Wisdom Tooth’s Revenge: Deep Neck Space Infection and Mediastinitis After Molar Tooth Extraction

Posted By F. Eymen Ucisik-Keser
Wisdom Tooth’s Revenge: Deep Neck Space Infection and Mediastinitis After Molar Tooth Extraction

Deep cervical space infections have become less common as a result of widespread use of antibiotics. However radiologists and clinicians must still be familiar with this condition due to its potential to spread rapidly and result in high morbidity and mortality. We hereby present a case of full blown odontogenic infection presenting with multiple deep neck abscesses, mediastinitis and empyema. An otherwise healthy 24 year old female who a week earlier underwent an uncomplicated removal of all four third molar teeth presented to the ER with increasing throat pain, "spitting pus" that is “dripping down her throat”, cough, pain on inspiration and fevers. A contrast enhanced CT of the neck and chest showed fluid collections in multiple deep neck spaces including retropharyngeal, prevertebral, parapharyngeal and visceral neck spaces, with extension into the mediastinum (Fig 1). Unfortunately, the extent of the infection was underestimated and the patient was discharged home with antibiotics. Patient subsequently returned to the ER days later with more extensive disease evidenced by mediastinitis and empyema (Fig 2), requiring multiple surgical interventions including a thoracotomy to drainage of the collections and pulmonary decortication. Also, a fistula at the posterior oropharyngeal wall opening into the retropharyngeal space was identified via fluoroscopic examination (Fig 3). Patient eventually recovered and was discharged after a lengthy hospital stay during which she underwent multiple surgical interventions and received broad spectrum antibiotics for infection with multiple organisms including alpha Streptococcus, Enterobacter, anaerobe gram negative bacilli and yeast. Figure 1a, b: Contrast enhanced neck CT axial views at the hyoid bone (1a) and thyroid (1b) level reveal multiple, interconnected fluid collections within the deep spaces of the neck, including retropharyngeal, prevertebral, right lateral pharyngeal and right visceral spaces, as well as bilateral carotid sheaths. Note the obliteration of the right piriform recess by the adjacent fluid collection and soft tissue edema. C: Carotid Sheath, I: Fluid in between the fasciae of infrahyoid muscles, L: Lateral pharyngeal space, Pi: Left piriform recess, Pr: Prevertebral space, R: Retropharyngeal space, Th: Thyroid gland, V: Visceral space. Figure 2a-c: Coronal and sagittal contrast enhanced CT images, reveal a heterogeneous fluid collection extending from the prevertebral space (asterisk, 2b) into the mediastinum (black plus signs, 2a-c). Extension is demonstrated by the black arrow in 2b. In addition there is a large left multiloculated pleural fluid collection (white plus signs, 2a and 2c) in contiguity with the mediastinal fluid collection. Figure 3a: Sagittal view from contrast enhanced neck CT demonstrates a fluid collection within the retropharyngeal/alar space (asterisk) extending from the posterior wall of the oropharynx (OP) inferiorly to at least T3 vertebral leve

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