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.

Persistent Necrotizing Mediastinitis after Dental Extraction

“…In the present case, the infection originated due to tooth extraction. The infectious process reached submandibular, cervical, and mediastinal regions, in agreement with Fukuchi et al's explanation [9], i.e., odontogenic infections of the oropharynx can expand to the mediastinum through respiratory movements and negative intrathoracic pressure.…”

Mediastinitis necrotizante descendente de origen dental: revisión de la literatura y presentación de un caso

“…3,18 La tomografía computarizada (TC) cervicotorácica es una herramienta invaluable e indispensable en el diagnóstico de MND, tanto en la detección inicial de la infección como en el monitoreo de la respuesta al tratamiento. 8 La visualización del mediastino ensanchado con múltiples niveles de fluidos y burbujas de aire ectópicas confirman el diagnóstico. 3 Los exámenes de laboratorio muestran eucocitosis y elevación de la proteína C reactiva.…”

“…6 Es por ello que la MND se puede clasificar en tres grupos de acuerdo a la extensión anatómica: tipo I = localizada en el mediastino anterior superior, por arriba de la bifurcación traqueal o carina (forma localizada); tipo II = localizada por debajo de la bifurcación traqueal (forma difusa), la cual es subdivida en: tipo IIA (mediastino anterior inferior) y tipo IIB (mediastino posterior inferior). 2,[7][8][9] Numerosos reportes indican que pacientes inmunodeprimidos 10 son más susceptibles a experimentar infecciones odontogénicas graves así como en pacientes de la tercera edad o con enfermedades sistémicas asociadas como diabetes, insuficiencia hepática, insuficiencia renal 7 y VIH, entre otras. Aunque estas condiciones no son determinantes para el desarrollo del padecimiento, ya que se puede presentar en pacientes sanos.…”

Rare mediastinal complications of dental procedures

“…Dental extraction is a frequent procedure that has the potential to cause lethal complications if not performed under appropriate conditions. Complications encountered after dental extraction range in a variety of disorders including head and neck emphysema, pneumomediastinum, pharyngeal abscess, septic thrombophlebitis of internal jugular vein, mediastinitis and mediastinal abscess, peribronchovascular inflammation in the lung parenchyma, and septicemia [1][2][3][4]. Pneumomediastinum, which is defined as entrapment of free air in the mediastinal space, was first described by Laënnec in 1819 [5].…”

“…The usage of high-speed air-tribune drills can lead to the introduction of air into soft tissues and has been reported as the most common cause of this complication [6][7][8]. Oral flora may also spread to the neck through the cervical fascia and cause deep neck infection or descending necrotizing mediastinitis (DNM) [3,9]. Herein, we report two cases of pneumomediastinum and one case with severe deep neck inflammation, thrombophlebitis of jugular vein, mediastinitis and empyema occurred following molar tooth extraction by using air-tribune drills.…”