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ORIGINAL ARTICLE
Year : 2012  |  Volume : 15  |  Issue : 3  |  Page : 344-348

Retrospective evaluation of necrotizing fasciitis in university college hospital, Ibadan


1 Department of Dental and Maxillofacial Surgery, University Teaching Hospital, Ado Ekiti, Nigeria
2 Department of Oral and Maxillofacial Surgery, University College Hospital, Ibadan, Nigeria

Date of Acceptance12-Nov-2011
Date of Web Publication6-Sep-2012

Correspondence Address:
O S Obimakinde
Dental and Maxillofacial Surgery Department, University Teaching Hospital, PMB 5355, Ado-Ekiti
Nigeria
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/1119-3077.100644

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   Abstract 

Context: Cervicofacial necrotizing fasciitis (CNF), although a potentially fatal fulminant infection has been largely under-reported in the dental literature.
Aims: To report our experience with cases seen and treated at the University College Hospital, Ibadan, Nigeria.
Settings and Design: A descriptive retrospective clinical study.
Materials and Methods: A retrospective survey of cases treated between January 2002 and January 2007 was done. Diagnosis of CNF was established by fascia necrosis found on surgical exploration. Patients' age, sex, medical status, etiology of infection, bacteriology, and treatment received and complications were reviewed.
Statistical Analysis Used: SPSS version 15.
Results: Of the 48 cases of cervicofacial infection admitted during the study period, only 12 cases of CNF were found. Male:Female ratio was 4:8. The mean age of patients was 58.83 ± 11.91 years while the age range was 42-83 years. Those that had immunocompromised medical conditions included three cases each of diabetes mellitus and chronic nutritional anaemia and one case of retroviral infection. Mixed bacterial isolates of anaerobes and enterobacteriaceae were found in 10 cases while beta hemolytic streptococci were the sole isolate in two cases. All patients had serial debridement combined with intravenous antibiotic medications. Complications included anterior chest wall infection in three patients and one case of pleural effusion. The only mortality occurred in the patient with retroviral infection.
Conclusions: We advocate early recognition, surgical debridement and intensive medical care for treatment of CNF in order to reduce morbidity and mortality from this condition.

Keywords: Cervicofacial, necrotizing fasciitis, infection, bacteriology


How to cite this article:
Obimakinde O S, Okoje V N, Akinmoladun V I, Fasola A O, Arotiba J T. Retrospective evaluation of necrotizing fasciitis in university college hospital, Ibadan. Niger J Clin Pract 2012;15:344-8

How to cite this URL:
Obimakinde O S, Okoje V N, Akinmoladun V I, Fasola A O, Arotiba J T. Retrospective evaluation of necrotizing fasciitis in university college hospital, Ibadan. Niger J Clin Pract [serial online] 2012 [cited 2020 Mar 30];15:344-8. Available from: http://www.njcponline.com/text.asp?2012/15/3/344/100644


   Introduction Top


Necrotizing fasciitis is a potentially fatal bacterial soft tissue infection which has been described by several authors. [1] It was first described in 1871 by Joseph Jones who referenced more than 2600 during the American civil war. [2] Meleny in 1924 named the disease ''streptococcal gangrene'' and described the condition as a more generalized lesion when he isolated haemolytic streptococci in 20 cases studied. [3] However, recent studies are in support of the polymicrobial etiology of the disease. [4],[5],[6] Various names that has been ascribed to this lesion include hospital gangrene, necrotizing erysipelas, streptococcal gangrene and suppurative fasciitis. [6],[7] The term necrotizing fasciitis was coined by Wilson in 1952 because of the characteristic fascia necrosis that is associated with the lesion. [8]

