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Cervicofacial necrotizing fasciitis: A rare disease with a high mortality requiring early debridement for survival
Fasceítis necrosante cervicofacial: una infección severa que requiere tratamiento quirúrgico temprano
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Martínez, Christopher R. McHenry, Leopoldo Meneses Rivadeneira" "autores" => array:3 [ 0 => array:4 [ "nombre" => "Alan Y." "apellidos" => "Martínez" "email" => array:1 [ 0 => "aymartinez@gmail.com" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 1 => array:3 [ "nombre" => "Christopher R." "apellidos" => "McHenry" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 2 => array:3 [ "nombre" => "Leopoldo" "apellidos" => "Meneses Rivadeneira" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] ] "afiliaciones" => array:2 [ 0 => array:3 [ "entidad" => "Departamento de Cirugía, MetroHealth Medical Center, Case Western Reserve University School of Medicine, Cleveland, OH, United States" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Instituto de Medicina Tropical Alexander von Humboldt, Universidad Peruana Cayetano Heredia, Lima, Peru" "etiqueta" => "b" "identificador" => "aff0010" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "<span class="elsevierStyleItalic">Corresponding author</span>." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Fasceítis necrosante cervicofacial: una infección severa que requiere tratamiento quirúrgico temprano" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0015" "etiqueta" => "Fig. 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 948 "Ancho" => 1802 "Tamanyo" => 242400 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">Different defects after aggressive debridement.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Necrotizing fasciitis (NF) is an uncommon soft tissue infection that results in the rapid and progressive necrosis of the connective tissue and muscle fascia. In more advanced stages, it involves the skin and muscle, and the mortality rate is high. Cervicofacial NF (CNF) is a rare condition that constitutes between 2.6% and 5% of all the cases of FN.<a class="elsevierStyleCrossRefs" href="#bib0115"><span class="elsevierStyleSup">1,2</span></a> It is not common for any one center to gather significant clinical experience with CNF.</p><p id="par0010" class="elsevierStylePara elsevierViewall">There are many historical accounts of and references to NF that date back to Hippocrates (500 BC), who reported diffuse lesions that would not heal. Pouteau and Gillespie, in 1783 and 1785, respectively, described malignant, gangrenous ulcers.<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">3</span></a> In 1871, Joseph Jones, who had been a Confederate surgeon in the United States Civil War, was the first to offer a precise description of NF, which he referred to as “hospital gangrene”.<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">4</span></a> Meleney reported 20 cases of hemolytic streptococcal gangrene in 1924<a class="elsevierStyleCrossRef" href="#bib0135"><span class="elsevierStyleSup">5</span></a> and, in 1952, Wilson used the term necrotizing fasciitis for the first time.<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">6</span></a> The information on the presentation, management and results of the treatment of patients with NF in the head and neck region is limited.</p><p id="par0015" class="elsevierStylePara elsevierViewall">Necrotizing fasciitis is classified according to 3 different types, depending on the microbiological findings. Type 1 is a polymicrobial infection produced by a combination of anaerobic and aerobic bacteria, whereas type 2 is a monomicrobial infection due mainly to group A β-hemolytic streptococcus and, less frequently, to other streptococci and staphylococci; type 3 is a monomicrobial infection caused by a marine <span class="elsevierStyleItalic">Vibrio</span> species.<a class="elsevierStyleCrossRef" href="#bib0145"><span class="elsevierStyleSup">7</span></a> The clinical signs of NF include swelling, erythema, pain, skin blistering and crepitus.<a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">8</span></a> The purpose of this article is to review our experience and report the demographic data, treatment microbiological findings and reconstruction carried out in 5 patients with CNF.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Materials and methods</span><p id="par0020" class="elsevierStylePara elsevierViewall">We carried out a retrospective review of the cases of CNF treated between December 2002 and December 2012 in the oral and maxillofacial surgery units of 2 centers (MetroHealth Medical Center [MHC] in Cleveland, Ohio, United States, and the Instituto de Medicina Tropical Alexander von Humboldt [IMT] of the Universidad Peruana Cayetano Heredia in Lima, Peru). A total of 590 moderate and severe maxillofacial infections were identified, 7 of which (1.19%) were diagnosed as CNF. At the MHC, we identified 332 infections with 4 cases (1.2%) of CNF, and the IMC reported 258 cases, including 3 (1.16%) of CNF. Moderate maxillofacial infections were considered to be those that involved one or more of the following fascial spaces: submandibular, submental, sublingual, pterygomandibular, superficial temporal and deep temporal. Severe maxillofacial infections were defined as any infection that required in-hospital management and/or threatened to compromise the lateral pharyngeal, retropharyngeal, pretracheal and danger spaces, as well as mediastinal and intracranial infections.