Multidisciplinary Approach in the Treatment of Descending Necrotizing Mediastinitis: Twenty-Year Single-Center Experience

Abstract

Descending necrotizing mediastinitis (DNM) is an acute, rare, severe condition with high mortality, but the optimal management protocol is still controversial. We retrospectively analyzed the results of multidisciplinary management in patients treated for DNM at our center over the last twenty years. Fifteen male patients, mean age 49.07 ± 14.92 years, were treated: 9 with cervico-pharyngeal etiopathogenesis, 3 peri-tonsillar/tonsillar, 2 odontogenic, 1 post-surgical; 6 with DNM type I, 6 with type IIA, and 3 with type IIB (Endo’s classification). Mean time between diagnosis and treatment was 2.24 ± 1.61 days. In all cases, mediastinum drainage via thoracotomy was performed after neck drainage via cervicotomy, associated with tooth treatment in two; one required re-operation; tracheostomy was necessary in 9, temporary intensive care unit stay in 4; 6 developed complications, without post-operative mortality. Main isolated germs were Staphylococci and Candida; 7 had polymicrobial infection. The most used antibiotics were meropenem, metronidazole, teicoplanin, third-generation cephalosporins and clyndamicin; anti-fungal drugs were fluconazole, caspofungin and anidulafungin. On multivariate analysis, presence of cardiovascular disease was statistically significantly associated with longer chest tube duration and hospital stay. DNM requires early diagnosis and treatment to reduce mortality and morbidity. The most effective treatment should provide a multidisciplinary approach, combining cervicotomy and thoracotomy to drain all infectious collections with administration and monitoring of the proper antimicrobial therapy.

Risk Factors Associated with Post-Operative Complications in Multidisciplinary Treatment of Descending Necrotizing Mediastinitis

“…Our results confirmed that the strategy suggested by De Palma et al [ 13 ] is effective: only transcervical drainage of the mediastinum by cervicotomy (performed in three patients) seemed to be a risk factor for postoperative complications in our series.…”

“…Another point of strength in our results is the low rate of tracheotomy (16.9%) compared to the reported 60% of other series [ 13 ]. On this point, indeed, we agree with Kim [ 19 ], who considered tracheotomy not always necessary in DNM.…”

“…Despite the main limitations of our work, related to small sample size and the retrospective nature of the study, which prevent the analysis to drive strong conclusions, we report the results of a quite large series compared to other studies [ 11 , 12 , 13 , 16 , 17 ] in the relative short period of 10 years, considering the rarity of the disease. The main strengths of this study are the good results in terms of mortality (11.1%) and low rate of post-operative complications (44.4%), lower than the data reported in the literature [ 2 , 3 ] and similar to De Palma’s results (null mortality with 40% complications in a young population with a mean age of 49.07 ± 14.92 years [ 13 ]). These results are even more interesting when considering the age of our population (27.8% being over 60 years old), as this resulted in being a risk factor for complications…”

“…On the contrary, in a recent work, De Palma et al [ 13 ] recommended a lateral thoracotomy in addition to cervicotomy also in patients with initially limited mediastinitis, with the aim of obtaining a toilette of pleural collections and a mediastinal debridement (after opening the mediastinal pleura).…”

Antibiotics and Infectious Respiratory Diseases

“…The last two articles in our Special Issue focus on two topics of antimicrobial resistance. De Palma shares 20 years of experience in treating mediastinitis, a pathology with high morbidity, mortality and polymicrobial etiology [ 8 ].…”