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CASE REPORT
Year : 2019  |  Volume : 22  |  Issue : 6  |  Page : 869-871

Mediastinitis as complication of odontogenic infection: A case report


1 Department of Oral and Maxillofacial Surgery, Faculty of Dentistry, Erciyes University, Kayseri, Turkey
2 Department of Oral and Maxillofacial Surgery, Faculty of Dentistry, Gaziosmanpasa University, Tokat, Turkey
3 Department of Otorhinolaringology, Faculty of Medicine, Gaziosmanpasa University, Tokat, Turkey

Date of Acceptance01-Jan-2019
Date of Web Publication12-Jun-2019

Correspondence Address:
Dr. E Soylu
Department of Oral and Maxillofacial Surgery, Faculty of Dentistry, Erciyes University, Kayseri
Turkey
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/njcp.njcp_539_18

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   Abstract 


Odontogenic infections are one of the most common dental problems, which affect 80%–90% of the population. Untreated odontogenic infections can cause life-threatening complications such as necrotizing fasciitis, descending necrotizing mediastinitis, internal jugular vein thrombosis, cavernous sinus thrombosis, carotid artery pseudoaneurysm or rupture, and systemic inflammatory response syndrome. This report aims to present a mediastinitis case, in a 22-year-old healthy male patient, which originated from an odontogenic infection. The patient was hospitalized because of worsening general health status, despite the antibiotherapy. Computed tomography (CT) scan revealed that periapical abscess was spreading to the mediastinum through retropharyngeal space. The patient was successfully treated by IV antibiotherapy, transcervical drainage, and extraction of tooth.

Keywords: Complication, mediastinitis, odontogenic infection, transcervical drainage


How to cite this article:
Soylu E, Erdil A, Sapmaz E, Somuk B T, Akbulut N. Mediastinitis as complication of odontogenic infection: A case report. Niger J Clin Pract 2019;22:869-71

How to cite this URL:
Soylu E, Erdil A, Sapmaz E, Somuk B T, Akbulut N. Mediastinitis as complication of odontogenic infection: A case report. Niger J Clin Pract [serial online] 2019 [cited 2019 Sep 17];22:869-71. Available from: http://www.njcponline.com/text.asp?2019/22/6/869/260038




   Introduction Top


Caries, pulpitis, gingivitis, periodontitis, pericoronitis, and endodontic infections are the leading causes of odontogenic infections and are still affecting 80%–90% of the population.[1] Most odontogenic infections can be treated successfully using antibiotherapy, suitable dental treatments, extraction, incision, and drainage. Nevertheless, mortality rates from odontogenic infections remain high owing to microorganisms' antibiotic resistance mechanisms and contiguity to vital anatomic structures.[1]

An odontogenic infection in the maxillofacial region can pass through the physiological spaces and spread to the mediastinum and cause mediastinitis.[2] By reaching the mediastinum, an infection unveils the following symptoms: chest pain, severe dyspnea, unremitting fever, and an expanded mediastinum, as viewed radiologically. These infections spread through the mediastinum in three ways: (a) the paratracheal route to the anterior mediastinal space; (b) the lateral pharyngeal route to the medial mediastinal space; and (c) the retropharyngealretrovisceral route to the posterior mediastinal space.[3],[4]

The mortality rates from this life-threatening condition remain between 7% and 20%, even after antibiotic use.[5],[6]

This report aimed to present a case of mediastinitis caused by an odontogenic infection in a systemically healthy adult that was successfully treated with tooth extraction after cervical drainage.


