CASE REPORT

EARLY MANAGEMENT AND WOUND DRESSING

SELECTION FOR CERVICAL NECROTIZING FASCIITIS:
A CASE REPORT
Deka Dharma Putra∗,1 , Endang Sjamsuddin∗ and Seto Adiantoro∗∗
∗ Resident of Oral and Maxillofacial Surgery Department, Faculty of Dentistry Universitas Padjadjaran, Bandung, Indonesia., ∗∗ Staff of Oral and Maxillofacial
Surgery Department, Faculty of Dentistry Universitas Padjadjaran, Bandung, Indonesia.

ABSTRACT Necrotizing Fasciitis (NF) is a severe soft tissue infection characterized by rapidly progressing necrosis,
involving skin, fascia, fat and subcutaneous tissue. NF can develop at the head and neck region. This rare condition
requires prompt diagnosis, emergency treatment, and precise wound dressing selection. The objective of this study
is to describe early management and wound dressing selection in cervical NF case. A 48-years-old female came with
swelling and spontaneous drainage at both sides of lower jaw, chin, and neck region. The patient was diagnosed with
necrotising fasciitis at cervical region. Aggressive necrotomy debridement was done to manage infection. The wound
was treated by modern dressing without requiring skin graft procedure. The patient did not have any complaint and
fully satisfied with the treatment result. Necrotising fasciitis is a life-threatening, single or polymicrobial infection of
soft tissue. This disease rarely involves the head and neck region; if it occurs, it is usually due to the spread of infection
from the teeth or pharynx. Satisfying outcomes can be achieved with early diagnosis, aggressive surgical, empirical
antimicrobial therapy, and post-operative management with an appropriate dressing. There are many kinds of wound
dressing available that challenges operator to choose an appropriate one to treat NF. A correct dressing can decrease
healing time, provides cost-effective care, and improves patient quality of life. In conclusion, early management and
appropriate wound dressing selection are critical to improve the clinical outcome and decrease patient’s long term
morbidity.
KEYWORDS necrotising fasciitis, cervical, early management, wound dressing

spreads along the facial plane.[2] Giuliano et al. classified NF

into two subtypes: polymicrobial infection (usually caused by a
combination of Gram-positive cocci, Gram-negative rods, and
Introduction
anaerobes), and monomicrobial infection (caused by Streptococ-
Necrotising fasciitis (NF) is a severe soft tissue infection which cus and/or Staphylococcus aureus). Polymicrobial infection is
characterised by rapidly progressing necrosis, involving fascia often diagnosed in immunocompromised patients and usually
and subcutaneous tissues.[1] Cervical NF is a fulminant infec- occurs in the perineum and trunk area.[3]
tion with high mortality and necrosis of connective tissue that NF is generally limited in the subcutaneous tissue and mus-
cle involvement is rare. The disease causes tissue necrosis and
Copyright © 2019 by the Bulgarian Association of Young Surgeons
spreads rapidly along the facial plane due to its being polybacte-
DOI:10.5455/IJMRCR.Necrotizing-fasciitis
First Received: August 09, 2019 rial and the synergistic effect of enzymes formed by the bacteria.
Accepted: September 09, 2019 The most common factor is pathogen streptococcal. Involvement
Associate Editor: Ivan Inkov (BG) of head and neck area are rare and more common in extremities,
1
Resident of Oral and Maxillofacial Surgery Department, Faculty of Dentistry genital region, and abdomen.[4]
Universitas Padjadjaran, Bandung, Indonesia; Email: Dekadrg @ gmail.com
The main reasons for the disease are odontogenic infections

Deka Dharma Putra et al./ International Journal of Medical Reviews and Case Reports (ARTICLE IN PRESS)
Figure 1: Extra oral preoperative.
Figure 2: Intra oral preoperative.
and trauma. It is commonly seen in middle-aged individuals.
The early stage of the disease looks like abscess and cellulitis.
The covering skin is usually red and taut. Hyperesthesia or
anaesthesia can be identified by touch. The benign nature of
the disease is the most crucial reason for late diagnosis. The
diagnosis can be made by subcutaneous gas formation.[5] The
present of immune compromising conditions predisposes to cer-
vical NF as well as increase morbidity and mortality. Satisfactory
outcomes can be achieved with early diagnosis and aggressive
surgical therapy in concert with empirical antimicrobial ther-
apy.[6]

Case report Figure 3: Chest x-ray, neck soft tissue AP and Lateral x-ray.

