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Original Article |

Nonoperative Catheter Management for Cervical Necrotizing Fasciitis With and Without Descending Necrotizing Mediastinitis FREE

Yuka Sumi, MD; Hiroshi Ogura, MD; Yasushi Nakamori, MD; Isao Ukai, MD; Osamu Tasaki, MD; Yasuyuki Kuwagata, MD; Takeshi Shimazu, MD; Hiroshi Tanaka, MD; Hisashi Sugimoto, MD
[+] Author Affiliations

Author Affiliations: Department of Traumatology and Acute Critical Medicine, Osaka University Graduate School of Medicine (Drs Sumi, Ogura, Ukai, Tasaki, Kuwagata, Shimazu, Tanaka, and Sugimoto), and Critical Care and Trauma Center, Osaka Prefectural Hospital Organization, Osaka General Medical Center (Dr Nakamori) Osaka, Japan. Dr Sumi is now with the Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts.


Arch Otolaryngol Head Neck Surg. 2008;134(7):750-756. doi:10.1001/archotol.134.7.750.
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Objective  To evaluate the clinical utility of catheter drainage for cervical necrotizing fasciitis (CNF) with and without descending necrotizing mediastinitis (DNM).

Design  Retrospective analysis.

Setting  Department of Traumatology and Acute Critical Medicine, Osaka University Graduate School of Medicine.

Patients  Thirty-two patients with clinically and radiographically diagnosed CNF with and without DNM were included.

Interventions  Catheters were introduced into the infected space through the patients' necks under sonographic and x-ray fluoroscopic guidance.

Main Outcome Measures  Treatments, clinical course, complications, and mortality were evaluated.

Results  Catheter drainage was successfully performed in all patients. The CNF was due to pharyngeal infection in 14 patients (44%) and dental infection in 14 other patients (44%). Mediastinal extension occurred in 14 patients (44%). Overall mortality was 3.1%; only 1 patient with DNM died due to Clostridium sepsis. Both pharyngeal origin and diabetes mellitus were significantly associated with the development of DNM. More intensive treatment is necessary for patients with CNF with DNM than for patients with CNF without DNM.

Conclusion  Percutaneous catheter drainage may be used as an effective treatment for CNF with and without DNM.

Figures in this Article

Cervical necrotizing fasciitis (CNF) and descending necrotizing mediastinitis (DNM) are progressive polymicrobial infections associated with high mortality rates (25%-40%).13 They most commonly originate from dental or pharyngeal infection. Because of the rapid and fulminant course of necrotizing fasciitis, prompt recognition, adequate antimicrobial therapy, and early radical surgical debridement are the keys to a successful outcome.4 On the basis of computed tomography (CT) findings, many authors have recommended transcervical or transthoracic surgical mediastinal drainage5,6; others have reported a thoracoscopic approach.79 The optimal surgical drainage method is controversial.

Since October 1998, we have performed percutaneous catheter drainage instead of conventional surgical drainage for the treatment of CNF and DNM (Figure 1). Our research group recently reported that percutaneous catheter drainage as a novel treatment for CNF and DNM is less invasive than conventional surgical drainage, and it controlled infection effectively.10We found several advantages of percutaneous catheter drainage compared with open surgical drainage. Percutaneous catheter drainage areas are less likely to become secondarily infected by antibiotic-resistant bacteria, and percutaneous catheter drainage seems superior to surgical drainage in terms of pain control and prevention of protein leakage from the wound. In the present study, we evaluated the clinical utility of our method for treatment of CNF with and without DNM.

Place holder to copy figure label and caption
Figure 1.

The changes in treatment for cervical necrotizing fasciitis (CNF) and descending necrotizing mediastinitis. A, Neck swelling with redness in patient with CNF. B, Neck after surgical drainage. C, Neck after percutaneous catheter drainage.

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PATIENTS

Thirty-two patients who were hospitalized in our critical care center between October 1998 and July 2005 with clinically and radiographically diagnosed CNF with or without DNM were included in this study. Radiographic diagnosis drew on CT (Asteion TSX-021A; Toshiba Medical Systems Corporation, Otawara, Tochigi, Japan) in all cases showing diffuse thickening of cervical fascial planes and fat with gas tracking along fascial planes. Multidetector CT was carried out with a field of view of 240 mm, a collimation of 4 × 1 mm, effective section thickness of 2 mm, increment of 1 mm, scan time of 0.75 seconds per 360° rotation, and tube voltage of 120 kV, 230 mA per section. The images were transferred to a workstation (Terarecon Aquarius Workstation, version 3.1; San Mateo, California), running a software package for generating multiplanar reconstructions and maximum intensity projections. All patients were treated with percutaneous catheter drainage. Patients who had undergone aggressive surgical treatment before admission to our center were excluded from the study.

