10.59987/ads/2015.2.64-68
Aims. Deep neck infections are rare but potentially fatal complication of pulpal abscess of the teeth. If an infection can progress rapidly from a toothache to a life threatening infection, then it is critical that dentists be able to recognize the danger signs and identify the patients who are at risk. Mediastinitis is a severe inflammatory process involving the connective tissues that fills the intracellular spaces and surrounds the organs in the middle of the chest. This pathology has both an acute and a chronic form and, in most cases, it has an infectious etiology. This study want to expose the experience acquired in the Oral and Maxillo- facial Sciences Department, Policlinico Umberto I, “Sapienza” University of Rome, regarding two clinical cases of disseminated necrotizing mediastinitis starting from an odontogenic abscess.
Methods. We report two clinical cases of disseminated necrotic mediastinitis with two different medical and surgical approaches. The radiographic and photographic documentation of the patients was collected in the pre-and post-operatively. All patients underwent a CT scan and MRI.
Results. Mediastinitis can result from a serious odontogenic abscess, and the extent of its inflammation process must be never underestimated. Dental surgeons play a key role as a correct diagnosis can prevent further increasing of the inflammation process.
Conclusions. A late diagnosis and an inadequate draining represent the major causes of the elevated mortality rate of disseminated necrotizing mediastinitis.
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Annali di stomatologia
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Disseminated necrotic mediastinitis spread from odontogenic abscess: our experience
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Disseminated necrotic mediastinitis spread from odontogenic abscess: our experience
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                                                                                                        Original article



    Disseminated necrotic mediastinitis spread from
    odontogenic abscess: our experience




                                                                                                          i
                                                                                                        al
                                                                                                     on
    Fabio Filiaci MD, PhD1                                       nosis can prevent further increasing of the inflam-
    Emiliano Riccardi MD1                                        mation process.
    Valeria Mitro MD1                                            Conclusions. A late diagnosis and an inadequate
    Pasquale Piombino MD, PhD2                                   draining represent the major causes of the elevat-
    Claudio Rinna MD1                                            ed mortality rate of disseminated necrotizing me-




                                                                                           zi
    Alessandro Agrillo MD1                                       diastinitis.
    Claudio Ungari MD, PhD1
                                                                 Key words: odontogenic abscess, mediastinitis,




                                                                             na
                                                                 pulpal abscess.
    1   Oral and Maxillofacial Sciences Department, Policlini-
        co Umberto I, “Sapienza” University of Rome, Italy
    2   Maxillofacial Surgery Department, Federico II Uni-       Introduction




                                                                   er
        versity of Naples, Italy
                                                                 Mediastinitis is a severe inflammatory process involv-
                                                                 ing the connective tissues that fills the intracellular
    Corresponding author:                                        spaces and surrounds the organs in the middle of the
    Emiliano Riccardi


                                                           t     chest. This pathology has both an acute and a chron-
                                                        In
    Oral and Maxillofacial Sciences Department, Policlini-
    co Umberto I, “Sapienza” University of Rome
                                                                 ic form and, in most cases, it has an infectious etiolo-
                                                                 gy. Major sources of mediastinal infections can be:
    Via Valentino Banal 31                                       direct contamination, haematic or lymphatic dissemi-
    00177 Rome, Italy                                            nation, spreading from the neck or retroperitoneal
    E-mail: emiliano.riccardi@hotmail.it                         space, from the lung or the pleura (1).
                                           ni
                                                                 The disseminated necrotic mediastinitis (DNM) is, on
                                                                 the other hand, a suppurative acute infection of the
    Summary                                                      mediastinal tissue always coming from infective
                                  io

                                                                 pathologies of the neck or odontogenic abscesses
    Aims. Deep neck infections are rare but potential-           (2). This rare pathology includes a high mortality rate
    ly fatal complication of pulpal abscess of the               (between 25 and 40%) which is made worse by de-
    teeth. If an infection can progress rapidly from a           layed diagnosis and therapy (2). Whenever on odon-
                          iz



    toothache to a life threatening infection, then it is        togenic or cervical abscess fails to respond to the
    critical that dentists be able to recognize the dan-         therapy, it spreads into the mediastinum and the
    ger signs and identify the patients who are at risk.         pleura, causing a severe and generalized sepsis.
           Ed




