Download PDF
J Neurol Surg B Skull Base 2022; 83(S 02): e521-e529
DOI: 10.1055/s-0041-1733973
Original Article

Treatment Outcomes for Osteoradionecrosis of the Central Skull Base: A Systematic Review

Noah Shaikh 
1   Department of Otolaryngology, West Virginia University, Morgantown, West Virginia, United States
,
Chadi A. Makary 
1   Department of Otolaryngology, West Virginia University, Morgantown, West Virginia, United States
,
Lindsey Ryan
2   Department of Otolaryngology, Augusta University, Augusta, Georgia, United States
,
Camilo Reyes
2   Department of Otolaryngology, Augusta University, Augusta, Georgia, United States
› Author Affiliations
› Further Information
Also available at
    Permissions and Reprints

Abstract

Objective Osteoradionecrosis (ORN) of the skull base can have catastrophic consequences if not detected early and managed appropriately. This is a systematic review of the different treatment modalities for skull base ORN and their outcomes.

Study Design This study is a systematic review.

Materials and Methods Two researchers extracted information including patient population, surgical technique, outcomes of interest, and study design. A computerized search of Medline, Embase, and the Cochrane library (January 1990–June 2020) looked for several papers on the subject of skull base ORN.

Results A total of 29 studies had met inclusion criteria, including data from 333 patients. Nasopharyngeal carcinoma was the most common primary tumor (85%). Average age at diagnosis of ORN was 55.9 years (range = 15–80 years) and 72.3% of patients were males. The average time to diagnosis of ORN after radiation therapy was 77 months with an average radiation dose of 76.2 Gy (range = 46–202 Gy). Nighty-eight patients (29.4%) also had chemotherapy as part of their treatment regimen. Although all parts of the central skull base were reported to be involved, the clivus and sphenoid bone were the most commonly reported subsites. Trial of medical treatment had a success rate of 41.1%. About 66% of patients needed surgical treatment, either primarily or after failing medical treatment. Success rate was 77.3%. Overall, the surgical treatment was superior to medical treatment (p < 0.0001).

Conclusion ORN is a rare complication of the treatment of skull base tumors. Most cases require surgical treatment, including endoscopic debridement or free flap reconstruction, which has a high success rate.

Level of Evidence Level 3 evidence as a systematic review of case studies, case reports, retrospective, and prospective trials with no blinding or controls.

Keywords

osteoradionecrosis - skull base - reconstruction - side effects - rhinology - evidence-based medicine - radiation therapy - systematic review - outcome

Authors' Contributions

C.A.M., L.R., and C.R. involved in the conception and design of study. C.A.M., L.R., and N.S. supported in the acquisition of data. C.A.M., L.R., N.S., and C.R. dedicated to analysis and interpretation of data. C.A.M. and L.R. helped in drafting of article. C.A.M., L.R., N.S., and C.R. critically revised the article.


Note

This study is a systematic review of literature and does not require institutional review board approval.


Supplementary Material



Publication History

Received: 20 December 2020

Accepted: 11 July 2021

Article published online:
18 August 2021

© 2021. Thieme. All rights reserved.

Georg Thieme Verlag KG
Rüdigerstraße 14, 70469 Stuttgart, Germany

 

