AtlasInfectionsCervicofacial Necrotising Fasciitis

Maxillofacial Infections

Cervicofacial Necrotising Fasciitis

aka NF · Flesh-eating Infection

Rapidly progressive polymicrobial infection of subcutaneous tissue and fascia with high mortality; requires emergent surgical debridement and broad-spectrum antibiotics.

Rx
Emergent debridement + IV abx
Abx
Pip-tazo + clinda + vanco
Mortality
20–40%

§ overviewOverview

Life-threatening soft-tissue infection producing widespread fascial necrosis, often with relative sparing of underlying muscle and overlying skin early in the disease.

§ icdICD Classification

M72.6

§ riskRisk Factors

  • 01Odontogenic infection
  • 02Diabetes
  • 03Immunosuppression, alcoholism
  • 04IV drug use
  • 05Recent surgery/trauma

§ clinicalClinical Features

  • 01Rapidly spreading painful cellulitis disproportionate to skin findings
  • 02Skin: erythema → dusky discolouration → haemorrhagic bullae → necrosis
  • 03Crepitus (gas)
  • 04Systemic toxicity: fever, tachycardia, hypotension, altered mentation (SIRS/sepsis)

§ differentialDifferential Diagnosis

  • 01Ludwig angina
  • 02Cellulitis
  • 03Erysipelas
  • 04Cervicofacial actinomycosis

§ investigationsInvestigations

  • 01Do NOT delay surgery for imaging in obvious cases
  • 02LRINEC score
  • 03CT/MRI: gas in fascial planes, fascial thickening
  • 04Blood cultures, wound cultures
  • 05Frozen section: fascial necrosis

§ labsLaboratory Findings

  • 01Leucocytosis or leucopenia
  • 02Elevated CRP, lactate, creatinine
  • 03Hyponatraemia (< 135)
  • 04Coagulopathy

§ classificationClassification

  • 01Type I: polymicrobial (aerobic + anaerobic) — most head-neck NF
  • 02Type II: monomicrobial Group A Streptococcus ± S. aureus
  • 03Type III: Vibrio, Aeromonas
  • 04Type IV: fungal (immunocompromised)

§ treatmentTreatment

  • 01Immediate aggressive surgical debridement — the mainstay; repeat every 24 h until clean
  • 02Empirical broad-spectrum: piperacillin–tazobactam + clindamycin + vancomycin/linezolid
  • 03Clindamycin suppresses exotoxin production
  • 04IVIG for streptococcal toxic shock
  • 05ICU support: fluids, vasopressors, ventilation
  • 06Hyperbaric oxygen adjunctive
  • 07Reconstruction after infection controlled

§ complicationsComplications

  • 01Descending mediastinitis
  • 02Sepsis, MODS
  • 03Airway compromise
  • 04Death

§ prognosisPrognosis

Mortality 20–40% (higher with mediastinitis, delayed surgery, comorbidity).

§ examKey Examination Points

  • 01Pain out of proportion + rapid spread → suspect NF
  • 02Skin appearance underestimates fascial destruction

§ revisionQuick Revision Summary

  • 01Polymicrobial · early aggressive debridement · clindamycin + β-lactam · high mortality

§ vivaBDS Viva Questions

  • 01Types of NF?
  • 02LRINEC score?
  • 03Why clindamycin?

§ mcqsMCQs — Assessment (3)

Question 1

Definitive treatment:

Question 2

Clindamycin adjunct role:

Question 3

Most feared complication of cervicofacial NF:

References

  1. Stevens DL. Clin Infect Dis 2014

Draft — pending faculty review. Educational use only; verify against current guidelines and primary sources before clinical application.