Advances in Oral and Maxillofacial Surgery 6 (2022) 100254

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Advances in Oral and Maxillofacial Surgery

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Outcomes of necrotizing fasciitis in the head and neck region in the United
Kingdom-a case series and literature review☆
Hira Nazir a, *, Chiew Ying Chieng b, Simon N. Rogers b, c, Ramunas Nekrasisus a, Martin Dodd b,
Neil Shah a
a
Queen’s Hospital, Rom Valley Way, Romford, RM7 0AG, UK
b
Regional Maxillofacial Unit, Aintree University Hospital, Lower Lane, Liverpool, UK
c
Evidence-Based Practice Research Centre (EPRC), Faculty of Health and Social Care, Edge Hill University, St Helens Road, Ormskirk, UK

A R T I C L E I N F O A B S T R A C T

Keywords: Introduction: Necrotising fasciitis (NF) is a relatively rare but aggressive infection with high mortality and
Necrotising morbidity if not treated early. Presentation can be vague which can contribute to the treatment delays and poorer
Fasciitis patients’ outcomes. The aim of this paper was to reflect on incidence, causation, management and mortality of
Odontogenic
head and neck (HN) NF cases in the UK by conducting a literature review and present a case series.
Infection
Method: The literature search was undertaken using PubMed, CINAHL, EMBASE and Medline for HN NF in
Cervical
accordance to PRISMA. Our case series were collected from patients treated between 2010 and 2020 in two
hospitals; in East London and Merseyside regions. The data parameters include patients’ demographics, co-
morbidities, radiographic investigations, management, microbiology, length of stay and mortality.
Results: A total of fifty-one cases were included. Only 59.5% of cases reported of underlying health condition. The
main origin of infection was odontogenic (29.4%) and traumatic (27.5%). Before their acute presentation of NF,
41.2% had sought medical treatment either from primary care or emergency services. All patients received IV
antibiotics of varying types and 90.2% had surgical debridement. Overall, the mortality rate was 17.6%; cases of
traumatic origin had a higher mortality (35.7%).
Conclusion: There is a need for awareness for early detection of clinical diagnosis of H&N NF in primary care and
emergency services. Prompt referral to the specialist services is crucial to allow early management and improve
patients’ outcomes particularly in patients with a history of H&N trauma.

1. Introduction Beta haemolytic streptococcus type A is well known to be one of the

Necrotising fasciitis (NF) is a fast progressing infection of the soft
tissues defined as the necrosis of the subcutaneous tissues and under­
lying fascia [1]. Cervicofacial NF is often a sequalae of an underlying
primary infection or injury such as a laceration, graze, following tooth
infection or extraction but has also been reported without any known
cause [1–3]. Mortality and morbidity are high for NF and directly linked
to prompt diagnosis and initiation of definitive treatment [1,4]. At the
early stages, presentation can be rather vague as signs and symptoms
such as acute pain, swelling and erythema are also seen in other in­
fections. This challenge contributes towards the delay in diagnosis and
treatment and therefore poorer prognostic outcomes.
most common causative bacteria in NF, however, many other bacteria,
fungi and viruses also shown to be associated with the infection [1,5].
Pre-existing medical co-morbidities have been strongly linked to NF;
particularly diabetes and cardiovascular disease, with around a third of
patients presenting with no underlying medical conditions [6].
There has been a vast array of presentations and diagnostic features
described in previous literature reviews of NF. Severe pain is the most
common complaint alongside more vague systematic presentations
including malaise, flulike symptoms and fever. As pain is one of the
hallmarks presentations for NF it is rather subjective making diagnosis
undistinguishable from other acute presentations. Shindo et al. reported
a total of 35 patients with NF in the facial region in a literature review in

The paper has not been submitted to another journal or presented at any meeting. There is no conflict of interest to declare.
☆

* Corresponding author. Oral and Maxillofacial Department, Queen’s Hospital, Rom Valley Way, Romford, RM7 0AG, UK.
E-mail addresses: hira.nazir6@nhs.net (H. Nazir), chiew.chieng1@nhs.net (C. Ying Chieng), simonn.rogers@liverpoolft.nhs.uk (S.N. Rogers), Ramunas.
nekrasius@nhs.net (R. Nekrasisus), martin.dodd@liverpoolft.nhs.uk (M. Dodd), Neil.Shah3@nhs.net (N. Shah).

