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Silver E, Bial N, Yusupov S. Descending Necrotizing Mediastinitis Resulting From Sialadenitis Without Sialolithiasis. Cureus 2022; 14:e24709. [PMID: 35663683 PMCID: PMC9162483 DOI: 10.7759/cureus.24709] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/02/2022] [Indexed: 11/13/2022] Open
Abstract
Descending necrotizing mediastinitis (DNM) is an uncommon and life-threatening condition that arises from an oropharyngeal infection and descends along the cervical fascial planes into the mediastinum. Without aggressive surgical management, a high mortality rate exists. We report a case of an otherwise healthy 49-year-old male who presented with an abscess formation of the right submandibular gland secondary to sialadenitis without sialolithiasis. Computed tomography revealed fluid collection around the right submandibular gland suggestive of sialadenitis without sialolithiasis with severe inflammation and leftward deviation of the aerodigestive tract. Despite multiple drainages, the infection eventually progressed inferiorly into the mediastinum, resulting in DNM. After multiple takebacks to the operating room for exploration and washout of the neck and chest, intensive care unit management, and aggressive IV antibiotic therapy, the patient eventually had a successful recovery and was discharged home. In this paper, the etiology, anatomy, pathophysiology, and management of DNM are discussed. To our knowledge, this is the first report in the literature of DNM developing from sialadenitis without sialolithiasis in the submandibular gland.
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Ho CY, Chin SC, Chen SL. Management of Descending Necrotizing Mediastinitis, a Severe Complication of Deep Neck Infection, Based on Multidisciplinary Approaches and Departmental Co-Ordination. EAR, NOSE & THROAT JOURNAL 2022:1455613211068575. [PMID: 35023759 DOI: 10.1177/01455613211068575] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
OBJECTIVES Descending necrotizing mediastinitis (DNM) developing after deep neck infection (DNI) is a potentially lethal disease of the mediastinum with a mortality rate as high as 40% prior to the 1990s. No standard treatment protocol is available. Here, we present the outcomes of our multidisciplinary approaches for treating DNM originating from a DNI. METHODS Between June 2016 and July 2021, there were 390 patients with DNIs admitting to our tertiary hospital. A total 21 patients with DNIs complicated with DNM were enrolled. The multidisciplinary approaches included establishment of airway security, appropriate surgery and antibiotics, extracorporeal membrane oxygenation, and intensive care unit management. The clinical variables were analyzed. RESULTS Two patients died and 19 survived (mortality 9.5%). The patients who died had a higher mean C-reactive protein (CRP) level than did those who survived (420.0 ± 110.3 vs 221.8 ± 100.6 mg/L) (P = .038). The most common pathogens were Streptococcus constellatus and Streptococcus anginosus. From 2001 to 2021, the average mortality rate of studies enrolling more than 10 patients was 16.1%. CONCLUSION Multidisciplinary approaches, early comprehensive medical treatment, and co-ordination among departments significantly reduce mortality. Patients with severe inflammation and high CRP levels require intensive and aggressive interventions.
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Affiliation(s)
- Chia-Ying Ho
- Division of Chinese Internal Medicine, Center for Traditional Chinese Medicine, 38014Chang Gung Memorial Hospital, Taoyuan, Taiwan
- School of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Shy-Chyi Chin
- School of Medicine, Chang Gung University, Taoyuan, Taiwan
- Department of Medical Imaging and Intervention, 38014Chang Gung Memorial Hospital, Linkou, Taiwan
| | - Shih-Lung Chen
- School of Medicine, Chang Gung University, Taoyuan, Taiwan
- Department of Otorhinolaryngology and Head and Neck Surgery, 38014Chang Gung Memorial Hospital, Linkou, Taiwan
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Kim Y, Han S, Cho DG, Jung WS, Cho JH. Optimal Airway Management in the Treatment of Descending Necrotizing Mediastinitis Secondary to Deep Neck Infection. J Oral Maxillofac Surg 2021; 80:223-230. [PMID: 34582808 DOI: 10.1016/j.joms.2021.08.159] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2021] [Revised: 08/13/2021] [Accepted: 08/17/2021] [Indexed: 10/20/2022]
Abstract
PURPOSE To review our experiences of descending necrotizing mediastinitis (DNM) secondary to deep neck infection (DNI) and determine appropriate airway management for decreasing mortality and morbidity of patients with DNM. METHODS Medical records of 20 patients (8 women and 12 men) who had been managed for DNM secondary to DNI between March 2006 and December 2019 were analyzed. Diagnosis and extent of infection were confirmed by computed tomography of the neck and chest. The upper airway was closely monitored with a fiberoptic laryngoscope. Complications were evaluated according to various types of airway management in our serial cases. RESULTS Five (25%) out of 20 patients died as a result of septic shock and multiorgan failure. None of these patients died of accidental airway obstruction or airway management mishaps. Keeping short-term orotracheal intubation was safe and adequate after the initial surgery. Early tracheotomy was performed for 4 patients and it was significantly associated with mortality (P = .032). Three patients who underwent late tracheotomy had no mortality. Patients with tracheotomy had longer duration of overall hospital stay than those without tracheotomy. CONCLUSIONS Well-controlled airway management might decrease mortality, hospitalization, and airway complications in patients with DNM secondary to DNI. Keeping orotracheal intubation rather than upfront tracheotomy should be first considered when managing airway along with examination of the upper airway with a fiberoptic laryngoscope.
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Affiliation(s)
- Yoonho Kim
- Resident, Department of Otorhinolaryngology-Head and Neck Surgery, The Catholic University of Korea, Seoul, Republic of Korea
| | - Sungjun Han
- Clinical Assistant Professor, Department of Otorhinolaryngology-Head and Neck Surgery, The Catholic University of Korea, Seoul, Republic of Korea
| | - Deog Gon Cho
- Professor, Department of Thoracic and Cardiovascular Surgery, The Catholic University of Korea, Seoul, Republic of Korea
| | - Won-Sang Jung
- Clinical Associate Professor, Department of Radiology, The Catholic University of Korea, Seoul, Republic of Korea
| | - Jung-Hae Cho
- Assistant Professor, Department of Otorhinolaryngology-Head and Neck Surgery, The Catholic University of Korea, Seoul, Republic of Korea.
