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Friday, July 22, 2011

A 46-year-old man presents with oral swelling, ulceration, and pain 3 years after completion of combined external irradiation and brachytherapy for right-sided tongue cancer.

1.1 Review the following CT images. The imaging findings could represent: (Check all that
apply and click the Submit button.)...toate

rasp.corecte

Tumor recurrence Mandibular osteoradionecrosis Osteomyelitis

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F . External beam radiotherapy has a higher incidence of ORN compared with interstitial therapy( (The risk of ORN is greatest when an interstitial implant is used as a radiation source. T Good oral hygiene and performing the necessary dental procedures before the radiation treatment starts reduce the risk of ORN. F . because of the high dose of radiation delivered to the bone in a short time interval when the implant is close to it).) T In the head and neck. The mentum and angle of the mandible are the most frequent sites for ORN. the most common site for osteoradionecrosis (ORN) is the mandible.corecte Atrophy Osteoradionecrosis Pathologic fractures Radiation-induced malignancy 2.2 Regarding the following statements: (Please respond to the following with TRUE or FALSE.) toate rasp.1 Radiation-induced changes in bone include which of the following: (Check all that apply and click the Submit button.2.

) Chin-barbie . Chin and angle are sites of muscle insertions where transcortical vascularization of the bone occurs.(Devascularization of the irradiated mandible is central to the pathogenesis of ORN. providing relative protection to these areas.

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Figure 1 and Figure 2: Axial CT images in bone window through the horizontal and vertical rami of the mandible show several areas of cortical discontinuity inthe lingual and buccal cortices of the mandible. . with fragmentation of the involved bone segment (yellow arrows).

Risk factors include advanced stage of primary lesion. Peak=varf. Mandibular osteoradionecrosis (ORN) is a rare and dreaded complication of such treatment. The peak incidence of ORN occurs the first 3 months following radiotherapy. compare with the opposite normal side (red arrow). after tumor recurrence has been ruled out. It is defined as clinical and radiologic evidence of mandibular necrosis within the radiation field. poor oral . The pathogenetic mechanism is impaired vascular and lymphatic flow as a consequence of radiation-induced endothelial damage and fibrosis. with a second peak occurring 2 years after radiotherapy completion. dental disease.maxim DISCUTII Radiotherapy is an integral part of treatment for a vast majority of head and neck cancers. DIAGNOSTIC Osteoradionecrosis of the mandible   Infection and tumor recurrence mimic osteoradionecrosis (ORN) and need to be ruled out before considering the diagnosis.Figure 3: Axial CT image through the involved bone segment shows the associated soft tissue swelling (yellow arrow).

and rinsing with antiseptic solution. differentiation of osteomyelitis from ORN is seldom possible on imaging alone. Severe necrosis requires surgical debridement and reconstruction. remain stable for months to years. mandibular ORN appears as dissimilar lytic areas interspersed with areas of increased density (sclerosis). or heal with conservative management. An associated fracture may also be seen. measures include removal of initiating trauma. often complicated by pathologic fractures. high dose of radiation. On panoramic radiographs. and infection. intraoral gas may be entrapped within the necrotic bone as a consequence of dehiscence of the overlying mucosa. hyperbaric oxygen therapy. and large radiation field. Although presence of gas has been associated traditionally with osteomyelitis. ulceration and necrosis of the mucous membranes are seen with exposure of the underlying necrotic bone. Tumor recurrence and osteomyelitis can have similar appearance. Dreaded= de temut ruled out= exclus clues(cluz) = indicii seldom= rareori noteworthy= remarcabil heal spontaneously(hils sponteniasli)=videca spontan rinsing =clatire . and. CT shows interruptions in cortical margins in almost all cases of ORN. Bone changes are frequently accompanied by soft tissue swelling and enhancement. Associated bone fractures and fragmentation are often seen. fistulization. Although certain clues can help. Clinically. Peak occurrence of ORN is seen during the first 3 months following radiotherapy. in fact.hygiene. curettage. with the second peak noted after 2 years of completion. It is noteworthy that most tumor recurrences are seen within 2 years. Small asymptomatic bone exposures may heal spontaneously. they may coexist.