapeutic effect of LIPUS on osteoradionecrosis.

Regeneration of mandibular osteoradionecrosis with autologous cross-linked serum albumin scaffold

Osteoradionecrosis is one of the most severe complications of radiotherapy administered for head and neck tumors. We present the first two cases of advanced and refractory mandibular osteoradionecrosis treated by application of a novel autologous cross-linked 3D serum matrix. Patients were followed clinically and radiographically up to 24 months. Complete wound healing and intact mucosal cover were achieved in both cases. At 12 months, the radiographic values showed an almost complete regeneration of the bone defect, which continued a favourable progression increased to the maximum by 24 months after surgery. The use of an autologous serum-derived scaffold proved to be a quick, predictable, cost-effective and safe adjunct to the conservative surgical treatment of this pathology.

Bisphosphonate-induced reactive oxygen species inhibit proliferation and migration of oral fibroblasts: A pathogenesis of bisphosphonate-related osteonecrosis of the jaw

BACKGROUND

The onset mechanism for bisphosphonate-related osteonecrosis of the jaw (BRONJ) has been reported, with a focus on bone remodeling, biofilm formation, and epithelial cell proliferation and migration. However, the involvement of stromal cells, especially fibroblasts, in the oral cavity is unclear. Therefore, this study was focused on how bisphosphonates (BPs) affect orthotopic periodontal ligament fibroblasts from the viewpoint of oxidative stress compared with ectopically obtained fibroblasts.

METHODS

Normal human periodontal ligament fibroblasts (HPdLFs) and normal human dermal fibroblasts (NHDFs) were used to gain insight into the functional differences in sensitivity and reactions to BPs. Cell growth assay, measurement of reactive oxygen species (ROS) and nitric oxide (NO) production, and wound-healing assay in vitro were performed. Maxillary first molars were extracted in C57BL/6 mice and either BP, N-acetyl-cysteine (NAC), and BP or saline were administered.

RESULTS

BP-induced IC₅₀ values were significantly lower in HPdLFs (30.6 µM) than in NHDFs (109.7 µM). BP resulted in an increase in ROS, but not NO generation in HPdLFs. BPs also inhibited proliferation and migration of HPdLFs but not NHDFs, while the addition of a ROS inhibitor, NAC, reversed those inhibitions. A BRONJ mouse model in which BP was administered and then the tooth was extracted, impaired wound healing of the socket was observed. When NAC was administered before tooth extraction, wound healing was significantly improved.

CONCLUSION

These results suggest that BP causes fibroblasts obtained from the oral cavity but not from skin to generate ROS and that the subsequent ROS-mediated inhibition of fibroblast growth and migration definitely delays wound healing, thereby contributing to BRONJ pathogenesis.

