负压引流联合胸腔闭式引流治疗颌面颈部多间隙感染伴下行性坏死性纵隔炎的临床观察

目的:总结负压封闭引流(vacuum sealing drainage,VSD)联合胸腔镜下闭式引流治疗颌面颈部多间隙感染伴下行性坏死性纵隔炎(descending necrotizing mediastinitis,DNM)的诊疗经历,为临床提供参考.方法:回顾性分析2016年1月—2017年12月于江苏大学附属人民医院耳鼻咽喉科及口腔科治疗的3例颌面颈部多间隙感染伴DNM患者的临床资料.结果:共3例患者,男性2例,女性1例,年龄41～53岁,经颌面颈胸部CT检查确诊,均在全麻下行颈部切开VSD联合胸腔镜下闭式引流,颈部VSD装置于术后1周左右在全身麻醉下取出,胸腔闭式引流管置管约36 d,患者平均住院时间为48 d(44～57 d),术后随访33～50个月,感染未复发.结论:VSD联合胸腔镜下闭式引流治疗颌面颈部多间隙感染合并DNM,引流效果可靠、手术创伤小,患者满意,具有一定的临床应用价值.     

负压引流联合胸腔闭式引流治疗颌面颈部多间隙感染伴下行性坏死性纵隔炎的临床观察

目的:总结负压封闭引流(vacuum sealing drainage,VSD)联合胸腔镜下闭式引流治疗颌面颈部多间隙感染伴下行性坏死性纵隔炎(descending necrotizing mediastinitis,DNM)的诊疗经历,为临床提供参考.方法:回顾性分析2016年1月—2017年12月于江苏大学附属人民医院耳鼻咽喉科及口腔科治疗的3例颌面颈部多间隙感染伴DNM患者的临床资料.结果:共3例患者,男性2例,女性1例,年龄41～53岁,经颌面颈胸部CT检查确诊,均在全麻下行颈部切开VSD联合胸腔镜下闭式引流,颈部VSD装置于术后1周左右在全身麻醉下取出,胸腔闭式引流管置管约36 d,患者平均住院时间为48 d(44～57 d),术后随访33～50个月,感染未复发.结论:VSD联合胸腔镜下闭式引流治疗颌面颈部多间隙感染合并DNM,引流效果可靠、手术创伤小,患者满意,具有一定的临床应用价值.     

111例下行性坏死性纵隔炎的诊断与治疗

目的: 探讨下行性坏死性纵隔炎的临床特点、早期诊断和治疗方法,以降低该病的死亡率。方法: 回顾分析2013年1月—2016年10月于上海交通大学医学院附属第九人民医院诊治的下行性坏死性纵隔炎病例,总结其性别、年龄、合并症、感染源、影像学检查结果、细菌学检查结果、治疗手段和治疗结果。结果: 共收集111例患者,平均年龄56.6±12.5岁,男女比为5.9∶1。主要感染源为牙源性感染,其次为腺源性感染。52例（46.8%）患者有合并症,其中以Ⅱ型糖尿病最常见。所有患者均行颈胸部CT检查。主要致病菌为链球菌。所有患者均行全身抗感染治疗和颈部切开排脓,106例患者经颈部切口行上纵隔引流,9例行开胸手术清创引流。死亡率为6.3%。结论: 胸部CT检查是早期诊断下行性坏死性纵隔炎的有效手段。早期诊断、有效的抗菌治疗、充分的切口引流及全身支持治疗是降低死亡率的主要措施。     

下颌骨颈胸CT连续扫描在牙源性下行坏死性纵隔炎诊治中的意义

目的:探讨下颌骨颈胸CT连续扫描在牙源性下行坏死性纵隔炎(DNM)诊治中的作用.方法:回顾性总结12例牙源性DNM的临床资料,对其临床表现、治疗及CT诊断结果进行分析.结果:10例可见病灶牙及颌骨变化,下颌颈胸CT连续扫描显示感染自颌面向胸部扩散的连续过程,表现为口底、颌下广泛积气、积脓,经颈部间隙达纵隔,3例为上纵隔感染,9例扩散到下后纵隔;8例伴胸腔积脓、肺部感染,2例心包积脓、积气.结论:牙源性下行坏死性纵隔炎发病急、扩散快、病情凶险、死亡率高,值得警惕.早诊断、早治疗是提高治愈的有效方法.颌面颈胸连续CT扫描是判断感染扩散范围、确定引流部位的有力手段.     

