Cervical Necrotizing Fasciitis With Descending Mediastinitis: Literature Review and Case Report

C-reactive protein and neutrophil-to-lymphocyte ratio as key inflammatory indicators in the diagnosis of cervical necrotizing fasciitis

BACKGROUND

Cervical necrotizing fasciitis (CNF) is a life-threatening bacterial infection with a diagnostic challenge. Currently, there is insufficient evidence on the diagnostic accuracy of inflammatory indicators in CNF.

OBJECTIVE

This study aims to identify key inflammatory indicators and assess their diagnostic accuracy for CNF.

METHODS

A diagnostic case-control study was conducted at a tertiary healthcare facility from January 2020 to December 2023. Laboratory data from patients with CNF and non-CNF at admission were evaluated. Key inflammatory indicators were identified through consistent outcomes from multivariable logistic regression and receiver operating characteristic curves analyses. The diagnostic accuracy of these indicators, with the results of combined tests, were calculated.

RESULTS

CNF was confirmed in 21 of the 67 patients investigated. C-reactive protein (CRP) and neutrophil-to-lymphocyte ratio (NLR) were identified as key inflammatory indicators, with sensitivities of 0.905 and 0.810, and specificities of 0.870 and 0.913, respectively, at CRP threshold of 165.0 mg/L and NLR of 15.8. Combining CRP and NLR in parallel and serial tests increased sensitivity to 0.952 and specificity to 1.0, respectively.

CONCLUSIONS AND SIGNIFICANCE

CRP and NLR have been verified as key inflammatory indicators with satisfactory diagnostic abilities for CNF diagnosis, providing a strong foundation for future studies.

Incidence of Mortality and Its Relation to Comorbidity in Ludwig's Angina: A Retrospective Study

Introduction

Ludwig's angina is a serious life-threatening infective condition of maxillofacial region due to odontogenic origin which is clinically diagnosed by its clinical signs and symptoms. Airway management and early surgical decompression is the main stay of management. The mortality rates in Ludwig's angina remains multivariate. There is a paucity in literature regarding the mortality rates of this disease.

Aim and Objectives

Aim of this retrospective study is to describes the characteristics, probable cause of death and mortality rates of patients with co-morbidities presenting to the emergency department (ED) who were subsequently admitted with a primary diagnosis of Ludwig's angina.

Materials and Method

Study was conducted in the department of maxillofacial surgery in a tertiary care teaching hospital from Jan 2011 to Dec 2022. Data of 17 patients who were clinically diagnosed as Ludwig's angina were included in the study. The comorbidity, source of odontongenic cause, mode of intubation and the outcome of the disease were evaluated.

Result

Comparison of categorical variables was done using Fishers exact test. A p-value of <0.7 was considered statistically significant. The results suggested that Out of 17 patients 12 patients (70.5%), 7 male and 5 females had comorbidities and four cases (23.5%) had complication of death, all having co-morbidities.

Summary

It concludes that associated comorbidity has a significant role in progress and outcome of the disease and incidence of death is more common in cases having associated comorbidity.

Demographic, clinical, and paraclinical features of patients operated with the diagnosis of acute descending necrotizing mediastinitis: a retrospective study in Southern Iran

INTRODUCTION

Descending necrotizing mediastinitis (DNM) is a type of acute mediastinitis that is rarely reported but is regarded as a fatal disease despite improvements in technological methods and antibiotic therapies. We aimed to determine the demographic, clinical, and paraclinical features of patients diagnosed with acute DNM.

METHODS

In this retrospective study, patients' hospital records with a diagnosis of DNM admitted to the Namazi hospital in southern Iran during 18 years (2002-2019) were reviewed. Demographic and clinical features were recorded and subsequently analyzed via SPSS 22.

RESULTS

Out of 67 mediastinitis patients, 25 (37.3%) were diagnosed as DNM with an average age of 37.2 ± 16.7 years, and 68% were male. Regarding etiology, 52.0% were due to neck infection. Based on the technique of surgery, 52% of the patients underwent the combined method, which was mostly among type I and IIA DNM, while thoracotomy was mostly performed on type IIB DNM (P = 0.08). Based on the incision, type IIA and IIB had the highest frequency of thoracotomy and cervicothoracic incisions (P = 0.02 and 0.002). Puss discharge was significantly lower in type I DNM (P = 0.01). Based on the presenting symptoms of our patients, the majority (72.0%) had a chief complaint of neck pain, followed by chills and fever (48%). There were no reports of mortality during our short-term follow-up.

CONCLUSION

We report one of the largest retrospective studies of DNM patients in our referral center, with a high prevalence of the disease among younger populations, especially under 40 years. The method of treatment should be chosen based on the extent of infection and can be limited to neck exploration in upper mediastinal infections, though thoracic or combined approach in more broad infections.

Head and Neck Necrotizing Fasciitis: Abbreviated SOFA Score Associated With Death and Infection Spread

Objective

Describe features unique to head and neck (H&N) necrotizing fasciitis (NF) compared to other anatomic regions and specify a prognostic score associated with death and descending necrotizing mediastinitis (DNM).

Study Design

Retrospective cohort.

Setting

Tertiary care, level 1 trauma center.

Methods

A single-institution database identified 399 confirmed cases of NF between 2006 and 2021, 33 of which involved the H&N. Patients with confirmed H&N NF were sorted into cohorts based on clinical outcomes, with the "poor" outcomes group defined by death and/or DNM.

Results

Thirty-three patients with H&N NF were included. Compared to NF of other regions, patients with H&N NF had a significantly lower mortality rate (6.06% vs 20.8%, p = .041) and significantly lower rates of obesity (27.3% vs 63.7%, p < .001) and hypertension (42.4% vs 60.9%, p = .038). Within the H&N group, there were 2 deaths (6.06%) and 8 cases of DNM (24.2%). Diabetes was associated with poor outcomes (p = .047), as was an abbreviated sequential organ failure assessment score for necrotizing fasciitis (nfSOFA) of 2 or greater (p = .015).

Conclusion

H&N NF is unique among other forms of NF, with a lower mortality rate and lower rates of obesity and hypertension in affected patients. Within the H&N cohort, worse outcomes were associated with diabetes as well as a nfSOFA score of 2 or greater. Timely surgical debridement alongside broad-spectrum antibiotics remains the mainstay of treatment for NF; however, this simple prognostic score may play a role during the early stages of care for patients with H&N NF.