We evaluated clinical features of all patients with CNF and compared those with DNM (DNM group, n = 14) and without DNM (non-DNM group, n = 18). The following patient characteristics were evaluated: sex, age, primary site of infection, findings of initial microbiologic culture, underlying condition, time from appearance of symptoms to admission at our center, initial C-reactive protein level, and total leukocyte count (immature to total neutrophil ratio). The following aspects of medical treatment were evaluated: number of catheters, duration of mechanical ventilation, duration of antibiotic therapy, and length of the intensive care unit (ICU) stay. Clinical outcomes were evaluated according to length of the ICU stay, complications, and mortality rate.

CATHETER DRAINAGE

Intravenous contrast-enhanced CT with iodine-based contrast agents was performed in all patients, and CT was used to confirm the extent of infection and to identify the space requiring drainage (Figure 2 and Figure 3). After nasotracheal intubation and under general anesthesia, percutaneous catheter drainage was performed in a room equipped for fluoroscopy. Under real-time sonographic guidance (LOGIQ 500 PRO; General Electric Yokogawa Medical Systems, Tokyo, Japan), a fine needle was inserted through the neck around the thyroid into the infected space targeting any low-echoic lesion with fluid collection or hyperechoic folliculi showing scattered collections of gas (Figure 4).

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Figure 2.

Contrast-enhanced computed tomographic scan shows cervical necrotizing fasciitis without descending necrotizing mediastinitis. Marked edema of the subcutaneous fat is present with gas in the left masticator space to buccal space (arrow).

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Figure 3.

Contrast-enhanced computed tomographic scan shows cervical necrotizing fasciitis with descending necrotizing mediastinitis. Thickening of fat and collections of gas are seen from the left posterior cervical space to the anterior and posterior mediastinum (arrows).

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Place holder to copy figure label and caption
Figure 4.

Illustrated catheter drainage. A, Ultrasonogram of the neck of a patient with cervical necrotizing fasciitis. Under sonographic guidance, a fine needle is inserted between the thyroid and the carotid artery (CA) (arrow) targeting any low-echoic lesion with fluid collection or hyperechoic folliculi showing scattered collections of gas (arrowheads). B, Axial scheme of the procedure illustrated in panel A. JV indicates jugular vein.

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For catheter drainage, a No. 7 French catheter kit for percutaneous transhepatic bile duct drainage (PTCD Kit; Create Medic, Yokohama, Japan) was used. We were able to guide the catheter using an angiography guidewire with contrast medium into all infected spaces, retropharyngeal, parapharyngeal, anterior mediastinum, and posterior mediastinum. Fluid extracted from each catheter was sent to the laboratory for bacterial culture analysis. To examine the efficacy of catheter drainage, we injected contrast medium from each catheter and performed CT scanning (Figure 5). If the scan revealed any infected space without contrast medium, drainage was considered insufficient and another catheter was added. Multidetector CT with thin slice increments allowed high resolution coronal and sagittal reformations, which facilitated depicting catheter placement and course (Figure 6). Catheters were removed when we confirmed radiographic improvement and decrease and sterility of the drainage fluid.

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Figure 5.

Computed tomography (CT) images taken before (A) and after (B) catheter drainage. A, The CT image shows infection present in the sublingual space. B, The CT image acquired after catheter drainage shows contrast medium present in the infected spaces.

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Figure 6.

Computed tomography scans after catheter drainage. The large image on the left represents a maximum intensity projection image with numbered lines indicating planes of further evaluation: (1) at the neck level, there is a catheter in the retropharyngeal space (arrow); (2) at the upper thorax level, there is a catheter in the anterior mediastinum and another 2 in the posterior mediastinum (arrows); and (3) at the middle thorax level, there is a catheter in the anterior mediastinum and another in the posterior mediastinum (arrows) (same catheters as seen in subpanel 2).

