Necrotising fasciitis of the posterior neck crossing the midline: A case report

INTRODUCTION AND IMPORTANCE: Craniofacial necrotising fasciitis is a complex condition, with high mortality given its propensity to descend via the deep neck spaces into the chest and mediastinum. Management requires optimal antimicrobial therapy with associated aggressive surgical debridement. PRESENTATION OF CASE: A 64-year-old man presented to ENT with a posterior neck swelling. Despite incision and drainage of the swelling following a trial of antimicrobial therapy, it increased in size, with areas of overlying necrosis demonstrated. Based on radiological and clinical findings, a diagnosis of necrotising fasciitis was made. He was taken to theatre for debridement. Intra-operatively, carotid sheath suppuration was noted, after tissue retraction resulted in copious bleeding from the anterior wound bed, requiring vigorous resuscitation and clamping of underlying structures to achieve haemostasis. Senior ENT and vascular surgery involvement was quickly sought to achieve haemostasis, however bleeding from the wound bed was difficult to control. This was due to the significant watershed area at the posterior neck which would not have been amenable to selective vessel ligation. After multiple cardiac arrests, a team decision was taken to discontinue resuscitation. CLINICAL DISCUSSION: Operating in this area of anatomical complexity required input from a number of different specialty teams. Although input from infectious diseases, microbiology, plastic surgery and tissue viability was commendable, there was room for optimising this further. Early patient referral to a tertiary centre where on-site input was available from maxillofacial surgery and plastic surgery would have been beneficial; a set-up commonly seen in regional trauma networks. CONCLUSION: This case demonstrates the intricacies surrounding a rare occurrence of necrotising fasciitis of the neck crossing the midline. Multi-disciplinary team involvement is imperative and should be encouraged at an early stage.