SORE THROAT GONE BAD: DESCENDING NECROTIZING MEDIASTINITIS

Abstract

TOPIC: Chest Infections TYPE: Fellow Case Reports INTRODUCTION: Descending necrotizing mediastinitis (DNM) is a rare yet dangerous complication of oropharyngeal infections with mortality rates up to 50%. DNM was first described in 1983 and it clinically manifests as a sequalae of a primary odontogenic or pharyngeal infectious focus with supporting radiological features of mediastinitis. Due to its high mortality rates, prompt imaging and initiation of antibiotics remains cornerstone of management. CASE PRESENTATION: A 42 year old male came to our emergency department with complaints of sore throat, fever, chills, odynophagia and hoarseness for 2 days. He reported having a sore throat for a few weeks for which he did not seek treatment. He was septic on arrival with WBC count of 17.9 and CT scan of the neck showing extensive right peritonsillar abscess extending to the retropharynx and uvula. The patient was initially started on Clindamycin and subsequently switched to Unasyn and Azithromycin. Repeat CT neck on day 4 showed improvement in the abscess but the patient continued to spike fevers and developed recurrent hemoptysis. Antibiotics were changed to Vancomycin + Piperacilin/Tazobactam and he underwent a laryngoscopy with subsequent right tonsillectomy and parapharyngeal space exploration. The patient clinically improved but repeat CT scan on day 12 showed paratracheal mediastinal abscesses, extending into the posterior mediastinum behind the esophagus concerning for descending necrotizing mediastinal abscess. A multidisciplinary team meeting was conducted with the thoracic surgeon and consensus was to continue antibiotics and perform periodic imaging with prompt surgery if he deteriorates. Antibiotics were narrowed when tonsillar cultures reported S.Viridans sensitive to Piperacilin/Tazobactam. The patient completed a 24 day antibiotic regimen and was discharged home to complete 2 weeks of Augmentin therapy. On follow up in clinic 2 weeks later the patient made a complete recovery. DISCUSSION: DNM can be a fatal complication of mediastinitis. Our patient was previously healthy who progressed through the full spectrum of pharyngitis; ranging from simple infection to peritonsillar abscess to mediastinitis and eventually DNM. Due to its rare incidence, there was diagnostic and therapeutic delay patient in our patient. However due to a multi disciplinary team approach comprising of a hospitalist, critical care physician, radiologist, ENT and cardiothoracic surgeon our patient made a complete recovery without having to undergo surgical intervention. Awareness of DNM should be addressed so that timely intervention is performed. CONCLUSIONS: We recommend physicians keep DNM high in the differential when routine management for pharyngeal/odontogenic infections fails. REFERENCE #1: Sancho LM, Minamoto H, Fernandez A, et al. Descending necrotizing mediastinitis: a retrospective surgical experience. Eur J Cardiothorac Surg 1999; 16: 200–205 REFERENCE #2: Scaglione M, Pinto A, Romano S, et al. Determining optimum management of descending necrotizing mediastinitis with CT; experience with 32 cases. Emerg Radiol 2005; 11: 275–2 REFERENCE #3: Mihos P, Potaris K, Gakidis I, et al. Management of descending necrotizing mediastinitis. J Oral Maxillofac Surg 2004; 62: 966–972. DISCLOSURES: No relevant relationships by carol epstein, source=Web Response No relevant relationships by Steven Epstein, source=Web Response No relevant relationships by Huzaifah Salat, source=Web Response