CASE REPORT

Eben L. Rosenthal, MD, Section Editor

CLAVICULAR OSTEOMYELITIS: A RARE COMPLICATIONOF HEAD AND NECK CANCER SURGERY

Paul Burns, AFRCSI, Patrick Sheahan, FRCS (ORL), Jaime Doody, MD, John Kinsella, FRCS (ORL)

Department of Otalaryngology–Head and Neck Surgery, St. James’s Hospital, Dublin,Ireland. E-mail: pauljburns@eircom.net

Accepted 31 August 2007Published online 28 January 2008 in Wiley InterScience (www.interscience.wiley.com). DOI: 10.1002/hed.20762

Abstract: Background. We report the 10th case in the Eng-

lish-language literature describing clavicular osteomyelitis that

presented after radical treatment for laryngeal carcinoma and

discuss the pertinent diagnostic and therapeutic measures. It

presented a diagnostic dilemma. The differential diagnosis

included tumor recurrence, metastatic bone disease, and post-

radiotherapy complications.

Methods and Results. A 45-year-old man who was a heavy

smoker and known drug abuser presented with acute airway

compromise and was diagnosed with squamous cell carcinoma

involving the glottis and subglottis. Total laryngectomy, total thy-

roidectomy, and bilateral neck dissection were performed, and

the patient underwent chemoradiotherapy. On follow-up 1 year

later, the patient was seen with left stomal dehiscence and a

large area of cellulitis extending across the left clavicle and

down to the axilla. At surgery, a large anterior chest wall abscess

was found. Biopsy showed no evidence of tumor. After aggres-

sive treatment, the patient remains disease free.

Conclusions. This condition is rarely encountered after major

head and neck surgery. Aggressive surgical debridement and

antibiotic therapy remains the mainstay of treatment. Prompt di-

agnosis and treatment are mandatory due to the potential life-

threatening complications associated with the condition. Bony

resection will aid in adequate flap placement. VVC 2008 Wiley

Periodicals, Inc. Head Neck 30: 1124–1127, 2008

Keywords: clavicular osteomyelitis; head and neck surgery;

radiotherapy; pectoralis major flap

Clavicular osteomyelitis is a rare but importantentity that should be familiar to all head and necksurgeons as a potential complication. Involvementof the clavicle in an infective process is exceptionaland usually secondary to spread of infection fromadjacent areas, often associated with some predis-posing factors such as head and neck surgery,radiation therapy, subclavian vein catheteri-zation, or immunosuppression in transplantpatients.1 Aggressive surgical attention is of pri-mary importance, and appropriate antibiotic ther-apy will assist in complete recovery.2 A literaturesearch using Medline was performed in whichonly 9 previous case reports of clavicular osteomy-elitis have been documented after head and neckcancer surgery, none of which describe life-threat-ening hemorrhage as a complication. This processdeveloped after major surgery and chemoradia-tion for squamous cell carcinoma of the glottis. Wereport the case of a patient with clavicular osteo-myelitis associated with head and neck surgery,and describe the complications associated withthis condition along with our management issues.We discuss its possible pathogenesis, differentialdiagnosis, and therapeutic options.

This article was awarded first prize at the Royal Academy of Medicine Oto-laryngology SectionWinter Meeting, Dublin, Ireland, December 2006.

Correspondence to: P. Burns

VVC 2008 Wiley Periodicals, Inc.

1124 Clavicular Osteomyelitis and Head and Neck Cancer Surgery HEAD & NECK—DOI 10.1002/hed August 2008

CASE REPORT

In May 2005, a 45-year-old man admitted to theAccident and Emergency Department was seenwith acute airway compromise. The patient wasa heavy smoker and a known drug abuser. Heproceeded to undergo a tracheostomy under localanesthesia, followed by laryngoscopy whichrevealed a bulky glottic tumor causing severe air-way obstruction. Biopsies revealed invasive mod-erately differentiated squamous cell carcinoma.CT and positron emission tomography scansshowed a T4N0M0 tumor involving the glottisand subglottis. A total laryngectomy, with totalthyroidectomy and bilateral selective neck dissec-tions, was performed. The patient underwent ad-juvant chemoradiotherapy consisting of 6 weeksof cisplatin and 34 sessions of 70 Gy. The patientcontinued to smoke cigarettes, marijuana, andheroin directly through the stoma. He deniedcocaine abuse.

