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Oncoscience, Volume 12, 2025
Research Perspective
Necrotizing fasciitis of the head and neck – clinical features,
diagnostics, and management strategies
Anna Aydin
1
, Lawik Revend
2
, Doha Revend
3
, Oliver Schuck
1
and Florian Dudde
1
1
Department of Oral and Maxillofacial Surgery, Army Hospital Hamburg, Hamburg, Germany
2
Department of Plastic Surgery, Army Hospital Berlin, Berlin, Germany
3
Department of Otolaryngology, Head and Neck Surgery, Army Hospital Berlin, Berlin, Germany
Correspondence to
: Florian Dudde,
Keywords
: necrotizing fasciitis; cervicofacial infection; surgical emergency; debridement; airway management
Received
: June 11, 2025
Accepted
: December 12, 2025
Published
: December 23, 2025
Copyright:
© 2025 Aydin et al. This is an open access article distributed under the terms of the
Creative Commons Attribution License
(CC BY 4.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are
credited.
ABSTRACT
Background: Necrotizing fasciitis (NF) of the head and neck is a rare but rapidly
progressive and life-threatening soft tissue infection that constitutes a true surgical
emergency. Due to the complex anatomy of the cervicofacial region and the proximity
to the upper airway, early diagnosis and management are particularly challenging,
and delayed recognition is associated with high morbidity and mortality. This article
aims to provide a concise and clinically oriented overview of the presentation,
diagnostic pitfalls, and current management strategies for cervicofacial necrotizing
fasciitis.
Methods: A narrative review of the available literature was conducted and
complemented by clinical experience from a tertiary referral center. Key aspects
including etiology, risk factors, clinical features, imaging findings, laboratory
parameters, microbiology, surgical management, airway control, and adjunctive
therapies were synthesized and critically discussed.
Results: Cervicofacial NF often presents with disproportionate pain, rapidly
progressive swelling, and early systemic toxicity. Odontogenic infections represent
the most common source, frequently in the presence of systemic comorbidities
such as diabetes mellitus or immunosuppression. Contrast-enhanced computed
tomography is the imaging modality of choice, whereas laboratory scoring systems
such as the LRINEC score show limited sensitivity in head and neck infections.
The cornerstone of treatment is immediate and aggressive surgical debridement
combined with broad-spectrum intravenous antibiotics, early airway protection, and
intensive care support. Repeated surgical interventions are frequently required. The
role of adjunctive hyperbaric oxygen therapy remains controversial and cannot be
routinely recommended based on current evidence.
Conclusion: Necrotizing fasciitis of the head and neck requires a high index
of suspicion, prompt imaging, and decisive multidisciplinary management. Early
surgical intervention and airway control are critical determinants of outcome. Given
the rarity of cervicofacial NF, further multicenter studies and registries are needed to
refine diagnostic tools, identify prognostic factors, and optimize treatment strategies,
particularly in high-risk populations such as immunocompromised and oncologic
patients.
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INTRODUCTION
Necrotizing fasciitis (NF) of the head and neck
region is a rare but life-threatening soft tissue infection
characterized by rapidly progressing fascial necrosis,
systemic toxicity, and high mortality [1, 2]. It represents a
surgical emergency that requires prompt recognition and
aggressive multidisciplinary treatment. The condition most
frequently arises in the lower extremities or abdominal
wall; cervicofacial manifestations account for fewer than
5% of cases but are associated with unique diagnostic and
therapeutic challenges due to the complex anatomy and
proximity to the upper airway [3, 4].
While the underlying etiology is often odontogenic,
other sources include pharyngeal or parotid infections,
trauma, or iatrogenic injury [5–7]. Systemic risk factors
such as diabetes mellitus, immunosuppression, alcoholism,
and chronic renal failure are frequently present and
significantly influence the clinical course and prognosis [8].
CLINICAL PRESENTATION
Patients with cervicofacial NF often present with
severe pain, swelling, erythema, and crepitus, often
disproportionate to clinical findings [9]. As the infection
progresses, cutaneous manifestations such as skin
discoloration, bullae, or necrosis may appear. Systemic
signs include fever, tachycardia, hypotension, and signs
of sepsis [10]. The progression from cellulitis to deep
fascial involvement can occur within hours. Airway
compromise is a critical and early concern in head and
neck NF [6, 11]. Trismus, dysphagia, and dyspnea can
be early indicators of descending infection and possible
airway obstruction [4–6, 11]. In many cases, early
elective intubation or tracheotomy is essential to secure
the airway.
