Philippine E-Journals

Descending Necrotizing Mediastinitis and Empyema due to Odontogenic Infection: a Case Report

Ma. Alexis Kleanthe Suñer | Emmanuel Tadeus S. Cruz

 

Abstract:

Objective: To report a case of descending necrotizing mediastinitis and empyema due to odontogenic infection Methodology Design: Case study Setting: Tertiary hospital Patient: 1 Case Report J.S., a 22-year-old previously healthy male, was admitted because of difficulty of breathing. Two weeks ago, the patient had toothache of the left mandibular molar with swelling and abscess formation. After a week, the patient developed submandibular swelling and antibiotics which afforded minimal relief. After several days, the swelling descended in the left infraclavicular area. Progression of the swelling, poor oral intake and difficulty of breathing prompted consultation and subsequent admission in ICU. Blood cultures were collected which showed no growth of organisms, and vancomycin and piperacillin/tazobactam were started. Neck and chest CT scans showed abscess formation in the submandibular and pharyngeal spaces with intrathoracic extension into the superior and anterior mediastinum. Empyema on the right was also noted. Incision and drainage of the neck abscess with exploration and chest tube thoracostomy was done. The patient showed gradual improvement and was discharged after three weeks. Conclusion Odontogenic infection should be addressed and treated promptly to avoid spread of infection. Although rarely encountered, descending necrotizing mediastinitis may develop, a severe infection of the mediastinal tissues that sometimes lead to mortality. Adequate antibiotic coverage and aggressive surgical drainage which may require thoracostomy are vital to improve prognosis such as in this case. With the onset of the antibiotic era and advances in dental and medical management of head and neck infections, severe and life-threatening complications of deep neck space infections secondary to odontogenic and oropharyngeal infections are rare nowadays.1 Acute mediastinitis is most commonly associated with iatrogenic injury secondary to cardiothoracic surgery, and rarely from odontogenic infections. Descending necrotizing mediastinitis (DNM) is a life-threatening complication with a high mortality rate.2 More uncommon is the development of empyema as a complication of descending necrotizing mediastinitis.3 Infection spreads downward from the head and neck, usually odontogenic in origin, to travel through fascial planes of the neck and into the mediastinum and thorax with the help of gravity and negative intrathoracic pressure.4 This study aims to present a case of deep neck infection secondary to odontogenic infection complicated by descending necrotizing mediastinitis and empyema and to discuss the diagnosis and management.