On routine outpatient follow-up 1 year aftertreatment, a wound dehiscence on the left side ofthe stoma was noticed. Biopsies showed inflam-matory tissue only with no evidence of recurrence.A barium swallow showed no evidence of apharyngocutaneous fistula. On review 1 monthlater, he complained of worsening pain and swel-ling around the left stomal dehiscence and overthe head of the ipsilateral clavicle. On examina-tion, there was a large area of cellulitis extendingfrom the stoma, across the left clavicle, and overthe left chest down to the axilla. Purulent secre-tions were evident in relation to the stomal dehis-cence. The patient was admitted and a CT scan ofthe neck and mediastinum performed. Thisshowed marked irregularity of the parastomalsoft tissues on the left. The clavicle showed poor

definition of the cortical margins with markedlucency consistent with osteomyelitis. Intraosseusgas was also evident (Figure 1). At this time, noabscess was evident. Broad spectrum, intrave-nous antibiotics were commenced and repeat biop-sies performed. Again, these showed no evidenceof malignancy. The patient’s general conditioncontinued to decline, so he was brought to theoperating room for exploration of the dehiscenceunder anesthesia. At surgery, a huge anteriorchest wall abscess extending from the stoma tothe left axilla was found. In addition, the soft tis-sues covering the medial half of the clavicle werenecrotic, and the clavicle itself appeared discol-ored and moth-eaten. The clavicle was freely mo-bile from the sternum. Drainage of the anteriorchest wall abscess was performed through theopen neck wound, and also through a separateincision in the axilla. Extensive surgical debride-ment of the affected soft tissues and curettage ofthe necrotic bone was also performed (Figure 2).Cultures from the drainage grew Staphylococcusaureus, and blood cultures grew Streptococcusmilleri. Further biopsies were taken; these onceagain revealed nonspecific inflammatory tissuewith no evidence of tumor. During treatment withhigh-dose intravenous antibiotics (flucloxacillin 2g, 4 times daily; benzylpenicillin 2.4 g, 3 timesdaily; and clindamycin 500 mg, 3 times daily), thepatient suffered a massive hemorrhage from hisleft inominate vein. He underwent emergencysurgery in which the hemorrhage was controlledwith nylon sutures, under the guidance of our car-diothoracic colleagues. Because of the extensivebony sequestration, themedial end of the left clav-icle was resected. Pus was noted within the clavi-cle after resection. Cultures of the clavicle grew

FIGURE 1. Axial CT scan at the level of the clavicles showing

a midline defect consistent with the laryngeal stoma. There is

destruction of the medial end of the left clavicle with air pockets

in the medulla and thickening of surrounding soft tissues, con-

sistent with osteomyelitis.

FIGURE 2. Intraoperative picture showing a 6- 3 4-cm left par-

astomal defect with left clavicular exposure and partial destruc-

tion of the medial end. Also visible are an endotracheal tube

and a Blom-Singer valve. [Color figure can be viewed in the

online issue, which is available at www.interscience.wiley.com.]

Clavicular Osteomyelitis and Head and Neck Cancer Surgery HEAD & NECK—DOI 10.1002/hed August 2008 1125

Escherichia coli. A contralateral pectoralis majorpedicled flap was used to cover the dehiscent area.Proper placement of the flap into the base of thedehiscent area was impeded by the sternum, andleft first and second costal cartilages, leaving apotential space between the base of the dehiscenceand the flap. Thus, there was inadequate protec-tion of the local vessels. Two weeks later, thepatient suffered another large hemorrhage on theward. He underwent emergency surgery again tocontrol the bleeding. The manubrium and first 2costal cartilages were resected, and adequateplacement of an ipsilateral pectoralis major flapwas achieved. The patient subsequently devel-oped bilateral pleural effusions requiring bilateralchest drains, followed by acute respiratory dis-tress syndrome. However, 2 years after his initialpresentation with laryngeal carcinoma, heremains well and disease free.

