Medicine
Necrotizing fasciitis of the neck and chest
T. M u t o 1, K. S a t o 2, M. K a n a z a w a 1 1The First Department of Oral Surgery, School
of Dentistry, Higashi-Nippon-Gakuen University, Hokkaido, and 2Department of Oral Surgery, School of Medicine, Chiba University, Japan
Report of a case T. Muto, K. Sato, M. Kanazawa: Necrotizing fasciitis o f the neck and chest. Report o f a case. Int. J. Oral Maxillofac. Surg. 1992; 21." 236-238. Abstract. A case is presented o f necrotizing fasciitis of the neck a n d chest characterized by rapid progressive necrosis o f s u b c u t a n e o u s tissue, fascia a n d skin. T h e diagnosis a n d m a n a g e m e n t is discussed.
Necrotizing fasciitis is caused by bacterial infection a n d is characterized by progressive necrosis o f the superficial fascia, s u b c u t a n e o u s fat, a n d superior surface o f the deep fascia, a n d results in necrosis o f the skin 1°. M o s t cases rep o r t e d involved the t r u n k 1°' 17, ~8, genital areal2, i8, chest wall u' ~2 or extremities 6, 7, ~2, 13, i7, ~8. Only a few cases h a v e b e e n r e p o r t e d to affect the head a n d neck region~4, 8, 9,14-16. I f t r e a t m e n t is delayed, infection can spread a n d involve the s u b c u t a n e o u s tissues, resulting in widespread necrosis a n d m o d e r a t e to severe systemic toxic reaction 3, 6. In the h e a d a n d neck area it also has the p o t e n t i a l to spread to the m e d i a s t i n u m a n d the chest wall a n d m a y thus cause serious airway p r o b l e m s 4, 8, 14
2 g amoxycillin i.v./day. His condition improved subjectively but after 4 days skin erythema and necrosis appeared (Fig. 2). The patient was brought under general anesthesia and drainage was achieved through incision and exploration (Fig. 3). The skin appeared to be undermined until the level of the superficial fascia and necrotic tissue was removed. There was a moderate amount of non-smelling serous exudate. This fluid was sent for aerobic and anaerobic culture. Gram stain revealed Peptostreptococcus, Escherichia coli, and Klebsiella. He was then given 1.8 g lincomycin i.v./day in addition to amoxycillin. Two days after surgery, the skin over the anterior chest became darker in color and serous fluid continued to flow from the drains. At this time a diagnosis of necrotizing fasciitis was made, and the patient was again
Key words: necrotizing fasciitis; inflammatory
disease Accepted for publication 20 March 1992
brought under general anesthesia to explore the area through wide incisions in the cervical and anterior chest regions. Tissue necrosis again appeared to be limited to the subcutaneous tissue and superficial fascia. Complete debridement was carried out, and after 10 days the inflammatory process appeared to be arrested (Fig. 4). The wounds became covered with granulation tissue and 5 days later a split-thickness skin graft was used to cover the defect (Fig. 5).
Discussion In 1924 MELENEY presented the first rep o r t o n a series o f cases o f necrotizing fasciitis. In all his cases fl-hemolytic streptococcus was cultured a n d he,
Case report A 66-year-old Japanese man was admitted to our hospital because of considerable bilateral swelling in the submandibular, cervical, and chest regions. The swelling had begun in the left submandibular area 6 days prior to admission and had progressed rapidly. At admission, the patient appeared to be ill although his temperature was 37.3°C. He had a bilateral submandibular swelling with induration extending to the neck as well as erythema in the neck and chest area and local skin necrosis (Fig. 1). Oral examination revealed several carious teeth but without pulpitis and slight gingivitis of the remaining teeth. Radiographs of the jaws did not show any abnormalities. Routine laboratory values including blood tests, liver and kidney function tests were normal except for: WBC, 16,700/mm3; platelet count, 52 x 103/mm3; albumin, 3.0 g/ dl; calcium, 7.8 mg/dl and LDH, 316 U/1. A provisional diagnosis of cellulitis or erysipelas was made and the patient was given
Fig. 1. The neck and anterior chest showing the erythematous swelling at admission.
