Mandibular Osteoradionecrosis Management: A Roundtable Discussion - Part 1

Podcast Transcript

Paul Bryson: Welcome to Head and Neck Innovations, a Cleveland Clinic podcast for medical professionals exploring the latest innovations, discoveries, and surgical advances in otolaryngology - head and neck surgery.

Thanks for joining us for another episode of Head and Neck Innovations. I'm your host, Paul Bryson, Director of the Cleveland Clinic Voice Center. You can follow me on X, formerly Twitter, @PaulCBryson, and you can get the latest updates from Cleveland Clinic Otolaryngology-Head and Neck Surgery by following @CleClinicHNI on X. That's @CleClinicHNI. You can also find us on LinkedIn at Cleveland Clinic Otolaryngology - Head and Neck Surgery, and Instagram at Cleveland Clinic Otolaryngology.

We have a special episode today, so we have a roundtable panel with four of our facial plastic and reconstructive osteoradionecrosis specialists. I'm excited to speak with my colleagues, Dr.’s Michael Fritz, Sara Liu, Peter Ciolek, and Brandon Prendes. Welcome everybody to Head and Neck Innovations.

Well it's great to see you all here again, you're all returning guests to the podcast. We've had the opportunity to kind of talk about a range of different topics within your practices, but you want to just take a minute, introduce yourselves to our listeners, sort of what your specialties are, and we have a lot to cover with us today, so feel free to make it as short or long as you want.

Brandon Prendes: Alright, I'll go first. I'm Brandon Prendes. I'm one of the head and neck cancer and reconstructive surgeons here at the Cleveland Clinic. So I take care of patients with tumors but also heavily invested in their long-term survivorship, and that's how I got involved in the osteoradionecrosis practice.

Sara Liu: I'm Sara Liu. I am one of the facial plastic and reconstructive surgeons here at the Cleveland Clinic. I take care of pretty broad range of patients for facial plastics concerns, aesthetic concerns and reconstructive. I also do some gender affirmation facial surgery.

Peter Ciolek: I'm Peter Ciolek, I'm also a facial plastic surgeon and I'm part of the head and neck cancer team here. More so on the reconstructive side.

Michael Fritz: And I'm Michael Fritz. I'm the oldest facial plastic and reconstructive surgeon here. And like Peter and Sara, my practice spans from cosmetic facial surgery all the way to reconstruction, and my passion through the years has always been in the edges of facial reconstruction, particularly taking care of cancer patients.

Paul Bryson: Well, thank you guys. Certainly as a colleague, it's been inspiring to see the evolution of what you've been able to do over the years. Certainly just so much complex care patients with really difficult problems that you have helped and try to help. I wanted, before we dive into this, there's a new paper that you and the group have put out on mandibular osteoradionecrosis. Can you give the listener just a little bit of background, just describe what osteoradionecrosis is, who gets it? Is this something that most people that get head and neck radiation can expect to get? Or just paint the picture a little bit about who these patients are and how they come to seek help from you?

Michael Fritz: I guess I'll start. So osteoradionecrosis is a secondary phenomenon of having had radiation therapy for cancer. Most of patients that we see are well along their cancer journey and have already been cured, essentially, and are just living their lives. But the damage of radiation therapy, although it's a huge benefit in terms of allowing people to survive, it kind of leaves behind it quite a bit of damage. It's problems with blood supply and healing basically. And that particularly affects the bone. So when folks have problems, usually with their teeth, it sets up a cascade of events where you get kind of chronic bone infection exposure and then continuing destruction. The body just can't heal itself because of the lack of blood supply and the condition of the tissues that's been treated for cancer.

Paul Bryson: I was going to say, so what are some of the, over the years, what have people tried to either treat this or head this off? Just walk me back a little bit. I know you guys, we're going to talk quite a bit about this reconstructive pathway, but what have people tried over the years? How do you prevent this?

Brandon Prendes: So I think probably one of the biggest advancements is in the changing of the doses of radiation therapy. So techniques over time have gone from kind of 3D radiation treatment to more IMRT where they can target different tissues, give high doses to tumors, but try to avoid things that are important like the carotid artery, the spine, and the mandible. So I think that's one way that we've kind of intended to lessen osteoradionecrosis over time. Unfortunately, even in the era of IMRT, it's still a significant problem for patients with head and neck cancer because their tumors are close to the mandible. You can't get really high doses in the tumor and completely avoid the jaw. Other things people have tried to do to avoid it is pre-treatment dental care. So having patients take care of their cavities and their poor dentation prior to treatment, because if you have that dental extraction or the dental work done after radiation therapy, then a lot of times that's what sets up the cascade that Dr. Fritz talked about.

