頸部壞死性筋膜炎及胸腔并發症－病例報告及文獻回顧

Cervical Necrotizing Fasciitis with Thoracic Complications-Report of a Case and Review of the Literature

秀曉敏(Shiaou-Min Ghi) ； 黃穰基(Yong-Kie Wong) ； 陳嘉瑋(Chai-Wei Chen)

《中華民國口腔顎面外科學會雜誌》 7卷1期 (1996/03) Pp. 15-26

https://doi.org/10.7104/CJOMS.199603.0015

摘要

壞死性筋膜炎(Necrotizing fasciitis)是一種少見的感染性疾病，主要侵犯軀幹、會陰以及下肢；頭頸部的病例頗爲罕見，且發生原因以齒源性感染居首位。當壞死性筋膜炎侵犯後咽間隙、氣管前間隙及頸動脈鞘間隙時，感染過程就很容易沿縱膈腔，往下延伸至心包膜、肋膜，引發胸腔内之併發症。本報告提出一病例原爲齒源性感染，後導致頸部壞死性筋膜炎，感染過程並沿縱膈腔往下蔓延造成胸部併發症。病患爲37歲男性，主訴右下臼齒疼痛、右頷下區腫痛，併有吞嚥及張口困難，歷時3天，昱日腫痛擴展至下頦區。病人於盧德維氏咽峽炎之診斷下經由急診住院。雖經適當廣效抗生素治療及外科切開引流，病況卻未改善。於切開引流術後第三天，患者主訴肋骨下區疼痛及胸悶，吾人查察頸部及鎖骨上區皮膚呈現瀰漫性紅腫，併有壓迫性之波動感及捻髮聲，急照之胸部X光及電腦斷層攝影檢查顯現炎性反應往下延伸至深頸部及縱膈腔。緊急外科切開探查顯示深頸筋膜呈液化性壞死，並引流出大量惡臭之洗碗水樣膿液。壞死性筋膜炎合併胸部併發症得以確立。膿液細菌培養顯示klebsiella pneumonia及A族β-溶血性鏈球菌等菌種感染。術後經由多次的積極擴創引流並正確的使用抗生素、同時會診感染科、胸腔科及心臟科醫師協同治療，終將病情控制下來，病人並於住院38天後平安出院。本文闡述疾病進行過程，吾人所作之檢查及治療方針，並強調治療之成功首重早期診斷、積極施行外科擴創和引流，以及正確使用抗生素。

關鍵字

壞死性筋膜炎 ； 併發癥 ； 深頸部感染

並列摘要

A 37-year-old man suffered from toothache of the R't lower wisdom tooth, tender red swelling in the R't submandibular region, accompanied by dysphagia about 3 days. He received RCT of #45, #48 & antibiotics treatment in local clinics, but the symptom did not relieve. The tender swelling extended to the submental region in the other day. So he called at our SER for help and was admitted to our section under the impression of Ludwig's angina.
Although the broad spectrum IV antibiotics therapy in combination with I & D procedure were performed, the symptoms did not get improved. On the third day of hospitalization, pt complained substernal pain and dyspnea. The overlying skin of the neck region showed generalized brown edema, erythema, tenderness with crepitation and fluctuation. Emergent chest X-ray film & Computed tomography revealed gas in the soft tissues of the neck and a widened mediastinum.
The patient was quickly taken to the operation room, bilateral incision and drainage of the neck using transverse incision was performed while the patient was under general anesthesia. Abundant of foul-smelling, dark purulent and necrotic subcutaneous tissue were found throutghout the neck, and the diagnosis of necrotizing fasciitis was confirmed with the demostration of liquefactive necrosis of the fascia. Wound cultures showed the presence of Klebsiela pneumonia and group A β-hemolytic streptococcus. Daily debridement and irrigation with betadine solution continued for 7 more days. Insertion of chest tube and pericardiocentesis were performed for resolution of pulmonary & pericardial effusion.
The patient gradually improved and was decannulated. Then discharged from the hospital 38 days after admission. We consider that the survial of necrotizing fasciitis patients depend upon early diagnosis, radical surgical debridement in combination with appropriate antibiotics, the highly alterness and cooperation of clinicians.