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 Table of Contents  
Year : 2019  |  Volume : 6  |  Issue : 2  |  Page : 113-115

Necrotizing fasciitis of the face and neck following a dental procedure

1 Department of Otorhinolaryngology, Baby Memorial Hospital, Calicut, Kerala, India
2 Department of Internal Medicine, Baby Memorial Hospital, Calicut, Kerala, India
3 Department of Oral and Maxillofacial Surgery, Baby Memorial Hospital, Calicut, Kerala, India

Date of Web Publication19-Aug-2019

Correspondence Address:
Dr. Robin George Manappallil
Department of Internal Medicine, Baby Memorial Hospital, Calicut - 673 004, Kerala
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/sjos.SJOralSci_34_19

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Necrotizing fasciitis (NF) is a severe, life-threatening infection of the soft tissue, characterized by the rapid progression of necrosis in the superficial fascia and subcutaneous tissue. The involvement of the face is a rare scenario. The patient being described underwent root canal procedure for the right upper premolar following which she developed NF involving the face and neck. She underwent extensive debridement of necrotic tissue and was discharged in stable condition.

Keywords: Face, necrotizing fasciitis, root canal treatment, steroids

How to cite this article:
Bhaskaran M, Manappallil RG, Manuel R, Gopi J. Necrotizing fasciitis of the face and neck following a dental procedure. Saudi J Oral Sci 2019;6:113-5

How to cite this URL:
Bhaskaran M, Manappallil RG, Manuel R, Gopi J. Necrotizing fasciitis of the face and neck following a dental procedure. Saudi J Oral Sci [serial online] 2019 [cited 2022 Aug 15];6:113-5. Available from: https://www.saudijos.org/text.asp?2019/6/2/113/264764

  Introduction Top

Necrotizing fasciitis (NF) is a highly infectious condition which spreads aggressively through the superficial fascia and subcutaneous tissue. Previously, it used to be called streptococcal gangrene, as Group A Streptococcus was the leading etiological agent of monomicrobial NF. Methicillin-resistant Staphylococcus aureus strains, Clostridium perfringens, and mixed aerobic–anaerobic bacteria are the other causative organisms.[1] The involvement of the face in NF is rare and is associated with a high mortality and can result in severe facial disfigurement.[2],[3],[4],[5],[6] Our patient developed NF of the face extending to the neck following a dental procedure, but recovered from it without any cosmetic problems.

  Case Report Top

A 30-year-old female presented to the medicine department with complaints of pain and progressive swelling of the right side of her face for 5 days. She had undergone root canal procedure for the right upper premolar, at a local dental clinic, 5 days ago. The same night of the procedure, she developed pain and mild swelling of the right cheek. The next day morning, her pain and swelling increased [Figure 1]. She contacted her dentist (over the phone), who advised her to take antibiotics (amoxicillin + clavulanic acid 625 mg twice daily). On day 2, her swelling increased involving the right half of her face and lips. She went to a local practitioner who mistook her condition for angioedema and gave her intravenous hydrocortisone (100 mg) and oral levocetirizine (5 mg twice daily) and asked her to stop antibiotics in view of an allergic reaction. On day 5, as her symptoms worsened, she presented to our hospital.
Figure 1: Swelling of the right cheek

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On examination, she was conscious and febrile (100°F). Her pulse rate was 100/min and blood pressure was 110/70 mmHg. She had a diffuse, tender swelling of the right cheek extending to the neck along with labial and orbital edema [Figure 2]. Her right labial mucosa showed necrotic ulcerations [Figure 3]. Her systemic examinations were normal. Her complete blood counts showed neutrophilic leukocytosis (white blood cell, 18,500 cell/mm3 with neutrophils 92% and lymphocytes 8%). Her chest X-ray and other blood investigations such as renal and liver functions, HbA1c, and bleeding parameters were normal.
Figure 2: Swelling of the right cheek extending to the neck along with labial and orbital edema

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Figure 3: Necrotic ulcerations of the right labial mucosa

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She was started on intravenous antibiotics (piperacillin + tazobactam 4.5 gm q 6 h and linezolid 600 mg q 12 h). Under general anesthesia, a sublabial incision was made from the right upper incisor to the right 2nd molar, and the flap was elevated. Plenty of cheesy, necrotic, and foul-smelling material was sucked out and sent for histopathological examination. Through a midline submental incision, the submental and submandibular spaces were opened, and about 100 ml of blood-stained fluid was drained.