Paul Bryson: There's been some historical things that you'll read about like hyperbaric oxygen or vitamin supplements and things like that. Is there much evidence to support this, or is this something that's sort of carried on through the literature and practice without the advantages of good outcomes?

Sara Liu: So hyperbaric oxygen therapy is still frequently used for it. I think the studies that initially were done are pretty flawed, and so rates of success are not great, but unfortunately people still are recommended to undergo it, and it doesn't come without significant cost to the patient, both financially and in terms of morbidity.

Paul Bryson: There's been a lot of excitement about your new publication on management of mandibular osteoradionecrosis that was recently published in Otolaryngology-Head and Neck Surgery or the “White Journal.” It sounds like a true game changer for patients. Can you share a little bit of the history on how you evolved this treatment paradigm and tell us a little bit about what you're doing?

Michael Fritz: Yeah, so it's kind of a long story, Paul, and really starts initially when I was in practice awhile ago, and this was the standard decades before, we basically had nothing to do to stop osteoradionecrosis except hyperbaric oxygen, which everyone acknowledged wasn't, we didn't really think it was very effective. The newest studies that are randomized, controlled and pretty well done show that it really isn't effective, but that was really the only tool we had in our toolbox and we would tell people, we're going to treat you with antibiotics, we're going to treat you with hyperbaric oxygen, and we're going to stare at you and just hope that it doesn't get worse because the cost of the treatment was really high. It was taking a segment of the jaw out and then rebuilding it with a free vascularized bone. Usually the fibula, now that works really well, you can replace that bone with a fibula, but the problem is you're going through a whole bunch of radiated tissue to get there and you're kind of stressing these bodies that have been through quite a bit.

Not only does that set up really big wound healing problems, and that complication rate for segmental resection and reconstruction is pretty high even at the best centers, but it also risks changing patient’s already compromised function. So if you have trouble speaking, if you've got scarring in your mouth, if even on the outside in terms of the movement of your mouth, your nerves on your facial nerve branches are all buried in scar. And so getting there and doing the surgery, a lot of times left people much worse off, even though they didn't have an infection in their jaw anymore in terms of speaking, swallowing, moving their face. So we would just sit and tell them, it's too big of a cost, let's wait, and if the jaw breaks or if it gets really bad and we can't placate you with antibiotics, then we're going to cut it out and fix it.

But there was no in-between solution until we started doing minimal access perforator flaps with anterior lateral thigh fascia. We'd been doing that for a while and I had a very smart oral surgeon partner who suggested that we do this for osteoradionecrosis. That was kind of the in-between stage. It was clearly bad. There were two molars that were going to have to come out. It was going to be about half of the height of the jaw, but the patient had still a lot of good mandible on the scan and she said, well, why can't we just cover this up? And she suggested kind of a larger reconstruction, but we knew very well that we could do these little minimal access perforator flaps, which we've talked about in other podcasts. But essentially the cost of an anterior lateral thigh is less than a skin graft in terms of patient pain, a recovery, basically the whole gamut.

And these are short operations in comparison and short hospital stays. So we did this perforator flap on this first gentleman, and he left the first day after surgery and he never turned back, never had another problem. So at that point we figured we were onto something and it makes a lot of sense. You've got a hole over the bone, it can't heal because of the blood supply interrupted in the condition of the tissue. So if we put new fresh tissue with a great blood supply on top of it, and just take away the bad bone and leave the good bone, that we can get it to heal. And so with that in mind and with the success we had when we started doing that, and with the changes in the way we looked at hyperbaric oxygen and with a couple of medications that have come out, penicillin and tocopherol and clodronate, which we don't endorse, but it was also in that combination. All these changes, really we thought mandated a new look at how we approach this disease. And in order to guide people on how you approach it, you have to be able to grade it, you have to be able to stage the disease. So that's your mark in terms of dictating what your options are, where you go. And that was kind of the whole impetus behind this, the success of what we called mandibular rescue flaps, which are those perforator flaps and then these other changes in treatment that we've found out about.

Paul Bryson: Can you talk about, walk us through the staging system?

