Descending necrotising mediastinitis: a safe treatment algorithm

Abstract

Descending necrotising mediastinitis can complicate oropharyngeal infection and has a high associated mortality. We present three cases treated in our department and propose a treatment algorithm based on our experience and literature review. The primary oropharyngeal infection was peritonsillar abscess in two cases and odontogenic abscess in one. Two patients underwent cervicotomy and later thoracotomy. The third underwent cervicotomy with transcervical mediastinal drainage and later required pericardial drainage via a subxiphoid incision. All recovered fully and were discharged within 6 weeks. To enable successful treatment, diagnosis needs to be prompt and surgical drainage adequate. Thoracic management of the chest is essential.

A Case of an Acute Cervicomediastinal Hematoma Secondary to the Spontaneous Rupture of a Parathyroid Adenoma

“…This disease is a rare and serious infection with a high mortality rate [14%-50%] that originates from a pharyngeal or dental infection. [17][18][19][20][21] Our patient presented with symptoms similar to those of DNM. The patient's clinical symptoms included the gradual deterioration of neck pain, neck swelling and inflammatory reactions, and the tomographical manifestations included swelling of the retropharyngeal soft tissue, a low-density lesion located in the mediastinum and a pleural or pericardial effusion.…”

Descending necrotizing mediastinitis

“…2,3 It is associated with high mortality unless it is diagnosed and treated promply. 4 Old age and chronic medical conditions are important predisposing factors. 2,3 We report a young patient with DNM who survived despite a considerable delay in diagnoses and a complicated course in the intensive care unit (ICU).…”

“…[3][4][5] Recently, a better prognosis was described 6,7 and attributed to early diagnosis using CT scan, early aggressive surgical intervention, proper antibiotic therapy, and advanced ICU management. Prolonged ICU and hospital length of stay is the rule for most patients.…”

“…8 Frequently, there is a need for repeated drainage either surgically or by percutaneous route as reported in most of published series. 4,5 Other transthoracic approaches such as sternotomy, clamshell incision, a subxiphoid approach, and video-assisted thoracic surgery have been described. 5,9 In this case, surgical intervention was aggressive via cervical dissection, debridement, and drainage of pus with bilateral thoracotomy, pleuropericardial window for debridement and drainage of mediastinal and pleural collections and repeating the drainage of the remaining or newly formed collections by a less invasive percutaneos CT guided aspiration.…”

Surgery for acute mediastinitis in oesophageal perforations and descending necrotising infection: complications, mortality and protective factors

“…Generally the acute processes are due to gram-positive bacterial infections that produce purulent collections. 1 Acute mediastinitis is a life-threatening situation that is associated with high morbidity and mortality rates. It may sometimes be hard to diagnose and manage, since its clinical presentation is non-specific and similar to other systemic infections or septic conditions.…”