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The International Federation           of Head and Neck Oncologic Societies Current Concepts in Head and Neck Surgery and ...
Radiation Therapy               General Statements       •  Radiation alone or with other treatment         modalities is ...
Mucositis                     Acute (Early)                                     Acute                                     ...
Acute       Mucositis2012
Mucositis       Symptoms        •  Intense pain        •  Food and fluid intake decreases        •  Speech and swallowing ...
WHO Oral Mucositis Scale                                                 Severe                                           ...
Mucositis                Clinical Characteristics       Grade I Painless ulcers, erythema, or mild                        ...
Mucositis               Clinical CharacteristicsGrade II Painful erythema, edema, or ulcers but eating                 or ...
Mucositis               Clinical Characteristics           Grade III Pseudomembranous surface   Ulcers, extensive erythema...
Mucositis               Clinical Characteristics                 Grade IV Ulcerations Oral mucositis to the extent that al...
Mucositis       Management        •  Mucosal coating agents        •  Cleansing devices        •  Chlorhexidine        •  ...
Acute Skin Reactions2012
2012
2012
2012
Late Xerostomia2012
Xerostomia       Pathogenesis         –  Irreversible acinar cell damage       Clinical Characteristics         –  50% dec...
Xerostomia       Symptoms        •  Difficulty in eating, speaking, & swallowing        •  Taste disorders2012
Pre-treatment Strategies                Current       IMRT / Conformal beam design       Radioprotective agents         • ...
Tumor                      Dose                      Tissue       Conventional            Intensity       Radiotherapy    ...
Sparing the parotid glands with IMRT        significantly reduces the incidence of         xerostomia and leads to recover...
Xerostomia                 Treatment       •  Lubricants       •  Gustatory stimulation       •  Drug intervention       •...
Late Radiation Caries2012
Radiation Caries       Pathogenesis         •  Shift to cariogenic microflora and            xerostomic environment       ...
Late Trismus2012
Trismus       •  More common with high posterior fields of        radiation       –  as muscles of mastication are in fiel...
Trismus       Pathogenesis         •  Direct effects of radiation on muscles and/or TMJ       Clinical Characteristics    ...
Late Radiation       Induced Malignancies2012
Late Complications Following RT          No            Event occurs         event         above threshold                 ...
Late Complications Following RT                    Xerostomia                    Soft tissue                     fibrosis ...
2012
Late       Osteoradionecrosis2012
Background       •  Devastating complication of radiation         therapy that can be more difficult to         treat than...
Osteoradionecrosis is the clinical condition in which irradiated bone becomes devitalized and exposed through the overlyin...
Osteoradionecrosis is perhaps the most dreaded latecomplication of radiotherapy affecting mandibular bone more        freq...
The Etiology of       Osteoradionecrosis2012
Pathophysiology of Osteoradionecrosis.       Direct radiation effects on normal tissue may be                      lethal ...
The irradiated mandible, periosteum, and overlying        soft tissue undergo hyperemia, inflammation,                    ...
3 “H” Hypothesis &             OsteoradionecrosisHypovascularity        Hypoxia          Hypocellularity                  ...
The incidence of osteoradionecrosis varies considerably between various  studies and is reported to be between 1-40% of pa...
2012          S. Vudiniabola, C. Pirone, J. Williamson, A. N. Goss: Hyperbaric oxygen in the therapeutic       management ...
2012       M.J. Wahl, Int J Radiation Oncology Biol Phys, 64:3, 661–9, 2006
• Osteoradionecrosis presents as a broad       spectrum of disease severity       • It is rare at radiation therapy doses ...
Factors Affecting the Occurrence of Osteoradionecrosis.                1. Field of irradiation 2012                       ...
2. The dose of irradiation          Total doses above 64 Gy resulted in 95% of cases with       osteoradionecrosis of the ...
3. Time after radiation treatment       Most of the reported cases of osteoradionecrosis of the mandible              occu...
4. Variation in treatment fractionations       Conventional fractionation and total dose 67,0-72,0 Gy: ORN 20,1%       Hyp...
5. Type of radiation treatmentBrachytherapy is reported to cause the highest rate of osteoradionecrosis of       the mandi...
Intensity Modulated Radiation Therapy (IMRT)Conformal radiotherapy reduces the dosage to the mandibular bone when         ...
