Guideline of surgical management based on diffusion of descending necrotizing mediastinitis.

BACKGROUND: Descending necrotizing mediastinitis resulting from oropharyngeal abscess, is a serious, life-threatening infection. Exisiting strategies for surgical management, such as transcervical mediastinal drainage or aggressive thoracotomic drainage, remain controversial. METHODS: Four patients, (three males and one female) were treated for descending necrotizing mediastinitis resulting from oropharyngeal infection. Two had peritonsillar abscesses, while the others experienced dental abscess and submaxillaritis. Descending necrotizing mediastinitis received its classification according to the degree of diffusion of infection diagnosed by computed tomography. Mediastinitis in two cases, (Localized descending necrotizing mediastinitis-Type I), was localized to the upper mediastinal space above the carina. In the others, infection extended to the lower anterior mediastinum (Diffuse descending necrotizing mediastinitis-Type IIA), and to both anterior and posterior lower mediastinum (Diffuse descending necrotizing mediastinitis-Type IIB). The spread of infection to the pleural cavity occurred in three cases. RESULTS: The surgical outcome concerning each of the patients was successful. Radical cervicotomy (unilateral in three patients, bilateral in the other) in conjunction with mechanical ventilation with continuous postoperative positive airway pressure, was performed in all cases. Tracheostomy was established in three patients and pharyngostomy in two. The two descending necrotizing mediastinitis-Type I cases were successfully managed with transcervical mediastinal drainage. The descending necrotizing mediastinitis-Type IIA case received treatment through transcervicotomy and anterior mediastinal drainage through a subxiphoidal incision. The patient with descending necrotizing mediastinitis-Type IIB required posterior mediastinal drainage through a right standard thoracotomy followed by left minimal thoracotomy. CONCLUSIONS: The mediastinal infection, the extent of which has been accurately determined by computed tomograms, necessitates radical cervicotomy followed by pleuromediastinal drainage. Situations where infection has spread to posterior medisatinum, particularly when it reaches in the level of the carina (descending necrotizing mediastinitis-type I), may not always require aggressive mediastinal drainage. In comparison, diffuse descending necrotizing mediastinitis-Type IIB demands complete mediastinal drainage with debridement via thoracotomy. Subxiphoidal mediastinal drainage without sternotomy may provide adequate drainage in diffuse descending necrotizing mediastinitis-Type IIA.     

Management of descending necrotizing mediastinitis: an aggressive treatment for an aggressive disease.

BACKGROUND: Descending necrotizing mediastinitis represent a virulent form of mediastinal infection requiring prompt diagnosis and treatment to reduce the high mortality associated with this disease. Surgical management and a particularly optimal form of mediastinal drainage remain controversial. METHODS: Over a 10-year period, 12 patients were treated at our institution. Surgical treatment consisted of 1 or several cervical drainages, associated with drainage of the mediastinum through a thoracic approach in 11 patients. Thoracic procedures included radical surgical debridement of the mediastinum with complete excision of the tissue necrosis, decortication, and pleural drainage with adequate placement of chest tubes for mediastinopleural irrigation. Transcervical mediastinal drainage was performed in only 1 patient. RESULTS: The outcome was favorable in 10 patients, 9 of whom had mediastinal drainage through thoracotomy. Two patients were initially drained through a minor thoracic approach; the first died of tracheal fistula and the second required new drainage through a thoracotomy. The patient who had transcervical mediastinal drainage without a thoracic approach presented an abscess limited to the anterior and superior mediastinum. In 3 patients, ongoing mediastinal sepsis required a second thoracotomy. CONCLUSION: A stepwise approach with transcervical mediastinal drainage is first justified in patients with very limited disease to the upper mediastinum. However, ongoing mediastinal sepsis requires new drainage, through a major thoracic approach, without delay. Extensive mediastinitis can not be adequately treated without mediastinal drainage including a thoracotomy. This aggressive surgical policy has allowed us to maintain a low mortality rate (16.5%) in a series of 12 patients with this highly lethal disease.     

Descending necrotizing mediastinitis: a retrospective surgical experience.

