Case Report

Vacuum-assisted closure for the treatment of cervical and mediastinal necrotizing fasciitis

Necrotizing fasciitis is a severe soft tissue infection that is uncommon in the head and neck region. Despite the advancement of care over the past few decades, the mortality rate remains high. Negative pressure wound therapy (NPWT), an advanced wound-healing technique, has become increasingly popular for a wide variety of complicated wounds. Since December 2015, we have used this technique in the management of necrotizing fasciitis of the head and neck. We report a consecutive case series treated with NPWT as the initial surgical procedure.

Seven patients who received a surgical diagnosis of necrotizing fasciitis of the head and neck underwent surgery under general anesthesia. After complete debridement, an NPWT device was applied for positive drainage of the involved areas. The drainage tube was connected to a central negative pressure system. The device was not replaced or removed until the infection was controlled. Then, a conventional drainage approach was used.

Of the 7 patients, 6 underwent the surgical procedure and NPWT once; the remaining patient underwent these procedures twice. The infectious cavities showed a clean wound covered with healthy granulation formation during the removal of the NPWT device. The following course was uneventful. The mean time for wound healing was 17.3 ± 6.1 days.

NPWT provides various advantages compared with conventional debridement and drainage, resulting in excellent clinical outcomes. This method could be recommended as an alternative approach in the management of necrotizing fasciitis in the head and neck region.

La cellulite cervico-faciale nécrosante d’origine dentaire est une pathologie grave qui impose une prise en charge rapide et efficace. Le but de ce travail est de décrire les difficultés diagnostiques et thérapeutiques rencontrées lors de la prise en charge.

Il s’agissait d’une étude prospective réalisée dans le service de chirurgie thoracique de l’hôpital du Mali de janvier 2011 à février 2015. Nous avons colligé les dossiers de 19 patients qui ont présenté une cellulite cervico-faciale nécrosante d’origine dentaire. Les aspects anatomo-cliniques, les modalités thérapeutiques et les difficultés rencontrées ont été décrites.

La douleur dentaire et la fièvre étaient les maîtres symptômes suivis de l’œdème cervical. La tomodensitométrie thoracique a permis de poser le diagnostic dans tous les cas. La cervicotomie avec mise à plat des collections étaient le geste opératoire le plus fréquemment réalisé. Le drainage pleural a été réalisé que dans 6 cas. La mortalité était de 15,8 %.

Les cellulites cervico-faciales nécrosantes d’origine dentaire sont des pathologies graves avec une morbi-mortalité élevée. L’examen-clé est la tomodensitométrie. La prise en charge médico-chirurgicale précoce en urgence par les mesures de réanimation, l’antibiothérapie adaptée, l’excision des tissus nécrotiques et le drainage des collections constituent les piliers du traitement.

Necrotizing cellulitis of dental origin is a serious disease and requires prompt and effective management to avoid adverse outcomes. The purpose of this work is to describe the diagnostic and therapeutic difficulties encountered in this condition.

This was a prospective study in the thoracic surgery department of Mali Hospital from January 2011 to February 2015. We collected consecutively 19 cases of complicating cervico-facial cellulitis of dental origin. The anatomical and clinical aspects, therapeutic modalities and difficulties are described.

Dental pain and fever were the predominant symptoms followed by cervical edema. Chest CT-scan was the basis for the diagnosis in all cases. Cervicotomy with debridement was the most performed surgical procedure. Pleural drainage was performed in 6 cases. Three patients (15.8%) died.

Necrotizing cellulitis of dental origin is a serious disease with high morbidity and mortality. The key radiological examination is the thoracic CT-scan. Early medico-surgical management by emergency care, tailored antibiotic therapy, removal of necrotizing tissues and drainage of collections are required to deliver a good outcome.

Dental infections are common and are mainly due to dental caries. When left untreated, these infections can lead to severe life-threatening sepsis.

The authors reported a case of a severe odontogenic deep neck space infection in a 54-year-old male. The patient was a heavy smoker with incidentally discovered diabetes. He was successfully treated by surgical drainage combined with an improvised Vacuum-Assisted Closure (VAC) system. The results of surgical drainage followed by insertion of an improvised VAC system were spectacular. The abscess resolved in response to dual-agent antibiotic therapy on day 17 and blood glucose control was achieved with insulin. Full-thickness skin graft was performed to repair the necrotic zone of the neck.

The use of VAC can be a valuable alternative to conventional dressings and hyperbaric oxygen therapy in poorly equipped conditions. Public awareness campaigns remain the most effective form of prevention against these odontogenic infections.

Optimal management of full-thickness wounds requires a thorough knowledge of wound-healing principles and practices. In the absence of underlying disease, almost every full-thickness wound will heal with minimal intervention; however, the process can be enhanced by judicious wound management. The first clinical decision to be made is whether to repair the wound or to allow it to heal by second intention. This decision is guided by a host of objective and subjective factors. Reconstruction options include primary closure, flaps, and grafts. Materials to aid reconstruction, including the introduction of tissue adhesives, continue to evolve. Both primary and secondary intention wounds are aided by occlusive dressings and adjutants. A plethora of wound-healing adjuncts have been developed to aid wound healing in diseased states, and a working knowledge of their use is beneficial in managing all full-thickness wounds.

En dehors des traitements conventionnels, la prise en charge des dermohypodermites bactériennes nécrosantes et des fasciites nécrosantes repose sur des traitements non médicamenteux. L'oxygénothérapie hyperbare et les pansements sont les techniques les plus utilisées. L'intérêt de l'oxygénothérapie hyperbare est bien établi dans les études expérimentales tandis que les preuves cliniques sont faibles. La conférence de consensus a conclu que cette technique ne pouvait être considérée que comme adjuvant d'un protocole thérapeutique associant réanimation, chirurgie et antibiothérapie. Les pansements occlusifs conventionnels à base de compresse de gaze humide ou grasse sont largement utilisés. Des pansements aux alginates de calcium ou à l'argent pourraient apporter un bénéfice. Une alternative aux pansements conventionnels pourrait être les pansements en pression négative.

Beside conventional therapy, the management of necrotizing cellulitis and fasciitis is based on non-pharmacological treatments. Hyperbaric oxygen therapy and dressings are the most frequently used techniques. The usefulness of hyperbaric oxygen therapy is clearly demonstrated in experimental studies while the efficacy of this technique is poorly assessed in clinical practice. The French consensus conference has concluded to an adjuvant role of hyperbaric oxygen therapy combined to intensive care management, surgery and antibiotic therapy. Occlusive conventional dressings using humid or vaseline gauze dressings are largely used. Calcium alginate or silver coated dressings might be useful. In addition, vacuum-assisted closure therapy could be proposed in replacement of conventional dressings.