Surgical debridement and adjunctive hyperbaric oxygen in cervical necrotizing fasciitis

Efficacity of hyperbaric oxygen therapy for necrotizing fasciitis in the maxillofacial region: The review of the literature

Necrotizing fasciitis (NF) is a rare, dangerous, potentially fatal infectious disease of soft tissue. The treatment consists of antibiotic therapy, surgical debridement and subsequent reconstruction. Hyperbaric oxygen (HBO) therapy has been applied in NF patients recently, so our aim was to gather the findings and outcomes for HBO therapy. A PubMed and Google Scholar literature search was conducted regarding the effect of HBO therapy in patients with NF following key words: 'necrotizing fasciitis' AND 'maxillofacial region' OR 'head and neck' AND 'hyperbaric oxygen' OR 'HBO'. A total of 3333 studies have been identified, of which only 16 articles met the inclusion criteria of this review. A conclusion was made, that aggressive combinations of antibiotics and surgical debridement followed by incorporation of HBO therapy, as an adjuvant treatment, in patients with NF and in company by immunoglobulin therapy are showing promising results. In addition, multi-centric studies should be in consideration for further research.

Cervical Necrotizing Fasciitis and Shock in the Post-Operative Pediatric Patient

Cervical necrotizing fasciitis (CNF) is a rare infection that can quickly lead to devastating patient outcomes. Considering the vital importance of surrounding neck structures, rapid control of the infection is essential. Infection is most frequently polymicrobial and occurs in the adult patient in the context of certain medical comorbidities. Complications are typically limited to tissue destruction in the form of necrosis. There are no current reports describing CNF complicated by acute shock in the post-operative pediatric patient. Here, we present a pediatric case of CNF complicated by acute shock following Sistrunk procedure for removal of a supposed thyroglossal duct cyst. This case illustrates a potential post-operative complication that can be seen within the pediatric patient. Although most reported examples of CNF are polymicrobial and result from odontogenic infection, providers should be aware of other potential sources of disease. It is important for the pediatric surgeon to rapidly identify CNF and consequent shock, as prompt medical and surgical interventions are critical to offering the best chance of patient survival.

Necrotizing fasciitis of the face: current concepts in cause, diagnosis and management

PURPOSE OF REVIEW

Necrotizing fasciitis of the face is uncommon but potentially life threatening. With adequate multidisciplinary treatment, mortality and has significantly improved. This article highlights current concepts and supporting literature in the management of facial necrotizing fasciitis.

RECENT FINDINGS

Management of necrotizing fasciitis involving the face requires a multisciplinary team approach, including early medical and surgical intervention. With early haemodynamic support, broad spectrum antibiotics and aggressive surgical debridement, mortality has reduced significantly. Soft-tissue reconstruction can be effectively utilized once the infection has been adequately treated. Although some adjunctive treatment such as vacuum assisted closure dressing has shown to be of benefit, other treatments such as hyperbaric oxygen remains controversial.

SUMMARY

Necrotizing fasciitis is an aggressive soft tissue involving that rapidly spreads along fascial planes. Necrotizing fasciitis involving the face is rare owing to its rich blood supply but is also difficult to manage due to the complex regional anatomy. Common sources are odontogenic, sinugenic, peritonsillar or salivary gland infections and often polymicrobial. The principles of treatment include early and aggressive haemodynamic support, broad spectrum antibiotics and aggressive surgical debridement. Often times repeat debridements following close monitoring is required. Reconstructive options are viable only after the infection has been adequately treated. Although mortality has significantly improved, mediastinal involvement, multiple comorbidities and delayed treatment confers a worse prognosis.

Biological factors predicting the length of hospital stay in odontogenic cellulitis

OBJECTIVE

The purpose of this study was to assess whether common biological factors are correlated with a longer hospital stay.

STUDY DESIGN

All patients having odontogenic cellulitis, treated from January 2019 to December 2019 at Lille University Hospital, and requiring surgical drainage under general anesthesia, were included, retrospectively. Data, such as length of hospital stay and biological factors, namely, C-reactive protein (CRP) level, Laboratory Risk Indicator for Necrotizing Fasciitis (LRINEC) score, and bacterial samples were collected.

