J Rhinol.  2021 Jul;28(2):120-124. 10.18787/jr.2021.00353.

A Case of Free Flap Reconstruction after Endoscopic Debridemnt for Recalcitrant Nasopharyngeal Osteoradionecrosis Without Facial Incision

• Kang YJ
• Hong SD
• Chung MK

• KMID: 2518679
• DOI: http://doi.org/10.18787/jr.2021.00353

Abstract

High-dose radiation therapy is the treatment of choice for nasopharyngeal cancer, and clinical outcomes have improved in recent decades. A certain proportion of patients, however, suffer from post-radiation nasopharyngeal necrosis (PRNN). Patients with PRNN complain of headache, foul odor, or symptoms of cranial nerve palsies. Clinically, intracranial infection or bleeding from carotid artery damage may lead to sudden death or severe deterioration in quality of life. Although the prognosis of PRNN was poor, endoscopic debridement with local vascularized flap recently showed favorable outcomes, and many centers are using this technique with a nasoseptal flap. However, if the flap fails or does not fully cover necrotized tissues, necrosis inevitably reoccurs. In this situation, free flap transfer with a facial incision using a transmaxillary approach is used, but some drawbacks exist. In this report, we propose a new resurfacing technique for recurrent PRNN using a transoral-cervical free flap tunneling approach into the nasopharynx without a facial incision after endoscopic debridement.

Keyword

Nasopharynx cancerㆍRadiotherapyㆍOsteonecrosisㆍNasoseptal flapㆍFree flap; 비인두암·방사선 치료·골괴사·비중격 피판술·유리피판 이식술

Figure

• 

  Fig. 1. Endoscopic, radiologic, intraoperative image of nasopharynx radionecrosis. A: Transnasal endoscopic view showed mucosal necrosis on right nasopharynx. B: T1 Gadolinium enhanced MRI showed irregular enhancement and non-enhancing lesion around the right lateral and posterior wall of nasopharynx (black arrow). C: Intraoperative endoscopic view after endoscopic debridement. Remained muscle looks relatively healthy.

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  Fig. 2. Endoscopic, radiologic image of recurrent nasopharynx radionecrosis. A: Recurrent necrosis inferior to well adapted nasoseptal flap. B: T1 Gadolinium enhanced MRI showed nonenhanced area (necrosis) surrounded by enhanced muscle (black arrow).

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  Fig. 3. Postoperative endoscopic and radiologic image of flap wound, surgical schematic diagram. A: Postop 2 weeks transoral view. Arrow indicates flap. B: Postop 2 weeks transnasal view. Arrow indicates flap. C: Postop 4 months transoral view. Arrow indicates flap. D: Postop 4 months transnasal view. Arrow indicates flap. E: Postop 14 months transoral view. Arrow indicates flap. F: Postop 14 months transnasal view. Arrow indicates flap. G: Postop 14 months T1 Gadolinium enhanced MRI showed well enhanced NSF and well positioned free flap (white arrow). H: Surgical Schematic diagram of transoral approach anterolateral thigh free flap into nasopharynx without facial incision.

Reference

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