Rare Insights: Temporoparietal Necrotizing Fasciitis Stemming From a Dental Source

Necrotizing fasciitis (NF) of the face is a rare yet serious condition requiring prompt and comprehensive management. This approach typically involves input from various medical specialties such as infectious disease specialists, critical care physicians, and surgeons. The primary goals are early recognition, aggressive surgical debridement, appropriate antibiotic therapy, and supportive care. Prompt diagnosis is crucial, based on symptoms like severe pain, rapidly spreading erythema, and systemic signs of infection. Broad-spectrum antibiotics are initiated empirically, and adjusted based on culture results. Urgent surgical debridement is crucial, removing all necrotic tissue. Careful consideration must be given to preserve vital structures. Close monitoring and intensive care may be necessary, especially for severe cases. Soft tissue reconstruction may follow once the infection is controlled, aiming to restore function and aesthetics. Long-term follow-up is essential to observe for complications and recurrence.


Introduction
Necrotizing fasciitis (NF) is a severe soft tissue infection primarily spreading through fascial planes.It is usually accompanied by systemic inflammatory response syndrome (SIRS) and needs prolonged intensive care treatment [1].Although necrotizing fasciitis can affect various parts of the body, including the extremities, abdomen, and perineum, it can also arise in the oro-pharyngeal and maxillofacial regions [2].In the head and neck region, odontogenic causes are most prevalent, leading to rapid tissue infiltration, vascular compromise, and potential organ failure or limb loss [3].The condition is commonly referred to as the "flesh-eating disease" due to its aggressive nature and ability to cause extensive tissue destruction.Early NF diagnosis is challenging due to subtle symptoms unless triggered by toxic shock syndrome or organ failure [3].Advanced cases manifest with significant tissue loss, vascular complications, or systemic involvement, often leading to fatal outcomes.If not treated at once with appropriate drugs or surgery, it may spread through the bone marrow and cortex, reaching muscle layers, fascial spaces, and thence various vital organs [4].Aggressive forms are often the result of underestimation of the infection, late diagnosis, erroneous surgical approach, and septic complications.However, NF involving the temporalis muscle remains infrequently reported.In the current study, we present a case of Temporal Necrotizing Fasciitis due to a suspected odontogenic cause in a geriatric patient.

Case Presentation
A 77-year-old female patient presented to our outpatient department with the complaint of severe pain and pus discharge from the right side of the head (Figure 1) with general malaise in the past 10-15 days approximately.The pain was gradual in onset, throbbing, continuous, and localized in nature.While inspecting inflamed, slough tissue with draining pus from the right tempo-parietal and right retromolar region.Upon examination, there was crepitus and fluctuant swelling noted in the right temporo-parietal region.A thorough intra-oral examination was done for the patient upon which a grossly decayed tooth in the lower right mandibular region was found.Contrast Enhanced Computed Tomograph (CECT) of the Head (Figure 2, Figure 3) was done for this patient, which showed evidence of peripherally enhancing collection with internal enhancing septations noted over the right fronto-parieto-temporal regions with multiple air density foci within.The collection approximately measured 9.5 x 2.9 x 12 cm.Inferiorly collection is seen extending into the right infratemporal fossa, masticator, and submandibular spaces.

FIGURE 2: Axial Section of Contrast-Enhanced Computed Tomograph (CECT) Head
There is evidence of peripherally enhancing collection with internal enhancing septations within noted over the right frontoparieto temporal regions with multiple air density foci within.The collection approximately measures 9.5 x 2.9 x 12 cm (Axial Plane Topography with Volume Computerized Tomography Contrast (APTVCC)).Inferiorly collection is seen extending into the right infratemporal fossa, masticator, and submandibular spaces.There is involvement of the medial pterygoid and superficial and deep fibers of the temporalis muscle.Masseter muscle also shows heterogeneous enhancement and is mildly bulky as compared to the opposite side.

Tomograph (CECT) Head
There is evidence of peripherally enhancing collection with internal enhancing septations within noted over the right frontoparieto temporal regions with multiple air density foci within (coronal section).
The general condition of the patient was poor with severe nutritional cachexia, Body Mass Index of 10.82, reduced air entry in the bilateral lower lobe, and crepitus in the left lower lobe of the lung.Following routine investigations were sent for the patient (Table 1).The patient was planned for surgical drainage of space infection under general anesthesia.After preanesthetic checkup high risk and poor prognosis fitness was obtained.The patient's relatives were not willing to get operated on under general anesthesia, hence it was planned under local anesthesia.Before starting the antibiotics, we sent pus from the extraoral temporoparietal and intraoral retromandibular region for the culture and sensitivity test.We initiated empirical antibiotic therapy for the patient until the final culture report was available.
Incision and drainage under local anesthesia were done.Right auriculotemporal nerves, zygomaticotemporal, lesser occipital, posterior auricular nerve and mandibular nerve blocks were given.Incision and drainage of the right superficial temporal, deep temporal, buccal, lateral pharyngeal, and submandibular space were done.The extraction of 2nd and 3rd right mandibular molar teeth with through curettage was done.The dead and decayed soft tissue debridement is done meticulously.The submandibular space was explored and through the same incision lateral pharyngeal space exploration and drainage followed by corrugated rubber drains (Figure 4) were placed in respective areas.The patient started on IV antibiotics according to the blood counts.After 24 hours of incubation, no growth was there in the sent specimen for culture sensitivity.Post-operative blood transfusion and supportive care were given.There was an improvement in the patient's general condition the post-operative routine labs are given in Table 2.

TABLE 2: Postoperative Investigations
Due to some circumstances, the patient's relatives discontinued the treatment and took discharge against medical advice.

FIGURE 1 :
FIGURE 1: Pre-operative image showing necrotizing fasciitis over right temporal region Pre-operative image showing necrotizing fasciitis over right temporal region with sloughed margins and exposed temporal bone.

FIGURE 3 :
FIGURE 3: Coronal Section of Contrast-Enhanced Computed

FIGURE 4 :
FIGURE 4: Post-operative image showing corrugated rubber drain placement over the right temporal and submandibular region It is also showing signs of healing over the right temporal region.