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MULUNGUSHI UNIVERSITY
NDOLA TEACHING HOSPITAL
DENTAL DEPARTMENT
PRESENTATION: CERVICAL NECROTIZING FASCIITIS
PRESENTER: MUBANGA VINCENT
OUTLINE
• INTRODUCTION
• EPIDEMIOLOGY
• RISK FACTORS
• CLASSIFICATION
• PATHOPHYSIOLOGY
• CLINICAL PRESENTATION
• DIAGNOSTICS
• MANAGEMENT
• COMPLICATIONS
• PROGNOSIS
• REFERENCES
• Fascia is an internal connective tissue which forms bands or sheets that surround and
support muscles, vessels and nerves in the body.
• In the neck, these layers of fascia not only act to support internal structures, but also help to
compartmentalise structures of the neck. There are two fascias in the neck – the superficial
cervical fascia and the deep cervical fascia.
Superficial Cervical Fascia
• The superficial cervical fascia is the subcutaneous layer of the skin in the neck. This thin layer
contains the muscles of facial expression, including the platysma muscle in the neck. The
cutaneous nerves, superficial vessels, and superficial lymph nodes course within the superior
cervical fascia.
Deep Cervical Fascia
• The deep cervical fascia is deep to the superficial fascia. The deep cervical fascia is
condensed in various regions to form the following sublayers: the investing layer of the deep
cervical fascia, the pretracheal fascia, the prevertebral fascia, and the carotid sheath. The
function of the deep fascia is to provide containment of muscles and viscera in
compartments, to enable structures to slide over each other, and to serve as a conduit for
neurovascular bundles.
Investing Fascia
• The investing fascia attaches as follows:
• Posteriorly to the nuchal ligament, completely encircling the neck and
splitting to enclose the sternocleidomastoid and trapezius muscles.
• Superiorly to the hyoid bone and then splitting to enclose the
submandibular gland.
• Along the mandible and splitting to enclose the parotid gland.
• Superiorly to the mastoid process, occipital bone, and zygomatic arch.
• Inferiorly along the acromion, scapular spine, clavicle, and manubrium.
Pretracheal Fascia
• The pretracheal fascia forms a tubular sheath in the anterior part of the neck. The
pretracheal fascia extends superiorly from the hyoid bone and inferiorly to the thorax,
where it blends with the fibrous pericardium. The pretracheal fascia:
• Encloses the infrahyoid muscles.
• Encloses separately the thyroid gland, trachea, and esophagus.
• Blends laterally with the carotid sheath.
• Is contiguous inferiorly with the buccopharyngeal fascia ofPrevertebral Fascia
• The prevertebral fascia forms a tubular sheath around the vertebral column and the
prevertebral muscles, which are attached to the vertebral column. The prevertebral
muscles are:
• Anteriorly, the longus colli and capitis muscles.
• Laterally, the anterior, middle, and posterior scalene muscles.
• Posteriorly, the deep cervical muscles.
The prevertebral fascia:
• Attaches superiorly from the base of the skull and inferiorly to the
endothoracic fascia in the thorax.
• Extends laterally as the axillary sheath, which surrounds the axillary
vessels and brachial plexus of nerves to the upper limb.
• Contains, within its connective tissue fibers, the cervical sympathetic
trunk and ganglia.
Carotid Sheath
• The carotid sheath also is a tubular fascial investment that extends superiorly
between the cranial base and inferiorly to the root of the neck.
• The carotid sheath blends with the investing, pretracheal, and prevertebral layers
of the deep cervical fascia.
• The carotid sheath contains the common and internal carotid arteries, internal
jugular vein, and vagus nerve [cranial nerve (CN) X]. In addition, the carotid sheath
contains deep cervical lymph nodes, sympathetic fibers, and the carotid sinus
nerve.
Retropharyngeal Space
• The retropharyngeal space is a potential space consisting of loose connective tissue
between the prevertebral and the buccopharyngeal fascia.
