Cervicofacial necrotizing fasciitis

Diabetes Research and Clinical Practice 72 (2006) 206–208 www.elsevier.com/locate/diabres Brief report Cervicofacial necrotizing fasciitis Bettina Hohlweg-Majert *, Nils Weyer, Marc C. Metzger, Ralf Schön Department of Oral and Maxillofacial Surgery, University Hospital Freiburg, Hugstetterstrasse 55, D-79106 Freiburg, Germany Received 14 September 2005; accepted 21 September 2005 Available online 30 January 2006 Abstract Cervical necrotizing fasciitis is a fast spreading acute soft tissue inflammation. Death can occur within 12–24 h. Early identification and treatment is needed. We report the case of a 75 year old woman with diabetes and high cholesterol, adipositas who developed cervical necrotizing fasciitis of odotongenic origin with massive subcutaneous air collection and first sign of septicaemia. Surgical treatment with debridement and drainage in combination with intravenous broadbased antibiotics as well as daily irrigation of the wound with iodine solution (Betaisodona1) and metronidazol (local antibiotic treatment) was performed. The patient recovered completely. Surgical debridement combined with broad-spectrum of antibiotics showed satisfying result for the management of cervical necrotizing fasciitis of dentogenous origin. # 2005 Elsevier Ireland Ltd. All rights reserved. Keywords: Cervicofacial fasciitis; Dentogenous complications; Radiology; Surgical debridement 1. Introduction The incidence of soft tissue infections is increased in immunocompromised patients with diabetes mellitus, cancer, vascular insufficiencies, HIV, organ transplantation, alcoholism or neutropenia [1]. Necrotizing fasciitis known as ‘‘flesh-eating disease’’, is a rapidly progressive, spreading inflammatory process which is located in the deep fascia with secondary necrosis of the subcutaneous tissue. The presence of gas forming organisms causes subcutaneous air and crepitation may be noticed during the physical examination. Symptoms may include local manifestations such as painful oedema or notable paraesthesia, * Corresponding author. Tel.: +49 761 270 4701; fax: +49 761 270 4758. E-mail address: bettina.majert@unklinik-freiburg.de (B. Hohlweg-Majert). erythema and crepitus as a result of the infection dissecting along the platysma and skin necrosis [1,2]. The presence of gas in the tissue or an orange peel appearance of the involved skin are highly suggestive for a craniofacial necortizing fasciitis [3]. Death can occur in 12–24 h due to sepicaemia. 2. Methods A 75 year old woman was admitted with a massive cervical swelling, fever and reduced general condition. She was noted to have altered mental status and difficulties with breathing. A right-sided swelling of the submandibular area and neck associated with erythema, which extended to the clavicles was obvious. Her medical history showed a poorly controlled diabetes mellitus type II with polyneuropathy, hypercholesterolaemia, generalized arteriosclerosis, hypertension, adipositas and alcohol abuse. Subcutaneous crepitus 0168-8227/$ – see front matter # 2005 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.diabres.2005.09.012 B. Hohlweg-Majert et al. / Diabetes Research and Clinical Practice 72 (2006) 206–208 207 White blood cell count of 14 500 ml 1, platelet 444 000 ml 1, hemoglobin 9.1 g/dl, CRP of 20 mg/l with a blood sugar of 234 mg/dl was found. 3. Results Fig. 1. Preoperative view of extensive cervical swelling with subcutaneous necrosis and emphysema. was palpable in the anterior aspect of the neck. Skin was necrotic in an area of 3 cm  2 cm in the submandibular region (Fig. 1). Multiple carious teeth, massive plaque, leaking of pus lingually in region 47 and a swelling of the floor of the mouth was found intraorally. The second right lower molar was decayed and mobile. There was no parapharyngeal swelling. The panoramic radiograph showed a desolated dention with multiple missing teeth and apical radiolucency in region 37 and 47. A computer tomography of the neck and chest revealed extensive soft tissue emphysema. Gas collection in the subcutaneous tissue of the neck extended from pyterygomaxillary area caudally to clavicular region (Fig. 2). There was no evidence of mediastinal inflammatory involvement. Under general anaesthesia with oral endotracheal intubation the second right molar was extracted before an extraoral cervical incision was performed in the area of skin necrosis. Extensive necrosis of the subcutaneous plane from the middle third of the right sternocleidomastoid muscle to the submandibular region of the left side was revealed. Pus was drained and necrotic subcutaneous tissue debrided. A large soft tissue pocket