CC BY-NC-ND 4.0 · J Neurol Surg Rep 2023; 84(03): e87-e91
DOI: 10.1055/s-0043-1772200
Original Report

Bilateral Inferior Turbinate Flaps for Salvage Reconstruction after Proton Beam Radiotherapy for Clival Chordoma

1   Department of Otolaryngology – Head & Neck Surgery, University of California San Diego, La Jolla, California, United States
Megana Saripella
2   School of Medicine, University of California San Diego, La Jolla, California, United States
Adam S. DeConde
1   Department of Otolaryngology – Head & Neck Surgery, University of California San Diego, La Jolla, California, United States
Thomas L. Beaumont
3   Department of Neurological Surgery, University of California San Diego, La Jolla, California, United States
› Author Affiliations


Clival chordoma is a rare, aggressive, notochord-derived tumor primarily managed with surgery via an endoscopic endonasal approach (EEA) and adjuvant proton beam radiotherapy. Reconstruction is commonly performed with a nasoseptal flap (NSF) at the time of initial surgery. While failures of the NSF are rare, they can occur following the initial surgery or in the setting of osteoradionecrosis. Salvage repair typically requires transfer of alternative vascularized tissues outside of the previously radiated field including regional scalp flaps such as pericranial or temporoparietal fascial flaps, or free vascularized tissue transfer. Here we describe the case of a 29-year-old woman with a history of clival chordoma with widespread skull base osteomyelitis secondary to NSF necrosis after proton beam radiotherapy. We describe successful skull base reconstruction with intranasal bilateral inferior turbinate flaps based on the sphenopalatine artery with lateral nasal wall extension, despite prior proton beam therapy and a failed prior vascularized intranasal reconstruction.

Publication History

Received: 08 February 2023

Accepted: 17 June 2023

Article published online:
11 August 2023

© 2023. The Author(s). This is an open access article published by Thieme under the terms of the Creative Commons Attribution-NonDerivative-NonCommercial License, permitting copying and reproduction so long as the original work is given appropriate credit. Contents may not be used for commercial purposes, or adapted, remixed, transformed or built upon. (

Georg Thieme Verlag KG
Rüdigerstraße 14, 70469 Stuttgart, Germany

  • References

  • 1 McMaster ML, Goldstein AM, Bromley CM, Ishibe N, Parry DM. Chordoma: incidence and survival patterns in the United States, 1973-1995. Cancer Causes Control 2001; 12 (01) 1-11
  • 2 Walcott BP, Nahed BV, Mohyeldin A, Coumans JV, Kahle KT, Ferreira MJ. Chordoma: current concepts, management, and future directions. Lancet Oncol 2012; 13 (02) e69-e76
  • 3 Culebras D, Torales J, Reyes LA. et al. Extended endoscopic endonasal surgery for clival chordoma and chondrosarcoma: our experience in 14 cases. Neurocirugia (Astur : Engl Ed) 2018; 29 (04) 201-208
  • 4 Hadad G, Bassagasteguy L, Carrau RL. et al. A novel reconstructive technique after endoscopic expanded endonasal approaches: vascular pedicle nasoseptal flap. Laryngoscope 2006; 116 (10) 1882-1886
  • 5 Thorp BD, Sreenath SB, Ebert CS, Zanation AM. Endoscopic skull base reconstruction: a review and clinical case series of 152 vascularized flaps used for surgical skull base defects in the setting of intraoperative cerebrospinal fluid leak. Neurosurg Focus 2014; 37 (04) E4
  • 6 Yip J, Macdonald KI, Lee J. et al. The inferior turbinate flap in skull base reconstruction. J Otolaryngol Head Neck Surg 2013; 42 (01) 6
  • 7 Fortes FS, Carrau RL, Snyderman CH. et al. The posterior pedicle inferior turbinate flap: a new vascularized flap for skull base reconstruction. Laryngoscope 2007; 117 (08) 1329-1332
  • 8 Hanasono MM, Sacks JM, Goel N, Ayad M, Skoracki RJ. The anterolateral thigh free flap for skull base reconstruction. Otolaryngol Head Neck Surg 2009; 140 (06) 855-860
  • 9 Arosio AD, Coden E, Karligkiotis A. et al. Temporoparietal fascia flap endonasal transposition in skull base reconstruction: surgical technique. World Neurosurg 2021; 146: 118
  • 10 Yamada H, Toda M, Fukumura M. et al. Cerebrospinal fluid leakage due to nasoseptal flap partial necrosis: a pitfall for skull base reconstruction of endoscopic endonasal surgery. Surg Neurol Int 2020; 11 (121) 121
  • 11 Chabot JD, Patel CR, Hughes MA. et al. Nasoseptal flap necrosis: a rare complication of endoscopic endonasal surgery. J Neurosurg 2018; 128 (05) 1463-1472
  • 12 Harvey RJ, Parmar P, Sacks R, Zanation AM. Endoscopic skull base reconstruction of large dural defects: a systematic review of published evidence. Laryngoscope 2012; 122 (02) 452-459
  • 13 Lavigne P, Faden DL, Wang EW, Snyderman CH. Complications of nasoseptal flap reconstruction: a systematic review. J Neurol Surg B Skull Base 2018; 79 (10, Suppl 4): S291-S299
  • 14 Zanation AM, Carrau RL, Snyderman CH. et al. Nasoseptal flap reconstruction of high flow intraoperative cerebral spinal fluid leaks during endoscopic skull base surgery. Am J Rhinol Allergy 2009; 23 (05) 518-521
  • 15 Ruffner R, Pereira MC, Patel V, Peris-Celda M, Pinheiro-Neto CD. Inferior meatus mucosal flap for septal reconstruction and resurfacing after nasoseptal flap harvest. Laryngoscope 2021; 131 (05) 952-955
  • 16 Lee DH, Yoon TM, Lee JK. et al. Clinical utility of the inferior turbinate flaps in the reconstruction of the nasal septum and skull base. J Craniofac Surg 2012; 23 (04) e322-e326
  • 17 Gil Z, Margalit N. Anteriorly based inferior turbinate flap for endoscopic skull base reconstruction. Otolaryngol Head Neck Surg 2012; 146 (05) 842-847
  • 18 Kim SM, Park HW, Park MS. et al. Fulminant meningitis after radiotherapy for clival chordoma. Brain Tumor Res Treat 2013; 1 (02) 107-110
  • 19 Moon JH, Kim EH, Kim SH. Various modifications of a vascularized nasoseptal flap for repair of extensive skull base dural defects. J Neurosurg 2019; 132 (02) 371-379