- Email: [email protected]
Reconstruction of mandible and surrounding soft tissues in patient with necrotizing fasciitis
Copyright 9 Munksgaard 1996
Int. J. Oral Maxillofac. Surg. 1996; 25:98-100 Printed in Denmark. All rights reserved
InternationalJournalof
Ord &
MaxillCacialSurgery ISSN 0901-5027
Aesthetic and reconstructivesurgery
Reconstruction of mandible and surrounding soft tissues in patient with necrotizing fasciitis
Paul C. Salins, Sanjeev Saxena, Jomon K.John Department of Maxillofacial and Reconstructive Surgery, SDM College of Dental Sciences and Hospital, Dharwad, India
P. C. Salins, S. Saxena, J. K. John: Reconstruction of mandible and surrounding soft tissues in patient with necrotizing fasciitis. Int. J. Oral Maxillofac. Surg. 1996; 25: 98-100. 9 Munksgaard, 1996 Abstract. Necrotizing fasciitis is rare in the orofacial region, with fewer than 20 cases reported in the literature. Extension of the disease process to involve the underlying bone has not been previously reported. A patient is presented in whom destruction of superficial skin and fascia, necrosis of a portion of the mandible, and involvement of the parotid gland complicated reconstruction.
Necrotizing fasciitis is a severe bacterial infection of the fascial planes which is relatively rare in the head and neck region and is found more commonly in the extremities, the trunk, and the perineum. Selective necrosis of the fascia is the hallmark of this condition, which predisposes to the destruction of the overlying skin and, if treatment is delayed, to the necrosis of deep fascia, and
Fig. 1. Patient at day 3, showing early infection.
even muscle 2,6,7. However, involvement of bone in the head and neck region has not been previously reported. Necrotizing fasciitis clinically follows an aggressive course associated with a mortality rate of approximately 400/03. A case of necrotizing fasciitis is described in which both the overlying skin and the associated mandibular segment underwent necrosis.
Key words: necrotizingfasciitis; reconstruction; temporal island flap.
Accepted for publication7 July 1995
This report describes the reconstruction of the mandible and the surrounding soft tissues and discusses some typical difficulties related to this condition. Case report
A 45-year-old, moderately built, and poorly nourished woman presented to the S D M College of Dental Sciences, Dharwad, India,
Fig. 2. Extent of defect after 10 days, showing granulating margins and exposed ramus of mandible. Note nonbleeding bur holes.
Necrotizing fasciitis
Fig. 3. Radiograph taken on day 20, demonstrating isolated areas of necrosis,
with a large, moderately painful swelling of the left side of the cheek extending to the upper half of the neck. This was associated with partial limitation of mouth opening and difficulty in swallowing. A week before, she had borne a healthy female child. Her symptoms followed facial swelling associated with toothache of the mandibular left second molar, for which she had applied the folk therapy of a poultice of kerosene and chillies. On examination, she had a pallid complexion and appeared toxic. The swelling was diffuse and brawny, and the overlying skin
Fig. 5. Final result, showing minimal deformity.
99
Fig. 4. Radiograph confirming injection of calcium hydroxide into soft tissues in order to induce fibrosis.
appeared tense and erythematous. Bilateral circumorbital edema and an edematous soft palate and uvula on the left side were noted. The left mandibular second molar was carious and tender to percussion. She had a temperature of 39~ and blood indices were normal except for a hemoglobin level of 7 gm %. Immediate treatment consisted of i.v. fluid replacement and nutritional support consisting of a protein-rich diet, vitamin supplements, and iron. A combination of i.v. amoxicillin (500 mg) and metronidazole (500 mg) three times daily was started.
On day 2, the general condition of the patient showed definite improvement. A change in the character of the swelling, i.e., crepitus and softening of the underlying tissues without definite fluctuation, became evident. On day 3, large quantities of thick, creamy, foul-smelling pus escaped from areas of skin which had broken dowr/(Fig. 1). At the same time, necrotic fibrous strands could be pulled out. They were cultured. Management consisted of irrigation with hydrogen peroxide and povidone iodine after removal of necrotic fascia from the exposed surfaces of the masseter and sternocliedomastoid muscles. The mandibular left second molar was extracted under local anesthesia. The culture revealed the presence of Staphylococci, Proteus, and Bacteroides. By day 10, pus discharge had stopped, leaving a large defect with granulating margins (Fig. 2). Destruction of the ductal system of the parotid gland led to discharge of saliva into the defect. The parotid gland along with the masseter had grossly contracted, exposing the outer cortex of the mandible, which appeared chalky white and necrotic. Radiographically, however, no definite sequestrum could be identified. Necrosis of both the cortices was confirmed by making bur holes. Radiographic examination at day 20 still failed to show a clear demarcation between normal and necrotic bone, although some alterations indicative of osteomyelitis could be seen (Fig. 3). It was decided to conduct a resection of the necrotic part of the mandible and to reconstruct immediately with a free iliac crest bone graft. The margins of the defect were partially excised and granulation tissue was removed. The soft tissues were carefully separated from the bone until a firmly adherent bleeding periosteum was seen, at which point the osteotomies were carried out. Contraction of the parotid gland rendered identification of facial nerve branches and the location of the exact source Of salivary discharge impossible. Since some degree of fibrosis had occurred, it was possible to place multiple vicryl sutures randomly on the exposed gland surface to constrict the discharging ductules
100
Salins et al.
