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Nagaoka M, Motegi M. Exclusive Transcervical Drainage for Posterior Mediastinal Abscess Originating from a Mandibular Molar. J Craniofac Surg 2024:00001665-990000000-01445. [PMID: 38597603 DOI: 10.1097/scs.0000000000010094] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2022] [Accepted: 02/16/2024] [Indexed: 04/11/2024] Open
Abstract
The progression of a cervical abscess toward the mediastinum is rare but remains one of the most serious diseases, even in the era of antibiotics. A mediastinal abscess can originate from an odontogenic infection and presents a challenge for otolaryngologists and craniofacial surgeons, particularly when it spreads caudally to the tracheal bifurcation. For successful treatment of such an abscess, patients are generally referred to a thoracic surgeon for drainage. We present a distinctive case of an odontogenic infection-induced wide mediastinal abscess that could be drained only through cervical manipulation by using a sump-type tube. The patient was discharged on postoperative day 55 without any complications. This is the first report showing that descending mediastinal abscesses extending below the tracheal bifurcation could be drained by head and neck surgeons alone. The technique is easy and hence reproducible, safe, and convenient to perform.
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Affiliation(s)
- Masato Nagaoka
- Department of Otorhinolaryngology, The Jikei University School of Medicine, Minato-Ku, Tokyo, Japan
| | - Masaomi Motegi
- Department of Otorhinolaryngology-Head and Neck Surgery, Gunma University Graduate School of Medicine, Maebashi, Gunma, Japan
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Yamamoto H, Isogai J. Transient constrictive pericarditis following coxsackievirus A4 infection as a rare cause of acute mediastinitis: A case report. Heliyon 2023; 9:e19555. [PMID: 37809423 PMCID: PMC10558803 DOI: 10.1016/j.heliyon.2023.e19555] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2023] [Revised: 08/08/2023] [Accepted: 08/25/2023] [Indexed: 10/10/2023] Open
Abstract
Background Transient constrictive pericarditis (TCP) is a distinct constrictive pericarditis (CP) subtype characterized by acute pericardial inflammation and transient constrictive physiology. If left untreated, it may progress to irreversible CP requiring pericardiectomy. However, making an early diagnosis of TCP remains difficult. Case presentation A 51-year-old man presented with fever, chest pain, and dyspnea following preceding flu symptoms. An initial investigation suggested right-sided heart failure. Laboratory results revealed elevated inflammatory markers and hepatic enzyme levels. Echocardiography revealed pericardial effusion with a normal ejection fraction and diastolic ventricular septal bounce suggestive of pericardial constriction. Computed tomography suggested acute descending mediastinitis with pericarditis and pleuritis; however, detailed examinations ruled out this possibility. The constellation of increased serological inflammation, pericardial thickness/effusion, and constrictive physiology suggested TCP, confirmed by cardiac magnetic resonance (CMR) and hemodynamic studies. CMR also revealed coexistent myocarditis. After a thorough assessment for the cause of TCP, a viral etiology was suspected. Paired serology for virus antibody titers revealed a significant increase only in coxsackievirus A4 (CVA4) titers. With prompt anti-inflammatory treatment, the patient's pericardial structure and function and concomitant inflammation of the surrounding tissues were nearly completely recovered, leading to a final diagnosis of TCP caused by CVA4. The subsequent clinical course was uneventful without recurrence at the 1-year follow-up. Conclusions Here we described the first case of TCP caused by CVA4 concurrent with mediastinitis, myocarditis, and pleuritis, all of which were successfully resolved with anti-inflammatory treatment. Acute mediastinitis secondary to TCP is rare. This case highlights the clinical importance of assessing pericardial diseases as a source of acute mediastinitis and considering CVA4 as an etiology of TCP. An evaluation including multimodal cardiac imaging and serology for virus antibody titers may be useful for an exploratory diagnosis of TCP in right-sided heart failure patients with pericardial effusion.
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Affiliation(s)
- Hiroyuki Yamamoto
- Department of Cardiovascular Medicine, Narita-Tomisato Tokushukai Hospital, Chiba, Japan
| | - Jun Isogai
- Division of Radiology, Asahi General Hospital, Asahi, Japan
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Mahran H, Hassanein AG, Rizq M. Trends and Outcome of Aggressive Fascial Space Infections. Surg Infect (Larchmt) 2023; 24:475-481. [PMID: 37279453 DOI: 10.1089/sur.2023.079] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/08/2023] Open
Abstract
Background: Odontogenic infections are common and self-limiting in most cases; however, they can lead to severe consequences, considerable morbidity and can even be fatal despite modern medical therapy. Patients and Methods: This retrospective study included patients with severe deep fascial space infections treated in the Maxillofacial Surgery Unit, General Surgery Department, Faculty of Medicine, Sohag University, Sohag Governorate, Egypt, and the Department of Oral and Maxillofacial Surgery, King Fahd Specialist Hospital (tertiary referral center), Burayda City, Qassim Province, Saudi Arabia, from June 2017 to June 2022. Results: This study included 296 patients, 161 (54.4%) males, 135 (45.6%) females. The fifth decade of life was the most common vulnerable age group. Forty-three percent of patients had diabetes mellitus, 26.6% were hypertensive, and 13.3% were on long-term steroid therapy. In 83% of patients, the offending tooth was identified but in 17% of patients no dental cause was identified. The lower third molar tooth was most commonly involved. Sixty-nine (23.3%) patients had submandibular space infections. Fifty-three (17.9%) patients had canine space infections. Thirty (10.1%) patients had submasseteric space infection. Twenty-eight (9.5%) patients had submental space infections. Twenty-three (7.8%) patients had combined infection of the submasseteric, submandibular, and pterygomandibular spaces, whereas 19 (6.4%) patients presented with Ludwig's angina. Conclusions: Odontogenic infections are common. The submandibular space is the most commonly affected single space. These infections could lead to lethal complications in immunocompromised patients, especially patients with diabetes mellitus. These infections require urgent surgical intervention to decrease hospital stays and avoid potentially lethal complications.
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Affiliation(s)
- Hamada Mahran
- Maxillofacial Surgery Unit, General Surgery Department, Faculty of Medicine, Assiut University, Asyut, Egypt
- King Fahd Specialist Hospital, Burayda, Qassim Province, Saudi Arabia
| | - Ahmed Gaber Hassanein
- Maxillofacial Surgery Unit, General Surgery Department, Faculty of Medicine, Sohag University, Akhmim, Sohag Governorate, Egypt
| | - Moataz Rizq
- Oral and Maxillofacial Surgeon, Alexandria, Egypt
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Descending necrotizing mediastinitis: etiopathogenesis, diagnosis, treatment and long-term consequences-a retrospective follow-up study. Eur Arch Otorhinolaryngol 2023; 280:1983-1990. [PMID: 36478116 PMCID: PMC9988808 DOI: 10.1007/s00405-022-07769-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2022] [Accepted: 11/29/2022] [Indexed: 12/13/2022]
Abstract
PURPOSE The primary aim of this retrospective study was to analyze the progression of descending necrotizing mediastinitis (DNM), evaluate the impact of comorbidities on complications and mortality and to observe long-term consequences of DNM on dysphagia and measurements quality of life. DNM is a serious infectious disease that requires multimodal treatment. Current literature varies in conclusions of risk factors, management and outcome of DNM. In addition, little is known about persisting effects on quality of life. METHODS Retrospective data analysis of 88 patients with DNM representing the largest single-center study. Recording data of patients and diseases as well as clinical progression from 1997 to 2018. Two questionnaires were sent to the participants to measure quality of life and to detect dysphagia. RESULTS 88 patients were included. The most frequently found pathogen were Streptococcus spp. (52%). 75% of the patients underwent multiple surgeries, mean count of surgical procedures was 4.3 times. 84% received intensive care treatment. Median length of stay on the intensive care unit was 7 days. 51% had pre-existing comorbidities associated with reduced tissue oxygenation (e.g., diabetes). The most common complication was pleural effusion (45%). During the observation period, the mortality rate was 9%. 12 questionnaires could be evaluated. 67% of the participants were affected by dysphagia at the time of the survey. CONCLUSIONS Descending necrotizing mediastinitis (DNM) is a severe disease requiring an immediate initiation of multimodal treatment. Although quality of life usually isn´t impaired permanently, dysphagia may often persist in patients after DNM.
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Konishi T, Sakata A, Inokuchi H, Kumazawa R, Matsui H, Fushimi K, Tanabe M, Seto Y, Yasunaga H. Treatments and outcomes of adult parapharyngeal and retropharyngeal abscess: 1882 cases from a Japanese nationwide database. Am J Otolaryngol 2023; 44:103770. [PMID: 36577172 DOI: 10.1016/j.amjoto.2022.103770] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2022] [Accepted: 12/18/2022] [Indexed: 12/27/2022]
Abstract
PURPOSE Although parapharyngeal and retropharyngeal abscesses are potentially fatal deep neck abscesses, there is limited evidence for the treatment courses for adult patients with these abscesses. We aimed to describe the practice patterns and clinical outcomes of adult patients undergoing an emergency surgery for parapharyngeal or retropharyngeal abscesses using a nationwide database. MATERIALS AND METHODS We identified patients aged ≥18 years who underwent emergency surgery for parapharyngeal (para group, n = 1148) or retropharyngeal (retro group, n = 734) abscesses from July 2010 to March 2020, using a nationwide inpatient database. We performed between-group comparisons of the baseline characteristics, treatment course, and outcomes. RESULTS Compared with the retro group, the para group was more likely to be older (median, 66 vs. 60 years; P < 0.001) and have several comorbidities, such as diabetes (21 % vs 16 %; P = 0.010) and epiglottitis (33 % vs. 26 %; P = 0.002), except for peritonsillar abscess (14 % vs. 22 %; P < 0.001) and tonsillitis (2.1 % vs. 13 %; P < 0.001). Regarding intravenous drugs administered within 2 days of admission, approximately half of the patients received steroids, non-antipseudomonal penicillins, and lincomycins. The para group received more comprehensive treatments, such as tracheostomy, intensive care unit admissions, and swallowing rehabilitation, within total hospitalization than the retro group. Moreover, it demonstrated higher in-hospital mortality (2.7 % vs. 1.1 %; P = 0.017) and morbidity (16 % vs. 9.7 %; P < 0.001), and longer length of hospitalization than the retro group. CONCLUSION The current nationwide study provided an overview of the characteristics, treatments, and outcomes for patients who underwent an emergency surgery for parapharyngeal or retropharyngeal abscess.