OBJECTIVE: Descending necrotizing mediastinitis (DNM) is a primary complication of cervical or odontogenical infections that can spread to the mediastinum through the anatomic cervical spaces. We reviewed the last 10 years of our surgical experience in DNM and commented on early diagnosis and aggressive surgical treatment in these patients. METHODS: Five males (71%) and two females (29%), mean age 34 years, with DNM, were surgically treated. Primary oropharyngeal infection occurred in three (43%) and odontogenic abscess in four (57%) patients. All had serious cervical and mediastinal infections with severe respiratory and hemodynamic repercussions, i.e. bacteremia, systemic arterial hypotension and obnubilation. Diagnosis was confirmed by computerized chest tomography. RESULTS: All patients underwent surgical drainage of the cervical region by bilateral transverse cervicotomy with debridement of the necrotic and infected tissues, associating ample mediastinal drainage with or without thoracotomy. Six patients (86%) evolved well and were discharged after a mean of 35 days. Two patients (29%) required reoperation due to local surgical complications: empyema and dehiscence of the sternum. One patient (14%) died on the second postoperative (p.o.) day due to renal and respiratory insufficiency. Cultures of DNM showed the development of associated aerobic and anaerobic flora in 71% of the operated patients and only aerobic in 29%. CONCLUSION: Early diagnosis by CAT scan of the neck and thorax aids in rapid indication of a surgical approach of DNM. Performing ample cervicotomy with mediastinal drainage generally associated with thoracotomy can significantly reduce the mortality rate for this condition to 14%.     

Two cases of descending necrotizing mediastinitis

Descending necrotizing mediastinitis (DNM) is relatively rare inflammatory lesion with high mortality unless an appropriate surgical treatment is undertaken. Recently we successfully treated two surgical cases of DNM. In both cases, the disease started with pharyngeal abscess, and the mediastinal swelling followed. The surgery consisted with neck drainage and the mediastinal drainage through thoracotomy at the same time. A continuous mediastinal irrigation was performed postoperatively, and both patients recovered well. Immediate drainage of the primary lesion and the mediastinum is important once the diagnosis of DNM is established.     

Successfully treated descending necrotizing mediastinitis through thoracotomy using a pedicled muscular serratus anterior flap

Descending necrotizing mediastinitis (DNM) is rare and aggressive. A 68-year-old female with no medical history, was admitted to our institution for cervical cellulitis. After a conventional medical treatment, multiple abscesses of the upper mediastinum appeared on computed tomography (CT) findings. Although two cervicotomies were performed, a new necrotic abscess appeared in the anterior upper and middle mediastinum. An extensive debridement of cellulitis and abscess extended to the pericardium was made by thoracotomy. Middle mediastinum and pericardium were covered and reconstructed by a right pedicled serratus anterior flap. After radical surgery, follow-up was uneventful. Early extensive and complete debridement of cervical and mediastinal collections and irrigation with broad-spectrum intravenous antibiotics is essential. Combined surgery is the best approach in DNM. The use of a pedicled muscular flap helps control the sepsis. In such cases, serratus anterior flap is a flap of choice because it is reliable and always available even in a skinny patient, contrary to omentum. In this life-threatening disease, an early aggressive combined surgery with debridement of all necrotic tissues extended to the pericardium if necessary associated with a pedicled flap is mandatory.     

Guideline of surgical management based on diffusion of descending necrotizing mediastinitis

