Descending Necrotizing Mediastinitis Resulting from Pharyngitis with Perforation of the Aryepiglottic Fold

Case Reports in Emergency Medicine
10 Sep, 2020 ,

Alexandra Pulst-Korenberg et.al. presented a case of a  18-year-old male who presented to the emergency room with 5 days of severe sore throat, intermittent fevers, and vomiting and was found to have extensive posterior pharyngeal and mediastinal air along with extravasation of contrast on computed tomography, consistent with perforation of the left aryepiglottic fold as well as descending necrotizing mediastinitis. Successful treatment required swift resuscitation including broad-spectrum antibiotics and significant coordination of emergent operative intervention between otolaryngology and cardiothoracic surgery. 

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A healthy 18-year-old male living in a mobile home in rural Washington with his family noticed mild throat and left ear pain 5 days prior to presentation. His symptoms steadily worsened and became severe 3 days prior to admission to the point where ibuprofen 600 mg and chloraseptic spay provided only minimal relief. In the 2 days prior to admission, he developed fever to 38.4 degree Celsius, malaise, poor oral intake, nonproductive cough, dysphagia, odynophagia, and 3-4 episodes of nonbilious and nonbloody vomiting. The remainder of his history was notable only for a tethered spinal cord which was repaired as an infant, a 1–1.5 pack per day cigarette use, and no alcohol or illicit drug use. On presentation to the local rural hospital, he was noted to be febrile and tachycardic, though handling his secretions adequately, and was nontoxic appearing.

After laboratory analysis revealed a leukocytosis of 26,000, raising the initial concern for a more serious infection, a CT scan of his neck with IV contrast was obtained, revealing “extensive air in the parapharyngeal and retropharyngeal space extending to the supraclavicular region and mediastinum.” He was treated with IV fluids, an antipyretic, morphine, clindamycin 900 mg IV, and dexamethasone 4000 mg IV and was transferred to a tertiary care center for a higher level of care and specialty consultation. He had improved hemodynamics after these interventions, with a heart rate of 79, blood pressure of 111/69, and a temperature of 37.7 degrees Celsius.

On arrival to the tertiary care center, he was managing his secretions, reporting some persistent throat discomfort, and intermittently spitting up saliva with small flecks of blood for purposes of comfort. Physical exam was notable for absence of distress, mild tenderness, and erythema to anterior neck left greater than right, poor dentition, symmetrical tonsillar swelling with no uvular deviation, and pharyngeal erythema. Given lack of stridor, shortness of breath, or inability to tolerate secretions, there was no immediate concern for airway compromise.

A repeat CT scan of the neck soft tissues with IV and oral contrast obtained approximately 7 hours after the initial scan demonstrated extensive fluid and gas collections within the parapharyngeal and retropharyngeal spaces extending from the skull base to the anterior mediastinum that were radiographically concerning for necrotizing soft tissue infection, as well as a small amount of contrast extravasation at the left aryepiglottic fold/pyriform sinus, concerning for perforation and communication with the retropharyngeal fluid and gas collections.

Operative culture of the retropharyngeal fluid collection eventually grew viridans streptococci, Candida dubliniensis, alpha hemolytic streptococci, yeast, in addition to mixed anaerobic flora and Gram-positive cocci unable to be further speciated.

Upon viewing the initial CT scan, the care team, including the otolaryngology and thoracic surgery team, felt the patient had retropharyngeal cellulitis with soft tissue gas/air extending to the mediastinum, the differential diagnosis of which included primary cellulitis, mediastinitis, and perforation of unclear etiology with a possible odontogenic source.

The patient's overall presentation, with initially compromised hemodynamics and systemic signs and symptoms of infection (tachycardia, fever, leukocytosis, and oropharyngeal erythema/oedema), was clearly concerning for more than a simple viral or streptococcal pharyngitis and is highly suggestive of sepsis. The second CT which included both oral and IV contrast was critical in pointing toward a far more serious infection than is typically associated with retro- and parapharyngeal abscesses. The presence of multiple air and fluid collections was radiographically concerning for necrotizing soft tissue infection including the mediastinum, rather than a simple cellulitis of the soft tissues of the neck and oropharynx. This CT also pointed toward a possible source, based on the contrast extravasation indicative of perforation. Esophageal perforation, mucosal ulceration or preexisting inflammation, and malignancy predisposing the patient to perforation also should be included in the differential for any patient with unexplained oropharyngeal perforation, though was felt to be less likely here given the imaging findings, short duration of symptoms, and young age.

Otolaryngology and thoracic surgery were consulted soon after arrival to the ED for admission and likely operative intervention. The patient was admitted to the surgical intensive care unit for continued resuscitation and carefully watched on possible impending airway compromise due to the amount of inflammation potentially leading to significant airway edema. Antibiotic coverage was broadened from the initial clindamycin to 2 grams of vancomycin IV and 4.5 grams of piperacillin-tazobactam IV based on the concern for sepsis, perforation, and extensive air concerning for mediastinitis and necrotizing soft tissue infection. He was also instructed to have nothing by mouth, given maintenance fluids in anticipation of operative management, and his pain was controlled with IV hydromorphone. The initial management plan also involved a plan for an esophagram to evaluate the location of perforation and possibility of multiple perforations, which would change operative management. In the morning of hospital day 2, a third CT scan revealed marked expansion of the gas and fluid within the soft tissues of the parapharyngeal, retropharyngeal, and mediastinal spaces. The patient was therefore taken to the operating room, and a transoral drainage of his retropharyngeal abscess was conducted via open incision by otolaryngology with culture obtained.

The patient initially improved, but on hospital day 4, he began complaining of chest pain and reduced neck range of motion, with exam notable for tachycardia and blanching erythema on his chest. His white blood cell count had increased over the preceding days from 24,000 to 44,000/microL. A repeat CT of the chest with IV contrast demonstrated bilateral pleural effusions and pericardial effusion, both of which are known complications of mediastinitis. The patient was then taken to the operating room by thoracic surgery, who placed bilateral thoracostomy tubes and a mediastinal Jackson–Pratt drain, with extensive purulent material drained. Transcervical drainage and washout of recurrent retropharyngeal abscess was performed during the same operative period by otolaryngology. Ultimately, operative management required multiple washouts of the retropharyngeal abscess cavity, multiple right thoracotomy washouts, and a pericardial window.

The patient received twice daily washouts for 5 days. By hospital day 14, the thoracostomy tubes and Jackson–Pratt drain were removed. He was further evaluated by dentistry who noted heavy accumulation of plaque and poor dental hygiene with gingivitis but did not identify any intervenable oral pathology or clear nidus of odontogenic infection.

The patient was transitioned to oral antibiotics and discharged on hospital day 17 with amoxicillin/clavulanate 875 mg twice daily for 15 days postoperatively, as recommended by infectious disease, with follow-up arranged for primary care, dentistry, otolaryngology, and thoracic surgery.