Article
Acute descending necrotizing mediastinitis and pericardial empyema secondary to previous oropharyngeal infection
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Published: | October 14, 2013 |
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Outline
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Objective: The descending necrotizing mediastinitis (DNM) is a rare but rapidly progressing disease with a potentially fatal outcome, originating from odontogenical or cervical infections. Early diagnosis with immediate and aggressive treatment is essential to prevent its rapid progression and further lifethreatening complications.
Methods: We present the case of a 50-year-old woman with acute mediastinitis and pericardial empyema secondary to oropharyngeal infection.
Results: The patient suffered from symptoms such as sore throat, dysphagia, pharyngitis, and swollen painful cervical lymph nodes the day before she turned to the emergency department. Streptococci A test was negative and calculated antibiotic treatment was initially started. Within 24 hours massive worsening of general condition occurred. The C-reactive protein increased from 77 mg/L to 478 mg/L while leukocytes decreased from initially 21,5 G7l to 2,5 G/l. CT scan was performed showing not only a massive swelling of the retropharynx but also pleural effusions and signs of an infection of the mediastinal tissue. Due to increasing dyspnoea an emergency intubation was required. Sternotomy, pericardial fenestration, and complete mediastinal debridement was immediately performed conforming the diagnosis of descending necrotising mediastinitis and pericardial empyema with pleural effusions. Pharyngolaryngoscopy showed epiglottitis and retropharyngeal phlegmon which was treated by otorhinolaryngologist. A thrombosis of the V. jugularis interna (Lemierre’s syndrome) was observed postoperatively and required special therapy (heparinizing). The patient was discharged home in good condition on the 16th hospital day.
Conclusion: Descending necrotizing mediastinitis, pericardial empyema, and Lemierre’s syndrome are rare but lifethreatening situations. Rapid aggressive surgical approach is important for the outcome. This case underlines the importance of awareness and early diagnosis of complications in the context of odontogenical or cervical infections with the need for immediate surgical intervention.