Cardiovascular complications in head & neck microvascular flap reconstruction: A retrospective risk stratification and outcomes assessment.

BACKGROUND: To determine the incidence and predictors of cardiac complications (CC) in head & neck microvascular flap reconstruction. METHODS: A series of 216 microvascular flaps performed between 2012 and 2015 were analyzed using the Revised Cardiac Risk Index (CRCI) and the Charlson Comorbidity Index (CCI). Multivariate regression analysis was undertaken for predictive factors of outcomes. RESULTS: Twenty patients developed CC (9.7%) with transient cardiac arrhythmia (6.5%) and myocardial infarction (2.8%) occurring most frequently. Univariate analyses demonstrated significant differences between the two groups in terms of their age, smoking status, occurrence of peripheral vascular disease, CCI, RCRI, length of hospitalization and duration of anesthesia. Multivariate analyses showed that RCRI (p < 0.001) and amount of blood transfused (p = 0.02) were independent predictors of CC. CONCLUSIONS: Cardiac complications are uncommon in head and neck microvascular flap surgery. The RCRI is a useful screening tool for estimating cardiac complication risk and improving patient and flap outcomes.

Using the patients concerns inventory for distress screening in post-treatment head and neck cancer survivors.

PURPOSE: Cancer patients can experience significant distress during their cancer trajectory, which impacts upon clinical outcomes and quality of life. Screening for distress using holistic assessments can help identify and address unmet concerns/needs. The purpose of this study was to evaluate the relationship between concerns and distress, and the impact of distress on clinic outcomes in post-treatment head and neck cancer patients. METHODS: 170 patients attending routine follow-up clinics were prospectively recruited. All patients completed the Patient Concerns Inventory (PCI) and the Distress thermometer (DT) at preconsultation. RESULTS: The rate of significant distress (i.e. DT cut-off score ≥4) was 36% (62/170). Significantly distressed patients selected more items overall than patients without distress (mean, median (QR) of 5.40, 5 (2-8) vs 2.61, 2 (0-4), p < 0.001). Significant distress was most strongly associated with Physical and Functional well-being (p < 0.001) and Psychological and Emotional well-being domains (p = 0.001). On balance, very little difference was noted between cut-off points of either ≥4 or ≥5 PCI items of concern selected. Both cut-off points demonstrated an acceptable level of sensitivity, specificity and predictive values for significant distress. Consultations were longer with increasing numbers of concerns. CONCLUSIONS: Just over one-third of patients are significantly distressed. They were more likely to express a higher number of concerns. A cutoff score ≥4 or ≥5 PCI items selected can identify those at risk of significant distress. Concerns causing significant distress were related to emotional/psychological issues and physical function.

Margin Analysis: Malignant Salivary Gland Neoplasms of the Head and Neck.

There are no established protocols for the optimum surgical margin required for salivary gland malignancies. Factors including histologic diagnosis and TNM stage have been shown to be important in prognosis and survival outcome and mandate special consideration of margin size. Salivary cancers are treated differently at different anatomic sites, and different histologic types show a propensity for major or minor glands. Low-grade malignancies are treated with soft tissue margins of 1 cm or less. The facial nerve is preserved unless infiltrated and encased. Adenoid cystic carcinoma and carcinoma ex pleomorphic adenoma require more complex planning to obtain negative margins.

Screening for distress using the distress thermometer and the University of Washington Quality of Life in post-treatment head and neck cancer survivors.

The primary aim was to determine the efficacy of the Distress Thermometer (DT) in screening for anxiety and mood problems against the University of Washington Quality of Life, version 4 (UWQOL). Secondary aims were to evaluate the association between demographic, clinical and health-related QOL variables with significant distress. Two hundred and sixty one disease-free HNC ambulatory patients attending routine follow-up clinics were prospectively recruited. Both DT and UWQOL were completed pre-consultation. Receiver operating characteristic (ROC) curve analyses of DT score for anxiety dysfunction yielded an area under the curve (AUC) of 0.877, with a sensitivity of 84% (43/51) and specificity of 76% (159/210) for a DT cut-off of ≥4; with a corresponding AUC of 0.825 for mood with sensitivity 78% (28/36) and specificity 71% (159/225). Treatment with radiotherapy and a longer consultation time were associated with significant distress (DT ≥4). Significant distress was also reported in two third of those reporting less than "Good" overall QOL. Distress levels were particularly associated with poor Social-Emotional function, more so than the association seen with poor physical function. DT is a reasonable screening tool for distress in the HNC population. The DT cut-off score ≥4 was effective in identifying those with significant distress. Significant distress is associated in survivors with poor health-related quality of life, those who received radiotherapy and patients who have longer consultation times in clinic.