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Affiliation(s)
- Takaaki Konishi
- Department of Breast and Endocrine Surgery, Graduate School of Medicine, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo 113-8655, Japan; Department of Clinical Epidemiology and Health Economics, School of Public Health, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo 113-8655, Japan.
| | - Aki Sakata
- Department of Otorhinolaryngology, Kanto Central Hospital, 6-25-1 Kamiyoga, Setagaya-ku, Tokyo 158-8531, Japan
| | - Haruhi Inokuchi
- Department of Rehabilitation Medicine, The University of Tokyo Hospital, 7-3-1 Hongo, Bunkyo-ku, Tokyo 113-8655, Japan
| | - Ryosuke Kumazawa
- Department of Clinical Epidemiology and Health Economics, School of Public Health, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo 113-8655, Japan; Center for Clinical Sciences, National Center for Global Health and Medicine, 1-21-1 Toyama, Shinjuku-ku, Tokyo 162-8655, Japan
| | - Hiroki Matsui
- Department of Clinical Epidemiology and Health Economics, School of Public Health, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo 113-8655, Japan
| | - Kiyohide Fushimi
- Department of Health Policy and Informatics, Tokyo Medical and Dental University Graduate School, 1-5-45 Yushima, Bunkyo-ku, Tokyo 113-8519, Japan
| | - Masahiko Tanabe
- Department of Breast and Endocrine Surgery, Graduate School of Medicine, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo 113-8655, Japan
| | - Yasuyuki Seto
- Department of Breast and Endocrine Surgery, Graduate School of Medicine, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo 113-8655, Japan
| | - Hideo Yasunaga
- Department of Clinical Epidemiology and Health Economics, School of Public Health, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo 113-8655, Japan
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Hasjim BJ, Ostowari A, Holmes WN, Yu Y, Yu P, Reyna T, Bhatt J, Awan S, Goodman LF. Methicillin-resistant staphylococcus aureus descending necrotizing mediastinitis in an infant. JOURNAL OF PEDIATRIC SURGERY CASE REPORTS 2022. [DOI: 10.1016/j.epsc.2022.102572] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
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Risk Factors of Descending Necrotizing Mediastinitis in Deep Neck Abscesses. Medicina (B Aires) 2022; 58:medicina58121758. [PMID: 36556959 PMCID: PMC9788205 DOI: 10.3390/medicina58121758] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2022] [Revised: 11/27/2022] [Accepted: 11/28/2022] [Indexed: 12/03/2022] Open
Abstract
Background and Objectives: Cervical space infection could also extend to the mediastinum due to the anatomical vicinity. The mortality rate of descending necrotizing mediastinitis is 85% if untreated. The aim of this study was to identify risk factors for the progression of deep neck abscesses to descending necrotizing mediastinitis. Materials and Methods: We retrospectively reviewed the medical records of patients undergoing surgical treatment of deep neck abscesses from August 2017 to July 2022. Computed tomography (CT) was performed in all patients. Before surgery, lab data including hemoglobulin (Hb), white blood cell count, neutrophil percentage, C-reactive protein (CRP) level, and blood glucose were recorded. Patients' characteristics including gender, age, etiology, and presenting symptoms were collected. Hospitalization duration and bacterial cultures from the wound were also analyzed. Results: The C-reactive protein (CRP) level was higher in patients with a mediastinal abscess than in patients without a mediastinal abscess (340.9 ± 33.0 mg/L vs. 190.1 ± 72.7 mg/L) (p = 0.000). The submandibular space was more commonly affected in patients without a mediastinal abscess (p = 0.048). The retropharyngeal (p = 0.003) and anterior visceral (p = 0.006) spaces were more commonly affected in patients with a mediastinal abscess. Conclusions: Descending necrtotizing mediastinitis results in mortality and longer hospitalization times. Early detection of a mediastinal abscess on CT is crucial for treatment. Excluding abscesses of the anterior superior mediastinum for which transcervical drainage is sufficient, other mediastinal abscesses require multimodal treatment including ENT and thoracic surgery to achieve a good outcome.
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Velasquez-Rodriguez JG, Maisterra S, Ramos R, Escobar I, Gornals JB. The Role of Endoscopic Ultrasound in the Interventional Management of Mediastinal Collections: A Narrative Review. Cureus 2022; 14:e27803. [PMID: 36106250 PMCID: PMC9452048 DOI: 10.7759/cureus.27803] [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: 08/08/2022] [Indexed: 11/17/2022] Open
Abstract
The numerous causes underlying mediastinal lesions require different diagnostic and therapeutic approaches, including conservative, minimally invasive, and surgical interventions. Solid lesions of a malignant nature, mostly located in the anterior mediastinum, are properly treated with surgical resection either with or without adjuvant schemes. In contrast, a surveillance program is usually recommended with solid benign tumors, depending on their size and related symptomatology. In the management of mediastinal collections, when a drainage intervention is required (suspicion of infection and symptomatology), a minimally invasive nonsurgical procedure or thoracic surgery is considered. The minimally invasive nonsurgical procedures that can be available are percutaneous radiology-guided imaging (abdominal ultrasound (US) or computed tomography (CT) scan), complete single-aspiration guided by endoscopic ultrasound (EUS) or endobronchial ultrasound (EBUS), and transmural drainage guided by EUS. Surgical debridement is feasible to treat collections, but as this entails considerable risk of postoperative complications, it is chosen only when other minimally invasive therapies are not possible. The published literature related to the interventional endoscopic approach to mediastinal lesions is scarce. Nevertheless, reports in this field reveal that interventional EUS may have a role in both the diagnosis of and therapeutic approach to mediastinal lesions, mainly in the management of mediastinal collections.
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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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Chen YH, Zheng HY, Li ZX, Wu YC, Niu ZX, Peng YH, Zhao JF, Sun Q. Distribution of bacteria infected by metagenomic sequencing technology in maxillofacial space. HUA XI KOU QIANG YI XUE ZA ZHI = HUAXI KOUQIANG YIXUE ZAZHI = WEST CHINA JOURNAL OF STOMATOLOGY 2021; 39:475-481. [PMID: 34409806 PMCID: PMC8381121 DOI: 10.7518/hxkq.2021.04.016] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Received: 06/22/2020] [Revised: 03/05/2021] [Indexed: 01/23/2023]
Abstract
OBJECTIVES This study aimed to compare and analyze the consistency and difference between metageno-mic next-generation sequencing (mNGS) and conventional bacterial culture in the detection of pathogenic microorganisms in maxillofacial space infection, as well as to provide a new detection method for the early clinical identification of pathogenic bacteria in maxillofacial space infection. METHODS The clinical data of 16 patients with oral and maxillofacial space infections in the First Affiliated Hospital of Zhengzhou University from March 2020 to June 2020 were collected. mNGS and conventional bacterial culture methods were used to detect pus. We then analyzed and compared the test results of the two methods, including the test cycle, positive detection rate, anaerobic bacteria, facultative anaerobes and aerobic bacteria detection rates, distribution of pathogenic bacteria, relative species abundance, and resistance genes. RESULTS The average inspection period of mNGS was (18.81±3.73) h, and the average inspection period of bacterial culture was (83.25±11.64) h, the former was shorter than the latter (P<0.05). The positive detection rate of mNGS was 100% (16/16), and the positive detection rate of conventional bacterial culture was 31.25% (5/16), the former was higher than the latter (P<0.05). The detection rate of mNGS anaerobic bacteria was 93.75% (15/16), the detection rate of bacterial culture anaerobes was 0 (0/16), the former was higher than the latter (P<0.05). Using mNGS, the detection rate of facultative anaerobes in bacterial culture was 75.00% (12/16), and the detection rate of facultative anaerobes in bacterial culture was 25.00% (4/16), the former was higher than the latter (P<0.05). The detection rate of aerobic bacteria in bacterial culture was 12.50% (1/16), the former was higher than the latter (P>0.05). mNGS detected 15 kinds of pathogenic bacteria, among which 3 were Gram positive, 12 were Gram negative, 49 were non-pathogenic, 16 were Gram positive, and 32 were Gram negative, 1 was fungus. CONCLUSIONS Compared with conventional bacterial culture, mNGS has the characteristics of short test time, high sensitivity, and high accuracy. Thus, it is a new detection method for the early identification of pathogenic bacteria in maxillofacial space infection and is beneficial to the early clinical diagnosis and treatment of the disease.
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Affiliation(s)
- Yi-Heng Chen
- Dept. of Stomatology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou 450052, China
| | - Hong-Yu Zheng
- Dept. of Stomatology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou 450052, China
| | - Zi-Xuan Li
- Dept. of Stomatology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou 450052, China
| | - Yong-Chao Wu
- Dept. of Stomatology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou 450052, China
| | - Zhi-Xing Niu
- Dept. of Stomatology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou 450052, China
| | - Yan-Hui Peng
- Dept. of Stomatology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou 450052, China
| | - Jun-Fang Zhao
- Dept. of Stomatology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou 450052, China
| | - Qiang Sun
- Dept. of Stomatology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou 450052, China
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Guan X, Liang X, Liang X, Wang F, Qian W, Zhang W. A new classification of descending necrotizing mediastinitis and surgical strategies. ANNALS OF TRANSLATIONAL MEDICINE 2021; 9:356. [PMID: 33708983 PMCID: PMC7944333 DOI: 10.21037/atm-21-121] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Background Descending necrotizing mediastinitis (DNM) is an inflammation occurring in the oropharynx and descending to the deep cervical space and mediastinum, which is a serious infectious disease. The investigation of a new classification system and treatment methods for DNM is still necessary. Methods A total of 139 patients with DNM caused by odontogenic or pharyngeal infection were retrospectively analyzed in last 20 years in the Ninth People's Hospital Affiliated to Shanghai Jiao Tong University School of Medicine. The patients were divided into the traditional treatment Group T (Group T: 43 patients) and the new classification Group N (Group N: 96 patients). A new DNM classification was developed based on the progression of mediastinal infection as follows: type Ia: infection in the anterosuperior mediastinum; type I: infection in the anterior mediastinum; type II: infection in the posterior mediastinum; and type III: infection of the whole mediastinum. Results There were 49, 8, 10, and 29 patients classified as type Ia, I, II, and III, respectively in the Group N. The type Ia DNM patients were managed with transcervical mediastinal drainage, and the patients with types I and II DNM underwent open (thoracoscopic) surgery, 1 patient within types I died. The 29 patients with type III were managed with unilateral or bilateral open (thoracoscopic) surgery, among them, 8 patients died. The mortality rate for patients with type III DNM was 27.6%. The overall mortality rate in Group N was 9.4%. The mortality rate for patients in the Group T was 25.6%. The mortality rate of Group N was significantly lower than that of Group T (P<0.05). Conclusions We have carried out a new clinical classification of DNM, and selected the appropriate treatment method according to the classification, and achieved a better effect than the traditional treatment method.
