Abstract
Purpose
Cervical necrotizing fasciitis (CNF) is a severe and debilitating disease that requires intensive care unit (ICU) management and prompt surgical treatment to reduce morbidity and mortality. The aim of this study was to estimate the incidence and factors associated with severe complications of CNF.
Methods
We reviewed the medical records of consecutive patients hospitalized in an ICU from 2007 to 2012. The data were collected retrospectively; initial cervical and thoracic computed tomography (CT) scans, performed on admission, were reviewed by an experienced and blinded radiologist to determine CNF complications.
Results
A cohort of 160 patients admitted for CNF was included. The following complications of CNF were found: bilateral extension of CNF (28 %), internal jugular vein thrombosis (21 %), descending necrotic effusion (14 %), mediastinitis (24 %), and mortality (4 %); 53 % had at least one complication, and 48 % had at least one cervical complication. On the basis of a univariate analysis, the significant independent factors are odynophagia, dyspnea, oral glucocorticoids intake before admission, and pharyngeal source. Oral nonsteroidal anti-inflammatory drug intake before admission does not have any impact. The initial CNF complications increased both the duration of mechanical ventilation and the length of stay in the ICU. On the basis of a multivariate analysis, the independent factors for severe complications are pharyngeal CNF and oral glucocorticoid intake before admission.
Conclusions
Our study demonstrated that an initial cervico-thoracic CT scan revealed a high incidence of cervical and mediastinal CNF complications that all needed immediate management. Those severe complications might be avoidable as they were associated, at least partially, with prehospital oral glucocorticoid intake.
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References
Petitpas F, Blancal JP, Mateo J, Farhat I, Naija W, Porcher R, Beigelman C, Boudiaf M, Payen D, Herman P, Mebazaa A (2012) Factors associated with the mediastinal spread of cervical necrotizing fasciitis. Ann Thorac Surg 93:234–238
Tran Ba Huy P, Blancal JP, Verillaud B, Mebazaa A, Herman P (2011) Cervico-facial fascitiis. A major ENT emergency. Bull Acad Natl Med 195:661–676; discussion 676–668
Bou-Assaly W, McKellop J, Mukherji S (2010) Computed tomography imaging of acute neck inflammatory processes. World J Radiol 2:91–96
Becker M, Zbaren P, Hermans R, Becker CD, Marchal F, Kurt AM, Marre S, Rufenacht DA, Terrier F (1997) Necrotizing fasciitis of the head and neck: role of CT in diagnosis and management. Radiology 202:471–476
Yeguiayan JM, Yap A, Freysz M, Garrigue D, Jacquot C, Martin C, Binquet C, Riou B, Bonithon-Kopp C, the FSG (2012) Impact of whole-body computed tomography on mortality and surgical management of severe blunt trauma. Crit Care 16:R101
Perry JJ, Stiell IG, Sivilotti ML, Bullard MJ, Emond M, Symington C, Sutherland J, Worster A, Hohl C, Lee JS, Eisenhauer MA, Mortensen M, Mackey D, Pauls M, Lesiuk H, Wells GA (2011) Sensitivity of computed tomography performed within six hours of onset of headache for diagnosis of subarachnoid haemorrhage: prospective cohort study. BMJ 343:d4277
Larvin M, Chalmers AG, McMahon MJ (1990) Dynamic contrast enhanced computed tomography: a precise technique for identifying and localising pancreatic necrosis. BMJ 300:1425–1428
Pinto A, Scaglione M, Scuderi MG, Tortora G, Daniele S, Romano L (2008) Infections of the neck leading to descending necrotizing mediastinitis: role of multi-detector row computed tomography. Eur J Radiol 65:389–394
Bedos JP (2006) Necrotising cutaneous infections and necrotizing fasciitis: what antibiotic agents to use and how? Ann Fr Anesth Reanim 25:982–985
Le Gall JR, Lemeshow S, Saulnier F (1993) A new Simplified Acute Physiology Score (SAPS II) based on a European/North American multicenter study. JAMA 270:2957–2963
Endo S, Murayama F, Hasegawa T, Yamamoto S, Yamaguchi T, Sohara Y, Fuse K, Miyata M, Nishino H (1999) Guideline of surgical management based on diffusion of descending necrotizing mediastinitis. Jpn J Thorac Cardiovasc Surg 47:14–19
Steyerberg EW, Eijkemans MJ, Harrell FE Jr, Habbema JD (2001) Prognostic modeling with logistic regression analysis: in search of a sensible strategy in small data sets. Med Decis Making 21:45–56
Munoz A, Castillo M, Melchor MA, Gutierrez R (2001) Acute neck infections: prospective comparison between CT and MRI in 47 patients. J Comput Assist Tomogr 25:733–741
Mikaeloff Y, Kezouh A, Suissa S (2008) Nonsteroidal anti-inflammatory drug use and the risk of severe skin and soft tissue complications in patients with varicella or zoster disease. Br J Clin Pharmacol 65:203–209
de Gans J, van de Beek D, European Dexamethasone in Adulthood Bacterial Meningitis Study I (2002) Dexamethasone in adults with bacterial meningitis. N Engl J Med 347:1549–1556
Subramanian V, Saxena S, Kang JY, Pollok RC (2008) Preoperative steroid use and risk of postoperative complications in patients with inflammatory bowel disease undergoing abdominal surgery. Am J Gastroenterol 103:2373–2381
Markel TA, Lou DC, Pfefferkorn M, Scherer LR 3rd, West K, Rouse T, Engum S, Ladd A, Rescorla FJ, Billmire DF (2008) Steroids and poor nutrition are associated with infectious wound complications in children undergoing first stage procedures for ulcerative colitis. Surgery 144:540–545; discussion 545–547
Acknowledgments
We acknowledge the contributions of Pr Payen de la Garanderie.
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Take-home message: In an ICU cohort of patients with cervical necrotizing fasciitis, a CT scan on admission revealed severe cervical and mediastinal complications in half of the patients. Those complications might be avoidable as they were associated, at least partially, with prehospital oral glucocorticoids intake.
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134_2015_3830_MOESM1_ESM.tif
Supplementary material 1 (TIFF 695 kb). Fig. 2: Diagnosis and source of CNF (contrast-enhanced 64-section MDCT axial images and volume rendering reconstruction): A A unilateral left pharyngeal CNF with a pharyngeal collection and diffuse unilateral infiltration. B The neck at an upper level shows a unilateral gland CNF with a diffuse infiltration from parotiditis without collection. C Unilateral right dental CNF with collection and infiltration and dental fistula. D 3D reformation of Fig. 1c shows the dental fistula
134_2015_3830_MOESM2_ESM.tif
Supplementary material 2 (TIFF 1007 kb). Fig. 3: Mediastinitis. A Posterior mediastinitis with descending collection by prevertebral area. B An anterior mediastinitis at the level of the supra aortic vessels. C An inferior mediastinitis with descending posterior mediastinum. D Compression of the airways in the lower neck caused by the collection
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Nougué, H., Le Maho, AL., Boudiaf, M. et al. Clinical and imaging factors associated with severe complications of cervical necrotizing fasciitis. Intensive Care Med 41, 1256–1263 (2015). https://doi.org/10.1007/s00134-015-3830-1
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DOI: https://doi.org/10.1007/s00134-015-3830-1