Extensive Regional Metastasis of High-Grade Mucoepidermoid Carcinoma of an Unknown Primary Tumor.

PURPOSE: Mucoepidermoid carcinoma (MEC) is the most common salivary carcinoma. It arises most frequently in the major salivary glands, but can also arise in minor glands or intraosseous sites. MEC of an unknown primary occurs very rarely. The present report documents only the third case reported in medical studies. METHODS: A 66-year-old man with previous carcinoma in situ (CIS) of the left posterior oral tongue that had been excised in 2004 and again in 2010 presented with a hard lymph node, 3 × 2 cm at level II of the right neck in July 2015. Positron emission tomography-computed tomography (PET-CT) revealed multiple, bilateral cervical lymphadenopathy, with no primary site identified. Fine needle aspiration biopsy and cytologic examination from the right neck was positive for malignancy, suggestive of metastatic squamous cell carcinoma. Panendoscopy and biopsy revealed CIS at the tongue bases and tonsils bilaterally (p16-negative). The patient's case was presented to a tumor board, and definitive concurrent cispl.atin-based chemoradiation was recommended for TisN2cM0, stage IVA oropharyngeal CIS, which was completed in November 2015. PET-CT in January 2015 showed complex interval changes, with some areas demonstrating improvement (ie, no uptake in the left neck) and worsening in others (ie, increased metabolic activity in the right neck), suggestive of residual disease. Repeat PET-CT in March 2016 showed increased nodal involvement and increasing standardized uptake value. Bilateral modified radical neck dissection was undertaken, and histologic examination showed high-grade MEC in 51 of 61 lymph nodes with extracapsular spread and soft tissue involvement. RESULTS: The patient died in May 2016 at 2 months after surgery. CONCLUSIONS: Metastatic MEC of an unknown primary is a diagnostic challenge. PET-CT might not be the most reliable diagnostic investigation to identify the primary or metastatic foci, such as was demonstrated in the present case.

Sustained response of HER2-positive metastatic salivary adenocarcinoma, not otherwise specified, treated with trastuzumab.

OBJECTIVE: Adenocarcinoma-not otherwise specified (AD-NOS) is an aggressive salivary gland carcinoma subtype with poor prognosis. Her2/neu-targeted therapy may be beneficial in cases of overexpression (20% of AD-NOS). Here, a case of metastatic AD-NOS of the submandibular gland showing sustained complete response to trastuzumab is reported, and the existing literature is reviewed. STUDY DESIGN AND RESULTS: A 68-year-old male with poorly differentiated AD-NOS of the submandibular gland with multiple metastases (T3 N2 bM1) underwent radical surgery and adjuvant radiation. The primary lesion demonstrated Her2/neu overexpression, and treatment with trastuzumab was initiated. The patient remains alive without evidence of disease at 36-months after treatment (three cycles of trastuzumab). Literature review of all published trastuzumab-based therapy studies (1990-2015) for salivary gland carcinoma is included. CONCLUSIONS: Definitive clinical trials of trastuzumab-based interventions are challenging to undertake in rare tumors. This report adds to increasing evidence for trastuzumab-based therapy in salivary carcinomas, where sustained partial response at 36-months is achievable.

The Value of the "Papillon" Anterolateral Thigh Flap for Total Pharyngolaryngectomy Reconstruction: A Retrospective Case Series.

PURPOSE: The tubed, buried anterolateral thigh (ALT) flap is a popular reconstruction method for total pharyngolaryngectomy defects. The "papillon"-designed ALT flap, described by Hayden et al, offers an alternative method of using the ALT flap in this situation. We report our early experience with the papillon ALT flap in a patient cohort. PATIENTS AND METHODS: On retrospective review, all patients who underwent reconstruction of circumferential total pharyngolaryngectomy defects with the papillon ALT flap from February 2012 to February 2015 were identified from our departmental database. Demographic and clinical data, operative details, and complications were analyzed from the records. RESULTS: Seven patients were included in this study. The mean length of hospital stay was 15 days (range, 10 to 32 days). Acute complications occurred in 5 of 7 patients, namely, partial flap loss managed by a pectoralis flap (1 of 7 [14%]); an early pharyngocutaneous fistula (4 of 7 [57%]) managed by simple repair, wound packing, or delayed repair; and a donor-site hematoma (1 of 7 [14%]). At follow-up (range, 2 to 24 months), there was 1 stricture formation, but no chronic fistula. All patients were able to swallow orally. CONCLUSIONS: Early results using the papillon ALT flap suggest that this technique is a viable alternative to the standard tubed ALT flap design. The advantages of this design include the following: 1) it offers simultaneous vascularized skin to resurface anterior neck skin deficiency without resorting to additional tissue elsewhere; 2) direct monitoring of the ALT flap is possible; and 3) any pharyngocutaneous fistula is exteriorized to the surface without compromising the internal neck structures and can be easily identified and repaired directly in the office.

