Necrotizing fasciitis and velopharyngeal aplasia by dr.damodhar.m.v

Plastic Surgery

Presented by,

Dr. Damodhar. M.V

Case Report

Case Report - 1

Evaluation Classification Reversible tx Surgery

Plastic

Personal data

Name: Ali Mohammed Yahya Gamre (Fighter)

Age: 67 y/o

Sex: Male

MRN: 27902

Marital status: Married with children

Chief Complaint

Right thigh lateral aspect bed sore, Gangrenous

superficial patch at the tip of his right big toe.

Personal data / past history


Plastic

Past history

Previous cerebellar stroke

Type 2 DM,

Irritable bowel syndrome

Past Surgical history

Case presentation Plastic & Reconstruction surgery

> Clinical examination

> History

> Investigations

> Multidisciplinary approach

> Surgical procedures

Physical examination


Plastic

Physical examination (systemic)

General appearance: Poorly built, Severely malnourished, emaciated

Vital sign: BP:138/64mmHg, PR: 72/min, RR: 22/min, BT:35.2

>

>

> Chest & Lung: percussion: normal; auscultation: wheezing(+), rales(+)

Heart: Regular heart beat, No murmus

Abdomen: Soft, lax,

Extremities: Joint stiffness(+),

CNS: GCS 7, sluggish pupillary reaction.

Local examination

evaluation classification reversible tx surgery

Plastic

Foul smelling, discharging wound extending from the

right hip to back almost up to the lower scapular

region on the right side.. Skin hot and tender up to

the lower scapular region.

Wound



> History

> Investigations



Laboratory investigations


Plastic

Wound culture

Hb: 8.1

Hematocrit- 24.9

Leucocytes: 10.8

D-Dimer-1.7

LDH-335

Blood work up

Radiological Study


Plastic

Conclusion:

-Extensive DVT of the right lower limb as described .

-Soft tissue edema at the right leg

X-ray and Doppler



> History

> Radiologic investigations



Multidisciplinary approach


Plastic

Internal medicine:

Managing Type 2 DM, previous stroke, patient was on ventilator on

and off due to impaired lung function

Surgical:

Insertion of feeding gastrostomy and regular care of gastrostomy

tube.

Plastic Surgery:

Wound debridement and serial debridement's was done at regular

intervals.



> History

> Investigations


> Clinical diagnosis & treatment plan



Plastic clinical diagnosis & treatment plan

Type 2 DM, previous stroke with on

and off respiratory distress

Primary Diagnosis

wide spreading wound over the right hip

and back suggestive of Necrotizing

Fasciitis

Clinical diagnosis and

staging:

Necrotizing fasciitis

Type 2

Secondary Diagnosis


Plastic

To stop the spread of infection:

• Cefotaxime,

• Cefuroxime

• Ciporfloxacin

Surgical Debridement

• Wide excision and through

debridement of wound.

• Regular change of dressing

• Serial debridement's was planned.

Clinical diagnosis & treatment plan



> History

> Investigations


> Clinical diagnosis & treatment plan


Surgical procedures


Plastic

Wound debridement


Necrotizing Fasciitis- Review



Plastic

History

- Hippocrates in the 5th century BC noted it,

known as malignant ulcer, gangrenous ulcer putrid ulcer.

- Was termed as hospital gangrene in the 18th century

- In1871 after the Civil War was called hospital

gangrene by a war surgeon

- In 1924 called hemolytic streptococcal gangrene



Plastic

History

-In 1952 the term “Necrotizing fasciitis” was used.

-It was termed as the “killer bug”, “flesh eating bacteria” by

the media

-1989 toxic shock syndrome and strep A necrotizing fasciitis

reported

-Estimated 10,000-15,000 strep A infections with 5% of

patients developing necrotizing fasciitis



Plastic

Definition & Risk Factors

• Immunosuppression

• Diabetes

• Other chronic disease

• Malnutrition

• Advanced age

• Obesity

• Renal failure

• Malignancy

Fulminant, deep-seated infection with necrosis of fascia and soft-tissue, generally sparing of muscle and possible sparing of the skin

-Hasham S, Matteucci P, Stanley PR, Hart NB. Necrotising fasciitis. BMJ. 2005 Apr 9;330(7495):830-3



Plastic

Clinical Features- Early

-Most frequently involved areas :

1) Extremities

2) Perineum

3) Trunk

-Can advance over hours or days

-Early symptoms

Pain, swelling, induration, fever,

tachycardia

Severe pain out of proportion

with exam



Plastic

Clinical Features- Late

- Tense skin

- Color changes

(red-purple->dusky blue->

black)

-Bullae – initially clear-

hemorrhagic

-Crepitus (only about 10-40%)

-Sepsis / Multiorgan failure



Plastic

Diagnosis

- High index of suspicion, mainly a clinical diagnosis.