549例头颈部多间隙感染严重并发症分析

目的 ：探讨头颈部多间隙感染严重并发症的种类、发生率及其预后。方法 ：回顾分析2006年2月—2014年7月间就诊的549例头颈部多间隙感染患者,对其病因、易感因素、伴随系统性疾病、治疗方法、严重并发症、治疗结果等进行总结。使用SPSS 19.0软件包对数据进行统计学分析。结果 ：549例头颈部多间隙感染患者中,66例出现严重并发症,发生率为12.20%。其中,下行性纵隔炎最多 (37例,56.06%),其次为呼吸道梗阻 (27例,40.91%)、肺炎 (12例,18.18%)、 心包炎 (6例,9.09%)、眶内感染 (2例,3.03%)、多器官衰竭 (2例,3.03%)、颅内感染 (2例,3.03%),以及心源性猝死 (1例,占1.52%)。所有合并严重并发症的患者均接受全身抗感染治疗和头颈部切开引流术。其中33例下行性纵隔炎患者接受纵隔切开引流,27例呼吸道梗阻的患者接受气管切开或气管内插管。12例患者在治疗过程中死亡。高龄和有全身系统性疾病的患者更易发生严重并发症。结论 ：下行性纵隔炎是头颈部间隙感染最常见的并发症,而呼吸道梗阻最易导致死亡。及时广泛切开引流及全身抗感染治疗是目前治疗头颈部多间隙感染的有效方法,尤其对减少严重并发症的发生意义重大。     

下行性坏死性纵隔炎的诊疗进展

下行性坏死性纵隔炎（descending necortizing mediastinitis,DNM）是口腔颌面部感染的重症并发症,最常见的病因为牙源性感染和咽部感染,当感染沿着颈部间隙扩散至纵隔时,临床表现为颌面部肿胀,颈胸部发红、肿胀,呼吸困难等。DNM的早期诊断和治疗可有效降低死亡率。目前,DNM的治疗尚无标准化的通用指南,临床上常用的治疗方式多为外科手术清创引流联合抗生素治疗。本文就近年来国内外有关DNM诊疗的研究进展作一综述。     

26例牙源性下行性坏死性纵隔感染的CT影像学特点分析

目的：探讨下行性坏死性纵隔感染（descending necrotizing mediastinitis,DNM）的CT影像学特点。方法：应用64层螺旋CT,对26例牙源性DNM患者进行颈部和胸部扫描,描述感染的部位、范围、扩散途径等影像学特征。结果：DNM的CT影像表现为脓肿、非包裹性积液和积气。26例患者均出现颈部多间隙感染。其中,18例咽喉部肿胀、移位。颈部均为皮下组织蜂窝织炎和（或）深筋膜间隙感染。气管间隙、颈动脉间隙、椎前间隙是炎症向下扩散的通道。胸部前上纵隔感染11例,前纵隔感染4例,后纵隔脓肿4例,全纵隔感染7例。依据CT影像,采取不同清创引流方法,全组死亡1例,死亡率为3.8%。结论：头颈、胸部增强CT扫描对DNM的诊断具有重要价值,还可为手术方式的选择提供影像学依据。     

70例牙源性下行性坏死性纵隔炎临床分析

目的: 分析牙源性下行性坏死性纵隔炎患者的临床特征,为诊断和治疗提供参考。 方法: 回顾分析2014年1月—2016年12月上海交通大学医学院附属第九人民医院收治的牙源性下行性坏死性纵隔炎患者,收集、分析患者的一般资料、感染来源、临床症状、实验室检查、细菌培养、治疗和预后。采用SPSS 22.0软件包对数据进行统计学分析。 结果: 本组70例患者中,男57例,女13例,平均年龄57.8±11.42岁。主要的发病来源为下颌前磨牙及第一、第二磨牙（38.6%）。根尖周炎是最常见的牙源性感染的病因。治疗包括抗生素和经颈部纵隔引流（63例）、胸廓切开术（7例）。死亡率为5.7%。影响牙源性下行性坏死性纵隔炎患者预后的危险因素为发生并发症（P<0.005）和严重脓毒症或败血性休克（P<0.002）。 结论: 成功治疗牙源性下行性坏死性纵隔炎的关键是对疑似症状的迅速诊断、快速CT扫描和彻底的纵隔引流。     

