Descending Necrotizing Mediastinitis: Complication of a Simple Dental Infection,☆☆,

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Abstract

Descending necrotizing mediastinitis (DNM) is a rare complication of periodontic infection. The delay in diagnosis of DNM is believed to contribute to its high mortality rate. We report the case of a healthy 23-year-old man who was seen in the urgent care center, given the diagnosis of dental infection, prescribed penicillin, and sent home. He returned 48 hours later complaining of myalgias, purulent drainage from around his teeth, chest pain, and dyspnea. DNM was diagnosed, and aggressive treatment comprising thoracotomy, cervical incision and drainage, and antibiotics was begun. The patient responded well to treatment and was discharged from the hospital on postoperative day 20. Prompt diagnosis and immediate therapy are imperative for this rare condition. [Haraden BM, Zwemer FL Jr: Descending necrotizing mediastinitis: Complication of a simple dental infection. Ann Emerg Med May 1997;29:683-686.]

Section snippets

INTRODUCTION

Dental infections and abscesses are common in the general population. Although dental infections are usually benign, they can lead to serious complications. Two major complications are Ludwig's angina and descending necrotizing mediastinitis (DNM). These rare but life threatening conditions must not be overlooked by a physician during the assessment of tooth pain. In this report we describe a case of DNM due to a dental infection and discuss diagnosis and management.

CASE REPORT

A previously healthy 23-year-old man presented to the urgent care center with the complaint of tooth pain of 5 days' duration. He described pain in the right submandibular area that radiated to his right ear. The patient denied fever, chills, and neck or chest pain but did have some difficulty swallowing, although he was able to handle his secretions and his speech was normal. The patient denied nausea and vomiting but had decreased his fluid intake because of pain. Physical examination

DISCUSSION

Patients who present with dental abscesses usually respond well to antibiotics and outpatient referral and generally have an uncomplicated course. We report a case of DNM that developed in an otherwise healthy individual who had no signs at initial presentation of the fulminating course to come.

The two most dangerous complications of a simple dental infection are DNM and Ludwig's angina. Ludwig's angina can lead to DNM, but the converse is not true. Although both conditions can originate from a

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From the Department of Medicine* and the Emergency Department, Jewish Hospital at Washington University Medical Center, Washington University School of Medicine, St Louis, MO.

☆☆

Address for reprints: Frank L Zwemer Jr, MD Emergency Department Jewish Hospital at Washington University Medical Center 216 South Kingshighway St. Louis, MO 63110 314-454-7905 Fax 314-454 -7998 E-mail [email protected]

Reprint no. 47/1/81215

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