Management of descending necrotizing mediastinitis

OBJECTIVE/HYPOTHESIS: Descending necrotizing mediastinitis is caused by downward spread of neck infections and constitutes a highly lethal complication of oropharyngeal lesions. This infection previously had a much worse prognosis. In recent years, more aggressive management has been recommended. The aim of this study is to evaluate the results with the association of thoracotomy and cervicotomy, medical care in an intensive care unit, and daily washing of drained cervical and thoracic tissues. STUDY DESIGN: Retrospective study of 17 patients treated from 1984 to 1998. METHOD: Descending necrotizing mediastinitis was consecutive to pharyngitis (6 cases), peritonsillar abscess (3 cases), dental abscess (6 cases), foreign body infection (1 case), and laryngitis (1 case). Corticotherapy was reported in seven cases. Twelve patients had no particular medical history. Mean age was 42 years. Mean duration of signs before diagnosis was 6 days. Thoracotomy was associated with the cervical approach in 14 cases, whereas 3 patients were treated by cervicotomy only. RESULTS: Fourteen patients of 17 (82.3%) were successfully treated. Three deaths occurred. The mean duration of hospitalization in the intensive care unit was 30 days, and the mean total duration of hospitalization was 45 days. CONCLUSION: Descending necrotizing mediastinitis must be detected as soon as possible by computed tomography (CT) scanning in patients with persistent symptomatologia after treatment for oropharyngeal infections. Prompt surgical drainage with thoracotomy and cervicotomy in all cases of mediastinal involvement below the tracheal carena, use of CT scanning to monitor the disease evolution, and medical management in an intensive care unit significantly reduces the mortality rate to less than 20%.     

颈性下行性纵隔脓肿15例分析

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Severe sepsis as a complication of descending necrotizing mediastinitis due to a peritonsillar abscess. A case study

Descending necrotic mediastinitis is a serious illness which, among others, follows acute bacterial infections located in a cervical area. One of the most frequent causes of this illness, not connected with surgical interventions, is a peritonsillar and peridental abscess. The process originally placed in the peritonsillar area spreads along the cervical fascia engulfs mediastinum. Inflammatory process of the mediastinum considerably worsens the prognosis and obligates to decisive surgical (mediastinum drainage) and pharmacological (antibiotic therapy) treatments. The following works presents the course of the illness of a 55-year-old man who was diagnosed with severe sepsis in the course of the peritonsillar abscess. After surgical provision of the abscess (incision) the patient was qualified for the therapy with activated protein C (Xigris, Lilly). The patient condition initially improved, however, after 8 days a descending necrotic mediastinitis with ambilateral pleural abscess was diagnosed. The administration of the treatment within 48 days of hospitalization (antibiotic therapy, thoracotomy, flow drainage of the mediastinum, tracheotomy, respirotherapy) brought about the effect of complete recovery.     

Descending cervical mediastinitis: the multidisciplinary surgical approach

European Archives of Oto-Rhino-Laryngology - Descending cervical mediastinitis (DCM) is defined as spread of oropharyngeal or odontogenic infection into the mediastinum. It occurs uncommonly and...     

Descending cervical mediastinitis: report of 15 cases]

OBJECTIVE: To analyze the cause, diagnosis and treatment of descending cervical mediastinitis. METHODS: Fifteen cases of descending cervical mediastinitis, which were treated from January 1985 to December 1997, were retrospectively reviewed. There were 10 males and 5 females, ranging in age from 2.5 to 82 years. RESULTS: The cause of descending cervical mediastinitis included odontogenic infection, suppurative tonsillitis, suppurative otitis media (cholesteatoma) complicating Mouret abscess, pharyngeal injury by foreign body and esophageal perforation. Different ways of drainage were adopted. Twelve cases were cured and three died. CONCLUSION: The key to successful management of descending cervical mediastinitis is early recognition, prompt and effective surgical drainage and appropriate antibiotics.     

Clinical features of 5 patients with descending necrotizing mediastinitis originating from deep neck infection

Descending necrotizing mediastinitis originating from deep neck infection is one of the most serious diseases in the head and neck region. Delayed diagnosis leads to death. We examined 5 cases of descending necrotizing mediastinitis, successfully treated with antibiotics and surgical drainage. Abscess was found in the lower part of the anterior mediastinum in 3 cases and the posterior mediastinum in 2 cases. We first conducted transcervical mediastinal drainage for 3 cases, however, thoracotomy was eventually required in all cases. For cases of abscess in the lower part of the anterior mediastinum, early and aggressive surgical drainage in collaboration with thoracic surgeons is very important and can improve survival.     

Tonsillitis to mediastinitis

Parapharyngeal abscess secondary to quinsy is a well understood complication; however, its incidence has significantly declined following early use of effective antibiotics. Tracking of infection from the parapharyngeal space through the anatomical planes to cause mediastinitis has a significant mortality rate and requires early detection and aggressive management. A case of quinsy leading to mediastinitis, pericarditis and pleural effusions is presented. It highlights the potentially life-threatening complications of a commonly encountered ENT problem.     

Supraglottitis complicated by mediastinitis

A rare case of supraglottitis complicated by mediastinitis is presented. Despite aggressive treatment with broadspectrum intravenous antibiotics, the patient persisted to have generalized supraglottitis. Subsequent computed tomography (CT) scanning revealed that she had developed a frank fluid collection starting at the suprasternal notch, extending retrosternally into the superior mediastinum. She recovered with conservative management and did not require aggressive mediastinal drainage as advocated by the literature.     

