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Chapter 39

Noma (Cancrum Oris)

This terribly mutilating condition, characterized by extensive gangrene of the cheek and adjacent tissues in poorly nourished infants and children, is little known to American and European physicians. Yet it is an affliction that was known to such ancient physicians as Hippocrates and Galen, and in 1617 the following highly accurate description of the condition was penned by a Chinese surgeon of the Ming Dynasty: "Dzo-ma-ga (running horse gangrene) is a disease that spreads very rapidly. No time should be wasted by the physician. It usually occurs after measles, smallpox, or other exanthematous diseases. At the beginning of the disease, foul black gangrene appears next to the teeth. Then the dead tissues fall away and expose the underlying roots. A few days later, the cheek may be perforated, the lip necrosed."

Today, cancrum oris (or noma, from the Greek word meaning "to devour") is a problem in tropical Africa and many other parts of the tropics, not because of any increase in its frequency, but rather because many children who would previously have died of their infection now survive with antibiotic treatment. However, the resulting grotesque facial defects, with complete exposure of the underlying mandible and/or maxilla, are impossible to correct without extensive plastic surgery, a luxury unavailable in many tropical countries where noma occurs. This mutilating condition affects primarily young children (in classical noma, 80% of patients are 2 to 6 years old), but neonates and adults can also suffer the facial ravages of noma. The availability of intravenous antibiotics in most developing countries has reduced the death rate for children and adults to less than 10%, but neonatal noma still has a high mortality.

Synonyms

Noma. Cancrum oris. Gangrenous stomatitis. Necrotizing ulcerogingivostomatitis. Infective gangrene of the mouth. Water cancer. Sp: Estomatitis gangrenosa. Fr: Stomatite gangréneuse. Ger: Stomatitis gangrenosa: noma.

Definition

Noma is an acute, rapidly progressive, gangrenous, ulcerative process beginning in the mouth and extending to the soft tissues of the lips, nose and cheek. The underlying bones of the alveolar ridge of the mandible, the maxilla, palate, and occasionally the orbit may be exposed, but the soft tissue destruction is greater, often extending to the tonsils and area of the temporomandibular joint.

Noma occurs predominantly in undernourished children, usually as a complication of an acute viral infection, especially measles. It is a destructive and mutilating condition, which may rarely involve other sites, including the scalp, ear, or eyelid. Once the sloughing tissue has separated, healing of the ulcerated areas is rapid, but terrible soft tissue defects remain, and trismus and difficulty in eating, drinking, and retaining saliva result from the ensuing extensive fibrosis.

Geographic Distribution

Currently, noma is encountered most often in Africa, Asia, Southeast Asia and South America. It is rare in North America and Western Europe. Neonatal noma is more common in the Western world than the childhood and adult types.

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