Background: Descending necrotizing mediastinitis resulting from oropharyngeal abscess, is a serious, life-threatening infection. Exisiting strategies for surgical management, such as transcervical mediastinal drainage or aggressive thoracotomic drainage, remain controversial.Methods: Four patients, (three males and one female) were treated for descending necrotizing mediastinitis resulting from oropharyngeal infection. Two had peritonsillar abscesses, while the others experienced dental abscess and submaxillaritis. Descending necrotizing mediastinitis received its classification according to the degree of diffusion of infection diagnosed by computed tomography. Mediastinitis in two cases, (Localized descending necrotizing mediastinitis-Type I), was localized to the upper mediastinal space above the carina. In the others, infection extended to the lower anterior mediastinum (Diffuse descending necrotizing mediastinitis-Type IIA), and to both anterior and posterior lower mediastinum (Diffuse descending necrotizing mediastinitis-Type IIB). The spread of infection to the pleural cavity occurred in three cases.Results: The surgical outcome concerning each of the patients was successful. Radical cervicotomy (unilateral in three patients, bilateral in the other) in conjunction with mechanical ventilation with continuous postoperative positive airway pressure, was performed in all cases. Tracheostomy was established in three patients and pharyngostomy in two. The two descending necrotizing mediastinitis-Type I cases were successfully managed with transcervical mediastinal drainage. The descending necrotizing mediastinitis-Type IIA case received treatment through transcervicotomy and anterior mediastinal drainage through a subxiphoidal incision. The patient with descending necrotizing mediastinitis-Type IIB required posterior mediastinal drainage through a right standard thoracotomy followed by left minimal thoracotomy.Conclusions: The mediastinal infection, the extent of which has been accurately determined by computed tomograms, necessitates radical cervicotomy followed by pleuromediastinal drainage. Situations where infection has spread to posterior mediastinum, particularly when it reaches in the level of the carina (descending necrotizing mediastinitis-type I), may not always require aggressive mediastinal drainage. In comparison, diffuse descending necrotizing mediastinitis-Type IIB demands complete mediastinal drainage with debridement via thoracotomy. Subxiphoidal mediastinal drainage without sternotomy may provide adequate drainage in diffuse descending necrotizing mediastinitis-Type IIA.     

Descending necrotizing mediastinitis. Diagnosis and surgical treatment

AIM: Descending necrotizing mediastinitis (DNM) is an unusual and severe disease with a high mortality rate. Surgical management remains controversial. Our investigations reviews the most effective surgical treatment in the management of this rare pathology. METHODS: Seven patients with DNM and treated over a 20-year period are reported. All patients were evaluated according to the classification suggested by Endo et al. of the degree of mediastinal diffusion, based on CT scan findings. Five patients underwent combined cervical drainage and thoracotomy, 2 patients were treated with cervical drainage alone. RESULTS: The outcome was favorable in 5 patients, 4 treated with a combined cervical and thoracic approach and 1 with a cervical approach alone. Two patients that underwent a combinated cervical and thoracic approach alone, died of septic shock. Overall mortality rate was 28.5%. CONCLUSION: Early diagnosis and early, aggressive surgical treatment are required to improve the poor prognosis of DNM. Although a unique surgical management is still not completely accepted, we state, in agreement with other authors, a wide approach consisting of a cervical drainage and mediastinotomy in case of upper mediastinitis and a combined cervical and thoracic approach in case of lower mediastinitis. In the course of thoracotomy a wide excision of necrotic and particularly fat mediastinal tissue is needed, to avoid a recurrent infection. A continuous cervico-mediastinal irrigation system is suggested during the postoperative period.     

A case of an elderly patient treated for descending necrotizing mediastinitis

We report a case of descending necrotizing mediastinitis (DNM). DNM is a serious infection, and preventing death requires early diagnosis and draining of the infection focus. An 84-year-old man was admitted to our hospital complaining of a swollen neck and pain when swallowing. He had had a tooth extracted at a neighboring dental clinic 2 days previously. Cervicothoracic computed tomography (CT) scan demonstrated gas bubbles and unencapsulated abscesses in the cervical spaces and anterosuperior and posterior mediastinum, extending below the carina. He was diagnosed as DNM caused by odontogenic infection. Cervical drainage was performed, in addition to mediastinal drainage using video-assisted thoracic surgery (VATS). Complications were sepsis, disseminated intravascular coagulation (DIC), and heart failure after surgery, but he recovered following intensive care. This was a lifesaving case of DNM for which mediastinal drainage was performed with VATS.     

Descending necrotizing mediastinitis treated by mediastinal drainage through bilateral thorax; report of a case

Descending necrotizing mediastinitis is a severe infection spreading from the cervical region to the mediastinal connective tissue. The mortality rate was high and appropriate treatment is necessary to obtain favorable results. The present study describes a case of a 69-year-old man with severe descending necrotizing mediastinitis due to parapharyngeal abscess. The patient was successfully treated with cervical drainage, surgical debridement of the mediastinum via small thoracotomy. Postoperatively, continuous mediastinal and pleural irrigation with saline was performed. Swallowing disturbance due to dissection of cervical muscles prolonged duration of hospital stay. Eventually, the patient recovered and was able to eat by muscle rehabilitation.     

