Original contribution
Cervical necrotizing fasciitis with mediastinitis: a rare occurrence in the pediatric age

Presented as a poster at the 6th International Conference on Pediatric Otorhinolaryngology, Athens, Greece, May 16–19, 2004.
https://doi.org/10.1016/j.amjoto.2006.06.003Get rights and content

Abstract

Necrotizing fasciitis (NF) is a life-threatening, progressive, bacterial soft tissue infection characterized by necrosis of skin, subcutaneous tissues, fasciae, and muscles. It usually occurs in adults and is most often localized to the abdominal wall, the extremities, the perineum, the pelvis, and the thoracic region. Localization to the head and neck area is rarely encountered, especially in pediatric patients. Early diagnosis and prompt, aggressive surgical treatment associated with intravenous, broad-spectrum antibiotic therapy are mandatory to successfully control the disease. To date, only anecdotal cases of cervical NF in the pediatric age have been described. We report a case of cervical NF with mediastinitis in a 13-year-old girl who underwent successful immediate surgery and prolonged intravenous antibiotic therapy. A literature review is also presented with particular emphasis on etiology, clinical and radiological presentation, diagnosis, and treatment of this rare disorder.

Introduction

Necrotizing fasciitis (NF), an uncommon and severe bacterial infection of the subcutaneous tissues, is characterized by widespread necrosis of fasciae and soft tissues, with a rapid course and a high mortality rate. Several terms such as acute streptococcal gangrene, bacterial synergistic gangrene, Meleney's synergistic gangrene, necrotizing soft tissue infections, and synergistic necrotizing cellulitis have been used to describe NF [1], [2], although this extremely variable nomenclature basically refers to variations of the same pathologic entity [3]. This inflammatory process is rarely seen in the pediatric population and its occurrence in the head and neck has been only occasionally reported in this age group [4], [5], [6], [7], [8], [9], [10], [11]. We describe a pediatric case of cervical NF complicated by mediastinitis that was successfully treated by immediate aggressive surgery and prolonged antibiotic therapy.

Section snippets

Case reports

In June 2003, a 13-year-old girl who had idiopathic dystonic syndrome since birth was admitted to the Department of Pediatric Otorhinolaryngology, Spedali Civili, Brescia, Italy, for a painful, left submandibular swelling with bruising and fever lasting 2 days. One month before, the child had been seen at a peripheral hospital for care of her second inferior left molar tooth and had received a 10-day antibiotic course. Four days before admission, the patient started to refuse food because of an

Discussion

Necrotizing fasciitis is a rare and life-threatening disease that was first described by Jones [12] as a complication of germy disorder supervening on gunshot wounds during the American Civil War in the 19th century. In 1924, Meleney [13] reported 20 cases of patients affected by hemolytic Streptococcus gangrenes as a consequence of insect bites or minor trauma. At the beginning of the 1950s, Wilson [14] described 22 cases of severe infections and necrosis of superficial and subcutaneous

Conclusion

The clinician should be aware that NF of the neck, a life-threatening disease that may potentially complicate with mediastinitis, can occur also in the pediatric age. Early diagnosis based on a careful clinical examination and CT findings is crucial to offer the patient the best chance for survival and to plan the most adequate and immediate surgical treatment. Prompt aggressive surgery with debridement of soft tissues and prolonged intravenous antibiotic therapy are mandatory to obtain

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