Radiotherapy is an effective treatment for nasopharyngeal carcinoma. However, irradiation has many acute and chronic side effects. Postradiation nasopharyngeal necrosis (PRNN) is necrosis of the surrounding and affiliated tissues of the nasopharynx, including the mucosa, muscle, and skull base. The necrosis can occur several months or years after radiotherapy and becomes life-threatening when the carotid sheath is involved. A 63-year-old woman was diagnosed with stage IV nasopharyngeal carcinoma and underwent concurrent chemoradiotherapy with adjuvant chemotherapy. The tumor recurred 9 months later, and she underwent left modified radical neck dissection and laser-assisted nasopharyngectomy. She also received postoperative cetuximab-based bioradiotherapy. After radiotherapy, endoscopic examination revealed necrosis of the soft tissue and accumulation of pus in the left side of the nasopharynx. The patient received regular endoscopic local treatment and antibiotic treatment, but the necrosis and pus persisted. Four months after surgery, she was admitted to our hospital due to severe left-sided headache. Magnetic resonance imaging showed a soft tissue lesion in the left side of the nasopharynx, suspected to be extensive nasopharyngeal necrosis or tumor recurrence. Transnasal endoscopic biopsy and debridement was performed, but massive bleeding occurred due to internal carotid artery rupture during tissue dissection of the parapharyngeal space. Hemostasis was achieved after local compression. A pedicled posterior nasoseptal flap was created to cover the raw surface of the nasopharynx. Postoperative computed tomography and angiography showed a
pseudoaneurysm in the left internal carotid artery, and a stent was placed. However, the patient died of hydrocephalus caused by suspected infection of the central nervous system. Patients with PRNN should be carefully assessed before surgery, especially those with carotid artery involvement. (J Taiwan Otolaryngol Head Neck Surg 2020; 55:166-171)
