Clin Exp Otorhinolaryngol.  2022 Nov;15(4):354-363. 10.21053/ceo.2022.00465.

Endoscopic Debridement of Post-Radiation Nasopharyngeal Necrosis: The Effects of Resurfacing With a Vascularized Flap

• Song B
• Kim HY
• Jung YG
• Baek CH
• Chung MK
• Hong SD

• KMID: 2536534
• DOI: http://doi.org/10.21053/ceo.2022.00465

Abstract

Objectives
. Post-radiation nasopharyngeal necrosis (PRNN) is a serious complication that severely impacts the quality of life and survival of nasopharyngeal carcinoma patients. Endoscopic debridement is considered the first-line treatment for PRNN. This study aimed to analyze clinical outcomes, focusing on the mucosal resurfacing status and the effectiveness of salvage operations.
Methods
. Twenty-seven patients who underwent endoscopic debridement were retrospectively analyzed. The patients were divided into two groups according to the initial surgical modality: debridement with a nasoseptal flap (NSF; n=21) and debridement only (no NSF; n=6). Clinical features, postoperative mucosal status, internal carotid artery (ICA) rupture, survival, and final mucosal status were evaluated. The NSF group was categorized according to flap viability to analyze risk factors for flap failure.
Results
. Regardless of the initial modality, most patients experienced symptom improvement (96.0% for headache and 100% for foul odor); however, complete cranial nerve palsy did not improve in any patients. In the NSF group, complete healing was observed in 66.7%, while all patients in the no-NSF group underwent salvage surgery because none maintained complete healing. In the NSF group, 19.0% of patients required salvage surgery. After the last operation, favorable symptom improvement was noted (100% for headache and 90.0% for foul odor), and 77.8% had completely healed mucosa, whereas only 14.8% and 7.4% had partial healing and persistent necrotic mucosal status. The necrotic or uncovered NSF subgroup showed statistically non-significant tendencies for old age, advanced necrosis stage, advanced T stage, ICA involvement, high frequency and dose of radiation therapy, diabetes mellitus, and underlying comorbidities. Two ICA ruptures and three deaths occurred.
Conclusion
. Resurfacing the nasopharynx with NSF after endoscopic debridement showed better outcomes than debridement only for PRNN treatment. Despite initial NSF failure, additional resurfacing reconstructive surgery offers advantages in symptom mitigation, quality of life, and survival.

Keyword

Free Flaps; Nasopharyngeal Carcinoma; Osteoradionecrosis; Pedicled Flap; Radiation; Reconstructive Surgery

Figure

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  Fig. 1. Postoperative mucosal status. (A) Complete healing. (B) Partial healing. (C) Persistent necrosis.

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  Fig. 2. Stages of necrosis. (A) Early: mucosal necrosis alone. (B) Middle: necrosis involving mucosa, muscle, and tendon. (C) Late: osteoradionecrosis.

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  Fig. 3. A representative example of debridement with a nasoseptal flap (NSF) as the initial operation (case 14). (A) Preoperative endoscopic image of radionecrosis. (B) Preoperative magnetic resonance imaging (MRI) shows extensive necrotic lesions on both sides of the nasopharynx, extending to the left internal carotid artery and eroding the clivus. (C) Seventeen months after the operation, a viable NSF with complete mucosal healing was achieved. (D) MRI shows fully viable nasopharyngeal tissue without any remnant necrotic tissue.

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  Fig. 4. A case of a salvage operation with an anterolateral thigh free flap (ALTFF) (case 4). (A) Preoperative endoscopic image shows extensive necrosis throughout the entire nasopharynx, nearly extending to the superior margin of the oropharyngeal wall. (B) Intraoperative endoscopic image after debridement; resurfacing with a flap was not performed. (C) A postoperative examination shows extensive necrotic tissue again. (D) Four months after a salvage operation with repetitive debridement and ALTFF; complete healing was achieved.

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  Fig. 5. Flowchart and treatment outcomes. NSF, nasoseptal flap; Op, operation; ALTFF, anterolateral thigh free flap; IT, inferior turbinate; MTF, middle turbinate flap.

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  Fig. 6. An example of persistent necrosis under completely healed mucosa in a patient who was free of symptoms (case 8). (A) Preoperative endoscopic image of radionecrosis. (B) Intraoperative endoscopic image after the debridement of necrotic tissue. (C) Fifty-two months after debridement with a nasoseptal flap (NSF); completely healed mucosa with a viable NSF is observed. (D) Preoperative computed tomography (CT) scan shows radionecrosis involving the nasopharyngeal deep tissue near the right internal carotid artery (ICA). (E) CT scan 4 months postoperatively. (F) CT scan 52 months postoperatively; remaining necrotic tissue is seen near the ICA, without any progression compared to the preoperative imaging.

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