CT features of descending necrotizing mediastinitis—a pictorial essay

Scaglione, Mariano; Pinto, Antonio; Giovine, S; Nuzzo, Loredana Di; Giuliano, Vincenzo; Romano, Luigia

doi:10.1007/s10140-007-0606-0

Cited by 38 publications

(26 citation statements)

References 8 publications

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“…In contrast, DNM is a widespread infection of the neck and mediastinum along deep fascial planes that requires aggressive surgical debridement [1,9,10]. Several case reports and small case series have examined the optimal diagnostic modalities, antibiotic therapy, role of CT scanning and surgical approaches [3,9,[11][12][13][14][15][16][17][18]. Since delay in diagnosis is the primary factor contributing to mortality, the standard of therapy is a comprehensive approach including initial broad spectrum antibiotics, early CT scanning of the neck and thorax, early and wide debridement of cervical and thoracic infection, post-operative ICU monitoring, and surveillance CT scanning and re-operation, as required by clinical course [2,4].…”

Section: Review: Descending Necrotising Mediastinitis E Weaver Et Almentioning

confidence: 99%

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

Weaver¹,

Nguyen²,

Brooks³

2010

Eur Respir Rev

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Descending necrotising mediastinitis is a rare and serious infection with a high mortality rate, which complicates pharyngeal or odontogenic infection. Early recognition and treatment are essential in order to minimise morbidity. Evaluation with computed tomography is necessary to confirm the diagnosis and facilitate surgical planning. In addition to prompt empirical antiobiotic therapy, surgical intervention is necessary in nearly all cases. Surgical drainage and debridement may be performed through cervicotomy alone, or through combined cervicotomy and thoracotomy, depending upon the extent of disease. Hyperbaric oxygen therapy may play an auxiliary role. We present two recent cases with characteristic imaging findings, and review the relevant literature. KEYWORDS: Computed tomography, mediastinitis CASE ONEA 60-yr-old male presenting with neck swelling, dysphagia and hoarseness had been extubated 2 days previously following a pneumonia. He had a past medical history of laryngeal cancer treated 10 yrs ago with external beam radiation and chemotherapy. On examination he had bilateral diffuse neck erythema, oedema and right-sided induration. Fibre-optic laryngoscopy showed scabbing of the right hypopharynx and erythematous swelling of the false vocal folds, aryepiglottic folds, and epiglottis. Over the course of 12 h, he developed septic shock with a blood pressure of 70/ 30 mmHg, heart rate of 135 beats?min, and a temperature of 103uF. He was started empirically on vancomycin and piperacillin/tazobactam. After stabilisation in the intensive care unit (ICU), computed tomography (CT) imaging of the neck and chest was performed. There was a large amount of subcutaneous air tracking into the deep fascial planes of the anterior neck, oedematous laryngeal mucosa, and bilateral loculated fluid collections tracking throughout the anterior neck extending to the superior mediastinum ( fig. 1). CT imaging of the chest showed a complex air and fluid collection in the anterior mediastinum extending to the base of the neck ( fig. 2). After review of the images, the patient was taken to the operating room for a combined procedure performed by both head and neck surgeons and thoracic surgeons. Bilateral anterior neck dissections were performed, and blunt dissection, irrigation and debridement were carried out to several centimeters below the sternal manubrium. Penrose drains were left in place. Then, left anterior thoracotomy with debridement of the anterior mediastinum, left pleural decortication and a pericardial window were performed by the thoracic surgeons. Microbiology of the anterior mediastinal fluid grew multiple organisms including Fusobacterium, Prevotella, Bacteroides fragilis, Peptostreptococcus, and a heavy growth of Streptococcus intermedius. Pathology of the pharyngeal lesions showed necrosis and granulation tissue. No neoplasm was identified. The patient later received a tracheostomy and pectoralis myocutaneous flap repair of the neck without sequelae. His total ICU length of stay was 32 days, and hi...

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Section: Review: Descending Necrotising Mediastinitis E Weaver Et Almentioning

confidence: 99%

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

Weaver¹,

Nguyen²,

Brooks³

2010

Eur Respir Rev

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“…6 The early contrast-enhanced CT of the neck and thorax is the single most important tool for early diagnosis of DNM. [5][6][7][8] Features of DNM on CT include increased density of the adipose tissue, myositis, cervical lymphadenopathy, and/or mediastinal fluid collection (with or without gas). 8 Bilateral empyemas seen on CT are pathognomonic for acute mediastinitis and treatment should begin immediately.…”

Section: Discussionmentioning

confidence: 99%

“…[5][6][7][8] Features of DNM on CT include increased density of the adipose tissue, myositis, cervical lymphadenopathy, and/or mediastinal fluid collection (with or without gas). 8 Bilateral empyemas seen on CT are pathognomonic for acute mediastinitis and treatment should begin immediately. 3 Emergency physicians must consider a diagnosis of DNM and have a low threshold for CT scanning in patients who present systemically unwell with chest pain, upper respiratory tract infection, and a recent diagnosis of EBV.…”

