The efficacy of proanthocyanidins and secnidazole in the treatment of chronic periodontitis after scaling and root planing therapy.

The aim of this study is to evaluate the clinical and microbiological effect of the systemic antibiotic therapy of proanthocyanidins and secnidazole on periodontitis. Seventy-five subjects with chronic periodontitis were randomly divided into two treatment groups (secnidazole or proanthocyanidins) and one placebo control group (25 cases each). Plaque index (PI), gingival index (GI), gingival bleeding index (BI), probing pocket depth (PPD), and clinical attachment level (CAL) were carried out at baseline, post-treatment and 3 months after treatment. Microbial analysis was performed at baseline and post-treatment. The results show that the two treatment groups had greater mean reduction in BI, GI, and PPD evaluated at both post-treatment and 3 months after treatment compared to the control group (p less than 0.05), but there were no significant differences in those of PI and CAL (except CAL evaluated at post-treatment, p 0.05). After treatment, culturable bacteria counts significantly decreased. In conclusion, the adjunctive use of proanthocyanidins or secnidazole in combination with scaling and root planing in adults with periodontitis is effective in reducing the pathogenic flora and achieves significantly better clinical results to a certain degree.

Severe neck infections that require wide external drainage: clinical analysis of 17 consecutive cases.

Infections in the neck layers and spaces are potentially life-threatening diseases causing further complications, like mediastinitis, airway obstruction, or sepsis. Despite of the need for a conservative approach, they still regularly require surgical intervention. Records of 17 patients with severe neck infections that were treated by wide external incision and open wound management were retrospectively analyzed. The aim of the study was to clinically characterize these most serious neck infections. The most common presenting symptoms were neck pain and tense neck mass (94-94%) regularly with fever (65%), always accompanied by a marked elevation of C reactive protein level (average 192 uG/l). These findings were constant and very similar among both the deep neck infection and necrotizing fasciitis cases. More than half of the patients (53%) had at least one systemic co-morbidity. The parapharyngeal space was most commonly affected (83%), but extended disease involving more than two major neck regions was found in 13 cases (76%). Dental (29%) was the most common primary infection, followed by peritonsillar abscess (23%), Microbiological results showed a wide variety of corresponding bacteria. Mediastinitis was developed in three cases (18%), and airway obstruction requiring tracheostomy in two cases (12%). All the patients survived. Severe neck infections are a heterogenous group of diseases regarding to the primary site of infection, microbiology, localisation and host reaction. However, rapidly developed, painful, tense neck mass with a highly elevated CRP level should always alert for an extended or phlegmonous process in the layers or spaces of the neck.

The Public Recognizes Plastic Surgeons as Leading Experts in the Treatment of Congenital Cleft and Craniofacial Anomalies.

OBJECTIVE: The aim of this study is to assess the public perception of plastic surgeons (PS) as craniofacial surgery specialists. METHODS: Members of the public (N = 1514) were asked to choose 1 or 2 specialists that they perceived to be an expert for 13 craniofacial surgery-related scenarios. Response patterns were distributed as "plastic surgeon alone" (PS alone), "PS combined with other specialists", or "no plastic surgeon" (No PS). Sociodemographic data, previous plastic surgery contact, and source of reported information were also collected. RESULTS: "Plastic surgeon alone" was significantly (all P < 0.05) more recognized as experts than all other response patterns particularly in congenital anomalies-related scenarios (83.33%). There was a significantly (all P < 0.05) poor understanding of the role of PSs in head/neck infection management, chronic facial palsy management, dental disease management, head and neck cancer surgery, vascular malformation surgery, and facial fracture surgery. Sex, age, education level, health care professional, prior plastic surgery contact, and source of reported information were not significant (all P < 0.05) determinants of "PS" as the response in bivariate and multivariate analyses. CONCLUSIONS: Public recognized PSs as experts primarily in treatment of congenital cleft and craniofacial anomalies, but as the overall scope of craniofacial surgery practice was poorly understood and known, improved public education is needed.

Effects of macroporous monofilament mesh on infection in a contaminated field.