A global science mapping analysis on odontogenic infections

OBJECTIVES

Odontogenic infections are common and a topic of core interest for dentists, and maxillofacial surgeons. The aim of this study was to conduct a bibliometric analysis of the global literature on odontogenic infection and explore the top 100 most cited papers to identify the common causes, sequelae and management trends.

METHODS

Following a comprehensive literature search, a list of top 100 most cited papers was created. The VOSviewer software (Leiden University, The Netherlands) was used to create a graphical representation of the data, and statistical analyses were performed to analyze the characteristics of the top 100 most cited papers.

RESULTS

A total of 1,661 articles were retrieved with the first article published in 1947. There is an exponential upward trend on the number of publications (R2 = 0.919) and a majority of papers are in English language (n = 1,577, 94.94%). A total of 22,041 citations were found with a mean of 13.27 per article. The highest number of publications were recorded from developed countries. There was a male predilection in the reported cases and the most common sites included the submandibular and parapharyngeal spaces. Diabetes mellitus was identified as the commonest co-morbidity. Surgical drainage was ascertained to be the preferred method of management.

CONCLUSIONS

Odontogenic infections remain prevalent and have a global distribution. Although prevention of odontogenic infection through meticulous dental care is ideal, early diagnosis and prompt management of established odontogenic infections is important to avoid morbidities and mortality. Surgical drainage is the most effective management strategy. There is lack of consensus regarding the role of antibiotics in the management of odontogenic infections.

Descending necrotizing mediastinitis: etiopathogenesis, diagnosis, treatment and long-term consequences-a retrospective follow-up study

PURPOSE

The primary aim of this retrospective study was to analyze the progression of descending necrotizing mediastinitis (DNM), evaluate the impact of comorbidities on complications and mortality and to observe long-term consequences of DNM on dysphagia and measurements quality of life. DNM is a serious infectious disease that requires multimodal treatment. Current literature varies in conclusions of risk factors, management and outcome of DNM. In addition, little is known about persisting effects on quality of life.

METHODS

Retrospective data analysis of 88 patients with DNM representing the largest single-center study. Recording data of patients and diseases as well as clinical progression from 1997 to 2018. Two questionnaires were sent to the participants to measure quality of life and to detect dysphagia.

RESULTS

88 patients were included. The most frequently found pathogen were Streptococcus spp. (52%). 75% of the patients underwent multiple surgeries, mean count of surgical procedures was 4.3 times. 84% received intensive care treatment. Median length of stay on the intensive care unit was 7 days. 51% had pre-existing comorbidities associated with reduced tissue oxygenation (e.g., diabetes). The most common complication was pleural effusion (45%). During the observation period, the mortality rate was 9%. 12 questionnaires could be evaluated. 67% of the participants were affected by dysphagia at the time of the survey.

CONCLUSIONS

Descending necrotizing mediastinitis (DNM) is a severe disease requiring an immediate initiation of multimodal treatment. Although quality of life usually isn´t impaired permanently, dysphagia may often persist in patients after DNM.

Eight Tales of Cervical Necrotizing Fasciitis and Free Tissue Transfer

OBJECTIVES

Aggressive surgical debridement is required in cervical necrotizing fasciitis, and in severe defects, subsequent free tissue transfer might be necessary. However, there is concern that the inflammatory environment of the infection site may threaten free flap viability, particularly with concerns for thrombosis of feeding vessels and compromised tissue integration. Cases in the head and neck area are rare, so there are limited data regarding outcomes of free tissue transfer in these patients.

METHODS

A retrospective chart review assessed patients with cervical necrotizing fasciitis treated at an academic tertiary hospital between 2015 and 2021. Twenty-five patients were identified, and eight required free tissue transfer after adequate surgical debridement. Treatment, hospital course, and demographic data were collected on these eight patients.

RESULTS

All flaps had full survival at follow up (median follow up 3 months, range 1-39 months) without concerns for vascular compromise.

CONCLUSION

These data suggest that in patients with large soft tissue defects due to cervical necrotizing fasciitis, free tissue transfer may be a safe treatment modality.

Surgical Experience with Descending Necrotizing Mediastinitis: A Retrospective Analysis at a Single Center

Background

We analyzed our experience with descending necrotizing mediastinitis (DNM) treatment and investigated the efficacy of video-assisted thoracoscopic surgery (VATS) for mediastinal drainage.

Methods

This retrospective analysis included patients who underwent surgical drainage for DNM at our hospital from 2005 to 2020. We analyzed patients' baseline characteristics, surgical data, and perioperative outcomes and compared them according to the mediastinal drainage approach among patients with type II DNM.

Results

Twenty-five patients (male-to-female ratio, 18:7) with a mean age of 54.0±12.9 years were enrolled in this study. The most common infection sources were pharyngeal infections (60%). Most patients had significantly increased white blood cell counts, elevated C-reactive protein levels, and decreased albumin levels on admission. The most common DNM type was type IIB (n=16, 64%), while 5 and 4 patients had types I and IIA, respectively. For mediastinal drainage, the transcervical approach was used in 15 patients and the transthoracic approach (VATS) in 10 patients. The mean length of hospital stay was 26.5±23.8 days, and the postoperative morbidity and in-hospital mortality rates were 24% and 12%, respectively. No statistically significant differences were found among patients with type II DNM between the transcervical and VATS groups. However, the VATS group showed shorter mean antibiotic therapy duration, drainage duration, and hospital stay length than the transcervical group.

Conclusion

DNM manifested as severe infection requiring long-term inpatient treatment, with a mortality rate of 12%. Thus, active treatment with a multidisciplinary approach is crucial, and mediastinal drainage using VATS is considered relatively safe and effective.

Evaluation of clinical parameters affecting the prognosis in surgically treated patients with descending necrotizing mediastinitis - A retrospective study

OBJECTIVES

Descending necrotizing mediastinitis (DNM) is the most serious complication of maxillofacial infections followed with high mortality. The objective of this retrospective study was to evaluate possible prognostic clinical factors for survival of patients with DNM based on single center clinical data.

METHODS

The study enrolled patients admitted to the Emergency Center of Vojvodina with the diagnosis of DNM either as the primary diagnosis or with discharged diagnosis after surgical treatment during 11-years period. The data were obtained from patient medical records.

RESULTS

After final analysis total of 28 charts were randomized for statystical analysis, 19 charts in survivors and 9 in non-survivors group. The most common cause of infection in survivors group was odontogenic and in non-survivors group pharyngeal infection. On multivariate regression analysis of collected data results of control computed tomography, preoperative Endo status, early postoperative C-reactive protein (CRP) and procalcitonine (PCT) values and postoperative complications were statistically significant predictors for mortality.

