An algorithm for early diagnosis of cervicofacial necrotising fasciitis

Abstract

Cervicofacial necrotising fasciitis (CNF) is a potentially fatal infection which can occasionally present in the head and neck. An early diagnosis and aggressive treatment is imperative for minimising the associated mortality and morbidity. The early clinical features are usually non-specific which makes it difficult to differentiate it from other less serious infections. Necrosis of the skin is a late feature. Although it is more common in the immunocompromised, it can also affect normal individuals. We discuss our experience of five patients with CNF, review of literature and algorithm for early diagnosis of CNF. With experience, we were able to diagnose the subsequent cases early and minimise the mortality and morbidity. In conclusion, the incidence of CNF has increased in the last decade partly due to an increased clinical awareness. Early intervention is essential to minimise the mortality and morbidity. It should be managed by a team of at least otolaryngologists, intensivist, microbiologist and plastic surgeons; cardiothoracic surgeons may be required. Treatment involves early aggressive surgical debridement/fasciotomy, intravenous antibiotics and general metabolic support in the intensive care unit.

Necrotising fasciitis of odontogenic origin

“…Once initiated, the disease progresses rapidly through contiguous facial spaces causing necrosis of fascia and the overlying skin which is the hallmark of this condition. Necrosis of muscle, gland tissue and bone can also lead to considerable destruction 4. These infections can be difficult to recognise in their early stages, but they progress rapidly and require aggressive treatment to combat the associated high morbidity and mortality.…”

Acute laryngeal abscess following acute sinusitis: A rare presentation in the modern era

“…[3] It must also be differentiated from cervicofascial necrotizing fasciitis, which usually has skin involvement in the form of discoloration or necrosis and laryngeal involvement may comprise of necrosis or blackening of laryngeal mucosa or cartilage. [9] The condition can be confirmed by CT scan and biopsy and requires debridement of the necrotic material.…”

Bilateral Dysfunction of Superior Laryngeal Nerves as a consequence of Cervical Necrotising Fasciitis: A case report

“…4 Initially, there is Klinični primer/Case report a patchy,6 smooth,9 shiny10 erythema of the cervical skin, without sharp demarcation from uninvolved skin.9 It is accompanied by edema, crepitation, tenderness, pain on palpation2 and fever.6 The pain is more severe than expected,4 and may be felt deep in the muscles11, but the affected skin area may also be insensitive.12 Later on, the skin becomes dusky, covered with blisters and bullae and finally necrotises. 4 If left untreated, the skin breaks down and copious purulent debris and "dishwater" fluid ensue.1 The sepsis develops within 48 hours of symptom onset. 2 Laboratory tests show a very rapid rise of CRP values4 and leukocytosis with a left shift.…”

“…8 Intravenous broad-spectrum antibiotics should be given in high doses. 4 Initially, an antibiotic effective against aerobic and anaerobic bacteria infection is prescribed. Later on, the therapy should be targeted against the microorganisms isolated from the microbiological samples.8 Nutritional, hemodynamic and intensive care supportive measures are vital.4,7 Surgical treatment is the key intervention.…”