Figure 2: Distribution of bacteriological findings in cervicofacial cellulitis.

ICU management included mechanical ventilation, hemodynamic stabilization in septic shock, infection control with empirical broad-spectrum antibiotics adapted to antibiogram results, analgesia, corticosteroids in selected cases, systematic prophylactic anticoagulation (and curative in thrombophlebitis), and frequent local wound care.

Hyperbaric oxygen therapy was used in 2 patients with necrosis and refractory evolution, with favorable outcomes.

Complications included mediastinitis (3.7%), thrombophlebitis (5.6%), and septic shock (9.4%).
The mortality rate was 17%.

Prognostic factors

• Poorly controlled diabetes
• Consultation delay > 10 days
• Diffuse swelling
• Dental portal of entry
• CRP > 122 mg/L at admission
• Mediastinitis

Cervicofacial cellulitis, also referred to as necrotizing fasciitis in the Anglo-Saxon literature, is an extensive bacterial infection involving the fascial spaces of the head and neck. Characterized by extensive tissue necrosis that may lead to severe disfigurement, it can spread to the mediastinum. These fascial planes, whose physiological role is to facilitate sliding between muscle groups, are interconnected, thereby promoting the rapid spread of initially localized infections. The locoregional portal of entry is variable, most commonly pharyngeal or dental [1–3].

In addition to local tissue damage, these infections are associated with the systemic effects of life-threatening sepsis. Cervicofacial cellulitis therefore constitutes a medico-surgical emergency with potential life-threatening implications. Prognosis depends on the number of anatomical spaces initially involved, the presence of mediastinal extension, the rapidity of clinical deterioration, the occurrence of severe sepsis, and the development of potentially serious locoregional complications [3,4].

Cervicothoracic CT scanning should be performed as early as possible [5], followed by prompt surgical intervention [6].

In contrast to conventional intubation techniques performed under general anesthesia, airway management should preferably be carried out under local anesthesia in the operating room with the patient awake. CT imaging allows assessment of the orotracheal pathway. Fiberoptic intubation is often required due to the frequent presence of pharyngolaryngeal edema with posterior displacement of the tongue base [7]. This pathological condition hinders conventional laryngeal exposure and may also compromise mask ventilation in the supine patient. Tracheostomy is not recommended as a first-line approach, as it may facilitate the spread of infection from the cervical focus to the respiratory tract.

The surgical approach must allow access to all involved anatomical compartments; therefore, precise mapping of the infection is established based on CT findings [5]. Excision of necrotic tissue is essential to control the infectious process.

Intensive care management is an integral part of the initial treatment of cervicofacial cellulitis, alongside surgical management. Intravenous antibiotic therapy should be initiated immediately after bacteriological sampling (blood cultures and intraoperative local samples). It is initially empirical, targeting suspected pathogens—particularly streptococci (notably groups A, F, and the milleri group) and anaerobes such as Prevotella spp. and Peptostreptococcus spp. [8,9]. The regimen should be broad-spectrum, bactericidal, synergistic, and ensure adequate tissue penetration [10].

In our series, the mortality rate remained relatively high (17%) compared with the literature. This may be explained by the following prognostic factors:

• Delay in consultation: In most cases, this exceeded 10 days from symptom onset. Consequently, patients presented to the emergency department at advanced stages of infection, where edema and the size of collections posed significant challenges for airway management. Furthermore, the infection had often already spread to adjacent anatomical structures, worsening the prognosis.
• Poorly controlled diabetes: Elevated blood glucose levels and increased glycated hemoglobin were observed in 22% of patients, creating a vulnerable clinical condition and facilitating the spread of infection, sometimes extending into the thoracic region.
• Diffuse form of cervicofacial cellulitis.
• Dental portal of entry: The polymicrobial flora of the oral cavity and dental caries promote the development of swellings, predominantly in the mandibular region, often associated with collections extending to the cervical and upper thoracic regions. This can be explained anatomically by the arrangement of fascial planes and musculoskeletal structures.
• Elevated C-reactive protein (CRP).
• Mediastinitis: Among patients who developed mediastinitis, the mortality rate reached 20%, reflecting the severity and advanced stage of infection, which significantly worsens the prognosis.

In a retrospective study conducted by Romdhane et al. [11], including 159 cases and based on a multivariate analysis using a logistic regression model incorporating all variables associated with severe forms, similar prognostic factors were identified, in addition to male sex, age > 60 years, and streptococcal infection [12].