Skull Base Osteoradionecrosis in Nasopharyngeal Carcinoma: Long‐Term Outcomes of Vascularized Flaps

Objectives Skull base osteoradionecrosis (ORN) is a late but debilitating complication of previously irradiated nasopharyngeal carcinoma (NPC). Patients often suffer from chronic pain and recurrent bleeding, which can culminate in a carotid blowout. This study examines the natural history of skull base ORN over a long follow‐up, and the outcomes with conservative and surgical management. Methods A retrospective review (June 2011 to December 2025) of radiated NPC patients with skull base ORN managed at a tertiary center was performed. Outcome measures were symptom control, incidence of carotid blowout and survival. Results There were 28 patients with a follow‐up of 23.0 (14.0–31.0) years. Signs of ORN developed at 14.0 (6.0–23.0) years after radiotherapy. The most common symptom was recurrent bleeding (85.7%). The incidence of carotid blowout was 53.6%. Survival after ORN diagnosis was 5.0 (2.0–8.0) years. Eighteen patients (64.3%) were managed conservatively. Ten patients (35.7%) underwent endoscopic debridement and vascularized flap reconstruction. Patients who underwent surgery had better symptom control, lower incidence of carotid blowout (20.0% vs. 72.2%, p = 0.008) and longer overall survival (29.0 [10.0–31.0] vs. 21.5 [14.0–36.0] years, p < 0.001) than those managed conservatively. Conclusions Survival after skull base ORN diagnosis was generally poor. Conservative management was associated with poorer symptom control and frequently progressed to carotid blowout eventually. Early recognition of ORN and timely surgical debridement with vascularized flap reconstruction in appropriately selected patients may provide better symptom control, reduce progression to carotid blowout, with a potential survival benefit.