Abstract
We conducted a retrospective review of 11 cases of adult cervical necrotizing fasciitis that were treated at our institution over a period of 5-plus years. The most common etiology was a dental infection, which was seen in 7 of the 11 patients (64%). Most cultures were sterile because all of these patients had been referred to us after they had already been treated elsewhere with intravenous antibiotics and without surgical intervention. Under our management, patients spent an average of 21.6 days in the hospital, and they underwent an average of 1.6 debridements under general anesthesia. Aggressive wound care, broad-spectrum antibiotic therapy, and timely surgical intervention resulted in an overall survival rate of 91% (10/11), including a 75% survival (3/4) for patients with thoracic extension.
Introduction
Cervical necrotizing fasciitis is a fulminant infection associated with necrosis of connective tissue, spread along fascial planes, and high mortality. It is usually odontogenic and polymicrobial, and it occurs more frequently in immunocompromised and postoperative patients.
Necrotizing fasciitis was first described during the American Civil War by Joseph Jones, a Confederate Army surgeon, who reported cases of “hospital gangrene” that were characterized by skin discoloration (blue-gray or black) and a loss of superficial and deep fascia. 1 In 1918, Pfanner described a patient with beta-hemolytic streptococcal infection, and he named the process necrotizing erysipelas. 2 The term necrotizing fasciitis was first used by Wilson in 1952 in describing cases with similar presentations that were caused by staphylococcal infections. 3
Patients with necrotizing fasciitis often have a high fever and are acutely and severely ill. Soft-tissue crepitance from gas is a reliable physical indicator. The overlying skin may be exquisitely tender, edematous, and erythematous. As the necrosis progresses, the skin becomes pale and then dusky. Blisters or bullae form, and sloughing can occur within 48 hours of the initial manifestations.
Early surgery is critical for treating necrotizing fasciitis, and empiric broad-spectrum intravenous antibiotic therapy—such as a combination of a third-generation cephalosporin, penicillin or cloxacillin, an aminoglycoside, and either clindamycin or metronidazole—should be initiated immediately. All devitalized soft tissue and skin must be excised. The surgical wound should be left open for continued wound drainage and packed with antimicrobial-soaked gauze. Daily debridement is indicated until the wound stabilizes. Airway control with tracheotomy is almost always indicated at the time of initial debridement.
In this article, we describe our experience over 5-plus years in treating cervical necrotizing fasciitis.
Patients and Methods
We conducted a retrospective review of all patients with cervical necrotizing fasciitis who had been diagnosed and treated at our institution from January 1999 through August 2004. The absolute study criterion for the diagnosis of cervical necrotizing fasciitis was the presence of extensive fascial necrosis with widespread undermining of necrotic tissue at the time of surgical exploration. Other supporting criteria were a histopathologic report consistent with this diagnosis and microbiology cultures showing a mixed aerobic and anaerobic bacterial infection. Pathologic findings and cultures were supportive of the diagnosis, but intraoperative findings of fascial necrosis and gangrenous tissue were considered diagnostic.
Patients’ charts were then analyzed for age, sex, the source of infection, anatomic sites involved, microbiology cultures, sensitivities, comorbidities, antimicrobial therapy, the number of surgical interventions, total hospital days, complications, and outcomes.
Results
From a total of 50 patients seen, 11 patients—7 men and 4 women, aged 25 to 80 years (mean: 50.9)—met our inclusion criteria. The most common etiology was a dental infection, which was seen in 7 of the 11 patients (64%). One patient acquired cervical necrotizing fasciitis during the postoperative period following a segmental mandibulectomy for malignant melanoma. He developed a hematoma in the wound that induced a secondary necrotizing fasciitis in the overlying flap.
Most patients experienced a spread of infection in the submental, submandibular, sublingual, retropharyngeal, and parapharyngeal spaces. Infection had spread to the superior mediastinum in 4 patients (1 of whom died) and to the posterior mediastinum in 2. The patient who died had already undergone drainage through a small submandibular incision at another institution. He was brought to us in sepsis and cardiac arrhythmia. His neck was reexplored, but he died during recovery from anesthesia.
Most of the cultures, including those for anaerobes, were sterile because all of these patients had been referred to us after they had already been treated elsewhere with intravenous antibiotics and without surgical intervention. Comorbidities included anemia (hemoglobin level < 10 g/dl) in 5 patients (45%), diabetes mellitus in 3 patients (27%), and chronic obstructive pulmonary disease, congestive heart failure, and steroid dependence in 1 patient each (9.1%).
