Osteoradionecrosis of the skull after radiation therapy for invasive carcinoma

Osteoradionecrosis (ORN) of the skull is a rare but fatal complication of radiation therapy for the treatment of head and neck malignancies. The pathogenesis of ORN follows the "3Hs Theory" proposed by Marx (J Oral Maxillofac Surg 1983;41:283-288) in which radiation induces tissue injury by causing vessel thrombosis (hypovascularity), which leads to hypoxia, and results in cell death of the skin and the underlying structure of the bony element (hypocellularity) including the deep visceral structures. This note details a patient with severe and extensive ORN of the parietooccipital region of the skull because of a large dose of radiation therapy for the treatment of an invasive basal cell carcinoma of the scalp. The patient's condition was further complicated by an extensive infection with methicillin-resistant Staphylococcus aureus, which leads to meningitis and cerebral edema as well as cerebritis. The patient was successfully treated with interdisciplinary medical and surgical aggressive therapy and radical procedures involving 4 separate trips to the operating room for an 18-month period. Success was achieved because of early clinical diagnosis of ORN, aggressive eradication of infected and necrotic tissues including the brain, and restoration of functioning and viable tissues through the use of local flaps to change an open wound to a closed wound.