CONCLUSIONS

Based on results of this study, extent of infection in the mediastinum based on Endo's criteria, progression of infection on control cervicothoracic CT, increase of CRP and PCT values in immediate postoperative period and presence of postoperative complications and septic shock provide poor prognosis for patients with DNM.

Risk Factors Associated with Post-Operative Complications in Multidisciplinary Treatment of Descending Necrotizing Mediastinitis

BACKGROUND

Descending necrotizing mediastinitis (DNM) is a severe, life-threatening complication of oropharyngeal infections with cervical necrotizing fasciitis. In this study, we aimed to identify any possible factors that correlate with favorable outcomes.

METHODS

We retrospectively analyzed our series of 18 patients who underwent surgical treatment for DNM from a cervical abscess. Gender, age, symptoms, etiopathogenesis, comorbidities, time to surgery from diagnosis, degree of diffusion, identified microorganisms, surgical procedure, days in the intensive care unit, need for tracheostomy, complications, and surgical outcomes were reviewed.

RESULTS

The main type of surgery was thoracotomy + cervicotomy in eight cases (50.0%), followed by cervicotomy +VATS in four (22.2%). Seven patients (38.9%) had two or more surgeries; a bilateral operation was necessary for four patients. Evaluating the risk factors associated with post-operative complications, age ≥ 60 years (p:0.031), cervicotomy alone as surgical approach (p = 0.040), and the bilateral approach (p = 0.048) resulted in significance in terms of the univariate analysis; age ≥ 60 years (p = 0.04) and cervical approach (p = 0.05) maintained their significance in terms of the multivariate analysis.

CONCLUSIONS

The low mortality of our series emphasizes the importance of an extensive and immediate surgical drainage of both the neck and the mediastinum. Mediastinal drainage from cervicotomy seems to be a risk factor for post-operative complications. Minimally invasive surgery on the chest cavity, such as with Uniportal-VATS, could be a good approach above all in elderly patients and all those cases where bilateral access is required.

Application of the laboratory risk indicator for necrotizing fasciitis score to the head and neck: a systematic review and meta-analysis

BACKGROUND

Recent studies have attempted to verify the predictive capability of the Laboratory Risk Indicator for Necrotizing Fasciitis (LRINEC) for cervical necrotizing fasciitis (CNF).

METHODS

The two authors independently reviewed six databases (PubMed, Cochrane, Embase, Web of Science, SCOPUS and Google Scholar databases were searched). Seven cohort studies were included in the analysis. Sensitivity and specificity were determined by extracting items from binary classification from each paper. The diagnostic accuracy of the included studies was evaluated using QUADAS ver. 2.

RESULTS

The diagnostic odds ratio (OR) of LRINEC for CNF with the cutoff value of 6 was 13.9952 (95% CI, 3.8537; 50.8255, I²  = 76.7%). The area under the SROC curve was 0.842, suggesting acceptable diagnostic accuracy. The correlation between sensitivity and false positive rate was 0.055, indicating that it was not heterogeneous. The sensitivity, specificity, and negative predictive values were 0.7503 ([0.4637; 0.9126], I²  = 79.1%), 0.8455 ([0.7084; 0.9250], I²  = 96.0%) and 0.9829 ([0.9089; 0.9970], I²  = 93.7%), respectively. In the comparison of subgroups according to a LRINEC score (6-8, and), the cutoff value of 6 showed moderate sensitivity (75%) and high specificity (85%) and greater diagnostic power than other cutoff values.

CONCLUSIONS

LRINEC is a useful adjunctive tool for predicting CNF in patients with a soft tissue infection. In addition, a more accurate diagnosis is possible by using the LRINEC score with a cutoff value of 6.

The characteristics of oro-cervical necrotizing fasciitis-Comparison with severe cellulitis of oro-cervical region and necrotizing fasciitis of other body regions

Background

Necrotizing fasciitis (NF) is an acute and life-threatening soft-tissue infection however rarely seen in oro-cervical region. Therefore, the details of oro-cervical NF (OCNF) are not well known. The purpose of this study was to investigate the characteristics of OCNF by comparing it with severe cellulitis of oro-cervical region (OCSC) or NF of other body regions (e.g., limb, perineum, and trunk) (BNF), respectively.

Materials and methods

At first, various risk factors for OCNF in oro-cervical severe infection (OCSI; composed of OCNF and OCSC), including neutrophil-to-lymphocyte ratio (NLR) and Laboratory Risk Indicator for Necrotizing Fasciitis (LRINEC) score, were investigated by univariate and multivariate analyses. Next, the differences between OCNF and BNF, including inflammatory markers and mortality, were investigated.

Results

In the present study, 14 out of 231 OCSI patients had OCNF. Multivariate analyses of OCSI patients showed that NLR ≥15.3 and LRINEC score ≥6 points were significantly related to OCNF. During the same period, 17 patients had BNF. The OCNF group had significantly higher inflammatory markers than the BNF group when diagnosis, but significantly lower clinical stages at the time and mortality as outcomes.

Conclusion

We found that compared to BNF, OCNF can be detected at lower clinical stage by using indexes, such as NLR and LRINEC score, besides clinical findings, which may help contributing to patient’s relief.

Prognostic factors for descending necrotizing mediastinitis development in deep space neck infections-a retrospective study

OBJECTIVES

Descending necrotizing mediastinitis (DNM) is the most serious complication of deep neck infections (DNI). The objective of this retrospective study was to evaluate prognostic factors for DNM development in deep space neck infections.

METHODS

The study enrolled patients admitted to the Emergency Center of Vojvodina with the diagnosis of multispace DNI with or without DNM either as the primary diagnosis or with discharged diagnosis after surgical treatment during 7-year period. The data were obtained from patient medical records.

RESULTS

After final analysis total of 141 charts were randomized for statystical analysis, 124 charts in DNI and 17 in DNI + DNM groups. The most common cause of infection in both groups was odontogenic. On multivariate regression analysis of collected data infection of retropharyngeal, pretracheal and carotid space, C-reactive protein and procalcitonine values were statistically significant predictors for DNM development.

CONCLUSIONS

Treatment and diagnosis of DNM requires multidisciplinary approach, with prompt clinical and radiological examinations, empirical broad spectrum antibiotic therapy and radical surgical debridement. Multispace neck infection and especially infection of retropharyngeal, carotid and pretracheal spaces are the most sensitive predictors for DNM development in deep space neck infections.

