Cervical necrotizing fasciitis of odontogenic origin

Cervical necrotizing fasciitis (CNF) is a progressive and destructive bacterial infection of the subcutaneous tissue and fascia in the head and neck. The infection often involves a mixture of Streptococcus species, Staphylococcus species, Fusobacterium species or Actinobacter species.¹ Importantly CNF is frequently associated with significant morbidity and mortality, usually due to septic shock, disseminated intravascular coagulation (DIC) or multiple organ failures.² While the cause of head and neck infections is often odontogenic in origin, the progression to life-threatening necrotizing fasciitis is relatively rare in this region given the robust blood supply. A Danish study reported an incidence of 2 per 1,000,000 of the population per year.³ Owing to the infrequent nature of CNF, it may not be recognized by emergency, medical or surgical clinicians until the disease has progressed significantly. Characteristically, patients may appear acutely ill or have a history of recent dental or maxillofacial trauma or long-standing dental neglect. Patients can also present to the emergency department with symptoms of fever, tachycardia, dehydration and hypotension. Clinical examination may reveal clinical signs of cyanosis of the overlying skin and soft tissue of the neck with mottling, cellulitis, tension and necrosis. Crepitus is often felt due to the presence of gas-producing micro-organisms. Severe forms of CNF can also extend to the thoracic, and even the upper abdominal region, which is often life threatening.⁴ Patients with underlying immune conditions such as diabetes mellitus (DM), human immunodeficiency virus (HIV) infection, or those on long-term immunosuppressants are predisposed to the condition and may have an increase risk or morbidity or mortality.¹ Management of the condition requires prompt diagnosis, urgent airway and haemodynamic support, aggressive surgical and serial debridement, if required, and empirical intravenous antibiotics with further tailored treatment dependent on culture and sensitivity.