Descending mediastinitis

Abstract

Introduction: Descending mediastinitis is a complication of acute polymicrobial oropharyngeal or cervicofacial infections. It occurs when the infection spreads to the mediastinum through the space between the prevertebral and alar layers of the deep cervical fascia. It is a rare entity with high mortality (19-40%). It primarily affects young adults, predominantly males. This poster aims to demonstrate through images the natural history of descending mediastinitis in a patient with a peritonsillar abscess.

Case Report: A 64-year-old male with a history of type 2 diabetes mellitus, hypertension, and hypothyroidism presented with a 3-week history of odynophagia, dysphagia, trismus, fever, back pain, and chest pain. Despite multiple antibiotic regimens, the patient showed a sluggish response. Upon admission, the patient exhibited halitosis, purulent tonsillitis, edematous neck with generalized erythema, and hemodynamic instability, necessitating mechanical ventilation. Based on tomographic findings of mediastinitis and the patient's clinical deterioration, surgical treatment, and broad-spectrum antibiotic therapy were initiated empirically. The patient underwent tonsillectomy, drainage of the left peritonsillar abscess, left laterocervical and submental cervicotomy, lateral thoracotomy, mediastinotomy, and mediastinal drainage. The patient received long-term vancomycin and meropenem in the ICU and was discharged after 2 months.

Conclusions: Contrast-enhanced computed tomography is crucial for diagnosing and making decisions regarding the most effective treatment in cases of suspected descending mediastinitis. Treatment remains controversial, but there is consensus that surgery may be indicated as initial therapy in cases of abscesses and collections. Early initiation of therapy improves prognosis, mortality, and morbidity in patients.