Mediastinitis Following Cervical Suppuration

Abstract

INFECTION of the mediastinum may originate from so many different sources and have such divergent manifestations that the term "mediastinitis" means little unless qualified by a description of its type and kind. The process may range from a simple, nonsuppurative inflammation in association with pericarditis, bronchitis, influenza or pneumonia to a very grave, often lethal, diffuse suppurative phlegmon. A chronic variety is seen in tuberculosis which is sometimes called mediastinopericarditis. Tuberculosis also involves the tracheobronchial lymph nodes with occasional suppuration to form a tuberculous mediastinal abscess. These same nodes are infected in many upper respiratory infections, and should they suppurate, a pyogenic mediastinal abscess results. This -phase of the subject has recently been emphasized by Lerche.35 Pyogenic abscesses also follow invasion of the mediastinum from contiguous lung abscesses, empyema, cervical infection, spondylitis, perforating wounds or retroperitoneal infection. These abscesses usually develop slowly enough to allow time for diagnosis, localization and drainage. They have been cured by spontaneous rupture into the trachea or esophagus, repeated aspirations by needle puncture, dorsal mediastinotomy, sternal trephine or cervical drainage. In contrast, a mediastinal phlegmon spreading through so vital a spot may be quickly lethal unless strenuous efforts are undertaken for its control. This diffuse suppuration of the mediastinum may come from any of the sources causing localized abscess if the speed and magnitude of the contamination is sufficient; but the visceral perforations of 'chest and neck are its commonest cause, and of these the cervical lesions are the most frequent. The consideration of diffuse suppurative mediastinitis might well begin with a study of infections in the neck that gravitate into the mediastinum. This demands a knowledge of the fascial spaces connecting the two, for the infection travels along these and it is in them that the surgeon must intercept or drain it. The spaces lie between layers of the cervical fascia, a structure that is so complex that if followed through all of its ramifications is apt to resemble a maze. The subject may be greatly simplified by considering only that part of the cervical fascia and its spaces which significantly relates to the spread of infection. For this purpose it is sufficient to deal with the viscerovascular compartment which contains the visceral space in the center and around it, the previsceral space, the retrovisceral space and the vascular sheath on either side.The first experiments designed to study the compartments of the neck were undertaken by Bichat.2 But many years elapsed before an intensive 588

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

“…Knowledge of neck anatomy is essential for planning surgical approaches in DNM, and several detailed reviews of the relevant anatomy are available [2,22,31,32].…”

Mediastinum Drainage by Cervicotomy in the Neck and Mediastinum Cellulitis: About 12 Cases

“…Described for the first time by Pearse [1] in 1938, Descending necrotizing mediastinitis (DNM) is a rare [2], acute polymicrobic infection of the mediastinum that develops rapidly after an odontogenic or oropharyngeal infection. The responsible pathogens are mainly aerobic and anaerobic bacteria of the oralmicroflora.…”

“…Several approaches are described for the optimal transthoracic approach, including the subxiphoid approach, clamshell incision, median sternotomy, and thoracoscopic approach. Although each of these techniques has potential advantages and disadvantages, the posterolateral thoracotomy incision remains the standard [1,[18][19][20]. It allows comprehensive access to a hemithorax, including the ipsilateral mediastinum and pericardium, and provides the broadest exposure of the prevertebral and paraesophageal planes without the risk of sternal osteomyelitis, which may follow a sternotomy or clamshell incision.…”

Mediastinal Irrigation in the Treatment of Descending Necrotizing Mediastinitis

“…We decided to re-operate on our second patient based on CT findings. In the first modern series of patients with DNM published in 1938, Pearse reported that 49% of patients died during their treatment [9]. Base on these results, a standard transcervical and transthoracic approach is recommended for all DNM patients.…”