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Radiology Quiz Case 2—Diagnosis

Radiology Quiz Case 2—Diagnosis Diagnosis: Cervical necrotizing fasciitis (CNF), odontogenic origin The patient was taken to the operating room for a neck exploration, which revealed a fetid odor and bilateral necrosis of his sternocleidomastoid and strap muscles, which were aggressively debrided. He had bilateral chest tubes placed for drainage and underwent dental extractions. He was also treated with broad-spectrum antibiotics. The cervical skin flaps were kept open, debrided twice a day, and loosely packed with gauze soaked with half-strength hydrogen peroxide. He subsequently developed a pharyngocutaneous fistula, which was treated conservatively with packing and pressure dressings. Cultures yielded Peptostreptococcus species, Enterococcus, Clostridium difficile, Eikenella corrodens, and Candida albicans, and his antibiotic therapy was appropriately modified based on the culture sensitivities. He remained in the hospital for 5 weeks, after which he was transferred to a rehabilitation center. He subsequently underwent decannulation and is currently swallowing without any difficulty. Cervical necrotizing fasciitis is an acute soft tissue infection that involves the cutaneous and fascial planes of the neck. It has a rapid onset and fulminant course, warranting early diagnosis and intervention. While this disease process is rare in the head and neck (incidence, 2.6%),1 it is associated with significant morbidity and mortality (ranging from 6% to 76%1), both of which increase with delay in diagnosis. The most common causes of CNF are odontogenic and oropharyngeal infections, spreading by extension along fascial planes and vascular compartments2 and causing vascular thrombosis, with eventual tissue death. Myonecrosis occurs at the end stage of CNF. Other reported cases associated with CNF include laryngectomy, tonsillectomy, acute pharyngitis, peritonsillar abscess, acute epiglottitis, pharyngeal perforation, and injection of steroids in the neck.1,3 Reported risk factors include diabetes, obesity, immunosuppression, renal failure, intravenous drug abuse, treatment with nonsteroidal anti-inflammatory agents, cardiovascular disease, tobacco and alcohol abuse, and prior radiation therapy for malignancy.2,4,5 The complications of CNF include mediastinitis, septic shock, jugular vein thrombosis, airway obstruction, pneumonia, and pleural effusions.1-3 Mediastinal involvement portends a much worse prognosis (mortality >50%),6 and develops by propagation of the infection from the head and neck to the mediastinum through the retropharyngeal or prevertebral space or along the carotid sheath. The clinical presentation includes a history of pain around the head and neck for less than a week, with rapid exacerbation of symptoms such as dysphagia, odynophagia, trismus, paresthesia, and dyspnea.2,5 Physical findings include local manifestations such as painful edema, erythema, crepitus, and skin necrosis.2 These signs may initially be confused with acute cellulitis or an abscess. The presence of gas in the tissues or an orange peel appearance of the involved skin and rapid progression of symptoms are highly suggestive of CNF.1 Abnormal presentation of gas in the cervical tissues has been considered a hallmark of CNF.7 Computed tomography may be more sensitive in delineating the extent of disease,8 particularly when there is mediastinal involvement.2 Leukocytosis is usually present. The bacteria that cause CNF are usually polymicrobial.2,5 In the cervical region, the mixed aerobic-anaerobic organisms reflect oral flora, with the most common aerobes and anaerobes being Streptococcus and Bacteroides, respectively.2,5 The polymicrobial composition and the synergistic effect of the enzymes produced by the bacteria allow the infection to move rapidly along fascial planes, causing tissue necrosis.5 Appropriate treatment for CNF includes immediate recognition based on a high index of suspicion, initiation of broad-spectrum antibiotic therapy, and aggressive early surgical debridement. The use of broad-spectrum antibiotics to cover aerobic and anaerobic organisms, with adjustments based on culture sensitivities, is indicated. Because the disease process involves vascular thrombosis that may preclude antibiotic penetration into the site of infection, early and adequate surgical debridement is crucial.9 Aggressive and meticulous debridement to viable tissue should be undertaken at the initial exploration. Operative findings include necrotic fascia and muscle extending longitudinally along fascial planes. Repeated debridement, either in the operating room or at the bedside, until no further necrotic tissue is noted is usually necessary. Airway management is critical and usually involves tracheotomy, as neck edema and necrosis increase the difficulty of intubation.5,6 Aggressive hemodynamic and nutritional support are equally important. Adjunctive treatment options reported in the literature include hyperbaric oxygen4,5 and the use of maggots.10 Hyperbaric oxygen therapy may be beneficial in cases involving clostridial infections; however, in critically ill patients, adverse effects such as oxygen toxicity, barotrauma, and pneumothorax may occur. The prognosis is poor in patients who have undergone an incorrect initial surgical procedure.2 Keys to successful outcome include prompt recognition, early radical debridement, and antimicrobial therapy. Residents and fellows in otolaryngology are invited to submit quiz cases for this section and to write letters to the ARCHIVES commenting on cases presented. Quiz cases should follow the patterns established. See "Instructions for Authors." Material for CLINICAL PROBLEM SOLVING: RADIOLOGY should be mailed to the Editor. Reprints not available from the authors. References 1. Tung-Yiu WJehn-Shyun HChing-Hung CHung-An C Cervical necrotizing fasciitis of odontogenic origin: a report of 11 cases. J Oral Maxillofac Surg.2000;58:1347-1352.PubMedGoogle Scholar 2. Mohammedi ICeruse PDuperret SVedrinne JMBouletreau P Cervical necrotizing fasciitis: 10 years' experience at a single institution. Intensive Care Med.1999;25:829-834.PubMedGoogle Scholar 3. Tovi FFliss DMZirkin HJ Necrotizing soft-tissue infections in the head and neck: a clinicopathological study. Laryngoscope.1991;101:619-625.PubMedGoogle Scholar 4. Scher RL Hyperbaric oxygen therapy for necrotizing cervical infections. Adv Otorhinolaryngol.1998;54:50-58.PubMedGoogle Scholar 5. Whitesides LCotto-Cumba CMyers RAM Cervical necrotizing fasciitis of odontogenic origin: a case report and review of 12 cases. J Oral Maxillofac Surg.2000;58:144-151.PubMedGoogle Scholar 6. Lalwani AKKaplan MJ Mediastinal and thoracic complications of necrotizing fasciitis of the head and neck. Head Neck.1991;13:531-539.PubMedGoogle Scholar 7. Fisher JRConway MJTakeshita RTSandoval MR Necrotizing fasciitis of the head and neck: importance of roentgenographic studies for soft-tissue gas. JAMA.1979;241:803-806.PubMedGoogle Scholar 8. Becker MZbaren PHermans R et al Necrotizing fasciitis of the head and neck: role of CT in diagnosis and management. Radiology.1997;202:471-476.PubMedGoogle Scholar 9. Majeski JAAlexander JWl Early diagnosis, nutritional support, and immediate extensive debridement improve survival in necrotizing fasciitis. Am J Surg.1983;145:784-787.PubMedGoogle Scholar 10. Dunn CRaghavan UPfleiderer AG The use of maggots in head and neck necrotizing fasciitis. J Laryngol Otol.2002;116:70-72.PubMedGoogle Scholar http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Archives of Otolaryngology - Head & Neck Surgery American Medical Association