<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">9</span></a></p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Results</span><p id="par0025" class="elsevierStylePara elsevierViewall">Seven patients with CNF were identified on the basis of the data provided by the centers in which the present study was conducted. Two patients were excluded because of insufficient clinical data and a lack of follow-up. All of the patients were adults of the male sex, with ages between 30 and 61 years. Three patients were black, one was mestizo and another was white. All of them presented with severe pain, erythema, swelling, necrosis and subcutaneous gas. The clinical photographs can be seen in <a class="elsevierStyleCrossRefs" href="#fig0005">Figs. 1 and 2</a>.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0030" class="elsevierStylePara elsevierViewall">The demographic and bacteriological data, location and type of reconstruction carried out are summarized in <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>. Two patients had systemic comorbidities: patient no. 3 had morbid obesity and patient no. 4 had type 1 diabetes mellitus and hypertension. The only death in our case series was that of a patient involved in a traffic accident as a pedestrian, who had multiple injuries (facial and rib fractures) and an in-hospital course complicated by prolonged ventilatory support and multiple respiratory tract infections.</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0035" class="elsevierStylePara elsevierViewall"><a class="elsevierStyleCrossRefs" href="#fig0015">Figs. 3 and 4</a> show the defects in the 5 reported patients.</p><elsevierMultimedia ident="fig0015"></elsevierMultimedia><elsevierMultimedia ident="fig0020"></elsevierMultimedia><p id="par0040" class="elsevierStylePara elsevierViewall">Patient no. 1 underwent reconstruction with a skin graft. In patient no. 2, an advancement flap was created. Patient no. 3 underwent supraclavicular flap creation. The defect in patient no. 4 was closed by means of an advancement flap. Patient no. 5 underwent repair with a submental artery island flap which, unfortunately, failed; the defect subsequently healed by second intention, leaving a conspicuous scar; the patient refused to undergo revision of the scar.</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Discussion</span><p id="par0045" class="elsevierStylePara elsevierViewall">Necrotizing fasciitis is a serious infection associated with a mortality rate that can reach approximately 30%.<a class="elsevierStyleCrossRef" href="#bib0160"><span class="elsevierStyleSup">10</span></a> The most important factors in the reduction of the mortality are early diagnosis and early aggressive surgical treatment. The key findings that lead to a correct diagnosis are a combination of the clinical presentation (pain, which generally is severe and disproportionate with respect to the physical findings, erythema, swelling and induration, tenderness to touch beyond the region of erythema, subcutaneous crepitus, skin blistering and skin discoloration).<a class="elsevierStyleCrossRefs" href="#bib0165"><span class="elsevierStyleSup">11,12</span></a> The radiographic signs include gas in soft tissues, very often associated with fluid collection in the connective tissue and cervical fascia. Reactive lymphadenopathy can also be observed.<a class="elsevierStyleCrossRefs" href="#bib0175"><span class="elsevierStyleSup">13,14</span></a> The microbiological studies performed in our patients revealed polymicrobial infections in 4 and monomicrobial infection in 1 (patient no. 1), in whom only <span class="elsevierStyleItalic">Proteus mirabilis</span> was isolated. Streptococci and staphylococci were the predominant aerobic bacteria. The majority of the anaerobic bacteria isolated were peptostreptococci and <span class="elsevierStyleItalic">Prevotella</span> species.</p><p id="par0050" class="elsevierStylePara elsevierViewall">McHenry et al. reported 65 patients with necrotizing soft tissue infections and only 2 (3%) were found in head and neck, whereas 37 (57%) were located in trunk and 26 (40%) in extremities. The mortality rate was 29%; the 2 patients with CNF survived. In their series, McHenry et al. found a number of factors that had a significant impact on the outcome, including time from hospital admission to operation, percentage of body surface area involved, acidosis, peripheral vascular disease, the number of systemic diseases and age. When the factors were correlated with mortality, the only statistically significant factor was a prolonged time between admission and surgical treatment.