- Case report
- Open Access
- Open Peer Review
Deep neck infection and descending mediastinitis as lethal complications of dentoalveolar infection: two rare case reports
© The Author(s). 2018
- Received: 14 December 2017
- Accepted: 23 May 2018
- Published: 7 July 2018
We report two cases of innocuous dentoalveolar infections which rapidly progressed to deep neck abscesses complicated by descending mediastinitis in a resource-constrained rural mission hospital in the Cameroon.
The clinical presentations of a 35-year-old man and a 32-year-old woman both of Fulani origin in the Northern region of Cameroon were similar with submandibular fluctuant and tender swelling and differential warmth to palpation. The patients had tachycardia, high grade pyrexia, and normal blood pressure. Further physical and neurological examinations were unremarkable. An ultrasound scan of the neck swellings showed submandibular turbid collections. Plain chest radiographs confirmed empyema thoraces. Our patients had serial drainage of the neck abscesses as well as closed thoracostomy tube drainage which were connected to pleurovac and suctioning machines, with significant amount of pus drainage. Both patients were admitted to our intensive care unit for close monitoring. The first patient continued to make satisfactory clinical progress and was discharged by the fourth week of admission. The patient who had human immunodeficiency viral infection died on the fifth postoperative day.
The possibility of lethal complications and the associated morbidity and mortality portray this clinical entity as an important public health concern. Clinicians taking care of patients with dentoalveolar and oropharyngeal infections need to be sensitized to these potentially fatal complications. Alternatively, strategies to improve oral health and reduce the incidence of dental caries, the main cause of dental abscess, would maximize use of resources; especially in resources-constrained centers like ours in Banso Baptist Hospital.
- Case report
- Dentoalveolar abscess
- Descending mediastinitis
Acute dental abscess usually occurs secondary to dental caries, trauma, or failed root treatment . Dentoalveolar infections are one of the most common diseases in the oral and maxillofacial region [2, 3]. Complications are associated with a mortality rate of 10–40% . With the advent of modern antibiotics, mortality rates have significantly reduced [5, 6]. Multiple severe complications of dentoalveolar infection have been reported, such as airway obstruction, Ludwig angina, descending mediastinitis, necrotizing fasciitis, cavernous sinus thrombosis (CST), sepsis, thoracic empyema, cerebral abscess, and osteomyelitis [7–9]. Most oropharyngeal infections are self-limiting and contained. However, they can spread through the fascia and deep neck spaces while progressing inferiorly into the mediastinum, especially in the diabetic, immunocompromised, or debilitated patient [10–12]. We report two interesting cases of seemingly innocuous dentoalveolar infections which rapidly progressed to deep neck abscesses complicated by descending mediastinitis, which are life-threatening infections in resource-limited settings, such as Banso Baptist Hospital, Cameroon.
A 32-year-old woman of Fulani origin in the Northern region of Cameroon presented to our surgical ward with a 5-day history of a painful right submandibular swelling with involvement of the right side of her neck and upper anterior chest wall. There was associated right upper quadrant abdominal pain. These symptoms were preceded by 1-week history of right second and third mandibular teeth infection which was left untreated. She was newly diagnosed with retroviral infection but yet to commence highly active antiretroviral treatment (HAART) before admission. She had right submandibular fluctuant and tender swelling, which was warm to palpation. Further physical and neurological examinations were unremarkable. She had tachypnea 32 breaths/minute, tachycardia 140 beats/minute, fever 38.5 °C, and blood pressure 120/70 mmHg. An ultrasound scan of the submandibular and neck swelling showed right submandibular turbid collection with inflamed muscles. A chest radiograph revealed blunting of the right costophrenic angle. Thoracocentesis revealed a pleural fluid analysis of marked leukocytosis 57,000 cells/ul, predominantly Gram-positive cocci.
Lethal descending mediastinitis complicating dentoalveolar abscess was a rare presentation to us in Banso Baptist Hospital until now. Our data correlated well with previously published literature. The two patients are of Fulani origin in the Northern region of Cameroon. They are nomadic in nature and feed predominantly on milk and dairy products as staple food with very poor oral hygiene habits. In this case report, both patients had a preexisting history of untreated teeth infections which involved the mandibular molars, due to the proximity of their apices to the submandibular spaces. This may explain a rapid and downward spread of the infectious process which progressed to involve a large part of the neck and anterior mediastinum tissues [13, 14]. In the first index patient the pathogens isolated were of a polymicrobial pattern comprising mixed aerobic (Gram-positive cocci, commonly streptococci) and anaerobic (Bacteroides species essentially Peptostreptococcus species) bacteria; while the primary and single pathogen isolated in both neck and mediastinum samples of the second index patient was facultative anaerobe viridans group streptococci [13, 14]. The pathogens in both cases are essentially a very common cause of mediastinitis and deep neck infection [13–16]. A complex mix of strict anaerobes and facultative anaerobes account for most infections (59–75%), which can prove challenging to non-specialist microbiology laboratories [17–19]. One literature report described an interesting case of dentoalveolar infection complicated by descending necrotizing mediastinitis . In that case the infectious process was caused by polymicrobial flora (Streptococcus constellatus and Propionibacterium acnes) . Another author reported two cases of Propionibacterium growth (out of 118 patients) in deep space head and neck infections . The poor oral health practices of Cameroonian Fulanis and the delay in presentation are the most significant risk factors for morbidity and mortality in these two patients . The diagnosis of immunosuppressive illness (untreated HIV infection) in the second patient corroborated the fact that an innocuous neck infection in such patients can progress inferiorly with significantly high fatality. An appropriate management of deep neck infection and mediastinitis includes intravenously administered antibacterial therapy and surgical drainage of the cervical and mediastinal collections . In our case immediate, extensive, and recurrent surgical drainage allowed for a successful and early control of the source of infection.
Finally, clinicians taking care of patients with dentoalveolar and oropharyngeal infections should be sensitized to this potentially fatal complication. Recognition of the classic signs of severe dentoalveolar infections by the general practitioner and expeditious referral to a higher level of care benefits the patient and may be lifesaving. Alternatively, strategies to improve oral health and reduce the incidence of dental caries, the main cause of dental abscess, would maximize use of resources.
Dr Nyoh-Tabi Claudia Yeah-Dibouh MDD, Dental Surgeon, Department of Dental Surgery, Banso Baptist Hospital, Cameroon. Who provided professional support during the writing of this case report and also read and approved the final manuscript.
Availability of data and materials
The author conceived of the study and participated in its design and coordination and helped to draft the manuscript; the author also read and approved the final manuscript.
Ethics approval and consent to participate
Ethical approval not required for case reports at my institution.
Consent for publication
Written informed consent was obtained from the patients for publication of this case report and any accompanying images. A copy of the written consents is available for review by the Editor-in-Chief of this journal.
The author declares that they have no competing interests.
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