RESULTS

Significant moderate-strong correlations were found between postoperative length of stay and patients' LRINEC score (r_s = 0.556) and presurgical CRP level (r_s = 0.579). There was a significant moderate correlation between postoperative length of stay and presurgical procalcitonin level (r_s = 0.451), and a weak correlation between postoperative length of stay and presurgical white blood cell count (r_s = 0.282). Linear regression verified CRP as an independent predictor of length of hospital stay, showing a significant linear relationship between them (p < 0.0001). A significant regression equation was found (F(1,65) = 27.089; p = 0.0001), with an R² of 0.294.

CONCLUSION

In this study, CRP was the key biological predictor of length of hospital stay.

STATEMENT OF CLINICAL RELEVANCE

The ability to predict length of hospital stay and identify patients requiring intensive care management, using simple and inexpensive biological parameters (such as CRP), will enable more cost-effective care and efficient hospital bed management.

Adjunctive hyperbaric oxygen treatment for necrotising soft-tissue infections: A systematic review and meta-analysis

INTRODUCTION

Surgical intervention, broad-spectrum antibiotics and intensive care support are the standard of care in the treatment of necrotising soft-tissue infections (NSTI). Hyperbaric oxygen treatment (HBOT) may be a useful adjunctive treatment and has been used for almost 60 years, but its efficacy remains unknown and has not been systematically appraised. The aim was to systematically review and synthesise the highest level of clinical evidence available to support or refute the use of HBOT in the treatment of NSTI.

METHODS

The review was prospectively registered (PROSPERO; CRD42020148706). MEDLINE, EMBASE, CENTRAL and CINAHL were searched for eligible studies that reported outcomes in both HBOT treated and non-HBOT treated individuals with NSTI. In-hospital mortality was the primary outcome. Odds ratio (ORs) were pooled using random-effects models.

RESULTS

The search identified 486 papers of which 31 were included in the qualitative synthesis and 21 in the meta-analyses. Meta-analysis on 48,744 patients with NSTI (1,237 (2.5%) HBOT versus 47,507 (97.5%) non-HBOT) showed in-hospital mortality was 4,770 of 48,744 patients overall (9.8%) and the pooled OR was 0.44 (95% CI 0.33-0.58) in favour of HBOT. For major amputation the pooled OR was 0.60 (95% CI 0.28-1.28) in favour of HBOT. The dose of oxygen in these studies was incompletely reported.

CONCLUSIONS

Meta-analysis of the non-random comparative data indicates patients with NSTI treated with HBOT have reduced odds of dying during the sentinel event and may be less likely to require a major amputation. The most effective dose of oxygen remains unclear.

Cervical necrotizing fasciitis affects only immunocompromized patients? Diagnostic challenges, treatment outcomes and clinical management of eleven immunocompetent adult patients with a still fatal disease

PURPOSE

Cervical Necrotizing fasciitis (CNF) has been reported as an unusual rapidly progressive, life-threatening, inflammatory disease that is known to affect predominately immunocompromised patients. Few case reports have been sporadically published involving immunocompetent adults. This is the first study presents a series of immunocompetent CNF patients.

MATERIALS AND METHODS

A retrospective chart review study was performed on immunocompetent adults with CNF from January 2003 to December 2019. The diagnosis was histologically confirmed. We analyzed epidemiological, clinical, laboratory and imaging findings and discussed them along with the treatment plan.

RESULTS

A total of eleven adult patients were included in the study. The average age was 43 years, ranging from 17 to 62 years. The average hospitalization time was 28 days, ranging from 10 to 129 days. All patients presented with cervical erythema and odynophagia. The causative factors are known in nine patients. Tissue cultures demonstrated mixed flora in six patients. Seven underwent a temporary tracheostomy. Wide neck exploration incisions were performed in all patients as the diagnosis was established after imaging findings. In nine cases the anterior-upper mediastinum was affected but only in two patients extension of the surgical planes to the mediastinum was performed. Four patients developed polyserositis. Nine patients survived and two developed multiorgan failure and died.

