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

Abstract

Objectives Osteoradionecrosis (ORN) of the skull base and craniovertebral junction is a challenging complication of radiation therapy (RT). Severe cases often require surgical intervention through a multi‐modal approach. With the evolution in endoscopic surgery and advances in skull base reconstruction, there is an increasing role for microvascular free tissue transfer (MFTT). We describe an endoscopic‐assisted approach for the management of ORN of the skull base using fascia lata for MFTT. Study Design Retrospective case series. Methods Between 2017 and 2021, a review of all cases in which fascia lata MFTT was utilized for skull base ORN was performed. Patient demographics, preoperative characteristics, and postoperative outcomes with long‐term follow‐up were reviewed. Results Five patients were identified. Mean duration to onset of ORN was 17 months following RT. A trial of antibiotics, hyperbaric oxygen (HBO), and/or limited debridement was attempted without success. Refractory pain and progressive osteomyelitis were unifying symptoms. All patients underwent endoscopic debridement of the affected region of ORN prior to MFTT. Vascularized fascia lata was inset through a combined endonasal and transoral corridor. There was improvement in chronic pain in the postop setting with no patients requiring continued antibiotics or HBO therapy. Mean post‐op follow‐up was 23 months. Conclusions With continued evolution in endoscopic, minimally invasive approaches, there is an expanding indication for early surgical management in refractory ORN. Fascia lata MFTT is a novel and effective strategy for the management of ORN of the skull base and upper cervical spine with excellent postoperative outcomes and limited patient morbidity. Level of Evidence 4 Laryngoscope, 133:562–568, 2023

Evaluation of Anterolateral Thigh Fascia Lata Rescue Flap for Mandibular Osteoradionecrosis

“…To our knowledge, the ALTFL rescue flap procedure is currently the only available treatment option with high efficacy and low morbidity for moderate stage ORN . Our findings from the present study indicate a halt in ORN progression in nearly all patients postoperatively.…”

“…Our institution has highlighted the anterolateral thigh fascia lata (ALTFL) rescue flap as a surgical option that can halt ORN progression, thus obviating the need for osteocutaneous reconstruction. Previously published case series have demonstrated efficacy in various head and neck subsites with low morbidity and complication rates and abbreviated hospital stays. During the past decade, we have gained substantial experience with the ALTFL rescue flap in the setting of mandibular ORN and are presenting our findings of the long-term outcomes.…”

Fascia Lata: Another Workhorse for Complex Skull Base Reconstruction

“…To round out the discussion on the growing versatility of FL in skull base surgery, this tissue can also be harvested as a "free flap" and used in vascularized free tissue transfer which we have employed on rare occasion for especially recalcitrant CSF leaks and as a novel strategy to manage osteoradionecrosis of the skull base. [40][41][42][43] As far as other considerations, interestingly there was no significant difference in successful repair between cases that employed an SA drain and those that did not. There is a heterogenous body of literature regarding the use of CSF diversion following skull base surgery, with some studies advocating limited use [44][45][46] and others recommending more regular use.…”

“…To round out the discussion on the growing versatility of FL in skull base surgery, this tissue can also be harvested as a “free flap” and used in vascularized free tissue transfer which we have employed on rare occasion for especially recalcitrant CSF leaks and as a novel strategy to manage osteoradionecrosis of the skull base. 40–43…”

Multidisciplinary Management of Total Anterior Skull Base Osteoradionecrosis

“…5 The time of onset of ORN after RT varies with studies reporting latency times between 17 months and 116 months. [5][6][7] The management of ORN requires aggressive multidisciplinary surgical and medical treatment, including debridement, intravenous antibiotics, and hyperbaric oxygen (HBO) therapy. 8,9 Following debridement of necrotic tissue various reconstructive options can be utilized.…”