Deep neck infection and descending mediastinitis as lethal complications of dentoalveolar infection: two rare case reports

A 35-year-old man of Fulani origin in the Northern region of Cameroon, previously healthy, presented to our surgical ward with severe left submandibular non-fluctuant swelling, which was erythematous and warm to palpation. Furthermore, mild trismus and sublingual edema were noted. Otherwise, physical and neurological examinations were unremarkable. He had a sinus tachycardia of 110 beats/minute, fever 39 °C, and blood pressure 140/85 mmHg. A chest radiograph on admission was normal. He had a 1-month history of a left mandibular second and third molar teeth untreated infection (periodontitis). He was urgently transferred to our operating room (OR) where he underwent surgical drainage of the left submandibular abscess; he was then admitted to our intensive care unit (ICU) while sedated, mechanically ventilated, hemodynamically stable, and febrile (38.7 °C). Laboratory tests were noted for extensive leukocytosis (30,000 cells/ul). Immediately on ICU admission, broad-spectrum parenteral antibiotic therapy (intravenously administered ceftriaxone 1 gm 12 hourly and intravenously administered metronidazole 500 mg 8 hourly) was initiated. The following day, extensive bilateral submandibular abscess collection (left >> right) and multiple cervical lymphadenopathy were shown on an urgently performed superficial ultrasonography scan and he was transferred to our OR again for exploration of deep neck abscess. He was co-managed by the dental surgery team. On the second day of admission, he had extraction of the left mandibular second and third molar teeth by the dental surgeon. A large amount of purulent fluid was drained; 3 days later cultures were positive for mixed aerobic (Gram-positive cocci, commonly streptococci) and anaerobic (Bacteroides species essentially Peptostreptococcus species) bacteria. He remained febrile (39.3 °C) with a white blood cell (WBC) count of 24.5, although hemodynamically stable. An additional chest radiograph and ultrasound scan of the soft tissue neck and chest 2 days later showed minimal collection in the anterior superior mediastina space and significant abscess in both pleural spaces (empyema thoracis), which was far greater in his left hemithorax. An urgent left closed thoracostomy tube drainage (CTTD) was performed and connected to pleurovac and suction. A large amount (approximately 800 cc) of purulent fluid, pH 7.18, was drained from his left pleural space; he was transferred back to the ICU. Bacterial culture samples of serous fluid were positive again for mixed microbial flora as above. He continued intravenously administered antibiotics therapy with ceftriaxone, ciprofloxacin, and metronidazole only due to bacterial susceptibility of isolated growth of polymicrobial flora. Figure 1 is a post-incision and drainage photograph of this patient showing multiple neck wounds and sinuses. Figure 2 is a plain chest radiograph showing the left thoracic empyema. During the next 4 days he went to OR two additional times for surgical debridement, drainage, and washout of neck wounds. He continued the neck wound washout and antibiotic therapy over the next 3 weeks. He was discharged from the unit 4 weeks after admission.

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.

She was urgently transferred to our OR where she underwent surgical drainage of the right submandibular abscess and right CTTD connected to pleurovac and suction; she was then admitted to our ICU while sedated, ventilated on oxygen by facemask, hemodynamically stable, and febrile (38.7 °C). A laboratory test was notable for extensive leukocytosis (17,000 cells/ul). Immediately on ICU admission broad-spectrum parenteral antibiotic therapy (intravenously administered ceftriaxone 1 gm 12 hourly and intravenously administered metronidazole 500 mg 8 hourly) was initiated. On the following day, she underwent extensive washout of abscess spaces of the submandibular region and neck. The culture of the submandibular abscess isolated viridans streptococci after 72 hours and the bacteria of the isolated growth were susceptible to Augmentin and doxycycline. Figure 3 is a pre-incision and drainage photograph of this patient showing right submandibular abscess. Figure 4 is a plain chest radiograph and computed tomography (CT) slides showing the left thoracic empyema. Her postoperative period was essentially unremarkable with our patient showing significant relief of symptoms. On the fifth day of admission she developed sudden onset of cardiac arrest from which she could not be resuscitated and was certified dead approximately 1 hour later.