Clinical features and outcome of patients with descending necrotizing mediastinitis: prospective analysis of 34 cases

Palma, Daniela Maria; Giuliano, Simone; Cracchiolo, Andrea; Falcone, Marco; Ceccarelli, Giancarlo; Tetamo, Romano; Venditti, Mario

doi:10.1007/s15010-015-0838-y

Cited by 61 publications

(73 citation statements)

References 37 publications

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“…Mediastinitis describes a process of either inflammation and/or infection of the connective tissues and structures contained within the mediastinum. Due to the vital nature of those structures contained within the mediastinum, mediastinitis is associated with a high degree of morbidity and mortality with most cases requiring admission and treatment in the ICU [1]. The three most common aetiologies of mediastinitis are described below and include DSWI, oesophageal perforation and DNM.…”

Section: Definitions Epidemiology and Risk Factorsmentioning

confidence: 99%

“…Descending necrotizing mediastinitis is caused by odontogenic (36%e47%), pharyngeal (33%e45%) or cervical (15%) infections. In 6% of cases, the source of infection is unknown [1,21]. As listed in Table 1, the main risk factors for DNM include impaired immune function, diabetes, the use of oral glucocorticoids, and reduced tissue oxygenation caused by heart failure, respiratory insufficiency and peripheral artery occlusive disease.…”

Section: Descending Necrotizing Mediastinitismentioning

confidence: 99%

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Mediastinitis in the intensive care unit patient: a narrative review

Pastène

Cassir

Tankel

et al. 2020

Clinical Microbiology and Infection

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Background: Mediastinitis is a rare but severe infection, defined as an inflammation of the connective tissues and structures within the mediastinum. Due to its proximity to vital structures, mediastinitis represents a highly morbid pathological process associated with a high risk of mortality. In most cases mediastinitis requires treatment in the intensive care unit. Objectives: To highlight to the reader the clinical features of mediastinitis, to attempt to define each clinical scenario, to describe the responsible pathogens and finally to depict both the medical and surgical treatments. Sources: We performed a literature search of the PubMed and Cochrane libraries, limited for articles published between January 2003 and December 2018, reporting on acute mediastinitis. Content: The term covers different entities of different aetiologies including deep sternal wound infection related to sternotomy; oesophageal perforation or anastomosis leakage; and finally descending necrotizing mediastinitis, often secondary to oropharyngeal abscess. The responsible pathogens and therefore subsequent management depends on the underlying aetiology. Empirical antimicrobial therapy should cover the suspected microorganisms while surgery and supportive measures should aim to reduce the inoculum of pathogens by providing adequate drainage and debridement. Implications: Literature concerning mediastinitis in the intensive care unit is relatively scarce. We have collated the evidence and reviewed the different causes and treatment options of acute mediastinitis with a particular focus on microbiological epidemiology. Future research in larger cohorts is needed to better understand the treatment of this difficult disease.

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Section: Definitions Epidemiology and Risk Factorsmentioning

confidence: 99%

Section: Descending Necrotizing Mediastinitismentioning

confidence: 99%

Mediastinitis in the intensive care unit patient: a narrative review

Pastène

Cassir

Tankel

et al. 2020

Clinical Microbiology and Infection

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“…Images of retropharyngeal abscess could show the narrowing of upper airway and the space-occupying lesion with ring enhancement in the retropharyngeal space by contrast CT scan. Wheezing history in this patient was probably imitated by stridor from upper airway compromise 1. Infections in retropharyngeal space could quickly spread down to mediastinum and cause descending necrotising mediastinitis 2.…”

Section: Descriptionmentioning

confidence: 82%

Fatal case of descending necrotising mediastinitis

Sato

Watari

Tokuda³

2017

BMJ Case Reports

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DescriptionA 56-year-old man presented with a 4-day history of fever and sore throat followed by 1 day of wheezing. On examination, he appeared in acute distress. The blood pressure was 129/76 mm Hg, the pulse was 88 per min, the respiratory rate was 22 per min and the temperature was 38.2°C. Auscultation over the upper airway area noted stridor. Chest radiograph showed tracheal stenosis and air along the aorta (figure 1). At the emergency department, he developed respiratory arrest, and the trachea was incubated. CT scan with intravenous contrast showed a space-occupying lesion behind the pharynx and mediastinum emphysema (figure 2). A diagnosis of retropharyngeal abscess with descending necrotising mediastinitis was made. Despite antimicrobial therapy in intensive care, he developed septic shock and died on day 4 after the admission. Patients with retropharyngeal abscess usually have fever, sore throat, odynophagia, drooling and fatigue with dyspnoea and stridor mimicking wheezing in severe cases. Images of retropharyngeal abscess could show the narrowing of upper airway and the space-occupying lesion with ring enhancement in the retropharyngeal space by contrast CT scan. Wheezing history in this patient was probably imitated by stridor from upper airway compromise.1 Infections in retropharyngeal space could quickly spread down to mediastinum and cause descending necrotising mediastinitis. 2This fatal infection produces air in the mediastinum which can be recognised by imaging such as CT scan.contributors RS cared for the patient. RS, TW and YT wrote the paper. Figure 1 The disrupted narrow trachea and air along the aorta in the mediastinum were observed in chest radiograph. Fatal case of descending necrotising mediastinitis Figure 2Sagittal image of CT revealed abscess of 13.2 cm long (black arrowhead) down to the aortic arch surrounding the trachea in mediastinum which compressed the trachea. There was air in anterior and posterior mediastinum and behind the aorta (white arrowhead). Learning points► Descending necrotising mediastinitis (DNM) is a rare but life-threatening disease, and thus, high index of suspicion for this in patients with severe sore throat is essential. ► The complications of DNM include sepsis, great vessel erosions, haemorrhage, cardiac or respiratory problems, as well as abscess in the posterior mediastinum that can cause the airway obstruction, leading respiratory arrest. ► Rapid tracheal intubation or tracheostomy for the airway management should be considered when stridor is noted in patients with severe sore throat.

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“…It is important to start the diagnostic investigation by the physical evaluation associated with vital signs accompanied by thoraciccervical imaging and laboratorial tests such as complete blood count and blood culture [4,5]. CT scans can demonstrate increases in cardiac and mediastinal boss [6,7] as well as evidence of lung collections characteristic of pleural effusion and pericardial effusion, when circumscribed to the cardiac area. These findings are present in the described case report, and the net collection present in the interpleural space evidenced by chest CT resulted in approximately 1000mL in the right thorax.…”

Section: Discussionmentioning

confidence: 99%

“…Infections in posterior lower teeth are associated in greater number to this condition due to their straight drainage to the submandibular space, which is located near the retropharyngeal and lateral pharyngeal spaces [8,10]. Piperacillinin combination with Tazobactam can be used as first-line therapy to DNM treatment in view of the polymicrobial characteristic of the infection and the broad spectrum of action of these drugs [6]. In the presented case report, Sodium Piperacillin associated to Tazobactam demonstrated a satisfactory result, culminating in total Remission of Infection.…”

Section: Discussionmentioning

confidence: 99%