International Journal of Pediatric Otorhinolaryngology 76 (2012) 18571860

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International Journal of Pediatric Otorhinolaryngology

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Case report

Cervical necrotizing fasciitis in children under two years of age

Victor Chung a,*, Andrew Scott b
a
b

Department of Otolaryngology and Head & Neck Surgery, Tufts Medical Center, Boston, MA, USA
Divisions of Pediatric Otolaryngology and Facial Plastic Surgery, Floating Hospital for Children at Tufts Medical Center, Boston, MA, USA

A R T I C L E I N F O

A B S T R A C T

Article history:
Received 24 May 2012
Received in revised form 16 June 2012
Accepted 3 September 2012
Available online 12 October 2012

We present two cases of life-threatening, necrotizing infections of the head and neck region, a rare
infectious process in young children, that progressed to bacteremia and sepsis in two toddlers. To date
there have been no reports of cervical necrotizing fasciitis in toddlers under two years of age.
Immunocompromised children may be at higher risk for developing fulminent infections. Optimal
management requires a combination of medical and surgical interventions. An aggressive surgical
approach may be required to adequately clear the infection.
2012 Elsevier Ireland Ltd. All rights reserved.

Keywords:
Necrotizing fasciitis
Head and neck
Toddler
Cervical
Treatment
Infection
Pediatric

1. Introduction
Necrotizing fasciitis is a rare clinical head and neck entity that is
predominantly an adult disorder. It has been described in the
pediatric literature for neonates [1]. We report 2 cases of cervical
necrotizing fasciitis in an 18-month-old male and 15-month-old
female, where we discuss the management in this previous
undescribed population. Informed consents were obtained from
the patients parents.

2. Case report #1
A 18-month-old male, ex-23-week premature infant, who
recently underwent an expansion laryngotracheoplasty to treat his
acquired grade III subglottic stenosis, had a hospital course
complicated by a pressure ulcer on his occiput. He returned to the
operating room for endoscopic dilation and granulation tissue
excision. He had been on prolonged corticosteroid therapy for his
airway pathology. Following a recent dilation, he developed a
postoperative pneumonia and pneumonitis, which was treated

* Corresponding author at: Department of Otolaryngology, Head & Neck Surgery,

Tufts Medical Center/Floating Hospital for Children, USA. Tel.: +1 617 636 2820;
fax: +1 617 636 1479.
E-mail address: vchung@tuftsmedicalcenter.org (V. Chung).
0165-5876/$ see front matter 2012 Elsevier Ireland Ltd. All rights reserved.
http://dx.doi.org/10.1016/j.ijporl.2012.09.012

empirically with piperacillin and tazobactam and vancomycin

while intubated in the pediatric intensive care unit.
On post-operative day #4, in the setting of gram-positive septic
bacteremia, a new and discrete ecchymotic lesion appeared on his
right posterior neck. Over a period of hours the site developed local
edema, a deep violaceous hue, and central necrosis. Computed
tomography scan showed uid between fascial planes of the
posterior paraspinal muscles, but there was no formed abscess or
gas collection. Punch biopsies, consistent with dermal necrosis,
were taken at bedside (see Fig. 1). He was emergently taken to the
operating room for radical debridement of skin, soft tissue, and
deep muscle to viable margins and posterior neck dissection (see
Fig. 2). Pathology report conrms necrotic process in the Level V
specimen: acute inammation of deep fascia, soft tissue, muscle,
and adipose tissue consistent with necrotizing fasciitis and
myositis. Bedside debridement was performed as necessary, with
twice daily dressing changes. Empiric antibiotic therapy included
vancomycin, gentamicin, and piperacillin and tazobactam. The
patient was supported in the intensive care unit with vasopressors
and mechanical ventilation. Blood cultures yielded Streptococcus
viridans. Medical therapy was narrowed to vancomycin and
metronidazole to match culture results and included coverage
for a concomitant Escherichia coli pneumonia.
On post-operative day #4, a revision tracheostomy was
performed. One week after the infection had stabilized, no
additional debridement of necrotic tissue was necessary and a
lower island trapezius myocutaneous ap reconstruction lled the

