Cervical necrotizing fasciitis associated with descending necrotizing mediastinitis

ABSTRACT: We report a case of potentially fatal cervical necrotizing fasciitis and descending necrotizing mediastinitis due to deep neck infection in a 66-year-old male patient with no history or evidence of immunocompromising disorders. On admission, he had painful neck movements and the skin over his neck was red, hot and tender. A computerized tomography (CT) scan of his neck and chest showed evidence of air collection in soft tissues. He was treated with broad-spectrum intravenous antibiotics and early massive cervical drainage. Prompt diagnosis by CT of the neck and chest enabled an early surgical treatment of cervical necrotizing fasciitis. Although acute mediastinitis is a fatal infection involving the connective tissues that fill the interpleural spaces and surround the median thoracic organs, an extensive cervicotomy combined with appropriate antibiotics can prevent the need for mediastinal drainage.     

Successful management of descending necrotizing mediastinitis

Descending necrotizing mediastinitis is a critical infection and the mortality rate remains high. Early aggressive surgical drainage and antibiotic therapy are essential for treatment. We evaluated the efficiency of transthoracic drainage using a minimally invasive technique in 11 cases of descending necrotizing mediastinitis between May 2002 and March 2008. We performed a right-side minithoracotomy with thoracoscopic assistance, and the mediastinum was thoroughly drained. The length of hospitalization ranged from 30 to 117 days. The postoperative course was good in all patients, and the outcome was favorable. All patients were discharged without major complications. We recommend employing a minithoracotomy with thoracoscopic assistance for aggressive treatment of descending necrotizing mediastinitis.     

Acute mediastinitis arising from pancreatic mediastinal fistula in recurrent pancreatitis

Acute mediastinitis is a fatal disease that usually originates from esophageal perforation and surgical infection. Rare cases of descending necrotizing mediastinitis can occur following oral cavity and pharynx infection or can be a complication of pancreatitis. The most common thoracic complications of pancreatic disease are reactive pleural effusion and pneumonia, while rare complications include thoracic conditions, such as pancreaticopleural fistula with massive pleural effusion or hemothorax and extension of pseudocyst into the mediastinum. There have been no reports of acute mediastinitis originating from pancreatitis in South Korea. In this report, we present the case of a 50-year-old female suffering from acute mediastinitis with pleural effusion arising from recurrent pancreatitis that improved after surgical intervention.     

Akute Mediastinitis

Acute mediastinitis, an inflammation involving the mediastinal organs and mediastinal connective tissue, requires aggressive surgical treatment. Data suggest high mortality. The vast majority of acute mediastinal infections arise either from perforation of the esophagus or from transsternal cardiac procedures. A small number of cases result from a spreading infection from the head and neck (descending necrotizing mediastinitis). An uncommon cause is iatrogenic infected mediastinitis due to other medical procedures.     

Descending necrotizing mediastinitis caused by group A streptococcus (serotype M1T1).

We present a fatal case of descending necrotizing mediastinitis secondary to group A Streptococcus (serotype M1T1). Group A Streptococcus is a well-described cause of necrotizing fasciitis, but there have only been 4 previous cases documenting its involvement in descending necrotizing mediastinitis. This is the first case report to describe involvement of the M1 serotype in this condition.     

Rapidly propagating descending necrotizing mediastinitis as a consequence of intravenous drug use

Descending necrotizing mediastinitis (DNM) is a devastating complication of cervical or odontogenic infections that can spread downward to the mediastinum through anatomic spaces. We report the case of an intravenous drug user who presented with rapidly propagating acute pericarditis and DNM as the early presentations of pyomyositis of the sternocleidomastoid muscle and deep neck infection. The patient was successfully treated with antibiotics and surgical drainage. Clinicians should be aware that pathogens injected into the carotid sheath may spread to the mediastinum and/or pericardium and manifest as DNM and/or pericarditis prior to infectious signs and symptoms at the site of injection.     