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Mediastinitis necrosante descendente: reporte de caso y revisión de la literatura. CIRUGIA CARDIOVASCULAR 2021. [DOI: 10.1016/j.circv.2020.05.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
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Ma C, Zhou L, Zhao JZ, Lin RT, Zhang T, Yu LJ, Shi TY, Wang M. Multidisciplinary treatment of deep neck infection associated with descending necrotizing mediastinitis: a single-centre experience. J Int Med Res 2019; 47:6027-6040. [PMID: 31640429 PMCID: PMC7045650 DOI: 10.1177/0300060519879308] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
Objective Deep neck infection (DNI) associated with descending necrotizing mediastinitis (DNM) is a highly lethal condition. This retrospective review was performed to share our experience performing multidisciplinary management of DNI associated with DNM during a 7-year period. Methods We reviewed 16 patients who had been surgically treated for DNM at Peking Union Medical College Hospital from April 2010 to July 2017. The clinical outcomes were analysed to determine the most appropriate therapeutic strategy. Results Five women and 11 men were included in this study. Their mean age was 54.9 ± 14.3 years. DNM-associated infections most commonly occurred secondary to odontogenic infections (n = 10). Thirteen patients required tracheotomy because of tracheal compression. All patients underwent unilateral or bilateral cervicotomy. Six patients with DNM localized in the upper mediastinal space underwent transcervical mediastinal drainage, while 10 patients with DNM extending to the lower mediastinum were treated by cervicotomy and video-assisted thoracoscopic surgery. Three patients died of multiple organ failure. Conclusion Multidisciplinary treatment can achieve favourable outcomes in >80% of patients with DNM. Early diagnosis, proper airway management, and adequate surgical drainage are crucial for reducing mortality in patients with DNM, and minimally invasive procedures also play an important role.
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Affiliation(s)
- Chao Ma
- Department of Stomatology, Peking Union Medical College Hospital (PUMCH), Chinese Academy of Medical Science (CAMS) and Peking Union Medical College (PUMC), Beijing, China
| | - Lian Zhou
- Department of Stomatology, Peking Union Medical College Hospital (PUMCH), Chinese Academy of Medical Science (CAMS) and Peking Union Medical College (PUMC), Beijing, China
| | - Ji-Zhi Zhao
- Department of Stomatology, Peking Union Medical College Hospital (PUMCH), Chinese Academy of Medical Science (CAMS) and Peking Union Medical College (PUMC), Beijing, China
| | - Run-Tai Lin
- Department of Stomatology, Peking Union Medical College Hospital (PUMCH), Chinese Academy of Medical Science (CAMS) and Peking Union Medical College (PUMC), Beijing, China
| | - Tao Zhang
- Department of Stomatology, Peking Union Medical College Hospital (PUMCH), Chinese Academy of Medical Science (CAMS) and Peking Union Medical College (PUMC), Beijing, China
| | - Li-Jiang Yu
- Department of Stomatology, Peking Union Medical College Hospital (PUMCH), Chinese Academy of Medical Science (CAMS) and Peking Union Medical College (PUMC), Beijing, China
| | - Tian-Yin Shi
- Department of Stomatology, Peking Union Medical College Hospital (PUMCH), Chinese Academy of Medical Science (CAMS) and Peking Union Medical College (PUMC), Beijing, China
| | - Mu Wang
- Department of Stomatology, Peking Union Medical College Hospital (PUMCH), Chinese Academy of Medical Science (CAMS) and Peking Union Medical College (PUMC), Beijing, China
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Abstract
Infection of the neck is a relatively common emergency department complaint. If not diagnosed and managed promptly, it may quickly progress to a life-threatening infection. These infections can result in true airway emergencies that may require fiberoptic or surgical airways. This article covers common, as well as rare but emergent, presentations and uses an evidence-based approach to discuss diagnostic and treatment modalities.
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Affiliation(s)
- Renjie Michael Li
- Department of Emergency Medicine, Loma Linda University Medical Center, 11234 Anderson Street MC A-108, Loma Linda, CA 92354, USA
| | - Michael Kiemeney
- Department of Emergency Medicine, Loma Linda University School of Medicine, 11234 Anderson Street MC A-108, Loma Linda, CA 92354, USA.
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Abstract
BACKGROUND Descending necrotizing mediastinitis (DNM) originates from odontogenic or oropharyngeal infections which spread along preformed cervicothoracic spaces into the mediastinum and requires emergency multidisciplinary treatment. MATERIAL AND METHODS A total of seven patients were diagnosed with DNM based on typical radiological features in a cervicothoracic computed tomography (CT) scan and subsequently underwent standardized transcervical and open transthoracic radical debridement. RESULTS The initially detected polymicrobial spectrum of pathogens was dominated by streptococci followed by enterobacteriae. After calculated antibiotic treatment a shift in the spectrum of pathogens was noted and in particular a mycotic superinfection occurred in 43 % of the cases. Anterolateral thoracotomy was performed for radical removal of tissue necrosis and mediastinothoracic drainage extending to the posterior mediastinum was placed. In selected cases, cervico-mediastino-thoracic tubes were transmediastinally placed by the rendevouz technique either in the previsceral or retrovisceral mediastinal space. Despite predominantly advanced mediastinitis (Endo classification type II B) in this patient cohort, the mortality only reached 14 %. CONCLUSION Rapid diagnosis, anatomical knowledge, understanding of the progression of infections as well as critical care, antimicrobial treatment and multidisciplinary radical surgical therapy are paramount for successful treatment of DNM. We favor anterolateral thoracotomy as the standard open transthoracic approach to the mediastinum. Placement of cervico-mediastino-thoracic irrigation drains can help to limit DNM.
