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Passemard L, Hida S, Barrat A, Sakka L, Barthélémy I, Dang NP. Eyelid and periorbital necrotizing fasciitis, a severe preseptal infection, a systemic review of the literature and anatomical illustrations. JOURNAL OF STOMATOLOGY, ORAL AND MAXILLOFACIAL SURGERY 2023:101498. [PMID: 37178871 DOI: 10.1016/j.jormas.2023.101498] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/02/2023] [Accepted: 05/10/2023] [Indexed: 05/15/2023]
Abstract
In necrotizing fasciitis, aggressive surgical debridement and broad-spectrum antibiotics are the cornerstone of treatment but cannot be proposed for the eyelid and periorbital area because of the risk of blindness, eyeball exposure and disfiguration. The aim of this review was to determine the most effective management of this severe infection while preserving eye function. A literature search of the PubMed, Cochrane Library, ScienceDirect and Embase databases was conducted for all articles published up to March 2022; 53 patients were included. Management was probabilistic, combining antibiotic therapy with skin (+/- orbicularis oculi muscle) debridement in 67.9 % of cases, and probabilistic antibiotic therapy alone in 16.9% of cases. Radical surgery with exenteration was performed in 11.1% of patients; 20.9% of patients had complete loss of vision, and 9.4% died of the disease. Aggressive debridement was rarely necessary possibly because of the anatomical particularities of this region.
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Affiliation(s)
- Léa Passemard
- University Hospital of Clermont-Ferrand, CHU Clermont-Ferrand, Department of Oral and Maxillofacial surgery, F-63000, Clermont-Ferrand, France..
| | - Sarah Hida
- University Hospital of Clermont-Ferrand, CHU Clermont-Ferrand, Department of Oral and Maxillofacial surgery, F-63000, Clermont-Ferrand, France..
| | - Antoine Barrat
- University Hospital of Clermont-Ferrand, CHU Clermont-Ferrand, Department of Oral and Maxillofacial surgery, F-63000, Clermont-Ferrand, France..
| | - Laurent Sakka
- Laboratoire d'anatomie, Faculté de Médecine, Université d'Auvergne, 28, place Henri-Dunant, 63001 Clermont-Ferrand cedex 1, France..
| | - Isabelle Barthélémy
- University Hospital of Clermont-Ferrand, CHU Clermont-Ferrand, Department of Oral and Maxillofacial surgery, F-63000, Clermont-Ferrand, France.; UMR Inserm/UdA, U1107, Neuro-Dol, Trigeminal Pain and Migraine, Université d'Auvergne, Clermont-Ferrand, 63003, France..
| | - Nathalie Pham Dang
- University Hospital of Clermont-Ferrand, CHU Clermont-Ferrand, Department of Oral and Maxillofacial surgery, F-63000, Clermont-Ferrand, France.; UMR Inserm/UdA, U1107, Neuro-Dol, Trigeminal Pain and Migraine, Université d'Auvergne, Clermont-Ferrand, 63003, France..
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Nazir H, Ying Chieng C, Rogers SN, Nekrasisus R, Dodd M, Shah N. Outcomes of necrotizing fasciitis in the head and neck region in the United Kingdom-a case series and literature review. ADVANCES IN ORAL AND MAXILLOFACIAL SURGERY 2022. [DOI: 10.1016/j.adoms.2022.100254] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
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The Skin-Sparing Debridement Technique in Necrotizing Soft-Tissue Infections: A Systematic Review. J Surg Res 2021; 264:296-308. [PMID: 33845413 DOI: 10.1016/j.jss.2021.03.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2020] [Revised: 02/18/2021] [Accepted: 03/03/2021] [Indexed: 12/19/2022]
Abstract
BACKGROUND Skin-sparing debridement (SSd) was introduced as an alternative to en bloc debridement (EBd) to decrease morbidity caused by scars in patients surviving Necrotizing soft-tissue infections (NSTI). An overview of potential advantages and disadvantages is needed. The aim of this review was to assess (1) whether SSd is noninferior to EBd regarding general outcomes, that is, mortality, length of stay (LOS), complications, and (2) if SSd does indeed result in decreased skin defects. METHODS A systematic literature search was performed according to the PRISMA guidelines. All human studies describing patients treated with SSd were included, when at least of evidence level consecutive case series. Studies describing up to 20 patients were pooled to improve readability and prevent overemphasis of findings from single small studies. RESULTS Ten studies, one cohort study and nine case series, all classified as poor based on Chambers criteria for case series, were included. Compared to patients treated with EBd, patients treated with SSd had no increased mortality rate, LOS or complication rate. SSd-treated patients had a high rate (75%) of total delayed primary closure (DPC) in the pooled case series. CONCLUSION The current available evidence is of insufficient quality to conclude whether SSd is noninferior to EBd for all assessed outcomes. There are suggestions that SSd may result in a decreased need for skin transplants, which could potentially improve the (health related) quality of life in survivors. Experienced surgical teams could cautiously implement SSd under close monitoring, ideally with uniform outcome registry.