CONCLUSION

There seem to be no differences between immunocompetent and immunocompromised CNF patients, in regards to clinical, imaging and laboratory findings as well as their treatment plan.

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.

Deep neck space infections: an upward trend and changing characteristics

PURPOSE

This study reviews our experience with deep neck space infections (DNIs) requiring surgical intervention, including cervical necrotizing fasciitis. The aim of the study was to identify predisposing and aggravating factors of the disease and recognize the possible factors that can lead to life-threatening complications and slow down the healing process.

METHODS

We compare the results to previous data from 1985 to 2005 to find possible alterations and changing trends. The characteristics of four lethal cases are described. This retrospective analysis includes patient data from 2004 to 2015 in tertiary referral hospital and in total, 277 patients were found.

RESULTS

Surgical drainage through a neck opening ± intraoral incision was made in 215 (77.6%) patients, an intraoral incision was only made in 62 patients (22.4%). ICU care was needed in 66 (23.8%) cases. Odontogenic etiology (44.8%) was the most common origin. The most common comorbidity was a psychiatric disorder and/or dementia and occurred in 55 (19.9%) patients. Patients with underlying illnesses were more likely to be admitted to the ICU (p = 0.020), required a longer ICU stay (p = 0.004) and repeated surgery (p = 0.009). Gas formation seemed to be predictive of a more severe course of infection. Early extraction of the odontogenic foci was related to a lower length of stay (LOS) (p = 0.039).

CONCLUSION

The annual numbers have risen from 14 to 24 cases per year when compared to previous data. DNIs remain a cause of lethal complications; the mortality was 1.4% and overall complications occurred in 61 (22.0%) patients.

Odontogenic necrotizing fasciitis: a systematic review of the literature

Background

While odontogenic soft tissue infections of the head and neck are common, progression to necrotizing fasciitis is relatively rare. Necrotizing fasciitis is a potentially life-threatening and rapidly progressive soft tissue infection that can lead to significant skin and soft tissue loss, mediastinitis, vascular thrombosis or rupture, limb loss, organ failure, and death.

Methods

A PubMed literature search was conducted for case reports and case series on odontogenic necrotizing fasciitis. Individual patient data was analyzed and compiled and demographic, treatment, microbiology, and mortality data were extracted. Fisher’s exact test was used to examine the relationship between death from odontogenic necrotizing fasciitis and diabetes mellitus (DM) and human immunodeficiency virus (HIV) positivity.

Results

A total of 58 studies totaling 164 patients were identified. Thirty-three patients had DM and 3 were HIV +. All patients underwent aggressive surgical debridement and treatment with IV antibiotics. Twenty patients were also treated with hyperbaric oxygen. There were 16 deaths reported, for a mortality rate of 9.8%. The mortality rate among patients with DM was 30.3 and 0% among HIV positive patients. There was a statistically significant increase in the mortality rate in DM patients with odontogenic necrotizing fasciitis (p = 0.0001, odds ratio for death 9.1).

Conclusions

Necrotizing fasciitis arising from odontogenic infection is a rapidly progressive and life-threatening illness. Prompt recognition of the infection, aggressive and often serial surgical debridement, and aggressive broad-spectrum antibiotics are necessary to prevent serious morbidity and mortality. Patients with diabetes mellitus are at a significantly increased risk of death from odontogenic necrotizing fasciitis.

Cervical necrotizing fasciitis: Systematic review and analysis of 1235 reported cases from the literature

BACKGROUND

Cervical necrotizing fasciitis is a progressive soft tissue infection with significant morbidity and mortality.

METHODS

A case review of cervical necrotizing fasciitis managed at our institution (2007-2017) and a systematic review of PubMed, MEDLINE, and EMBASE databases using the algorithm "(cervical OR neck) AND necrotizing fasciitis."

RESULTS

There were 1235 cases from 207 articles which were included in our clinical review. Mean age for cervical necrotizing fasciitis was 49.1 years (64.23% men). Etiology was odontogenic (47.04%), pharyngolaryngeal (28.34%), or tonsillar/peritonsillar (6.07%). There were 2 ± 0.98 organisms identified per patient; streptococci (61.22%), staphylococci (18.09%), and prevotella (10.87%). There were 2.5 ± 3.22 surgical debridements undertaken. Descending necrotizing mediastinitis occurred in 31.56% of patients. Mean length of stay in the hospital was 29.28 days and overall mortality was 13.36%.