重症口腔颌面头颈部多间隙感染临床分类探讨

目的 ：探讨一种新的口腔颌面头颈部多间隙感染临床分类方法。方法 ：回顾攀枝花市中心医院2015年7月—2022年3月采用全麻手术治疗的120例重症口腔颌面头颈部多间隙感染患者的临床及影学资料,探讨一种新的分类方法。采用SPSS 17.0软件包对数据进行统计学分析。结果：重症口腔颌面头颈部多间隙感染可分为5类。Ⅰ类82例（68.33%）,感染集中在舌骨-颧弓平面范围,通过下颌下切口能充分引流各间隙感染;Ⅱ类13例（10.83%）,感染向上波及颞深间隙,需行下颌下及颞部2个切口充分引流;Ⅲ类14例（11.67%）,感染向下波及锁骨以上的颈下部间隙,需行下颌下及锁骨上切口充分引流;Ⅳ类5例（4.17%）,感染波及颞部到锁骨上范围,需结合下颌下、颞部及锁骨上多个切口引流;Ⅴ类6例（5%）,感染突破锁骨平面波及纵隔、胸腔,必须联合心胸外科行纵隔及胸腔引流。从Ⅰ类到Ⅴ类患者病情逐渐加重,治疗难度逐渐递增,风险逐渐提高,平均ICU监护时长、住院时长、住院花费及抗菌药费用等医疗资源消耗也逐渐增加（P<0.0001）。结论：重症口腔颌面头颈部多间隙感染危及生命,多学科联合是治疗的前提。对该病进行合...     

口咽部感染并发化脓性纵膈炎-附6例临床病例

目的报道口咽部感染并发化脓性纵膈炎（称为下行性坏死性纵膈炎descending necrotizing mediastinitis DNM）的病例资料，供临床作借鉴。方法报道6例口咽部感染并发化脓性纵膈炎病例的临床特点及治疗方法。结果本病的感染多为厌氧茵和需氧茵的混合感染；内脏后间隙是感染由口咽部向纵膈扩散的主要途径；治疗的关键是全身抗菌素应用＋颈纵膈引流。结论DNM是一种发展迅速的致死性炎性疾病。早期的诊断、有效的治疗、多学科协同配合抢救可以大大降低死亡率。     

Significant rise in neck infections progressing to descending necrotizing mediastinitis during the COVID-19 pandemic quarantine

To present five patients with DNM, who were treated during the first quarantine for Coronavirus disease 2019 (Covid-19).Five patients with DNM were treated in our department during the first lockdown. The mean age of the patients was 42,2 years and four were male. Two patients were immunocompromised. Repeated surgical drainage was performed in all patients, whereas four were also subjected to elective tracheostomy during their first operation. The mean hospitalization duration was 55,4 days and mortality was 40%.During the first lockdown for the Covid-19, a rise in the ratio of DNM cases to the overall incidence of cervicofacial infections was observed in our department. All patients with DNM were operated on an emergency basis and were subsequently admitted to the ICU. We consider the effect of the quarantine as a decisive factor for this escalation, because according to the department archives, there had not been any cases of DNM originating from a dental infection, for the past 5 years. Additionally, past studies from the same department reported no more than 6 cases over a 10 year period.     

Management of descending necrotizing mediastinitis.

PURPOSE: One of the most dreaded and the most lethal form of mediastinitis is descending necrotizing mediastinitis (DNM). PATIENTS AND METHODS: Between January 1990 and June 2001, 6 patients (mean age, 54.5 years; age range, 19 to 72 years) with DNM were treated in the Department of Thoracic Surgery of General Hospital of Attica "K.A.T." The primary etiology was odontogenic abscess in 3 patients and peritonsillar abscess in the other 3. Diagnosis was confirmed by computed tomography of the neck and chest. All patients underwent surgical drainage of the involved cervical region and mediastinum by monolateral cervicotomy and left thoracotomy. RESULTS: The delay between the occurrence of thoracic symptoms and mediastinal drainage varied from 1 to 4 days. The thoracic approach and the side of the thoracotomy depended on the involved mediastinal compartments and side of pleural effusion. The duration of mediastinal drainage varied from 8 to 22 days (mean, 12.5 days). One patient died of multiorgan failure related to postoperative septic shock. CONCLUSION: Delayed diagnosis and inadequate drainage are the main causes of the high mortality rate of DNM. Routine use of the computed tomography scan is highly recommended in patients with a deep cervical infection for early detection of mediastinitis at a time when the chest roentgenogram is still normal. If one realistically hopes to avoid the high mortality rate, aggressive surgical drainage and debridement of the neck and drainage of the mediastinum via a posterolateral thoracotomy by a multidisciplinary team of surgeons are required.     

