Descending necrotizing mediastinitis: Transcervical drainage is not enough

Wheatley, Michael J.; Stirling, Mack C.; Kirsh, Marvin M.; Gago, Otto; Orringer, Mark B.

doi:10.1016/0003-4975(90)90022-x

Cited by 259 publications

(174 citation statements)

References 24 publications

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“…In reported cases of DNM, successful surgical management involves a combination of cervical and mediastinal drainage with or without open thoracotomy [3,4,8,15,21,29,30,[36][37][38][39][40][41][42][43][44]. ENDO et al [29] proposed a classification scheme to facilitate management of DNM based on CT assessment of the extent of infection.…”

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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“…We observed that the was not sufficient for the treatment of the infection, because, in their sample, 20 (46%) of the 43 patients initially submitted to cervicotomy subsequently required thoracotomy to control mediastinitis. (15) Other surgical approaches, such as clamshell thoracotomy, median sternotomy, anterolateral thoracotomy, and bilateral thoracotomy, have been proposed. (8)(9)(10)(11) Currently, minimally invasive intervention with the aid of video-assisted thoracoscopy is widely used.…”

Section: Resultsmentioning

confidence: 99%

Mediastinite descendente necrosante: tratamento cirúrgico torácico minimamente invasivo

et al. 2010

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OBJETIVO: Relatar uma série de casos de pacientes com mediastinite descendente necrosante (MDN) tratados com cirurgia torácica minimamente invasiva. MÉTODOS: Relatamos os casos de três pacientes com MDN submetidos à desbridamento mediastinal através de cirurgia torácica videoassistida no Hospital São Paulo, São Paulo (SP), desde a sua admissão até o desfecho final. RESULTADOS: Os três pacientes apresentaram boa evolução pós-operatória, com tempo médio de internação de 16,7 dias. CONCLUSÕES: Concluímos que a videotoracoscopia é uma técnica efetiva para a drenagem mediastinal no tratamento da MDN, com os benefícios da cirurgia minimamente invasiva: menos dor pós-operatória, menor liberação de fatores inflamatórios, retorno precoce às atividades diárias e melhores resultados estéticos.

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“…Howell et al 2 have described numerous complications of mediastinal infection such as empyema, erosion of the aorta, costal osteomyelitis, aspiration pneumonia, and recurrent abscesses. Four approaches for mediastinal drainage have been reported: transcervical, 3 standard thoracotomy, 4 and transthoracic via a subxiphoid 5 or clamshell incision. 6 Roberts et al 7 reported a case of thoracoscopic drainage and debridement of a posterior mediastinal abscess and emphasised the decreased morbidity of this approach compared with thoracotomy, and the improved drainage compared with cervical drainage alone.…”

Section: Discussionmentioning

confidence: 99%

Mediastinitis from odontogenic infection. A case report

Pappa

Jones

2005

Br Dent J

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We report a case of mediastinitis complicating a dental infection in a 40-year-old male. Despite drainage of the localised neck abscess and the administration of systemic antibiotics, his submandibular abscess extended to involve the pericardial and pleural cavities. Drainage procedures and thoracotomies were required to treat the empyema and purulent pericarditis. Computed tomography was used to follow the progression of disease and assess the efficacy of treatment.

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Descending necrotizing mediastinitis: Transcervical drainage is not enough

Cited by 259 publications

References 24 publications

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

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

Mediastinite descendente necrosante: tratamento cirúrgico torácico minimamente invasivo

Mediastinitis from odontogenic infection. A case report

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