  • References

  • 1 Eiving J. Radiation osteitis. Acta Radiol 1926; 6 (1–6): 399-412
    CrossrefPubMedGoogle Scholar
  • 2 Rice N, Polyzois I, Ekanayake K, Omer O, Stassen LF. The management of osteoradionecrosis of the jaws–a review. Surgeon 2015; 13 (02) 101-109
    CrossrefPubMedGoogle Scholar
  • 3 Adel M, Chang KP. Using a nasoseptal flap for the reconstruction of osteoradionecrosis in nasopharyngeal carcinoma: a case report. J Otolaryngol Head Neck Surg 2016; 45: 27
    CrossrefPubMedGoogle Scholar
  • 4 Delanian S, Lefaix JL. The radiation-induced fibroatrophic process: therapeutic perspective via the antioxidant pathway. Radiother Oncol 2004; 73 (02) 119-131
    CrossrefPubMedGoogle Scholar
  • 5 Ang E, Black C, Irish J. et al. Reconstructive options in the treatment of osteoradionecrosis of the craniomaxillofacial skeleton. Br J Plast Surg 2003; 56 (02) 92-99
    CrossrefPubMedGoogle Scholar
  • 6 Epstein J, van der Meij E, McKenzie M, Wong F, Lepawsky M, Stevenson-Moore P. Postradiation osteonecrosis of the mandible: a long-term follow-up study. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1997; 83 (06) 657-662
    CrossrefPubMedGoogle Scholar
  • 7 Teng MS, Futran ND. Osteoradionecrosis of the mandible. Curr Opin Otolaryngol Head Neck Surg 2005; 13 (04) 217-221
    CrossrefPubMedGoogle Scholar
  • 8 Schwartz HC, Kagan AR. Osteoradionecrosis of the mandible: scientific basis for clinical staging. Am J Clin Oncol 2002; 25 (02) 168-171
    CrossrefPubMedGoogle Scholar
  • 9 Murray CG, Daly TE, Zimmerman SO. The relationship between dental disease and radiation necrosis of the mandible. Oral Surg Oral Med Oral Pathol 1980; 49 (02) 99-104
    CrossrefPubMedGoogle Scholar
  • 10 Reuther T, Schuster T, Mende U, Kübler A. Osteoradionecrosis of the jaws as a side effect of radiotherapy of head and neck tumour patients–a report of a thirty year retrospective review. Int J Oral Maxillofac Surg 2003; 32 (03) 289-295
    CrossrefPubMedGoogle Scholar
  • 11 Thorn JJ, Hansen HS, Specht L, Bastholt L. Osteoradionecrosis of the jaws: clinical characteristics and relation to the field of irradiation. J Oral Maxillofac Surg 2000; 58 (10) 1088-1093 , discussion 1093–1095
    CrossrefPubMedGoogle Scholar
  • 12 Marx RE. A new concept in the treatment of osteoradionecrosis. J Oral Maxillofac Surg 1983; 41 (06) 351-357
    CrossrefPubMedGoogle Scholar
  • 13 Støre G, Boysen M. Mandibular osteoradionecrosis: clinical behaviour and diagnostic aspects. Clin Otolaryngol Allied Sci 2000; 25 (05) 378-384
    CrossrefPubMedGoogle Scholar
  • 14 Oh HK, Chambers MS, Martin JW, Lim HJ, Park HJ. Osteoradionecrosis of the mandible: treatment outcomes and factors influencing the progress of osteoradionecrosis. J Oral Maxillofac Surg 2009; 67 (07) 1378-1386
    CrossrefPubMedGoogle Scholar
  • 15 Beumer J, Harrison R, Sanders B, Kurrasch M. Osteoradionecrosis: predisposing factors and outcomes of therapy. Head Neck Surg 1984; 6 (04) 819-827
    CrossrefPubMedGoogle Scholar
  • 16 Hart GB, Mainous EG. The treatment of radiation necrosis with hyperbaric oxygen (OHP). Cancer 1976; 37 (06) 2580-2585
    CrossrefPubMedGoogle Scholar
  • 17 Mainous EG, Hart GB. Osteoradionecrosis of the mandible. Treatment with hyperbaric oxygen. Arch Otolaryngol 1975; 101 (03) 173-177
    CrossrefPubMedGoogle Scholar
  • 18 Davis JC, Dunn JM, Gates GA, Heimbach RD. Hyperbaric oxygen. A new adjunct in the management of radiation necrosis. Arch Otolaryngol 1979; 105 (02) 58-61
    CrossrefPubMedGoogle Scholar
  • 19 Kraut RA. Prophylactic hyperbaric oxygen to avoid osteoradionecrosis when extractions follow radiation therapy. Clin Prev Dent 1985; 7 (05) 17-20
    PubMedGoogle Scholar
  • 20 Maier A, Gaggl A, Klemen H. et al. Review of severe osteoradionecrosis treated by surgery alone or surgery with postoperative hyperbaric oxygenation. Br J Oral Maxillofac Surg 2000; 38 (03) 173-176
    CrossrefPubMedGoogle Scholar
  • 21 Delanian S, Chatel C, Porcher R, Depondt J, Lefaix JL. Complete restoration of refractory mandibular osteoradionecrosis by prolonged treatment with a pentoxifylline-tocopherol-clodronate combination (PENTOCLO): a phase II trial. Int J Radiat Oncol Biol Phys 2011; 80 (03) 832-839
