Cervical necrotizing fasciitis due to bacterial tonsillitis

Predictive Performance Neutrophil-to-Lymphocyte Ratio of Acute Tonsillitis with Deep Neck Space Infection in Adult Patients

The aim of this study was to examine the neutrophil-to-lymphocyte ratio (NLR) in patients diagnosed with a deep neck infection (DNI) to identify helpful indicators for the initial differential diagnosis. This study was conducted as a single-center, retrospective cohort study that utilized data from the electronic medical records of patients who visited the emergency department in a tertiary university hospital between February 2018 and April 2022. The study enrolled patients aged ≥18 years who were diagnosed with tonsillitis with or without DNI during the study period. The NLR of patients without DNI was 6.1 ± 5.03, and the NLR of patients with acute tonsillitis with DNI was 8.0 ± 5.67, showing significant differences. The rate of admission in the general wards (GWs) and ICUs was significantly higher in patients with DNI, and the length of hospital stay was also significantly longer in patients with DNI. Older age, male, lower body temperature, C-reactive protein, and NLR were significant independent risk factors for DNI in patients with tonsillitis. The cutoff value for predicting DNI in patients with body temperature <37.5 was 3.09. The NLR of patients with tonsillitis, especially those with normal body temperature, can be used to predict their prognosis.

Early diagnosis of craniofacial necrotising fasciitis: Analysis of clinical risk factors

Necrotising fasciitis (NF) is a rapidly progressing fatal disease. Craniofacial necrotising fasciitis (CNF) is limited to the region above the mandibular margin, and early diagnosis is particularly difficult in the absence of related studies. Ten-year data of patients with craniofacial infection were collected from four separate hospitals. Based on the diagnostic criteria, patients were classified into abscess and CNF. The risk factors for early diagnosis were analysed by comparing the two groups. Simple abscess was found in 176 patients, and CNF was detected in 25 patients. The risk factors associated with CNF include old age, presence of odontogenic infection, elevated white blood cell count (WBC), increased C-reactive protein (CRP), high levels of creatinine (Cr) and glucose (Glu) and low levels of haemoglobin (Hb) and albumin (Alb). In addition, fever above 38°C and sinusitis at the time of admission and progressive sepsis after admission were also risk factors. Among the statistically significant risk factors, low Alb level showed the greatest association with CNF progression. Appropriate management of CNF via early diagnosis and extensive surgical intervention based on identified risk factors can reduce the mortality rate, complications and unnecessary medical expenses. Clinical question/level of evidence: Diagnostic, III.

Toward automated severe pharyngitis detection with smartphone camera using deep learning networks

PURPOSE

Severe pharyngitis is frequently associated with inflammations caused by streptococcal pharyngitis, which can cause immune-mediated and post-infectious complications. The recent global pandemic of coronavirus disease (COVID-19) encourages the use of telemedicine for patients with respiratory symptoms. This study, therefore, purposes automated detection of severe pharyngitis using a deep learning framework with self-taken throat images.

METHODS

A dataset composed of two classes of 131 throat images with pharyngitis and 208 normal throat images was collected. Before the training classifier, we constructed a cycle consistency generative adversarial network (CycleGAN) to augment the training dataset. The ResNet50, Inception-v3, and MobileNet-v2 architectures were trained with transfer learning and validated using a randomly selected test dataset. The performance of the models was evaluated based on the accuracy and area under the receiver operating characteristic curve (ROC-AUC).

RESULTS

The CycleGAN-based synthetic images reflected the pragmatic characteristic features of pharyngitis. Using the synthetic throat images, the deep learning model demonstrated a significant improvement in the accuracy of the pharyngitis diagnosis. ResNet50 with GAN-based augmentation showed the best ROC-AUC of 0.988 for pharyngitis detection in the test dataset. In the 4-fold cross-validation using the ResNet50, the highest detection accuracy and ROC-AUC achieved were 95.3% and 0.992, respectively.

CONCLUSION

The deep learning model for smartphone-based pharyngitis screening allows fast identification of severe pharyngitis with a potential of the timely diagnosis of pharyngitis. In the recent pandemic of COVID-19, this framework will help patients with upper respiratory symptoms to improve convenience in diagnosis and reduce transmission.

Cervical necrotizing fasciitis as a complication of acute epiglottitis managed with minimally aggressive surgical intervention: Case report

Cervical necrotizing fasciitis secondary to epiglottitis is rare. The standard treatment of this severe condition has long been early and aggressive surgical debridement and adequate antimicrobial therapy. We report the case of an immunocompetent 59-year-old man who developed cervical necrotizing fasciitis as a complication of acute epiglottitis. We were able to successfully manage this patient with conservative surgical treatment (incision and drainage, in addition to antibiotic therapy) that did not involve aggressive debridement.