CLINICAL RELEVANCE

If the infection from deep neck spaces reach retropharyngeal, carotid or pretracheal space, the DNM is probable to occur.

TRIAL REGISTRATION

ClinicalTrials.gov ID NCT04865003. Date of registration 27.4.2021.

Detection of aerobe-anaerobe mixed infection by metagenomic next-generation sequencing in an adult suffering from descending necrotizing mediastinitis

BACKGROUND

Descending necrotizing mediastinitis (DNM) is one of the most virulent forms of mediastinitis. The main causes of high mortality in DNM are believed to stem from difficulty and delay in the diagnosis. Fast and accurate identification of pathogens is important for the treatment of these patients. Metagenomics next-generation sequencing (mNGS) is a powerful tool to identify all kinds of pathogens, especially for rare and complex infections.

CASE PRESENTATION

A 64-year-old male patient was admitted to the intensive care unit (ICU) with unconsciousness, dyspnea, and swelling in the mandible and neck. Computed tomography (CT) scan results combined with clinical laboratory examination indicated DNM. Vancomycin and imipenem were used, and vacuum sealing drainage was applied for debridement and drainage of the infected area. The positive mNGS results of drainage fluid confirmed the presence of mixed infection caused by Streptococcus anginosus, Prevotella oris, and several other anaerobes. The antibiotics were adjusted to piperacillin/tazobactam and tinidazole according to the mNGS results and antimicrobial susceptibility testing of cultured pathogens. After 11 days of antibiotic therapy, the infection symptoms of the neck and mediastinum improved, and the patient was transferred out of the ICU on the 26th day after negative result of drainage fluid culture.

CONCLUSION

This case suggested that mNGS is a promising technology for precise and fast pathogens identification with high sensitivity, which may guide the diagnosis of infectious diseases in the future trend.

New laboratory predictive tools in deep neck space infections

Introduction

Deep neck space infections (DNSIs) are a group of infective suppurative diseases involving deep neck spaces and cervical fascia. Necrotising and septic evolutions are rare, but severe complications can dramatically affect the prognosis and should be promptly managed. Clinical examination often has low sensitivity, although instrumental diagnosis may delay te treatment. We investigated two laboratory tools, LRINEC (Laboratory Risk Indicator for the Necrotizing fasciitis) and NLR (neutrophil to lymphocyte ratio), in the expectation to find a rapidly available predictive indicator that may help in distinguishing necrotising complications and/or systemic septic involvement.

Methods

A retrospective observational cohort study was performed on 118 patients who had underwent surgical treatment for DNSIs at our Surgical Unit. LRINEC, NLR and the product LRINEC x NLR were calculated.

Results

Statistical analysis showed that these scores may have utility in rapidly predicting the risk of necrotising fasciitis and systemic involvement at an early diagnostic stage.

Conclusions

Further studies with a larger cohort may be necessary in order to increase the sensitivity and specificity.

Comparison of death and survival cervical necrotizing fasciits cases

BACKGROUND

Cervical Necrotizing Fasciitis (CNF) is associated with a high mortality rate. The occurrence of mediastinitis with CNF may increase mortality up to 70%.

AIMS

We aimed to identify the differences between surviving and deceased cases.

METHODS

The present study was conducted retrospectively by scanning the files of 16 patients between the ages of 19-71 who were diagnosed with CNF. Patients were divided into two groups as the surviving patient group (SPG) and the deceased patient group (DPG). Both groups were compared in terms of age, gender, Laboratory Risk Indicator for Necrotizing Fasciitis (LRİNEC) score, duration of symptom onset to hospital admission, use of antibiotherapy prior to admission, duration of hospitalization, presence of diabetes mellitus (DM), presence of dental etiology, mediastinitis, and respiratory distress at the time of admission.

RESULTS

Diabetes mellitus was the most common comorbid disease. 5 out of 7 deceased patients had DM. Dental events were the most common etiology. Rapid surgical debridement and airway management was the first treatment method. The most frequently isolated species in the culture was Streptococcus. 6 of 11 patients who developed mediastinitis deceased at the end of the process.

CONCLUSION

Dental pathologies mostly play a role in the etiology. It is obvious that dentists, another occupational group that frequently encounters this patient group, have a critical role in this process. Therefore, precise attention should be given to dental problems in patients with diabetes, and hospitalization and initiation of broad-spectrum antibiotherapy should be considered in case of suspicion of deep neck infection.

Referral pattern of oral and maxillofacial surgery cases in Sudan: A retrospective age-and sex-specific analysis of 3,478 patients over four years

Oral and maxillofacial surgery (OMFS) is a specialty widening in its scope. An objective analysis of the referral pattern can provide essential information to improve healthcare. This four-year retrospective study was implemented in Khartoum Teaching Dental Hospital. Data (age, sex, diagnosis, and type of treatment) were collected from patient records. Disease frequency, as well as the effect of sex and age, were analyzed for each group. The frequency of treatment types was also assessed. Data were collected from a total of 3,478 patients over the four-year study period. There was a male predominance with the third decade of life being the most common age group. Pathological diseases were the most common (37%) reason for referral, followed by trauma (31%). Temporomandibular joint (TMJ) disorders and dentoalveolar extraction were the least frequently observed. Open reduction and internal fixation (ORIF) was the most commonly performed procedure (28%). These data represent the epidemiology of oral and maxillofacial diseases in Sudan. Given that the third decade of life is the most represented age group, it is beneficial to learn the long-term consequences of these diseases in these young patients and to use modern surgical techniques to improve their lives.

A new classification of descending necrotizing mediastinitis and surgical strategies

Background

Descending necrotizing mediastinitis (DNM) is an inflammation occurring in the oropharynx and descending to the deep cervical space and mediastinum, which is a serious infectious disease. The investigation of a new classification system and treatment methods for DNM is still necessary.

Methods

A total of 139 patients with DNM caused by odontogenic or pharyngeal infection were retrospectively analyzed in last 20 years in the Ninth People's Hospital Affiliated to Shanghai Jiao Tong University School of Medicine. The patients were divided into the traditional treatment Group T (Group T: 43 patients) and the new classification Group N (Group N: 96 patients). A new DNM classification was developed based on the progression of mediastinal infection as follows: type Ia: infection in the anterosuperior mediastinum; type I: infection in the anterior mediastinum; type II: infection in the posterior mediastinum; and type III: infection of the whole mediastinum.