New Therapeutic Approaches to Osteoradionecrosis: Literature Review

AbstractRadiotherapy is an important treatment of oral and maxillofacial malignancies. Among the various effects of this locoregional therapy, osteoradionecrosis (ORN) plays a prominent role due to its physical and psychological impact on cancer patients. In the literature, the therapeutic approach of ORN varies from a conservative to invasive surgery treatment. Objective: collect in the scientific literature, concise and current information about the benefits of using these therapies in the ORN. The present literature review selected articles based on the titles that addressed osteoradionecrosis treatment, as well as the evaluation systems adopted. After previous analysis, 22 relevant articles were included on the proposed theme. According to the literature, several hypotheses have been established to explain the etiopathogenesis of ORN, as numerous evaluation systems have been developed in the last years. Regarding the main therapeutic modalities used, new less invasive therapies have acquired space, such as ozone therapy, laser therapy associated with photodynamic therapy and drugs, such as vitamin, antifibrotic and anti-resorptive. However, in spite of the promising results, new randomized clinical trials have to be performed in an attempt to discover the real effectiveness of these therapies in the ORN. Therefore, it becomes a challenging issue for dental surgeons, since it requires the constant monitoring and long term of these patients, due to the risk of progression or recurrence of this condition.Keywords: Radiotherapy. Osteoradionecrosis. Conservative Treatment. Ozone. Photochemotherapy.ResumoA radioterapia compreende um tratamento importante no tratamento de tumores malignos orais e maxilofaciais. Dentre os diversos efeitos oriundos desta terapia locoregional, a osteorradionecrose (ORN) apresenta um papel de destaque devido ao seu impacto físico e psicológico ao paciente oncológico. A abordagem terapêutica da ORN pode variar do tratamento conservador ao tratamento invasivo através da cirurgia. Objetivo coletar na literatura científica informações concisas e atuais acerca dos benefícos do uso dessas terapias na ORN. A presente revisão narrativa de literatura teve a seleção de artigos com base nos títulos que abordaram as terapias empregadas na osteorradionecrose, bem como os sistemas de avaliação adotados. Após análise prévia, foram incluídos 39 artigos relevantes sobre a temática proposta. De acordo com a literatura, várias hipóteses foram estabelecidas para explicar a etiopatogenia da ORN, assim como inúmeros sistemas de avaliação foram desenvolvidos nos últimos anos. Com relação as principais modalidades terapêuticas empregadas, novas terapias menos invasivas têm adquirido espaço, a exemplo da ozonioterapia, laserterapia associada à terapia fotodinâmica e medicamentos antioxidantes, antifibróticos e antireabsortivos. Todavia, apesar dos resultados promissores, novos ensaios clínicos precisam ser realizados, para se descobrir a real eficácia dessas terapias na ORN. Portanto, torna-se uma questão desafiadora para os Cirurgiões dentistas, uma vez que requer o monitoramento constante e a longo prazo desses pacientes, devido ao risco de progressão ou recidiva desta afecção.Palavras-chave: Radioterapia. Osteoradionecrosis. Tratamento Conservador. Ozônio. Fotoquimioterapia.

Anterior Skull Base Reconstruction following Ablative Surgery for Osteoradionecrosis: Case Report and Review of Literature

Introduction:

Osteoradionecrosis is one of many potentially severe complications of radiotherapy for nasopharyngeal carcinoma. Osteoradionecrosis of the skull base is life-threatening due to the critical proximity of the pathological process to vital structures, for example, the intracranial cavity, the upper spine, and major blood vessels. Reconstructive options following surgical debridement of the anterior skull base and upper spine osteonecrosis have been scarcely described in the literature.

Case presentation and management:

We present a rare case of osteoradionecrosis of the clivus and cervical vertebrae C1-C2 in a patient previously treated with chemoradiotherapy for nasopharyngeal carcinoma, presenting as severe soft tissue infection of the neck. Aggressive surgical debridement and reconstruction with a two-paddle free anterolateral thigh flap was performed using a combination of transcervical and transnasal endoscopic approaches. A novel endoscopic procedure in the sphenoid sinus enabled flap anchoring in this complex area.

Discussion:

Surgical modalities for osteoradionecrosis of the skull base and upper spine are discussed and review of the literature is presented.

Conclusion:

Reconstruction of the anterior skull base with a well-vascularized free flap following ablative surgery should be considered in management of life-threatening osteoradionecrosis of the area. Endoscopic opening of the sphenoid sinus and creating a funnel-shaped stem is a newly described technique that guarantees precise placement of the flap and is a valuable adjunct to the reconstructive armamentarium.

Treatment of mandibular osteoradionecrosis by periosteal free flaps

Mandibular osteoradionecrosis (ORN) is one of the most serious complications of radiotherapy of the head and neck, and is characterised by hypoxia, hypovascularisation, and hypocellularity. Periosteal free flaps have intrinsic osteogenic, and extrinsic neoangiogenic, properties that are related to the periosteum. Our objective was to present our experience with the use of periosteal free flaps in the treatment of ORN (Notani class I or II) that are refractory to conservative management or have a large area of bone (≥2 cm) exposed. We organised a single-centre, retrospective study between 2003 and 2013 and describe the management of 11 patients (4 women and 7 men) who were being treated for refractory mandibular ORN. Thirteen periosteal free flaps were used: inner femoral condylar periosteum (n = 4), iliac crest (n = 1), external brachial with humeral periosteum (n = 1), and forearm with radial periosteum (n = 7). During follow-up we found three acute complications (haematoma, partial necrosis, and total vascular necrosis) that required immediate construction of a second periosteal free flap. There were also two chronic complications (fistula and post-traumatic fracture). With only one progressive lesion identified, the ORN was stopped in 11/12 patients. Two examples of osteoconduction were identified on postoperative images at six months and two years. Because of its osteoconductive and neoangiogenic capacities, the periosteal free flap seems to offer a real biological dimension to the treatment of ORN, and its efficiency favours its early revascularisation.

