The Use of Hyperbaric Oxygen Therapy in the Management of Osteoradionecrosis of the Skull Base

Objective: To review our experience with the use of hyperbaric oxygen (HBO) as part of the treatment regimen for patients with osteoradionecrosis (ORN) of the skull base.

Design: Retrospective chart review of all patients treated with hyperbaric oxygen for skull base osteoradionecrosis over the past 20 years.

Setting: A large regional tertiary care facility.

Participants: Accumulated cases of anterior, central, and lateral skull base osteoradionecrosis treated with hyperbaric oxygen therapy.

Main Outcome Measures: Alteration in clinical course, symptom improvement, resolution of pain, ability to tolerate further surgical procedures for skull base or facial defects, and closure of nasocutaneous fistulae.

Results: Review of MEEI Norman Knight Hyperbaric Medicine Center records revealed 11 patients with skull base ORN treated in the past 20 years; 8 patients with anterior or central and 3 with lateral skull base osteoradionecrosis were identified. On average, ORN developed 1-2 years post-radiation therapy. The most common complaints at the time of diagnosis were pain and purulent drainage.

Three distinct groups were identified: (1) Three patients with ORN of the lateral temporal bone were treated with antibiotics and HBO, and all patients had durable resolution of their symptoms (pain and otorrhea). (2) Three patients had anterior or central skull base ORN with sinonasal drainage and headache/facial pain. These patients experienced resolution of pain and drainage after local debridement (via endoscopic sinus surgery), HBO, and antibiotics. (3) Four patients had facial soft tissue breakdown in addition to anterior skull base erosion that resulted in sinocutaneous fistulae. HBO improved the wound bed and stopped drainage and pain in all patients, but did not close fistulae. Vascularized tissue did close the fistula in two patients, while multiple attempts at closure did not succeed in the remaining two patients. One patient died from recurrent malignancy two months after HBO.

Conclusions: In our institution, hyperbaric oxygen therapy is an adjunct to treatment of skull base osteoradionecrosis, as part of a regimen that also includes antibiotic therapy and surgical debridement. HBO appears to help stabilize skull base wound beds in patients afflicted with osteoradionecrosis. Surgery is necessary to close sinocutaneous fistulae, but given the fragile nature of surrounding tissues, patients should be adequately counseled for the possibility of recurrent skin defects.