NOMA (noma; grech, nome ulcer, spread of an ulcer; synonym water cancer) — the peculiar form of the extending wet gangrene arising, as a rule, at sharp weakening of protective forces of an organism. Children aged from 2 up to 15 years after heavy inf get sick. diseases (diphtheria, measles, dysentery, etc.); and at adult N. occurs at children of chest age extremely seldom. Separate cases of N. are usually observed, however at sharp deterioration in living conditions the number of diseases increases.
More often process is localized on a face, in some cases generative organs, area of an anus are surprised, the neck, auricles is more rare.
The etiology and a pathogeny
the Aetiology and a pathogeny are not found out. N.'s emergence is connected by hl. obr. with sharp decrease in body resistance and acquisition in this regard saprophytic flora of an organism of pathogenic properties. Nek-ry researchers on the basis of kliniko-experimental data noted that the large role in N.'s development is played by Clostridium perfringens, however in nekrotizirovanny fabrics at N. also large number of other various microorganisms (spirochetes, cocci, fungi, anaerobic bacteria) is found and therefore to allocate any one etiol, the factor does not work well. As a rule, there is an association of fuzospirokhetny flora, edge, being saprophytic, gains at N. pathogenic properties, as well as at Simanovsky's quinsy — Plauta — Vincent (see. Quinsy ). N.'s emergence is promoted also by the avitaminosis which is often observed at the exhausted and weakened patients.
At morfol, a research find a picture of wet gangrenes (see), localized most often in cheeks. The amount of defeat is usually limited to bottom edge of an eye-socket, a nose, a chin, a submaxillary pole, temporal area. In atypical cases necrotic changes extend to a neck, soft tissues of the head, eyelids, eyebrows. Defeat is always more expressed from an oral cavity, the sphacelism takes bones, teeth, muscles. Macroscopic changes depend on a stage of process: in the beginning there is a mucous membrane ulcer, usually on edge of a jaw in molars, then there is a face edema, fabrics are strained. Further on site hypostasis there is a scab in the form of «slip», to-ry then is torn away. At the same time the struck fabrics have an appearance of ragged mass of black-green color with off-flavor, sequesters with the subsequent their mutilation can be formed. If the line of demarcation forms and there comes sloughing, then at recovery massive hems, cicatricial contractures are formed, and also there are extensive defects of fabrics difficult for recovery.
At N. of a vagina or crotches are observed the similar phenomena. Big vulvar lips, a hymen, sometimes the walls of a vagina and fabric surrounding an anal orifice collapse.
At microscopic examination in the struck fabrics the amorphous mass of a detritis is visible, among to-rykh crystals fat to - t, hemosiderin, colonies of various microorganisms often meet. In experimental conditions on laboratory animals in a stage of hypostasis of a noma observe thrombosis of capillaries with existence of cell-bound immune complexes in their endothelium, the expressed hypostasis of fabrics, infiltration by lymphoid and histiocytic elements.
N. is especially characteristic proceeds on a face. The disease is often preceded by ulcer and necrotic stomatitis or an ulitis. On a mucous membrane in a corner of a mouth the bubble with muddy or hemorrhagic contents, and then a small dark blue necrotic spot appears. In 1 — 3 day process begins to extend quickly and passes to skin, cheeks, lips and the subject fabrics; there is various degree a puffiness of all person. Around the center skin gets pale wax coloring with a nacreous shade (a wax-like zone), on the periphery skin becomes shining, vitreous (vitreous hypostasis). At a palpation in the field of hypostasis on skin there are fingerprints. The peristatic hyperemia is absent. Further the wax-like zone is exposed to necrosis, process occupies big sites fabrics (fig.). Devitalized fabrics exude a pungent putrefactive smell. After removal nekrotizirovavshikhsya fabrics from walls of a wound liquid is emitted muddy, with a putrefactive smell, bleeding is almost always absent. Course of process long. At successful treatment and a favorable outcome on border of the struck and normal fabrics signs of a dermahemia appear. After rejection of nekrotizirovanny fabrics there is bleeding, granulations are formed and the wound is gradually cleared. However process of clarification of a wound proceeds slowly, the died on the spot fabrics big defects, in the subsequent the dense and deeply located hems, to-rye, in addition to a disfiguration are formed, deprive of the patient of an opportunity to eat normally. Jaws sometimes are close as a result of a contracture. In especially hard cases process takes lips, all cheek, Nov, the chin, is bared a bone.
At defeat of generative organs (noma pudendi), hl. obr. at girls, process also begins with emergence on a mucous membrane of vulvar lips of a small bubble with muddy contents, proceeds similar to process on a face and can extend to a crotch and a pubis.
Process proceeds without serious consequences. General serious condition; patients are sleepy, consciousness is sometimes darkened, euphoria is less often observed. Body temperature keeps within 38 — 39 °. Pulse is speeded up. The quantity of leukocytes is very variable, however the leukopenia is more often observed. The deviation to the left, lack of eosinophilic granulocytes is noted. ROE accelerated to 70 mm an hour. In urine of squirrels and hyaline cylinders.
Diagnosis does not represent difficulties; the initial stage of a disease can remain unnoticed only with small children. It is necessary to distinguish N. from so-called nomopodobny processes in the form of a necrosis of soft tissues of an oral cavity, and sometimes and skin of circumoral area at an agranulocytosis and heavy cardiovascular frustration at adults, to-rye demonstrate extremely heavy disease. At differential diagnosis it is necessary to consider that nomopodobny processes are not followed by a vitreous cutaneous dropsy on the periphery.
Treatment shall be directed to increase in body resistance and suppression of pathogenic microflora. High-calorific food, polyvitamins, hemotransfusion (50 — 100 ml) is shown. Infiltration of fabrics in a circle of defeat of 1% by solution of novocaine in combination with antibiotics of a broad spectrum of activity is recommended, at the same time antibiotics enter intramusculary. And intravenously enter antigangrenous serum into a circle of the struck center. The wound is closed a bandage with antibiotics or with an antiseptic agent (potassium permanganate, Furacilin, cuprous sulfate). It is reasonable to apply interdental struts to prevention of contractures. After a wound repair make plastic surgeries.
At an adverse current of the patient can die in 2 — 3 weeks from heavy intoxication, sepsis, sometimes aspiration pneumonia. Till an era of antibiotics of Nome often came to an end letalno (to 75%). With the advent of sulfanamide drugs and antibiotics the lethality sharply decreased.
Hygienic care of children and careful sanitation of an oral cavity of patients inf. diseases: good nutrition, vitamin-rich.
Bibliography: Vernadsky Yu. I. Fundamentals of surgical stomatology, page 236, Kiev, 1970; Gavrilov E. I. Ulcer and necrotic stomatitises at patients with disturbance of blood circulation, the Doctor business, No. 6, page 645, 1959; M. D. Neskolko's Oaks of observations of a noma at adults, Stomatology, No. 4, page 53, 1966; Evdokimov A. I. and Vasilyev G. A. Surgical stomatology, page 213, M., 1964; Hansen D. A. Cancrum oris’ S. Afr. med. J., v. 46, p. 392, 1972; S i-rol J., Vedy J. et Sabrie A. Le noma ou la laideur oubliee, Ann. Derm. Syph. (Paris), t. 99, p. 511, 1972.
V. I. Zausayev; T. H. Thrush (stalemate. An.).