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Miller LE, Shaye DA. Noma and Necrotizing Fasciitis of the Face and Neck. Facial Plast Surg 2021; 37:439-445. [PMID: 33517575 DOI: 10.1055/s-0041-1722894] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022] Open
Abstract
Necrotizing fasciitis (NF) is part of the class of necrotizing soft tissue infections characterized by rapid fascial spread and necrosis of the skin, subcutaneous tissue, and superficial fascia. If left untreated, NF can rapidly deteriorate into multiorgan shock and systemic failure. NF most commonly infects the trunk and lower extremities, although it can sometimes present in the head and neck region. This review provides an overview of NF as it relates specifically to the head and neck region, including its associated clinical features and options for treatment. Noma, a related but relatively unknown disease, is then described along with its relationship with severe poverty.
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Affiliation(s)
- Lauren E Miller
- Department of Otolaryngology-Head and Neck Surgery, Massachusetts Eye and Ear, Harvard Medical School, Boston, Massachusetts
| | - David A Shaye
- Department of Otolaryngology-Head and Neck Surgery, Massachusetts Eye and Ear, Harvard Medical School, Boston, Massachusetts.,Division of Facial Plastic and Reconstructive Surgery, Department of Otolaryngology-Head and Neck Surgery, Massachusetts Eye and Ear, Harvard Medical School, Boston, Massachusetts.,Doctors without Borders, Noma Project, Sokoto, Nigeria
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Shivalingappa S, Manjunath KN, Waiker V, Kumaraswamy M, Odeyar U. Necrotising Fasciitis: Appearances Can Be Deceptive. World J Plast Surg 2021; 10:43-52. [PMID: 33833953 PMCID: PMC8016375 DOI: 10.29252/wjps.10.1.43] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND Necrotizing fasciitis is a potentially fatal infection of β hemolytic Group-A Streptococcus, often occurring in patients with other comorbidities, but can occur in healthy individuals as well. It commonly affects the extremities, perineum, and abdominal wall. The aim of this study was to highlight various presentations of necrotizing fasciitis in unusual anatomical sites with delayed diagnosis and treatment. METHODS In a retrospective analysis, seven cases of unusual presentations of necrotizing fasciitis were enrolled during a period of five years treated in a tertiary centre. RESULTS The patients were between 23 and 80 years. Four were males and three were females. Four out of seven were diabetic. All patients had septicemia (hypovolemic shock, with leucocytosis, thrombocytopenia and deranged coagulation parameters) on admission in the intensive care unit. All seven patients had minimal cutaneous manifestation and the remote primary pathology was diagnosed in two patients. Six patients out of seven survived and the morbid state continued in one patient in view of malignancy of rectum in one patient. The overall outcome was satisfactory in five out of seven cases. CONCLUSION Pain disproportionate to the local inflammation with florid constitutional symptoms should raise suspicion of necrotizing fasciitis. Early diagnosis, of stabilization of hemodynamics, emergency fasciotomy, staged debridement and the initiation of broad spectrum antibiotics reduced the morbidity and mortality. The disease may manifest with uncommon presentations and sometimes lead to the diagnosis of primary aetiology.
