|ORIGINAL RESEARCH REPORT
|Year : 2016 | Volume
| Issue : 3 | Page : 143-148
Challenges in the management of cervicofacial necrotizing fasciitis in Sokoto, Northwest Nigeria
Adebayo Aremu Ibikunle1, Abdurrazaq Olanrewaju Taiwo1, Olalekan Micah Gbotolorun2, Ramat Oyebunmi Braimah1
1 Department of Surgery/Dental and Maxillofacial Surgery, Usmanu Danfodiyo University/Usmanu Danfodiyo University Teaching Hospital, Sokoto, Nigeria
2 Department of Oral and Maxillofacial Surgery, Lagos University Teaching Hospital, Lagos, Nigeria
|Date of Web Publication||4-Jul-2016|
Olalekan Micah Gbotolorun
Department of Oral and Maxillofacial Surgery, Lagos University Teaching Hospital, Lagos
Source of Support: None, Conflict of Interest: None
Introduction: Necrotizing fasciitis (NF) is a rapidly progressive, potentially fatal tissue infection with primary involvement of the subcutaneous fascia and resultant necrosis of the skin and subcutaneous tissues with relative sparing of the underlying muscles and bones. It pursues a fulminant, unrelenting course if treatment is not instituted early and aggressively. The aim of this paper was to document the clinical features and challenges encountered in the management of cervicofacial NF (CNF) in Usmanu Danfodiyo University Teaching Hospital, Sokoto. In addition, the hypothesis that there is a correlation between the duration of disease at presentation and length of hospital stay was tested. Patients and Methods: A retrospective review of cases of CNF managed between December 2014 and November 2015 at our center was done. Demographic and clinical data were retrieved. Patients were managed in strict adherence to the established hospital protocol. Results: Thirteen cases managed for CNF were included in this study, all of whom were of low socioeconomic status. The duration of symptoms before presentation ranged from 2 to 21 days with a mean (standard deviation [SD]) of 7.6 (5.2). The length of hospital stay ranged from 7 to 44 days, with a mean (SD) of 19.5 (11.3). A statistically significant correlation between the duration of disease before presentation and length of hospital stay was observed (P < 0.05). Conclusion: NF, though rarely seen in some climes, is still a present health challenge in our environment. Despite improvements in healthcare indices, the associated morbidity and mortality rate is still quite high. The management of CNF in a resource-limited environment like ours presents grim challenges.
Keywords: Cervicofacial necrotizing fasciitis, debridement, odontogenic
|How to cite this article:|
Ibikunle AA, Taiwo AO, Gbotolorun OM, Braimah RO. Challenges in the management of cervicofacial necrotizing fasciitis in Sokoto, Northwest Nigeria. J Clin Sci 2016;13:143-8
|How to cite this URL:|
Ibikunle AA, Taiwo AO, Gbotolorun OM, Braimah RO. Challenges in the management of cervicofacial necrotizing fasciitis in Sokoto, Northwest Nigeria. J Clin Sci [serial online] 2016 [cited 2019 Sep 19];13:143-8. Available from: http://www.jcsjournal.org/text.asp?2016/13/3/143/185252
| Introduction|| |
Necrotizing fasciitis (NF) is an acute rapidly progressive, potentially fatal soft tissue infection with primary involvement of the subcutaneous fascia and resultant necrosis of the skin and subcutaneous tissues with relative sparing of the underlying muscles. ,, It is a surgical emergency which pursues a fulminant, unrelenting course if treatment is not instituted early and aggressively. Wilson coined the term "Necrotizing Fasciitis" in 1952, however, it has been recognized as far back as the fifth century BC when it was described by Hippocrates as a complication of erysipelas. , In its historical evolution, it has been known at different times by several names which include, necrotizing erysipelas, acute nonclostridial crepitant cellulitis, synergistic necrotizing cellulitis, hemolytic streptococcal gangrene, hospital gangrene, suppurative fasciitis, and phagedena. ,
The disease is said to be rare with incidence of 0.4-1.3% reported from developed nations. , However, a study demonstrated an average of 14 cases per annum in Sub-Saharan Africa.  Owing to its rich vascular supply, the head and neck region is seldom affected compared to other anatomic site. ,, Ndukwe et al.  and Obimakinde et al.  from Southwest Nigeria reported figures of 16 and 12 cases of cervicofacial NF (CNF), respectively, over a period of 10 and 5 years.
