1
|
Liao TI, Ho CY, Chin SC, Wang YC, Chan KC, Chen SL. Sequential Impact of Diabetes Mellitus on Deep Neck Infections: Comparison of the Clinical Characteristics of Patients with and without Diabetes Mellitus. Healthcare (Basel) 2024; 12:1383. [PMID: 39057526 PMCID: PMC11276557 DOI: 10.3390/healthcare12141383] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2024] [Revised: 07/06/2024] [Accepted: 07/08/2024] [Indexed: 07/28/2024] Open
Abstract
BACKGROUND Deep neck infections (DNIs) can compromise the airway and are associated with high morbidity and mortality rates. Diabetes mellitus (DM) is a metabolic disorder characterized by chronic hyperglycemia that is associated with several comorbidities. We compared the clinical characteristics of DNI patients with and without DM. METHODS This study recorded the relevant clinical variables of 383 patients with DNIs between November 2016 and September 2022; of those patients, 147 (38.38%) had DM. The clinical factors between DNI patients with and without DM were assessed. RESULTS Patients with DM were older (p < 0.001), had higher white blood cell counts (p = 0.029) and C-reactive protein levels (CRP, p < 0.001), had a greater number of deep neck spaces (p = 0.002) compared to patients without DM, and had longer hospital stays (p < 0.001). Klebsiella pneumoniae was cultured more frequently from patients with DM than those without DM (p = 0.002). A higher CRP level (OR = 1.0094, 95% CI: 1.0047-1.0142, p < 0.001) was a significant independent risk factor for DM patients with prolonged hospitalization. The lengths of hospital stays in patients with poorly controlled DM were longer than those with well-controlled DM (p = 0.027). CONCLUSIONS DNI disease severity and outcomes were worse in patients with DM than those without DM. Antibiotics effective against Klebsiella pneumoniae should be used for DNI patients with DM. DNI patients with DM and high CRP levels had more prolonged hospitalizations. Appropriate blood glucose control is essential for DNI patients with DM.
Collapse
Affiliation(s)
- Ting-I Liao
- School of Medicine, Chang Gung University, Taoyuan 33302, Taiwan; (T.-I.L.); (C.-Y.H.); (S.-C.C.); (K.-C.C.)
| | - Chia-Ying Ho
- School of Medicine, Chang Gung University, Taoyuan 33302, Taiwan; (T.-I.L.); (C.-Y.H.); (S.-C.C.); (K.-C.C.)
- Division of Chinese Internal Medicine, Center for Traditional Chinese Medicine, Linkou Chang Gung Memorial Hospital, Taoyuan 33305, Taiwan
| | - Shy-Chyi Chin
- School of Medicine, Chang Gung University, Taoyuan 33302, Taiwan; (T.-I.L.); (C.-Y.H.); (S.-C.C.); (K.-C.C.)
- Department of Medical Imaging and Intervention, Linkou Chang Gung Memorial Hospital, Taoyuan 33305, Taiwan
| | - Yu-Chien Wang
- Department of Otorhinolaryngology & Head and Neck Surgery, New Taipei Municipal Tucheng Hospital, New Taipei City 23652, Taiwan;
- Department of Otorhinolaryngology & Head and Neck Surgery, Linkou Chang Gung Memorial Hospital, Taoyuan 33305, Taiwan
| | - Kai-Chieh Chan
- School of Medicine, Chang Gung University, Taoyuan 33302, Taiwan; (T.-I.L.); (C.-Y.H.); (S.-C.C.); (K.-C.C.)
- Department of Otorhinolaryngology & Head and Neck Surgery, Linkou Chang Gung Memorial Hospital, Taoyuan 33305, Taiwan
| | - Shih-Lung Chen
- School of Medicine, Chang Gung University, Taoyuan 33302, Taiwan; (T.-I.L.); (C.-Y.H.); (S.-C.C.); (K.-C.C.)
- Department of Otorhinolaryngology & Head and Neck Surgery, Linkou Chang Gung Memorial Hospital, Taoyuan 33305, Taiwan
| |
Collapse
|
2
|
Hsiao FY, Ho CY, Chan KC, Wang YC, Chin SC, Chen SL. Assessment of the Elderly Adult Patients with Deep Neck Infection: A Retrospective Study. EAR, NOSE & THROAT JOURNAL 2023:1455613231177184. [PMID: 37278212 DOI: 10.1177/01455613231177184] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/07/2023] Open
Abstract
Background: Deep neck infection (DNI) is a potentially lethal infectious disease affecting middle-aged adults and can compromise the airway. There are limited data on the prognosis and outcomes of elderly (aged > 65 years) DNI patients, who tend to be immunocompromised. This study analyzed the clinical characteristics of elderly and adult (aged 18-65 years) DNI patients. Methods: Between November 2016 and November 2022, 398 patients with DNIs, including 113 elderly patients, were admitted to our hospital and enrolled in this study. The relevant clinical variables were investigated and compared. Results: The elderly DNI patients had longer hospital stays (P < .001), higher C-reactive protein levels (P = .021), higher blood sugar levels (P = .012), and a higher likelihood of diabetes mellitus (P = .025) than the adult patients. The higher blood sugar level is an independent risk factor for elderly (odds ratio = 1.005, 95% confidence intervals 1.002-1.008, P < .001). Moreover, the rates of intubation to protect the airway (P = .005) and surgical incision and drainage (I&D; P = .010) were higher in the elderly group. However, there were no group differences in pathogen distributions. Conclusion: The elderly DNI patients in this study had a more severe disease course, and poorer prognosis than the adult patients, as well as higher rates of intubation and I&D. However, the pathogen distributions did not differ significantly between the groups. Prompt intervention and treatment are important for elderly DNI patients.
Collapse
Affiliation(s)
- Fu-Yuan Hsiao
- School of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Chia-Ying Ho
- School of Medicine, Chang Gung University, Taoyuan, Taiwan
- Division of Chinese Internal Medicine, Center for Traditional Chinese Medicine, Chang Gung Memorial Hospital, Linkou, Taiwan
| | - Kai-Chieh Chan
- School of Medicine, Chang Gung University, Taoyuan, Taiwan
- Department of Otorhinolaryngology-Head and Neck Surgery, Chang Gung Memorial Hospital, Linkou, Taiwan
| | - Yu-Chien Wang
- School of Medicine, Chang Gung University, Taoyuan, Taiwan
- Department of Otorhinolaryngology-Head and Neck Surgery, Chang Gung Memorial Hospital, Linkou, