Endoscopic management of postradiation skull base osteoradionecrosis

Abstract

How to Cite this Article Spillinger A Park K Shenouda K Folbe AJ Endoscopic management of postradiation skull base osteoradionecrosis Int Forum Allergy Rhinol-Osteoradionecrosis (ORN) of the skull base is a rare but potentially life-threatening complication after radiotherapy in the treatment of nasopharyngeal carcinoma (NPC). It portends a poor prognosis, mainly due to risk of exsanguination from internal carotid artery (ICA) rupture. 1 Limited data exist regarding the use of conservative therapies, such as hyperbaric oxygen, tocopherol, and pentoxifylline, and surgery remains the mainstay treatment. 2,3 Despite the major role of surgery in managing skull base ORN, there exists a paucity of literature regarding experiences with endoscopic endonasal approaches. The objective of this study was to perform a systematic review and metaanalysis to synthesize experiences with endoscopic skull base surgery (ESBS) and determine resolution and complication rates.

Free Tissue Transfer for Skull Base Osteoradionecrosis: A Novel Approach in the Endoscopic Era

“…In 1983, Marx originally introduced the theory of ORN, wherein RT creates a hypo‐vascular and hypoxic environment that increases the tendency of long‐term tissue breakdown and poor healing, subsequently resulting in chronic pain, bony destruction, and non‐healing wounds 1 . Due to the dense anatomy in the head and neck region, the mandible, maxilla, skull base, and spine are frequently within the RT treatment field and prone to developing ORN 2–11 . Currently, multiple surgical and non‐surgical measures exist in the treatment algorithm of ORN including hyperbaric oxygen, intravenous antibiotics, and the PENTOCLO protocol incorporating tocopherol, pentoxifylline, and clodronate therapy with promising results 12–14 .…”

“…1 Due to the dense anatomy in the head and neck region, the mandible, maxilla, skull base, and spine are frequently within the RT treatment field and prone to developing ORN. [2][3][4][5][6][7][8][9][10][11] Currently, multiple surgical and nonsurgical measures exist in the treatment algorithm of ORN including hyperbaric oxygen, intravenous antibiotics, and the PENTOCLO protocol incorporating tocopherol, pentoxifylline, and clodronate therapy with promising results. [12][13][14] However, in the case of refractory ORN, surgical debridement is a bail-out strategy albeit with mixed efficacy.…”

“…2,3,8,9,15 In recent literature, endoscopic skull base approaches for debridement have offered effective treatments in certain cases of skull base ORN, providing improved access and loco-regional reconstructive options when available. 3,9,11,15,[19][20][21][22][23] However, despite surgical debridement and the myriad of other nonsurgical treatments, ORN can persist with devastating complications, and thus vascularized tissue transfer has been proposed as a promising alternative in arresting progression in refractory cases. 2,6,10,15 Though microvascular free tissue transfer (MFTT) in skull base reconstruction has been studied, the implementation of MFTT in endoscopic skull base surgery (ESBS) remains fairly novel with continued investigation.…”

“…Several studies have explored the role of tissue debridement, wherein necrotic and de‐vascularized bone and surrounding tissue are progressively resected, which serves to remove the nidus for infection and to promote tissue healing with neo‐vascularization 2,3,8,9,15 . In recent literature, endoscopic skull base approaches for debridement have offered effective treatments in certain cases of skull base ORN, providing improved access and loco‐regional reconstructive options when available 3,9,11,15,19–23 . However, despite surgical debridement and the myriad of other non‐surgical treatments, ORN can persist with devastating complications, and thus vascularized tissue transfer has been proposed as a promising alternative in arresting progression in refractory cases 2,6,10,15 …”

When is a multidisciplinary surgical approach required in sinonasal tumours with cranial involvement?

“…Bone-including free flaps have also been reported for reconstruction requiring a rigid vascularized framework, with special reference to those harvested from the subscapular system due to its versatility in terms of bony and soft tissue components 89,90 . Skull base infection and osteoradionecrosis also benefit from transfer of non-infected, non-irradiated, (re-)vascularized tissue following necrosectomy and debridement, which should be delivered in the context of a comprehensive therapy includ-ing a combination of tailored antibiotics, pentoxifylline, alpha-tocopherol, and hyperbaric oxygen therapy [91][92][93] .…”