A case of cervical fasciitis complicated by mediastinitis and pre-peritoneal abscess: the role of video-assisted thoraco
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CASE REPORT
A case of cervical fasciitis complicated by mediastinitis and pre-peritoneal abscess: the role of video-assisted thoracoscopic surgery Riccardo Lenzi 1
&
Geri Fratini 2 & Elisa Dinelli 3 & Jacopo Matteucci 1 & Gianfranco Menconi 4 & Luca Muscatello 1,3
Received: 6 May 2020 / Revised: 7 August 2020 / Accepted: 12 August 2020 # Indian Association of Cardiovascular-Thoracic Surgeons 2020
Abstract Cervical necrotizing fasciitis (CNF) is the name for a group of bacterial infections characterized by necrosis of the fascia and subcutaneous cellular tissue of the neck. Descending necrotizing mediastinitis (DNM) is a well-known and feared complication of CNF that severely affects the prognosis. Abdominal involvement is rare. The mainstay of treatment is prompt and aggressive medical therapy and surgical debridement of all involved sites. The role of video-assisted thoracoscopic surgery (VATS) in this setting, even if already reported in the literature, is not universally adopted. We present a case of CNF complicated by DNM and pre-peritoneal involvement, treated with open surgical drainage of the neck and video-assisted thoracoscopic debridement of the mediastinal space. Keywords Cervical fasciitis . Deep neck infection . Mediastinitis . Video-assisted thoracoscopic surgery
Introduction Cervical necrotizing fasciitis (CNF) defines a group of bacterial infections characterized by necrosis of the fascia and subcutaneous cellular tissue of the neck, frequently as a consequence of an infection spreading from a dental focus or the peritonsillar space [1, 2]. It is usually a severe polymicrobial infection, with high morbidity and mortality, especially in patients with comorbidities and immunosuppression. Through infection propagation along the fasciae and deep spaces of the neck that continue with mediastinal fascia and the pericardium, it can cause a descending necrotizing mediastinitis (DNM). The diagnostic criteria of DNM include clinical manifestation of severe or
* Riccardo Lenzi [email protected] 1
Unit of Otorhinolaryngology, Azienda USL Toscana Nord Ovest, Apuane Hospital, Via E. Mattei 31, 54100 Massa, Italy
2
Unit of General Surgery, Azienda USL Toscana Nord Ovest, Versilia Hospital, Camaiore (LU), Italy
3
Unit of Otorhinolaryngology, Azienda USL Toscana Nord Ovest, Versilia Hospital, Camaiore (LU), Italy
4
Unit of General Surgery, Service of Thoracic Surgery, Azienda USL Toscana Nord Ovest, Spedali Riuniti, Livorno, Italy
pharyngeal infection, radiologic features of mediastinitis on computed tomography (CT) scan, documentation of necrotizing mediastinal infection at operation or postmortem, and established relationship between oropharyngeal infection and development of DNM [3]. With isolated CNF, mortality is reported to be 13–14% after prompt and aggressive treatment [4], but when associated with extension into the mediastinum, mortality can be up to 40% [3]. Abdominal dissemination by contiguity is rare, and few reports are present in the literature [5, 6]. CNF diagnosis is based on a comb
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