Lateral skull-base osteoradionecrosis: a 15-year

series of 20 consecutive cases and a suggested

management protocol
cambridge.org/jlo Emma Richards , Jameel Muzaffar, Raghu Kumar, Peter Monksfield and
Richard Irving
ENT Department, Queen Elizabeth Hospital Birmingham, University Hospital Birmingham NHS Foundation Trust,
Main Article Birmingham, UK

Emma Richards takes responsibility for the

integrity of the content of the paper
Abstract
Background. Temporal bone osteoradionecrosis is a rare but significant complication of radi-
Cite this article: Richards E, Muzaffar J, ation for head and neck malignancies. Various management techniques have been described,
Kumar R, Monksfield P, Irving R. Lateral skull-
base osteoradionecrosis: a 15-year series of 20 but no clear protocol exists.
consecutive cases and a suggested Methods. A retrospective case review of patients with temporal bone osteoradionecrosis man-
management protocol. J Laryngol Otol 2024; aged over 15 years was carried out to highlight multidisciplinary team (MDT) management.
138:1149–1153. https://doi.org/10.1017/ The review findings were compared with the published literature and a protocol was derived
S002221512400077X
for the management of future cases.
Received: 4 February 2024 Results. A total of 20 patients were included. The sites of osteoradionecrosis included the
Revised: 3 March 2024 external auditory canal, the middle ear and the lateral skull base, presenting with features
Accepted: 9 April 2024 including recalcitrant pain, infection, neuropathies and intracranial sepsis. Treatments
First published online: 27 August 2024
included hyperbaric oxygen, antibiotics, debridement and, in advanced cases, lateral temporal
Keywords: bone resection with vascularised tissue transfer. Post-operative and long-term outcomes were
head and neck neoplasms; temporal bone; discussed.
radiology; radiotherapy; osteoradionecrosis Conclusion. Early temporal bone osteoradionecrosis may be managed conservatively.
Refractory osteoradionecrosis can be life-threatening because of intracranial complications
Corresponding author:
Emma Richards; and sepsis. Such cases need an MDT approach with radical skull-base surgery for removal
Email: [email protected] of necrotic foci and reconstruction using vascularised tissue transfer.

Introduction
Radiation therapy, as either primary or adjuvant therapy, is a major treatment modality
for head and neck cancers.1 Although radiation has proved to be effective for the man-
agement of cancer, it is well recognised that adjacent healthy tissues are also affected
by immediate and delayed side effects.2 With the increased survival of patients treated
for a head and neck malignancy there has been an increase in the incidence of post-
radiation sequalae.3,4 These include otitis media, sensorineural hearing loss, local tissue
breakdown and osteoradionecrosis.4–6
Osteoradionecrosis, first described in 1926 by Ewing,7 involves avascular necrosis due
to degeneration of the blood vessels following exposure to high-dose radiation.7
This ischaemic bone is particularly susceptible to injury and infection.5,7 Osteoradionecrosis
of the temporal bone is a rare but potentially devastating complication of head and neck
radiotherapy.1,8 Although rarer than osteoradionecrosis of the mandible,6,9 it is an important
topic of discussion because of the complexity of treating this region.1
Osteoradionecrosis of the temporal bone may be limited to the tympanic bone or
extend diffusely to involve the lateral skull base.10 The temporal bone is thought to be par-
ticularly susceptible because of its superficial location, limited blood supply and anatom-
ical communication with the flora of the upper aerodigestive tract via the Eustachian
tube.1,10 Within this, the tympanic part is most commonly affected11 because of its par-
ticularly perilous blood supply and resident flora.5 In addition, its compact bone is less
resistant to irradiation than callous bone. This tolerance is further reduced when the
bone is infected or affected by neoplasm.10,12
Risk factors for the development of osteoradionecrosis include age, diabetes, continued
tobacco use and immunosuppression.5,13,14 When disease is localised, patients often pre-
sent with mild symptoms, particularly otalgia and otorrhoea.9,10,15 On examination there
is often bony sequestrum within the external auditory canal (EAC).10 Patients with loca-
lised disease are managed conservatively.5,6,9,14–16 Diffuse disease, however, is potentially
life-threatening.5,14 Affected patients may develop facial nerve paralysis and intracranial
complications including meningitis, cerebrospinal fluid (CSF) leak, brain abscesses and
sigmoid sinus thrombosis.5,11 Despite the potential severity of this disease process,
there remains a lack of evidence for best management.14,15,17 Medical therapy is symp-
© The Author(s), 2024. Published by
Cambridge University Press on behalf of tomatic and helps to limit spread, but surgery to remove sequestrum is often indicated
J.L.O. (1984) LIMITED and various methods have been described.14

