Descending Necrotizing Mediastinitis: Surgical Drainage and Tracheostomy

Brunelli, Alessandro; Sabbatini, Armando; Catalini, G.; Fianchini, Aroldo

doi:10.1001/archotol.1996.01890240034008

Cited by 65 publications

(30 citation statements)

References 19 publications

Supporting

Mentioning

Contrasting

Unclassified

Order By: Relevance

“…Endo et al [38] classified DNM into diffuse and localized types according to the degree of diffusion of infection diagnosed by CT, and suggested differential surgical management according to this classification. In DNM type 1, which localizes the infection to the upper mediastinal area above the tracheal bifurcation, transcervical drainage is adequate to drain mediastinal pus [22,35,38,39,41,42].…”

Section: Management Approachesmentioning

confidence: 99%

Update on Necrotizing Mediastinitis: Causes, Approaches to Management, and Outcomes

Sandner

Börgermann

2011

Curr Infect Dis Rep

View full text Add to dashboard Cite

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.

show abstract

Section: Management Approachesmentioning

confidence: 99%

Update on Necrotizing Mediastinitis: Causes, Approaches to Management, and Outcomes

Sandner

Börgermann

2011

Curr Infect Dis Rep

View full text Add to dashboard Cite

show abstract

“…In reported cases of DNM, successful surgical management involves a combination of cervical and mediastinal drainage with or without open thoracotomy [3,4,8,15,21,29,30,[36][37][38][39][40][41][42][43][44]. ENDO et al [29] proposed a classification scheme to facilitate management of DNM based on CT assessment of the extent of infection.…”

Section: Review: Descending Necrotising Mediastinitis E Weaver Et Almentioning

confidence: 99%

“…ENDO et al [29] proposed a classification scheme to facilitate management of DNM based on CT assessment of the extent of infection. Type I (or localised) DNM, defined as infection localised to the upper mediastinum above the tracheal bifurcation, may be adequately managed with mediastinal drainage via a transcervical approach without opening the chest cavity [34,40,45]. Diffuse DNM is subclassified as type IIA if infection involves the lower anterior mediastinum or as type IIB if the anterior and posterior lower mediastinum is involved [29].…”

Section: Review: Descending Necrotising Mediastinitis E Weaver Et Almentioning

confidence: 99%

Descending necrotising mediastinitis: two case reports and review of the literature

Weaver¹,

Nguyen²,

Brooks³

2010

Eur Respir Rev

View full text Add to dashboard Cite

Descending necrotising mediastinitis is a rare and serious infection with a high mortality rate, which complicates pharyngeal or odontogenic infection. Early recognition and treatment are essential in order to minimise morbidity. Evaluation with computed tomography is necessary to confirm the diagnosis and facilitate surgical planning. In addition to prompt empirical antiobiotic therapy, surgical intervention is necessary in nearly all cases. Surgical drainage and debridement may be performed through cervicotomy alone, or through combined cervicotomy and thoracotomy, depending upon the extent of disease. Hyperbaric oxygen therapy may play an auxiliary role. We present two recent cases with characteristic imaging findings, and review the relevant literature. KEYWORDS: Computed tomography, mediastinitis CASE ONEA 60-yr-old male presenting with neck swelling, dysphagia and hoarseness had been extubated 2 days previously following a pneumonia. He had a past medical history of laryngeal cancer treated 10 yrs ago with external beam radiation and chemotherapy. On examination he had bilateral diffuse neck erythema, oedema and right-sided induration. Fibre-optic laryngoscopy showed scabbing of the right hypopharynx and erythematous swelling of the false vocal folds, aryepiglottic folds, and epiglottis. Over the course of 12 h, he developed septic shock with a blood pressure of 70/ 30 mmHg, heart rate of 135 beats?min, and a temperature of 103uF. He was started empirically on vancomycin and piperacillin/tazobactam. After stabilisation in the intensive care unit (ICU), computed tomography (CT) imaging of the neck and chest was performed. There was a large amount of subcutaneous air tracking into the deep fascial planes of the anterior neck, oedematous laryngeal mucosa, and bilateral loculated fluid collections tracking throughout the anterior neck extending to the superior mediastinum ( fig. 1). CT imaging of the chest showed a complex air and fluid collection in the anterior mediastinum extending to the base of the neck ( fig. 2). After review of the images, the patient was taken to the operating room for a combined procedure performed by both head and neck surgeons and thoracic surgeons. Bilateral anterior neck dissections were performed, and blunt dissection, irrigation and debridement were carried out to several centimeters below the sternal manubrium. Penrose drains were left in place. Then, left anterior thoracotomy with debridement of the anterior mediastinum, left pleural decortication and a pericardial window were performed by the thoracic surgeons. Microbiology of the anterior mediastinal fluid grew multiple organisms including Fusobacterium, Prevotella, Bacteroides fragilis, Peptostreptococcus, and a heavy growth of Streptococcus intermedius. Pathology of the pharyngeal lesions showed necrosis and granulation tissue. No neoplasm was identified. The patient later received a tracheostomy and pectoralis myocutaneous flap repair of the neck without sequelae. His total ICU length of stay was 32 days, and hi...