A case of labio-facial necrotizing fasciitis complicating acne

BACKGROUND

Facial necrotizing fasciitis is extremely rare. Most of the cases reported in literature are related to dental, sinus, tonsillar and salivary glands causes, but rarely as consequence of skin infection. We report a unique case of lower lip cellulitis, which was initially misdiagnosed as angioedema and subsequently progressed into lower lip necrotizing fasciitis.

CASE PRESENTATION

This is a case report of necrotizing fasciitis involving the lower lip as a consequence of infected skin acne in a 19 year old black female. The patient had been diagnosed earlier as a case of angioedema by a physician and treated accordingly. She was mildly anemic, hyponatremic and hypokalemic. Treatment was started immediately by incision, drainage and full debridement of the whole necrotic tissue. Triple antibiotic therapy was administered and daily irrigation and dressing were performed until full recovery. Complete healing occurred within a month by secondary intention.

CONCLUSION

This case demonstrates the misdiagnosis of a lip swelling leading to the development of labiofacial necrotizing fasciitis, a serious and life threatening condition. Lip angioedema is a common condition; however, lip fasciitis is rare. A broad differential diagnosis in case of lower lip swelling is essential to avoid inappropriate treatment delay.

[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 fasciitis of face--our experience in its management

Necrotising fasciitis (NF) is a severe soft tissue infection which spreads rapidly through fascial planes, characterised by soft tissue necrosis and potentially life threatening. Involvement of the face from NF is rare. Only 35 such cases have been reported in the literature since 1960. It is associated with a high mortality and results in severe disfigurement of the face, posing challenging reconstructive problems. The authors present their experience on the comprehensive management of NF of face with severe disfigurement affecting a young female patient.

Hospital epidemiology of emergent cervical necrotizing fasciitis

Background:

Necrotizing fasciitis (NF) is a surgical emergency. It is a rapidly progressing infection of the fascia and subcutaneous tissue and could be fatal if not diagnosed early and treated properly. NF is common in the groin, abdomen, and extremities but rare in the neck and the head. Cervical necrotizing fasciitis (CNF) is an aggressive infection of the neck and the head, with devastating complications such as airway obstruction, pneumonia, pulmonary abscess, jugular venous thrombophlebitis, mediastinitis, and septic shock associated with high mortality.

Aim:

To assess the presentation, comorbidities, type of infection, severity of disease, and intensive care outcome of CNF.

Methods:

Medical records of the patients treated for NF in the surgical intensive care unit (SICU) from January 1995 to February 2005 were reviewed retrospectively.

Results:

Out of 94 patients with NF, 5 (5.3%) had CNF. Four patients were male. The mean age of our patients was 41.2 ± 14.8 years. Sixty percent of patients had an operative procedure as the predisposing factor and 80% of patients received nonsteroidal anti-inflammatory drugs (NSAIDs). The only comorbidity associated was diabetes mellitus (DM) in 3 patients (60%). Sixty percent of the cases had type1 NF. Mean sequential organ failure assessment (SOFA) score on admission to the ICU was 8.8 ± 3.6. All patients had undergone debridement at least two times. During the initial 24 h our patients received 5.8 ± 3.0 l of fluid, 2.0 ± 1.4 units of packed red blood cells (PRBC), 4.8 ± 3.6 units of fresh frozen plasma (FFP), and 3.0 ± 4.5 units of platelet concentrate. The mean number of days patients were intubated was 5.2 ± 5.1 days and the mean ICU stay was 6.4 ± 5.2 days. Sixty percent of cases had multiorgan dysfunction (MODS) and one patient died, resulting in a mortality rate of 20%.

Conclusion:

According to our study, CNF represents around 5% of NF patients. CNF was higher among male patients and in patients with history NSAIDs and dental surgeries. Type 1 NF was more common and DM was the only comorbid condition seen in this limited number of patients. The low mortality may be due to the early diagnosis and aggressive surgical treatment combined with optimal supportive intensive care management.

Cervical necrotizing fasciitis due to methicillin-resistant Staphylococcus aureus: a case report

Cervical necrotizing fasciitis is an uncommon but potentially fatal infection characterized by rapidly progressive, widespread necrosis of the superficial fascia. The authors report a case of cervical necrotizing fasciitis of odontogenic origin in a male with uncontrolled diabetes mellitus. An early diagnosis was based on clinical examination, confirmed by computed tomography (CT) scan, which showed multiple collections of air in the left submandibular, submental and cervical region. Broad spectrum antibiotic therapy was started quickly followed by surgical drainage and debridement. Pus culture was positive for methicillin-resistant Staphylococcus aureus. Four days after admission, mediastinitis was revealed by CT and drainage was conducted through a transcervical incision. The patient was treated successfully with antimicrobial therapy, repeated surgical debridement and supportive care.

Optimal treatment of cervical necrotizing fasciitis associated with descending necrotizing mediastinitis

Background

Cervical necrotizing fasciitis (CNF) associated with descending necrotizing mediastinitis (DNM) is a rapidly evolving and life-threatening condition. The aim of this retrospective study was to describe a treatment strategy for CNF with DNM and present a management algorithm for mediastinal extensions of CNF.