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Putra MA, Romolo H, Syafina AB, Sani AA, Wuryantoro, Wardoyo S, Susanti DS. Descending necrotizing mediastinitis: Management and controversies. ACTA ACUST UNITED AC 2016. [DOI: 10.1177/2055552016672997] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background: Descending necrotizing mediastinitis has been known to be a life-threatening condition. It is most likely to be lethal without a prompt diagnosis and aggressive surgical management. In the surgical management of this subset of mediastinitis, a debate remains as to whether a transthoracic incision should be mandatory in addition to cervical approach. Methods: This is a single-center retrospective study performed at Cipto Mangunkusumo Hospital from January 2012 to June 2014. Patients with descending necrotizing mediastinitis were treated with broad-spectrum antibiotics and with cervical and transthoracic approach (via sternotomy) surgical debridement. Results: There were 16 consecutive cases of descending necrotizing mediastinitis. One patient did not undergo sternotomy and was ruled out from the study. The mean intensive care unit stay was 26.4 days, with a mean hospital stay of 46.7 days. There were three mortality cases reported and a total of three cases that needed reoperation. There was neither post-operative sternal dehiscence nor osteomyelitis found. Conclusion: Considering there are no post-operative sternal-related infection reported in this study, sternotomy should be considered as an access in descending necrotizing mediastinitis management. In the three mortality cases reported, two patients came with preoperative sepsis and one had iatrogenic subclavian artery injury.
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Affiliation(s)
- Muhammad Arza Putra
- Thoracic, Cardiac, and Vascular Surgery Division, Department of Surgery, Rumah Sakit Cipto Mangunkusumo (RSCM), DKI Jakarta, Indonesia
- Faculty of Medicine, Universitas Indonesia, Jakarta, Indonesia
| | - Harvey Romolo
- Faculty of Medicine, Universitas Indonesia, Jakarta, Indonesia
| | | | | | - Wuryantoro
- Thoracic, Cardiac, and Vascular Surgery Division, Department of Surgery, Rumah Sakit Cipto Mangunkusumo (RSCM), DKI Jakarta, Indonesia
- Faculty of Medicine, Universitas Indonesia, Jakarta, Indonesia
| | - Suprayitno Wardoyo
- Thoracic, Cardiac, and Vascular Surgery Division, Department of Surgery, Rumah Sakit Cipto Mangunkusumo (RSCM), DKI Jakarta, Indonesia
- Faculty of Medicine, Universitas Indonesia, Jakarta, Indonesia
| | - Dhama Shinta Susanti
- Thoracic, Cardiac, and Vascular Surgery Division, Department of Surgery, Rumah Sakit Cipto Mangunkusumo (RSCM), DKI Jakarta, Indonesia
- Faculty of Medicine, Universitas Indonesia, Jakarta, Indonesia
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Panda NK, Mann SB, Sharma SC. Mediastinitis following deep neck infections : A therapeutic challenge. Indian J Otolaryngol Head Neck Surg 2012; 52:391-5. [PMID: 23119735 DOI: 10.1007/bf02991489] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
OBJECTIVE To emphasize the salient features of surgical management of Mediastinitis occurring secondary to deep neck infections. STUDY DESIGN Case series. Retrospective analysis SETTING Institutional teaching department Patients Four consecutive cases of mediastinal abscess treated between 1990 to 1996. Selection criteria were presence of deep neck infection radiological evidence of widening of mediastinum and confirmation of mediastinal infection at surgery. Computerized tomography of neck and thorax was done in one case to document the extent of abscess. SARGICAL MANAGEMENT: All the patients underwent transcervical drainage of neck abscess and superior mediastintomy. The involved spaces in the neck and mediastinum were irrigated with betadine antimicrobial solution and negative suction drains put in the superior mediastinum ta facilitate contituous drainage of the mediastinum. One patient required intercostal chest drainage for associated empyema. Tracheotomy was done in all the patients. RESULTS All the patients survived and discharged after a hospital stay of around three weeks. CONCLUSIONS Mediastinal complication of deep neck infections can he alarmingly rapid and can be effectively managed by early recognition and aggressive surgical drainage combined with antibiotic therapy after appropriate aerobic and anaerobic cultures.
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Affiliation(s)
- N K Panda
- Department of Otolaryngology, Postgraduate Institute of Medical Education and Research, Chandigarh, (India)
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Yoshii Y, Shimizu K, Watanabe S, Takagi M, Kuwano K. [A case of descending necrotizing mediastinitis caused by infection with Streptococcus agalactiae in a patient with diabetes mellitus]. KANSENSHOGAKU ZASSHI. THE JOURNAL OF THE JAPANESE ASSOCIATION FOR INFECTIOUS DISEASES 2012; 86:768-772. [PMID: 23367853 DOI: 10.11150/kansenshogakuzasshi.86.768] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/01/2023]
Abstract
We report a case with an atypical presentation of descending necrotizing mediastinitis (DNM). A 47-year-old woman with a medical history of untreated type 2 diabetes mellitus and influenza type A virus infection 2 weeks prior to admission was referred to our hospital complaining of right cervical pain and right upper limb swelling. A chest enhanced computed tomographic (CT) scan showed a ring-enhanced mass-like shadow extending from the right sternomastoid muscle down to the right upper mediastinum, compressing the right subclavicular vein. We diagnosed the patient as having DNM based on a physical examination and the CT findings. Because the abscess extended from deep in the neck to the upper mediastinum and right upper pleural space, emergent abscess debridement and drainage was required. After hospitalization, antibiotics (Ampicillin/Sulbactam 12 g/day) were also administered based on Gram-stain findings from the drainage fluid, which showed Gram-positive cocci resembling a string of beads. A culture of the drainage fluid identified Streptococcus agalactiae. Aggressive abscess drainage and early antibiotic therapy resulted in a favorable response. She was discharged without complications on the 33rd hospital day. DNM is well known as a rare but lethal disease. In this case, the presence of diabetes mellitus and post-influenza infection might have been risk factors for a serious S. agalactiae infection. Early aggressive therapy and adequate drainage are recommended for patients with DNM.
