why Dr. Aaron and his colleagues elected to introduce a new term when "autotransfusion" is clearer semantically and has also been a part of the literature to date. DAVID H. BARNHOUSE, MD to
Pittsburgh
of "allotransfusion" instead of "autotransfusion" got by the authors, the editors, and the editorialist is inexplicable.\p=m-\ d. Drs. Lamm and Barnhouse are,
course, correct. How the term
Necrotizing Fasciitis Complicating Dental
Extraction
To the Editor.\p=m-\Werecently treated a case of necrotizing fasciitis of the neck following removal of a tooth that emphasizes the role of aggressive surgical treatment in this entity.
Report of
a
Case.\p=m-\A51-year-old
nondiabetic man underwent extraction of a noninfected right upper second molar. Two days later he had marked facial swelling with a temperature of 40.6 C (105 F). Abscesses of the right temporal, buccal, submandibular, submental, and parapharyngeal spaces were drained.
Beta-hemolytic streptococci
grew
from the cultures. Intravenous administration of penicillin was started, and he improved for 48 hours. He then spiked to 39.4 C (103 F) and rapidly developed severe swelling inferiorly to the clavicles. Brawny, noncrepitant induration extending to the nipples appeared within three hours. Roentgenograms showed a widened superior mediastinum and gas in the
retropharyngeal
space. A low transverse cervical incision was made, superior and inferior flaps created, and the deep cervical fascia widely exposed. The cervical fascia was necrotic; dark brown, foul-smell¬ ing fluid was present without frank pus. Each compartment of the deep cervical fascia was opened and de¬ brided, including the retropharyngeal-prevertebral space, but care was taken to preserve the carotid sheath. The retrosternal space was drained of 200 ml of foul-smelling fluid, and the mediastinal fascia bluntly dissected to allow adequate drainage. Postoperatively, the fas¬ ciitis did not spread; the induration of the chest wall cleared rapidly, and the patient recovered. Early complete surgical debride¬ ment with removal of all necrotic nonviable tissue is the primary treat-
ment of
necrotizing fasciitis.1 In the neck, all compartments must be widely opened, while leaving the ca¬
rotid sheath intact as an added pro¬ tection to the carotid artery. Failure to control the necrotizing process early generally leads to a fatal out¬ come. Crowson recently described a similar patient with fasciitis of the neck following tooth removal who died in spite of vigorous debride¬ ment.- Knowledge of this clinical en¬ tity and its proper management is es¬ sential to the surgeon who may be consulted to help treat such a compli¬ cation. J. DAVID RICHARDSON, MD GERALD L. Fox, DDS FREDERICK L. GROVER, MD ANATOLIO B. CRUZ, JR., MD, MS San Antonio, Tex 1. Andrews EC, Cruz AB Jr: Necrotizing fasciitis: Diagnosis and treatment. Tex Med 65:50-55, 1969. 2. Crowson WN: Fatal necrotizing fasciitis developing after tooth extraction. Am Surg 39:525-527, 1973.
above down, manually milking stones from the neck of the gallbladder into the fundus, followed by the appli¬ cation of a clamp across the neck. A needle is easily introduced at this point for the injection of the radio¬ paque media. Third, and probably of greatest im¬ portance, is a point emphasized by
Philip Partington of Cleveland as a safety measure in those patients in whom the regional anatomy is ob¬ scured by disease. A cholangiogram obtained early in the course of the dissection usually by means of a needle in the gallbladder, will clarify the anatomical obscurities. It will also demonstrate anomalies of the ductal system when they are present. Those surgeons who have not previously uti¬ lized cholangiography at an early time during difficult dissections will find it extremely helpful. The patient who unknowingly escapes injury to his ducts will, of course, derive the greatest benefit.
CHARLES ECKERT, MD
Albany, NY
Operative Cholangiography To the Editor.\p=m-\Thearticle on "Operative Cholangiography" by Sachatello and Griffen (Arch Surg 109:454, 1974) brought to mind a few comments on the subject that may be appropriate. Most of these points have been made by others, but they still will benefit by the emphasis of repetition. First, if operative cholangiography is to be of greatest usefulness it should be used in all cases, not in just those patients with anatomical findings suggesting choledochal disease or pancreatitis. Reliance on the usual clinical criteria for exploration of the common duct has long since been discredited as inadequate for maximal clearance of calculi from the extrahepatic biliary tree. The accuracy of this statement is attested to by the many articles on retained stones that have been published. Furthermore, when roentgenograms are obtained on an occasional basis, they will frequently suffer from technical inadequacies. Needless to say, optimum results from roentgenograms of any sort require technical excellence. Second, in patients with very small ducts the technique that I have seen Crile use provides satisfactory visual¬ ization without risk of injury or other technical misadventure. This consists of mobilizing the gallbladder from
Consultants We wish to acknowledge with preciation the valued services of
ap¬ our
consultants in the year October 1973 through October 1974.-Eds.
Herbert L. Abrams Murray F. Brennan John F. Burke Bradford Cannon John T. Chaffey Theodore L. Colton J. Englebert Dunphy M. Michael Eisenberg Angelo J. Eraklis Robert M. Filler Edwin G. Fischer Howard A. Frank Cushman D. Haagensen B. Leonard Holman Michael Hume Ruth B. Kundsin Simeon Locke William V. McDermott, Jr. William A. Meissner Harry Z. Mellins Francis D. Moore Alfred P. Morgan Leonard F. Peltier
Stephen C. Schoenbaum Francis J. Scholz Paul A. Sugerbaker . Richard Tyler
Downloaded From: http://archsurg.jamanetwork.com/ by a University of California - San Diego User on 06/08/2015
Pittsburgh
of "allotransfusion" instead of "autotransfusion" got by the authors, the editors, and the editorialist is inexplicable.\p=m-\ d. Drs. Lamm and Barnhouse are,
course, correct. How the term
Necrotizing Fasciitis Complicating Dental
Extraction
To the Editor.\p=m-\Werecently treated a case of necrotizing fasciitis of the neck following removal of a tooth that emphasizes the role of aggressive surgical treatment in this entity.
