• Pazienti con osteoradionecrosi della mandibola sottoposta a radioterapia con almeno 6000 cGy da almeno 6 mesi e non più di 15 anni
• Pazienti con ulcera torpida radionecrotica della testa e del collo dopo radioterapia con almeno 6000 cGy da almeno 6 mesi e non più di 15 anni che non risponde ad altri trattamenti

• Proctite post attinica che non risponde ad altri trattamenti
• Profilassi dell’osteoradionecrosi nell’estrazione dentaria in mandibola irradiata con dosi superiori a 6000 cGy in un periodo compreso tra i 6 mesi e i 15 anni precedenti.
• Cistite emorragica resistente alla terapia convenzionale

SOMA scales

Stage I

Presenza di esposizione ossea, in paziente ancora non sottoposto a pulizia chirurgica (sequestrectomia)

“All patients who meet the definition of osteoradionecrosis except those with cutaneous fistulae, pathologic fracture, or radiographic evidence of bone resorption. (These three subsets of patients are classified as Stage III.) Stage I patients receive 30 HBOT treatments. Wounds are maintained with irrigation only or with saline rinses. No bone is surgically removed. If, after 30 treatments, the wound shows improvement, as evidenced by decrease in amount of exposed bone; less resporption or spontaneous sequestration of exposed bone; or decreased softening of exposed bone; the patient completes another 10 treatments. The total 40 HBOT treatments are meant to achieve full mucosal cover. If there is no clinical improvement after 30 HBOT treatments or complete resolution, such as extended or continued exposure of bone, absence of mucosal proliferation, or presence of inflammation, the patient is advanced further to Stage II. (See Technical Treatment Protocol for suggestions on pressure levels and duration of individual treatments)”.

Stage II

Paziente sottoposto a chirurgia (sequestrectomia) dell’osso necrotico e a tentativo ricostruttivo con lembo muco-periostale

“Surgeons attempt a local surgical debridement to identify those patients with only superficial or cortical bone involvement, and who can be resolved without jaw resection. A transoral alveolar sequestrectomy is performed with fine saline-cooled, air-driven saws. Minimal periosteal manipulation is done for labial access to the mandible. The lingual periosteum is allowed to remain completely attached until the specimen is delivered, and then only that which is attached to the specimen is reflected from bone. The resultant mucoperiosteal flaps are closed in three layers over a base of bleeding bone. If healing progresses without complication, HBOT is continued with 10 additional sessions. If the wound dehisces, leaving exposed non-healing bone, the patient is advanced to Stage III. In those patients who initially present with orocutaneous fistulae, with pathologic fracture, or with radiographic osteolysis to the inferior border, the initial 30 HBOT treatments are given, and the patient enters Stage III directly”.

Stage III

Presenza di fistole cutanee, fratture patologiche, osteolisi del bordo inferiore della mandibola. Deiscenza di precedente intervento di copertura con lembo muco-periostale.

“After 30 HBOT treatments, the patient undergoes a transoral partial jaw resection, the margins of which are determined at the time of surgery by the presence of bleeding bone. The segments of the mandible are stabilized either with extraskeletal pin fixation or with maxillo mandibular fixation. If there was an orocutaneous fistula, or large soft tissue loss, primary closure or soft-tissue reconstruction is accomplished during this surgery. HBOT is continued for another 10 treatments, and the patient is advanced to Stage III-R”.

Stage III-R

Paziente sottoposto a intervento di resezione della mandibola e di ricostruzione dei tessuti molli

“These patients present the most difficult cases. Early reconstruction and rehabilitation produces the best results. Ten weeks after resection, the soft tissues are healing, and the potential graft bed is free from contamination and infection. Bony reconstruction is undertaken from a strictly transutaneous approach without oral flora contamination. Ten post-reconstructive HBOT treatments are given, and the jaw fixation is maintained for eight weeks. If no further surgery is required, the patient begins appointments with a maxillofacial prosthodontist for full prosthetic rehabilitation one month after release of his fixation. If additional surgery is required, such as a tongue release, vestibuloplasty, or excision of redundant tissue, surgeons schedule procedures one month after fixation is released. After surgery, the patient is referred to a maxillofacial prosthodontist”. 

Bibliografia utilizzabile ai fini dell’individuazione delle prove di efficacia

No Clinical evidence

 1 Rapporto di Technology Assessment AHRQ Gowrl Raman, Bruce Kupelnick, Priscilla Chew, Joseph Lau “A Horizon Scan: Uses of Hyperbaric Oxigen Therapy” ottobre 2006. Riporta la revisione sistematica di Pasquier D., Hoelscher T., Schmutz J. “Hyperbaric oxigen therapy in the treatment of radio-induced lesions in normal tissues: a literature review” Radiotherapy and Oncology 72(1):1-13, 2004. Gli autori identificano un RCT che dimostra che l’OTI riduce l’osteoradionecrosi nei tessuti sottoposti a terapia radiante dopo estrazione dentaria.

Altra bibliografia raccolta sull’argomento

1. Annane D., Depondt J., Aubert P., Villart M., “Hyperbaric oxygen therapy for radionecrosis of the jaw: a randomized, placebo-controlled, double-blind trial” from the ORN96 study group. Journal of Clinical Oncology: official journal of the American Society of Clinical Oncology 2004; Vol 22; Issue 24; pages 4893-900 che giunge alla conclusione che l’OTI non è di beneficio nei pz con radionecrosi della mandibola.
2. Feldmeier JJ, Heimbach RD, Davolt DA, Court WS, Stegmann BJ, Sheffield PJ. Hyperbaric oxygen as an adjunctive treatment for delayed radiation injury of the chest wall: a retrospective review of twenty-three cases. Undersea Hyperb Med 1995; 22:383-93
3. Feldmeier JJ, Heimbach RD, Davolt DA, Court WS, Stegmann BJ, Sheffield PJ. Hyperbaric oxygen an adjunctive treatment for delayed radiation injuries of the abdomen and pelvis. Undersea Hyperb Med 1996; 23:205-13
4. Feldmeier JJ. Hyperbaric oxygen for delayed radiation injuries. Undersea Hyperb Med 2004; 31:133-45
5. Mayer R, Klemen H, Quehenberger F, et al. Hyperbaric oxygen–an effective tool to treat radiation morbidity in prostate cancer. Radiother Oncol 2001; 61:151-6