Descending necrotizing mediastinitis: An analysis of the effects of serial surgical debridement on patient mortality

A global science mapping analysis on odontogenic infections

OBJECTIVES

Odontogenic infections are common and a topic of core interest for dentists, and maxillofacial surgeons. The aim of this study was to conduct a bibliometric analysis of the global literature on odontogenic infection and explore the top 100 most cited papers to identify the common causes, sequelae and management trends.

METHODS

Following a comprehensive literature search, a list of top 100 most cited papers was created. The VOSviewer software (Leiden University, The Netherlands) was used to create a graphical representation of the data, and statistical analyses were performed to analyze the characteristics of the top 100 most cited papers.

RESULTS

A total of 1,661 articles were retrieved with the first article published in 1947. There is an exponential upward trend on the number of publications (R2 = 0.919) and a majority of papers are in English language (n = 1,577, 94.94%). A total of 22,041 citations were found with a mean of 13.27 per article. The highest number of publications were recorded from developed countries. There was a male predilection in the reported cases and the most common sites included the submandibular and parapharyngeal spaces. Diabetes mellitus was identified as the commonest co-morbidity. Surgical drainage was ascertained to be the preferred method of management.

CONCLUSIONS

Odontogenic infections remain prevalent and have a global distribution. Although prevention of odontogenic infection through meticulous dental care is ideal, early diagnosis and prompt management of established odontogenic infections is important to avoid morbidities and mortality. Surgical drainage is the most effective management strategy. There is lack of consensus regarding the role of antibiotics in the management of odontogenic infections.

Surgical therapy and outcome of descending necrotizing mediastinitis in Chinese: a single-center series

Background

Descending Necrotizing Mediastinitis (DNM) is an acute and often fatal infection that affects the neck and mediastinum. DNM treatment consists of broad-spectrum antibiotics, early diagnosis, and surgical debridement with multidisciplinary cooperation. However, owing to the rarity and complexity of this disease, the mortality rate is high. This retrospective study analyzed a single-center experience of managing DNM in Chinese patients over the last 10 years.

Methods

A single-center, retrospective, observational, and descriptive study was conducted on 31 patients with DNM at Peking Union Medical College Hospital from 2012 to 2022. Case report forms were used to collect data which were then analyzed with a focus on surgical management and outcomes.

Results

This study examined the outcomes of 31 patients diagnosed with DNM at our hospital. The most common comorbidities on admission were hypertension (48%) and diabetes mellitus (42%). The degree of diffusion of DNM according to Endo's classification was classified as follows: type I in 7 patients (22.6%), type IIA in 5 (16.1%), and type IIB in 19 patients (61.3%). Among these patients, 13 (41.9%) were found to have a single microbial infection, while 16 (51.6%) were found to have polymicrobial infections. In all cases, neck drainage was performed via cervicotomy, with multiple drains (64.5%) and vacuum sealing drainage (VSD) (35.5%). Mediastinal drainage was performed via a cervical mediastinotomy (51.6%), video-assisted thoracic surgery (VATS) (41.9%), or thoracotomy (6.5%). The 30-day mortality rate was 25.8% and 24.0 days of the average length of hospital stay.

Conclusion

Early accurate diagnosis and timely intervention have been shown to be correlated with a positive prognosis. Cervicothoracic CT (computed tomography) is essential for the diagnosis, staging, and evaluation of the optimal surgical treatment. Cervicotomy and video-assisted thoracoscopic surgery with percutaneous drainage is effective, even in advanced cases. Additionally, the application of VSD in cervical incision did not improve prognosis but may shorten the length of ICU (intensive care unit) and hospital stays.

Demographic, clinical, and paraclinical features of patients operated with the diagnosis of acute descending necrotizing mediastinitis: a retrospective study in Southern Iran

INTRODUCTION

Descending necrotizing mediastinitis (DNM) is a type of acute mediastinitis that is rarely reported but is regarded as a fatal disease despite improvements in technological methods and antibiotic therapies. We aimed to determine the demographic, clinical, and paraclinical features of patients diagnosed with acute DNM.

METHODS

In this retrospective study, patients' hospital records with a diagnosis of DNM admitted to the Namazi hospital in southern Iran during 18 years (2002-2019) were reviewed. Demographic and clinical features were recorded and subsequently analyzed via SPSS 22.

RESULTS

Out of 67 mediastinitis patients, 25 (37.3%) were diagnosed as DNM with an average age of 37.2 ± 16.7 years, and 68% were male. Regarding etiology, 52.0% were due to neck infection. Based on the technique of surgery, 52% of the patients underwent the combined method, which was mostly among type I and IIA DNM, while thoracotomy was mostly performed on type IIB DNM (P = 0.08). Based on the incision, type IIA and IIB had the highest frequency of thoracotomy and cervicothoracic incisions (P = 0.02 and 0.002). Puss discharge was significantly lower in type I DNM (P = 0.01). Based on the presenting symptoms of our patients, the majority (72.0%) had a chief complaint of neck pain, followed by chills and fever (48%). There were no reports of mortality during our short-term follow-up.

CONCLUSION

We report one of the largest retrospective studies of DNM patients in our referral center, with a high prevalence of the disease among younger populations, especially under 40 years. The method of treatment should be chosen based on the extent of infection and can be limited to neck exploration in upper mediastinal infections, though thoracic or combined approach in more broad infections.

Surgical management of descending necrotizing mediastinitis: strategy for thoracic interference

BACKGROUND

The present descriptive study shares the overall experience of treating all these patients where different surgical process was adopted depending on the treatment required after carefully evaluating the risk factors and comorbidities.

