February 29, 2024
J Diagn Treat Oral Maxillofac Pathol 2024;8: 10–19.
DOI: 10.23999/j.dtomp.2024.2.1
Under a Creative Commons license
Pavlenko RA, Fesenko II, Ashotuni TR. Case report: Eyelid and periorbital necrotizing fasciitis: Experience from the Kyiv Regional Clinical Hospital. J Diagn Treat Oral Maxillofac Pathol 2024;8(2):10–19. https://doi.org/10.23999/j.dtomp.2024.2.1
https://ir.kmu.edu.ua/handle/123456789/790
Necrotizing fasciitis (NF) is an extremely severe infection that can lead to cosmetic and functional problems. It is characterized by rapidly progressing necrotizing infection of the superficial fascia with secondary necrosis of the overlying skin. According to a systematic review by Amrith and colleagues (2013), periorbital NF resulted in death in 8.5% of cases. Overall, the mortality rate from NF, usually due to multisystemic shock, ranges from 12% to 57%. In the literature, the following synonyms of the term NF may be used: streptococcal gangrene, hospital gangrene, gangrenous erysipelas, necrotising erysipelas, Fournier's gangrene, and purulent-necrotic process. The purpose of this article is to present to the public the experience of the staff of the Kyiv Regional Clinical Hospital in the treatment of NF of the eyelids and periorbital area in a 38-year-old male patient with the presentation of the result of treatment after one month. Summing up our experience in treating NF, we note that despite extensive areas of necrosis of the eyelid skin, its regenerative capabilities remain at an extremely high level due to existing vascularization and appropriate comprehensive treatment.
Necrotizing fasciitis, purulent-necrotic process, eyelids, periorbital area, skin
Necrotizing fasciitis (NF) is an extremely severe infection that can lead to cosmetic and functional problems.1 It is characterized by rapidly progressing necrotizing infection of the superficial fascia with secondary necrosis of the overlying skin.1 According to a systematic review by Amrith and colleagues (2013), periorbital NF resulted in death in 8.5% of cases.1,2 Overall, the mortality rate from NF, usually due to multisystemic shock, ranges from 12% to 57%.3 In the literature, the following synonyms of the term NF may be used: streptococcal gangrene, hospital gangrene, gangrenous erysipelas, necrotising erysipelas, Fournier's gangrene, and purulent-necrotic process.2,4
The purpose of this article is to present to the public the experience of the staff of the Kyiv Regional Clinical Hospital in the treatment of NF of the eyelids and periorbital area with the presentation of the result of treatment after one month.
On April 14, 2012, a 38-year-old male patient was brought by ambulance to the Admission and Diagnostic Department of the Kyiv Regional Clinical Hospital. According to the patient, he was beaten with brass knuckles a few days ago. After the beating, he was at home with facial swelling, after which the swelling began to be accompanied by redness of the skin, increased body temperature, and the appearance of purulent discharge in the left periorbital area.
On examination (Figs 1 and 2), the patient had complete closure of the eyelids of the left eye due to eyelids edema, redness and painful swelling of the skin of the left half of the face, the left temporal region, and the left periorbital region with multiple areas of necrosis. In the left suprabrow area, purulent discharge was also noted in the area of necrosis. Less erythematous edema was noted on the contralateral side. The swelling was significantly smaller on the right side, soft to palpation, and almost painless.
The surgery was performed under general anesthesia. No incisions were made in the periorbital area, and the tissues in the necrotic areas were bluntly dissected to the bone to evacuate the purulent content. A significant amount of purulent discharge was observed in all layers of the periorbital tissues and in the upper and lower eyelid area. However, the spread of the purulent process into the orbit was not observed. Two skin incisions and approaches were made: along the left nasolabial fold and in the area of the left zygomatic arch. An incision of the mucosa and access was also made in the area of the left maxillary tuberosity. These three approaches were created for revision of the infraorbital area, temporal and infratemporal fossa. After the surgical revision, rubber drains were installed in the periorbital tissue areas and three double tubular drains were placed in the three created accesses. Irrigation was carried out with antiseptic solutions, including Betadine solution. During the stay in the intensive care unit, surgical teams performed washing with antiseptic solutions and dressings.
The patient spent three days after the operation in the intensive care unit with appropriate therapy, which included cephalosporins and metronidazole.
Figure 3 demonstrate condition of the soft tissues on day 5 after surgery. The pronounced edema and erythema of the soft tissue start to decrease. The final formation of areas of necrosis with their clear demarcation from intact tissues is noted. These days, procedures are being carried out to irrigate areas of necrosis with Betadine solution.
Figure 4 shows the result of periorbital tissues healing on day 31 (i.e., May 15, 2012) after the surgery. The patient is able to lower the upper eyelid and close the left eye. No skin grafting procedures were performed during the first month after surgery.
The patient was recommended further plastic surgery.