A 48-years-old female patient was referred from a general hospi-

tal in Bandung area with swelling and spontaneous drainage at
both sides of lower jaw, chin, and neck region. Approximately a
month before admission, patient complained toothache at her
right lower jaw, but she did not seek any treatment. In the past
14 days, patient complained a swelling at her right lower jaw
and went to private clinic to be treated. She was given antibiotics
and analgesic medicines. About nine days later, the swelling got
more significant and widespread along chin, left lower jaw and
neck region. The swelling followed by spontaneous drainage
and unpleasant odour. Patient’s condition was getting worse
since 3 hours ago so that she was brought to general hospital
in Bandung then referred to Hasan Sadikin hospital for further
treatment afterwards.
Patient felt pain on swallowing with stiffness in the neck.
There was no sign of hoarseness, hot potato voice, and altered
voice. History of systemic disease was denied. Examination of
vital signs in emergency room showed patient’s blood pressure
rate 110/70 mmHg, heart rate 110 times/minutes, body tem-
perature 36,6 C, respiratory rate 20 times/minutes, and SpO2
rate 99% (free air). Extraoral examination revealed the presence
of asymmetrical face, necrotic tissue and spontaneous drainage
at both sides of submandible region, submental, and anterior
neck region with 10x5x2 cm in size. The swelling is localized,
Figure 4: Necrotomy debridement procedure.
reddish coloured, followed with febrile temperature and pain
on palpation.
Intraoral examination revealed generalised hyperemia of gin-

Deka Dharma Putra et al./ International Journal of Medical Reviews and Case Reports (ARTICLE IN PRESS)
 Figure 7: Post operative day XV.
Figure 5: Pus swab for culture resistance test.

