{"id":"938ccb6a-cd2d-42ed-a039-ba41f3ce5176","slug":"recurrent-subgaleal-abscess-following-cervicofacial-necrotizing-fasciitis-a-case-report","title":"Recurrent subgaleal abscess following cervicofacial necrotizing fasciitis: A case report","authors":["Emin Tabipoğlu","Ayşe Gül Özer","Fatih Bera Gürtaş","Efecan Çekiç","Mustafa Berker"],"abstract":"Background: Subgaleal abscess (SGA) is an uncommon but potentially life-threatening condition characterized by pus accumulation between the galea aponeurotica and skull periosteum. Necrotizing fasciitis (NF) of the head and neck is an aggressive infection with high morbidity and mortality. While SGAs have been reported following trauma, neurosurgical interventions, or regional infections, recurrent SGA secondary to cervicofacial NF (CNF) has not previously been documented. Case Description: We present the case of a 75-year-old woman with diabetes mellitus and multiple comorbidities who developed CNF complicated by recurrent SGA. Despite initial drainage procedures, the patient experienced repeated relapses due to capsule formation. Definitive resolution was achieved only after complete capsule excision, in addition to culture-directed antibiotic therapy. Conclusion: Recurrent SGA complicating CNF is exceedingly rare. This case underscores the importance of early recognition, thorough surgical intervention including capsule excision, and vigilant follow-up to achieve durable infection control in patients with significant comorbidities. Subgaleal abscesses (SGAs) are rare but clinically significant entities. They usually occur after trauma, neurosurgical procedures, or through contiguous spread from adjacent infections, and carry a risk of severe sequelae such as cranial osteomyelitis, epidural abscess, or intracranial extension. [ 2 , 3 ] Necrotizing fasciitis (NF) is an aggressive soft-tissue infection characterized by rapid fascial and subcutaneous tissue necrosis. Mortality rates for cervicofacial NF (CNF) range between 18% and 40%, despite modern advances in imaging, surgical technique, and antimicrobial therapy.[ 4 ] Diabetes mellitus and other chronic comorbidities are recognized risk factors for both NF and poor wound healing outcomes.[ 6 ] Although isolated reports exist of SGA associated with scalp infections or otogenic sources, no cases of recurrent SGA secondary to CNF have been published to date. Here, we present a rare case of recurrent SGA complicating CNF, with emphasis on the pathophysiology of recurrence and the role of capsule excision in definitive management.[ 8 ] A 75-year-old woman with type 2 diabetes mellitus, coronary artery disease, and hypertension presented to the emergency department with a 2-week history of the right facial and cervical swelling and 5 days of severe pain. She denied any recent trauma, odontogenic infection, or upper respiratory symptoms. One week prior, she had received a single intramuscular dose of ceftriaxone as an outpatient. Initial Evaluation and First Intervention: On examination, there was non-erythematous, non-fluctuant swelling extending from the right preauricular area to the lateral neck. Laboratory tests [ Table 1 ] demonstrated leukocytosis, elevated C-reactive protein, and increased erythrocyte sedimentation rate. Trends in inflammatory markers. Contrast-enhanced computed tomography (CT) and magnetic resonance ımaging (MRI) revealed NF of the right cervicofacial region with possible mandibular condyle osteomyelitis [ Figure 1 and Table 1 ]. The patient was empirically started on meropenem (1 g IV every 8 h) and teicoplanin (6 mg/kg IV once daily) and was taken to the operating room (OR) for neck exploration, abscess drainage, and tracheostomy for airway protection. Intraoperative cultures grew Streptococcus constellatus, and antibiotic therapy was de-escalated to piperacillin-tazobactam (4.5 g IV every 6 h) plus tigecycline (100 mg IV loading dose, then 50 mg IV every 12 h). First Recurrence and Second Drainage: Three days later, the patient developed a tense, fluctuant swelling over the right temporal-occipital region without erythema or fever. Under local anesthesia, a 1.5 cm incision was made above the right ear, and 60–70 mL of yellow purulent fluid was aspirated [ Figure 2a ]. The cavity was irrigated with saline, vancomycin powder was applied subcutaneously, and two Hemovac drains were placed. Post-procedurally, antibiotic therapy was changed to sulbactamampicillin (3 g IV every 6 h). Two days afterward, swelling recurred despite the Hemovac drains. The patient returned to the OR; the same incision was reopened, the Hemovac drains were exchanged for a Jackson-Pratt drain, and daily dressings with a cohesive bandage were applied. Sulbactamampicillin was discontinued on postoperative day 5, and oral moxifloxacin 400 mg once daily was initiated. Second Recurrence and Definitive Surgery: On day 10, swelling reappeared in the same region. Under general anesthesia, the prior temporal-occipital incision was extended, and a 2 cm zygomatic incision was added. Approximately 100 mL of pus and organized fibrous membranes were encountered. Using curettes and Adson-Madson forceps, the capsule was completely excised, with extension into the frontal compartment to remove adherent membrane. The field was irrigated with saline and hydrogen peroxide, and a new Jackson-Pratt drain was placed. a) Preoperative contrast-enhanced axial T1-weighted MRI demonstrating a large right frontoparietal subgaleal collection (yellow arrows). b) Early postoperative contrast-enhanced axial T1-weighted MRI obtained after the first surgery, showing interval evacuation of the subgaleal component with expected postoperative changes (yellow arrows). c) Axial brain CT performed prior to the second surgery, illustrating reaccumulation of the right frontoparietal subgaleal collection (yellow arrows). d) Postoperative axial brain CT following the second surgery, demonstrating complete evacuation of the collection (yellow arrows). Clinical photographs of the patient’s scalp demonstrating the progression and resolution of the subgaleal swelling.(a) Pre-drainage view showing a large, tense, subgaleal bulging over the left frontoparietal region (white arrows).(b) Follow-up photograph after surgical drainage and antibiotic therapy showing marked reduction of the swelling and well-healed incision site (white arrows). Outcome: The patient’s postoperative course was uneventful. The Jackson-Pratt drain was removed on postoperative day 7. At 1-month follow-up, there was no clinical or radiologic evidence of recurrence [ Figure 2b ].","thumbnailUrl":"https://sni-digital-videos.s3.amazonaws.com/articles/938ccb6a-cd2d-42ed-a039-ba41f3ce5176/featured/hero-1781558110676.png","publishDate":"2025-12-12T00:00:00.000Z","doi":"10.25259/SNI_956_2025","categories":["Infection","Case Report"],"fullTextUrl":"https://surgicalneurologyint.com/api/articles/938ccb6a-cd2d-42ed-a039-ba41f3ce5176/pdf"}