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

Abstract

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.