<a class="elsevierStyleCrossRef" href="#bib0175"><span class="elsevierStyleSup">13</span></a> This finding has also been reported by other authors.<a class="elsevierStyleCrossRefs" href="#bib0185"><span class="elsevierStyleSup">15•18</span></a> In our study, the rate of mortality was 20%, which is similar to or slightly lower than those observed by other authors.<a class="elsevierStyleCrossRefs" href="#bib0160"><span class="elsevierStyleSup">10,19•22</span></a> In patient no. 4 of our series, there was a delay in the identification of a postoperative infection. The surgical wound was edematous, but showed no signs of skin necrosis. This delay in the identification of the infection may have contributed to his death, although it most probably was multifactorial, related to multiple comorbidities, injuries, hospital-acquired pneumonia and respiratory failure.</p><p id="par0055" class="elsevierStylePara elsevierViewall">Owing to the fact that early aggressive surgical treatment is the key factor for survival, CNF should be suspected in patients with erythema and induration of the skin, severe pain that is disproportionate with respect to the physical findings, tenderness to the touch in areas free of erythema, rapid progression and hemodynamic instability, although the most important clinical signs of this disease are crepitus, blistering and skin necrosis.</p><p id="par0060" class="elsevierStylePara elsevierViewall">Cervicofacial NF is commonly secondary to an odontogenic infection, and is less often found to be secondary to traumatism. On rare occasions, no etiological factor or obvious portal of entry for the bacteria is identified, as occurred in patient no. 1 of our series. This spontaneous presentation of NF has been reported in up to 20% of the patients.<a class="elsevierStyleCrossRef" href="#bib0200"><span class="elsevierStyleSup">18</span></a></p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Conclusion</span><p id="par0065" class="elsevierStylePara elsevierViewall">Cervicofacial NF is a rare infection associated with high rates of morbidity and mortality. Early diagnosis and rapid and aggressive surgical treatment can reduce these rates.</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Ethical disclosures</span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Protection of human and animal subjects</span><p id="par0070" class="elsevierStylePara elsevierViewall">The authors declare that the procedures followed were in accordance with the regulations of the relevant clinical research ethics committee and with those of the Code of Ethics of the World Medical Association (Declaration of Helsinki).</p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Confidentiality of data</span><p id="par0075" class="elsevierStylePara elsevierViewall">The authors declare that they have followed the protocols of their work center on the publication of patient data.</p></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Right to privacy and informed consent</span><p id="par0080" class="elsevierStylePara elsevierViewall">The authors have obtained the written informed consent of the patients or subjects mentioned in the article. The corresponding author is in possession of this document.</p></span></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0110">Conflicts of interest</span><p id="par0085" class="elsevierStylePara elsevierViewall">The authors declare they have no conflicts of interest.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:12 [ 0 => array:3 [ "identificador" => "xres821679" "titulo" => "Abstract" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Purpose" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Methods" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Results" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Conclusions" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec818665" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres821680" "titulo" => "Resumen" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0025" "titulo" => "Propósito" ] 1 => array:2 [ "identificador" => "abst0030" "titulo" => "Mèc)todos" ] 2 => array:2 [ "identificador" => "abst0035" "titulo" => "Resultados" ] 3 => array:2 [ "identificador" => "abst0040" "titulo" => "Conclusiones" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec818664" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:2 [ "identificador" => "sec0010" "titulo" => "Materials and methods" ] 6 => array:2 [ "identificador" => "sec0015" "titulo" => "Results" ] 7 => array:2 [ "identificador" => "sec0020" "titulo" => "Discussion" ] 8 => array:2 [ "identificador" => "sec0025" "titulo" => "Conclusion" ] 9 => array:3 [ "identificador" => "sec0030" "titulo" => "Ethical disclosures" "secciones" => array:3 [ 0 => array:2 [ "identificador" => "sec0035" "titulo" => "Protection of human and animal subjects" ] 1 => array:2 [ "identificador" => "sec0040" "titulo" => "Confidentiality of data" ] 2 => array:2 [ "identificador" => "sec0045" "titulo" => "Right