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Li J, Zhang S, Ouyang D, Zeng L, Qiao Y, Deng W, Liao G, Liang Y. Favorable effects of open surgery on patients with extensive skull base osteoradionecrosis through a personalized sequential approach: A case series. J Craniomaxillofac Surg 2024; 52:302-309. [PMID: 38368207 DOI: 10.1016/j.jcms.2024.01.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2023] [Revised: 11/04/2023] [Accepted: 01/16/2024] [Indexed: 02/19/2024] Open
Abstract
The present study aimed to investigate outcomes following open surgery for extensive skull base ORN. Open surgery through a personalized sequential approach was employed to deal with five cases of extensive skull base ORN. Two patients with mild cases underwent regional debridement and sequestrectomy, and three patients with severe cases underwent extensive resection with reconstruction using free anterolateral thigh (ALT) flap. Biological glues and vascularized flaps were used for obturation of the skull base bony defect to prevent postoperative cerebrospinal fluid (CSF) leakage. The infections were controlled by antibiotic administrations which strictly followed the principles of antimicrobial stewardship (AMS). As results, both regional debridement plus sequestrectomy and extensive resection achieved satisfied outcomes in all patients. No severe complications and delayed hospitalization occurred. During the follow-up period (8-19 months), all patients were alive, pain free, without crusting or purulent discharge, and no sequestration or CSF leakage occurred. In conclusion, a personalized sequential approach including open surgery, pedicled/vascularized free flap reconstruction and AMS was advocated for patients with extensive skull base ORN.
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Affiliation(s)
- Jingyuan Li
- Hospital of Stomatology, Guanghua School of Stomatology, Sun Yat-sen University, Guangzhou, Guangdong, People's Republic of China; Guangdong Provincial Key Laboratory of Stomatology, Sun Yat-sen University, Guangzhou, Guangdong, People's Republic of China
| | - Sien Zhang
- Hospital of Stomatology, Guanghua School of Stomatology, Sun Yat-sen University, Guangzhou, Guangdong, People's Republic of China; Guangdong Provincial Key Laboratory of Stomatology, Sun Yat-sen University, Guangzhou, Guangdong, People's Republic of China
| | - Daiqiao Ouyang
- Hospital of Stomatology, Guanghua School of Stomatology, Sun Yat-sen University, Guangzhou, Guangdong, People's Republic of China; Guangdong Provincial Key Laboratory of Stomatology, Sun Yat-sen University, Guangzhou, Guangdong, People's Republic of China
| | - Lijuan Zeng
- Hospital of Stomatology, Guanghua School of Stomatology, Sun Yat-sen University, Guangzhou, Guangdong, People's Republic of China; Guangdong Provincial Key Laboratory of Stomatology, Sun Yat-sen University, Guangzhou, Guangdong, People's Republic of China
| | - Yongjie Qiao
- Hospital of Stomatology, Guanghua School of Stomatology, Sun Yat-sen University, Guangzhou, Guangdong, People's Republic of China; Guangdong Provincial Key Laboratory of Stomatology, Sun Yat-sen University, Guangzhou, Guangdong, People's Republic of China
| | - Wei Deng
- Hospital of Stomatology, Guanghua School of Stomatology, Sun Yat-sen University, Guangzhou, Guangdong, People's Republic of China; Guangdong Provincial Key Laboratory of Stomatology, Sun Yat-sen University, Guangzhou, Guangdong, People's Republic of China
| | - Guiqing Liao
- Hospital of Stomatology, Guanghua School of Stomatology, Sun Yat-sen University, Guangzhou, Guangdong, People's Republic of China; Guangdong Provincial Key Laboratory of Stomatology, Sun Yat-sen University, Guangzhou, Guangdong, People's Republic of China.
| | - Yujie Liang
- Hospital of Stomatology, Guanghua School of Stomatology, Sun Yat-sen University, Guangzhou, Guangdong, People's Republic of China; Guangdong Provincial Key Laboratory of Stomatology, Sun Yat-sen University, Guangzhou, Guangdong, People's Republic of China.