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 1150 E Richards, J Muzaffar, R Kumar et al.

Table 1. The original cancer diagnoses Results and analysis

Initial diagnosis Cases (n (%)) We identified 20 patients with osteoradionecrosis of the tem-
poral bone who met the inclusion criteria and were managed
Squamous cell carcinoma, ear 5 (24)
surgically by our MDT between January 2006 and December
Nasopharyngeal cancer 2 (9) 2021. The patients included 12 males and 8 females, with a
Parotid cancer 2 (9) mean age of 66 years (range, 24–82 years).
Recurrent jugulotypmanic paraganglioma 2 (9)
The original cancer diagnoses were variable (Table 1).
The most common malignancy was squamous cell carcinoma
Osteosarcoma, ear 2 (9)
of the ear (5 cases), followed by the nasopharyngeal carcinoma
Chondrosarcoma, temporomandibular joint 2 (9) (2 cases), cancer of the parotid gland (2 cases), recurrent jugu-
Submandibular gland cancer 1 (5) lotypmanic paraganglioma (2 cases), osteosarcoma of the ear
(2 cases) and chondrosarcoma of the temporomandibular
Squamous cell carcinoma maxilla 1 (5)
joint (2 cases). Other treated malignancies included malignant
Malignant melanoma, eyelid 1 (5) melanoma of the eyelid and rhabdomyocarcoma of the ear.
Rhabdomyosarcoma, ear 1 (5) Of our 20 cases, 14 (70 per cent) were treated with primary
Medulloblastoma, cerebellum 1 (5)
radiotherapy and 6 (30 per cent) with adjuvant radiotherapy.
Eleven patients (55 per cent) received conventional external
beam radiotherapy, 5 (25 per cent) received hyper-fractionated
radiotherapy, 2 (10 per cent) received proton beam therapy
and 2 (10 per cent) received intensity-modulated radiation
Materials and methods
therapy (Figure 1). The radiation dose ranged between 45
Our aim was to produce a surgical protocol for advanced cases and 60 Gy. The mean onset of osteoradionecrosis following
of osteoradionecrosis of the lateral skull base based on over a radiation was 2.8 years, but onset varied widely between 1.2
decade of experience at our tertiary centre in the UK. and 15 years.
Advanced cases were defined as those with symptoms and dis- The most common symptoms at diagnosis of osteoradione-
ease progression necessitating surgical management. crosis were otalgia and otorrhoea. Patients also presented with
These patients had pain and discharge that could not be sequestrum, cholesteatoma, cranial neuropathy and intracra-
adequately managed with medical therapy. Patients presenting nial sepsis. Of our patients, 16 (80 per cent) were cancer-free,
with osteoradionecrosis of the temporal bone between January 2 (10 per cent) had radio-recurrent cancer as well as osteora-
2006 and December 2021 and requiring surgery involving flap dionecrosis and 2 (10 per cent) were palliative (Figure 2).
reconstruction following treatment with either primary or The mean time in progression with medical therapy, including
adjuvant radiotherapy for head and neck malignancies were hyperbaric oxygen, to curative surgery was 21 months (range,
included in the study. There were no exclusion criteria. 11–38 months).
A retrospective case review was conducted from electronic As per our inclusion criteria, all 20 patients underwent sur-
records. Information including the original cancer type, loca- gery requiring repair of defect for their advanced osteoradione-
tion and management with primary or adjuvant radiotherapy crosis. Overall, 70 per cent of patients (14 of 20) had small
was collected. The dates and type of radiotherapy administered defects that were managed using a temporalis muscle rota-
were recorded where known. Any medical therapy, including tional flap, 20 per cent (4 of 20) had moderate defects repaired
hyperbaric oxygen therapy, was also noted, along with details using gracilis, serratus anterior or latissimus dorsi flap and the
of pre-operative facial nerve function. Multidisciplinary team final 10 per cent (2 of 20) had large defects managed with
(MDT) recommendations were reviewed, and surgical notes anterolateral thigh and/or vastus lateralis chimeric flaps.
and post-operative results recorded. Long-term outcomes A 100 per cent successful flap take-up rate was achieved.
were also assessed. Subsequently a protocol was developed There were no major operative complications and no
by the skull-base MDT for the management of future cases. surgery-related mortality in our population group. A 40 per
This retrospective case note review did not require formal cent morbidity rate was reported, with causes recorded as
ethics committee review after completing the National pain, trismus, cranial neuropathy, wound sepsis, rehabilitation
Decision Tool developed by the Medical Research Council time, physiotherapy and prolonged hospitalisation. It is not
Regulatory Support Centre in partnership with the Health possible to distinguish this morbidity from morbidity that
Research Authority. would have been present without operative management.