Figure 6: A. Post operative day I , B. POD II, C. POD III, D. POD

IV. Figure 8: Two months after procedure. The wound completely
healed.

Deka Dharma Putra et al./ International Journal of Medical Reviews and Case Reports (ARTICLE IN PRESS)
 giva, gangrene of pulp teeth 35, 44 and gangrene radices of tooth
17, 15, 27, 28, 36 and 46. There were plaques and calculus with
mouth opening was about 2 cm wide.
The laboratory findings showed white blood count 9.170
/mm3, Hemoglobin (13,7 g/dL), timely blood glucose (95
mg/dL) and other laboratory findings were within normal limit
without any signs of systemic disease. Some radiographic exam-
inations were performed in the emergency room such as chest
x-ray, neck soft tissue AP and lateral x-ray. From the chest x-
ray, there was no sign of tuberculosis and cardiomegaly. The
neck soft tissue AP and lateral x-ray showed appearance of soft
tissue radiopaque density with radiolucency inside located in
submandible and submental region with the suspicion of ab-
scess. There was also narrowed air column figure as high as
vertebrae cervical 3 to 4.
The patient was also consulted to ENT Department, and the
examination result showed there was no sign of retropharyngeal
abscess, parapharyngeal abscess, and upper airway obstruc-
tion. Based on all of the examination performed, the diagnosis
referred to Necrotizing Fasciitis at cervical, both side of sub-
mandible and submentale region due to gangrene radices of
teeth 36, 46 and gangrene of pulp teeth 34, 45. It was confirmed
that there was no sign of sepsis in this patient but mild dehy-
dration. After the diagnosis was made, mild rehydration was
done to patient and urine catheter inserted to evaluate the urine
output. Pus swab performed for culture resistance test and to
Figure 9: Cadexomer iodine powder 0.9%[17]. sensitivity of antibiotic test. While waiting for the laboratory
results, empirical antibiotics (Ceftriaxone 1 gram, Metronidazole
500 mg) and analgesic (Ketorolac 30 mg) were given through
intravenous infusion. Ranitidine 50 mg IV also provided to de-
crease stomach acid production. The involvement of infected
tissue evaluated and performed complete necrotomy debride-
ment. The wound washed by copious irrigation and antiseptic.
Teeth 34, 36, 45, 46 were extracted to control the source of infec-
tion which was cervical necrotizing fasciitis. The patient was
hospitalized for three days to improve the general condition.
After necrotomy procedure was done, the wound treated
with modern dressing which was cadexomer iodine 0.9% and
polyurethane foam absorbent dressing from day I. Dressing se-
lection was based on wound characteristic. In this case, the
wound still contained purulent exudate after the surgery. For
this kind of wound, cadexomer iodine 0.9% was chosen as an
antiseptic and polyurethane foam absorbent dressing as an ab-
sorber. After the wound cleaned, the antiseptic dressing was
sown with thickness about 3 mm and absorber attached to the
wound. The dressing could be changed after three days or
whenever the dressing full of exudates. The wound needs to
wash with copious irrigation in each dressing replacement. This
dressing used until all the purulent exudate disappears. The
laboratory results came in 7 days after procedure and showed
the causes of infection was Streptococcus agalactiae and still
sensitive to almost all kind of antibiotics.
After all of the purulent exudate disappear, the patient in-
structed to apply hydrocolloid gel on the wound (raw surface)
to accelerate wound healing.
Two months after procedure, the wound completely healed,
the edges of raw surface completely fused and minimized scar
Figure 10: Polyurethane foam absorbent dressing[18]. tissue formation. The wound healing process occurred by sec-
ondary healing without need of skin grafts. There were no
residual raw surface, skin contracture, hyperesthesia or anaes-
thesia. There was also no limitation of head movements so it
could be in extension position rightly. The patient did not have