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2
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Dhanda AK, McKee SP, Allen DZ, Ahmed OG, Yaeger KA, Kim LM, Kain JJ. Multidisciplinary Management of Total Anterior Skull Base Osteoradionecrosis. J Neurol Surg Rep 2024; 85:e11-e16. [PMID: 38288031 PMCID: PMC10824591 DOI: 10.1055/a-2236-6162] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2023] [Accepted: 12/18/2023] [Indexed: 01/31/2024] Open
Abstract
Cases of delayed osteoradionecrosis (ORN) of the anterior skull base have unique management considerations. A 59-year-old woman with a history of basaloid squamous cell carcinoma of the sinonasal cavity with intracranial extension through the anterior skull base developed delayed radiation sequelae of anterior skull base ORN. She underwent an initial endoscopic resection in 2011 with persistent disease that required an anterior craniofacial resection with left medial maxillectomy in 2012. She had a radiologic gross total resection with microscopic residual disease at the histologic margins prompting adjuvant chemoradiotherapy to target volume doses of 66 to 70 Gy with concurrent cisplatin chemotherapy. She subsequently developed an intracranial abscess in 2021 along the anterior skull base that required a craniotomy and endoscopic debridement. Despite aggressive surgical and medical therapy, she had persistent intracranial infections and evidence of skull base ORN. She ultimately underwent a combined open bifrontal craniotomy and endoscopic resection of the necrotic frontal bone and dura followed by an anterolateral thigh free flap reconstruction with titanium mesh cranioplasty. The patient recovered well from a microvascular free-tissue reconstruction without concern for cerebrospinal fluid leak. Anterior skull base reconstruction with free tissue transfer is a commonly utilized method for oncologic resections. Here, an anterolateral free flap was effectively used to treat an anterior skull base defect secondary to a rare indication of skull base ORN.
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Affiliation(s)
- Aatin K. Dhanda
- Department of Otolaryngology – Head and Neck Surgery, Houston Methodist Hospital, Houston, Texas, United States
| | - Sean P. McKee
- Department of Otorhinolaryngology – Head and Neck Surgery, McGovern Medical School of the University of Texas Health Science Center at Houston, Houston, Texas, United States
| | - David Z. Allen
- Department of Otorhinolaryngology – Head and Neck Surgery, McGovern Medical School of the University of Texas Health Science Center at Houston, Houston, Texas, United States
| | - Omar G. Ahmed
- Department of Otolaryngology – Head and Neck Surgery, Houston Methodist Hospital, Houston, Texas, United States
| | - Kurt A. Yaeger
- Depeartment of Neurosurgery, Houston Methodist Hospital, Houston, Texas, United States
| | - Laura Minhui Kim
- Department of Otolaryngology – Head and Neck Surgery, Houston Methodist Hospital, Houston, Texas, United States
| | - Joshua J. Kain
- Department of Otolaryngology – Head and Neck Surgery, Houston Methodist Hospital, Houston, Texas, United States
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3
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Sreenath SB, Grafmiller KT, Tang DM, Roof SA, Woodard TD, Kshettry VR, Recinos PF, Sindwani R, Fritz MA. Free Tissue Transfer for Skull Base Osteoradionecrosis: A Novel Approach in the Endoscopic Era. Laryngoscope 2023; 133:562-568. [PMID: 35920134 DOI: 10.1002/lary.30315] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2022] [Revised: 05/17/2022] [Accepted: 07/07/2022] [Indexed: 11/07/2022]
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.