Figure 1. Type of radiation received.

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 The Journal of Laryngology & Otology 1151

Figure 2. Cancer status of patients presenting with

osteoradionecrosis. ORN = osteoradionecrosis; RT =
radiotherapy.

Average follow up was for a period of 23 months (range, administered.1 However, this was not supported by Pathek
5–84 months). Ten patients (50 per cent) were disease-free and Bryce5 or Sharon et al.11 In our study, patients were
with no recurrence of osteoradionecrosis. Two patients (10 found on average to have received 45–60 Gy.
per cent) were treated with palliative intent because of recur- It has been recognised that there is a latency period between
rence of their original pathology ( jugulotypmanic paragan- radiotherapy and the development of osteoradionecrosis.1,5,10
glioma and medulloblastoma). Eight patients (40 per cent) Pathek and Bryce5 reported an average latency of 8 years
died during the follow-up period, with a mean time of death (range, 6–11 years) from radiation to the development of dif-
post-surgery of 15 months (range, 5–32 months). Of these, fuse osteoradionecrosis,5 whilst Lovin et al.16 reported a mean
three patients died as a result of disease recurrence whilst time of 10 years.16 Our mean time to development of osteor-
five died as a result of unrelated causes. adionecrosis post-radiation was shorter, at 2.8 years, but ran-
From our findings a management algorithm was designed ged from 1.2 to 15 years, again showing a wide variation.
by the MDT as shown in Figure 3 and this algorithm has Currently there does not seem to be a relationship between
now been incorporated into our skull-base MDT. the latency period and the severity of osteoradionecrosis.10
Consistent with our results, Yuhan et al.15 showed that otal-
gia and otorrhoea are the most common initial symptoms.15
Discussion The most commonly used classification for osteoradionecrosis
With the increasing survival of patients following treatment is by Ramsden et al.10 and divides cases into localised, where
including radiotherapy for head and neck malignancies,3,4 bone erosion is limited to the EAC, and diffuse, where it affects
the incidence of osteoradionecrosis of the temporal bone is more of the ear and mastoid.10,19
set to increase. The hypoxic, hypovascular and hypocellular As reflected in our protocol (Figure 3), it is widely estab-
environment induced by radiotherapy leads to impaired colla- lished that limited disease associated with minimal symptoms
gen synthesis and cell production, with resultant tissue break- should be managed conservatively with regular aural toilet and
down and increased prevalence of chronic infection in the antibiotic therapy.10,14 This is particularly as the goal of treat-
ischaemic bone.5,7,18 ment for localised disease is directed at symptom control16
Whilst some risk factors, such as diabetes mellitus, may be rather than complete removal or resolution of the necrotic
modifiable,14 many, such as patient age, are not. Ramsden bone.15
et al.10 noted that the development of osteoradionecrosis was The algorithm proposed by Sharon et al.11 also recom-
more frequently seen when the temporal bone was in close mended initial conservative management, with culture-
proximity to the focus of radiation.10 The superficial location directed topical antibiotics, topical antiseptics, periodic clinic
of the temporal bone and thin overlying soft tissue make debridement and pain management,11 as did Kammeijer
this region particularly susceptible,10 and unfortunately when et al.19 Yuhan et al.15 performed a systematic review on the
treating malignancies in this region, especially of the ear, management of osteoradionecrosis of the temporal bone and
this focus cannot be changed.1 Rudge1 found that the extent found that 89 per cent of all cases treated conservatively had
of necrosis was proportional to the dose of radiation adequately resolved presenting symptoms at last follow up.15
Pathak and Bryce5 found that being over 60 years of age was
an indicator of those who failed under conservative manage-
ment within 2 years5 and these cases may therefore need closer
monitoring and aural toileting. These patients are more likely
to progress to stage 2 management (Figure 3), which we pro-
pose necessitates local debridement in the form of canalplasty,
meatoplasty or mastoidectomy and consideration of hyper-
baric oxygen therapy.
The systemic review performed by Yuhan et al.15 found that
21.5 per cent of cases received conservative management and
60.9 per cent underwent surgical management.15 Hyperbaric
oxygen was used in conjunction with surgical treatment in
11.3 per cent of cases.15 Kammerijer et al.19 outlined their
Figure 3. Management algorithm devised by the multidisciplinary team. ORN = guidelines to reflect the localised and diffuse osteoradionecro-
osteoradionecrosis; IV = intravenous; TMJ = temporomandibular joint sis described by Ramsden et al.10 They suggest that when those

