Necrotizing descending mediastinitis by Acinetobacter Baumannii in an out-patient: a case report

Background Complicated cervico-facial cellulitis is an infectious disease which can have fatal prognosis. Necrotizing descending mediastinitis is a rare and fatal complication of cervico-thoracic cellulitis. This is the case of necrotizing descending mediastinitis complicating by a multi-resistant Acinetobacter Baumannii in a 27-year-old female, with early management of hemodynamic, respiratory and surgical emergencies, and very careful post-operative care, resulting in very satisfying outcome. Case presentation The patient presented was first treated with broad spectrum antibiotics for Ludwig’s angina for 10 days, then presented with a swelling of sub-mandibular, sub-mental, and cervical regions, a mild respiratory distress, with clinical enhancement of dyspnea in proclive position, tachycardia of 100 beats per minute, and arterial blood pressure of 10/5. Clinical exam showed a tight trismus, with oral opening inferior to 1 cm, no inflammatory signs in facial and cervical swollen areas, and a saturation of 95% in proclive position. Auscultation suspected a pericardial effusion. CT scan with and without injected contrast medium showed diffuse abscesses of sub-mental, sub-mandibular, retro-pharyngeal, para-pharyngeal regions, along with mediastinal abscesses and pericardial effusion. Trans-thoracic ultrasound showed 2 cm pericardial effusion, preserved function of myocardium, and without signs of tamponade. The diagnosis of necrotizing descending mediastinitis with pericardial effusion was established. The patient underwent a course of wide spectrum antibiotic therapy, low doses of cathecholamine, and a surgical drainage through cervical approach of all implicated zones. The surgical dissection was thorough and difficult due to diffuse fibrosis found in tissues of cervical regions. Two hundred milliliters of pus was evacuated, with a placement of surgical drains and Delbet blades. Bacteriological exam found an Acinetobacter Baumannii sensitive to colistin only. The post-operative outcome showed clinical and biological enhancement; however, a residual mediastinal collection appeared in control CT scan after 48 h, which indicated a surgical revision through mediastinoscopy. The post-operative outcome was satisfying with stabilized clinical, biological, and radiological aspects. Conclusions Necrotizing descending mediastinitis is an infectious disease correlated with a very elevated mortality rate, and management is based on airway control, antibiotic therapy, and surgical treatment, as well as the post-operative intensive unit care. Early diagnosis and appropriate management enhances outcome and decreases mortality significantly.

Descending Mediastinitis in a Child: Diagnostic Challenges and a Different Treatment Approach

In children, spontaneous mediastinitis is a rare, severe and commonly misdiagnosed disease. Although standard of care treatment frequently involves surgery, we report a case of mediastinitis in a five-year-old child, successfully treated with 4 weeks of intravenous antibiotics. Ultrasound imaging was used to monitor patient response to conservative treatment while reducing radiation exposure.

Descending mediastinitis secondary to deep neck abscess in a healthy patient: Case report

Necrotizing descending mediastinitis is an emergency which can be fatal in most cases. 80% to 85% of patients who develop descending necrotizing mediastinitis are young, previously healthy persons. We present the case of a healthy patient who, after a neck abscess, developed descending necrotizing mediastinitis complicated by atypical interstitial pneumonia.

Odontogenic cervical necrotizing fasciitis with descending mediastinitis: a case report and discussion

<p class="abstract">Mr KE is a 46 years old gentleman with a background of type 2 diabetes mellitus who was referred to our department for severe polymicrobial cervical necrotising fasciitis with descending mediastinitis after mandibular dental extraction. He was managed with endotracheal intubation, cervicotomy and video assisted thorascopic surgery (VATS), antibiotic and antifungal therapy and myocutaneous flap coverage. This case describes a classical presentation of an uncommon pathology and discusses options for airway management, surgical debridement, antimicrobial therapy and definitive defect coverage. </p>

THE ANALYSIS OF RENDERING ASSISTANCE BY A SICK ACUTE DESCENDING MEDIASTINITIS

Summary. Objective — to lead the analysis of diagnostics and treatment of patients with an acute descending mediastinitis for improvement of results of their treatment. Materials and methods. The analysis of results of treatment of 34 patients is presented by an acute mediastinitis. Patients with a descending mediastinitis made up — 61,8 % (21). The reasons of it became dontogenous phlegmons — 8 (23,5 %) and phlegmons of a neck owing to nonspecific lymphadenites and paratonsillar abscesses — 13 (38,2 %) Results. For a while from the beginning of disease up to a mediastinotomy the choice of additional methods of research influenced: at carrying out of roentgenography it has made (11,0±2,3) day, at carrying out of a computer tomography — (4,0±0,5) day. The lethality among group of a descending mediastinitis made up 19,0 % (4 patients). Direct authentic correlation of a lethality and augmentation of a leukocytic index of an intoxication (LII) in 10 days after operative treatment noted. Conclusions. The computer tomography is most diagnostically valuable (up to 100 %) research in monitoring a condition of the patient at stages of his treatment. The leukocytic index of an intoxication can serve as accessible supervising and prognostic criterion of a condition of the patient at an acute mediastinitis.