https://doi.org/10.1016/j.adoms.2022.100254
Received 4 January 2022; Accepted 13 January 2022
Available online 21 January 2022
2667-1476/© 2022 The Authors. Published by Elsevier Ltd on behalf of British Association of Oral and Maxillofacial Surgeons. This is an open access article under
the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
H. Nazir et al.
1997 [1]. In 2018, Gore et al. found 164 patients presented with NF from
odontogenic source alone over a period of 31 years [2]. There has been
much debate regarding the rise of NF cases over the years, particularly
with an increase in the number of patients suffering from immunosup­
pressive diseases such as HIV, diabetes and arteriosclerotic diseases [7].
To our knowledge, literature review on UK-based head and neck
necrotising fasciitis cases has not been previously published. Hence the
aim of this study was to report on the incidence, causation, management
and mortality of NF cases in the UK in addition to our case series.
2. Methodology
2.1. Literature review
A literature search using NICE Healthcare Databases Advanced
Search (HDAS) which includes PubMed, CINHAL, EMBASE and Medline
was conducted with specific key words including ‘necrotizing fasciitis’
OR ‘necrotising fasciitis’, ‘flesh-eating’, ‘head’, ‘facial bones, ‘ear’, ‘face’,
‘scalp’, ‘skull base’, ‘neck’, ‘parapharyngeal space’, ‘cranium’ and ‘cer­
vical’. A total of 744 papers were found. The Preferred Reporting Items
for Systemic Reviews and Meta-Analysis (PRISMA) guidelines were used
to analyze the studies. The flowchart below identifies the study selection
process (Fig. 1). All 744 papers were reviewed manually. Following
exclusions of duplicates, non-UK based papers, non-NF of head and neck
and review articles without case reports or series, a total of 30 papers
were identified. Three additional papers identified from bibliography
review was included. For the purpose of this review, all case reports and
case studies were included regardless of age as long as they had patient
Fig. 1. Flow diagram for study selection of Head and Neck Necrotising fasciitis in the UK.
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Advances in Oral and Maxillofacial Surgery 6 (2022) 100254
specific data which could be analysed and a formal diagnosis of
necrotising fasciitis of the head and neck was made. A total of 44 cases
were retrieved from our literature search (Supplementary Table A.)
[8–39].
2.2. Case series
Furthermore, another 7 cases were included from our experience for
data analysis from one district hospital in East London and a regional
unit in Merseyside from 2010 to 2020 (Supplementary Table B).
2.3. Data collection
Our data parameters include patients’ demographics, source of
infection, radiographic investigations, antimicrobials, surgical man­
agement, microbiology, length of hospital stay and mortality. These data
were recorded and analysed on Microsoft Excel.
3. Results
A total of 51 cases were found and analysed collectively. The median
age of patients was 47 (Range 12 to 91). The ratio of male to female
patients was 1.13:1. The average number of days of presentation to the
Emergency Department was 3 days, ranging from 1 to 14 days. Before
their acute presentation of NF, 41.2% (n = 21) of patients sought
medical treatment either from the dentists, general practitioners, and
Emergency Department of which 20 patients were on antimicrobial
therapy and one had debridement and wound closure. Only 34 cases
H. Nazir et al. Advances in Oral and Maxillofacial Surgery 6 (2022) 100254

