OBJECTIVES: To report a case of acute tonsillitis that subsequently developed descending necrotizing mediastinitis, and to discuss the signs and symptoms, differential diagnosis, pathophysiology, diagnostic criteria, ancillary procedures and management.

METHODS:
Design: Case Report

Setting: Tertiary Private and Government Hospital

Patient: One

RESULTS:  A 36-year-old woman was admitted with a 2-day history of sore throat and a diagnosis of acute exudative tonsillitis. She complained of sore throat accompanied by dyspnea, neck and chest pain which rapidly progressed to mediastinitis. She was transferred to a tertiary government hospital where video assisted thoracoscopic surgery with bilateral deloculation,  mediastinoscopy and bronchoscopy revealed purulent discharge from the right main stem bronchus with multiloculated effusion in the left lung and posterolateral loculated effusion in the right lung. Her condition improved and she was discharged after a month of antibiotic therapy.

CONCLUSION: Acute tonsillitis seldom leads to a life-threatening complication such as mediastinitis. Descending necrotizing mediastinitis develops when acute tonsillar infection progresses and descends to the mediastinum. It is a surgical emergency which requires mediastinal drainage, thoracotomy and long-term antimicrobials. Clinicians who manage oropharyngeal infections should be aware of this rare but lethal complication which may occur even in non-immunocompromised individuals.