(25) Necrotizing Fasciitis of the Head and Neck

Abstract: Statement of the problem:
Necrotizing fasciitis of the head and neck is a rare but devastating condition that carries a high morbidity and mortality. Most cases reported in the literature are of odontogenic origin and occur in immunocompromised patients with multiple comorbidities. We present two cases of rapidly progressive necrotizing infection of non-odontogenic etiology.

2. Materials and methods:
Case series illustrating presentation and management of these patients.

3. Methods of data analysis:
Photographic and laboratory evidence illustrating the cases.

4.

Results:
Case 1: A 30-year-old female attended the Emergency Department of another hospital shortly after experiencing nasal trauma. She was assessed clinically and underwent a CT scan, and she was discharged with a final diagnosis of a nasal fracture. Six hours later she returned to the ED with worsening facial swelling and malaise. She was admitted to the ICU and was noted to have discontinuous areas of necrosis in the periorbital areas bilaterally as well as the left neck and chest. These latter regions were debrided prior to transfer to our institution for treatment with hyperbaric oxygen. Microbiological cultures grew Streptococcus pyogenes. After hyperbaric oxygen therapy, she underwent serial debridements in order to gain control of the infection which undermined the entire scalp, upper face, and midface. Despite this, the only significant facial skin necrosis was in the periorbital region. The globes were protected with temporary tarsorrhaphies and infection did not extend into the deep orbit at any stage.

Case 2: A 59-year-old female with type 2 diabetes mellitus, high BMI, and peripheral artery disease attended the Emergency Department of another hospital with a 2-week history of right-sided neck swelling. A CT scan showed gas formation and tissue space collection with no obvious source. The patient was taken to the OR where, via a cervical incision, the infected tissue spaces were drained, and necrotic tissue in a subplatysmal tissue plane was discovered. The patient was admitted to the ICU postoperatively and treated with hyperbaric oxygen therapy and vancomycin, tazobactam-piperacillin, and clindamycin. She grew MSSA and Streptococcus mitis from her blood cultures. Over the ensuing week she underwent serial debridements during which time an area of submandibular skin became necrotic and was debrided. This was ultimately treated with a vacuum dressing.

5. Outcomes data:
Clinical photographs and laboratory data (WCC, CRP, microbiology) showing disease progression and resolution.

6.

Conclusions:
A diagnosis of necrotizing fasciitis mandates aggressive serial debridement to gain control of the infection and prevent death from sepsis. Owing to the excellent vascularity of the head and neck, skin may survive despite wide undermining by necrotic fascial layers. This may allow resection to be relatively more conservative than treatment of equivalent disease in the limbs.

7. References
Davoudian P, Flint NJ. Necrotizing fasciitis. Continuing Education in Anaesthesia, Critical Care & Pain. 2012 Oct 1;12(5):245-50.

Pertea M, Fotea MC, Luca S, Moraru DC, Filip A, Olinici-Temelie D, Lunca S, Carp AC, Grosu OM, Amarandei A, Veliceasa B. Periorbital Facial Necrotizing Fasciitis in Adults: A Rare Severe Disease with Complex Diagnosis and Surgical Treatment – A New Case Report and Systematic Review. Journal of Personalized Medicine. 2023 Nov 16;13(11):1612.