(cancrum oris)

Facial  gangrenous (ulcero-necrotic) stomatitis of intra-oral origin.

Malnutrition is the favouring factor of this infection: so it is a disease of the poor countries of Africa, Asia and South America. At present, the main site is in the perisaharian zone of Africa from Mauritania to Ethiopia. The majority of cases are 2 to 6 years of age at the time of acute infection. In addition to malnutrition, other favouring factors are: intercurrent infection (malaria, herpes, measles) and poor oral hygiene causing small mucosal lesions. The initial pathogenic germs are commensals of the oral flora (especially Fusobacterium necrophorum, Fusobacterium nucleatum, Borrelia vincentii) but early bacterial superinfection is the rule.

Clinical picture:

-        acute phase: a small intra-oral lesion that evolves into a blister, then deep ulcer which extends to surrounding tissues and bone structures; necrosis appears in ten days. 80 % of mortality by infectious complications during the acute phase.

-        chronic phase:  the scarring process can result in fibrosis and cords, with contractures and especially a permanent trismus associated with ankylosis or intermaxillary bone fusion.

Treatment:

-        acute phase: amoxicilline + metronidazole as well as fluids, electrolytes and proteins intake

-        initial surgery: resection of necrotic soft tissues

-        reconstructive surgery: according to the location and extension of the lesions.

Anesthetic implications:

difficult intubation (fibroscopy through the cutaneomucous defect) due to the acquired deformities of the face and permanent trismus; usually, presence of oropharyngeal secretions: atropine if ketamine is used.

References : 

-         Servant J-M, Chaussard M, Revol M, Foussadier F. 
Chirurgie du Noma en Afrique, 
in « Les plaies de l’enfant » R Vanwijck & L Forest-Lalande, Sauramps Médical, 2009,  p 171-199.

-         Tassonyi E, Lehmann C, Gunning K, Coquoz E, Montandon D. 
Fiberoptically-guided intubation in children with gangrenous stomatitis (Noma). 
Anesthesiology 1990; 73: 348-9.

-         Eipe N, Neuhoeffer E-S, La Rosée G, Choudhrie R, Samman N, Kreusch T. 
Submental intubation for cancrum oris : a case report. 
Pediatr Anesth 2005; 15: 1009-12.

-         Coupe MH, Johnson D, Seigne P, Hamlin B. 
Airway management in reconstructive surgery for Noma (cancrum oris). 
Anesth Analg 2013; 117: 211-8. 

-        Sund GC, Muvunyi P, Harling MJ.
Airway management through a facial defect resulting from Noma (orofacial gangrene) : a case report.
A&A Practice 2020 ; 14 :e01319

Updated: February 2021