Cervical Necrotizing Fasciitis in an Uncontrolled Diabetic Male Patient: A Multimodal Management Approach

Abstract

Cervical necrotizing fasciitis is a rare, life-threatening infection, often odontogenic. We report a case of idiopathic cervical necrotizing fasciitis in an uncontrolled diabetic patient, successfully managed through a multidisciplinary approach with good wound healing. A 54-year-old male with type 2 diabetes mellitus presented with a 10-day history of painful neck swelling and purulent discharge on the left side of the neck. Clinical examination revealed signs of necrotizing infection, confirmed by laboratory tests and contrast-enhanced computed tomography (CECT), which showed a large necrotic collection with gas formation extending to the supra-glottic region. Management included broad-spectrum antibiotics, insulin therapy, and urgent surgical debridement. Extensive necrosis involving the neck and laryngeal structures necessitated a second debridement on day seven, followed by negative pressure wound therapy. A split-thickness skin graft on day 14 led to complete healing, and the patient was discharged on day 21 with full recovery at the one-month follow-up. Cervical necrotizing fasciitis poses a high risk due to its proximity to vital structures and potential for mediastinal spread. Early diagnosis through imaging and clinical evaluation, along with aggressive surgical debridement and advanced wound care, is essential. This case underscores the importance of a multimodal strategy and optimal diabetes control in facilitating recovery and minimizing hospital stay. Idiopathic cervical necrotizing fasciitis, though rare, demands prompt diagnosis and intervention. An integrated approach, incorporating early imaging, repeated debridement, negative pressure therapy, and skin grafting, can significantly enhance patient outcomes. In this case, comprehensive management resulted in recovery within 21 days, shorter than the typical hospital stay for similar cases.

Keywords: cervical; debridement; idiopathic origin; multi-disciplinary; necrotizing fasciitis; skin grafting; wound negative pressure therapy.

Figure 1. Preoperative image showing necrotizing infection (yellow arrow).

Figure 2. CT images showing the extent of necrotizing infection.

(A) Axial view of the upper boundary: arrow 1 (mandible), arrow 2 (air and fluid). (B) Axial view of the lower boundary: arrow (subcutaneous air). (C) Sagittal and (D) coronal views: arrow 1 (mandible), arrow 2 (fluid with air shadow), and arrow 3 (clavicle).

Figure 3. Image after first surgery with arrows pointing to corrugated drains.

Figure 4. Intraoperative and postoperative images.

(A) Day seven post-initial debridement, arrows (1) and (2) mark infection spread. (B) Post-second debridement wound status, an arrow pointing to the depth of the involved area. (C) With NPWT dressing. (D) Wound post-NPWT treatment. NPWT: negative pressure wound therapy.

Figure 5. Post-skin graft follow-up image showing healed graft site with satisfactory integration (yellow arrow).