Case 42 - Necrotizing Fasciitis
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Let's look at this patient who had left sided neck pain, fever,
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and there were areas of breakdown in the skin.
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We start off superiorly looking at the brain.
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The brain tissue looks fine.
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The vessels of the circle of Willis look fine.
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The orbit got a little bit of enlargement
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of the optic nerve sheath complex.
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And then we see this area of air in the temporalis muscle
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of the masticator space. Let's follow that air downward.
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So we see new air here at the pterygoid muscle, as well
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as at the coronoid process of the left mandible.
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In the left side of the neck,
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we have air in the parapharyngeal space,
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anterior to the carotid sheath,
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and there is mass effect displacing the airway from
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left to right. Continuing in the left side of the neck,
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we also see involvement of the buccal space, as well as the area
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around the parotid tissue, which is coursing along
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the expected location of Stensen's duct.
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The left side of the neck continues to show areas of
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abnormality in the parapharyngeal space with all this
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air collection, again, airway displaced medially.
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And here we have air in the retropharyngeal space,
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a collection of purulent material coming into the
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peritonsillar region, and then into the floor of the mouth,
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submandibular space, submental space,
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and we're also seeing a trek even to the posterior triangle
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and the supraclavicular fossa, and then from there, into the
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visceral space of the head and neck
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structures and strap muscles.
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Here you have just beads of air along the clavicle in the
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supraclavicular and infraclavicular space, and
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then even towards the axilla.
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Well, clearly,
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as you hear me describe this, this is transpatial.
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It's going across the fascia of the masticator space,
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the parotid space, the parapharyngeal space,
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the retropharyngeal space, the visceral space,
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as well as the submandibular and submental space,
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and then into the supraclavicular
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fossa and even into the axilla.
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This is destroying the fascia that normally would separate an
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infectious process into one of the spaces and confine it.
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It's just eating right through the fascia.
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This is known as necrotizing fasciitis,
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a very virulent infection that is very hard to eradicate,
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requires intravenous antibiotic and often requires debridement
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of dead tissue that is occurring in the neck.
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At this point, with this... as diffuse as this is,
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this patient is unlikely to survive this infection.
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You also want to look and make sure that you don't see
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areas where there has been breakdown in the skin surface.
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Because that could be a secondary infection of staph.
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epididymis or staph. aureus, extending into the area
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where there already is an aggressive infection.
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So just a horrifying infection,
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necrotizing fasciitis.
David M Yousem, MD, MBA
Professor of Radiology, Vice Chairman and Associate Dean
Johns Hopkins University
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