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Affiliation(s)
- Yutaka Yoshii
- Department of Respiratory Medicine, The Jikei University Kashiwa Hospital
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Katabathina VS, Restrepo CS, Martinez-Jimenez S, Riascos RF. Nonvascular, nontraumatic mediastinal emergencies in adults: a comprehensive review of imaging findings. Radiographics 2012; 31:1141-60. [PMID: 21768244 DOI: 10.1148/rg.314105177] [Citation(s) in RCA: 46] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Given their high frequency, mediastinal emergencies are often perceived as being a result of external trauma or vascular conditions. However, there is a group of nonvascular, nontraumatic mediastinal emergencies that are less common in clinical practice, are less recognized, and that represent an important source of morbidity and mortality in patients. Nonvascular, nontraumatic mediastinal emergencies have several causes and result from different pathophysiologic mechanisms including infection, internal trauma, malignancy, and postoperative complications, and some may be idiopathic. Some conditions that lead to nonvascular, nontraumatic mediastinal emergencies include acute mediastinitis; esophageal emergencies such as intramural hematoma of the esophagus, Boerhaave syndrome, and acquired esophagorespiratory fistulas; spontaneous mediastinal hematoma; tension pneumomediastinum; and tension pneumopericardium. Although clinical findings of nonvascular, nontraumatic mediastinal emergencies may be nonspecific, imaging findings are often definitive. Awareness of various nonvascular, nontraumatic mediastinal emergencies and their clinical manifestations and imaging findings is crucial for making an accurate and timely diagnosis to facilitate appropriate patient management.
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Affiliation(s)
- Venkata S Katabathina
- Department of Radiology, University of Texas Health Science Center, San Antonio, TX 78229, USA.
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Sandner A, Börgermann J. Update on necrotizing mediastinitis: causes, approaches to management, and outcomes. Curr Infect Dis Rep 2011; 13:278-86. [PMID: 21369879 DOI: 10.1007/s11908-011-0174-z] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
Descending necrotizing mediastinitis (DNM) is one of the most feared and fatal forms of mediastinitis, occurring as a complication after odontogenic or cervicofascial infections or after cervical trauma. Delayed recognition, underestimation of the extent of disease, and insufficient therapy promote spread of infection. Primary treatment of DNM includes surgical eradication of the pharyngeal or odontogenic infection focus, and a concomitant major drainage applied to the neck and the mediastinum. However, the mortality rate of DNM remains high, even with the routine use of CT scanning, antibiotics, advancements in anesthesia and intensive care, and immediate surgical drainage. The present state of the optimal management of DNM is discussed controversially, in particular the question of whether thoracotomy should be performed routinely or if minimally invasive procedures (eg, video-assisted thoracoscopy) may be introduced. This review reports on the incidence and course of this disease and discusses management approaches to DNM.
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Affiliation(s)
- Annett Sandner
- Department of Otorhinolaryngology, Head and Neck Surgery, Martin Luther University Halle-Wittenberg, Magdeburger Strasse 12, 06097, Halle/Saale, Germany,
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Hsu RF, Wu PY, Ho CK. Transcervical drainage for descending necrotizing mediastinitis may be sufficient. Otolaryngol Head Neck Surg 2011; 145:742-7. [PMID: 21521889 DOI: 10.1177/0194599811406064] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
OBJECTIVE Descending necrotizing mediastinitis (DNM) is a serious form of mediastinitis with a high mortality rate. It is caused by the downward spread of an oropharyngeal or cervicofascial infection. The optimal surgical approach for this often fatal disease is controversial. This article describes the authors' experience and characterizes the surgical strategies and treatment outcomes of patients with DNM. STUDY DESIGN Case series with chart review. SETTING A tertiary referral medical center. SUBJECTS AND METHODS This study conducted a retrospective chart review of patients with deep neck infections treated at a medical center from 1994 to 2007 and identified 29 patients with DNM. The clinical characteristics and outcomes were compared between patients treated with transcervical drainage alone (group I) and those with both cervical and thoracic drainage (group II). RESULTS There were 20 patients in group I and 9 patients in group II. The overall mortality rate was 10.3%. The mean duration of the hospital stay was 29.3 ± 15.5 days. There was no statistically significant difference in age, sex distribution, or duration from the appearance of symptoms to hospital admission between the 2 groups. The duration of hospital stay, tracheotomy rate, and mortality rate also did not differ significantly between the 2 groups. However, the numbers of surgeries were significantly higher in group II than in group I. CONCLUSION Transthoracic mediastinal drainage is not a compulsory therapy, but timely, aggressive, transcervical mediastinal drainage with extensive debridement is very important for a good outcome when treating DNM patients.
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Affiliation(s)
- Ruey-Fen Hsu
- Department of Otolaryngology, E-DA Hospital, I-Shou University, Kaohsiung, Taiwan, ROC
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Descending necrotizing mediastinitis of odontogenic origin--personal experience and literature review. Folia Med (Plovdiv) 2010; 52:13-20. [PMID: 21053669 DOI: 10.2478/v10153-010-0002-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
UNLABELLED Descending necrotizing mediastinitis is the most severe form of mediastinal infection. The aim of the study was to present the optimal diagnostic and treatment approach to this severe, life-threatening condition. PATIENTS AND METHODS Three patients (men, aged 75, 73, and 63) with descending necrotizing mediastinitis hospitalised between April 2007 and February 2009 have been included in the study. The diagnosis of the condition was made based on cervico-thoracic computed tomography and surgical findings. The surgical treatment in each of the cases included bilateral longitudinal cervicotomy, transversal suprasternal cervicotomy and posterior-lateral thoracotomy. RESULTS The period between the initiation of ambulatory treatment of the dental infection and diagnosing the mediastinitis was 9, 8 and 11 days, respectively. Engagement of all cervical spaces and mediastinal sections with polybacterial (three or more agents) dental infection, originating from third and fourth lower molars was present in each of the patients. Chronic alcoholism and diabetes are factors influencing the course of mediastinitis. The outcome in all the three patients was lethal (within 72 hours). CONCLUSION Success in the treatment of descending necrotic mediastinitis of odontogenic origin may be expected only in case of early diagnose and aggressive cervical and mediastinal drainage, performed by bilateral longitudinal cervicotomy and posterior-lateral thoracotomy.