Retrospective study of 200 cases of nasopharyngeal carcinoma

Nasopharyngeal carcinoma is frequently diagnosed in advanced stages due to the anatomic characteristics of its site of origin and of the inspecificity of many of its clinical manifestations. However, cure rates are directly related with the early diagnosis. In this study of 200 patients affected by this tumor we analyse the different clinical manifestations, their chronology and their value as early indicators of nasopharyngeal tumour.     

Secondary superior mediastinitis in otorhinolaryngology

The factors responsible for superior mediastinitis are described in 12 patients with inflammatory pathologies of ENT-organs, with emphasis on the anatomical-topographic characteristics of the neck and mediastinum subcutaneous spaces. Clinical symptoms typical of anterior and posterior superior mediastinitis are summarized. Procedures of emergency treatment of secondary superior mediastinitis are described. It is emphasized that the first thing to be done is to treat areas of primary inflammation and thus to prevent infection propagation in the mediastinum. It is recommended to open the mediastinum as soon as possible and to drain it actively. It is also recommended to include reinfusion with autoblood of patients exposed to UV irradiation to the combined therapeutic protocols.     

Retrospective study and review of polymorphous low-grade adenocarcinoma

OBJECTIVES/HYPOTHESIS: We review a single institution's experience with polymorphous low-grade adenocarcinoma. To our knowledge, this is the largest patient series of polymorphous low-grade adenocarcinoma with clinical follow-up in the otolaryngology literature. STUDY DESIGN: We retrospectively identified 19 patients with polymorphous low-grade adenocarcinoma who had adequate clinical follow-up and pathologic specimens available for examination. METHODS: All pathologic materials were reviewed by one head and neck pathologist. RESULTS: The median follow-up was 9.6 years. The most frequently affected sites were the hard palate (12 patients) and soft palate (9 patients). Fifteen patients had their initial treatment at our institution, and four patients presented with a recurrent tumor. Five patients had a local recurrence after surgery; of those patients, two had initially presented with recurrent tumors. Local tumors recurred as late as 15 years after the initial surgery. One patient had regional nodal disease 20 years after the initial procedure, and another had lung metastasis. No patients received chemotherapy. The most common initial diagnoses were polymorphous low-grade adenocarcinoma, adenoid cystic carcinoma, and pleomorphic adenoma. CONCLUSIONS: Polymorphous low-grade adenocarcinoma is an increasingly recognized malignancy that originates predominantly in the minor salivary gland. Our experience confirms good local control after a wide local excision is performed, but local recurrences can occur despite having negative margins after surgery. The delayed local recurrences and regional nodal metastases noted in our series show that prolonged follow-up is needed. This series also reports one of the first pathologically confirmed cases of distant metastasis.     

颌骨放射性骨坏死93例治疗分析

目的 分析颌骨放射性骨坏死的临床特点及治疗方法,为临床诊治该疾病提供参考.方法 对2000-2010年北京大学口腔医院口腔颌面外科收治的93例颌骨放射性骨坏死患者病历资料进行回顾性分析.66例患者接受1个疗程放疗,放疗剂量34～90Gy,平均64.6 Gy,其中22例在骨坏死症状暴露前有拔牙或牙槽外科手术等创伤刺激.末次放疗与症状暴露间隔时间为放疗后2周至33年,平均间隔54个月.病变发生于下颌骨79例,上颌骨13例,上下颌骨均有累及1例.结果 56例患者行颌骨切除术并行游离组织瓣修复,49例手术成功,7例术后出现血管危象,其中3例进行血管危象探查,并重新吻合血管皮瓣成活,2例去除皮岛及血管蒂改行游离骨移植并成活,2例行皮瓣摘除直接拉拢缝合.56例患者术后1例坏死复发,53例术后咀嚼、吞咽等功能恢复良好,2例颌骨切除患者仅行钛板修复,术后均出现钛板外露.20例行刮治术,9例术后坏死复发.15例行颌骨切除术后未作修复,2例坏死复发,余术后咀嚼、吞咽等功能均较差.结论 颌骨放射性骨坏死一般发生于下颌骨,手术治疗主张颌骨切除并行游离组织瓣修复,应慎行刮治术及单纯钛板修复.     

Retrospective study of complications of surgery for laryngeal cancer

Surgery, alone or in combination with other therapeutic measures, is one of the main approaches to curing laryngeal cancer. The risk of complications is implicit in any surgical procedure. We describe our experience with general and local complications in surgery for laryngeal cancer and examine their relation to tumor extension and surgical technique. A review was made of a series of 431 patients who underwent surgery for laryngeal cancer over a 10-year period (1982-1991). Twenty-two patients (5.1%) had systemic complications, including upper gastrointestinal hemorrhage (n = 5), massive cervical hemorrhage (n = 5), and four renal failure. Minor complications were recorded in 77 cases (17.8%), predominantly pharyngocutaneous salivary fistula, which developed in 55 patients (13.8%). The incidence of local complications was significantly greater in patients with extensive local spread (T4). There were no differences among patients with regional spread. The surgical technique and type of pharyngoesophageal reconstruction played no role in the development of complications. Preoperative radiotherapy did not influence on the development of salivary fistulas.