   Case Report Top


A 22-year-old male patient referred to our Oral and Maxillofacial Surgery Clinic with complaints of pain and swelling in the lower left jaw. Following clinical and radiological examinations, a diagnosis of acute periapical infection of tooth no 37 was made. [Figure 1] Amoxycillin+clavulanic acid 2 × 1 g, ornidazole 2 × 500 mg, and IM diclofenac sodium 2 × 75 mg were prescribed. After 4 days, the patient's clinical condition worsened, and he was referred to the emergency department. A full blood exam revealed his C-reactive protein level was 401.56 mg/l, and the white blood cells were 14.08 × 103 K/mm3. The patient was admitted to the Otorhinolaryngology Department, commenced on 2 × 600 mg of clindamycin. In the CT evaluation, abscess accumulations were detected in the parapharyngeal, retropharyngeal, and submental spaces[Figure 2]. Under general anesthesia, to obtain drainage from parapharyngeal and retropharyngeal spaces, a peritonsillar approach was performed. An incision was made at the pole of left tonsilla palatina; through this incision, the parapharyngeal and retropharyngeal spaces were reached by blunt dissection. During dissection effluxing, yellowish-green, foul-smelling pus was seen. Pus and blood samples were obtained in this intervention, but these samples did not reveal any particular microorganism. Patient therapy was changed to 4 g of piperacillin sodium + tazobactam sodium at 4 × 500 mg after consultation with the Infectious Diseases Clinic.
Figure 1: Orthopantomograph view indicates periapical infection of lower left second molar that caused the abscess formation

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Figure 2: CT view shows spreading of the abscess to the retropharyngeal space. (Green arrows show abscess formation)

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After the first intervention, a second CT examination was performed, when the post-interventional symptoms failed to improve. This second examination showed that the abscess had spread to the upper mediastinal cavity [Figure 3]. A second operation using a transcervical approach was planned. A transverse cervical skin incision was made through the right retromandibular area, subplatysmal flaps were raised, the anterior border of the left sternocleidomastoid muscle was exposed, and the left sternocleidomastoid muscle and carotid sheath were retracted laterally. By blunt dissection, at the posterior aspect of the sternocleidomastoid muscle, between the anterior surfaces of the cervical vertebrae and the posterior surface of the esophagus, an abscess was detected and evacuated. The drainage was provided by placing penrose drains in the operation area [Figure 4]a,[Figure 4]b,[Figure 4]c.
Figure 3: Thoracal CT shows spread of abscess between arcus aorta and vertebrae (Green arrow shows abscess localization)

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Figure 4: (a) Route of drain following a transcervical incision in the patients with medistinitis (Green arrow indicates the drain). (b) The CT image taken from the vocal cord level shows that the abscess is spreading to the retropharyngeal space, and the relation between the drain and a. carotis interna is observed. (Green arrow shows drain, the red arrow indicates a. carotis interna, and white arrow shows abscess). (c) CT shows endpoint of the drain and relation with arcus aorta. (Green arrow indicates the drain, and the red arrow shows arcus aorta)

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A total of 110 ml drainage from the abscess was achieved over two postoperative days. Following relieve of clinical condition, tooth no 37 was extracted under local anesthesia followed by intraoral periapical and submucosal abscess drainage. Total drainage of 40 ml was achieved over 2 days from cervical drains after the extraction, and these drains were removed after 8 postoperative days. The patient was discharged after being hospitalized for 14 days.


   Discussion Top


Odontogenic infections are usually seen as localized infections. However, if these infections cannot be brought under control, they can cause bacteremia, bacterial endocarditis, mediastinitis, cavernous sinus thrombosis, suppurative jugular vein thrombophlebitis, arterial carotid erosion, maxillary sinusitis, osteomyelitis, and deep neck infections.[6]

Adovica et al. reported that odontogenic infections are the most common cause (70.6%) of deep neck infections.[7] Deep neck infections also cause the most common and most dangerous complications, including acute airway obstruction, mediastinitis, Lemierre syndrome, suppurative jugular vein, internal thrombophlebitis, arterial carotid aneurysm or rupture, necrotizing cervical fasciitis, and pneumonia.[7]

Estrera et al. has described diagnostic criteria for descending necrotizing mediastinitis as follows: (a) symptoms of clinically severe oropharyngeal infection; (b) radiographic findings of mediastinitis with CT; (c) the presence of a mediastinal infection, which is detected during an operation or autopsy; and (d) a relationship between an oropharyngeal infection and descending necrotizing mediastinitis.[8] For these criteria, in the present case, an infection in the maxillofacial region was diagnosed. In the CT examination, due to the spread of infection, the oropharyngeal airway narrowing at the left side and an abscess spread through the posterior aspect of the sternocleidomastoid muscle at the level of half of the thyroid gland was identified.