CONCLUSION

Physicians and surgeons must be vigilant of the diagnosis of cervical necrotizing fasciitis as early clinical findings may be subtle and prompt identification to facilitate aggressive intervention is required to preclude catastrophic local and systemic morbidity and mortality.

Cervical Necrotizing Fasciitis of Odontogenic Origin and Hyperbaric Oxygen Therapy

Necrotizing fasciitis (NF) is an infection of the soft tissues pathology with high mortality that spreads through the fascial planes and rarely seen in head and neck region. The cause of infection is often odontogenic problems. Broad-spectrum antibiotics, surgical debridement, and hyperbaric oxygen therapy (HBO) are important for the treatment of disease. We report a case of cervical NF in a 33-year-old woman who was treated with rapid surgical debridement and simultaneous HBO.

Hyperbaric oxygen may only be optional in head and neck necrotizing fasciitis: a retrospective analysis of 43 cases and review of the literature

BACKGROUND

Necrotizing fasciitis in the head and neck (NF-HN) is a rare and potentially life-threatening condition. The use of hyperbaric oxygen therapy (HBOT) in the acute regimen is disputed and there is a lack of evidence of therapeutic effect. This study aims to describe a retrospective cohort of patients with NF-HN and investigate the use of HBOT and consequences thereof.

METHODS

All patients treated for NF-HN at Aarhus University Hospital (AUH) between 2002 and 2014 were included in this retrospective cohort. Data regarding demographics, treatment and a one-year follow-up was registered. A review of the literature on NF-HN and HBOT was performed.

RESULTS

Forty-three patients were consecutively treated for NF-HN during the period. All patients were treated in accordance with current guidelines with HBOT as a variable. Thirty patients received HBOT, and 13 patients were omitted from HBOT for different reasons. In the HBOT group were no mortalities vs. three mortalities in the non-HBOT group two late deaths due to precursory underlying cancer of the head and neck, and one early death shortly after admittance. We found higher rates of complications (63% vs. 25%) and sequelae (77% vs. 40%) among the HBOT group compared to the non-HBOT group.

CONCLUSIONS

Our findings suggest that HBOT for NF-HN may only be optional and that the decision relies on an individual assessment of each patient. Further research is needed concerning the evidence of HBOT and towards selecting the patients benefitting from HBOT.

Necrotizing fasciitis as a complication of odontogenic infection: a review of management and case series

BACKGROUND

The aims of the present study were to establish the incidence of head and neck necrotizing fasciitis (NF) in the Adelaide Oral and Maxillofacial Surgery Unit; review the current literature regarding the management of head and neck NF; and determine the evidence for the role of hyperbaric oxygen therapy in the management of NF.

METHODS

A retrospective audit of all patients admitted to the Royal Adelaide Hospital Oral and Maxillofacial Surgery Unit 2006-2015 with severe odontogenic infections was carried out. Patient demographics were recorded and treatment details were collected and analysed.

RESULTS

A total of 672 patients were admitted for management of severe odontogenic infections. Of these, three were identified as NF. One case was treated using hyperbaric oxygen as an adjunct to conventional surgical and medical management. Two cases were managed using aggressive surgical management alone. Two patients survived. The incidence of head and neck NF in South Australia is 48/100 000 infections per year.

CONCLUSIONS

The first-line treatment of severe odontogenic infections remains conventional surgical and medical management; however, hyperbaric oxygen therapy may have an additional role in the management of NF and other rare severe infections in medically complex patients.

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.