Radiology Quiz Case 2—Diagnosis

Archives of Otolaryngology - Head & Neck Surgery , Volume 130 (4) – Apr 1, 2004

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Publisher
American Medical Association
Copyright
Copyright © 2004 American Medical Association. All Rights Reserved.
ISSN
0886-4470
eISSN
1538-361X
DOI
10.1001/archotol.130.4.482
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Abstract

Diagnosis: Cervical necrotizing fasciitis (CNF), odontogenic origin The patient was taken to the operating room for a neck exploration, which revealed a fetid odor and bilateral necrosis of his sternocleidomastoid and strap muscles, which were aggressively debrided. He had bilateral chest tubes placed for drainage and underwent dental extractions. He was also treated with broad-spectrum antibiotics. The cervical skin flaps were kept open, debrided twice a day, and loosely packed with gauze soaked with half-strength hydrogen peroxide. He subsequently developed a pharyngocutaneous fistula, which was treated conservatively with packing and pressure dressings. Cultures yielded Peptostreptococcus species, Enterococcus, Clostridium difficile, Eikenella corrodens, and Candida albicans, and his antibiotic therapy was appropriately modified based on the culture sensitivities. He remained in the hospital for 5 weeks, after which he was transferred to a rehabilitation center. He subsequently underwent decannulation and is currently swallowing without any difficulty. Cervical necrotizing fasciitis is an acute soft tissue infection that involves the cutaneous and fascial planes of the neck. It has a rapid onset and fulminant course, warranting early diagnosis and intervention. While this disease process is rare in the head and neck (incidence, 2.6%),1 it is associated with significant morbidity and mortality (ranging from 6% to 76%1), both of which increase with delay in diagnosis. The most common causes of CNF are odontogenic and oropharyngeal infections, spreading by extension along fascial planes and vascular compartments2 and causing vascular thrombosis, with eventual tissue death. Myonecrosis occurs at the end stage of CNF. Other reported cases associated with CNF include laryngectomy, tonsillectomy, acute pharyngitis, peritonsillar abscess, acute epiglottitis, pharyngeal perforation, and injection of steroids in the neck.1,3 Reported risk factors include diabetes, obesity, immunosuppression, renal failure, intravenous drug abuse, treatment with nonsteroidal anti-inflammatory agents, cardiovascular disease, tobacco and alcohol abuse, and prior radiation therapy for malignancy.2,4,5 The complications of CNF include mediastinitis, septic shock, jugular vein thrombosis, airway obstruction, pneumonia, and pleural effusions.1-3 Mediastinal involvement portends a much worse prognosis (mortality >50%),6 and develops by propagation of the infection from the head and neck to the mediastinum through the retropharyngeal or prevertebral space or along the carotid sheath. The clinical presentation includes a history of pain around the head and neck for less than a week, with rapid exacerbation of symptoms such as dysphagia, odynophagia, trismus, paresthesia, and dyspnea.2,5 Physical findings include local manifestations such as painful edema, erythema, crepitus, and skin necrosis.2 These signs may initially be confused with acute cellulitis or an abscess. The presence of gas in the tissues or an orange peel appearance of the involved skin and rapid progression of symptoms are highly suggestive of CNF.1 Abnormal presentation of gas in the cervical tissues has been considered a hallmark of CNF.7 Computed tomography may be more sensitive in delineating the extent of disease,8 particularly when there is mediastinal involvement.2 Leukocytosis is usually present. The bacteria that cause CNF are usually polymicrobial.2,5 In the cervical region, the mixed aerobic-anaerobic organisms reflect oral flora, with the most common aerobes and anaerobes being Streptococcus and Bacteroides, respectively.2,5 