to privacy and informed consent" ] ] ] 10 => array:2 [ "identificador" => "sec0050" "titulo" => "Conflicts of interest" ] 11 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2014-02-13" "fechaAceptado" => "2014-04-15" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec818665" "palabras" => array:5 [ 0 => "Necrotizing" 1 => "Cervicofacial" 2 => "Infection" 3 => "Mortality" 4 => "Debridement" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec818664" "palabras" => array:5 [ 0 => "Fasceítis necrosante" 1 => "Cervicofacial" 2 => "Infección" 3 => "Mortalidad" 4 => "Desbridamiento" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:3 [ "titulo" => "Abstract" "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Purpose</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">To review the clinical experience, management and outcome of cervicofacial necrotizing fasciitis (CNF) in patients treated in our institution.</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Methods</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">A retrospective review of patients with CNF from two large health care institutions completed over a 10-year period.</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Results</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Five patients with complete data were identified. CNF was polymicrobial in 4 and monomicrobial in one patient and occurred as a result of odontogenic infection in 3, trauma in 1, and was idiopathic in one patient. All patients were treated with extensive debridement, broad spectrum antibiotics, and reconstruction with flaps. There was one death.</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Conclusions</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Early diagnosis and rapid aggressive debridement are key elements for reducing mortality and optimizing the cosmetic and functional outcome in patients with CNF.</p></span>" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Purpose" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Methods" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Results" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Conclusions" ] ] ] "es" => array:3 [ "titulo" => "Resumen" "resumen" => "<span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Propósito</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Revisar la experiencia clínica, el manejo quirúrgico y los resultados del tratamiento de pacientes con fasceítis necrosante cervicofacial (FNC) en nuestras instituciones.</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Mèc)todos</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Un estudio retrospectivo de pacientes con FNC en un periodo de 10 años en 2 instituciones acadèc)micas.</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Resultados</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Cinco pacientes con datos completos (clínicos, imágenes, cultivos microbiológicos, tratamiento y seguimiento) fueron identificados. La FNC resultó de una infección polimicrobiana en 4 pacientes y monomicrobiana en un paciente. La etiología de FNC fue odontogèc)nica en 3 pacientes, postraumatismo en un paciente e idiopática en un paciente. Todos los pacientes fueron tratados con tratamiento quirúrgico (desbridamiento) agresivo temprano, antibióticos de amplio espectro y reconstrucción con diferentes tipos de colgajos. Se registró una mortalidad.</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Conclusiones</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">El diagnóstico temprano y un tratamiento quirúrgico agresivo son elementos clave en reducir la mortalidad y optimizar los resultados funcionales y cosmèc)ticos en los pacientes con FNC.</p></span>" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0025" "titulo" => "Propósito" ] 1 => array:2 [ "identificador" => "abst0030" "titulo" => "Mèc)todos" ] 2 => array:2 [ "identificador" => "abst0035" "titulo" => "Resultados" ] 3 => array:2 [ "identificador" => "abst0040" "titulo" => "Conclusiones" ] ] ] ] "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Martínez AY, McHenry CR, Meneses Rivadeneira L. Fasceítis necrosante cervicofacial: una infección severa que requiere tratamiento quirúrgico temprano. Rev Esp Cir Oral Maxilofac. 2014. <span class="elsevierStyleInterRef" id="intr0005" href="http://dx.doi.org/10.1016/j.maxilo.2014.04.008">http://dx.doi.org/10.1016/j.maxilo.2014.04.008</span>.</p>" ] ] "multimedia" => array:5 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 958 "Ancho" => 1802 "Tamanyo" => 230678 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">The initial clinical characteristics of our patients with cervicofacial necrotizing fasciitis.</p>" ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Fig. 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 756 "Ancho" => 1801 "Tamanyo" => 252223 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Examples of computed tomography slices and 3D reconstruction.</p>" ] ] 2 => array:7 [ "identificador" => "fig0015" "etiqueta" => "Fig. 