Descending Necrotizing Mediastinitis: Surgical management and results C.Aránzazu Pérez, PhD1; J.D. Contreras, MD1; CA. Rómbola, MD2 , M.I Rodríguez MD1; F.J. Diaz, MD1 T. García, MD; JC. Ceballos, MD3

ENT Department1 , Thoracic Surgery Department2 , Pulmonology Department3

Complejo Hospitalario Universitario de Albacete. Spain

Descending necrotizing medistinitis (DNM), is

commonly caused by odontogenic infection,

peritonsillar abscess or retropharyngeal

abscess. The diagnosis must be stablished

rapidily. Because mortality rates are too high,

aggressive surgical treatment is indicated. This

investigation reviews the effects of surgical

drainage on the survival of patients with DNM.

PATIENTS AND METHOD

A retrospective review of patients from 2003

through 2010 with a diagnosis of DNM was

performed. Their records were abstracted for

personal demographics, hospital course,

surgical treatment, morbility and mortality. The

records of all patients were statistically analyzed

for the impact of several clinical factors on

survival.

RESULTS:

We treated 15 patients (13 men, 2 woman) in

whom DNM was identified. DNM was consecutive

to dental abscess (6 cases), pharingitis (6 cases),

foreign body infection (2 case) and after

tracheotomy (1 case). The mean age of the

patients was 56 years (range, 27 to 85 years).

Surgical treatment consisted : in 8 patients

combined transthoracic mediastinal and cervical

drainage and 7 with a less aggressive surgical

approach, such as cervical drainage and

transcervical mediastinal drainage. Four patients

required reoperation. Traqueotomy was

performed in 6 patients. Three deaths occurred.

The mean duration of hospitalitation was 29

days.

CONCLUSION

Descending necrotizing mediastinitis must be

detected as soon as possible by computer

tomography scanning in patients with persistent

symptomatologia after treatment for pharyngeal

infections. It´s important an early diagnosis and

aggressive treatment. Ample cervicotomy

associated with mediastinal drainage is essential

in managing these critical ill patients and can

significantly reduce the mortality rate.

ABSTRACT

Descending necrotizing mediastinitis (DNM), is a life-

threatening disease originating from odontogenic,

pharyngeal or cervical infections that spreads along

fascial planes into the mediastinum. The infection is

usually polymicrobic or mixed aerobic/anaerobic.

Because delayed diagnosis and treatment lead to

mortality and because the validity of antibiotics is

limited, radical debridement of all affected tissue is

required for DNM. The optimal management of DMN

remains controversial, in particular the question of

whether cervical drainage alone or routine

thoracotomy should be performed.

We reported about our experience with 15 patients

affected by DNM and its surgical management.

INTRODUCTION

METHODS AND MATERIAL

RESULTS

Between 2003 and 2010, 15 patients (13 males and 2

woman) were diagnosed and treated for DNM. The

mean age was 56 (range 27-85). All cases met the

criteria stablished by Estrera for the diagnosis (Figure

1). In addition to demographic data, we recorded the

original pathology, the length of time between the

initial symphtoms and hospitalitation, mediastinal

involvement, the type of pathogen, the type of surgery,

the length of hospital stay and the result.

1. Clinical manifestation of severe oropharyngeal infection.

2. Demostration of characteristic imaging features of mediastinitis (CT)

3. Documentation of necrotizing mediastinal infection at operation.

4. Stablishment of a relationship between oropharyngeal infection and

developement of necrotizing process.

Figure 1.The criteria of Estrera

A cervical infection was clinically obvious in all cases. The delay between onset symptoms and admission to our hospital was 8 days (range from 3 to 18) . Of the 15

patients, 8 had mediastinitis at admission and 7 developed mediastinitis during admission (despite antibiotic treatment and surgical drainage in some cases 3). The

primary focus of infection was odontogenic and pharyngeal in 12 patients (Table 1).

A cervicothoracic Computed Tomography (CT) scan results facilitated diagnosis in all cases and revealed heterogeneous infiltration, gas effusion, abscesses and fluid

collections (Figure 2).

After clinical diagnosis, urgent surgical drainage was performed and empirical broad-spectrum intravenous antibiotic was initiated.

In all cases a collar bilateral incision was carried out, involved cervical spaces were opened, debridement of necrotic tissue and drainage were performed (in two cases we

did a thoracoscopic drainage by cervical approach too) . In seven patients the infection was resolved.

In the remaining eight patients we made a drainage of the mediastinal collection by a thoracic approach with a posterolateral thoracotomy (right in 7 and left in one) .

(Figures 3-5) .A temporary tracheotomy was performed in 6 patients . Mediastinal drains were inserted and used for irrigation following surgery . CT was performed 2 or 3

days after surgery

All the patients were admitted to the intensive unit care after surgery. The mean duration of intensive care stay was 14 (range 2-40) days. Three patients died, one in the

unit care by multiorganic failure and the other two in the hospital by pulmonary hemorrhage once and exacerbation of cardiac pathology the other.

Abbreviattions: M-man; W- woman.

* Diagnosis of mediastinitis at the same time of admission at hospital

Table 1: Personal data and source of infection

DISCUSSION

CONCLUSIONS

REFERENCES

1. DNM is caused by downward spread of neck infections an constitutes a

hight lethal complication of oropharyngeal lesions.

2. It´s necessary an early diagnosis using cervicothoracic CT and

inmediate multidisciplinary medical and surgical therapy.

3. The primary treatment of DNM includes intravenous broadspectrum

antibiotics .

4. Aggressive cervical and mediastinal drainage will be performed. A

cervical approach is adequate when the mediastinitis is limited to the

upper mediastinum and transthoracic drainage when the mediastinitis

has spread below the carina.