Surgical treatment for patients with descending necrotizing mediastinitis

Descending necrotizing mediastinitis (DNM) originating from deep cervical infection is a rare and serious clinical condition with a high mortality rate. Clinical feature of 5 patients undergone surgical drainage for DNM, between 2006 and 2009 were assessed. There were 3 male and 2 female patients whose age ranged from 57 to 83 years old (mean 69.8). All 5 patients had no underlying disease except for 1 patient with severe dental caries. The primary infections of these patients were tonsillitis and pharyngitis. The mean duration from onset of symptom to the referral to our hospital was 14 days (ranged 2 to approximately 41). Two patients underwent cervical drainage for upper mediastinum, and 3 patients were required mediastinal drainage by thoracotomy. There was no post-operative death. Early and aggressive surgical drainage of the neck and mediastinum by a multidisciplinary team of surgeons is very important in the treatment of DNM.     

Successful video-thoracoscopic drainage for descending necrotizing mediastinitis

Descending necrotizing mediastinitis (DNM) is a rare but severe disease with a high mortality rate. We report a case of a 77-year-old woman with DNM who was treated using video-thoracoscopic drainage and a Blake drain. She was admitted to our hospital with a 3-day history of a sore throat. Computed tomography (CT) revealed a peritonsillar abscess descending into the anterior and posterior mediastinum below the carina. She was diagnosed with DNM, and emergency surgery was performed. The mediastinal abscess was drained via video-thoracoscopy, and a 24F Blake drain was inserted into the mediastinum. Following mediastinal drainage, cervical drainage was performed for treatment of the retropharyngeal abscess. The outcome of videothoracoscopic mediastinal drainage was satisfactory, and no further invasive treatment was required. We believe that video-thoracoscopic mediastinal drainage is an effective, minimally invasive treatment for DNM with subcarinal spread. Blake drains are useful for mediastinal drainage.     

Descending necrotizing mediastinitis: surgical management.

OBJECTIVE: Descending necrotizing mediastinitis (DNM) is a primary complication of cervical or odontogenical infections that can spread to the mediastinum through the anatomic cervical spaces. METHODS: Between April 1994 and April 2000, 13 patients, mean age 39.23+/-18.47 (median 38, range 16-67) years, with DNM were submitted to surgical treatment. Primary odontogenic abscess occurred in six, peritonsillar abscess in five and post-traumatic cervical abscess in two patients. Diagnosis was confirmed by computed tomography (CT) of the neck and chest. All patients underwent surgical drainage of the cervico-mediastinal regions by a bilateral collar incision associated with right thoracotomy in ten cases. RESULTS: Six patients out of 13 required reoperation. Two patients previously submitted only to cervical drainage required thoracotomy; four patients, which have been submitted to cervico-thoracic drainage, underwent contralateral thoracotomy in two cases and ipsilateral reoperation in two cases. Ten patients evolved well and were discharged without major sequelae; three patients died of multiorgan failure related to septic shock. Mortality rate was 23%. CONCLUSION: Early diagnosis by CT of the neck and chest suggest a rapid indication of surgical approach to DNM. Ample cervicotomy associated with mediastinal drainage via large thoracotomic incision is essential in managing these critically ill patients and can significantly reduce the mortality rate for this condition, often affecting young people, to acceptable values.     