BACKGROUND: The aim of this study was to evaluate whether the type of the mesh and proper surgical technique can influence the outcome of a tension-free hernia repair in a contaminated filed. MATERIALS AND METHODS: This study was based on the model of bacterial peritonitis in rats induced with a mixture composed of Escherichia coli and Bacteroides fragilis. Two animals were used as a control group without induced peritonitis and 10 animals with mesh implanted inside of the peritoneal cavity. For the 20 animals in the studied group, bacterial fluid was applied into the abdominal cavity together with the mesh implantation. In 10 cases, the mesh was fixed flatly upon the surface of the peritoneum; in the other 10, the mesh was rolled and then fixed within the peritoneal cavity. After 5 weeks, the animals were operated on again, and the meshes, the peritoneal fluid and, if present, any granulomas were taken for bacterial cultivation. RESULTS: The results of the bacterial cultivation of the material from the control group (without mesh) and from the rats with flatly fixed mesh were almost completely negative (0/10 and 1/10, respectively). In 9 out of 10 rats that were exposed to the rolled mesh for 5 weeks, the colonisation of meshes with both B. fragilis and E. coli was found (p < 0.0198). CONCLUSIONS: When properly fixed, flat mesh, even in a contaminated field, may allow for a proper mesh healing and does not influence the ability to cure bacterial peritonitis in an animal model. A bad surgical technique, such as inadequately positioned or rolled mesh, may cause persistent peritoneal bacteraemia.

Transcervical removal of an impacted third molar: an uncommon indication.

This article presents a case of and reviews the literature involving the extraoral approach for surgical removal of an ectopic mandibular third molar tooth. Case reports describing extraction of the mandibular third molar using the extraoral approach are very limited. This article describes an unusual case of an impacted, infected, ectopic right mandibular third molar that was positioned at the inferior border and had caused an extraoral draining sinus. Furthermore, the roots were intimately involved with the inferior alveolar nerve (IAN) and had perforated the buccal cortex of the mandible. Surgical removal using a transcervical submandibular approach was deemed necessary to try to preserve the IAN and avoid fracture of the mandible in this 74-year-old patient.

Dislocation of preformed antibiotic-loaded cement spacers (Spacer-G): etiological factors and clinical prognosis.

This study assesses the factors associated with the dislocation of the Spacer-G and its clinical prognosis. Seventy-four spacers were reviewed. Acetabular bone defects, proximal femoral cementation of the spacer and its relationship to the size of the head spacer were not associated with dislocation. The only variable that it was possible to associate with dislocation was when the previous stem, prior to the spacer placement, was a cemented stem. In patients who experienced a dislocation, infection was not cured during the interim period more frequently than patients who had not experienced a dislocation (P = 0.001) and the final clinical hip evaluation was also worse (P < 0.001). The study concludes that the surgeon should assess different surgical aspects in order to avoid mechanical complications such as dislocation and its consequences.

Unusual case of exacerbation of sub-acute descending necrotizing mediastinitis.

Descending necrotizing mediastinitis is a life-threatening complication of an oropharyngeal infection that requires prompt and aggressive medical and surgical therapy. Herein, we report unusual case of man suffering of sub-acute mediastinal infection due to odontoiatric abscess which exacerbated at 3 months after its first presentation. Chest X-ray and CT scan demonstrated soft-tissue swelling of the neck and encapsulated fluid collections with gas bubbles within anterior mediastinum, especially on the right side. Bilateral anterior neck dissections were performed and blunt dissection, irrigation and debridement were carried out to several centimetres below the sternal manubrium. Then, right standard thoracotomy was performed with debridement of the anterior mediastinum. Four tubes were placed in the mediastinum and pleural cavity on the right side, and two tubes were placed in the left thoracic cavity. Follow-up CT scans of neck and chest showed the resolution of infection.

Good results in postoperative and hematogenous deep infections of 89 stable total hip and knee replacements with retention of prosthesis and local antibiotics.

