Multimodal strategy for the management of sphenoid osteoradionecrosis: Preliminary results

Abstract

Objective Osteoradionecrosis (ORN) of the sphenoid is a rare but potentially lethal complication that can occur after irradiation of nasopharyngeal and clival malignancies. The objective of this study was to describe a multimodal treatment strategy tailored to the clinical signs and to the radiological extent of the disease, and to report on its preliminary results. Methods Retrospective monocentric study at a tertiary skull base center. Patients treated for a sphenoid ORN from January 2014 to August 2018 were identified and charts were retrospectively reviewed for demographics, histologic tumor type, previous treatments of the tumor, clinical signs at presentation, radiological data, treatment, and outcomes. Sphenoid ORN was treated by a combination of medical therapy, endovascular treatment, and/or surgery. The use of each of these therapeutic modalities was based on the extent of ORN and on the presenting signs. Results Seven patients were included: four patients underwent endovascular treatment with occlusion of the internal carotid artery, five patients underwent surgical debridement, and covering of the exposed bone by a local flap, seven patients received antibiotics (in combination with pentoxyphilline, tocopherol, and clodronate in one case). Three patients died after progression of the ORN. The global survival rate was 57% (4/7) with a mean follow‐up of 24 months. In one case, ORN was treated successfully by medical treatment only, with a combination of antibiotics, pentoxyphilline, tocopherol, and clodronate. Conclusion This retrospective study describes the results of a management strategy adapted to the extent of the disease in sphenoid ORN and based on medical therapy only, or on a combination of medical therapy, interventional radiology, and/or surgery. Level of evidence 4

Endoscopic management of postradiation skull base osteoradionecrosis

“…This study is the first systematic review and meta‐analysis focusing on disease resolution and major complication rates after ESBS in the management of skull base ORN. The pooled resolution rate of 64% identified in this analysis is in agreement with the literature showing that ESBS is an effective treatment approach for skull base ORN, providing adequate access and reconstructive options 1–3,6–10 . However, there was significant heterogeneity in the data, which may be attributed to the fact that the a priori definitions of efficacy were inconsistent between studies.…”

“…8 Notably, several studies reported worse outcomes in patients who underwent multiple courses of radiotherapy due to local NPC recurrence. [1][2][3]7,8 In the largest study included in this analysis, multiple radiotherapy courses was an independent negative predictor of overall survival after ESBS (p = 0.026), with a mortality rate 3.2-fold higher than for patients with a single course. 8 Only 1 study reported major complications after ESBS, which occurred in 3 patients.…”

“…The pooled resolution rate of 64% identified in this analysis is in agreement with the literature showing that ESBS is an effective treatment approach for skull base ORN, providing adequate access and reconstructive options. [1][2][3][6][7][8][9][10] However, there was significant heterogeneity in the data, which may be attributed to the fact that the a priori definitions of efficacy were inconsistent between studies. Examples of efficacy measures included Sino-Nasal Outcome Test (SNOT-22) scores, 9 mucosal healing and re-epithelialization of tissue flaps, 6,7 and overall survival.…”

“…6 In instances of an exposed ICA, some authors have advocated for obtaining a balloon occlusion test (BOT) preoperatively. 3,7 In addition to allowing prophylactic intervention in high-risk patients, a BOT can assess the safety of embolizing the ICA intraoperatively should vascular trauma of the ICA ensue. 7 The quality and reliability of a meta-analysis hinges on the level of evidence of the studies included.…”

“…It portends a poor prognosis, mainly due to risk of exsanguination from internal carotid artery (ICA) rupture 1 . Limited data exist regarding the use of conservative therapies, such as hyperbaric oxygen, tocopherol, and pentoxifylline, and surgery remains the mainstay treatment 2,3 …”