The Dental Extraction After Radiation                 Therapy2012
Extractions & Osteonecrosis       Traditional Concepts       •  Twice the risk of ORN is seen when selected         teeth ...
Tooth extraction and dental disease in irradiated regions have long been       recognized as the major risk factors in the...
Nearly 85% of 1,194 irradiated patients followed in the       MSKCC Dental Service from 1998 through 2001 did not         ...
In conclusion, the present study showed a low       prevalence of ORN related to exodontia: only 2          ORN (0.5%) cas...
Incidence of ORN in the mandible                               Angle                               12%                    ...
2012
Classification of Osteoradionecrosis of the                  Mandible2012
There are several classifications for mandibular osteoradionecrosisand they all stage the disease according to the severit...
2012       RTOG: Radiation Therapy Oncology Group                     Jereczek-Fossa BA and Orecchia R, Cancer Treatment R...
2012       Epstein J et al, Oral Surg 1997
Stage I         Superficial          Ulceration2012   Exposed cortical             bone                          Schwartz ...
Stage II     Exposed medullary            bone   + soft tissue changes2012                           Schwartz HC and Kagan...
Stage III      Sinus/Fistula   Pathologic Fracture2012                         Schwartz HC and Kagan AR, Am J Clin Oncol 2...
Management of Early and             Advanced         Osteoradionecrosis2012
The Role of Hyperbaric Oxygen2012
The Role of Hyperbaric Oxygen    HBO treatment involves the delivery of 100% oxygen at highpressure in special chambers. T...
Most of the literature indicates that HBO has no impact       on tumor growth - be it stimulatory or inhibitory.2012
However, the general consensus is that HBO   does not offer any significant clinical benefits or                improvemen...
Advocates of HBO therapy support the view that HBO represents the only medical treatment for osteoradionecrosis. HBO can r...
The Role of Hyperbaric Oxygen HBO has been used as an adjunctive conservative measure along           with antibiotics and...
The role of HBO in the                         treatment of                     osteoradionecrosis.                       ...
The use of HBO in the treatment of osteoradionecrosis despite its widespread   use had been largely theoretical or anecdot...
The role of HBO in         the treatment of        osteoradionecrosis.             The study by             Annane et al  ...
The trial was terminated prematurely because of the failure to demonstrate   any beneficial effect of HBO over placebo (19...
The study by Annane resulted into strong criticism and        disbelief by several authors quoting that it violated an    ...
Although the cohort was small it seems that HBO  was of little benefit. HBO is demanding for patients       and has cost i...
HBO therefore remains ineffective as a stand-alone       therapy or even as a reliable adjuvant. Variability       among i...
The use and efficacy of HBO prior to tooth extraction             has been debated in the literature. Those who argue agai...
The use of HBO therapy prior to implant placement has        also been debated. The use of HBO may decrease       morbidit...
Management of Early and             Advanced         Osteoradionecrosis2012
Established ORN does not regress                 spontaneously.        It either stabilizes or gradually                  ...
2012
2012
2012
One of the adverse factors implemented in the     development of ORN is the Radiation Induced              Fibrosis (RIF) ...
With this treatment applied to 18 patients with advanced ORN,     16 (89%) recovered after a median 6 months of treatment....
Selection of Treatment in ORN              Stage I       Superficial Ulceration       Exposed cortical bone               ...
Stage I: Perform 30 HBO dives (1 dive per day, Monday-Friday) to 2.4                          atmospheres for 90 minutes. ...
Selection of Treatment in ORN             Stage II       Exposed medullary bone        + soft tissue changes              ...
Stage II: Perform transoral sequestrectomy         with primary wound closure followed by           continued HBO to a tot...
Selection of Treatment in ORN           Stage III          Sinus/Fistula       Pathologic Fracture                        ...
2012
Stage III: Perform transcutaneous mandibular resection, wound       closure, and mandibular fixation with an external fixa...
The only successful treatment of advanced       (Stage III) mandibular osteoradionecrosis is the       surgical resection ...
Conservative measures, such as limited debridement        and HBO therapy, may be effective in preventing the        progr...
Patients who initially present with advanced disease        (stage II or III) are unlikely to respond to HBO and          ...
2012
2012
2012
Reconstructive options in the treatment of       severe (Stage III) mandibular osteoradionecrosis             1. The radia...