Deka Dharma Putra et al./ International Journal of Medical Reviews and Case Reports (ARTICLE IN PRESS)
any complaint and fully satisfied with the treatment result. with the presence of purulent exudate. Antimicrobial dressings
include iodine-based preparations, and silver-releasing agents
Discussion have been formulated to be non-cytotoxic. Cadexomer iodine
is bactericidal to all gram-positive and gram-negative bacteria
Cervical necrotising fasciitis is an infection that rapidly pro- as well as fungi, and it facilitates a moist wound environment.
gresses in the facial region. It tends to occur in males. The It is a starch-based polymer bead that promotes the absorption
mortality rate is about 19-40%.[4] The common cause of cervical of fluid, exudate, debris, and bacteria while facilitating the con-
necrotising fasciitis is a dental infection which may progress trolled release of iodine at levels that are not toxic to human
ascending to the base of skull, and descending to the thorax and skin cells. Cadexomer iodine is less cytotoxic than other iodine
mediastinum7. Immunocompromised patients and those who products locally at the wound site. However, it may be absorbed
suffer from systemic illnesses such as diabetes mellitus are at systemically and can be fatal to susceptible individuals (con-
an increased risk of developing this infection. It may also affect comitant thyroid disease). A recent meta-analysis reported that
previously healthy individuals (13-31%)[4,8]. Significant com- cadexomer iodine dressings might be associated with improved
plications from NF are mediastinal involvement, septic shock, healing compared to standard of care [16].
pleural effusion, lung empyema, airway obstruction, rupture of Foam dressings are made of polyurethane base and perme-
vital vessels, brain abscess, disseminated intravascular coagu- able to both gases and water vapor. Their hydrophilic properties
lation (DIC), sepsis, acute renal failure, and respiratory failure allow high absorptive properties while they also provide ther-
[9,10]. mal insulation. These highly versatile dressings are indicated
This evolving emergency state requires prompt diagnosis for wounds with moderate to heavy exudates, granulating or
(both clinical and radiological), implementation of pharmacolog- slough covered partial and full-thickness wounds, donor sites,
ical measures (broad-spectrum IV generation antibiotic therapy minor burns, and diabetic ulcers. They are not recommended in
based on blood and wound cultures), and emergent surgery[5,8]. dry or eschar covered wounds and arterial ulcers due to their
In this case, patient suffered from necrotizing fasciitis, which ability to dry wounds further.
spread to the submandibular region after an infected second They can be left in place for up to 4–7 days but should be
lower molars tooth and progressed over a broad region of the changed once saturated with exudates. Their composition makes
neck. A right radiological examination should be requested as them atraumatic upon removal. If changed daily, they can also
soon as possible to determine the extent of the disease and to be used on infected wounds. In this case, the use of these two
evaluate the airway correctly. Neck soft tissue x-ray performed dressings has provided wound healing which gave a very satis-
to see the formation of subcutaneous gas and abscess also to fying result.[19]
evaluate the sign of retropharyngeal and parapharyngeal ab-
scess. Conclusion
The first step of treatment is to check the airway. Medical
treatment requires a broad range of antibiotics together with Necrotizing fasciitis (NF) is a severe soft tissue infection which
fluid and electrolyte replacements. Emergency surgical debride- characterised by rapidly progressing necrosis, involving fascia
ment of affected tissue is the primary management modality for and subcutaneous tissues. This evolving emergency state re-
NF. Surgical debridement, necrotomy, and fasciotomy are the quires prompt diagnosis, implementation of pharmacological
main aspects of surgical treatment [5,11,12]. Surgical interven- measures, and emergent surgery. Surgical intervention is a life-
tion is life-saving and must be performed as early as possible saving procedure that has to be performed immediately.
since a delayed treatment beyond 12 hours in fulminant forms Another important thing is to treat the wound properly and
of NF can prove fatal. Emergency surgical debridement should select the right dressings regarding the type of wound. The
be performed in all patients within 12-15 hours after admis- wound requires a proper dressing to quicken healing time, pre-
sion. In any case, over 24 hours delay is unacceptable, as the vent complications, and provide an ideal wound healing. The
mortality rate can be nine times greater when primary surgery wound caused by necrotizing fasciitis is infected and contained
is performed 24 hours after onset of symptoms. Surgical de- purulent exudate. This type of wound requires a dressing that
bridement should be repeated during the next 24 hours or later, has anti-bacterial effect and can absorb purulent exudate. In
depending on the clinical course of necrotizing infection and this case, the use of cadexomer iodine 0.9% powder as an anti-
vital functions [13,14]. In this case, surgery performed to the bacterial dressing and polyurethane foam as an absorbent dress-
patient 3 hours after admission. Four areas must be addressed ing of purulent exudate gave a satisfying result in healing the
at the first debridement. These are (1) confirming the diagno- wound, minimized the complications, and decrease patient’s
sis of necrotizing fasciitis and isolating the causative organism; long term morbidity.
(2) delineating the extent of the infection; (3) complete surgical
excision of infected tissue; and (4) post-excision wound care. Conflict of Interest
Once culture results are obtained, antibiotic treatment should
There are no conflicts of interest to declare by any of the authors
be modified to be effective on the effective organisms [15]. The
of this study.
extensive surgical debridement will result in large raw wounds.
Patients, particularly those who are coagulopathic from sepsis,
are at risk of postoperative haemorrhage. Besides, immunocom- Funding
promised patients are at risk of secondary infection. Wound care None
aims to minimize both of these risks. Further dressing changes
should be dictated by the condition of the debrided wound [15].
References
In this case, wound treated with modern dressing; cadexomer
iodine 0.9% and polyurethane foam absorbent dressing. This 1. Green RJ, Dafoe DC, Raffin TA.Necrotizing fasciitis.
dressing material is chosen considering the infected wound type Chest.1996;110(1): 219-229.

