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Case Report

Mediastinitis as Complication of Odontogenic Infection: A Case Report

E Soylu, A Erdil1, E Sapmaz2, BT Somuk2, N Akbulut1

Department of Oral and Odontogenic infections are one of the most common dental problems, which

Abstract
Maxillofacial Surgery,
Faculty of Dentistry, Erciyes
University, Kayseri, Turkey,
Departments of 1Oral and
Maxillofacial Surgery,
Faculty of Dentistry, and
2
Otorhinolaringology, Faculty
of Medicine, Gaziosmanpasa
University, Tokat, Turkey
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.

Date of Acceptance: Keywords: Complication, mediastinitis, odontogenic infection, transcervical

01-Jan-2019 drainage

Introductıon This report aimed to present a case of mediastinitis

C aries, 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]
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caused by an odontogenic infection in a systemically
healthy adult that was successfully treated with tooth
extraction after cervical drainage.
Case Report
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
Address for correspondence: Dr. E Soylu,
Department of Oral and Maxillofacial Surgery, Faculty
of Dentistry, Erciyes University, Kayseri, Turkey.
E‑mail: dtemrahsoylu@hotmail.com
This is an open access journal, and articles are distributed under the terms of the
Creative Commons Attribution‑NonCommercial‑ShareAlike 4.0 License, which allows
others to remix, tweak, and build upon the work non‑commercially, as long as
appropriate credit is given and the new creations are licensed under the identical
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For reprints contact: reprints@medknow.com

DOI: 10.4103/njcp.njcp_539_18

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

© 2019 Nigerian Journal of Clinical Practice | Published by Wolters Kluwer ‑ Medknow 869

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Soylu, et al.: Mediastinitis due to odontogenic infection
Figure 1: Orthopantomograph view indicates periapical infection of lower
left second molar that caused the abscess formation
Figure 3: Thoracal CT shows spread of abscess between arcus aorta and
vertebrae (Green arrow shows abscess localization)
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.
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
870 Nigerian Journal of Clinical Practice  ¦  Volume 22  ¦  Issue 6  ¦  June 2019
Figure 2: CT view shows spreading of the abscess to the retropharyngeal
space. (Green arrows show abscess formation)
a b
c
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)
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 4a‑c].
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
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Soylu, et al.: Mediastinitis due to odontogenic infection
postoperative days. The patient was discharged after
being hospitalized for 14 days.
Discussion
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.
Nigerian Journal of Clinical Practice  ¦  Volume 22  ¦  Issue 6  ¦  June 2019
Conclusions
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.
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