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Affiliation(s)
| | - K N Manjunath
- Department of Plastic and Reconstructive Surgery, Ramaiah Medical College, Bangalore, India
| | - Veena Waiker
- Department of Plastic and Reconstructive Surgery, Ramaiah Medical College, Bangalore, India
| | - M Kumaraswamy
- Department of Plastic and Reconstructive Surgery, Ramaiah Medical College, Bangalore, India
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Compton RA, Konstantinou EK, Kapadia MK, Scott AR. Optimizing aesthetics following surgical management of periorbital necrotizing fasciitis. Am J Otolaryngol 2020; 41:102668. [PMID: 32841764 DOI: 10.1016/j.amjoto.2020.102668] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2020] [Accepted: 08/08/2020] [Indexed: 10/23/2022]
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Khurana S, Pushker N, Naik SS, Changole MD, Ghonsikar V, Bajaj M. Periorbital necrotising fasciitis in infants: Presentation and management of six cases. Trop Doct 2015; 45:188-93. [DOI: 10.1177/0049475515575671] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Purpose To present the clinical features and management of infants presenting with periorbital necrotising fasciitis (NF). Methods Retrospective case series. Results Six children were studied. The age at presentation was in the range of 5–11 months (median, 8 months). All children presented with acute onset eyelid inflammation and necrosis with fever, lethargy and poor oral intake. The management included intravenous antibiotics and repeated surgical debridement. The infection healed by 2–3 weeks in all cases, resulting in cicatricial ectropion and lagophthalmos. Full thickness skin grafting (with a Hughes tarso-conjunctival graft in one child) was performed in all patients at 3–5 weeks subsequently. Repeat surgery was required in three children. Adequate globe coverage and cosmesis was achieved in five children. Conclusion NF of eyelids is a potentially fatal infection that requires urgent and vigorous management and heals with sequelae that may need more than one surgical intervention over a period of time. Adequate cosmetic and functional outcomes can be achieved.
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Affiliation(s)
- Saurbhi Khurana
- Doctor, Dr Rajendra Prasad Centre for Ophthalmic Sciences, All India Institute of Medical Sciences, New Delhi, India
| | - Neelam Pushker
- Professor, Dr Rajendra Prasad Centre for Ophthalmic Sciences, All India Institute of Medical Sciences, New Delhi, India
| | - Sreedhara S Naik
- Doctor, Dr Rajendra Prasad Centre for Ophthalmic Sciences, All India Institute of Medical Sciences, New Delhi, India
| | - Milind Devidas Changole
- Doctor, Dr Rajendra Prasad Centre for Ophthalmic Sciences, All India Institute of Medical Sciences, New Delhi, India
| | - Vishnukant Ghonsikar
- Doctor, Dr Rajendra Prasad Centre for Ophthalmic Sciences, All India Institute of Medical Sciences, New Delhi, India
| | - Mandeep Bajaj
- Professor, Dr Rajendra Prasad Centre for Ophthalmic Sciences, All India Institute of Medical Sciences, New Delhi, India
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Abstract
PURPOSE To describe a modified wound closure technique in cases of necrotizing fasciitis and to describe its efficacy and usefulness. METHODS The clinical characteristics of patients that underwent extensive debridement and modified wound closure were recorded and documented. RESULTS Seven patients (5 males, 2 females; mean age = 40.9 years, standard deviation = 25.3 years) underwent debridement and modified wound closure. At discharge from the hospital, 6 patients (84.7%) achieved vision of 20/25 of better, although 1 patient lost all vision in the affected eye. Six patients (84.7%) experienced improvement in their visual acuity between admission to and discharge from the hospital. After a mean follow-up interval of 6.3 months, 5 patients (71.4%) did not require additional reconstructive interventions. CONCLUSIONS In cases of periorbital necrotizing fasciitis, extensive debridement with a modified wound closure is a technically feasible intervention and produced excellent clinical, functional, and aesthetic results.