in order to arrest the salivary fistula without compromising facial nerve branches. The iliac crest graft was secured in place with wires after ensuring that the granulation tissue bed was completely free from necrotic tissue. A superficial temporal island flap was utilized to reconstruct the skin defect. A full-thickness postauricular skin graft covered the donor site. On postoperative day 4, saliva was seen discharging extraorally through a small dehiscence at the posteroinferior margin of the wound. The patient was put on 15 mg probanthin three times a day, and calcium hydroxide was injected between the parotid gland and the bone graft (Fig. 4). This was followed by injection of tetracycline into the area, and there was a gradual reduction in the discharge of saliva. Sutures were removed on postoperative day 7, at which time the discharge of saliva had completely stopped. On follow-up at 1 year, except for minimal paresis of the zygomatic division of the left facial nerve, the patient appeared to be making good progress (Fig. 5).
Discussion The folk medicine practice of counterirritation, as well as drainage through cauterization, is c o m m o n in certain parts of India. Nevertheless, fulminating infections developing as a consequence of such treatments are rare. Application of poultices and cauterization may lead to local debilitation of tissues, which, in a malnourished patient, predispose to cancrum oris. The superficial necrosis caused by these methods promotes the growth of a particular flora
(Bacteriodes fusiformis), which is responsible for the ensuing nonspecific necrosis. However, the patient described applied a kerosene/chillies poultice which did not produce superficial ulceration; therefore, the skin erythema reflected the subcutaneous necrotizing process. This led to the development of necrotizing fasciitis rather than cancrum oris. Although most authors advocate radical excision 1,2,4-6,s, a conservative approach was pursued in order to protect the facial nerve branches. The almost complete recovery o f nerve function, in spite of a grossly distorted anatomy, vindicates our approach. Local tissue advancement was not possible because infection had rendered the surrounding tissue fibrotic and unsuitable for mobilization. A deltopectoral flap was considered initially but was abandoned in favor o f a one-stage temporal island flap. The forehead defect was covered with a full-thickness skin graft which resulted in minimum cosmetic deformity. Our technique of m a n a g i n g the parotid fistula and persistent infection by local injection of calcium hydroxide relies on the high alkalinity of this chemical, which we have found to be efficacious, because mixed infections o f the orofacial region are characterized and indeed often identified by the acidic environment they tend to induce. In addition, calcium hydroxide and tetracy-
cline locally produce fibrosis, which helps to limit the dead space.
References 1. BALCERAKRJ, SISTO JM, BOSACK RC. Cervicofacial neerotizing fasciitis: report of three cases and literature review. J Oral Maxillofac Surg 1988: 46: 450-9. 2. GAUKRO~ERMC. Cervicofacial necrotising fasciitis. Br J Oral Maxillofac Surg 1992: 30: 111-14. 3. LEFROCK JL, MOLAVI A. Necrotizing skin and subcutaneous infections. Br J Antimicrob Chemother 1982: 9: 183-7. 4. MCANDREW PG, DAVIS SJ, GRIFFITHS RW. Necrotizing fasciitis caused by dental infection. Br J Oral Maxillofac Surg 1987: 25: 314-22. 5. MRUTHUNJAYAB. Necrotizing fasciitis: report of a case. J Oral Surg 1981: 39: 60-2. 6. RAPOPORTY, HIMELFARBMZ, ZIKK D, et al. Cervical necrotizing fasciitis of odontogenic origin. Oral Surg 1991: 172: 15-18. 7. RICHARDSONJn, FOX GL, GROCER FL, et al. Necrotizing fasciitis of the neck: a complication of dental extraction. Tex Med 1975: 71: 69-74. 8. STEELA. An unusual case of necrotizing fasciitis. Br J Oral Maxillofac Surg 1987: 25: 328-33. Address: Dr Paul C. Salins Department of OMF Surgery SDM College of Dental Sciences Sattur Dharwad 580 009 Karnataka India
Int. J. Oral Maxillofac. Surg. 1996; 25:98-100 Printed in Denmark. All rights reserved
InternationalJournalof
Ord &
MaxillCacialSurgery ISSN 0901-5027
Aesthetic and reconstructivesurgery
Reconstruction of mandible and surrounding soft tissues in patient with necrotizing fasciitis
Paul C. Salins, Sanjeev Saxena, Jomon K.John Department of Maxillofacial and Reconstructive Surgery, SDM College of Dental Sciences and Hospital, Dharwad, India
P. C. Salins, S. Saxena, J. K. John: Reconstruction of mandible and surrounding soft tissues in patient with necrotizing fasciitis. Int. J. Oral Maxillofac. Surg. 1996; 25: 98-100. 9 Munksgaard, 1996 Abstract. Necrotizing fasciitis is rare in the orofacial region, with fewer than 20 cases reported in the literature. Extension of the disease process to involve the underlying bone has not been previously reported. A patient is presented in whom destruction of superficial skin and fascia, necrosis of a portion of the mandible, and involvement of the parotid gland complicated reconstruction.