2012       Militsakh ON et al, Otolaryngol-Head and Neck Surg 2005
2012
2012
2012
2012
2012
Reconstructive options in the treatment of       severe (Stage III) mandibular osteoradionecrosis             1. The radia...
2012       Shaha A et al, Head Neck 1997
2012
2012
2012
2012
2012
Reconstructive options in the treatment of       severe (Stage III) mandibular osteoradionecrosis            1. The radial...
•  Iliac crest (DCIA)       •  Scapula       •  Latissimus dorsi       •  Rectus Abdominis       •  Lateral arm       •  L...
The rate of post-operative complications during          the surgical treatment of mandibular osteoradionecrosis is extrem...
2012
2012
2012
Conclusion       •  Early ORN can be managed conservatively       •  Successful treatment of advanced ORN         depends ...
The question whether HBO should be a         precedent treatment or should be administered post-operatively or not at all ...
Conclusions       •    Combined modality treatment for oral cancers is            associated with multiple early and late ...
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Complications from radiation therapy by A. Rapidis

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Complications from radiation therapy by A. Rapidis

  1. 1. The International Federation of Head and Neck Oncologic Societies Current Concepts in Head and Neck Surgery and Oncology 2012Complications from Radiation Therapy Alexander Rapidis
  2. 2. Radiation Therapy General Statements •  Radiation alone or with other treatment modalities is used in a significant number of patients with advanced stage oral cancer •  A therapeutic dose of 50-70 Gy is externally delivered to the tumor •  Usually, increments of 200 cGy/day is delivered until the accumulated dose is2012 achieved
  3. 3. Mucositis Acute (Early) Acute Skin Reactions Infection Chronic XerostomiaOral Complications of radiotherapy Radiation caries Chronic (Late) Trismus Radiation induced malignancies Osteoradionecrosis 2012
  4. 4. Acute Mucositis2012
  5. 5. Mucositis Symptoms •  Intense pain •  Food and fluid intake decreases •  Speech and swallowing becomes difficult •  Its intensity may require ceasing therapy2012
  6. 6. WHO Oral Mucositis Scale Severe Oral Mucositis Grade 0 1 2 3 4 None Soreness Erythema, Ulcers, Mucositis +/– ulcers extensive to the extent erythema erythema that Patients alimentation is No can Patients not possible ulceration swallow cannot solid diet swallow solid diet2012
  7. 7. Mucositis Clinical Characteristics Grade I Painless ulcers, erythema, or mild soreness in the absence of ulcers2012
  8. 8. Mucositis Clinical CharacteristicsGrade II Painful erythema, edema, or ulcers but eating or swallowing possible 2012
  9. 9. Mucositis Clinical Characteristics Grade III Pseudomembranous surface Ulcers, extensive erythema. Patients cannot swallow solid diet2012
  10. 10. Mucositis Clinical Characteristics Grade IV Ulcerations Oral mucositis to the extent that alimentation is not possible2012
  11. 11. Mucositis Management •  Mucosal coating agents •  Cleansing devices •  Chlorhexidine •  Recombinant keratinocyte growth factor •  GMCSF (Combined Therapy) •  Thalidomide?2012 •  Low-level laser therapy?