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Abstract
Necrotizing fasciitis (NF) is a severe infection characterized by rapidly progressing necrotizing infection of the superficial fascia with secondary necrosis of the overlying skin. Periorbital NF is uncommon because of the excellent blood supply to that area; nevertheless, it can sometimes result in death. The aim of this study is to present a systematic review and analyse the factors associated with death. We carried out a systematic literature review of all cases of periorbital NF published in the English language over the past 20 years and present the predisposing conditions, triggering factors, organisms causing NF, presence or absence of toxic shock and the prognosis. The significance of various risk factors leading to death was analysed. We traced a total of 94 patients with periorbital NF from 61 reports. There were no triggering incidents in 25 cases (26.6%). In 48 cases (51.1%), the organism responsible for NF was Group A beta haemolytic Streptococcus. Toxic shock occurred in 29 (30.9%) cases, and loss of vision in 13 (13.8%). Surgical debridement was carried out in 80 (85.1%) cases. There were eight cases (8.5%) of death. This seems to be less than previously reported figures. Toxic shock syndrome (p < 0.001), type 1 infections (p = 0.018), facial involvement (p = 0.032) and blindness because of periorbital NF (p = 0.035) were significantly associated with mortality. Mortality caused by NF arising from the periorbital area seems to be on the decline. However, it is important to recognize it early and institute treatment to avoid toxic shock that leads to death. Type 1 infections, although rare in periorbital area, are not associated with immunocompromised status and nevertheless carry a significant risk of mortality. Major morbidity is loss of vision followed by soft-tissue defects affecting function and cosmesis.
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Affiliation(s)
- Shantha Amrith
- Department of Ophthalmology, National University Health System, Singapore City, SingaporeDepartment of Ophthalmology, Kasturba Medical College, Manipal University, Manipal, IndiaSingapore Eye Research Institute, Singapore National Eye Center, Singapore City, Singapore
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Laouar K, Ruban JM, Baggio E, Dupeyron G. [Cosmetic blepharoplasty complicated by necrotizing periorbital fasciitis: a case report]. J Fr Ophtalmol 2012; 35:437.e1-8. [PMID: 22633216 DOI: 10.1016/j.jfo.2011.07.018] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2011] [Revised: 07/12/2011] [Accepted: 07/19/2011] [Indexed: 10/28/2022]
Abstract
Necrotizing periorbital or palpebro-orbital fasciitis represents a unique anatomical site for necrotizing fasciitis, which is an extremely rare and very severe, potentially devastating bacterial infection, rapidly leading to facial necrosis with loss of vision and even death of the patient from toxic shock. In this paper, we report a case of necrotizing periorbital fasciitis as a complication of cosmetic lower eyelid blepharoplasty. Necrotizing fasciitis most often affects the upper and lower limbs, the trunk and the perineal area. It is rarely observed in the facial region due to the rich blood supply in this area. The most commonly implicated pathogen is group A, β-hemolytic "pyogenic"Streptococcus, either alone or in combination with other bacteria, such as staphylococcus or pseudomonas. Mortality varies according to the series and anatomical site. The mortality rate for necrotizing fasciitis is approximately 28 %. It is slightly lower in the periorbital area (15 %). Risk factors for death include alcoholism, diabetes mellitus, immunocompromise, hematologic or pulmonary diseases, and the identity of the causative agent (group A Streptococcus), although approximately 50 % of patients have no predisposing conditions. Management of periorbital necrotizing fasciitis is based on early detection of initial symptoms and on aggressive multidisciplinary treatment including surgical debridement of necrotic areas and antibiotic coverage. The timeliness of treatment and the multidisciplinary approach are considered to be the two essential factors in influencing the mortality and morbidity of this condition.
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Affiliation(s)
- K Laouar
- Service d'ophtalmologie, centre hospitalo-universitaire Carémeau, place du Pr.-Debré, 30029 Nîmes, France.
