Nasopharyngeal carcinoma (NPC) is the most common head and neck malignancy in Southeast Asia (Chen et al. 2019; Bray et al. 2024). China, with a high incidence of NPC, accounted for approximately 46.8 % of new global cases in 2020 (Sung et al. 2021). Currently, radiation therapy remains the treatment of choice for incipient NPC, with reliable results; however, some patients develop immediate or long-term toxic reactions after high doses of radiotherapy due to local tissue irradiation (Sun et al. 2014). Post-radiotherapy nasopharyngeal necrosis (PRNN) is one of the long-term adverse reactions of radiotherapy for NPC, with an incidence rate of 2.9 %. Skull base osteoradionecrosis (ORN) is a devastating adverse reaction developed by the continued progression of PRNN, occurring in approximately 70 % of PRNN cases (Hua et al. 2009; Li et al. 2019; Yang et al. 2021).

Necrosis and infection of the skull base and adjacent tissues caused by ORN can lead to intractable headaches, foul odor, recurrent epistaxis, and cranial nerve palsy, which have a serious negative impact on a patient's physical and psychological well-being, significantly reducing the patient's quality of life (QOL) (Huang et al. 2006). Similarly, the residual long-term adverse effects of radiotherapy, such as difficulty in opening the mouth, and chewing or swallowing dysfunction can significantly affect nutritional status, including albumin, prealbumin, hemoglobin, and body mass index(BMI); thus, adversely affecting prognosis (Pu et al. 2022; Zeng et al. 2024). Additionally, necrosis and infection can invade the internal carotid artery (ICA) and expose it to the necrotic lumen, leading to death secondary to nasopharyngeal hemorrhage (Hua et al. 2009; Chen et al. 2013). Patients with ICA exposure reportedly have an 80 % higher risk of death than unexposed patients (Yang et al. 2017).

Complete excision of necrotic tissue is the mainstay of treatment for PRNN and ORN; however, past outcomes have been unsatisfactory. In the literature, the cure rate of PRNN after excising purely necrotic lesions is reportedly only 13.4 %–28.6 % (Hua et al. 2009; Chen et al. 2013). The reasons affecting surgical efficacy are unclear.The complex anatomy of the nasopharynx, which makes it difficult to perform extended radical resection, as well as the poor healing ability of the local tissues and the poor viability of reconstructive materials after radiotherapy, may be the reasons for surgical failure. Zou et al. (2018) used a tipped nasal septal mucosal flap after necrosectomy to treat patients with PRNN and ORN, and the 2-year overall survival (OS) was higher than that reported in the literature. Dai et al. (2023) achieved similar results in a prospective study of 18 patients with ORN, suggesting the efficacy of necrotic tissue resection combined with skull base repair during the same period. Li et al. (2024) similarly advocated a sequential treatment approach for patients with ORN, including surgery and flap repair.

However, much of the published literature focuses on the surgery itself and lacks attention to the prognosis, QOL, and nutritional status of patients with ORN. This study aimed to provide insights into the clinical efficacy of this therapy in patients with ORN, fill the existing knowledge gap, and deepen the understanding of patient management.