Necrotizing cervical fasciitis: Prognosis based on a new grading system

We conducted a 10-year retrospective study to determine the prognosis of necrotizing cervical fasciitis (NCF). Our study population included 38 patients-32 males and 6 females, aged 10 months to 70 years (mean: 55 yr)-who had presented for management of NCF at our tertiary care hospital between Jan. 1, 2000, and Dec. 31, 2009. We classified each case into four categories based on the duration of disease prior to presentation, the severity of disease, and other factors that influence outcomes. We found that the most important factor in determining prognosis was the time interval between the onset of NCF and subsequent presentation for specialist or surgical intervention. Patients with a higher grade of NCF had longer hospital stays. Although aggressive surgical and medical intervention is the gold standard for the management of NCF, many of our patients presented with a relatively healthy appearing wound, which could mislead the evaluating clinician and delay prompt management. We believe that our new grading system will help obviate this problem and make clinicians more vigilant when faced with a new case of necrotizing fasciitis.

Necrotizing fasciitis: eight-year experience and literature review

Objectives

To describe clinical, laboratory, microbiological features, and outcomes of necrotizing fasciitis.

Methods

From January 1, 2004 to December 31, 2011, 115 patients (79 males, 36 females) diagnosed with necrotizing fasciitis were admitted to Mackay Memorial Hospital in Taitung. Demographic data, clinical features, location of infection, type of comorbidities, microbiology and laboratory results, and outcomes of patients were retrospectively analyzed.

Results

Among 115 cases, 91 survived (79.1%) and 24 died (20.9%). There were 67 males (73.6%) and 24 females (26.4%) with a median age of 54 years (inter-quartile ranges, 44.0–68.0 years) in the survival group; and 12 males (50%) and 12 females (50%) with a median age of 61 years (inter-quartile ranges, 55.5–71.5 years) in the non-surviving group. The most common symptoms were local swelling/erythema, fever, pain/tenderness in 92 (80%), 87 (76%) and 84 (73%) patients, respectively. The most common comorbidies were liver cirrhosis in 54 patients (47%) and diabetes mellitus in 45 patients (39%). A single organism was identified in 70 patients (61%), multiple pathogens were isolated in 20 patients (17%), and no microorganism was identified in 30 patients (26%). The significant risk factors were gender, hospital length of stay, and albumin level.

Discussion

Necrotizing fasciitis, although not common, can cause notable rates of morbidity and mortality. It is important to have a high index of suspicion and increase awareness in view of the paucity of specific cutaneous findings early in the course of the disease. Prompt diagnosis and early operative debridement with adequate antibiotics are vital.

Necrotising fasciitis of odontogenic origin

Necrotising fasciitis (NF) is a rare infection of the fascial planes, which is less common in head and neck, because of the rarity and higher vascularity in the region. We report a case of necrotising fasciitis in a 43-year-old man, arising from a dental infection treated successfully by early diagnosis, prompt surgical management, antibiotic therapy and adjunctive hyperbaric oxygen (HBO) therapy. The diagnosis of descending NF must always be considered in a patient who presents with a history of oropharyngeal infection with evidence of neck swelling, chest pain, and dyspnea or respiratory distress. Aggressive surgical debridement of all involved tissue along with intravenous antibiotic therapy should be initiated before aerobic and anaerobic cultures are obtained. HBO may also be of some benefit in the treatment of this potentially fatal infection.

[Hyperbaric oxygen therapy for necrotizing soft tissue infections: contra]

INTRODUCTION

Hyperbaric oxygen therapy (HBOT) is discussed as an adjuvant option to treat necrotizing soft tissue infections (NSTI). While the Federal Joint Committee decided in 2007 not to support HBOT for the indication necrotizing fasciitis and Fournier's gangrene, it was decided to accept HBOT for treatment of clostridial myonecrosis for the German health insurance. Thus, in Germany necrotizing fasciitis (NF) is not a confirmed indication for HBOT. Against this background the cons of the clinical benefits of HBOT should be formulated.

METHODS

A literature search (MEDLINE/EMBASE/COCHRANE/manual search) using the keywords "necrotizing fasciitis", "Fournier's gangrene", "necrotizing cellulitis", "necrotizing soft tissue infections" as well as "hyperbaric medicine", "hyperbaric therapy" and "hyperbaric treatment" was carried out. An analysis of the spatial distribution of German hyperbaric oxygen chambers enabling intensive care (HOC-IC) was made.