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Methicillin Resistant Staphylococcus Aureus Infection in Descending Necrotizing Mediastinitis From Retropharyngeal Perforation. J Wound Ostomy Continence Nurs 2010; 37:209-13. [DOI: 10.1097/won.0b013e3181d0feea] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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Sokouti M, Nezafati S. Descending necrotizing mediastinitis of oropharyngeal infections. J Dent Res Dent Clin Dent Prospects 2009; 3:82-5. [PMID: 23230490 PMCID: PMC3517278 DOI: 10.5681/joddd.2009.021] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2009] [Accepted: 07/14/2009] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND AND AIMS Descending necrotizing mediastinitis (DNM) is a rare and life-threatening infection. Management of this condition is very difficult and before 1990s, DNM had a mortality rate of 40% despite the use of antibiotics. One of the etiologies of this condition is rapid downward spread of oropharyngeal infection along the cervical fascia planes into the medi-astinum. MATERIALS AND METHODS Patients with DNM from odontogenic, peritonsillar and retropharyngeal origins, who underwent surgical treatment from 1990 to 2007, were reviewed. Data extracted from medical records of the patients included age, gender, origin of the infection, surgical approaches, and the cause of mortality. Descriptive data were expressed as a Mean ± SE. RESULTS Thirteen patients aged 15 to 56 (mean, 34.5 years old; 8 males and 5 females) were studied. The origins of infection included odontogenic abscess in 10 cases and peritonsillar and retropharyngeal abscess in 3 patients. The mean duration from onset of symptoms to the surgery was 12.18 ± 0.98 days (range 3 to 24 days) and the mean duration from initial surgery to dis-charges was 28.51 ± 3.25 days (range 5 to 92 days). Post-operative mortality was seen in three patients. CONCLUSION Descending necrotizing mediastinitis can arise from odontogenic abscesses and must be detected as early as possible, as it is a life-threatening infection.
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Affiliation(s)
- Mohsen Sokouti
- Associate Professor, Department of Thoracic Surgery, Faculty of Medicine and Imam Reza Hospital, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Saeed Nezafati
- Assistant Professor, Department of Oral and Maxillofacial Surgery, Faculty of Dentistry, Tabriz University of Medical Sciences, Tabriz, Iran
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Scaglione M, Pezzullo MG, Pinto A, Sica G, Bocchini G, Rotondo A. Usefulness of Multidetector Row Computed Tomography in the Assessment of the Pathways of Spreading of Neck Infections to the Mediastinum. Semin Ultrasound CT MR 2009; 30:221-30. [DOI: 10.1053/j.sult.2009.02.009] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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Lemierre Syndrome and Descending Necrotizing Mediastinitis Following Dental Extraction. J Oral Maxillofac Surg 2008; 66:1720-5. [DOI: 10.1016/j.joms.2007.12.002] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2007] [Revised: 09/17/2007] [Accepted: 12/01/2007] [Indexed: 11/18/2022]
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Chen KC, Chen JS, Kuo SW, Huang PM, Hsu HH, Lee JM, Lee YC. Descending necrotizing mediastinitis: a 10-year surgical experience in a single institution. J Thorac Cardiovasc Surg 2008; 136:191-8. [PMID: 18603075 DOI: 10.1016/j.jtcvs.2008.01.009] [Citation(s) in RCA: 59] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/24/2007] [Revised: 01/02/2008] [Accepted: 01/05/2008] [Indexed: 11/17/2022]
Abstract
OBJECTIVE Early diagnosis and aggressive surgical drainage are very important for successful treatment of descending necrotizing mediastinitis. However, the surgical techniques used for this condition remain controversial. We report our 10-year experience of managing this devastating disease, focusing on the multidisciplinary, minimally invasive operative procedures and the unique bacteriologic factors in Taiwan. METHODS Between January 1997 and January 2007, we retrospectively reviewed 18 patients with descending necrotizing mediastinitis who were treated in the National Taiwan University Hospital. Diagnosis and Endo classification were confirmed by computed tomography of the neck and chest. RESULTS Eight women and 10 men were included in this study. The mean age was 57.8 +/- 15.2 years. Cervical drainage was performed in the involved area in all patients. The methods for mediastinal drainage included transcervical (n = 10), video-assisted thoracic surgical drainage (n = 6), subxiphoid drainage (n = 1), and mediastinoscopy-assisted drainage (n = 1). We could not rescue 3 patients because of uncontrolled sepsis before surgery, for a mortality rate of 16.7%. Klebsiella pneumoniae uniquely represents the most common pathogen in diabetic patients (P = .01), leading to more complicated courses in older patients (P =.04) and requiring more surgical interventions (P =.05) than other pathogens. CONCLUSION Transcervical mediastinal drainage is first justified in patients with limited disease in the upper mediastinum. For those with involvement of the lower anterior mediastinum, an additional subxiphoid approach is suggested. Cervicotomy with video-assisted mediastinal drainage is an excellent combination for involvement of the posterior mediastinum and pleural space. Klebsiella pneumoniae uniquely represents the most important and threatening causative pathogen for diabetic patients with descending necrotizing mediastinitis.
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Affiliation(s)
- Ke-Cheng Chen
- Department of Surgery, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei, Taiwan
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Pinto A, Scaglione M, Scuderi MG, Tortora G, Daniele S, Romano L. Infections of the neck leading to descending necrotizing mediastinitis: Role of multi-detector row computed tomography. Eur J Radiol 2008; 65:389-94. [DOI: 10.1016/j.ejrad.2007.09.024] [Citation(s) in RCA: 44] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2007] [Revised: 09/07/2007] [Accepted: 09/08/2007] [Indexed: 12/01/2022]
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Righini CA, Motto E, Ferretti G, Boubagra K, Soriano E, Reyt E. [Diffuse cervical cellulites and descending necrotizing mediastinitis]. ACTA ACUST UNITED AC 2008; 124:292-300. [PMID: 17689483 DOI: 10.1016/j.aorl.2007.02.001] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2006] [Accepted: 02/01/2007] [Indexed: 11/18/2022]
Abstract
OBJECTIVES To give a report on the progress in physical examination, investigations and treatment of diffuse cervical cellulites (DCC) associated with descending necrotizing mediastinitis. MATERIALS AND METHODS A Retrospective study (1995-2005) of patients presenting DCC with mediastinitis was made. All had a cervical and thoracic Computed tomography (CT) scan. The references were collected by a Medline search. RESULTS Six men and 2 women, average ages 53 years were treated. Four had an immunodeficient status. Two had had an anti-inflammatory drug treatment without antibiotic treatment. The average for diagnosis and treatment was 4 days. In 2 cases we found a dental origin and in 6 cases a pharyngeal origin. The most frequently identified germs were streptococcus beta haemolytic group A and Prevotella. In 4 cases, no physical sign of mediastinitis was noted. The diagnosis of mediastinitis was made thanks to the thoracic CT scan. All the patients were treated by broad-spectrum antibiotic therapy. All had cervical and thoracic surgical drainage. Mediastinal drainage was made by cervical way in 3 cases and by thoracotomy in 5 cases. One patient died. CONCLUSIONS The DCC with mediastinum extension are serious infectious emergencies with a high mortality rate. Clinical diagnosis of mediastinitis is difficult. A thoracic CT scan should be performed systematically. Performing thoracotomy best controls mediastinal drainage.