mentioned patients’ reported signs and symptoms on presentation with Table 1

the most common being swelling (n = 12), pain (n = 13) and pyrexia (n Clinical Characteristics of NF cases in UK.
= 13). Parameter UK (n = 51)
42 cases reported detailed medical history of which 40.5% (n = 17)
Age, years 47 (12 – 91)
were fit and well, 26.2% (n = 11) had cardiovascular diseases, 16.7% (n Sex
= 7) had diabetes and 26.2% (n = 11) were poly co-morbid. Only six Male 52.9% [27]
patients were reported to be alcohol dependent and two were intrave­ Female 47.1% [24]
nous drug users with hepatitis C. Clinical presentation
Swelling 23.5% [12]
26 cases reported detailed white cell count of which the median was Pain 25.5% [13]
21.3 × 10,000/μl (ranging from 5–46.2 × 10,000/μl). 13 cases Pyrexia 25.5% [13]
mentioned C-Reactive protein with a median of 256 mg/L and a range of Source of infection
28–421 mg/L. Further investigations were reported in 37 cases of which Odontogenic 29.4% [15]
Trauma 27.5% [14]
67.6% (n = 25) CT scans, 37.8% (n = 14) plain films, 16.2% (n = 6)
Tonsilitis 11.8% [6]
ultrasound scans and 2.70% (n = 1) MRI. Others 11.8% [6]
All patients received intravenous antibiotics. Metronidazole (n = 25) Unknown 19.6% [10]
was the most prescribed antibiotic, followed by cephalosporins (n = 17), Background medical history
benzylpenicillin (n = 11), and flucloxacillin (n = 6). When examining Diabetes mellitus 16.7% [7]
Cardiovascular disease 21.6% [11]
trend over the years, benzylpencillin was the most prescribed antibiotic Alcoholism 9.80% [5]
whereas now metronidazole appears to be the most popular. Among the Hepatitis C 3.92% [2]
reported microbiology, beta-haemolytic streptococcus were found in 13 No medical co-morbidities 33.3% [17]
patients and streptococcus milleri were each identified in 10 patients, 9 Unknown 17.6% [9]
Attended to ED or primary care prior to presentation 41.2% [21]
patients with mixed anaerobes and 7 with streptococcus pyogenes.
Inflammatory markers
The aetiology of NF was unknown for 19.6% (n = 10) of cases. White cell count (10,000/μl) 21.3 (5–46.2)
Odontogenic infections were the common cause at 29.4% (n = 15) fol­ C-Reactive Protein (mg/L) 256 (28 – 421)
lowed by trauma at 27.5% (n = 14), tonsilitis at 11.8% (n = 6) and Imaging
others 11.8% (n = 6). Others include epiglottis infection, Bezold’s ab­ Plain films 27.5% [14]
Ultrasound scan 11.8% [6]
scess, paranasal sinusitis, Herpes Zoster, iatrogenic steroid injection in
CT 49.0% [25]
cervical region and piriform fossa infection. MRI 1.96% [1]
90.2% (n = 46) of patients had one or more surgical debridement, Unknown 27.5% [14]
19.6% (n = 10) had a surgical tracheostomy and 23.5% (n = 12) were Antimicrobial Therapy
Metronidazole 49.0% [25]
intubated. 10.9% (n = 5) cases who received surgical debridement
Benzylpenicillin 21.6% [11]
demised due to delayed diagnosis, multi-organ failure and multiple pre- Flucloxacillin 11.8% [6]
existing medical comorbidities. Of those who did not have surgical Cephalosporins 33.3% [17]
debridement, 80% (n = 4) demised due to cardiac arrests (n = 3) and Meropenem 3.92% [2]
decision of palliation (n = 1). 56.9% (n = 29) of patients required to be Piperacillin and Tazobactam 7.84% [4]
Gentamicin 15.7% [8]
intubated of which a further 21.6% (n = 11) needed a tracheostomy.
Vancomycin 1.96% [1]
Mortality rate for intubated patients was 27.6% (n = 8), two of these also Microbiology
had a tracheostomy giving a mortality of 18.2% (n = 2). B-haemolytic streptococcus 25.5% [13]
The median length of stay was 28 days (range 1–95 days). 54.9% (n Streptococcus pyogenes 13.7% [7]
Streptococcus milleri 21.6% [11]
= 28) patients were reported to have cervical or facial reconstruction
Gram + ve bacteria 11.8% [6]
ranging from split thickness skin graft to extensive surgery such as free- Gram -ve bacteria 7.84% [4]
flap transfer whereas two cases healed via secondary intention only. Surgical debridement 90.2% [46]
This data is summarized in Table 1. Airway management
51 case reports detailed the outcome of a patient, of which 9 Intubation 56.9% [29]
Surgical Tracheostomy 21.6% [11]
demised. This gives a mortality rate for NF in the UK as 17.6% (n = 9),
Complications
with NF due to trauma carrying a mortality rate of 35.7% (n = 5) and Multi-organ failure 3.92% [2]
odontogenic NF alone having a mortality rate of 6.67% (n = 1). Cardiac arrests 5.88% [3]
Death 17.6% [9]
Length of stay, days, median (range) 28 (1 – 95)
4. Discussion
Reconstruction
Skin graft only 29.4% [15]
4.1. Gender Pedicled flap reconstruction 9.80% [5]
Free flap transfer 3.92% [2]
The aim of this review was to assess incidence, causation, manage­
ment and mortality of necrotising fasciitis in the UK. A longitudinal
the UK. A correlation was seen between the sites where published cases
cohort study by Bodansky et al. revealed the incidence of overall NF to
were reported and deprivation index (Figs. 2 and 3.). [41] There were
be higher in men in the UK [40]. However, gender does not appear to be
more NF cases reported in deprived areas compared to flourished areas
a risk factor of non-odontogenic cause of NF of H&N in the UK (ratio M:
of the country such as Liverpool and certain areas of London Borough.
F, 1:1.1).

