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.     

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.     

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。     

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。     

Mediastinitis caused by an infected mandibular cyst

Descending necrotizing mediastinitis is a potentially fatal condition which may occur seldom as a consequence of oral infections. This report describes the management of a patient with mediastinitis due to an infected dentigerous cyst.     

牙源性下行性坏死性纵隔炎的治疗及护理

目的：总结牙源性感染累及前纵隔的下行性坏死性纵隔炎的护理经验。方法：14例下行性坏死性纵隔感染患者（年龄30,70岁．平均年龄45岁）．均为牙源性感染。其中,前上纵隔感染9例,整个前纵隔感染5例,所有患者均给予心理护理、呼吸道护理．同时加强营养支持．积极治疗及控制基础疾病;术后根据引流管位置,做好双套管冲洗及胸腔冲洗．确保引流通畅。结果：除1例患者早期因感染性休克死亡外,其余患者均痊愈,死亡率为8.3％,发生肺部感染6例．ARDS2例,肾功能不全1例。结论：下行性坏死性纵隔炎需根据感染的部位采取相应的治疗措施,严密观察病情变化。通畅的引流及科学的呼吸道护理．是控制病情发展和预防并发症发生的关键。     

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。     

59例口腔颌面部多间隙感染继发下行坏死性纵隔炎的回顾性分析

目的通过分析口腔颌面部多间隙感染继发下行坏死性纵隔炎(descending necrotizing mediastinitis,DNM)患者的临床特点,为该病的防治提供依据。方法收集2010年3月~2020年3月新疆医科大学附属口腔医院颌面肿瘤外科收治的59例诊断为DNM患者的病例资料进行回顾性分析,所有患者通过胸部增强CT确诊,并转入重症监护病房(intensive care unit,ICU)治疗。对患者临床数据进行统计分析。结果DNMⅠ型患者21例(35.6%),DNMⅡA型患者19例(32.2%),DNMⅡB型患者19例(32.2%)。所有DNM患者均行急诊手术,Ⅰ型及ⅡA型患者经前纵隔剑突下切开引流配合胸腔引流;ⅡB型患者开胸纵隔彻底清创,术后引流;59例DNM患者的脓液全部送细菌培养,其中19例培养为阳性;全身抗炎治疗。死亡患者5例(8.5%),生存患者54例(91.5%)。与生存组相比,死亡组中年龄≥65岁、有糖尿病患者、入院到转入ICU时间间隔≥6 d、APACHEⅡ评分≥20、ICU治疗时间≥10 d、感染性休克患者占比高,差异有统计学意义(P<0.05)。结论及时转入ICU、配合早期手术、积极治疗全身系统性疾病和全身抗菌治疗是降低DNM死亡率的关键。     

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.     

A conservative approach in the management of inflammatory dentigerous cyst in transitional dentition: a case report

Dentigerous cysts are benign odontogenic cysts that develop from the reduced enamel epithelium related to the crown of an unerupted and/or impacted tooth. Inflammatory dentigerous cyst is a variety of dentigerous cyst that is mostly found in the mixed dentition, and the treatment modalities range from enucleation to marsupialization. By extracting the infected primary teeth, opening the cyst, and ensuring continuous drainage, spontaneous eruption of the involved permanent teeth occurs into the dental arch even if they are severely dislocated. The purpose of this report is to describe the successful treatment of a large dentigerous cyst by conservative surgical management.     

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。     

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。     

输液管在儿童替牙期含牙囊肿开窗术中的应用

目的:探讨输液管在儿童替牙期含牙囊肿开窗引流术中的作用。方法 :分析2003-12—2011-12我院口腔颌面外科收治的经病理证实为含牙囊肿的替牙期儿童病例22例,平均年龄11岁,所有病例术前均拍摄曲面断层片和局部小牙片,囊肿直径3～5 cm,其中含多生牙9例。术中拔除部分乳牙及多生牙,于拔牙创处开窗,切取部分囊壁,拔牙创口置直径0.4 cm、长约1.0～1.5 cm输液管,并固定于牙龈或邻近牙齿。每日冲洗,术后3个月、6个月、1年随访,同时拍摄曲面断层片检查。结果:所有病例在开窗术后早期局部轻度红肿疼痛,3个月后囊肿明显减小,6～7个月时骨质膨隆消失,10～11个月时X线检查囊肿低密度影像消失。13例恒牙自行正位萌出,4例出现尖牙与侧切牙错位萌出,5例恒牙未自行萌出。在开窗引流期间,无1例患者伤口感染,均引流通畅。结论:输液管在儿童替牙期含牙囊肿开窗引流术中,具有操作简单、患者术后依从性高、创伤痛苦小、复诊次数少、引流通畅、成本低廉、易于推广等特点,是治疗儿童替牙期含牙囊肿的较理想方法。     

Rare complications of a dental abscess

This article describes a case involving a poorly treated odontogenic infection, which was complicated by mediastinitis, thoracic empyema, pericarditis, and ascites. A posterolateral thoracotomy was necessary as incisional surgical drainage proved to be inadequate. A multidisciplinary approach of descending necrotizing mediastinitis and its complications is essential.     

