Diagnosis and management of odontogenic mediastinitis

Odontogenic descending necrotizing mediastinitis (DNM) is a rare but sometimes fatal complication of tooth infections. The mortality rate remains high, up to 40%, and there is no consensus on optimal workup and management currently. This review aims to summarize cases of odontogenic DNM in the literature to optimize management strategies and aid physicians in its early recognition. A systematic review of the Ovid Medline, EMBASE Classic and Pubmed databases was conducted using PRISMA guidelines. Original research studies reporting an odontogenic etiology of DNM were included. Our search identified 226 articles. Final inclusion consisted of 60 studies describing 204 cases. Most patients were male (80.4%) with a mean age of 47.64 ± 15.96 years old. Patients primarily presented with edema (57.7%), fever (42.3%), trismus (37.2%), dyspnea, (26.9%), dysphagia (26.9%). Common radiologic findings were abscesses or fluid collection in the mediastinum (53.1%), air in the soft tissues (50.0%), pleural effusion or empyema (37.5%), mediastinal widening (32.8%), and pericardial effusion (7.8%). Patients were treated with intravenous antibiotics and a variety of surgical techniques such as cervicotomy only (51.2%), thoracotomy only (15.9%), cervicotomy and chest tube (3.5%). The mortality rate was 14.2% with a mean length of hospital stay of 30.1 ± 20.2 days. This systematic review reports and analyzes epidemiological, clinical and treatment-related data regarding patients with odontogenic DNM. Effective disease recognition and patient-specific targeted treatment are needed to ensure treatment success. Further research is needed to promote implementation of such data into clinical practice, with potential to reduce the associated mortality rate.