4.2. Aetiology 4.3. Co-morbidity

Although odontogenic infections (29.4%) and trauma (27.5%) were
the most common causes of NF in the UK, other studies showed odon­
togenic infections made up the majority of NF cases (47.04%) with
trauma only contributing to 4.86% cases [4]. This may be contributed by
ease of access to oral healthcare and affordability of dental treatments in
According to a systematic review of cervical NF by Gunaratne et al.,
diabetes mellitus (18.8%) followed by alcoholism (9.09%) were re­
ported to be the most common co-morbidities [4]. in our UK study, a
similar number had diabetes (16.7%) however more patients reported to
have an alcohol dependence (14.3%). Living in a developed country did

3
H. Nazir et al.
Fig. 2. Sites of reported cases in this review.
not seem to reduce the incidence of diabetics contracting NF. NF in the
limbs has been well documented in diabetic patients due to poor cir­
culation and hypoxic tissues; odontogenic and mediastinal NF have also
been shown to be more prevalent in diabetics and the immunocom­
promised [2,4,42].
It has previously been highlighted that NF is common in those with
co-morbidities [2,4]. In our review, necrotising fasciitis is almost as
common in immunocompetent individuals as the immunocompromised
with only a marginal increase of incidence of NF in those with
pre-existing medical co-morbidities. Although the degree of suspicion
should be high in the immunocompromised, a delay in diagnosis in
healthy individuals can also lead to worse outcomes hence all patients
should receive the same rapid access to treatment when NF is suspected
and thus should be dealt with as a surgical emergency.
4.4. Presentation
To the best of our knowledge, no published review of head and neck
NF included signs and symptoms (S&S) specifically. Goh et al. conducted
a systematic literature review of NF, regardless of site, and found
swelling (80.8%), pain (79%) and erythema (70.7%) to be the most
commonly reported S&S [43]. Our literature review supports swelling
and pain to be the most common presentation followed by pyrexia in
H&N.
4.5. Diagnostic criteria
WBC and CRP are poor indicative markers for NF on initial pre­
sentations as their range are varied. Laboratory values alone should
4
Advances in Oral and Maxillofacial Surgery 6 (2022) 100254
never be used to diagnose NF in the head and neck. In terms of imaging,
CT scans remain the most popular choice of diagnosis. It can be argued
that such imaging in early NF can be non-diagnostic and hence delay
definitive treatment. In our review, the reported CT findings were var­
iable from soft tissue oedema and inflammation, loss of clarity of the fat
planes and finally, gas locules or fluid collection [9,10,12–14,16,21,27,
33,34]. The presence of gas locules is the main predictor of NF but not all
CT reports of gas locules in this review. Hence, the sensitivity of CT for
NF diagnosis is not dependable and should be used as a diagnostic aid to
the clinical picture. Scoring scores system such as Laboratory Risk In­
dicator for Necrotising Fasciitis (LRINEC) have been described for use
NF diagnosis. LaMothe et al. reported that there was insufficient evi­
dence to support the use of LRINEC for early head and neck NF cases but
can be a valuable adjunct [44]. Hence, the diagnosis of NF should be
purely clinical.
4.6. Microbes
Streptococcous remained the most common causative organism
globally and in the UK (61.2% and 44.8% respectively) although poly­
microbes were also prevalent (48%) with anaerobes accounting to a
majority of those [11]. Streptococcus A infections are monitored na­
tionally due to a high mortality rate. A review by McGurk et al. high­
lighted the underestimate in reporting most of these infections due to a
polymicrobial nature [45].
4.7. Airway management
Management of the airway in NF can be challenging for both
H. Nazir et al.
Fig. 3. Distribution of Deprivation index 2019 by local authority. (Reproduced from the English Indices of Deprivation 2019)
anesthetists and surgeons. Tracheostomy increases the risk of spread of
infection to the mediastinum when the pre-tracheal space is involved
[46]. There are also risks of tracheal stenosis, aspiration of pus, loss of