The tissue biopsy, which was sent for histopathology, revealed necrotic tissue. Blood and pus cultures were sterile. She was discharged on day 7 of admission in stable condition. On review after 10 days, she was perfectly fine with minimal facial deviation to the right [Figure 4].
Figure 4: Posttreatment

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  Discussion Top

The term “NF” was coined by Wilson in the year 1952. It is regarded as a surgical emergency, which requires extensive debridement of the necrotic tissue till fresh viable tissue growth is seen.[6] The pathophysiological features include the formation of microthrombi and vasculitis with eventual intravascular coagulation and spreading of necrosis. Clinically, these patients present with severe pain, erythema, skin blisters, and systemic toxicity.[2],[3],[4],[5],[6] The diagnosis is made clinically and confirmed by histopathological examination of the tissue.[7] The administration of broad-spectrum antibiotics along with daily antibiotic dressings plays a key role.[8] However, due to the emergence of resistant strains, antimicrobial combination therapy is warranted.[9],[10] Adjuvant hyperbaric oxygen therapy may provide additional benefits.[11],[12]

NF of the head and neck region is rare and is usually preceded by odontogenic, tonsillar, or pharyngeal infections.[13] Diabetes mellitus, excessive alcohol intake, and immunosuppression are known risk factors.[2] The bacterial invasion occurs as a result of a precipitating event that produces a break in the epidermis. An extensive resection of the skin and subcutaneous tissue of the face can result in long-term deformity. However, to control the infection, all necrotic tissues must be removed. In NF, the skin is less affected as compared to the subcutaneous tissue; hence, a wide base skin flap can be raised and used to cover the deformity. This will also aid in the clearance of the necrotized subcutaneous tissue.[14] Reconstructive procedures should be planned only after complete resolution of the disease and once the recipient bed is healthy.

A literature search revealed only a few cases of NF involving the face and neck. Some had good outcomes, whereas others had severe disfigurement of the face.[15],[16],[17],[18],[19] An early diagnosis, broad-spectrum antibiotic administration, along with aggressive surgical debridement, followed by reconstruction of the resultant soft-tissue defects, is essential for the successful management of facial NF.

  Conclusion Top

NF of the head and neck is a rare entity and can lead to severe disfigurement if not recognized and managed promptly. The treatment involves aggressive medical and surgical management, along with adequate wound care and frequent dressing. Because the condition mainly affects the subcutaneous tissue rather than the skin, special attention should be given in clearing necrotic tissue under the surrounding skin. Our patient was not diabetic and developed NF involving the right half of her face extending to the neck following dental procedure. She underwent extensive debridement along with antibiotic therapy and recovered with minimal facial deviation.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given her consent for her images and other clinical information to be reported in the journal. The patient understands that her name and initials will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