DIAGNOSTIC STRATEGIES
Early diagnosis is key to reducing mortality. Clinical
suspicion should be confirmed with contrast-enhanced
computed tomography (CT), which typically reveals
fascial thickening, gas formation, and fluid collections
along fascial planes [12, 13] (Figures 1 and 2). In some
cases, magnetic resonance imaging (MRI) may offer
higher soft tissue resolution, but its availability and speed
are limiting factors in the acute setting [14]. Laboratory
findings typically include elevated white blood cell
counts, C-reactive protein (CRP), creatine kinase (CK),
and lactate levels [15]. The Laboratory Risk Indicator
for Necrotizing Fasciitis (LRINEC) score has been
proposed as a diagnostic aid but has limited sensitivity
in cervicofacial cases [16]. Several factors contribute
to the reduced diagnostic utility of LRINEC in the head
Figure 1: Sagittal CT imaging in cervicofacial necrotizing fasciitis.
Sagittal contrast-enhanced computed tomography (CT)
scan of the neck demonstrating hallmark features of cervicofacial necrotizing fasciitis, including subcutaneous emphysema, diffuse fascial
thickening, and fluid tracking along the deep cervical spaces. The sagittal plane highlights the craniocaudal spread of infection and illustrates
the rapid progression along anatomical compartments.
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and neck region. First, gas-forming organisms, such as
Clostridium
spp., are less commonly involved in CNF
than in infections of the trunk or limbs, which lowers
the incidence of radiologically visible emphysema and
correlating inflammatory patterns. Second, smaller
anatomical compartments in the head and neck region
may limit the extent of tissue destruction and systemic
inflammatory response, particularly in the early stages—
resulting in lower CRP, WBC, or creatinine values and
thus underestimating LRINEC scores.
Moreover, overlapping laboratory profiles with
deep neck abscesses, peritonsillar infections, or even
severe pharyngitis can further reduce specificity. Thus,
LRINEC should not be solely relied upon in the evaluation
of suspected cervicofacial necrotizing infections. Instead,
clinical vigilance and early imaging (CT or MRI) remain
the cornerstone of timely diagnosis in locating the CNF
in the head and neck region. Microbiological cultures
from blood and wound samples often yield polymicrobial
growth, including aerobic and anaerobic organisms.
Group A Streptococcus (GAS) and Staphylococcus
aureus (including MRSA) are common pathogens [17].
However, odontogenic NF is frequently polymicrobial
with contributions from oral anaerobes such as Prevotella
and Fusobacterium species [17, 18].
DIFFERENTIAL DIAGNOSIS AND
CLINICAL DISTINCTION
In its early stages, cervicofacial necrotizing fasciitis
(CNF) may be difficult to distinguish from other deep
neck infections. Common differential diagnoses include
cellulitis, peritonsillar or parapharyngeal abscesses,
Ludwig’s angina, and infected lymphadenopathy [17, 18].
These entities often present with swelling, erythema, and
pain, but lack the rapid progression, skin changes (e.g.,
bullae, necrosis), crepitus, or systemic toxicity seen in
NF [9–11]. Imaging plays a crucial role in differentiation.
While cellulitis typically shows soft tissue edema without
gas formation or fascial plane involvement, necrotizing
fasciitis is characterized by subcutaneous emphysema,
fluid tracking along fascial planes, and lack of tissue
enhancement. A high index of suspicion, combined with
early CT evaluation, remains critical for distinguishing NF
from its mimics.
MANAGEMENT
The cornerstone of NF treatment is early and
aggressive surgical debridement, combined with broad-
spectrum intravenous antibiotics and intensive supportive
Figure 2: Contrast-enhanced CT scan demonstrating hallmark features of cervicofacial necrotizing fasciitis.
