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Osteomyelitis (Refractory and including malignant otitis externa)

This is defined by the UHMS as osteomyelitis that persists or recurs after appropriate interventions have been performed or where acute osteomyelitis has not responded to accepted management techniqures. It also includes individuals who have failed to respond to definitive surgical debridement (if possible) and four to six weeks of appropriate antibiotic therapy. Those with malignant otitis externa fall within this category.

The rationale for using HBO starts on the basis that the oxygen tension within osteomyelitic bone often drops as shown by Mader and Ninikoski. Esterhai confirmed that HBO will increase the PO2 within rabbit tibia to above that required for leukocyte oxidative killing. Further to this Mader’s study showed directly increased phagocytic activity at higher oxygen concentrations.

HBO has also been shown to improve penetration of certain anti-biotics into tissues due to oxygen dependent mechanisms. In particular, it is helpful for aminoglycosides and cephalosporoins (Mendel (1999).

There is evidence that HBO enhances osteogenesis by improving osteoclast function. Ueng showed bone healing to be superior with the use of HBO in animal studies.

Finally, the same principles of wound healing and evidence (as discussed on our Problem Wound healing page) does have some relevance in this cohort. Many individuals will have an overlying wound and are often diabetic.

Of note, Tisch showed a significant improvement in patients with Malignant Otitis Externa where 21 out of 22 patient with anti-biotic referactory MOE were cured after HBOT.

Individuals felt to be most suitable are those who have failed with conventional treatment and /or have a Cierny-Madar stage 3B or 4B. Those with high risk, such as spinal, skull or sternal osteomyelitis, are likely to be considered at a lower stage.

Treatment entails 20-40 HBOT daily session over 4-8 weeks. Response is considered and this is as an adjunct to gold standard treatment.

To refer a patient, please follow this link.

For more information on the patient experience please follow this link.


Hyperbaric Oxygen Therapy Indications (2014)

Lindell K, Weaver MD Editors

Undersea and Hyperbaric Medical Society

13th Edition

2014 :P113-138

Esterhai (1986)

Esterhai JL Jr et al.

Effect of hyperbaric oxygen exposure on oxygen tension within the medullary canal in the rabbit tibial osteomyelitis model.

J Orthop Res

1986; 4(3):330-336

Niinikoski (1972)

Ninnikoski J, Hunt TK

Oxygen Tensions in healing bone

Surg Gynaecol Obstet


Mader (1980)

Mader JT, Brown GL, Guckian JC et al.

Amechanism for the amelioration by hyperbaric oxygen of experimental staphylococcal osteomyelitis in rabbits.

J Infect Dis


Mendel (1999)

Mendel V et al

Therapy with hyperbaric oxygen and cefazolin for experimental osteomyelitis due to Staphlococcus aureus in rats

Undersea Hyperbar Med


Strauss (1987)

Straus MB

“Refractory Osteomyelitis”

J Hyperbaric Med


Tisch (2006)

Tisch M, Maier H

Malignant external otitis.

2006; 85(10):763-769;quiz770-773

Ueng (1998)

Ueng SW et al

Bone healing of tibial lengthening is enhanced by hyperbaric oxygen therapy: a study of bone mineral and torsional strength on rabbits.

J Trauma

1998; 44(4):676-681


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