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ANTIBIOTIC THERAPY

Treatment with benzylpenicillin potassium (20 million U/d) for 2 days and imipenem cilastatin (1 g/d) for 7 days was initially administered to all patients. In all cases, the initial regimen was subsequently modified according to bacteriologic findings and antibiotic sensitivity testing. Termination of antibiotic therapy was dependent on improved CT findings and a decreased C-reactive protein level. Amphotericin B (900 mg/d) was also administered to each patient via nasogastric tube for decontamination of the gastric tract.

STATISTICAL ANALYSIS

Data are presented as mean (SD). The unpaired t test was used for analysis of differences between CNF with and without DNM. The χ2 test was used to analyze differences in the origin of infection. Statistical significance was accepted at P < .05.

OVERALL PATIENT CHARACTERISTICS

Over a 7-year period, 32 patients with CNF with or without DNM were referred to our ICU. The patients included 26 men (81%) and 6 women (19%) ranging in age from 19 to 81 years (mean [SD] age, 58.7 [16.7] years). Mean time from the onset of symptoms until hospitalization was 5.3 (2.2) days. In 11 of the 32 cases (34%), an underlying condition that may have favored development of the infection was found: diabetes mellitus in 8 cases, renal failure in 2, and alcoholism in 1. In the remaining 21 cases, CNF developed in otherwise healthy patients. Cervical necrotizing fasciitis was due to pharyngeal infection in 14 patients (44%), dental infection in 14 other patients (44%), parotitis in 1 patient, and an unknown cause in 3 patients. Mediastinal extension occurred in 14 patients (44%).

MICROBIOLOGIC FINDINGS OF PRIMARY CULTURES

Numerous bacteriologic cultures were performed in each case (Table 1). Specimens obtained by puncture aspiration of the site of infection showed the presence of mixed flora of anaerobic and aerobic bacteria. Streptococcus species and Prevotella or Bacteroides were most commonly isolated. Clostridium species was found in only 1 instance.

Table Graphic Jump LocationTable 1. Microbiologic Findings of Primary Cultures
CLINICAL OUTCOMES

Overall mortality was 3.1%; only 1 patient died. This was a patient with DNM who died from Clostridium sepsis. The mean (SD) duration of antibiotic therapy was 12.9 (11.4) days. The mean duration of mechanical ventilation was 9.9 (8.8) days, and mean length of the ICU stay was 22.5 (19) days. Complications included jugular vein thrombosis in 8 patients, septic shock in 4, compromised airway in 2, empyema in 2, and bronchocavitary fistula in 1.

Two patients with DNM experienced complications during the catheter insertion procedure. One had mediastinal hemorrhage due to minor arterial injury, but the hemorrhage stopped spontaneously. The other had esophageal puncture when the catheter was introduced from the neck into the posterior mediastinum. The puncture wound was treated conservatively without further complication.

DIFFERENCES IN CLINICAL FEATURES OF CNF WITH AND WITHOUT DNM

No statistically significant difference was found between the DNM and non-DNM groups in mortality or complications. No statistically significant difference was found between the 2 groups in sex ratio (male to female ratio in the non-DNM group, 14:4 vs 12:2 in the DNM group), age (55.7 [19.4] years in the non-DNM group vs 62.6 [12.0] years in the DNM group), results of initial microbiologic culture, time from the appearance of symptoms to admission to our center (5.3 [2.5] days in the non-DNM group vs 5.2 [2.5] days in the DNM group), C-reactive protein level, or total leukocyte count (Table 2).

Table Graphic Jump LocationTable 2. Clinical Characteristics of Patients With Cervical Necrotizing Fasciitisa

The presence of diabetes (n = 1 in the non-DNM group vs n = 7 in the DNM group) and primary site of infection differed significantly between the 2 groups. The CNF was of pharyngeal origin in 22% of patients without DNM (n = 4) and in 71% of patients with DNM (n = 10). The mean (SD) hemoglobin A1c level was 5.1% (0.6%) in the non-DNM group and 7.4% (2.6%) in DNM group (P = .004). To convert hemoglobin A1c to a proportion of total hemoglobin, multiply by 0.01. Both pharyngeal origin and diabetes mellitus were significantly associated with the development of DNM (Figure 7).

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Figure 7.

Risk factors for mediastinal invasion in cervical necrotizing fasciitis (CNF). A, In patients with descending necrotizing mediastinitis (DNM), 71% of infections were of pharyngeal origin (P = .005). B, Patients with DNM had higher hemoglobin A1c (HbA1c) levels than patients without DNM. To convert HbA1c to a proportion of total hemoglobin, multiply by 0.01 (error bars indicate SD).

