Aggressive Treatment Including Endonasal Surgical Sequestrectomy with Vascularized Nasoseptal Flap Can Improve Outcomes of Skull Base Osteoradionecrosis

Sung-Woo Cho; Sang Y. Han; Yoonjae Song; Jeong-Whun Kim; Hyun J. Kim; Dong-Young Kim; Chae-Seo Rhee; Yun J. Bae; Ji-hoon Kim; Hong-Gyun Wu; Jae S. Bang; Tae-Bin Won

doi:10.1055/s-0040-1722669

Journal of Neurological Surgery Part B: Skull Base, Table of Contents

J Neurol Surg B Skull Base 2022; 83(S 02): e15-e23
DOI: 10.1055/s-0040-1722669

Original Article

Aggressive Treatment Including Endonasal Surgical Sequestrectomy with Vascularized Nasoseptal Flap Can Improve Outcomes of Skull Base Osteoradionecrosis

Sung-Woo Cho

¹Department of Otorhinolaryngology–Head and Neck Surgery, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, South Korea

,

Sang Y. Han

¹Department of Otorhinolaryngology–Head and Neck Surgery, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, South Korea

,

Yoonjae Song

¹Department of Otorhinolaryngology–Head and Neck Surgery, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, South Korea

,

Jeong-Whun Kim

¹Department of Otorhinolaryngology–Head and Neck Surgery, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, South Korea

,

Hyun J. Kim

²Department of Otorhinolaryngology–Head and Neck Surgery, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, South Korea

,

Dong-Young Kim

²Department of Otorhinolaryngology–Head and Neck Surgery, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, South Korea

,

Chae-Seo Rhee

¹Department of Otorhinolaryngology–Head and Neck Surgery, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, South Korea

²Department of Otorhinolaryngology–Head and Neck Surgery, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, South Korea

,

Yun J. Bae

³Department of Radiology, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, South Korea

,

Ji-hoon Kim

⁴Department of Radiology, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, South Korea

,

Hong-Gyun Wu

⁵Department of Radiation Oncology, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, South Korea

,

Jae S. Bang

⁶Department of Neurosurgery, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, South Korea

,

Tae-Bin Won

¹Department of Otorhinolaryngology–Head and Neck Surgery, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, South Korea

²Department of Otorhinolaryngology–Head and Neck Surgery, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, South Korea

› Author Affiliations

Abstract

Objective Skull base osteoradionecrosis (SB-ORN) is a serious, potentially lethal complication of radiation therapy. We aimed to review the clinical characteristics and outcomes of SB-ORN according to the extent of treatment.

Design Retrospective analysis design was used for this study.

Setting The study was conducted in two tertiary care hospitals.

Participants Patients included who had been clinically diagnosed with SB-ORN from January 2006 to 2017.

Main Outcome Measures Clinical characteristics, including demographics, predisposing factors, presenting symptoms, radiological findings, treatment modalities, and treatment outcomes, were reviewed. Treatment was classified into conservative and aggressive types. Aggressive treatment included radical surgical removal of soft tissue and bony sequestrum with the placement of vascularized tissue. Treatment outcome was analyzed in terms of clinical control, survival, and carotid artery blow out.

Results Fifteen patients (11 males and 4 females) were identified during the study period. Eight patients were managed conservatively, whereas seven patients were managed with aggressive treatment. The 2-year survival was 75% in the aggressive treatment group and 15% in the conservative group (log-rank, p = 0.049). The estimated 2-year blow out free rate was 46.7% for the conservative group and 100% for the aggressive group (log-rank, p = 0.100).

Conclusion In patients with SB-ORN, aggressive management, including surgical removal of sequestrum and coverage with a pedicled flap, is associated with increased survival.