Descending necrotizing mediastinitis due to odontogenic infections

OBJECTIVE: Acute purulent mediastinitis caused by oropharyngeal infection is termed descending necrotizing mediastinitis. Such infections usually have a fulminate course, leading to sepsis and frequently to death. The purpose of this study is to show the importance of early diagnosis, aggressive surgical intervention, and optimal antibiotics chemotherapy in controlling this fatal infectious disease. STUDY DESIGN: Two patients with descending necrotizing mediastinitis due to odontogenic infection who were treated at our institution are described. RESULTS: Both patients survived. CONCLUSIONS: From the patients, 23 different aerobic and anaerobic bacteria were isolated. All of the isolates were susceptible to carbapenem. Early evaluation by means of cervicothoracic computed tomography scanning was extremely useful for diagnosis and surgical planning. Knowledge of anatomic pathways from the mouth to the mediastinum is essential. We believe that tracheostomy is not always necessary. In both of the cases presented, mediastinal drainage was completed through use of a transcervical approach. However, a more aggressive drainage including tracheostomy might be necessary when the infection extends below the carina.     

Inflammatory dentigerous cysts of children treated by tooth extraction and decompression--report of four cases

Inflammatory dentigerous cysts are only found in the mixed dentition. The four cases presented here illustrate the uncomplicated behavior of these cysts when properly treated. By extracting the infected primary teeth, opening the cyst and ensuring continuous drainage, it is possible to achieve spontaneous eruption of the involved permanent teeth into the dental arch even if they are badly dislocated. Simultaneous with the eruption of the permanent teeth, ossification of the bony defect can take place. The reparatory process is completed in one to two years.     

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。     

Spontaneous regression of bilateral dentigerous cysts: a case report

A dentigerous cyst is the most common developmental odontogenic cyst and believed to be slowly progressive in nature.This case report describes an incidental finding of spontaneous regression of bilateral dentigerous cysts associated with lower impacted third molars in a 30-year-old, fully dentate female.Together with three other similar reports, a few possible explanations are postulated and the understanding of natural history of dentigerous cysts is questioned. CLINICAL RELEVANCE: The discovery of a dentigerous cyst in a patient always warrants special attention.This article highlights the fact that surgical treatment is not the only solution for a dentigerous cyst and, in rare cases, conservative management can save the patient from having unnecessary surgery.     

口腔颌面、颈深部及纵隔感染的诊断与处理:附6例分析

目的：探讨口腔颌面部感染引发颈深部及纵隔感染的临床表现、治疗和转归。方法：回顾分析1998～2005年在我科就诊的6例患者，分析其感染来源、相关全身疾病、细菌培养结果、并发症及治疗结果。结果：6例患者中，男4例，女2例，年龄30～82岁，平均年龄47岁。感染来源分别为牙源性感染4例（下颌第三磨牙冠周炎），上呼吸道感染1例，1例原因不明，2例伴有糖尿病。临床主要表现为双侧下颌下、颈部广泛肿胀，脓肿形成，同时伴有胸前区充血、肿胀及脓液渗出。X线及CT检查显示，4例纵隔及胸腔内有脓肿形成。细菌培养结果以杆菌为主。经广泛局部切开引流、胸腔引流及抗生素治疗后，4例痊愈，2例死亡（死亡率33．3％）。结论：口腔颌面、颈深部及纵隔感染死亡率较高：胸部增强CT扫描对早期诊断有很高的价值：一旦确诊，应及早行多部位切开引流和胸腔引流；细菌培养对抗生素应用具有重要指导意义，而支持治疗和多学科协助治疗是成功抢救的关键。     

Primary cilia in the pathogenesis of dentigerous cyst: a new hypothesis based on role of primary cilia in autosomal dominant polycystic kidney disease

Autosomal dominant polycystic kidney disease (ADPKD), an inherited disease, leads to cyst formation in the kidneys. In this condition, the kidneys are grossly enlarged with multiple cysts that result in kidney failure in a majority of individuals. This condition is also associated with cysts in other organs. Recent research has focused on defects in signaling mediated by the primary cilia as the causative factor in ADPKD. Primary cilia are also present in odontogenic epithelium. Dentigerous cyst also is a developmental cyst whose pathogenesis is controversial. Recent studies have shown that loss of Ptch and Shh signaling pathways are involved in the cystogenesis of dentigerous cyst. The Shh signaling pathway is active in the primary cilia. A scanning electron microscopic study of a dentigerous cyst wall in an ADPKD patient showed structures similar to primary cilia. Based on the presentation of a dentigerous cyst in an autosomal dominant polycystic kidney patient and the demonstration of primary cilia like structures on the cyst wall by using a scanning electron microscope, a new hypothesis for the pathogenesis of dentigerous cyst is proposed.