Coronal
contrast-enhanced computed tomography (CT) image of a patient with cervicofacial necrotizing fasciitis, illustrating characteristic
radiologic features including diffuse fascial thickening, gas formation in the subcutaneous and deep cervical spaces, and fluid collections
extending along fascial planes.
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care [19, 20]. Table 1 summarizes the key diagnostic tools
and therapeutic approaches currently recommended for
cervicofacial NF (Table 1). Empiric antibiotic regimens
should cover gram-positive, gram-negative, and anaerobic
organisms, often including a combination of piperacillin/
tazobactam plus clindamycin, as well as carbapenems
or third-generation cephalosporins plus Metronidazole
[19]. Antimicrobial regimens are later adjusted based on
culture sensitivities. In many cases, repeated debridement
is necessary within 24–48 hours [20, 21]. The surgical
approach must be extensive and not limited to visible
necrosis, often requiring dissection along fascial planes
and removal of all non-viable tissue. Cervical incisions,
mandibular release, and drainage of mediastinal extensions
(if present) may be required [6]. Airway management
is central to therapy [6, 22]. Elective tracheostomy is
preferred in many cases due to anticipated prolonged
airway compromise and the need for repeated surgeries
[6]. Involvement of anesthesiologists and intensive care
teams is essential early on. Hyperbaric oxygen therapy
(HBOT) has been proposed as an adjunct treatment,
particularly in cases of anaerobic infection and extensive
tissue involvement, though high-level evidence for
improved outcomes is limited [23]. However, the use of
HBOT in NF remains controversial. While the theoretical
benefits include enhanced oxygenation of hypoxic tissues,
suppression of anaerobic bacteria, and improved leukocyte
function, the clinical evidence is inconsistent, particularly
in cervicofacial cases. A recent systematic review by
Huang et al. concluded that while HBOT may reduce
mortality and the number of debridements in selected
cases, the heterogeneity of study designs, small sample
sizes, and absence of randomized trials limit the strength
of these conclusions [23]. Moreover, most available data
pertain to extremity or truncal infections, with limited
generalizability to head and neck NF.
A recent systematic review by Tseros et al. (2023)
analyzed 161 published cases of cervical necrotizing
fasciitis (CNF) treated with HBOT and found a mortality
rate of 7.6%, which is significantly lower than the 13.4%
reported in an earlier review of CNF cases irrespective
of HBOT use [24]. The authors concluded that HBOT
may reduce mortality and complications in selected
patients. However, the study also highlighted substantial
limitations, including the absence of randomized
controlled trials, heterogeneity of diagnostic criteria, small
patient numbers, and a potential publication bias favoring
positive outcomes. Moreover, most deaths occurred in
patients with purely aerobic infections, suggesting that
HBOT may be more effective in infections involving
anaerobes. From a practical standpoint, access to HBOT
is often restricted to specialized centers, and delays
associated with transfer may offset potential benefits.
Adverse effects such as barotrauma, oxygen toxicity,
and logistic barriers must also be considered. Given
these constraints, routine use of HBOT in cervicofacial
NF cannot currently be recommended, but may be
considered on a case-by-case basis—particularly in
extensive anaerobic infections and when early surgical
and antibiotic management is ensured.
OUTCOME AND FOLLOW UP
Despite advances in supportive care, mortality rates
in cervicofacial NF remain between 10 % and 30% [25].
Factors associated with poor prognosis include delayed
surgical intervention, age >60 years, diabetes, renal
insufficiency, and septic shock on admission [26, 27].
Functional and aesthetic sequelae are common and
require reconstructive planning after infection control
[28]. Long-term follow-up focuses on wound healing,
scar contracture management, and restoration of oral
Table 1: Diagnostic and therapeutic overview in cervicofacial necrotizing fasciitis
Aspect
Modality/Approach
Remarks
Surgical Timing
Immediate radical debridement
Key prognostic determinant
Empiric Antibiotic
Therapy
Piperacillin/tazobactam + clindamycin;
imipenem/meropenem/ertapenem +
clindamycin; ceftriaxone + metronidazole +
clindamycin
Broad-spectrum coverage including anaerobes
Adjusted per culture sensitivity
Narrowed once pathogen(s) identified
Initial Imaging
Contrast-enhanced computed tomography
(CT)
Rapid, widely available; detects gas, fascial
thickening, fluid collections
Magnetic resonance imaging (MRI)
Superior soft tissue contrast, but slower and less
accessible in emergencies
Laboratory Tools
CRP, WBC, CK, Lactate
Elevated in most cases, but nonspecific
LRINEC Score
Limited sensitivity in head and neck infections
Adjunctive Measures
Hyperbaric oxygen therapy (HBOT)
Controversial; may aid tissue salvage in selected
cases
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functions [6, 28]. Psychological support is often necessary
due to the traumatic nature of the disease and potential
disfigurement.
