Necrotizing fasciitis of the neck

Case contributed by Hoe Han Guan


Left neck swelling, odynophagia and intermittent fever for 2 weeks.

Patient Data

Age: 50 years
Gender: Female

Large area of subcutaneous emphysema associated with soft tissue swelling at the left neck. This soft tissue swelling has caused significant trachea displacement to the right side.

A huge bizarre-shaped air-fluid collection (mainly air-density) at the left anterior cervical space with involvement of multiple different adjacent neck spaces (transpatial), namely left pharyngeal mucosal and left visceral spaces medially, left masticator space, left parotid space and left buccal space laterally and left pharyngeal space superiorly. Due to the large mass effect of this collection, significant displacement of adjacent medial structures, resulting in a marked displacement of the hypopharynx, larynx, trachea, and thyroid gland to the right side. The tracheal lumen is still patent (25% stenosis). 
These collections do not show significant rim enhancement or well-defined wall margin. No retropharyngeal or danger space extension.

Posteriorly, the collection encompasses the adjacent left internal jugular vein within the left carotid space. A few air pockets were seen intra-luminally within the proximal and distal part of the left IJV, representing left IJV thrombophlebitis. 

Laterally, the normal left sternocleidomastoid muscle (SCM) is not seen, in keeping with infiltration of the left SCM by the collection. Medially, normal left strap muscles are also involved.

No extension of the collection into anterior and superior mediastinum. Multiple enlarged nodes in the left-sided cervical regions.

Case Discussion

Overall CT features are suggestive of left neck necrotizing fasciitis with left internal jugular vein thrombophlebitis and significant airway displacement. The patient has newly diagnosed diabetes mellitus, which is commonly associated with necrotizing fasciits.

Proceed with urgent surgery and tracheostomy. Intraoperative findings: Multi-loculated abscesses involving multiple left deep neck compartments. 100cc pus evacuated. The underlying fascia and muscles are unhealthy, macerated, and sloughy. The underlying tissue was debrided and curetted. 

Necrotizing fasciitis is rare in the head and neck region and commonly occurs in the abdomen, groin, and extremities. Whenever necrotizing fasciitis is suspected, immediate CT examination is mandatory for assessing the extension and guiding the surgical approach.

To differentiate between head and neck necrotizing fasciitis and the more common neck abscess, the following points would be helpful:

  • Necrotizing fasciitis usually shows an area of fluid accumulation without significant rim enhancement at the periphery post-contrast administration 1.
  • necrotizing fasciitis usually has multiple air locules/gas in different fascial planes of deep neck spaces, though sometimes it can present without air locules. The abscess sometimes has an air-fluid level but without the presence of multiple tiny air locules in different fascial planes. Viewing the CT neck in the lung window is very helpful for assessing air locules.
  • Necrotizing fasciitis has a bizarre-shaped hypodense collection. The abscess has a relatively well-defined or multiloculated collection.
  • Necrotizing fasciitis involves multiple neck compartments, where abscesses are usually confined to one compartment.

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