METHODS

The present study was conducted at the Department of Thoracic Surgery, Choray Hospital, Vietnam between the period of 2010 to 2020. We have treated 95 patients altogether in this duration.

RESULTS

We were able to save most of the patients by applying thoracotomy and thoracic irrigation for most of the patients based on the observed indications that were identified immediately after the compulsory standard cervicotomy. The indication for thoracic interference was considered when the infection was deeply spread into the mediastinum and cannot get out through cervicotomy, although the most effective method of drainage was applied.

CONCLUSION

Our statistical investigation of the patient data suggested the possible association and influence of comorbidity such as diabetes. Therefore, we recommend that in specific cases thoracotomy along with thoracic irrigation and repetitive surgical draining could be a better option to reduce the infection and the mortality rate.

TRIAL REGISTRATION

Retrospectively registered.

Efficacy of Continuous Saline Irrigation Therapy for Descending Necrotizing Mediastinitis

Objectives  Descending necrotizing mediastinitis (DNM) is a poor prognosis disease. This study aims to examine the patient background and treatment of DNM and to identify more effective treatments for DNM. Methods  The patient background and treatment of 11 patients who underwent surgery for DNM between November 2010 and June 2021 were studied. The patients were divided into six patients who underwent continuous saline irrigation (group I) and five patients who did not (group N). The differences in the drainage duration and length of hospital stay between the two groups were retrospectively investigated. Results  Eleven patients were treated for DNM: six male and five female, with a median age of 61 years (35-79). Comorbidities included diabetes mellitus in three cases; one patient was administered steroids. The pathways of occurrence were anterior tracheal gap/vascular visceral gap/posterior visceral gap in group I (2/1/2) and group N (0/2/4). Progression was I/IIA/IIB according to Endo's classification in group I (1/1/4) and group N (3/1/1). The mean duration of irrigation was 9.0 ± 3.7 days, and the drainage duration in group I was 17.5 ± 8.2 days, which was significantly shorter than 31 ± 13.6 days in group N ( p  < 0.048). The hospital stays in group I was 29.3 ± 8.4 days, which was significantly shorter than that in group N (68 ± 27.1 days; p  < 0.015). Conclusions  Irrigation therapy significantly shortened the drainage duration and hospital stay. Irrigation is a useful treatment for DNM.

Head and Neck Necrotizing Fasciitis: Abbreviated SOFA Score Associated With Death and Infection Spread

Objective

Describe features unique to head and neck (H&N) necrotizing fasciitis (NF) compared to other anatomic regions and specify a prognostic score associated with death and descending necrotizing mediastinitis (DNM).

Study Design

Retrospective cohort.

Setting

Tertiary care, level 1 trauma center.

Methods

A single-institution database identified 399 confirmed cases of NF between 2006 and 2021, 33 of which involved the H&N. Patients with confirmed H&N NF were sorted into cohorts based on clinical outcomes, with the "poor" outcomes group defined by death and/or DNM.

Results

Thirty-three patients with H&N NF were included. Compared to NF of other regions, patients with H&N NF had a significantly lower mortality rate (6.06% vs 20.8%, p = .041) and significantly lower rates of obesity (27.3% vs 63.7%, p < .001) and hypertension (42.4% vs 60.9%, p = .038). Within the H&N group, there were 2 deaths (6.06%) and 8 cases of DNM (24.2%). Diabetes was associated with poor outcomes (p = .047), as was an abbreviated sequential organ failure assessment score for necrotizing fasciitis (nfSOFA) of 2 or greater (p = .015).

Conclusion

H&N NF is unique among other forms of NF, with a lower mortality rate and lower rates of obesity and hypertension in affected patients. Within the H&N cohort, worse outcomes were associated with diabetes as well as a nfSOFA score of 2 or greater. Timely surgical debridement alongside broad-spectrum antibiotics remains the mainstay of treatment for NF; however, this simple prognostic score may play a role during the early stages of care for patients with H&N NF.

Trends and Outcome of Aggressive Fascial Space Infections

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.

A case of descending necrotizing mediastinitis complicated by internal jugular thrombosis in a setting of MRSA bacteremia

BACKGROUND

Acute Descending Necrotizing Mediastinitis is a rare but serious illness that carries a high mortality rate. It is not commonly part of the Emergency Physician's differential diagnoses for the chief complaint of chest pain when there has been no recent instrumentation to the area. Because the disease is so uncommon, there is a relative paucity of reports of the illness.

CASE REPORT

We report the case of a 58-year-old male with a past medical history of HIV and history of intravenous drug use (IVDU) who presented to the Emergency Department with anterior chest pain for several days in addition to 3 days of fever and chills. The patient's presentation raised concern for intrathoracic infection and the diagnosis of Descending Necrotizing Mediastinitis complicated by internal jugular thrombosis was confirmed by contrast enhanced computed tomography and sonography.

New improved incision-tubing approach for bronchoesophageal Fistula with mediastinal abscess after esophagectomy: A case report

Bronchoesophageal fistula is a serious threat to the survival after esophagectomy for esophageal cancer. The erosion of mediastinal abscess post anastomotic leakage is the most likely directly cause. However, the bronchoesophageal fistula with gastric conduit necrosis and mediastinal abscess is refractory to either surgical or conservative treatment. In the article, a unique case of Bronchoesophageal fistula with mediastinal abscess after gastric conduit necrosis is presented. A 74-year-old female was detected the right inferior bronchus-esophageal fistula with mediastinal abscess on 15 postoperative day after esophagectomy for esophageal cancer. A successful new improved minimally invasive management was performed.