show abstract

“…Some authors also believe that the use of tracheostomy in order to avoid airway obstruction due to pharyngeal abscess or infl ammation of the tracheal wall is necessary. 9,32,35 Nevertheless, others believe that tracheostomy can spread the infection to non-involved areas and hinder subsequent surgical treatment. 8,35 However, tracheostomy should be considered in cases of prolonged mechanic ventilation.…”

Section: Referencesmentioning

confidence: 99%

Descending mediastinitis: a review

2006

View full text Add to dashboard Cite

CONCLUSION:Since DM is a lethal condition if not promptly treated, it must always be considered to represent an emergency situation. deep neck into three major fascial pathways by which oropharyngeal infections can spread towards the mediastinum (Table 1). The three layers are the pretracheal or superfi cial, visceral and prevertebral layers. In turn, there are three main fascial pathways. The fi rst of these is the pretracheal pathway, which is anterior to the trachea and ends in the anterior mediastinum at the level of the carina. This space is limited superiorly by the thyroid cartilage and is the most superfi cial of these spaces. The second is the lateropharyngeal pathway, which extends from the base of the skull to the aortic arch and drains into the middle mediastinum. This is formed by fusion of the major layers of the cervical fascia, and it has communication with all the cervicofascial spaces. It is also called the "perivascular space", because it is surrounded by the carotid sheath and thus contains the carotid artery, internal jugular vein and vagus nerve. Finally, the retropharyngeal pathway is located between the esophagus and spine and is also called the "prevertebral" or "retrovisceral" space. 1,10 This interfascial space starts at the C6 level of the spine and continues as far as the T1 level (where the alar fascia joins the inferior constrictor muscles of the pharynx); from that point onwards, the so-called "danger space" starts. This name is given because this space is patent from the skull base to the diaphragm, thereby allowing the spread of infection to the mediastinum. When infection reaches this level, the prognosis is usually poor.About 70% of the cases of DM occur through the retropharyngeal pathway 9-11 and 8% occur via the pretracheal route. 9 The latter is more common in infections originating from thyroid gland. 9 The remainder of the cases occur via perivascular spreading and, in these cases, the process is frequently complicated with arterial hemorrhage. In general, pharyngeal abscesses spread into the retropharyngeal space to reach the posterior mediastinum, whereas submental and submaxillary abscesses spread towards the anterior mediastinum.12 It is important to remember that transdiaphragmatic spread via either the esophageal hiatus or the vena cava foramen may also occur, especially in immunocompromised patients. 2Epidemiology and Epidemiology and classifi cation classifi cation DM mainly affects young adults. The median age is 36 years and 86% of the patients are men. 13 Odontogenic infection is the most common cause of descending mediastinitis, 8,14 especially when the second and third lower molars are involved. It accounts for 40-60% of the cases. The second most common cause is retropharyngeal abscess (14%). Peritonsillar abscesses makes up 11% of the etiologies. Either retropharyngeal or peritonsillar abscess may cause violation of the lateropharyngeal spaces and downward spread of the infection to the mediastinum.12 Less common causes include cervical lymphadenitis (7%)...

show abstract

Descending Necrotizing Mediastinitis: Surgical Drainage and Tracheostomy

Cited by 65 publications

References 19 publications

Update on Necrotizing Mediastinitis: Causes, Approaches to Management, and Outcomes

Update on Necrotizing Mediastinitis: Causes, Approaches to Management, and Outcomes

Descending necrotising mediastinitis: two case reports and review of the literature

Descending mediastinitis: a review

Contact Info

Product

Resources

About