Retrospective study of osteoradionecrosis in the jaws of patients with head and neck cancer

Objectives

Osteoradionecrosis (ORN) is one of the most severe complications resulting from radiotherapy (RT) in patients with head and neck cancer (HNC). It is characterized by persistent exposed and devitalized bone without proper healing for greater than 6 months after a high dose of radiation in the area. To describe the profile and dental management of ORN in HNC patients undergoing RT in an oncological clinical research center.

Materials and Methods

A retrospective descriptive study was performed to analyze dental records from HNC patients with ORN treated at an oncological clinical research center from 2013 to 2017. A total of 158 dental records for HNC patients were selected from a total of 583 records. Afterwards, this number was distributed to three examiners for manual assessments. Each examiner was responsible for selecting dental records that contained an ORN description, resulting in 20 dental records.

Results

Mean patient age was 60.3 years with males being the most affected sex (80.0%). The most affected area was the posterior region of the mandible (60.0%) followed by the anterior region of the mandible (20.0%) and the posterior region of the maxilla (10.0%). The factors most associated with ORN were dental conditions (70.0%) followed by isolated systemic factors (10.0%) and tumor resection (5.0%). There was total exposed bone closure in 50.0% of cases. The predominant treatment was curettage associated with chlorhexidine 0.12% irrigation (36.0%).

Conclusion

Poor dental conditions were related to ORN occurrence. ORN management through less invasive therapies was effective for the closure of exposed bone areas and avoidance of infection.

Severe Pain Due to Paraspinal Abscess Formation in Two Patients with Squamous-Cell Carcinoma of the Head and Neck after Multimodal Treatment Including Cetuximab

BACKGROUND

Patients with squamous-cell carcinoma of the head and neck (SCCHN) on palliative therapy usually have a bad prognosis and suffer from various symptoms. With increasing use of targeted agents in cancer patients at the end of life, the correct assignment of therapy-related symptoms becomes increasingly difficult as cancer-related symptoms usually increase as well.

CASE REPORT

We report on 2 cases of patients with SCCHN who received multimodal treatment including palliative therapy with cetuximab. Both patients developed severe thoracic and cervicothoracic pain following treatment. In both cases, extensive paraspinal abscess formation proved to be the underlying cause. One patient was treated conservatively; the other one had to undergo surgical intervention.

CONCLUSIONS

Awareness of multifaceted therapy-related complications is mandatory when patients receive multimodal treatment including targeted therapies. Unexplained pain syndromes in this context should raise suspicions concerning possible infectious complications and should lead to early use of magnetic resonance imaging.

Management of Radiation Toxicity in Head and Neck Cancers

Head and neck cancers account for approximately 3% of all cancers in the United States with 62,000 new cases diagnosed annually. The global incidence is approximately 700,000 new cases a year. There has also been a recent increase in human papilloma virus-related oropharyngeal cancers. External beam radiation therapy (RT) is commonly used as an effective therapy for head and neck (H&N) cancers. This is used as a definitive treatment (alone or in combination with chemotherapy) or as an adjuvant treatment after surgical resection of the tumors. Because of the complex anatomy of the H&N region, several critical structures in and around the area receive radiation treatment. This includes the neural structures (brainstem, spinal cord, and brachial plexus), salivary glands, mucosa, major blood vessels, and swallowing musculature. Careful RT planning is necessary to avoid or mitigate the side effects of treatment. This review discusses some of the major acute and late side effects of RT for H&N cancers and provides evidence-based guidelines for their management. Patient-reported outcomes and quality-of-life implications are also discussed.

Predictive factors for osteoradionecrosis of the jaws: A retrospective study

BACKGROUND

Osteoradionecrosis of the jaw (ORNJ) is a well-recognized complication of radiotherapy. The purpose of this study was to assess predictive factors for the development of ORNJ.

METHODS

A retrospective study of 325 patients with head and neck squamous cell carcinoma (HNSCC) treated at one institution between January 1, 1999, and December 31, 2008, was conducted. Outcome measure was the presence/absence of ORNJ. Time to event was recorded and Cox proportional hazard regression analysis was used to determine statistically significant predictive factors.