Report of
a
Case.\p=m-\A51-year-old
nondiabetic man underwent extraction of a noninfected right upper second molar. Two days later he had marked facial swelling with a temperature of 40.6 C (105 F). Abscesses of the right temporal, buccal, submandibular, submental, and parapharyngeal spaces were drained.
Beta-hemolytic streptococci
grew
from the cultures. Intravenous administration of penicillin was started, and he improved for 48 hours. He then spiked to 39.4 C (103 F) and rapidly developed severe swelling inferiorly to the clavicles. Brawny, noncrepitant induration extending to the nipples appeared within three hours. Roentgenograms showed a widened superior mediastinum and gas in the
retropharyngeal
space. A low transverse cervical incision was made, superior and inferior flaps created, and the deep cervical fascia widely exposed. The cervical fascia was necrotic; dark brown, foul-smell¬ ing fluid was present without frank pus. Each compartment of the deep cervical fascia was opened and de¬ brided, including the retropharyngeal-prevertebral space, but care was taken to preserve the carotid sheath. The retrosternal space was drained of 200 ml of foul-smelling fluid, and the mediastinal fascia bluntly dissected to allow adequate drainage. Postoperatively, the fas¬ ciitis did not spread; the induration of the chest wall cleared rapidly, and the patient recovered. Early complete surgical debride¬ ment with removal of all necrotic nonviable tissue is the primary treat-
ment of
necrotizing fasciitis.1 In the neck, all compartments must be widely opened, while leaving the ca¬
rotid sheath intact as an added pro¬ tection to the carotid artery. Failure to control the necrotizing process early generally leads to a fatal out¬ come. Crowson recently described a similar patient with fasciitis of the neck following tooth removal who died in spite of vigorous debride¬ ment.- Knowledge of this clinical en¬ tity and its proper management is es¬ sential to the surgeon who may be consulted to help treat such a compli¬ cation. J. DAVID RICHARDSON, MD GERALD L. Fox, DDS FREDERICK L. GROVER, MD ANATOLIO B. CRUZ, JR., MD, MS San Antonio, Tex 1. Andrews EC, Cruz AB Jr: Necrotizing fasciitis: Diagnosis and treatment. Tex Med 65:50-55, 1969. 2. Crowson WN: Fatal necrotizing fasciitis developing after tooth extraction. Am Surg 39:525-527, 1973.
above down, manually milking stones from the neck of the gallbladder into the fundus, followed by the appli¬ cation of a clamp across the neck. A needle is easily introduced at this point for the injection of the radio¬ paque media. Third, and probably of greatest im¬ portance, is a point emphasized by
Philip Partington of Cleveland as a safety measure in those patients in whom the regional anatomy is ob¬ scured by disease. A cholangiogram obtained early in the course of the dissection usually by means of a needle in the gallbladder, will clarify the anatomical obscurities. It will also demonstrate anomalies of the ductal system when they are present. Those surgeons who have not previously uti¬ lized cholangiography at an early time during difficult dissections will find it extremely helpful. The patient who unknowingly escapes injury to his ducts will, of course, derive the greatest benefit.
CHARLES ECKERT, MD
Albany, NY
Operative Cholangiography To the Editor.\p=m-\Thearticle on "Operative Cholangiography" by Sachatello and Griffen (Arch Surg 109:454, 1974) brought to mind a few comments on the subject that may be appropriate. Most of these points have been made by others, but they still will benefit by the emphasis of repetition. First, if operative cholangiography is to be of greatest usefulness it should be used in all cases, not in just those patients with anatomical findings suggesting choledochal disease or pancreatitis. Reliance on the usual clinical criteria for exploration of the common duct has long since been discredited as inadequate for maximal clearance of calculi from the extrahepatic biliary tree. The accuracy of this statement is attested to by the many articles on retained stones that have been published. Furthermore, when roentgenograms are obtained on an occasional basis, they will frequently suffer from technical inadequacies. Needless to say, optimum results from roentgenograms of any sort require technical excellence. Second, in patients with very small ducts the technique that I have seen Crile use provides satisfactory visual¬ ization without risk of injury or other technical misadventure. This consists of mobilizing the gallbladder from
Consultants We wish to acknowledge with preciation the valued services of
ap¬ our
consultants in the year October 1973 through October 1974.-Eds.
Herbert L. Abrams Murray F. Brennan John F. Burke Bradford Cannon John T. Chaffey Theodore L. Colton J. Englebert Dunphy M. Michael Eisenberg Angelo J. Eraklis Robert M. Filler Edwin G. Fischer Howard A. Frank Cushman D. Haagensen B. Leonard Holman Michael Hume Ruth B. Kundsin Simeon Locke William V. McDermott, Jr. William A. Meissner Harry Z. Mellins Francis D. Moore Alfred P. Morgan Leonard F. Peltier
Stephen C. Schoenbaum Francis J. Scholz Paul A. Sugerbaker . Richard Tyler
Downloaded From: http://archsurg.jamanetwork.com/ by a University of California - San Diego User on 06/08/2015
