Cervical necrotising fasciitis with pharyngeal perforation: treatment and reconstruction

Flap coverage for necrotising soft tissue infections: A systematic review

BACKGROUND

Necrotising soft tissue infections (NSTI) are destructive and often life-threatening infections of the skin and soft tissue, necessitating prompt recognition and aggressive medical and surgical treatment. After debridement, the aim of surgical closure and reconstruction is to minimize disability and optimize appearance. Although skin grafting may fulfil this role, techniques higher on the reconstructive ladder, including local, regional and free flaps, are sometimes undertaken. This systematic review sought to determine the circumstances when this is true, which flaps were most commonly employed, and for which anatomical areas.

METHODS

A systematic review of the literature was conducted utilising electronic databases (Medline, Embase, Cochrane Library). Full text studies of flaps used for the management of NSTI's (including Necrotising Fasciitis and Fournier Gangrene) were included. The web-based program 'Covidence' facilitated storage of references and data management. Data obtained in the search included reference details (journal, date and title), the study design, the purpose of the study, the study findings, number of patients with NSTI included, the anatomical areas of NSTI involved, the types of flaps used, and the complication rate.

RESULTS

After screening 4555 references, 501 full text manuscripts were assessed for eligibility after duplicates and irrelevant studies were excluded. 230 full text manuscripts discussed the use of 888 flap closures in the context of NSTI in 733 patients; the majority of these were case series published in the last 20 years in a large variety of journals. Reconstruction of the perineum following Fournier's gangrene accounted for the majority of the reported flaps (58.6%). Free flaps were used infrequently (8%), whereas loco-regional muscle flaps (18%) and loco-regional fasciocutaneous flaps (71%) were employed more often. The reported rate of partial or complete flap loss was 3.3%.

CONCLUSION

Complex skin and soft tissue defects from NSTIs, not amenable to skin grafting, can be more effectively and durably covered using a spectrum of flaps. This systematic review highlights the important contribution that the plastic surgeon makes as an integral member of multidisciplinary teams managing these patients.

False vocal cord perforation with abscess treated by negative pressure wound therapy

Perforation of the larynx is very rare but may result in severe airway complications that include pneumothorax, pneumonia, mediastinitis, and retropharyngeal abscess. If conservative treatment fails, aggressive treatments including reconstructive surgery with pedicle flap are considered. Negative pressure wound therapy has been used for large skin defects, necrotizing fasciitis, pharyngocutaneous fistula, stoma dehiscence, osteoradionecrosis of the mandible, chyle fistula, flap failure, and lymphangioma in the field of head and neck surgery. We report a case of false vocal cord perforation with abscess successfully treated by negative pressure wound therapy after abscess treatment. The result suggests that negative pressure wound therapy can be an alternative or adjunctive approach for larynx perforation when the perforation is difficult to close after conservative therapy.

[Submental island flap: a review of the literature]

The submental island flap is a precious tool in reconstructive surgery. It was described by Martin in 1993, inspired by platysma flaps. In our days, we can find many reliable techniques for this procedure. We reviewed the main studies of the literature that described a total of 528 patients. The rate of partial necrosis was 5.1%, complete necrosis 1.7%, and reversible lesions of the marginal mandibular branch of the facial nerve 1.1%. His versatility makes this flap appropriate for the reconstruction of every part of the face: cheeks, nose, forehead, moustache, beard, and hairs. It can also be used de-epidermised with very good results, for the reconstruction of the buccal cavity, the tongue, the roof of the mouth, the larynx, and the proximal part of the esophagus. The SMAP (Submentalis Artery Perforator flap) is an alternative flap that provides even better cosmetic results. The development of indocyanine green and infrared cameras will allow in a close future to decrease the postoperative complications.

Necrotizing fasciitis of the chest wall with a retropharyngeal abscess: case report and literature review

We herein report a case of a diabetic 49-year-old woman with anterior chest wall necrotizing fasciitis that caused a retropharyngeal abscess and discuss the literature surrounding necrotizing soft tissue infections of the chest wall. The patient was treated with serial wound debridements, antibiotic therapy, and percutaneous drainage and serial irrigation of the retropharyngeal abscess with a silicone catheter. The resulting defect was grafted with a split thickness skin graft.

Management of necrotizing fasciitis in diabetic patients

Necrotizing fasciitis is a life-threatening condition in diabetic patients; its management and salvage of the patient is a formidable challenge. Diabetes mellitus is one of the serious conditions associated with necrotizing fasciitis. It is a disorder that primarily affects the microvascular circulation. We review our experience and present our approach to necrotizing fasciitis in patients with diabetes mellitus. All cases of necrotizing fasciitis treated at Inonu University, Turgut Ozal Medical Center, from January 1997 to December 2003 were reviewed. A review of 59 charts identified 11 cases that met the study criteria. Cases with necrosis due to other obvious causes were excluded. Three patients had spread of infection with no fatality. An average of 42 hospital days (22-64 days), 17 intensive care unit days (7-28 days), and three surgical procedures (2-7) per patient was required. Necrotizing fasciitis is an extremely serious exceptional infectious process affecting subcutaneous soft tissue with skin gangrene and vascular thromboses. Clearly, the mortality and morbidity associated with necrotizing fasciitis even in diabetes can be decreased with clinical awareness, early diagnosis, effective surgical debridement, and intensive supportive care.

Neglected peritonsillar abscess resulting in necrotizing soft tissue infection of the neck and chest wall

Necrotizing soft tissue infection (NSTI) of the neck and chest wall resulting from neglected peritonsillar abscess is a relatively rare but highly lethal surgical condition which has received little attention in the literature. The case of a 54-year-old male patient affected by this unusual infection is reported. Our recent experience and literature data suggest that NSTI resulting from peritonsillar abscess is rapidly spreading and life threatening. High index of suspicion, early diagnosis, broad-spectrum antibiotics and aggressive surgical debridement are essential to its successful treatment.

Necrotizing soft tissue infections of the head and neck: case reports and literature review

A small but nevertheless important part of a surgeon's experience comprises necrotizing soft tissue infections of the head and neck. The purpose of this report is to heighten awareness of necrotizing soft tissue infections in any patient with an infection of the head and neck. The article also outlines an appropriate management strategy for use in the treatment of patients with this potentially fatal condition. Prompt diagnosis and early radical surgical debridement are significant factors in avoiding a fatal outcome in these patients. This article reviews the literature on necrotizing soft tissue infections of the head and neck and presents cases from our recent experience.

Ascending necrotising fasciitis as a result of odontogenic infection: a report of two cases

Necrotising fasciitis is a severe soft tissue infection which spreads rapidly through fascial planes, is characterised by soft tissue necrosis and is potentially life-threatening. It is a rare entity in the head and neck region. The management of this condition is difficult and early diagnosis and aggressive surgical and medical management are essential. This paper reports two cases of necrotising fasciitis as a result of ascending odontogenic infection involving the temporalis muscle.

Cervical necrotizing fasciitis and radiotherapy: a report of two cases

Two cases of cervical necrotizing fasciitis are presented. Both are unusual in that they had had radiotherapy for head and neck malignancy six and 14 years previously with no evidence of tumour recurrence. One case of necrotizing fasciitis has previously been cited in the literature associated with radiotherapy (Krespi et al., 1981). The two cases are discussed along with a review of the literature.