Cervical necrotizing fasciitis with mediastinitis: a rare occurrence in the pediatric age

Cervicofacial cellulitis: The impact of non-steroidal anti-inflammatory drugs. A study of 70 cases

INTRODUCTION

Cervicofacial cellulitis (CFC) is a severe infection of the subcutaneous cellular tissue, and is one of the most serious head and neck infectious emergencies. In a series of 70 cases treated between 2007 and 2012, we noticed a strong correlation between use of non-steroidal anti-inflammatory drugs (NSAIDs) and evolution of head and neck infections toward CFC, including two cases of necrotic CFC extending to the mediastinum, which were fatal.

MATERIAL AND METHODS

The cases included in the series comprised patients admitted to emergency and requiring hospitalization due to the severity of presenting symptoms. There were 70 such cases of CFC between 2007 and 2012; cases managed on an outpatient basis were excluded, as were cases of orbital CFC, CFC of sinus origin and mastoiditis.

RESULTS

Eighty percent of patients took NSAIDs, on self-medication or by prescription (community physician, dentist, pharmacist). The most frequent molecules were tiaprofenic acid and diclofenac. CFC extension was restricted in most cases to the maxillary and/or ipsilateral subhyoid region, with 5 cases of lower cervical extension and 2 of mediastinal involvement, which both proved fatal.

CONCLUSION

CFC is a severe infection that can be life-threatening, and represents a diagnostic and therapeutic emergency. Among other risk factors, use of NSAIDs is frequently reported; these should therefore be used with caution if at all in head and neck infection, especially of odonto-stomatological origin.

Techniques for early diagnosis and management of cervicofacial necrotising fasciitis

BACKGROUND

Cervicofacial necrotising fasciitis carries high rates of morbidity and mortality, and is not often initially suspected due to its rarity and misleadingly innocuous presentation. We propose an algorithm for the timely diagnosis and management of cervicofacial necrotising fasciitis.

METHODS

Retrospective review of seven patients ultimately diagnosed with cervicofacial necrotising fasciitis.

RESULTS

In these seven patients, common presenting symptoms included sore throat, fever and neck pain. On initial examination and imaging, only three had obvious findings. One patient's diagnosis was facilitated via a bedside cut-down procedure. Six patients underwent surgical debridement. Four required tracheotomy, and five wounds closed via secondary intention. There were two deaths.

CONCLUSION

The severity of cervical necrotising fasciitis and its rapid spread necessitate early diagnosis and timely surgical management. The presentation often appears benign. A high index of clinical suspicion should be maintained in cases of neck cellulitis with nonspecific clinical findings, especially in diabetic or otherwise immunocompromised patients. A normal computed tomography scan does not rule out necrotising fasciitis. A cut-down procedure may be critical to early diagnosis in some cases.

Craniocervical necrotising fasciitis--an interesting case with review of the literature

Craniocervical necrotising fasciitis (CCNF) is an aggressive and potentially fatal infection associated with high morbidity and mortality if early intervention is not implemented. Patients are often unwell at presentation, the clinical picture is often unclear thus presenting with diagnostic difficulty. We report a case of CCNF presenting at an advanced stage and discuss the condition including its management and associated complications.

Does diclofenac increase the risk of cervical necrotizing fasciitis in a rat model?

Non-steroidal anti-inflammatory drugs (NSAIDs) are known for aggravating in vitro infections and were reported in many cases of cervical necrotizing fasciitis (CNF). We developed a rat model of CNF, mimicking as closely as possible the human-CNF, to study the effect of a NSAIDs, diclofenac, as a promoting factor. Twenty rats were injected bilaterally in the neck with peptostreptococcus and with a fresh saliva specimen for another 20 rats. Half of each group was given an intramuscular injection of 4 mg/kg diclofenac at the time of inoculation and 24 h later, and the other half saline injections; rats were killed at day 7 and clinical, bacterial and histological studies were performed to assess the infectious process and the incidence of CNF. No statistically significant difference was found between groups treated with diclofenac vs. the saline injection groups. However a significant correlation was noted between clinical observation, bacterial density and histological signs of inflammation. CNF has a high mortality rate and the use of NSAIDs in conditions potentially leading to CNF is very common. However, our rat model does not support the hypothesis of a promoting role of diclofenac which was occasionally suggested in the medical literature. This study suggests that diclofenac does not seem to increase the risk of occurrence of CNF. Nonetheless, NSAIDs can mask inflammatory signs of an already spreading CNF.

Necrotizing fasciitis in children: diagnostic and therapeutic aspects

BACKGROUND

Necrotizing fasciitis (NF) is a severe life-threatening soft tissue infection characterized by rapidly spreading necrosis of the fascia and the subcutaneous tissue. Its incidence owing to invasive Streptococcus pyogenes has significantly increased in children recently. Our experience with NF in children to describe diagnostic and therapeutic aspects is hence presented herein.

METHODS

Records of children who were treated for NF in our unit from 1999 to 2006, inclusive, were reviewed retrospectively. Information recorded for each patient included medical history, clinical characteristics, diagnostic procedures, treatment methods, and the outcome.

RESULTS

Thirteen patients with a mean age of 35 months were treated for NF during the study period. All of the 13 children had no previous immunosuppression. The predisposing factors were composed of varicella lesions, intramuscular injections, application of a cream containing menthol to the cervical region, penetrant gluteal trauma, omphalitis, dental abscess, and streptococcal toxic shock syndrome. The most common site of the initial involvement was the abdominal wall, followed by the gluteal region and thigh, head and neck, and upper and lower extremities. The initial skin presentations were induration or cellulitis and erythema and edema with progression to skin discoloration and bullae formation. Fever and tachycardia were the most common clinical features. S. pyogenes was the most common causative microorganism, followed by Staphylococcus epidermidis and Pseudomonas aeruginosa. All patients underwent extensive surgical debridement and received appropriate antibiotics and supportive therapy. Twelve patients survived, and 1 patient with delayed diagnosis of NF died of septic shock.

CONCLUSION

Although these infections are rare in children, their lethal potential and early diagnostic signs must be recognized. All children with NF should undergo early surgical debridement to prevent delay in treatment. The mortality and morbidity associated with NF in children can be decreased with clinical awareness, early diagnosis, and adequate and urgent surgical debridement followed by intensive supportive care and early wound resurfacing.