Results

There were 49, 8, 10, and 29 patients classified as type Ia, I, II, and III, respectively in the Group N. The type Ia DNM patients were managed with transcervical mediastinal drainage, and the patients with types I and II DNM underwent open (thoracoscopic) surgery, 1 patient within types I died. The 29 patients with type III were managed with unilateral or bilateral open (thoracoscopic) surgery, among them, 8 patients died. The mortality rate for patients with type III DNM was 27.6%. The overall mortality rate in Group N was 9.4%. The mortality rate for patients in the Group T was 25.6%. The mortality rate of Group N was significantly lower than that of Group T (P<0.05).

Conclusions

We have carried out a new clinical classification of DNM, and selected the appropriate treatment method according to the classification, and achieved a better effect than the traditional treatment method.

Labio-facial Necrotizing Fasciitis in a Young Patient

ABSTRACT

Necrotizing fasciitis (NF) is an infection of the deeper tissues that results in progressive destruction of muscle fascia and overlying subcutaneous fat. It has a fast and destructive course. Moreover, it is related to immunosuppression and could be fatal. The aim of this study is to report a clinical case of a young patient, without immunosuppression, who developed NF evolution due to an erroneous diagnosis of abscess at the beginning of the disease. Patient was submitted to broad-spectrum antibiotic therapy and aggressive surgical treatment. Adequate treatment led to a satisfactory evolution in a short period of time. Early recognition and adequate treatment are essential for a favorable prognosis.

Management and postoperative use of double-cannula irrigation-drainage tube in cervical necrotizing fasciitis: a Chinese single-institution experience of 46 patients

PURPOSE

This study aimed to analyze a Chinese institution's experience with managing cervical necrotizing fasciitis (CNF) and observe the effects of a new therapeutic approach for postoperative drainage system.

METHODS

A retrospective study was established including a total of 46 CNF patients who underwent surgical debridement between April 2006 and April 2018. Analyses of demographic data, etiology, comorbidity, microbiology, complications, treatment methods, duration of treatment, and treatment outcomes were obtained.

RESULTS

There were 16 kinds of microbes cultured in 29 patients. Diabetic patients were more commonly infected by microbes (P < 0.05). There was a significant reduction in the number of operative time (P < 0.05) and length of hospitalization (P < 0.01) with postoperative therapy of double-cannula irrigation-drainage (DCID) system.

CONCLUSION

CNF management includes controlling for comorbidities especially glycemic control and reasonable utilization of antibiotics and aggressive postoperative therapy. DCID system can effectively reduce operative frequency and duration of hospitalization.

Successful Treatment with the Chin-down Maneuver of Dysphagia Secondary to Descending Necrotizing Mediastinitis: A Case Study

Background:

Descending necrotizing mediastinitis is a potentially fatal polymicrobial infection that often leads to dysphagia after treatment. Such dysphagia is likely the result of fibrosis and scarring from inflammatory changes in the fascial space. A case is presented in which the mechanism of dysphagia was verified using two-dimensional analysis of the muscle lengths of the suprahyoid and infrahyoid muscles.

Case:

A 57-year-old woman presented with a hyoid and laryngeal movement disorder with pharyngeal residue secondary to descending necrotizing mediastinitis. To treat this disorder, the chin-down maneuver was performed, and it immediately improved hyoid and laryngeal elevation and reduced pharyngeal residue at the epiglottic valleculae and pyriform sinus. Analysis of the mechanism of these improvements revealed that combined head and neck flexion, compared with neck flexion, decreased the distance between the origin and insertion (DOI) of the sternohyoid muscle (SM) and increased the muscle contraction rate and the maximum contraction duration of the geniohyoid muscle (GM) during swallowing.

Discussion:

In the present case, the patient had restrictions in extension of the SM that applied resistance to GM contraction. Compensation of this condition was achieved by combined head and neck flexion, which decreased the DOI of the SM, thereby improving the contractile function of the GM.

Cervical Necrotizing Fasciitis After Surgery of a Mandibular Fracture

INTRODUCTION

Cervical necrotizing fasciitis (CNF) is a rapid progressing and potentially fatal infection of connective tissues that spreads along the fascial planes. It commonly develops from odontogenic sources. In this article, the authors present a case of CNF which was developed after open reduction and internal fixation (ORIF) of a mandibular fracture.

CLINICAL CASE

A 19-year-old male patient with no past medical history was admitted due to a mandibular fracture. Following ORIF surgery, on third post-operative day, Physical examination revealed extensive cervical swelling extending from submandibular to suprasternal area, with tender and erythematous skin. Soon after confirmation of CNF diagnosis, surgical debridement and wide spectrum antibiotic therapy was performed. The residual soft tissue defect was reconstructed following infection subsidence.

CONCLUSION

Our study aims to highlight the risk of CNF development during postoperative period of a simple mandibular fracture ORIF surgery which is considered a routine maxillofacial procedure. Early detection and adequate emergency treatment including immediate surgical intervention are critical in the management of these patients.

Descending Necrotizing Mediastinitis Resulting from Pharyngitis with Perforation of the Aryepiglottic Fold

Descending necrotizing mediastinitis and pharyngeal perforation are uncommon complications of pharyngitis that are associated with high morbidity and mortality. This case report describes a previously healthy 18-year-old male who presented to the emergency room with 5 days of severe sore throat, intermittent fevers, and vomiting and was found to have extensive posterior pharyngeal and mediastinal air along with extravasation of contrast on computed tomography, consistent with perforation of the left aryepiglottic fold as well as descending necrotizing mediastinitis. The patient had a complicated hospital course including multiple operative interventions, abscess formation, and development of pericardial and pleural effusions. Successful treatment required swift resuscitation including broad-spectrum antibiotics and significant coordination of emergent operative intervention between otolaryngology and cardiothoracic surgery. It is important to recognize descending necrotizing mediastinitis as a clinical entity that may result from oropharyngeal infections as early intervention significantly decreases subsequent complications and mortality. Furthermore, pharyngeal perforation is an extremely rare complication which requires either CT with oral contrast or esophagram for diagnosis.

