A case of an elderly patient treated for descending necrotizing mediastinitis

Abstract

We report a case of descending necrotizing mediastinitis (DNM). DNM is a serious infection, and preventing death requires early diagnosis and draining of the infection focus. An 84-year-old man was admitted to our hospital complaining of a swollen neck and pain when swallowing. He had had a tooth extracted at a neighboring dental clinic 2 days previously. Cervicothoracic computed tomography (CT) scan demonstrated gas bubbles and unencapsulated abscesses in the cervical spaces and anterosuperior and posterior mediastinum, extending below the carina. He was diagnosed as DNM caused by odontogenic infection. Cervical drainage was performed, in addition to mediastinal drainage using video-assisted thoracic surgery (VATS). Complications were sepsis, disseminated intravascular coagulation (DIC), and heart failure after surgery, but he recovered following intensive care. This was a lifesaving case of DNM for which mediastinal drainage was performed with VATS.

Descending necrotizing mediastinitis secondary to a dental infection

“…In cases of descending necrotizing mediastinitis, the infection originates in the fasciae of the head and neck, infiltrating into the mediastinum via the cervical fasciae, facilitated by gravity, respiration, and negative intrathoracic pressure. The most common anatomical pathway by which the infection spreads is the lateral pharyngeal space to the retrovisceral space (retropharyngeal) (implicated in 70% of cases), thereby extending inferiorly to the mediastinum 15 - 17. In the case reported here, the mediastinal infection developed after the extraction of a third molar and rapidly progressed to the superficial and deep fasciae of the face, severely affecting the deep layers of the cervical fascia before arriving at the mediastinum.…”

“…However, other causes are known, among which are the extent of the head and neck infection 20 , 21. Dental infections are the most common of such infections 10 , 17 , 22…”

Odontogenic cervical necrotizing fasciitis with descending mediastinitis: a case report and discussion

“…It may not be routine but in centers with expertise and equipment for VATS, it can offer a minimally invasive option for mediastinal drainage in patients unfit for radical surgery even in extensive subcarinal disease (type II DNM). 12,13…”

Descending Necrotizing Cervicomediastinitis Secondary to Esophageal Perforation: Management in a Hospital with Limited Resources

“…Reconstruction of the digestive tract can be accomplished in the same setting or delayed (as in our cases) depending on the general state of the patient and the degree of mediastinal contamination. 25 Prognosis is closely dependent on the cause and localization of the esophageal perforation as well as the treatment given, presence of esophageal disease, associated injuries and nutritional state. 5 The mean HLOS of patients with penetrating esophageal trauma is 40 days (3-90 days), and the global mortality continues to be high (10-40%), tending to the high end when resection techniques are involved, and when complications are present (14-67%), presence of malnutrition (40%) and delay in treatment (25-40%).…”