title: Combined endoscopic transnasal and transoral approach for extensive upper cervical osteoradionecrosis.
abstract: OBJECTIVE
  Osteoradionecrosis (ORN) is a rare yet well-recognized complication following radiotherapy to the head and neck. We illustrate the only case of a spontaneous extrusion of the sequestered C1 arch through the oral cavity and discuss our experience with a combined endoscopic transnasal and transoral approach for cervical ORN.
  
  
  METHODS
  A 56-year-old female presented with a 3-month history of blood-stained nasal discharge. She had been treated with radiotherapy for nasopharyngeal carcinoma 25 years earlier. Flexible nasal endoscopy demonstrated an exposed bone with an edematous posterior nasopharyngeal mass. Computed tomography showed a pre-vertebral mass with destruction of C1 and C2. She underwent occipito-cervical fusion followed by a combined transnasal and transoral endoscopic debridement of non-viable bone in the same perioperative setting. Healing of the raw mucosa was by secondary intention and reconstruction was not performed.
  
  
  RESULTS
  Histopathological examination reported ulcerated inflamed granulation tissue with no evidence of malignancy. During follow-up, she remained neurologically intact with no recurrence.
  
  
  CONCLUSIONS
  Using both nasal and oral spaces allows placement of the endoscope in the nasal cavity and surgical instruments in the oral cavity without splitting the palate. Hence, the endoscopic transnasal and transoral approach has vast potential to be effective in carefully selected cases of cervical ORN.
authors.affiliation: Department of Otolaryngology, Faculty of Medicine, University Malaya, Lembah Pantai, 50603, Kuala Lumpur, Malaysia.
authors.forename: Sien Hui
authors.initials: SH
authors.lastname: Tan
authors.affiliation: Department of Neurosurgery, Faculty of Medicine, University Malaya, Lembah Pantai, 50603, Kuala Lumpur, Malaysia.
authors.forename: Dharmendra
authors.initials: D
authors.lastname: Ganesan
authors.affiliation: Department of Otolaryngology, Faculty of Medicine, University Malaya, Lembah Pantai, 50603, Kuala Lumpur, Malaysia.
authors.forename: Wan Z A
authors.initials: WZ
authors.lastname: Rusydi
authors.affiliation: Department of Neurosurgery, Faculty of Medicine, University Malaya, Lembah Pantai, 50603, Kuala Lumpur, Malaysia.
authors.forename: Hari
authors.initials: H
authors.lastname: Chandran
authors.affiliation: Department of Otolaryngology, Faculty of Medicine, University Malaya, Lembah Pantai, 50603, Kuala Lumpur, Malaysia. prepageran@yahoo.com.
authors.forename: Narayanan
authors.initials: N
authors.lastname: Prepageran
authors.affiliation: Department of Neurosurgery, Faculty of Medicine, University Malaya, Lembah Pantai, 50603, Kuala Lumpur, Malaysia.
authors.forename: Vicknes
authors.initials: V
authors.lastname: Waran
mesh_terms: D002277:Carcinoma; D003646:Debridement / Q000379:methods; D004724:Endoscopy / Q000379:methods; D005260:Female; D006801:Humans; D008875:Middle Aged; D009055:Mouth; D009296:Nasal Cavity; D000077274:Nasopharyngeal Carcinoma; D009303:Nasopharyngeal Neoplasms / Q000532:radiotherapy; D010025:Osteoradionecrosis / Q000000981:diagnostic imaging / Q000601:surgery*; D013123:Spinal Fusion / Q000379:methods*; D014057:Tomography, X-Ray Computed
keywords: Cervical vertebrae; Endoscopy; Nasopharyngeal carcinoma; Odontoid process; Osteoradionecrosis