Early open thoracotomy and mediastinopleural irrigation for severe descending necrotizing mediastinitis

Iwata, Takekazu; Sekine, Yasuo; Shibuya, Kazuhiro; Yasufuku, Kazuhiro; Iyoda, Akira; Iwamoto, Toshihiko; Saitō, Yukio; Fujisawa, Takehiko

doi:10.1016/j.ejcts.2005.05.018

Cited by 48 publications

(44 citation statements)

References 15 publications

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“…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%

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

Weaver¹,

Nguyen²,

Brooks³

2010

Eur Respir Rev

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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...

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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

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“…The most common causes of mediastinitis are esophageal perforations and infections after operations through sternotomy incisions. Occasionally acute mediastinitis occurs as a complication of infections that arise from odontogenic or cervicofascial infections, or cervical trauma [4].…”

Section: Introductionmentioning

confidence: 99%

A case of Candida mediastinitis after dental extraction

Badiee

Alborzi

Farhoudi

2010

J Infect Dev Ctries

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Acute mediastinitis is a serious infection involving the connective mediastinal tissue in the interpleural spaces and other thoracic structures. Candida albicans mediastinitis is a rare clinical entity associated with high mortality and morbidity. We present a rare case of a previously healthy and immunocompetent man with Candida mediastinitis due to retropharyngeal abscess after dental extraction, who presented with odynophagia and fever. Antibiotics were prescribed and surgical drainage was performed after diagnosis of mediastinitis by CT scan; however, the patient remained febrile. The second culture obtained during irrigation of the mediastinum was positive for Candida albicans and the patient was responsive to antifungal therapy and survived. This case illustrates the need to consider a fungal cause in immunocompetent patients with mediastinitis who are not responsive to broad spectrum antibiotics and surgical drainage.

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“…Drainage via open thoracotomy was performed on two cases; however, case 2 died on postoperative day 15 from acute respiratory distress syndrome (ARDS). 4 Extensive infection and complications including diabetes suggest poor prognostic factors. 4,7 According to Endo's classifi cation, the present case was DNM type 2B and required complete mediastinal drainage with debridement via open thoracotomy.…”

Section: Discussionmentioning

confidence: 99%

“…Our search found case reports on DNM for which surgical management was carried out in four cases aged over 80 years (Table 1). [3][4][5][6] There are few case reports on patients aged over 80 years. Drainage via open thoracotomy was performed on two cases; however, case 2 died on postoperative day 15 from acute respiratory distress syndrome (ARDS).…”

Section: Discussionmentioning

confidence: 99%

A case of an elderly patient treated for descending necrotizing mediastinitis

Suga

Inoue

Takeichi

et al. 2011

Gen Thorac Cardiovasc Surg

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We report a case of descending necrotizing mediastinitis (DNM). DNM is a serious infection, and preventing death requires early diagnosis and draining of the infection focus. An 84-year-old man was admitted to our hospital complaining of a swollen neck and pain when swallowing. He had had a tooth extracted at a neighboring dental clinic 2 days previously. Cervicothoracic computed tomography (CT) scan demonstrated gas bubbles and unencapsulated abscesses in the cervical spaces and anterosuperior and posterior mediastinum, extending below the carina. He was diagnosed as DNM caused by odontogenic infection. Cervical drainage was performed, in addition to mediastinal drainage using video-assisted thoracic surgery (VATS). Complications were sepsis, disseminated intravascular coagulation (DIC), and heart failure after surgery, but he recovered following intensive care. This was a lifesaving case of DNM for which mediastinal drainage was performed with VATS.

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Early open thoracotomy and mediastinopleural irrigation for severe descending necrotizing mediastinitis

Abstract: Our treatment strategy for severe DNM was efficacious for early treatment and reduced the mortality rate. Early detection of DNM, and immediate thoracotomy and irrigation of the mediastinum and thoracic cavity, are recommended.

Cited by 48 publications

References 15 publications

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

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

A case of Candida mediastinitis after dental extraction

A case of an elderly patient treated for descending necrotizing mediastinitis

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