1. Estrera AS, Landay MJ, Grisham JM et al.Descending necrotizing mediastinitis. Surg

Gynecol Obstet 1983;157:545-52.

2. Endo S, Murayama F, Hasegawa T et al. Guideline of surgical management based on

diffusion of descending necrotizing mediastinitis. Jpn J Thorac Cardiovasc Surg 1999;

47:14-9.

3. Roccia F, Pecorari GC, Oliaro A et al. Ten years of descending necrotizing mediastinitis:

management of 23 cases. J Oral Maxillofac Surg 2007; 65:1716-1724.

4. Deu-Martin M, Saez-Barba M, López Sanz I et al. Mortality risk factors in descending

necrotizing mediastintis. Arch Bronconeumol 2010; 46:182-187

Odontogenic and pharyngeal infections are the most common cause

of DNM. The majority of DNM are mixed polymicrobial aerobic and

anaerobic reflecting its pharyngeal or odontogenic nature. It can affect all

age groups but it´s more frequent in the fourth and fifth decade.

Early diagnosis of DNM will be done. It´s easy the diagnosis of cervical

infection but the diagnosis of mediastinitis is often difficult. CT of the

neck and thorax is mandatory if the process is suspected and it´s used

preoperatively to asses the extent of the necrotising process and

stablished the optimal approach for efficient drainage.

Inmediate surgical drainage though wide neck exposure and

exploration of fascial compartments with extensive debridement is

essential. The cervical wounds are not closed until the pathologic

changes regress completly.

According to several investigator, superior mediastinal drainage

through a cervical approach is adequate when the mediastinitis is limited

to upper mediastinum and transthoracic drainage (thoracotomy) has to

be performed when the mediastinitis has spread below the carina. And

when more than one mediastinal space is envolved, the standard

treatment should be a combined cervical and thoracic approach in the

same operation. The need for tracheotomy should be assessed on an

individual basis.

In addition to surgical treatment, postoperative intensive care

management is an essential determinant for outcome.

Figure 5

Vision through open thoracotomy for mediastinal abscess.

Drainage from the neck to posterior mediastinum for washing.

Figure 4

Cervical necrotizing fasciitis of odontogenic origin (patient

5). Tissue necrosis and acumulation of seropurulent content

between the facias and spaces.

Figure 3

Status post wound revision and incision and drainage of

collection of patient 8. Vision drains inserted at level of the

anterior mediastinum for irrigating.

C. Aránzazu Pérez Fernández

ENT Department. General Hospital of

Albacete. Spain

Email: arapi61@hotmail.com

Website: www.chospab.es

CONTACT

Abbreviations:S- Supracarinal; I-Infracarinal; C- Cervicotomy drainage; CVAM- Cervicotomy And Video-assisted

mediastinoscopic drainage; RT- right posterolateral thoracotomy; LT- left Posterolateral thoracotomy; T- tracheotomy.

Figure 2

A. Axial CT scan shows fluid collection containing

gas in the visceral space, the left cervical space. B. The fluid

Collection spreads to the anterior mediastinum .

Patient 8 A B

Table 2. Description of treatment and outcome

Case

Type of surgery No of

tubes Postoperatory complications Bacteria Length of stay Outcome

1 C 2 Toxic shock None 17 Died

2 C + RT + T 4 None alpha hemolytic streptococci 28 Hospital discharge

3 CVAM 1 None Enterobacter coaclae 11 Hospital discharge

4 C + RT 2 Pneumony Streptococcus viridans 35 Hospital discharge

5 C + RT + T 4 Toxic shock Streptcoccus viridans 47 Died

6 C 2 None None 28 Hospital discharge

7 C + T 2 None Streptococcus viridans 28 Hospital discharge

8 CVAM 1 Pneumony None 59 Died

9 C + RT 3 None None 16 Hospital discharge

10 C + RT 4 Cerebral ischemic stroke Streptococcus viridans 22 Hospital discharge

11 C + T 2 Pneumony Prevotella sp 15 Hospital discharge

12 C + T 2 None Streptococcus viridans 28 Hospital discharge

13 C + RT 4 Toxix shock Streptococcus viridans 34 Hospital discharge

14 C + RT 4 Pleural effusion Streptococcus viridans 30 Hospital discharge

Case

Age

/Gender Past history Cause

Time from symptoms

to admission

Clinical diagnosis

Development of

Mediastinitis (days)

1 63/M No Odontogenic

Infection 4 Cervical necrotizing fascitis 0 *

2 46/M Alcoholism Pharyngeal infection 3 Parapharyngeal abscess 13

3 46/M No Foreign infection body 7 Parapharyngeal abscess 0

4 45/M No Pharyngeal infection 5 Parapharyngeal abscess 0

5 36/M DM type I

Alcoholism Odontogenic infection 15 Cervical necrotizing fascitis 0

6 72/M NO Odontogenic infection 18 Cervical necrotizing fascitis 0

7 59/M No Odontogenic infection 15 Ludwig´s angina 6

8 85/M No Odontogenic infection 10 Parapharyngeal abscess 9

9 60/M DM type II Pharyngeal Infection 7 Retropharyngeal abscess 0

10 69/M NO Pharyngeal infection 4 Parapharyngeal abscess 2

11 80/M No After tracheotomy 8 Parapharyngeal abscess 7

12 43/M Obesity Pharyngeal infection 4 Parapharyngeal abscess 0

13 44/W Obesity Foreign infection body 3 Cervical necrotizing fascitis 0

14 27/W No Odontogenic infection 10 Ludwig´s angina 6