descending necrotizing mediastinitis ( dnm ) is a mediastinal infection resulting from the spread of an oropharyngeal infection , with extension via the cervical fascial layers . after the initial oropharyngeal infection , dnm often presents as an extensive deep cervical infection , with mediastinitis developing within a few days . this life - threatening condition is often misdiagnosed in its early stages because of its rarity and non - specific symptoms . computed tomography ( ct ) is an invaluable tool in the diagnosis of dnm , both in the initial detection of infection and in monitoring the response to treatment . antibiotic therapy for complicated oropharyngeal infections has primarily involved penicillins and other broad - spectrum antibiotics . unfortunately , the advent of antibiotics has only slightly decreased the mortality rate of dnm , which remains between 20 and 50% , probably because of delayed diagnosis . prompt control of the upper airway with tracheotomy , aggressive surgical drainage of deep cervical spaces and the mediastinum as well as intravenous broad - spectrum antibiotic therapy are mandatory for successful treatment . several cases of dnm following tooth extraction have been reported ; however , few reports have described dnm treated with removal of odontogenic infection following mediastinal or cervical drainage . we present a case of dnm resulting from odontogenic infection treated successfully with extraction of ten teeth over three procedures after mediastinal and cervical drainage . a 43-year - old previously healthy man was referred to our hospital for disturbance of consciousness after a 4-day history of appetite loss . tachycardia ( 140/bpm ) , hypotension ( 70/40 mm hg ) and a high fever ( 39.1c ) at presentation suggested septic shock . laboratory assays showed a white blood cell count of 3,400/ml , a platelet count of 33,000/ml , a blood urea nitrogen level of 58.0 mg / dl , a creatinine level of 1.15 mg / dl and a c - reactive protein level of 57.8 mg / dl . blood culture grew streptococcus constellatus sensitive to penicillins ; because of the progressive infection , doripenem was chosen for its broad spectrum and administered intravenously for 12 days . ct revealed gas collection on the right side of the mid - thoracic esophagus with bilateral pleural effusion ( fig . tube thoracostomy was performed on the left hemithorax , with drainage of 700 ml of tea - colored and purulent pleural effusion ( fig . the intraoperative diagnosis was dnm ( type iib , according to the classification of endo et al . ) , without perforation of the wall of the mid - thoracic esophagus , which was covered with pus ( fig . on postoperative day 4 ( pod 4 ) , repeat ct revealed a dental abscess in the root of the right maxillary canine tooth ( fig . the patient was referred to the department of oral and maxillofacial surgery , where the canine tooth and three additional teeth with radicular cysts were extracted as the likely cause of dnm . dental culture grew methicillin - resistant staphylococcus aureus ( mrsa ) with sensitivity to vancomycin , which was administered intravenously for 14 days . the patient received antibiotic therapy with daptomycin after the 14 days of vancomycin , but his fever persisted . on pod 40 , percutaneous endoscopic gastrostomy was performed to change from total parenteral nutrition to enteral nutrition . four additional teeth with radicular cysts were removed on pod 33 , followed by two more on pod 40 , for a total of ten teeth extracted ( fig . the patient moved to a nearby rehabilitation hospital on pod 96 and remained healthy at follow - up examination 1 year later . the criteria for diagnosing dnm were defined by estrera et al .   as follows : ( 1 ) clinical manifestation of severe oropharyngeal infection , ( 2 ) radiologic features of mediastinitis on ct , ( 3 ) documentation of necrotizing mediastinal infection at surgery or on postmortem examination , and ( 4 ) established relationship between oropharyngeal infection and development of dnm . delayed diagnosis and surgery explain the high mortality rate associated with dnm . however , this case confirms that dnm can progress despite the initiation of medical and surgical treatment . early extensive and complete drainage / debridement of the cervical and mediastinal fluid collections and administration of broad - spectrum intravenous antibiotics is essential because dnm is a polymicrobial disease . the choice of the optimal operative procedure is determined based on the extent of infection , which is evaluated with ct . type iia extends to the lower anterior mediastinum , type iib to the posterior mediastinum . that report recommended transcervical mediastinal drainage for type i , mediastinal drainage by epigastric incision for type iia and thoracotomy for type iib cases . our patient , who had type iib dnm , underwent mediastinal drainage via thoracotomy at the initial surgery , although a transcervical approach was also required to adequately drain the deep neck . since we judged that drainage alone would not control the cause of primary infection , tooth extraction was performed to remove the site of odontogenic infection . however , local signs are usually not as evident as poor general status , as was the case in our patient . since extensive fascial communication exists between the gums , neck and mediastinum , odontogenic infections can rapidly spread to the mediastinum , facilitated by gravity , respiration and negative intrathoracic pressure . there have been several reports of patients who required tooth extraction during hospitalization for dnm caused by an odontogenic infection . our patient required the extraction of ten teeth over three procedures before his fever resolved . to the best of our knowledge , there are no prior reports of patients requiring such prolonged dental treatment following mediastinal and cervical drainage for dnm . dnm is a severe infection that requires prolonged treatment and long - term antibiotics and that can involve drug - resistant bacteria . however , cases requiring prolonged infection control can develop mrsa infection over the course of treatment . in our case monitoring and control of drug - resistant bacteria with frequent culture and sensitivity testing as well as administration of appropriate antibiotics are important . in conclusion , odontogenic infection should be considered a risk factor for dnm . despite the high mortality rate associated with this condition , prompt diagnosis , aggressive drainage , removal of the source of infection and careful postoperative care can save patients with dnm . all procedures followed were in accordance with the ethical standards of the responsible committee on human experimentation ( institutional and national ) and with the helsinki declaration of 1964 and later revision . informed consent or substitute for it was obtained from the present patient for being included in the study .
descending necrotizing mediastinitis ( dnm ) is a rare condition in which oropharyngeal infection spreads to the mediastinum via the cervical fascia . 
 delayed diagnosis and surgery result in a high mortality rate among patients with dnm . 
 we present a case of dnm resulting from odontogenic infection treated successfully with tooth extraction following mediastinal and cervical drainage . 
 a 43-year - old , previously healthy japanese man was admitted to our hospital for treatment of acute mediastinitis . computed tomography revealed gas collection around the mid - thoracic esophagus and bilateral pleural effusion . 
 we performed mediastinal drainage via right thoracotomy . 
 cervicotomy was performed on postoperative day 14 to drain a residual cervical abscess . 
 the patient required the extraction of ten teeth over three procedures to address primary odontogenic infection before his fever resolved on postoperative day 40 . 
 prompt diagnosis , aggressive drainage and removal of the source of infection can improve survival among patients with this life - threatening disease .