口腔颌面部多间隙感染合并化脓性心包炎的诊断与治疗

目的:总结口腔颌面部多间隙感染合并化脓性心包炎的临床特点及诊治经验。方法:2005—2010年共收治4例口腔颌面部多间隙感染合并化脓性心包炎病例,对其临床资料作回顾性分析。结果:患者均为男性,年龄27~52岁,病因均为牙源性感染。自口腔颌面部间隙感染至确诊纵隔感染0~12 d,平均6 d;纵隔感染至确诊心包炎0~7 d,平均2.5 d;治疗时间9~63 d,平均42.5 d。病原菌包括唾液链球菌、粪肠球菌、阴沟肠杆菌及嗜麦芽寡氧单孢菌等。经头颈、纵隔、心包脓肿切开引流,静脉注射抗生素,气管切开呼吸机辅助通气及全身支持治疗后,3例治愈,1例死亡。结论:口腔颌面部间隙感染导致化脓性心包炎病情凶险,而下行扩散的过程隐匿,须重视患者的胸部症状。早期诊断,及时、充分的引流是治疗关键;细菌培养对抗生素使用具有指导意义。     

头颈部感染致坏死性纵隔炎九例

目的 通过回顾9例下行性坏死性纵隔炎患者的临床资料,总结其诊断及治疗的经验,以期提高治愈率,改善预后.方法 2005年12月至2008年12月共收治9例下行性坏死性纵隔炎患者,均为男性,年龄38-78岁,平均55.7岁,其中8例接受手术治疗,采用颈根部横切口引流4例,颈胸联合切开引流4例.结果 9例中2例死亡,其中1例未接受手术治疗,另1例因术后并发多器官功能衰竭死亡,其余7例均治愈出院.结论 诊断和治疗不及时是导致下行性坏死性纵隔炎高病死率的主要原因,各学科相互合作及早期外科干预可以降低其病死率,提高疗效.     

C反应蛋白在下行性坏死性纵隔炎中的预警作用

目的: 探讨口腔颌面颈部多间隙感染继发下行性坏死性纵隔炎（descending necrotizing mediastinitis,DNM）的危险因素,为DNM的早期诊断和早期治疗提供依据。方法: 收集2016年12月—2017年12月于上海交通大学医学院附属第九人民医院口腔外科急诊首诊的口腔颌面颈部多间隙感染患者的一般资料,包括感染来源、实验室检查、是否发生DNM及治疗结果等。根据是否发生DNM,将患者分为2组,采用SPSS 22.0软件包对2组中连续型变量进行t检验或t'检验,二分类变量及等级变量进行Fisher 精确检验。结果: 201例口腔颌面颈部多间隙感染患者中,继发DNM 14例,发生率为6.97%。201例患者中,男142 例,女59例;平均年龄（52.98±17.12）岁。最常见的原发疾病为根尖周炎（90例）,占44.8%,其次为智牙冠周炎（50例,24.9%）;发病源的最常受累部位为下颌后牙区,为140例（69.7%）。单因素分析显示,发病部位（P<0.001）、中性粒细胞百分比（P=0.004）、C反应蛋白（P<0.001）均为DNM的危险因素。结论: 对于C反应蛋白较高的口腔颌面颈部多间隙感染患者,要高度怀疑发生DNM的可能。     

Challenges of tracheostomy in COVID-19 patients in a tertiary centre in inner city London

The rapid global spread of SARS-CoV-2, the causative agent of COVID-19, has dominated healthcare services, with exponential numbers requiring mechanical ventilation in the intensive care unit (ICU). Tracheostomy facilitates respiratory and sedative weaning but risks potential viral transmission. This study reviewed the tracheostomy provision, techniques, and outcomes for a single-centre prospective cohort during the resource-pressured COVID-19 period. Seventy-two of 176 patients underwent tracheostomy at a median 17 days: 44 surgical (open), 28 percutaneous. Their median age was 58 years, the male to female ratio was 2.4:1, 75.1% were of BAME backgrounds, 76% had a BMI ≥ 25 kg/m², and 65% had ≥2 major co-morbidities. Seventy-nine percent of patients were weaned from sedation at a median 2 days, 61% were weaned from mechanical ventilation at a median 10 days, 39% were discharged from the ICU at a median 11.5 days, and 19.4% were discharged home at a median 24 days. All patients survived the procedure. The mortality rate was 9.7% at a median 12 days. No clinician reported COVID-19 symptoms within 14 days of the procedure. The role of tracheostomy in COVID-19 is currently unclear. Delivery of tracheostomy by maxillofacial surgeons relieved the workload pressure from ICU clinicians. The choice of technique was influenced by the patient and resource factors, resulting in a mixed cohort of open and percutaneous tracheostomy in COVID-19 patients. Preliminary data suggest that open tracheostomy is as favourable as percutaneous tracheostomy for COVID-19 patients, and is safe for clinicians.