Clin Exp Otorhinolaryngol.  2009 Sep;2(3):115-119.

Chondroradionecrosis of the Larynx: Diagnostic and Therapeutic Measures for Saving the Organ from Radiotherapy Sequelae

• Roh JL

Abstract

OBJECTIVES
Chondroradionecrosis (CRN) of the larynx is a rare but fatal complication of radiotherapy. We determined the optimal diagnostic methodology and management of laryngeal CRN in six patients. METHODS: We retrospectively reviewed the records of six patients with Chandler grade IV laryngeal CRN who had received prior radiotherapy (mean total radiation dose, 66.7+/-4.5 Gy) at a tertiary care hospital. Two patients underwent transoral laser microresection of their laryngeal carcinoma plus postoperative radiotherapy. All patients underwent endoscopy, computed tomography (CT), positron emission tomography (PET), removal of necrotic tissue, biopsy under suspension laryngoscopy, administration of antibiotics, and hyperbaric oxygen therapy (HBO). Their diagnostic and therapeutic results were assessed. RESULTS: CT showed CRN of the anterior larynx in three patients and CRN of the posterior larynx in three patients, with one patient having a false-positive result on PET. HBO consisted of a mean of 36+/-6 dives. After early debridement and HBO, five patients showed CRN improvement, but one had aggravation and subsequently underwent total laryngectomy. None of these patients showed local tumor recurrence on pathologic examination or during a mean follow-up of 24 months. CONCLUSION: Although CRN of the larynx may be detected by endoscopic and imaging work-ups, detection may require pathologic examination. Early debridement and HBO may effectively treat CRN, saving the functional larynx.

Keyword

Chondroradionecrosis; Larynx; Diagnosis; Treatment; Hyperbaric oxygen therapy

MeSH Terms

Anti-Bacterial Agents
Biopsy
Debridement
Endoscopy
Follow-Up Studies
Humans
Hyperbaric Oxygenation
Laryngectomy
Laryngoscopy
Larynx
Positron-Emission Tomography
Recurrence
Retrospective Studies
Tertiary Healthcare
Anti-Bacterial Agents

Figure

• 

  Fig. 1 Chondroradionecrosis of the anterior larynx after concurrent chemoradiotherapy (case no. 1). (A) Contrast-enhanced axial CT scan showing an infiltrative mass in the anterior glottis and subglottis (asterisk). (B) CT scan 4 months after completion of radiotherapy showing air bubbles around the thyroid cartilage in the glottis and subglottis (arrow). (C) Improvement of radionecrosis after early removal of necrotic tissue and HBO.

• 

  Fig. 2 Chondroradionecrosis of the posterior larynx after transoral laser microresection plus postoperative radiotherapy (case no. 3). (A) Laryngoscopic photograph showing erosion and sloughing in the right posterior larynx (arrow). (B) Contrast-enhanced axial CT scan showing erosion, air bubbles, and absence of the right arytenoid cartilage (arrow). (C) PET/CT scan showing hot uptake (maximum standardized uptake value, 7.4) in the right arytenoid area (arrow), which was interpreted as tumor recurrence (false positive).

Reference

1. Marx RE, Hohnson RP. Davis JC, Hunt TK, editors. Studies in the radiobiology of osteoradionecrosis and their clinical significance. Problem wounds: the role of oxygen. 1988. New York (NY): Elsevier;p. 65–123.

2. Lederman M. Radiation therapy in cancer of the larynx. JAMA. 1972; 9. 221(11):1253–1254. PMID: 5068627.

3. Chandler JR. Radiation fibrosis and necrosis of the larynx. Ann Otol Rhinol Laryngol. 1979; Jul–Aug. 88(4 Pt 1):509–514. PMID: 475247.

4. Greenwood TW, Gilchrist AG. Hyperbaric oxygen and wound healing in post-irradiation head and neck surgery. Br J Surg. 1973; 5. 60(5):394–397. PMID: 4706488.

5. Hao SP, Chen HC, Wei FC, Chen CY, Yeh AR, Su JL. Systematic management of osteoradionecrosis in the head and neck. Laryngoscope. 1999; 8. 109(8):1324–1327. PMID: 10443843.

6. Ferguson BJ, Hudson WR, Farmer JC Jr. Hyperbaric oxygen therapy for laryngeal radionecrosis. Ann Otol Rhinol Laryngol. 1987; Jan–Feb. 96(1 Pt 1):1–6. PMID: 3813371.

7. Filntisis GA, Moon RE, Kraft KL, Farmer JC, Scher RL, Piantadosi CA. Laryngeal radionecrosis and hyperbaric oxygen therapy: report of 18 cases and review of the literature. Ann Otol Rhinol Laryngol. 2000; 6. 109(6):554–562. PMID: 10855566.

8. Oppenheimer RW, Krespi YP, Einhorn RK. Management of laryngeal radionecrosis: animal and clinical experience. Head Neck. 1989; May–Jun. 11(3):252–256. PMID: 2722502.

9. Zbaren P, Caversaccio M, Thoeny HC, Nuyens M, Curschmann J, Stauffer E. Radionecrosis or tumor recurrence after radiation of laryngeal and hypopharyngeal carcinomas. Otolaryngol Head Neck Surg. 2006; 12. 135(6):838–843. PMID: 17141070.

10. Berger G, Freeman JL, Briant TD, Berry M, Noyek AM. Late post radiation necrosis and fibrosis of the larynx. J Otolaryngol. 1984; 6. 13(3):160–164. PMID: 6544830.

11. Fitzgerald PJ, Koch RJ. Delayed radionecrosis of the larynx. Am J Otolaryngol. 1999; Jul–Aug. 20(4):245–249. PMID: 10442778.

12. Rowley H, Walsh M, McShane D, Fraser I, O'Dwyer TP. Chondroradionecrosis of the larynx: still a diagnostic dilemma. J Laryngol Otol. 1995; 3. 109(3):218–220. PMID: 7745338.

13. McGuirt WF, Greven KM, Keyes JW Jr, Williams DW 3rd, Watson N. Laryngeal radionecrosis versus recurrent cancer: a clinical approach. Ann Otol Rhinol Laryngol. 1998; 4. 107(4):293–296. PMID: 9557763.

14. Hermans R, Pameijer FA, Mancuso AA, Parsons JT, Mendenhall WM. CT findings in chondroradionecrosis of the larynx. AJNR Am J Neuroradiol. 1998; 4. 19(4):711–718. PMID: 9576660.

15. Greven KM, Williams DW 3rd, Keyes JW Jr, McGuirt WF, Harkness BA, Watson NE Jr, et al. Distinguishing tumor recurrence from irradiation sequelae with positron emission tomography in patients treated for larynx cancer. Int J Radiat Oncol Biol Phys. 1994; 7. 01. 29(4):841–845. PMID: 8040032.

16. Annane D, Depondt J, Aubert P, Villart M, Géhanno P, Gajdos P, et al. Hyperbaric oxygen therapy for radionecrosis of the jaw: a randomized, placebo-controlled, double-blind trial from the ORN96 study group. J Clin Oncol. 2004; 12. 22(24):4893–4900. PMID: 15520052.

17. Feldmeier JJ, Heimbach RD, Davolt DA, Brakora MJ. Hyperbaric oxygen as an adjunctive treatment for severe laryngeal necrosis: a report of nine consecutive cases. Undersea Hyperb Med. 1993; 12. 20(4):329–335. PMID: 8286987.