An esophageal cancer case unresectable due to tuberculous fibrosing mediastinitis: report of a case

We present a case of esophageal carcinoma in which esophagectomy was not possible because of tuberculous fibrosing mediastinitis. A 77-year-old man was diagnosed with carcinoma of the thoracic esophagus and admitted to our hospital. Chest radiography on admission revealed no abnormality except pleural thickening of the pulmonary apices, suggesting a history of subclinical infection of tuberculous pleurisy. The patient underwent surgery with a curative intent. Thoracotomy revealed that the mediastinum had been replaced with dense fibrous tissues and was widely encased with laminar calcification. Esophagectomy was not performed because it was considered impossible to do so safely. Although diagnosis of fibrous mediastinitis was not made preoperatively, review of the preoperative computed tomographic scans revealed proliferation of mediastinal soft tissues that were associated with patchy and laminar calcifications. Tuberculous fibrosing mediastinitis is an uncommon but clinically important disease for physicians who are involved in the diagnosis and treatment of esophageal cancer.     

Update on Necrotizing Mediastinitis: Causes,Approaches to Management,and Outcomes

Descending necrotizing mediastinitis (DNM) is one of the most feared and fatal forms of mediastinitis, occurring as a complication after odontogenic or cervicofascial infections or after cervical trauma. Delayed recognition, underestimation of the extent of disease, and insufficient therapy promote spread of infection. Primary treatment of DNM includes surgical eradication of the pharyngeal or odontogenic infection focus, and a concomitant major drainage applied to the neck and the mediastinum. However, the mortality rate of DNM remains high, even with the routine use of CT scanning, antibiotics, advancements in anesthesia and intensive care, and immediate surgical drainage. The present state of the optimal management of DNM is discussed controversially, in particular the question of whether thoracotomy should be performed routinely or if minimally invasive procedures (eg, video-assisted thoracoscopy) may be introduced. This review reports on the incidence and course of this disease and discusses management approaches to DNM.     

The pattern of lymphatic metastases in superficial squamous cell carcinoma of the esophagus

BACKGROUND/AIMS: Lymphatic spread patterns in relation to the location of primary tumors of the superficial thoracic esophageal squamous cell carcinoma have not been well established. We therefore analyzed patterns of lymph node metastasis in these patients. METHODOLOGY: We reviewed medical records of 65 patients who underwent systematic three-field dissection for superficial squamous carcinoma of the thoracic esophagus from 1993 through 2000. RESULTS: Lymph node involvement was found in 0% (0/13) and 44% (23/52) of patients whose tumor invaded the muscularis mucosa and submucosal layer, respectively. The 5-year survival rate was 77% in the node-negative group and 59% in the node-positive group (P<0.05). None of the patients with upper thoracic esophageal cancer had metastasis to the mediastinal and abdominal nodes. Patients with lower thoracic esophageal tumors (Lt) had no metastasis to the cervical nodes. Patients with middle thoracic esophageal tumors (Mt) and Lt patients rarely had metastasis (2-5%) in the lower mediasinal nodes (Nos. 108-112). No patient with superficial thoracic esophageal cancer had metastasis to the subcarinal nodes in this study. CONCLUSIONS: In our series, no patient with intramucosal carcinoma had lymphatic metastases. Some patients with submucosal cancers metastasized beyond regional lymph nodes. However, this study suggests that subcarinal nodes might not need to be sampled or dissected in patients with superficial carcinoma of the thoracic esophagus. In Mt and Lt patients, metastases to the mediastinal nodes were infrequent (2-7%). Mediastinal nodes other than #107 can easily be sampled through cervical and abdominal incisions. Therefore, combined with lymph node sampling in cervical, mediasinal and abdominal stations through cervical and abdominal incisions, esophagectomy without thoracotomy might be acceptable in Mt and Lt patients with superficial squamous cell carcinoma of the esophagus.     

Value of multislice CT scan in redo cardiac surgery with previous Lita graft

Redo cardiac surgery is commonly performed in the current era. We describe a clinical scenario in a patient with a patent left internal thoracic artery to left anterior descending artery graft, requiring replacement of ascending aortic aneurysm with previous coronary artery bypass operation complicated by mediastinitis. A pre-operative 64 slice computed tomographic scan helped us plan and perform replacement of ascending aorta safely.     

Mediastinitis complicating cardiac operations: evidence of postoperative causation

An excess rate of mediastinitis complicating cardiac operations occurred in one of two hospitals served by the same surgeons. The rates were 4% at hospital A and 0.48% at hospital B for the same period (P = .002). At hospital A five patients who underwent a thoracic reoperation experienced postoperative pneumonia or bacteremia prior to onset of mediastinitis; these infections were caused by the same bacterial species. This circumstance provided a unique opportunity for comparing infection control practices, in which one hospital served as a control for interventional changes. At hospital A regular and temporary critical care nursing personnel, who took care of both infected and uninfected patients, did not antisepticize their hands before manipulation of percutaneous catheters. After cohorts of nurses were formed and antisepsis of the hands with alcohol was strictly enforced (no diminution in the number of temporary personnel was instituted), the frequency of mediastinitis decreased significantly among patients who underwent reoperations at hospital A (P = .002), but no concurrent change was noted at hospital B. Preventable postoperative remote-site infection may lead to mediastinitis.     

