Osteoradionecrosis and pathological fracture: mandible

Case contributed by Melbourne Uni Radiology Masters
Diagnosis certain


Increasing jaw pain. Past history of tonsillar squamous cell carcinoma. Prior radiotherapy.

Patient Data

Age: 75-year-old
Gender: Male

Panoramic radiographic (OPG)


Lytic destruction of the right mandible, adjacent to the angle, with surrounding sclerosis. 

The orbits and visualized brain are unremarkable.

Destruction of the right hemimandible angle and body keeping with history of radionecrosis. Artefact from dental amalgam limits the assessment in this location. Within this limitation, no definite superficial or deep collection is identified in this location.

Saliva glands are symmetrical and unremarkable.

The thyroid glands are not enlarged. Bilateral hypodense nodules are non-specific on CT, it would be better assessed with ultrasound if clinically indicated.

Limited images of the lungs demonstrates extensive centrilobular emphysematous change, asymmetrical right apical scarring and left upper lobe 0.6 cm nodule. Comparison to prior imaging and clinical correlation is recommended. NGT in situ, distal extent not imaged.

Note is made of high-grade stenosis of the right carotid bulb and origin of the right ICA.

CONCLUSION:​ Right hemimandible osteoradionecrosis. Please note that superimposed osteomyelitis cannot be confirmed or excluded on imaging. No evidence of established collection. Clinical correlation advised.

MACROSCOPIC DESCRIPTION: 1. "Distal 47 mandible bone": Four irregular fragments of hard tan bone 18x15x3mm in aggregate. Placed into decal. A1. 2. "46 site mandible bone": An irregular fragment of hard tan bone up to 4mm. Placed into decal. A1. 3. "Soft tissue from mandible fracture line": Multiple pieces of rubbery to soft tan tissue 16x10x3mm in aggregate. A1. 

MICROSCOPIC DESCRIPTION: 1. The sections show fragments of necrotic cortical lamellar bone. The osteocytes have lost their nuclear staining. There is granular material, bacterial colonies and occasional clusters of neutrophils on the surface. No tumor is seen. The features are consistent with osteoradionecrosis. 2. The sections show some fragments of viable cortical lamellar bone. There is no evidence of osteoradionecrosis. Focal fibrosis is present. No tumor is seen. 3. The sections contain thickened squamous mucosa with some calcified bony trabeculae and connective tissue. The squamous cells show reactive changes. Scattered neutrophils are seen in the epithelium, along with clumps of bacteria. No evidence of dysplasia or malignancy is identified. The bony trabeculae appear viable.

DIAGNOSIS: 1. Distal 47 mandible bone: Osteoradionecrosis. 2. 46 site mandible bone: Viable bone with focal fibrosis. 3. Soft tissue from mandible fracture line: Reactive and inflamed squamous mucosa. No evidence of dysplasia or malignancy.

Case Discussion

The differential diagnosis for osteoradionecrosis is osteomyelitis and squamous cell carcinoma that infiltrates the mandible (i.e. T4 disease). Previous history is vital for narrowing the diagnosis, and imaging findings need to be correlated with clinical findings +/- biopsy. 

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