Possible Prognostic Factors for the Mortality in Cervicofacial Necrotizing Fasciitis and Deep Neck Infection patients 李哲雄 . 廖漢聰 Department of Plastic and Reconstructive Surgery, Chang Gung Memorial Hospital Chang Gung University, College of Medicine, Taoyuan, Taiwan

Background

Background Necrotizing fasciitis in cervicofacial region ‘‘flesh-eating disease’’ rapidly progressive and a fulminate course spreading inflammatory process deep fascia with secondary necrosis of the subcutaneous tissue Rarely occurs in the head and neck incidence about 2.6%

Background Symptoms High mortality rate Detection tool Symptoms may include local manifestations Dissecting along the platysma and skin necrosis High mortality rate Detection tool MRI CT Sonography Early diagnosis and intervention

Background Etiology Treatment Trauma Operative incision Pre-existing ulcer Insect bites Haematogenous spread from other septic foci Dentogenous, peritonsillar, odontogenic origin or sinusitis Tumor or radiotherapy Surgical debridement and drainage is the key, if needed repetitively Airway protection Resuscitation Broad-spectrum of antibiotics

Background Reported risks Life threatening condition Diabetes Immuno-suppression Renal failure Intravenous drug abuse Cardiovascular disease Alcohol abuse Radiation therapy Mediastinitis Septic shock Jugular vein thrombosis Airway obstruction Pneumonia

Background Organism aerobic, anaerobic or polymicrobial infection Beta hemolytic group A streptococcal infection Group A streptococcus ± Staphylococcus aureus, Klebsiella pneumonia Anaerobes predominating Peptostreptococcus --Prevotella Porphyromonas --Bacteroides Clostridia

Purpose Cervicofacial Necrotizing fasciitis and deep neck infection: One of the most devastating infectious diseases Affects not only the aesthetic issue High mortality and morbidity rate Here we analyze and identify Comparison between mortality and non-mortality group Possible prognostic risk factors

material and method

Patient Groups Between January, 2012 to December, 2014 Overall 198 patients who admitted to Chang Gung Memorial Hospital, Linkou With Cervicofacial necrotizing fasciitis or deep neck infection Retrospective recorded by proved IRB

Collective Parameters Basic information Age, Gender, Personal history, Underlying disease Peri-admission treatment Medication, Chemotherapy, Antibiotic treatment, onset to hospital Laboratory data change Image findings and involved locations Mechanism Airway involvement Management Surgery, antibiotic, Abscess aspiration Following operations Outcomes ICU stay, admission time, mortality, intubation

Statistics Analysis IBM SPSS 22.0 software Descriptive statistics Independent t test Pearson Chi square test Binary logistic regression analysis P<0.05 consider as statistical significant

results

Population Distribution (11.1%) N=198 N=176 (88.9%)

Basic data In Mortality patients: No gender difference No personal history difference

Basic data In Mortality patients: More senior in mortality group No difference in number of involved area and symptom detection to hospital

Underlying disease In Mortality patients: More underlying disease of: HTN Cancer history CVA AIDS

* * * * * *

Involved location Mortality case: More involved in Mediastinum Prevertibral/paraspinal Skull base

Clinical Presentation Mortality case: More presented with Tooth ache Less presented with Sorethroat

Pre-admission Treatment No preadmission treatment difference

Mechanism The mechanism In mortality patient: * * * The mechanism In mortality patient: More tumor related infection, herpes infection with secondary infection Less of unknown reason

Laboratory data No difference in the value of laboratory data

Treatment In mortality patient: No difference in Less aspiration of pus Need more aggressive sugar control No difference in HBO, IVIG and dexamethaxone use * *

Outcome In Mortality patient: More ICU stay/ shock/intubation rate Higher mortality rate Sepsis Respiratory failure Tumor bleeding No difference in bacteremia * * * * *

Outcome In mortality patient: Longer admission duration

Univariate and multiviariate binary logistic analysis

Discussion and conclusion

Discussion Necrotizing fasciitis or deep neck infection in cervicofacial region Devastating infectious diseases Affects not only the aesthetic issue But also high mortality and morbidity rate Identified possible risk factors

Discussion In Mortality patients: No gender and personal history of ABC prominence Any underlying disease HTN. CVA. HN or non HN cancer history. AIDS Underlying disease does affect final outcome:

Discussion In Mortality patients: Mean age is higher than non-mortality group No difference in from onset to hospital Not related to numbers of area involved The number of involved area doesn’t affect the outcome but the key location  Higher mortality rate in some critical area

Discussion In Mortality patients: Involved location: Mediastinum Prevertibral/paravertibral/paraspinal Skull base Critical location involvement: Higher mortality rate and difficult for debridement Multiple areas involvement does not indicate higher mortality but specific locations

Discussion In Mortality patients: Etiology: More tumor related infection Herpes zoster related secondary infection Compare with non-mortality group Less unknown reason More previous cancer treatment related etiology

Discussion In Mortality patients: Outcome More ICU stay / shock / intubation rate Higher mortality rate Sepsis Respiratory failure Tumor bleeding No difference in bacteremia Similar subsequent number of operations Control airway obstruction, vessel bleeding and infection control are the saving way Longer admission duration

Discussion In univariate analysis Possible risk factors for predicting mortality: Admission duration Admit to ICU Age Tumor related mechanism Number of associated operations Sugar control Intubation Airway involvement Mediastinum involvement Prevertebral involvement Skull base involvement Hypertension Cancers CVA

Discussion Limitations Limited cased number Retrospective study non-cohort study Limitations

CONCLUSION

Conclusion What affect the prognosis: Knowing these factors The location Extended to mediastinum, prevertebral space and skull base showed poor prognosis Aggressive control of sugar Comorbidity : history of hypertension and CVA were also high risk factors for mortality Tumor-related disease Control airway obstruction Longer admission duration Knowing these factors Guidance in the emergency room to pay attention to the high mortality cases

Thank you for your attention