The Alar Fascia and Danger Space: A Modern Review

PURPOSE

Given the advancements in dissection modalities over the last decade, what is the current understanding of the alar fascia and its clinical implications as an access point into the danger space (DS)? The aim of the study is to provide an updated review of the alar fascia and danger space.

METHODS

A comprehensive search of the alar fascia and danger space was performed through PubMed databases up to August 2022. Thirty-two sagittal E12 sheet plastination slices of the head and neck were analyzed under a stereomicroscope to assess the morphology and continuity of the retropharyngeal, alar, and prevertebral fasciae (PVF and their respective potential spaces).

RESULTS

Recent advancements have provided evidence that the alar fascia is a true fascial layer between the retropharyngeal and danger spaces within the deep cervical region. Although its composition, histological features, and borders remain topics of controversy, the alar fascia is comprised of dense connective tissue and may serve as a physical barrier to prevent the spread of infection into the danger space. Complications arising from deep neck infections that invade the danger space include mediastinitis, necrotizing fasciitis, and empyema.

CONCLUSION

A proper understanding of the anatomy, structure, function, and potential spaces is crucial to assessing the alar fascia and danger space routinely in clinical practice, especially when imaging.

Management of descending necrotizing mediastinitis with severe thoracic empyema using minimally invasive video-assisted thoracoscopic surgery: a case report

BACKGROUND

Descending necrotizing mediastinitis (DNM) is a rare but serious complication of odontogenic or pharyngeal infection spreading into the mediastinum. Very few childhood cases of DNM have been described.

CASE DESCRIPTION

We report a case of DNM complicated with severe thoracic empyema in a previously healthy 6-year-old girl who was successfully treated using minimally invasive video-assisted thoracoscopic surgery (VATS). The patient presented with odynophagia and dental pain, followed by rapid clinical deterioration including high fever, tachypnea, and left chest pain. As chest computed tomography (CT) revealed features of DNM, she was transferred from the local hospital to our hospital for intensive care. Empirical treatment was started with meropenem and linezolid. However, her tachypnea and dyspnea progressed rapidly. An ultrasound-guided left-sided thoracentesis drained 80 mL of brown sticky pus and the pus culture yielded Streptococcus constellatus. A contrast-enhanced CT scan demonstrated large mediastinal abscess and severe thoracic empyema. We performed debridement and drainage of the mediastinum and pleura using VATS. She recovered and was discharged on hospital day 18.

CONCLUSIONS

Early diagnosis by cervicothoracic CT and multidisciplinary approaches including intensive care, broad-spectrum antibiotics, and aggressive surgical intervention are crucial to reducing morbidity and mortality. VATS is a minimally invasive and appropriate treatment strategy for children with DNM, especially complicated with thoracic empyema.

Unveiling the Pathogenic Bacteria Causing Descending Necrotizing Mediastinitis

The combination of maxillofacial infections (MI) with descending necrotizing mediastinitis (DNM) is a complex disease characterized by rapid development and high mortality. Here, we performed metagenomic next-generation sequencing (mNGS) using samples from 21 patients with MI and eight patients with DNM. In this study, we found that the species richness of the DNM group was higher than that of the MI group, and the species diversity of the DNM group was higher than that of the MI group, with no statistically significant differences between groups (P > 0.05). LefSE analysis revealed that the main species differing between groups were Bacillus, Lactobacillus, Streptococcaceae, and Streptococcus (S. constellatus and S. anginosus). In addition, the PLS-DA analysis revealed that the dominant groups in the DNM group at the species level were S. constellatus, S. anginosus, Streptococcus intermedius, Prevotella oris, Mogibacterium timidum, and Eubacterium nodatum. Next, we correlated the clinical characteristics of the patients with the relative abundance of the pathogens identified in the LefSe and PLS-DA analyses. The relative abundance of S. anginosus was positively correlated with C-reactive protein (CRP) and calcitoninogen (PCT) but negatively correlated with the percentage of lymphocytes (Lymph%) (P < 0.05). On the other hand, M. timidum was positively correlated with the percentage of neutrophils (Neut%) and glycated hemoglobin (GLU) (P < 0.05), and Parvimonas micra was positively correlated with CRP (P < 0.05).

Necrotizing Mediastinitis Following Dental Extraction: A Case Report

Introduction

Necrotizing mediastinitis is a rare complication following a dental procedure. It is frequently lethal and requires prompt diagnosis with advanced imaging, administration of broad-spectrum antimicrobials, and early surgical consultation.

Case Report

A 19-year-old, otherwise healthy male presented to the emergency department with chest pain, muffled voice, and facial and neck swelling six days following dental extraction. He was found to have a retropharyngeal abscess causing necrotizing mediastinitis and septic shock. The patient was started on broad-spectrum antimicrobials, required 10 surgical procedures, and experienced a prolonged hospitalization.

Conclusion

Consider necrotizing mediastinitis in patients presenting with chest pain and signs of retropharyngeal infection after dental procedures. Prompt imaging, antimicrobial therapy, and surgical consultation is critical in treating this frequently fatal disease.

