Necrotizing fasciitis of the neck.

Necrotizing fasciitis of the neck is a rare, life-threatening bacterial infection, often odontogenic in origin. (1,2) It spreads rapidly along the fascial planes and causes extensive tissue necrosis that can lead to death. Both group A streptococci and a combination of aerobic and anaerobic bacteria have been implicated as causes. (2)

We evaluated a 48-year-old woman who had presented with a severely edematous neck, fever, dysphagia, odynophagia, and difficulty breathing. An infectious focus had been previously identified in the floor of the mouth. She had a history of diabetes and alcoholism. Computed tomography (CT) revealed diffuse cellulitis and myositis with obliteration of the fascial planes (figure). She underwent endotracheal intubation, surgical debridement, and antibiotic therapy. After 3 months, the inclusions in the neck were well healed and the patient only complained of minimal dysphagia.

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Necrotizing fasciitis was once thought to be primarily caused by an extension of a dental or pharyngotonsillar infection, but other factors have since been implicated, including sinus infections, epiglottitis, insect bites, trauma, and previous surgery. (2) Delayed or inadequate treatment of necrotizing fasciitis can lead to its rapid extension throughout the fascial planes of the neck. The possible consequences include further extension into the retropharyngeal space and mediastinum, with considerable necrosis of the soft tissues and vascular involvement. (2,3)

CT findings in patients with necrotizing fasciitis include diffuse cellulitis with thickening, edema, and infiltration of the skin and subcutaneous tissues. (2) Myositis, compartmental fluid, and gas collections may also be seen. Magnetic resonance imaging with contrast enhancement may be more sensitive than CT in demonstrating the extensive inflammatory process, cellulitis, and fasciitis with abscess formation. Even when necrotizing fasciitis is clinically suspected or even already diagnosed, diagnostic imaging is still essential to assess multispatial involvement with compromise of the airways, formation of abscesses, and gas collections. (2,4,5)

References

(1.) Persaud R, Krahe D, Georgalas C, et al. Life-threatening necrotizing fasciitis of the neck: An unusual consequence of a sore throat. Ann R Coll Surg Engl 2004;86:253-7.

(2.) Sakran W, Mazzawi S, Merzel Y, Colodner R. Streptococcal necrotizing fasciitis with toxic shock syndrome following cervical adenitis. Int J Pediatr Otorhinolaryngol 2004;68:1209-13.

(3.) Hamza NS, Farrel J, Strauss M, Bonomo RA. Deep fascial space infection of the neck: A continuing challenge. South Med J 2003;96:928-32.

(4.) Fenton CC, Kertesz T, Baker G, Sandor GK. Necrotizing fasciitis of the face: A rare but dangerous complication of dental infection. J Can Dent Assoc 2004;70:611-15.

(5.) Delman BN, Weissman JL, Som PM. Skin and soft-tissue lesions. In: Sore PM, Curtin HD. eds. Head and Neck Imaging. 4th ed. Vol. II. St. Louis: Mosby; 2004:2190.

Enrique Palacios, MD, FACR; Rafael Rojas, MD

From the Department of Radiology, Tulane University Medical Center (Dr. Palacios), and the Department of Radiology, Louisiana State University Health Sciences Center (Dr. Rojas), New Orleans.