Necrotizing fasciitis is a severe bacterial infection of the fascial planes which is relatively rare in the head and neck region and is found more commonly in the extremities, the trunk, and the perineum. Selective necrosis of the fascia is the hallmark of this condition, which predisposes to the destruction of the overlying skin and, if treatment is delayed, to the necrosis of deep fascia, and
Fig. 1. Patient at day 3, showing early infection.
even muscle 2,6,7. However, involvement of bone in the head and neck region has not been previously reported. Necrotizing fasciitis clinically follows an aggressive course associated with a mortality rate of approximately 400/03. A case of necrotizing fasciitis is described in which both the overlying skin and the associated mandibular segment underwent necrosis.
Key words: necrotizingfasciitis; reconstruction; temporal island flap.
Accepted for publication7 July 1995
This report describes the reconstruction of the mandible and the surrounding soft tissues and discusses some typical difficulties related to this condition. Case report
A 45-year-old, moderately built, and poorly nourished woman presented to the S D M College of Dental Sciences, Dharwad, India,
Fig. 2. Extent of defect after 10 days, showing granulating margins and exposed ramus of mandible. Note nonbleeding bur holes.
Necrotizing fasciitis
Fig. 3. Radiograph taken on day 20, demonstrating isolated areas of necrosis,
with a large, moderately painful swelling of the left side of the cheek extending to the upper half of the neck. This was associated with partial limitation of mouth opening and difficulty in swallowing. A week before, she had borne a healthy female child. Her symptoms followed facial swelling associated with toothache of the mandibular left second molar, for which she had applied the folk therapy of a poultice of kerosene and chillies. On examination, she had a pallid complexion and appeared toxic. The swelling was diffuse and brawny, and the overlying skin
Fig. 5. Final result, showing minimal deformity.
99
Fig. 4. Radiograph confirming injection of calcium hydroxide into soft tissues in order to induce fibrosis.
appeared tense and erythematous. Bilateral circumorbital edema and an edematous soft palate and uvula on the left side were noted. The left mandibular second molar was carious and tender to percussion. She had a temperature of 39~ and blood indices were normal except for a hemoglobin level of 7 gm %. Immediate treatment consisted of i.v. fluid replacement and nutritional support consisting of a protein-rich diet, vitamin supplements, and iron. A combination of i.v. amoxicillin (500 mg) and metronidazole (500 mg) three times daily was started.
On day 2, the general condition of the patient showed definite improvement. A change in the character of the swelling, i.e., crepitus and softening of the underlying tissues without definite fluctuation, became evident. On day 3, large quantities of thick, creamy, foul-smelling pus escaped from areas of skin which had broken dowr/(Fig. 1). At the same time, necrotic fibrous strands could be pulled out. They were cultured. Management consisted of irrigation with hydrogen peroxide and povidone iodine after removal of necrotic fascia from the exposed surfaces of the masseter and sternocliedomastoid muscles. The mandibular left second molar was extracted under local anesthesia. The culture revealed the presence of Staphylococci, Proteus, and Bacteroides. By day 10, pus discharge had stopped, leaving a large defect with granulating margins (Fig. 2). Destruction of the ductal system of the parotid gland led to discharge of saliva into the defect. The parotid gland along with the masseter had grossly contracted, exposing the outer cortex of the mandible, which appeared chalky white and necrotic. Radiographically, however, no definite sequestrum could be identified. Necrosis of both the cortices was confirmed by making bur holes. Radiographic examination at day 20 still failed to show a clear demarcation between normal and necrotic bone, although some alterations indicative of osteomyelitis could be seen (Fig. 3). It was decided to conduct a resection of the necrotic part of the mandible and to reconstruct immediately with a free iliac crest bone graft. The margins of the defect were partially excised and granulation tissue was removed. The soft tissues were carefully separated from the bone until a firmly adherent bleeding periosteum was seen, at which point the osteotomies were carried out. Contraction of the parotid gland rendered identification of facial nerve branches and the location of the exact source Of salivary discharge impossible. Since some degree of fibrosis had occurred, it was possible to place multiple vicryl sutures randomly on the exposed gland surface to constrict the discharging ductules
100
Salins et al.