Fig. 2. Four days after admission, part of the skin of the left submandibular area and anterior chest wall changed in color to black.
Necrotizing fasciitis
therefore, named the disease "acute hemolytic streptococcal gangrene". WILSOY17 found fl-hemolytic streptococcus in only 58% of his cases, and pointed out that the term "necrotizing fasciitis" should be preferred to other descriptive names because fascial necrosis is the most consistent manifestation of the disease. Some authors 12'13,17,18emphasize that the condition is preceded by a trivial skin injury, i.e. laceration, abrasion or
237
usually becomes paresthetic or anesthetic ~7. As the disease progresses, the affected skin takes on a dusky or purplish color with irregular or well-defined borders. By the 4th or 5th day, cutaneous necrosis due to thrombosis of nutrient vessels becomes apparent. By the 8th or 10th day, the necrotic tissue begins to separate by suppuration. Muscles, bone and other tissues are not Fig. 3. The left submandibular area showing ex- primarily involved unless they become exposed TM. tensive necrosis of" the The diagnosis of necrotizing fasciitis subcutaneous tissue at incision and fascico- is made when necrosis of subcutaneous tomy. tissue and fascia is seen. To determine the areas affected, exploration by finger or probe is useful 12. As soon as the diagnosis is made, treatment should consist of proper antimicrobial treatment and wide surgical opening over the entire length of the fascial plane should be carried out 2, 17. Split-thickness skin grafts are necessary to cover the denuded areas 11. Many cases have been reported in which mixed organisms have been cultured including anaerobic bacteria3, 4, 9, Fig. 4. Ten days after de- 11,15,16. GUILIANOet al. 5and Sa~EL16have bridement, the process pointed out that synergism between has been arrested and aerobic and anaerobic organisms probthe wound is covered by ably is responsible for this disease and granulation tissue. they stressed the importance of adequate anaerobic coverage. The antimicrobial treatment should include drugs active against anaerobes, such as metronidazole, without waiting for culture results. Thereafter, the regimen may be changed depending on bacterial identification and sensitivities. STEEL I6 reported a case which was controlled with penicillin and metronidazole only. In the case presented, however, a broad spectrum antimicrobial treatment was first used, which was supplemented by lyncomycin. Extensive surgical interFig. 5. One month after vention was also delayed because of misinterpretation of the clinical course. split-thickness skin graft ing, good healing was Only after extensive skin excision and obtained. debridement was the process finally brought under control. Initial therapy for necrotizing fasciitis injection. There are also several reports indicating that an odontogenic infection should consist of antimicrobial treatment including anaerobic coverage. caused by a periapical lesion2, 11,15,16 or Prompt and radical surgical treatment preceding tooth extraction3, 14 may play should be carried out if the situation a role. In the case presented, neither deteriorates. skin injury nor dental infection could be traced. In the case presented, however, the diagnosis was initially missed and adeThe spread of necrotizing fasciitis can be alarmingly rapid. Within 24 to 48 h, quate treatment was therefore delayed. the parts involved may show edematous This report is intended to remind oral swelling with redness. While in the early and maxillofacial surgeons to maintain stage, the region may be painful, it later a high level of awareness when dealing
238
M u t o et al.
with h e a d and neck infections, because necrotizing fasciitis may be overlooked.