Descending necrotising mediastinitis: report of two cases

Descending necrotising mediastinitis is a severe infection spreading from the cervical region to the mediastinal connective tissue. It represents a virulent form of mediastinal infection, requiring prompt diagnosis and treatment to reduce the high mortality associated. An optimal debridement and drainage through an open thoracotomy access are the keys for a successful outcome. Two patients, males, 70 and 75-years-old with descending necrotising mediastinitis were treated in our Institution in April '05. One had an odontogenic abscess and the other had a retropharyngeal abscess. Operative procedures included thoracotomy with radical surgical debridement of the mediastinum and excision of necrotic tissue associated with transcervical surgical debridement and drainage. Postoperatively mediastinum-pleural and cervical irrigation with iodopovidone 2 per thousand was performed until a culture of pleural effusion become negative. Postoperatively both patients suffered from severe complication including septic shock and acute respiratory distress syndrome. The 70-years-old patient had an acute renal failure too. Postoperatively the length of the intensive care unit stay was 40 and 42 days, respectively. The outcome was favorable in both patients. Early detection and immediate open surgical treatment could be the best way to reduce morbidity and mortality rate. Descending Necrotising Mediastinitis cannot be adequately treated without mediastinal and cervical excision of necrotic tissue and drainage including an open thoracic and cervical approach.     

Successful treatment for descending necrotizing mediastinitis with severe thoracic emphysema using video-assisted thoracoscopic surgery

Descending necrotizing mediastinitis (DNM) is a rare, highly fatal disease that occurs as a complication of a cervical or odontogenic infection spreading into the mediastinum. We herein report of a 50-year-old man with DNM and severe thoracic emphysema who was successfully treated using surgical drainage by videoassisted thoracoscopic surgery (VATS) and a transcervical approach. Chest enhanced computed tomography on admission revealed massive left pleural effusion, pneumothorax, absolute collapse of the left lung, and a mediastinal shift to the right side with emphysema. We urgently performed left thoracic and mediastinal drainage using VATS. Retropharyngeal and upper mediastinal drainage was performed transcervically on the third hospital day. He recovered and was discharged on hospital day 57. Surgical drainage is the most important therapy in the treatment of DNM, but there is no standard surgical approach. We believe that VATS is a less invasive, effective modality for draining the posterior mediastinum.     

Descending necrotizing mediastinitis: a case report and review of the literature

Descending necrotizing mediastinitis (DNM) is a highly fatal disease and as infection spreads along deep cervical planes into the mediastinum, widespread cellulitis, necrosis, abscess formation, and sepsis may occur. Early diagnosis is crucial for starting aggressive treatment without delay. Cervicothoracic computed tomography (CT) scanning may be useful for early diagnosis and preoperative evaluation of the surgical approach. Optimal treatment includes broad-spectrum antimicrobial therapy and extensive cervicomediastinal and transthoracic drainage. Clamshell incision provides an excellent exposure of both thoracic cavities and all mediastinal structures with minimal morbidity. We report here a fatal case of DNM with bilateral empyema and purulent pericarditis due to an odontogenic abscess with a brief review of the literature.     

Successful thoracoscopic debridement of descending necrotizing mediastinitis

Descending necrotizing mediastinitis results from odontogenic, deep neck infection that spreads along fascial planes into the mediastinum. Although the optimal surgical approach remains controversial, nearly half of the cases require mediastinal debridement by thoracotomy. We report a case of successful thoracoscopic debridement for descending necrotizing mediastinitis due to odontogenic infection that failed to be drained by transcervical approach. Because of less invasiveness as compared with standard thoracotomy, the thoracoscopic approach should be used as early as possible in case of unsuccessful transcervical approach.     

Successful treatment for descending necrotizing mediastinitis: a case report

A 21-year-old female was admitted to our hospital because of high fever, neck swelling, and dyspnea. She was diagnosed as descending necrotizing mediastinitis (DNM) extended from odontogenic infection. On the day of admission, she underwent cervical drainage. Next day, the CT scan showed an abscess below the tracheal bifurcation and bilateral pleural effusion. Mediastinal drainage was performed through a right thoracotomy, and a left thoracic tube was inserted. Anaerobic Peptostreptococcus was found with bacteriological culture. After the mediastinal drainage, bilateral thoracic irrigation was performed through the thoracic tubes. Left thoracic tube was removed on the 8th day and right one was removed on the 20th day after the thoracotomy. She was discharged on the 42nd day. DNM is relatively rare, but it is lethal disease with high mortality. Immediate and sufficient mediastinal drainage is indispensable for the disease.     

Early open thoracotomy and mediastinopleural irrigation for severe descending necrotizing mediastinitis.

