Case 42 - Necrotizing Fasciitis

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Report

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INDICATION: Patient had a R-sided broken tooth which progressed to an intra-buccal abscess. Patient underwent extraction 6 days prior and received clindamycin x24h and discharged home. Patient returned to the GBMC 3 days ago with increased pain, swelling, and decreased ROM of the neck. He was given another dose of Clindamycin PO and sent home. Patient returned to GBMC 3/5 with unresolved pain, increased swelling, and dysphagia. He underwent CT of head/neck which showed subcutaneous emphysema from LEFT infratemporal fossa to LEFT clavicular/axillary region (lateral to LEFT zygoma) indicative of gas-forming cellulitis without drainable fluid collection.

TECHNIQUE:

Axial images of the neck from the level of the frontal sinuses to the thoracic inlet following intravenous contrast.

FINDINGS:

There is a gas containing collection which extends superiorly to the temporalis muscle at the level of the lateral orbital wall on the left side. It involves the muscles of mastication on the left side near the coronoid process of the left side of the mandible. There also is gas and fluid collecting in the left parapharyngeal space from the nasopharyngeal level to the hyoid bone level. There also is gas in the retropharyngeal space. Gas extends into the floor of the mouth and along the left submandibular gland which is enlarged. The sternocleidomastoid muscle on the left side is also enlarged and edematous and has necrotic portions in it. The fluid and gas collection causes displacement of the airway from left to right. It extends into the strap muscles at the level of the hyoid bone and thyroid cartilage. There is extension to the supraclavicular fossa and the axilla on the left side. A fluid and gas collection is seen superficial to the left lobe of the thyroid gland.

The left internal carotid artery is not encased by the inflammatory disease however there are portions of external carotid artery branches in close proximity.

The posterior triangle of the left side of the neck also shows air and fluid extending even into the scapular region on the left side.

A small amount of air is seen in the retropharyngeal space to the right of midline at the level of base of the tongue. There is edema in the left palatine tonsil and glossotonsillar sulcus region as well as in the preepiglottic fat. Scattered enlarged lymph nodes are present in the jugular chain.

The upper lung fields are clear.

The left third mandibular maxillary tooth has been extracted. There is trivial mucosal thickening in the maxillary antra.

IMPRESSION:

Severe necrotizing fasciitis affecting the entire left side of the neck from the temporalis region at the lateral orbital wall to the thoracic inlet with infiltration of the floor of mouth, parapharyngeal space, retropharyngeal space, sternocleidomastoid,. Thyroidal tissues and supraclavicular fossa as well as the periscapular region on the left side.

Introduction

Introduction to Emergency Head, Neck & Spine Imaging

Clinical Scenario 1 (Updated)

Orbital Trauma/Inflammation

Clinical Scenario 2

Facial/Neck Trauma

Clinical Scenario 3

Sore Throat Pain and Fever

Clinical Scenario 4

Mass in the Neck

Clinical Scenario 5

Cervical Spine Trauma

Clinical Scenario 6

Fever, Back Pain

Clinical Scenario 7

Head & Neck Emergencies

Case 42 - Necrotizing Fasciitis