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Affiliation(s)
- C-A Righini
- Service d'ORL et de chirurgie cervicofaciale, CHU A.-Michallon, 38043 Grenoble cedex 09, France.
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Siemers F, Strüber M, Mailänder P, Berger A, Machens HG. Descending necrotising mediastinitis--an unknown complication in burn patient. Burns 2007; 34:1044-6. [PMID: 17949914 DOI: 10.1016/j.burns.2007.06.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2007] [Accepted: 06/24/2007] [Indexed: 10/21/2022]
Affiliation(s)
- Frank Siemers
- Plastic Surgery, Handsurgery, Burn Unit, University Hospital Schleswig Holstein, Campus Lübeck, Ratzeburger Allee 160, 23538 Lübeck, Germany.
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Sandner A, Börgermann J, Kösling S, Silber RE, Bloching MB. Descending necrotizing mediastinitis: early detection and radical surgery are crucial. J Oral Maxillofac Surg 2007; 65:794-800. [PMID: 17368383 DOI: 10.1016/j.joms.2005.11.075] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2005] [Accepted: 11/01/2005] [Indexed: 10/23/2022]
Affiliation(s)
- Annett Sandner
- Department of Otorhinolaryngology, Head and Neck Surgery, Martin Luther University, Halle Wittenberg, Halle, Germany.
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Gorlitzer M, Grabenwoeger M, Meinhart J, Swoboda H, Oczenski W, Fiegl N, Waldenberger F. Descending Necrotizing Mediastinitis Treated With Rapid Sternotomy Followed by Vacuum-Assisted Therapy. Ann Thorac Surg 2007; 83:393-6. [PMID: 17257957 DOI: 10.1016/j.athoracsur.2006.09.059] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2006] [Revised: 09/15/2006] [Accepted: 09/18/2006] [Indexed: 12/31/2022]
Abstract
BACKGROUND Descending necrotizing mediastinitis (DNM) is a life-threatening emergency after oropharyngeal infection. The diagnosis must be established rapidly. DNM is associated with septic shock and respiratory insufficiency. Because mortality rates may be as high as 60%, aggressive surgical treatment is indicated. METHODS Between December 2001 and December 2005, 5 patients (3 men, 2 women) with DNM, average age of 69 years (range, 24 to 72 years), were treated at our department. Surgical treatment consisted of one or more cervical drainages and drainage of the mediastinum through sternotomy after mediastinitis had been confirmed by computed tomography. The latter investigation also revealed mediastinal abscess and empyema. After radical debridement, a vacuum-assisted closure device was inserted. RESULTS The outcome was favorable in 4 patients. A 72-year-old woman died of prolonged septic shock and subsequent multiple organ failure. Tracheotomy was performed in all patients to create an airway. The duration of the intensive care unit stay was 51 +/- 24.2 days. CONCLUSIONS Rapid and extensive cervical and mediastinal debridement is mandatory in patients with DNM. A vacuum-assisted closure device is useful because it promotes tissue approximation and stimulates the ingrowth of granulation tissue.
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Affiliation(s)
- Michael Gorlitzer
- Department of Cardiovascular Surgery, Hospital Hietzing, Vienna, Austria.
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Macarrón CPC, Palomino AP, Matute de Cárdenas JA, Villa NS, Fernández LM. Descending necrotizing mediastinitis in a child with chickenpox. J Thorac Cardiovasc Surg 2007; 133:271-2. [PMID: 17198834 DOI: 10.1016/j.jtcvs.2006.09.030] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/20/2006] [Accepted: 09/05/2006] [Indexed: 11/19/2022]
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Sandner A, Börgermann J, Kösling S, Bloching MB. „Descending necrotizing mediastinitis“ infolge tiefer Halsinfektionen. HNO 2006; 54:861-7. [PMID: 16625372 DOI: 10.1007/s00106-006-1396-5] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND "Descending necrotizing mediastinitis" (DNM) is a rare but potentially life-threatening complication of deep neck infections caused by the rapid downward spread of a oropharyngeal infection along the facial planes into the mediastinum. MATERIAL AND METHODS Between June 1997 and December 2004, 6 patients with DNM were treated in our department. The primary etiology was a peritonsillar abscess in 2 cases, a parapharyngeal abscess in 3 cases and in 1 case an odontogenic abscess. Most patients presented with risk factors such as diabetes mellitus or alcoholism, the mean age was 44.3 years and the mean duration of signs before diagnosis was 6.3 days. Thoracotomy was associated with the cervical approach in 4 cases and tracheostomy was also performed in 4 cases. RESULTS Four patients were successfully treated, the mean duration of hospitalisation was 48.2 days and 2 patients died from sepsis and multiorgan failure despite intensive treatment. CONCLUSIONS Descending necrotizing mediastinitis must be detected as soon as possible. The mean symptoms are persistent complaints after treatment of oropharyngeal infections, which may be masked by analgetic treatment. Only an immediate computer tomographic scanning, aggressive surgical drainage and debridement of the neck and the mediastinum can reduce the high mortality rate.
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Affiliation(s)
- A Sandner
- Klinik und Poliklinik für Hals-Nasen-Ohrenheilkunde, Kopf- und Halschirurgie, Martin-Luther-Universität, Halle-Wittenberg.
