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      Descending necrotizing mediastinitis in a healthy young adult

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          Abstract

          A 26-year-old man with right lower mandibular and chest pain, fever, and respiratory distress was urgently transported to our hospital. CT images revealed gas collection and an abscess from the neck to the mediastinum with bilateral pleural effusion. Descending necrotizing mediastinitis (DNM) induced by an odontogenic infection of a right mandibular molar abscess was diagnosed. The cervical and mediastinal areas were drained, extensive debridement was performed, necrotic tissue was excised, and broad-spectrum antibiotics were administered immediately. Prompt diagnosis and intensive care were necessary for managing the DNM, and the patient was discharged with no comorbidities.

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          Most cited references 18

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          ST-segment elevation in conditions other than acute myocardial infarction.

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            Deep neck infection: analysis of 185 cases.

            This study reviews our experience with deep neck infections and tries to identify the predisposing factors of life-threatening complications. A retrospective review was conducted of patients who were diagnosed as having deep neck infections in the Department of Otolaryngology at National Taiwan University Hospital from 1997 to 2002. Their demographics etiology, associated systemic diseases, bacteriology, radiology, treatment, duration of hospitalization, complications, and outcomes were reviewed. The attributing factors to deep neck infections, such as the age and systemic diseases of patients, were also analyzed. One hundred eighty-five charts were recorded; 109 (58.9%) were men, and 76 (41.1%) were women, with a mean age of 49.5 +/- 20.5 years. Ninety-seven (52.4%) of the patients were older than 50 years old. There were 63 patients (34.1%) who had associated systemic diseases, with 88.9% (56/63) of those having diabetes mellitus (DM). The parapharyngeal space (38.4%) was the most commonly involved space. Odontogenic infections and upper airway infections were the two most common causes of deep neck infections (53.2% and 30.5% of the known causes). Streptococcus viridans and Klebsiella pneumoniae were the most common organisms (33.9%, 33.9%) identified through pus cultures. K. pneumoniae was also the most common infective organism (56.1%) in patients with DM. Of the abscess group (142 patients), 103 patients (72.5%) underwent surgical drainages. Thirty patients (16.2%) had major complications during admission, and among them, 18 patients received tracheostomies. Those patients with underlying systemic diseases or complications or who received tracheostomy tended to have a longer hospital stay and were older. There were three deaths (mortality rate, 1.6%). All had an underlying systemic disease and were older than 72 years of age. When dealing with deep neck infections in a high-risk group (older patients with DM or other underlying systemic diseases) in the clinic, more attention should be paid to the prevention of complications and even the possibility of death. Early surgical drainage remains the main method of treating deep neck abscesses. Therapeutic needle aspiration and conservative medical treatment are effective in selective cases such as those with minimal abscess formation. (c) 2004 Wiley Periodicals, Inc.
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              Descending necrotizing mediastinitis.

              From January 1975 through July 1981, ten patients with mediastinitis complicating an oropharyngeal infection, that is, a form of mediastinitis best termed as DNM, were encountered at our institution. Based upon rather relatively stringent diagnostic criteria, 21 other instances were found in the literature from 1960 to 1980, a time period well into the antibiotic era. The predominant underlying oropharyngeal infection was of odontogenic origin, specifically, infection involving the mandibular molars. Bacteriologically, DNM is most frequently a polymicrobial process, with anaerobes playing a major role. Although there has been a decline in the over-all incidence of DNM since the introduction of antibiotics, its morbid and lethal nature persists, as evidenced by the present prohibitive mortality of approximately 42 per cent. Delayed diagnosis and inadequate drainage procedures are the primary underlying factors contributing to this high mortality. At present, CT scan is the single most important tool for the early diagnosis of DNM. This noninvasive procedure also helps determine the adequacy of the surgical drainage procedure performed. However, with all the presently available diagnostic tools, it is still the high index of suspicion by physicians toward patients with unrelenting oropharyngeal or deep neck infection that is of utmost importance for making an early diagnosis of DNM. In view of our experience and that of others, we believe that only through aggressive combined medical and surgical management can the highly morbid, if not lethal, course of DNM be reversed. It should be emphasized that, to accomplish successful operative intervention, a thorough knowledge of the complex anatomy of the region is crucial.
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                Author and article information

                Journal
                Ther Clin Risk Manag
                Ther Clin Risk Manag
                Therapeutics and Clinical Risk Management
                Therapeutics and Clinical Risk Management
                Dove Medical Press
                1176-6336
                1178-203X
                2018
                17 October 2018
                : 14
                : 2013-2017
                Affiliations
                [1 ]Department of General Internal Medicine 4, Kawasaki Medical School, Okayama, Japan, placidus.aura@ 123456mail.com
                [2 ]Department of Otolaryngology, Kawasaki Medical School, Okayama, Japan
                [3 ]Department of General Surgery, Kawasaki Medical School, Okayama, Japan
                [4 ]Department of Anesthesiology and Intensive Care Medicine, Kawasaki Medical School, Okayama, Japan
                [5 ]Department of Pathology, Kawasaki Medical School, Okayama, Japan
                Author notes
                Correspondence: Nobuaki Ochi, Department of General Internal Medicine 4, Kawasaki Medical School, 2-6-1, Nakasange, Kita-ku, Okayama 700-8505, Japan, Tel +81 86 225 2111, Fax +81 86 232 8343, Email placidus.aura@ 123456mail.com
                Article
                tcrm-14-2013
                10.2147/TCRM.S176520
                6202047
                © 2018 Ochi et al. This work is published and licensed by Dove Medical Press Limited

                The full terms of this license are available at https://www.dovepress.com/terms.php and incorporate the Creative Commons Attribution – Non Commercial (unported, v3.0) License ( http://creativecommons.org/licenses/by-nc/3.0/). By accessing the work you hereby accept the Terms. Non-commercial uses of the work are permitted without any further permission from Dove Medical Press Limited, provided the work is properly attributed.

                Categories
                Case Report

                Medicine

                healthy young adult, descending necrotizing mediastinitis, odontogenic infection

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