Original ContributionSurgical management of temporal bone osteoradionecrosis: Single surgeon experience of 47 cases☆
Introduction
Osteoradionecrosis (ORN) is a rare yet well-studied complication of radiation therapy in the management of head and neck cancer. In the past half-century, both use of external beam radiation and survival of patients with head and neck malignancy have greatly increased. This in turn, has increased the incidence of ORN and other post-radiation sequelae. A wealth of literature exists regarding ORN of the mandible; however, ORN of the temporal bone (ORNTB) has become of greater interest in recent years. ORN is caused by the inclusion of osseous structures within the radiation field of an aero digestive malignancy. This undue exposure is thought to cause endarteritis and inflammation that eventually leads to periosteal hypoxemia leading to tissue necrosis. Multiple factors predispose the temporal bone to ORN, including its position within the skull base, thin overlying soft tissue, and a tenuous vascular supply [1], [2], [3], [4].
ORNTB has been associated with treatment of parotid, oropharynx, nasopharynx, and brain malignancies [5], [6]. Exposure to high doses of external beam radiation can result in multiple sequalae, all of which can fall under the umbrella of ORNTB. These late stage complications can also be divided into soft tissue and bony sequalae, or localized and diffuse [2]. Soft tissue complications include external canal stenosis or ulceration, otitis externa, sensorineural hearing loss, and cholesteatoma [5], [7]. In addition, ORNTB predisposes patients to middle ear space infections which can have a coupling effect to worsen ORNTB [8]. Intracranial complications of ORNTB include abscesses, sigmoid sinus thrombosis, meningitis, malignant otitis externa, skull base osteomyelitis, internal carotid aneurysm, and death [9].
Treatment options of ORNTB can be categorized into conservative and surgical. Conservative management includes regular canal cleaning, otic drops (peroxide vs antibiotics for purulent otorrhea), systemic antibiotics, and minor sequestrectomies/debridement. Surgical intervention also has a range; mastoidectomy, subtotal petrosectomy, and variations of lateral temporal bone resections (LTB) [8]. There has been mention of hyperbaric oxygen in the literature but with few studies demonstrating efficacy.
LTB represent a complicated challenge for the reconstructive surgeon. The temporal bone has an intricate role in the skull base, separating CSF and intracranial contents from the aero digestive tract and external environment. Moving up the reconstructive ladder, local flap and free flap reconstruction are the few options flexible enough to properly reconstruct LTB defects. With advances in free flap reconstruction, the goals of defect management have moved from simple coverage to functional outcomes and cosmesis [10], [11].
In this study, the management and outcomes of 47 patients treated for ORNTB by a single surgeon practice are reported. While conservative management is often the initial option for patients, the goal of this study was to demonstrate the favorable outcomes in patients treated with primary surgical intervention.
Section snippets
Patients and methods
Prior to beginning this study, Institutional Review Board (IRB) approval was gained from JPS Hospital.
This study was a retrospective analysis of a single surgeon's experience with primary surgical treatment for temporal bone osteoradionecrosis (ORN) from January 1998 to January 2016 at a tertiary referral private practice in Fort Worth, Texas. The study sought to report outcomes, namely patient survival and flap loss, following resection of necrotic temporal bone followed by reconstruction with
Results
Following exclusion of patients not appropriate for the study, 47 patients were found to meet the inclusion criteria. There were 37 males and 9 females, with a combined average age of 66.2 years.
Table 1 represents patient outcomes from those developing temporal bone ORN following primary external beam radiation. 30 patients developed temporal bone ORN following primary radiation therapy, all of which were resected and reconstructed. 12 patients had squamous cell carcinoma (SCC) of the conchal
Discussion
The data reported in this paper represents the largest single surgeon experience of surgical treatment for temporal bone osteoradionecrosis. Based on a review of 47 cases, resection and flap reconstruction of necrotic temporal bone could be a viable option in comparison to pure conservative management. Surgically treated patients in this report obtained good symptomatic relief and long-term control of ORN. As local flap reconstruction tended to break down more often (p = 0.02), regional and free
Conclusion
Analysis of these 47 cases of temporal bone ORN from a single surgeon experience demonstrates that surgical excision is a viable solution for treatment and the use of hyperbaric oxygen may not provide a substantial contribution in the face of primary surgical treatment. It appears that reconstruction with regional flaps or free tissue transfer may be a more reliable method compared to local flap coverage.
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No financial disclosures or conflict of interest.