BACKGROUND: Deep postoperative and hematogenous prosthesis infections may be treated with retention of the prosthesis, if the prosthesis is stable. How long the infection may be present to preclude a good result is unclear. PATIENTS AND METHODS: We retrospectively studied 89 deep-infected stable prostheses from 69 total hip replacements and 20 total knee replacements. There were 83 early or delayed postoperative infections and 6 hematogenous. In the postoperative infections, treatment had started 12 days to 2 years after implantation. In the hematogenous infections, symptoms had been present for 6 to 9 days. The patients had been treated with debridement, prosthesis retention, systemic antibiotics, and local antibiotics: gentamicin-PMMA beads or gentamicin collagen fleeces. The minimum follow-up time was 1.5 years. We investigated how the result of the treatment had been influenced by the length of the period the infection was present, and by other variables such as host characteristics, infection stage, and type of bacteria. RESULTS: In postoperative infections, the risk of failure increased with a longer postoperative interval: from 0.2 (95% CI: 0.1-0.3) if the treatment had started ≥ 4 weeks postoperatively to 0.5 (CI: 0.2-0.8) if it had started at ≥ 8 weeks. The relative risk for success was 0.6 (CI: 0.3-0.95) if the treatment had started ≥ 8 weeks. In the hematogenous group, 5 of 6 infections had been treated successfully. INTERPRETATION: A longer delay before the start of the treatment caused an increased failure rate, but this must be weighed against the advantage of keeping the prosthesis. We consider a failure rate of < 50% to be acceptable, and we therefore advocate keeping the prosthesis for up to 8 weeks postoperatively, and in hematogenous infections with a short duration of symptoms.

Healing of apical periodontitis through modern endodontic retreatment techniques.

The presence of apical periodontitis in teeth which have undergone initial root canal treatment is largely attributed to bacteria residing in or invading from the apical root canal space. Bacteria-associated apical periodontitis will not heal spontaneously, nor will systemic antibiotics eradicate the infection. Only endodontic retreatment, endodontic surgery, or extraction will control the bacterial etiology. Modern retreatment is an effective means of addressing apical periodontitis. A mandibular premolar with apical periodontitis, apical root resorption, and overfilled gutta percha was retreated with post removal, retrieval of gutta percha from beyond the apex, ultrasonic irrigation and disinfection, and placement of a collagen internal matrix to facilitate a well-controlled MTA apical fill. The magnification and illumination imparted by the operating microscope was integral to achievement of treatment objectives. The patient's symptoms were resolved and complete osseous healing occurred. During treatment planning, clinicians should consider the capability of modern endodontic techniques to overcome technical challenges, often allowing the natural dentition to be preserved and restored to function days after retreatment.

[Infectious complications of stress urinary incontinence treatment with TVT procedure]. / Powiklania infekcyjne leczenia wysilkowego nietrzymania moczu metoda tasmy TVT.

We present case report of 51-year-old female patient admitted to surgery ward because of presence of pyogenic discharge in perianal region since 7 months. Eighteen months earlierthe patient underwent stress urinary incontinence procedure with use of TVT synthetic implant. Diagnosis of wast, bilateral, composite vagino-perianal fistule was made. After carrying out four operations with two stage sling removal final postfistule wound healing was obtained.

Cement-in-cement revision of the femur in infected hip arthroplasty in 89 patients across two centres.

AIMS: Femoral cement-in-cement revision is a well described technique to reduce morbidity and complications in hip revision surgery. Traditional techniques for septic revision of hip arthroplasty necessitate removal of all bone cement from the femur. In our two centres, we have been using a cement-in-cement technique, leaving the distal femoral bone cement in selected patients for septic hip revision surgery, both for single and the first of two-stage revision procedures. A prerequisite for adoption of this technique is that the surgeon considers the cement mantle to be intimately fixed to bone without an intervening membrane between cement and host bone. We aim to report our experience for this technique. METHODS: We have analyzed patients undergoing this cement-in-cement technique for femoral revision in infection, and present a consecutive series of 89 patients. Follow-up was undertaken at a mean of 56.5 months (24.0 to 134.7) for the surviving cases. RESULTS: Seven patients (7.9%) required further revision for infection. Ten patients died of causes unrelated to their infection before their two-year review (mean 5.9 months; 0.9 to 18.6). One patient was lost to follow-up at five months after surgery, and two patients died of causes unrelated to their hip shortly after their two-year review was due without attending. Of the remaining patients, 69 remained infection-free at final review. Radiological review confirms the mechanical success of the procedure as previously described in aseptic revision, and postoperative Oxford Hip Scores suggest satisfactory functional outcomes. CONCLUSION: In conclusion, we found that retaining a well-fixed femoral cement mantle in the presence of infection and undertaking a cement-in-cement revision was successful in 82 of the patients (92.1%) in our series of 89, both in terms of eradication of infection and component fixation. These results are comparable to other more invasive techniques and offer significant potential benefits to the patient. Cite this article: Bone Joint J 2022;104-B(2):212-220.

