Ross Talisa, Acharya Vikas, Patel Arran, Tatla Taran
Northwick Park Hospital, London Northwest University Healthcare NHS Trust, Watford Road, Harrow, HA1 3UJ, United Kingdom; Imperial College London, South Kensington, London, SW7 2BU, United Kingdom.
Northwick Park Hospital, London Northwest University Healthcare NHS Trust, Watford Road, Harrow, HA1 3UJ, United Kingdom.
Int J Surg Case Rep. 2021 May;82:105851. doi: 10.1016/j.ijscr.2021.105851. Epub 2021 Apr 1.
Craniofacial necrotising fasciitis is a complex condition, with high mortality given its propensity to descend via the deep neck spaces into the chest and mediastinum. Management requires optimal antimicrobial therapy with associated aggressive surgical debridement.
A 64-year-old man presented to ENT with a posterior neck swelling. Despite incision and drainage of the swelling following a trial of antimicrobial therapy, it increased in size, with areas of overlying necrosis demonstrated. Based on radiological and clinical findings, a diagnosis of necrotising fasciitis was made. He was taken to theatre for debridement. Intra-operatively, carotid sheath suppuration was noted, after tissue retraction resulted in copious bleeding from the anterior wound bed, requiring vigorous resuscitation and clamping of underlying structures to achieve haemostasis. Senior ENT and vascular surgery involvement was quickly sought to achieve haemostasis, however bleeding from the wound bed was difficult to control. This was due to the significant watershed area at the posterior neck which would not have been amenable to selective vessel ligation. After multiple cardiac arrests, a team decision was taken to discontinue resuscitation.
Operating in this area of anatomical complexity required input from a number of different specialty teams. Although input from infectious diseases, microbiology, plastic surgery and tissue viability was commendable, there was room for optimising this further. Early patient referral to a tertiary centre where on-site input was available from maxillofacial surgery and plastic surgery would have been beneficial; a set-up commonly seen in regional trauma networks.
This case demonstrates the intricacies surrounding a rare occurrence of necrotising fasciitis of the neck crossing the midline. Multi-disciplinary team involvement is imperative and should be encouraged at an early stage.
颅面坏死性筋膜炎是一种复杂病症，因其易于通过颈部深层间隙蔓延至胸部和纵隔，故死亡率较高。治疗需要优化抗菌治疗并联合积极的外科清创术。
一名64岁男性因后颈部肿胀就诊于耳鼻喉科。在进行抗菌治疗试验后，尽管对肿胀部位进行了切开引流，但肿胀仍增大，出现了覆盖区域的坏死。根据影像学和临床检查结果，诊断为坏死性筋膜炎。他被送往手术室进行清创。术中，在组织牵拉导致前伤口床大量出血后，发现颈动脉鞘化脓，需要积极复苏并钳夹深层结构以实现止血。迅速寻求耳鼻喉科和血管外科资深医生参与以实现止血，但伤口床出血难以控制。这是由于后颈部存在重要的分水岭区域，无法进行选择性血管结扎。在多次心脏骤停后，团队决定停止复苏。
在这个解剖结构复杂的区域进行手术需要多个不同专科团队的参与。尽管传染病、微生物学、整形外科和组织活力方面的参与值得称赞，但仍有进一步优化的空间。早期将患者转诊至有颌面外科和整形外科现场支持的三级中心会有益处；这种设置在区域创伤网络中很常见。
本病例展示了围绕罕见的颈部中线交叉坏死性筋膜炎的复杂性。多学科团队的参与至关重要，应在早期予以鼓励。
