Necrotizing Soft-Tissue and Retropharyngeal Space Infections and Mediastinitis
Martin A. Gomez, Beatriz Mejia
N Engl J Med 2024;391: e5
DOI: 10.1056/NEJMicm2312959
A 50-year-old man with no known medical history presented to the emergency department with a 3-day history of tooth and jaw pain on the left side, fever, and shortness of breath. He lived in a rural area and had never visited a physician or dentist. Physical examination was notable for poor dentition, trismus, and stridor. There was also erythema, warmth, and crepitus extending from the cheek down to the upper chest on the left side (Panel A). Computed tomography of the neck and chest showed severe periodontitis, caries, and periapical tooth abscesses with associated soft-tissue inflammation and gas formation extending into the retropharyngeal space, chest wall, and superior and posterior mediastinum (Panel B). A diagnosis of odontogenic infection resulting in necrotizing soft-tissue infection, retropharyngeal space infection, and mediastinitis was made. Retropharyngeal abscesses may lead to mediastinitis when the infection drains into the “danger” space between the alar and prevertebral layers of the deep cervical fascia. Treatment with multiple washouts, broad-spectrum antimicrobial agents, and reconstructive surgery was given. Type 2 diabetes was also newly diagnosed, and management was provided. After a 45-day hospital stay, the patient was discharged home in good condition and placed on a soft diet.