Necrotizing fasciitis is a worldwide condition with greater prevalence in the preantibiotic era. [9] It mainly affects the extremities, trunk and perineum and less commonly the cervical and facial region. [4],[5],[6] Although mortality from the disease has been reported to have improved after the advent of antibiotics, it remains a common affliction in the developing and underdeveloped nations due to poverty and lack of awareness. [9],[10] Young et al. [11] reported a mortality rate of 30% in 2005 indicating that management of the condition is still suboptimal. Cervicofacial necrotizing fasciitis [CNF] result mainly from dental infections and has been largely underreported. [4],[5],[10] It is associated with high morbidity because of the airway and other vital structures in the neck including the great vessels. Several reports indicated that the rapid progression of the disease is responsible for the high mortality associated with this condition. [6],[12]

Although some authors reported that co-morbid medical conditions like diabetes mellitus, alcoholism, vascular insufficiencies, retroviral infection or neutropenia are contributory to the poor prognosis of this disease. [10],[11],[12],[13],[14] On the contrary, Obiechina et al. [6] in a previous study done locally ruled out the importance of underlying medical condition in the etiology of CNF. However, more recent studies showed that immunocompromised medical diseases play significant role in progression and prognosis of CNF. Ndukwe et al. [9] in a study of craniocervical necrotizing fasciitis in Ile-Ife, Nigeria, reported that preexisting ill health was one of the factors responsible for the only mortality in their series. Periodic evaluation of CNF helps to identify prognostic indicators of the condition and plan aggressive intervention and preventive strategies. This informed the need for the present study which aimed to report our experience of twelve patients with CNF, highlighting comparison with previous studies especially those done locally.


   Materials and Methods Top


The study setting was the Oral and Maxillofacial Surgery department of the University College Hospital Ibadan, a major referral centre for settlements in Oyo State and other adjoining states in Southwestern Nigeria.

A retrospective survey of cases of cervicofacial infections admitted to the department of Oral and Maxillofacial Surgery, University College Hospital, Ibadan, Nigeria between January 2002 and January 2007 was done. Parameters studied include age, sex, medical status, etiology and bacteriology of infection, antimicrobial treatment, and duration of symptom, surgical treatment and complications.

The data obtained from our records were summarized in a table. Statistical analysis was done with SPSS version 15.


   Results Top


Of the 48 cases of orofacial infection identified during the study period, only 12 were diagnosed as CNF. There were 8 female and 4 male patients with a mean age of 58.83 ± 11.91 years. The age range was 42-83 years. Odontogenic infection was the etiology of CNF in all cases with periodontal infection constituting 66.7% [n=8] while apical infection from dental caries made up 33.3% of the cases [n=4]. Mandibular molar was the offending tooth in 10 cases while the maxillary molar teeth were involved in only two lesions. None of the lesions developed after tooth extraction. All patients gave a positive history of dental pain and swelling which initially mimicked odontogenic space abscess. Submandibular/upper cervical region was more commonly involved than other sites [Table 1].
Table 1: Demography of the patients, etiology, bacteriology, and treatment offered. It also showed the systemic illness present in some of the patients

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All patients were admitted and placed on intravenous infusion of 0.9% normal saline alternated with 4.3% dextrose saline. All patients presented with cervicofacial swelling which was warm, erythematous and associated with fever. The average temperature on admission was 38.1°C. In those patients with swelling, bullae formation became evident within 48 h of admission. Purulent exudate was also observed from the wound at this stage. All patients had incision and drainage with debridement under local anesthesia and fascia necrosis was demonstrated during exploration. Broad spectrum antibiotics were administered intravenously along with metronidazole immediately after pus was obtained for culture.

Streptococcus pyogenes was the sole isolate in two of the cases while it was among the mixed isolates in three other cases. Anaerobes were mainly in mixed isolates and these include culture of Fusobacterium sp. in three patients and two cases where  Bacteroides melaninogenicus Scientific Name Search us was cultured. Pseudomonas sp., klebsiela sp., E coli, and Staphylococcus aureus are other bacteria that were cultured from the lesions. The organisms were cultured from pus exudates and necrotic fascia. No organism was cultured in two cases probably because the patients had been on systemic antibiotic medication before presentation.