Perter Ciolek: Yeah, so our new staging system now is based on really two things. It describes the severity of the disease and also directs the management. So I think that's one of the areas where this staging system has the advantage over previous staging systems that either did one or the other, but not both. And it also incorporates this new treatment paradigm of the ALT rescue flap. So previously, again, therapy really early on people did conservative debridement, they did antibiotics, they did HBO, and then end stage disease patients were left with the option of segmental resection and fibular free flap. And we've added this whole treatment protocol or technique for patients in the moderate range. And so we have a staging system that has five levels based on size of the defect, the depth of the disease, the relationship of the disease to the nerve and the mandibular canal, and the potential for through and through fracture of the mandible. And so this has been a total game changer in terms of how we look at and how we manage the disease as a whole, from all the way from early stage to pathologic fracture.

Michael Fritz: So if we're walking through each step at each stage, the first stage is when it's just limited to the tooth, the dental alveolar unit, so just the bones surrounding the teeth. And it's smaller in this stage, so it's under 2.5 centimeters in size. And that's meaningful because the studies on pentoxifylline and tocopherol show that there's really good efficacy in healing this bone. And this is Trental, which is a medication they'd use mainly for people with vascular disease where they have cramping in their legs or just to help, it helps the red blood cells become basically more bendy so that they can move through the blood vessels better. And then tocopherol is vitamin E, which is an antioxidant, also a little bit of blood thinner. So these medications have done well for superficial disease that's small. And so the reason for our first stage is that this will probably respond very well to medical management and it doesn't require major surgery.

And then as we get along in the further stages, the Stage II is still just below the dental alveolar unit or a large surface area. So essentially the next stage where it's bigger than the first stage and it's much less likely to heal with the PENTO, which is what pentoxifylline and tocopherol is called for short. The advantage though, you still have when you're Stage II is you still have a ton of good bone of your jaw. And even if it progressed, even if you wanted to try the medical management, that's okay because you're not going to lose until it goes really far into the jaw and causes bigger problems. So in that stage, we give people the option of just putting it to rest and doing a rescue flap, which 97% of the time does that, or they can try medical management and close observation when it starts becoming further down, down towards the inferior alveolar nerve canal, which is a bigger Stage II.

And then Stage III is when we go below the inferior alveolar nerve canal, which is a nerve that travels in the middle of the jaw, and it's a really good anatomic landmark that we can see on both panorex as X-rays and CT scans. So it's just a really good landmark. So if it's kind of deep to that canal or below that canal, then we start offering people a little more aggressively that they should do this because it's very unlikely they're going to get away with any medical management, but they still don't need a segmental resection. They're still kind of in a good position.

A Stage IV is when we're really getting borderline and you have less than about a centimeter of the jaw remaining, so it could break at some point. And so we supplement that with bone graft from the hip. But interestingly enough, the rescue flaps have done incredibly well, just as well with Stage IV disease as they've done with Stage II disease, which we thought was pretty unexpected. This is a really hostile radiating environment with infection, and we're putting bone graft in there. But I think the key is that we are wrapping it with incredibly healthy tissue, with a great blood supply, and then delivering antibiotics for six weeks. And the key to all these rescue operations is we're doing deep culture directed antibiotics, so we're treating the infection and we're instituting a mechanism of blood supply to allow the treatment to get to the areas that need the treatment.

And then Stage V disease is full thickness break in the jaw, which vast majority of the time we're doing a segmental resection and a reconstruction just like would traditionally be done. However, we are doing that via different techniques, which we may talk about at a different podcast where people are doing much better, where we're not making external incisions.

Paul Bryson: Well, this has been a great discussion so far. Let's pick up next time. for more information on our osteoradionecrosis research, visit our Consult QD website at ConsultQD.ClevelandClinic.org. That's ConsultQD.ClevelandClinic.org. And to speak with one of our facial plastic and reconstructive surgeons, or submit a referral, please call 216.444.8500. That's 216.444.8500. Dr.’s Fritz, Ciolek, Liu and Prendes, thanks for joining Head and Neck Innovations.

All: Thanks Paul. Thanks for having us. Thank you.

Paul Bryson: Thanks for listening to Head and Neck Innovations. You can find additional podcast episodes on our website at clevelandclinic.org\podcasts, or you can subscribe to the podcast on iTunes, Google Play, Spotify, SoundCloud, or wherever you listen to podcasts. Don't forget, you can access realtime updates from Cleveland Clinic experts in otolaryngology – head and neck surgery on our Consult QD website at consultqd.clevelandclinic.org/headandneck. Thank you for listening and join us again next time.