• The retropharyngeal space serves as a potential conduit for the spread of infection
from the pharyngeal region to the mediastinum.
• Extends from the base of the skull to the posterior mediastinum
INTRODUCTION
• Necrotizing fasciitis is a highly aggressive infectious process characterized
by spreading along the fasciae planes. It can rapidly involve overlying skin,
subcutaneous tissues, muscle, and other adjacent soft tissues structure
• Cervical necrotizing fasciitis is characterized by cutaneous necrosis,
suppurative fasciitis, thrombosis of small blood vessels in the
subcutaneous tissue, and extreme systemic toxicity
• It is a severe condition, with a high death risk, and prognosis is
aggravated by spread of the infection through the fasciae,
EPIDEMIOLOGY
• The incidence in the head and neck is 1-10% (Ulusoy,2020)
• According to a retrospective study done on seven patients from 2015 to
2019 in india,six were male and one was female. The mean age was 49.8
years (range: 38-70 years). Etiology was found to be odontogenic
infection in five (71%) cases (Gupta, 2022)
Risk factors
• Recent head/neck surgery
• Recent trauma
• Recent dental extraction
• peritonsillar abscess
• pharyngeal infection
• IV drug use
Immunosuppression
• diabetes mellitus
• steroid administration
• arteriosclerosis
• chronic renal failure
• hypothyroidism
• obesity
• alcoholism
• cancer
• cirrhosis
• a poor nutritional state
CLASSIFICATION
Necrotizing fasciitis can be classified into categories,
• Type 1 infections representing polymicrobial infections
-mixed aerobic and anerobic bacteria
• Type 2 involving Group A Streptococcus
- typically streptococcus pyogenes,
Pathophysiology
• Entry of orgainsms through disrupted mucosal or skin barrier of the head/neck
• Rapid spread along fascial planes and small vessels that supply the cervical soft
tissues
• Release of exotoxins causes necrosis of fat, blood vessels and nerves
• Thrombosis of small vessels aggravates ischemia and necrosis
• Edema can also occur secondary to venous and lymphatic spread. This spread
can also cause thrombosis of blood vessels that leads to tissue ischemia and
possible gangrene of subcutaneous fat and the dermis. Once the fascia breaks
down, infection of the muscle leads to myositis. Although rare, subcutaneous
emphysema, known colloquially as gas gangrene, can also occur in the
necrotizing tissue and is often caused by Clostridium species.
Clinical Presentation
Cutaneous
• severe pain, extending beyond the obviously involved areas
and disproportionate to examination findings
• painful edema
• erythema
• warmth
• Neck crepitation
• loss of sensation in the affected area( paresthesias)
• submandibular abscess.
• purple skin discoloration
• bullae
Others
• fever
• chills
• malaise
• trismus
• airway compression
• dysphagia
Diagnostics
• laboratory studies
FBC: leukocytosis
Inflammatory markers (such as CRP, ESR, procalcaitonin) will be elevated
Cytokines will be elevated
• Microbiology
blood cultures (2 sets)
Gram stain and culture from deep tissues
• Imaging
CT/MRI- gas in soft tissue
- fascial thickening and edema
- fluid collections on deep fascial planes
- intermuscular septal edema
X-ray - may detect gas in soft tissue
Laboratory risk indicator for necrotizing fasciitis
score
• There are multiple laboratory value scoring systems that have been developed to support
the diagnosis. The scoring system with the highest positive (92%) and negative (96%)
predictive value is the laboratory risk indicator for necrotizing fasciitis (LRINEC), developed
by Wong and colleagues.The LRINEC score was devised from a comparison of 89 patients
with an NSTI and 314 patients with severe cellulitis or abscess, or both.The scoring system
scores patients on various laboratory values including C-reactive protein, WBC count,
hemoglobin level, serum sodium level, serum creatinine level, and serum glucose level at
hospital admission. For an overview of the scoring system in table form
Laboratory risk indicator for necrotizing fasciitis
score
A score ≥6 is a relatively specific indicator of necrotizing fasciitis (specificity 83.8%), but a score <6 is not sensitive
(59.2%) enough to rule out necrotizing fasciitis.