Following incision and drainage, rubber drains were inserted and necrotic tissues were excised as they appear [Figure 1], [Figure 2] and [Figure 3]. Fasciotomy was done and wound were dressed 12 hourly with gauze soaked with dilute hydrogen peroxide. All patients had extraction of the offending teeth.
Figure 1 : Same patient after the initial debridement of the wound and fasciotomy. The hemorrhagic appearance showed that the debridement was extended to vital tissues

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Figure 2 : Same patient after completion of serial wound debridement. The wound has healed leaving an area devoid of skin cover. She was subsequently referred to plastic surgery division for skin graft

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Figure 3 : One of the patients in our series. Image shows extensive necrosis and sloughing of the cervical fascia

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Complications were seen in patients who had co morbid conditions; these include mediastinitis and pleural effusion in two patients with diabetes mellitus and chest infection in a patient with nutritional anaemia. The only mortality occurred in the patient who was found to have HIV infection in the course of investigation. He developed overwhelming infection and later died of septicaemic shock.


   Discussion Top


Necrotizing fasciitis is a severe, potentially fatal infection involving the subcutaneous soft tissues. It may involve any part of the body, but commonly affect the extremities. Reports of CNF in the literature were mostly case reports. The condition is regarded as a surgical emergency due to associated high rate of morbidity and mortality. [1],[4],[5],[6]

In our series, the etiology of CNF was odontogenic with the mandibular molars being the worst culprit. This is in agreement with other studies where mandibular molars were implicated in the etiology of the disease. [4],[5],[6] Other authors have also reported other causes of CNF such as trauma, tonsilar, and pharyngeal infections, cervical adenitis and tumor infections. [5],[10],[15]

Our study showed a female preponderance with a male:female ratio of 4:8. However, earlier studies from Southwestern Nigeria by Ndukwe et al. [9] and Obiechina et al. [6] showed higher male preponderance [5:2 and 5:3, respectively]. Increasing female population and better healthcare seeking attitude of the female gender may explain this change in trend.

The role of co morbid diseases in the etiology and prognosis of CNF has been well documented in the literature. [5],[9],[10] Only diabetes mellitus [n=3], nutritional anaemia [n=3] and one case of HIV infection were the systemic diseases present in our series. On the contrary, Obiechina et al. [6] reported that none of the patients in their series had underlying medical condition and therefore suggested that medical conditions may not have an important role in the etiology of necrotizing fasciitis of odontogenic origin. However, findings from the present study and other recent ones showed that underlying medical conditions are major contributory factors.

CNF typically mimics odontogenic infection at the early stage and the mode of presentation can be misleading. However, the presence of an unusual erythema on a dark skin with accompanying vesicle formation is a pointer to the diagnosis of CNF. Subcutaneous crepitations precede gangrene and sloughing of the fascia. Other features include rapid spread to the neck areas, severe pain and radiographic finding of subcutaneous gas. In agreement with earlier studies, the submandibular space is the most commonly involved site in our series. This may be due to the proximity of the apices of the mandibular molar teeth to the submandibular space which favors a direct spread of infection to this region from the offending teeth. The infection typically spreads downward to involve other areas in the neck. Early recognition and aggressive serial debridement is beneficial at this stage. Hyperbaric oxygen [HBO] therapy has been advocated because of its beneficial effect. [16] HBO delivers 100% oxygen to the tissues thereby warding off anaerobe and aiding tissue healing.

Morbidity and mortality from CNF have been reported to be directly related to a number of variables such as preexisting systemic disease, delayed referrals, financial constraints, age and extent of spread of the lesion. The only mortality in our series involved the patient with retroviral infection who developed overwhelming infection and died of septicaemic shock. Other patients with underlying medical conditions were successfully co managed with the physicians in the relevant specialties.