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With respect to treatment, more catheters were used for patients in the DNM group than for patients in the non-DNM group (6.9 [4.1] for the DNM group vs 2.4 [1.2] for the non-DNM group) (P = .002), and the mean duration of mechanical ventilation was significantly longer for patients with DNM than for patients without DNM (13.8 [11.7] days for the DNM group vs 7.2 [4.8] days for the non-DNM group) (P = .04). No statistically significant difference was found between the 2 groups in the duration of antibiotic therapy or ICU stay. More intensive treatment was required by patients with DNM than by patients without DNM (Figure 8).

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Figure 8.

Cervical necrotizing fasciitis (CNF) treatment in patients with and without descending necrotizing mediastinitis (DNM). Error bars indicate SD. A, More catheters were needed to treat patients with DNM than to treat those without DNM. B, The mean duration of mechanical ventilation was significantly longer in patients with DNM than in those without DNM.

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Necrotizing fasciitis is a fast-spreading soft tissue infection of polymicrobial origin characterized by necrosis of the subcutaneous tissue and superficial fascia. The invasiveness is often influenced by synergistic interactions among multiple species. A predominance of male patients is commonly reported in the literature. Despite the introduction of antimicrobial therapy and CT imaging, CNF with DNM has continued to produce mortality rates between 25% and 40%.13 Spread of infection from the cervical region to the thorax is considered an ominous sign; the associated mortality is high.11 This poor prognosis could be in part due to the difficulty of establishing and maintaining adequate surgical drainage as DNM spreads among the fascial compartments of the neck and chest.1

Because of the anatomic relations in the cervicothoracic region and the progressive nature of DNM, controversy exists as to the optimal surgical approach. Our group recently reported that percutaneous catheter drainage as a novel treatment for CNF and DNM controlled infection effectively and was superior to surgical drainage in terms of pain control and prevention of protein leakage from the wound.10 In the present study, we evaluated the clinical course of 32 patients with CNF treated with percutaneous catheter drainage and compared clinical outcomes between those with and those without DNM.

All patients except 1 survived without serious complication. The mortality rate of 3.1% in our study was lower than that previously reported in the literature.14 Although some authors believe that early radical surgical drainage is the most important factor affecting outcome,12,13 we effectively controlled CNF even with DNM by percutaneous catheter drainage. Streptococcus was found in 84% of our cases (n = 27), and Bacteroides or Prevotella was found in 69% (n = 22). We used benzylpenicillin potassium to target Gram-positive cocci and imipenem cilastatin to target Gram-negative bacteria, particularly anaerobes, and these antibiotics were effective. Percutaneous catheter drainage is a closed drainage system that decreases secondary infection by antibiotic-resistant bacteria. Only 1 patient died, and this was due to Clostridium sepsis. Nakamura et al14 reported that most gas-producing infections in the head and neck region are nonclostridial and proceed along fascia, whereas clostridial infections progress in muscular layers and are often lethal.

We evaluated the clinical features of CNF with and without DNM. In this series, 14 patients with thoracic extension of infection experienced mediastinitis. Both pharyngeal origin and diabetes mellitus were significantly associated with the development of DNM. Anatomic spread of infection from the craniocervical region to the thorax is well recognized. Potential spaces in the neck (pretracheal, retrovisceral, and prevertebral) contain loose tissue and, by virtue of their communication with the pericardium, parietal pleura, and mediastinum, readily serve as portals of entry for oropharyngeal or cervical infection into the chest.1,15 Easy spread from the pharyngeal source to the parapharyngeal or retropharyngeal space allows for downward spread into the mediastinum.16 This anatomic feature accounts for pharyngeal origin as a factor associated with DNM. In other recent studies of DNM, the infection was more frequently of pharyngeal origin than of dental origin.1,1719

Several factors, including obesity, diabetes mellitus, severe liver disease, immunosuppression, and renal failure, have been implicated in the occurrence of necrotizing fasciitis.4 Patients with diabetes mellitus, which impairs leukocyte function and contributes to suppression of the host's immune system, have been considered at an unusually high risk of developing the infection. Our study showed that diabetes mellitus is a factor significantly associated with DNM.