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Affiliation(s)
- Xin Guan
- Department of Thoracic Surgery, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Xiang Liang
- Department of Thoracic Surgery, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Xi Liang
- Department of Thoracic Surgery, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Feng Wang
- Department of Thoracic Surgery, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Wentao Qian
- Department of Oral Surgery, Shanghai Ninth People's Hospital, College of Clinical Medicine, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Weijie Zhang
- Department of Oral Surgery, Shanghai Ninth People's Hospital, College of Clinical Medicine, Shanghai Jiao Tong University School of Medicine, Shanghai, China
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Pulle MV, Puri HV, Asaf BB, Bishnoi S, Malik M, Kumar A. Predictors of Mortality after Surgery for Empyema Thoracis in Chronic Kidney Disease Patients. THE KOREAN JOURNAL OF THORACIC AND CARDIOVASCULAR SURGERY 2020; 53:392-399. [PMID: 33234767 PMCID: PMC7721523 DOI: 10.5090/kjtcs.20.111] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 08/24/2020] [Revised: 09/28/2020] [Accepted: 10/13/2020] [Indexed: 11/16/2022]
Abstract
Background Surgical treatment of empyema thoracis in patients with chronic kidney disease is challenging, and few studies in the literature have evaluated this issue. In this study, we aim to report the surgical outcomes of empyema and to analyze factors predicting perioperative mortality in patients with chronic kidney disease. Methods This retrospective study included data from 34 patients with chronic kidney disease (estimated glomerular filtration rate <60 mL/min/1.73 m2 for 3 or more months) who underwent surgery for empyema between 2012 and 2020. An analysis of demographic characteristics and perioperative variables, including complications, was carried out. Postoperative mortality was the primary outcome measure. Results Patients' age ranged from 20 to 74 years with a 29-to-5 male-female ratio. The majority (n=19, 55.9%) of patients were in end-stage renal disease (ESRD) requiring maintenance hemodialysis. The mean operative time was 304 minutes and the mean intraoperative blood loss was 562 mL. Postoperative morbidity was observed in 70.5% of patients (n=24). In the subgroup analysis, higher values for operative time, blood loss, intensive care unit stay, and complications were found in ESRD patients. The mortality rate was 38.2% (n=13). In the univariate and multivariate analyses, poor performance status (Eastern Cooperative Oncology Group >2) (p=0.03), ESRD (p=0.02), and late referral (>8 weeks) (p<0.001) significantly affected mortality. Conclusion ESRD, late referral, and poor functional status were poor prognostic factors predicting postoperative mortality. The decision of surgery should be cautiously assessed given the very high risk of perioperative morbidity and mortality in these patients.
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Affiliation(s)
| | | | - Belal Bin Asaf
- Centre for Chest Surgery, Sir Ganga Ram Hospital, New Delhi, India
| | - Sukhram Bishnoi
- Centre for Chest Surgery, Sir Ganga Ram Hospital, New Delhi, India
| | - Manish Malik
- Department of Nephrology, Sir Ganga Ram Hospital, New Delhi, India
| | - Arvind Kumar
- Centre for Chest Surgery, Sir Ganga Ram Hospital, New Delhi, India
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Stevens C, Ladd P, Ghadersohi S, Gitomer SA. Minimally invasive transoral image-guided drainage of a retropharyngeal abscess with mediastinal extension. Int J Pediatr Otorhinolaryngol 2020; 138:110288. [PMID: 32836140 DOI: 10.1016/j.ijporl.2020.110288] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2020] [Revised: 07/23/2020] [Accepted: 07/30/2020] [Indexed: 11/16/2022]
Abstract
Retropharyngeal abscess (RPA) in children is a serious deep neck space infection that rarely is complicated by extension into the mediastinum. RPA with mediastinal abscess requires prompt surgical management, generally via external or transoral approach. We present the case of a 3-year-old boy with RPA with mediastinal extension who was managed with a unique multidisciplinary surgical approach with otolaryngology and interventional radiology. A transoral approach was utilized to pass a transnasal drain with image guidance into the mediastinal fluid collection. This report reviews the presentation and surgical management of RPA with mediastinal extension and describes a unique minimally invasive approach to drainage.
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Affiliation(s)
| | - Patricia Ladd
- Division of Pediatric Radiology, Department of Radiology, University of Colorado School of Medicine, Aurora, CO, USA
| | - Saied Ghadersohi
- Department of Otolaryngology - Head and Neck Surgery, University of Colorado School of Medicine, Aurora, CO, USA; Children's Hospital Colorado, Aurora, CO, USA
| | - Sarah A Gitomer
- Department of Otolaryngology - Head and Neck Surgery, University of Colorado School of Medicine, Aurora, CO, USA; Children's Hospital Colorado, Aurora, CO, USA.
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14
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Brisset J, Daix T, Tricard J, Evrard B, Vignon P, Barraud O, François B. Spontaneous community-acquired PVL-producing Staphylococcus aureus mediastinitis in an immunocompetent adult - a case report. BMC Infect Dis 2020; 20:354. [PMID: 32429852 PMCID: PMC7236110 DOI: 10.1186/s12879-020-05076-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2020] [Accepted: 05/07/2020] [Indexed: 12/17/2022] Open
Abstract
Background Mediastinitis caused by hematogenous spread of an infection is rare. We report the first known case of community-acquired mediastinitis from hematogenous origin in an immunocompetent adult. This rare invasive infection was due to Panton-Valentine Leucocidin-producing (PVL+) methicillin-susceptible Staphylococcus aureus (MSSA). Case presentation A 22-year-old obese man without other medical history was hospitalized for febrile precordial chest pain. He reported a cutaneous back abscess 3 weeks before. CT-scan was consistent with mediastinitis and blood cultures grew for a PVL+ MSSA. Intravenous clindamycin (600 mg t.i.d) and cloxacillin (2 g q.i.d.), secondary changed for fosfomycin (4 g q.i.d.) because of a related toxidermia, was administered. Surgical drainage was performed and confirmed the presence of a mediastinal abscess associated with a fistula between the mediastinum and right pleural space. All local bacteriological samples also grew for PVL+ MSSA. In addition to clindamycin, intravenous fosfomycin was switched to trimethoprim-sulfamethoxazole after 4 weeks for a total of 10 weeks of antibiotics. Conclusions We present the first community-acquired mediastinitis of hematogenous origin with PVL+ MSSA. Clinical evolution was favorable after surgical drainage and 10 weeks of antibiotics. The specific virulence of MSSA PVL+ strains played presumably a key role in this rare invasive clinical presentation.
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Affiliation(s)
- Josselin Brisset
- Réanimation polyvalente, CHU Dupuytren, 2 avenue Martin Luther King, F-87000, Limoges, France.,Maladies infectieuses, CHU Dupuytren, F-87000, Limoges, France
| | - Thomas Daix
- Réanimation polyvalente, CHU Dupuytren, 2 avenue Martin Luther King, F-87000, Limoges, France. .,Inserm CIC 1435 & UMR 1092, CHU Dupuytren, F-87000, Limoges, France.
| | - Jérémy Tricard
- Chirurgie cardiaque, CHU Dupuytren, F-87000, Limoges, France
| | - Bruno Evrard
- Réanimation polyvalente, CHU Dupuytren, 2 avenue Martin Luther King, F-87000, Limoges, France
| | - Philippe Vignon
- Réanimation polyvalente, CHU Dupuytren, 2 avenue Martin Luther King, F-87000, Limoges, France.,Inserm CIC 1435 & UMR 1092, CHU Dupuytren, F-87000, Limoges, France
| | - Olivier Barraud
- Inserm CIC 1435 & UMR 1092, CHU Dupuytren, F-87000, Limoges, France.,Laboratoire de Bactériologie - Virologie - Hygiène, CHU Dupuytren, F-87000, Limoges, France
| | - Bruno François
- Réanimation polyvalente, CHU Dupuytren, 2 avenue Martin Luther King, F-87000, Limoges, France.,Inserm CIC 1435 & UMR 1092, CHU Dupuytren, F-87000, Limoges, France
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15
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Sakai T, Matsutani N, Ito K, Mochiki M, Mineda J, Shirai S, Kanaoka R, Yamauchi Y, Saito Y, Sakao Y, Kawamura M. Deep cervical and paratracheal drainage for descending necrotizing mediastinitis. Asian Cardiovasc Thorac Ann 2019; 28:29-32. [PMID: 31840524 DOI: 10.1177/0218492319896515] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Background Descending necrotizing mediastinitis is life-threatening and extends into the deep cervical fascia including the pretracheal, perivascular and retrovisceral, and prevertebral spaces. Deep cervical and paratracheal drainage via a transcervical approach prevents the spread of infection into the deep mediastinum. It is effective for local neck drainage and important in the primary treatment of descending necrotizing mediastinitis. Transthoracic mediastinal drainage is also effective for treating this condition. Methods Nine patients with descending necrotizing mediastinitis were treated by deep cervical and paratracheal drainage via a transcervical approach at our institution from April 2007 to December 2017. Four patients with diagnoses of extensive descending necrotizing mediastinitis had progressive extension of abscesses into the lower mediastinum, below the level of the carina. The other five had localized descending necrotizing mediastinitis with infection in the upper mediastinum above the level of the carina. Results All 9 patients (4 with extensive and 5 with localized descending necrotizing mediastinitis) initially underwent deep cervical and paratracheal drainage via a transcervical approach, and all recovered. Two of the patients with extensive infection required no additional surgical intervention. Conclusions Fluid collections in the deep cervical fascia must be drained urgently. Deep cervical and paratracheal drainage via a transcervical approach effectively controls all types of descending necrotizing mediastinitis, and it is less invasive than transthoracic approaches via thoracotomy. However, a thoracotomy for mediastinal drainage must be considered if infection is not controlled by transcervical drainage. Thoracic surgeons and otolaryngologists must plan efficacious treatment before surgical procedures for descending necrotizing mediastinitis.