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Affiliation(s)
- Satyan B Sreenath
- Head and Neck Institute, Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland Clinic, Cleveland, Ohio, U.S.A.,Department of Otolaryngology-Head and Neck Surgery, Indiana University, Indianapolis, Indiana, U.S.A
| | - Kevin T Grafmiller
- Head and Neck Institute, Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland Clinic, Cleveland, Ohio, U.S.A
| | - Dennis M Tang
- Department of Otolaryngology-Head and Neck Surgery, Cedars-Sinai Medical Center, Los Angeles, California, U.S.A
| | - Scott A Roof
- Head and Neck Institute, Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland Clinic, Cleveland, Ohio, U.S.A.,Department of Otolaryngology-Head and Neck Surgery, Icahn School of Medicine at Mt. Sinai, New York, New York, U.S.A
| | - Troy D Woodard
- Head and Neck Institute, Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland Clinic, Cleveland, Ohio, U.S.A.,Department of Neurological Surgery, Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, Ohio, U.S.A.,Minimally Invasive Cranial Base and Pituitary Surgery Program, Rose Ella Burkhardt Brain Tumor and Neuro-Oncology Center, Neurological Institute, Cleveland Clinic, Cleveland, Ohio, U.S.A
| | - Varun R Kshettry
- Head and Neck Institute, Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland Clinic, Cleveland, Ohio, U.S.A.,Department of Neurological Surgery, Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, Ohio, U.S.A.,Minimally Invasive Cranial Base and Pituitary Surgery Program, Rose Ella Burkhardt Brain Tumor and Neuro-Oncology Center, Neurological Institute, Cleveland Clinic, Cleveland, Ohio, U.S.A
| | - Pablo F Recinos
- Head and Neck Institute, Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland Clinic, Cleveland, Ohio, U.S.A.,Department of Neurological Surgery, Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, Ohio, U.S.A.,Minimally Invasive Cranial Base and Pituitary Surgery Program, Rose Ella Burkhardt Brain Tumor and Neuro-Oncology Center, Neurological Institute, Cleveland Clinic, Cleveland, Ohio, U.S.A
| | - Raj Sindwani
- Head and Neck Institute, Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland Clinic, Cleveland, Ohio, U.S.A.,Department of Neurological Surgery, Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, Ohio, U.S.A.,Minimally Invasive Cranial Base and Pituitary Surgery Program, Rose Ella Burkhardt Brain Tumor and Neuro-Oncology Center, Neurological Institute, Cleveland Clinic, Cleveland, Ohio, U.S.A
| | - Michael A Fritz
- Head and Neck Institute, Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland Clinic, Cleveland, Ohio, U.S.A.,Department of Neurological Surgery, Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, Ohio, U.S.A
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4
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Dai Q, Shi YX, Zhang HK, Song XL, Liu Q, Zhao KQ, Yang JY, Wang L, Sun XC, Yu HM. Salvage endoscopic surgery for skull base osteoradionecrosis in nasopharyngeal carcinoma patients: A prospective, observational, single-arm clinical study. Rhinology 2023; 61:61-70. [PMID: 36286011 DOI: 10.4193/rhin22.303] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
BACKGROUND Postradiation skull base osteoradionecrosis (ORN) is a severe complication that occurs after radiotherapy in patients with nasopharyngeal carcinoma (NPC) that can severely affect quality of life (QOL) and be life threatening. Only 13.4% - 28.6% of patients can be cured by traditional repeated endoscopic debridement. Here, we introduced salvage endoscopic surgery for skull base ORN patients and evaluated its clinical efficacy. METHODS This was a prospective, observational, single-arm clinical study. Clinical data from 18 skull base ORN patients who underwent radical endoscopic necrectomy followed by reconstruction using a septal pedicled mucosal flap or temporal muscle flap were included in the study. The endpoint was an overall survival (OS) of 2 years. The numeric rating scale (NRS) scores for pain and foul odor were analyzed to determine the efficacy and safety of this surgery. RESULTS A total of 21 patients were recruited, 18 of whom completed the study and were analyzed. All surgeries were successfully performed. During the 2-year study, the OS rate of the entire cohort was 75%. The median NRS score for pain decreased from 6.44 +- 2.62 to 0.50 +- 0.71, and the NRS score for foul odor decreased from 1.89±1.08 to 1 after surgery. CONCLUSIONS Salvage endoscopic necrectomy followed by construction using a septal pedicled mucosal flap or temporal muscle flap is a novel, safe, and effective treatment for ORN in patients with NPC. CLINICAL TRIAL REGISTRATION This study was approved by the independent ethics committee of the Eye, Ear, Nose and Throat Hospital of Fudan University (IEC No. 2019095-1). Written informed consent was obtained from all patients. The study was registered with the Chinese Clinical Trial registry (ChiCTR2000029327).