    Mediastinitis is a severe inflammatory process in-           Patients suffering from this pathology are admitted to
    volving the connective tissues that fills the intra-         hospitals in very critical conditions and in many cases
    cellular spaces and surrounds the organs in the              the therapy is not effective even if started on time. In
    middle of the chest. This pathology has both an              fact, DNM mortality rate is still very high (about 40%)
    acute and a chronic form and, in most cases, it              and comes with many complications, such as septic
    has an infectious etiology. This study want to ex-           shock, occlusion of respiratory airways, jugular
IC




    pose the experience acquired in the Oral and Max-            thrombosis and erosion of major vascular structures
    illo-facial Sciences Department, Policlinico Umber-          with consequent blood overflowing (3).
    to I, “Sapienza” University of Rome, regarding two           With this research we want to show the experience
    clinical cases of disseminated necrotizing medias-           acquired at the Maxillo-facial Department of Policlini-
C




    tinitis starting from an odontogenic abscess.                co Umberto I, “Sapienza” University of Rome, regard-
    Methods. We report two clinical cases of dissemi-            ing two patients with disseminated necrotizing medi-
    nated necrotic mediastinitis with two different              astinitis starting from an odontogenic abscess. Their
    medical and surgical approaches. The radi-                   clinical character, diagnosis and treatment were ana-
                                                                 lyzed. A protocol is recommended for managing sus-
©




    ographic and photographic documentation of the
    patients was collected in the pre-and post-opera-            pected cases.
    tively. All patients underwent a CT scan and MRI.
    Results. Mediastinitis can result from a serious
    odontogenic abscess, and the extent of its inflam-           Patients and methods
    mation process must be never underestimated.
    Dental surgeons play a key role as a correct diag-           A retrospective review was conducted of patients who

    64                                                                              Annali di Stomatologia 2015; VI (2): 64-68
    Disseminated necrotic mediastinitis spread from odontogenic abscess: our experience


    were diagnosed with odontogenic abscess and dis-              Patient 2 A 50-year-old patient was admitted to the
    seminated necrotizing mediastinitis from December             maxillofacial Department with a phlegmon in the bilat-
    2009 to December 2011. Two patients were included             eral latero-cervical area and in the anterior-superior
    in this study. Their etiology, associated systemic dis-       mediastinal area. The patient suffered from a slight
    eases, bacteriology, radiology, treatments, duration          toothache at the left mandibular mid-arcade, and was




                                                                                                           i
    of hospitalization, complications and outcomes were           therefore under antibiotic therapy with clindamycin




                                                                                                         al
    review. The diagnosis of disseminated necrotizing             and amoxicillin.
    mediastinitis was confirmed through clinical examina-         Afterwards, he had fever and on clinical examination he
    tions and thoracic CT scans.                                  presented swelling in the left mandibular and sub-




                                                                                                      on
                                                                  mandibular area, lasting for about a month, loss of func-
    Patient 1. A 26-year-old patient admitted to the              tion of ATM, fever with shivers and breathing difficulties.
    Emergency Room with fever (39° C), a tense-elastic            At CT of the neck was performed. This showed a vo-
    bruised area in the right buccal region and spread            luminous swelling (6 cm approximately) with visible
    side-cervical bilateral, with massive pain, hyperemic         gas-filled bubbles in the left sub-mandibular and un-




                                                                                             zi
    skin and bilateral trismus. CT scan results showed a          der chin area, with impregnated tissues in the deep
    voluminous abscess mass involving the right parotid           peripheral area.
    and laterocervical area up to the carotid bifurcation,        The patient underwent a tracheotomy and the phleg-




                                                                               na
    and the bilateral under-chin and sub-mandibular area          mon drainage through a percutaneous laterocervical
    that was displacing the laryngeal lamp to the left up         and sub-mandibular incision.
    to the plan over the tongue. There was also a thick-          He was then administered an antibiotic therapy with
    ening and edema of right genial area soft tissues, but        clindamycin and amoxicillin; due to the persistence of




