Survival and Closure by Secondary Intention of a Pharyngocutaneous Fistula After Fulminant Descending Necrotizing Mediastinitis

Descending necrotizing mediastinitis is a rare, life-threatening extension of deep neck infection. We report the case of a 51-year-old woman who initially presented with a sore throat and was treated as uncomplicated pharyngitis before rapidly developing neck swelling, chest pain, dyspnea, septic shock, pneumomediastinum, and bilateral pleural empyemas. Combined cervicothoracic exploration showed dishwater fluid in the neck and mediastinum without esophageal perforation, and cultures grew Streptococcus anginosus and mixed oral flora with Actinomyces odontolyticus bacteremia. Her course was complicated by stress-induced cardiomyopathy, acute kidney injury requiring continuous renal replacement therapy, and vasopressor-associated digital ischemia. On hospital day 17, repeat exploration identified a large left hypopharyngeal pharyngocutaneous fistula communicating with the open neck wound. Because of critical illness and poor peripheral perfusion, flap reconstruction was deferred. The fistula was managed with repeated antiseptic packing, strict gastrostomy feeding, salivary suctioning, glycopyrrolate, scopolamine, and later botulinum toxin injections to the parotid and submandibular glands. The defect gradually contracted and closed by secondary intention over approximately 10 weeks. This case highlights that, in carefully selected high-risk patients, structured conservative management with salivary suppression may allow closure of a large pharyngocutaneous fistula after fulminant descending necrotizing mediastinitis.