Descending necrotizing mediastinitis caused by Streptococcus constellatus in an immunocompetent patient: case report and review of the literature

Descending necrotizing mediastinitis is a severe infection of the mediastinum. This syndrome manifests as fever and chest pain following cough and sputum production. A 49-year-old woman presented with fever and a 14-day history of pneumonia. CT showed mediastinal abscesses with a giant calcified mediastinal lymph node (21 × 18 mm) and pneumonia. Bronchoscopy by EBUS-TBNA under general anesthesia was performed. The pathogen found in the puncture culture was Streptococcus constellatus, and antibiotics (mezlocillin/sulbactam 3.375 IVGTT q8h) was administered. A proximal right main bronchial neoplasm, suspected lung cancer, was found and conformed to inflammatory granuloma. A total of 22 months post-discharge the patient was clinically stable. We also conducted a review of the literature for all Streptococcus constellatus descending necrotizing mediastinitis infections between 2011 and 2017.

Characteristics and outcomes of Ludwig's angina in patients admitted to the intensive care unit: A 6-year retrospective study of 29 patients

Background/Purpose

Ludwig's angina (LA) still presents regularly and various characteristics are documented, but patients admitted to the Intensive Care Unit (ICU) has not been studied. The purpose of this study was to investigate the clinical characteristics and outcomes of patients with LA who were admitted to ICU.

Materials and methods

We retrospectively reviewed all 29 patients with LA who were admitted to the ICU of a university hospital from January 2013 to October 2018. Results were evaluated via descriptive analysis. The Log–Rank test was used to analyze the hospital/ICU length of stay (LOS).

Results

The male: female ratio was 2.63:1. Mean age was 53.41 ± 16.57 years (range 8–78 years). Concomitant conditions comprised diabetes mellitus in 10 patients (34.48%), and hypertension in six (20.69%). The main reason for ICU admission was surgical (44.83%). The mean Acute Physiology, Age, Chronic Health Evaluation II (APACHE II) and the Sequential Organ Failure Assessment (SOFA) scores were 13.52 ± 3.18 and 3.83 ± 2.89, respectively. Twenty-eight patients (96.55%) received respiratory support. Sixteen patients (55.17%) had positive bacterial culture results. Fourteen bacterial strains were detected, most of which were gram-positive (72.72%). Mean LOS was 6.89 ± 14.39 days (range 0.5–73 days), and 24.79 ± 16 days in the hospital. The ICU mortality rate was 10.34%. Compared with LA patients without descending necrotizing mediastinitis (DNM), those with DNM had longer ICU and hospital LOS. The laboratory investigations were higher.

Conclusion

LA patients in ICU were predominantly male, with a wide range age, high incidence of complications, long hospital LOS.

Persistent Necrotizing Mediastinitis after Dental Extraction

Mediastinitis is a rare, progressive, and destructive infectious process due to cervical or odontogenic infections, which, if not diagnosed early, may lead to several complications, including airway involvement and even an imminent risk of death. Herein, we report an unusual case of a 37-year-old male with a bilateral submandibular hard swelling after the left third molar extraction. After surgical intervention with submandibular drainage and antibiotic therapy, the infection persisted without explanation, since the patient was not hypertensive, did not have diabetes mellitus or sexually transmitted infections such as HIV or syphilis, and did not smoke or drink alcoholic beverages. A thoracic surgeon then intervened, treating the mediastinitis surgically by drainage, thus obtaining a significant improvement of the patient's health. Mediastinitis is a serious condition. Clinicians and maxillofacial surgeons should be alert to make an immediate diagnosis and select the appropriate treatment in order to prevent worsening of the patient's clinical condition.

[General anesthesia and intensive care for patients surgically treated for deep neck odontogenic infections]

The study objectives were to determine the significance of deep neck odontogenic infections severity to predict the postoperative morbidity. Observational study was conducted in 2014-2015. A continuous sample of 38 patients who were urgently hospitalized in the Novosibirsk Regional Clinical Hospital with deep neck odontogenic infections and operated on the day of hospitalization was analyzed. SAPS scale rates correlated positively with the duration of the artificial lungs ventilation (ALV). The positive balance of the introduced and withdrawn liquid in the first day of the postoperative period is associated with the ALV duration, which requires accurate dosing of the infusion volumes. The described protocol of perioperative care significantly decreases morbidity in patients with deep neck odontogenic infections.

Senile Lemierre syndrome complicated with descending necrotizing mediastinitis: A case report

RATIONALE

Senile patients with LS complicated with DNM are rarely seen in clinical practice, and extensive cervical incision and drainage plus administration of effective antibiotics are the basis for treatment. Currently, the treatment controversy mainly has focused on whether mediastinal incision and drainage is necessary for patients with type I DNM, and whether anticoagulation therapy is required for jugular venous emboli and distant metastatic emboli induced by LS.

PATIENT CONCERNS

A female, 76 years old, developed pain of tonsil on right side 5 days ago, and felt that the pain aggravated complicated with dysphagia and swelling pain of neck on both sides since then.

DIAGNOSES

She was diagnosed with LS complicated with type I DNM.

INTERVENTIONS

Tazobactam and Piperacillin 4.5 q8h and Ornidazole 100 ml q6h ivgtt were administered empirically,and secondary extensive cervical incision and drainage was performed under general anesthesia, after which low molecular weight heparin 4250 U q12h SC was administered. G test was performed 3 days later, which showed (1,3)-β-D-glucan >1000 pg/ml. Bridging anticoagulation therapy, low molecular weight heparin 4250 U q12h SC, and Warfarin 2.5 mg qd po were given one week later. Low molecular weight heparin SC was discontinued and only Warfarin po was administered after treatment of bridging therapy for 3 days.

OUTCOMES

CT of head and neck was reexamined on post-admission d24 and revealed that neck infection was improved on both sides, jugular vein distension on right side was restored to normal, abscess and pneumatosis of superior mediastinum were improved, distension of pulmonary artery on both sides was normalized, WBC was 9.94×109/L, neutrophil count was 4.43×109/L, CRP level was 9.8mg/L, D-D level was 0.81mg/L, PCT level was 0.800ng/mL and G test suggested (1,3)-β-D-glucan pf 27.1 pg/mL.

LESSONS

Concomitant use of anticoagulants on the basis of repeated cervical incision and drainage + administration of effective antibiotics can obtain excellent therapeutic efficacy in the treatment of patient with LS complicated with type I DNM.

Taking heed of the 'danger space': acute descending necrotising mediastinitis secondary to primary odontogenic infection

Descending necrotising mediastinitis (DNM) is an uncommon clinical entity which may arise secondary to primary odontogenic or neck infection in susceptible patients. Infection may spread contiguously via the alar or 'danger' space, a potential anatomical space posterior to the true retropharyngeal space.¹ Spread of infection to the mediastinum almost always necessitates urgent cardiothoracic surgical intervention.^2-4 This case report describes a male patient whose clinical deterioration following the diagnosis of submandibular abscess was investigated with CT imaging of the chest, where a diagnosis of DNM was made. Diagnosis was confirmed following surgical intervention and aspiration of pus from the mediastinum.

