Management of Temporal Bone Osteoradionecrosis: Surgical and Adjunctive Therapies

Objective: To investigate surgical and adjunctive therapies and associated outcomes in patients with radiotherapy induced temporal bone osteoradionecrosis. Study Design: Retrospective Case Review Setting: Tertiary referral center Patients: Six patients diagnosed with radiotherapy induced ORN of the temporal bone treated at Duke U Medical Center between May 2007 to August 2008. Interventions: The clinical history, therapeutic interventions and disease specific outcomes were retrospectively reviewed for the study patients. All six patients were treated with surgical therapy. Four patients underwent lateral temporal bone resection while two others underwent complete mastoidectomies. One underwent canalplasty with meatoplasty. All six patients underwent tissue transfer to the resection site, 3 with temporalis muscle flaps, 1 with a temporalparietal fascial flap, 1 with rectus free tissue transfer, and 1 with epidermal transfer. Four patients underwent closure of the EAC. Three patients underwent hyperbaric oxygen therapy. All patients underwent prolonged courses of antibiotic therapy. Main Outcome Measures: 1) Patients free from temporal bone necrosis and infection. 2) Complete healing of the primary wound. Mean follow up was 13.5 months. Results 1. Ewing J. Radiation osteitis. Acta Radiol 1926;6:399-412 2. Block E. Radiation injury of the temporal bone. Z Hals Nas Ohrenheilkol 1952;3:45-46 3. Ramsden et al. Osteoradionecrosis of the temproral bone. J Laryngo Otol 1975;89:941-955 4. Xu el at. Surgical Treatment of ORN of the temporal bone in patients with NP carcinoma. J Larungol Otol. 2008;122:1175-79 5. Narozny et al. Hyperbaric oxygen therapy in the treatment of complications of irradiation in the head and neck area. Undersea Hyperb Med 2005;32(2):103-10 References Methods: This study is retrospective case review of medical records of patients treated at Duke University Medical Center between 2006 to the present. Patients with the diagnosis of osteoradionecrosis of the temporal bone were identified. The records of the identified patients were reviewed and the therapeutic interventions and clinical outcomes will be noted. The main outcome measures will include patients free from temporal bone necrosis and infection, and complete healing of the primary wound. Methods and Materials Conclusions Table 1: Clinical Characteristics Age/Sex Initial Diagnosis Interval to ORN Presenting Symptoms Patient 1 64/F Recurrent multiple pleomorphic adenoma 144 months otalgia, otorrhea, fevers Patient 2 61/M Auricular SSCa 15 months otalgia, otorrhea, Patient 3 71/F Parotid ductal carcinoma 132 months Otorrhea, vertigo Patient 4 55/F Parotid Mucoepidermoid Ca 36 months Disequilibrium, otorrhea, otalgia Patient 5 77/M Cutaneous SSCa with locoregional spread 24 months Canal stenosis, otorrhea, facial nerve paralysis Patient 6 69/M Cutaneous SSCa 12 months Skin breakdown, otorrhea, vertigo Table 2: Treatments Medical Therapy Surgical Therapy HBO Patient 1 Abx/debridement/HBO x 7 months Lateral temporal bone resection, superficial TP facial flap Yes – 39 dives Patient 2 Abx/debridements x 6 months Lateral temporal bone resection, temporalis muscle flap No Patient 3 Abx/debridements x 8 wks, then abx/HBO between surgery 1st: Typanomastoidectomy 2nd: EAC debridement, closure with temporalis muscle flap Yes – 30 between surgeries Patient 4 Abx/debridements x 2 yrs MR mastoidectomy, closure of EAC, temporalis muscle flap No Patient 5 Abx/debridements Canalplasty with debridement, meatoplasty No Patient 6 Abx/debridements Lateral temporal bone resection, Rectus free tissue transfer Yes – 70 dives pre-op Table 3: Treatment Results Interval from surgery Status at last follow up Complications Patient 1 10 mo Healed without evidence of infection/necrosis Mastocutanoues fistula, 8 months post surgery, resolved with conservative therapy Patient 2 11 mo Healed without evidence of infection/necrosis Minor wound deheisence post-op Patient 3 23 mo Pinpoint EAC Fistula with occasional drainage Wound breakdown after 1st tympanomastoidectomy Patient 4 18 mo Healed without evidence of infection/necrosis none Patient 5 8 mo Recurrent SSCa none Patient 6 10 mo Healed without evidence of infection/necrosis none Figure 1. Preoperative Temporal Bone CT scans demonstrating tegmen and lateral SCC deheisence in patient 6. Five of six (83.6%) patients were free of temporal bone necrosis and infection at last follow up. One patient has a pinpoint opening in the EAC which drains periodically and responds to local measures. Three patients (50%) suffered post-op complications: One patient suffered partial necrosis of the external ear which was treated with regular in-office debridements and antibiotics. One patient developed an abscess in the cavity which resolved after drainage and antibiotics. One patient suffered wound dehiscence post operatively which healed with conservative therapy. Another patient developed a post op mastocutaneous fistula which responded to local measures. There was no statistical association with HBO therapy and outcome. 1. ORN of the temporal bone presents a difficult clinical problem which often requires both surgical and medical therapies. 2. Goals of treatment include removal of all necrotic tissue, and resolution of chronic infection. Obliteration of infected cavities with vascularised flaps is effective. 3. Postoperative wound complications are common. 4. Hyperbaric oxygen may be a useful adjunct to therapy but is not sufficient as a solo modality. Radiotherapy is a common therapeutic modality used to treat malignant neoplasms in the head and neck. Osteoradionecrosis (ORN) of the temporal bone is a rare complication of radiotherapy, but the associated morbity is serious and can be difficult to successfully treat. Osteoradionecrosis has been reported since the clinical use of radiation therapy with Dr. Ewing publishing one of the first reports in 1926 (1). ORN of the temporal bone secondary to radiation therapy for malignancy was described by Dr. Block in 1953. (2) In 1975, Ramsden published a series of 29 patients with temporal bone ORN and he devised a classification schema dividing cases into two groups: localized or diffuse. Cases characterized as localized were noted to have involvement of the EAC only while diffuse cases involved the mastoid and/or middle ear as well. (3) Temporal bone osteoradionecrosis is a difficult clinical problem with significant associated morbidity. This retrospective review documents our experience utilizing medical, surgical and hyperbaric oxygen therapies. Background Results