Descending necrotizing mediastinitis of odontogenic origin - Management by minimal invasive approach

Nikhil Arora; Ashiya Goel; Pratik Kumar; Aarushi Wadhawan

doi:10.4103/sjoh.sjoh_7_22

CASE REPORT

Year : 2022 | Volume : 24 | Issue : 2 | Page : 82-84

Descending necrotizing mediastinitis of odontogenic origin - Management by minimal invasive approach

Nikhil Arora, Ashiya Goel, Pratik Kumar, Aarushi Wadhawan
Department of Otorhinolaryngology, Pt. B. D. Sharma PGIMS, Rohtak, Haryana, India

Date of Submission	30-Jan-2022
Date of Decision	26-Apr-2022
Date of Acceptance	01-May-2022
Date of Web Publication	10-Jun-2022

Correspondence Address:
Dr. Pratik Kumar
Department of Otorhinolaryngology, Pt. B. D. Sharma PGIMS, Rohtak - 124 001, Haryana
India

Source of Support: None, Conflict of Interest: None

DOI: 10.4103/sjoh.sjoh_7_22

Abstract

Descending necrotizing mediastinitis is an uncommon, rapidly progressive pathology originating from odontogenic or cervical infections. It usually has a fulminant course, frequently leading to sepsis and mortality. A rare case of cervical necrotizing fasciitis and descending mediastinitis in a healthy young man, after an odontogenic infection with a successful outcome without aggressive surgical debridement, has been presented.

Keywords: Descending necrotizing mediastinitis, odontogenic, percutaneous drainage

How to cite this article:
Arora N, Goel A, Kumar P, Wadhawan A. Descending necrotizing mediastinitis of odontogenic origin - Management by minimal invasive approach. Saudi J Otorhinolaryngol Head Neck Surg 2022;24:82-4

How to cite this URL:
Arora N, Goel A, Kumar P, Wadhawan A. Descending necrotizing mediastinitis of odontogenic origin - Management by minimal invasive approach. Saudi J Otorhinolaryngol Head Neck Surg [serial online] 2022 [cited 2022 Oct 4];24:82-4. Available from: https://www.sjohns.org/text.asp?2022/24/2/82/347294

Introduction

Acute mediastinitis usually develops after open cardiac surgery (incidence rate 1%–2.65%) or due to esophageal perforation resulting from iatrogenic intervention, trauma, foreign body ingestion, or neoplasm.^[1] Pearse first described the term “descending necrotizing mediastinitis” for an infection arising from the head and neck, most commonly from an oropharyngeal or odontogenic focus, then extending along with the fascial spaces and descending down into the mediastinum.^[2] Descending necrotizing mediastinitis has a high mortality rate between 40% and 50%.^[3] A computed tomographic (CT) scan is an extremely useful tool for the diagnosis, surgical planning, and postoperative assessment of descending necrotizing mediastinitis. Early and sometimes multiple, radical debridement along with intravenous broad-spectrum antibiotic therapy has remained the cornerstone in the management of this condition.^[4] However, with the advancement of medical science, less invasive surgical techniques may replace conventional aggressive debridement as the treatment of choice for descending necrotizing mediastinitis. An unusual case of descending necrotizing mediastinitis which is improved only by ultrasound-guided percutaneous catheter drainage is being presented.

