What Is the Current Management of Osteoradionecrosis of the Temporal Bone Following Head and Neck Cancer Radiotherapy?

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BACKGROUND

Osteoradionecrosis (ORN) of the temporal bone is a rare but serious late-stage complication of head and neck radiation. The most common symptoms include otorrhea, hearing loss, otalgia, tinnitus, and facial nerve palsy following radiation therapy for cancers of the nasopharynx, parotid, ear, skin, and central nervous system. The pathophysiology of temporal bone ORN is related to the lateral/superficial location of the bone with respect to skin and soft tissue, which provides limited protection, reduced blood supply, and easy pathogen access via the Eustachian tube. While the true incidence of ORN of the temporal bone is unknown, a single-institution retrospective chart review of 82 patients undergoing surgery and subsequent radiotherapy for head and neck malignancies over 10 years from 2011 suggested an 8.5% incidence. Though ORN of the temporal bone is rare, progression of the disease can contribute to intracranial complications (i.e., abscess, central nervous system infections) as well as cranial neuropathies, with even benign symptoms having a significant negative impact on patients’ quality of life.

There is wide variability regarding the management of this condition, with limited multi-institutional research to provide comprehensive evidence-based management. This, in part, is due to the rarity of the condition and the low sample size of patients included in current studies. As there are no prospective interventional trials for this disease, we are limited to treatments based upon case series.

BEST PRACTICE

Temporal bone ORN is a rare but devastating complication of treatment for certain head and neck malignancies. Evidence suggests that medical management with topical antimicrobials, in-office debridement, PENTO [a protocol combining pentoxifylline and tocopherol], HBO [hyperbaric oxygen] therapy, and pain management may be an effective treatment for all patients, particularly those with localized disease. Surgical management should be reserved for those with diffuse disease, intractable pain, uncontrolled infections, cholesteatomas, and ages greater than 60 years. Further research needs to be done with randomized control trials and on novel methods to determine the best course of action for patients.