2025 Poster Presentations
P269: ENDONASAL FLAPS FOR VASCULARIZED VENTRAL SKULL BASE RECONSTRUCTION IN THE SETTING OF OSTEORADIONECROSIS
Farhoud Faraji, MD, PhD; Angel Perez; Thomas L Beaumont; Carol H Yan; Adam S DeConde; UC San Diego Health
Osteoradionecrosis of the ventral skull base may occur after radiotherapy of nasopharyngeal or other skull base tumors. Contemporary management of this challenging clinical entity entails debridement and sequestrectomy of radionecrotic bone followed by defect reconstruction using vascularized tissue. The reconstructive toolbox for osteoradionecrosis (ORN) includes pedicled endonasal flaps such as the pedicled nasoseptal flap (NSF), regional pericranial flaps, and microvascular free tissue transfer (mfTT). In this reconstructive ladder, endonasal flaps confer the least donor site morbidity. However, the emergence of NSF as a workhorse for primary reconstruction after the resection of anterior skull base tumors often renders it unavailable for secondary reconstruction. As a result, literature describing endonasal flap for skull base reconstruction in the setting ORN remains limited. We present a series of cases demonstrating the utility of endonasal flaps, including the NSF and the posteriorly pedicled extended inferior turbinate flap (ITF), for ventral skull base ORN.
Patients ranged from 29-72 years of age, two were male, and two were female. Three underwent chemoradiotherapy for nasopharyngeal carcinoma and one for clival chordoma. Three underwent a single round of either gamma or proton radiotherapy. One first underwent first gamma radiotherapy followed by proton radiotherapy 12 years later. Upon diagnosis of ORN, each patient underwent debridement followed by reconstruction incorporating a combination of NSFs and ITFs. All patients received broad spectrum antibiotics, and two of four patients received hyperbaric oxygen therapy. All cases demonstrated complete mucosalization over the defect. Three of four patients demonstrated significant improvement in ORN by magnetic resonance imaging, while one patient showed symptomatic improvement but persistent ORN.
Notably, three of the cases demonstrate that bilateral NSF or extended ITF can reach the C1/C2 junction, and may be secured to the prevertebral fascia with sutures via a transoral endoscopic approach. Our case series establishes the extended ITF, with or without contralateral NSF, as a useful endonasal addition to the toolbox for ventral skull base reconstruction and delineates its extent, showing that it may be particularly useful for defects extending inferiorly into the oropharynx.