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 1152 E Richards, J Muzaffar, R Kumar et al.

with localised osteoradionecrosis are not symptomatically con- covering the resultant defect,3 and this is reflected in stage 3
trolled, they should be managed as per diffuse A osteoradione- of our algorithm. However, significant complications continue
crosis, defined as computed tomography evidence supporting to be reported in those undergoing such surgery, including
diffuse disease associated with little pain and infection, and persistently discharging fistulae.11
intact functional hearing.19 They also suggest sequestrectomy Free flaps can provide much better functional and aesthetic
in these cases.19 results compared with local and regional flaps.25 However,
Hyperbaric oxygen therapy aims to increase tissue oxygen- there are a number of considerations when selecting an appro-
ation, which in turn promotes neovascularisation and wound priate flap. These include the size and location of the defect,
healing.18 Sharon et al.11 recommended other therapies in the the blood supply of both the flap and the recipient site, and,
form of intravenous (IV) antibiotics and hyperbaric oxygen in importantly, the aim of the reconstruction in terms of aesthetic
patients who developed increasing pain, progressive infection and functional outcomes.25
and cranial neuropathies despite conservative management.11 The anterolateral thigh chimeric flap, which relies on the
Our algorithm includes IV antibiotics as an option in stage 1, descending branch of the lateral circumflex femoral artery, has
dependent on clinical findings. There is some evidence from been described for use in the reconstruction of large soft tissue
small randomised controlled trials to support hyperbaric oxygen defects in this region and to correct facial palsy.25 This flap is
therapy in late radiation-induced tissue injury.20 Reported clin- easily obtained and offers sufficient muscle bulk to fill large
ical outcomes have been variable, with Sharon et al.11 finding defects. There is also access to redundant motor nerves such
that of their six patients who received hyperbaric oxygen ther- as a branch of the motor nerve to the vastus lateralis which is
apy, no patients achieved resolution of the necrotic bone. It was, suitable for grafting.26 It is also possible to alter the thickness
however, felt to aid post-operative healing in one patient.11 of the subcutaneous fat in the anterolateral region to achieve
It should be noted that although hyperbaric oxygen is often appropriate flap thickness at the reconstruction site.27 This miti-
incorporated into treatment algorithms for osteoradionecrosis, gates the complications of fat liquefaction and seroma associated
evaluation of its benefit is currently limited by small patient with fat transfer and dermal grafts.25 Lóderer et al.25 reported
cohorts, concurrent surgical management and varied treat- that there was minimal morbidity at the donor site.25 This
ment protocols.14 The use of hyperbaric oxygen is affected single-stage approach is generally associated with fewer compli-
by geographical limitations with only eight chambers across cations and better neural regeneration than a multistep
England.21 It is also a significant undertaking for patients approach.25 Direct nerve anastomosis or cable grafting is the
both physically and mentally, with the most common protocol preferred reconstruction technique, yielding the best functional
involving 40 treatments,22 each typically lasting 90 minutes.23 outcomes in patients undergoing facial nerve sacrifice.25
We propose a more manageable 10 treatments. The risks of Our surgically treated patients in this report obtained good
treatment include temporary visual problems, Eustachian symptomatic relief and long-term control of osteoradionecro-