Management
• Effective treatment and management of cervical necrotizing fasciitis is
based on early recognition, aggressive surgical intervention, use of
broad-spectrum antibiotics, and supportive therapy.
• It is important to explore and drain all involved fascial planes. To carry
out an adequate, wide, extensive fasciotomy with exposure and
exploration of all compartments, the surgeon must understand the
complex anatomy of the cervical fasciae and deep neck spaces.
Complications
• airway obstruction,
• pneumonia
• pulmonary abscess
• septic shock
• jugular venous thrombophlebitis
• mediastinitis
Prognosis
• The factors that can affect prognosis include advanced age, anemia,
hyperglycemia, involvement of multiple spaces, comorbidities, and
presence of complications
• The mortality rate in cervical NF may range from 4% to 50% depending on
the virulence of causative organisms and comorbidities (Sandner,2015)
REFERENCES
• Ulusoy B, Duran A: A case of necrotizing fasciitis mimicking an abscess in the
deep neck space. B-ENT. 2020, 16:51-4
• Gupta V, Sidam S, Behera G, et al. (December 10, 2022) Cervical Necrotizing
Fasciitis: An Institutional Experience. Cureus 14(12): e32382.
doi:10.7759/cureus.32382 https://www.cureus.com/articles/127368-cervical-
necrotizing-fasciitis-an-institutional-experience#!/ [ assecced on 06/02/2024]
• Sandner A, Moritz S, Unverzagt S, Plontke SK, Metz D: Cervical necrotizing
fasciitis--the value of the laboratory risk indicator for necrotizing fasciitis score as
an indicative parameter. J Oral Maxillofac Surg. 2015, 73:2319-33.
10.1016/j.joms.2015.05.035
• Becker M, Zbären P, Hermans R, et al.: Necrotizing fasciitis of the head and neck:
role of CT in diagnosis and management. Radiology. 1997, 202:471-6.
10.1148/radiology.202.2.9015076

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CERVICAL NECROTIZING FASCIITIS BY VINCENT MUBANGA.pptx

  • 1. MULUNGUSHI UNIVERSITY NDOLA TEACHING HOSPITAL DENTAL DEPARTMENT PRESENTATION: CERVICAL NECROTIZING FASCIITIS PRESENTER: MUBANGA VINCENT
  • 2. OUTLINE • INTRODUCTION • EPIDEMIOLOGY • RISK FACTORS • CLASSIFICATION • PATHOPHYSIOLOGY • CLINICAL PRESENTATION • DIAGNOSTICS • MANAGEMENT • COMPLICATIONS • PROGNOSIS • REFERENCES
  • 3. • Fascia is an internal connective tissue which forms bands or sheets that surround and support muscles, vessels and nerves in the body. • In the neck, these layers of fascia not only act to support internal structures, but also help to compartmentalise structures of the neck. There are two fascias in the neck – the superficial cervical fascia and the deep cervical fascia. Superficial Cervical Fascia • The superficial cervical fascia is the subcutaneous layer of the skin in the neck. This thin layer contains the muscles of facial expression, including the platysma muscle in the neck. The cutaneous nerves, superficial vessels, and superficial lymph nodes course within the superior cervical fascia. Deep Cervical Fascia • The deep cervical fascia is deep to the superficial fascia. The deep cervical fascia is condensed in various regions to form the following sublayers: the investing layer of the deep cervical fascia, the pretracheal fascia, the prevertebral fascia, and the carotid sheath. The function of the deep fascia is to provide containment of muscles and viscera in compartments, to enable structures to slide over each other, and to serve as a conduit for neurovascular bundles.
  • 4. Investing Fascia • The investing fascia attaches as follows: • Posteriorly to the nuchal ligament, completely encircling the neck and splitting to enclose the sternocleidomastoid and trapezius muscles. • Superiorly to the hyoid bone and then splitting to enclose the submandibular gland. • Along the mandible and splitting to enclose the parotid gland. • Superiorly to the mastoid process, occipital bone, and zygomatic arch. • Inferiorly along the acromion, scapular spine, clavicle, and manubrium.
