purulent conditions of the mediastinum and lungs spread by continuity through the interfascial spaces of the neck are among the rarest complications of odontogenic inflammatory processes of the oral cavity .
descending necrotizing mediastinitis ( dnm ) is a noteworthy example of such infection , originating from inflammatory conditions within the oral cavity and teeth .
descending necrotizing mediastinitis develops in patients between 30 and 50 years old and occurs six times more frequently among men .
the symptoms characteristic of dnm include strong retrosternal pain ( intensifying during breathing and coughing ) , rapid breathing , tachycardia , increased body temperature , and inflammatory infiltration of the neck and chest .
treatment consists in combining broad - spectrum antibiotic therapy with radical dissection and drainage of the purulent foci located in the chest and mediastinum . despite intensive treatment ,
dnm mortality remains high , amounting to as much as 20 - 50% of cases .
the aim of this study was to present the case of a 26-year - old woman treated at the clinical department of maxillofacial surgery and the department of anesthesiology and intensive care of the regional specialist hospital in rzeszw , in whom , in consequence of odontogenic infection and phlegmon of the face and neck , dnm developed with numerous lung and mediastinal abscesses , resulting in the patient 's death . descending necrotizing mediastinitis as a complication of odontogenic infections
is rarely encountered in everyday practice ; therefore , it appears purposeful to report the case of this patient who was recently treated at our department .
the 26-year - old female patient was admitted to the clinical department of maxillofacial surgery of the regional specialist hospital in rzeszw due to a swelling of the left cheek ( which spread to the mental region before involving bilaterally the submandibular region ) , difficulties with swallowing , and limited jaw opening .
several days before the appearance of the swelling , the patient had experienced tooth pain on the left side of the mandible , which she found difficult to locate precisely .
a clinical examination was performed , revealing a massive swelling of the left cheek and the submandibular and mental regions .
neck lymph nodes on both sides were unavailable for examination due to the swelling as well as significant local pain .
intraoral examination revealed insufficient oral hygiene , numerous tooth roots and teeth with their pulp in a state of gangrenous decay , and pain on percussion of teeth 36 and 46 .
the mucous membrane of the floor of the oral cavity had undergone inflammatory changes , and a hard , painful infiltrate was present .
the patient 's life parameters were within normal ranges : body temperature 31.1c , heart rate 80 bpm , arterial pressure 140/80 mmhg .
laboratory investigation revealed high leukocytosis ( 43 100/mm ) , electrolyte impairments  reduced levels of sodium and chlorides ( na 130
mmol / l and cl 95.0 mmol / l ) , glucose concentration increased to approximately 180 mg / dl , and crp 44.3 mg / dl .
the remaining parameters , i.e. morphology , coagulation parameters , biochemical tests , urea , and creatinine , were within the normal ranges .
ultrasound examination of the neck revealed a hypoechogenic area of irregular shape located in the mental region at the depth of 1.5 to 4 cm  probably an inflammatory infiltrate .
lymph nodes around the salivary gland and the right corner of the mandible were of irregular shape , hypoechogenic , and swollen to 22  13 mm .
panoramic radiography revealed extensive damage to the hard tissue of teeth 18 , 46 , and 47 , reaching the pulp chambers of the teeth ; presence of tooth roots 14 , 26 , and 34 ; and thinned bone structure characteristic of chronic periapical periodontitis in the vicinity of the apexes of teeth 34 , 46 , and 47 ( fig .
panoramic radiograph image  day of admission the patient underwent pharmacological treatment , receiving antibiotics ( clindamycin ) , analgesics , and steroids ( dexamethasone ) ; subsequently , under general anesthesia , she underwent the removal of teeth deemed to constitute the foci of inflammation ( 14 , 26 , 34 , 46 , 47 ) ; the abscess forming in the mental and submandibular regions was incised and drained .
, sensitive to the following antibiotics : penicillin g , amoxicillin , piperacillin , amoxicillin / clavulanic acid , metronidazole , clindamycin , and cefotetan .