tube dysfunction and seizures.24 sis. However, our findings are based on a small cohort with
Whilst conservative management has been shown to be heterogenicity in presentation, making it difficult to draw
appropriate for patients with limited disease, it may not be suf- overall conclusions. To the best of our knowledge, no multi-
ficient, and refractory disease may arise. Sharon et al.11 found centre study has yet been performed, and given the rarity of
that 18 out of 33 patients in their study went on to require sur- this presentation it is unlikely that this will be undertaken in
gical management because of intractable pain, persistent infec- the near future. In addition, consideration of the interpretation
tion or the development of cholesteatoma.11 Our study showed of outcomes is needed. Consensus is required on what consti-
a mean time between medical therapy and surgery with cura- tutes successful treatment, be it complete eradication of
tive intent of 21 months. exposed bone, resolution of symptoms or reduction of symp-
Kammerijer et al.19 reserved subtotal petrosectomy for toms to acceptable levels.11
those with diffuse B disease, who they define as those in
whom there is severe pain and infection and/or no functional
• Osteoradionecrosis is a serious potential complication of radiation for
hearing because of the risk–benefit balance of the more exten- head and neck cancer
sive surgery.19 Yuhan et al.15 found that less than 60 per cent • The temporal bone is particularly at risk because of its location, blood
of mastoidectomies led to complete resolution, but over 90 per supply and connection to the upper aerodigestive tract
• Presentation of osteoradionecrosis can be with otalgia, otorrhoea, facial
cent of lateral temporal bone resections resolved.15 Sharon palsy, cerebrospinal fluid leak and meningitis
et al.11 specified that the aim of surgery was to gain symptom • Management of osteoradionecrosis is difficult, but local management
control rather than complete removal of necrotis bone.5,11 with regular aural toilet and antibiotics can help with early disease
This view was justified in that it has been shown that there • In the most severe cases of osteoradionecrosis, resection and flap
reconstruction may be required to restore vascularity and function
are increased risks of operating in radiated temporal bone,
including higher than expected rates of facial nerve dehiscence,
oval window and lateral canal fistulae, dural exposure, CSF
leak and lateral canal procedures.20 These risks are thought Osteoradionecrosis is a rare and difficult clinical entity
to occur because of the poor blood supply to the EAC, requiring co-ordinated MDT input. The key guiding prin-
which is then further decreased by surgery.5 However, it ciple is to restore vascularity to the dying bone and facial
should be noted that our algorithm differs in its consideration nerve. Outcomes are promising, with 50 per cent of cases
and recommendation of reconstruction in appropriate cases. now disease-free. We advocate the protocol described here
As in our advanced cases, the symptom severity and poten- as part of a multidisciplinary approach to this complex con-
tially life-threatening nature of diffuse disease makes more dition. Larger multicentre studies may provide a better
aggressive management necessary.3,5,10 Flexibility from local understanding of the optimum treatment strategy in any
flaps or free flaps is needed to reconstruct defects of the lateral individual patient.
temporal bone. With advancing techniques in reconstruction,
Competing interests. None declared
cosmesis is now of increasing focus rather than simply

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 The Journal of Laryngology & Otology 1153

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