Surgical Management of Skull Base Osteoradionecrosis in the Cancer Population - Treatment Outcomes and Predictors of Recurrence: A Case Series

Skull base osteoradionecrosis: from pathogenesis to treatment

PURPOSE OF REVIEW

This review aims to provide a comprehensive analysis of skull base osteoradionecrosis (ORN), a severe and rare complication of radiotherapy for head and neck malignancies. It explores pathogenesis, clinical presentation, diagnostic strategies, and management approaches, emphasizing the importance of multidisciplinary care in addressing this challenging condition.

RECENT FINDINGS

Skull base ORN results from radiotherapy-induced tissue damage, characterized by hypovascularity, hypoxia, and necrosis, often compounded by secondary infections. Advances in radiotherapy techniques, such as intensity-modulated radiotherapy and heavy particles, have reduced ORN incidence, though cases persist, particularly in high-dose radiotherapy fields. Emerging treatments, including hyperbaric oxygen therapy and the pentoxifylline-tocopherol protocol, show promise but lack robust evidence for standardized use. Surgical interventions, especially those incorporating vascularized tissue reconstruction, have demonstrated favorable outcomes in refractory cases. Recent studies underscore the utility of multimodal imaging techniques, including MRI and PET/CT, for distinguishing ORN from tumor recurrence.

SUMMARY

Skull base ORN represents a complex and potentially life-threatening condition requiring tailored, multidisciplinary management. Although advancements in diagnostics and therapeutics have improved outcomes, significant challenges remain, particularly in developing standardized protocols. Further research is needed to refine treatment strategies and improve evidence-based practices for this entity.

Presentation and Optimal Management of Anterior and Central Skull Base Osteoradionecrosis: Systematic Review and Meta-Analysis

OBJECTIVE

To conduct a systematic review and meta-analysis to compare the efficacy of conservative treatment versus surgical debridement versus debridement followed by vascularized tissue coverage to provide evidence-based guidance on the management of osteoradionecrosis of the anterior and central skull base.

DATA SOURCES

PubMed, Embase, and Cochrane Library.

REVIEW METHODS

Systematic review and data sources including PubMed, Embase, and Cochrane Library were accessed using PRISMA guidelines. Meta-analysis was performed on treatment type and resolution of osteoradionecrosis.

RESULTS

A total of 13 articles met the inclusion criteria. Patients were categorized into conservative medical treatment versus surgical treatment. Conservative treatment included patients undergoing hyperbaric oxygen therapy, antibiotics, pentoxifylline-tocopherol-clodronate, or a combination of the three. Eight out of 197 patients treated with conservative therapy had resolution of symptoms (4.1%) while 135 of 188 patients treated with surgical intervention had resolution of symptoms (71.8%). Of these, 104 patients (91.2%) in the vascularized tissue group experienced resolution of symptoms.

CONCLUSION

Surgery was superior to medical treatment alone in the resolution of skull base osteoradionecrosis. Vascularized surgical treatment fared significantly better when compared with both surgical debridement only and/or medical treatment. Our findings suggest that surgical treatment should be considered earlier in patients with skull base osteoradionecrosis to prevent severe or fatal sequelae.

LEVEL OF EVIDENCE

NA Laryngoscope, 135:982-990, 2025.

Endoscopic Endonasal Surgery of Skull Base Osteoradionecrosis with the Internal Carotid Artery Invaded: Clinical Characteristic and Surgical Strategy

Objective

This study aims to summarize the clinical characteristics of skull base osteoradionecrosis (ORN) with the internal carotid artery (ICA) involvement and to distill the key surgical techniques that can enhance the protective measures for ICA.

Methods

We conducted a retrospective, observational study over a six-year period from February 2017 to May 2023. We included patients who were diagnosed with osteoradionecrosis with invasion of the internal carotid artery and collected their demographic information, pathology results, complication rates, ect. The goal was the alleviated rate after the surgery and the anatomic consideration during the surgery. We compared the verbal rating score (VRS) of headache pre- and post-operation by the Wilcoxon rank-sum test.

Results

A retrospective analysis was conducted on 19 patients diagnosed with ORN, with a mean age of 53.73 yr (range, 32-68 yr). Among them, 17 patients (89.47%) were nasopharyngeal carcinoma (NPC), 1 patient (5.23%) was squamous cell carcinoma of the sphenoid sinus, and 1 patient (5.23%) had adenoid cystic carcinoma. After the surgery, 1 fatality occurred within 2 months, which was attributed to a severe parapharyngeal space infection.1 patient succumbed to ICA rupture two days post-operation. Additionally, 1 patient experienced ORN recurrence 2 years after the initial surgery. The mean follow-up period for the study was 37.47 mo (range 2 -77 mo). The alleviation rate was 89.4%. The results revealed a significant decrease in VRS after the surgery (Z=-3.921, P=0.000). Finally, we summarized clinical evidences of ICA involvement, such as the formation of pseudoaneurysm.

Conclusion

A four-quadrant division of SBORN as a standardized and systematic approach is meaningful to guide surgical intervention for osteoradionecrosis. There are relevant clinical and imaging evidences that can predict the rupture of ICA.

