颈部坏死性筋膜炎伴下行性坏死性纵隔炎的临床特征、诊断及治疗

Clinical characteristics,diagnosis and treatment of cervical necrotizing fasciitis combined with descending necrotizing mediastinitis

目的总结颈部坏死性筋膜炎(CNF)伴下行性坏死性纵隔炎(DNM)的临床特征、诊断和治疗方法。方法回顾性分析2015年1月—2020年5月昆明医科大学第二附属医院收治的6例CNF伴DNM患者的病历资料。结果6例均早期行颈部清创引流,其中2例行胸腔镜纵隔切开引流术,1例行胸壁清创术;5例患者因气管压迫引起呼吸困难行气管切开。术后根据药敏试验结果调整使用抗菌药物,继续抗感染、营养支持,积极治疗基础疾病,每日冲洗伤口,加强换药,2例术后分别再清创1次及4次。6例患者病程中均有发热,并出现颈胸部症状,进展迅速,感染指标降钙素原(PCT)及C反应蛋白(CRP)均较高,颈胸部CT可见颈部多发蜂窝状积气影(“气泡征”),并延伸至纵隔。3例治愈,3例死亡。治愈病例随访1~4年未见复发。结论颈胸部CT“气泡征”是早期诊断CNF伴DNM的“金标准”,救治关键在于早期诊断及尽早手术清创引流。

Objective To summarize the clinical features,diagnosis and treatment methods of cervical necrotizing fasciitis(CNF)combined with descending necrotizing mediastinitis(DNM).Methods Medical records of 6 patients with CNF combined with DNM and treated in the Second Affiliated Hospital of Kunming Medical University from January 2015 to May 2020 were analyzed retrospectively.Results Six patients all underwent neck debridement and drainage in the early stage,2 of whom underwent thoracoscopic mediastinal incision and drainage,1 underwent chest wall debridement,and 5 underwent tracheotomy due to dyspnea caused by tracheal compression.After operation,antimicrobial use was adjusted according to antimicrobial susceptibility testing results,patients continued anti-infection and nutritional support,actively treated underlying diseases,rinsed the wound every day,strengthened dressing change,and performed debridement once and 4 times in 2 cases respectively.All 6 patients had fever,as well as symptoms of neck and chest during disease course,which progressed rapidly.Infection indicator procalcitonin(PCT)and C-reactive protein(CRP)were both high,multiple honeycomb pneumatosis(“bubble sign”)in the neck was found through neck thoracic CT,and extended to the mediastinum.3 cases were cured and 3 cases died.The cured cases were followed up for 1-4 years and recurrence was not found.Conclusion The“bubble sign”showed by neck and chest CT is the“gold standard”for early diagnosis of CNF combined with DNM,the key to cure the disease lies in early diagnosis,timely surgical debridement and drainage.