RESULTS

A total of 250 articles with n=2,556 NSTI patients (n=993 treated by HBOT) was found and 50% of the articles were case reports or series. There were only ten retrospective studies comparing the effects of HBOT with non-HBO treatment and none of them verified the benefit of HBOT in NF patients. In Germany only nine hyperbaric oxygen chambers (HOC-IC) enable intensive care. Currently, patient data are not included in scientific studies or multicenter studies, while studies assessing the benefit with higher evidence levels have been required for more than 15 years.

CONCLUSIONS

The previously published human clinical studies do not confirm any therapeutic benefit of HBOT in NF patients. Any time delay in the start of surgical therapy by HBOT would not be acceptable. In Germany a comprehensive clinical care with HOC is not possible. On average the additional costs of HBO treatment for NF patients is approximately 8,000-25,000 <euro>/patient which is not generally reimbursed by health insurance companies. Initializing a register study to assess the benefit of HBOT in NF patients appears feasible and is urgently needed.

[Necrotizing fasciitis due to a peritonsillar abscess]

BACKGROUND

Necrotizing fasciitis is a potentially life-threatening complication of severe cervical soft tissue inflammation. The characteristic feature is the rapid spread of the infection, which descends and potentially leads to mediastinitis and sepsis.

METHODS

Within a year, 4 patients with peritonsillar abscess (PTA) and necrotizing fasciitis were treated at Dessau Medical Center. Therapy consisted of abscess tonsillectomy, immediate surgical debridement, extensive wound drainage, early tracheostomy, and systemic antibiotics.

RESULTS

Symptoms decreased after intensive care and surgical removal. All patients were discharged after wound healing. The death of the oldest, multimorbid patient several weeks later was ascribed to the accompanying diseases.

CONCLUSION

Early diagnosis, aggressive surgical debridement in association with tracheostomy and intravenous antibiotic therapy may reduce mortality significantly.

Necrotizing craniocervical soft tissue infections: clinical experience and personal considerations

Necrotizing cervical soft tissue infections (NCSTIs) are devastating uncommon clinical entities that are often life threatening. We report two patients suffering from NCSTI and treated at our institution. Diagnosis of NCSTI has been confirmed histologically and surgically. Both patients were managed with very aggressive treatment (medical and surgical) and survived with minimal morbidity. Early diagnosis and aggressive, multimodality treatment can reduce mortality and morbidity rates. Thoracic and mediastinal involvement requires appropriate management. A strong clinical suspicion remains one of the most important aspects of the management of such shattering conditions.

Necrotizing fasciitis of the neck after total laryngectomy

Necrotizing fasciitis (NF) is an unusual, life threatening, rapidly advancing infection characterized by widespread fascial and subcutaneous tissue necrosis and gangrene of the skin. It most commonly affects the extremities, abdominal wall and perineum, whereas cervical NF is rare. NF of the head and neck is often caused by both aerobic and anaerobic microorganisms found in the upper aerodigestive tract. Usually, cervical NF originates from odontogenic, tonsillar and pharyngeal infection, and it is very rarely a complication of surgical procedure. Without immediate surgical treatment, cervical NF leads to mediastinitis and fatal sepsis. There is only one case of cervical NF after total laryngectomy described in the literature. We report two cases of cervical NF after total laryngectomy, selective neck dissection and primary vocal prosthesis insertion. In both cases, the infection spreads to thoracic region and in one of them NF was associated with Lemierre's syndrome, i.e., thrombosis of the internal jugular vein. In both patients, vocal prosthesis was inserted during the infection and did not influence the healing process.

Hyperbaric oxygen treatment in three cases of necrotizing infection of the neck

Necrotizing infections of the head and neck are rare conditions in our hospital. Clinical and microbiological characteristics of three consecutive cases treated in Haukeland University Hospital in western Norway in the year 2010 are described. Two cases of Lemierre's syndrome and one case with a descending necrotizing mediastinitis (DNM) were diagnosed. All three cases were treated with broad spectrum antibiotics and in two cases surgery was possible. Hyperbaric oxygen treatment (HBOT) with intensive care facilities became recently available at our hospital, and this treatment was used in all these patients regardless of surgery. In one case we describe the use of HBOT on the basis of strong clinical suspicion of anaerobic infection only. Bacterial identification by partial sequencing of the 16SrDNA gene proved to be a useful supplement to conventional culture techniques. All the cases all demonstrated a significant clinical improvement after introduction of HBOT. When HBOT is available, it should be considered as adjunctive treatment in extensive infections with anaerobes.

