Cases reported "Osteoradionecrosis"

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1/34. Delayed radionecrosis of the larynx.

    radiation has been used to treat carcinoma of the larynx for more than 70 years. Radionecrosis is a well-known complication of this modality when treating head and neck neoplasms. It has been described in the temporal bone, midface, mandible, and larynx. Laryngeal radionecrosis is manifested clinically by dysphagia, odynophagia, respiratory obstruction, hoarseness, and recurrent aspiration. The vast majority of patients who develop laryngeal radionecrosis present with these symptoms within 1 year of treatment; however, delayed presentations have been reported up to 25 years after radiotherapy. We present, in a retrospective case analysis, an unusual case of laryngeal radionecrosis in a patient who presented more than 50 years after treatment with radiotherapy for carcinoma of the larynx. The cases of delayed laryngeal necrosis in the literature are presented. This represents the longest interval between treatment and presentation in the literature. The details of the presentation, clinical course, and diagnostic imaging are discussed. The pathogenesis, clinical features, and treatment options for this rare complication are reviewed. Early stage (Chandler I and II) laryngeal radionecrosis may be treated conservatively and often observed. Late stage (Chandler III and IV) cases are medical emergencies, occasionally resulting in significant morbidity or mortality. Aggressive diagnostic and treatment measures must be implemented in these cases to improve outcome. This case represents the longest interval between initial treatment and presentation of osteoradionecrosis in the literature. A structured diagnostic and therapeutic approach is essential in managing this difficult problem.
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2/34. osteoradionecrosis of the hyoid bone: a report of 3 cases.

    PURPOSE: osteonecrosis of the hyoid bone is an uncommon disease that has only been described occasionally in the literature. MATERIALS AND methods: We report 3 cases of osteonecrosis of the hyoid bone after radiation therapy for carcinoma at various sites in the head and neck region. RESULTS: Imaging computed tomography (CT) scans were performed for all 3 cases and did aid in the diagnosis. In 1 case, a 201thallium scintigraphy and a bone scan (99mtechnetium-diphosphonate) were performed and this confirmed the diagnosis of osteoradionecrosis. CONCLUSION: osteoradionecrosis of the hyoid bone may be misdiagnosed as recurrent neoplasm. Although recurrent or persistent neoplastic disease must initially be ruled out, it is subsequently important to correctly identify osteonecrosis of the hyoid bone, because its surgical treatment is simple and the prognosis is good.
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3/34. osteoradionecrosis of the cervical vertebrae and occipital bone: a case report and brief review of the literature.

    osteoradionecrosis (ORN) is a common complication of radiation therapy. We present the first case reported in the literature of ORN involving the first and second cervical vertebrae and occipital bone in a patient who was treated with surgery and radiation therapy 9 years prior for a TxN3M0 squamous cell carcinoma of the left neck arising from an unknown primary origin. A brief review of the pathophysiology and treatment of this pathological process is also presented. Although the mandible is the most commonly affected site in the head and neck, ORN may develop in an unusual location without any preceding trauma and display an insidious but rapidly progressive course. The pathophysiology of ORN is believed to be a complex metabolic and homeostatic deficiency created by radiation-induced cellular injury and fibrosis, which is characterized by the formation of hypoxic, hypovascular, and hypocellular tissue. The irradiated bone loses its capability to increase the metabolic requirements and nutrient supply required to replace normal collagen and cellular components lost through routine wear. This results in tissue breakdown and the formation of a chronic nonhealing wound. infection plays only a contaminant role, with trauma being a possible initiating factor. diagnosis of ORN begins with a complete physical examination, including fiberoptic examination and biopsy of any suspicious lesion to eliminate the possibility of recurrent tumor. Treatment of ORN commonly requires the debridement of necrotic bone and hyperbaric oxygen therapy. The head and neck surgeon must possess a high degree of suspicion to promptly diagnose ORN and initiate early treatment. Because of similarities in clinical presentation, the most important step in the initial management of suspected ORN is to eliminate the possibility of tumor recurrence or a new primary.
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4/34. Possibilities of preventing osteoradionecrosis during complex therapy of tumors of the oral cavity.

