(43) The Vanderbilt Experience on the Management of Odontogenic Necrotizing Fasciitis of the Head and Neck During the COVID-19 Pandemic

Abstract:

Purpose: Necrotizing fasciitis is a life-threatening infection characterized by fulminant tissue necrosis, microvascular thrombosis, and systemic toxicity. Necrotizing fasciitis of the head and neck (NFHN) represents a rare subset of this disease, with 1%-2.6% of odontogenic infections progressing to NFHN.1,2. The purposes of this study were to estimate the frequency of presentation of odontogenic infection as NFHN during the COVID-19 pandemic and compare the frequency and features of NFHN to previously published pre-COVID-19 data.

Methods: This retrospective cohort study enrolled all patients with odontogenic deep space infections treated by the Department of Oral and Maxillofacial Surgery at Vanderbilt University Medical Center in Nashville, Tennessee, from December 2019 to February 2023. ICD-10 and CPT codes related to the diagnosis and treatment of cellulitis, abscess, and NFHN were used to select subjects, with NFHN representing the outcome variable of interest. Incidence and clinical features of NFHN subjects identified during the COVID-19 pandemic were compared to a retrospective study conducted between July 2016 and December 2019 within the department[3]. Clinical features including history of COVID-19 infection, clinical and radiographic presentations, microbiologic data, Laboratory Risk Indicator for Necrotizing Fasciitis (LRINEC) score, systemic inflammatory response syndrome (SIRS) as an indicator of sepsis, morbidity, and mortality were recorded.

Results: In total, 258 odontogenic deep space infections were managed during the study timeframe, with 12 cases (4.65%) meeting the diagnostic criteria for NFHN. This represents a substantial increase compared to the previously reported pre-COVID incidence of 3.07%[3]. Seven of the NFHN patients were female and 5 were male, with a mean age of 59 years. Common comorbidities included a smoking history, type 2 diabetes, hypertension, and obesity. Ten of the 12 patients (83%) had soft-tissue gas formation noted on CT imaging. Of the 9 patients with sufficient data to calculate a LRINEC score, 7 (78%) had a score ≥ 6 consistent with a diagnosis of necrotizing fasciitis. The average LRINEC score was 7, which is higher than the pre-COVID score of 5.28 previously reported[3]. Also, 58.3% of patients treated for odontogenic NFHN met the SIRS criteria for sepsis compared to 60% in the pre-COVID cohort3. The average initial triage-to-surgical intervention time was 7 hours and 19 minutes, with an average length of stay of 18.5 days. NFHN subjects underwent 6.5 surgical procedures on average. The most common predominant organisms included Streptococcus, Candida, and Prevotella. Two patients required tracheostomy, 1 developed mandibular osteomyelitis complicated by pathologic fracture, and 3 required free flap reconstruction. One mortality was due to multi-system failure on admission. Results of this study are summarized in Table 1.

Conclusion: NFHN is a rapidly progressing infection frequently caused by an odontogenic source. Physical examination and contrasted CT imaging, supplemented by scoring systems such as LRINEC and signs of sepsis, should be used to rapidly triage patients with a suspicion for NFHN for urgent surgical management. Our results suggest an increase in the frequency of odontogenic infections progressing to NFHN and a higher average LRINEC score during the pandemic. Future research efforts will focus on qualitative comparisons of the clinical features of NFHN between these two time periods. References 1. Zemplenyi K, Lopez B, Sardesai M, Dillon JK. Can progression of odontogenic infections to cervical necrotizing soft tissue infections be predicted?. Int J Oral Maxillofac Surg 46:181-188, 2017 2. Sandner A, Moritz S, Unverzagt S, Plontke SK, Metz D. Cervical Necrotizing Fasciitis--The Value of the Laboratory Risk Indicator for Necrotizing Fasciitis Score as an Indicative Parameter. J Oral Maxillofac Surg 73:2319-2333, 2015 3. LaMothe, A., Czechura, T., Lin, S., Vega., L, McKenna, S. Necrotizing Fasciitis of the Head and Neck of Odontogenic Origin: A Retrospective Review. J Oral Maxillofac Surg 78:e88, 2022020;78(10):e88. https://doi.org/10.1016/j.joms.2020.07.174.

Table 1: Summary of Results
Table 2: Glossary of Terms