Keywords

carcinoma - endoscopy - osteoradionecrosis - radiotherapy - skull base

Full Text

References

References
1 Chang KP, Tsang NM, Chen CY, Su JL, Hao SP. Endoscopic management of skull base osteoradionecrosis. Laryngoscope 2000; 110 (07) 1162-1165
2 Han P, Wang X, Liang F. et al. Osteoradionecrosis of the skull base in nasopharyngeal carcinoma: incidence and risk factors. Int J Radiat Oncol Biol Phys 2018; 102 (03) 552-555
3 Lee CC, Ho CY. Post-treatment late complications of nasopharyngeal carcinoma. Eur Arch Otorhinolaryngol 2012; 269 (11) 2401-2409
4 Martos-Fernández M, Saez-Barba M, López-López J, Estrugo-Devesa A, Balibrea-Del-Castillo JM, Bescós-Atín C. Pentoxifylline, tocopherol, and clodronate for the treatment of mandibular osteoradionecrosis: a systematic review. Oral Surg Oral Med Oral Pathol Oral Radiol 2018; 125 (05) 431-439
5 Huang XM, Zheng YQ, Zhang XM. et al. Diagnosis and management of skull base osteoradionecrosis after radiotherapy for nasopharyngeal carcinoma. Laryngoscope 2006; 116 (09) 1626-1631
6 Liu J, Ning X, Sun X, Lu H, Gu Y, Wang D. Endoscopic sequestrectomy for skull base osteoradionecrosis in nasopharyngeal carcinoma patients: a 10‑year experience. Int J Clin Oncol 2019; 24 (03) 248-255
7 Fu KK, Newman H, Phillips TL. Treatment of locally recurrent carcinoma of the nasopharynx. Radiology 1975; 117 (02) 425-431
8 Marx RE. Osteoradionecrosis: a new concept of its pathophysiology. J Oral Maxillofac Surg 1983; 41 (05) 283-288
9 Sathasivam HP, Davies GR, Boyd NM. Predictive factors for osteoradionecrosis of the jaws: A retrospective study. Head Neck 2018; 40 (01) 46-54
10 Katsura K, Sasai K, Sato K, Saito M, Hoshina H, Hayashi T. Relationship between oral health status and development of osteoradionecrosis of the mandible: a retrospective longitudinal study. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2008; 105 (06) 731-738
11 Lyons A, Ghazali N. Osteoradionecrosis of the jaws: current understanding of its pathophysiology and treatment. Br J Oral Maxillofac Surg 2008; 46 (08) 653-660
12 Kolokythas A, Rasmussen JT, Reardon J, Feng C. Management of osteoradionecrosis of the jaws with pentoxifylline-tocopherol: a systematic review of the literature and meta-analysis. Int J Oral Maxillofac Surg 2019; 48 (02) 173-180
13 Magremanne M. Successful treatment of grade III osteoradionecrosis with mandibular fracture with pentoxifylline, tocopherol and clodronate. J Stomatol Oral Maxillofac Surg 2018; 119 (06) 518-522
14 Aggarwal K, Goutam M, Singh M. et al. Prophylactic use of pentoxifylline and tocopherol in patients undergoing dental extractions following radiotherapy for head and neck cancer. Niger J Surg 2017; 23 (02) 130-133
15 Glicksman JT, Khalili S, Fung K, Parnes LS, Agrawal SK. Pentoxifylline-tocopherol-clodronate combination: a novel treatment for osteoradionecrosis of the temporal bone. Head Neck 2015; 37 (12) E191-E193
16 Robard L, Louis MY, Blanchard D, Babin E, Delanian S. Medical treatment of osteoradionecrosis of the mandible by PENTOCLO: preliminary results. Eur Ann Otorhinolaryngol Head Neck Dis 2014; 131 (06) 333-338
17 Delanian S, Chatel C, Porcher R, Depondt J, Lefaix JL. Complete restoration of refractory mandibular osteoradionecrosis by prolonged treatment with a pentoxifylline-tocopherol-clodronate combination (PENTOCLO): a phase II trial. Int J Radiat Oncol Biol Phys 2011; 80 (03) 832-839
18 Jenwitheesuk K, Mahakkanukrauh A, Punjaruk W. et al. Efficacy of adjunctive hyperbaric oxygen therapy in osteoradionecrosis. Biores Open Access 2018; 7 (01) 145-149
19 Bennett MH, Feldmeier J, Hampson N, Smee R, Milross C. Hyperbaric oxygen therapy for late radiation tissue injury. Cochrane Database Syst Rev 2012; (05) CD005005
20 Annane D, Depondt J, Aubert P. et al. Hyperbaric oxygen therapy for radionecrosis of the jaw: a randomized, placebo-controlled, double-blind trial from the ORN96 study group. J Clin Oncol 2004; 22 (24) 4893-4900
21 Kalra GS, Midya M, Bedi M. Access to the skull base - maxillary swing procedure - long term analysis. Ann Maxillofac Surg 2018; 8 (01) 86-90
22 Huang WB, Wong STS, Chan JYW. Role of surgery in the treatment of osteoradionecrosis and its complications after radiotherapy for nasopharyngeal carcinoma. Head Neck 2018; 40 (02) 369-376
23 Choi NY, Kim HJ, Baek CH. Surgical management of extensive osteoradionecrosis in nasopharyngeal carcinoma patients with the maxillary swing approach and free muscular flaps. Clin Otolaryngol 2017; 42 (05) 1100-1104
24 Hao SP, Chen HC, Wei FC, Chen CY, Yeh AR, Su JL. Systematic management of osteoradionecrosis in the head and neck. Laryngoscope 1999; 109 (08) 1324-1327 , discussion 1327–1328
25 Strawberry CW, Jacobs JS, McCraw JB. Reconstruction for cervical irradiation ulcers with myocutaneous flaps. Head Neck Surg 1984; 6 (04) 836-841
26 Fujioka M. Surgical Reconstruction of Radiation Injuries. Adv Wound Care (New Rochelle) 2014; 3 (01) 25-37
27 Waghmare CM. Radiation burn--from mechanism to management. Burns 2013; 39 (02) 212-219
28 Liu JK, Schmidt RF, Choudhry OJ, Shukla PA, Eloy JA. Surgical nuances for nasoseptal flap reconstruction of cranial base defects with high-flow cerebrospinal fluid leaks after endoscopic skull base surgery. Neurosurg Focus 2012; 32 (06) E7
29 Wheless SA, McKinney KA, Carrau RL. et al. Nasoseptal flap closure of traumatic cerebrospinal fluid leaks. Skull Base 2011; 21 (02) 93-98
30 Hadad G, Bassagasteguy L, Carrau RL. et al. A novel reconstructive technique after endoscopic expanded endonasal approaches: vascular pedicle nasoseptal flap. Laryngoscope 2006; 116 (10) 1882-1886
31 Cheng KY, Lee KW, Chiang FY, Ho KY, Kuo WR. Rupture of radiation-induced internal carotid artery pseudoaneurysm in a patient with nasopharyngeal carcinoma--spontaneous occlusion of carotid artery due to long-term embolizing performance. Head Neck 2008; 30 (08) 1132-1135