Head and Neck Imaging

Necrotizing fasciitis

acute, severe and potentially life-threatening infection by streptococcus or a mixed bacterial population (including anaerobic bacteria). The infection propagates through the soft tissues, without respecting fascial barriers. It occurs in immunocompromised patients, but also in otherwise healthy individuals. Necrotizing fasciitis is an uncommon disease in the head and neck. It often begins insidiously, with nonspecific soft tissue swelling, erythema and fever. At an early stage, differentiation from cellulitis may be clinically impossible. However, in necrotizing fasciitis early aggressive surgical intervention is mandatory, as antibiotic treatment alone is insufficient; untreated, it will lead to mediastinitis and/or septic complications, with a high mortality rate.

The role of imaging is to diagnose necrotizing fasciitis at an early stage. Reliable CT features include (Fig.1):

  • thickening and infiltration of the cutis and subcutis (cellulitis)

  • enhancement and infiltration of the superficial and deep cervical fascia (fasciitis)

  • enhancement and thickening of the platysma, sternocleidomastoid and strap muscles (myositis)

  • fluid collections in multiple neck compartments.

    Variable CT features are gas collections, mediastinitis, and pleural and pericardial effusions.

    Complications due to progressive disease after initial surgical debridement may be detected by follow-up imaging. In these patients, repetitive surgical exploration and drainage of new collections, is often necessary to control the disease.

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    Fig.1

    a, b. Axial contrast-enhanced CT images of neck reveal diffuse cellulitis, fluid collections, myositis (e.g. left sternocleidomastoid muscle, arrow) and fasciitis (e.g. surrounding right sternocleidomastoid muscle, arrowheads) (courtesy by Minerva Becker, MD, Geneva, Switzerland).
    Necrotizing fasciitis, Fig.1 (a)
    Necrotizing fasciitis, Fig.1 (b)