                                                                    er
    there was no remarkable fluid collection in the medi-         his critical conditions, after 7 days he underwent a
    astinum, or presence of lymphadenopathy.                      neck and chest CT that showed many abscesses
    Later on, the patient underwent an incision in the            emerging in the left latero-cervical sub-mandibular
    under chin area, with drainage of purulent materials;         area with gas-filled bubbles. These bubbles were



                                                         t
    the pull-out of the third molar with drainage of puru-        spreading upwards, involving the massetere muscle,
                                                      In
    lent materials on the level of the alveolus and finally
    the positioning of a drainage. Cultures exams found
                                                                  and downwards involving the parotid up to the biking
                                                                  area, involving also the para-pharingeal space. The
    gram positive cocci and gram negative bacilli; inad-          collection was extending medially to the pre-vertebral
    diction, streptococcus anginosus and ralstonia pick-          area and right latero-cervical space, where a fluid col-
    etti, both sensitive to ampicillin (MIC<2), were iso-         lection with air bubbles was detected, involving left
                                                 ni
    lated.                                                        supra-clavear area and anterior-superior mediastinum,
    There was an improvement of the patient’s general             where fluid collections, delimitated by vascular walls,
    condition, together with lower body temperature and           occupied the right para-tracheal region (10 cm). For
                                    io

    an enhancement of ABG values. The mediastinal ex-             these reasons the patient underwent a toilette and
    tension with the fluid collection in the right para-tra-      phlegmon drainage through laterocervical access.
    cheal area, was 30x35 mm and there was a spread-              Later on, a new angio-CT of the neck and the chest
    ing for 15 cm in pre- and retro-tracheal spaces. After-       was performed: it showed a slight improvement of ab-
                           iz



    wards, he was treated with beta-lactam antibiotic 2 g         scess lesions, that fairly change at the latero-cervical
    every 8 hours and aminoglycoside 1,5 g every 24               level, and the presence of increasing abscess lesions
    hours, while therapy was started with enoxaparin              at the anterior-superior mediastinum, localized mostly
          Ed




    sodium 6000 U every 24 hours. Due to the persis-              to the right side. Because of these complications the
    tence of breathing difficulties, the patient underwent a      patient had a right cervicotomy and a right thoracoto-
    right videothoracoscopy that showed the lung com-             my 10 days after hospitalization in order to evacuate
    pletely adherent to the mediastinum.                          those fluid collections. There was an improvement of
    A right thoracotomy was then performed, which re-             general conditions and no fever. Microbiological cul-
    vealed parietal pleura with intense inflammatory reac-        ture found the presence of Streptococcus and Candi-
IC




    tion. On the pleural dome there was a purulent ab-            da. Thorax X-ray didn’t show any important alteration.
    scess, that was drained washing the pleural cavity            CT of neck and thorax showed parenchymatous in-
    with iodine solution and with the resection of the lung       flammatory tissue (about 5 cm) in the left sub-
    apex, hemostasis and drainage catheters positioning.          mandibular area spreading to parapharyngeal and
C




    So the patient started improving his condition. 7 days        vascular space, which caused a light compression of
    after surgery another CT of neck and thorax was per-          the left lateral wall. There was also a little abscess (3
    formed that showed a big reduction of the many su-            cm) in the laterocervical area which obliterated the
    perior abscesses with normal and symmetric airways.           left pyriform sinus. In the mediastinum there was in-
©




    The right pre-tracheal and the small localized fluid          flammatory tissue (4 cm) that spread in the right
    collection at the mediastinum disappeared. There              para-tracheal area, but was reduced compared to
    was just a fluid collection behind the right bronchus         previous control (8 cm). The post-surgery course
    and pulmonary vein (2 x 2 cm).                                showed a slow improvement of the patient’s clinical
    After three weeks of antibiotic therapy, the patient          conditions. He underwent regular washings with dis-
    was discharged in good clinical conditions, after the         infectant and peroxide while daily medications were
    removal of draining wires.                                    carried on with the neck exposed and plugged with