OUP accepted manuscript

Descending necrotizing mediastinitis (DNM) is a severe, life-threatening disease and requires prompt treatment. The primary treatment for DNM is cervical and mediastinal drainage in addition to antibiotic treatment. However, the most appropriate drainage approach and the effectiveness of additional treatment remain unclear. In this study, we performed cervical and mediastinal drainage for three patients with type IIB DNM using the cervical approach alone. Continuous saline irrigation was administered as additional treatment. There is little evidence for the use of saline irrigation for DNM. We propose that this combination treatment may be more effective and has the potential to improve patient prognosis. In our report, the average drainage duration was 13 days, and the average hospital stay was 30 days. Furthermore, both drainage duration and hospital stay were shorter than those in previously reported cases. Our case series provides valuable insight into the use of combination treatment to treat DNM.

Descending necrotizing mediastinitis and the proposal of a new classification

Objective

Methods

Results

Conclusions

Significant rise in neck infections progressing to descending necrotizing mediastinitis during the COVID-19 pandemic quarantine

To present five patients with DNM, who were treated during the first quarantine for Coronavirus disease 2019 (Covid-19). Five patients with DNM were treated in our department during the first lockdown. The mean age of the patients was 42,2 years and four were male. Two patients were immunocompromised. Repeated surgical drainage was performed in all patients, whereas four were also subjected to elective tracheostomy during their first operation. The mean hospitalization duration was 55,4 days and mortality was 40%. During the first lockdown for the Covid-19, a rise in the ratio of DNM cases to the overall incidence of cervicofacial infections was observed in our department. All patients with DNM were operated on an emergency basis and were subsequently admitted to the ICU. We consider the effect of the quarantine as a decisive factor for this escalation, because according to the department archives, there had not been any cases of DNM originating from a dental infection, for the past 5 years. Additionally, past studies from the same department reported no more than 6 cases over a 10 year period.

Detection of aerobe-anaerobe mixed infection by metagenomic next-generation sequencing in an adult suffering from descending necrotizing mediastinitis

BACKGROUND

Descending necrotizing mediastinitis (DNM) is one of the most virulent forms of mediastinitis. The main causes of high mortality in DNM are believed to stem from difficulty and delay in the diagnosis. Fast and accurate identification of pathogens is important for the treatment of these patients. Metagenomics next-generation sequencing (mNGS) is a powerful tool to identify all kinds of pathogens, especially for rare and complex infections.

CASE PRESENTATION

A 64-year-old male patient was admitted to the intensive care unit (ICU) with unconsciousness, dyspnea, and swelling in the mandible and neck. Computed tomography (CT) scan results combined with clinical laboratory examination indicated DNM. Vancomycin and imipenem were used, and vacuum sealing drainage was applied for debridement and drainage of the infected area. The positive mNGS results of drainage fluid confirmed the presence of mixed infection caused by Streptococcus anginosus, Prevotella oris, and several other anaerobes. The antibiotics were adjusted to piperacillin/tazobactam and tinidazole according to the mNGS results and antimicrobial susceptibility testing of cultured pathogens. After 11 days of antibiotic therapy, the infection symptoms of the neck and mediastinum improved, and the patient was transferred out of the ICU on the 26th day after negative result of drainage fluid culture.

CONCLUSION

This case suggested that mNGS is a promising technology for precise and fast pathogens identification with high sensitivity, which may guide the diagnosis of infectious diseases in the future trend.

Optimal Airway Management in the Treatment of Descending Necrotizing Mediastinitis Secondary to Deep Neck Infection

PURPOSE

To review our experiences of descending necrotizing mediastinitis (DNM) secondary to deep neck infection (DNI) and determine appropriate airway management for decreasing mortality and morbidity of patients with DNM.

METHODS

Medical records of 20 patients (8 women and 12 men) who had been managed for DNM secondary to DNI between March 2006 and December 2019 were analyzed. Diagnosis and extent of infection were confirmed by computed tomography of the neck and chest. The upper airway was closely monitored with a fiberoptic laryngoscope. Complications were evaluated according to various types of airway management in our serial cases.

RESULTS

Five (25%) out of 20 patients died as a result of septic shock and multiorgan failure. None of these patients died of accidental airway obstruction or airway management mishaps. Keeping short-term orotracheal intubation was safe and adequate after the initial surgery. Early tracheotomy was performed for 4 patients and it was significantly associated with mortality (P = .032). Three patients who underwent late tracheotomy had no mortality. Patients with tracheotomy had longer duration of overall hospital stay than those without tracheotomy.

CONCLUSIONS

Well-controlled airway management might decrease mortality, hospitalization, and airway complications in patients with DNM secondary to DNI. Keeping orotracheal intubation rather than upfront tracheotomy should be first considered when managing airway along with examination of the upper airway with a fiberoptic laryngoscope.

Surgical multidisciplinary approach in the management of odontogenic or non-odontogenic neck infections

In recent years, in our university hospital, the number of odontogenic and non-odontogenic abscesses has been rapidly increasing. We included 70 patients from January 4^th 2018 to February 19^th 2020 affected by the odontogenic ones. Deep neck infection can spread to the chest and is associated with high morbidity and mortality. The purpose of this mini-review is to demonstrate that, in case of complications, a multidisciplinary approach is needed to treat these infections, so that all practitioners should work together to achieve the patient’s rapid recovery.