Section: Discussionmentioning

confidence: 99%

Acute Mediastinitis as a Complication of Epstein-Barr Virus

Lloyd

Tran

2015

CJEM

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Acute mediastinitis is a rare, potentially life-threatening condition that is most commonly seen as a complication of esophageal perforations or cardiac surgery. The term "descending necrotizing mediastinitis" (DNM) is used to describe oropharyngeal infections that spread to the mediastinum, most commonly following odontogenic infections, peritonsillar or retropharyngeal abscesses, cervical lymphadenitis, trauma, or endotracheal intubation. Infectious mononucleosis is another rare cause of DNM. The mortality of acute mediastinitis is high, while the mortality for DNM is even higher. Major determinants of mortality are delayed diagnosis and/or treatment. While DNM is seen infrequently, its severe nature makes it essential that emergency physicians consider the diagnosis in patients presenting with upper respiratory infections, chest pain, and systemic symptoms, and also in patients with a recent diagnosis of EBV, in order to mitigate a high rate of morbidity and mortality. RÉSUMÉLa médiastinite aiguë est une maladie rare, potentiellement mortelle, qui résulte la plupart du temps d'une perforation de l'oesophage ou d'une opération cardiaque. L'expression « médiastinite nécrosante descendante » (MND) fait référence aux infections oropharyngées, qui se propagent au médiastin; il s'agit en général d'infections odontogènes, de phlegmons périamygdaliens ou d'abcès rétropharyngiens, de lymphadé-nite cervicale, de traumas ou d'intubations endotrachéales. La mononucléose infectieuse donne rarement lieu à une MND. Si la mortalité attribuable à la médiastinite aiguë est élevée, celle attribuable à la MND l'est encore plus. Les principaux déterminants de la mortalité sont un retard dans la pose du diagnostic ou la mise en route du traitement. Bien que les cas de MND soient rares, la gravité de la maladie exige que les médecins d'urgence envisagent le diagnostic chez les patients présentant une infection des voies respiratoires supérieures, des douleurs thoraciques et des symptômes généraux ainsi que chez les patients chez qui une infection à virus Epstein-Barr a été diagnostiquée depuis peu, afin d'abaisser le taux élevé de morbidité et de mortalité. Keywords: EBV, Acute Necrotizing Mediastinitis, Descending Necrotizing Mediastinitis CASE REPORTA previously healthy 39-year-old male initially presented to the emergency department (ED) with an upper respiratory tract infection characterized by cough, nasal congestion, rhinorrhea, bilateral earache with drainage, sore throat, nausea and vomiting. On physical examination, he was found to have bilateral ear effusions and upper airway congestion. He had normal heart sounds and his lungs had equal and clear air entry bilaterally. He had a temperature of 37°C (98.6°F), a heart rate of 113 beats per minute, respiratory rate of 16 breaths per minute, blood pressure of 114/79 mm Hg, and an oxygen saturation of 98% on room air. His chest x-ray was normal. He was diagnosed with a suspected viral illness, likely influenza, and discharged home. Two days later, this patient returned...

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“…D escending necrotizing mediastinitis (DNM) is a rare but severe life threatening complication of infection in the oropharyngeal region that descends to the mediastinum through the connecting deep and superficial cervical fascial planes. 1 The primary origin of the infection can be an odontogenic infection, pharyngeal soft tissue infection, sinusitis, or following cervical trauma. 2,3 It is associated with high mortality unless it is diagnosed and treated promply.…”

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confidence: 99%

“…These can rupture into the submandibular and parapharyngeal spaces and reach the mediastinum mainly along the retropharyngeal space, but spread can also occur along the perivascular and pretracheal spaces. 1,5 The etiological organisms are mostly mixed polymicrobial aerobic and anaerobic infections. 3,11 The effect of gravity and the negative intrathoracic and pleural pressure during inspiration, and the absence of barriers in the fascial planes are important pathophysiological factors in the extension of deep neck infections to the mediastinum.…”

mentioning

confidence: 99%

Descending necrotizing mediastinitis

2007

Dental Abstracts

191

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Descending necrotizing mediastinitis (DNM) is a rare but severe life threatening complication of oropharyngeal infections. We report a young lady who had severe pharyngitis complicated by anterior neck infection that descended to the mediastinum causing necrotizing mediastinitis. The course of her illness was complicated with septic shock, acute kidney injury, tracheo-esophageal fistula, and critical illness polyneuropathy. There was considerable delay in her diagnosis; however, she survived after aggressive surgical intervention, wide spectrum antibiotics, and appropriate intensive care management. Early and repeated chest imaging using computed tomography was vital for the detection and follow up of this case. There is a need to increase physicians' awareness of this condition that can complicate odontogentic or pharyngeal infection, procedures, or trauma.

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CT features of descending necrotizing mediastinitis—a pictorial essay

Cited by 38 publications

References 8 publications

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

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

Acute Mediastinitis as a Complication of Epstein-Barr Virus

Descending necrotizing mediastinitis

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