How head and neck consultants manage patients' emotional distress during cancer follow-up consultations: a multilevel study.

Head and neck cancer (HNC) patients suffer substantial emotional problems. This study aimed to explore how utterance-level variables (source, type and timing of emotional cues) and patient-level variables (e.g. age, gender and emotional well-being) relate to consultants' responses (i.e. reducing or providing space) to patient expressions of emotional distress. Forty-three HNC outpatient follow-up consultations were audio recorded and coded, for patients' expressions of emotional distress and consultants' responses, using the Verona Coding Definitions of Emotional Sequence. Multilevel logistic regression modelled the probability of the occurrence of consultant-reduced space response as a function of patient distress cue expression, controlling for consultation and patient-related variables. An average of 3.5 cues/concerns (range 1-20) was identified per consultation where 84 out of 152 total cues/concerns were responded by reducing space. Cue type did not impact on response; likewise for the quality of patient emotional well-being. However, consultants were more likely to reduce space to cues elicited by patients, as opposed to those initiated by themselves. This reduced space response was more pronounced as the consultation continued. However, about 6 min into the consultation, this effect (i.e. tendency to block patients) started to weaken. Head and neck consultants' responses to negative emotions depended on source and timing of patient emotional expressions. The findings are useful for training programme development to encourage consultants to be more flexible and open in the early stages of the consultation.

The Patients Concerns Inventory in head and neck cancer: comparison between self-completed paper and touch screen versions in the clinic setting.

BACKGROUND: The Patients Concerns Inventory (PCI) is a practical tool for patients to highlight their concerns and needs for discussion in consultations. OBJECTIVE: To use paper and touch-screen technology (TST) versions of the PCI, to see if there were differences in issues raised by patients before consultation and in issues discussed during consultation. METHODS: Two consultants participated. Also 105 of their post-operative head and neck cancer patients in 122 consultations completed paper or TST versions of the PCI before consultation, April 2010 to April 2012. RESULTS: There were no statistically significant differences between paper and TST in how many PCI concerns were selected by patients or discussed in consultation, nor in length of consultation. Fear of recurrence, chewing/eating, dental health, swallowing, salivation, head & neck pain, speech and sleeping issues were common concerns across both paper and TST. Fewer than 10% of patients encountered any problems when completing either form of PCI. Interestingly, the two consultants used the PCI differently, reflected in different levels of agreement between items highlighted on the PCI and items subsequently discussed - κappa-coefficients of agreement were 0.68 for the paper and 0.66 for the TST version of the PCI (consultant A) and 0.55 for the paper and 0.32 for the TST version of the PCI (consultant B). CONCLUSIONS: This study found that the paper version of the PCI was an acceptable alternative to the TST version.

Fear of recurrence among head and neck cancer survivors: longitudinal trends.

BACKGROUND: Fear of recurrence (FoR) following head and neck cancer (HNC) treatment is a major patient concern but is infrequently discussed in outpatient settings and may cause significant detrimental effect on patient psychological well-being. AIM: The aim of this paper is to determine longitudinal trends and predictors of significant FoR. METHOD: Prospective data collection was obtained in 189 post-treatment HNC patients with 456 clinic attendances from October 2008 to January 2011. All patients completed Patient Concerns Inventory (PCI), University of Washington Quality of Life Questionnaire version 4 and the FoR questionnaires using a combination of paper and touch-screen technology. RESULTS: The prevalence of significant FoR was 35%, which was stable longitudinally. Logistic regression-delineated predictors of significant FoR were young age (<65 years), anxiety/mood and patient-reported FoR. Conventional prognostic factors including standard clinicopathological factors, treatment modality and length of follow-up did not predict significant FoR. Over time, 20% of patients reported significant FoR intermittently, whereas 30% experienced it consistently. The remaining 50% did not experience significant FoR. DISCUSSION: Patient-related characteristics were more important than clinicopathological prognostic factors in predicting significant FoR, potentially creating a mismatch between the doctors' perception of patient's experience of FoR with what patients may experience. In the long term, FoR is expressed across a spectrum extending from 'normal' FoR to persistent significant FoR with an intermediate category of intermittent significant FoR. Those patients experiencing intermittent and consistent levels of significant FoR may benefit from psychological support. This study confirmed that self-reported screening FoR using the PCI is a valuable tool in identifying significant FoR.