Comparison of preoperative computed tomography and surgical findings in maxillofacial infections.

PURPOSE: To examine the accuracy of computed tomography (CT) in predicting the presence of surgically confirmed abscess in patients presenting with deep maxillofacial infections (DMIs). MATERIALS AND METHODS: The medical records of 36 patients with clinically suspected DMI were reviewed. All patients underwent preoperative CT scan to determine whether abscess or cellulitis was present. The operative reports of all patients were compared with their preoperative CT scan findings. RESULTS: Of 36 patients, 30 had abscess predicted by preoperative CT scan. The positive predictive value for DMI based on CT findings interpreted by an oral surgeon and confirmed as an abscess at operation was 90%, whereas the negative predictive value was 33%. When findings were interpreted by a radiologist, the positive predictive value was 94.1% whereas the negative predictive value was 26.3%. Thirty patients had abscess predicted by preoperative CT scan when interpreted by an oral surgeon, whereas seventeen had abscess predicted by a radiologist. At operation, 3 of 30 patients had cellulitis whereas 27 had abscess, for a false-positive rate of 60% and false-negative rate of 12.9%. On the basis of preoperative radiography, 1 of 17 patients had cellulitis whereas 16 had abscess, for a false-positive rate of 16.7% and a false-negative rate of 46.7%. The agreement between CT and operative findings in predicting abscess by an oral surgeon was 80.6% and by a radiologist was 58.3%. CONCLUSION: CT yielded high sensitivity for the detection of DMI abscess but poor specificity, likely because of the paucity of cellulitis.

De Marco Formula effectiveness as an adjunctive therapy to prevent infected ischemic diabetic foot amputation and reduce plasma fibrinogen.

BACKGROUND: De Marco Formula (DMF) is a new procaine chemical combination of Procaine HCl and polyvinylpyrrolidone. A prospective randomized controlled clinical trial demonstrated that infected ischemic diabetic foot treatment with DMF for 52 days as an adjuvant with conventional therapy reduced major amputations. OBJECTIVE: To evaluate the possible association of clinical effectiveness and plasma fibrinogen reduction with DMF therapy. METHODS: Adult patients, 24 male/23 female, suffering from infected ischemic diabetic foot ulcers were randomly assigned to receive conventional therapy alone (group A, N=24) or combined with DMF (receiving 0, 15 ml/kg day i.m.) for ten days and then twice a week until lesion healing or completion of 52 days (group B, N=23). Fibrinogen concentrations were determined before and after a ten-day treatment period. Treatment clinical responses were considered favorable if major amputations were not needed. Pre and post-treatment fibrinogen values were compared within each group and between groups. Differences were considered statistically significant for p<0, 05. RESULTS: Fifty percent of group A patients (12/24) and 21.7% of the Group B (5/23) showed unfavorable responses (a 56.6% reduction for group B). There were not statistical differences between pre and post-treatment fibrinogen within Group A (406.7±49.08 vs. 354.6±62.5, p=0,11). However, post-treatment values were significantly lower within Group B (298.9±15.24 vs. 487.1±49.08, p=0, 0016). Patients who showed favorable responses had statistically lower fibrinogen concentrations than those with unfavorable responses (280±5.1 vs. 310±7,1, p=0.002) within group B. CONCLUSION: DMF combined with conventional therapy for infected ischemic diabetic foot was associated with plasma fibrinogen decrease.

Comparison of static and mobile antibiotic-impregnated cement spacers for the treatment of infected total knee arthroplasty.

Infection after total knee arthroplasty (TKA) is a devastating complication, and two-stage reimplantation has evolved as an effective treatment option. This study was undertaken to compare the clinical results and radiological changes associated with static or mobile cement spacer placement for the treatment of infected TKA. Between July 2000 and February 2007, 36 consecutive patients were treated by two-stage reimplantation using antibiotic-impregnated cement spacers (AICS) for infected TKAs. Static spacers were used in 20 knees and mobile spacers in 16 knees. Clinical outcomes included success rates of TKR revisions, ranges of motion (ROM), and Hospital for Special Surgery knee scores (HSS), pain and function scores of the Knee Society (KS), joint exposure methods, and bone loss. In this study, mobile spacers provided better ranges of motion and functional knee scores without concomitant increases in infection rate and bone loss in the initial and mid-term periods.