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Fig. 3. Healed site of trapezius lower island ap reconstruction of posterior neck

defect.
Fig. 1. Punch biopsy sites at center of necrosis and gross margin of normal tissue.

cervical defect. The patient has done well, not requiring further
intervention at the 16-month interval (see Fig. 3).
3. Case report #2
A 15-month-old female, born at full term, who was admitted
after one week of rhinorrhea and cough, presented to the
emergency department with fever 38.5 8C and left peritonsillar
and neck swelling with a leukocyte count of 35,000/mm3. She was
empirically started on clindamycin and vancomycin. Computed
tomography scan showed a large heterogeneous collection with an
indistinct enhancing rim and multiple gas pockets medial to the
left mandibular ramus with extension into the left submandibular,
parapharyngeal and masticator spaces (see Fig. 4). The family did
not note any airway symptoms or prior trauma.
The patient was taken urgently to the operating room for
examination under anesthesia and left neck exploration. There was
a 1 cm  1 cm hole along the lingual surface of the mandible and

posterior oor of mouth just medial and inferior to the left

retromolar trigone. Soft tissue necrosis communicated oral cavity
to the skull base, prompting a transcervical incision and drainage
of left parapharyngeal space and masticator spaces abscesses,
aggressive debridement of left parapharyngeal space necrotic
tissue, and selective neck dissection of Level Ib. Specimen
pathology conrmed broadipose tissue with hemorrhage, acute
inammation, and extensive necrosis. The wound site was
thoroughly packed with betadine-soaked strip gauze, which was
serially removed over 3 days. The patient recovered in the pediatric
intensive care unit, where she received volume resuscitation,
ventilatory support, intravenous antibiotics, and wound care. The
patient was placed on vancomycin and piperacillin and tazobactam for a suspected polymicrobial process, conrmed later by
culture growth. Surveillance endoscopy showed draining wound
site, but no further necrosis. Repeat computed tomography scan
conrmed no discrete uid collection (see Fig. 5). Immunologic
work-up was normal.
The patient was extubated on post-operative day #5 and
discharged home on oral linezolid and metronidazole. At her 12month follow-up she is without functional decit or need for
further intervention (see Fig. 6).
4. Discussion

Fig. 2. Posterior neck dissection * labels splenius capitus muscle. Arrow labels spinal
accessory nerve.

Jones rst described necrotizing fasciitis as hospital gangrene in

1871. Meleny described 20 cases of streptococcal gangrene in
1924. And Wilson is credited with coining the term necrotizing
fasciitis, which described the typical clinical presentation:
tachycardia, fever, and local infection leading to a severe, often
fulminating infection with necrosis of the subcutaneous and
supercial tissues [2].
In our review of the literature, we found the necrotizing fasciitis
data to be largely based in the adult literature. Adult necrotizing
fasciitis of the head and neck region are rare with a majority of
these infections with dental etiology or trauma-related [3]. The
majority of pediatric cases are outside the head and neck region,
with the exception of neonatal cases describing scalp lesions
secondary to fetal monitor trauma [1] and a case report of
pharyngeal necrotizing fasciitis as a complication of adenotonsillectomy [4]. Treatment of pediatric necrotizing fasciitis is generally
extrapolated from the strategies of adult management. Cervical
necrotizing fasciitis in the under-two-year-old population has not
been previously described.

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Fig. 4. Coronal and axial computed tomography scans with gas in deep fascial planes.

