Surgical Challenges in the Management of Advanced Osteoradionecrosis of the Mandible

Review Article

Austin J Otolaryngol. 2015;2(3): 1036.

Surgical Challenges in the Management of Advanced Osteoradionecrosis of the Mandible

Jacob D’Souza1*, Martin Batstone2 and Simon Rogers3,4

1Maxillofacial Unit, Royal Surrey County Hospital, UK

2Maxillofacial Unit, Royal Brisbane Hospital, Australia

3Regional Maxillofacial Unit, Aintree University Hospital, UK

4Evidence-Based Practice Research Centre (EPRC), Edge Hill University, UK

*Corresponding author: Jacob D’Souza, Maxillofacial/Head & Neck Surgeon, Royal Surrey County Hospital, Egerton Road, Guildford, GU2 7XX, UK

Received: February 12, 2015; Accepted: March 24, 2015; Published: March 26, 2015

Abstract

Advanced Osteoradionecrosis is a severe problem associated with complex oro-cutaneous damage and pathological fracture. The morbidity is significant, oth in terms of aesthetics and function, with detrimental consequences on the quality of life. The mainstay of treatment for advanced ORN is radical surgery involving free tissue transfer. The challenging nature of such reconstructive urgery is set out in the context of a patient previously treated for cancer, whether surgery and radiotherapy or chemoradiotherapy, and therefore significant comorbidities. The clinician is thus presented with challenging decisions to bemade with regards to conservative vs. radical treatment of these patients and the choice of reconstruction.

The aim of this paper is to highlight the difficulties encountered in the decision-making process and the reconstructive challenges of ORN, reflecting on the experience of the authors at the three international centres. For the ease of description, we have divided the problems and solutions encountered into eight different sections.

Keywords: Osteoradionecrosis; Free flap; Vascular access; Soft tissue; Bone; Plates; Reconstruction

Introduction

Osteoradionecrosis (ORN) may be defined as ‘exposed and necrotic bone associated with ulcerated or necrotic soft tissue which persists for greater than 3 months in an area that had been previously irradiated, and not caused by tumour recurrence’ [1]. The risk for developing ORN is life-long, but the majority of cases develop within the first 2 years following radiotherapy (RT) [2,3]. The incidence of ORN is higher in the mandible, especially the dentate mandible [1,2,4]. The progressive loss of soft and hard tissues has adverse effects on the quality of life (QOL). The management of ORN, be it conservative or surgical, is a major challenge. Surgical intervention should be considered in the context of the patient’s medical co-morbidities and social situation. The extent of surgical resection should prevent the unfavourable outcome of non-union, risk of plate infection and progressive ORN. Of further significance is often the lack of suitable vessels in the neck, both in terms of availability and adequate diameter and free flap (FF) donor sites [5,6]. A multi-disciplinary team (MDT) approach, led by an experienced reconstructive surgeon is mandatory in achieving a favourable outcome. The purpose of this paper is to share our experience from three major international centres, the difficulties encountered in the decision-making process and surgery, focusing especially on reconstruction. The centres are University Hospital Aintree, Liverpool, UK; Royal Surrey County Hospital, Guildford, UK and Royal Brisbane Hospital, Brisbane, Australia (Table 1).