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  • 6. Pretracheal Fascia • The pretracheal fascia forms a tubular sheath in the anterior part of the neck. The pretracheal fascia extends superiorly from the hyoid bone and inferiorly to the thorax, where it blends with the fibrous pericardium. The pretracheal fascia: • Encloses the infrahyoid muscles. • Encloses separately the thyroid gland, trachea, and esophagus. • Blends laterally with the carotid sheath. • Is contiguous inferiorly with the buccopharyngeal fascia ofPrevertebral Fascia • The prevertebral fascia forms a tubular sheath around the vertebral column and the prevertebral muscles, which are attached to the vertebral column. The prevertebral muscles are: • Anteriorly, the longus colli and capitis muscles. • Laterally, the anterior, middle, and posterior scalene muscles. • Posteriorly, the deep cervical muscles.
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  • 8. The prevertebral fascia: • Attaches superiorly from the base of the skull and inferiorly to the endothoracic fascia in the thorax. • Extends laterally as the axillary sheath, which surrounds the axillary vessels and brachial plexus of nerves to the upper limb. • Contains, within its connective tissue fibers, the cervical sympathetic trunk and ganglia.
  • 9. Carotid Sheath • The carotid sheath also is a tubular fascial investment that extends superiorly between the cranial base and inferiorly to the root of the neck. • The carotid sheath blends with the investing, pretracheal, and prevertebral layers of the deep cervical fascia. • The carotid sheath contains the common and internal carotid arteries, internal jugular vein, and vagus nerve [cranial nerve (CN) X]. In addition, the carotid sheath contains deep cervical lymph nodes, sympathetic fibers, and the carotid sinus nerve. Retropharyngeal Space • The retropharyngeal space is a potential space consisting of loose connective tissue between the prevertebral and the buccopharyngeal fascia. • The retropharyngeal space serves as a potential conduit for the spread of infection from the pharyngeal region to the mediastinum. • Extends from the base of the skull to the posterior mediastinum
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  • 11. INTRODUCTION • Necrotizing fasciitis is a highly aggressive infectious process characterized by spreading along the fasciae planes. It can rapidly involve overlying skin, subcutaneous tissues, muscle, and other adjacent soft tissues structure • Cervical necrotizing fasciitis is characterized by cutaneous necrosis, suppurative fasciitis, thrombosis of small blood vessels in the subcutaneous tissue, and extreme systemic toxicity • It is a severe condition, with a high death risk, and prognosis is aggravated by spread of the infection through the fasciae,
  • 12. EPIDEMIOLOGY • The incidence in the head and neck is 1-10% (Ulusoy,2020) • According to a retrospective study done on seven patients from 2015 to 2019 in india,six were male and one was female. The mean age was 49.8 years (range: 38-70 years). Etiology was found to be odontogenic infection in five (71%) cases (Gupta, 2022)
  • 13. Risk factors • Recent head/neck surgery • Recent trauma • Recent dental extraction • peritonsillar abscess • pharyngeal infection • IV drug use Immunosuppression • diabetes mellitus • steroid administration • arteriosclerosis • chronic renal failure • hypothyroidism • obesity • alcoholism • cancer • cirrhosis • a poor nutritional state
  • 14. CLASSIFICATION Necrotizing fasciitis can be classified into categories, • Type 1 infections representing polymicrobial infections -mixed aerobic and anerobic bacteria • Type 2 involving Group A Streptococcus - typically streptococcus pyogenes,
  • 15. Pathophysiology • Entry of orgainsms through disrupted mucosal or skin barrier of the head/neck • Rapid spread along fascial planes and small vessels that supply the cervical soft tissues • Release of exotoxins causes necrosis of fat, blood vessels and nerves • Thrombosis of small vessels aggravates ischemia and necrosis • Edema can also occur secondary to venous and lymphatic spread. This spread can also cause thrombosis of blood vessels that leads to tissue ischemia and possible gangrene of subcutaneous fat and the dermis. Once the fascia breaks down, infection of the muscle leads to myositis. Although rare, subcutaneous emphysema, known colloquially as gas gangrene, can also occur in the necrotizing tissue and is often caused by Clostridium species.
