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Chronic Neck Pain After Oromandibular Reconstruction

Educational Objective
Based on this clinical scenario and the accompanying image, understand how to arrive at a correct diagnosis.
1 Credit CME

A 64-year-old woman with a history of hyperlipidemia, hypertension, HIV infection, coronary artery disease, and squamous cell carcinoma of the left mandible treated with composite resection, left neck dissection, and fibula free flap (FFF) reconstruction followed by postoperative radiotherapy presented with sharp, shooting left neck pain. Beginning 5 months after her reconstruction, the patient reported point tenderness on the left jaw, facial swelling, and electric pain with severity of 7 out of 10 in the left neck that occurred with talking or eating. Her postoperative course was complicated by osteoradionecrosis post-tracheostomy, plate removal, and left segmental mandibulectomy. She received regular physical therapy and lymphedema therapy and was seen by Physical Medicine and Rehabilitation, who treated her with onabotulinum toxin A injections; neither provided significant resolution of her symptoms. Review of a computed tomography scan of the head and neck (Figure 1) performed on follow-up 5 years after initial reconstruction demonstrated a long, hyperdense structure in the left submental, submandibular region with accompanying soft-tissue thickening. On further review of prior imaging, this calcification appeared as a new finding in various scans dating back to 5 months after FFF reconstruction compared with preoperative imaging. There was no fluorodeoxyglucose avidity in the area of question on multiple positron emission tomography scans done during this follow-up window.

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D. Ossification of the free flap pedicle

A painful neck mass is most worrisome for recurrence during surveillance of head and neck cancer.1,2 Though traumatic neuroma or chronic postoperative pain is possible,3 ossification of the FFF pedicle is the correct diagnosis for the following reasons. First, the lesion was stable over 5 years, with lack of fluorodeoxyglucose avidity on positron emission tomography, making recurrence less likely. Second, despite standard-of-care palliation techniques, her symptoms were recalcitrant. Third, the linear radiopacity located in the submental triangle, where the pedicle often courses, makes ossification more likely than a neuroma.

The FFF is the standard for oromandibular reconstruction because of its high success rate and low donor-site morbidity.2 A rare complication is pedicle ossification. Often asymptomatic, it may present as a firm, tender neck mass with trismus and pain with mastication and ipsilateral neck rotation.4,5 Diagnostic imaging including computed tomography or panoramic radiographs can confirm this finding. Most commonly, pedicle ossification is detected incidentally on surveillance imaging.4 The true incidence is unknown, with reports ranging from 4% to 65%; surprisingly, only 2.5% present symptomatically.4,6 Ossification is more common in younger patients and those not receiving high-dose adjuvant radiotherapy.4

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Article Information

Corresponding Author: Steven B. Cannady, MD, Department of Otolaryngology–Head and Neck Surgery, University of Pennsylvania, Penn Medicine Washington Square, 800 Walnut St, 18th Floor, Philadelphia, PA 19107 (steven.cannady@pennmedicine.upenn.edu).

Published Online: July 29, 2021. doi:10.1001/jamaoto.2021.1685

Conflict of Interest Disclosures: None reported.

Additional Contributions: We thank the patient for granting permission to publish this information.

Pipkorn  P , Licata  J , Kallogjeri  D , Piccirillo  JF .  Association of symptoms and clinical findings with anticipated outcomes in patients with recurrent head and neck cancer.   JAMA Otolaryngol Head Neck Surg. 2018;144(8):738-745.PubMedGoogle ScholarCrossref
Kim  BB , Kaleem  A , Alzahrani  S , Yeoh  M , Zaid  W .  Modified fibula free flap harvesting technique for prevention of heterotopic pedicle ossification.   Head Neck. 2019;41(7):E104-E112.PubMedGoogle Scholar
Huang  LF , Weissman  JL , Fan  C .  Traumatic neuroma after neck dissection.   AJNR Am J Neuroradiol. 2000;21(9):1676-1680.PubMedGoogle Scholar
Karagozoglu  KH , Winters  HA , Forouzanfar  T , Schulten  EA .  Periosteal ossification of the vascular pedicle after reconstruction of continuity defects of the mandible and the maxilla with fibular free flaps.   Br J Oral Maxillofac Surg. 2013;51(8):965-967.PubMedGoogle ScholarCrossref
Baserga  C , Massarelli  O , Bolzoni  AR ,  et al.  Fibula free flap pedicle ossification.   J Craniomaxillofac Surg. 2018;46(9):1674-1678.PubMedGoogle ScholarCrossref
DeConde  AS , Vira  D , Blackwell  KE , Moriarty  JM , Sercarz  JA , Nabili  V .  Neck mass due to pedicle ossification after oromandibular reconstruction.   Laryngoscope. 2011;121(10):2095-2099.PubMedGoogle ScholarCrossref
Mays  AC , Gillenwater  AM , Garvey  PB .  Rare presentation of heterotopic ossification along a fibula free flap pedicle in a high-volume microvascular reconstruction practice.   Head Neck. 2018;40(3):E21-E24.PubMedGoogle ScholarCrossref
Autelitano  L , Colletti  G , Bazzacchi  R , Biglioli  F .  Ossification of vascular pedicle in fibular free flaps.   Int J Oral Maxillofac Surg. 2008;37(7):669-671.PubMedGoogle ScholarCrossref
Finley  JM , Acland  RD , Wood  MB .  Revascularized periosteal grafts.   Plast Reconstr Surg. 1978;61(1):1-6.PubMedGoogle ScholarCrossref
AMA CME Accreditation Information

Credit Designation Statement: The American Medical Association designates this Journal-based CME activity activity for a maximum of 1.00  AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Successful completion of this CME activity, which includes participation in the evaluation component, enables the participant to earn up to:

  • 1.00 Medical Knowledge MOC points in the American Board of Internal Medicine's (ABIM) Maintenance of Certification (MOC) program;;
  • 1.00 Self-Assessment points in the American Board of Otolaryngology – Head and Neck Surgery’s (ABOHNS) Continuing Certification program;
  • 1.00 MOC points in the American Board of Pediatrics’ (ABP) Maintenance of Certification (MOC) program;
  • 1.00 Lifelong Learning points in the American Board of Pathology’s (ABPath) Continuing Certification program; and
  • 1.00 CME points in the American Board of Surgery’s (ABS) Continuing Certification program

It is the CME activity provider's responsibility to submit participant completion information to ACCME for the purpose of granting MOC credit.

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