Management of extensive cervical necrotizing fasciitis with split-thickness skin grafting in an elderly diabetic patient: a case report

Introduction and importance Cervical necrotizing fasciitis is a rare but life-threatening soft-tissue infection characterized by rapid fascial and subcutaneous tissue destruction. Early diagnosis, aggressive surgical debridement, broad-spectrum antimicrobial therapy, and management of associated comorbidities are essential for survival. Extensive debridement may result in large cervical defects requiring definitive reconstruction. Case presentation A 72-year-old man with diabetes mellitus presented with a progressively worsening ulcerative neck wound. Contrast-enhanced computed tomography demonstrated extensive subcutaneous emphysema, collections, inflammatory changes, and fat stranding involving the bilateral anterior neck, submandibular, and parotid spaces, with extension toward the suprasternal region. Cervical necrotizing fasciitis was diagnosed on the basis of the clinical and radiological findings. Wound culture grew Pseudomonas spp. The patient received intravenous antimicrobial therapy and underwent four serial surgical debridements at approximately 48-hour intervals until no further necrotic tissue was identified and a healthy granulating wound bed was achieved. A split-thickness skin graft harvested from the right thigh was then applied to the cervical defect. Approximately 95% graft take was achieved, with satisfactory healing and no evidence of recurrent infection. The patient was discharged after approximately one month of hospitalization and remained clinically well at 1-month follow-up. Clinical discussion Cervical necrotizing fasciitis requires urgent surgical source control because of its potential for rapid tissue destruction and extension through cervical fascial planes. Diabetes mellitus is an important comorbidity in severe necrotizing soft-tissue infection. Following eradication of infection, reconstruction should be individualized according to defect size and depth, wound-bed vascularity, and exposure of vital structures. In this patient, a split-thickness skin graft provided definitive coverage after serial debridement and preparation of a healthy wound bed. Conclusion Successful management of extensive cervical necrotizing fasciitis requires timely diagnosis, repeated surgical debridement, appropriate antimicrobial and supportive therapy, optimization of comorbidities, and careful wound-bed preparation. In selected defects with a suitable vascularized wound bed, split-thickness skin grafting can provide satisfactory definitive coverage. This single case does not establish superiority of skin grafting over flap reconstruction.