Hyperbaric Oxygen as Adjunctive Therapeutic in Management of Craniocervical Necrotizing Fasciitis: Case Series and Treatment Protocol

Abstract Background Odontogenic infections are commonly encountered in OMS practices. Rarely, odontogenic infections can progress into craniocervical necrotizing fasciitis (CCNF). CCNF of the head and neck is a rare, potentially lethal disease process involving infection and subsequent destruction of fascial planes. Mortality ranges from 33% to 50% if the mediastinum is involved.1,2 CCNF diagnosis is based on clinical suspicion. Typical findings include dishwater-like purulence and easy spread of fascial planes using fingers.3 Treatment for CCNF usually consists of aggressive surgical debridement, source control, and intravenous antibiotics. Patients often experience prolonged hospital stays, around 24-33 days1,2 and require 2-5 debridements.1 Hyperbaric oxygen (HBO) has shown promising results as an adjunctive therapy in management. The authors' study reviewed their institution's protocols for CCNF of odontogenic origin and use of HBO in their treatment. Methods Patients with deep neck fascial space infections of odontogenic origin at Hennepin County Medical Center (HCMC) were included. Inclusion criteria were odontogenic infections involving fascial spaces with a high degree of concern for CCNF based on clinical and radiographic presentation at the time of treatment and/or confirmed CCNF. Exclusion criteria were patients with deep fascial space infections of non-odontogenic source and those who did not receive HBO. Five patients were identified. Data, such as age, gender, length of hospital stay (LOS), intervention by outside providers, hierarchical condition category (HCC), and bacteria species, were recorded for each patient. Descriptive statistics were used to summarize quantitative variables. Results From 2016 to 2020, 5 patients were identified who had odontogenic infections, with high concern for necrotizing fasciitis based on clinical presentation for CCNF. There were 3 females and 2 males, with an average age of 44.6+/-8.65 years. The mean number of washouts/debridement procedures was 4.4+/-1.25. Patients required on average 3.4+/-0.87 HBO dives. The mean LOS was 18.8+/-6.37 days. Three patients underwent care by an outside provider prior to admission to the hospital, while 2 sought care at an urgent care or emergency department. The HCC for these patients ranged from 0 to 3. All patients grew milleri group streptococcus; 3 patients grew Candida species. No mortalities were recorded. Discussion This protocol involved initiating HBO dives within 24 hours of suspected or confirmed CCNF, followed by subsequent daily surgical debridements and HBO sessions. The HBO dives were at 2.8 ATA for 45 minutes followed by staged decompression for a total of 90 minutes. This protocol resulted in shorter LOS. In 1994, a comparative study with a comparable population was completed at this institution, in which HBO was not used for suspected CCNF. This study showed 2.8 average surgical debridements and LOS of 34 days, compared to 18.8+/-6.37 days in the authors' study.4 The increased number of surgical debridements in the authors' series theoretically decreased the bacterial burden, compared to the previous series. HBO theoretically reduced the bacterial burden, improved immune response, and spurred healing. HBO may reduce LOS for CCNF patients and should be considered as adjunctive therapy.