Case Presentation: A 41-year-old female with a history of hypertension, depression, and alcohol abuse presented to the emergency department with right facial swelling and pain after biting her cheek the previous night. The patient first noticed a small, unconcerning “red bump” on her cheek that was minimally painful earlier that morning. She was admitted to the internal medicine service for presumed cellulitis; however, within hours of presentation, her swelling and erythema rapidly progressed to the entire right jaw with extension to the anterior and right lateral neck. Due to concerns for necrotizing fasciitis, otolaryngology was emergently consulted for surgical evaluation. Within thirty minutes, arrangements for both surgical and postoperative management were coordinated. Prior to transport, the patient developed septic shock with acute hypoxic respiratory failure, and emergent surgical debridement and tracheostomy was performed. She completed antibiotic therapy for GAS infection with wound care management, underwent successful decannulation, and was discharged home without need for cosmetic reconstruction.
Discussion: Necrotizing fasciitis of the head and neck is a rare, rapidly progressive, and life-threatening infection. It more commonly affects the extremities, perineum, and trunk following trauma or surgery. Cervicofacial involvement is usually secondary to minor trauma or dental or oropharyngeal infections with group A beta-hemolytic streptococcus (GAS) as the most common causative agent. Identified risk factors of this subtype include immunosuppression, diabetes mellitus, and alcohol abuse. Treatment is prompt surgical debridement for source control, antibiotics, and vigilant post-surgical dressing changes. Without timely intervention, the disease can lead to severe disfigurement or death. This case illustrates the benefits of early detection and prompt surgical treatment of necrotizing fasciitis of the head and neck. Although the patient was initially managed for cellulitis, the rapid mobilization of appropriate medical care after diagnosis led to a favorable outcome without the need for subsequent reconstructive surgery. Due to its rare involvement of the cervicofacial region and often benign initial appearance, symptoms of warmth and redness with necrotizing fasciitis are often mistaken for cellulitis. Characteristic skin blistering and necrosis occur later in the disease process, often after muscle and subcutaneous destruction provide a nidus for organism proliferation. Crepitus may not always be present. Surgical debridement should not be delayed for imaging studies, especially in cases with high physician suspicion.
Conclusions: Delay in surgical treatment has been identified as a contributing factor to significant morbidity and mortality, with reported mortality rates up to 73% and 40% for untreated and treated patients, respectively. After complete surgical debridement, resulting severe disfigurement can pose a challenge for facial reconstruction. Increased awareness of necrotizing fasciitis of the head and neck, and a low threshold for aggressive surgical intervention, can help lower mortality rates and lead to improved patient outcomes in an otherwise destructive and deadly disease.