鼻内镜下不同修复材料治疗鼻咽癌放疗后颅底骨坏死累及颈内动脉30例的临床疗效分析

Clinical efficacy analysis of different repair materials under nasal endoscopy for 30 cases of skull base osteoradionecrosis involving the internal carotid artery following radiotherapy for nasopharyngeal carcinoma

摘要:

目的 探讨鼻内镜下应用不同修复材料治疗鼻咽癌放疗后颅底骨坏死累及颈内动脉患者的临床疗效、并发症发生情况及远期随访结局。方法 回顾性分析2021年1月—2025年6月于广西壮族自治区人民医院耳鼻咽喉头颈科诊治的30例鼻咽癌放疗后颅底骨坏死合并颈内动脉受累患者的临床资料，所有患者均接受鼻内镜下颅底坏死病灶清除术，术者根据患者颅底缺损的解剖学特征，分别采用颞肌瓣（n=8）、带蒂鼻中隔黏膜瓣（n=8）、生物材料（n=8）及阔筋膜（n=6）完成Ⅰ期颅底缺损修复重建。观察并统计患者术后症状缓解情况、并发症发生率及远期生存状态，采用Kaplan-Meier法绘制生存曲线并评估患者的生存预后。结果 30例患者术后随访时长为7~62个月，中位随访时间为22个月。患者术前主要临床症状为：头痛18例（60.0%）、鼻臭12例（ 40.0%）、鼻出血8例（26.7%）。术后各临床症状改善率分别为：头痛13/18（72.2%）、鼻臭10/12（83.3%）、鼻出血6/8（ 75.0%）；术后总体症状改善23例（76.7%），症状无改善4例，症状部分改善3例（表现为头痛未缓解但鼻臭改善）。本组患者同期行气管切开术9例（30.0%），术后共发生大出血并发症6例（20.0%）；其中颞肌瓣组术后大出血发生率为0%（0/8），低于其余修复材料组的27.3%（6/22）。术后随访期间共4例患者死亡（13.3%），其余26例（86.7%）患者至末次随访时仍存活，其1、2、 3年总体生存率分别为93.3%、89.3%和80.3%。结论 鼻内镜下坏死病灶清除联合Ⅰ期颅底重建是治疗鼻咽癌放疗后颅底骨坏死累及颈内动脉的有效方案，术后症状改善效果确切。颞肌瓣具有组织供量充足、血供稳定可靠的特征，在降低术后大出血并发症风险方面具备一定优势。本研究属于探索性小样本临床研究，所得结论仅为初步结果，相关结论仍需大样本量、长期随访的临床研究进一步验证。

Abstract:

Objective To investigate the clinical efficacy, complications, and long-term follow-up outcomes of treating patients with nasopharyngeal carcinoma who have skull base osteoradionecrosis involving the internal carotid artery using different repair materials under nasal endoscopy. Methods The clinical data of 30 patients with nasopharyngeal carcinoma radiation-induced skull base osteoradionecrosis involving the internal carotid artery who were treated in the Department of Otorhinolaryngology Head and Neck at the People’s Hospital of Guangxi Zhuang Autonomous Region from January 2021 to June 2025 were retrospectively analyzed. All patients underwent endoscopic debridement of necrotic skull base lesions. Primary reconstruction was performed using different materials according to the characteristics of skull base defects, including temporalis muscle flaps (n=8), pedicled nasal septal mucosal flaps (n=8), biological materials (n=8), or fascia lata (n=6). Postoperative symptom relief, complications, and survival outcomes were evaluated. Kaplan-Meier survival analysis was performed to estimate overall survival. Results The postoperative follow-up duration of the 30 patients ranged from 7 to 62 months, with a median follow-up time of 22 months. The main preoperative symptoms included headache in 18 cases (60.0%), foul nasal odor in 12 cases (40.0%), and epistaxis in 8 cases (26.7%). After surgical intervention, symptom improvement was observed in 13/18 (72.2%) for headache, 10/12 (83.3%) for foul nasal odor, and 6/8 (75.0%) for epistaxis. Overall, symptomatic improvement was achieved in 23 patients (76.7%), while 4 patients showed no improvement, and 3 patients experienced partial improvement (manifested as headache not relieved but improvement in nasal odor). Tracheostomy was performed in 9 patients (30.0%) during the same hospitalization. Postoperative massive hemorrhage occurred in 6 patients (20.0%). Notably, the incidence of massive hemorrhage in the temporalis muscle flap group was 0% (0/8), which was lower than that in the other material groups [27.3% (6/22)]. During the follow-up period, 4 patients (13.3%) died. The remaining 26 patients (86.7%) were still alive at the last follow-up. The 1-, 2-, and 3-year overall survival rates were 93.3%, 89.3%, and 80.3%, respectively. Conclusions Endoscopic debridement combined with primary skull base reconstruction is an effective treatment strategy for nasopharyngeal carcinoma radiation-induced skull base osteoradionecrosis involving the internal carotid artery, providing substantial postoperative symptom relief. The temporalis muscle flap offers advantages including sufficient tissue volume and reliable vascular supply, and exhibits certain benefits in reducing the risk of postoperative massive hemorrhage. As an exploratory study with a small sample size, the obtained conclusions are only preliminary results and require validation through large-scale and long-term follow-up clinical studies.