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11
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The Vacuum-Assisted Closure in Treating Craniofacial Wounds. J Oral Maxillofac Surg 2010; 68:935-42. [DOI: 10.1016/j.joms.2009.09.113] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2009] [Accepted: 09/22/2009] [Indexed: 11/19/2022]
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12
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Fungal Periorbital Necrotizing Fasciitis in an Immunocompetent Adult. Ophthalmic Plast Reconstr Surg 2009; 25:334-5. [DOI: 10.1097/iop.0b013e3181ab7518] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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13
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Schurr C, Burghartz M, Miethke T, Kesting M, Hoang N, Staudenmaier R. Management of facial necrotizing fasciitis. Eur Arch Otorhinolaryngol 2008; 266:325-31. [PMID: 19043730 DOI: 10.1007/s00405-008-0870-y] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2008] [Accepted: 11/10/2008] [Indexed: 10/21/2022]
Abstract
Necrotizing fasciitis is a progressive, life-threatening, bacterial infection of the skin, the subcutaneous tissue and the underlying fascia, in most cases caused by ss-hemolytic group A streptococcus. Only early diagnosis and aggressive therapy including broad spectrum antibiotics and surgical intervention can avoid systemic toxicity with a high mortality rate. This uncommon disease generally occurs in the lower extremities and trunk, and only rarely affects the head and neck region. When located in the face necrotizing fasciitis is associated with severe cosmetic and functional restrictions due to the invasive infection and often to the necessary surgical treatment. Generally surgical intervention cannot be performed in the face as aggressively as in the extremities and trunk, since a lot of vital structures are found in a relatively small area. In the following article, we present the successful diagnostic and therapeutic management of an isolated facial necrotizing fasciitis as a consequence of a nasal bone fracture with a minor dermal cut.
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Affiliation(s)
- Christian Schurr
- Klinik für Hals-Nasen-Ohren-Heilkunde, Technische Universität München, Munich, Germany.
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Balbierz JM, Ellis K. Streptococcal infection and necrotizing fasciitis—implications for rehabilitation: a report of 5 cases and review of the literature. Arch Phys Med Rehabil 2004; 85:1205-9. [PMID: 15241775 DOI: 10.1016/j.apmr.2003.12.024] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
Five cases are presented of patients who were diagnosed with necrotizing fasciitis secondary to (1) hip disarticulation (in a paraplegic patient); (2) tooth abscess with extensive neck dissection, complicated by sepsis and hypotension with resultant dysphagia and ischemic encephalopathy; (3) below-knee amputation, anoxia, and severe debility; (4) emergent above-knee amputation; and (5) percutaneous endoscopic gastrostomy placement. The latter patient developed abdominal and chest wall necrotizing fasciitis that required skin grafting. Four patients were treated in an acute rehabilitation setting and returned home, and the fifth was rehabilitated in a subacute facility. This report emphasizes the importance of carefully monitoring rehabilitation patients, especially those with impaired sensation.
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Affiliation(s)
- Janet M Balbierz
- Division of Physical Medicine and Rehabilitation, University of Utah School of Medicine, 30 N 1900 E, Salt Lake City, UT 84132-2119, USA.
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Fujiki N, Nakamura H, Nonomura M, Ishijima K, Konishi Y. Bilateral vocal fold paralysis caused by polyarteritis nodosa. Am J Otolaryngol 1999; 20:412-4. [PMID: 10609489 DOI: 10.1016/s0196-0709(99)90084-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- N Fujiki
- Department of Otolaryngology, Shizuoka City Hospital, Japan
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Whetzel TP, Sykes JM, Reilly DA. Acute reconstruction of massive cervicofacial necrotizing fasciitis with Estlander and free scapular/parascapular flaps. Otolaryngol Head Neck Surg 1999; 120:101-4. [PMID: 9914557 DOI: 10.1016/s0194-5998(99)70377-3] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- T P Whetzel
- Division of Plastic and Reconstructive Surgery, University of California-Davis Medical Center, Sacramento 95817, USA
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17
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Affiliation(s)
- M H Ali
- Department of Surgery, King Fahad Hospital, Al Baha, Saudi Arabia
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18
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Abstract
Necrotizing fasciitis (NF) is a rapidly progressive soft tissue infection with high morbidity and mortality rates. Its occurrence in the head and neck region is uncommon, the majority of reported cases being limited to involvement of the neck, usually from infections of dental or pharyngeal origin. Involvement of the face from NF is rare; only 35 such cases have been reported in the literature since 1960. It is not only associated with a high mortality but can also result in severe disfigurement of the face, posing challenging reconstructive problems. Successful management of facial NF requires early diagnosis, prompt institution of broad spectrum antibiotics, aggressive surgical debridement to control the infection, and reconstruction of the resultant soft tissue defects. This report describes four additional cases of facial necrotizing fasciitis. One of the four patients died as a result of sepsis and multi-organ system failure. Two of the three surviving patients had significant facial disfigurement. A comprehensive review of the facial NF cases reported in the literature is also provided. Based on our experience with facial NF and the results of all previous case reports, the clinical manifestations, pathogenesis, and management of this disease are discussed.
