Descending necrotizing mediastinitis: cervicotomy or thoracotomy?

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.

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.

Favorable results of early diagnosis by cervicothoracic computed tomography scans for descending necrotizing mediastinitis

OBJECTIVES

We studied results of early diagnosis by cervicothoracic computed tomography and early aggressive surgery for descending necrotizing mediastinitis.

METHODS

Between 1990 and 1999, 5 patients with descending necrotizing mediastinitis were surgically treated in our institute. Computed tomography scans confirmed mediastinitis in all cases, even though chest x-ray films demonstrated a widening mediastial shadow in only 2. Soon after surgical drainage of the deep neck infection and diagnosis of descending necrotizing mediastinitis, all patients underwent surgical mediastinal drainage. Mediastinitis was drained by thoracotomy in 1, managed thoracoscopically in 1 and cervicomediastinally drained in 3.

RESULTS

The outcome was favorable in all patients.

CONCLUSIONS

Early diagnosis by cervicothoracic computed tomography and early aggressive surgery for descending necrotizing mediastinitis are essential to favorable outcome.

Descending necrotizing mediastinitis: a modified algorithmic approach to define a new standard of care

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.

Descending necrotising mediastinitis: a case report illustrating a trend in conservative management

The mortality rate from descending necrotising mediastinitis (DNM) has declined since its first description in 1938. The decline in mortality has been attributed to earlier diagnosis by way of contrast-enhanced computed tomographic (CT) scanning and aggressive surgical intervention in the form of transthoracic drainage. We describe a case of DNM with involvement of anterior and posterior mediastinum down to the diaphragm, managed by cervicotomy and transverse cervical drainage with placement of corrugated drains and a pleural chest drain, with a delayed mediastinoscopy and mediastinal drain placement. We advocate a conservative approach with limited debridement and emphasis on drainage of infection in line with published case series.

Thoracoscopic drainage of ascending mediastinitis arising from pancreatic pseudocyst

Acute mediastinitis is a life-threatening disease. Common etiologies include surgical infection, esophageal perforation, and descending necrotizing mediastinitis from the oral cavity or pharynx. Mediastinitis caused by pancreatic disease is rare. The most common thoracic complication of pancreatic disease is reactive pleural effusion. We report a case of acute mediastinitis and bilateral empyema thoracis arising from a pancreatic pseudocyst. We utilized thoracoscopy to drain the mediastinum without drainage of the intra-abdominal cyst. The patient recovered well after operation.

Descending necrotizing mediastinitis: a 10-year surgical experience in a single institution

OBJECTIVE

Early diagnosis and aggressive surgical drainage are very important for successful treatment of descending necrotizing mediastinitis. However, the surgical techniques used for this condition remain controversial. We report our 10-year experience of managing this devastating disease, focusing on the multidisciplinary, minimally invasive operative procedures and the unique bacteriologic factors in Taiwan.

METHODS

Between January 1997 and January 2007, we retrospectively reviewed 18 patients with descending necrotizing mediastinitis who were treated in the National Taiwan University Hospital. Diagnosis and Endo classification were confirmed by computed tomography of the neck and chest.

RESULTS

Eight women and 10 men were included in this study. The mean age was 57.8 +/- 15.2 years. Cervical drainage was performed in the involved area in all patients. The methods for mediastinal drainage included transcervical (n = 10), video-assisted thoracic surgical drainage (n = 6), subxiphoid drainage (n = 1), and mediastinoscopy-assisted drainage (n = 1). We could not rescue 3 patients because of uncontrolled sepsis before surgery, for a mortality rate of 16.7%. Klebsiella pneumoniae uniquely represents the most common pathogen in diabetic patients (P = .01), leading to more complicated courses in older patients (P =.04) and requiring more surgical interventions (P =.05) than other pathogens.

CONCLUSION

Transcervical mediastinal drainage is first justified in patients with limited disease in the upper mediastinum. For those with involvement of the lower anterior mediastinum, an additional subxiphoid approach is suggested. Cervicotomy with video-assisted mediastinal drainage is an excellent combination for involvement of the posterior mediastinum and pleural space. Klebsiella pneumoniae uniquely represents the most important and threatening causative pathogen for diabetic patients with descending necrotizing mediastinitis.