NF is oftentimes a polymicrobial infection with a dominance of Group A Streptococcus species and anaerobic Bacteroides, although those of monomicrobial, clostridial, and fungal origin have been described. ,, Predisposing factors for NF include diabetes mellitus, neutropenia, peripheral vascular disease, alcoholism, intravenous drug abuse, and malnutrition. , These predisposing factors also have prognostic significance, especially if not recognized and controlled early.  In the early stages, NF is difficult to differentiate from cellulitis and other superficial skin infections. ,
Early reports of mortality rates ranged from 50% to 73%, but these rates have gradually reduced over the years, especially in the developed world.  More recently reported mortality rates range from 21.9% to 30%. , Nevertheless, it still leaves a lot to be desired. There is paucity of research on CNF from Northwestern Nigeria region. The aim of this report is to present the pattern of presentation, management, challenges of management, and complications of CNF in our center.
| Patients and methods|| |
This was a review of patients with CNF that presented to the Department of Dental and Maxillofacial Surgery, Usmanu Danfodiyo University Teaching Hospital (UDUTH), Sokoto, Nigeria, between December 2014 and November 2015. UDUTH is a prime referral center for communities in Sokoto State and Northwestern Nigeria.
Data retrieved include age, gender, occupation, etiology, time of presentation, symptoms/signs, medical status, nutritional status, hematocrit, and microbiological culture and sensitivity, treatment, complications, and duration of hospital admission. Evaluation of nutritional status was by laboratory investigations of the total protein and albumin. All patients were admitted and resuscitated with intravenous infusion of normal saline and dextrose saline. In patients with feeding challenges such as reduced mouth opening, low appetite, and extreme weakness, the Nasogastric tube (NGT) was inserted.
Broad-spectrum antibiotics were administered empirically while awaiting the results of microscopy culture and sensitivity (MCS). Where needed, a change of the empirical antibiotics to definitive ones based on the results of MCS was made. The sources of infection were identified and promptly removed. Underlying predisposing factors were identified, and patients were treated accordingly. Serial surgical debridement was instituted until infection was controlled; with the advent of healthy granulation tissue [Figure 4] and [Figure 5], the wounds were dressed with povidone iodine-soaked gauze. The irrigants used were normal saline and dilute sodium hypochlorite (one part of sodium hypochlorite in 100 parts of normal saline). In the initial stages, gauze drains soaked in povidone iodine were used. In extensive cutaneous involvement, gamgee pack was used. Three of the patients also had alginate-based dressings because of the extensive nature of tissue destruction.
Data were recorded and analyzed using IBM SPSS Statistics for Windows version 20 (Armonk, NY, USA: IBM Corp.) and results were presented with descriptive statistics. Correlation and linear regression analyses were conducted to examine the relationship between duration of disease before the presentation and the length of hospital stay. The level of statistical significance was set at P ≤ 0.05.
| Results|| |
A total of 13 cases diagnosed and treated for CNF were included in this study. There were nine males and four females with a male to female ratio of 2.3:1 and a mean age of 27.3 years (standard deviation [SD]: 11.9, range: 3-58 years) [Table 1]. Most of the patients/surrogate (92.4%) were either unemployed or low-income earners, and they belonged to Class IV or V socioeconomic classification as described by Oyedeji. 