In patients with CNF without DNM, fewer catheters were needed to achieve drainage (non-DNM group, 2.4 [1.2] vs DNM group, 6.9 [4.1]), and the duration of mechanical ventilation was shorter (non-DNM group, 7.2 [4.8] days vs DNM group, 13.8 [11.7] days). More intensive treatment was needed for our patients with DNM than for those without DNM. However, even in patients with DNM, we were able to effectively control infection. Under real-time sonographic guidance and fluoroscopy, catheters could be inserted and added into the targeted infected space including mediastinum in all cases. The low mortality and complication rates in our study support the notion that percutaneous catheter drainage may be a safe and effective treatment for CNF in patients with or without DNM. Furthermore, percutaneous catheter drainage is less invasive than surgical drainage.10 Thus, catheter drainage can serve as an alternative approach for management of CNF with and without DNM.

In 32 patients with CNF treated with percutaneous catheter drainage, both pharyngeal origin and diabetes mellitus were significantly associated with the development of DNM. More intensive treatment (greater number of catheters, longer duration of mechanical ventilation) was necessary for patients with DNM than for patients without DNM. The low mortality rate in our study showed that percutaneous catheter drainage may be used as an effective treatment for CNF with and without DNM.

Correspondence: Yuka Sumi, MD, Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, 330 Brookline Ave, DANA No. 813, Boston, MA 02215 (yukasumi020503@yahoo.co.jp).

Submitted for Publication: February 27, 2007; final revision received October 1, 2007; accepted October 2, 2007.

Author Contributions: Dr Sumi had full access to all the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis. Study concept and design: Sumi, Ogura, Nakamori, Kuwagata, Tanaka, and Sugimoto. Acquisition of data: Sumi, Ukai, Tasaki, Shimazu, and Sugimoto. Analysis and interpretation of data: Sumi, Ogura, Kuwagata, Shimazu, and Sugimoto. Drafting of the manuscript: Sumi, Ogura, Nakamori, Ukai, Tasaki, Kuwagata, Shimazu, Tanaka, and Sugimoto. Critical revision of the manuscript for important intellectual content: Ogura, Shimazu, and Sugimoto. Statistical analysis: Sumi and Tasaki. Administrative, technical, and material support: Ogura, Ukai, Tasaki, Kuwagata, Shimazu, and Sugimoto. Study supervision: Ogura, Nakamori, Kuwagata, Shimazu, Tanaka, and Sugimoto.

Financial Disclosure: None reported.