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Affiliation(s)
- Takashi Sakai
- Department of Surgery, Teikyo University School of Medicine, Tokyo, Japan
| | - Noriyuki Matsutani
- Department of Surgery, Mizonokuchi Hospital, Teikyo University School of Medicine, Tokyo, Japan
| | - Ken Ito
- Department of Otolaryngology, Teikyo University School of Medicine, Tokyo, Japan
| | - Masato Mochiki
- Department of Otolaryngology, Teikyo University School of Medicine, Tokyo, Japan
| | - Joji Mineda
- Department of Otolaryngology, Teikyo University School of Medicine, Tokyo, Japan
| | - Suguru Shirai
- Department of Surgery, Teikyo University School of Medicine, Tokyo, Japan
| | - Rie Kanaoka
- Department of Surgery, Teikyo University School of Medicine, Tokyo, Japan
| | - Yoshikane Yamauchi
- Department of Surgery, Teikyo University School of Medicine, Tokyo, Japan
| | - Yuichi Saito
- Department of Surgery, Teikyo University School of Medicine, Tokyo, Japan
| | - Yukinori Sakao
- Department of Surgery, Teikyo University School of Medicine, Tokyo, Japan
| | - Masafumi Kawamura
- Department of Surgery, Teikyo University School of Medicine, Tokyo, Japan
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16
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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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17
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Liao HC, Chuang JH, Hsu HH, Chen KC, Chen JS. Video-assisted thoracoscopic surgery for thoracic empyema in patients on maintenance hemodialysis. Surg Endosc 2019; 34:1641-1647. [PMID: 31286249 DOI: 10.1007/s00464-019-06935-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2018] [Accepted: 06/12/2019] [Indexed: 12/29/2022]
Abstract
OBJECTIVE Thoracic empyema in uremic patients on maintenance hemodialysis is a challenging situation. The clinical characteristics are rarely reported, and the surgical outcomes remain unclear. We report our experience with video-assisted thoracoscopic surgery in these patients during 10-year period of time. METHODS Between 2005 and 2015, we retrospectively reviewed the clinical characteristics, bacteriological studies, and thoracoscopic surgical results of 23 empyema patients undergoing maintenance hemodialysis. RESULTS The mean patient age was 67.1 ± 12.9 years. All patients had additional preexisting systemic diseases. The mean duration of hemodialysis was 34.7 ± 25.8 months. The infections causing empyema were pneumonia in 11 (47.8%), blood stream infection in 8 (34.8%), and uremic pleuritis in 4 (17.4%). Among the 22 identified microorganisms, the most common pathogen was methicillin-resistant Staphylococcus aureus (31.8%). After thoracoscopic surgery, 8 patients (34.8%) required additional procedures for complications, including 2 patients who required repeated thoracoscopy for hemothorax and 6 (26.1%) patients who required open drainage for residual empyema. The mean hospital stay was 62.4 days, and 6 patients (26.1%) died in the hospital. Univariate and multivariate analyses revealed that maintenance hemodialysis longer than 5 years was a significant factor associated with in-hospital mortality (odds ratio: 14.8, 95% confidence interval 1.5-151.6; p < 0.0001). CONCLUSION While surgical management of thoracic empyema in uremic patients undergoing maintenance hemodialysis is associated with high rates of complication and mortality, thoracoscopic surgery is feasible, especially for patients undergoing hemodialysis for less than 5 years.
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Affiliation(s)
- Hsien-Chi Liao
- Department of Surgery, National Taiwan University Hospital and National Taiwan University College of Medicine, No. 7, Chung Shan South Road, Taipei, 100, Taiwan
| | - Jen-Hao Chuang
- Department of Surgery, National Taiwan University Hospital and National Taiwan University College of Medicine, No. 7, Chung Shan South Road, Taipei, 100, Taiwan
| | - Hsao-Hsun Hsu
- Department of Surgery, National Taiwan University Hospital and National Taiwan University College of Medicine, No. 7, Chung Shan South Road, Taipei, 100, Taiwan
| | - Ke-Cheng Chen
- Department of Surgery, National Taiwan University Hospital and National Taiwan University College of Medicine, No. 7, Chung Shan South Road, Taipei, 100, Taiwan. .,Institute of Biomedical Engineering, College of Medicine and College of Engineering, National Taiwan University, Taipei, Taiwan.
| | - Jin-Shing Chen
- Department of Surgery, National Taiwan University Hospital and National Taiwan University College of Medicine, No. 7, Chung Shan South Road, Taipei, 100, Taiwan
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18
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Petersen da Costa Ferreira C, Yumi Nakai M, Schmiele Namur C, Ribeiro Tenório L, Gonçalves AJ. Subphrenic abscess secondary to cervical abscess and fasciitis from dental focus: case report. J Med Case Rep 2019; 13:110. [PMID: 31029172 PMCID: PMC6487072 DOI: 10.1186/s13256-019-2036-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2018] [Accepted: 02/28/2019] [Indexed: 11/24/2022] Open
Abstract
Background Cervical fasciitis is a group of severe infections with high morbimortality. Reports in the literature of patients with cases evolving with mediastinal dissemination of deep cervical abscess are common. However, cases of abdominal dissemination by contiguity are much rarer. Case presentation A 34-year-old Caucasian man presented to the emergency department with a 15-day history of left neck edema, local pain, and fever. Seventeen days prior to presentation, he had undergone odontogenic surgical treatment in a dental clinic. Laboratory examinations did not show meaningful changes. He underwent computed tomography of the neck, thorax, and abdomen, which showed evidence of left collection affecting the retromandibular, submandibular, parapharyngeal, vascular, and mediastinal spaces, bilateral pleural effusion, right subphrenic collection and a small amount of liquids between intestinal loops. A cervical, thoracic, and abdominal surgical approach at the same surgery was indicated for odontogenic cervical abscess, descending necrotizing mediastinitis, and subphrenic abscess. The patient remained in the intensive care unit for three days, and he was discharged on the 22nd day after surgery with no drains and no tracheostomy. His outpatient discharge occurred after 6 months with no sequelae. Conclusions Aggressive surgical treatment associated with antibiotic therapy has been shown to be effective for improving the clinical course of cervical fasciitis. Despite the extension of the infection in our patient, a surgical approach of all infectious focus associated with a broad-spectrum antibiotic therapy led to a good clinical evolution and has significant implications for aggressive treatment.
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Affiliation(s)
| | - Marianne Yumi Nakai
- Head & Neck Surgery Discipline, Surgery Department, Irmandade da Santa Casa de Misericórdia de São Paulo, São Paulo, Brazil
| | | | - Lucas Ribeiro Tenório
- Head & Neck Surgery Discipline, Surgery Department, Irmandade da Santa Casa de Misericórdia de São Paulo, São Paulo, Brazil
| | - Antonio José Gonçalves
- Head & Neck Surgery Discipline, Surgery Department, Irmandade da Santa Casa de Misericórdia de São Paulo, São Paulo, Brazil
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19
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Descending necrotizing mediastinitis after sequestrectomy in a patient with bisphosphonate-induced osteonecrosis of the jaw: A case report. Mol Clin Oncol 2018; 9:215-218. [PMID: 30101025 PMCID: PMC6083425 DOI: 10.3892/mco.2018.1656] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2017] [Accepted: 06/11/2018] [Indexed: 11/05/2022] Open
Abstract
An 83-year-old woman underwent mastectomy for breast cancer of the right breast in 2008. In addition to hormone therapy and irradiation, zoledronate was started for bone metastasis 6 months postoperatively. Five years after the operation, the patient developed osteonecrosis of the jaw, and underwent sequestrectomy because of uncontrollable pain in the mandible. The patient visited our hospital for a 1-week history of fever and right facial swelling with pain, and was diagnosed with right mandibular cellulitis. Despite antibiotic therapy, the patient fell into shock. Follow-up computed tomography showed gas formation extending down to the posterior mediastinum, which was compatible with descending necrotizing mediastinitis (DNM). The patient succumbed to septicemia on the third hospital day. The mortality rate of DNM greatly increases in patients with advanced cancer because clinicians cannot perform radical treatment due to the impaired general condition and limited life expectancy. DNM advances by the hour; therefore, repeated computed tomography is essential when antibiotic therapy does not improve the patient's condition. Attention must be paid to detect signs of DNM in such patients. To the best of our knowledge, this is the first report in English regarding DNM caused by bisphosphonate-induced osteonecrosis of the jaw.
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20
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Yang X, Yang YF, Zhu ZC, Xu TS, Cheng YN, Sun ZY. Senile Lemierre syndrome complicated with descending necrotizing mediastinitis: A case report. Medicine (Baltimore) 2018; 97:e11903. [PMID: 30170383 PMCID: PMC6392631 DOI: 10.1097/md.0000000000011903] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
RATIONALE Senile patients with LS complicated with DNM are rarely seen in clinical practice, and extensive cervical incision and drainage plus administration of effective antibiotics are the basis for treatment. Currently, the treatment controversy mainly has focused on whether mediastinal incision and drainage is necessary for patients with type I DNM, and whether anticoagulation therapy is required for jugular venous emboli and distant metastatic emboli induced by LS. PATIENT CONCERNS A female, 76 years old, developed pain of tonsil on right side 5 days ago, and felt that the pain aggravated complicated with dysphagia and swelling pain of neck on both sides since then. DIAGNOSES She was diagnosed with LS complicated with type I DNM. INTERVENTIONS Tazobactam and Piperacillin 4.5 q8h and Ornidazole 100 ml q6h ivgtt were administered empirically,and secondary extensive cervical incision and drainage was performed under general anesthesia, after which low molecular weight heparin 4250 U q12h SC was administered. G test was performed 3 days later, which showed (1,3)-β-D-glucan >1000 pg/ml. Bridging anticoagulation therapy, low molecular weight heparin 4250 U q12h SC, and Warfarin 2.5 mg qd po were given one week later. Low molecular weight heparin SC was discontinued and only Warfarin po was administered after treatment of bridging therapy for 3 days. OUTCOMES CT of head and neck was reexamined on post-admission d24 and revealed that neck infection was improved on both sides, jugular vein distension on right side was restored to normal, abscess and pneumatosis of superior mediastinum were improved, distension of pulmonary artery on both sides was normalized, WBC was 9.94×109/L, neutrophil count was 4.43×109/L, CRP level was 9.8mg/L, D-D level was 0.81mg/L, PCT level was 0.800ng/mL and G test suggested (1,3)-β-D-glucan pf 27.1 pg/mL. LESSONS Concomitant use of anticoagulants on the basis of repeated cervical incision and drainage + administration of effective antibiotics can obtain excellent therapeutic efficacy in the treatment of patient with LS complicated with type I DNM.