Genomic determinants of normal tissue toxicity after radiotherapy for head and neck malignancy: a systematic review.

Interindividual variations in radiotoxicity responses exist despite uniform treatment protocols. It is speculated that normal genetic variants, particularly single nucleotide polymorphisms (SNPs) may influence normal head and neck (HN) tissue radiotoxicity. This first-ever systematic review was undertaken to evaluate the association of SNPs with normal HN tissues radiotoxicity. Multiple databases (1950-February 2012) were reviewed using a combination of related keywords and MeSH terms. All published HN radiotoxicity studies with sufficient relevant data for extraction were included. The outcomes evaluated were acute and late radiotoxicity endpoints. Methodological quality assessment based on the STrengthening the REporting of Genetic Association (STREGA) statement was performed. Seven articles from 692 articles searched fulfilled the eligibility criteria. Recruited sample sizes were small (range, 32-140). There were 5/7 case-control studies. All studies used multimodality treatment with heterogeneous radiation parameters. Candidate gene approach was used in all studies. Fourteen SNPs from 9 genes were evaluated from the following pathways: DNA damage response, radiation fibrogenesis and oxidative/xenobiotic metabolism. Acute radiotoxicity events were associated with SNPs of DNA repair genes (OR, 3.01-4.08). SNPs of TGFß1 were associated with osteoradionecrosis (OR, 4.2) and subcutaneous fibrosis. Genetic association studies in HN radiotoxicity currently provide hypothesis-generating findings that require validation in larger studies. Future studies must incorporate critical methodological issues and technological improvements, including using a genome-wide approach. Headway is possible through case-pooling of existing clinical trial data which could create a larger sample size of well-characterized treatment and endpoints. Also, on-going HN cancer clinical trials should consider extending their toxicity evaluation to include genetic association studies.

Bilateral asynchronous renal cell carcinoma with metastatic involvement of the tongue.

Renal cell carcinoma (RCC) has a propensity for distant organ metastasis and late recurrence, involving not only the ipsilateral but also contralateral kidney. Lingual metastasis by RCC is rare. We present an unusual case of bilateral asynchronous RCC. Involvement of the right kidney was discovered only after a metastatic tongue lesion was diagnosed. The original RCC had been treated by left nephrectomy 14 years previously. Due to end-stage primary pulmonary malignancy, and poor function of the remaining kidney, immunotherapy was unsuitable. Palliative local resection of the lingual metastasis alleviated functional difficulties and was preventative against airway obstruction, but the patient died five months later.

Identifying pain-related concerns in routine follow-up clinics following oral and oropharyngeal cancer.

AIM: To describe clinical characteristics of head and neck cancer (HNC) patients with pain and those wishing to discuss pain concerns during consultation. METHODS: Cross-sectional, questionnaire study using University of Washington Quality of Life, version 4 (UW-QOL) and the Patients Concerns Inventory (PCI) in disease-free, post-treatment HNC cohort. Significant pain on UW-QOL and indicating "Pain in head and neck" and "Pain elsewhere" on PCI. RESULTS: One hundred and seventy-seven patients completed UW-QOL and PCI. The prevalence of self-reported pain issues was 38% (67/177) comprising 25% (44/177) with significant problems despite medications and 13% (23/177) with lesser or no problems but wishing to discuss pain. Patients aged under 65 years and patients having treatment involving radiotherapy were more likely to have pain issues. Just over half, 55% (24/44) of patients with significant pain did not express a need to discuss this. Those with significant pain or others wanting to discuss pain in clinic had greater problems in physical and social-emotional functioning, reported suboptimal QOL, and also had more additional PCI items to discuss in clinic compared to those without significant pain and not wishing to discuss pain. CONCLUSION: Significant HNC-related pain is prevalent in the disease-free, posttreatment cohort. Onward referral to a specialist pain team may be beneficial. The UW-QOL and PCI package is a valuable tool that may routinely screen for significant pain in outpatient clinics.