Freeman  RKVallieres  EVerrier  EDKarmy-Jones  RWood  DE Descending necrotizing mediastinitis: an analysis of the effects of serial surgical debridement on patient mortality. J Thorac Cardiovasc Surg 2000;119 (2) 260- 267
PubMed
Mathieu  DNeviere  RTeillon  CChagnon  JLLebleu  NWattel  F Cervical necrotizing fasciitis: clinical manifestations and management. Clin Infect Dis 1995;21 (1) 51- 56
PubMed
Takao  MIdo  MHamaguchi  K  et al.  Descending necrotizing mediastinitis secondary to a retropharyngeal abscess. Eur Respir J 1994;7 (9) 1716- 1718
PubMed
Mohammedi  ICeruse  PDuperret  SVedrinne  JMBouletreau  P Cervical necrotizing fasciitis: 10 years' experience at a single institution. Intensive Care Med 1999;25 (8) 829- 834
PubMed
Wheatley  MJStirling  MCKirsh  MM  et al.  Descending necrotizing mediastinitis: transcervical drainage is not enough. Ann Thorac Surg 1990;49 (5) 780- 784
PubMed
Inoue  YGika  MNozawa  KIkeda  YTakanami  I Optimum drainage method in descending necrotizing mediastinitis. Interact Cardiovasc Thorac Surg 2005;4 (3) 189- 192
PubMed
Isowa  NYamada  TKijima  T  et al.  Successful thoracoscopic debridement of descending necrotizing mediastinitis. Ann Thorac Surg 2004;77 (5) 1834- 1837
PubMed
Roberts  JRSmythe  WRWeber  RW  et al.  Thoracoscopic management of descending necrotizing mediastinitis. Chest 1997;112 (3) 850- 854
PubMed
Min  HKChoi  YSShim  YMSohn  YIKim  J Descending necrotizing mediastinitis: a minimally invasive approach using video-assisted thoracoscopic surgery. Ann Thorac Surg 2004;77 (1) 306- 310
PubMed
Nakamori  YFujimi  SOgura  H  et al.  Conventional open surgery versus percutaneous catheter drainage in the treatment of cervical necrotizing fasciitis and descending necrotizing mediastinitis. AJR Am J Roentgenol 2004;182 (6) 1443- 1449
PubMed
Bahu  SJShibuya  TYMeleca  RJ  et al.  Craniocervical necrotizing fasciitis: an 11-year experience. Otolaryngol Head Neck Surg 2001;125 (3) 245- 252
PubMed
Voros  DPissiotis  CGeorgantas  D  et al.  Role of early and extensive surgery in the treatment of severe necrotizing soft tissue infection. Br J Surg 1993;80 (9) 1190- 1191
PubMed
Corsten  MJShamji  FMOdell  PF  et al.  Optimal treatment of descending necrotizing mediastinitis. Thorax 1997;52 (8) 702- 708
PubMed
Nakamura  SInui  MNakase  M  et al.  Clostridial deep neck infection developed after extraction of a tooth: a case report and review of the literature in Japan. Oral Dis 2002;8 (4) 224- 226
PubMed
Moncada  RWarpeha  RPickleman  J  et al.  Mediastinitis from odontogenic and deep cervical infection: anatomic pathways of propagation. Chest 1978;73 (4) 497- 500
PubMed
Skitarelić  NMlandina  RMorovic  MSkitarelic  N Cervical necrotizing fasciitis: sources and outcomes. Infection 2003;31 (1) 39- 44
PubMed
Marty-Ane  CHAlauzen  MAlric  PSerres-Cousine  OMary  H Descending necrotizing mediastinitis: advantage of mediastinal drainage with thoracotomy. J Thorac Cardiovasc Surg 1994;107 (1) 55- 61
PubMed
Iwata  TSekine  YShibuya  K  et al.  Early open thoracotomy and mediastinopleural irrigation for severe descending necrotizing mediastinitis. Eur J Cardiothorac Surg 2005;28 (3) 384- 388
PubMed
Hirai  SHamanaka  YMitsui  NIsaka  MMizukami  T Surgical treatment of virulent descending necrotizing mediastinitis. Ann Thorac Cardiovasc Surg 2004;10 (1) 34- 38
PubMed

Figures

Place holder to copy figure label and caption
Figure 1.

The changes in treatment for cervical necrotizing fasciitis (CNF) and descending necrotizing mediastinitis. A, Neck swelling with redness in patient with CNF. B, Neck after surgical drainage. C, Neck after percutaneous catheter drainage.

Graphic Jump Location
Place holder to copy figure label and caption
Figure 2.

Contrast-enhanced computed tomographic scan shows cervical necrotizing fasciitis without descending necrotizing mediastinitis. Marked edema of the subcutaneous fat is present with gas in the left masticator space to buccal space (arrow).

Graphic Jump Location
Place holder to copy figure label and caption
Figure 3.

Contrast-enhanced computed tomographic scan shows cervical necrotizing fasciitis with descending necrotizing mediastinitis. Thickening of fat and collections of gas are seen from the left posterior cervical space to the anterior and posterior mediastinum (arrows).

Graphic Jump Location
Place holder to copy figure label and caption
Figure 4.

Illustrated catheter drainage. A, Ultrasonogram of the neck of a patient with cervical necrotizing fasciitis. Under sonographic guidance, a fine needle is inserted between the thyroid and the carotid artery (CA) (arrow) targeting any low-echoic lesion with fluid collection or hyperechoic folliculi showing scattered collections of gas (arrowheads). B, Axial scheme of the procedure illustrated in panel A. JV indicates jugular vein.

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Place holder to copy figure label and caption
Figure 5.

Computed tomography (CT) images taken before (A) and after (B) catheter drainage. A, The CT image shows infection present in the sublingual space. B, The CT image acquired after catheter drainage shows contrast medium present in the infected spaces.

Graphic Jump Location
Place holder to copy figure label and caption
Figure 6.

Computed tomography scans after catheter drainage. The large image on the left represents a maximum intensity projection image with numbered lines indicating planes of further evaluation: (1) at the neck level, there is a catheter in the retropharyngeal space (arrow); (2) at the upper thorax level, there is a catheter in the anterior mediastinum and another 2 in the posterior mediastinum (arrows); and (3) at the middle thorax level, there is a catheter in the anterior mediastinum and another in the posterior mediastinum (arrows) (same catheters as seen in subpanel 2).