DISCUSSION

The clavicle is an exceedingly rare site for osteo-myelitis,3 and hence, there is no consensus in theliterature on its etiology or management. It hasbeen reported following central line,4 and Swan-Ganz catheter placement.5 However, infectionmay also occur from hematogenous dissemina-tion, spread of contiguous infection, or directtraumatic seeding of bacteria. Risk factorsinclude prior radiotherapy, immunosuppression,systemic bacterial infection, and loss of periostealintegrity.6 Patients with head and neck cancerare often malnourished, and this, coupled withalcohol and tobacco abuse, leads to small vesseldisease and delayed wound healing. Piazza et al7

stated that clavicular osteomyelitis appearswithin days to weeks of surgery. Our case differsfrom this in that initial presentation was 12months after surgery. This may be explained byour patient’s persistent drug abuse, and hence,dehabilitated state. Pharyngocutaneous fistulamay lead to direct seeding of oral flora in a woundbed. Hypothyroidism, associated with laryngec-tomy and radiotherapy, may lead to delayedwound healing and increased risk.7

Garnick et al8 described the pathogenesis of os-teomyelitis. Blood supply to the bone is compro-mised secondary to an inflammatory reaction,which leads to increased intraosseus pressure.Purulence dissects the periosteum from the bone,furthering the vascular compromise. Bony necro-sis serves as a nidus for further bacterial in-volvement. Garnick et al also describes chronic os-

teomyelitis in the setting of persistent infectionssecondary to the presence of sequestered bone.8

Gerszten et al3 discussed the epidemiology ofosteomyelitis and found that the most commonbacteria found in osteomyelitis is Staphylococcusaureus. Other common organisms include Kleb-siella and Staphylococcus epidermidis. Winslowand Meyers2 found that osteomyelitis related tohead and neck surgery may be positive for Strepto-coccus, Bacteroides, and Escherichia coli, and thatblood cultures are positive in 50% of patients.

Presentation of clavicular osteomyelitis is acute,with fever and swelling of the affected shoulderand arm. A history of local surgical procedures,with or without radiation, may be elicited. Diagno-sis is based on laboratory and radiological findings.In patients with head and neck cancer, of para-mount concern is recurrence of malignancy. Biop-sies are essential, as are cultures from the affectedarea. Our patient underwent 3 separate biopsies,which revealed inflammatory tissue only. Probertet al9 stated that a differential diagnosis shouldinclude sternoclavicular arthritis, osteoradionecro-sis, aseptic necrosis, bony metastases, and primaryclavicular neoplasms, although exceedingly rare.

Gold et al10 discussed the importance of radiol-ogy in confirming the diagnosis. Conventionalplain films show a diffuse periosteal reaction,bone rarefaction, and lytic lesions. Sequestra andsclerosis appear later. CT may delineate abscessformation and subcutaneous or intraosseus gasformation. MRI may be helpful if the diagnosis isuncertain and may be helpful in distinguishingcellulitis from osteomyelitis. According to Jacob-son et al,11 the 3-phase bone scan helps distin-guish soft tissue inflammation from bony involve-ment, although the false-positive rate is high. Itsspecificity in postoperative patients remainsimperfect.

The literature agrees that aggressive andearly treatment is strongly indicated.6,8,12,13

Treatment is aimed at eradication of infection toprevent serious consequences such as sepsis, me-diastinitis, and hemorrhage from the great ves-sels. Intravenous antibiotics should be institutedas soon as the diagnosis is suspected and contin-ued for 4–8 weeks. Wide local debridement is themainstay of treatment. Clavicular osteomyelitisoften involves the sternoclavicular joint and thisarea should be explored surgically to ensureeradication of the infection. Total excision of theclavicle causes no functional disability14 andensures that devascularized bone does not act asa nidus for further infection. Flap coverage of the

1126 Clavicular Osteomyelitis and Head and Neck Cancer Surgery HEAD & NECK—DOI 10.1002/hed August 2008

defect may be required. Additional coveragebetween the stoma and the clavicle will protectthe great vessels and provide necessary bulk. Asseen in our case, torrential hemorrhage withexposure of the great vessels is a realistic andserious consequence of the infective process. Welearned that bone should be resected to allowadequate flap placement, and this should be pre-formed at the first opportunity.

Prevention is paramount. Sternoclavicularskeletonization should be avoided during stomato-plasty. Subclavian catheterization should beavoided in conjunction with head and neck sur-gery where possible, as bacterial seeding mayoccur where the periosteum is damaged due torepeated attempts at cannulation.4

CONCLUSION

Clavicular osteomyelitis is a rare complication ofmajor head and neck surgery. Its frequencyincreases in those who have received radiotherapyand present predisposing factors. Early diagnosisand aggressive medical and surgical treatmentare indicated to prevent potentially life-threaten-ing complications. Bony resection should be per-formed early to allow adequate flap placement.

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