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A 79-year-old male presents with an open right clavicle fracture secondary to osteoradionecrosis. He is scheduled for a right neck dissection, clavicle debridement, and potential left pectoralis major flap.

Three years back, he underwent a tonsillectomy and then a selective right neck dissection and brachial plexus exploration for squamous cell carcinoma. This was followed by a 5-week course of high-dose cisplatin chemotherapy and radiation. Progression of radiation damage resulted in eventual clavicle fracture and protrusion through the skin.

The remainder of his past medical history is significant for osteoarthritis, controlled hypothyroidism, and acid reflux. Other past surgical history includes hip and knee arthroplasties and inguinal hernia repair. He quit smoking 30 years back, consumes little alcohol, and exercises regularly. His medications include amoxicillin/clavulanate, acetaminophen, celecoxib, rabeprazole, and levothyroxine.

On examination, he is in no apparent distress. His vital signs are: blood pressure 130/80, heart rate 76 beats per minute, respiratory rate 18 breaths per minute, temperature 36.5°C, and oxygen saturation 98% on room air. He is 183 cm tall and weighs 84 kg (BMI 25.1 kg·m−2). Auscultation of his chest yields normal heart sounds with no extra heart sounds or murmurs, and clear breath sounds bilaterally.

Airway examination reveals a Mallampati III classification. Mouth opening, thyromental distance, and mandibular protrusion were within normal limits. Neck extension is severely limited (see Figure 37.1). He has full natural dentition. Examination and palpation of his neck reveal woody, indurated tissue extending from his right ear superiorly to larynx anteriorly, to the dressing that covers the open wound mid-clavicle (see Figures 37.1 and 37.2). His larynx is immobile.


Limited cervical spine extension in a patient with history of right neck dissection and radiotherapy.


Appearance of the external neck following right neck dissection and radiotherapy. Note the telangiectasia, loss of normal skin creases, and thickened appearance of the anterior neck on the irradiated side.


What Anatomic and Pathophysiologic Changes Occur Following Radiotherapy to the Structures of the Oral Cavity and Neck?

Radiotherapy inflicts a radiochemical injury to both normal and malignant cells.1 The damage is related to the total radiation dose and the method of radiotherapy delivery. In order to achieve adequate tumor control, damage to normal tissues is inevitable.1–3 Radiation also activates various cellular signaling pathways that lead to the release of proinflammatory and profibrotic cytokines and vascular injury.4 Early (acute) tissue toxicities from radiotherapy are arbitrarily considered to occur within 90 days of the commencement of treatment, and late effects beyond 90 days of treatment.2,5 Early side effects are observed during or shortly after a course of radiotherapy, whereas ...

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