References 1. BAI-INAM, CANALISRE Necrotizing fasciitis (streptococcal gangrene) of the face. Arch Otolaryngol 1980: 106:648 51. 2. BALCERAK R J, SISTO JM, BOSACK RC. Cervicofascial necrotizing fasciitis: Report of three cases and literature review. J. Oral Maxillofac Surg 1988: 46: 450~9. 3. CROWSONWN. Fatal necrotizing fasciitis developing after tooth extraction. Am Surg 1973: 39: 525-7. 4. GALLIALJ, JOHNSONJT. Cervical necrotizing fasciitis. Otolaryngol Head Neck Surg 1981: 89: 935-7. 5. GIULIANOA, LEWISF, HADLEYK, BLAISDELLFW. Bacteriology of necrotizing fasciitis. Am J Surg 1977: 134: 52-7. 6. HAMMARH, WANGER L. Erysipelas and
necrotizing fascitis. Br J Dermatol 1977: 96: 40%19. 7. KOEHN GG. Necrotizing fasciitis. Arch Dermatol 1978: 114: 581-3. 8. KRESPIYP, LAWSONW, BLAUGRUNDSM, BmLER HE Massive necrotizing infection of the neck. Head Neck Surg 1981: 3: 475-81. 9. KuBO S, ABE K, OKA M. Necrotizing fasciitis of the middle third of the face. J Cranio-Maxillofac Surg 1989: 17: 92-5. 10. LEDINOHAMM, TEm~anI MA. Diagnosis, clinical course and treatment of acute dermal gangrene. Br J Surg 1975: 62: 364-72. 11. MCANDREW PG, DAVIES SJ, GRIFFITH RW. Necrotizing fasciitis caused by dental infection. Br J Oral Maxillofac Surg 1987: 25: 314-22. 12. MELENEY FL. Hemolytic streptococcus gangrene. Arch Surg 1924: 9: 317-64. 13. RErN JM, COSMANB. Bacteroides necrotizing fasciitis of the upper extremity. Plast Reconstr Surg 1971: 48: 592-4. 14. RICHARDSON JD, Fox GL, GROVER FL,
CRUZ AB. Necrotizing fasciitis of the neck: A complication of dental extraction. Arch Surg 1975: 71:69 71. 15. ROSER SM, CHOW AW, BRADY FA. Necrotizing fasciitis. J Oral Surg 1977: 35: 730~. 16. STEEL A. An unusual case of necrotizing fasciitis. Br J Oral Maxillofac Surg 1987: 25: 328-33. 17. WILSONB: Necrotizing fasciitis. Am Surg 1952: 18:416 31. 18. WroTE WL. Hemolytic streptococcus gangrene. A report of seven cases. Plast Reconstr Surg 1953: 11: 1-14.
Address:
Dr Toshitaka Muto. DDS, PhD. Department of Oral Surgery School of Dentistry Higashi-Nippon-Gakuen University Tobetsu-cho, Ishikari-gun, Hokkaido, 061-02 Japan
Necrotizing fasciitis of the neck and chest
T. M u t o 1, K. S a t o 2, M. K a n a z a w a 1 1The First Department of Oral Surgery, School
of Dentistry, Higashi-Nippon-Gakuen University, Hokkaido, and 2Department of Oral Surgery, School of Medicine, Chiba University, Japan
Report of a case T. Muto, K. Sato, M. Kanazawa: Necrotizing fasciitis o f the neck and chest. Report o f a case. Int. J. Oral Maxillofac. Surg. 1992; 21." 236-238. Abstract. A case is presented o f necrotizing fasciitis of the neck a n d chest characterized by rapid progressive necrosis o f s u b c u t a n e o u s tissue, fascia a n d skin. T h e diagnosis a n d m a n a g e m e n t is discussed.
Necrotizing fasciitis is caused by bacterial infection a n d is characterized by progressive necrosis o f the superficial fascia, s u b c u t a n e o u s fat, a n d superior surface o f the deep fascia, a n d results in necrosis o f the skin 1°. M o s t cases rep o r t e d involved the t r u n k 1°' 17, ~8, genital areal2, i8, chest wall u' ~2 or extremities 6, 7, ~2, 13, i7, ~8. Only a few cases h a v e b e e n r e p o r t e d to affect the head a n d neck region~4, 8, 9,14-16. I f t r e a t m e n t is delayed, infection can spread a n d involve the s u b c u t a n e o u s tissues, resulting in widespread necrosis a n d m o d e r a t e to severe systemic toxic reaction 3, 6. In the h e a d a n d neck area it also has the p o t e n t i a l to spread to the m e d i a s t i n u m a n d the chest wall a n d m a y thus cause serious airway p r o b l e m s 4, 8, 14
2 g amoxycillin i.v./day. His condition improved subjectively but after 4 days skin erythema and necrosis appeared (Fig. 2). The patient was brought under general anesthesia and drainage was achieved through incision and exploration (Fig. 3). The skin appeared to be undermined until the level of the superficial fascia and necrotic tissue was removed. There was a moderate amount of non-smelling serous exudate. This fluid was sent for aerobic and anaerobic culture. Gram stain revealed Peptostreptococcus, Escherichia coli, and Klebsiella. He was then given 1.8 g lincomycin i.v./day in addition to amoxycillin. Two days after surgery, the skin over the anterior chest became darker in color and serous fluid continued to flow from the drains. At this time a diagnosis of necrotizing fasciitis was made, and the patient was again
Key words: necrotizing fasciitis; inflammatory
disease Accepted for publication 20 March 1992
brought under general anesthesia to explore the area through wide incisions in the cervical and anterior chest regions. Tissue necrosis again appeared to be limited to the subcutaneous tissue and superficial fascia. Complete debridement was carried out, and after 10 days the inflammatory process appeared to be arrested (Fig. 4). The wounds became covered with granulation tissue and 5 days later a split-thickness skin graft was used to cover the defect (Fig. 5).