in order to arrest the salivary fistula without compromising facial nerve branches. The iliac crest graft was secured in place with wires after ensuring that the granulation tissue bed was completely free from necrotic tissue. A superficial temporal island flap was utilized to reconstruct the skin defect. A full-thickness postauricular skin graft covered the donor site. On postoperative day 4, saliva was seen discharging extraorally through a small dehiscence at the posteroinferior margin of the wound. The patient was put on 15 mg probanthin three times a day, and calcium hydroxide was injected between the parotid gland and the bone graft (Fig. 4). This was followed by injection of tetracycline into the area, and there was a gradual reduction in the discharge of saliva. Sutures were removed on postoperative day 7, at which time the discharge of saliva had completely stopped. On follow-up at 1 year, except for minimal paresis of the zygomatic division of the left facial nerve, the patient appeared to be making good progress (Fig. 5).
Discussion The folk medicine practice of counterirritation, as well as drainage through cauterization, is c o m m o n in certain parts of India. Nevertheless, fulminating infections developing as a consequence of such treatments are rare. Application of poultices and cauterization may lead to local debilitation of tissues, which, in a malnourished patient, predispose to cancrum oris. The superficial necrosis caused by these methods promotes the growth of a particular flora
(Bacteriodes fusiformis), which is responsible for the ensuing nonspecific necrosis. However, the patient described applied a kerosene/chillies poultice which did not produce superficial ulceration; therefore, the skin erythema reflected the subcutaneous necrotizing process. This led to the development of necrotizing fasciitis rather than cancrum oris. Although most authors advocate radical excision 1,2,4-6,s, a conservative approach was pursued in order to protect the facial nerve branches. The almost complete recovery o f nerve function, in spite of a grossly distorted anatomy, vindicates our approach. Local tissue advancement was not possible because infection had rendered the surrounding tissue fibrotic and unsuitable for mobilization. A deltopectoral flap was considered initially but was abandoned in favor o f a one-stage temporal island flap. The forehead defect was covered with a full-thickness skin graft which resulted in minimum cosmetic deformity. Our technique of m a n a g i n g the parotid fistula and persistent infection by local injection of calcium hydroxide relies on the high alkalinity of this chemical, which we have found to be efficacious, because mixed infections o f the orofacial region are characterized and indeed often identified by the acidic environment they tend to induce. In addition, calcium hydroxide and tetracy-
cline locally produce fibrosis, which helps to limit the dead space.
References 1. BALCERAKRJ, SISTO JM, BOSACK RC. Cervicofacial neerotizing fasciitis: report of three cases and literature review. J Oral Maxillofac Surg 1988: 46: 450-9. 2. GAUKRO~ERMC. Cervicofacial necrotising fasciitis. Br J Oral Maxillofac Surg 1992: 30: 111-14. 3. LEFROCK JL, MOLAVI A. Necrotizing skin and subcutaneous infections. Br J Antimicrob Chemother 1982: 9: 183-7. 4. MCANDREW PG, DAVIS SJ, GRIFFITHS RW. Necrotizing fasciitis caused by dental infection. Br J Oral Maxillofac Surg 1987: 25: 314-22. 5. MRUTHUNJAYAB. Necrotizing fasciitis: report of a case. J Oral Surg 1981: 39: 60-2. 6. RAPOPORTY, HIMELFARBMZ, ZIKK D, et al. Cervical necrotizing fasciitis of odontogenic origin. Oral Surg 1991: 172: 15-18. 7. RICHARDSONJn, FOX GL, GROCER FL, et al. Necrotizing fasciitis of the neck: a complication of dental extraction. Tex Med 1975: 71: 69-74. 8. STEELA. An unusual case of necrotizing fasciitis. Br J Oral Maxillofac Surg 1987: 25: 328-33. Address: Dr Paul C. Salins Department of OMF Surgery SDM College of Dental Sciences Sattur Dharwad 580 009 Karnataka India