    Annali di Stomatologia 2015; VI (2): 64-68                                                                            65
    F. Filiaci et al.


    iodoform gauze. Finally, after 2 weeks, the patient          ship between mediastinitis and oropharyngeal infec-
    was discharged in good general condition.                    tion is clearly established. Primary sites of infection
                                                                 are periodontal abscess, retropharyngeal abscesses
                                                                 and peritonsillar abscess. According to Wheatley et
    Discussion                                                   al. (11) most common primary oropharingeal infection




                                                                                                           i
                                                                 is odontogenic with mandibular second or third molar




                                                                                                         al
    Descending mediastinitis is an acute infection sec-          abscess.
    ondary to severe cervical infection, and odontogenic         Soft tissues infections with odontogenic origins tend
    abscess is the most common primary infection. Infec-         to spread through the tissue surrounding the teeth,




                                                                                                      on
    tions in the head and neck can spread down into the          through locus minori resistentiae, up to all closest ar-
    retropharyngeal space (71% of cases) or carotid              eas (12).
    sheath (21% of cases), gravity-facilitated, breathing
    and negative intrathoracic pressure (4, 5).                  Clinical symptoms: periodontal infections include
    According to the International Literature, the clinical      gum disease, periodontitis, fascial plans infections




                                                                                            zi
    cases above described, show most of the potential            can cause trysmus, pain of the body and the corner
    emergencies that might arise from on odontogenic in-         of the mandible, swelling and disfagia. It can spread:
    fection. Their complications can cause systemic on-          through inferior hole of the orbit or through the orbit




                                                                              na
    sets that might compromise to the death the patient’s        itself, causing a cellulitis with proptosis, optic neuritis
    general conditions. It was reported that 49% of pa-          and abducent nerve plasty. The infection can also
    tients died during their treatment in the first know arti-   spread in extra-oral position and present like an evi-
    cle published about mediastinitis in 1938 (6).               dent swelling, a low pain, trysmus, and just few gen-




                                                                   er
    An example of most critical clinical evolution of odon-      eral symptoms. Potentially it could spread to perior-
    togenic infections, that usually spread directly, is Lud-    bitary tissues and paranasal sinuses. Moreover it
    wing’s Angina, a necrotic fasciitis of head and neck         could be an intraoral extension without swelling and
    that finally reaches the mediastinum causing medias-         drainage. We could find a swelling in parotid space
    tinitis (7).


                                                           t     with pain and clinical signs. Potentially it could spread
    Odontogenic infections can be divided into: den-
    toalveolar, periodontal, and facial plans. They can
                                                        In       to posterior pharyngeal space (so called “danger
                                                                 space”). Finally the infection can affect sublingual
    spread through contiguity causing jaws sinus,                space, causing sub-chin edema with rash and tense
    mandibular osteomielitis, cavernous sinus throm-             skin bilaterally.
    bophlebitis, internal jugular vein thrombophlebitis,
                                           ni
    erosion of the internal carotid artery, Ludwing’s Angi-      Ludwig’s angina: it’s a neck and mouth floor soft tis-
    na and discending necrotic mediastinitis (7). They           sue gangrenous cellulitis (4). Both patients, at the
    can also spread in an hematogenic way causing an             moment of hospitalization, were suffering from Lud-
                                 io

    infective endocarditis, infections of articular prothesis,   wig’s Angina.
    spondilodiscitis, streptococcus sepsis (in patients af-      Diagnostic criteria are:
    fected by leukemia) (7).                                     1) bilateral involvement
    Delayed diagnosis and inadequate drainage process-           2) submandibular and sublingual areas involvement
                        iz



    es were primary underlying factors contributing to this      3) rapidly progressive cellulitis with no abscess or
    high mortality (8). The earlier detection and treatment          lymphatic involvement
    as a result of contrast-enhanced CT imaging con-             4) the infection must be begin from the mouth floor,
          Ed