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 948 "Ancho" => 1802 "Tamanyo" => 242400 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">Different defects after aggressive debridement.</p>" ] ] 3 => array:7 [ "identificador" => "fig0020" "etiqueta" => "Fig. 4" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr4.jpeg" "Alto" => 634 "Ancho" => 1802 "Tamanyo" => 170326 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">Examples of the outcome of surgical treatment in patients 1, 3 and 5.</p>" ] ] 4 => array:7 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "tabla" => array:2 [ "leyenda" => "<p id="spar0070" class="elsevierStyleSimplePara elsevierViewall">B: black; G: gender; M: male; MR: mixed race; R: race; W: white.</p>" "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Case/age/G/R \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Site \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Bacteriology \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Initial presentation \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Initial white blood cell count \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Antibiotic therapy \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Reconstruction \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Outcome \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">1/61/M/MR \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Submandibular, right lateral neck \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top"><span class="elsevierStyleItalic">Proteus mirabilis</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Swelling, pain, erythema and skin discoloration (black), skin blistering, subcutaneous gas, pus \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">24,600 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Ceftazidime, ciprofloxacin, clindamycin \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Partial-thickness skin graft \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Survival \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">2/30/M/B \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Submental \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top"><span class="elsevierStyleItalic">Prevotella</span> spp., <span class="elsevierStyleItalic">Clostridium difficile</span>, <span class="elsevierStyleItalic">Peptostreptococcus micros</span>, <span class="elsevierStyleItalic">Streptococcus milleri</span>, <span class="elsevierStyleItalic">Streptococcus intermedius</span>, Coagulase-negative <span class="elsevierStyleItalic">Staphylococcus</span> spp., <span class="elsevierStyleItalic">Candida albicans</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Swelling, pain, erythema and skin discoloration (grayish), skin blistering, subcutaneous gas, pus \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">25,400 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Vancomycin, piperacillin/tazobactam, ertapenem \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Advancement flap \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Survival \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">3/60/M/W \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Sub mental, chin \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top"><span class="elsevierStyleItalic">Streptococcus intermedius</span>, <span class="elsevierStyleItalic">Prevotella corporis</span>, <span class="elsevierStyleItalic">Bacteroides fragilis</span>, <span class="elsevierStyleItalic">Staphylococcus</span> spp., <span class="elsevierStyleItalic">Gemella morbillorum</span>, <span class="elsevierStyleItalic">Streptococcus constellatus</span>, <span class="elsevierStyleItalic">Prevotella melaninogenica</span>, <span class="elsevierStyleItalic">Prevotella oris</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Swelling, pain, erythema and skin discoloration (black), skin blistering, subcutaneous gas, pus \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">10,900 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Ampicillin/sulbactam, vancomycin \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Supraclavicular flap \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Survival \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">4/56/M/B \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Submandibular, right lateral neck \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top"><span class="elsevierStyleItalic">Prevotella buccae</span>, <span class="elsevierStyleItalic">Prevotella intermedia</span>, <span class="elsevierStyleItalic">Peptostreptococcus asaccharolyticus</span>, <span class="elsevierStyleItalic">Bacillus</span> species, <span class="elsevierStyleItalic">Streptococcus constellatus</span>, Saprophytic <span class="elsevierStyleItalic">Neisseria</span> species, <span class="elsevierStyleItalic">Eikenella</span> species, α-hemolytic streptococcus, not enterococcus or pneumococcus, anaerobic Gram<span class="elsevierStyleHsp" style=""></span>+<span class="elsevierStyleHsp" style=""></span>cocci \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Swelling, pain, fever, erythema, pus \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">13,700 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Ampicillin/sulbactam, vancomycin, piperacillin/tazobactam \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Advancement flap \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Death \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">5/39/M/B \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Right cheek \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top"><span class="elsevierStyleItalic">Pseudomonas aeruginosa</span>, <span class="elsevierStyleItalic">Streptococcus gordonii</span>, <span class="elsevierStyleItalic">Klebsiella pneumoniae</span>, <span class="elsevierStyleItalic">Bacteroides capillosus</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Swelling, pain, pus, skin discoloration \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">25,400 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Ampicillin/sulbactam, vancomycin \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Submental artery island flap \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Survival \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1381538.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0065" class="elsevierStyleSimplePara elsevierViewall">Demographic and clinical characteristics of the patients and treatment of cervicofacial necrotizing fasciitis in each.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:22 [ 0 => array:3 [ "identificador" => "bib0115" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Cervicofacial necrotizing fasciitis" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "B. 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| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 October | 44 | 7 | 51 |
| 2024 September | 87 | 9 | 96 |
| 2024 August | 130 | 6 | 136 |
| 2024 July | 100 | 8 | 108 |
| 2024 June | 43 | 2 | 45 |
| 2024 May | 30 | 3 | 33 |
| 2024 April | 28 | 7 | 35 |
| 2024 March | 52 | 7 | 59 |
| 2024 February | 81 | 3 | 84 |
| 2024 January | 83 | 10 | 93 |
| 2023 December | 68 | 7 | 75 |
| 2023 November | 73 | 6 | 79 |
| 2023 October | 113 | 7 | 120 |
| 2023 September | 55 | 7 | 62 |
| 2023 August | 68 | 7 | 75 |
| 2023 July | 75 | 8 | 83 |
| 2023 June | 66 | 13 | 79 |
| 2023 May | 96 | 3 | 99 |
| 2023 April | 109 | 3 | 112 |
| 2023 March | 97 | 5 | 102 |
| 2023 February | 70 | 4 | 74 |
| 2023 January | 73 | 6 | 79 |
| 2022 December | 70 | 7 | 77 |
| 2022 November | 71 | 17 | 88 |
| 2022 October | 66 | 16 | 82 |
| 2022 September | 93 | 7 | 100 |
| 2022 August | 68 | 13 | 81 |
| 2022 July | 59 | 8 | 67 |
| 2022 June | 51 | 12 | 63 |
| 2022 May | 68 | 15 | 83 |
| 2022 April | 74 | 15 | 89 |
| 2022 March | 104 | 19 | 123 |
| 2022 February | 121 | 3 | 124 |
| 2022 January | 107 | 14 | 121 |
| 2021 December | 47 | 9 | 56 |
| 2021 November | 80 | 21 | 101 |
| 2021 October | 108 | 13 | 121 |
| 2021 September | 75 | 23 | 98 |
| 2021 August | 75 | 21 | 96 |
| 2021 July | 54 | 19 | 73 |
| 2021 June | 59 | 20 | 79 |
| 2021 May | 143 | 49 | 192 |
| 2021 April | 165 | 28 | 193 |
| 2021 March | 132 | 4 | 136 |
| 2021 February | 70 | 16 | 86 |
| 2021 January | 88 | 21 | 109 |
| 2020 December | 72 | 16 | 88 |
| 2020 November | 125 | 15 | 140 |
| 2020 October | 85 | 6 | 91 |
| 2020 September | 44 | 7 | 51 |
| 2020 August | 67 | 20 | 87 |
| 2020 July | 49 | 9 | 58 |
| 2020 June | 50 | 17 | 67 |
| 2020 May | 50 | 12 | 62 |
| 2020 April | 42 | 12 | 54 |
| 2020 March | 63 | 7 | 70 |
| 2020 February | 47 | 8 | 55 |
| 2020 January | 52 | 25 | 77 |
| 2019 December | 60 | 11 | 71 |
| 2019 November | 32 | 4 | 36 |
| 2019 October | 51 | 7 | 58 |
| 2019 September | 63 | 7 | 70 |
| 2019 August | 43 | 8 | 51 |
| 2019 July | 66 | 15 | 81 |
| 2019 June | 115 | 24 | 139 |
| 2019 May | 158 | 59 | 217 |
| 2019 April | 94 | 36 | 130 |
| 2019 March | 10 | 7 | 17 |
| 2019 February | 29 | 8 | 37 |
| 2019 January | 14 | 7 | 21 |
| 2018 December | 9 | 12 | 21 |
| 2018 November | 15 | 6 | 21 |
| 2018 October | 24 | 17 | 41 |
| 2018 September | 29 | 6 | 35 |
| 2018 August | 19 | 1 | 20 |
| 2018 July | 28 | 1 | 29 |
| 2018 June | 29 | 1 | 30 |
| 2018 May | 16 | 1 | 17 |
| 2018 April | 28 | 1 | 29 |
| 2018 March | 16 | 1 | 17 |
| 2018 February | 28 | 0 | 28 |
| 2018 January | 17 | 0 | 17 |
| 2017 December | 25 | 3 | 28 |
| 2017 November | 27 | 2 | 29 |
| 2017 October | 28 | 5 | 33 |
| 2017 September | 24 | 1 | 25 |
| 2017 August | 17 | 2 | 19 |
| 2017 July | 20 | 0 | 20 |
| 2017 June | 30 | 4 | 34 |
| 2017 May | 48 | 4 | 52 |
| 2017 April | 28 | 15 | 43 |
| 2017 March | 52 | 10 | 62 |
| 2017 February | 54 | 8 | 62 |
| 2017 January | 34 | 2 | 36 |
| 2016 December | 39 | 6 | 45 |
| 2016 November | 81 | 2 | 83 |
| 2016 October | 87 | 14 | 101 |
| 2016 September | 137 | 9 | 146 |
| 2016 August | 77 | 6 | 83 |
| 2016 July | 49 | 2 | 51 |
| 2016 June | 73 | 15 | 88 |
| 2016 May | 56 | 43 | 99 |
| 2016 April | 46 | 25 | 71 |
| 2016 March | 55 | 26 | 81 |
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