https://doi.org/10.1177/0003489419865558 Annals of Otology, Rhinology & Laryngology 1–7 © The Author(s) 2019 Article reuse guidelines: sagepub.com/journals-permissions DOI: 10.1177/0003489419865558 journals.sagepub.com/home/aor Article Introduction Nasopharyngeal carcinoma (NPC) is a malignant tumor originating from the epithelium of the nasopharynx. NPC is an uncommon malignancy in certain parts of the world, although it is highly endemic in Southern China and Southeast Asia. 1,2 Combination of chemotherapy and radio- therapy is a standard treatment modality in the vast majority of cases. Osteoradionecrosis (ORN) is one of the most severe complications of radiotherapy for NPC. Radiation- induced hypocellularity, hypovascularity, and altered osteo- blast and osteoclast ratio lead to ischemic necrosis and fibro-atrophic changes of the affected bones. 3-5 Mechanically and metabolically incompetent bone is prone to pathologi- cal fracture and to infection. The anatomical location of the NPC determines the area of radiation therapy. Potential bone involvement includes the mandible, skull base, and upper spine. Despite recent improvements in radiation 865558AOR XX X 10.1177/0003489419865558Annals of Otology, Rhinology & LaryngologyChapchay et al research-article 2019 1 Department of Plastic, Reconstructive and Hand Surgery, Hebrew University School of Medicine, Hadassah Medical Center, Jerusalem, Israel 2 Department of Otolaryngology / Head and Neck Surgery, Hebrew University School of Medicine, Hadassah Medical Center, Jerusalem, Israel *Equal contribution Corresponding Author: Katya Chapchay, MD, Department of Plastic, Reconstructive and Hand Surgery, Hadassah University Medical Center, Ein Kerem, P.O.B. 12000, Jerusalem, 91120, Israel. Email: chapchayka@gmail.com Anterior Skull Base Reconstruction following Ablative Surgery for Osteoradionecrosis: Case Report and Review of Literature Katya Chapchay, MD 1 , Jeffrey Weinberger, MD 2 , Ron Eliashar, MD 2* , and Neta Adler, MD 1* 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. Keywords osteoradionecrosis, nasopharyngeal carcinoma, skull base reconstruction, anterolateral thigh flap, endoscopic sinus surgery