- Laboratory investigations:LeucocytosisAcidosisAltered coagulation profileAbnormal renal function

- Plain radiography:Soft tissue gas

- CT or MRI:May delineate extent of diseaseSoft tissue gas

- Incisional exploration or biopsy (can be done at bedside):Tissue culture to identify pathogens and sensitivities

-Hasham S, Matteucci P, Stanley PR, Hart NB. Necrotising fasciitis. BMJ. 2005 Apr 9;330(7495):830-3



Plastic

Management

- Aggressive resuscitation and sepsis managementFrequently multi-organ failure (esp. ARF or ARDS)

Broad IV antibioticsGram positive, gram negative and anaerobic coverage

clindamycin - inhibiting streptococcal toxin production

Vancomycin- if MRSA concerns

Continue IV antibiotics until debridement's complete

-Anaya D, Dellinger EP. Necrotizing soft-tissue infection: diagnosis and management. -Clinical Infect Dis. 2007 Mar 1;44(5):705-10



Plastic

Surgical Management

-Early and aggressive debridement important

-Surgery may also be needed for diagnosis

-Serial debridement's until no further necrosis or infection is seen

-Beware of hemorrhage (DIC common)

-Reconstructive surgery once fully stabilized and infection eliminated

-Anaya D, Dellinger EP. Necrotizing soft-tissue infection: diagnosis and management. -Clinical Infect Dis. 2007 Mar 1;44(5):705-10



Plastic

Mortality

• Type I: 20%, *

• Type II: 30-35%*

• Admission to surgery time > 24 hr independent predictor of mortality after controlling for age, sex, DM, and Hypotension*

• Amputation does not affect mortality

• Cervical necrotizing fasciitis: ~20%

• Fournier's gangrene: ~20-40%

*Wong CH, Chang HC, Pasupathy S, et al. J Bone Joint Surg Am 2003; 85:1454-1460

Case Report – 2 A Very Rare Case Velopharyngeal

Incompetence


Plastic

Personal data

Name: Muqbel Al Mutairi

Age: 6y/o

Sex: Male

MRN: 27279

Chief Complaint

Defective speech, nasal emmision with regurgitation

of food.

Left side unilateral soft palate aplasia.

Velopharyngeal Insufficiency


Plastic

• He is the only son of a 30-year-old father and 23-year-old mother

with 2nd degree consanguinity. The family history was normal.

• He was assessed by speech and language by ENT specialists in our

hospital.

• Severe consistent hypernasality, consistent nasal emission, cleft-type

misarticulations and nasal grimace were observed.

• Physical examination:

Revealed that the left side of her velum appeared shorter

tonsillar pillar was absent on the left side Nasal

endoscopic examination was done

Velopharyngeal Insufficiency


Plastic

It is hard to explain this rare condition’s

pathogenesis,

but it may occur in three ways:

• The first theory is an atypical cleft case.

• The second theory is that this condition could

occur as a part of branchial arch syndrome.

However, there were no data to support this

theory.

• The last theory involves vasculature during

embryogenesis. A pathology (such as

torsion, occlusion, etc.) in the ascending palatine

artery during embryogenesis would cause this

situation.

The Cleft Palate-Craniofacial Journal 49(4) pp. 494–497 July 2012

’ Copyright 2012 American Cleft Palate-Craniofacial Association

Figen O¨ zgu¨ r, M.D., Haldun Onuralp Kamburog˘ lu, M.D., F.E.B.O.P.R.A.S.

Asymmetric

Plastic & Reconstructive Surgery Plastic

Plastic Surgery Team

Thank you,

Dr.Damodhar.M.V

Necrotizing fasciitis and velopharyngeal aplasia by dr.damodhar.m.v

Healthcare

plastic surgerypresented

right hip

right lower limb

wound debridement

debridement of wound

right leg xray

right big toe

regular intervals