This paper describes the case of a patient who developed a pharyngotonsillitis and Ludwig's angina, and as a complication the most rare and grave mediastinitis, a descending necrotizing mediastinitis. The patient developed and adult respiratory distress syndrome secondary to mediastinal spread of a peritonsillar abscess. Only the combination of "aggressive" surgical and medical therapy resulted in survival of the patient. Important is the management of patients in Critical Care presenting complications associated with this illness.