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Cirino LMI, Elias FM, Almeida JLJD. Descending mediastinitis: a review. SAO PAULO MED J 2006; 124:285-90. [PMID: 17262162 DOI: 10.1590/s1516-31802006000500011] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/26/2005] [Accepted: 08/17/2006] [Indexed: 11/21/2022] Open
Abstract
CONTEXT Mediastinitis is an inflammation of connective tissue that involves mediastinal structures. When the condition has an infectious origin located in the cervical or oral region, it is termed "descending mediastinitis" (DM). DATA SOURCES The subject was examined in the light of the authors' own experiences and by reviewing the literature available on the subject. The Medline, Lilacs and Cochrane databases were searched for articles, without time limits, screening for the term "descending mediastinitis". The languages used were English and Spanish. DATA SYNTHESIS There are three main fascial pathways by which oral or cervical infections can reach the mediastinum: pretracheal, lateropharyngeal and retropharyngeal. About 70% of DM cases occur via the retropharyngeal pathway. The mortality rate is about 50%. According to infection extent, as seen using computed tomography, DM can be classified as focal (type I) or diffuse (type II). The clinical manifestations are nonspecific and resemble other systemic infections or septic conditions. The primary treatment for DM consists of antibiotics and surgical drainage. There are several approaches to treating DM; the choice of approach depends on the DM type and the surgeon's experience. In spite of all the improvements in knowledge of the microbiology and physiopathology of the disease, controversies still exist regarding the ideal duration of antibiotic therapy and whether tracheostomy is really a necessary procedure. CONCLUSION Since DM is a lethal condition if not promptly treated, it must always be considered to represent an emergency situation.
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Affiliation(s)
- Luis Marcelo Inaco Cirino
- Department of Surgery, Hospital Universitário, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil
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Scaglione M, Pinto A, Romano S, Giovine S, Sparano A, Romano L. Determining optimum management of descending necrotizing mediastinitis with CT; experience with 32 cases. Emerg Radiol 2005; 11:275-80. [PMID: 16133621 DOI: 10.1007/s10140-005-0422-3] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2005] [Accepted: 03/18/2005] [Indexed: 10/25/2022]
Abstract
To determine the value of helical computed tomography (CT) in the diagnosis, management and outcome of patients suspected of having descending necrotizing mediastinitis (DNM). Thirty-two patients with suspected DNM were submitted to contrast-enhanced single detector-row helical CT, four detector-row CT and 16 detector-row CT of the neck and chest. In 10/32 patients (group 1) no abnormality was observed in the neck or in the chest spaces on CT scan. These patients were all treated non-operatively. In 12/32 patients (group 2) CT showed the presence in the neck spaces of fluid collections, fasciitis, cellulitis, myositis, jugular vein thrombosis and lymphadenopathy; in all these patients the chest was unaffected. A cervical drainage was performed in ten patients. In the remaining ten patients (group 3), the neck infection involved the mediastinal spaces in all the cases and the pleural and pericardial spaces; CT findings included mediastinal cellulitis and fluid collections, pleural and pericardial effusions, venous thrombosis and lymphadenopathy. In these patients, a cervico-mediastinal drainage was performed and antibiotics were administered. The CT provides a highly accurate depiction of the presence and the spread of DNM. The CT findings and the extension of disease are important factors in order to predict for patient management and outcome.
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Affiliation(s)
- Mariano Scaglione
- Emergency and Trauma CT Section, Department of Radiology, Cardarelli Hospital, Via Cardarelli 9, 80131, Naples, Italy.
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Successful Conservative Treatment of Descending Necrotizing Mediastinitis With Fistula Formation in the Hypopharynx. INFECTIOUS DISEASES IN CLINICAL PRACTICE 2005. [DOI: 10.1097/01.idc.0000152478.00791.d5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Mora R, Jankowska B, Catrambone U, Passali GC, Mora F, Leoncini G, Passali FM, Barbieri M. Descending Necrotizing Mediastinitis: Ten Years’ Experience. EAR, NOSE & THROAT JOURNAL 2004. [DOI: 10.1177/014556130408301116] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Descending necrotizing mediastinitis is a rare disease that is usually caused by a spreading, diffuse inflammatory reaction (phlegmon) to an odontogenic infection or peritonsillar abscess. Reported mortality rates range from 25 to 40%. The use of antibiotics and advances in resuscitation procedures and critical care techniques have not essentially improved survival, and an effective treatment has not been clearly established. We report the findings of our 10-year study of 21 patients affected by phlegmon and/or fasciitis of the neck. The aim of our contribution is to help define the clinical criteria and diagnostic procedures that will improve the early diagnosis of mediastinal sepsis secondary to neck fasciitis and to suggest optimal treatment approaches. Our experience indicates that (1) cervical drainage alone is sufficient for cases of cervical phlegmon or mediastinal involvement that are limited to a single superior mediastinal space and (2) thoracotomy and drainage of mediastinal collections is necessary when mediastinal sepsis is more extensive.
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Affiliation(s)
- Renzo Mora
- ENT Department, University of Genoa, Italy
| | | | - Ugo Catrambone
- Regional Division of Thoracic Surgery, San Martino Hospital, Genoa
| | | | | | - Giacomo Leoncini
- Regional Division of Thoracic Surgery, San Martino Hospital, Genoa
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Biasotto M, Pellis T, Cadenaro M, Bevilacqua L, Berlot G, Di Lenarda R. Odontogenic infections and descending necrotising mediastinitis: case report and review of the literature. Int Dent J 2004; 54:97-102. [PMID: 15119800 DOI: 10.1111/j.1875-595x.2004.tb00262.x] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
Descending necrotising mediastinitis is a rare complication secondary to oral surgery or odontogenic infections which ultimately spreads to the mediastinum through the anatomical cervical spaces. Delay in diagnosis, despite broad-spectrum antimicrobical therapy and extensive surgical intervention, results in an unacceptably high mortality rate (almost to 40%). A case study is presented as a rationale for a review of the current literature and to analyse the evolution in therapies, both medical and surgical from Pearse in 1938 to today.
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Makeieff M, Gresillon N, Berthet JP, Garrel R, Crampette L, Marty-Ane C, Guerrier B. Management of descending necrotizing mediastinitis. Laryngoscope 2004; 114:772-5. [PMID: 15064640 DOI: 10.1097/00005537-200404000-00035] [Citation(s) in RCA: 81] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
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%.