Case Report

A 29-year-old male [Figure 1] presented to the emergency department with a 5-day history of odynophagia, cervical swelling, persistent fever, chest discomfort, and shortness of breath. A few days before, this patient had experienced a left-sided lower molar ache, for which he had received 5 days of oral antibiotics. His neck movements were markedly restricted by pain; he also had trismus, dysphonia, and subcutaneous emphysema. After an otolaryngological examination, the patient was subjected to contrast-enhanced cervicothoracic CT to confirm the clinical diagnosis and evaluate the extent of infection. CT scan showed a collection of air and fluid in the left submandibular, parapharyngeal, pretracheal, and retrotracheal regions [Figure 2]. Diffuse enhancement of mediastinal fat with areas of air-fluid levels in the anterior mediastinal compartment was also noted along with left sided pleural effusion [Figure 3]. Laboratory investigations were within normal range, except for neutrophilia. The patient was admitted to the intensive care unit. Cervical abscess was drained percutaneously with a wide bore needle, and empyema was drained with the insertion of left-sided chest tube. Mycobacterium tuberculosis in the abscess fluid and pleural tap was ruled out with acid-fast staining, polymerase chain reaction, and culture. Tumor markers, electrocardiogram, and abdominal ultrasound showed no abnormal changes. Culture of cervical abscess fluid yielded Pseudomonas sp., and the patient was treated with intravenous piperacillin-tazobactam and amikacin. A repeat CT revealed a retrosternal collection treated with ultrasound-guided percutaneous catheter drainage under local anesthesia. The patient recovered subsequently. The chest tubes were replaced by empyema tubes without suction and were withdrawn gradually. Further radiological investigations showed complete resolution of the mediastinal and cervical air-fluid collections. After a total hospital stay of 1 month, the patient was discharged under stable conditions.

Figure 1: Patient with diffuse neck swelling

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Figure 2: Coronal computed tomography neck showing air and fluid collection in parapharyngeal and perivascular space

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Figure 3: Coronal computed tomography neck showing air and fluid collection in the anterior mediastinum with left-sided pleural effusion (marked with arrow)

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Discussion

Descending necrotizing mediastinitis has an incidence of 1.5%–3.6% in patients with deep neck infections.^[5] Head and neck pathologies, commonly oropharyngeal or odontogenic infections, less frequently acute epiglottitis, cervical lymphadenitis, parotitis, thyroiditis, jugular intravenous drug abuse, and traumatic endotracheal intubation can lead to cervical necrotizing fasciitis and descending necrotizing mediastinitis.^[6]

The presence of immunocompromising conditions predisposes for mediastinal extension of cervical necrotizing fasciitis. It is hypothesized that rapid downward spread of descending necrotizing mediastinitis is aided by the presence of negative thoracic pressure, poorly vascularized fascial spaces that lack cellular immune defenses, local tissue hypoxia resulting from multiple small vessel thromboses, and anaerobic bacterial enzymes that promote collagen breakdown and disruption of fascia.^[7] Involvement of pretracheal and perivascular space can cause suppurative pericarditis and empyema. Prevertebral space infections can lead to posterior mediastinitis.

The most commonly isolated pathogens in descending necrotizing mediastinitis are a mixture of the aerobic (such as Streptococcus, Staphylococcus aureus, and Klebsiella pneumoniae) and anaerobic bacteria (Peptostreptococcus, Bacteroides fragilis, Prevotella, and Porphyromonas).^[8] Empirical broad-spectrum antibiotic regimens covering these bacteria such as piperacillin-tazobactam and vancomycin and clindamycin with either third-generation cephalosporins or a quinolone are used.

In our case, Pseudomonas sp. was identified in the cervical fluid collection, which is quite uncommon. Even with the absence of other comorbidities, cervical necrotizing fasciitis rapidly progressed in our patient. Since prevertebral spaces were not involved, posterior mediastinitis was spared.

Various surgical options including cervical drainage alone to a combination of cervicotomy and transthoracic drainage using mediastinoscopy, thoracoscopy, thoracotomy, median sternotomy, or a clamshell incision have been described in the literature.^[9],[10] In our case, ultrasound-guided percutaneous drainage was carried out, which was less invasive, reduced morbidity, and shortened the hospital stay. Percutaneous catheter drainage areas also have a lower risk of developing secondary infections and better pain control and may also prevent protein leakage from the wound.^[11],[12]

Conclusion

CT imaging is the most valuable modality for diagnosis and planning surgical management of descending necrotizing mediastinitis. In the last decade, due to a very high mortality rate, early and aggressive surgical debridement with open procedures has been practiced. We advocate that in this era, minimally invasive techniques can be explored to treat cervical necrotizing fasciitis and descending necrotizing mediastinitis, but more research is required to formulate the most suitable treatment protocol.

Informed consent

Written and informed consent was taken from the patient.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given his consent for his images and other clinical information to be reported in the journal. The patient understands that his name and initials will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

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