    tributed to decrease in mortality rate.                          and in 80% of cases, from the II and III molar (4,
                                                                     13).
    Microbiology: intravenous antibiotic therapy is the          Gram positive cocchi and anaerobics are the ethio-
    initial treatment, and empirical medication is often         logic agents involved with the infection. Leaning fac-
    used. The bacteriological results of these patients          tors are: cavities, recent dental treatments, diabetes
    show that pus culture and sensitivity tests are essen-       mellitus, malnutrition, alcoholism, immunodepression
IC




    tial. The most common organism isolated seem to be           and trauma (4).
    streptococcus sanguis, mutans and actinomyces vis-           On a clinical examination, it can be identified as a se-
    cosus, that live mostly on the tooth area (9), also          vere pathology with fever, septic status, pain wooden-
    streptococcus salivarius and veillonella, that are easi-     hard swelling, uplist and protrusion of the tongue,
C




    ly detected on the tongue and in the mucous mem-             trysmus (50%), disfagia, disartria, disfonia, neck stiff-
    brane, together with fusobacterium, bacteriodes pig-         ness (13). Clinical complications are due to airways
    mentati and spirochete anaerobie. They establish             obstruction.
    compounds within the gum recess (6). Dental cavi-            According to the International Literature, therapy in-
©




    ties, gum diseases and several forms of periodontitis        cludes the constant monitoring of airways, difficult in-
    are associated to different patterns of bacterial com-       tubation and a preventive tracheotomy (4).
    pounds, such as mutans streptococcus, usually de-            The following medications must be administered:
    tected on teeth with cavities (9, 10).                       - Desametasone (10 mg bolus followed by 4 mg every
                                                                     6 h to 48 h)
    Anatomic considerations: diagnosis of disseminat-            - Nebulized epinephrine (1 ml 1:1000 in 5 ml of
    ed necrotic mediastinitis mandates that the relation-            physiological solution 0.9%)

    66                                                                               Annali di Stomatologia 2015; VI (2): 64-68
    Disseminated necrotic mediastinitis spread from odontogenic abscess: our experience


    -    High doses of antibiotics intravenously: G peni-         Mediastinitis
         cillin + metronidazole or clyndamicine; amoxi-
         cillin/clavulanic acid                                   It’s an acute or chronic inflammatory disease of medi-
    - Patient must be remained seated                             astinic connective tissue. Acute mediastinitis are due to
    - Surgical draining and/or tissue decompression               Gram positive cocci which cause a mediastinic suppu-




                                                                                                             i
         from on side (13).                                       ration; they can be primitive or often follow esophageal




                                                                                                           al
    Clinical symptoms of Ludwig’s angioma infections of           lesions for trauma, foreign body or tumors; they are
    the facial plans can affect the lateropharyngeal area,        characterized by fever, retrosternal pain, leukocytosis;
    that is divided through the stiloideus process into           they can affect mediastinic organs (lung, heart, large




                                                                                                        on
    front compartment (soft and connective tissues) and           vessels) with really serious complications.
    back compartment (vascular-nervous wreck). This               Therapy is based on antibiotics administration, checking
    partition is fundamental to detect the different syn-         general conditions and removing the cause if possible.
    drome that may arise (4, 13).                                 Chronic mediastinitis are characterized by fibrotic scle-
    Front compartment syndrome, is characterized by               rosis of mediastinic space, with serious functional com-




                                                                                              zi
    fever with shiver, high pain, trysmus, swelling of the        plications for circulation and breathing; they often follow
    mandibular corner, dysphagia and medial displace-             granulomatous lesions (TBC, syphilis) in the medias-
    ment of the pharyngeal lateral wall (4, 7).                   tinic connective tissue or autoimmunitary disease. We




                                                                                na
    Back compartment syndrome, is characterized by sep-           must also consider that a mediastinitis could cause a
    tic status, low pain, cranial nerves involvement (IX-         mediastinic syndrome (Tabs. 1-3) (15).
    XII), airways obstruction due to laryngeal edema, in-
    ternal jugular thrombosis, internal carotid erosion (7).
                                                                  Table 1. Diagnostic examination.