Enhanced patient reported outcome measurement suitable for head and neck cancer follow-up clinics.

BACKGROUND: The 'Worse-Stable-Better' (W-S-B) question was introduced to capture patient-perceived change in University of Washington Quality of Life (UW-QOL) domains. METHODS: 202 head and neck cancer patients in remission prospectively completed UW-QOL and Patients Concerns Inventory (PCI). For each UW-QOL domain, patients indicated whether over the last month things had worsened (W), remained stable (S) or were better (B). RESULTS: 202 patients at 448 attendances selected 1752 PCI items they wanted to discuss in consultation, and 58% (1024/1752) of these were not covered by the UW-QOL. UW-QOL algorithms highlighted another 440 significant problems that the patient did not want to discuss (i.e. the corresponding items on the PCI were not selected).After making allowance for UW-QOL algorithms to identify 'significant problems' and PCI selection of corresponding issues for discussion there remained clear residual and notable variation in W-S-B responses, in particular to identify patients with significant problems that were getting worse, and patients without significant problems that wanted to discuss issues that were getting worse. Changes in mean UW-QOL scores were notably lower for those getting worse on the W-S-B question, typically by 10 or more units a magnitude that suggests clinically important changes in score. CONCLUSIONS: The W-S-B question adds little questionnaire burden and could help to better identify patients who might benefit from intervention. The results of this study suggest that the UW-QOL with the W-S-B modification should be used together with the PCI to allow optimal identification of issues for patient-clinician discussion during routine outpatient clinics.

Leonard buttons: a reliable method of intraoperative intermaxillary fixation in bilateral mandibular fractures.

PURPOSE: To retrospectively audit outcomes of using Leonard buttons (LBs) as intraoperative intermaxillary fixation in conjunction with open reduction-internal fixation of bilateral mandibular fractures. PATIENTS AND METHODS: Seventy-seven patients were included in this study. The fracture reduction score was obtained from postoperative radiographs by use of 3-tiered scoring system. Medical case notes were obtained for clinicodemographic data, including operation length, postoperative occlusion scores, periodontal status, and complications. RESULTS: The cohort predominantly comprised male patients (87%), with a mean age of 26 years. The major cause of injury was interpersonal violence (87%). The fracture pattern most treated was angle-parasymphysis fracture (70.1%). The mean length of follow-up was 83.81 ± 79.33 days. The mean overall reduction score was 6.95 ± 1.03 in the LB group and 6.40 ± 1.68 in the arch bar (AB) group (P = .275). When the occlusion scores were evaluated, the difference between the 2 groups was statistically significant (P = .027). The mean operation length was shorter in the LB group compared with the AB group (142.05 ± 32.31 minutes vs 161.00 ± 24.04 minutes, P = .013). Oral hygiene was poor in 7 patients in the LB group (11.3%) and in 5 patients in the AB group (33.3%) (P = .05). No significant correlation was observed between number of LBs placed with overall reduction and occlusion scores. No significant relation was observed for number of LBs and periodontal status, infection, and nonunion. CONCLUSIONS: This pilot study suggests that LBs are able to achieve equally good reduction as ABs but have better occlusion scores, with a shorter operating time, and show better gingival health. LBs are a viable alternative to ABs in providing intraoperative intermaxillary fixation for bilateral mandibular fractures. However, further prospective, randomized studies should be undertaken to obtain conclusive evidence.

Patient-reported outcomes in breast oncology: a review of validated outcome instruments.

AIMS AND BACKGROUND: Patient-reported outcomes (PROs) include areas of health-related quality of life but also broader concepts such as patient satisfaction with care. The aim of this review is to give an account of all instruments with potential use in patients with a history of treatment for breast cancer (including surgery, chemotherapy and/or radiotherapy) with evidence of validation in the breast cancer population. METHODS: All instruments included in this review were identified as PRO measures measuring breast-related quality of life and/or satisfaction that had undergone development and validation with breast oncology patients. We specifically looked for PRO measures examining patient satisfaction and/or quality of life after breast cancer treatment. Following an evaluation of 323 papers, we identified 15 instruments that were able to satisfy our inclusion criteria. RESULTS: These instruments are the EORTC QOL-C30 and QLQ-BR23 (European Organization for Research and Treatment of Cancer Quality of Life Questionnaire-Breast Cancer Module), the FACT-B (Functional Assessment of Cancer Therapy-Breast Cancer), the SLDS-BC (Satisfaction with Life Domains Scale for Breast Cancer), the BIBCQ (Body Image after Breast Cancer Questionnaire), the HIBS (Hopwood Body Image Scale), the PBIS (Polivy Body Image Scale), the MBROS (Michigan Breast Reconstruction Outcomes Study) Satisfaction and Body Image Questionnaires, the BREAST-Q, the BCTOS (Breast Cancer Treatment Outcome Scale), the BCQ, the FACT-ES (Functional Assessment of Cancer Therapy-Endocrine System), the MAS (Mastectomy Attitude Scale), and the Breast Cancer Prevention Trial Symptom Checklist (BCPT). CONCLUSIONS: Suggestions for future directions include (1) to use and utilize validated instruments tailored to clinical practice; (2) to develop a comprehensive measurement of surgical outcome requiring the combination of objective and subjective measures; (3) to aim for a compromise between these two competing considerations in the form of a scale incorporating both generalizability in cancer-related QOL and specificity in breast cancer issues.

