Acute necrotic descendent mediastinitis

1. Acute necrotic descendent
mediastinitis – slow recovery,
complicated by cervical defect,
superior aperture defect and
chronic pneumothorax
Hasan E.1, Tunea C.1, Miron I.1, Butas M.2,Petrache I.1,3, Burlacu O.1,3
1.Spitalul Clinic Municipal de Urgență Timișoara, Clinica de Chirurgie
Toracică
2. Spitalul Clinic Municipal de Urgență Timișoara, Secția ATI
3. Universitatea de Medicină și Farmacie „Victor Babeș” Timișoara

2.  Acute necrotic descendent mediastinitis (DNM) with
odontogenic source is unfortunately very frequent in
our country, due to poor oral hygiene.
 It has a high mortality
 The patients who survive it have a high, difficult to
treat complication rate.
Introduction

3.  We present the case of a 24 year old female patient
 Admitted with DNM, secondary to a left
submandibular abscess, diagnosed 10 days prior to
presentation.
Material and Method

4. Clinical Presentation
 Poor general status;
 Fever;
 Throat pain;
 Inflammatory signs
present to cervical and
upper thoracic region.

5. CT scan
The CT scan showed the submandibular collection, anteriorly fused into the
mediastinum, pericardium and both pleural spaces.

6. Material and Method
 A gonion to gonion
cervicotomy was performed,
 Opening the
 left lateral pharyngeal,
 left submandibular,
 left and right submandibular,
 left supra-omo-hyoidian
spaces,
 extraction of the left molars,
right pleural drainage.

7.  A left thoracotomy was performed,
 Anterior and posterior mediastinotomy,
 Pleuro-pericardial fenestration,
 Pleural drainage and ascendant subxyphoidian mediastinal
drainage.
 Wide spectrum antibiotherapy and antifungal therapy was
administrated.
 Oro-tracheal intubation was maintained for 7 days.
 Daily dressings and repeated lavage was performed.
Material and Method

8. CT scan the next day

9. CT scan 7th postop. day

10.  The postop. recovery was slow, the patient needed
prolonged intubation.
 The right chest drain was removed on day 10 postop.
 The mediastinal drain was removed after 8 days.
 Due to cervical infection, colonization with Pseudomonas
A., the patient developed a wide cervical cutaneous defect,
which communicated with the superior mediastinum and
the left pleural space,
 This lead to maintenance of a chronic left pneumothorax.
Results

11. Results

12. Results
 We performed sealing of the
fistula with separate non
resorbable stiches,
 The persistence of the
pneumothorax required a
thoracoscopy for
deloculation, suture of the
superior mediastinal pleura
and repositioning of the
chest drains.

13. Results – after thoracoscopy
 Thoracoscopy sealed the
mediastinal pleura and
the upper aperture.
 Complete lung
reexpansionig was
obtained.

14. Results
 The cervical defect was
covered with skin graft.
 Hospital stay was 50 days,
 15 were spent in ICU.

15. Results

16. Late Results
 Patient was unhappy with
exterior neck aspect;
 Skin expanders were
used;
 The neck was
reconstructed after one
month.

17. Final Aspect

18.  Odontogenic DNM still remains difficult to manage.
 The presence of a multidisciplinary team composed
by thoracic, maxillary and facial surgeons, a plastician
and an anesthetist is the key of success for these
cases.
 Young age and the lack of comorbidity is an
advantage for survival.
 To prevent this pathology a thorough dental
screening for infections is mandatory.
Conclusions

19. TAKE HOME MESSAGE: take care of your teeth!!!