Acute Necrotizing mediastinitis (ANM) is a lethal disease which without antibiotic therapy and surgical Intervention can lead to about 40% mortality. With the development of imaging technology, spiral computed tomography (CT) scanning and shortening of the time of diagnosis and surgery, the prognosis of these patients is excellently improved. This study describes the clinical presentation, management and outcome of 4 patients (mean age: 35 years) with ANM. All patients were operated on by a trans-cervical approach, and only one patient was operated on by a trans-thoracic one. After surgery, patients were transferred to the intensive care unit and underwent daily washing and debridement with antibiotic treatments. Odontogenic infection (2 cases), pharyngeal perforation and cervical esophageal perforation were the causes of the ANM. Infection of cervical space (perivisceral spaces) and superior Mediastinum were found in all patients, and Infection below the carina was found in two. All patients were discharged with a good, general condition after an average of 24 days. Early diagnosis of ANM with clinical presentation and on-time CT scanning, early drainage and careful post operation care are very important in the management of patients with ANM and can improve the outcome of trans-cervical drainage to an acceptable technique.