Mandibular Osteoradionecrosis Management: A Roundtable Discussion - Part 2

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.

I'm joined again today by our team of facial plastic and reconstructive osteoradionecrosis specialists, Dr.’s Michael Fritz, Sara Liu, Peter Ciolek, and Brandon Prendes. If you haven't listened to part one of our discussion on the new grading system for osteoradionecrosis management, be sure to give it a listen. Let's dive back in.

It seems like it's kind of evolved in grown over time and it seems like even in the most severe instances you have good options for people. It seems like the bone graft. Was there ever any concern that the bone graft wouldn't survive or does new bone get laid down with this?

Peter Ciolek: I think the concern is we’re operating on an infected field and in general, non-vascularized grafts don't do well in that sort of environment. I think the advantage we have is that we tend to perform a pretty aggressive debridement of all necrotic bone until we're down to healthy bleeding bone. We irrigate out with an antiseptic solution and then that area, if needed, is packed with the bone graft obtained from the patient and then wrapped in vascularized tissue, which can provide a blood supply to that bone graft, the surrounding affected mandible, and then also hopefully deliver antibiotics to that previously infected environment. And our follow-up imaging on many of these patients shows improved bone stock in the mandible well beyond the area of debridement.

Paul Bryson: That's great to hear. I am not involved in that space, so it's always interesting to see how things all come together. Sometimes free grafts in different areas may not be receptive to an environment with the blood supply issues that you talk about.

Brandon Prendes: I think just to interject, I think one of the game changers that I didn't necessarily expect is when you take these iliac crest bone grafts, we use kind of long-acting local anesthetic for these patients and they really have minimal kind of recovery. They're walking the day after surgery and they don't have a ton of morbidity from that bone graft. And a key to the minimal access approach that we use is that everything we're talking about, these anterolateral thigh flaps, even when we add the free bone grafts, in the worst-case scenarios, really severe Stage IV disease, if the patient then fractures down the road, we haven't typically gone into their radiated neck, we haven't made external cuts. So if they do need a fibula free flap down the road, what a lot of people don't understand is we really haven't burnt any of the bridges. We haven't created more scars that would make that more difficult down the road. So you still have that as a very viable backup plan as it's kind of the standard of care. But in most patients we're finding they don't need that.

Paul Bryson: Can you walk me through sort of the patient’s journey, what's the process here? I know certainly we talked about surgery. Are you working collaboratively with some other services like infectious disease or otherwise? How do patients do that they meet with? What are the discussions like? I know it seems like there's some moving parts with these patients.

Sara Liu: So generally patients will see one of us first and we'll counsel them on surgery whether or not they need it. When it comes time for surgery, we do these as a two-surgeon team approach, and that just helps minimize the time that the patient has to spend on anesthesia. So one of us will be at the leg doing the free flap harvest, and then somebody else is up with the head doing the mandible debridement and looking for blood vessels to hook the free flap up too postoperatively. These patients, generally with a lot of our head and neck reconstruction, free flap patients, they end up staying in the hospital for five, seven, sometimes 10 days. These patients for the rescue flaps, our length of stay, it's one to two days and usually less than three for sure, and they're drinking postop day zero. We do often get infectious disease involved, especially if the cultures grow, anything that is a little unusual or is resistant to the regular antibiotics that we use.

Paul Bryson: And these are oral antibiotics, you're not having to get a PICC line for patients or is it sometimes…

Sara Liu: Oftentimes it's oral, but if they are growing something that's very resistant to then if we need to, then they will get PICC lines for IV.

Paul Bryson: And then just to be clear with the rescue flap, not having to put in temporary feeding tubes, and some of the things that might be associated with more of a traditional open reconstruction?

Michael Fritz: There's a lot of patients that come to us and they've already been consulted that they're going to have a trach, either a nasal feeding tube or even a PEG, and they're going to have this big huge operation. And then we'll, just because this isn't an incredibly difficult operation for a microvascular surgeon that does perforator flaps to do once they've been trained in it, but it's been developed here and really there aren't a lot of places that know a lot about it. So they're still offering kind of the old school treatment, which again works and is a reasonable approach, but it's an order of magnitude bigger operation. So folks are very surprised when they come here and we’re like, “Nope. Yeah, you won't need a trach, won't need a feed tube, probably leaving in a day or two.” And those are real predictions. We don't have folks that have big bumps in the road.

Peter Ciolek: And then the nice thing is, I think with how minimally invasive this technique is and how well patients do after surgeries, we've been able to accommodate patients from all over the country. So these are patients that may come in for one initial consult visit where we review their imaging and their previous treatment, suggested treatment plan, and then the next time they see us is for surgery and they may stay in the hospital for several days, maybe stay another day in a hotel, and then the next visit we may do is virtual to check in on them. They can even follow up locally sometimes just to check on their incisions, but again, that's an order of magnitude less than the morbidity they would incur with a segmental mandibular and fibular free flap where oftentimes patients are requiring tracheostomy, prolonged feeding tubes and so much more care.