Treatment referral before and after the introduction of the Liverpool Patients Concerns Inventory (PCI) into routine head and neck oncology outpatient clinics.

PURPOSE: Holistic needs assessment is a key recommendation in improving supportive and palliative care in adults with cancer. The Patients Concerns Inventory (PCI) is a holistic needs assessment tool designed for head and neck cancer survivors in outpatient setting. Routine screening of potential unmet needs in a clinic may result in increased onward referrals, thus placing a burden on existing healthcare services. The aim of this study was to compare the referral trends following consultation in the time periods before and after introduction of PCI in an oncology outpatient clinic. METHOD: A cross-sectional cohort of disease-free survivors of oral/oropharyngeal cancers of a single consultant was prospectively exposed to PCI from July 2007 to April 2009. The PCI is a self-completed questionnaire consisting of 55 items of patient needs/concern and a list of multidisciplinary professionals, whom patients may wish to talk to or be referred to. Retrospective analysis of referral patterns from clinic letters in two periods in the pre-PCI and post-PCI exposure was performed. Prospective analysis of consultations was performed to determine the outcome of PCI-highlighted items. RESULTS: There was no change in the prevalence of onward referral with the introduction of PCI, i.e. 21 referrals per 100 patients seen in outpatients. However, the proportion of referrals to oral rehabilitation and psychological support increased. Referrals to certain services, e.g. speech and language and dentistry, remained consistently in demand. Many PCI-highlighted needs were dealt in a clinic with by the consultant and/or other professionals during a multidisciplinary consultation. CONCLUSIONS: Routine use of PCI promotes target efficiency by directing and apportioning appropriate services to meet the needs for supportive care of head and neck cancer survivors.

Perivascular epithelioid cell tumor (PEComa) of the cheek.

We present the unusual case of a perivascular epithelioid cell tumor (PEComa) occurring within the cheek of a 32-year-old woman. PEComa is a rare, recently described, family of tumors with diverse clinicopathologic expression and which express melanocytic and muscle markers. It mainly affects the abdominopelvic region and rarely occurs in somatic soft tissue or skin. To our knowledge, this is the first reported case of PEComa occurring in the facial cutaneous tissues. Other possible diagnoses considered included benign mesenchymal tumors of smooth muscle or neural origin. However, the cytomorphologic and immunohistochemical profile were most suggestive of PEComa. The tumor was completely excised, but in view of uncertainty as to how this entity would behave in an unusual location, lifelong follow up is recommended. After complete excision, there was no recurrence in 4 years.

Osteoradionecrosis of the jaws: current understanding of its pathophysiology and treatment.

During the past 80 years a number of theories about the pathogenesis of osteoradionecrosis (ORN) have been proposed, with consequent implications for its treatment. Until recently tissue hypoxia and its consequences were accepted as the primary cause, and this led to the use of hyperbaric oxygen (HBO) for both treatment and prevention of complications of radiotherapy in the head and neck. The benefit of HBO has not been validated. A new theory for the pathogenesis of ORN has proposed that damage to bone is caused by radiation-induced fibrosis. Cells in bone are damaged as a result of acute inflammation, free radicals, and the chronic activation of fibroblasts by a series of growth factors. New treatments have therefore been devised that include pentoxifylline, a vasodilator that also inhibits fibrosis, and tocopherol (vitamin E) to reduce damage caused by free radicals. Impressive results in terms of reversing the process of ONR have been reported using these agents. It has been suggested that this theory and these agents could be the basis of future treatment and prevention of ORN.