TRIO Best Practice articles are brief, structured reviews designed to provide the busy clinician with a handy outline and reference for day-to-day clinical decision making. The ENTtoday summaries below include the Background and Best Practice sections of the original article. View the complete Laryngoscope articles free of charge.
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January 2016Background
Mandibular osteoradionecrosis (ORN) is a potentially debilitating complication of ionizing radiotherapy, with an incidence-reported to range from 5% to 15%. ORN is most commonly defined as exposed, irradiated, nonhealing bone of at least two to three months duration without evidence of tumor recurrence. Although this complication often occurs within the first 6 to 12 months following radiotherapy, reports of late cases imply a lifelong risk. Risk factors for ORN include radiation dose (>60 Gy), previous dental extraction, radiation to the posterior mandible, infection, large tumor size, malnutrition, poor oral hygiene, and alcohol and tobacco abuse. Although most often associated with dental extractions or mucosal trauma, spontaneous cases of ORN are described.
The clinical presentation of ORN ranges from mild pain, dysesthesia, halitosis, and exposed necrotic bone, to more advanced symptoms including intractable pain, infection, orocutaneous fistula, and pathologic fracture. There are numerous classification systems used to describe the severity of ORN. Most involve a staging system from mild to severe based on both clinical and radiographic findings. Historically, the treatment of ORN employed a multimodality approach utilizing conservative measures for early disease (antibiotic therapy, debridement, and irrigation) while reserving surgical resection and reconstruction for more advanced or refractory cases. Hyperbaric oxygen (HBO) therapy continues to be employed for treatment of all stages of ORN despite its lack of proven efficacy and the lack of randomized controlled trial data.
Best Practice
Widely accepted evidence-based guidelines for the use of HBO therapy in the prevention and management of ORN have not been established. Protocols utilizing HBO therapy, once considered the standard of care, are no longer recommended for the prevention or treatment of ORN. Newer theories describing the pathogenesis of ORN have stimulated the evolution of conservative management strategies to include drugs such as pentoxifylline and tocopherol. Bony replacement with free flap reconstruction is appropriate for patients with severe ORN that fail to resolve with conservative treatment (Laryngoscope. 2013;123:555–556).