Methods

Patients diagnosed and treated for CNF with DNM over 14 years in a tertiary referral centre were included.

Results

Seventeen adult patients were included. The origin of infection was mainly oropharyngeal. The diagnosis of CNF/DNM was based on clinical and computed tomography findings. All patients underwent cervicotomy for CNF. In ten patients, DNM was located above the carina and could be accessed by a cervical approach. In seven patients, DNM was below the carina, and necessitated sternotomy for anteroinferior mediastinal involvement and posterolateral thoracotomy for posteroinferior mediastinal involvement. All patients received broad-spectrum antibiotics. One patient died 3 days after surgery. The median hospital stay was 30 days. There was no recurrence during long-term follow-up.

Conclusion

Prompt diagnosis and early surgical treatment are essential for reducing mortality in CNF/DNM. All patients should undergo extensive cervicotomy. The surgical approach to the mediastinum depends on the supracarinal or infracarinal location of the disease.

Cervical necrotising fasciitis and descending mediastinitis secondary to unilateral tonsillitis: a case report

Introduction

Cervical necrotizing fasciitis is an aggressive infection with high morbidity and mortality. We present a case of cervical necrotizing fasciitis and descending mediastinitis in a healthy young man, caused by unilateral tonsillitis with a successful outcome without aggressive debridement.

Case presentation

A 41-year-old man was admitted to our unit with a diagnosis of severe acute unilateral tonsillitis. On admission, he had painful neck movements and the skin over his neck was red, hot and tender. Computed tomography scan of his neck and chest showed evidence of cervical necrotizing fasciitis and descending mediastinitis secondary to underlying pharyngeal disease. He was treated with broad-spectrum intravenous antibiotics. His condition improved over the next 3 days but a tender and fluctuant swelling appeared in the suprasternal region. A repeat scan showed the appearance of an abscess extending from the pretracheal region to the upper mediastinum which was drained through a small transverse anterior neck incision. After surgery, the patient's condition quickly improved and he was discharged on the 18th day of admission.

Conclusion

Less invasive surgical techniques may replace conventional aggressive debridement as the treatment of choice for cervical necrotizing fasciitis and descending necrotizing mediastinitis.

[Diffuse cervical cellulites and descending necrotizing mediastinitis]

OBJECTIVES

To give a report on the progress in physical examination, investigations and treatment of diffuse cervical cellulites (DCC) associated with descending necrotizing mediastinitis.

MATERIALS AND METHODS

A Retrospective study (1995-2005) of patients presenting DCC with mediastinitis was made. All had a cervical and thoracic Computed tomography (CT) scan. The references were collected by a Medline search.

RESULTS

Six men and 2 women, average ages 53 years were treated. Four had an immunodeficient status. Two had had an anti-inflammatory drug treatment without antibiotic treatment. The average for diagnosis and treatment was 4 days. In 2 cases we found a dental origin and in 6 cases a pharyngeal origin. The most frequently identified germs were streptococcus beta haemolytic group A and Prevotella. In 4 cases, no physical sign of mediastinitis was noted. The diagnosis of mediastinitis was made thanks to the thoracic CT scan. All the patients were treated by broad-spectrum antibiotic therapy. All had cervical and thoracic surgical drainage. Mediastinal drainage was made by cervical way in 3 cases and by thoracotomy in 5 cases. One patient died.

CONCLUSIONS

The DCC with mediastinum extension are serious infectious emergencies with a high mortality rate. Clinical diagnosis of mediastinitis is difficult. A thoracic CT scan should be performed systematically. Performing thoracotomy best controls mediastinal drainage.

Cervical complications following routine tonsillectomy and adenoidectomy

PURPOSE OF REVIEW

Fortunately, patients undergoing adenotonsillectomies have far more complaints than complications. Sore throats, dysphagia, and neck pain are frequent and expected symptoms after surgery. Differentiating these symptoms from early signs of severe cervical complications can be difficult. Such complications are rare but include atlanto-axial subluxation (Grisel's syndrome), cervical necrotizing fasciitis, cervical emphysema and cervical oseteomyelitis. Due to the frequency with which adenotonsillectomies are performed, most otolaryngologists will encounter these events during their career. This article is thereby intended to elucidate the early warnings, appropriate diagnostic workup, and therapeutic modalities for cervical complications following adenotonsillectomies.

RECENT FINDINGS

Early recognition and intervention can prevent devastating morbidity and mortality described with cervical complications. Computed tomography scanning remains the gold standard for diagnosing cervical complications after adenotonsillectomy. Although a range of severity exists in cervical complications, most cases can be managed conservatively with broad spectrum antibiotics, observation, bedrest and immobilization in cases of Grisel's syndrome. Cervical necrotizing fasciitis requires a high index of suspicion and urgent management to avoid fatal consequences.

SUMMARY

This is a review of the most frequently encountered, although rare, cervical complications following adenotonsillectomies. It gives the reader an insight into the efficient diagnosis and management of these complications.