Learning Objectives:
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• To describe the presentation, investigation and treatment of a severe case of temporal bone ORN.
Introduction:
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• Osteororadionecrosis (ORN) of the temporal bone can result from radiotherapy to the ear.
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• We describe the strategy utilised to manage a severe case of temporal bone ORN complicated by superimposed infection.
Case report:
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• A 75-year old male presented with a 4-month history of severe headache, right otalgia, otorrhea and hearing loss.
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• The patient had undergone excision of a right pinna BCC followed by radiotherapy 15 years ago.
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• Examination revealed a 5 cm diameter tender fluctuant swelling over his right temple, pus in the ear canal and an eroded posterior canal wall.
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• A diagnosis of severe temporal bone ORN was made.
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• 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.
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• 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.
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• Pus culture grew S. anginosus requiring treatment with 7 days of IV co-amoxiclav followed by 5 weeks of PO amoxicillin.
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• 2 months post surgery the patient was completely pain free and follow up CT confirmed radiological resolution.
Conclusions:
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• 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.
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• Potential sequelae include osteomyelitis, CSF leak, meningitis and fatality.
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• Patients may present with severe otalgia, chronic otorrhea and swelling.
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• The mainstay of treatment is surgical debridement and abscess drainage. Long-term antibiotics are needed to treat an associated osteomyelitis.