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Affiliation(s)
- Marc Makeieff
- Otolaryngology Head and Neck Surgery Department, Gui de Chauliac Hospital, University of Medicine, Montpellier, France.
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Chang KJ, Chen WJ, Chen SY, Tsai KC, Yuan A. Descending necrotizing mediastinitis from upper respiratory infection. Am J Emerg Med 2004; 22:125-6. [PMID: 15011233 DOI: 10.1016/j.ajem.2003.12.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022] Open
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Mediastinum. Surgery 2001. [DOI: 10.1007/978-3-642-57282-1_58] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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de Dios García-Díaz J, Sanz Moreno J, Martínez Arrieta F, Daguerre Tolou M. [Descending necrotizing mediastinitis of uncertain origin]. Rev Clin Esp 2000; 200:290-1. [PMID: 10901013 DOI: 10.1016/s0014-2565(00)70635-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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Sakamoto H, Aoki T, Kise Y, Watanabe D, Sasaki J. Descending necrotizing mediastinitis due to odontogenic infections. ORAL SURGERY, ORAL MEDICINE, ORAL PATHOLOGY, ORAL RADIOLOGY, AND ENDODONTICS 2000; 89:412-9. [PMID: 10760723 DOI: 10.1016/s1079-2104(00)70121-1] [Citation(s) in RCA: 51] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
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.
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Affiliation(s)
- H Sakamoto
- Tokai University, Department of Oral Surgery, School of Medicine, Kanagawa, Japan
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Tsunoda R, Suda S, Fukaya T, Saito K. Descending necrotizing mediastinitis caused by an odontogenic infection: a case report. J Oral Maxillofac Surg 2000; 58:240-2. [PMID: 10670608 DOI: 10.1016/s0278-2391(00)90348-3] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Affiliation(s)
- R Tsunoda
- Kanto Teishin Hospital, Department of Otolaryngology, Tokyo, Japan
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Freeman RK, Vallières E, Verrier ED, Karmy-Jones R, Wood DE. Descending necrotizing mediastinitis: An analysis of the effects of serial surgical debridement on patient mortality. J Thorac Cardiovasc Surg 2000; 119:260-7. [PMID: 10649201 DOI: 10.1016/s0022-5223(00)70181-4] [Citation(s) in RCA: 119] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES Descending necrotizing mediastinitis is a polymicrobial infection originating in the oropharynx with previously reported mortality rates of 25% to 40%. This investigation reviews the effects of serial surgical drainage and debridement on the survival of patients with descending necrotizing mediastinitis. METHODS A retrospective review of patients from 1980 through 1998 with a diagnosis of descending necrotizing mediastinitis was performed. Their records were abstracted for personal demographics, hospital course, morbidity, and mortality. Also abstracted were all reports of patients with descending necrotizing mediastinitis published in English between 1970 and 1999. RESULTS We treated 10 patients in whom descending necrotizing mediastinitis was identified. The mean age of the patients was 38 years. They underwent a mean of 6 +/- 4 computed tomographic imaging studies, 4 +/- 1 transcervical drainage procedures, and 2 +/- 1 transthoracic drainage procedures. Three patients required abdominal exploration and 4 underwent tracheostomy. No deaths occurred. In contrast, 96 patients with descending necrotizing mediastinitis were identified from the literature with a mean age of 38 years. They underwent a mean of 2 +/- 1 computed tomographic imaging studies, 2 +/- 1 transcervical drainage procedures, and 0.7 + 0.3 transthoracic drainage procedures. Sixteen (17%) patients required abdominal exploration and 34 (35%) underwent tracheostomy. Twenty-eight (29%) patients from the literature cohort died during their treatment. CONCLUSION Descending necrotizing mediastinitis remains a life-threatening infection. On the basis of experience accrued in treating these patients, an algorithm incorporating computed tomographic imaging for diagnosis and surveillance and serial transcervical and transthoracic operative drainage is outlined in the hope of reducing the excessive mortality of descending necrotizing mediastinitis.
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Affiliation(s)
- R K Freeman
- Division of Cardiothoracic Surgery, University of Washington Medical Center, Seattle, WA 98195-6310, USA
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Marty-Ané CH, Berthet JP, Alric P, Pegis JD, Rouvière P, Mary H. Management of descending necrotizing mediastinitis: an aggressive treatment for an aggressive disease. Ann Thorac Surg 1999; 68:212-7. [PMID: 10421143 DOI: 10.1016/s0003-4975(99)00453-1] [Citation(s) in RCA: 103] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
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.
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Affiliation(s)
- C H Marty-Ané
- Service de Chirurgie Thoracique et Vasculaire, Hôpital Arnaud de Villeneuve, Montpellier, France
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Kiernan PD, Hernandez A, Byrne WD, Bloom R, Dicicco B, Hetrick V, Graling P, Vaughan B. Descending cervical mediastinitis. Ann Thorac Surg 1998; 65:1483-8. [PMID: 9594903 DOI: 10.1016/s0003-4975(98)00142-8] [Citation(s) in RCA: 88] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Descending cervical mediastinitis is an uncommonly reported presentation of infection originating in the head or neck and descending into the mediastinum, which is fraught with impressive morbidity and mortality rates of 30% to 40% or more. We present the INOVA-Fairfax-Alexandria Hospital experience with descending cervical mediastinitis, January 1, 1986, to April 1, 1997; in addition we review the English-language medical and surgical literature with regard to this entity. Computed tomography and magnetic resonance imaging serve to aid both diagnosis and management. The application of broad-spectrum antibiotics should initially be empiric, with an eye to coverage of mixed aerobic and anaerobic infections. Definitive treatment mandates early and aggressive surgical intervention. All affected tissue planes, cervical and mediastinal, must be widely debrided, often leaving them open for frequent packing and irrigation. The treating physician must remain always alert to the further extension of infection, which, if it occurs, must be further debrided and drained. Tracheostomy serves a dual role of further opening cervical fascial planes and securing an often compromised airway.
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Affiliation(s)
- P D Kiernan
- Section of Thoracic Surgery, INOVA Health Systems, Annandale, Virginia, USA
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