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21
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Abu-Omar Y, Kocher GJ, Bosco P, Barbero C, Waller D, Gudbjartsson T, Sousa-Uva M, Licht PB, Dunning J, Schmid RA, Cardillo G. European Association for Cardio-Thoracic Surgery expert consensus statement on the prevention and management of mediastinitis. Eur J Cardiothorac Surg 2017; 51:10-29. [PMID: 28077503 DOI: 10.1093/ejcts/ezw326] [Citation(s) in RCA: 101] [Impact Index Per Article: 14.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2016] [Revised: 08/10/2016] [Accepted: 08/11/2016] [Indexed: 12/24/2022] Open
Abstract
Mediastinitis continues to be an important and life-threatening complication after median sternotomy despite advances in prevention and treatment strategies, with an incidence of 0.25-5%. It can also occur as extension of infection from adjacent structures such as the oesophagus, airways and lungs, or as descending necrotizing infection from the head and neck. In addition, there is a chronic form of 'chronic fibrosing mediastinitis' usually caused by granulomatous infections. In this expert consensus, the evidence for strategies for treatment and prevention of mediatinitis is reviewed in detail aiming at reducing the incidence and optimizing the management of this serious condition.
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Affiliation(s)
- Yasir Abu-Omar
- Department of Cardiothoracic Surgery, Papworth Hospital NHS Foundation Trust, Cambridge, UK
| | - Gregor J Kocher
- Division of General Thoracic Surgery, Bern University Hospital / Inselspital, Switzerland
| | - Paolo Bosco
- Department of Cardiothoracic Surgery, Papworth Hospital NHS Foundation Trust, Cambridge, UK
| | - Cristina Barbero
- Department of Cardiovascular and Thoracic Surgery, University of Turin-Italy, Città della Salute e della Scienza-San Giovanni Battista Hospital, Torino, Italy
| | - David Waller
- Department of Thoracic Surgery, Glenfield Hospital, Leicester, UK
| | - Tomas Gudbjartsson
- Department of Cardiothoracic Surgery, Landspitali University Hospital and Faculty of Medicine, University of Iceland, Reykjavík, Iceland
| | - Miguel Sousa-Uva
- Unit of Cardiac Surgery, Hospital Cruz Vermelha, Lisbon, Portugal
| | - Peter B Licht
- Department of Cardiothoracic Surgery, Odense University Hospital, Odense, Denmark
| | - Joel Dunning
- Department of Cardiothoracic Surgery, James Cook University Hospital, Middlesbrough, UK
| | - Ralph A Schmid
- Department of Cardiothoracic Surgery, Papworth Hospital NHS Foundation Trust, Cambridge, UK
| | - Giuseppe Cardillo
- Unit of Thoracic Surgery, Azienda Ospedaliera S. Camillo Forlanini, Lazzaro Spallanzani Hospital, Rome, Italy
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22
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Mazzella A, Santagata M, Cecere A, La Mart E, Fiorelli A, Tartaro G, Tafuri D, Testa D, Grella E, Perrotta F, Bianco A, Mazzarella G, Santini M. Descending necrotizing mediastinitis in the elderly patients. Open Med (Wars) 2016; 11:449-460. [PMID: 28352835 PMCID: PMC5329867 DOI: 10.1515/med-2016-0080] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2016] [Accepted: 08/19/2016] [Indexed: 12/20/2022] Open
Abstract
Descending Necrotizing Mediastinitis (DNM) is a polymicrobic, dangerous and often fatal process, arising from head or neck infections and spreading along the deep fascial cervical planes, descending into the mediastinum. It can rapidly progress to sepsis and can frequently lead to death. It has a high mortality rate, up to 40% in the different series, as described in the literature. Surgical and therapeutic management has been discussed for long time especially in an elderly patient population. The literature has been reviewed in order to evaluate different pathogenesis and evolution and to recognise a correct therapeutic management.
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Affiliation(s)
| | - Mario Santagata
- Maxillo-Facial Surgery Unit, Second University of Naples, Italy
| | - Atirge Cecere
- Maxillo-Facial Surgery Unit, Second University of Naples, Italy
| | - Ettore La Mart
- Maxillo-Facial Surgery Unit, Second University of Naples, Italy
| | | | | | - Domenico Tafuri
- Department of Sport Sciences and Wellness, University of Naples "Parthenope", Naples, Italy
| | - Domenico Testa
- Department of Anesthesiologic, Surgical and Emergency Sciences, Otolaryngology, Head and Neck Surgery Unit, Second University of Naples, Naples, Italy
| | - Edoardo Grella
- Department of Cardiothoracic and Respiratory Sciences, Second University of Naples/Hosp. Monaldi, Italy
| | - Fabio Perrotta
- Department of Cardiothoracic and Respiratory Sciences, Second University of Naples/Hosp. Monaldi, Italy
| | - Andrea Bianco
- Department of Cardiothoracic and Respiratory Sciences, Second University of Naples/Hosp. Monaldi, Piazza Miraglia, 2, 80138 Naples, Italy
| | - Gennaro Mazzarella
- Department of Cardiothoracic and Respiratory Sciences, Second University of Naples/Hosp. Monaldi, Italy
| | - Mario Santini
- Thoracic Surgery Unit, Second University of Naples, Italy
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23
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A case of necrotizing mediastinitis induced by acute pyopericardium. JOURNAL OF ACUTE DISEASE 2016. [DOI: 10.1016/j.joad.2016.08.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022] Open
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24
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Guan X, Zhang WJ, Liang X, Liang X, Wang F, Guo X, Zhou Y. Optimal surgical options for descending necrotizing mediastinitis of the anterior mediastinum. Cell Biochem Biophys 2015; 70:109-14. [PMID: 24696071 DOI: 10.1007/s12013-014-9865-z] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
The mortality rates from descending necrotizing mediastinitis (DNM) are between 25 and 40 % mainly because of delayed diagnosis and inappropriate surgical treatment. This study was undertaken to examine two surgical options for DNM and determine the optimal surgical option for DNM of the anterior mediastinum. Fifteen cases of DNM of the anterior mediastinum, January 2001 and October 2010, were retrospectively reviewed. Eleven were anterosuperior mediastinitis, with infection located above the tracheal bifurcation and four had infections involving the entire anterior mediastinum. Depending on the location of mediastinitis, open drainage of the submandibular and neck abscesses, in addition to other surgical treatments, was performed. If the infection was anterosuperior, transcervical mediastinal drainage or thoracotomy was performed. If the entire anterior mediastinum was involved, necrotic tissue was removed with thoracoscopic via subxiphoid incision, the bilateral pleurae were opened for drainage, and a tunnel connecting the neck incision and the subxiphoid incision through the whole anterior mediastinum was made for drainage. The anterosuperior mediastinitis cases were treated with either transcervical mediastinal drainage (n = 8) or thoracotomy (n = 3). Patients healed after an average of 24.5 and 20.0 days in the hospital, respectively. For the four other cases, one patient died of septic shock, while the other three patients were healed after and an average of 43.3 days in the hospital. Mortality rate was 6.7 %. The surgical procedure used to treat DNM should be selected according to the location of the infection. DNM involving the anterosuperior mediastinum can be treated by transcervical mediastinal drainage. If anterosuperior mediastinitis spreads to the side of the trachea, open thoracotomy is a suitable therapy. If the entire anterior mediastinum is involved, debridement and drainage of the anterior mediastinum should be performed with a thoracoscope via the subxiphoid incision.
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Affiliation(s)
- Xin Guan
- Department of Thoracic Surgery, Ninth People's Hospital, Shanghai Jiaotong University School of Medicine, 5th Building 4 Flour, 639 Zhi Zao Ju Road, Shanghai, 200011, People's Republic of China,
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Bali RK, Sharma P, Gaba S, Kaur A, Ghanghas P. A review of complications of odontogenic infections. Natl J Maxillofac Surg 2015; 6:136-43. [PMID: 27390486 PMCID: PMC4922222 DOI: 10.4103/0975-5950.183867] [Citation(s) in RCA: 65] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Life-threatening infections of odontogenic or upper airway origin may extend to potential spaces formed by fascial planes of the lower head and upper cervical area. Complications include airway obstruction, mediastinitis, necrotizing fascitis, cavernous sinus thrombosis, sepsis, thoracic empyema, Lemierre's syndrome, cerebral abscess, orbital abscess, and osteomyelitis. The incidence of these "space infections" has been greatly reduced by modern antibiotic therapy. However, serious morbidity and even fatalities continue to occur. This study reviews complications of odontogenic infections. The search done was based on PubMed and Google Scholar, and an extensive published work search was undertaken. Advanced MEDLINE search was performed using the terms "odontogenic infections," "complications," and "risk factors."
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Affiliation(s)
- Rishi Kumar Bali
- Department of Oral and Maxillofacial Surgery, JN Kapoor DAV (C) Dental College and Hospital, Yamunanagar, Haryana, India
| | - Parveen Sharma
- Department of Oral and Maxillofacial Surgery, JN Kapoor DAV (C) Dental College and Hospital, Yamunanagar, Haryana, India
| | - Shivani Gaba
- Department of Oral and Maxillofacial Surgery, JN Kapoor DAV (C) Dental College and Hospital, Yamunanagar, Haryana, India
| | - Avneet Kaur
- Department of Oral and Maxillofacial Surgery, JN Kapoor DAV (C) Dental College and Hospital, Yamunanagar, Haryana, India
| | - Priya Ghanghas
- Department of Oral and Maxillofacial Surgery, JN Kapoor DAV (C) Dental College and Hospital, Yamunanagar, Haryana, India
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Cervical Necrotizing Fasciitis--The Value of the Laboratory Risk Indicator for Necrotizing Fasciitis Score as an Indicative Parameter. J Oral Maxillofac Surg 2015; 73:2319-33. [PMID: 26079692 DOI: 10.1016/j.joms.2015.05.035] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2015] [Accepted: 05/22/2015] [Indexed: 11/20/2022]
Abstract
PURPOSE Cervical necrotizing fasciitis (CNF) is uncommon, difficult to diagnose, and rapidly progressive. The objective of the present study was to determine the predictive value of the laboratory risk indicator for necrotizing fasciitis (LRINEC) score for CNF. MATERIALS AND METHODS The LRINEC score for 16 consecutive cases of CNF and 595 cases of severe non-necrotizing neck infections was determined over a 6.5-year period in a single-center retrospective cohort study and case report. CNF was confirmed by histologic examination and operative report documentation. RESULTS Using a cutoff score of 6, the LRINEC score had a sensitivity of 0.94 (95% confidence interval [CI] 0.92 to 0.96) and specificity of 0.94 (95% CI 0.70 to 1.00). The positive predictive value was 0.29 (95% CI 0.17 to 0.44), and the negative predictive value was 0.99 (95% CI 0.99 to 1.00). CONCLUSIONS The LRINEC score can detect early cases of CNF. Patients with a LRINEC score of ≥6 must be carefully evaluated for the presence of CNF.