On clinical examination, they all presented with moderate to severe pain and either a swelling with features of a necrotizing soft tissue infection or with a pus discharging sinus or ulceration [Figure 1]. The pus was intensely foul smelling typical of its characteristic dishwater discharge. The cervicofacial ulcers had ragged, undermined edges and underlying necrotic fascia could be easily identified [Figure 2]. The surrounding skin was dark in color, anesthetic in the central regions, and significantly hyperesthetic in the bordering areas. Four of them had extension of the disease into the anterior chest and abdominal walls [Figure 3].
Intraorally, there were teeth pathologies such as dental caries, periodontal disease, and pericoronitis. In addition, mucosal burns secondary to the topical application of Aspirin were observed. The duration of symptoms before hospital presentation ranged from 2 to 21 days with a mean (±SD) of 7.6 (5.2) days. One of the patients had uncontrolled diabetes mellitus at presentation. The mandibular molars with caries or its sequelae were implicated in all cases.
Results for packed cell volume (PCV) at presentation were retrieved successfully for 12 patients. The PCV results ranged from 10% to 34%, with a mean (±SD) of 21.85 (8.9) [Table 2]. The PCV was lower than 30% in nine (69.2%) of the patients. Subjects with PCV of less than 20% were transfused until their PCV was at least 25%. The white blood cell count was low in two patients (15.4%), both of whom also had low PCV. Records of serum albumin and protein levels at presentation were successfully retrieved for nine patients. They all exhibited low levels of albumin, however, two subjects had total serum protein values that were within the normal reference range [Table 2]. Electrolyte, creatinine, and urea values were within normal range in all patients.
MCS yielded no growth in ten of the cases (76.9%), with a positive growth of Pseudomonas aeruginosa, Staphylococcus aureus, and Streptococcus spp. in the remaining three patients [Table 3]. The empirical antibiotics used in 9 of the cases were intravenous (IV) ceftriaxone 1 g 12 hourly and IV metronidazole 500 mg 8 hourly. This combination was changed to IV ciprofloxacin 500 mg 8 hourly in combination with IV metronidazole 500 mg 8 hourly as indicated by the result of the MCS. Furthermore, all subjects were placed on hematinics of ferrous sulfate 200 mg daily, tablets Vitamin C 200 mg 8 hourly, and tablets Vitamin B comple × 100 mcg 12 hourly until the patient is in the rehabilitation phase of treatment. All the patients had serial debridement done until the infection was controlled. Mechanical debridement with normal saline and dilute sodium hypochlorite was used in all patients. Wound dressings were done with gamgee and alginate in five and three of the patients, respectively. All other patients had conventional gauze dressings. NGT was inserted in five patients for an average duration of 6 days (range of 4-10 days).
|Table 3: Bacteriology, treatment, complications, duration of hospital admission and outcome|
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The mortality rate was 46.2% (6), all of whom were adults above 18 years of age [Table 3]. Septic shock was the cause of death in all mortality recorded. The length of hospital stay ranged from 7 to 44 days with a mean (±SD) of 19.5 (11.3) days [Table 3]. Complications seen include mediastinitis, otitis media, and aspiration pneumonitis; these complications were observed in 38.5% of the cases. Statistically significant positive correlation was observed between the duration of disease at presentation and the length of hospital stay. The linear regression model with duration of disease before presentation predictor produced R² =0.560, F = 11.460, P = 0.008.
| Discussion|| |
An incidence of 13 cases in 1 year was observed, which is significantly higher than the figures reported by two earlier studies of 16 and 12 cases, over a period of 10 years and 5 years, respectively. , This indicates that CNF, although rare in developed nations and Southern Nigeria, remains a major disease burden in our region. , This may be attributed to the low socioeconomic status, cultural food beliefs, and poor health-seeking behavior among the populace. ,,, Majority of patients seen were of low socioeconomic status, with majority of them being subsistent farmers and cattle herders. Socioeconomic status has been correlated with low health awareness, malnutrition, and poor health indices. , Most of the patients seen were males similar to findings of several investigators. ,, However, Obimakinde et al.  reported a female predominance. In addition, most of the patients were in the third decade of life, similar to other reports. ,,
Majority of the patients were found to have applied aspirin or other caustic traditional condiments topically, which may have led to the development of mucosal ulcerations. This may have compromised the integrity of the mucosal barrier to ingress of microorganisms, thereby increasing the chances of CNF initiation. Infections originating from mandibular molars were implicated in all cases in agreement with other studies.  This is because the molars are more often involved in dental caries and its sequelae more than any other teeth. , Several factors such as uncontrolled diabetes mellitus and nutritional deficiencies may make patients susceptible to the development of CNF owing to adverse impact on immunity and wound healing. , Patients' nutritional status may have been further compromised by painful mastication and trismus. Notably, patients with nutritional deficiencies had a significantly longer duration of hospital stay.