Septic shock from descending necrotizing mediastinitis - combined treatment with IgM-enriched immunoglobulin preparation and direct polymyxin B hemoperfusion: a case report

Background

Descending necrotizing mediastinitis is a common and progressive polymicrobial infection involving the neck and chest with a high death rate (10 to 40%). From a microbiological point of view, descending necrotizing mediastinitis is sustained by Gram-positive bacteria (43–62%), anaerobes (46–78%), and, rarely, Gram-negative bacteria. Data collected during the Antibiotic Resistance-Istituto Superiore di Sanità project confirmed that Italy is positioned among the countries with the highest levels of resistance in most pathogenic species under surveillance. In particular, 32.9% of Klebsiella pneumoniae isolates were resistant to carbapenem, 33.6% of Staphylococcus aureus to methicillin, and 28.7% and 43.9% of Escherichia coli isolates to third-generation cephalosporins and fluoroquinolones, respectively.

Case presentation

We describe the case of a 38-year-old white man with septic shock due to descending necrotizing mediastinitis sustained by multidrug-resistant Gram-negative and Gram-positive bacteria treated after surgery with an IgM-enriched immunoglobulin preparation and polymyxin B hemoperfusion therapy.

Conclusion

Despite the contrasting data on the use of immunoglobulins and polymyxin B hemoperfusion in septic shock and the lack of literature in cases of acute mediastinitis caused by both Gram-negative and Gram-positive multidrug-resistant bacteria, we obtained an improvement in clinical conditions and the survival of our patient, against all odds.

Should we consider IgG hypogammaglobulinemia a risk factor for severe complications of Ludwig angina?: A case report and review of the literature

RATIONALE

Cervical necrotizing fasciitis (CNF) and descending necrotizing mediastinitis (DNM) are rare forms of complication of Ludwig angina. These potentially lethal infections are difficult to recognize in early stages and are often associated with predisposing factors like diabetes and immunocompromised states. Moreover, IgG hypogammaglobulinemia (hypo-IgG) is considered to be a risk factor of mortality in patients with septic shock; however, it is not routinely quantified in patients with extremely serious infections, particularly in cases with no history or evidence of immunocompromising disorders.

PATIENT CONCERNS

We present a case of a 58-year-old woman who survived Ludwig angina, complicated by CNF and DNM. Despite a rapid diagnosis, aggressive surgical debridement and broad-spectrum antibiotics, the infection and necrosis advanced, requiring multiple surgical interventions and long intensive care unit (ICU) support.

CONCLUSION

We hypothesize that detecting a low level of endogenous IgG and treating with adjuvant passive immunotherapy was key in determining a favorable outcome.

Descending necrotizing mediastinitis after a trigger point injection

Descending necrotizing mediastinitis (DNM) is a rare form of mediastinal infection. Most cases are associated with esophageal rupture. DNM after a trigger point injection in the upper trapezius has not been described previously. We present a case of DNM after a trigger point injection in the upper trapezius. A 70-year-old man visited the emergency department with chest discomfort and fever after a trigger point injection in the left upper trapezius. Chest computed tomography showed evidence of DNM, and antibiotic therapy was immediately administered intravenously. Because of the risk of sudden death, poor prognosis due to underlying disease, and his age, he declined surgical treatment and died of septic shock. Although trigger point injections are generally considered safe, caution should be used in patients with an underlying disease or in the elderly. Early diagnosis, broad-spectrum antibiotics, and aggressive surgical management are essential to improve the prognosis.

A Fatal Aortic Arch Rupture Due to Descending Necrotizing Mediastinitis in a 24-year-old Woman

Descending necrotizing mediastinitis (DNM) is a life-threatening disease which often develops from a purulent infection of the oral cavity and is associated with high rates of mortality. Here we report the case of a young patient who died from an aortic arch rupture in context of DNM developed from an odontogenic infection caused by Prevotella buccae. Based on the current knowledge on this very rare vascular complication, we discuss factors that may have contributed to this fatal issue and future issues to optimize care provided to patients.

Candida parapsilosis associated with cervical necrotizing fasciitis and descending mediastinitis

Background

This report presents an immunocompetent lady suffering from Candida parapsilosis associated with polybacterial cervical necrotizing fasciitis and descending mediastinitis. A literature review and management of invasive candidiasis is discussed.

Methods

A 57-year-old healthy lady presented with cervical necrotizing fasciitis and descending mediastinitis. She was promptly managed with emergency debridement. Both blood and tissue culture yielded multiple microorganisms including C. parapsilosis.

Results

The patient recovered progressively. She was discharged 2 months later.

Conclusions

Fungal infection is emerging in this medical era. Vigilance in patient management and as well as considering atypical microorganisms in aetiology may improve patient outcome.

Necrotizing odontogenic fasciitis of head and neck extending to anterior mediastinum in elderly patients: innovative treatment with a review of the literature

BACKGROUND

Necrotizing fasciitis (NF) of odontogenic origin affecting the head and neck region is a rare but serious clinical condition, which, if diagnosed late, can lead to a fatal outcome. The early diagnosis of necrotizing fasciitis can be difficult. Delay in diagnosis leads to increase in the area of necrosis with a resulting increase in cosmetic deformity and life-threatening complication. In this study, we present two cases of elderly patients with aggressive NF affecting the neck and anterior mediastinum, which were of odontogenic origin.

METHODS

In the two patients selected necrotic skin and soft tissue were removed and wide exposure was achieved with debridement of the neck at the level of the affected layer of superficial cervical fascia. Saline solution was used as irrigation to treat the patients with acute necrotizing fasciitis. Difficulties in managing this condition with NF extent to deep anterior mediastinum is related to clavicle osteotomy or thoracotomy need with high surgical risks. In our technique, by gentle suction in anterior mediastinum, necrotic tissue resection was possible without any osteotomy need.

CONCLUSIONS

Suctioning resection technique associated with hyperbaric, metabolic rebalance, and amino acid support in association with three types antibiotic therapy are fundamental points for correct therapy strategy, leading to full recovery and healing of NF patients even if in very unfavorable conditions. Multidisciplinary approach is paramount for proper treatment of this disease.