  • 16. Clinical Presentation Cutaneous • severe pain, extending beyond the obviously involved areas and disproportionate to examination findings • painful edema • erythema • warmth • Neck crepitation • loss of sensation in the affected area( paresthesias) • submandibular abscess. • purple skin discoloration • bullae Others • fever • chills • malaise • trismus • airway compression • dysphagia
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  • 19. Diagnostics • laboratory studies FBC: leukocytosis Inflammatory markers (such as CRP, ESR, procalcaitonin) will be elevated Cytokines will be elevated • Microbiology blood cultures (2 sets) Gram stain and culture from deep tissues
  • 20. • Imaging CT/MRI- gas in soft tissue - fascial thickening and edema - fluid collections on deep fascial planes - intermuscular septal edema X-ray - may detect gas in soft tissue
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  • 23. Laboratory risk indicator for necrotizing fasciitis score • There are multiple laboratory value scoring systems that have been developed to support the diagnosis. The scoring system with the highest positive (92%) and negative (96%) predictive value is the laboratory risk indicator for necrotizing fasciitis (LRINEC), developed by Wong and colleagues.The LRINEC score was devised from a comparison of 89 patients with an NSTI and 314 patients with severe cellulitis or abscess, or both.The scoring system scores patients on various laboratory values including C-reactive protein, WBC count, hemoglobin level, serum sodium level, serum creatinine level, and serum glucose level at hospital admission. For an overview of the scoring system in table form
  • 24. Laboratory risk indicator for necrotizing fasciitis score A score ≥6 is a relatively specific indicator of necrotizing fasciitis (specificity 83.8%), but a score <6 is not sensitive (59.2%) enough to rule out necrotizing fasciitis.
  • 25. Management • Effective treatment and management of cervical necrotizing fasciitis is based on early recognition, aggressive surgical intervention, use of broad-spectrum antibiotics, and supportive therapy. • It is important to explore and drain all involved fascial planes. To carry out an adequate, wide, extensive fasciotomy with exposure and exploration of all compartments, the surgeon must understand the complex anatomy of the cervical fasciae and deep neck spaces.
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  • 27. Complications • airway obstruction, • pneumonia • pulmonary abscess • septic shock • jugular venous thrombophlebitis • mediastinitis
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  • 29. Prognosis • The factors that can affect prognosis include advanced age, anemia, hyperglycemia, involvement of multiple spaces, comorbidities, and presence of complications • The mortality rate in cervical NF may range from 4% to 50% depending on the virulence of causative organisms and comorbidities (Sandner,2015)
  • 30. REFERENCES • Ulusoy B, Duran A: A case of necrotizing fasciitis mimicking an abscess in the deep neck space. B-ENT. 2020, 16:51-4 • Gupta V, Sidam S, Behera G, et al. (December 10, 2022) Cervical Necrotizing Fasciitis: An Institutional Experience. Cureus 14(12): e32382. doi:10.7759/cureus.32382 https://www.cureus.com/articles/127368-cervical- necrotizing-fasciitis-an-institutional-experience#!/ [ assecced on 06/02/2024] • Sandner A, Moritz S, Unverzagt S, Plontke SK, Metz D: Cervical necrotizing fasciitis--the value of the laboratory risk indicator for necrotizing fasciitis score as an indicative parameter. J Oral Maxillofac Surg. 2015, 73:2319-33. 10.1016/j.joms.2015.05.035 • Becker M, Zbären P, Hermans R, et al.: Necrotizing fasciitis of the head and neck: role of CT in diagnosis and management. Radiology. 1997, 202:471-6. 10.1148/radiology.202.2.9015076