Severe Odontogenic Infections during Pregnancy and Related Adverse Outcomes. Case Report and Systematic Literature Review

Odontogenic infections have the potential to develop into deep-space infections and may cause severe diseases with possible life-threatening complications. Dental infections during pregnancy require special attention in terms of possible complications and treatments due to the potential to affect the lives of two individuals. A case of a 36-year-old pregnant patient with a submandibular abscess caused by an odontogenic infection is reported, followed by a comprehensive systematic review of the literature in order to retrieve information regarding severe odontogenic infections and adverse pregnancy outcomes. The review was conducted according to the PRISMA guidelines using PubMed, Scopus, and Google Scholar databases. A total of 69 cases were included in the qualitative analysis. The mean age was 27.72 years. Patients were managed with surgery in combination with antibiotics. Nine infectious-related cesarean sections were detected, and preterm birth was associated in 3 cases, low birth weight in 2 cases, death of the fetus in 9 cases (13%), and maternal death in 4 cases (5.8%). The possible compromise of oral health during pregnancy is well known; however, severe odontogenic infections are rarely considered in the literature, and they may be associated with severe and life-threatening complications for both mother and the fetus.

Descending necrotising mediastinitis: how a sore throat can result in purulent peritonitis

This is a rare case of descending necrotising mediastinitis (DNM) that originated as an oropharyngeal infection, before spreading caudally to include all compartments of the mediastinum and the peritoneum beyond. The mediastinitis was treated early and aggressively with drainage, lavage and debridement in conjunction with broad-spectrum antimicrobial treatment. This case includes a right cervical incision, and a seldom needed surgical laparotomy approach to address the intra-abdominal involvement, and necessity of peritoneal washout. Following a prolonged Intesive Care Unit (ICU) stay and antibiotic course as well as other interventions detailed, the patient made a remarkable recovery and was discharged 101 days post presentation. This report goes on to discuss the rapidly evolving, life-threatening nature of DNM as well as providing an overview of possible management options, outlining how we think such cases should be approached and the clinical suspicion required in a deteriorating patient.

[Descending Necrotising Mediastinitis: the Choice of Drainage]

INTRODUCTION

Descending necrotising mediastinitis (DNM) is a rare, but very severe, septic condition, caused by the spread of infection from the neck to the mediastinum. Delay in diagnosis and inadequate surgical procedures may lead to a life-threatening situation.

MATERIAL

We retrospectively evaluated a group of patients who suffered from DNM and were treated in our department by mediastinal drainage in the last 10 years (2010 - 2019). All patients required one of the following methods of drainage: cervicomediastinal, mediastinothoracic or cervicomediastinothoracic "Rendevouz" drainage (MTC-D). In the group, we evaluated the source of infection, microbiologic findings, method of mediastinal drainage, length of hospitalisation, ventilation duration and inflammatory laboratory parameters.

RESULTS

In total, we treated 22 patients with DNM, including 14 men and 8 women, aged 23 - 85 years, with a mean age of 54.1 years. After the spread of infection, in 8 cases the initial cervicomediastinal type of drainage had to be followed by one of the types of thoracic drainage. As the final method, in 8 patients we chose irrigation drainage from the cervical approach, from thoracotomy in 6 cases and in 8 cases irrigation CMT-D. The method of mediastinal drainage was chosen according to the initial CT findings, and further intervention was chosen according to CT signs during the treatment. Four patients died of DNM (mortality 18.2%). Pharyngeal focus was responsible for 15 cases of DNM; odontogenic infection caused 6 DNM cases; in 1 case the origin was unclear. Although we always chose the method individually and CMT-D for the most difficult cases, there were no statistically significant (p < 0.05) differences between the evaluated parameters. For CMT-D, there was even a shorter hospital stay (not significant) and ventilation duration.

CONCLUSION

In cases of DNM with severe inflammation of caudal and distal compartments of the mediastinum we consider CMT-D as an ideal method of treatment. This appraoch is radical enough and in our group of patients, despite the severity of this illness, both the length of treatment and mortality were sufficient.

Catastrophic descending necrotizing mediastinitis of the anterior and posterior compartments: A case report

Descending necrotizing mediastinitis (DNM) is a medical emergency with a high associated morbidity and mortality.

DNM may arise secondary to primary odontogenic or neck infection in susceptible patients and it may spread contiguously via the “danger” space to the mediastinum. This case report is focused on complications following an odontogenic infection in a healthy 48-year-old male that led to a massive inflammation associated an extensive empyema.

After chest and neck computed tomographic scan a diagnosis of cervical necrotizing fasciitis with DNM was made. A multidisciplinary approach with an urgent surgical intervention and the finding of the right antibiotic therapy resulted to be successful. After 2 weeks the patient was dismissed in better health condition.

Complications of peritonsillar abscess

Background

The vast majority of patients with peritonsillar abscess (PTA) recover uneventfully on abscess drainage and antibiotic therapy. However, occasionally patient´s condition deteriorates as the infection spread in the upper airway mucosa, through cervical tissues, or hematogenously. The bacterial etiology of PTA is unclarified and the preferred antimicrobial regimen remains controversial. The current narrative review was carried out with an aim to (1) describe the spectrum of complications previously recognized in patients with peritonsillar abscess (PTA), (2) describe the bacterial findings in PTA-associated complications, and (3) describe the time relation between PTA and complications.

Methods

Systematic searches in the Medline and EMBASE databases were conducted and data on cases with PTA and one or more complications were elicited.

Results

Seventeen different complications of PTA were reported. The most frequently described complications were descending mediastinitis (n = 113), para- and retropharyngeal abscess (n = 96), necrotizing fasciitis (n = 38), and Lemierre´s syndrome (n = 35). Males constituted 70% of cases and 49% of patients were > 40 years of age. The overall mortality rate was 10%. The most prevalent bacteria were viridans group streptococci (n = 41, 25%), beta-hemolytic streptococci (n = 32, 20%), F. necrophorum (n = 21, 13%), S. aureus (n = 18, 11%), Prevotella species (n = 17, 10%), and Bacteroides species (n = 14, 9%). Simultaneous diagnosis of PTA and complication was more common (59%) than development of complication after PTA treatment (36%) or recognition of complication prior to PTA (6%).