According to Endo et al.'s mediastinal abscess spread classifications, this dissemination of the abscess in the present case was a type 1.[9] In the present case, the first drainage was attempted with the peritonsillar approach according to the initial radiological examination. However, when the abscess extension progressed to the upper mediastinum, a regression of symptoms was achieved after the drainage using the transcervical approach. For the complete treatment of the case, it was necessary to perform a tooth extraction, which was the primary cause of infection, within the hospitalization period.[10]

Antibacterial therapy is also an essential component in the treatment of odontogenic mediastinitis. Antibiotic therapy should be applied on a long-term basis, and the antibiotics used should be selected from the groups that may also affect resistant microorganisms.[10] For this purpose, in the present case, the combination of piperacillin sodium + tazobactam sodium was administered.


   Conclusions Top


To prevent life-threatening, mediastinitis-like complications, odontogenic infections must be closely monitored, and effective and broad-spectrum antibiotics should be used as pharmacological treatments. Nevertheless, if mediastinitis develops as a complication, high-dose and long-term antibiotic therapy should be administered, surgical drainage should be applied in the early period, and the course of the infection should be monitored closely after the symptoms were regressed.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

1.
Irani S. Orofacial bacterial infectious diseases: An update. J Int Soc Prev Community Dent. 2017;7(Suppl 2):S61-7.  Back to cited text no. 1
    
2.
Sakamoto H, Aoki T, Kise Y, Watanabe D, Sasaki J. Descending necrotizing mediastinitis due to odontogenic infections. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2000;89:412-9.  Back to cited text no. 2
    
3.
İsmi O, Yeşilova M, Özcan C, Vayisoǧlu Y, Görür K. Difficult cases of odontogenic deep neck infections: A report of three patients. Balkan Med J 2017;34:172-9.  Back to cited text no. 3
    
4.
Pearse HE. Mediastinitis following cervical suppuration. Ann Surg 1938;108:588-611. Available from: http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=1387034 &tool=pmcentrez&rendertype=abstract.  Back to cited text no. 4
    
5.
Makeieff M, Gresillon N, Berthet JP, Garrel R, Crampette L, Marty-Ane C, et al. Management of descending necrotizing mediastinitis. Laryngoscope 2004;114:772-5.  Back to cited text no. 5
    
6.
Suárez A, Vicente M, Tomás JA, Floría LM, Delhom J, Baquero MC. Cervical necrotizing fasciitis of nonodontogenic origin. Am J Emerg Med 2014;32:1441.e5-6.  Back to cited text no. 6
    
7.
Adoviča A, Veidere L, Ronis M, Sumeraga G. Deep neck infections: Review of 263 cases. Otolaryngol Pol 2017;71:37-42.  Back to cited text no. 7
    
8.
Estrera AS, Landay MJ, Grisham JM, Sinn DP, Platt MR. Descending necrotizing mediastinitis. Surg Gynecol Obstet 1983;157:545-52.  Back to cited text no. 8
    
9.
Endo S, Murayama F, Hasegawa T, Yamamoto S, Yamaguchi T, Sohara Y, et al. Guideline of surgical management based on diffusion of descending necrotizing mediastinitis. Jpn J Thorac Cardiovasc Surg 1999;47:14-9.  Back to cited text no. 9
    
10.
Opitz D, Camerer C, Camerer D-M, Raguse JD, Menneking H, Hoffmeister B, et al. Incidence and management of severe odontogenic infections-A retrospective analysis from 2004 to 2011. J Cranio-Maxillofacial Surg 2015;43:285-9.  Back to cited text no. 10
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4]



 

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