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Affiliation(s)
- M L Shindo
- Department of Otolaryngology-Head and Neck Surgery, University of Southern California, Los Angeles, USA
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19
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Hadfield PJ, Motamed M, Glover GW. Synergistic necrotizing cellulitis resulting from peri-tonsillar abscess. J Laryngol Otol 1996; 110:887-90. [PMID: 8949306 DOI: 10.1017/s002221510013525x] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
This case demonstrates the rare but potentially fatal condition of synergistic necrotizing cellulitis of the head and neck. Although similar to necrotizing fasciitis, this is more extreme as it also destroys muscle. Peri-tonsillar abscess is a recognized cause, but has not previously been described in this country, however it is a condition commonly referred to otolaryngologists and awareness of the complication of synergistic necrotizing cellulitis is necessary to allow early recognition and prompt treatment. This should be by broad-spectrum intravenous antibiotics with extensive surgical debridement and drainage procedures repeated as necessary. Although this case had a successful outcome, many patients do not survive, particularly if treatment is delayed or inadequate.
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Affiliation(s)
- P J Hadfield
- Department of Otolaryngology, Northwick Park Hospital, Harrow, Middlesex, UK
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20
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Waldhausen JH, Holterman MJ, Sawin RS. Surgical implications of necrotizing fasciitis in children with chickenpox. J Pediatr Surg 1996; 31:1138-41. [PMID: 8863250 DOI: 10.1016/s0022-3468(96)90103-7] [Citation(s) in RCA: 23] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Varicella (chickenpox) affects approximately 90,000 children each year. Although most cases resolve, some develop necrotizing soft tissue infections secondary to group A streptococcus and staphylococcus. Delay in diagnosis is common. At the time of initial presentation, the need for surgical intervention is not always clear. The authors conducted a retrospective review of 30 patients with varicella (seen from December 1993 to June 1995) for whom there was clinical concern for necrotizing soft tissue infection. Various parameters were examined, including tachycardia, band count, temperature, and clinical symptoms, to differentiate the children who required surgery from those who did not. Of the 30, 22 underwent surgery. Eighteen had necrotizing fasciitis and required debridement, and four had abscesses that were incised and drained. Eight patients had simple cellulitis and did not require operation. Group A streptococcus was the most common organism cultured. All patients were treated with appropriate antibiotics. Twenty of the 22 surgical patients had elevated band count (> or = 5%), 21 had tachycardia, and 18 were febrile at the time of presentation (> 4 days after the onset of chickenpox). Although all patients with necrotizing fasciitis had tachycardia, this sign was a less specific indicator for surgery than was increased band count. Severe pain, erythemia, and induration was the most common signs/symptoms in the surgical patients. The survival rate for these 30 patients was 100%, and there was little long-term morbidity. The authors recommend immediate surgical intervention for children with chickenpox who present more than 2 or 3 days after the onset of the viral illness with symptoms that include fever, tachycardia, and an elevated band count in association with an erythematous, indurated, painful lesion. With this sign/symptom complex, the presumptive diagnosis must be necrotizing fasciitis until proven otherwise. If the patient has suspicious symptoms or if these symptoms are associated with tachycardia or an elevated band count, the patient warrants admission, institution of intravenous fluids, nafcillin, clindamycin, and close observation over several hours. If the symptoms progress over the next few hours or if the tachycardia persists despite rehydration and antibiotics, the patient should be taken to the operating room for exploration. The authors strongly endorse such exploration despite the risk of a negative operation, because the morbidity and mortality associated with delayed surgical treatment are potentially significant. With prompt aggressive surgical and medical treatment, a good outcome can be anticipated for these patients.
