Successful thoracoscopic debridement of descending necrotizing mediastinitis

Isowa, Noritaka; Yamada, Tetsu; Kijima, Takeshi; Hasegawa, Kazuki; Chihara, Koji

doi:10.1016/s0003-4975(03)01260-8

Cited by 44 publications

(24 citation statements)

References 5 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%

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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%

“…In their series, all patients that underwent both cervicotomy and thoracotomy survived. More recently, less invasive approaches successfully employing thoracoscopic or mediastinoscopic drainage have been reported [11,14,[48][49][50][51][52][53][54][55].…”

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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“…Today, optimal management of DNM remains controversial [22][23][24][25]. In particular, the adequacy of cervical drainage alone is being debated.…”

Section: Introductionmentioning

confidence: 99%

Update on Necrotizing Mediastinitis: Causes, Approaches to Management, and Outcomes

Sandner

Börgermann

2011

Curr Infect Dis Rep

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Descending necrotizing mediastinitis (DNM) is one of the most feared and fatal forms of mediastinitis, occurring as a complication after odontogenic or cervicofascial infections or after cervical trauma. Delayed recognition, underestimation of the extent of disease, and insufficient therapy promote spread of infection. Primary treatment of DNM includes surgical eradication of the pharyngeal or odontogenic infection focus, and a concomitant major drainage applied to the neck and the mediastinum. However, the mortality rate of DNM remains high, even with the routine use of CT scanning, antibiotics, advancements in anesthesia and intensive care, and immediate surgical drainage. The present state of the optimal management of DNM is discussed controversially, in particular the question of whether thoracotomy should be performed routinely or if minimally invasive procedures (eg, video-assisted thoracoscopy) may be introduced. This review reports on the incidence and course of this disease and discusses management approaches to DNM.

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“…Other reports, documenting the excellent rate of resolution of the infection, without the need for further surgical intervention, have followed. (4,7,12) The postoperative evolution should be rigorously monitored, imaging studies being conducted only when there is suspicion of smaller but septate collections; these collections can and should, whenever possible, be approached by techniques of tomography-guided drainage under local anesthesia, coinciding with the aforementioned concept.…”

Section: Resultsmentioning

confidence: 99%

“…The patient was for the treatment of descending necrotizing mediastinitis; the authors of those studies sought to show that cervicotomy combined with videoassisted thoracoscopy allows ample and efficient access to the mediastinum, thereby making it possible to perform mediastinal exploration, debridement, and drainage, which collectively constitute the sine qua non for the treatment of this disease. (4,7,(12)(13)(14) The objective of the present study was to report a case series of patients with descending necrotizing mediastinitis who were satisfactorily treated with minimally invasive thoracic surgery.…”

Section: Introductionmentioning

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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Successful thoracoscopic debridement of descending necrotizing mediastinitis

Cited by 44 publications

References 5 publications

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

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

Update on Necrotizing Mediastinitis: Causes, Approaches to Management, and Outcomes

Mediastinite descendente necrosante: tratamento cirúrgico torácico minimamente invasivo

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