Vol 2 | Issue 1 | Jan-Apr 2016 | page:12-14 | Ankit Kedia, Saikat Sengupta, Gaurab Maitra, Shantanu Panja.
Authers: Ankit Kedia, Saikat Sengupta, Gaurab Maitra, Shantanu Panja.
 Department of Anaesthesiology,Apollo Gleneagles Hospital, Kolkata India.
 Department of Otorhinolaryngology, Apollo Gleneagles Hospital, Kolkata India.
Address of Correspondence
Dr. Ankit Kedia
Department of Anaesthesiology, Apollo Gleneagles Hospital, Kolkata, India.
Introduction: Anaesthetic management of cervicofacial necrotizing fasciitis is challenging in view of the difficult airway and existing comorbidities. The airway should be managed by experienced anaesthesiologist with readiness of difficult airway cart. In the case report presented, we note that airway management should be done early, as the rapid progression of the swelling around the neck can make the task more difficult and thereby increase the morbidity and mortality.
Keywords: Cervicofacial necrotizing faciitis, Difficult airway, Awake fiberoptic intubation.
Key Messages: Cervicofacial necrotising fasciitis is associated with rapid deterioration of airway, and airway should be secured as early as possible to prevent the hazard of complete airway obstruction.
Cervicofacial necrotizing fasciitis is a rare but aggressive infection of the soft tissues and fascial planes of the neck causing local necrosis and systemic toxicity. The diagnosis is a clinical one supported by laboratory investigations and imaging. The mainstay of treatment is immediate hemodynamic resuscitation of the patient, along with airway management and aggressive surgical debridement. Additional surgeries may be necessary before soft tissue coverage is undertaken . It is usually polymicrobial in nature and is associated with dental infections . Airway management is challenging and timely airway intervention is crucial as the disease process involves rapid airway deterioration. The American Society of Anaesthesiologists difficult airway algorithm  lays down logical sequence of decision making, which significantly reduces the incidence of airway associated complications.
A 53 year old gentleman was admitted to our hospital with a history of painful swelling of cheeks, chin and neck for 7 days. It started about a month ago with pain in the left lower jaw followed by localised swelling in the left cheek. He was undergoing treatment for dental caries in the left lower premolar tooth. The patient received oral third generation cephalosporins for the same, but the swelling increased in size spreading in submandibular region and to the right side. The patient attended the otorhinolaryngology out-patient department of our hospital where he was advised urgent admission for surgical drainage. The patient was diabetic and hypertensive for last 5 years and was taking glimepiride, metformin, amlodipine and bisoprolol.
Preliminary examination revealed signs of sepsis with a temperature of 101 F, and a heart rate of 114/min. There was no hypotension. His blood glucose was found to be 480mg/dl. However, there was no evidence of ketoacidosis on urine dipstick. The swelling occupied the submandibular and bilateral parotid region with erythema of the overlying skin. Along the midline, the swelling extended from the mentum to the sternum. The swelling was warm and tender to touch, with underlying subcutaneous emphysema. Systemic examination did not reveal any abnormality of cardiovascular, respiratory and central nervous system. Initial assessment of the airway revealed an interincisor distance of 4cm (Figure 1). Computed tomography scan of the neck revealed unobstructed airway with pockets of air in subcutaneous tissue of neck. There was no evidence mediastinal extension in the CT scan images (Figure 1). Over the next four hours, the swelling increased in size, inter-incisor distance decreased to 2cm with appearance of blisters, bluish discolouration and increased subcutaneous emphysema over the neck (Figure 2). His neck movement was restricted by pain. With a working diagnosis of cervicofacial necrotizing fasciitis, the patient was started on intravenous meropenem empirically along with variable rate intravenous insulin infusion under the supervision of the endocrinologist, and posted for surgery. Plan of airway management included awake fibreoptic nasotracheal intubation as there was no obvious focus of infection in the pharynx and the computed tomography scan of neck showed a patent airway. The otolaryngologist was requested to be prepared for emergency tracheostomy as a backup plan during the intubation. The patient was counseled about the procedure of awake fibreoptic nasal intubation and the need to maintain the endotracheal tube postoperatively till the oedema subsides. The patient’s nasal cavity was prepared with oxymetazoline drops and lignocaine spray. After thorough preoxygenation and providing continuous oxygen delivery through nasal prongs placed in mouth, the fibreoptic endoscope was inserted and the airway was anaesthetised using spray as you go technique. A 7.5mm internal diameter cuffed, reinforced, Murphy Eye Mallinckrodt Lo-ContourTM Oral/Nasaltracheal tube was inserted after examination of the pharynx and the position of the tip of the tube was confirmed visually. The patient was then anaesthetised using intravenous propofol 2mg/kg and neuromuscular paralysis achieved with atracurium 0.5mg/kg. The surgical anaesthesia was maintained using desflurane and intermittent boluses of atracurium. Fentanyl was used to provide analgesia along with intravenous paracetamol. The pus collection was drained and necrotic tissue was debrided by the otolaryngologist. The samples collected were sent for microbiological evaluation. At the end of the surgery, the patient was shifted to intensive care unit with the nasotracheal tube in place. Enteral nutrition was initiated via nasogastric tube. On the first postoperative day, the patient was extubated over an airway exchange catheter after confirming the presence of air leak air around the deflated cuff of the endotracheal tube in the presence of difficult airway cart. The patient was shifted out of intensive care unit on the second postoperative day. The pus sample grew Klebsiella pneumoniae, while the lymph node samples were positive for acid fast bacilli. The antibiotic therapy was modified based on culture and sensitivity report, and anti tubercular treatment was initiated. After repeated debridements and adequate pain control, the patient was discharged on the sixth postoperative day with the instruction of regular outpatient follow up and dressing changes.