in the area of the gas collection was debrided and drained using multiple silicon drains. Swaps and soft tissue specimens were taken for diagnostic reasons before debridement and wound irrigation with iodine solution (Betaisodona1; Mundipharma GmbH; Limburg, Germany). On postoperative day one white blood cell count decreased from 14 500 to 9800 ml 1. Postoperatively intubation for 2 days was indicated due to a compromised airway. Chemotherapy with intravenous antibiotics including penicillin, meropenem and metronidazol was administrated. Irrigation of the wound with Betaisodona1 and metronidazol was performed twice a day for 5 days. Streptococcus intermedius, black pigmented Bacteroides and Bacteroides species were cultured in the swaps. On postoperative CT scans no sign showed no mediastal involvement was found. The postoperative period was complicated due to left heart decompensation and the patient remained in the intensive care unit for 8 days. Laboratory values improved with white blood cell count of 6600 ml 1 on postoperative day 2, and continued to normalize. The patient was discharged with a good general condition and recovered from a preoperative altered mental status. 4. Discussion Fig. 2. Axial view of CT image of the cervicofacial necrotizing fasciitis with cervical subcutaneous gas collection and swelling. Cervical necrotizing fasciitis is an acute soft tissue infection that involves the cutaneous and facial planes of the neck. It has a rapid onset and a fulminate course, warranting early diagnosis and intervention. Surgical debridement and drainage is the key to a successful management. This disease rarely occurs in the head and neck section with an incidence about 2.6%. It is associated with a high mortality rate of 6–76% [4]. Necrotizing fasciitis can be caused by trauma, operative incision, pre-existing ulcer, insect bites or haematogenous spread from other septic foci [1,5,6]. 208 B. Hohlweg-Majert et al. / Diabetes Research and Clinical Practice 72 (2006) 206–208 Causes for infection may be dentogenous, peritonsillar or sinusitis [7]. There are reports of craniofacial necrotizing fasciitis (CNF) due to odontogenic origin [2,4,8,9]. Myonecrosis can occur in the end stage of CNF. Reported risk factors include diabetes, immunosuppression, renal failure, intravenous drug abuse, cardiovascular disease, alcohol abuse and radiation therapy [1,4]. The life threatening complications include mediastinitis, septic shock, jugular vein thrombosis, airway obstruction and pneumonia [2,9,10]. Spread of the infection from the head and neck to the mediastinum from the retropharyngeal or prevertebral space demonstrates a mortality of more than 50%. Insoluble gas such as nitrogen and hydrogen may be produced by Bacteroides and can be detected by CT or MRT. The causative organisms may be aerobic, anaerobic or mixed. In the neck up to 60% of the main pathogens are anaerobic Peptostreptococcus, Bacteroides and Fusobacterium species. Frequently initiating bacteria of CNF are group A haemolytic streptococci, streptococcus pyrogenes and staphylococcus aurens [3,11–13]. Other pathogens may be found as Bacteriodes, Clostrium, Proteus, Klebsiella, Vibro, Enterobacteriaceae [1,14]. Odontogenic infections are often polymicrobial [7]. Broad-spectrum of antibiotics and often more than one antibiotic including a penicillinase-resistent penicillin for streptococcal and staphylococcal bacteria, and aminoglycoside for Gram-negative bacteria, clindamezin or metronidazole for anaerobic organisms may be indicated [2,3]. Morbidity and mortality can be reduced by an early surgical procedure with an aggressive debridement [9,10,14,15]. Endotracheal intubation may be needed to maintain the airway and intensive care may be indicated. Broad-spectrum of antibiotics should be given as soon as possible. Surgical debridement has to be performed if needed repetitively [1,3,9]. With adequate surgical and antibiotic treatment the mortality rate associated with necrotizing fasciitis of odontogenic origin is 19.2% [16]. It is reported that a therapy with a net containing 100 maggots (Biobag, Bionmonde, Germany) is successfully used to avoid the multiple surgical debridement [17]. The effect of hyperbaric oxygen for the therapy of CNF is controversially discussed [3,18,19]. A combination of extensive surgical debridement and administration of broad based spectrum of antibiotics was used for the successful management of cervical necrotizing fasciitis of odontogenic origin with presented case report. It seems still to be the best way of choice. Reference [1] C.H. Wong, A. Kurup, Y.S. Wang, K.S. Heng, K.C. 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