Descending mediastinitis: a review

Abstract

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%)...

Descending necrotizing mediastinitis: 5 years of published data in Japan

“…Because polymicrobial CNF/DNM is more commonly seen, antibiotics need to be broad enough to cover Gram‐positive cocci,Gram‐negative rods, and anaerobic bacteria. Several empirical regimens include piperacillin–tazobactam and vancomycin and clindamycin with ceftriaxone or carbapenems have been described in the published reports . It is suggested that, in cases of DNM complicated by streptococcal toxic shock syndrome, the use of protein synthesis inhibitors such as clindamycin proves more effective than penicillin .…”

Acute focal infections of dental origin

“… and Cirino et al. , reviewing the literature of descending necrotizing mediastinitis, found that, despite prompt pharmacologic and surgical intervention, delayed diagnosis is still responsible for a high mortality rate (about 40–50%).…”

“…Dental infection is the most common cause, but also infections in the mouth, pharynx, tonsils and salivary glands can be involved as well as trauma and surgical infections. Biasotto et al (8) and Cirino et al (14), reviewing the literature of descending necrotizing mediastinitis, found that, despite prompt pharmaco-logic and surgical intervention, delayed diagnosis is still responsible for a high mortality rate (about 40-50%).…”

Crossing the Barrier: When the Diaphragm Is Not A Limit

“…The vena caval foramen is not considered part of the continuum because its adherence to the vein wall does not allow subserous tissue [3]. Nevertheless, this foramen has occasionally been described as a potential pathway for bidirectional disease migration, both in retroperitoneal abscesses [11] and in cases of descending mediastinitis [14]. In addition, the caval lumen by itself can act as a transphrenic pathway, usually described in (macroscopic) transvenous spread of some neoplastic diseases [4] (Fig.…”