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HYPOTYMPANOPHARYNGEAL FISTULA : A COMPLICATION OF TEMPORAL BONE
OSTEORADIONECROSIS
ELTON M LAMBERT MD, RON J. KARNI MD, SANCACK YUKSEL MD
DEPARTMENT OF OTORHINOLARYNGOLOGY-HEAD AND NECK SURGERY UNIVERSITY OF TEXAS-HEALTH SCIENCES
CENTER AT HOUSTON
Objectives: To present a rare case of osteoradionecrosis of the temporal
bone that resulted in the formation of fistulous tracts between the
hypotympanum and posterolateral pharyngeal wall.
Study Design: Case report.
Methods: 61 year old male with a history of oropharyngeal cancer
treated with chemoradiation nine years prior to his presentation of
right ear pain and associated otorrhea. He was found to have
osteoradionecrosis of the temporal bone and underwent lateral
temporal bone resection. Fistulous tracts were found between the
hypotympanum and the posterolateral pharyngeal wall at the level of
the oropharynx. Necrotic bone was resected within the temporal bone
and the hypotympanum that was obliterated with muscle and Tisseel.
Results: Upon follow-up laryngoscopy the fistulous tracts appeared to
be healing well with no apparent communication as evidenced by
methylene blue test.
Conclusions: Temporal bone osteoradionecrosis can be a serious
complication of radiation to the head and neck. To our knowledge this is
the first report of this entity resulting in the formation of a fistula
between the tympanic cavity and pharynx. When managing temporal
bone osteoradionecrosis one must not only keep in mind pathology
related to the temporal bone but related structures including the
pharynx, intracranial cavity and great vessels.
Case Report
• 61 year old male presented with long standing right sided
otorrhea and ear pain
• Prior history of Oropharyngeal Cancer treated with
chemoradiation at an outside institution
• CT scan revealed diffuse temporal bone osteoradionecrosis
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Introduction
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B
A
Ewing et al in 1926 first reported osteonecrosis after radiation
therapy
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Soft Tissue Injury to the temporal bone
Otitis externa
Osteoradionecrosis
Malignant otits externa
Meningitis and brain abscess
Symptoms
Crusting (100%)
Otalgia (91%)
Otorrhea (91%)
Hearing Impairment (73%)
Foul Odor (45%)
Retroauricular Fistula (9%)
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A
B
Figure 2 A) Right posterior pharyngeal wall fistulous tracts (asterix)
communicating with to Hypotympanum B ) Suction placed within
Hypotympanum to display communication with the posteriolateral
pharyngeal wall
Block et al in 1956 reported osteomyelitis of the temporal bone 15
years after radiation for syringomyelia
Ramsden et al reported 26 patients with temporal bone radiation
injury
Localized disease (69%)
Diffuse disease (31%)
Case Report
• The patient underwent right lateral temporal bone resection
with findings including
-Diffuse bony necrosis of right external auditory canal
-Exposure of carotid artery and jugular bulb
-Multiple Fistuolous tracts between hypotympanum and
posterolateral pharyngeal wall
• Hypotympanum was obliterated with temporalis muscle and
mastoid cavity obliterated with fat and temporalis muscle
• Follow up endoscopy after keeping patient NPO revealed
resolution of fistulous tracts
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->
C
D
Figure 1 A) Axial CT of the right temporal bone at the level of
the cochlea showing diffuse bony destruction of the external
auditory canal, mastoid cortex and areas of the petrous
portions of the temporal bone B) Soft tissue cuts at the same
level as demonstrating subperiosteal abscess formation (*) C)
Axial CT of the Right temporal bone at the level of the
petrous portion of the carotid canal exhibiting bony erosion
of the right carotid canal (asterix) D) Soft tissue CT of the
neck demonstrating extension into the right SCM (arrow)
Conclusion
• Osteoradionecrosis of the temporal bone can be a serious
consequence of radiation injury to the temporal Bone
• Osteoradionecrosis can lead to sequealae such as osteomyelitis,
CSF leak and meningitis; carotid artery aneurysms
• Management of temporal bone osteoradionecrosis can involve long
term Antibiotics, Hyperbaric oxygen and surgical debridement
• This reports highlights the importance of temporal bone
osteoradionecrosis in previously radiated patients and the serious
sequelae
REFERENCES
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