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Affiliation(s)
- Q Dai
- Department of Otolaryngology, Eye and ENT Hospital, Fudan University, Shanghai, 200031, PR China
| | - Y-X Shi
- Department of Otolaryngology, Eye and ENT Hospital, Fudan University, Shanghai, 200031, PR China
| | - H-K Zhang
- Department of Otolaryngology, Eye and ENT Hospital, Fudan University, Shanghai, 200031, PR China
| | - X-L Song
- Department of Otolaryngology, Eye and ENT Hospital, Fudan University, Shanghai, 200031, PR China
| | - Q Liu
- Department of Otolaryngology, Eye and ENT Hospital, Fudan University, Shanghai, 200031, PR China
| | - K-Q Zhao
- Department of Otolaryngology, Eye and ENT Hospital, Fudan University, Shanghai, 200031, PR China
| | - J-Y Yang
- Department of Otolaryngology, Eye and ENT Hospital, Fudan University, Shanghai, 200031, PR China
| | - L Wang
- Department of Otolaryngology, Eye and ENT Hospital, Fudan University, Shanghai, 200031, PR China
| | - X-C Sun
- Department of Otolaryngology, Eye and ENT Hospital, Fudan University, Shanghai, 200031, PR China
| | - H-M Yu
- Department of Otolaryngology, Eye and ENT Hospital, Fudan University, Shanghai, 200031, PR China; Research Units of New Technologies of Endoscopic Surgery in Skull Base Tumor (2018RU003), Chinese Academy of Medical Sciences; Beijing, 200031, PR China
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李 峰, 蔡 泽, 许 卫, 周 慧, 麦 颖, 刘 晓, 潘 文, 章 诗. [Clinical application of nasal mucosa flap in the repair of nasopharyngeal skull base bone exposure after radiotherapy for nasopharyngeal carcinoma]. LIN CHUANG ER BI YAN HOU TOU JING WAI KE ZA ZHI = JOURNAL OF CLINICAL OTORHINOLARYNGOLOGY, HEAD, AND NECK SURGERY 2021; 35:929-934. [PMID: 34628818 PMCID: PMC10127696 DOI: 10.13201/j.issn.2096-7993.2021.10.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Received: 07/02/2021] [Indexed: 11/12/2022]
Abstract
Objective:To observe the effect of nasal mucosa flap in the repair of nasopharyngeal skull base bone exposure after radiotherapy for nasopharyngeal carcinoma, and to provide a basis for the repair with nasal mucosa flap in skull base bone exposure after radiotherapy. Methods:The clinical data of 8 patients who underwent nasal endoscopic surgery were analyzed retrospectively. The survival of mucosal flap, the mucosal epithelialization of bone defect or exposed site, the improvement of main clinical symptoms and complications were followed up after operation. Results:Severe mucosal flap necrosis and bone exposure occurred in 1 case after operation, in the other 7 cases, the mucosal flap survived and the mucosal epithelium of nasopharynx recovered well. After operation, most of the patients' clinical symptoms such as headache and nasal odor were improved compared with those before operation. Conclusion:Nasal mucosal flap is a safe and minimally invasive autogenous material with good biocompatibility. It has a good application prospect in repairing bone defect or exposure of nasopharyngeal skull base after radiotherapy and is worth popularizing in clinic.
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Affiliation(s)
- 峰 李
- 广东医科大学附属医院耳鼻咽喉头颈外科(广州,524001)Department of Otorhinolaryngology Head and Neck Surgery, Affiliated Hospital of Guangdong Medical University, Guangzhou, 524001, China
| | - 泽虹 蔡
- 广东医科大学附属医院耳鼻咽喉头颈外科(广州,524001)Department of Otorhinolaryngology Head and Neck Surgery, Affiliated Hospital of Guangdong Medical University, Guangzhou, 524001, China
| | - 卫华 许
- 广东医科大学附属医院耳鼻咽喉头颈外科(广州,524001)Department of Otorhinolaryngology Head and Neck Surgery, Affiliated Hospital of Guangdong Medical University, Guangzhou, 524001, China
| | - 慧 周
- 广东医科大学附属医院耳鼻咽喉头颈外科(广州,524001)Department of Otorhinolaryngology Head and Neck Surgery, Affiliated Hospital of Guangdong Medical University, Guangzhou, 524001, China
| | - 颖达 麦
- 广东医科大学附属医院耳鼻咽喉头颈外科(广州,524001)Department of Otorhinolaryngology Head and Neck Surgery, Affiliated Hospital of Guangdong Medical University, Guangzhou, 524001, China
| | - 晓瑜 刘
- 广东医科大学附属医院耳鼻咽喉头颈外科(广州,524001)Department of Otorhinolaryngology Head and Neck Surgery, Affiliated Hospital of Guangdong Medical University, Guangzhou, 524001, China
| | - 文芳 潘
- 广东医科大学附属医院耳鼻咽喉头颈外科(广州,524001)Department of Otorhinolaryngology Head and Neck Surgery, Affiliated Hospital of Guangdong Medical University, Guangzhou, 524001, China
| | - 诗富 章
- 广东医科大学附属医院耳鼻咽喉头颈外科(广州,524001)Department of Otorhinolaryngology Head and Neck Surgery, Affiliated Hospital of Guangdong Medical University, Guangzhou, 524001, China
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Shaikh N, Makary CA, Ryan L, Reyes C. Treatment Outcomes for Osteoradionecrosis of the Central Skull Base: A Systematic Review. J Neurol Surg B Skull Base 2021; 83:e521-e529. [PMID: 35832934 DOI: 10.1055/s-0041-1733973] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2020] [Accepted: 07/11/2021] [Indexed: 10/20/2022] Open
Abstract
Abstract
Objective Osteoradionecrosis (ORN) of the skull base can have catastrophic consequences if not detected early and managed appropriately. This is a systematic review of the different treatment modalities for skull base ORN and their outcomes.