Classic necrotizing fasciitis presents as a discrete skin lesion

that develops erythematous discoloration, transitioning to gray,
green, or purple. Eventual vesicle or bulla formation is associated
with necrosis [2]. Our cases displayed both extremes. Case #1 had
classic skin ndings, developing local edema, a deep violaceous
hue, and central necrosis in a period of hours. Case #2 had no
external skin ndings on exam.
Necrotizing fasciitis has been described in the pediatric
pharynx. Roberson reports a case of pharyngeal necrotizing
fasciitis as a complication of adenotonsillectomy. Involvement of
the deep neck space often presents with inability to manage
secretions, irritability or lethargy, throat pain, dysphagia, odynophagia, mufed voice, torticollis, dehydration, fever, and a
compromised airway [4]. Our patient in Case #2 can be accurately
described by this presentation, but she was without acute airway
symptoms.
On radiologic study subcutaneous emphysema is indicative of
anaerobic conditions for gas producing organisms [5]. Among our
patients, our patient with pharyngeal necrotizing fasciitis demonstrated subcutaneous gas collection on computed tomography
imaging, prompting emergent management; however, our patient
with the classic skin ndings had no subcutaneous gas evident on
exam or imaging.

The mainstay of treatment is broad-spectrum intravenous

antibiotic coverage and aggressive surgical debridement. There is a
general consensus that early and aggressive surgical debridement
results in better survival in necrotizing fasciitis [6]. It is noted that
the adult literature also concludes that the drastic surgical
intervention required for survival often leaves patients with
pronounced disgurement [7].
Intraoperatively the goal is to drain affected fascial planes and
to debride necrotic tissue to the end point of bleeding/viable tissue
at all margins, with little regard for reconstructive consequences,
for the sake of a life saving surgery. The pediatric concept is the
same regardless of the patient being a small child and high risk of
disguring defect. In Case #1, effective debridement resulting in a
signicant posterior neck defect with exposed deep neck
neurovascular structures (see Fig. 2). Case #2, required a large
cervical incision and debridement to the level of the skull base.
Specimens are sent intraoperatively for pathologic conrmation
and culture. Scheduled return to the operating room for reinspection and further debridement is common. Patients will require
Intensive Care for airway management, hemodynamic support,
and central access for IV antibiotic therapy. Both patients remained
in the pediatric ICU for the majority of their hospital course.
Source infections are presumed to be polymicrobial, including
both anaerobic and aerobic bacteria. Necrotizing Fasciitis historically thought to be due to aerobic infections, primarily group A
beta hemolytic streptoccocus and staphylococcus aureus. As
culture techniques improved, the role of anaerobic organisms in
NF was identied. Empiric antibiotic therapy should reect these
results [8]. Moss et al. recommends a combination of penicillin or
cephalosporin for gram-positives, aminoglycoside for gramnegatives, and clindamycin or metronidazole for anaerobic

Fig. 5. Post-operative axial computed tomography scan with resolution of gas.

Fig. 6. Healed cervical incision at 12 months.

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V. Chung, A. Scott / International Journal of Pediatric Otorhinolaryngology 76 (2012) 18571860

organism [9]. Once intraoperative culture data reveals the

causative organism, the antibiotic regimen may be narrowed to
match microbial sensitivities.
It is understood that adults with diabetes, alcoholism, and
atherosclerotic disease are at higher risk for necrotizing fasciitis.
Pediatric cases of necrotizing fasciitis are more likely to be in
previously healthy individuals. Referring to our patient from Case
#1, his immune system had been iatrogenically suppressed by
repetitive courses of stress dose corticosteroids in his setting of
airway edema, while our other case had been previously healthy.
Initially the management priority is to clear the infection for
patient survival. Defect reconstruction and airway may be
addressed secondarily to infection resolution. In our patient, we
performed a trapezius island ap to repair the large posterior neck
defect. A group from Turkey advocates for early wound resurfacing
after major debridement. They believe that early split thickness
skin grafts prevents uid, electrolyte, and protein loss; with fewer
secondary infection [6].
5. Conclusion
Cervical necrotizing fasciitis is a rare infectious process in
young children. We described two cases representing instances of
life-threatening infection in which early diagnosis and aggressive
surgical treatment resulted in good outcomes. Immunocompromised children may be at higher risk for developing fulminent
infections. Optimal management requires a combination of
medical and surgical interventions. In addition to broad spectrum
antibiotics, an aggressive surgical approach, despite the risk of a
disguring defect, may be required to adequately clear the
infection for the best chance for survival.

Financial disclosure
None.
Conict of interest
None.
External funding
None.
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