Cirujano Dentista

Necrotizing soft tissue infections of the head and neck: Case reports and literature review
Jeremy McMahon, BDS, MBChB, FDS, FRCS,a Terrence Lowe, BDS, MBChB, FDSRCPS, FRCS,b and David A. Koppel, BDS, MBBS, FDS, FRCS,c Glasgow, Scotland
WEST OF SCOTLAND MAXILLOFACIAL SERVICE

A small but nevertheless important part of a surgeon’s experience comprises necrotizing soft tissue infections of thehead and neck. The purpose of this report is to heighten awareness of necrotizing soft tissue infections in any patient with an infection of the head and neck. The article also outlines an appropriate management strategy for use in the treatment of patients with this potentially fatal condition. Prompt diagnosis and early radical surgical debridement are significant factors in avoiding a fataloutcome in these patients. This article reviews the literature on necrotizing soft tissue infections of the head and neck and presents cases from our recent experience. (Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2003;95:30-7)

Necrotizing soft tissue infections constitute a small but nevertheless important part of a surgeon’s experience. The importance rests with the fact that advancingtissue necrosis signifies a life-threatening condition that demands prompt surgical intervention if a fatal outcome is to be averted. These infections respect no anatomic boundaries and present to surgeons of all specialties, maxillofacial surgery being no exception. To distinguish these from less serious infections requires a high level of awareness because their initial presentation may be deceptive.Delay in diagnosis has been demonstrated to be associated with an increased mortality in several studies.1-4 This infection is neither common nor rare, so that every surgeon is highly likely to encounter the condition but not with sufficient frequency to produce familiarity.5 The taxonomy applied to these infections is varied (Table), confusing, and not always conceptually useful. Dellinger3 statesthat much of this terminology may be dispensed with or simplified, and the separate syndromes cited in the medical literature may be considered different manifestations of the same pathologic process. The exception to this is the particular case of histotoxic clostridial myonecrosis (gas gangrene). This condition differs in important respects. Histologically, toxin-induced muscle necrosis proceedsrapidly in advance of actual bacterial invasion. Furthermore, this
a

Table. Terms applied to necrotizing soft tissue infections
Nonclostridial gas gangrene Hemolytic streptococcal gangrene Necrotizing erysipelas Synergistic necrotizing cellulitis Meleney’s bacterial gangrene Necrotizing cellulitis Fournier’s gangrene Necrotizing fasciitis

Consultant Maxillofacial Surgeon, West of ScotlandMaxillofacial Service. b Specialist Registrar, West of Scotland Maxillofacial Service. c Consultant Craniofacial/Maxillofacial Surgeon, West of Scotland Maxillofacial Service. Received for publication May 29, 2002; returned for revision Sep 5, 2002; accepted for publication Oct 1, 2002. © 2003, Mosby, Inc. 1079-2104/2003/$30.00 0 doi:10.1067/moe.2003.15

infection is more rapidly progressiveand has a higher mortality than its nonclostridial myonecrosis counterpart.4,6 Thus, the taxonomy can be reduced to 2 clinical entities: histotoxic clostridial myonecrosis and all other necrotizing soft tissue infections, both clostridial and nonclostridial. This classification has utility because the treatment is the same for all the described anatomic sites. We prefer the term necrotizing softtissue infection to the commonly applied term necrotizing fasciitis because the former provides a better conceptual framework for the radical surgical debridement required. The problem with the term necrotizing fasciitis is that it implies the process involves only subcutaneous fascial layers. Although this is not infrequently the case, it is by no means necessarily so. The necrotizing infective...