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Sumi Y. Descending necrotizing mediastinitis: 5 years of published data in Japan. Acute Med Surg 2014; 2:1-12. [PMID: 29123684 DOI: 10.1002/ams2.56] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2014] [Accepted: 04/25/2014] [Indexed: 12/29/2022] Open
Abstract
Descending necrotizing mediastinitis implies infection originating from the neck, most commonly an oropharyngeal or odontogenic focus, that spreads in the cervical fascial spaces and descends into the mediastinum. Early diagnosis is essential because descending necrotizing mediastinitis can rapidly progress to septic shock and organ failure. A comprehensive review of the current data of descending necrotizing mediastinitis in Japan was carried out using PubMed and ICHUSHI from the last 5 years. The symptoms, origins, comorbid conditions, treatment modalities, complications, and survival rates were analyzed. Tonsillar and pharyngeal origin was more identified compared to odontogenic origin. More than one-third of patients were diabetic and 28% of them were not identified as having any comorbidity. Streptococcus sp. and anaerobes were most isolated, reflecting the microflora of the oral cavity. Of the broad antibiotics, carbapenem was the most used as treatment, and clindamycin was the most co-given. Mediastinal drainage approach varied widely and the optimal approach is controversial. Twenty-one patients were treated with video-assisted thoracic surgical drainage and 15 cases by percutaneous catheter drainage, whereas transcervical approach was applied in 25 patients and thoracotomy was carried out in 21 patients. The overall mortality was 5.6%. Many authors advocated that the most effective management tool is a high degree of clinical suspicion followed by prompt and adequate drainage with intensive care including hemodynamic and nutritional support and repeat computer tomographic monitoring.
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Affiliation(s)
- Yuka Sumi
- Department of Emergency and Critical Care Medicine Juntendo University, Urayasu Hospital Chiba Japan
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Transoral negative-pressure catheter drainage of a retropharyngeal and mediastinal abscess. Am J Otolaryngol 2014; 35:313-7. [PMID: 24629587 DOI: 10.1016/j.amjoto.2014.02.005] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2013] [Revised: 01/20/2014] [Accepted: 02/06/2014] [Indexed: 11/21/2022]
Abstract
PURPOSE A retropharyngeal abscess (RPA) is an extremely rare entity in adults that has a tendency to spread vertically and cause a mediastinal abscess. Traditionally, immediate aggressive drainage is recommended via a transcervical or transthoracic approach for the treatment of a retropharyngeal abscess with mediastinal extension. Here, we present a case of a retropharyngeal and mediastinal abscess using a transoral negative-pressure catheter drainage approach. PATIENTS AND METHODS A 24-year-old woman was admitted with a 4-day history of severe sore throat and painful swallowing. Computed tomography identified a retropharyngeal abscess extending to the upper posterior mediastinum. We performed transoral negative-pressure catheter drainage. RESULTS The postoperative course was uneventful. The patient reported a rapid improvement in symptoms and had a good tolerance of the catheters in the nasal cavity. At 2 years postoperatively, physical examinations revealed no recurrence or surgical complications. CONCLUSIONS Transoral negative-pressure catheter drainage is a minimally invasive operation for the treatment of RPA in adults with or without a mediastinal abscess. This method could be recommended as an alternative approach in such cases.
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Chen KC, Chen HY, Lin JW, Tseng YT, Kuo SW, Huang PM, Hsu HH, Lee JM, Chen JS, Lai HS. Acute thoracic empyema: clinical characteristics and outcome analysis of video-assisted thoracoscopic surgery. J Formos Med Assoc 2014; 113:210-8. [PMID: 24512757 DOI: 10.1016/j.jfma.2013.12.010] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2013] [Revised: 12/27/2013] [Accepted: 12/31/2013] [Indexed: 10/25/2022] Open
Abstract
BACKGROUND/PURPOSE Acute thoracic empyema is a common clinical problem worldwide, resulting in substantial morbidity and mortality. The objective of this study was to report its clinical characteristics and to evaluate whether thoracoscopic surgery is associated with a lower rate of in-hospital mortality compared with nonoperative drainage. METHODS Between 2001 and 2010, we retrospectively reviewed the clinical characteristics, bacteriological studies, and treatment outcomes of 602 patients with acute thoracic empyema. Thoracoscopic surgery was performed in 417 (69.2%) patients, while the remaining patients underwent nonoperative drainage. After treatment, 77 patients (12.8%) died in the hospital. A propensity score-based process, matched on potential risk factors for in-hospital mortality, was performed to select patients with equalized potential prognostic factors in the thoracoscopy and nonoperative groups. The log-rank test was used to compare the survival time with discharge between the two matched groups. RESULTS Multivariate analysis showed that age, malignancy, chronic lung disease, chronic renal insufficiency, liver cirrhosis, polymicrobial infection, and positive bacterial culture were risk factors for in-hospital mortality. The propensity score-matched analysis showed that the in-hospital mortality difference was significant (p = 0.014) and the Kaplan-Meier survival analysis revealed a higher survival rate to discharge (p < 0.001 by log-rank test), both favoring thoracoscopy over nonoperative drainage. CONCLUSION Acute thoracic empyema carries a high mortality rate, especially in elderly patients with coexisting medical conditions and polymicrobial and positive bacterial cultures. Our study results also showed that thoracoscopy is feasible and might provide better chances for survival in borderline operable patients than nonoperative drainage.
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Affiliation(s)
- Ke-Cheng Chen
- Institute of Biomedical Engineering, College of Engineering, National Taiwan University, Taipei, Taiwan; College of Medicine, National Taiwan University, Taipei, Taiwan; Department of Surgery, National Taiwan University Hospital Yun-Lin Branch, Yun-Lin County, Dou-Liou, Taiwan; Department of Surgery, National Taiwan University Hospital, National Taiwan University College of Medicine, Taipei, Taiwan
| | - Hsuan-Yu Chen
- Institute of Statistical Science, Academia Sinica, Taipei, Taiwan
| | - Jou-Wei Lin
- Cardiovascular Center and Health Management Center, National Taiwan University Hospital Yun-Lin Branch, Yun-Lin County, Dou-Liou, Taiwan
| | - Yu-Ting Tseng
- Department of Surgery, National Taiwan University Hospital Yun-Lin Branch, Yun-Lin County, Dou-Liou, Taiwan
| | - Shuenn-Wen Kuo
- Department of Surgery, National Taiwan University Hospital, National Taiwan University College of Medicine, Taipei, Taiwan
| | - Pei-Ming Huang
- Department of Surgery, National Taiwan University Hospital, National Taiwan University College of Medicine, Taipei, Taiwan
| | - Hsao-Hsun Hsu
- Department of Surgery, National Taiwan University Hospital, National Taiwan University College of Medicine, Taipei, Taiwan
| | - Jang-Ming Lee
- Department of Surgery, National Taiwan University Hospital, National Taiwan University College of Medicine, Taipei, Taiwan.
| | - Jin-Shing Chen
- Department of Surgery, National Taiwan University Hospital Yun-Lin Branch, Yun-Lin County, Dou-Liou, Taiwan; Department of Surgery, National Taiwan University Hospital, National Taiwan University College of Medicine, Taipei, Taiwan.
| | - Hong-Shiee Lai
- Department of Surgery, National Taiwan University Hospital, National Taiwan University College of Medicine, Taipei, Taiwan.
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D'Cunha J, James M, Antonoff MB, Green CA, Andrade RS, Maddaus MA, Beilman GJ. Descending necrotizing mediastinitis: a modified algorithmic approach to define a new standard of care. Surg Infect (Larchmt) 2013; 14:525-31. [PMID: 24351133 DOI: 10.1089/sur.2012.079] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Descending necrotizing mediastinitis (DNM) is a highly morbid infectious process. This uncommon disease process has carried historically a substantial burden of morbidity and mortality. In this study we hypothesized that application of a prospective modified management algorithm would decrease the morbidity and mortality from this highly destructive process. METHODS We developed a systematic approach for managing DNM, focusing on serial debridement guided by imaging, in conjunction with the use of broad-spectrum antibiotics and modern principles of critical care. We reviewed all patients admitted with this disease process from 2007-2012. Data collected included demographic information, co-morbidities, laboratory data including culture results, operative details, imaging frequency and findings, complications, and survival. Continuous variables were reported as median values and ranges. RESULTS From 2007-2010, we treated eight patients with DNM. The median age of the patients was 33 y (range 28-63 y), and 63% were male. In accordance with our algorithm, the patients underwent serial imaging at regular intervals following operative debridement. The median number of imaging studies was 11 (range 4-19). The patients required a median of five operative debridements (range 1-15). In five patients, drainage was necessary through a cervical exploration. A thoracic approach was required in six patients (two thoracoscopic, four via thoracotomy). Additional procedures included thymectomy (n=2), anterior mediastinotomy, carotid sheath exploration and resections of the clavicle, first rib, manubrium, pectoralis major muscle, and sternocleidomastoid muscle. The most common etiologic agents were Peptostreptococcus spp. and Streptococcus anginosus. Study patients received a median of six different antibiotics (range 2-10) for a total of 42 d (range 34-55 d). These patients were hospitalized for a median of 29 days (range 16-56 d), with 15 d (range 7-48 d) spent in the intensive care unit. Remarkably, the rate of survival was 100% (median follow-up of 33 mo). The patients developed no major complications, required no re-admissions, and had no re-infections. CONCLUSIONS We applied an algorithmic approach to the treatment of DNM, consisting of aggressive operative debridement and enhanced by equally aggressive imaging. Our patients had excellent outcomes despite the widely known lethality of DNM. An aggressive approach may decrease complications and improve survival in this devastating disease process. Furthermore, our prospective experience with DNM suggests that this algorithm used in the present study should be the standard for managing patients with this challenging condition.