    CrossrefPubMedGoogle Scholar
  • 22 Huang WB, Wong STS, Chan JYW. Role of surgery in the treatment of osteoradionecrosis and its complications after radiotherapy for nasopharyngeal carcinoma. Head Neck 2018; 40 (02) 369-376
    CrossrefPubMedGoogle Scholar
  • 23 Daoudi H, Labeyrie MA, Guillerm S. et al. Multimodal strategy for the management of sphenoid osteoradionecrosis: preliminary results. Laryngoscope Investig Otolaryngol 2020; 5 (01) 19-23
    CrossrefPubMedGoogle Scholar
  • 24 Liu J, Ning X, Sun X, Lu H, Gu Y, Wang D. Endoscopic sequestrectomy for skull base osteoradionecrosis in nasopharyngeal carcinoma patients: a 10-year experience. Int J Clin Oncol 2019; 24 (03) 248-255
    CrossrefPubMedGoogle Scholar
  • 25 Habib A, Hanasono MM, DeMonte F. et al. Surgical management of skull base osteoradionecrosis in the cancer population - treatment outcomes and predictors of recurrence: a case series. Oper Neurosurg (Hagerstown) 2020; 19 (04) 364-374
    CrossrefPubMedGoogle Scholar
  • 26 Hirsch DL, Bell RB, Dierks EJ, Potter JK, Potter BE. Analysis of microvascular free flaps for reconstruction of advanced mandibular osteoradionecrosis: a retrospective cohort study. J Oral Maxillofac Surg 2008; 66 (12) 2545-2556
    CrossrefPubMedGoogle Scholar
  • 27 Gal TJ, Yueh B, Futran ND. Influence of prior hyperbaric oxygen therapy in complications following microvascular reconstruction for advanced osteoradionecrosis. Arch Otolaryngol Head Neck Surg 2003; 129 (01) 72-76
    CrossrefPubMedGoogle Scholar
  • 28 Huang XM, Zheng YQ, Mai HQ. et al. [Diagnosis and treatment on osteoradionecrosis of skull base after radiotherapy for nasopharyngeal carcinoma]. Zhonghua Er Bi Yan Hou Ke Za Zhi 2004; 39 (09) 558-561
    PubMedGoogle Scholar
  • 29 Brand Y, Lim E, Waran V, Prepageran N. Endoscopic transpterygoidal repair of a large cranial defect with cerebrospinal fluid leak in a patient with extensive osteoradionecrosis of the skull base: case report and technical note. J Laryngol Otol 2015; 129 (12) 1243-1247
    CrossrefPubMedGoogle Scholar
  • 30 Han P, Wang X, Liang F. et al. Osteoradionecrosis of the skull base in nasopharyngeal carcinoma: incidence and risk factors. Int J Radiat Oncol Biol Phys 2018; 102 (03) 552-555
    CrossrefPubMedGoogle Scholar
  • 31 Tan SH, Ganesan D, Rusydi WZ, Chandran H, Prepageran N, Waran V. Combined endoscopic transnasal and transoral approach for extensive upper cervical osteoradionecrosis. Eur Spine J 2015; 24 (12) 2776-2780
    CrossrefPubMedGoogle Scholar
  • 32 Pestana IA, Coan B, Erdmann D, Marcus J, Levin LS, Zenn MR. Early experience with fluorescent angiography in free-tissue transfer reconstruction. Plast Reconstr Surg 2009; 123 (04) 1239-1244
    CrossrefPubMedGoogle Scholar
  • 33 Chang KP, Tsang NM, Chen CY, Su JL, Hao SP. Endoscopic management of skull base osteoradionecrosis. Laryngoscope 2000; 110 (07) 1162-1165
    CrossrefPubMedGoogle Scholar
  • 34 Chapchay K, Weinberger J, Eliashar R, Adler N. Anterior skull base reconstruction following ablative surgery for osteoradionecrosis: case report and review of literature. Ann Otol Rhinol Laryngol 2019; 128 (12) 1134-1140
    CrossrefPubMedGoogle Scholar
  • 35 Chen HC, Lin CJ, Jen YM. et al. Ruptured internal carotid pseudoaneurysm in a nasopharyngeal carcinoma patient with skull base osteoradionecrosis. Otolaryngol Head Neck Surg 2004; 130 (03) 388-390
    CrossrefPubMedGoogle Scholar
  • 36 Choi WY, Sung KW, Kim YS. et al. Reconstruction for skull base defect using fat-containing perifascial areolar tissue. Ann Plast Surg 2017; 78 (06) 673-679
    CrossrefPubMedGoogle Scholar
  • 37 Hallak B, Morrison M, Kohler R, Bouayed S. Deep radiation-induced ulcer following nasopharyngeal carcinoma: surgical management. BMJ Case Rep 2019; 12 (11) e230700
    CrossrefPubMedGoogle Scholar
  • 38 Hu Z, Godoy BL, Zadeh G. Spontaneous cerebrospinal fluid rhinorrhea secondary to anterior fossa osteoradionecrosis. J Clin Neurosci 2013; 20 (09) 1314-1315
    CrossrefPubMedGoogle Scholar
