JOURNAL OF THE LOUISIANA STATE MEDICAL SOCIETY
Figure 2: CT post-contrast of the head and neck. (A) Mid-sagittal and (B) axial at the level of the pharynx reveal large areas of soft tissue edema involving the submental region and extending into the anterior aspect of the neck, right parapharyngeal area, left side of the face, left parotid gland area and posterolateral aspect of the neck on the left. Gas collections are identified in the submental, anterior aspect of the neck and posterolateral portion of the neck on the left. There is complete loss of the fascial planes. (C ) Axial section at the level of the superior mediastinum reveals a gas collection in the retrosternal area. All of these findings were consistent with extensive necrotizing fasciitis.
necessary as clinical suspicion may be sufficient. CT imaging is more sensitive (80%) but just as specific as plain radiographs. Magnetic Resonance Imaging (MRI) has been found to have a sensitivity of 100% and a specificity of 86%, lower than CT or plain radiography, but may not show findings early on. 5,6 Ultrasound is neither specific nor sensitive for diagnosing these patients but may be used for ruling out abscesses. 7 Necrotizing fasciitis is a rapidly progressive and potentially fatal infection that requires a high index of clinical suspicion to make a prompt diagnosis and initiate aggressive surgical debridement of affected tissue in order to ensure optimal outcomes. As most physicians will only see a single case in their careers and the consequences of missing the diagnosis can prove fatal, it is imperative that physicians become familiar with the signs and symptoms, so that prompt surgical and pharmacologic treatment can be initiated. Effective treatment of necrotizing soft tissue infections requires multi-modal imaging to determine the extent of involvement, multidisciplinary coordination among surgical teams, critical care teams, dieticians, microbiologists, psychiatrists, and prompt surgical exploration of the affected site to evaluate depth and extension into surrounding adipose and muscle tissue. Treatment involves early surgical debridement and broad- spectrum antibiotics that cover for gram-negative, gram- positive, and anaerobic bacteria for cases of suspected necrotizing fasciitis. Exploration should be done with careful dissection to the fascial layers to determine involvement of surrounding fat and muscle. 3 Broad-spectrum antibiotics should be started in all cases of suspected NSTI. Empiric therapy should include coverage for gram-positive, gram-negative, and anaerobes. Consideration for possible infection with methicillin-resistant Staphylococcus
aureus should be given and appropriate MRSA treatment should be initiated if suspected. Broad-spectrum antibiotic coverage should be continued until blood cultures allow optimization or the patient becomes hemodynamically stable. 3 Covering and reconstruction of the wound also plays a role in the outcome of the patient, as immediate tissue coverage protects against superinfection, as well as fluid and electrolyte loss, allowing for the patient to mobilize early while reducing pain. Patients and their families must be given a comprehensive review of their options, as many decisions play a large role in patients’ well emotional and physical well-being. Traditional reconstructive options include primary closure, split-thickness skin grafts, full-thickness skin grafts, delayed primary closure, healing by second intention, tissue expansion, and pedicled or free flaps. 3
146 J La State Med Soc VOL 169 SEPTEMBER/OCTOBER 2017
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