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Affiliation(s)
- J H Waldhausen
- Division of Pediatric Surgery, Children's Hospital and Medical Center, Seattle, WA 98105, USA
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Henrich DE, Smith TL, Mukherji S, Drake AF. Pediatric craniocervical necrotizing fasciitis. Ann Otol Rhinol Laryngol 1996; 105:72-4. [PMID: 8546431 DOI: 10.1177/000348949610500114] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Affiliation(s)
- D E Henrich
- Division of Otolaryngology-Head and Neck Surgery, University of North Carolina School of Medicine, Chapel Hill, USA
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22
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Banerjee AR, Murty GE, Moir AA. Cervical necrotizing fasciitis: a distinct clinicopathological entity? J Laryngol Otol 1996; 110:81-6. [PMID: 8745791 DOI: 10.1017/s0022215100132797] [Citation(s) in RCA: 57] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
Necrotizing fasciitis of the head and neck has previously been classified as a homogeneous group. We present two cases of necrotizing fasciitis confined to the neck and demonstrate with a review of the literature that cervical necrotizing fasciitis and craniofacial necrotizing fasciitis are two distinct clinicopathological conditions.
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Affiliation(s)
- A R Banerjee
- Department of Otorhinolaryngology, Leicester Royal Infirmary, UK
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Henrich DE, Smith TL, Shockley WW. Fatal craniocervical necrotizing fasciitis in an immunocompetent patient: a case report and literature review. Head Neck 1995; 17:351-7. [PMID: 7672978 DOI: 10.1002/hed.2880170414] [Citation(s) in RCA: 24] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023] Open
Abstract
BACKGROUND Craniocervical necrotizing fasciitis (CCNF) is a rapidly progressive, severe bacterial infection of the superficial fascial planes of the head and neck. Group A beta-hemolytic Streptococcus, staphylococcus aureus, and obligate anaerobic bacteria are common pathogens. The disease usually results from a dental source or facial trauma. Extensive fascial necrosis and severe systemic toxicity are common manifestations of CCNF. Recently the lay press has referred to necrotizing fasciitis in several articles about "flesh eating" bacteria, which have resulted in several deaths. METHODS We report the first case of a fatality in an otherwise immunocompetent patient. The patient was a 66-year-old black man with no identifiable source of infection and no history or evidence of immunocompromising disorders. RESULTS Despite aggressive surgical debridement and broad-spectrum antibiotic coverage, he died 30 hours after admission from multisystem organ failure secondary to overwhelming sepsis. CONCLUSION Treatment consists of early recognition of CCNF combined with aggressive surgical debridement and drainage of the involved necrotic fascia and tissue along with broad-spectrum intravenous antibiotic coverage. Although 11 other fatal cases of CCNF have been previously reported, all had an underlying medical problem which created an immunocompromised state, usually diabetes mellitus or chronic alcoholism. We present a case report and literature review along with a discussion of the related anatomy.
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Affiliation(s)
- D E Henrich
- Division of Otolaryngology/Head & Neck Surgery, University of North Carolina School of Medicine, Chapel Hill 27599-7070, USA
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Yamaoka M, Furusawa K, Uematsu T, Yasuda K. Early evaluation of necrotizing fasciitis with use of CT. J Craniomaxillofac Surg 1994; 22:268-71. [PMID: 7798356 DOI: 10.1016/s1010-5182(05)80074-5] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023] Open
Abstract
Gas bubbles are one of the important signs in the clinical diagnosis of necrotizing fasciitis, and radiographs are mandatory. An instance where gas bubbles not found on the plain radiographs were clearly shown by CT, which is a useful method for close monitoring and decompression of gas bubbles situated deeply in the spaces of the maxillo-facial and neck regions.
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Affiliation(s)
- M Yamaoka
- Oral and Maxillofacial Surgery Department II, Matsumoto Dental College, Nagano, Japan
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Abstract
We present a case of cervical necrotizing fasciitis following quinsy in a previously fit and healthy man. This is a potentially fatal condition with few specific clinical signs that requires early diagnosis and surgical debridement. Other features of the disease are discussed.
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