Professional paper

Posttraumatic clostridial necrotizing fasciitis of the head and neck with descending necrotizing mediastinitis treated by video-assisted thoracoscopic surgery - report of a case

Ivan Kovačić ; Zadar General Hospital, Department of surgery, Zadar
Marijan Kovačić ; Zadar General Hospital, Department of otorhinolaryngology and head and neck surgery, Zadar
Jakov Mihanović orcid.org/0000-0001-6450-2956 ; Zadar General Hospital, Department of surgery, Zadar
Martina Šarec Ivelj ; Polyclinic "Bagatin", Department of general, plastic, reconstructive and aesthetic surgery, Zagreb
Anela Tolić orcid.org/0000-0002-7217-4355 ; Zadar General Hospital, Department of radiology, Zadar
Ivan Bačić orcid.org/0009-0006-1581-1844 ; Zadar General Hospital, Department of surgery, Zadar

Abstract

Background: Necrotizing fasciitis of the head and neck with subsequent descending necrotizing mediastinitis is a highly lethal condition. The clostridial origin has a particularly aggressive course.
Case presentation: Herein we present a case of a 22-year-old male with clostridial necrotizing fasciitis of the head and neck complicated with descending necrotizing mediastinitis after a traumatic scalp wound. Three days after having sutured the wound at the Emergency Department, the patient became septic with marked cellulitis of the head and neck soft tissue. Urgent surgical wound debridement of necrotic tissue along with transcervical drainage of the upper mediastinum was performed. The patient was ventilator dependent, receiving vasoactive support and empiric broad-spectrum antibiotic therapy. Left-sided pleural effusion and CT signs of infection descent into the middle and lower mediastinum mandated further surgical intervention. A video-assisted thoracoscopic surgical approach was used to drain and debride the affected mediastinal and pleural spaces leading to a gradual stabilization of the patient followed by being transferred to the Surgical Department. Microbiological analysis revealed Clostridium perfringens as an infective agent. Further recovery was uneventful and the patient was dismissed on postoperative day 24.
Conclusion: Posttraumatic clostridial gas gangrene of the head and neck is a fulminant and life-threatening infection. It requires urgent clinical and radiological assessment. Treatment should be multidisciplinary based. The invasiveness and extent of surgery should be tailored for individual patients. Video-assisted thoracoscopic surgery technique is a safe and appealing approach to all mediastinal compartments. It offers less invasiveness, superior visibility and equal efficiency in terms of tissue debridement and mediastinal as well as pleural drainage.

Keywords

necrotizing fasciitis; mediastinitis; Clostridium perfringens; gas gangrene; video-assisted thoracoscopic surgery

Hrčak ID:

256628

URI

https://hrcak.srce.hr/256628

Publication date:

3.5.2021.

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