Necrotizing fasciitis in the head and neck region: a case report
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- Grabietz, P.D. & Nicolai, J.A. Eur J Plast Surg (2008) 30: 283. doi:10.1007/s00238-007-0177-z
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Necrotizing fasciitis is a potentially lethal disease. It starts as an infection of muscle fascia and soft tissue. The head and neck region is rarely involved. Spreading of the disease is very rapid and can lead to serious complications. This paper reports a patient with necrotizing fasciitis of the right upper eyelid which required debridement and intensive care admission.
KeywordsHead and neckNecrotizing fasciitisMuscle fasciaEyelidDebridement
Necrotizing fasciitis is a potentially lethal disease which was first described in 1883 by Fournier as a rapidly progressive infection of the scrotum, now well known as Fournier’s gangrene. It was Meleney in 1924 who first called this disease necrotizing fasciitis. The infection starts as an erysipelas and gradually develops into cellulitis which results in necrotizing fasciitis. Most of the time, a wound through which microorganisms penetrate is not seen. Muscle fascia and surrounding soft tissue are most frequently involved. The usual anatomical regions of involvement are the trunk, the lower extremities, the perineum, and the scrotum. The head and neck region, especially the face, is rarely involved. In case it is, the periorbital area is the location of preference to develop an infection [1, 3, 4, 8]. Less than 60 patients with necrotizing fasciitis in the head and neck region have been described in the literature [1, 3, 4, 8]. From a historical point of view, the disease is an infection by ß-hemolytic streptococci in combination with staphylococci . Although this combination remains very common, over the past few years, other mixtures of aerobic and anaerobic microorganisms have been described [1, 3, 4, 8]. Alcoholism and diabetes mellitus seem to predispose the onset of the condition [1, 3, 4, 8]. Rapid clinical identification and diagnosis is of essential importance to prevent significant complications. Extensive surgical debridement to remove all necrotic tissue combined with intravenous antibiotics is the main option in treating necrotizing fasciitis [2, 6].
Necrotizing fasciitis is a well-documented entity: 1,634 articles were found on PubMed using the term “necrotizing fasciitis,” but there were no major review articles. The face is not frequently involved, but the trunk, perineum, and lower extremities are. The process spreads very rapidly and can lead to severe complications such as multiorgan failure and death. The pathophysiology of this infection in the face does not appear to be different from that in other anatomical regions. Publications on necrotizing fasciitis almost always mention infection or necrosis of the fascia of the muscle. However, in the face, there is little or no fascia; thus, a severe infection in this area is limited to the subcutaneous tissue; skin and muscle are not involved. Staphylococcus aureus and ß-hemolytic Streptococcus are among the most cultured microorganisms. Peptostreptococcus magnus, Prevotella, Porphyromonas, and Fusobacterium are also found frequently in the head and neck region. From the perineum, Bacteroides fragilis, Clostridium, Enterobacteria, and Enterococcus are cultured . Necrotizing fasciitis is seldom seen in the face, but the clinical manifestation is the same as in other regions [1, 3]. A wound is rarely found, but can exist after minor trauma such as an insect sting or a scratch of a pet. One should not underestimate a sore throat, like in our patient. Dacryocystitis is also a well-documented cause . Making the diagnosis can be very difficult. Among the differential diagnosis of necrotizing fasciitis, gas gangrene, myositis, preseptal orbital cellulitis, trauma, and pyoderma gangrenosum are possibilities . Pyoderma gangrenosum is a destructive skin disorder characterized by painful ulcerative lesions and purplish undermined skin territories. This disorder is associated with underlying systemic diseases such as ulcerative colitis. Slow progression is an important difference in making the diagnosis of necrotizing fasciitis; this progresses rapidly [7, 10]. Delay in diagnosing or making the wrong diagnosis can lead to inadequate treatment and severe complications. Radiological modalities can be very helpful to assist in making the diagnosis . The aim of treatment is to limit extension of the infection by the use of antibiotics. The drug of choice is intravenous benzylpenicilllin, perhaps in combination with clindamycin . At the same time, aggressive surgical intervention must be performed to debride all necrotic tissue and surrounding tissue in the transition zone.