A Dental Abscess Gone Bad: An Atypical Diagnostic Dilemma
Dr Saba Iqbal, Dr Raluca Ene and Dr Venkat Sundaram. Glan Clwyd Hospital, Wales, United Kingdom.
We present an unusual case of facial necrotising fasciitis, with cranial nerve involvement at presentation. This poster follows the history of this case and explores diagnosis of death using neurological criteria in patients with facial and neurological deficits.
A 51 year old man, with a background history of hypertension, developed a maxillary dental abscess. 14 days later, he presented to the emergency department with pyrexia associated with right sided facial swelling and droop. He was found to have sepsis, right vocal cord palsy and right facial nerve palsy.
Day 0 Right-sided dental abscess.
Day 14 Presentation to A&E with sepsis and necrotising fasciitis.
Day 14 Emergency exploration.
Extensive necrosis in the retropharyngeal and parapharyngeal submandibular spaces as well as: muscles of mastication, orbicularis oculi, frontalis muscle, parotid gland and the facial nerve. These were excised.
Day 15 Right pupil efferent defect was investigated with a CT and MRI scan, which showed right temporal and cerebellar infarcts.
Day 15 Surgical re-exploration. Extension of necrosis. Further debridement and removal of infratemporal fossa contents.
Day 17 Patient developed signs of diabetes insipidus and on suspicion of cavernous venous sinus thrombosis, he was anticoagulated.
Day 18 Pupils fixed and dilated. Repeat CT head revealed extensive: subarachnoid haemorrhage, temporal and cerebellar infarcts and worsening evidence of necrotising fasciitis.
Day 18 Is brainstem death present?
Concerns about Brainstem Death Testing
In this case, there was evidence of cranial nerve involvement from the outset, with involvement of further structures during the course of the illness. There was, therefore, uncertainty about validity of brainstem death testing.
After local discussion, a unanimous decision was made to withdraw care without brainstem death testing. The patient was, incidentally, deemed unsuitable for organ donation.
Brainstem death testing can be complicated in scenarios where there is extensive facial trauma or cranial nerve deficit. Although there are no explicit guidelines in these instances, inability to reliably perform all tests on one side of the face need not be an impediment.
In cases where there is doubt, or bilateral involvement, ancillary tests such as cerebral angiography or electrophysiological tests, may be utilised 2. These may assist by reducing uncertainty, though they each have limitations and attract their own rates of false positive and false negative results.
It is possible to reliably perform brainstem death testing in the presence of facial injuries or cranial nerve deficits, provided all other stipulated conditions are met. Most importantly, the diagnosis of death needs to be safe. The built-in mechanism of using two experienced doctors for performing brainstem death testing should go some way towards addressing uncertainty.
Ultimately, diagnosing death by neurological criteria should be a clinical decision, based upon the circumstances and clinician comfort.
We thank the patient’s family for their assent for presentation and publication of this case.