European Journal of Plastic Surgery

, Volume 30, Issue 6, pp 283–286

Necrotizing fasciitis in the head and neck region: a case report

Authors

    • Department of Plastic SurgeryUniversity Medical Center Groningen
    • Department of Plastic and Reconstructive SurgeryEramus Medical Center
  • Jean-Philippe A. Nicolai
    • Department of Plastic SurgeryUniversity Medical Center Groningen
Case Report

DOI: 10.1007/s00238-007-0177-z

Cite this article as:
Grabietz, P.D. & Nicolai, J.A. Eur J Plast Surg (2008) 30: 283. doi:10.1007/s00238-007-0177-z

Abstract

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.

Keywords

Head and neckNecrotizing fasciitisMuscle fasciaEyelidDebridement

Introduction

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 [2]. 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].

Case report

A healthy 43-year-old male patient with a history of an inguinal hernia repair in the distant past who was not on any medications was seen in the Ophthalmology Department. There was redness and swelling of the right hemiface. He had been ill for the past weeks, this consisted of flu-like symptoms and pharyngeal pain. The day before presentation, he had a temperature of 38°C. At the medial corner of the right eye, a blister had formed the same day and developed into a large swelling involving the upper eyelid and the right hemiface over a period of 24 h. On presentation, the upper eyelid was very swollen, and the patient could not open his eye. He was in a preseptic condition: He had a blood pressure of 120/70 with a heart rate of 104 bpm; his temperature was 40.2°C. A computed axial tomography scan revealed a periorbital hematoma with a possible abscess (Figs. 1, 2, and 3). No involvement of the periorbita or maxillary sinus was seen.
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Fig. 1

Preoperative situation. Note the redness and swelling of the right hemiface

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Fig. 2

CAT scan of the orbit. A periorbital hematoma and a possible abscess are seen on the right side

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Fig. 3

Coronal CAT scan. The swelling on the right temporal area can be seen

A diagnosis of necrotizing fasciitis was made, and the patient was admitted and operated on immediately. Clindamycin and amoxicillin–clavulanic acid were given intravenously. The right upper eye was opened, and a portion of necrotic eyelid together with a quantity of pus was removed. The latter was sent for analysis. The removed fluid was situated between the skin and the orbicularis oculi muscle, and some pus was removed from the medial and lateral canthus. The orbicularis muscle itself was not involved. The area was extensively irrigated with saline and three Penrose drains were inserted. After surgery, the temperature decreased to 39.6°C. The WBC and C-reactive protein (CRP) decreased, respectively, to 10 E g/l and 100 mg/l. Redness and swelling also decreased (Fig. 4). To improve on the hemodynamic and respiratory situation, noradrenalin was administered intravenously. Gram-positive cocci in chains were seen in the specimen taken from the eyelid; thus, ciprofloxacin was added to the mixture of antibiotics. The condition of the patient gradually improved, and he was extubated the next day. During the next 24 h, his temperature increased to 39.4°C and his CRP to 150 mg/l. Through an extended preauricular incision similar to that used in facial rejuvenation surgery, the cheek was explored (Fig. 5). No necrosis of the underlying structures and the superficial and deep temporal fascia was seen. Soon after this operation, the temperature decreased again to 37.1°C, and he could be extubated and returned to the ward the next day. Staphylococcus aureus and Group A streptococcus were found in the pus specimen. The antibiotics regimen was changed to 6 million units of penicillin, six times a day. No microorganisms were grown from the blood cultures. The wound was irrigated three times a day with saline. The patient recovered very rapidly and remained free of fever. Antibiotics were continued intravenously for 2 weeks. Analysis by the pathologist of the piece of skin that was taken from the upper eyelid, revealed necrotizing fasciitis. Six weeks later, the patient had recovered completely and returned to work (Fig. 6). He had been seen regularly in the outpatient clinics.
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Fig. 4

Postoperative view after extensive debridement of the right upper eyelid

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Fig. 5

Two days after exploration using a preauricular incision

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Fig. 6

After 6 weeks, wound healing of the upper eyelid has taken place without significant morbidity

Discussion

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 [2]. 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 [5]. 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 [8]. 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 [9]. 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 [2]. At the same time, aggressive surgical intervention must be performed to debride all necrotic tissue and surrounding tissue in the transition zone.

Copyright information

© Springer-Verlag 2007