Case report of a submandibular abscess lethally tracking down through the mediastinum presenting as cardiac empyema

A 46-year-old male presented to our emergency with sudden severe shortness of breath and was found to have massive pericardial effusion causing cardiac tamponade and atrial fibrillation. He had to undergo immediate pericardiocentesis to relieve his symptoms and it drained frank pus indicating pericardial empyema as the underline cause of tamponade. On physical examination, patient was found to have a left submandibular tender swelling. He had increased inflammatory markers and on further imaging the CT showed massive diffuse mediastinal abscess. The patient had to undergo urgent surgery by multiple specialist surgeons in which large amount of pus was drained from the submandibular and mediastinum resulting in improvement of his condition and speeded his recovery. Key Messages • Thorough history and examination are of utmost importance. • Immediate treatment of pericardial tamponade is lifesaving. • High index of suspicion of descending mediastinitis should arise whenever purulent pericardial drainage is encountered. • Early diagnosis of mediastinal abscess by doing early radiographic investigations reduce mortality. • Head and neck abscesses must be treated properly to prevent life-threatening conditions.

Predictive factors of lethality and complications of deep fascial space infections of the neck

ABSTRACT Objective: to identify predictive factors for lethality and complications of deep fascial space infections of the neck (DFSIN), establishing an early and aggressive treatment in the neck before the progression to descending mediastinitis. Methods: we retrospectively analyzed 133 cases of DFSIN treated at Discipline of Head and Neck Surgery of the Medicine School of Santa Casa de Misericórdia de São Paulo. We accessed demographic characteristics, associated diseases, clinical presentation, laboratorial tests, length of hospital stay, number of involved anatomic neck spaces, intra-operative and microbiology findings. We analyzed these data using logistic regression to predict DFSIN lethality and life threatening complications (mediastinitis, septic shock, pneumonia, pleural empyema, skin necrosis). Results: lethality and complication ratios were 9% and 50.3%, respectively. The logistic regression model showed that patients with septic shock were more likely to have progression to death (p < 0.001) and, the presence of more than two involved neck spaces (p < 0.001) and older individuals (p = 0.017) were more likely to have complicated deep neck infections. Descending necrotizing mediatinitis increased the lethality ratio by 50%, and was associated to necrotizing fasciitis (p=0.012) and pleural empyema (p<0.001). Conclusion: septic shock is a lethal predictive factor and age as well as more than two involved neck spaces are the predictive factors for complications. Necrotizing fasciitis is an important factor for complications and death. Therefore, its surgical treatment must be more aggressive. Descending mediastinitis has a high lethal rate and the successful treatment is based on early diagnosis and aggressive surgical approach.

Hyperbaric oxygen therapy in a case of cervical abscess extending to anterior mediastinum, with isolation of Prevotella corporis

We present a case of an odontogenic abscess, first spreading at the lateral cervical level and then in mediastinum. We isolated an anaerobic bacterium, Prevotella corporis, rarely documented in literature. The mortality rates of cervical abscesses secondary to odontogenic infections and complicated by mediastinitis vary from 10% to 40%. Treatment of descending mediastinitis involves multidisciplinary teams such as otorhinolaryngology, thoracic surgeons, infectious disease physicians, anesthetists and intensivists. Due to the combined treatment with surgical drainage within 48 hours of hospitalisation, antibiotics and subsequent hyperbaric oxygen therapy, we have achieved complete recovery of the patient.

Features of adequate intubating security in patients with odontogenic and tonsilogenic neck phlegmons

Recently, a tracheostomy was considered the method of choice for provide ventilating of patients with deep neck phlegmons, but current trends recognize that tracheal intubation with bronchoscope is the most rational way of adequate breathing security in such patients. Objective - to investigate the peculiarities of features of adequate intu bating security in patients with odontogenic and tonsilogenic neck phlegmons. 70 patients with deep neck phlegmons of odontogenic 4(7 (67%)) and tonsilogenic origin - (23 (33%)) have been investigated. 47 (67%) suffered from descending mediastinitis. Tracheal intubation was performed using orotracheal laryngoscope, bronchoscope or through tracheostomy. 33 (47.1%) patients underwent orotra cheal intubation with a bronchoscope, 34 (48.6%) with a laryngoscope, and only in three cases (4.3%) tracheostomy was used. Bronchoscopic intubation was performed in 57.4% of patients with odontogenic phlegmons, and only in 26.1% cases of oropharyngeal spaces suppuration. The percentage of tracheostomies was the same in two groups of patients and showed 4.3%. Mortality rate was 12.9%. Thus, 57.4% of patients with odontogenic neck phlegmons need for bronchoscopic tracheal intubation, a tracheostomy is used extremely rarely (4.3%). Intubation with laryngoscope is possible in 70% of patients with tonsilogenic suppuration. Comparison of tracheal intubation in patients with deep neck phlegmons with and without descending mediastinitis is prospects for further research.