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Affiliation(s)
- Jonathan D'Cunha
- 1 Division of Thoracic and Foregut Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh , Pittsburgh, Pennsylvania
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Abstract
Infectious, traumatic, or neoplastic processes in the chest often result in fluid collections within the pleural, parenchymal, or mediastinal spaces. The same fundamental principles that guide drainages of the abdomen can be applied to the chest. This review discusses various pathologic conditions of the thorax that can result in the abnormal accumulation of fluid or air, and their management using image-guided methods.
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Affiliation(s)
- Shaunagh McDermott
- Division of Abdominal Imaging and Interventional Radiology, Department of Radiology, Massachusetts General Hospital, Boston, Massachusetts
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Lee MK, Choi SH, Ryu DW. Descending necrotizing Mediastinitis caused by Kocuria rosea: a case report. BMC Infect Dis 2013; 13:475. [PMID: 24112281 PMCID: PMC3852562 DOI: 10.1186/1471-2334-13-475] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2013] [Accepted: 09/24/2013] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND Kocuria species are gram-positive, non-pathogenic commensals. However, in immunocompromised patients such as transplant recipients, cancer patients, or patients with chronic medical conditions, they can cause opportunistic infections. CASE PRESENTATION We report the first case of descending necrotizing mediastinitis in a 58-year-old, relatively healthy woman caused by Kocuria rosea. CONCLUSION Descending necrotizing mediastinitis due to Kocuria rosea can be successfully treated with prompt surgical drainage combined with antimicrobial therapy.
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Affiliation(s)
- Mi Kyung Lee
- Department of Thoracic and Cardiovascular Surgery, College of Medicine, Wonkwang University, Shinyong-dong 344-2, Iksan, Jeonbuk, Republic of Korea.
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Dajer-Fadel WL, Ibarra-Pérez C, Sánchez-Velázquez LD, Borrego-Borrego R, Navarro-Reynoso FP, Argüero-Sánchez R. Descending necrotizing mediastinitis below the tracheal carina. Asian Cardiovasc Thorac Ann 2013; 22:176-82. [PMID: 24585789 DOI: 10.1177/0218492313485589] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND Descending necrotizing mediastinitis is a dreadful disease with a high mortality rate, particularly when below the tracheal carina. This study describes the epidemiologic, clinical, and paraclinical features of patients treated for this condition. METHODS We performed a single-center retrospective descriptive review of 60 patients with descending necrotizing mediastinitis below the tracheal carina, who were treated during a 7-year period, the largest study in the last 50 years. Demographic, clinical, paraclinical, and therapeutic variables were analyzed. RESULTS 43 (71.7%) patients were male. The mean age was 41.2 ± 14.7 years. Mean hospital length of stay was 25.0 ± 19.8 days. Comorbidities were present in 46.7% of patients, diabetes mellitus being the most common. Odontogenic infections (45%) were the most frequent source of descending necrotizing mediastinitis. Cultures showed Gram-negative bacilli in 68.3%, Gram-positive cocci in 38.3%, and fungi in 6.7%. Mortality was 35% (21 patients); risk factors for mortality were age (>35 years), diabetes mellitus among other comorbidities, and associated complications. CONCLUSIONS In this low socioeconomic status patient population, descending necrotizing mediastinitis below the carina causes high morbidity and mortality, the latter particularly associated with age, complications, diabetes mellitus and other comorbidities.
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Nei T, Inai S, Mikami I, Sato A, Okamoto J, Yokoshima K, Nakamizo M, Haraguchi S, Sonobe K, Saito R. Descending necrotizing mediastinitis associated with Lactobacillus plantarum. BMC Infect Dis 2013; 13:398. [PMID: 23987907 PMCID: PMC3847138 DOI: 10.1186/1471-2334-13-398] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2013] [Accepted: 08/28/2013] [Indexed: 12/02/2022] Open
Abstract
Background Descending necrotizing mediastinitis (DNM), a severe infection with a high fatality rate, develops in mediastinal spaces due mainly to deep cervical abscesses. The majority of causative microbes of DNM are Streptococci and oral anaerobes. DNM associated with Lactobacillus-infection is rather rare. Case presentation A 69-year-old male with an unremarkable past medical history was referred to our hospital for surgical resection of advanced laryngeal cancer. Full examination revealed a neck abscess and DNM with a background of untreated diabetes mellitus. Initially, he was treated with meropenem. However, Lactobacillus plantarum was isolated from surgical drainage of a mediastinal abscess. Despite using antibiotics capable of eradicating all isolates with susceptibilities not differing significantly from those of the neck and mediastinal abscesses, we attributed DNM to the L. plantarum detected only in the mediastinal abscess. After DNM treatment, he underwent total pharyngolaryngectomy with bilateral neck dissection followed by reconstruction using free jejunum. He was discharged fully recovered. Conclusion We concluded that L. plantarum as the sole cause of the mediastinal abscess in the present case cannot be ruled out. As the number of immunocompromised patients increases, we should be cautious regarding this “familiar” microbe.
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Affiliation(s)
- Takahito Nei
- Department of Infection Control and Prevention, Nippon Medical School, 1-1-5 Sendagi, Bunkyo-ku, Tokyo 113-8603, Japan.
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Vural FS, Girdwood RW, Patel AR, Zigiriadis E. Descending mediastinitis. Asian Cardiovasc Thorac Ann 2012; 20:304-7. [PMID: 22718719 DOI: 10.1177/0218492311434088] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
We studied 13 patients with mediastinal abscesses caused by oropharyngeal infections, who presented between April 2007 and June 2011. All patients were operated on after maxillofacial and ear, nose and throat surgeons had treated the primary source and drained all collections in the neck. Thoracic surgery was performed in the same session. Anterior mediastinal collections were drained via a small mediastinotomy. Posterior collections were approached via a thoracotomy. Chest computed tomography was essential to delineate the extent of disease. A thoracotomy approach was used in 7 patients; 2 of them required an anterior mediastinotomy on the opposite side. The others had an anterior mediastinotomy which was bilateral in 2 cases. After repeat computed tomography, 5 patients were operated on for suspected new loculations; tissue edema had caused false imaging in 3 of them. There was no mortality. Early after eradication of the source and pathways to the mediastinum, gravity drainage of mediastinal abscesses, and good antibiotic cover, with repeat computed tomography after 3 days, was an effective approach in this highly fatal disease.
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Affiliation(s)
- Fikret S Vural
- Division of Cardiothoracic Surgery, Charlotte Maxeke Johannesburg Academic Hospital, University of the Witwatersrand, Johannesburg, South Africa
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Jabłoński S, Brocki M, Kordiak J, Misiak P, Terlecki A, Kozakiewicz M. Acute mediastinitis: evaluation of clinical risk factors for death in surgically treated patients. ANZ J Surg 2012; 83:657-63. [DOI: 10.1111/j.1445-2197.2012.06252.x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/03/2012] [Indexed: 11/29/2022]
Affiliation(s)
- Sławomir Jabłoński
- Department of Thoracic Surgery, General and Oncological Surgery; Medical University of Lodz; Łódź; Poland
| | - Marian Brocki
- Department of Thoracic Surgery, General and Oncological Surgery; Medical University of Lodz; Łódź; Poland
| | - Jacek Kordiak
- Department of Thoracic Surgery, General and Oncological Surgery; Medical University of Lodz; Łódź; Poland
| | - Piotr Misiak
- Department of Thoracic Surgery, General and Oncological Surgery; Medical University of Lodz; Łódź; Poland
| | - Artur Terlecki
- Department of Thoracic Surgery, General and Oncological Surgery; Medical University of Lodz; Łódź; Poland
| | - Marcin Kozakiewicz
- Department of Faciomaxillary Surgery; Medical University of Lodz; Łódź; Poland
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Ishinaga H, Otsu K, Sakaida H, Miyamura T, Nakamura S, Kitano M, Tenpaku H, Takao M, Kobayashi M, Takeuchi K. Descending necrotizing mediastinitis from deep neck infection. Eur Arch Otorhinolaryngol 2012; 270:1463-6. [DOI: 10.1007/s00405-012-2182-5] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2012] [Accepted: 09/06/2012] [Indexed: 11/30/2022]
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Xu QY, Yin GW, Chen SX, Jiang F, Bai XJ, Wu JD. Fluoroscopically guided nose tube drainage of mediastinal abscesses in post-operative gastro-oesophageal anastomotic leakage. Br J Radiol 2012; 85:1477-81. [PMID: 22806622 DOI: 10.1259/bjr/53905073] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
OBJECTIVE The aim of this study was to retrospectively evaluate the technical success rates and clinical effectiveness of fluoroscopically guided nose tube drainage of mediastinal abscesses and a nasojejunum feeding tube in post-operative gastro-oesophageal anastomotic leakage (GEAL). METHODS From January 2006 to June 2011, 18 cases of post-operative GEAL with mediastinal abscesses after oesophagectomy with intrathoracic oesophagogastric anastomotic procedures for oesophageal and cardiac carcinoma were treated by insertion of a nose drainage tube and nasojejunum feeding tube under fluoroscopic guidance. We evaluated the feasibility of two-tube insertion to facilitate leakage site closure and complete resolution of the abscess, and the patients' nutritional benefit was also evaluated by checking the serum albumin level between pre- and post-enteral feeding via the feeding tube. RESULTS The two tubes were placed successfully under fluoroscopic guidance in 18 patients (100%). The procedure time for two-tube insertion ranged from 20 to 40 min (mean 30 min). 17 patients (94%) achieved leakage site closure after two-tube insertion and had a good tolerance of two tubes in the nasal cavity. The serum albumin level was significant, increased from pre-enteral feeding (2.49 ± 0.42 g dl(-1)) to the post-enteral feeding (3.58 ± 0.47 g dl(-1)) via the feeding tube (p<0.001). The duration of follow-up ranged from 1 to 49 months (mean 19 months). CONCLUSION The insertion of nose tube drainage and a nasojejunum feeding tube under fluoroscopic guidance is safe, and it provides effective relief from mediastinal abscesses in GEAL after oesophagectomy. Moreover, our findings indicate that two-tube insertion may be used as a selective procedure to treat mediastinal abscesses in post-operative GEAL. Advances in knowledge Directive drainage of mediastinal abscesses in post-operative GEAL may be an effective treatment.
