[SavageGlow]

Source. This case is out of Maharashtra, India:

A 43-year-old man presented with a tender neck and chest swelling, dyspnoea, fever and chest pain on inspiration preceded by toothache of 1 month duration. He stated that about 1 week earlier, his right jaw began to swell with associated tenderness and erythema. He denied history of drug abuse (except alcohol), diabetes mellitus or dental extraction. The patient has mild respiratory distress, no stridor or wheezing. The head and neck examinations were remarkable for tender, erythematous, crepitant swelling over the neck extending from the right submandibular region. There was sloughing of epidermis tissue over the involved area with no fistula or drainage noted. The examination of the oral cavity was remarkable for a foul, putrid odour with multiple carious teeth and mild trismus. There was a grossly carious right second mandibular molar with purulence at the gingival border. Chest radiograph revealed no mediastinal widening or infiltration.

The blood picture is normal apart from elevated leucocyte count. CT scan showed multiple air-filled and pus-filled pockets in the neck and there is no involvement of mediastinum.

The culture revealed predominance of aerobic and anaerobic streptococci and staphylococci along with Gram-negative species. Gentamycin was added to the existing regimen.

The patient was taken for surgery for incision and drainage of the submandibular region and submental region. Grey, foul-smelling, necrotic fascia and brown-grey, dishwater-coloured fluid were found. After removal of apparent necrotic tissue, high-pressure irrigation was used throughout the surgical site. The patient was started on ampicillin/sulbactam 3 gm and metronidazole 500 mg, intravenously every 8 h. Postoperatively, the patient developed an area of necrosis of overlying skin and was scheduled to return to the operating department after 3 days for further debridement (figure 1). Postoperative hyperbaric oxygen therapy (HBO) was started twice daily, lasting 1.5 h at 2.5 atmospheres for 7 days.

The general condition of the patient improved after commencement of HBO therapy and the resultant well-granulated wound (figure 2) is covered by split skin graft.

[kellyhound]

Grey, foul-smelling, necrotic fascia and brown-grey, dishwater-coloured fluid were found.

eeeew

[Pyramid_Head]

I can't imagine how painful and uncomfortable that must have been.