Improvement in mortality with hyperbaric oxygen therapy in cervical necrotising fasciitis: a systematic review of the literature

Background: Cervical necrotising fasciitis (CNF) is a rapidly progressive soft tissue infection with poor prognosis and high mortality. The mainstay of treatment is early debridement and broad-spectrum antibiotics, however the role of hyperbaric oxygen therapy (HBOT) as an adjuvant treatment is debated. We performed a systematic review of the literature encompassing all patients with CNF who underwent HBOT. review the use of HBOT in patients diagnosed with CNF to provide novel descriptive data and to review the overall influence this has on prognosis. Methods: A systematic review was conducted of all patients with CNF in the available literature from 1974 until 2022. A literature search was conducted of the PubMed, Medline and Embase databases to identify all published cases of CNF. All publications including the use of HBOT were reviewed and this data was collected. Non-English articles, paediatric (<18 years) cases, articles with no original data and irrelevant articles were excluded. Articles were reviewed by two reviewers and assessed for bias using the Joanna Briggs Institute checklist standardised tool developed for case reports and series. Data was electronically collated using Microsoft Excel (Microsoft Corp, 2018, Redmond, Washington) and statistically assessed using STATA 2017 (StataCorp. 2021. Stata Statistical Software: Release 17. College Station, TX: StataCorp LLC.) Results: A total of 161 patients from 28 articles were included. Primary infections in this subgroup were most commonly odontogenic (57.1%) and the most prominent infectious agent was streptococcus (76%). There was a total of 0.64 complications per patient and the overall mortality rate of patients was 7.5%. Conclusions: HBOT may be a useful adjunct to urgent surgical debridement and antibiotic therapy in patients with CNF. Through our systematic review of the literature, we have collated information on the epidemiology, aetiology, diagnosis, management, and outcome factors in these patients. The mortality rate of 7.5% in HBOT patients is lower than the previously published rate of CNF in a comparative systematic review by Gunaratne et. al in 2018. A randomised control trial regarding HBOT in CNF has not been historically feasible and there is variability regarding the diagnostic criteria used to diagnose CNF in the literature, which may increase the risk of bias within our study. Further research is required to identify the true value of HBOT in CNF.