Abstract
Cervical necrotizing fasciitis is an uncommon but potentially fatal infection characterized by rapidly progressive, widespread necrosis of the superficial fascia. The authors report a case of cervical necrotizing fasciitis of odontogenic origin in a male with uncontrolled diabetes mellitus. An early diagnosis was based on clinical examination, confirmed by computed tomography (CT) scan, which showed multiple collections of air in the left submandibular, submental and cervical region. Broad spectrum antibiotic therapy was started quickly followed by surgical drainage and debridement. Pus culture was positive for methicillin-resistant Staphylococcus aureus . Four days after admission, mediastinitis was revealed by CT and drainage was conducted through a transcervical incision. The patient was treated successfully with antimicrobial therapy, repeated surgical debridement and supportive care.
Necrotizing fasciitis is a potentially fatal infection characterized by rapidly progressive, widespread necrosis of the superficial fascia. The most frequently involved areas are the thorax, limbs, perineum, abdomen and groin. Cervical necrotizing fasciitis is uncommon, but increased numbers of cases have been reported in recent years . It is a severe condition with high mortality and prognosis is aggravated by the spread of the infection through the fasciae, with development of descending mediastinitis and septic shock. The most common causes of cervical necrotizing fasciitis are odontogenous or pharyngeal in origin . It mainly results from a polymicrobial or mixed aerobic–anaerobic infection, with a prevalence of Streptococcus species and anaerobic Bacteroides . Infections caused by methicillin-resistant Staphylococcus aureus (MRSA) are increasing and its resistance to most antibiotics makes treatment difficult. In previous studies on cervical necrotizing fasciitis, MRSA has not been reported as a pathogen. The authors report one case of cervical necrotizing fasciitis and descending mediastinitis due to MRSA.
Case report
On 21 December 2006, a 57-year-old man with a history of diabetes mellitus was referred to the authors’ clinic for swelling and tenderness in the bilateral submandibular region and dyspnea of 3 days’ duration. He had had a left mandibular toothache in the previous week and had consulted a community clinic where two oral antibiotics, cefradine and metronidazole, had been prescribed. At the authors’ clinic, the patient was febrile with a body temperature of 38.5 °C. Physical examination showed an ill-looking patient with a warm, tender and fluctuant left submandibular swelling extending down to the root of his neck. The maximal mouth opening was 15 mm. Intraoral examination showed the mouth floor was raised and swollen gingiva was found around the left mandibular molars. A complete blood cell count showed that his white cell count was 31.0 × 10 9 /l with 85% neutrophils. Hyperglycemia was detected with a serum glucose of 16.8 mmol/l. A provisional diagnosis of Ludwig’s angina resulting from odontogenic infection was given. An emergency tracheotomy was performed under local anesthesia. The patient was admitted and received intravenous ceftriaxone 4 g once daily, ornidazole 0.5 g twice daily and levofloxacin 0.1 g twice daily on an empirical basis.A subcutaneous injection of 5 u Novolin was given twice daily to control hyperglycemia. The next day, imaging studies were undertaken. Panoramic radiography demonstrated severe alveolar bone resorption around the left mandibular molars and a diagnosis of peridontitis was made ( Fig. 1 ). A computed tomography (CT) scan showed multiple collections of air in the left submandibular, submental and cervical region ( Fig. 2 ). The patient underwent left submandibular and anterior cervical incisions and drainage under local anesthesia. Extensive necrosis of the superficial fascia in the submandibular and cervical region was found during the operation. The adjacent adipose tissue and subcutaneous tissue were also involved to a variable extent. A foul odor was consistently present. Grayish, watery material could be seen spreading along multiple fascial planes. From this evidence, the diagnosis of cervical necrotizing fasciitis was made. A specimen from the neck was submitted to the laboratory for culture and sensitivity studies. A growth of MRSA was produced 5 days later. It was resistant to all antibiotics except vancomycin, so the antibiotic therapy described above was changed to intravenous norvancomycin 1.0 g twice daily. Supportive care was administered because of the patient’s poor health and hypoproteinemia, this included the use of human albumin, blood plasma, 18-amino acids, Soluvit and Intralipid.
4 days after admission, the patient received a thoracic CT scan to evaluate the mediastinum. Gas collections were confirmed in the posterosuperior mediastinum ( Fig. 3 ). Drainage was carried out by a thoracic surgeon through a transcervical incision. Two chest tubes were placed for mediastinal irrigation and drainage.
In the following days, six further surgical debridement procedures were performed taking care not to damage the major blood vessels, and dissection was carried out until fresh bleeding was seen ( Fig. 4 ). The wound was irrigated with 3% hydrogen peroxide and 0.25% chloramphenicol solution twice daily. Twenty days after admission, necrotic tissue and exudate greatly decreased, and the wound was granulating satisfactorily. The total leukocyte count, neutrophil count and blood glucose returned to normal levels. On 5 February 2007, a CT scan showed no signs of gas and fluid collection in the neck and thorax ( Fig. 5 ), so the chest tubes and tracheal cannula were removed. Vancomycin was given for 6 weeks. The patient was discharged after 50 days of hospitalization with no infection and complete healing of the cervical and submandibular regions.
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