Conclusion

Clinicians involved in the management of PTA patients should be aware of the wide range of complications, which may arise in association with PTA development. Especially males and patients  > 40 years of age seem to be at an increased risk of complicated disease. In addition to Group A streptococci and F. necrophorum, the current findings suggest that viridans group streptococci, S. aureus, Prevotella, and Bacteroides may also play occasional roles in the development of PTA as well as spread of infection. Complications occasionally develop in PTA patients, who are treated with antibiotics and surgical drainage.

Descending Necrotizing Mediastinitis: Analysis of 9 Cases in Our Hospital

OBJECTIVES

Descending necrotizing mediastinitis (DNM) is a serious and progressive infection involving the neck and chest and with high mortality if not treated quickly and properly. The aim of this study is to share our practices for managing this condition.

METHODS

We retrospectively evaluated 9 patients diagnosed with DNM in our hospital between January 2006 and October 2019. Age, gender, origin of infection, length of hospital stay, microorganisms present, type of surgical treatment, and clinical outcomes were reviewed.

RESULTS

All patients underwent surgery to drain neck and mediastinal secretions and collections. Three (33.3%) patients were treated with transcervical drainage alone, and 6 (66.7%) patients were treated with combined transcervical and transthoracic drainage. Reoperations were reported in 3 (33.3%) cases. The average length of hospital stay was 22.78 ± 10.05 days (range: 9-40 days). The average length of intensive care unit stay was 6.44 ± 10.10 days (range: 0-25 days). There were no in-hospital deaths, and all patients were discharged home with good outcomes.

CONCLUSIONS

To improve the prognosis of DNM, we suggest early and adequate debridement of all affected areas along with the proper use of antibiotics. A multidisciplinary approach involving both cardiothoracic and ENT surgeons is also required.

Assessment of Prognosis in Odontogenic Descending Necrotizing Mediastinitis: A Longitudinal Retrospective Study

Background: Descending necrotizing mediastinitis [DNM] is a serious complication of odontogenic infections, being associated with a high mortality rate. The diagnosis, classification, and management depend on computed tomography [CT] findings. Incision, drainage, and debridement represent the principal management. This study aimed to assess the prognosis in odontogenic DNM. Methods: The DNM type I was managed by transcervical mediastinal drainage, while in DNM type II, a right or left posterolateral thoracotomy was used. Data were compared among survivors and deceased to detect the risk factors affecting the prognosis. Results: This study included 63 patients. Transcervical mediastinal drainage was performed in 57 patients with Endo Type I while drainage through a right posterolateral thoracotomy was performed in the other five patients with Endo Type I and one patient with Endo Type IIA. Of patients in the study, 82.5% survived while 17.5% died because of multiple organ failure. Multiple complications and severe sepsis or septic shock as risk factors were statistically significant. Conclusion: A CT scan is the modality of choice for diagnosis and classification of DNM. Incision and drainage of the maxillofacial infection with mediastinal drainage and debridement represent the main management. Multiple complications and severe sepsis or septic shock were associated with poor prognosis.

Deep neck space infections: an upward trend and changing characteristics

PURPOSE

This study reviews our experience with deep neck space infections (DNIs) requiring surgical intervention, including cervical necrotizing fasciitis. The aim of the study was to identify predisposing and aggravating factors of the disease and recognize the possible factors that can lead to life-threatening complications and slow down the healing process.

METHODS

We compare the results to previous data from 1985 to 2005 to find possible alterations and changing trends. The characteristics of four lethal cases are described. This retrospective analysis includes patient data from 2004 to 2015 in tertiary referral hospital and in total, 277 patients were found.

RESULTS

Surgical drainage through a neck opening ± intraoral incision was made in 215 (77.6%) patients, an intraoral incision was only made in 62 patients (22.4%). ICU care was needed in 66 (23.8%) cases. Odontogenic etiology (44.8%) was the most common origin. The most common comorbidity was a psychiatric disorder and/or dementia and occurred in 55 (19.9%) patients. Patients with underlying illnesses were more likely to be admitted to the ICU (p = 0.020), required a longer ICU stay (p = 0.004) and repeated surgery (p = 0.009). Gas formation seemed to be predictive of a more severe course of infection. Early extraction of the odontogenic foci was related to a lower length of stay (LOS) (p = 0.039).

CONCLUSION

The annual numbers have risen from 14 to 24 cases per year when compared to previous data. DNIs remain a cause of lethal complications; the mortality was 1.4% and overall complications occurred in 61 (22.0%) patients.

Descending necrotizing mediastinitis in a healthy young adult

A 26-year-old man with right lower mandibular and chest pain, fever, and respiratory distress was urgently transported to our hospital. CT images revealed gas collection and an abscess from the neck to the mediastinum with bilateral pleural effusion. Descending necrotizing mediastinitis (DNM) induced by an odontogenic infection of a right mandibular molar abscess was diagnosed. The cervical and mediastinal areas were drained, extensive debridement was performed, necrotic tissue was excised, and broad-spectrum antibiotics were administered immediately. Prompt diagnosis and intensive care were necessary for managing the DNM, and the patient was discharged with no comorbidities.

