Descending Necrotizing Mediastinitis Treated with Tooth Extractions following Mediastinal and Cervical Drainage

Abstract

Descending necrotizing mediastinitis (DNM) is a rare condition in which oropharyngeal infection spreads to the mediastinum via the cervical fascia. Delayed diagnosis and surgery result in a high mortality rate among patients with DNM. We present a case of DNM resulting from odontogenic infection treated successfully with tooth extraction following mediastinal and cervical drainage. A 43-year-old, previously healthy Japanese man was admitted to our hospital for treatment of acute mediastinitis. Computed tomography revealed gas collection around the mid-thoracic esophagus and bilateral pleural effusion. We performed mediastinal drainage via right thoracotomy. Cervicotomy was performed on postoperative day 14 to drain a residual cervical abscess. The patient required the extraction of ten teeth over three procedures to address primary odontogenic infection before his fever resolved on postoperative day 40. Prompt diagnosis, aggressive drainage and removal of the source of infection can improve survival among patients with this life-threatening disease.

Keywords: Descending necrotizing mediastinitis; Drainage; Tooth extraction.

Fig. 1

CT images. a Gas collection (arrow) was observed on the right side of the mid-thoracic esophagus with bilateral pleural effusion on POD 4. b A dental abscess (arrow) was seen in the root of the right maxillary canine tooth. c A cervical abscess (arrow) was also seen in the posterior cervical esophagus on POD 4.

Fig. 2

Intraoperative findings. a Pleural effusion obtained from the left thoracostomy tube was tea-colored and purulent. b During drainage of the mediastinum via right thoracotomy, the wall of the mid-thoracic esophagus was found to have no perforation and to be covered with pus.

Fig. 3

Oral photograph. Ten teeth were extracted after initial surgery.