  12. 12. Acute Skin Reactions2012
  13. 13. 2012
  14. 14. 2012
  15. 15. 2012
  16. 16. Late Xerostomia2012
  17. 17. Xerostomia Pathogenesis –  Irreversible acinar cell damage Clinical Characteristics –  50% decreased salivation after 1 week of radiation –  75% decrease after 6 weeks –  95% decrease years after –  Thick ropey saliva2012 –  Candida albicans infection –  Dysphagia / Odynophagia
  18. 18. Xerostomia Symptoms •  Difficulty in eating, speaking, & swallowing •  Taste disorders2012
  19. 19. Pre-treatment Strategies Current IMRT / Conformal beam design Radioprotective agents •  Amifostine •  Antioxidants Salivary stimulation •  Pilocarpine; cevimeline; gustatory; •  other agents2012
  20. 20. Tumor Dose Tissue Conventional Intensity Radiotherapy Modulated Radiotherapy2012
  21. 21. Sparing the parotid glands with IMRT significantly reduces the incidence of xerostomia and leads to recovery of saliva secretion and improvements in associated quality of life, and thus strongly supports a role for IMRT in squamous-cell carcinoma of the head and neck.2012 www.thelancet.com/oncology Published online January 13, 2011
  22. 22. Xerostomia Treatment •  Lubricants •  Gustatory stimulation •  Drug intervention •  Submandibular gland relocation2012 •  Daily living “tricks” or maneuvers
  23. 23. Late Radiation Caries2012
  24. 24. Radiation Caries Pathogenesis •  Shift to cariogenic microflora and xerostomic environment Clinical Characteristics •  Cervical, cusp, & incisal decay •  Coronal fractures2012
  25. 25. Late Trismus2012
  26. 26. Trismus •  More common with high posterior fields of radiation –  as muscles of mastication are in field (10%) •  Retention of coronoid process •  Made worse by concomitant chemotherapy2012
  27. 27. Trismus Pathogenesis •  Direct effects of radiation on muscles and/or TMJ Clinical Characteristics •  Limited range of motion Management •  Prevent with stretching exercises •  Prophylactic or therapeutic pentoxifylline, a-2012 tocopherol
  28. 28. Late Radiation Induced Malignancies2012
  29. 29. Late Complications Following RT No Event occurs event above threshold dose, severity ↑ with dose Event can occur at any dose level Probability, not severity, ↑ with dose 2012 Increasing RT Dose
  30. 30. Late Complications Following RT Xerostomia Soft tissue fibrosis Osteoradionecros is Radiation associated tumors2012 Increasing RT Dose
  31. 31. 2012
  32. 32. Late Osteoradionecrosis2012
  33. 33. Background •  Devastating complication of radiation therapy that can be more difficult to treat than original tumor •  Clinical definition: Devitalized, irradiated bone that is exposed through overlying mucosa or2012 skin persisting for > 6 months
  34. 34. Osteoradionecrosis is the clinical condition in which irradiated bone becomes devitalized and exposed through the overlying skin or mucosa persisting without healing for 3 months. 2012 Marx RA, J Oral Maxillofac Surg 1983
  35. 35. Osteoradionecrosis is perhaps the most dreaded latecomplication of radiotherapy affecting mandibular bone more frequently than any other bone in the head and neck. 2012
  36. 36. The Etiology of Osteoradionecrosis2012
  37. 37. Pathophysiology of Osteoradionecrosis. Direct radiation effects on normal tissue may be lethal or sublethal Lethal damage is caused by ionization within the desoxyribonucleinic acid (DNA) preventing cell replication and resulting in tissue death2012 Sublethal damage may cause cell mutation leading to further neoplasia
  38. 38. The irradiated mandible, periosteum, and overlying soft tissue undergo hyperemia, inflammation, and endarteritis. These conditions ultimately lead to thrombosis, cellular death, progressive hypovascularity, and fibrosis.2012
  39. 39. 3 “H” Hypothesis & OsteoradionecrosisHypovascularity Hypoxia Hypocellularity Tissue injury (usually) Tissue breakdown / non-healing wound 2012
  40. 40. The incidence of osteoradionecrosis varies considerably between various studies and is reported to be between 1-40% of patients receiving radiotherapy in the head and neck area. Mendenhall WM J Clin Oncol 20042012 Reuther et al, Int J Oral Maxillofac Surg 2003
  41. 41. 2012 S. Vudiniabola, C. Pirone, J. Williamson, A. N. Goss: Hyperbaric oxygen in the therapeutic management of osteoradionecrosis of the facial bones. Int. J. Oral Maxillofae. Surg. 2000; 29: 435-438.