RESULTS

Fifty-nine patients had ORNJ. Statistical analysis using Cox regression analysis identified several statistically significant variables: dentoalveolar surgery; peri-resective surgery of the jaw; continued tobacco usage after radiotherapy, diabetes mellitus type 2 (DM2); and total radiation dose.

CONCLUSION

Patients at greater risk of developing ORNJ can be identified and measures can be instituted to reduce its incidence and expedite management when it does occur.

Osteoradionecrosis of the jaws: definition, epidemiology, staging and clinical and radiological findings. A concise review

Osteoradionecrosis (ORN) of the jaws is a pernicious complication of radiation therapy for head and neck tumours. This article aims to provide an update on data related to the definition, epidemiology, staging, and clinical and radiological findings of ORN of the jaws. Using certain keywords, an electronic search was conducted spanning the period from January 1922 to April 2014 to identify the available related investigations. Pooled data were then analysed. ORN is described as exposed irradiated bone that fails to heal over a period of 3 months without evidence of persisting or recurrent tumour. The prevalence of ORN varies in the literature. Several staging or scoring systems of ORN have been proposed. Clinical findings include ulceration or necrosis of the mucosa with exposure of necrotic bone. Radiological findings are not evident in the early stages of ORN. Furthermore ORN may not be apparent in imaging even when the disease is advanced. Taking into account the severity of ORN and the difficulties in diagnosing it early and accurately, the clinician should be aware of this complex entity in order to prevent its appearance or the development of more severe complications.

The use of the buccal fat pad flap for oral reconstruction

Many congenital and acquired defects occur in the maxillofacial area. The buccal fat pad flap (BFP) is a simple and reliable flap for the treatment of many of these defects because of its rich blood supply and location, which is close to the location of various intraoral defects. In this article, we have reviewed BFP and the associated anatomical background, surgical techniques, and clinical applications. The surgical procedure is simple and has shown a high success rate in various clinical applications (approximately 90%), including the closure of oroantral fistula, correction of congenital defect, treatment of jaw bone necrosis, and reconstruction of tumor defects. The control of etiologic factors, size of defect, anatomical location of defect, and general condition of patient could influence the prognosis after grafting. In conclusion, BFP is a reliable flap that can be applied to various clinical situations.

The Use of Hyperbaric Oxygen for the Prevention and Management of Osteoradionecrosis of the Jaw: A Dana-Farber/Brigham and Women's Cancer Center Multidisciplinary Guideline

BACKGROUND

Osteoradionecrosis of the jaw (ORN) is an infrequent yet potentially devastating complication of radiation therapy to the head and neck region. Treatment options include antimicrobial therapy, local sequestrectomy, resection, and the use of hyperbaric oxygen (HBO). Published data on ORN are difficult to compare because of the lack of a universally accepted classification and staging system, and the literature on the use of HBO to either prevent or successfully manage ORN is controversial and inconclusive. Therefore, we aimed to establish a standard approach for using HBO at our institution.

MATERIALS AND METHODS

A literature search was conducted of articles published in the English language between January 1980 and January 2016. Retrieved articles were evaluated by two independent reviewers. Isolated case reports, abstracts, case series, review articles, and cohort studies without a control group were excluded; summary data were extracted from the remaining studies. A panel of experts from Head and Neck Oncology and Oral Medicine from the Dana-Farber Cancer Institute and Brigham and Women's Hospital reviewed the summary data and established multidisciplinary guidelines on the use of HBO for the prevention and management of ORN.

RESULTS

Seven studies were evaluated and reviewed by the multidisciplinary panel. There was no consistent evidence in support of HBO for either the prevention or management of ORN.

CONCLUSION

Based on the available evidence and expert opinion, routine use of HBO for the prevention or management of ORN is not recommended and is rarely used at our institution. The Oncologist 2017;22:343-350 IMPLICATIONS FOR PRACTICE: The Division of Head and Neck Oncology of Dana-Farber/Brigham and Women's Cancer Center does not recommend the routine use of HBO for the prevention or management of ORN. Adjunctive HBO may be considered for use on a case-by-case basis in patients considered to be at exceptionally high risk who have failed conservative therapy and subsequent surgical resection.