The polymicrobial composition and the synergistic effect of the enzymes produced by the bacteria allow the infection to move rapidly along fascial planes, causing tissue necrosis.5 Appropriate treatment for CNF includes immediate recognition based on a high index of suspicion, initiation of broad-spectrum antibiotic therapy, and aggressive early surgical debridement. The use of broad-spectrum antibiotics to cover aerobic and anaerobic organisms, with adjustments based on culture sensitivities, is indicated. Because the disease process involves vascular thrombosis that may preclude antibiotic penetration into the site of infection, early and adequate surgical debridement is crucial.9 Aggressive and meticulous debridement to viable tissue should be undertaken at the initial exploration. Operative findings include necrotic fascia and muscle extending longitudinally along fascial planes. Repeated debridement, either in the operating room or at the bedside, until no further necrotic tissue is noted is usually necessary. Airway management is critical and usually involves tracheotomy, as neck edema and necrosis increase the difficulty of intubation.5,6 Aggressive hemodynamic and nutritional support are equally important. Adjunctive treatment options reported in the literature include hyperbaric oxygen4,5 and the use of maggots.10 Hyperbaric oxygen therapy may be beneficial in cases involving clostridial infections; however, in critically ill patients, adverse effects such as oxygen toxicity, barotrauma, and pneumothorax may occur. The prognosis is poor in patients who have undergone an incorrect initial surgical procedure.2 Keys to successful outcome include prompt recognition, early radical debridement, and antimicrobial therapy. Residents and fellows in otolaryngology are invited to submit quiz cases for this section and to write letters to the ARCHIVES commenting on cases presented. Quiz cases should follow the patterns established. See "Instructions for Authors." Material for CLINICAL PROBLEM SOLVING: RADIOLOGY should be mailed to the Editor. Reprints not available from the authors. References 1. Tung-Yiu WJehn-Shyun HChing-Hung CHung-An C Cervical necrotizing fasciitis of odontogenic origin: a report of 11 cases. J Oral Maxillofac Surg.2000;58:1347-1352.PubMedGoogle Scholar 2. Mohammedi ICeruse PDuperret SVedrinne JMBouletreau P Cervical necrotizing fasciitis: 10 years' experience at a single institution. Intensive Care Med.1999;25:829-834.PubMedGoogle Scholar 3. Tovi FFliss DMZirkin HJ Necrotizing soft-tissue infections in the head and neck: a clinicopathological study. Laryngoscope.1991;101:619-625.PubMedGoogle Scholar 4. Scher RL Hyperbaric oxygen therapy for necrotizing cervical infections. Adv Otorhinolaryngol.1998;54:50-58.PubMedGoogle Scholar 5. Whitesides LCotto-Cumba CMyers RAM Cervical necrotizing fasciitis of odontogenic origin: a case report and review of 12 cases. J Oral Maxillofac Surg.2000;58:144-151.PubMedGoogle Scholar 6. Lalwani AKKaplan MJ Mediastinal and thoracic complications of necrotizing fasciitis of the head and neck. Head Neck.1991;13:531-539.PubMedGoogle Scholar 7. Fisher JRConway MJTakeshita RTSandoval MR Necrotizing fasciitis of the head and neck: importance of roentgenographic studies for soft-tissue gas. JAMA.1979;241:803-806.PubMedGoogle Scholar 8. Becker MZbaren PHermans R et al Necrotizing fasciitis of the head and neck: role of CT in diagnosis and management. Radiology.1997;202:471-476.PubMedGoogle Scholar 9. Majeski JAAlexander JWl Early diagnosis, nutritional support, and immediate extensive debridement improve survival in necrotizing fasciitis. Am J Surg.1983;145:784-787.PubMedGoogle Scholar 10. Dunn CRaghavan UPfleiderer AG The use of maggots in head and neck necrotizing fasciitis. J Laryngol Otol.2002;116:70-72.PubMedGoogle Scholar

Journal

Archives of Otolaryngology - Head & Neck SurgeryAmerican Medical Association

Published: Apr 1, 2004

Keywords: diagnostic radiologic examination,radiology specialty

References