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A 75-year-old Asian man presented with Notani Grade 3 osteoradionecrosis of the right mandible with an orocutaneous fistula. He underwent ablative resection with fibular free flap and pectoralis major myocutaneous flap reconstruction. Unfortunately, the neck wound dehisced with purulent discharge from the mandible. Initial management involved antibiotic therapy, debridement, and wound dressings. Further breakdown ensued, exposing the bone and mandibular reconstruction plate (Fig. 1). We debrided the wound, sectioned the exposed plate at the wound edges, and covered with an Integra® dermal regeneration template and a sponge bolster dressing, which was unsuccessful.
Given these setbacks, a novel treatment alternative NATROX® (Inotec AMD), a device for the delivery of topical oxygen, was sought. NATROX® consists of a portable oxygen generator (rechargeable, battery-operated) and an oxygen delivery system (single-use ‘web’ device). We drilled small holes into the exposed bone and secured the delivery web onto the wound with adhesive tapes (Fig. 2). An Aquacel® (Convatec Inc) dressing covered the web to absorb exudate, with a protective dressing on top. The dressing and single-use web were renewed twice weekly in the first month, then once weekly for four months. Though the COVID-19 lockdown restricted his appointments, the patient changed the dressings at home without additional training or adverse effects. After six weeks, we noted partial coverage of the defect (Fig. 3) with substantial coverage of the bone and reconstruction plate after five months (Fig. 4).
Fig. 2NATROX® secured to the wound bed with adhesive tapes.
Managing wound breakdown is difficult and prolonged in patients with a history of radiotherapy. Radiation therapy depletes growth factors and damages microvasculature at its target, leading to poor healing.
Management strategies such as dressings, skin grafts, pedicled and free flaps, platelet-derived growth factor, dermal regeneration templates, and hyperbaric oxygen therapy, have been used with varying success.
NATROX® delivers 98% humidified oxygen to wounds at 13 ml/hour (£300-£500 per 12-week treatment at the time of writing) and has been used successfully to manage chronic diabetic foot ulcers where it has been shown to outperform standard dressings.
Oxygen plays many key roles in wound repair: it facilitates collagen deposition by driving collagen synthesis, inhibits infection by catalysing reactive oxygen species production, and encourages angiogenesis by increasing vascular endothelial growth factor (VEGF) expression.
While hyperbaric oxygen therapy is used, famously, topical oxygen therapy is a newer method for treating chronic wounds in which oxygen is delivered locally without patients needing to sit inside a chamber. This reduces the risk of oxygen toxicity, barotrauma, and ocular disturbances. As topical oxygen therapy is not reliant on local microvasculature, its use on irradiated wounds could prove promising.
Based on our literature review (PubMed, Medline, EMBASE) this is the first paper to our knowledge to present the use of NATROX® in the head and neck region. A recent case series highlighted successful management of early mandibular osteoradionecrosis using topical ozone gel.
We recognise the limitation of a single report, but research is sparse and our success with NATROX® highlights scope for further studies on this simple cost-effective therapy for challenging wounds in the head and neck.
Conflict of interest
We have no conflicts of interest.
Ethics statement/confirmation of patients’ permission
Ethics approval was not required. Patients’ permission was obtained.
Acknowledgements
We thank Mr Guy Robinson, Library Manager at Royal Free London NHS Foundation Trust for his assistance.
References
Jacobson L.K.
Johnson M.B.
Dedhia R.D.
et al.
Impaired wound healing after radiation therapy: a systematic review of pathogenesis and treatment.
NATROX oxygen wound therapy for managing diabetic foot ulcers and complex or chronic non-healing wounds (MIB208).
2020 (Available from URL: NATROX oxygen wound therapy for managing diabetic foot ulcers and complex or chronic non-healing wounds (nice.org.uk) (last accessed 27 April 2021))
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