A case of refractory descending necrotizing mediastinitis

Abstract

A 53-year-old woman with untreated diabetes mellitus (DM) and complaints of severe sore throat, dysphagia and dyspnea was referred to our hospital three days after onset of symptoms. Endoscopic examination demonstrated that the epiglottis and posterior wall of the pharynx were swollen without impaired vocal cord mobility. Blood examination showed elevated CRP (60.2mg/dl) and HbA1c (JDS)(12.6%) levels. CT revealed abscesses spreading into the retropharyngeal space, peritonsillar space, parapharyngeal space, visceral space, carotid space and mediastinum. We diagnosed this patient as having severe descending necrotizing mediastinitis (DNM) secondary to deep neck infection. Cervical drainage and transthoracic mediastinal drainage were carried out. After the drainage, systemic management was performed in an intensive care unit in the emergency department. The patient was given antibiotics intravenously and respiratory management involving endotracheal intubation. Mechanical ventilation was applied. However, reoperation and tracheotomy were required seven days after the initial drainage. After reoperation, drug-induced renal failure, acute heart failure, drug-induced liver dysfunction, colitis, pneumonia, anemia and pleural effusion occurred. We performed intensive treatment including hemodialysis and transfusion with the help of physicians. Fortunately, the patient recovered gradually and was discharged on the 101st hospital day without any sequelae.
We reviewed 68 DNM cases reported in Japan between 2007 and 2012. Seven out of 68 patients died, which is a mortality rate of 10.3%. Statistical analysis demonstrated a significant correlation between prognosis and shock at the first visit. The relationships between DM, odontogenic infection, Endo's classification and prognosis were not correlated.