   Conclusion Top


CNF remains a health burden in our population and its prognosis can be worsened by co morbid medical diseases. Its progression and complications can be halted if the condition and its etiologic agents are identified early and treated with aggressive surgical intervention, appropriate empiric antimicrobial cover with readjustment based on microbiologic findings.


   Acknowledgment Top


We acknowledge the resident doctors and the record staff for helping in retrieving the patients' records.

 
   References Top

1.Tiu A, Martin R, Vanniasingham P, MacComick AD, Hill AG. Necrotizing Fasciitis: Analysis of 48 cases in South Auckland, New Zealand. ANZ J Surg 2005;75:32-4.  Back to cited text no. 1
    
2.Jones J. Investigation upon the nature, causes and treatment of Hospital Gangrene as it prevailed in the confederate Armies 1861-1865 in US Sanitary Commission. Surgical Memoirs of the war of rebellion. New York: Reverside Press; 1871. p. 146-70.  Back to cited text no. 2
    
3.Meleny FL. Haemolytic Streptococcus gangrene. Arch Surg 1924;1:317-9  Back to cited text no. 3
    
4.Tung-Yiu W, Jehn-Shyun H, Ching-Hung C, Hung-An C. Cervical necrotizing fasciitis of odontogenic origin: A report of 11 cases. J Oral Maxillofac Surg 2000;58:1347-52.  Back to cited text no. 4
    
5.Subhashraj K, Jayakumar N, Ravindran C. Cervical necrotizing fasciitis: An unusual sequel of odontogenic infection. Med Oral Patol Oral Cir Bucal 2008;13:E788-91.  Back to cited text no. 5
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6.Obiechina AE, Arotiba JT, Fasola AO. Necrotizing fasciitis of odontogenic Origin in Ibadan Nigeria. Br J Oral Maxillofac Surg 2001;39:122-6.  Back to cited text no. 6
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7.Burge TS, Watson JD. Necrotising fasciitis. BMJ 1994;308:1453-4.  Back to cited text no. 7
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8.Wilson B. Necrotizing Fasciitis. Am Surg 1952;18:416-31.  Back to cited text no. 8
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9.Ndukwe KC, Fatusi OA, Ugboko VI. Craniocervical Necrotizing fasciitis in Ile Ife, Nigeria. Br J Oral Maxillofac Surg 2002;40:64-7.  Back to cited text no. 9
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10.Whitesides L, Cotto-Cumba C, Myers RA. Cervical Necrotizing Fasciitis of odontogenic origin: A case report and review of 12 cases. J Oral Maxillofac Surg 2000;58:144-51; discussion 152.  Back to cited text no. 10
    
11.Young MH, Aronoff DM, Engleberg NC. Necrotizing fasciitis: Pathogenesis and treatment. Expert Rev Anti Infect Ther 2005;3:279-94.  Back to cited text no. 11
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12.Fliss DM, Tovi F, Zirkin HJ. Necrotizing soft tissue infections of dental Origin. J Oral Maxillofac Surg 1990;48:1104-8.  Back to cited text no. 12
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13.De Backer T, Bossuyt M, Schoenaers J. Management of necrotizing fasciitis in the neck. J Craniomaxillofac Surg 1996;24:336-71.  Back to cited text no. 13
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14.Killey AC Seward GR, Kay LW. An Outline of oral Surgery, part 1. Bristol: Johnwright and Sons Limited 1975. p. 105-9.  Back to cited text no. 14
    
15.Jain S, Nagpure PS, Singh R, Garg D. Minor trauma triggering cervicofacial necrotizing fasciitis abscess. J Emerg Trauma Shock 2008;1:114-8.  Back to cited text no. 15
    
16.Langford FP, Moon RE, Stolp BW, Scher RL. Treatment of cervical necrotizing fasciitis with hyperbaric oxygen therapy. Otolaryngol Head Neck Surg 1995;112:274-8.  Back to cited text no. 16
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    Figures

  [Figure 1], [Figure 2], [Figure 3]
 
 
    Tables

  [Table 1]


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