Deka Dharma Putra et al./ International Journal of Medical Reviews and Case Reports (ARTICLE IN PRESS)
 2. Lorenzini G, Picciotti M, Di Vece L, Pepponi E, Brindisi L, et 17. https://www.marnemedical.com.au/product/
al.Cervical necrotizing fasciitis of odontogenic origin involv- iodosorb-powder-3g/ accessed on September 10, 2018
ing the temporal region-A case report. J Craniomaxillofac
Surg. 2011;39(8):570-573. 18. http://dermarite.com/product/dermafoam/ accessed on Septem-
ber 10, 2018
3. Giuliano A, Lewis F, Hadley K, Blaisdell FW.Bacteriology
of necrotizing fasciitis. Am J Surg. 1977;134(1): 52-57. 19. Sood A, Granick MS, Tomaselli NL.Wound Dressings Com-
perative Effectiveness Data. Advances In Wound Care.
4. Zhang WJ, Cai XY, Yang C, Zhou LN, Cai M, et al.Cervical 2014;8(3):511-529.
necrotizing fasciitis due to methicillin-resistant Staphylo-
cocus aureus: a case report. Int J Oral Maxillofac Surg.
2010;39(8):830-834.
5. Bono G, Argo A, Zerbo S, Triolo V, Procaccianti P. Cervical
necrotizing fasciitis and descending necrotizing medias-
tinitis in a patient affected by neglected peritonsillar ab-
scess: A case of medical negligence. J Forensic Leg Med.
2008;15(6):391-394.
6. Suykerbuyk C, Frykberg R. Necrotizing fasciitis : A Case
Report. The Journal od Diabetic Foot Complications. 2010;
2(1):1-5
7. Cavel O, Gil Z, Khafif A, Leider-Trejo L, Segev Y, et
al.Necrotizing fasciitis of the skull base and neck in a pa-
tient with AIDS and non- Hodgkin’s lymphoma. Skullbase.
2006;16(4):201-205
8. Mohammedi I, Ceruse P, Duperret S, Vedrinne J, Bouletreau
P.Cervical necrotizing fasciitis: 10 years’ experience at a
single institution. Intensive Care Med. 1999;25(8):829-834
9. Quereshy FA, Baskin J, Barbu AM, Zechel MA.Report of
cervicothoracic necrotizing fasciitis along with a current
review of reported cases. J Oral Maxillofac Surg. 2009;67(2):
419-423.
10. Tung-Yiu W, Jehn-Shyun H, Ching-Hung C, Hung-An
C.Cervical necrotizing fasciitis of odontogenic origin:
Case report of 11 cases. J Oral Maxillofacial Surg.
2000;58(12):1347-1352.
11. Mao JC, Carron MA, Fountain KR, Stachler RJ, Yoo GH,
et al.Craniocervical necrotizing fasciitis with and without
thoracic extension: Management strategies and outcome.
Am J Otolaryngol. 2009;30(1): 17-23.
12. Flanagan CE, Daramola OO, Maisel RH, Adkinson C, Od-
land RM.Surgical debridement and adjunctive hyperbaric
oxygen in cervical necrotizing fasciitis. Otolaryngol Head
Neck Surg.2009;140(5): 730-734.
13. Misiakos EP, Bagias G, Papadopoulos I, Danias N, Patapis
P, et al.Early Diagnosis and Surgical Treatment for Necro-
tizing Fasciitis: A Multicenter Study. Frontiers In Surgery
2017;5(4):1-7
14. Misiakos EP, Bagias G, Patapis P, Sotiropoulos D, et
al.Current concepts in the management of necrotizing fasci-
itis. Frontiers In Surgery.2014;36(1):1-10
15. Wong CH, Yam AKT, Tan ABH, Song C.Approach to de-
brideent in necrotizing fasciitis. The American Journal of
Surgery. 2008;196(3):e19-e24.
16. Dabiri G, Damstetter E, Phillips. Choosing a Wound Dress-
ing Based on Common Wound Chracteristics. Advances In
Wound Care.2016;5(1):32-41

Deka Dharma Putra et al./ International Journal of Medical Reviews and Case Reports (ARTICLE IN PRESS)