鼻咽癌再程放疗后颅底放射性骨坏死的手术清创与组织瓣修复

Surgical debridement and tissue flap reconstruction for skull base osteoradionecrosis after reirradiation in nasopharyngeal carcinoma

摘要:

目的 探讨颞肌瓣转移修复与鼻黏膜瓣修复在鼻咽癌再程放疗后颅底放射性骨坏死治疗中的应用价值及预后差异，为临床术式选择提供参考依据。方法 回顾性分析2021年11月—2025年5月收治的6例鼻咽癌再程放疗后颅底放射性骨坏死患者的临床资料，所有患者均经保守治疗无效后行外科手术治疗，其中2例采用颞肌瓣转移修复，4例采用鼻黏膜瓣修复(含带蒂鼻中隔黏膜瓣2例、游离下鼻甲黏膜瓣2例)。收集患者基线资料、手术相关信息、术后疗效及长期随访数据，对比两种修复方式的症状控制效果、并发症发生率及远期预后，并结合现有文献分析疗效差异机制。结果 2例颞肌瓣修复患者术后疼痛均完全缓解，术后随访6~18个月，颅底缺损愈合良好，无感染复发及组织瓣坏死。4例鼻黏膜瓣修复患者术后坏死范围均有所缩小，但未实现完全愈合，无严重手术相关并发症，其中1例患者在坏死发生后36个月因坏死迁延不愈并发颈内动脉破裂出血死亡，其余3例随访31~47个月，仍存在局部少量残留坏死组织。结论 相较于鼻黏膜瓣修复，颞肌瓣转移修复在鼻咽癌再程放疗后颅底放射性骨坏死伴感染治疗中，疼痛控制效果更显著、短期预后更佳，可作为此类患者的优选术式。鼻黏膜瓣修复疗效有限且长期预后存在不确定性，可作为无法耐受颞肌瓣手术患者的补充方案，术后需加强长期随访与病情监测。

Abstract:

Objective To explore the application value and prognostic differences of temporalis muscle flap transfer repair and nasal mucosal flap repair in the treatment of skull base osteoradionecrosis after reirradiation for nasopharyngeal carcinoma, so as to provide a reference for the selection of surgical methods in clinical practice. Methods A retrospective analysis was performed on the clinical data of 6 patients with skull base osteoradionecrosis after reirradiation for nasopharyngeal carcinoma admitted to our center from November 2021 to May 2025. All the patients underwent surgical treatment after ineffective conservative treatment, among which 2 cases were treated with temporalis muscle flap transfer repair, and 4 cases with nasal mucosal flap repair (including 2 cases of pedicled nasal septal mucosal flap and 2 cases of free inferior turbinate mucosal flap). Baseline data, surgery-related information, postoperative efficacy and long-term follow-up data of the patients were collected. The symptom control effect, complication rate and long-term prognosis of the two surgical methods were compared, and the mechanism of efficacy difference was analyzed in combination with existing literature. Results The postoperative pain completely disappeared in the 2 patients treated with temporalis muscle flap repair. During the 6 to 18 months of postoperative follow-up, the skull base defects healed well without infection recurrence or flap necrosis. The necrotic area was reduced in all the 4 patients treated with nasal mucosal flap repair, but complete healing was not achieved, and no severe surgery-related complications occurred. One patient died of internal carotid artery rupture and hemorrhage 3 years after the onset of necrosis due to persistent non-healing necrosis.The remaining 3 patients still had a small amount of residual necrotic tissue. Conclusions Compared with nasal mucosal flap repair, temporalis muscle flap transfer repair has a more significant pain control effect and better short-term prognosis in the treatment of skull base osteoradionecrosis with infection after reirradiation for nasopharyngeal carcinoma, and can be used as the preferred surgical method for such patients. Nasal mucosal flap repair has limited efficacy and uncertain long-term prognosis, and can serve as a supplementary scheme for patients who cannot tolerate temporalis muscle flap surgery. Postoperative long-term follow-up and monitoring should be strengthened.