Hyperbaric oxygen therapy for maxillary bone radiation-induced injury: A 15-year single-center experience

BACKGROUND

Although hyperbaric oxygen therapy (HBOT) is used to treat chronic radiation tissue injury, clinical evidence supporting its use in maxillary bone osteoradionecrosis (ORN) is lacking. Therefore, the purpose of this study was to report our results of collected patient outcomes from a single center's large experience using HBOT to treat maxillary bone ORN.

METHODS

From 1999 to 2015, 21 patients received treatment for maxillary bone ORN at our center. The medical records were retrospectively reviewed for the following variables: age, sex, comorbidities, tumor stage and site, previous surgery, previous radiotherapy or chemoradiation therapy, HBOT data, response to treatment and further management.

RESULTS

A positive clinical outcome from HBOT occurred in 85.7% of patients with ORN and was proven radiologically in 14 of 15 patients (93.3%). In 5 patients, reconstructive surgery was required thereafter.

CONCLUSION

Controversy exists regarding the management of ORN of the maxillofacial skeleton. Our large, single-center experience probably supports the efficacy of HBOT for maxillary bone ORN. © 2016 Wiley Periodicals, Inc. Head Neck 39: 275-278, 2017.

Osteoradionecrosis and intensity modulated radiation therapy: An overview

Osteoradionecrosis (ORN) is an ongoing topic, especially about its definition, pathogenesis, staging system and management algorithm. But what about its real incidence in intensity modulated radiotherapy (IMRT) era? This paper discusses the mandible in radiation therapy planning as organ at risk and reviews the literature for evidence of radiation damage, discussing likely dose constraints and the use of IMRT to reduce radiation dose to this structure. PubMed search was performed.

Hyperbaric oxygen therapy and osteonecrosis

Osteonecrosis of the jaw may be caused by radiation, medication, or infection. Optimal therapy requires a multimodal approach that combines surgery with adjuvant treatments. This review focuses on the use of adjunctive hyperbaric oxygen therapy for this condition. In addition to evidence regarding the basic and clinical science behind hyperbaric oxygen therapy, controversies in the field and economic implications are discussed.

Recurrent Malignancy in Osteoradionecrosis Specimen

PURPOSE

Osteoradionecrosis (ORN) is a well-known complication of head and neck radiation therapy. Statistically, the mandible is the most commonly affected site. The incidental finding of malignancy in the resection specimen has been documented but is somewhat rare. The aim of this review is to investigate the presence of recurrent carcinoma and sarcoma or new primary malignancies in resection specimens previously diagnosed and treated as ORN.

PATIENTS AND METHODS

This study is a retrospective case series. We conducted a chart review of all cases managed at the University of Miami Miller School of Medicine/Jackson Memorial Hospital. The inclusion criteria included a history of head and neck carcinoma treated with radiation of at least 6,000 cGy; clinical diagnosis of ORN; and surgical intervention with osseous resection for treatment of ORN. The study endpoint measured included microscopic evidence of malignancy in the resected ORN specimen. Additional data collected included gender, age, and type of primary pathology.

RESULTS

A total of 564 patients met the inclusion criteria. Of these patients, 14 had microscopic evidence of cancer in the specimen (2.48%) and 5 had a proven second primary malignancy in the foregut (1 in the lung, 0.18%, and 4 in the oropharynx, 0.70%). In 1 of the 14 patients, a high-grade sarcoma was diagnosed and the patient died within 1 year of diagnosis. In the treatment of our ORN patient population, a total of 19 malignancies were found collectively (3.37%). Of the 564 patients, 352 were men and 212 were women. The median age was 46 years (range, 33 to 97 years). Head and neck squamous cell carcinoma represented 531 cases in our sample, followed by 28 cases of salivary gland carcinoma and only 5 cases of sarcoma.

CONCLUSIONS

Although the finding of malignancy in ORN patients is relatively rare (3.37% in this study), oral and maxillofacial surgeons should be cognizant of its potential presence. The treatment of malignant disease is different than that of ORN, and a multidisciplinary treatment approach is recommended if a malignancy is diagnosed in an ORN patient.