Study Design This study is a systematic review.
Materials and Methods Two researchers extracted information including patient population, surgical technique, outcomes of interest, and study design. A computerized search of Medline, Embase, and the Cochrane library (January 1990–June 2020) looked for several papers on the subject of skull base ORN.
Results A total of 29 studies had met inclusion criteria, including data from 333 patients. Nasopharyngeal carcinoma was the most common primary tumor (85%). Average age at diagnosis of ORN was 55.9 years (range = 15–80 years) and 72.3% of patients were males. The average time to diagnosis of ORN after radiation therapy was 77 months with an average radiation dose of 76.2 Gy (range = 46–202 Gy). Nighty-eight patients (29.4%) also had chemotherapy as part of their treatment regimen. Although all parts of the central skull base were reported to be involved, the clivus and sphenoid bone were the most commonly reported subsites. Trial of medical treatment had a success rate of 41.1%. About 66% of patients needed surgical treatment, either primarily or after failing medical treatment. Success rate was 77.3%. Overall, the surgical treatment was superior to medical treatment (p < 0.0001).
Conclusion ORN is a rare complication of the treatment of skull base tumors. Most cases require surgical treatment, including endoscopic debridement or free flap reconstruction, which has a high success rate.
Level of Evidence Level 3 evidence as a systematic review of case studies, case reports, retrospective, and prospective trials with no blinding or controls.
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Affiliation(s)
- Noah Shaikh
- Department of Otolaryngology, West Virginia University, Morgantown, West Virginia, United States
| | - Chadi A. Makary
- Department of Otolaryngology, West Virginia University, Morgantown, West Virginia, United States
| | - Lindsey Ryan
- Department of Otolaryngology, Augusta University, Augusta, Georgia, United States
| | - Camilo Reyes
- Department of Otolaryngology, Augusta University, Augusta, Georgia, United States
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Helton M, Gardner JR, Dunlap Q, Pait TG, Sunde J, Vural E, Moreno MA. Free Tissue Transfer for Repair of Chronic Esophageal Perforations. OTO Open 2021; 5:2473974X211031472. [PMID: 34350371 PMCID: PMC8295968 DOI: 10.1177/2473974x211031472] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2021] [Accepted: 06/05/2021] [Indexed: 11/15/2022] Open
Abstract
Objective Anterior cervical discectomy and fusion have become a common intervention for cervical spine stabilization. However, complications can cause life-threatening morbidity. Among them, esophageal perforation is associated with severe morbidity, including dysphagia, malnutrition, and infection with the potential development of mediastinitis. Presentation is variable but often results in chronic morbidity. Herein we examine our experiences in the management of esophageal perforation with microvascular free tissue transfer. Study Design Retrospective review from January 2013 to September 2020. Setting Single academic tertiary care center. Methods This study comprised all patients (age, 41-73 years) undergoing free tissue transfer for the repair of chronic esophageal perforation secondary to anterior cervical discectomy and fusion at an academic tertiary care center. Four patients underwent repair via vastus lateralis myofascial onlay grafting for defects ≤2 cm in greatest dimension, while 1 patient underwent a fasciocutaneous radial forearm free flap repair of an 11 × 5-cm defect. Results Defect location ranged from hypopharynx to cervical esophagus. Mean operative time was 6.2 hours; the average length of stay for all patients was 6.6 days. Of 5 patients, 1 required additional hardware placement for spine stabilization. All patients underwent gastrostomy tube placement to bypass the surgical site during healing, and all eventually resumed an oral diet postoperatively. Recurrent fistula occurred in 1 of 5 patients. No flap failures were encountered in the study population. Conclusion Vastus lateralis myofascial onlay grafting and fasciocutaneous radial forearm free flap are robust, relatively low-morbidity interventions with a high success rate for definitive repair of chronic esophageal perforation. Repair should be undertaken in concert with a spine surgeon for management of the cervical spine.
