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A life-threatening complication of acute parotitis

Article  in  British Journal of Oral and Maxillofacial Surgery · July 2008

DOI: 10.1016/j.bjoms.2007.07.204 · Source: PubMed

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British Journal of Oral and Maxillofacial Surgery 46 (2008) 328–329

Short communication
A life-threatening complication of acute parotitis
G.J. Knepil a,∗ , G. Fabbroni b
a Department of Oral and Maxillofacial Surgery, Leeds Dental Institute, Leeds Teaching Hospitals NHS Trust, Leeds, United Kingdom
b Department of Oral and Maxillofacial Surgery, Leeds Dental Institute, United Kingdom

Accepted 19 July 2007

Available online 5 September 2007

Abstract

We present a case of necrotising fasciitis that complicated an episode of acute parotitis caused by Streptococcus milleri infection. Early
diagnosis and aggressive therapy is necessary to reduce the incidence of mortality of this severe infection.
© 2007 The British Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.

Keywords: Necrotising fasciitis; Streptococcus milleri; Acute parotitis

Introduction
Necrotising fasciitis is usually followed by septicaemia, sys-
temic toxicity and death. Early diagnosis is necessary to
reduce the morbidity and mortality. This type of infection is
uncommon in the head and neck, and early diagnosis may be
difficult. We present the first published case to our knowledge,
after acute parotitis caused by S. milleri.
Case report
A previously healthy 67-year-old man was admitted with a
four-day history of pain and swelling of the right side of
his face. He was dehydrated but apyrexial, and normoten-
sive with a heart rate of 78 beats/min. He had pronounced
swelling and erythema in the region of the right parotid gland,
and pus was expressed from the duct. A clinical diagnosis of
acute parotitis was made, and treatment comprising massage
of the gland, intravenous rehydration and antibiotics given
intravenously was initiated.
The following day he had several episodes of febrile rigors.
A computed tomogram (CT) showed a large submasseteric
∗ Corresponding author. Fax: +44 1482 675064.
E-mail address: gregor@doctors.net.uk (G.J. Knepil).
collection which was drained intraorally. The next day the
swelling and erythema had progressed down his neck and on
to his upper chest, where the soft tissues were extremely ten-
der. A further CT showed complete destruction of the parotid
gland, with signs of fluid and air in the neck and chest. When
the patient was returned to theatre for further drainage, we
found extensive undermining of the overlying soft tissues
by necrotic tissue and “dish water” pus (Fig. 1). A clinical
diagnosis of necrotising fasciitis was made.
We radically debrided the affected soft tissues, and gave
him clindamycin, benzylpenicillin, and metronidazole. The
progress of the necrotising fasciitis was halted on the eleventh
day after admission.
After that he generally improved over the next 10 days,
at which time the granulating soft tissue defect was repaired
with a split thickness skin graft (Fig. 2).
Discusssion
The incidence of necrotising fasciitis increases in middle
age, and is more common in patients with diabetes mellitus.1
The microbiological investigations in this case suggested a
polymicrobial infection dominated by S. milleri with fac-
ultative anaerobes of the enterococcus species, necrotising
fasciitis Type I.2 The S. milleri group is common in the

0266-4356/$ – see front matter © 2007 The British Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.
doi:10.1016/j.bjoms.2007.07.204
 G.J. Knepil, G. Fabbroni / British Journal of Oral and Maxillofacial Surgery 46 (2008) 328–329 329

mouth and gastrointestinal tract, but is increasingly recog-

nised as a highly aggressive pathogen in the head and neck.3
The infection in this case originated in the parotid gland
and spread downwards in a pattern consistent with cervical
necrotising fasciitis.4 The skin over the facial area remained
vital throughout, and was preserved. This case shows that
clinicians must be constantly aware of the clinical, microbio-
logical, and radiological signs of this rare but potentially fatal
and disfiguring disease.

References

1. Lin C, Yeh FL, Lin JT, et al. Necrotizing fasciitis of the head and neck:
an analysis of 47 cases. Plast Reconstr Surg 2001;107:1684–93.
2. Giuliano A, Lewis FJr, Hadley K, Blaidsell FW. Bacteriology of necro-
tizing fasciitis. Am J Surg 1977;134:52–7.
3. Hirai T, Kimura S, Mori N. Head and neck infections caused by Strep-
tococcus milleri group: an analysis of 17 cases. Auris Nasus Larynx
2005;32:55–8.
4. Djupesland PG. Necrotizing fasciitis of the head and neck: report
Fig. 1. Resection of infected tissue. Arrow points to “dish water” pus of three cases and review of the literature. Acta Otolaryngol Suppl
expressed from under “normal” looking skin. 2000;543:186–9.

Fig. 2. Infection site fully healed.

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