0:01

Let's look at this patient who had left sided neck pain, fever,

0:05

and there were areas of breakdown in the skin.

0:08

We start off superiorly looking at the brain.

0:11

The brain tissue looks fine.

0:13

The vessels of the circle of Willis look fine.

0:16

The orbit got a little bit of enlargement

0:19

of the optic nerve sheath complex.

0:21

And then we see this area of air in the temporalis muscle

0:26

of the masticator space. Let's follow that air downward.

0:30

So we see new air here at the pterygoid muscle, as well

0:34

as at the coronoid process of the left mandible.

0:38

In the left side of the neck,

0:39

we have air in the parapharyngeal space,

0:42

anterior to the carotid sheath,

0:44

and there is mass effect displacing the airway from

0:48

left to right. Continuing in the left side of the neck,

0:51

we also see involvement of the buccal space, as well as the area

0:56

around the parotid tissue, which is coursing along

1:00

the expected location of Stensen's duct.

1:04

The left side of the neck continues to show areas of

1:08

abnormality in the parapharyngeal space with all this

1:11

air collection, again, airway displaced medially.

1:15

And here we have air in the retropharyngeal space,

1:18

a collection of purulent material coming into the

1:24

peritonsillar region, and then into the floor of the mouth,

1:29

submandibular space, submental space,

1:32

and we're also seeing a trek even to the posterior triangle

1:37

and the supraclavicular fossa, and then from there, into the

1:41

visceral space of the head and neck

1:44

structures and strap muscles.

1:46

Here you have just beads of air along the clavicle in the

1:51

supraclavicular and infraclavicular space, and

1:54

then even towards the axilla.

1:56

Well, clearly,

1:57

as you hear me describe this, this is transpatial.

2:00

It's going across the fascia of the masticator space,

2:06

the parotid space, the parapharyngeal space,

2:08

the retropharyngeal space, the visceral space,

2:13

as well as the submandibular and submental space,

2:17

and then into the supraclavicular

2:19

fossa and even into the axilla.

2:22

This is destroying the fascia that normally would separate an

2:27

infectious process into one of the spaces and confine it.

2:30

It's just eating right through the fascia.

2:33

This is known as necrotizing fasciitis,

2:36

a very virulent infection that is very hard to eradicate,

2:41

requires intravenous antibiotic and often requires debridement

2:45

of dead tissue that is occurring in the neck.

2:49

At this point, with this... as diffuse as this is,

2:52

this patient is unlikely to survive this infection.

2:57

You also want to look and make sure that you don't see

3:00

areas where there has been breakdown in the skin surface.

3:04

Because that could be a secondary infection of staph.

3:08

epididymis or staph. aureus, extending into the area

3:11

where there already is an aggressive infection.

3:14

So just a horrifying infection,

3:17

necrotizing fasciitis.

Case 42 - Necrotizing Fasciitis

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