Urgent Infections of the Head and Neck

Infections of the head and neck are common and appropriately managed by primary care providers in most cases. However, some infections are associated with significant morbidity and require urgent recognition and management by specialty services. These include deep neck space infections originating in the oral cavity, pharynx, and salivary glands, as well as complicated otologic and sinonasal infection. This article provides a review of these conditions, including the pathophysiology, presenting features, and initial management strategy.

Group C strep mediastinitis

This case is significant to the practice of emergency medicine because it represents the development of an uncommon and potentially fatal mediastinal infection from a commonly encountered and appropriately treated community respiratory pathogen. Most published reports on mediastinitis are those that are status-post cardiothoracic surgery. In our report, we discuss a case of a healthy, young individual who developed this morbid entity from extension of a simple respiratory infection where Group C Streptococcus has been isolated as the causative organism, which to our knowledge has not been previously reported. Further, this report outlines how a community acquired pneumonia progressed to a life threatening illness despite proper initial treatment per local and national guidelines.

[Descending necrotizing mediastinitis : Treatment concept with focus on thoracic surgery]

BACKGROUND

Descending necrotizing mediastinitis (DNM) originates from odontogenic or oropharyngeal infections which spread along preformed cervicothoracic spaces into the mediastinum and requires emergency multidisciplinary treatment.

MATERIAL AND METHODS

A total of seven patients were diagnosed with DNM based on typical radiological features in a cervicothoracic computed tomography (CT) scan and subsequently underwent standardized transcervical and open transthoracic radical debridement.

RESULTS

The initially detected polymicrobial spectrum of pathogens was dominated by streptococci followed by enterobacteriae. After calculated antibiotic treatment a shift in the spectrum of pathogens was noted and in particular a mycotic superinfection occurred in 43 % of the cases. Anterolateral thoracotomy was performed for radical removal of tissue necrosis and mediastinothoracic drainage extending to the posterior mediastinum was placed. In selected cases, cervico-mediastino-thoracic tubes were transmediastinally placed by the rendevouz technique either in the previsceral or retrovisceral mediastinal space. Despite predominantly advanced mediastinitis (Endo classification type II B) in this patient cohort, the mortality only reached 14 %.

CONCLUSION

Rapid diagnosis, anatomical knowledge, understanding of the progression of infections as well as critical care, antimicrobial treatment and multidisciplinary radical surgical therapy are paramount for successful treatment of DNM. We favor anterolateral thoracotomy as the standard open transthoracic approach to the mediastinum. Placement of cervico-mediastino-thoracic irrigation drains can help to limit DNM.

[Acute and chronic mediastinitis]

BACKGROUND

A systematic approach to the etiology and possible course of acute mediastinitis is a prerequisite for adequate diagnostics and therapy. Chronic mediastinitis represents a rarity in the clinical practice.

MATERIAL AND METHOD

A selective literature search was carried out.

RESULTS

An acute infection of the mediastinum occurs after perforation of mediastinal structures, such as the esophagus and trachea mostly of iatrogenic origin and as descending necrotizing mediastinitis (DNM) from oropharyngeal foci. The mortality rate of esophageal injuries, irrespective of the cause is currently given as 12 %. A DNM results from an unobstructed spread along the cervicothoracic spaces and is a severe infection which manifests as a clinical picture of sepsis. The mortality rate given in the currently available literature is 14 %. Chronic mediastinitis is a very rare condition which is characterized by the proliferation of fibrous and collagenous tissue in the mediastinum. Whereas the pathogenesis remains unclear, there are indications for a Histoplasma capsulatum infection as the causal link. The prognosis is good.

CONCLUSION

After perforation of the esophagus or trachea there is always the risk of an infection of the mediastinum; therefore, the diagnosis is followed by further evaluation and early therapy. The DNM can cause unspecific symptoms of sepsis without an obvious focal point. It is important to be aware of a possible correlation between an oropharyngeal center of infection and mediastinitis in order to initiate appropriate diagnostic imaging in cases with the slightest suspicion. Chronic mediastinitis is a rare condition with varying courses and can be difficult to diagnose. An histological clarification for distinction from malignant diseases appears to be a sensible approach.

European Association for Cardio-Thoracic Surgery expert consensus statement on the prevention and management of mediastinitis

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.

Less invasive management of deep neck infection and descending necrotizing mediastinitis: A single-center retrospective study

By a 7-year retrospective review, we reported our experience in management of descending necrotizing mediastinitis (DNM) and deep neck infection (DNI). A retrospective design was used to reveal the clinical characteristics of DNI and DNM. The clinical outcome was analyzed to validate less invasive management. We reviewed 82 patients between 2009 and 2016, 12 of which were diagnosed as DNM by clinical and computed tomography findings. A total of 35 patients had relevant systemic conditions, mainly diabetes mellitus (19 patients). Most cases were secondary to oropharyngeal or dental infections. All patients underwent transcervical drainage, and 10 DNM patients were treated with additional closed thoracic drainage simultaneously. Twenty patients accepted more than 1 operation. Seven patients died as a result of sepsis and/or multiple organ failure. The mortality rate in our study was similar to that in other studies. In our opinion, less invasive therapies are useful to most patients. Transcervical drainage alone is optimal management for all DNI cases and some DNM cases. Additional closed thoracic drainage is enough for type I and IIA DNM with pleural effusion or empyema.