Is there association between severe multispace infections of the oral maxillofacial region and diabetes mellitus?

PURPOSE

This study aims to identify the impact of diabetes on the final outcome (length of hospital stay and development of complications) in patients with severe multispace infections in the head and neck. Furthermore, it intends to characterize significant clinical features of these patients compared with nondiabetics.

MATERIALS AND METHODS

A retrospective study was conducted in 117 patients who received treatment for multispace infections of the head and neck region from 2007 through 2010 at the Department of Oral and Maxillofacial Surgery, Shanghai Ninth Hospital. The study identified diabetic patients and compared them with nondiabetic patients. Demographics, etiology of infection, clinical parameters (time from first onset of symptoms to hospital admission, number of spaces affected, and distribution of involved spaces), and laboratory values (bacteriology, admission blood glucose level, admission white blood cell count, and percentage of neutrophils on admission) were analyzed for clinical significance. Statistical analyses of the results between groups were performed using the Student t test, χ(2) test, variance analysis, logistic regression analysis, and linear regression analysis.

RESULTS

Admission blood glucose level was the only factor influencing the complications in multispace infections in the oral-maxillofacial region. Compared with nondiabetic patients, diabetics had infections that involved more spaces, longer hospital stays, and more frequent complications. Some diabetic patients died. The disease status (with or without diabetes) was associated with clinical outcomes (length of hospital stay and complications) in the therapy procedures.

CONCLUSIONS

This study identifies uncontrolled diabetes mellitus as an important indicator of clinical features and outcomes in treating multispace infections of the oral-maxillofacial region.

[Necrotizing fasciitis. 2011 update]

Necrotizing fasciitis belongs to a group of complicated soft tissue infections that can be even life threatening. Despite growing knowledge about its etiology, predictors, and the clinical progression, the mortality remains at a high level with 20%. A relevant reduction can be achieved only by an early diagnosis followed by consistent therapy. The clinical findings in about 75% of the cases are pain out of proportion, edema and tenderness, blisters, and erythema. It is elementary to differentiate a necrotizing or a non-necrotizing soft tissue infection early. In uncertain cases it can be necessary to perform a surgical exploration to confirm the diagnosis. The histopathologic characteristics are the fascial necrosis, vasculitis, thrombosis of perforating veins, the presence of the disease-causing bacteria as well as inflammatory cells like macrophages and polymorphonuclear granulocytes. Secondly, both the cutis and the muscle can be affected. In many cases there is a disproportion of the degree of local and systemic symptoms. Depending on the infectious agents there are two main types: type I is a polymicrobial infection and type II is a more invasive, serious, and fulminant monomicrobial infection mostly caused by group A Streptococcus pyogenes.Invasive, severe forms of streptococcal infections seem to occur more often in recent years. Multimodal and interdisciplinary therapy should be based on radical surgical débridement, systemic antibiotic therapy as well as enhanced intensive care therapy, which is sometimes combined with immunoglobulins (in streptococcal or staphylococcal infections) or hyperbaric oxygen therapy (HBOT, in clostridial infections). For wound care of extensive soft tissue defects vacuum-assisted closure has shown its benefit.

Necrotizing fasciitis following laparoscopic left hemicolectomy for diverticulitis

Necrotizing fasciitis (NF) is a rapidly progressing bacterial infection of soft skin tissue layers, combined with high mortality rates. Association with laparoscopic surgery is rare. In this article, we report a case of a 61-year-old patient suffering from severe NF after laparoscopic left hemicolectomy with low anterior resection due to diverticulitis of sigmoid colon. Skin discolorations, combined with critical illness of the patient, led to the diagnosis of NF. Early recognition, intensive care treatment with stabilization of vital parameters, broad-band antibiotics, and aggressive debridement are the cornerstones for successful treatment of NF.

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.