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Affiliation(s)
- Matthew Helton
- Department of Neurosurgery, Jackson T. Stephens Spine and Neuroscience Institute, University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA
| | - James Reed Gardner
- Department of Otolaryngology-Head and Neck Surgery, University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA
| | - Quinn Dunlap
- Department of Otolaryngology-Head and Neck Surgery, University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA
| | - T Glenn Pait
- Department of Neurosurgery, Jackson T. Stephens Spine and Neuroscience Institute, University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA
| | - Jumin Sunde
- Department of Otolaryngology-Head and Neck Surgery, University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA
| | - Emre Vural
- Department of Otolaryngology-Head and Neck Surgery, University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA
| | - Mauricio Alejandro Moreno
- Department of Otolaryngology-Head and Neck Surgery, University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA
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8
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Pistochini A, Russo F, Coden E, Sileo G, Battaglia P, Bignami M, Volpi L, Castelnuovo P. Modified Posterior Pedicle Middle Turbinate Flap: An Additional Option for Skull Base Resurfacing. Laryngoscope 2020; 131:E767-E774. [PMID: 33280115 DOI: 10.1002/lary.29099] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2020] [Revised: 08/03/2020] [Accepted: 08/26/2020] [Indexed: 11/06/2022]
Abstract
OBJECTIVES/HYPOTHESIS Although the Hadad-Bassagusteguy flap represents the first choice for middle and posterior skull base reconstruction and coverage of exposed bony areas, in some cases it is unavailable. The aim of this study is to describe, as an alternative option in selected cases, a modified posterior pedicle middle turbinate flap (mPPMTF) extended to the lacrimal area. Anatomical features, step-by-step harvesting technique, and surgical applications are presented. STUDY DESIGN Anatomic dissection study and case report. METHODS Four mPPMTFs were raised in two fresh-frozen cadaver heads. A study of the vascular supply and measurements of length, width, and area of the flap were performed. The ability of the flap to cover the ventral skull base, particularly the upper clivus area, was tested. A clinical case in which an mPPMTF was used for clivus resurfacing after osteoradionecrosis is reported. RESULTS The vascular supply of the mPPMTF was identified as the middle turbinate branch of the sphenopalatine artery. The flap had a mean length of 6.92 cm, mean maximum width of 1.08 cm, and mean total area of 5.33 cm2 . The flap was able to reach the upper clivus, with a clival coverage ratio of 70.66%. In the clinical case, good surgical outcomes were observed, with accelerated re-epithelization without complications. CONCLUSIONS The mPPMTF represents an alternative to the Hadad-Bassagusteguy flap for posterior cranial fossa and nasopharynx resurfacing. The main drawbacks are its technically demanding and time-consuming harvesting. LEVEL OF EVIDENCE 4 Laryngoscope, 131:E767-E774, 2021.