Optimal surgical management of descending necrotising mediastinitis: our experience and review of literature

INTRODUCTION

Descending necrotising mediastinitis is a form of mediastinitis caused by odontogenic infection or deep cervical infections, which spreads to the mediastinum via the cervical fascial planes. Despite the increased use of CT scan as a diagnostic aid and the improvement in antibiotics, mortality in patients with descending necrotising mediastinitis remains high, reported between 25 and 40% in the literature. Surgical management and optimal form of mediastinal drainage remain controversial.

PATIENTS AND METHODS

We have treated three patients with descending necrotising mediastinitis at our institution. Two patients were male and one was female with mean age 54.3+/-12.5 years. One of the patients was a known diabetic. The primary oropharyngeal infection was Ludwig's angina, odontogenic abscess and parapharyngeal abscess. All patients underwent mediastinal drainage, one through midsternotomy and two through right thoracotomy in addition to cervical drainage. All the three patients had mixed aerobic and anaerobic infection.

RESULTS

There was no perioperative mortality. Mean ICU stay was 32 days (12-53 days). All three patients had septicaemic shock requiring prolonged inotropic support. Two patients required tracheostomy because of prolonged ventilation. All the patients had recurrent abscesses and collections either in neck or in chest requiring drainage either surgically or percutaneously under CT scan or ultrasound guidance, thus decreasing the need of repeated surgical procedures.

CONCLUSION

Descending necrotising mediastinitis is a potentially fatal condition. Early diagnosis, prompt surgical drainage, monitoring of disease process, appropriate medical management in an intensive care unit and a multi-disciplinary approach can significantly reduces the mortality in this otherwise fatal condition. Percutaneous drainage of recurrent abscesses and collections can decrease the need of repeated surgical procedures in these critically ill patients.

Descending necrotising mediastinitis: a safe treatment algorithm

Descending necrotising mediastinitis can complicate oropharyngeal infection and has a high associated mortality. We present three cases treated in our department and propose a treatment algorithm based on our experience and literature review. The primary oropharyngeal infection was peritonsillar abscess in two cases and odontogenic abscess in one. Two patients underwent cervicotomy and later thoracotomy. The third underwent cervicotomy with transcervical mediastinal drainage and later required pericardial drainage via a subxiphoid incision. All recovered fully and were discharged within 6 weeks. To enable successful treatment, diagnosis needs to be prompt and surgical drainage adequate. Thoracic management of the chest is essential.

Management of descending necrotizing mediastinitis

PURPOSE

One of the most dreaded and the most lethal form of mediastinitis is descending necrotizing mediastinitis (DNM).

PATIENTS AND METHODS

Between January 1990 and June 2001, 6 patients (mean age, 54.5 years; age range, 19 to 72 years) with DNM were treated in the Department of Thoracic Surgery of General Hospital of Attica "K.A.T." The primary etiology was odontogenic abscess in 3 patients and peritonsillar abscess in the other 3. Diagnosis was confirmed by computed tomography of the neck and chest. All patients underwent surgical drainage of the involved cervical region and mediastinum by monolateral cervicotomy and left thoracotomy.

RESULTS

The delay between the occurrence of thoracic symptoms and mediastinal drainage varied from 1 to 4 days. The thoracic approach and the side of the thoracotomy depended on the involved mediastinal compartments and side of pleural effusion. The duration of mediastinal drainage varied from 8 to 22 days (mean, 12.5 days). One patient died of multiorgan failure related to postoperative septic shock.

CONCLUSION

Delayed diagnosis and inadequate drainage are the main causes of the high mortality rate of DNM. Routine use of the computed tomography scan is highly recommended in patients with a deep cervical infection for early detection of mediastinitis at a time when the chest roentgenogram is still normal. If one realistically hopes to avoid the high mortality rate, aggressive surgical drainage and debridement of the neck and drainage of the mediastinum via a posterolateral thoracotomy by a multidisciplinary team of surgeons are required.

Descending necrotizing mediastinitis in early childhood: favorable outcome after aggressive treatment

OBJECTIVE

To report a case of descending necrotizing mediastinitis (DNM), an unusual illness in childhood that develops as a complication of oropharyngeal infection.

DESIGN

Descriptive case report.

SETTING

Pediatric intensive care unit.

PATIENT

A 19-month-old boy with a DNM that resulted from a pharyngeal abscess.

INTERVENTIONS

Aggressive surgical debridement; intravenous therapy with broad-spectrum antibiotics.

