Abstract
Background
Necrotizing soft tissue infections are uncommon bacterial infections characterized by necrosis of fascia and subcutaneous tissue. While rarely occurring in the head and neck, they most often spread inferiorly when associated with an odontogenic infection.
Methods
We present a rare case of a sixty-one-year-old male patient who developed a craniocervicofacial necrotizing soft tissue infection of odontogenic origin with extension to the scalp. Managed initially at a community hospital with access to the scalp via an anterior mid-forehead incision, the patient was eventually managed by our team with multiple soft tissue debridements and antimicrobial therapy.
Results
Aggressive surgical therapy and appropriate antimicrobial coverage resulted in resolution of the odontogenic necrotizing soft tissue infection of the scalp.
Conclusions
Given the destructive nature of the condition, aggressive surgical and antimicrobial therapy are crucial to minimize the morbidity and mortality associated with necrotizing soft tissue infections.
Highlights
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Necrotizing soft tissue infections are uncommon and are characterized by necrosis of fascia and subcutaneous tissue.
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These infections can quickly result in significant destruction and distortion of affected tissues, and potentially death.
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Early aggressive surgical therapy with associated broad-spectrum antimicrobial therapy is required.
1
Introduction
Craniocervicofacial necrotizing soft tissue infections are rare bacterial infections characterized by necrosis of fascia and subcutaneous tissue [ ]. Occurring most commonly in patients with comorbidities such as diabetes mellitus or immunosuppression, this condition is associated with significant morbidity, with mortality rates ranging from 25 to 35% despite treatment 1 . While the majority of patients affected are below forty years of age, this condition has been reported to affect individuals of all age groups, with no predilection for sex or race. Given the severity of this condition, early identification and treatment with broad-spectrum antibiotics as well as aggressive surgical debridement are imperative for successful treatment [ ].
The uncommon presentation of craniocervicofacial necrotizing soft tissue infection can be attributed to the relatively increased vascularity of the head and neck. The most commonly reported etiology of necrotizing soft tissue infection in this region is from odontogenic origin, however reports of other sources within the head and neck region in the literature also include otitis media, trauma, tonsillar, and salivary gland infections [ , ].
This case report presents a patient who developed a craniocervicofacial necrotizing soft tissue infection of odontogenic origin with extension to the scalp. In our review of the literature, numerous cases of necrotizing soft tissue infections of the head and neck region with infection spreading inferiorly were identified; conversely, only one case reporting extension to the scalp without intracranial involvement was identified (with the origin being right sided otitis media) [ ]. As such, we present this case, shared with the patient’s written consent, as a rare occurrence, discussing our methods of management.
2
Case report
A sixty-one-year-old male with a medical history significant for, hypertension, poorly controlled diabetes mellitus type II (HbA1c 8.9%), and a greater than twenty-five pack/year smoking history was transferred to our tertiary care medical centre from a community hospital due to a non-resolving facial and scalp infection. The patient had presented two weeks prior to the peripheral hospital with a four-week history of a painful right facial swelling. At the peripheral hospital, he was treated by the local surgical teams who performed two incision and drainage operations six days apart via a transverse forehead incision ( Fig. 1 ) as well as an oral incision in the posterior right maxilla. The presumed source of infection was the second right maxillary molar, suspected due to an associated carious lesion and evidence of adjacent buccal bone osteolysis. The tooth was extracted at the time of the first incision and drainage, and unfortunately a residual root remained. The patient remained admitted to the intensive care unit (ICU) for a total of twelve days prior to transfer to the Oral and Maxillofacial Surgery service at our centre due to incomplete resolution.
On transfer, the findings of the initial assessment were remarkable for significant right sided facial swelling, bogginess of the frontal region and purulent drainage from the surgical sites. Computed tomography (CT) showed evidence of an extensive, partially evacuated abscess in the frontal, temporal and parietal scalp bilaterally, continuous with a multiloculated abscess centered in the right masticator space and a thin, elongated abscess within the right temporalis muscle ( Fig. 2 ). The patient was admitted to the ICU, antimicrobial therapy with intravenous (IV) vancomycin was continued (as previously prescribed at outside hospital), and he was taken to the operating room for incision and drainage of his right facial spaces and scalp infection, extraction of the residual root, and debridement of the associated necrotic tissue. The intraoperative course was uneventful with extensive debridement of necrotic tissue involving the galea, pericranium and subcunateous connective tissue of the scalp, culminating in the placement of multiple Penrose and irrigating drains ( Fig. 1 ).