Discussion In 1924 MELENEY presented the first rep o r t o n a series o f cases o f necrotizing fasciitis. In all his cases fl-hemolytic streptococcus was cultured a n d he,
Case report A 66-year-old Japanese man was admitted to our hospital because of considerable bilateral swelling in the submandibular, cervical, and chest regions. The swelling had begun in the left submandibular area 6 days prior to admission and had progressed rapidly. At admission, the patient appeared to be ill although his temperature was 37.3°C. He had a bilateral submandibular swelling with induration extending to the neck as well as erythema in the neck and chest area and local skin necrosis (Fig. 1). Oral examination revealed several carious teeth but without pulpitis and slight gingivitis of the remaining teeth. Radiographs of the jaws did not show any abnormalities. Routine laboratory values including blood tests, liver and kidney function tests were normal except for: WBC, 16,700/mm3; platelet count, 52 x 103/mm3; albumin, 3.0 g/ dl; calcium, 7.8 mg/dl and LDH, 316 U/1. A provisional diagnosis of cellulitis or erysipelas was made and the patient was given
Fig. 1. The neck and anterior chest showing the erythematous swelling at admission.
Fig. 2. Four days after admission, part of the skin of the left submandibular area and anterior chest wall changed in color to black.
Necrotizing fasciitis
therefore, named the disease "acute hemolytic streptococcal gangrene". WILSOY17 found fl-hemolytic streptococcus in only 58% of his cases, and pointed out that the term "necrotizing fasciitis" should be preferred to other descriptive names because fascial necrosis is the most consistent manifestation of the disease. Some authors 12'13,17,18emphasize that the condition is preceded by a trivial skin injury, i.e. laceration, abrasion or
237
usually becomes paresthetic or anesthetic ~7. As the disease progresses, the affected skin takes on a dusky or purplish color with irregular or well-defined borders. By the 4th or 5th day, cutaneous necrosis due to thrombosis of nutrient vessels becomes apparent. By the 8th or 10th day, the necrotic tissue begins to separate by suppuration. Muscles, bone and other tissues are not Fig. 3. The left submandibular area showing ex- primarily involved unless they become exposed TM. tensive necrosis of" the The diagnosis of necrotizing fasciitis subcutaneous tissue at incision and fascico- is made when necrosis of subcutaneous tomy. tissue and fascia is seen. To determine the areas affected, exploration by finger or probe is useful 12. As soon as the diagnosis is made, treatment should consist of proper antimicrobial treatment and wide surgical opening over the entire length of the fascial plane should be carried out 2, 17. Split-thickness skin grafts are necessary to cover the denuded areas 11. Many cases have been reported in which mixed organisms have been cultured including anaerobic bacteria3, 4, 9, Fig. 4. Ten days after de- 11,15,16. GUILIANOet al. 5and Sa~EL16have bridement, the process pointed out that synergism between has been arrested and aerobic and anaerobic organisms probthe wound is covered by ably is responsible for this disease and granulation tissue. they stressed the importance of adequate anaerobic coverage. The antimicrobial treatment should include drugs active against anaerobes, such as metronidazole, without waiting for culture results. Thereafter, the regimen may be changed depending on bacterial identification and sensitivities. STEEL I6 reported a case which was controlled with penicillin and metronidazole only. In the case presented, however, a broad spectrum antimicrobial treatment was first used, which was supplemented by lyncomycin. Extensive surgical interFig. 5. One month after vention was also delayed because of misinterpretation of the clinical course. split-thickness skin graft ing, good healing was Only after extensive skin excision and obtained. debridement was the process finally brought under control. Initial therapy for necrotizing fasciitis injection. There are also several reports indicating that an odontogenic infection should consist of antimicrobial treatment including anaerobic coverage. caused by a periapical lesion2, 11,15,16 or Prompt and radical surgical treatment preceding tooth extraction3, 14 may play should be carried out if the situation a role. In the case presented, neither deteriorates. skin injury nor dental infection could be traced. In the case presented, however, the diagnosis was initially missed and adeThe spread of necrotizing fasciitis can be alarmingly rapid. Within 24 to 48 h, quate treatment was therefore delayed. the parts involved may show edematous This report is intended to remind oral swelling with redness. While in the early and maxillofacial surgeons to maintain stage, the region may be painful, it later a high level of awareness when dealing
238
M u t o et al.