    In recent years, there has been a dramatic increase in the number of tumors of the head and neck. Their successful treatment is one of the greatest challenges for physicians dealing with oncotherapy. An organic part of the complex therapy is preoperative or postoperative irradiation. Application of this is accompanied by a lower risk of recurrences, and by a higher proportion of cured patients. Unfortunately, irradiation also has a disadvantage: the development of osteoradionecrosis, a special form of osteomyelitis, in some patients (mainly in those cases where irradiation occurs after bone resection or after partial removal of the periosteum). Once the clinical picture of this irradiation complication has developed, its treatment is very difficult. A significant result or complete freedom from complaints can be attained only rarely. attention must therefore be focussed primarily on prevention, and the oral surgeon, the oncoradiologist and the patient too can all do much to help prevent the occurrence of osteoradionecrosis. Through coupling of an up-to-date, functional surgical attitude with knowledge relating to modern radiology and radiation physics, the way may be opened to forestall this complication that is so difficult to cure.
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5/34. osteoradionecrosis of the mandible.

    osteoradionecrosis is a major complication of surgery or trauma in previously irradiated bone in the absence of tumor persistence. radiation-induced vascular insufficiency rather than infection causes bone death. It occurs most commonly in the mandible after head and neck irradiation. risk factors include the total radiation dose, modality of treatment, fraction size and dose rate, oral hygiene, timing of tooth extractions as well as the continued use of tobacco and alcohol. This condition is often painful, debilitating, and may result in significant bone loss. The recommended treatment guidelines are irrigation, antibiotics, hyperbaric oxygen therapy, and surgical techniques, including hemimandibulectomy and graft placements.
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6/34. An interim extraoral prosthesis used for the rehabilitation of a patient treated for osteoradionecrosis of the mandible: a clinical report.

    In patients with tumors of the head and neck, ionizing radiation delivered in dosages that will kill cancer cells induces unavoidable changes in normal tissue. Bone cells and vascularity may be irreversibly injured, leaving devitalized bone susceptible to the development of osteoradionecrosis. This clinical report describes the fabrication of an acrylic/rubber prosthesis retained by an orthodontic headgear. The prosthesis was used to improve the mastication, speech, and saliva control of a patient treated for osteoradionecrosis of the mandible.
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7/34. Internal carotid artery hemorrhage after irradiation and osteoradionecrosis of the skull base.

    OBJECTIVE: To evaluate the clinical presentation and management of internal carotid artery rupture after irradiation and osteoradionecrosis of the skull base. STUDY DESIGN AND SETTING: A retrospective review of the patients in an otorhinolaryngology-head and neck secondary and tertiary referral center. METHODOLOGY: From January 1993 to December 1996, patients with hemorrhage from internal carotid artery as a complication of irradiation and osteoradionecrosis of skull base were reviewed and analyzed. RESULTS: Four patients with internal carotid arterial rupture were included in this study. angiography was performed in all cases. Embolization of the aneurysm was performed on 2 patients and the remaining 2 patients underwent occlusion of their internal carotid arteries. Three of the 4 patients did not survive. The fourth is currently alive and well 18 months after embolization of 1 internal carotid artery. CONCLUSION: skull base osteoradionecrosis with bleeding from internal carotid artery is a potentially fatal complication of irradiation. angiography was the mainstay of diagnosis with embolization of the aneurysm and embolization or ligation of the internal carotid artery being the management options. Internal carotid artery occlusion is the definitive treatment provided cross circulation is adequate. SIGNIFICANCE: The advantages and disadvantages of the treatment options are discussed and a management protocol is proposed.
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8/34. osteoradionecrosis of the mandible after oromandibular cancer surgery.