IMPLICATIONS FOR ONCOLOGY
PATIENTS AND FUTURE DIRECTIONS
While NF is classically associated with metabolic
disorders such as diabetes or trauma, cancer patients
constitute a particularly vulnerable population.
Immunosuppression due to chemotherapy, neutropenia,
and radiotherapy-induced soft tissue changes are well-
documented risk factors for soft tissue infections and may
facilitate the rapid progression of necrotizing infections.
Furthermore, head and neck cancer patients often present
with anatomical alterations, impaired wound healing, or
colonization with resistant flora, all of which complicate
diagnosis and treatment. In our clinical experience,
oncologic patients with cervicofacial NF frequently
present atypically, and symptoms may be misattributed
to tumor progression or treatment side effects. This
underscores the need for heightened clinical vigilance and
low threshold for imaging in this subgroup.
Importantly, there is a paucity of data addressing the
outcomes of NF in cancer patients. We propose that future
multicenter studies stratify NF patients by oncologic
status to determine differential prognostic factors and
treatment responses. Additionally, the development of
early warning systems or biomarkers tailored to the
immunocompromised host may improve early recognition
and intervention. Given these considerations, cervicofacial
NF should be recognized not only as a surgical emergency
but also as a potential complication in oncologic care.
Enhanced awareness among head and neck oncologists,
radiation therapists, and oral surgeons is vital to ensure
prompt diagnosis and treatment in this high-risk
population.
EXPERT OPINION: UNRESOLVED
CHALLENGES AND RESEARCH
NEEDS
Despite improved understanding of NF, several
clinical dilemmas remain unresolved, particularly in
cervicofacial cases. Based on our experience and review
of the literature, we identify three major areas of ongoing
debate and future investigation:
1. Extent and Timing of Surgical Debridement: While
early radical surgery is widely accepted as the
cornerstone of NF management, the optimal extent of
debridement remains controversial. Involvement of the
face and neck raises questions of surgical morbidity,
aesthetic reconstruction, and preservation of function.
More granular criteria to guide surgical aggressiveness
in these anatomically complex regions are needed.
2. Limitations of Diagnostic Scoring Tools: Tools such as
the LRINEC score are poorly validated in cervicofacial
NF. Overreliance on such tools may delay surgical
consultation. Future research should aim to develop
scoring systems tailored to head and neck anatomy and
symptomatology, possibly incorporating radiologic
and molecular markers.
3. Adjunctive Therapies: The role of hyperbaric oxygen
therapy (HBOT) remains debated. While theoretically
beneficial for anaerobic infections and tissue
oxygenation, high-level evidence from prospective
studies is lacking. Additionally, the accessibility of
HBOT is variable, making it an impractical standard
in many institutions.
CONCLUSION
S
Necrotizing fasciitis of the head and neck is a rare
but devastating condition. Its successful management
hinges on early clinical suspicion, prompt imaging,
aggressive surgical debridement, airway protection, and
broad-spectrum antibiotics. A multidisciplinary approach
involving oral and maxillofacial surgeons, intensivists,
infectious disease specialists, and reconstructive
surgeons is vital to optimizing patient outcomes.
Due to its rarity, further multicenter studies and the
establishment of clinical registries may help better
define prognostic factors and therapeutic strategies in
cervicofacial NF.
AUTHOR CONTRIBUTIONS
FD and AA conceptualized the article. AA and
FD drafted the manuscript. LR, DR, and OS contributed
to literature review and critical revisions. All authors
reviewed and approved the final version of the manuscript.
CONFLICTS OF INTEREST
Authors have no conflicts of interest to declare.
FUNDING
No funding was used for this paper.
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