ORIGINAL ARTICLE Comparison of complications in free flap reconstruction for osteoradionecrosis in patients with or without hyperbaric oxygen therapy David Nolen, MD, 1 Steven B. Cannady, MD, 2 Mark K. Wax, MD, 3 Joseph Scharpf, MD, 4 Liana Puscas, MD, MHS, 1,5 Ramon M. Esclamado, MD, MS, 1 Michael Fritz, MD, 4 John Freiberger, MD, MPH, 6 Walter T Lee, MD 1,5* 1 Division of Otolaryngology–Head and Neck Surgery, Duke University Medical Center Department of Surgery, Durham, North Carolina, 2 Division of Head and Neck Surgery, Department of Otolaryngology, SUNY Downstate Medical Center (formerly at Rochester Head and Neck Center), New York, New York, 3 Department of Otolaryngology, Oregon Health and Science University, Portland, Oregon, 4 Head and Neck Institute, Cleveland Clinic, Cleveland, Ohio, 5 Section of Otolaryngology–Head and Neck Surgery, Durham Veterans Affairs Medical Center, Durham, North Carolina, 6 Department of Anesthesia Division of Hyperbaric Medicine, Duke University Medical Center Department of Surgery, Durham, North Carolina. Accepted 26 September 2013 Published online 20 January 2014 in Wiley Online Library (wileyonlinelibrary.com). DOI 10.1002/hed.23520 ABSTRACT: Background. Hyperbaric oxygen (HBO) therapy induces native tissue oxygenation. The hypothesis was patients with mandibular osteoradionecrosis (ORN) and a history of HBO therapy would have less free flap reconstruction complications than patients without HBO therapy. Methods. We conducted a multisite retrospective review involving radical debridement and free flap reconstruction for ORN between January 1, 1995 and June 30, 2011. Patients were stratified based on receiving prior HBO therapy or not. Results. Thirty-nine of 89 patients (43.8%) had HBO therapy whereas 50 of 89 (56.2%) did not. The HBO therapy group had significantly less patients with diabetes. There was no statistical difference in overall complication in patients between groups (p 5 .5478). However, there was marginal significance of increased infections in the patients with a history of HBO therapy (p 5 .0545). Conclusion. Although no significant differences in free flap reconstruction complication rates were observed between these 2 patient cohorts, there was marginal significance of increased infections in the patients with a history of HBO therapy. A prospective multi-institutional randomized study examining issues of infection would address issues inherent in this retrospective study. V C 2014 Wiley Periodicals, Inc. Head Neck 36: 1701–1704, 2014 KEY WORDS: osteoradionecrosis, hyperbaric oxygen, radiation complications, surgical complications, free flap reconstruction INTRODUCTION Radiation therapy is a well-recognized modality used to treat head and neck cancer. 1 In the 1970s, radiation ther- apy was used primarily as an adjuvant treatment. By the 1990s, with the advent of organ-preservation protocols, radiation therapy was being used with and without chem- otherapy as primary treatment. 2–4 Currently, radiation therapy is a well-accepted modality in both the primary and adjuvant treatment for cancer originating in the head and neck region. 3,5 Although this treatment modality can effectively treat head and neck cancer, it is not without morbidity. Poor wound healing, increased fistula rates, stenosis, lymphedema, dysphagia, carotid artery stenosis, and osteoradionecrosis (ORN) are all potential complica- tions of radiation therapy. 6–9 ORN is one of the most major complications, and it occurs in 1% to 6% of patients who receive radiation ther- apy to the head and neck region. 10 ORN results from ioniz- ing radiation–induced free radical injury that causes inflammation, microvascular thrombosis, fibrosis, and remodeling, with subsequent bone and tissue necrosis. 11–13 Furthermore, surgery in the setting of radiation also poses a unique set of challenges. Fibrosis and scarring compromise wound healing and result in high rates of postoperative complications. 14 Agra et al 9 noted a 53% postoperative complication rate after radiation with the most common being fistula, infection, and wound dehiscence. Hyperbaric oxygen (HBO) therapy has been used since 1960 to treat radiation-induced complications in the head and neck including ORN, laryngeal chondronecrosis, and soft tissue infections. 15–17 HBO therapy induces neovascu- larity, fibroblast proliferation, and stem cell production, which all augment wound healing. 17,18 HBO therapy in *Corresponding author: W. T. Lee, Division of Otolaryngology–Head and Neck Surgery, Duke University Medical Center Department of Surgery, Duke South Clinics, 5716 Fayetteville Street, Room 3561B, Durham, NC 27710. E-mail: walter.lee@duke.edu. Additional Supporting Information may be found in the online version of this article. This work was presented at the 2012 American Academy of Otolaryngology– Head and Neck Surgery Foundation (AAO-HNSF) Annual Meeting, Washington DC, September 9–12, 2012. David Nolen, Steven B. Cannady, Mark Wax, and Joseph Scharpf contributed equally to this work. Published 2014. This article is a U.S. Government work and is in the public domain in the USA. HEAD & NECK—DOI 10.1002/HED DECEMBER 2014 1701