Correct diagnosis and immediate treatment of purulent pathology of facial soft tissues are important not only for health, but also for preserving the patient's life in general.5–7 NF, being an aggressive purulent-necrotic process, also requires radical surgical treatment.8–11 In our case, the purulent content were evacuated, and all necessary conditions were created for the tissues in the periorbital area for reparative processes and spontaneous removal of necrosis, with their gentle excision.
Summing up our experience in treating NF, we note that despite extensive areas of necrosis of the eyelid skin, its regenerative capabilities remain at an extremely high level due to existing vascularization1 and appropriate comprehensive treatment.
Writing patient’s consent was obtained for publication the photos and data.
Drafting of the manuscript: Fesenko II. Critical revision of the manuscript: all authors. Approval of the final version of the manuscript: all authors.
The authors declare no conflict of interest.
No funding was received for this study.
Amrith S, Hosdurga Pai V, Ling WW. Periorbital necrotizing fasciitis -- a review. Acta Ophthalmol. 2013;91(7):596-603. https://doi.org/10.1111/j.1755-3768.2012.02420.x
Walters R. A fatal case of necrotising fasciitis of the eyelid. Br J Ophthalmol. 1988;72(6):428-431.
Knudtson KJ, Gigantelli JW. Necrotizing fasciitis of the eyelids and orbit. Arch Ophthalmol. 1998;116(11):1548-1549. https://doi.org/10.1001/archopht.116.11.1548
Tymofieiev OO. Manual of oral and maxillofacial surgery. 5th ed. Kyiv: Chervona Ruta-Turs; 2012.
Fesenko II. Odontogenic cutaneous fistula and abscess of the superficial peri-zygomatic area. J Diagn Treat Oral Maxillofac Pathol. 2022;6(10):131-134. https://doi.org/10.23999/j.dtomp.2022.10.2
Cherniak OS, Fesenko II. Periorbital abscessing furuncle. J Diagn Treat Oral Maxillofac Pathol. 2021;5(1):13–14. https://doi.org/10.23999/j.dtomp.2021.1.4
Cherniak OS, Ripolovska OV, Nozhenko OA, Fesenko II. Accuracy of ultrasound in diagnostics of odontogenic infection in layers of temporal and parotid masseter region. J Diagn Treat Oral Maxillofac Pathol. 2019;3(9):214-229. https://doi.org/10.23999/j.dtomp.2019.9.2
Stoyanovskyj I. Review of modern approaches in the diagnosis and treatment of necrotizing fasciitis. 2016. In Ukrainian.
Pertea M, Fotea MC, Luca S, et al. Periorbital facial necrotizing fasciitis in adults: A rare severe disease with complex diagnosis and surgical treatment-a new case report and systematic review. J Pers Med. 2023;13(11):1612. https://doi.org/10.3390/jpm13111612
Silverman RF, Hodgson N. Orbital necrotizing fasciitis. N Engl J Med. 2022;386(5):e10. https://doi.org/10.1056/nejmicm2113033
Yazıcı B, Sabur H, Toka F. Periocular necrotizing fasciitis causing posterior orbitopathy and vision loss: How to manage?. Turk J Ophthalmol. 2021;51(3):181-183. https://doi.org/10.4274/tjo.galenos.2021.17364
Звіт про випадок: некротизуючий фасціїт повік та періорбітальної ділянки: досвід з КНП КОР «Київська обласна клінічна лікарні»
Некротизуючий фасціїт (НФ) (синонім: некротичний фасціїт) – надзвичайно тяжкий інфекційний процес, який може призвести до косметичних і функціональних проблем. Характеризується швидко прогресуючою некротизуючою інфекцією поверхневої фасції з вторинним некрозом прилеглої шкіри. Відповідно до систематичного огляду Амріта і колег (2013), періорбітальний НФ призводив до смерті у 8,5% випадків. Загалом рівень смертності від НФ, зазвичай внаслідок мультисистемного шоку, коливається від 12% до 57%. У літературі можна знайти такі синоніми терміну НФ: стрептококова гангрена, госпітальна гангрена, гангренозна бешиха, некротична бешиха, гангрена Фурньє, гнійно-некротичний процес. Метою даної статті є ознайомлення громадськості з досвідом роботи співробітників Комунального неприбуткового закладу Київської обласної ради «Київська обласна клінічної лікарні» щодо лікування НФ повік та періорбітальної ділянки у пацієнта 38 років із представленням результату лікування через один місяць. Підсумовуючи наш досвід лікування НФ, зазначимо, що незважаючи на великі ділянки некрозу шкіри повік, її регенеративні можливості залишаються на надзвичайно високому рівні завдяки існуючій васкуляризації та відповідному комплексному лікуванню.
Некротизуючий фасціїт, гнійно-некротичний процес, повіки, періорбітальна ділянка, шкіра