with h e a d and neck infections, because necrotizing fasciitis may be overlooked.
References 1. BAI-INAM, CANALISRE Necrotizing fasciitis (streptococcal gangrene) of the face. Arch Otolaryngol 1980: 106:648 51. 2. BALCERAK R J, SISTO JM, BOSACK RC. Cervicofascial necrotizing fasciitis: Report of three cases and literature review. J. Oral Maxillofac Surg 1988: 46: 450~9. 3. CROWSONWN. Fatal necrotizing fasciitis developing after tooth extraction. Am Surg 1973: 39: 525-7. 4. GALLIALJ, JOHNSONJT. Cervical necrotizing fasciitis. Otolaryngol Head Neck Surg 1981: 89: 935-7. 5. GIULIANOA, LEWISF, HADLEYK, BLAISDELLFW. Bacteriology of necrotizing fasciitis. Am J Surg 1977: 134: 52-7. 6. HAMMARH, WANGER L. Erysipelas and
necrotizing fascitis. Br J Dermatol 1977: 96: 40%19. 7. KOEHN GG. Necrotizing fasciitis. Arch Dermatol 1978: 114: 581-3. 8. KRESPIYP, LAWSONW, BLAUGRUNDSM, BmLER HE Massive necrotizing infection of the neck. Head Neck Surg 1981: 3: 475-81. 9. KuBO S, ABE K, OKA M. Necrotizing fasciitis of the middle third of the face. J Cranio-Maxillofac Surg 1989: 17: 92-5. 10. LEDINOHAMM, TEm~anI MA. Diagnosis, clinical course and treatment of acute dermal gangrene. Br J Surg 1975: 62: 364-72. 11. MCANDREW PG, DAVIES SJ, GRIFFITH RW. Necrotizing fasciitis caused by dental infection. Br J Oral Maxillofac Surg 1987: 25: 314-22. 12. MELENEY FL. Hemolytic streptococcus gangrene. Arch Surg 1924: 9: 317-64. 13. RErN JM, COSMANB. Bacteroides necrotizing fasciitis of the upper extremity. Plast Reconstr Surg 1971: 48: 592-4. 14. RICHARDSON JD, Fox GL, GROVER FL,
CRUZ AB. Necrotizing fasciitis of the neck: A complication of dental extraction. Arch Surg 1975: 71:69 71. 15. ROSER SM, CHOW AW, BRADY FA. Necrotizing fasciitis. J Oral Surg 1977: 35: 730~. 16. STEEL A. An unusual case of necrotizing fasciitis. Br J Oral Maxillofac Surg 1987: 25: 328-33. 17. WILSONB: Necrotizing fasciitis. Am Surg 1952: 18:416 31. 18. WroTE WL. Hemolytic streptococcus gangrene. A report of seven cases. Plast Reconstr Surg 1953: 11: 1-14.
Address:
Dr Toshitaka Muto. DDS, PhD. Department of Oral Surgery School of Dentistry Higashi-Nippon-Gakuen University Tobetsu-cho, Ishikari-gun, Hokkaido, 061-02 Japan