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Affiliation(s)
- Andrea Pistochini
- Division of Otorhinolaryngology, Department of Surgical Specialties, ASST Sette Laghi, Ospedale di Circolo e Fondazione Macchi, Varese, Italy
| | - Federico Russo
- Division of Otorhinolaryngology, Department of Biotechnology and Life Sciences, University of Insubria-Varese, ASST Sette Laghi, Ospedale di Circolo e Fondazione Macchi, Varese, Italy
| | - Elisa Coden
- Division of Otorhinolaryngology, Department of Biotechnology and Life Sciences, University of Insubria-Varese, ASST Sette Laghi, Ospedale di Circolo e Fondazione Macchi, Varese, Italy
| | - Giorgio Sileo
- Division of Otorhinolaryngology, Department of Biotechnology and Life Sciences, University of Insubria-Varese, ASST Sette Laghi, Ospedale di Circolo e Fondazione Macchi, Varese, Italy
| | - Paolo Battaglia
- Division of Otorhinolaryngology, Department of Biotechnology and Life Sciences, University of Insubria-Varese, ASST Sette Laghi, Ospedale di Circolo e Fondazione Macchi, Varese, Italy.,Department of Biotechnology and Life Sciences, Head and Neck Surgery and Forensic Dissection Research Center, University of Insubria, Varese, Italy
| | - Maurizio Bignami
- Division of Otorhinolaryngology, Department of Biotechnology and Life Sciences, University of Insubria-Varese, ASST Sette Laghi, Ospedale di Circolo e Fondazione Macchi, Varese, Italy.,Department of Biotechnology and Life Sciences, Head and Neck Surgery and Forensic Dissection Research Center, University of Insubria, Varese, Italy.,Department of Otorhinolaryngology-Head and Neck Surgery, Ospedale Sant'Anna, San Fermo della Battaglia, Como, Italy
| | - Luca Volpi
- Division of Otorhinolaryngology, Department of Surgical Specialties, ASST Sette Laghi, Ospedale di Circolo e Fondazione Macchi, Varese, Italy
| | - Paolo Castelnuovo
- Division of Otorhinolaryngology, Department of Biotechnology and Life Sciences, University of Insubria-Varese, ASST Sette Laghi, Ospedale di Circolo e Fondazione Macchi, Varese, Italy.,Department of Biotechnology and Life Sciences, Head and Neck Surgery and Forensic Dissection Research Center, University of Insubria, Varese, Italy
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Chapchay K, Weinberger J, Eliashar R, Adler N. Anterior Skull Base Reconstruction following Ablative Surgery for Osteoradionecrosis: Case Report and Review of Literature. Ann Otol Rhinol Laryngol 2019; 128:1134-1140. [DOI: 10.1177/0003489419865558] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Introduction: Osteoradionecrosis is one of many potentially severe complications of radiotherapy for nasopharyngeal carcinoma. Osteoradionecrosis of the skull base is life-threatening due to the critical proximity of the pathological process to vital structures, for example, the intracranial cavity, the upper spine, and major blood vessels. Reconstructive options following surgical debridement of the anterior skull base and upper spine osteonecrosis have been scarcely described in the literature. Case presentation and management: We present a rare case of osteoradionecrosis of the clivus and cervical vertebrae C1-C2 in a patient previously treated with chemoradiotherapy for nasopharyngeal carcinoma, presenting as severe soft tissue infection of the neck. Aggressive surgical debridement and reconstruction with a two-paddle free anterolateral thigh flap was performed using a combination of transcervical and transnasal endoscopic approaches. A novel endoscopic procedure in the sphenoid sinus enabled flap anchoring in this complex area. Discussion: Surgical modalities for osteoradionecrosis of the skull base and upper spine are discussed and review of the literature is presented. Conclusion: Reconstruction of the anterior skull base with a well-vascularized free flap following ablative surgery should be considered in management of life-threatening osteoradionecrosis of the area. Endoscopic opening of the sphenoid sinus and creating a funnel-shaped stem is a newly described technique that guarantees precise placement of the flap and is a valuable adjunct to the reconstructive armamentarium.
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Affiliation(s)
- Katya Chapchay
- Department of Plastic, Reconstructive and Hand Surgery, Hebrew University School of Medicine, Hadassah Medical Center, Jerusalem, Israel
| | - Jeffrey Weinberger
- Department of Otolaryngology / Head and Neck Surgery, Hebrew University School of Medicine, Hadassah Medical Center, Jerusalem, Israel
| | - Ron Eliashar
- Department of Otolaryngology / Head and Neck Surgery, Hebrew University School of Medicine, Hadassah Medical Center, Jerusalem, Israel
| | - Neta Adler
- Department of Plastic, Reconstructive and Hand Surgery, Hebrew University School of Medicine, Hadassah Medical Center, Jerusalem, Israel
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