  42. 42. 2012 M.J. Wahl, Int J Radiation Oncology Biol Phys, 64:3, 661–9, 2006
  43. 43. • Osteoradionecrosis presents as a broad spectrum of disease severity • It is rare at radiation therapy doses of less 60 Gy • It is more common when brachytherapy is used • The mandible must be in the treatment volume area • Dental extractions, surgery or trauma usually proceed its onset • Secondary infection may be present2012
  44. 44. Factors Affecting the Occurrence of Osteoradionecrosis. 1. Field of irradiation 2012 Thorn JJ et al, J Oral Maxillofac Surg 2000
  45. 45. 2. The dose of irradiation Total doses above 64 Gy resulted in 95% of cases with osteoradionecrosis of the mandible in a cohort of 80 patients Thorn JJ et al, J Oral Maxillofac Surg 2000 Curi MM and Lauria L, J Oral Maxillofac Surg 19972012
  46. 46. 3. Time after radiation treatment Most of the reported cases of osteoradionecrosis of the mandible occur between 2-5 years after radiation treatment Thorn JJ et al; J Oral Maxillofac Surg 20002012 Fujita M et al, Int J Rad Oncol Biol Phys 1996
  47. 47. 4. Variation in treatment fractionations Conventional fractionation and total dose 67,0-72,0 Gy: ORN 20,1% Hyperfractionated irradiation and total dose 72,0-78,8 Gy: ORN 6,6%2012 Studer G et al, Strahlenther Onkol 2004
  48. 48. 5. Type of radiation treatmentBrachytherapy is reported to cause the highest rate of osteoradionecrosis of the mandible. The use of spacers may reduce its occurrence 2012 Miura M et al, Int J Radiation Oncology Biol Phys 1998
  49. 49. Intensity Modulated Radiation Therapy (IMRT)Conformal radiotherapy reduces the dosage to the mandibular bone when the mandible is not the target of treatment 2012 Claus F et al, Oral Oncology 2002
  50. 50. The Dental Extraction After Radiation Therapy2012
  51. 51. Extractions & Osteonecrosis Traditional Concepts •  Twice the risk of ORN is seen when selected teeth are extracted following radiation therapy •  Pre-radiation extractions associated with a lower risk of ORN •  Risk of ORN persists for years and reduced2012 healing capacity may be considered permanent
  52. 52. Tooth extraction and dental disease in irradiated regions have long been recognized as the major risk factors in the development of osteoradionecrosis. Thorn JJ et al, J Oral Maxillofac Surg 20002012 Støre G et al, Clin Otolaryngol 2002
  53. 53. Nearly 85% of 1,194 irradiated patients followed in the MSKCC Dental Service from 1998 through 2001 did not require dental extractions to prevent ORN. Our retrospective data review indicated that only 11 of 1,194 patients (0.92%) developed ORN, including 4 patients2012 (2.14%) who had extractions at MSKCC, a much lower rate than that typically reported in the literature.
  54. 54. In conclusion, the present study showed a low prevalence of ORN related to exodontia: only 2 ORN (0.5%) cases associated with 1.647 exodontia performed before radiotherapy and 1 ORN case (1.7%) in 290 exodontia after2012 irradiation. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2008;105:e1-e6
  55. 55. Incidence of ORN in the mandible Angle 12% Body Mental 86% 2%2012
  56. 56. 2012
  57. 57. Classification of Osteoradionecrosis of the Mandible2012
  58. 58. There are several classifications for mandibular osteoradionecrosisand they all stage the disease according to the severity of signs and symptoms in either Stages, Grades or Scores 2012
  59. 59. 2012 RTOG: Radiation Therapy Oncology Group Jereczek-Fossa BA and Orecchia R, Cancer Treatment Reviews 2002
  60. 60. 2012 Epstein J et al, Oral Surg 1997
  61. 61. Stage I Superficial Ulceration2012 Exposed cortical bone Schwartz HC and Kagan AR, Am J Clin Oncol 2002
  62. 62. Stage II Exposed medullary bone + soft tissue changes2012 Schwartz HC and Kagan AR, Am J Clin Oncol 2002
  63. 63. Stage III Sinus/Fistula Pathologic Fracture2012 Schwartz HC and Kagan AR, Am J Clin Oncol 2002
  64. 64. Management of Early and Advanced Osteoradionecrosis2012
  65. 65. The Role of Hyperbaric Oxygen2012
  66. 66. The Role of Hyperbaric Oxygen HBO treatment involves the delivery of 100% oxygen at highpressure in special chambers. The pressure of the oxygen inhaled by the patient is usually 2.4 times more than the atmospheric pressure and can be as high as 3 times more. 2012
  67. 67. Most of the literature indicates that HBO has no impact on tumor growth - be it stimulatory or inhibitory.2012
  68. 68. However, the general consensus is that HBO does not offer any significant clinical benefits or improvement in survival2012
  69. 69. Advocates of HBO therapy support the view that HBO represents the only medical treatment for osteoradionecrosis. HBO can revert the delayed radiation changes in tissues by generating steep oxygen gradients between the normal and the irradiated tissues causing oxygen to diffuse into the affected areas.2012
  70. 70. The Role of Hyperbaric Oxygen HBO has been used as an adjunctive conservative measure along with antibiotics and irrigation since the 1960s. Using Marx’s theory that osteoradionecrosis is a result of hypoxia, hypocellularity and hypovascularity, HBO seems likely to increaseoxygen supply in hypoxic tissues, stimulating fibroblast proliferation and angiogenesis. 2012