OBJECTIVE: Descending necrotizing mediastinitis (DNM) is a severe infection spreading from the cervical region to the mediastinal connective tissue. The mortality rate was reported as 40% until the 1980s. Since DNM is uncommon, few reports of large series of patients with DNM (i.e. more than 10 cases) have been published. The present aim was to evaluate our treatment strategy for DNM by retrospective chart review. METHODS: Retrospective chart review was performed in 10 patients with DNM between 1991 and 2003. The mean age was 53.8+/-23.3 years (median 58, range 16-82). The causes of DNM were primary peritonsillar or parapharyngeal abscess in 5 patients, post-extraction odontogenic abscess in 3, cervical abscess of post-tracheostomy in 1, and unknown in 1 patient. In nine cases, the abscess extended from the cervical region to the lower mediastinum. Immediately after the diagnosis of DNM, broad-spectrum antibiotics were administered empirically, and surgical treatments consisting of cervical drainage, thoracotomy with radical surgical debridement of the mediastinum and excision of necrotic tissue, decortication, and irrigation were performed in all cases. Post-operatively, mediastinopleural irrigation with saline was performed once or twice a day until a culture of pleural effusion became negative. RESULTS: The mean duration of chest tube retention was 26.7+/-17.0 days, and the mean hospital stay was 62.3+/-33.9 days. Five patients suffered from severe complications including septic shock, acute respiratory distress syndrome, disseminated intravascular coagulation, and pan-peritonitis due to duodenal perforation. The outcome was favorable in 8 patients. Of those with severe complications, two patients, who were older than 75 and had diabetes, died of multiple organ failure due to septic shock. Therefore, the mortality rate was 20%. CONCLUSION: Our treatment strategy for severe DNM was efficacious for early treatment and reduced the mortality rate. Early detection of DNM, and immediate thoracotomy and irrigation of the mediastinum and thoracic cavity, are recommended.     

Descending necrotizing mediastinitis: treatment of a delayed case

Descending necrotizing mediastinitis (DNM) is a severe and rare infection that can spread to the mediastinum through the anatomic cervical spaces, secondary to cervical or odontogenical infections. Delay of diagnosis and insufficient drainage always result in high mortality. We present a case of DNM with bilaterally pulmonary infiltration in a 45-year old woman. The cause of DNM was postextraction odontogenic abscess and delay of diagnosis which resulted in sepsis. Surgical treatment was performed as soon as possible in following sequence: cervical mediastinotomy, right thoracotomy, and pleural and mediastinal irrigation with saline. Although the diagnosis was delayed, invasive surgical interventions allowed successful eradication of the injection.     

Therapie der akuten Mediastinitis

Despite modern intensive care management, acute mediastinitis is still associated with a high morbidity and mortality (up to approximately 40?%). Effective antibiotic therapy, intensive care management, elimination of the causative sources of infection and drainage of the affected mediastinal compartments are the cornerstones of therapy in a multidisciplinary treatment concept. Early diagnosis, prompt and uncompromising initial therapy and planned computed tomography (CT) control after the first stages of therapy in order to decide on the necessity for surgical re-interventions are essential for achieving optimal results. Knowledge of the specific anatomical characteristics is crucial for the understanding of this disease and its treatment; therefore, the current knowledge on fascial layers and interstitial spaces from the neck to the mediastinum is described and discussed. A possible foudroyant spread of the infection, especially within the posterior mediastinum, has to be anticipated. The approach to the mediastinum depends on the mediastinal compartments affected, on the causative disease and on the patient’s clinical situation. The surgical approach should be adapted to the particular clinical situation of the individual patient and to the surgical experience of the surgeon. When in doubt, the more invasive approach to the mediastinum, such as bilateral thoracotomy, is recommended. An ascending mediastinitis due to pancreatitis is a very rare condition; however, as chest pains are often the main clinical sign surgeons should be aware of this differential diagnosis. An intraoperative brown-black serous fluid in the mediastinal tissue is virtually pathognomonic. The treatment results of esophageal perforation as the most frequent cause of mediastinitis have been improved by integration of various interventional procedures. Hyperbaric oxygen therapy or immunoglobulin treatment can play an auxiliary role in selected patients with acute mediastinitis.