, new purulent foci were incised and drained in the superolateral part of the neck ; a small amount of fetid , brown , bloody material was obtained .
interfascial spaces were connected and , subsequently , rinsed multiple times with solutions of metronidazole and sodium bicarbonate . after the incision and evacuation of the abscess , the patient reported a slight improvement in her well - being and an improvement in her ability to swallow .
laboratory investigation revealed a drop in leukocytosis to 15 800/mm ; the high level of crp persisted ( 53.7 mg / dl ) , as did the electrolyte impairments  reduced potassium ( k 2.6 mmol / l ) and high glycemic values ( up to 220 mg / dl ) .
potassium supplementation was maintained , and , additionally , a second antibiotic was introduced ( amoxicillin with clavulanic acid ) . during the 5 day of hospitalization , a stinging pain appeared in the patient 's interscapular area , intensifying during deep inhalation and cough . in the respiratory tract , a dense , mucous secretion was present , which the patient was unable to expectorate , mostly due to strong pain .
the dimensions of the cheek infiltrate decreased ; a dough - like swelling of the neck persisted , but did not show a tendency for abscess formation .
plain chest x - ray revealed the presence of fluid in the left pleural cavity reaching rib vii in the posterior axillary line , an obscured contour of the right dome of the diaphragm and the right costophrenic angle , small atelectatic consolidations in the right lower lung field , and an increased cardiac silhouette ( fig .
2 ) . photograph of the patient 's chest  4 day of hospitalization at the department of maxillofacial surgery left thoracocentesis was performed , but no fluid was obtained . from the 6/7 day of hospitalization ,
an internist consultation confirmed the suspicion of pneumonia and pleuritis as a complication of an odontogenic infection ; additionally , steroid diabetes was revealed .
the subsequently performed chest x - ray demonstrated an increased amount of fluid in both pleural cavities .
moreover , in the lower field of the right lung , a well - delineated shadow area ( 5  2.5 cm in size ) appeared , indicating the development of inflammation in this lobe .
bilateral thoracocentesis was performed ; in total , over 200 ml of fluid was evacuated and passed on for bacteriological examination .
as no significant improvement of the patient 's general condition was achieved , a chest and neck ct was performed , revealing spaces with dense fluid ( probably pus ) in the left side of the neck and air - filled spaces reaching the level of the mandibular ramus .
the fluid - filled spaces were located in the masseter muscle area , down to the parapharyngeal and retropharyngeal spaces , reaching laterally to the supraclavicular area and  entering  the chest 
the mediastinum was enlarged , reaching the size of 95  75 mm , up to the level of the cardiac waistline .
singular abscesses were present in lung parenchyma ; their largest sizes were 80 mm in the right lung and approximately 45 mm in the left .
fluid was present in the pleural cavities : up to 20 mm in width in the right cavity and up to 20 mm in the left .
subcarinal and paratracheal lymph nodes had increased in size to approximately 23 mm . there were no focal lesions in the bone structure of the examined area ( fig .
3 ) . after a thoracic surgeon was consulted , the patient was qualified for urgent surgery due to mediastinal phlegmon and the suspicion of empyemas in both pleurae .
bilateral drainage of the parapharyngeal spaces and the mediastinum was performed via cervical access ; right - sided thoracotomy with mediastinal incision and right lung decortication were conducted and followed with left - sided videoassisted thoracoscopic surgery ( vats ) .
opening the chest revealed the presence of organizing purulent material in the pleural cavity as well as necrotic lesions in the tissues of the mediastinum , extending to the pericardial sac and secreting purulent material .
irrigation drainage was introduced to the mediastinum and pleura . during the left - sided vats , cloudy fluid
was evacuated , adhesions were freed , fibrin was partially removed from the supradiaphragmatic area , and irrigation drainage was applied .
chest ct  8 day of hospitalization ( preoperative image ) after the surgery , the patient , exhibiting symptoms of sepsis and postoperative respiratory failure , was transferred directly from the operating theater at the department of maxillofacial surgery to the department of anesthesiology and intensive care ( daic ) . at the daic , in severe condition and under analgosedation ( midazolam , morphine sulfate )
chest x - ray performed during the 1 day of the patient 's stay at the daic showed a regression of lesions .
samples of material from the bronchial tree ( bronchofiberoscopy  bal ) were collected for bacteriological testing , along with pus drained from the pleural cavity and mediastinum , as well as blood and urine .
broad - spectrum antibiotic therapy was introduced ( cefotaxime , amicacin , metronidazole ) , along with steroid therapy , anti - fungal therapy , anticoagulative treatment , fluid therapy , and parenteral feeding . during the 1 day after thoracotomy ,
the patient 's circulation was stable : sap 110 - 120 mmhg , hr 100 - 115/min , sato2 98 - 99% with fio2 at 40% , diuresis 1500 ml / day , normal body temperature .
tests for the presence of hbvag , anti - hcv , and hiv were negative .
klebsiella pneumoniae esbl  a microorganism sensitive to the antibiotics already administered to the patient , was isolated from culture material collected from the bronchi .