  71. 71. The role of HBO in the treatment of osteoradionecrosis. The Marx protocol (1982)2012 Gal TJ et al, Arch Otolaryngol Head Neck Surg 2003
  72. 72. The use of HBO in the treatment of osteoradionecrosis despite its widespread use had been largely theoretical or anecdotal because of the paucity of controlled trials and the lack of unified assessment of symptom improvement. 2012 Epstein J et al, Oral Surg 1997
  73. 73. The role of HBO in the treatment of osteoradionecrosis. The study by Annane et al (2004) The first randomized, placebo-controlled, double-blind study assessing the efficacy and safety of HBO for the treatment of overt mandibular osteoradionecrosis and included 68 patients.2012 Annane D et al, J Clin Oncol 2004
  74. 74. The trial was terminated prematurely because of the failure to demonstrate any beneficial effect of HBO over placebo (19% vs. 33% respectively).They also reported the progression of disease in recovery in the arm of HBOpatients and better recovery rates in the arm of the placebo treated patients. 2012 Annane D et al, J Clin Oncol 2004
  75. 75. The study by Annane resulted into strong criticism and disbelief by several authors quoting that it violated an ethical principle by exposing the control group to the potentially serious risk of acute decompression illness; a risk not present in the treatment group. Others stated that a major error in Annane’s study was the fact that the studied group of patients with an osteoradionecrosis was not well defined. There were though supporters of the Annane study presenting evidence that the beneficial results of HBO2012 treatment are equivocal and the method is time consuming and expensive.
  76. 76. Although the cohort was small it seems that HBO was of little benefit. HBO is demanding for patients and has cost implications for the NHS; hence further clinical outcome data are urgently required with regard to its role in the management of ORN.2012
  77. 77. HBO therefore remains ineffective as a stand-alone therapy or even as a reliable adjuvant. Variability among investigation techniques at various centers makes it difficult to completely write off HBO as a potential therapeutic adjuvant. The debate is still going on.2012
  78. 78. The use and efficacy of HBO prior to tooth extraction has been debated in the literature. Those who argue against the use of HBO prior to tooth extraction state that: the overall risk of developing ORN with pre-radiation or postradiation extractions is quite low, HBO therapy is expensive, and it is time consuming2012
  79. 79. The use of HBO therapy prior to implant placement has also been debated. The use of HBO may decrease morbidity and increase the success of dental implant therapy. Recent studies have shown an increase in long- term dental implant failure in patients who did not receive HBO with implant placement.2012
  80. 80. Management of Early and Advanced Osteoradionecrosis2012
  81. 81. Established ORN does not regress spontaneously. It either stabilizes or gradually worsens.2012
  82. 82. 2012
  83. 83. 2012
  84. 84. 2012
  85. 85. One of the adverse factors implemented in the development of ORN is the Radiation Induced Fibrosis (RIF) and necrosis. It has been shown that RIF greatly regressed after antioxidant treatment with the combination of pentoxifylline, tocopherol and clodronate.2012 Delanian S et al Head Neck 2005
  86. 86. With this treatment applied to 18 patients with advanced ORN, 16 (89%) recovered after a median 6 months of treatment. The results of this trial raise many questions primarily about the precise mechanisms of action of the drugs used, which will remainunanswered until further randomized clinical trials will be conducted. 2012 Delanian S et al Head Neck 2005
  87. 87. Selection of Treatment in ORN Stage I Superficial Ulceration Exposed cortical bone Conservative management: Debridement Meticulous oral hygiene Antibiotics2012
  88. 88. Stage I: Perform 30 HBO dives (1 dive per day, Monday-Friday) to 2.4 atmospheres for 90 minutes. Reassess the patient to evaluate decreased bone exposure, granulationtissue that covers exposed bone, resorption of nonviable bone, and absence of inflammation. For patients who respond favorably, continue treatment to a total of 40 dives. For patients who are not responsive, advance to stage II. 2012
  89. 89. Selection of Treatment in ORN Stage II Exposed medullary bone + soft tissue changes Conservative Surgical management: Sequestrectomy in addition to other conservative measures HBO cannot revitalize dead bone2012
  90. 90. Stage II: Perform transoral sequestrectomy with primary wound closure followed by continued HBO to a total of 40 dives. If wound dehiscence occurs, advance patients to stage III. Patients who present with orocutaneous fistula, pathologic fracture, or resorption to the inferior border of the mandible advance2012 to stage III immediately after the initial 30 dives.
