Descending necrotizing mediastinitis

Abstract

Descending necrotizing mediastinitis can occur as a complication of oropharyngeal and cervical infections that spread to the mediastinum via the cervical spaces. Delayed diagnosis and inadequate mediastinal drainage through a cervical or minor thoracic approach are the primary causes of a high published mortality rate (near 40 %). Between 1985 and 1992, six men (mean age, 49 years) with descending necrotizing mediastinitis were surgically treated at our institution. The primary oropharyngeal infection was peritonsillar abscess (three cases) and odontogenic abscess (three cases). In aU cases, occurrence of respiratory insufficiency associated with serious cervical infection suggested the mediastinitis diagnosis. Computed tomographic scans confirmed the mediastinitis, showing mediastinal abscess and mediastinal emphysema. AU patients underwent surgical drainage of the deep neck infection combined with mediastinal drainage through a thoracic approach. The outcome was favorable in five patients who had mediastinal drainage through a thoracotomy; the patient who had mediastinal drainage through a minor thoracic approach (anterior mediastinotomy) died of tracheal fistula on postoperative day 18. In our experience, aggressive mediastinal drainage by a thoracotomy approach regardless of the level of mediastinal involvement led to improvement in survival of these patients, with a 17% mortality rate.

Descending necrotizing mediastinitis secondary to a dental infection

“…The surgical approaches to cervical drainage vary according to the location, extent, and degree of the infection 6 , 26 , 27. In our case, the infection was located in the upper mediastinum and we opted for high transcervical mediastinal drainage.…”

“…Physical examination can reveal fever and neck swelling. In addition, patients with a deep neck infection typically present with dehydration, sore throat, dysphagia, dysphonia (impaired glottal function), dyspnea and trismus 6. In the case under discussion here, the patient presented with fever, severe trismus, difficulty in swallowing, and difficulty in speaking, all of which are clear clinical signs of infection.…”

“…The use of intravenous broad-spectrum antibiotics is not effective without adequate cervical drainage, extensive debridement and excision of the necrotic tissue. In most cases, repeated cervical drainage is required due to persistent infection 6. In the case reported here, the patient was treated with a combination of antibiotic therapy comprising ceftriaxone (2 g every 12 hours), metronidazole (500 mg every 8 hours) and gentamicin (80 mg every 8 hours) and surgical drainage.…”

“…In rare cases, mediastinitis can arise after Ludwig’s angina or can be secondary to deep neck space infection, in general, due to the infection of the second or third inferior molar 4 , 5. Such cases are classified as descending necrotizing mediastinitis, and the clinical picture can be severe 6…”

Descending Necrotizing Mediastinitis: Mediastinal Drainage With or Without Thoracotomy

“…Patients with more extensive mediastinitis involving the lower mediastinum, below the level of the carina or the fourth thoracic vertebra, may be best managed with a thoracotomy or a suxyphoid approach in addition to drainage of their cervical lesion. Although the authors' suggestion is based on limited experience, it is supported by reports published in the literature recently [2,5].…”