                                                                    er
    Retro-pharyngeal infections present in back visceral
    compartment (esophagus, trachea, thyroid), that goes
                                                                  Microbiology:
    all the way down to the superior mediastinum. It also
    compromises the “danger space” that goes from the             • Collection, through an aspiration needle, of deep samples
    back of the mediastinum to the diaphragm. Clinical


                                                         t        • Immediate ground transfer for anaerobics and aerobics
                                                                  • Bacteriological examination
    symptoms include high fever, dysphagia, dispnea,
                                                      In
    neck stiffness, esophagus regurgitation, spontaneous          Imaging:
    draining of airways with suction, laryngeal spasm,
                                                                  • Scintigraphy with marked leukocytes: useful to mark
    bronchial erosion and jugular vein thrombosis (4).
                                                                  eventual osteomielitis
    According to the Literature and with regard to our ex-
                                                                  • Ultrasound: useful to analyzed collections from the sur-
                                                 ni
    perience, although we analyzed two patients only,             face
    where serious inflammatory processes are already              • Lateral neck X-Ray: it allows to estimate tracheal devia-
    ongoing, we usually adopt the diagnostic and thera-           tion or compression, and the presence of gas within
                                    io

    peutic pattern as indicated in the charts below.              necrotic tissues
                                                                  • CT: useful for evaluation of head, neck and facial areas
                                                                  (must be extended to the chest inany cases)
    Complications
                           iz



    We can divide them in:                                        Table 2. Surgical approach.
    1) Hematogenic complications: transient bacteremia,
          Ed




       infective endocarditis, infections of articular pros-      • Sick toot extraction
       thesis (7).                                                • Surgical drainage and necrotic tissues removal
    2) Contiguity complications: jaws sinus, mandibular           • Drainage optima Timing
       osteomyelitis, cavernous sinus thrombophlebitis,           • Systematic monitoring of fascial areas
       internal jugular vein thrombophlebitis (Lemierre
       Syndrome), erosion of the internal carotid artery
IC




       and descending necrotic mediastinitis (7).                 Table 3. Medical Therapy.

                                                                  • Antibiotic therapy (antibiotics retain local
    Lemierre Syndrome                                               diffusion and prevent the hematogen diffusion):
C




                                                                    A. Clinical findings:
    It’s a serious oro-pharynx infection with bacteremia,               a. Localised infection, no sepsis
    internal jugular vein pyogenic thrombophlebitis with                    Clyndamicine
    septic embolism. It’s unusual (<1/1.000.000), but it                    Amoxicillin/clavulanic acid or ampicillin/
©




    has been increasing during last year because                              sulbactam
    changes in antibiotic therapy for high airways infec-                   Metronidazole (no in monotheraphy)
    tions. It arises in young people, after EBV infection or            b. Life-threatening infection
    pharyngitis caused by streptococco. The main etio-                      Piperacillin/tazobactam or ticarcillin/
    logic agent is fusobacterium necrophorum. Main clini-                     clavulanic acid or carbapenemics
    cal findings are: high fever, cervical pain, septic           • Broad spectrum empirical therapy for
                                                                    immunnodepressed people
    shock, thrombocitopeny (14).

    Annali di Stomatologia 2015; VI (2): 64-68                                                                            67
    F. Filiaci et al.


    Conclusions                                                                 ical relevance and implications for diagnosis and treatment.
                                                                                Acta Otolaryngol. 2009;129:62-70.
                                                                           2.   Estrera AS, Landay MJ, Grisham JM, Sinn DP, Platt MR. De-
    From data collected at the Oral and Maxillo-facial Sci-
                                                                                scending necrotizing mediastinitis. Surg Gynecol Obstet.
    ences Department, Policlinico Umberto I “Sapienza”
                                                                                1983;157:545-52.
    University of Rome and according to the International




                                                                                                                         i
                                                                           3.   Kiernan PD, Hernandez A, Byrne WD, Bloom R, Dicicco B,
    Literature, we reached the following conclusions: me-




                                                                                                                       al
                                                                                Hetrick V, Graling P, Vaughan B. Descending cervical me-
    diastinitis remains a potential lethal infection that can                   diastinitis. Ann Thorac Surg. 1998;65:1483-88.
    result from a serious odontogenic abscess, and the                     4.   Furst IM, Ersil P, Caminiti M. A rare complication of tooth ab-
    extent of its inflammation process must be never un-                        scess-Ludwig’s angina and mediastinitis. J Can Dent Assoc.




