Infections of the neck leading to descending necrotizing mediastinitis: Role of multi-detector row computed tomography

Descending necrotizing mediastinitis is an acute, polymicrobial infection of the mediastinum, originating from odontogenic, oropharyngeal and cervical infections. Anatomical continuity of the fascial spaces between the neck and the mediastinum leads to an occasional mediastinal extension of deep neck infection as a serious sequela. An understanding of the anatomy of the deep spaces of the neck and familiarity with the imaging findings in descending necrotizing mediastinitis may allow rapid diagnosis and treatment of this rare and life-threatening complication of deep neck space infection. In this article, we discuss the current role of radiology in diagnosing descending necrotizing mediastinitis, in determining the level of infection and the pathways of spread of infections from the neck to the mediastinum and in planning a successful treatment.     

Frühtracheotomie nach medianer Sternotomie

Zusammenfassung Die Tracheotomie, insbesondere die Dilatationstracheotomie bietet Vorteile bei der Therapie langzeitbeatmeter Patienten. Trotzdem gibt es bei herzchirurgischen Patienten Vorbehalte gegen diese Therapie aufgrund der Befürchtungen, das Risiko einer Mediastinitis dadurch zu erhöhen.Wir untersuchten die Daten unserer Patienten über einen 3–Jahreszeitraum hinsichtlich durchgeführter Tracheotomien und gegebenenfalls daraus entstandenen Komplikationen.Von Januar 2002 bis Dezember 2004 wurden 2556 Patienten mittels medianer Sternotomie operiert. 62 (2,8%) davon wurden in den ersten 14 Tagen nach der Operation tracheotomiert (58 Dilatationstracheotomie, 4 konventionell).Eine Mediastinitis trat bei den tracheotomierten Patienten einmal (1,6%) gegenüber 32 (1,25%) bei den nichttracheotomierten Patienten auf (p = n.s.).Somit kommt es auch bei herzchirurgischen Patienten, die in den ersten 2 Wochen nach Sternotomie tracheotomiert werden, zu keiner höheren Inzidenz an Sternuminfektionen.     

Redo total aortic arch replacement using an extended homograft for graft infection

A 65-year-old man developed graft infection 3 years after total aortic arch replacement for a chronic dissecting aneurysm. Redo total aortic arch replacement was performed using an extended homograft following 2 days of open drainage of the mediastinum. The patient has been free from a recurrent mediastinitis over the last 3 years.     

Cervical necrotizing fasciitis: Report of 6 cases and review of literature

ObjectiveNecrotizing fasciitis in the cervical region is a rare entity, characterized by a fulminant infection that causes extensive necrosis of the subcutaneous tissue and fascial planes, with high mortality and morbidity rates. The origin is generally odontogenic or pharyngeal, involving a mixed flora of microorganisms. Descending infection and mediastinal involvement are usually associated and are the main complications. The aim of the present study was to review the cases treated in our department and analyze diagnosis and treatment, supplementing the understanding of the disease.MethodsA retrospective study was performed on the clinical records of patients admitted to our center between January 2005 and June 2010 with diagnosis of necrotizing cervical fasciitis.ResultsSix clinical records were reviewed. The origin of the infection was mainly oropharyngeal and odontogenic, with a mixed flora of Prevotella, Peptostreptococcus and coagulase-negative Staphylococcus. All patients presented mediastinal involvement: superior mediastinitis in 4 patients and superior and postero-inferior mediastinitis in 2 cases. All patients underwent early drainage by bilateral cervicotomy with mediastinal drainage by a cervical approach in those with superior mediastinal affection, and associated thoracotomy, in a single surgical step, for postero-inferior mediastinitis. Temporary tracheotomy was performed in all cases. All received broad spectrum antibiotics, with a medium hospital stay of 37 days. There were no deaths reported.ConclusionConcerning cervical necrotizing fasciitis, early diagnosis and surgical treatment associated to antibiotics and intensive medical care are essential to obtain a favorable outcome.     

Spontaneous pharyngoesophageal perforations

We report a case of spontaneous multiple perforations of pharyngoesophagus presenting with odynophagia and chest pain. Computed tomography identified a deep neck infection with necrotizing mediastinitis, and esophagography showed leakage of contrast from the pharyngeal wall, pyriform sinus, and thoracic esophagus. Empiric antibiotics, adequate debridement, and resection of the ruptured esophagus with reconstruction were required for complete resolution of the patient's symptoms. Although the simultaneous multiple perforations involving pharyngoesophagus are rare, clinicians should not neglect its possible occurrence.     

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.