1. 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

2. Background

3. 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%

4. 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

5. 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

6. 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

7. 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

8. 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

9. material and method

10. 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

11. 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

12. 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

13. results

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

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

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

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

18. * * * * * *

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

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

21. Pre-admission Treatment
No preadmission treatment difference

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

23. Laboratory data
No difference in the value of laboratory data

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

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

26. Outcome
In mortality patient:
Longer admission duration

27. Univariate and multiviariate binary logistic analysis

28. Discussion and conclusion

29. 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

30. 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:

31. 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

32. 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

33. 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

34. 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

35. 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

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

37. CONCLUSION

38. 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

39. Thank you for your attention