airway and death [47]. Endotracheal intubation in such cases can be
difficult with limited mouth access, oedema and distorted anatomy.
Advanced techniques in securing airways such as awake fibreoptic
intubation and video laryngoscopy have better success rates in patients
with NF [48]. More than half of patients (56.9% n = 29) presenting with
H&N NF required intubation. This figure is likely to be higher as most
case reports did not specifically state whether mechanical ventilation
was required. Around 65% of cases were close to the airway including
tonsillar, odontogenic and neck swellings and extensive surgical input
has been described. It is likely that these patients had some form of
assisted ventilation post operatively. Mortality for intubated patient was
significantly higher at 27.6% (n = 8) but there was no significant in­
crease if a tracheostomy was carried out. The sample size is rather low
though and a definitive conclusion cannot be drawn to whether a tra­
cheostomy in the region of NF increases mortality.
5
Advances in Oral and Maxillofacial Surgery 6 (2022) 100254
(41)
.
4.8. Global and UK mortality
Globally, mortality for NF has been reported to be 13.36% according
to Gunaratne et al. which can rapidly increase to 41% with mediastinal
extension [4]. Another study suggested mortality to range between 19
and 40% [49]. In the UK, odontogenic NF had a mortality of 9.8% [2].
The mortality rate for head and neck NF overall in the UK reported cases
appeared to be 18.0%. At least 3 of these patients had a mediastinal
extension which could contribute to the higher mortality rate.
If the origin was trauma (n = 14), mortality rose significantly to
35.7% (n = 5). Out of which four patient had further complications
including eschar formation, deep vein thrombosis of pelvis, heparin
induced thrombocytopenia, hypoxic brain injury secondary to cardiac
arrest.
4.9. Limitations and risk of bias
There are limitations to this review as most NF in the UK are not
published and hence, contributing towards a bias. Our selection of
comparative literature review may also contribute to a selection bias if
any comprehensive papers have been missed. For instance, Gore et al.
H. Nazir et al.
reported a small sample size of 164 cases whereas Gunaratne et al. re­
ported 1235 cases which may be more of a comprehensive sample for
comparison.
No national database for NF in the head and neck exists so there is no
way to accurately account for mortality and outcomes. All the publica­
tions included were retrospective case studies and case series, hence are
low value evidence. However due to the low incidence of necrotising
fasciitis, populating a high-quality study would be difficult. The details
of some reports were limited, and this further reduced our data set to
analyze parameters thoroughly. Although a thorough research of liter­
ature has been conducted, inevitably some UK case reports, or series
may have been missed in our review. Nevertheless, it is likely that
further cases would only serve to support the findings of this review.
5. Conclusion
Around one in five of patients with NF will die of their infection in
the UK. As nearly half of these cases had previous healthcare contact
prior to their emergency attendance, it is strongly advise to highlight the
need for clinical diagnosis in primary care and emergency services to
improve the outcome for this rare but very serious infection. Further­
more, research in the use of LRINEC scoring system NF in the head and
neck region is needed. As NFs remains a devastating infection with high
mortality and morbidity, it is apposite to reflect the adage ‘the best
antibiotic is surgery’.
Ethics statement/confirmation of patient permission
Ethics approval not required. Patient permission – no identifiable
information.
Declaration of competing interest
The authors declare that they have no known competing financial
interests or personal relationships that could have appeared to influence
the work reported in this paper.
Appendix A. Supplementary data
Supplementary data to this article can be found online at https://doi.
org/10.1016/j.adoms.2022.100254.
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