Cervicofacial necrotizing fasciitis is a rapidly spreading infection of the soft tissues of the neck and fascial planes. It is usually polymicrobial in nature. Group A Streptococcus is the most common mono microbial cause of the infection . It is associated with high mortality and early diagnosis and multi-disciplinary care is critical. The most commonly accepted treatment involves rapid surgical intervention and broad spectrum antibiotics .Further explorations may be necessary before soft tissue coverage is undertaken . It is most common in patients with an underlying systemic disease, such as diabetes, but can also be seen in healthy individuals . The initial source of infection is commonly of dental origin, but it can propagate from other regions in the head and neck . It is mainly a clinical diagnosis, and is often wrongly diagnosed in its early stages as cellulitis. One of the most important factors determining the patient outcome is the time to initiation and completion of therapy . An early diagnosis can be made by meticulous clinical examination and computed tomographic scans revealing pockets of air in the planes of cervical region . A normal computed tomography does not rule out necrotising fasciitis and a bedside cut down procedure with fascial biopsy maybe needed to expedite the diagnosis . The infection can also track down along the great vessels to the mediastinum . The disease poses challenges with regards to the airway management in the perioperative period. Early intervention to secure the airway is easier and can obviate the need for emergency or surgical airway management. Based on the rapid nature of disease progression seen in the photographs taken upon admission and four hours later in the preoperative room, it may be speculated that any further delay in intervention could have resulted in the disastrous consequence of complete airway obstruction. Other important anaesthetic concerns include hemodynamic management and glycemic control as the patients commonly present in a state of sepsis, severe sepsis or even septic shock . In the case presented, mask ventilation, supraglottic airway devices and laryngoscopy were not viable options, and the clinical scenario demanded the need to secure the airway with the patient awake . Hence, the decision to perform awake fibreoptic nasal intubation was made with surgical tracheostomy as a backup plan. No procedural sedation was used during intubation. The major drawbacks of a surgical airway were the altered anatomy and the potential to spread the infection along the airway leading to life threatening pulmonary infections . Potter et al, in a retrospective study of 85 patients with deep neck infections, suggested that use of tracheostomy allowed earlier movement out of the intensive care unit and was associated with lower cost of hospitalization . While there have been case reports of securing the airway under direct laryngoscopy under anaesthesia with ketamine without use of neuromuscular blockers, the author clearly mentions that fibreoptic awake intubation is a better alternative when available . The process of extubation should be as cautious as that of intubation. The disadvantage of immediate postoperative extubation in the operating room is the potential loss of airway patency and failure to secure it back in a planned manner. The extubation in the intensive care unit should be performed in the presence of difficult airway cart, over an airway exchange catheter, preferably after checking for the presence of air leak around the deflated cuff of the endotracheal tube.
The management of cervicofacial necrotizing fasciitis revolves around the pillars of hemodynamic management and airway control. We recommend early intervention to secure the airway in view of the rapidly progressive nature of the disease, as a delay of few hours can make the airway even more difficult. Preoperative counselling about the need to maintain endotracheal tube in situ with judicious use of analgesia and sedation in the postoperative period is essential followed by careful and planned extubation.
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|How to Cite this Article: Kedia A, Sengupta S, Maitra G, Panja S. Cervicofacial Necrotizing Fasciitis – Airway Management. Journal of Anaesthesia and Critical Care Case Reports Jan-Apr 2016; 2(1):12-14.|