Some patients underwent revision debridement of the wound under general anesthesia. On average, 1.6 debridements per patient were required under general anesthesia. Seven patients (64%) underwent tracheotomy; 5 of these tracheotomies were performed before the induction of anesthesia in order to establish an airway, and 2 were done at the end of debridement to prevent aspiration of a ruptured abscess into the oral cavity. All 7 patients were decannulated successfully. However, 1 of these patients returned 2 weeks later with stridor secondary to extensive fibrosis in the neck, which had caused a complete tracheal stenosis; this patient required another tracheotomy.
Patients spent an average of 21.6 days in the hospital. Complications included oliguria, foot cellulitis, aspiration pneumonia, pericarditis, mediastinitis, and the 1 case of tracheal stenosis. Eight patients (73%) developed abscess formation in the wound along with necrosis; the abscesses were attributed to their delayed presentation for surgery. Only 3 patients (27%) experienced skin loss; 1 of them required skin grafting, and the other 2 experienced spontaneous wound contraction and re-epithelialization. Underlying myonecrosis was seen in 10 of the 11 patients (91%). In 5 of them (45%), a communication was present between the cervical wound and the oral cavity, but only 2 of them required a tracheotomy to prevent aspiration.
Overall, 10 of the 11 patients (91%) survived, including 3 of the 4 (75%) with thoracic extension.
Discussion
All 11 patients with cervical necrotizing fasciitis who presented to our academic tertiary care center had already been treated with intravenous antibiotics by a general or dental practitioner. Most of these patients had been referred to us only after they had developed respiratory distress or sepsis syndrome. All had some degree of trismus, orthopnea, and drooling of pus with saliva.
Most reported cases of cervical necrotizing fasciitis have occurred as a result of dental caries, dental/surgical interventions, or oral trauma from burns, insect bites, etc. The anatomic spread of infection from the craniocervical region to the thorax is well described.4-6 Infection from dental caries, especially from the third molar, spreads to the submandibular area, then to the parapharyngeal space, and then along the carotid sheath to the superior mediastinum. Another route of spread is through the retropharyngeal or prevertebral space to the posterior mediastinum. Although mediastinal involvement heralds a grave outcome, it is not always fatal. A liberal low cervical incision or a thoracotomy by a cardiothoracic vascular surgeon can lead to a good recovery in such cases. Bahu et al reported a 35% mortality rate in patients who experienced a thoracic spread of cervical necrotizing fasciitis. 6
Airway management is a top priority in patients with cervical necrotizing fasciitis. Despite successful intubation, tracheotomy is sometimes required because of the possibility of an abscess rupture into the oral cavity, particularly in children. Whenever there is doubt about intubation, it should be performed.
Computed tomography (CT) is useful for early diagnosis, for planning surgery, and for assessing the response to treatment (figure 1). In a study of 14 cases of necrotizing fasciitis of the head and neck, Becker et al identified on CT specific findings such as diffuse thickening and enhancement of subcutaneous fat, cervical fascia, and chronic infection in muscles. 7 They reported that gas and fluid within the soft tissues were present in only 9 of their patients (64%).
A delay in obtaining CT should not prevent a surgeon from proceeding to early incision and drainage. The incision should be made liberally, and multiple incisions can be made if necessary. If the skin is already necrosed, the devitalized skin should be excised and the wound explored through the devitalized part. At our institution, when the skin's vitality appears to be intact, we make a MacFee incision (a double-horizontal incision) along the neck creases. This incision prevents the already-compromised skin flap from necrosing. A MacFee incision can be combined with a third parallel incision on the anterior chest wall to debride the necrosed part of the skin there (figure 2).
Postoperative Photograph Shows Three Horizontal and Parallel Incisions (Modified MacFee Procedure).
Antibiotics are prescribed according to culture and sensitivity, but empiric therapy can be started pending the laboratory report. We start our patients on a combination of a third-generation cephalosporin, penicillin or cloxacillin, an aminoglycoside, and either clindamycin or metronidazole. As noted earlier, most of the cultures in our study were sterile because all of our patients had already received intravenous antibiotic therapy prior to referral to us.
Hyperbaric oxygen therapy has also been advocated. Patients with cervical necrotizing fasciitis are prone to developing hypokalemia secondary to extensive tissue and fluid loss. If uncorrected, hypokalemia can lead to cardiac arrhythmias. Therefore, electrolyte balance must be maintained. The hemoglobin level should be kept above 10 g/dl and the serum protein level above 5 g/dl to promote rapid wound healing in such patients.
Twice-daily dressings, copious irrigation with an antiseptic solution or even saline, finger exploration of different neck spaces, and further debridement of necrotic issue are essential to wound care.