Abstract | March 24, 2024
When There’s More Than Meets The Eye: A Case Report of Rare Facial Necrotizing Fasciitis
Learning Objectives
- Clinicians need to have a high suspicion for FNF as physical exam findings can be subtle
- Cultures isolates of FNF are usually polymicrobial, with group A streptococcus, staphylococcus spp., and anaerobes being common isolates. Broad spectrum antibiotics, in addition to clindamycin, that cover these pathogens given promptly are important for patient outcomes.
- Definitive treatment is surgical debridement with a specialist familiar with surrounding anatomy.
Facial necrotizing fasciitis (FNF) is an uncommon presentation of this rapidly progressive soft tissue infection, attributed to the face’s excellent blood supply, accounting for approximately 10% of cases.1 Limited skin involvement is typical in FNF as a deep tissue source is a common culprit.3 A FNF infection involving skin caused by a deeper source indicates an advanced disease presentation, requiring clinicians to have a high suspicion for FNF.
A 66-year-old man with type 2 diabetes came to the Emergency Department for facial swelling and purulent mouth drainage for five days after a right mandibular 2nd molar extraction. Vital signs were normal. On exam, he had right facial edema with crepitus around the zygoma. (see Figure 1) Initial labs revealed a leukocyte count of 16K/uL, sodium of 132mEq/L, and glucose of 237mg/dl. Computed tomography (CT) of the head showed swelling in the right infraorbital area, cheek, and peri-mandibular area with extension to the mandible and air-fluid collections around the inner margin of the right mandible. (see Figure 2)
He received intravenous vancomycin, piperacillin/tazobactam, and clindamycin for empiric therapy. ENT quickly took the patient for debridement and irrigation of the abscess. Blood cultures remained negative and intraoperative cultures grew polymicrobial aerobic microbiota.
Most often, intraoperative cultures are polymicrobial, with group A streptococcus (GAS), staphylococcus spp., and anaerobes being common isolates. The definitive treatment for FNF is urgent surgical debridement by a specialist familiar with surrounding anatomy.1 Broad antibiotic coverage is vital to controlling disease before and after surgery1,2,3. The IDSA recommends clindamycin if GAS is suspected.
References and Resources
- Vandelaar LJ, Alava I. Cervical and craniofacial necrotizing fasciitis. Oper Tech Otolaryngol Head Neck Surg 2017; 28:238–243
- Vieira F, Allen SM, Stocks RM, Thompson JW. Deep neck infection. Otolaryngol Clin North Am 2008; 41:459–483. vii.
- Shindo ML, Nalbone VP, Dougherty WR. Necrotizing fasciitis of the face. Laryngoscope. 1997 Aug;107(8):1071-9. doi: 10.1097/00005537-199708000-00013. PMID: 9261011.