Scary gas: pathways in the axial body for soft tissue gas dissection (part I)

Gas is often encountered in abnormal locations in the torso, including within soft tissue compartments, vessels, and bones. The clinical significance of this gas ranges from incidental, benign, and self-limited to aggressive infection requiring immediate surgery. As a result of fascial interconnectivity and pressure differences between compartments, gas can dissect distant from its source. Gas can easily dissect between spaces of the extrapleural thorax, subperitoneal abdomen, deep cervical spaces, and subcutaneous tissues. The pleural and peritoneal cavities are normally isolated but may communicate with the other spaces in select situations. Dissection of gas may cause confusion as to its origin, potentially delaying treatment or prompting unnecessary and/or distracting workup and therapies. The radiologist might be the first to suggest and identify a remote source of dissecting gas when the clinical manifestation alone might be misleading. The purpose of this paper, the first in a three-part series on soft tissue gas, is to explore the various pathways by which gas dissects through the superficial and deep compartments of the torso.

Descending necrotizing mediastinitis with Lemierre's syndrome

Descending necrotizing mediastinitis is a severe infection of the mediastinum. Lemierre's syndrome manifests as thrombophlebitis in the cervical veins, which is caused by a neck infection. A 50-year-old woman had a fever with a 13-day history of neck pain. CT showed a deep neck abscess with vertebral vein thrombosis and mediastinal abscesses. Multiple small pulmonary nodules were found, suggesting septic pulmonary embolism. Emergency surgery for bilateral cervical and mediastinal drainage was performed, and antibiotics and anticoagulation agent was administered. Edoxaban was required to clear vein thrombosis and pulmonary embolization.

Descending necrotizing mediastinitis in the elderly patients

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.

Descending necrotizing mediastinitis: Management and controversies

Background:

Descending necrotizing mediastinitis has been known to be a life-threatening condition. It is most likely to be lethal without a prompt diagnosis and aggressive surgical management. In the surgical management of this subset of mediastinitis, a debate remains as to whether a transthoracic incision should be mandatory in addition to cervical approach.

Methods:

This is a single-center retrospective study performed at Cipto Mangunkusumo Hospital from January 2012 to June 2014. Patients with descending necrotizing mediastinitis were treated with broad-spectrum antibiotics and with cervical and transthoracic approach (via sternotomy) surgical debridement.

Results:

There were 16 consecutive cases of descending necrotizing mediastinitis. One patient did not undergo sternotomy and was ruled out from the study. The mean intensive care unit stay was 26.4 days, with a mean hospital stay of 46.7 days. There were three mortality cases reported and a total of three cases that needed reoperation. There was neither post-operative sternal dehiscence nor osteomyelitis found.

Conclusion:

Considering there are no post-operative sternal-related infection reported in this study, sternotomy should be considered as an access in descending necrotizing mediastinitis management. In the three mortality cases reported, two patients came with preoperative sepsis and one had iatrogenic subclavian artery injury.

Severe descending necrotizing mediastinitis: vacuum-assisted dressing did wonder

Descending necrotizing mediastinitis (DNM) is a rapidly progressive disease from the spread of cervical infection. Transcervical and transthoracic drainage was the recognized traditional surgical approach to achieve adequate clearance of infection. Non-invasive vacuum-assisted dressing is a new technique where applied negative pressure can help remove infective fluid and to promote wound healing. A 60-year-old man presented with odynophagia, fever and anterior neck swelling for 2 weeks. He was diagnosed to have anterior neck abscess and underwent surgical drainage. However, it did not respond well, but progressed to involve superior and inferior mediastinum. Vacuum-assisted dressing was applied for total of 2 weeks and the patient recovered without going through usual traditional transthoracic drainage. Vacuum drainage is a simple, safe and non-invasive method of managing DNM, in well selected group with small abscess cavity without airway obstruction and septicemia. This potential technique can lead to paradigm shift in treating life-threatening DNM.

Optimal surgical options for descending necrotizing mediastinitis of the anterior mediastinum

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.

A case of mediastinitis secondary to retropharyngeal abscess

A 50 year old male patient who consumed chicken bone soup, 4 days back, presented with dysphagia, high grade fever with chills, shortness of breath and swelling in face, neck and upper chest. Patient was toxic and in respiratory distress with room air oxygen saturation of 83%, which increased to 92% with 6 lit of oxygen through simple face mask. Indirect laryngoscopy revealed a retro pharyngeal abscess and CT chest revealed Sub-cutaneous and mediastinal emphysema. The abscess was immediately drained and followed with parenteral anti-microbials and high flow oxygen theapy. Patient improved and was discharged after 12 days. This case was reported as, foreign body causing Retro-pharyngeal abscess is a very rare entity in this anti-biotic era especially leading to a very rare complication of mediastinitis and Pneumomediastinum is unusual.

Odontogenic deep neck space infection as life-threatening condition in pregnancy

Odontogenic deep neck space infections represent a severe disease with possible life-threatening complications. Despite knowledge of these infectious diseases, treatment remains a challenge for every maxillofacial surgeon. Therapy of severe neck infections is even more crucial during pregnancy because of the possible life-threatening situation for both the mother and the foetus. The possible compromise of oral health during pregnancy is well known, however severe odontogenic infections are rarely considered in the literature. The following case report describes the dramatic course of a deep neck space infection in a pregnant patient, commencing with typical symptoms of localized odontogenic infection and ending in a critical, life-threatening condition for the patient and a lethal condition for the foetus. The case represents the first description of intrauterine, foetal death caused by a deep neck space infection. Implications for dental and medical treatment during pregnancy, especially regarding odontogenic infections, are presented and discussed with findings in the international literature.