Case report
Descending Necrotizing Mediastinitis: Early Detection and Radical Surgery Are Crucial

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Patients and Methods

Between June 1997 and December 2004, we managed 6 patients (5 men, 1 woman) with DNM (Table 1). The primary clinical symptoms that led to hospital admission were fever, dysphagia, odynophagia, impaired general health, and neck swelling. One patient was admitted emergently because of hemorrhage caused by paracetamol intoxication. Patients experienced symptoms for an average of 6.3 days before the condition was diagnosed. Two patients were already on antibiotics, and 3 had undergone local

Results

A cervical infection was clinically obvious in each case. Signs of severe infection in addition to worsening general condition were indicative of mediastinitis.

In 5 of 6 patients, CT scans of the neck and chest were clearly diagnostic by showing fluid collections, abscess cavities, gas formation, or diffuse infiltration. In 1 case (patient 6), artifacts complicated CT interpretation, and the patients’ mediastinitis was not recognized by this imaging method. Throughout each patient’s subsequent

Case 1

For illustration, we report the details of 2 cases.

This 42-year-old man was referred to us because of worsening dysphagia and odynophagia. He had not taken any oral nourishment for several days. In addition, his neck had become increasingly swollen and he was dyspnoic. Four days before admission the patient’s dentist had drained a submucous abscess in the area of the second left molar. Since then, the patient was on oral clindamycin. Under this management, he did not experience symptomatic

Discussion

The incidence of DNM is quite low. Therefore, most related publications are case reports1, 2, 3, 4 or reviews of patient groups observed over extended periods of time.5, 6, 7, 8, 9 During the past 7 years, we have treated 6 patients who developed DNM. DNM, a potentially life-threatening condition, is a feared complication of severe soft tissue infections of the neck. In 1938, an era where today’s modern antibiotics were unavailable, Pearse10 reported mortality rates greater than 50%. His

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      We found that orotracheal intubation should be the first trial and delayed tracheotomy was better than early tracheotomy if needed. When it comes to DNM secondary to DNI, it is imperative to diagnose the condition with CT (scanned from skull base to diaphragm) as quickly as possible and conduct immediate surgical drainage with a synchronous approach to the mediastinum.4 CT is important in making a diagnose of DNM, in determining the level of infection and the pathways of spread of infections from the neck to the mediastinum, and in planning a successful treatment.5

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      However, in those who are critically ill with odontogenic infections, <25% of blood and tissue cultures are positive [43]. This may reflect the finding that the patients referred from the community to the hospital with odontogenic infections are likely to have received a course of antibiotics before their admission [44]. The pathogens found in odontological infections commonly include Streptococcus spp., S. aureus, P. aeruginosa and Escherichia coli [43].

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    1

    Annett Sandner and Jochen Börgermann contributed equally to this article.

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