Mandibular osteoradionecrosis

Case contributed by Dr Henry Knipe

Presentation

Left mandibular lesion for characterisation. No further history is available.

Patient Data

Age: 60 years
Gender: Male
X-ray

Lytic destructive lesion involving the left hemimandible. No pathological fracture. 

CT

Lytic lesion centred on the left posterior mandible with destruction of the alveolus, expansion of the medullary cavity with cortical thinning and a cortical breach laterally. Low-density material has replaced normal marrow. Increased sclerosis seen anteriorly to the left first mandibular molar. 

Absent left submandibular gland, absent left internal jugular vein and absent superior left sternocleidomastoid muscle. Loss of fat planes in the left neck. 

The patient proceeded to biopsy under direct visualisation by the maxillofacial surgeons. 

Histopathology

Macroscopic description: "Bone": Six pieces of brown/pale tissue 2-6 mm.

Microscopic description: Section show fragments of lamellar bone with empty lacunae. The bone is surrounded by cellular debris and sheets of gram positive cocci. Numerous filamentous fungal hyphae consistent with Actinomyces are present. There is no evidence of malignancy.

Diagnosis: Left mandible bone: Features in keeping with osteoradionecrosis. 

Case Discussion

Based on the imaging findings the main differential diagnoses are, chronic osteomyelitisMRONJ, or osteoradionecrosis. Findings are not typical for invasion from an oral cavity squamous cell carcinoma, nor of a metastasis or lymphoma. 

The key to making the diagnosis is recognising evidence of prior neck dissection and resection of the left submandibular gland, and with that the assumption of prior radiation therapy, then osteoradionecrosis becomes the favoured diagnosis. Confirmation can then be made with appropriate history and biopsy. 

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Case information

rID: 44286
Case created: 15th Apr 2016
Last edited: 25th Feb 2017
System: Head & Neck
Inclusion in quiz mode: Included

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