  • 39 Huang XM, Zheng YQ, Zhang XM. et al. Diagnosis and management of skull base osteoradionecrosis after radiotherapy for nasopharyngeal carcinoma. Laryngoscope 2006; 116 (09) 1626-1631
    CrossrefPubMedGoogle Scholar
  • 40 Kakarala K, Richmon JD, Durand ML, Borges LF, Deschler DG. Reconstruction of a nasopharyngeal defect from cervical spine osteoradionecrosis. Skull Base 2010; 20 (04) 289-292
    Article in Thieme ConnectPubMedGoogle Scholar
  • 41 King AD, Griffith JF, Abrigo JM. et al. Osteoradionecrosis of the upper cervical spine: MR imaging following radiotherapy for nasopharyngeal carcinoma. Eur J Radiol 2010; 73 (03) 629-635
    CrossrefPubMedGoogle Scholar
  • 42 Liang KL, Jiang RS, Lin JC. et al. Central nervous system infection in patients with postirradiated nasopharyngeal carcinoma: a case-controlled study. Am J Rhinol Allergy 2009; 23 (04) 417-421
    CrossrefPubMedGoogle Scholar
  • 43 Liu SH, Chang JT, Ng SH, Chan SC, Yen TC. False positive fluorine-18 fluorodeoxy-D-glucose positron emission tomography finding caused by osteoradionecrosis in a nasopharyngeal carcinoma patient. Br J Radiol 2004; 77 (915) 257-260
    CrossrefPubMedGoogle Scholar
  • 44 London Jr NR, Ishii M, Gallia G, Boahene KDO. Technique for reconstruction of large clival defects through an endoscopic-assisted tunneled retropharyngeal approach. Int Forum Allergy Rhinol 2018; 8 (12) 1454-1458
    CrossrefPubMedGoogle Scholar
  • 45 Mut M, Schiff D, Miller B, Shaffrey M, Larner J, Shaffrey C. Osteoradionecrosis mimicking metastatic epidural spinal cord compression. Neurology 2005; 64 (02) 396-397
    CrossrefPubMedGoogle Scholar
  • 46 Ness JA, Chang HS, Grabowski CM, Marentette LJ. Osteoradionecrosis of the anterior cranium. Skull Base Surg 1996; 6 (04) 259-266
    Article in Thieme ConnectPubMedGoogle Scholar
  • 47 Raza A, Islam M, Lakshmanan P. Secondary atlanto-odontoid osteoarthritis with osteoradionecrosis of upper cervical spine mimicking metastasis. BMJ Case Rep. 2013 http://dx.doi.org/10.1136/bcr-2013-009319
    CrossrefPubMedGoogle Scholar
  • 48 Risso A, Zoia C, Gianformaggio C. et al. Tension pneumocephalus secondary to osteoradionecrosis of the clivus. Rep Pract Oncol Radiother 2016; 21 (01) 71-75
    CrossrefPubMedGoogle Scholar
  • 49 Ungar OJ, Abergel A, Safadi A, Zaretzki A, Yanko-Arzi R, Fliss DM. Anterior median skull base reconstruction using a vascularized free flap: rationale, patient selection and outcome. J Neurol Surg B Skull Base 2020; 81 (01) 30-36
    Article in Thieme ConnectPubMedGoogle Scholar
  • 50 Vieira S, Nabil A, Maza G. et al. Salvage free tissue transfer for clival osteoradionecrosis after repeat proton beam therapy. World Neurosurg 2020; 138: 485-490
    CrossrefPubMedGoogle Scholar
  • 51 Vlantis AC, Wong EWY, Chiu TW, Chan JYK. Vastus lateralis muscle free flap for skull base osteoradionecrosis in nasopharyngeal carcinoma. J Neurol Surg B Skull Base 2018; 79 (04) 349-352
    Article in Thieme ConnectPubMedGoogle Scholar
  • 52 Wang HC, Hwang JC, Peng JP, Hsieh CH, Liliang PC. Tension pneumocephalus–a rare complication of radiotherapy: a case report. J Emerg Med 2006; 31 (04) 387-389
    CrossrefPubMedGoogle Scholar
  • 53 Wang JJ, Wang Y, Chang PH, Lee TJ, Wang DH. Nontraumatic and postirradiated intracavernous carotid hemorrhage: an unusual case of epistaxis and review of the literature. Am J Otolaryngol 2011; 32 (02) 162-164
    CrossrefPubMedGoogle Scholar
  • 54 Wu CT, Lee ST. Delayed spontaneous tension pneumocephalus caused by radionecrosis of the skull base. Br J Neurosurg 1999; 13 (02) 214-216
    CrossrefPubMedGoogle Scholar
  • 55 Choi NY, Kim HJ, Baek CH. Surgical management of extensive osteoradionecrosis in nasopharyngeal carcinoma patients with the maxillary swing approach and free muscular flaps. Clin Otolaryngol 2017; 42 (05) 1100-1104
    CrossrefPubMedGoogle Scholar
  • 56 Lambade PN, Lambade D, Goel M. Osteoradionecrosis of the mandible: a review. Oral Maxillofac Surg 2013; 17 (04) 243-249
    CrossrefPubMedGoogle Scholar
  • 57 Costa DA, Costa TP, Netto EC. et al. New perspectives on the conservative management of osteoradionecrosis of the mandible: a literature review. Head Neck 2016; 38 (11) 1708-1716
    CrossrefPubMedGoogle Scholar