wide access to the interfascial spaces of the neck was maintained ; they were rinsed regularly in order to prevent premature occlusion of the draining duct . in accordance with the postoperative recommendations of the thoracic surgeon , irrigation drainage of both pleural cavities and
, the patient 's condition did not change : it was severe , but stable .
inflammation markers were reduced . due to the long - lasting secretion of purulent material from the drains ,
moreover , a new fluid - filled lesion appeared in the right pleural cavity , along with changes suggesting pneumonia ( fig .
bleeding was stopped pharmacologically , and the air leak , despite mechanical ventilation , was small and subsided on its own . during the 8 day at the daic , the patient 's condition deteriorated .
her body temperature rose rapidly to 39.2c , and ventilation conditions worsened , requiring the increase of fio2 to 0.5 .
during the 10 day at the daic , the patient 's general conditioned continued to deteriorate significantly . with fio2 at 50 - 100%
a non - depolarizing blocking agent ( vecuronium ) was added to the therapy , achieving a slight improvement in terms of ventilation conditions .
the results of cultures from the right pleural cavity indicated the presence of acinetobacter baumannii , a multiresistant bacterial strain resistant to the antibiotics previously administered to the patient . in accordance with the antibiogram
a multiresistant strain of enterococcus faecium , sensitive to linezolid , was cultured ; linezolid was subsequently added to the therapy . during the 11 day ,
pressor amines ( norepinephrine ) were added to the therapy . despite intensive treatment , signs of multiple organ dysfunction syndrome intensified .
the therapy was unsuccessful : the patient died during the 12 day of treatment at the daic .
abscesses and odontogenic inflammatory conditions of the head and neck are often encountered in clinical practice and are usually not difficult to diagnose and treat . in rare cases , such infections may spread through the interfascial spaces of the neck to the chest and mediastinum [ 1 , 2 ] .
the dnm case of a 26-year - old woman described above is an example of a complication which posed a significant diagnostic and treatment challenge and resulted in the patient 's death .
most authors list odontogenic infections related to pulp infections of the lower molars as the primary cause of dnm [ 3 , 4 ] . according to statistical data ,
such infections are responsible for 50 - 80% of dnm occurrences . in the present case
, the purulent complications also originated from dental neglect and the fact that the pulp of numerous lower molars of the patient was in a state of gangrenous decay .
the literature underscores that the typical bacterial flora of the upper airway and the gastrointestinal tract plays an important role in the etiopathogenesis of dnm [ 5 , 6 ] .
, streptococcus anginosus , candida albicans , klebsiella pneumoniae , enterococcus faecium , and acinetobacter baumannii .
descending necrotizing mediastinitis is a rare complication ; according to freeman , even thoracic surgeons rarely encounter this disease during their professional careers .
it is , therefore , understandable that this complication constitutes a significant problem in the practice of various specialized fields , including maxillofacial surgery .
knowledge of the pathogenesis and symptoms of dnm is of cardinal significance in diagnosing , treating , and predicting the course of the disease .
the clinical symptoms of dnm observed in our patient were similar to those described in the literature [ 79 ] ; however , it appears that they were erroneously interpreted as the signs of concomitant respiratory tract infection , which delayed the correct diagnosis .
deterioration of the patient 's general condition , growing leukocytosis , and rising crp and pct values are indications for supplementing the diagnostic investigation with head , neck , and chest ct with contrast .
literature data demonstrate the superiority of ct over conventional chest x - ray examinations in the early diagnosis of dnm .
the present case confirms the above , as the initial changes visible on the x - ray image were non - specific , and dnm was only diagnosed after the performance of a ct scan . in terms of surgical treatment
, it is of fundamental importance to remove any necrotic tissue as well as bacteria and their toxins and , subsequently , employ irrigation drainage . in conclusion , it should be underscored that chest pain , cough , and lack of improvement in the general condition of a patient after the drainage of abscesses around the jaw and neck should be indicative of remote lung complications , including dnm .
our observations confirm that , in the treatment of complicated inflammatory conditions of the head and neck , multi - specialist cooperation of maxillofacial surgeons , thoracic surgeons , and intensive care specialists , as well as , in some cases , otolaryngologists , is indispensable .
 this paper presents the case of a 26-year - old female patient in whom descending necrotizing mediastinitis ( dnm ) developed as a complication of an odontogenic purulent infection of the mouth . despite the efforts of a multidisciplinary treatment team , the patient died with symptoms of septic shock and multiple organ failure . according to the literature , and 
 as confirmed by our own observations , successful treatment requires early tomographic diagnosis , radical surgery , combination antibiotic therapy , and intensive care . 
Introduction
Aim of the study
Case study
Discussion
Disclosure