Michael Fritz: And then following all this, once patients have recovered, our oral maxillofacial prosthodontists are heavily involved in dental rehabilitation for them. We've just started doing some dental implants and these folks were very optimistic that the bone grafts that we’re taking, because they were putting in, they look so good and solid, will be fine for dental implants. It's not like we're putting implants in radiated bone anymore. We're putting implants in really healthy bone put in a newly vascularized bed. So for all intents and purposes, this is healthy mandibular bone that we've created. We expect people to get back to where they want to go in terms of dental rehab.

Paul Bryson: Yeah. Well, I congratulate you and the team. It's really remarkable for these patients. What else is on the horizon as far as additional research to help better manage this?

Michael Fritz: I just wanted to emphasize one component that I think is one of the best parts of this place and the way this surgery is done is that there's four of us who work interchangeably here. Each one of us can do every component of this surgery, and I think that makes it really easy to get folks on the schedule. Sometimes we'll do even three of these surgeries in a day, and occasionally we've done four, which in the world of free tissue transfer, free flap surgery, is seeing a lot, and often we'll do two in the same room and still be done in a very reasonable time for folks. So I think that the strength of this is our collaboration and we're always open to doing things better. So we just continue to change, that feeds the kind of innovative things that we're doing on the new horizon, which is actually not every single segmental resection of a jaw needs a fibula free flop, a big bone free flap in there.

If we have people that present with breaks in the jaw and all the other bone looks pretty healthy, we've actually been putting some spanning plates across it to stabilize it and grafting them as well. And that so far has worked very well. Our series is only, I think a dozen right now, but it's gone on to need a fibula free flap or any big resection, so it's basically the same operation as the rescue flap except for a stabilizing plate. We certainly can't do that for everybody. If you've got a bunch of destroyed bone that looks terrible and infected and it's going to be a big defect, for sure, the answer is the traditional answer, but at least we can give people that option. And then that big traditional resection, as I briefly mentioned earlier, all of us are doing that without external incisions in the neck, just enough of an incision to get blood vessels and otherwise the surgery is done through the mouth, which is super challenging in terms of visualization and getting the bone to fit perfectly and getting the geometry of the blood vessels. But because we all work so well together because of the way we've all been trained, we're interested in doing things that may be harder, that are much easier for the patients, and those folks have been leaving much faster, again without trach’s, without feeding tubes. So even when it's a big deal, I think we're probably doing a little bit better than most because of our general approach to everything.

Paul Bryson: Well, I really appreciate everybody's time today. I wanted to just give you the opportunity. Any final take, home messages or additional thoughts before we sign off today?

Brandon Prendes: I would just say that in terms of osteoradionecrosis, I mean we designed this protocol to try and help people, and there's a lot of people who are coming here from other places to seek care and we're able to provide that in a safe way, even for patients traveling for care. The growing number of oropharyngeal cancers in this country, in most modernized nations, is becoming a real problem and a real health issue for people, and radiation is a large part of that treatment. So unfortunately, I think going forward we'll probably continue to see a fair number of patients who need this care, and that's why we're excited to give them an option that's less invasive and gets them back to a good quality of life quickly.

Peter Ciolek: I think this is very important development in the treatment of ORN (osteoradionecrosis) because the way I think of it, these are patients that have been diagnosed and treated for head and neck cancer and oftentimes have gotten through that difficult stage in their life, and then they're faced with another problem that could potentially impact their quality of life more than their initial cancer diagnosis. And we've been able to offer them an option that is much better than what we could in the past.

Sara Liu: Traditionally, ORN is such a challenging thing to deal with, and I think that a lot of providers often shy away from it, and patients just kind of are in this limbo of waiting and seeing. So it's really gratifying to be able to provide care for these patients that's effective and kind of a definitive treatment and at a pretty low morbidity to them.

Michael Fritz: Then I guess I'd circle back to this paper. We all put a lot of time into this, and there are other folks that aren't here that put a great deal of time into it as well. There are a lot of nights that were spent in a lot of coffee shop meetings where we were just kind of pouring through all the data out there. And this paper is more than just us talking about the rescue flap technique. Actually, we even mentioned in this paper that if a center doesn't really know, they're not familiar with the rescue flap, you can even put another soft tissue free flap on if you follow these protocols well, but the point of this paper was to basically dive into every aspect of the treatment of osteoradionecrosis and get some kind of consensus on efficacy of each treatment. And that's hard because none of these studies are really clear or really incredibly well done.

But I think we did a really good job in just summarizing everything out there, and it's a pretty dense paper for a lay person to read or even for some physicians to read. Maybe they might fall asleep reading it, but it does really kind of, in as few words as possible, spell everything out, which is that pentoxifylline and tocopherol are effective for early disease. Hyperbaric oxygen really doesn't have a role in our modern management of osteoradionecrosis, and intervening early with debridement and culture directed antibiotics and some type of free flap with high vascularity, we prefer the anterolateral thigh rescue flap because it's so low morbidity, that's why we prefer that one, but some type of coverage with a really good blood supply can stop almost all osteoradionecrosis, so there's really no role anymore to stare at it. And there's a grading system in there that's actually color coded and matches with the treatment algorithm. So if you don't even look at the paper in any other fashion, if you just look at the stages and look at the colors and follow the flow diagram, it's actually really simple to kind of look at what your options are and what the best treatments are for this disease.

Paul Bryson: Thank you all again. I've really enjoyed our multi-week discussion on this game changing work. As a reminder to our listeners, 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. Thanks always.

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.