Fibular free flap reconstruction for the management of advanced bilateral mandibular osteoradionecrosis

Fibular osteoseptocutaneous flap has been widely used for unilateral mandibular reconstruction. However, reports about the effects of fibular osteoseptocutaneous flap for the reconstruction of bilateral mandibular defects are limited. In this study, we used free vascularized fibular flaps to successfully manage bilateral mandibular osteoradionecrosis(ORN) in 5 patients. Functional aspects were evaluated during the reconstruction process. All 5 patients had bilateral refractory ORN of the mandible and underwent radical resection between 2003 and 2011. The reconstruction surgery was performed in 2 stages using 2 free fibular flaps in 3 patients. In the other 2 patients, reconstruction was performed in a single stage using 2 separate flaps prepared from a single fibula. All patients had a healthy mandibular symphysis and meniscus of the temporomandibular joint, and these structures were preserved during the reconstruction.Of the 10 defects involving the mandible sides, 9 were successfully reconstructed. One microvascular composite flap failed because of radiation injury to the arterial endothelium at the recipient site. After the treatments, all patients had good esthetic and functional outcomes. Preoperative clinical features such as trismus and dysphagia were also markedly improved. Our surgical method may be an effective alternative for the clinical management of advanced bilateral mandibular ORN.

Osteoradionecrosis of the Jaws: Clinico-Therapeutic Management: A Literature Review and Update

Osteoradionecrosis is one of the most serious oral complications of head and neck cancer treatment. It is a severe delayed radiation-induced injury, characterized by bone tissue necrosis and failure to heal for at least 3 months. In most cases osteoradionecrosis gradually progresses, becoming more extensive and painful that leads to infection and pathological fracture. The present paper provides a literature review and update on the risk factors underlying osteoradionecrosis, its clinical and diagnostic particulars, prevention and most widely accepted treatment options including the latest treatment modalities. Lastly, a new early management protocol is proposed based on the current clinical criteria relating to osteonecrosis secondary to treatment with bisphosphonates, together with the adoption of new therapies supported by increased levels of evidence.

Hydrogen-rich saline may be an effective and specific novel treatment for osteoradionecrosis of the jaw

Hydrogen, a therapeutic medical gas, can exert antioxidant activity via selectively reducing cytotoxic reactive oxygen species such as hydroxyl radicals. Hydrogen-rich saline is an alternative form of molecular hydrogen that has been widely used in many studies, including metabolic syndrome, cerebral, hepatic, myocardial ischemia/reperfusion, and liver injuries with obstructive jaundice, with beneficial results. Osteoradionecrosis of the jaw is a serious complication following radiotherapy for head and neck cancers. It has long been known that most radiation-induced symptoms are caused by free radicals generated by radiolysis of H₂O, and the hydroxyl radical is the most reactive of these. Reducing the hydroxyl radical can distinctly improve the protection of cells from radiation damage. We hypothesized that hydrogen-rich saline might be an effective and specific method of managing and preventing osteoradionecrosis of the jaw.

Gluteus Maximus Turnover Flap for Sacral Osteomyelitis After Radiation Therapy

Developments in radiation therapy modalities offer alternative treatments for unresectable malignant tumors in the pelvis and trunk. However, poor vascularity as a result of radiation therapy makes the treated lesion susceptible to infection, and there are no established treatments for pelvic osteomyelitis with a large dead space after radiation therapy. The authors report 2 cases of sacral osteomyelitis after radiation therapy that were treated successfully with a gluteus maximus turnover flap. To create the flap, the distal portion of the lower third of the muscle was detached from the trochanter. The distal edge of the flap was turned toward the sacral defect and sewn to the remnant of the sacrum, which filled the dead space with the muscle bulk. A 68-year-old man with a recurrent sacral chordoma was treated with carbon ion radiation therapy; however, a sacral infection developed 5 months later. Debridement and a course of antibiotics could not control the infection and did not induce sufficient formation of granulation tissue in the large and deep dead space. The turnover flap with both gluteus maximus muscles cured the deep-seated infection and closed the wound. A 58-year-old woman had sacral osteoradionecrosis with infection. A turnover flap created with the left gluteus maximus muscle controlled the infection and closed the wound after the first operation, a V-Y flap, failed. This study showed that a gluteus maximus muscle turnover flap effectively controlled infectious lesions with large and deep dead space around the sacrum.