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Affiliation(s)
- Q Y Xu
- Department of Interventional Radiology, Cancer Hospital of Jiangsu Province, Cancer Institution of Jiangsu Province, Nanjing, China
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Kocher GJ, Hoksch B, Caversaccio M, Wiegand J, Schmid RA. Diffuse descending necrotizing mediastinitis: surgical therapy and outcome in a single-centre series. Eur J Cardiothorac Surg 2012; 42:e66-72. [DOI: 10.1093/ejcts/ezs385] [Citation(s) in RCA: 55] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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Erkmen CP, Wang H, Czum J, Paydarfar JA. Use of cervicothoracic anatomy as a guide for directed drainage of descending necrotizing mediastinitis. Ann Thorac Surg 2012; 93:1293-4. [PMID: 22450079 DOI: 10.1016/j.athoracsur.2011.08.081] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2011] [Revised: 08/18/2011] [Accepted: 08/30/2011] [Indexed: 11/30/2022]
Abstract
Descending necrotizing mediastinitis is a potentially lethal infection originating from the oropharynx. Adequate abscess drainage is crucial to successful treatment. We present novel management of descending necrotizing mediastinitis using a series of anterior mediastinal incisions adjoined by Penrose drains. The success of this treatment was dependent on radiographic documentation of infection confined to the anterior cervicothoracic plane.
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Affiliation(s)
- Cherie Parungo Erkmen
- Division of Cardiothoracic Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire 03756-0001, USA.
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Chen KC, Lin JW, Tseng YT, Kuo SW, Huang PM, Hsu HH, Lee JM, Chen JS. Thoracic empyema in patients with liver cirrhosis: clinical characteristics and outcome analysis of thoracoscopic management. J Thorac Cardiovasc Surg 2012; 143:1144-51. [PMID: 22244554 DOI: 10.1016/j.jtcvs.2011.12.024] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/12/2011] [Revised: 11/09/2011] [Accepted: 12/14/2011] [Indexed: 12/21/2022]
Abstract
OBJECTIVE Thoracic empyema in cirrhotic patients is a challenging situation, and the clinical characteristics are rarely reported. The objective of this study was to report the clinical characteristics among this group and to evaluate whether thoracoscopic intervention would affect clinical outcomes. METHODS Between 2001 and 2010, we retrospectively reviewed the clinical characteristics, bacteriologic studies, and treatment outcomes of 63 cirrhotic patients with thoracic empyema. A propensity-score based process, matched on age, sex, diabetes mellitus, malignancy, cause, and Child-Pugh classification (A, B, or C), was performed to equalize potential prognostic factors in thoracoscopy and nonthoracoscopy groups. The Kaplan-Meier curve and log-rank test were applied to compare the survival to discharge between the 2 matched groups. RESULTS The median patient age was 61 years. Thirty-two patients (51%) underwent thoracoscopic management, and the remaining patients underwent thoracocentesis or tube thoracostomy. The median hospital stay was 28 days, and 19 patients (30%) had in-hospital mortality. Multivariate analysis showed that Child-Pugh C disease and positive blood cultures were risk factors for in-hospital mortality (P = .016 and .027, respectively), whereas thoracoscopic management may be favorable for survival (P = .041). The propensity score-matched analysis showed a significant reduction in intensive care unit stay (P = .044) in the thoracoscopy group. Kaplan-Meier survival analysis revealed a higher survival to discharge, favoring thoracoscopy over non-thoracoscopy treatment (P = .035). CONCLUSIONS Management of thoracic empyema in cirrhotic patients is complicated and associated with a high mortality. With proper patient selection, thoracoscopic management is feasible and may provide a better chance of survival.
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Affiliation(s)
- Ke-Cheng Chen
- Department of Surgery, National Taiwan University Hospital Yun-Lin Branch, Yun-Lin County, Taiwan
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Petitpas F, Blancal JP, Mateo J, Farhat I, Naija W, Porcher R, Beigelman C, Boudiaf M, Payen D, Herman P, Mebazaa A. Factors associated with the mediastinal spread of cervical necrotizing fasciitis. Ann Thorac Surg 2011; 93:234-8. [PMID: 22115335 DOI: 10.1016/j.athoracsur.2011.09.012] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2011] [Revised: 08/31/2011] [Accepted: 09/02/2011] [Indexed: 11/25/2022]
Abstract
BACKGROUND We conducted a study to determine factors associated with the occurrence of mediastinitis in patients hospitalized for cervical necrotizing fasciitis (CNF). METHODS We reviewed the medical records of 130 consecutive patients in an intensive care unit (ICU) who were hospitalized with a diagnosis of CNF. Two radiologists reviewed cervical and thoracic computed tomography (CT) scans to determine the source and extension of the infection in each patient. RESULTS Among the cohort of 130 patients with CNF, 37 (28%) had mediastinitis at the time of their admission (which in 13 cases was superior, or above the aortic arch, and in 24 cases inferior). Cervical necrotizing fasciitis complicated by mediastinitis resulted in a longer stay in the ICU than did CNF without mediastinitis, of a mean of 29 days (range, 18 to 39 days) versus 14 days (range, 9 to 19) days, respectively (p<0.0001). Multivariate analysis revealed that the presence of mediastinitis was associated with oral intake of glucocorticoids before admission (odds ratio [OR], 2.17; range, 0.99 to 4.76), a pharyngeal focus of CNF (OR, 2.17; range, 1.04 to 4.53), or gas seen on an initial CT scan (OR, 4.49; range, 2.15 to 9.38). Both a pharyngeal focus of fasciitis and the presence of gas were strong independent predictors of inferior mediastinitis (OR, 15.1; range, 4.9 to 46.4; p<0.0001). CONCLUSIONS The present study is the first to describe three independent factors associated with extension of cervical fasciitis to the thoracic cavity, including glucocorticoid intake before admission, and confirms previous reports of a high incidence of mediastinitis in patients with CNF.
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Affiliation(s)
- Franck Petitpas
- Department of Anesthesiology and Critical Care, Lariboisière University Hospital, and University Paris 7, Paris, France
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Haremza C, De Dominicis F, Merlusca G, Berna P. Successfully treated descending necrotizing mediastinitis through thoracotomy using a pedicled muscular serratus anterior flap. Interact Cardiovasc Thorac Surg 2011; 13:456-8. [PMID: 21791516 DOI: 10.1510/icvts.2011.273813] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
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.
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Affiliation(s)
- Céline Haremza
- Department of Thoracic and Vascular Surgery, Amiens South Hospital, University of Picardie, Place Victor Pauchet, 80054 Amiens, Cedex 01, France
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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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González-García R, Risco-Rojas R, Román-Romero L, Moreno-García C, López García C. Descending necrotizing mediastinitis following dental extraction. Radiological features and surgical treatment considerations. J Craniomaxillofac Surg 2011; 39:335-9. [DOI: 10.1016/j.jcms.2010.10.001] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2010] [Revised: 08/21/2010] [Accepted: 10/04/2010] [Indexed: 11/16/2022] Open
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Video Assisted Thoracoscopic Surgery Is a Valuable Approach for the Management of Descending Necrotizing Mediastinitis. Ann Surg 2011; 253:1055; author reply 1055-6. [DOI: 10.1097/sla.0b013e3182172e6b] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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Arellano RS, Gervais DA, Mueller PR. Computed tomography-guided drainage of mediastinal abscesses: clinical experience with 23 patients. J Vasc Interv Radiol 2011; 22:673-7. [PMID: 21439848 DOI: 10.1016/j.jvir.2011.01.427] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2010] [Revised: 12/20/2010] [Accepted: 01/11/2011] [Indexed: 11/30/2022] Open
Abstract
PURPOSE To evaluate the technical and clinical success rates of computed tomography (CT)-guided percutaneous drainage of mediastinal abscesses. MATERIALS AND METHODS An interventional radiology database was used to identify patients who underwent CT-guided percutaneous drainage of mediastinal abscesses. Medical records were reviewed to evaluate abscess etiology, drainage technique, clinical outcome, and complications. RESULTS Over a 10-year period, 23 patients (20 men; average age, 54 y; range, 34-77 y) with 24 mediastinal abscesses underwent 25 CT-guided drainage procedures. Abscess etiologies included esophageal leak after esophagectomy (n = 6), perforated esophageal cancer (n = 4), Nissen fundoplication (n = 3), emetogenic esophageal rupture (n = 3), infectious (n = 2), cardiac surgery (n = 1), iatrogenic (n = 1), gastric strangulation (n = 1), Whipple procedure (n = 1), and thoracotomy for lung cancer (n = 1). Drainages were performed with tandem trocar (n = 14) or Seldinger (n = 11) technique. A total of 25 catheters were used: 8.5 F (n = 9), 10 F (n = 8), 12 F (n = 6), 14 F (n = 1), and 16 F (n = 1). The mean time of catheter drainage was 13.6 days. Technical success was achieved in all 25 attempts (100%). Twenty-two of the 23 patients had complete resolution of the abscess without the need for surgical debridement, for a clinical success rate of 95.6%. One patient underwent technically and clinically successful abscess drainage but required surgical exploration for repair of an anastomotic leak after esophagogastrectomy. There was one complication. One patient had inadvertent placement of a catheter within a pulmonary vein. The catheter was removed after 24 hours without hemodynamic consequences. CONCLUSIONS Percutaneous CT-guided drainage of mediastinal abscesses is an uncommon procedure, but the results of this study suggest that it is associated with high technical and clinical success rates.
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Affiliation(s)
- Ronald S Arellano
- Department of Radiology, Division of Abdominal Imaging and Intervention, Massachusetts General Hospital, 55 Fruit St., White 270, Boston, MA 02114, USA.
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Wang KY, Lin HJ, Chen YH. Retropharyngeal abscess with descending necrotizing mediastinitis. J Emerg Med 2010; 43:114-5. [PMID: 20566262 DOI: 10.1016/j.jemermed.2010.04.028] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2009] [Revised: 12/20/2009] [Accepted: 04/04/2010] [Indexed: 11/19/2022]
Affiliation(s)
- Kai-Yuan Wang
- Department of Emergency Medicine, Chi-Mei Medical Center, Yong Kang City, Tainan, Taiwan, R.O.C
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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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