Antibiotic Resistance in Severe Orofacial Infections

PURPOSE

This study assessed the antibiotic resistance profile in patients with severe orofacial infections treated at a single institution from 2009 through 2014. Factors contributing to resistance were studied. The resistance profile was compared with that of a cohort of similar patients treated a decade previously to identify changes in antibiotic resistance. In addition, the effect of antibiotic resistance on in-hospital course was studied.

MATERIALS AND METHODS

This was a 5-year retrospective cohort study. Patients were identified through the oral and maxillofacial surgery data registry. Inclusion criteria were patients treated for orofacial infection requiring hospital admission, surgical drainage, and availability of complete medical, surgical, and microbiological data. Patients with incomplete data or treated as outpatients or nonsurgically were excluded. Sixty patient charts were identified for review. Demographic data; medical, dental, and surgical histories; and hospital course and treatment specifics were obtained for each patient. Linear regression and logistic analyses were used to analyze the data.

RESULTS

Men composed 60% of the cohort (mean age, 45 yr). Average hospital stay was 5.5 days. Penicillin resistance was found in 32.5% of aerobic isolates and clindamycin resistance was found in 29.3%. Streptococcus viridans and Staphylococcus species showed increased resistance to clindamycin and erythromycin compared with historic controls. Younger patient age, surgical history, and number of cultured aerobes showed a relevant correlation to antibiotic resistance. The need for changes in antibiotics, repeat surgical drainage, and increased serum urea nitrogen levels correlated with longer hospital stay.

CONCLUSION

A serious increase in clindamycin and erythromycin resistance was found for S viridans and Staphylococcus species. Age, surgical history, and number of cultured aerobes showed a statistically meaningful correlation to antibiotic resistance. Presence of antibiotic resistance failed to show statistically relevant correlations to prolongation of hospital stay. Rather, the need for change in antibiotic regimen, the need for re-drainage, and increased serum urea nitrogen level were associated with longer hospital stay.

Diffuse descending necrotising mediastinitis and pleural empyema secondary to acute odontogenic infection resulting in severe dysphagia

We report a case of acute odontogenic sepsis in a 59-year-old man, presenting with diffuse, descending necrotising mediastinitis complicated by pleural empyema. Despite surviving the odds, his recovery was complicated by severe dysphagia, resulting in gastrostomy feeding for 6 months. Until now, severe dysphagia following descending necrotising mediastinitis has been unreported.

Lemierre's syndrome from odontogenic infection: Review of the literature and case description

Lemierre's syndrome (LS) is a rare potentially fatal sequel of head and neck infection, classically described as thrombophlebitis of the internal jugular vein (IJV) with cervical space infection extending into the thorax. Our objective was to answer the clinical question: "Does Lemierre syndrome (LS) from odontogenic infection differ from nonodontogenic LS in regard to clinical sequence, treatment, and survival." We reviewed the literature on the management of LS over the last two decades, with a focus on LS from odontogenic infection. Such a case is presented in order to portray the clinical sequence. Only 10 cases met the inclusion criteria (including the case presented). The recorded data were analyzed in comparison to large case series reviewing LS. Our data reflect the moderate differences in regard to IJV thrombosis and bacteriogram. There is an overall rise in published LS cases in the last 20 years. Odontogenic infection leading to LS is scarce, yet with survival rates similar to nonodontogenic LS. Repeated surgical interventions and aggressive wide spectrum antibiotic therapy remain the treatment of choice.

Retrospective Review of Management and Outcomes of Pediatric Descending Mediastinitis

Objectives

To review the management and outcomes of pediatric patients treated for descending mediastinitis at a single institution and contribute to an updated mortality rate.

Study Design

Case series with chart review.

Setting

Tertiary care pediatric hospital.

Subjects and Methods

This study is a 19-patient case series of all patients treated for descending mediastinitis at a tertiary pediatric hospital from 1997 to 2015, and it serves as an update to the case series published from this institution in 2008. Review of management included time to diagnosis, time to surgery, surgical procedures performed, and antibiotics administered. The primary outcomes measured were length of hospitalization and mortality.

Results

In addition to 8 previously reported patients, we identified 11 pediatric patients treated for descending mediastinitis in the period of review. All 19 patients were <18 months old, and all survived their hospitalization. Fourteen patients underwent surgical drainage at least twice. The median length of hospital stay was 15 days. Retropharyngeal abscess was the source of infection in 16 of 19 patients, and methicillin-resistant Staphylococcus aureus (MRSA) was the isolated organism in 14 of 15 positive cultures.

Conclusion

This review represents the largest reported series of pediatric patients with descending mediastinitis. With 100% survival, our results suggest that pediatric descending mediastinitis can be safely managed by prompt surgical drainage. Broad-spectrum antibiotics covering MRSA and a low threshold for repeat surgical intervention have been an important part of our successful approach and may decrease length of stay.

Cervical Necrotizing Fasciitis--The Value of the Laboratory Risk Indicator for Necrotizing Fasciitis Score as an Indicative Parameter

PURPOSE

Cervical necrotizing fasciitis (CNF) is uncommon, difficult to diagnose, and rapidly progressive. The objective of the present study was to determine the predictive value of the laboratory risk indicator for necrotizing fasciitis (LRINEC) score for CNF.

MATERIALS AND METHODS

The LRINEC score for 16 consecutive cases of CNF and 595 cases of severe non-necrotizing neck infections was determined over a 6.5-year period in a single-center retrospective cohort study and case report. CNF was confirmed by histologic examination and operative report documentation.

RESULTS

Using a cutoff score of 6, the LRINEC score had a sensitivity of 0.94 (95% confidence interval [CI] 0.92 to 0.96) and specificity of 0.94 (95% CI 0.70 to 1.00). The positive predictive value was 0.29 (95% CI 0.17 to 0.44), and the negative predictive value was 0.99 (95% CI 0.99 to 1.00).

CONCLUSIONS

The LRINEC score can detect early cases of CNF. Patients with a LRINEC score of ≥6 must be carefully evaluated for the presence of CNF.

Survival from cervical necrotizing fasciitis

Cervical necrotizing fasciitis (CNF) is an uncommon, yet clinically significant infection that rapidly progresses to involve the deep neck spaces. Early recognition and aggressive surgical intervention and debridement are important, as this disease is associated with a high morbidity and mortality. In this report, we present a case of CNF and descending mediastinitis from a non-odontogenic source in a patient presenting with neck swelling and odynophagia.