Descending Necrotizing Mediastinitis: Review of the Literature and Controversies in Management

Abstract

Any deep cervical infection has to be aggressively treated and CT scan of the chest should be performed to exclude the possibility of downward spread of the infection within the mediastinum. Early recognition of DNM is problematic because of its rarity and the non-specific symptoms in its early phase. DNM can rapidly progress to involve the entire mediastinum. Aggressive surgery upon diagnosis has to be performed, usually through a combination of cervicomediastinal and thoracic approach. Cervicomediastinal drainage alone for DNM not extending below the carina level or combined with subxiphoid drainage or anterior mediastinotomies is associated with higher mortality rates. Thoracotomy on the most involved side or bilateral thoracotomies give the best exposure for adequate mediastinal drainage. Median sternotomy or VATS procedures can be performed if one-lung ventilation can be tolerated by the patient. Pleural and pericardial cavities and all mediastinal spaces should be properly drained. Repeat CT scan of the neck and chest should be performed in all patients 48-72 hours after drainage of the infection or even earlier in case of further deterioration of the patient or persistent sepsis. Mortality rate in recent series ranges between 10% and 30%. The development of purulent pericarditis and/or failure of more than two organs before mediastinal drainage are associated with higher risk of fatal outcome. Prolonged ICU and hospital stays are the rule, while re-intervention rate for persistent sepsis exceeds 30%. The re-intervention rate is higher after mediastinal drainage performed through approaches which offer limited exposure to the whole mediastinum.

Descending necrotizing mediastinitis: Systematic review on its treatment in the last 6 years, 75 years after its description

“…We did not find randomized controlled trials or clinical practice guidelines published on the diagnosis and treatment of descending necrotizing mediastinitis; the best available evidence in adults was obtained from 26 published studies of clinical reviews of 4 or more cases of descending necrotizing mediastinitis with evidence level III (Table ).…”

“…Isolated case reports or series with less than 4 cases of descending necrotizing mediastinitis, which have low evidence level (IV), were not included for the purpose of analysis in this review. Reports of descending necrotizing mediastinitis published before the year 2009 were also not included because there are reviews of accumulated cases from the period from 1969 to 1989, from 1970 to 1997, and from 1998 to 2008, along with 5 meta‐analysis of these periods; all other case series published between 2009 to 2014 were included …”

Mediastinite Descendante Necrosante Aigue: Quatre Annees D’experience Dans Un Centre Hospitalier A Madagascar

“…Cette situation tardive a été objectivée dans certaines littératures où les patients sont vus par les chirurgiens thoraciques de façon tardive après installation de défaillance multiviscérale (Foroulis, 2011).…”

“…Selon certains auteurs, le délai entre le diagnostic et le traitement devrait être de moins de 24 h pour obtenir un bon résultat (Foroulis, 2011). Notre étude rapporte un diagnostic tardif de 57 heures lié au retard de réalisation des explorations étant donné les problèmes financiers des patients.…”

“…Les voies d'abord chirurgical pour aborder le médiastin dans cette pathologie reste un sujet de controverse. Une méta-analyse publiée par Corsten et al en 1997, rapporte que le médiastin ne peut être drainé par une chirurgie limitée par la voie xyphoïdienne ou par une médiastinostomie (chirurgie mini-invasive), la thoracotomie est la meilleure pour l'exploration allant de l'oesophage à l'espace pré-vertébral qui devrait être effectué minutieusement (Foroulis, 2011). D'autres auteurs affirment que la chirurgie doit toujours commencer par un drainage cervical (Doddoli, 2009).…”