Graphic Jump Location
Place holder to copy figure label and caption
Figure 7.

Risk factors for mediastinal invasion in cervical necrotizing fasciitis (CNF). A, In patients with descending necrotizing mediastinitis (DNM), 71% of infections were of pharyngeal origin (P = .005). B, Patients with DNM had higher hemoglobin A1c (HbA1c) levels than patients without DNM. To convert HbA1c to a proportion of total hemoglobin, multiply by 0.01 (error bars indicate SD).

Graphic Jump Location
Place holder to copy figure label and caption
Figure 8.

Cervical necrotizing fasciitis (CNF) treatment in patients with and without descending necrotizing mediastinitis (DNM). Error bars indicate SD. A, More catheters were needed to treat patients with DNM than to treat those without DNM. B, The mean duration of mechanical ventilation was significantly longer in patients with DNM than in those without DNM.

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Tables

Table Graphic Jump LocationTable 1. Microbiologic Findings of Primary Cultures
Table Graphic Jump LocationTable 2. Clinical Characteristics of Patients With Cervical Necrotizing Fasciitisa

References

Freeman  RKVallieres  EVerrier  EDKarmy-Jones  RWood  DE Descending necrotizing mediastinitis: an analysis of the effects of serial surgical debridement on patient mortality. J Thorac Cardiovasc Surg 2000;119 (2) 260- 267
PubMed
Mathieu  DNeviere  RTeillon  CChagnon  JLLebleu  NWattel  F Cervical necrotizing fasciitis: clinical manifestations and management. Clin Infect Dis 1995;21 (1) 51- 56
PubMed
Takao  MIdo  MHamaguchi  K  et al.  Descending necrotizing mediastinitis secondary to a retropharyngeal abscess. Eur Respir J 1994;7 (9) 1716- 1718
PubMed
Mohammedi  ICeruse  PDuperret  SVedrinne  JMBouletreau  P Cervical necrotizing fasciitis: 10 years' experience at a single institution. Intensive Care Med 1999;25 (8) 829- 834
PubMed
Wheatley  MJStirling  MCKirsh  MM  et al.  Descending necrotizing mediastinitis: transcervical drainage is not enough. Ann Thorac Surg 1990;49 (5) 780- 784
PubMed
Inoue  YGika  MNozawa  KIkeda  YTakanami  I Optimum drainage method in descending necrotizing mediastinitis. Interact Cardiovasc Thorac Surg 2005;4 (3) 189- 192
PubMed
Isowa  NYamada  TKijima  T  et al.  Successful thoracoscopic debridement of descending necrotizing mediastinitis. Ann Thorac Surg 2004;77 (5) 1834- 1837
PubMed
Roberts  JRSmythe  WRWeber  RW  et al.  Thoracoscopic management of descending necrotizing mediastinitis. Chest 1997;112 (3) 850- 854
PubMed
Min  HKChoi  YSShim  YMSohn  YIKim  J Descending necrotizing mediastinitis: a minimally invasive approach using video-assisted thoracoscopic surgery. Ann Thorac Surg 2004;77 (1) 306- 310
PubMed
Nakamori  YFujimi  SOgura  H  et al.  Conventional open surgery versus percutaneous catheter drainage in the treatment of cervical necrotizing fasciitis and descending necrotizing mediastinitis. AJR Am J Roentgenol 2004;182 (6) 1443- 1449
PubMed
Bahu  SJShibuya  TYMeleca  RJ  et al.  Craniocervical necrotizing fasciitis: an 11-year experience. Otolaryngol Head Neck Surg 2001;125 (3) 245- 252
PubMed
Voros  DPissiotis  CGeorgantas  D  et al.  Role of early and extensive surgery in the treatment of severe necrotizing soft tissue infection. Br J Surg 1993;80 (9) 1190- 1191
PubMed
Corsten  MJShamji  FMOdell  PF  et al.  Optimal treatment of descending necrotizing mediastinitis. Thorax 1997;52 (8) 702- 708
PubMed
Nakamura  SInui  MNakase  M  et al.  Clostridial deep neck infection developed after extraction of a tooth: a case report and review of the literature in Japan. Oral Dis 2002;8 (4) 224- 226
PubMed
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