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Management of temporal bone osteoradionecrosis complicated by osteomyelitis: a case report

Presenting Author: M Kuet

Published online by Cambridge University Press:  03 June 2016

M Kuet  and
MY Yung
M Kuet
Affiliation:
The Ipswich Hospital NHS Trust
MY Yung
Affiliation:
The Ipswich Hospital NHS Trust
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Abstract

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Learning Objectives:

  • • To describe the presentation, investigation and treatment of a severe case of temporal bone ORN.

Introduction:

  • • Osteororadionecrosis (ORN) of the temporal bone can result from radiotherapy to the ear.

  • • We describe the strategy utilised to manage a severe case of temporal bone ORN complicated by superimposed infection.

Case report:

  • • A 75-year old male presented with a 4-month history of severe headache, right otalgia, otorrhea and hearing loss.

  • • The patient had undergone excision of a right pinna BCC followed by radiotherapy 15 years ago.

  • • Examination revealed a 5 cm diameter tender fluctuant swelling over his right temple, pus in the ear canal and an eroded posterior canal wall.

  • • A diagnosis of severe temporal bone ORN was made.

  • • CT of the temporal bones demonstrated erosions of the mastoid and squamous portions of the temporal bone. The erosion of the squamous portion had created a bony defect with a large abscess overlying the exposed dura.

  • • The patient underwent urgent abscess drainage, debridement of necrotic periosteum, subtotal petrosectomy and blind pit closure without obliteration using biological material. A titanium plate was used to repair the lytic area of the skull. This was covered by the preserved temporo-parietal fascial flap.

  • • Pus culture grew S. anginosus requiring treatment with 7 days of IV co-amoxiclav followed by 5 weeks of PO amoxicillin.

  • • 2 months post surgery the patient was completely pain free and follow up CT confirmed radiological resolution.

Conclusions:

  • • Temporal bone ORN arises from radiation injury causing bone hypovascularity with subsequent cellular death. It may occur many years after radiotherapy to the head and neck.

  • • Potential sequelae include osteomyelitis, CSF leak, meningitis and fatality.

  • • Patients may present with severe otalgia, chronic otorrhea and swelling.

  • • The mainstay of treatment is surgical debridement and abscess drainage. Long-term antibiotics are needed to treat an associated osteomyelitis.