International Consensus Statement on Allergy and Rhinology: Sinonasal Tumors

BACKGROUND

Sinonasal neoplasms, whether benign and malignant, pose a significant challenge to clinicians and represent a model area for multidisciplinary collaboration in order to optimize patient care. The International Consensus Statement on Allergy and Rhinology: Sinonasal Tumors (ICSNT) aims to summarize the best available evidence and presents 48 thematic and histopathology-based topics spanning the field.

METHODS

In accordance with prior International Consensus Statement on Allergy and Rhinology documents, ICSNT assigned each topic as an Evidence-Based Review with Recommendations, Evidence-Based Review, and Literature Review based on the level of evidence. An international group of multidisciplinary author teams were assembled for the topic reviews using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses format, and completed sections underwent a thorough and iterative consensus-building process. The final document underwent rigorous synthesis and review prior to publication.

RESULTS

The ICSNT document consists of four major sections: general principles, benign neoplasms and lesions, malignant neoplasms, and quality of life and surveillance. It covers 48 conceptual and/or histopathology-based topics relevant to sinonasal neoplasms and masses. Topics with a high level of evidence provided specific recommendations, while other areas summarized the current state of evidence. A final section highlights research opportunities and future directions, contributing to advancing knowledge and community intervention.

CONCLUSION

As an embodiment of the multidisciplinary and collaborative model of care in sinonasal neoplasms and masses, ICSNT was designed as a comprehensive, international, and multidisciplinary collaborative endeavor. Its primary objective is to summarize the existing evidence in the field of sinonasal neoplasms and masses.

Anterior Skull Base Osteoradionecrosis in the Age of Intensity-Modulated Radiation Therapy: A Case Series

Background  Despites advances in radiation technology, skull base osteoradionecrosis (ORN) continues to be a rare, devastating, and hard to treat complication of radiotherapy. We present three cases of anterior skull base ORN in a cohort treated with intensity-modulated radiation therapy (IMRT). Case Series  Three patients developed anterior skull base ORN after receiving at least one round of IMRT. ORN was diagnosed through either nasal endoscopy or imaging findings. The first was a 59-year-old woman with a sinonasal squamous cell carcinoma. Her chemoradiation history was notable for reirradiation and a high dose of radiation (143.3 Gy). The second was a 55-year-old man with recurrent nasopharyngeal carcinoma, whose history was notable for a high dose of radiation (∼140 Gy) and for being reirradiated. The final patient was a 37-year-old woman with an unremarkable history who received radiotherapy (65.0 Gy) for an esthesioneuroblastoma. One patient was asymptomatic and did not receive ORN-specific therapy. The other two were treated with a combination of medical and surgical intervention with successful short-term outcomes (no evidence of infection). Conclusion  Anterior skull base ORN can be treated through conservative and surgical means to achieve successful short-term outcomes. Further investigation of long-term outcomes is warranted.

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

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.

Treatment of Skull Base Diseases: A Multidisciplinary Challenge

The skull base has always been regarded as a frontier by surgeons and radiation oncologists since it represents the interface between the intracranial and the extracranial compartment and hosts several critical anatomical structures with an extremely complex and close relationship [...].

Revisiting the Role of Surgical Resection for Brain Metastasis

Brain metastasis (BM) is the most common type of brain tumor in adults. The contemporary management of BM remains challenging. Advancements in systemic cancer treatment have increased the survival of patients with cancer. Although the treatment of BM is still complicated, advances in radiotherapy, including stereotactic radiosurgery and chemotherapy, have improved treatment outcomes. Surgical resection is the traditional treatment for BM and its role in the surgical resection of BM has been well established. However, refinement of the surgical resection technique and strategy for BM is needed. Herein, we discuss the evolving role of surgery in patients with BM and the future of BM treatment.

When is a multidisciplinary surgical approach required in sinonasal tumours with cranial involvement?

The term “sinonasal tumours” includes a large spectrum of diseases, which are characterized by heterogeneous biological behavior and prognosis, and located in a critical anatomic area. Diagnosis and treatment of sinonasal tumours require the contribution of different disciplines. A narrative review was performed to highlight the role of surgeons in contributing to a multidisciplinary approach to sinonasal tumours. Diagnosis and staging of sinonasal tumours is challenging and requires collaboration between surgeons, radiologists, and pathologists. The identification and management of critical extensions (orbital or intracranial encroachment, vascular abutment or encasement) is fundamental for successful treatment. Most cases of advanced sinonasal tumours can undergo surgical intervention by an adequately trained otorhinolaryngological team. The contribution of neurosurgeons and oculoplastic surgeons is required in selected scenarios. In rare circumstances, multidisciplinary reconstructive strategies can be indicated for complex tissue defects. Furthermore, a multidisciplinary approach is pivotal in the management of perioperative complications. While surgery remains the mainstay of treatment, the role of non-surgical adjuvant or even exclusive treatments is constantly expanding.

Treatment Outcomes for Osteoradionecrosis of the Central Skull Base: A Systematic Review

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.