Samples taken for MCS showed positive bacterial culture in three cases. The low number of positive cultures observed may have been because the samples were not subjected to anaerobic cultures or DNA probe assay due to limitation in resources. In addition, most of the patients had taken antibiotics in the days preceding presentation, which may result in sterile cultures. Furthermore, viral and fungal cultures were not done, which may have reduced the chances of culturing the culprit organisms. The mean hematocrit level recorded was below the optimal value. This may have predisposed them to the development of CNF and also protracted the recovery period. Infection states place high metabolic demands on the patients; therefore, low hemoglobin levels worsen an already dire situation. Moreover, the low levels of serum albumin observed in this series may be an indication of depleted reserves, thus reducing patients' ability to respond to an infective assault effectively.
Extensive serial debridement under sedation was the bedrock of management in these series. Mechanical debridement was done with copious amounts of normal saline and diluted sodium hypochlorite. Sodium hypochlorite has antimicrobial effects, odor-suppressing effects, and necrotic tissue dissolution capacity.  Sodium hypochlorite at a dilutional level of 1/100 has been shown to possess antimicrobial activities with no detrimental effects on fibroblasts.  Dressings of the wounds were done with gauze, gamgee, or alginate. Alginate has been documented as an occlusive hydrocolloid dressing that is said to provide moist environ conducive for healing.
NGT was found to be a useful adjunct for enteral nutrition in this series because some of the patients had feeding challenges because of trismus. Although several options for enteral feeding such as NGT feeding, percutaneous endoscopic gastrostomy (PEG), percutaneous endoscopic fluoroscopy, and surgical endoscopic gastrostomy exist, the two preferred modes of enteral feeding are the NGT and PEG.  The NGT is easily available, cheaper, requires lower expertise and is more culturally accepted, making it more suitable for use in our resource-limited environment. In addition, its use in short-term nutritional rehabilitation is encouraged. Enteral or peripheral intravenous multivitamins/minerals and amino acid supplementation was extensively utilized in the study. Care was taken to gradually replenish the patients nutritionally in order to prevent refeeding syndrome.
A higher mean duration of hospital admission was recorded in this study compared to reports by Subhashraj et al.,  from India, who recorded a mean length of hospital stay of 15 days among patients with CNF. However, the duration of hospital stay is comparable to reports from Nigeria.  The high duration of hospital stay recorded in this study may have been due to the late presentation by patients, evidenced by the severity and extent of the disease process at presentation. The most common complication observed was mediastinitis which was secondary to the descending NF. Two-thirds of the patients who developed this complication died in this series. Otitis media was seen in a 3-year-old female who had extension of NF to the mastoid and preauricular regions.
| Conclusion|| |
CNF is a rapidly spreading, potentially fatal disease, which may descend inferiorly to involve the thoracic and abdominal walls. It is a burdensome disease with possibility of long-lasting complications. Despite improvement in healthcare, morbidity and mortality are still undesirably high. Although rare in some parts of the world, the current study has demonstrated that it remains significant public health burden in our locality. Therefore, there is need for a concerted effort toward combating it. The need for early recognition of the disease process, management of the disease itself, as well as any underlying systemic derangement is of utmost importance.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
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Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]
[Table 1], [Table 2], [Table 3]