Osteoradionecrosis (ORN) of the mandible is a severe complication of radiation therapy for head and neck cancer. In this case series, the authors analyzed their treatment and quality of life outcomes over the past 6 years. A retrospective chart review of 42 patients treated surgically for advanced ORN was conducted. A telephone survey was conducted and quality of life (QOL) questionnaires were completed in a subset of patients. 30 patients responded to the telephone survey assessing QOL for speech, swallowing and overall functioning correlated with oral nutrition and performance status. Surgery for ORN can result in an improved QOL. Functional outcomes of oral intake, speech intelligibility, and eating in public correlated with patient rated QOL measures. A lack of improvement in QOL, despite the restoration of an intact mandible, relates to the persistent effects of chemoradiotherapy.
Radiation therapy plays an important role in the treatment of head and neck cancer. Osteoradionecrosis (ORN) is a late complication of radiation exposure, classically presenting as exposed bone through an opening in the overlying skin or mucosa, persisting as a non-healing wound for 3 months or more. Patients who develop ORN usually experience the full spectrum of collateral damage from radiation therapy (i.e. xerostomia, chronic trismus, dysguesia, dysphagia, decreased tongue mobility). These problems, in addition to the neuropathic pain and chronic drainage from super-infection, can leave patients physically and emotionally disabled Although numerous studies have examined the effects of surgical and/or chemoradiotherapy on quality of life (QOL), only one study to date has examined QOL after surgical treatment for ORN in a standardized fashion.
The classic treatment algorithm by Marx often involves multiple debridements and hyperbaric oxygen (HBO) therapy. In this algorithm, advanced (Stage III) ORN patients are treated with a staged resection and reconstruction which can leave patients further disabled during the interim period. In recent years, microvascular surgical techniques have improved tremendously. Success rates of free tissue transfer have been quoted as high as 98% in the literature. Additionally, imaging studies have also improved tremendously with the advent of high resolution computed tomography (CT) scanning. In this study, the authors review a case series of 47 patients over 6 years at Beth Israel Medical Centre. They discuss their management algorithm for patients with advanced ORN and the patient’s perceived functional outcomes after treatment, including normalcy of diet, eating in public, speech intelligibility, resolution of trismus, presence of pain and QOL.
Materials and methods
A cross sectional review of 42 patients with advanced ORN managed over the past 6 years at Beth Israel Medical Centre was conducted to identify potential patients for a telephone survey. This study was approved by the Institutional Review Board and all patients who were able to be reached provided consent to participate. All patients had Marx Stage III ORN. All patients were treated with a segmental mandibulectomy and free flap reconstruction. Charts were reviewed to determine location of disease utilizing the mandibular defect classification system described by Urken et al. ( Fig. 1 ), prior HBO therapy, extent of resection, type of flap used for reconstruction, complications (i.e. flap failure, exposed hardware), dental rehabilitation (extractions, implants, tissue borne or implant borne prosthesis), and length of follow-up. The telephone survey included administration of the Performance Status Scale (PSS). All domains of the PSS, including normalcy of diet, eating in public and understandability of speech, were obtained by one clinician (CL) questioning the patient. Survey information also included patient-reported approximate percentage oral nutrition, subjective pain level on a 1–10 scale, and the presence of trismus. The Karnofsky Performance Status (KPS) Scale Index was completed by CL, based on the telephone interview information, to classify the functional impairment. All patients who underwent the telephone survey were mailed paper QOL questionnaires including the Speech Handicap Index (SHI), European Organization for Research and Treatment of Cancer Quality of life Questionnaire-H&N 35 (EORTC H&N35), and the Eating Assessment Tool (EAT-10). For further clarification, the speech-language pathologist (SLP) evaluation of performance status using the PSS and KPS scale was completed via a telephone survey ( n = 30, i.e. 71% response rate) whereas the patient-rated QOL assessment was done using results of a postal survey ( n = 18, i.e. 60% response rate).