MEASUREMENTS AND MAIN RESULTS

Simple chest radiograph and computed tomographic scan, and routine culture were used to assess the patient. Administration of broad-spectrum antibiotics and surgical drainage resulted in clinical resolution of symptoms.

CONCLUSIONS

An aggressive approach (broad-spectrum antibiotics and surgical debridement) can improve the prognosis of DNM in children.

Innominate artery rupture after transcervical drainage for descending necrotizing mediastinitis

We present a case of innominate artery rupture after descending necrotizing mediastinitis (DNM) on day 36 of cervicomediastinal drainage. The patient recovered after aortosubclavian arterial bypass grafting followed by resection of the eroded artery. Because mechanical pressure caused by drains in addition to the inflammatory process can cause major vessel erosion, prolonged transcervical tube drainage for treating descending necrotizing mediastinitis should be avoided even if the drains applied are soft and thin.

Video-assisted thoracic surgery for diseases within the mediastinum

VATS and concepts of minimal access thoracic surgery have revitalized many aspects of general thoracic surgery, including the surgical approach to diseases and conditions of the mediastinum. Proven surgical options that have been shunned by patients and referring physicians because of the perceived morbidity of thoracotomy have been reconsidered with the emergence of these minimal access surgical options. Continued critical review of the accumulating experience in VATS techniques will refine the surgical indications for VATS and open thoracotomy.

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

OBJECTIVES

Descending necrotizing mediastinitis is a polymicrobial infection originating in the oropharynx with previously reported mortality rates of 25% to 40%. This investigation reviews the effects of serial surgical drainage and debridement on the survival of patients with descending necrotizing mediastinitis.

METHODS

A retrospective review of patients from 1980 through 1998 with a diagnosis of descending necrotizing mediastinitis was performed. Their records were abstracted for personal demographics, hospital course, morbidity, and mortality. Also abstracted were all reports of patients with descending necrotizing mediastinitis published in English between 1970 and 1999.

RESULTS

We treated 10 patients in whom descending necrotizing mediastinitis was identified. The mean age of the patients was 38 years. They underwent a mean of 6 +/- 4 computed tomographic imaging studies, 4 +/- 1 transcervical drainage procedures, and 2 +/- 1 transthoracic drainage procedures. Three patients required abdominal exploration and 4 underwent tracheostomy. No deaths occurred. In contrast, 96 patients with descending necrotizing mediastinitis were identified from the literature with a mean age of 38 years. They underwent a mean of 2 +/- 1 computed tomographic imaging studies, 2 +/- 1 transcervical drainage procedures, and 0.7 + 0.3 transthoracic drainage procedures. Sixteen (17%) patients required abdominal exploration and 34 (35%) underwent tracheostomy. Twenty-eight (29%) patients from the literature cohort died during their treatment.

CONCLUSION

Descending necrotizing mediastinitis remains a life-threatening infection. On the basis of experience accrued in treating these patients, an algorithm incorporating computed tomographic imaging for diagnosis and surveillance and serial transcervical and transthoracic operative drainage is outlined in the hope of reducing the excessive mortality of descending necrotizing mediastinitis.

Descending necrotizing mediastinitis: report of a case

A 47-year-old man was admitted to our hospital for treatment of an odontogenic infection. He presented with a fever, signs of sepsis, and neck swelling, and was initially diagnosed as having a neck abscess. After cervical drainage, he showed no improvement, and mediastinitis was detected by chest X-ray and computed tomography. A thoracotomy and mediastinal drainage was subsequently performed for descending necrotizing mediastinitis, which resulted in marked improvement. To date, only 83 cases of descending necrotizing mediastinitis have been reported in Japan. We present herein an additional case, followed by a review of the Japanese literature.

Thoracoscopic management of descending necrotizing mediastinitis

Descending necrotizing mediastinitis (DNM) is a lethal process originating from odontogenic, pharyngeal, or cervical infectious sources that descends along fascial planes into the mediastinum. Despite earlier use of antibiotics and surgical drainage, the mortality (>50%) has changed little since the first large series reported in the preantibiotic era. The surgical management remains controversial, with support ranging from cervical drainage alone to cervical drainage and routine thoracotomy. We report a case of thoracoscopic drainage and debridement of a mediastinal abscess resulting from descending necrotizing mediastinitis. The decreased morbidity of this approach compared with posterolateral thoracotomy and the improved drainage of the mediastinum compared with cervical drainage support this method as an attractive management of patients with DNM.