                                                                                                                    on
    derestimated. Dental surgeons play a key role as a                          2001;67:324-27.
    correct diagnosis can prevent further increasing of the                5.   Mihos P, Potaris K, Gakidis I, Papadakis D, Rallis G. Man-
    inflammation process. They should identify as soon as                       agement of descending necrotizing mediastinitis. J Oral Max-
                                                                                illofac Surg. 2004;62:966-972.
    possible the infection symptoms, especially when it’s
                                                                           6.   Pearse HE. Mediastinitis following cervical suppuration. Ann
    reaching deeper tissues. These symptoms are: fever,




                                                                                                          zi
                                                                                Surg. 1938;108:588-611.
    mouth floor swelling, inferior mandibular swelling,                    7.   Furst IM, Ersil P, Caminiti M. A rare complication of tooth ab-
    asymmetric pharyngeal walls swelling, trysmus.                              scess-Ludwig’s angina and mediastinitis. J Can Dent Assoc.
    A late diagnosis and an inadequate draining repre-




                                                                                         na
                                                                                2001;67:324-27.
    sent the major cause of the elevated mortality rate of                 8.   Mihos P, Potaris K, Gakidis I, Papadakis D, Rallis G. Man-
    DNM. The use of CT scan is highly recommendable                             agement of descending necrotizing mediastinitis. J Oral Max-
    in cases with deep cervical inflammation in order to                        illofac Surg. 2004;62:966-972.
    identify still showing no sign. To effectively contrast                9.   Lautermann J, Lehnerdt G, Beiderlinden M, Sudhoff H. In-
                                                                                fections of the deep neck spaces with accompanying me-




                                                                            er
    the elevated mortality rate, an aggressive surgical
                                                                                diastinitis. Laryngorhinootologie. 2005;84:171-75.
    drainage, the removal of residues from neck area and                  10.   Hardie JM, Bowden GH. The normal microbial flora of the
    mediastine drainage through a postero-lateral toraco-                       mouth. Soc Appl Bacteriol Symp Ser. 1974;3:47-83.
    tomy performed by a multi-function medical team are                   11.   Wheatley MJ, Stirling MC, Kirsh MM, Gago O, Orringer MB.
    necessary.


                                                                   t            Descending necrotizing mediastinitis: transcervical drainage
    Moreover, it is extremely important to research and
                                                                In        12.
                                                                                is not enough. Ann Thorac Surg. 1990;49:780-84.
                                                                                Kang SK, Lee S, Oh HK, Kang MW, Na MH, Yu JH, Koo BS,
    register all symptoms of an imminent collapse of air-
    ways, that include muffled voice, tongue or mouth                           Lim SP. Clinical features of deep neck infections and pre-
    floor uplift, beside the inability to tolerate or even                      disposing factors for mediastinal extension. Korean J Tho-
                                                                                rac Cardiovasc Surg. 2012;45:171-76.
    swallow salivary secretions.
                                                 ni
                                                                          13.   Saifeldeen K, Evans R. Ludwig’s angina. Emerg Med J.
                                                                                2004;21:242-43.
                                                                          14.   Chirinos JA, Lichtstein DM, Garcia J, Tamariz LJ. The evo-
    References                                                                  lution of Lemierre syndrome: report of 2 cases and review
                                      io

                                                                                of the literature. Medicine (Baltimore). 2002;81:458-65.
     1. Kinzer S, Pfeiffer J, Becker S, Ridder GJ. Severe deep neck       15.   Bulut M, Balci V, Akköse S, Armağan E. Fatal descending
        space infections and mediastinitis of odontogenic origin: clin-         necrotising mediastinitis. Emerg Med J. 2004;21:122-23.
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