Cervical necrotizing fasciitis and radiotherapy: a report of two cases

Radiation necrosis of the bone, cartilage or cervical soft-tissues following definitive high-precision radio(chemo)therapy for head-neck cancer: uncommon and under-reported phenomenon

Background

The impact of modern high-precision conformal techniques on rare but highly morbid late complications of head and neck radiotherapy, such as necrosis of the bone, cartilage or soft-tissues, is not well described.

Method

Medical records of head and neck cancer patients treated in prospective clinical trials of definitive high-precision radiotherapy were reviewed retrospectively to identify patients with necrosis.

Results

Twelve of 290 patients (4.1 per cent) developed radiotherapy necrosis at a median interval of 4.5 months. There was no significant difference in baseline demographic (age, gender), disease (primary site, stage) and treatment characteristics (radiotherapy technique, total dose, fractionation) of patients developing radiotherapy necrosis versus those without necrosis. Initial management included antibiotics or anti-inflammatory agents, tissue debridement and tracheostomy as appropriate followed by hyperbaric oxygen therapy and resective surgery for persistent symptoms in selected patients.

Conclusion

Multidisciplinary management is essential for the prevention, early diagnosis and successful treatment of radiotherapy necrosis of bone, cartilage or cervical soft tissues.

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.

Postirradiation Klebsiella pneumoniae-associated necrotizing fasciitis in the western hemisphere: a rare but life-threatening clinical entity

Necrotizing fasciitis (NF) caused by Klebsiella spp. is a unique entity, particularly, in Asia, where virulent strains of Klebsiella predominate. It is now clear that Klebsiella spp. are capable of causing NF either isolated or in the context of disseminated disease. We present a unique case of NF caused by Klebsiella pneumoniae in the Western hemisphere after radiotherapy in a hospitalized patient with significant comorbidities. Physicians should be aware of nosocomially acquired K. pneumoniae fasciitis after radiotherapy in the setting of chronic comorbidities, such as diabetes and malignancy. Early diagnosis, surgical intervention, and appropriate empirical antibiotics are essential for a favorable outcome in such rare but life-threatening cases of NF.

Antibiotic prophylaxis in clean-contaminated head and neck oncological surgery

BACKGROUND

Perioperative antibiotic prophylaxis has significantly reduced wound infection rates in clean-contaminated head and neck surgical procedures but controversy still remains regarding the optimal antibiotic regime.

OBJECTIVE

To examine the efficacy of different antibiotics in head and neck oncological surgery prophylaxis.

PATIENTS AND METHODS

In this prospective, double-blind clinical trial, 189 patients with carcinoma of the upper aerodigestive tract were randomized to receive amoxicillin-clavulanate or cefazolin intravenously up to 1h before surgery and at 8-h intervals for an additional three doses.

RESULTS

An overall wound infection rate of 22% was observed. The infection rate in patients receiving cefazolin was 24% (22/92) vs. 21% (20/97) in those receiving amoxicillin-clavulanate; the difference was not statistically significant. Postoperative overall non-wound infection developed in 12% (22/189) patients; the rate of infection was 9.8% (9/92) in patients receiving cefazolin vs. 13.4% (13/97) in those receiving amoxicillin-clavulanate, without a statistically significant difference between the two groups. Gram-negative bacteria were more often isolated with Pseudomonas aeruginosa as the dominant species. The risk of postoperative infection was more influenced by the type of surgical procedure than by disease stage.

CONCLUSION

In clean-contaminated head and neck oncologic surgery amoxicillin-clavulanate prophylaxis was at least as efficient as cefazolin. However, when taking into account the fact that beta-lactamase containing strains have recently been spreading, amoxicillin-clavulanate should be the logical first choice.

Cervical necrotizing fasciitis due to bacterial tonsillitis

Necrotizing fasciitis is a severe and potentially fatal soft tissue infection, but involvement of the head and neck is rare. We report on 4 cases of cervical necrotizing fasciitis arising from tonsillitis. One patient was diabetic and one had received steroids before disease development. One patient developed acute respiratory failure and died of septic shock. Three patients recovered, helped by early recognition, aggressive surgical intervention, appropriate broad-spectrum antibiotics, and supportive therapy. The common bacteria found in all abscess samples were Streptococcus sp., but mixed flora with anaerobic organisms was seen in all but 1 case. Tonsillitis and peritonsillar abscess must be suspected as a cause of cervical necrotizing fasciitis and a successful result can be achieved with immediate aggressive treatment.

Necrotizing fascitis of the head and neck--report of three cases and review of the literature

Necrotizing fasciitis (NF) of the head and neck is a rare but potentially life-threatening soft tissue infection primarily affecting the superficial fascial planes. It is caused by group A streptococci or by a synergistic combination of aerobe and anaerobe micro-organisms. If proper treatment is delayed, the infection may cause extensive necrosis of overlying skin, extend to deeper planes and produce severe systemic toxicity. Recent reviews suggest that cervical and facial NF should be considered separate clinical entities with different clinical features and prognosis. In both, early diagnosis with prompt, aggressive surgical and medical treatment is essential to a successful outcome. Three cases of NF of the neck secondary to peritonsillar/parapharyngeal infections are presented and the main characteristics of 117 well-characterized cases of cervical and facial NF are reviewed.