  91. 91. Selection of Treatment in ORN Stage III Sinus/Fistula Pathologic Fracture Extensive soft tissue involvement Extensive bony loss2012
  92. 92. 2012
  93. 93. Stage III: Perform transcutaneous mandibular resection, wound closure, and mandibular fixation with an external fixator or2012 maxillomandibular fixation, followed by an additional 10 postoperative HBO dives.
  94. 94. The only successful treatment of advanced (Stage III) mandibular osteoradionecrosis is the surgical resection of diseased tissues and their reconstruction with free tissue transfer2012
  95. 95. Conservative measures, such as limited debridement and HBO therapy, may be effective in preventing the progression of ORN. However, they fail to eradicate established ORN, which requires radical surgical resection followed by functional reconstruction with2012 well-vascularized tissue.
  96. 96. Patients who initially present with advanced disease (stage II or III) are unlikely to respond to HBO and conservative therapy. These patients require extensive debridement leading to large composite defects.2012
  97. 97. 2012
  98. 98. 2012
  99. 99. 2012
  100. 100. Reconstructive options in the treatment of severe (Stage III) mandibular osteoradionecrosis 1. The radial forearm osteocutaneous flap 2. The fibula osteocutaneous flap 3. The use of additional flaps2012
  101. 101. 2012 Militsakh ON et al, Otolaryngol-Head and Neck Surg 2005
  102. 102. 2012
  103. 103. 2012
  104. 104. 2012
  105. 105. 2012
  106. 106. 2012
  107. 107. Reconstructive options in the treatment of severe (Stage III) mandibular osteoradionecrosis 1. The radial forearm osteocutaneous flap 2. The fibula osteocutaneous flap 3. The use of additional flaps2012
  108. 108. 2012 Shaha A et al, Head Neck 1997
  109. 109. 2012
  110. 110. 2012
  111. 111. 2012
  112. 112. 2012
  113. 113. 2012
  114. 114. Reconstructive options in the treatment of severe (Stage III) mandibular osteoradionecrosis 1. The radial forearm osteocutaneous flap 2. The fibula osteocutaneous flap 3. The use of additional flaps2012
  115. 115. •  Iliac crest (DCIA) •  Scapula •  Latissimus dorsi •  Rectus Abdominis •  Lateral arm •  Lateral thigh2012
  116. 116. The rate of post-operative complications during the surgical treatment of mandibular osteoradionecrosis is extremely high and when they occur usually require additional surgery .2012 Ang E et al, Br J Plast Surg 2003 Gal TJ et al, Arch Otolaryngol Head Neck Surg 2003
  117. 117. 2012
  118. 118. 2012
  119. 119. 2012
  120. 120. Conclusion •  Early ORN can be managed conservatively •  Successful treatment of advanced ORN depends on resection of all necrotic tissue •  Predictable and prompt primary healing of surgical defect requires well-vascularized tissue •  Single-stage composite microvascular tissue transfer provides best opportunity to2012 achieve successful outcome
  121. 121. The question whether HBO should be a precedent treatment or should be administered post-operatively or not at all is unanswered.2012
  122. 122. Conclusions •  Combined modality treatment for oral cancers is associated with multiple early and late effects which impact QOL •  Oral complications are common following radiation for head and neck cancer •  Irradiation of parotid glands is the main cause of xerostomia •  IMRT reduces the risk of xerostomia •  Pharmacological approaches such as amifostine may have a similar effect •  The future challenge is to study interventions to reduce2012 adverse effects in the oral tissues and improve QOL

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