Osteoradionecrosis of the sternoclavicular joint after laryngopharyngeal radiation

Abstract

Objectives Adequate treatment of laryngopharyngeal malignancy often incorporates radiation therapy. Structures surrounding laryngopharynx exposed to traditional radiation doses are susceptible to posttreatment toxicity. Among poorly understood sequelae is the rare manifestation of sternoclavicular joint (SCJ) osteoradionecrosis (ORN). Methods Three institutional encounters prompted a comprehensive literature search, generating three published case reports. Systematic extraction and analysis (n = 6) of demographics, cancer history, comorbidities, ORN presentation, imaging, and management established the largest series to investigate this pathology. Results Patients were males (6), 54 to 70 years old, smokers (4), with Hypertension/dyslipidemia, myocardial infarction/coronary artery disease, second primary (2), diabetes mellitus (1), and myelofibrosis(1). Four underwent total laryngectomy, one primary, three as salvage. Five patients had concurrent chemoradiation (≥70 Gy). All patients presented with swollen, tender neck wounds concerning for persistent/recurrent malignancy. Computed tomography (CT) demonstrated bone erosion (5 of 5) and increased bone scan uptake (2 of 2). All responded to surgical exploration with drainage alone (1), sequestrectomy (2), or bone resection with synovectomy (3). Complete healing took 2 months to 3 years. One unrelated patient death occurred before control of ORN was achieved. Discussion Given varied patient characteristics, synergistic risk factors exist that alter bone radiation threshold, resulting in irreversible ischemic damage and osteoradionecrosis. Vascular susceptibility and inability to repair may regulate that threshold. Understanding this relationship will facilitate early detection and intervention. Conclusion Integrating cases of sternoclavicular joint ORN promotes awareness of atypical laryngopharyngeal radiation complications, elucidates contributing factors, educates physicians on presentation and management, and provides a platform for prospective investigation. Level of Evidence 4 Laryngoscope, 129:865–870, 2019

Surgical Management of Osteoradionecrosis: Perioperative Problems Encountered during 19 Years of Experience Managing Complicated Cases

“…Osteoradionecrosis of the sternoclavicular joint is treated by aggressive debridement with partial claviculectomy, partial sternectomy, and reconstruction using a pectoralis flap 25) . Use of a pectoralis major musculocutaneous flap remains an important reconstructive technique for skin defects in the neck because it is a low-risk procedure with acceptable morbidity 26,27) . The pectoralis major musculocutaneous pedicled flap is the most commonly indicated method for radiation-induced ulceration in the neck and osteoradionecrosis of the sternoclavicular joint 25,26,28) .…”