What is the value of hyperbaric oxygen therapy in management of osteoradionecrosis of the head and neck?

BACKGROUND Mandibular osteoradionecrosis (ORN) is a potentially debilitating complication of ionizing radiotherapy, with an incidence-reported to range from 5% to 15%. ORN is most commonly defined as exposed, irradiated, nonhealing bone of at least 2 to 3 months duration without evidence of tumor recurrence. Although this complication often occurs within the first 6 to 12 months following radiotherapy, reports of late cases imply a lifelong risk. Risk factors for ORN include radiation dose (>60 Gy), previous dental extraction, radiation to the posterior mandible, infection, large tumor size, malnutrition, poor oral hygiene, and alcohol and tobacco abuse. Although most often associated with dental extractions or mucosal trauma, spontaneous cases of ORN are described. The clinical presentation of ORN ranges from mild pain, dysesthesia, halitosis, and exposed necrotic bone, to more advanced symptoms including intractable pain, infection, orocutaneous fistula, and pathologic fracture. There are numerous classification systems used to describe the severity of ORN. Most involve a staging system from mild to severe based on both clinical and radiographic findings (Table I, published online as supporting information). Historically, the treatment of ORN employed a multimodality approach utilizing conservative measures for early disease (antibiotic therapy, debridement, and irrigation) while reserving surgical resection and reconstruction for more advanced or refractory cases. Hyperbaric oxygen (HBO) therapy continues to be employed for treatment of all stages of ORN despite its lack of proven efficacy and the lack of randomized controlled trial data (Table II, published online as supporting information).