Stevens DL. Infections of the skin, muscles, and soft tissues. In: Kasper F, Hauser L, Jameson L, editors. Harrison's Principles of Internal Medicine. 19th ed. McGraw Hill Education; New York. 2015. p. 1031-3.  Back to cited text no. 1
Wolf H, Rusan M, Lambertsen K, Ovesen T. Necrotizing fasciitis of the head and neck. Head Neck 2010;32:1592-6.  Back to cited text no. 2
Lazzeri D, Lazzeri S, Figus M, Tascini C, Bocci G, Colizzi L, et al. Periorbital necrotising fasciitis. Br J Ophthalmol 2010;94:1577-85.  Back to cited text no. 3
Dale RA, Hoffman DS, Crichton RO, Johnson SB. Necrotizing fasciitis of the head and neck: Review of the literature and report of a case. Spec Care Dentist 1999;19:267-74.  Back to cited text no. 4
Oguz H, Demirci M, Arslan N, Safak MA, Paksoy G. Necrotizing fasciitis of the head and neck: Report of two cases and literature review. Ear Nose Throat J 2010;89:E7-10.  Back to cited text no. 5
Benavides G, Blanco P, Pinedo R. Necrotizing fasciitis of the face: A report of one successfully treated case. Otolaryngol Head Neck Surg 2003;128:894-6.  Back to cited text no. 6
McGurk M. Diagnosis and treatment of necrotizing fasciitis in the head and neck region. Oral Maxillofac Surg Clin North Am 2003;15:59-67.  Back to cited text no. 7
Wang KC, Shih CH. Necrotizing fasciitis of the extremities. J Trauma 1992;32:179-82.  Back to cited text no. 8
Thomas AR, James RJ. Diseases caused by gram-negative enteric bacilli. In: Kasper F, Hauser L, Jameson L, editors. Harrison's Principles of Internal Medicine. 19th ed. McGraw Hill Education; New York. 2015. p. 1031-3.  Back to cited text no. 9
Gear AJ, Hellewell TB, Wright HR, Mazzarese PM, Arnold PB, Rodeheaver GT, et al. A new silver sulfadiazine water soluble gel. Burns 1997;23:387-91.  Back to cited text no. 10
Riseman JA, Zamboni WA, Curtis A, Graham DR, Konrad HR, Ross DS, et al. Hyperbaric oxygen therapy for necrotizing fasciitis reduces mortality and the need for debridements. Surgery 1990;108:847-50.  Back to cited text no. 11
Lin C, Yeh FL, Lin JT, Ma H, Hwang CH, Shen BH, et al. Necrotizing fasciitis of the head and neck: An analysis of 47 cases. Plast Reconstr Surg 2001;107:1684-93.  Back to cited text no. 12
Ali MH, Zayed ME. Necrotizing fasciitis of the head and neck: Report of three cases. Ann Saudi Med 1997;17:641-5.  Back to cited text no. 13
Cox H, Carruth J, Williams AP, Brightwell AP. Necrotising fasciitis. Appropriate skin flap may reduce deformity. BMJ 1994;309:341-2.  Back to cited text no. 14
Singh DV, Thomas S, Nair PP, Cyriac S, Tripathi GM. Necrotizing fasciitis of face – Our experience in its management. BMJ Case Rep 2011;2011. pii: bcr0720114453.  Back to cited text no. 15
McAllister P, O'Neill F, Bharadwaj G, O'Regan B, Laverick S. A presentation of facial necrotizing fasciitis with orbital involvement. J Surg Case Rep 2013;2013. pii: rjs033.  Back to cited text no. 16
Iynen I, San I, Bozkus F, Beklen H. Life-threatening necrotizing fasciitis of the neck: A case report. J Curr Surg 2011;1:35-7.  Back to cited text no. 17
Alvarez Hernández DA, Chávez AG, Rivera AS. Facial Necrotizing fasciitis in adults: A systematic review. Heighpubs Otolaryngol Rhinol 2017;1:20-31.  Back to cited text no. 18
Sangamesh NC, Vidya KC, Roopa GS, Sakri SB. Necrotizing fasciitis of odontogenic origin in a nonimmunocompromised patient: A rare case report. J Sci Soc [serial online] 2014;41:179-82. Available from: http://www.jscisociety.com/text.asp?2014/41/3/179/141216. [Last cited on 2019 Jul 01].  Back to cited text no. 19


  [Figure 1], [Figure 3], [Figure 2], [Figure 4]

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