    Although postoperative radiotherapy has proved effective in improving local control and survival in patients with head and neck cancers, its complications, especially mandibular osteoradionecrosis, reduce the quality of life. Mandibular surgery before the radiotherapy adds an additional risk factor for osteoradionecrosis. This study reviews patients in Chang Gung Memorial Hospital, Taipei, taiwan, over a 10-year period, who underwent intraoral cancer resection followed by postoperative radiotherapy and thereafter developed osteoradionecrosis of the mandible. A total of 24 men and three women with a mean age of 49.9 years were identified and included in the study. In 10 cases, tumor resection was performed with a marginal mandibulectomy; in eight cases, tumor resection was performed after mandibular osteotomy; and in three cases, a segmental mandibulectomy was performed, and the defect was reconstructed with a fibula osteoseptocutaneous flap. In six cases, tumor excisions were performed without interfering with the mandibular continuity. patients received postoperative external beam radiotherapy into the primary site and the neck, with a mean dose ( /-SD) of 5900 /- 1300 cGy in an average of 35 fractions during an average of 6.5 weeks. The average elapsed time between the end of radiation therapy and clinical diagnosis of osteoradionecrosis of the mandible was 11.2 months (range, 2 to 36 months). The time elapse between the end of the radiation therapy and the diagnosis of osteoradionecrosis was influenced by initial treatment (Kruskal-Wallis test: n = 27, chi-square = 12.884, p < 0.005), and this period was shorter if the mandibular osteotomy or marginal mandibulectomy was performed (the two lowest mean ranks in the test). However, if the initial surgery resulted in a segmental mandibulectomy reconstructed with a fibula osteoseptocutaneous flap, onset of the osteoradionecrosis was relatively late (Kruskal-Wallis test: n = 21, chi-square = 7.731, p = 0.052). After resection of osteoradionecrotic bone and surrounding soft tissue, 22 patients underwent reconstructive procedures with a fibula osteoseptocutaneous flap, and five patients underwent reconstructive procedures with an inferior genicular artery osteoperiosteal cutaneous flap. One fibula osteoseptocutaneous flap showed total failure and another showed a 25 percent skin loss; both were revised with pedicled flaps. The skin paddle of an inferior genicular artery flap was replaced with an anterolateral thigh flap because of anatomic variation of the skin vessel. Once the diagnosis of osteoradionecrosis is established, replacement of the dead bone and surrounding tissue with a vascularized free bone flap is inevitable, and a composite osteocutaneous free flap is a good option.
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9/34. The pedicled occipital artery scalp flap for salvage surgery of the neck.

    A small group of patients with complex head and neck cancer present with problems of wound healing following radiotherapy and reconstructive surgery. Provision of skin cover to the neck in these cases is often required and presents a challenge to the reconstructive surgeon. We present the use of a pedicled scalp flap based on the occipital artery for such defects. This flap is an axial patterned scalp flap incorporating hair-bearing skin. It may be up to 15 cm wide and can reach beyond the midline of the chin. The anatomy of the flap is described and its use illustrated in three cases. This flap is a useful addition to the options for reconstruction of neck defects in patients with head and neck cancer.
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10/34. Management of cervical metastases in advanced squamous cell carcinoma of the base of tongue.

    OBJECTIVE: To clarify the role of neck dissection following primary radiotherapy for treatment of squamous cell carcinoma of the base of tongue. DESIGN: Case series. SETTING: Academic, tertiary care medical center. patients OR OTHER PARTICIPANTS: A consecutive series of 45 patients with biopsy-proven squamous cell carcinoma of the base of tongue and cervical metastases treated with primary radiotherapy at The University of california, san francisco, was examined. patients with a prior history of neck irradiation, neck dissection, or head and neck cancer within 5 years were excluded. MAIN OUTCOME MEASURES: overall survival and regional control. RESULTS: Of the 45 patients treated with definitive radiotherapy, 25 (56%) achieved a complete response, 13 (29%) achieved a partial response, 4 (9%) were nonresponders, and 3 (7%) did not complete radiotherapy. Two thirds of the complete responders had N2 or N3 disease; 3 had recurrences in the neck, 1 of which was an isolated neck recurrence. Of the 13 partial responders, 5 had isolated persistence of disease, with 4 undergoing neck dissections. The only long-term survivors among the partial responders were those 4 who underwent a neck dissection. overall survival was 50% at 3 years and 32% at 5 years. Regional control for complete responders was 84% at 5 years. CONCLUSIONS: The low rate of isolated regional recurrence in patients with a complete response to radiotherapy supports the practice of surveillance alone in such patients. patients with less than a complete response appear to benefit from prompt surgical salvage.
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