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Case Report Diagnosis and Treatment of Acute Descending Necrotising Mediastinitis Caused by Pediatric Oropharyngeal Trauma

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Case Report Diagnosis and Treatment of Acute Descending Necrotising Mediastinitis Caused by Pediatric Oropharyngeal Trauma Int J Clin Exp Med 2016;9(2):5181-5188 www.ijcem.com /ISSN:1940-5901/IJCEM0018758 Case Report Diagnosis and treatment of acute descending necrotising mediastinitis caused by pediatric oropharyngeal trauma Xiaoyan Li, Kun Ni, Limin Zhao, Jiali Wu Department of Otolaryngology-Head and Neck Surgery, Shanghai Children’s Hospital, Shanghai Jiaotong University, Shanghai 200062, China Received October 19, 2015; Accepted January 18, 2016; Epub February 15, 2016; Published February 29, 2016 Abstract: Acute descending necrotizing mediastinitis (ADNM) is an acute necrotizing infection in which oropharyn- geal infection descends and involves the mediastinum, causing respiratory distress and sepsis. This paper reports the successful remedy of an ADNM case caused by oropharyngeal trauma in a 2-year-old child. Timely treatment, including abscess drainage in the chest, adequate application of broad-spectrum antibiotics and fully symptomatic support treatment are important steps towards healing. In this report, for suspected of oesophageal perforation, feeding with duodenal intubation was performed. Admitting physicians could use this report to familiarize them- selves with the handling necessary for this type of rare but deadly emergency case. Keywords: Acute necrotizing mediastinitis, oesophageal perforation, paediatric, trauma Introduction Committee of Shanghai Jiao Tong University. Written informed consent was obtained from all The occurrencee of paediatric acute descend- participants’ guardians. He was sent to a local ing necrotising mediastinitis (ADNM) is relative- hospital for medical treatment of mouth bleed- ly rare because of the extensive use of antibiot- ing. The oropharyngeal examination did not ics and the effective control of upper respira- exhibit any obvious abnormality, so he was dis- tory tract infection. Since its first report in charged and follow-up treatment was per- 1938, ADNM has been given considerable formed at home. However, his jaw swelled dur- attention by professional physicians because ing the night. The next morning, the parents of its low incidence but high risk. Reports on found that the boy’s mandibular swelling wors- ADNM caused by paediatric oropharyngeal ened. Thus, he was brought to our hospital for trauma are relatively rare. In this paper, a suc- physical examination, which revealed that the cessful remedy for a case of ADNM in a 2-year- boy’s mandibular swelling was significant, with old child caused by oropharyngeal trauma was tenderness. Skin temperature was normal, but analysed and discussed. This case study may mucosal damage can be observed on the right serve as a reference for the diagnosis and side of the sublingual mouth floor, without any treatment information of ADNM for otolaryn- significant leakage, bleeding or swelling. The gologists and paediatric emergency physici- child’s spirit was poor, his vital signs were sta- ans. ble and he was not suffering from fever. The Case report parents revealed that the boy’s eating and drinking conditions were normal, without vomit- The patient was a 2-year-old male who fell on ing, dysphagia, shortness of breath or discom- November 28, 2012 with chopsticks in his fort. The emergency blood routine test indicat- mouth. This study was conducted in accord- ed the following data: WBC 18.6×109/L and ance with the declaration of Helsinki. This study C-reactive protein (CRP) >160 mg/L. Cefuroxime was conducted with approval from the Ethics (100 mg/kg/day, intravenous infusion, Bid), Acute descending necrotising mediastinitis Figure 1. Enhanced neck-chest computed tomography (CT) scanning before treatment. A: Large gas accumulation is observed in the pre-vertebral space in median sagittal section of neck CT scanning. B: Large gas accumulation is observed in the pre-vertebral space in transverse section of chest CT scanning accompanied by corresponding hydropneumothorax and atelectasis changes in the right lung. C: Large gas accumulation is observed in the pre-ver- tebral section in transverse section of neck CT scanning. D: Subcutaeous pneumatosis in the mediastinum, throat gap, and bilateral chest is noted. Left pleural effusion is apparent in the coronary section of neck-chest CT scanning. ornidazole (100 ml/day, intravenous injection, ma in the neck and upper chest, with obvious qd) and dexamethasone injection (5 mg/day, crepitus. Dyspnoea sharply increased, and intravenous infusion, qd) were used. The pati- repeated intubation failed because the pharyn- ent was admitted for further observation. geal cavity was narrow and the glottis could not be exposed. Pernasal intubation was selected On the