Perforating oesophageal carcinoma presenting as necrotizing fasciitis of the neck.

A patient with a history of schizophrenia was admitted to our hospital in an already severe stage of necrotizing fasciitis of the neck, complicated with mediastinitis and gangrene. Later on, he also developed a vena cava superior syndrome and sepsis. In the few cases and small series described in the literature, necrotizing fasciitis of the neck is usually associated with surgery or trauma. Less frequently, an orodental or pharyngeal infection, often innocuous, is the underlying cause. None of these causes could be identified in our patient. Initially, on computer-assisted tomography (CT) scan, a tracheal rupture was suspected, but this diagnosis could not be confirmed on bronchoscopic examination. On gastroscopy, a stenotic oesophageal segment was discovered. Biopsy of this segment showed a poorly differentiated squamous cell carcinoma. The patient died in sepsis. Autopsy confirmed the presence of a large proximal oesophageal tumour with perforation. As far as we know, no case of a necrotizing fasciitis of the neck caused by perforation of a formerly unknown oesophageal carcinoma has been reported. Even mediastinitis, with or without gangrene, is rarely associated with oesophageal cancer, and in the few cases reported it is always due to fistulization after surgery.     

A new combined surgical procedure for severe descending necrotizing mediastinitis with bilateral empyema

In this report, we will describe the treatment of a 38-year-old man with severe descending necrotizing mediastinitis (DNM) with bilateral empyema. DNM is a rare disease with a high mortality rate, and when accompanied by bilateral empyema, this is particularly serious and potentially fatal. To improve the prognosis of such patients, the establishment of an adequate surgical procedure for satisfactory debridement and drainage is essential. This is the first report on a new combined surgical procedure consisting of right standard posterolateral thoracotomy and left video-assisted thoracoscopic surgery (VATS) for severe DNM with bilateral empyema.     

Clinical infections and nonsurgical treatment of parapharyngeal space infections complicating throat infection

The clinical features and management of eight patients with parapharyngeal space infection who presented with swelling of the neck subsequent to sore throat are described. In four patients the interval between the initial throat symptoms and swelling was 2 days or less, and the disease was rapidly progressive with stridor or a descending mediastinitis. In the other four cases, this interval was longer (4 to 14 days) and the infection was fairly localized. Computed tomography was useful for making the diagnosis, establishing that the infection had spread into other deep neck spaces and the mediastinum, distinguishing abscesses from diffuse cellulitis, guiding drainage aspiration, and assessing the response to therapy. None of the patients underwent extensive surgical drainage of the deep neck spaces. A nonsurgical approach with antibiotics, including high doses of benzylpenicillin, and computed tomography-guided selective needle aspirations proved successful. Even patients with distinct abscesses were completely cured.     

Combined endovascular and surgical treatment of primary aortoesophageal fistula

Primary aortoesophageal fistula is a rare cause of massive upper gastrointestinal bleeding. Conservative treatment of aortoesophageal fistula results in a 60% in-hospital mortality rate with no late survival, and conventional surgical treatment has a reported in-hospital mortality rate that approaches 40%. Thoracic endovascular aortic repair is an innovative and less invasive technique for the treatment of aortoesophageal fistula. It enables the rapid control of aortic bleeding and prevents fatal early exsanguination. However, the technique does not repair the esophagus, and there remains a substantial risk of mediastinitis and infection of the stent-graft. Herein, we report the cases of 2 patients in whom we used a combined treatment: thoracic endovascular aortic repair and delayed surgical repair of the esophagus. The esophageal repair involved direct suture of the esophageal wall and reinforcement with an intercostal muscle flap. Early follow-up evaluations suggest that our treatment of both patients was successful. We discuss the advantages and limitations of our technical choices and briefly review the pertinent medical literature.     