Tolerability and safety of conventional therapy combination with DeMarco formula for infected ischemic diabetic foot.

BACKGROUND: A study has found that major amputations are necessary on 69% of ischemic diabetic foot patients treated with conventional therapy. An uncontrolled study of 31 patients showed that only 33% needed major amputation after treatment with conventional therapy plus De Marco Formula (DMF), a novel formulation of procaine and Polyvinylpyrrolidone. OBJECTIVE: To assess the tolerability and safety of the combination of conventional therapy and De Marco Formula for infected ischemic diabetic foot. METHODS: Adult patients, 10 male/24 female, were treated with the conventional therapy for diabetic foot plus DMF (0.15 ml/kg/day IM) during ten days and then twice a week until healing of the lesions or completion of a 52-day period. Required amputations, lesion areas, adverse events occurrence and clinical laboratory parameters (hemoglobin, blood cell counts, glycosilated hemoglobin, total proteins, creatinine, alanine transaminase and alkaline phosphatase) were determined during the treatment period. RESULTS: Two slight (5.88%) and one moderate (2.94%) adverse events (mainly cutaneous rash) were reported. The last one was reported on the 15th day of treatment and DMF dosing was discontinued by patient's request. Clinical laboratory mean values remained within normal ranges during treatment except for blood leukocyte counts that pathologically elevated at baseline and decreased to normality by treatment end. This study has found that 18.08% of patients (N=6) needed a lower limb amputation with the combined treatments. The standard reported rate in Cuba is 25-29%. Furthermore, a progressive reduction of the mean lesion area from 51.29 cm2 at the beginning to 1.89 cm2 at the end of the treatment (p=0.000001) was observed. CONCLUSION: The treatment with De Marco Formula for 52 days as an adjuvant for the conventional therapy for infected ischemic diabetic foot was well tolerated and safe. These findings are consistent with those of a randomized prospective controlled study performed later.

Interim endodontic therapy for alveolar socket bone regeneration of infected hopeless teeth prior to implant therapy.

The immediate placement of implants in the fresh extraction sockets of infected teeth with periradicular and periapical lesions is contraindicated because of both the infection and the loss of architecture required for proper implant placement. There are 4 approaches for implant replacement of a hopeless tooth with lesions: (1) extraction and delayed implant placement; (2) extraction, debridement, guided bone regeneration (GBR), guided tissue regeneration (GTR), and delayed implant placement; (3) extraction, intrasocket debridement, and immediate implant placement; or (4) extraction, debridement, GBR, GTR, and simultaneous implant placement. The extraction of such hopeless teeth often results in large bone and soft tissue defects that are difficult to repair. This article introduces an alternative approach: interim endodontic implant site preparation, defined as a transitional, surgical, or nonsurgical endodontic treatment to regenerate the hopeless tooth bone defects and prepare the site for proper implant placement. This article describes 3 distinct interim endodontic protocols used to manage 5 patients, all of whom had severely infected hopeless teeth with large lesions and were treatment planned for implant replacement: the first, interim nonsurgical endodontic treatment to restore the normal anatomy of the infected hopeless tooth; the second, interim surgical endodontics on the hopeless tooth with preexisting endodontic treatment to regenerate apical bone for primary implant stability, thus avoiding the involvement of the maxillary sinus and other critical anatomic structures; and the third, interim surgical endodontics on the hopeless tooth with preexisting endodontic treatment to confine the size of the osseous defect and simplify the GBR and GTR procedures. The outcome of interim endodontic treatment on these 5 patients demonstrated that tooth extraction would have been a less predictable approach. The interim treatment changed the overall direction of the patients' dental care. When treated, these hopeless teeth served many preventive, biologic, and esthetic functions. The infections of the alveolar sockets were eliminated, the alveolar bone defects were repaired through normal bone regeneration, and sockets anatomies were maintained or restored. Furthermore, the patients were spared maxillary sinus surgery and the possible complications resulting from major GBR and GTR procedures. In summary, the interim treatment facilitated tooth extraction and immediate implant placement.

The microbiology of the acute dental abscess.

