CT Case 068
A 60-year-old male is brought in by ambulance with fevers >40°C, rigors and confusion.
He has been on antibiotics for the preceding 3 days due to a dental infection with associated facial swelling and had a dental extraction earlier the same day.
On examination he looks unwell. Vitals include temperature 41.9°C; GCS 14; BP 110/80, HR 95
Extensive swelling of the right side of the face extending from maxilla to the submental space, very tender to palpate with overlying erythema and subcutaneous crepitus palpable above the ear
He had limited mouth opening to 2 finger breaths, there was no visible discharge within the mouth. He had an expeditious CT scan organised after a bedside nasendoscopy showed no significant airway compromise.



Describe and interpret the CT images
There is necrotising deep soft tissue infection.
There is transpatial involvement from the right temporal fossa, masticator space, submandibular space and visceral space to the base of the neck, threatening to extend into the mediastinum.
CT shows predominantly abnormal soft tissue gas, small volume of fluid, oedema of the involved muscles and other soft tissue structures (right parotid and submandibular gland). There is associated mass effect with displacement and mild compression of the airways.
Outcome
Intra-operatively
Surgical management involved extensive exploration and debridement of the neck and face.
Multiple abscess pockets were found in the submental, submandibular, carotid spaces and adjacent to the right thyroid. The temporalis fascia was necrotic.
Consistent with the CT findings, intra-operatively there was extensive soft tissue necrosis.
There was a large amount of malodorous fluid with the classic ‘dishwater fluid’ appearance seen in necrotising fasciitis.
Clinical Pearls
Necrotising fasciitis is an aggressive infection of the soft tissues that starts in the subcutaneous tissues and spreads along fascial planes. Necrotising fasciitis is very unusual in the head and neck, more commonly it is seen in the extremities (CT Case 23) and perineum – Fournier gangrene (CT Case 51). In the face, common sources are odontogenic (as in this case), sinugenic or related to peritonsillar or salivary gland infections.
The patient was treated with broad-spectrum antibiotics; meropenem, vancomycin and clindamycin to cover the usual polymicrobial source. Blood cultures and intra-operative specimens grew Streptococcus milleri and his antibiotics were rationalised to penicillin alone. He had multiple trips to theatre for debridement; multiple abscess pockets were found in the submental, submandibular, carotid spaces and adjacent to the right thyroid. He also was transferred to a hyperbaric unit for several sessions of hyperbaric oxygen therapy and finally extubated on Day 12.
Hyperbaric oxygen (HBO) has been utilised to treat necrotising infections with mixed success and may have a role in select patient groups.
References
- Ahmadzada S, Rao A, Ghazavi H. Necrotizing fasciitis of the face: current concepts in cause, diagnosis and management. Curr Opin Otolaryngol Head Neck Surg. 2022 Aug 1;30(4):270-275.
- Park E, Hirsch EM, Steinberg JP, Olsson AB. Ascending necrotizing fasciitis of the face following odontogenic infection. J Craniofac Surg. 2012 May;23(3):e211-4.
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Dr Leon Lam FRANZCR MBBS BSci(Med). Clinical Radiologist and Senior Staff Specialist at Liverpool Hospital, Sydney
Sydney-based Emergency Physician (MBBS, FACEM) working at Liverpool Hospital. Passionate about education, trainees and travel. Special interests include radiology, orthopaedics and trauma. Creator of the Sydney Emergency XRay interpretation day (SEXI).
Provisional fellow in emergency radiology, Liverpool hospital, Sydney. Other areas of interest include paediatric and cardiac imaging.
Emergency Medicine Education Fellow at Liverpool Hospital NSW. MBBS (Hons) Monash University. Interests in indigenous health and medical education. When not in the emergency department, can most likely be found running up some mountain training for the next ultramarathon.