Evidence-Based Management of Osteoradionecrosis and Medication-Related Osteonecrosis of the Head and Neck

PROGRAM DESCRIPTION: Osteoradionecrosis (ORN) and medically-related osteonecrosis (MRON) can carry a progressive course that ultimately leads to significant morbidity and negatively impacts quality of life. The incidence of ORN is around 8% in head and neck cancer patients with intensity modulated radiation therapy while MRON is 2-5% following bisphosphonate and can be higher when given sequentially with antiresorptive drugs. While clinical presentation can be similar between the two processes (exposed necrotic bone with associated infection), there are differences in radiographic findings and pathogenesis. ORN appears to be directly caused by radiation damage to blood vessels within bone, while MRON disrupts normal bone remodeling by inhibiting osteoclast activity resulting in impaired bone healing and subsequent necrosis. The course will review the pathophysiology of each disease, the sites typically affected in each disease and will focus on the treatments associated. We discuss evidence-based medical management of the disease including pentoxifylline and tocopherol. Hyperbaric oxygen therapy (HBOT) has long been employed as a treatment and a comprehensive review of the literature will be explored. Other novel techniques including use of vascularized tissue to reverse the progression of the disease will be explored in addition to bony reconstruction for more advanced disease. Finally, a novel classification system is presented that is tailored to escalating treatment with advancing disease.

OUTCOME OBJECTIVE 1: 1. Review pathophysiology, incidence, anatomic sites of involvement and radiographic findings of ORN and MRON

OUTCOME OBJECTIVE 2: 2. Explore evidence behind contemporary management of the disease – including medical management and HBO. Expound on novel techniques involving vascularized tissue to reverse progression of ORN and MRON while utilizing bony reconstruction for more advanced cases

OUTCOME OBJECTIVE 3: 3. Review classifications systems and propose a novel classification system that pairs extent of disease with escalating management

BACKGROUND STATEMENT: A comprehensive review of the evidence behind the management of osteonecrosis is undertaken and a novel technique incorporating vascularized tissue to reverse the degradative process is proposed. A classification system is proposed that links extent of disease with treatments.

Comprehensive Otolaryngology Track Statement :