RESUMO
Necrotizing fasciitis is one of the most dangerous complication of an abscess and it is still a disease with a high mortality. In this work, we decided to consider two cases: the first one concerns a male subject, aged 66, deceased because of a fatal necrotizing fasciitis associated to a cervical descending mediastinitis, which evolved from a primary peritonsillar abscess; the second is about a 50-year-old woman with a perineal abscess, then evolved into necrotizing fasciitis associated to a fatal septis shock. After a systematic consideration of necrotizing fasciitis as pathology and an analysis of the possible related risks to a diagnostic or therapeutic delay, we analyzed the particular history of both cases to underline the possible critical issues in professional behavior of the medical staff intervened. KEY WORDS: Abscess, Medical malpractice, Mortality, Necrotizing fasciitis, Professional liability.
Assuntos
Diagnóstico Tardio , Fasciite Necrosante , Responsabilidade Legal , Imperícia , Tempo para o Tratamento , Abscesso/complicações , Abscesso/cirurgia , Antibacterianos/uso terapêutico , Celulite (Flegmão)/etiologia , Celulite (Flegmão)/terapia , Terapia Combinada , Complicações do Diabetes , Drenagem , Fasciite Necrosante/etiologia , Evolução Fatal , Feminino , Humanos , Oxigenoterapia Hiperbárica , Masculino , Mediastinite/etiologia , Pessoa de Meia-Idade , Abscesso Peritonsilar/complicações , Abscesso Peritonsilar/tratamento farmacológico , Abscesso Peritonsilar/cirurgia , Complicações Pós-Operatórias/etiologia , Choque Séptico/etiologia , Enfisema Subcutâneo/etiologia , Doenças da Vulva/complicações , Doenças da Vulva/cirurgiaRESUMO
OBJECTIVE: To outline the most appropriate treatment of descending necrotizing mediastinitis. MATERIALS AND METHODS: Three adult patients had mediastinitis occurring from a descending odontogenic infection in one case and oropharynx infection in two cases. All patients underwent extensive surgical debridement and a cervicomediastinal drainage through a cervical incision. All patients survived. DISCUSSION: Soft-tissue infections of the neck with mediastinitis demand early diagnosis aided by CT scan in order to decrease their threat to life. Extensive surgical debridement and a cervico mediastinal drainage through a cervical incision is adequate when mediastinitis is limited to the upper mediastinum. Thoracotomy has to be performed when the process spread below the carina. Patients must be treated initially aggressively with the aid of multidisciplinary support team (intensive care physicians, thoracic and head and neck surgeons). Early surgery must treat both neck and mediastin. While usually associated with greater than 40% mortality, all the patients in this series survived.