The acute dental abscess is frequently underestimated in terms of its morbidity and mortality. The risk of potential serious consequences arising from the spread of a dental abscess is still relevant today with many hospital admissions for dental sepsis. The acute dental abscess is usually polymicrobial comprising facultative anaerobes, such as viridans group streptococci and the Streptococcus anginosus group, with predominantly strict anaerobes, such as anaerobic cocci, Prevotella and Fusobacterium species. The use of non-culture techniques has expanded our insight into the microbial diversity of the causative agents, identifying such organisms as Treponema species and anaerobic Gram-positive rods such as Bulleidia extructa, Cryptobacterium curtum and Mogibacterium timidum. Despite some reports of increasing antimicrobial resistance in isolates from acute dental infection, the vast majority of localized dental abscesses respond to surgical treatment, with antimicrobials limited to spreading and severe infections. The microbiology and treatment of the acute localized abscess and severe spreading odontogenic infections are reviewed.

Sinoscopic treatment of rostral maxillary and ventral conchal sinusitis in 60 horses.

OBJECTIVE: To evaluate the use of sinoscopy for detection and treatment of ventral conchal sinus (VCS) and/or rostral maxillary sinus (RMS) disease in horses. STUDY DESIGN: Case series ANIMALS: Horses (n=60) with suspected paranasal sinus disease. METHODS: Horses were evaluated by sinoscopy through a conchofrontal sinus (CFS) portal with ventral conchal bulla (VCB) fenestration. Other endoscopic sinus approaches and adjunctive diagnostic tests; oral examination, computed tomography, radiography, scintigraphy and endoscopic examination of the upper portion of the respiratory tract were used in some horses. RESULTS: The CFS approach permitted adequate observation of the RMS and VCS in 53 horses (88%). Hemorrhage caused by VCB fenestration prevented examination of the RMS and/or VCS in 12 horses (21%). Observation of lesions was possible in all horses diagnosed with neoplasia, sinus cysts, and progressive ethmoidal hematomas. Endoscopy of the paranasal sinuses was useful diagnostically in 82% of horses with primary sinusitis. Other diagnostic modalities were usually required to confirm a diagnosis of dental sinusitis. CONCLUSIONS: Trephination into the CFS with VCB fenestration is a minimally invasive technique that provides consistent access to the RMS and VCS. It facilitates diagnosis of many sinus disorders and endoscopically guided treatment of many horses with sinus cysts and primary sinusitis, in combination with sinus lavage. CLINICAL RELEVANCE: Many diseases affecting the RMS and VCS can be diagnosed and resolved endoscopically using a CFS approach with VCB fenestration, thus avoiding the need for osteoplastic sinus surgery and its associated risks and complications.

The effect of different temporary abdominal closure techniques on fascial wound healing and postoperative adhesions in experimental secondary peritonitis.

BACKGROUND: Secondary peritonitis causes considerable mortality and morbidity. New strategies have been introduced like relaparotomy and temporary abdominal closure in the management of such persistent intra-abdominal infections. MATERIALS AND METHODS: Rats were divided into five groups each having ten animals. After induction of peritonitis, relaparotomies were done, and the abdomen was closed by different temporary abdominal closure techniques. After performing two relaparotomies during a 48-h period, all fascias closed primarily and incisional tensile strengths, hydroxyproline contents, and adhesions were measured on the following seventh day. RESULTS: The median values of tensile strength and hydroxyproline concentrations were lowest in skin-only closure rats. Intraperitoneal adhesion scores were highest in Bogota bag closure group. CONCLUSION: Primary, Bogota bag, and polyprolene mesh closures seem to be safe in terms of early fascial wound healing. Although it is easy to perform, skin-only closure technique has deleterious effects on fascial wound healing probably due to fascial retraction. Interestingly, Bogota bag has caused increased intraperitoneal adhesion formation.

Deep neck infection.

Deep neck infections present significant morbidity and mortality, particularly when associated with predisposing factors that impair a functional immunologic response. Familiarity with deep neck spaces and fascial planes is critical, because these form the basis for the emergent nature of the disease process. Common and potentially life-threatening complications include airway obstruction, jugular vein thrombosis, descending mediastinitis, sepsis, acute respiratory distress syndrome, and disseminated intravascular coagulation. The most common primary sources of deep neck infection are odontogenic, tonsillar, salivary gland, foreign body, and malignancy. Microbiology typically reveals mixed bacterial flora, including anaerobic species, that can rapidly progress to a fulminating necrotizing fasciitis. The treatment cornerstone remains securing the airway, providing efficient drainage and appropriate antibiotics, and improving immunologic status. A prolonged hospital stay should be anticipated.