second day, the boy’s swollen jaw signi- and finally succeeded with the guidance of the ficantly decreased, without fever or particular fibrolaryngoscope. Emergency chest radiogra- discomfort. The parents requested that the boy phy indicated that subcutaneous pneumatosis be taken home, but the chief physician stated existed in the bilateral neck and the right arm- that the disease situation was not stable. pit. Minor inflammation existed in the bilateral Potential risk of breathing difficulties existed, so the patient was admitted into the emergen- lungs, and the left lower part exhibited partial cy department. At noon, the patient suddenly atelectasis. Enhanced neck-chest computed exhibited shortness of breath and his neck tomography (CT) scanning indicated that a lar- swelled, so he was administered oxygen inhala- ge area of gas accumulated in the pre-vertebral tion and subjected to electrocardiography. space and that the right chest had hydropneu- Simultaneously, emergency bedside endotra- mothorax, accompanied by changes in right cheal intubation was performed with the assis- lung atelectasis and mediastinum; subcutane- tance of the Department of Anaesthesia. How- ous pneumatosis appeared in the throat clear- ever, the procedure failed because of unclear ance and bilateral chest, and effusion appeared glottic exposure and blood decrease in oxygen in the left thoracic cavity (Figure 1). The patient saturation. Thus, the patient was immediately immediately underwent subcutaneous punc- transferred to the intensive care unit (ICU). ture for evacuating, and closed-type drainage After admission to the Intensive Care Unit (ICU), was performed towards the right thoracic cavi- the patient exhibited subcutaneous emphyse- ty. The drainage liquid was yellow and turbid, 5182 Int J Clin Exp Med 2016;9(2):5181-5188 Acute descending necrotising mediastinitis Figure 2. Enhanced neck-chest computed tomography (CT) scanning after one month treatment. A: Abnormal me- diastinal sac shadow is observed in the retropharyngeal and right parapharyngeal space, accompanied by gas and contents. B: The bilateral lungs are extensively infected. C: The right pneumothorax and effusion are significantly reduced when compared to previous condition. with negative bacterial cultivation. Although no and changed the gastric tube nutrition to the positive pathogens were detected, combined duodenal feeding under the guidance of an with the symptoms and signs, the patient was endoscope. A large amount of purulent secre- determined to have suffered from deep neck tions was drained from the mediastinum. The space infection, which moved downward and CT scan suggested significant improvement involved the mediastinum. These data met the in the lungs after 10 days (Figure 3); hence, the diagnosis of DNM; therefore, the patient was ventilator was adjusted to the artificial nose given the broad-spectrum antibiotics Mepem oxygen inhalation. After 2 days of observation, (10 mg/kg/time, intravenous infusion, q8h), the patient exhibited better spontaneous Vancocin (10 mg/kg/time, intravenous infu- breathing, with 99% oxygen saturation and sion, q8h) for anti-infection, and methylpred- without significant liquid drainage from the nisolone (5 mg/kg/day, intravenous infusion, bilateral drainage tubes. In addition, the patient bid) for anti-inflammatory treatment based on had smooth breathing after removing the tra- experience. At the same time, the patient was cheal cannula and drainage tube. The duodenal nasally fed with the strengthened supportive feeding was continued for 10 days until the oral treatment. intake of milk exhibited no obvious abnormali- ties, and then the duodenal feeding tube was At 1 month after the treatment, the vital signs removed. After 1 week of observation, the CT of the patient became stable, and the chest scan review suggested that the abnormal sac drainage was gradually reduced. However, clear shadow in the neck and upper mediastinum fluid drainage was still leaking out daily. The CT shrank, the right pneumothorax was fundamen- scan review indicated abnormal sac shadow in tally absorbed and the pulmonary inflammation the mediastinum behind the retropharynx and improved (Figure 4). The continuous observa- right parapharyngeal space, accompanied by gas and contents; the bilateral lungs suffered tion indicated that the vital signs of the patient from extensive infection, whereas the right were stable; thus, the patient was discharged, pneumothorax and effusion were significantly with a total hospitalisation period of 66 days. reduced compared with the previous analysis The follow-up continued for 3 months. The fol- (Figure 2). Analysis of the disease suggested low up date indicated that the normal daily that the lung condition was not improved, medi- activities of the patient were normal. No abrupt- astinal abscess formed and oesophageal dam- ness, swallowing difficulty and breathing diffi-
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