Graft replacement and muscle wrap for infected aneurysm of thoracic aorta

A 68-year-old man was admitted with high fever and enlargement of the distal aortic arch on chest radiography. Computed tomography showed a huge proximal descending thoracic aortic aneurysm. Graft replacement of the proximal descending thoracic aorta was performed on an emergency basis, and a pectoralis major muscle flap was wrapped around the graft. Salmonella enteritidis was detected in the resected tissue. The patient recovered well, with no signs of infection.     

Pathology of inhalational anthrax in 42 cases from the Sverdlovsk outbreak of 1979.

A large epidemic of anthrax that occurred in Sverdlovsk (now Ekaterinburg), Russia, in 1979 resulted in the deaths of many persons. A series of 42 necropsies, representing a majority of the fatalities from this outbreak, consistently revealed pathologic lesions diagnostic of inhalational anthrax, namely hemorrhagic necrosis of the thoracic lymph nodes in the lymphatic drainage of the lungs and hemorrhagic mediastinitis. Bacillus anthracis was recovered in bacterial cultures of 20 cases, and organisms were detected microscopically in the infected tissues of nearly all of the cases. A novel observation was primary focal hemorrhagic necrotizing pneumonia at the apparent portal of entry in 11 cases. Mesenteric lymphadenitis occurred in only 9 cases. This remarkably large series demonstrated the full range of effects of anthrax bacteremia and toxemia (edema especially adjacent to sites of extensive infection and pleural effusions) and hematogenously disseminated infection [hemorrhagic meningitis (21 cases) and multiple gastrointestinal submucosal hemorrhagic lesions (39 cases)].     

Cirugía torácica videoasistida,trasplante pulmonar y mediastinitis,temas destacados de cirugía torácica en 2010

We reviewed the major issues in thoracic surgery relating to the advances made in our specialty in 2010. To do this, the 43^rd Congress of the Spanish Society of Pneumology and Thoracic Surgery held in La Coruña and the articles published in the Society's journal, archivos de bronconeumología, were reviewed. The main areas of interest were related to the development of video-assisted thoracic surgery, lung transplantation and descending mediastinitis. The new tumor-node-metastasis (TNM) classification (7^th edition), presented last year, was still a topical issue this year. The First Forum of Thoracic Surgeons and the Update in Thoracic Surgery together with the Nurses’ Area have constituted an excellent teaching program.     

Primary Aortoesophageal Fistula due to Thoracic Aortic Aneurysm: Successful Surgical Treatment

Aortoesophageal fistula is a rare emergency that presents a real challenge for cardiothoracic surgeons. There have been few reports of survivors. We present the case of a 70-year-old man with aortoesophageal fistula, mediastinal abscess, and severe septicemia consequent to esophageal erosion and rupture of a chronic degenerative descending thoracic aortic aneurysm. The patient underwent successful surgical treatment by aorto–aortic bypass and bipolar esophageal exclusion in conjunction with a cervical esophagostomy and a feeding gastrostomy. The pleural cavity was copiously irrigated and drained. Three months later, a retrosternal gastric bypass operation was performed successfully. The patient''s 6-month follow-up examination revealed no problems.Key words: Aneurysm, infected/surgery; aortic aneurysm, thoracic/complications/mortality/surgery; empyema; esophageal fistula/diagnosis/etiology/therapy; esophagostomy; mediastinitis; tomography, X-ray computed; vascular fistula/etiology/surgeryAortoesophageal fistula (AEF) is a rare cause of gastrointestinal bleeding. Surgery is crucial for survival. It is of great importance that both the thoracic aortic aneurysm and the esophageal erosion be treated in order to avoid massive hemorrhage and septic sequelae.^1,2     

Utility of omentoplasty for poststernotomy mediastinitis secondary to myocardial revascularization surgery

Acute poststernotomy mediastinitis is a serious complication of cardiac surgery and is associated with high mortality. Conservative treatment with local debridement, irrigating-suction systems, and specific antibiotic therapy is sometimes inadequate. Omentoplasty is occasionally used for reconstruction and the treatment of various chest diseases. This useful procedure is most often indicated for suppurative processes and radionecrosis, to complement myoplasty, or to cover a chest wall prosthesis. When used to treat poststernotomy mediastinitis secondary to cardiac surgery, omentoplasty improves control of infection and prognosis. We describe 2 cases of poststernotomy mediastinitis secondary to cardiac revascularization surgery in which omentoplasty was an effective treatment. Excellent control of infection was achieved.