title: A recent case of periorbital necrotizing fasciitis--presentation to definitive reconstruction within an in-theater combat hospital setting.
abstract: First described in 1924, necrotizing fasciitis (NF) is a rapidly progressing, severe suppurative infection of the superficial fascia, often associated with vascular thrombosis and necrosis of the overlying skin. Despite advances in medical therapy, the mortality remains high, with rates exceeding 25 to 50% in some studies. Early diagnosis and treatment is paramount in the management of this serious infection and should include wide surgical debridement and drainage of all necrotic tissues, coupled with aggressive parenteral antibiotics. This infectious process has been commonly associated with traumatic events in patients with compromised immune systems, diabetes, chronic steroid use, and alcoholism. The common microbacterial organisms associated with necrotizing fasciitis include Streptococcus pyogenes and Staphylococcus aureus and less commonly, facultative and anaerobic microorganisms. Most cases typically present in the extremities, trunk, and/or groin regions. Although this virulent soft tissue infection can occur within the face and neck areas, cases of isolated periorbital NF have been relatively uncommon. However, head and neck cases of NF have had high associated morbidity and mortality rates. In recent publications, the reported mortality rate for isolated periorbital NF was not insignificant, ranging from 8.5 to 12.5%. The prognosis, morbidity, and mortality rates will be greatly increased in those patients who present late in the infectious phase, have a delay in diagnosis and/or treatment, or who demonstrate extension of this virulent infection into the face, cervical, or sternal/mediastinal regions. An aggressive multimodal approach is required in treating periorbital necrotizing infection, with the main tenant remaining wide and adequate surgical debridement of affected tissues. This difficult clinical situation can create a subsequent challenge with respect to achieving good functional and cosmetic outcomes in those patients with periorbital NF. Delayed reconstruction of the eyelids with skin grafts and/or facial flaps is often required to avoid late complications such as cicatricial lid retraction, lid malposition, exposure keratopathy, and potential loss of vision. We describe a patient who presented to a military combat hospital with a virulent periorbital soft tissue infection. We have outlined his treatment course from the initial presentation through definitive reconstruction.
authors.affiliation: Department of Trauma and General Surgery, Role III Multinational Medical Unit, Kandahar, Afghanistan, Department of General Surgery, Naval Medical Center, San Diego, San Diego, CA, Assistant Professor, The Uniformed Services University of the Health Sciences, Bethesda, MD.
authors.forename: Kevin
authors.initials: K
authors.lastname: Casey
authors.affiliation: Resident, Department of Oral and Maxillofacial Surgery, Walter Reed National Military Medical Center, Bethesda, MD.
authors.forename: Peter
authors.initials: P
authors.lastname: Cudjoe
authors.affiliation: Chief Resident, Department of Oral and Maxillofacial Surgery, Walter Reed National Military Medical Center, Bethesda, MD.
authors.forename: J Marshall
authors.initials: JM
authors.lastname: Green
authors.affiliation: Department Head, Department of Trauma and General Surgery, Role III Multinational Medical Unit, Kandahar, Afghanistan, Plastic and Reconstructive Surgery Service, Walter Reed National Military Medical Center, Bethesda, MD, Adjunct Assistant Professor, University of Pittsburgh Medical Center, Pittsburgh, PA, Adjunct Assistant Professor, the Johns Hopkins University School of Medicine, Baltimore, MD, Assistant Professor, The Uniformed Services University of the Health Sciences, Bethesda, MD. Electronic address: ian.l.valerio.mil@health.mil.
authors.forename: Ian L
authors.initials: IL
authors.lastname: Valerio
mesh_terms: D055826:Afghan Campaign 2001-; D000346:Afghanistan; D003646:Debridement; D019115:Fasciitis, Necrotizing / Q000601:surgery*; D006772:Hospitals, Military / Q000458:organization & administration*; D006801:Humans; D008297:Male; D008875:Middle Aged; D009873:Operating Rooms / Q000458:organization & administration*; D009915:Orbit / Q000473:pathology*; D016038:Skin Transplantation