Catastrophic descending necrotizing mediastinitis of the anterior and posterior compartments: A case report

Abstract

Descending necrotizing mediastinitis (DNM) is a medical emergency with a high associated morbidity and mortality. DNM may arise secondary to primary odontogenic or neck infection in susceptible patients and it may spread contiguously via the "danger" space to the mediastinum. This case report is focused on complications following an odontogenic infection in a healthy 48-year-old male that led to a massive inflammation associated an extensive empyema. After chest and neck computed tomographic scan a diagnosis of cervical necrotizing fasciitis with DNM was made. A multidisciplinary approach with an urgent surgical intervention and the finding of the right antibiotic therapy resulted to be successful. After 2 weeks the patient was dismissed in better health condition.

Keywords: Cervical necrotizing fasciitis (CNF); Computed tomography scan; Descending necrotizing mediastinitis (DNM); Empyema; Odontogenic infection; Video-assisted thorascopic surgery (VATS).

Fig. 1

(A-E) Cervical and thoracic CT scan show air collection at the left carotid space (A). Left subclavian space and retroesophageal space are also involved by infection (B). Other collections are placed on the upper (C), anterior and posterior mediastinum (D, E). Bilateral pleural effusions are noted (asterisks in C, D, and E).

Fig. 2

Neck CT scan with sagittal reconstruction depicts air collections at pretracheal space, danger space, and prevertebral space.

Fig. 3

(A, B) Left sagittal CT angiography reconstruction displays rim-enhancing fluid collections at left carotid space and pretracheal space (A). Coronal CT angiography reconstruction shows abscesses on the cervical spaces, right hydropneumothorax, and extensive mediastinal empyema (B).

Fig. 4

(A, B) Cervical and thoracic CT angiography represent extensive mediastinal empyema on the anterior mediastinum (A), on the retrosternal space and posterior mediastinum (B). Multiloculated bilateral pleural effusions (triangles) and right hydropneumothorax (asterisk) are also displayed.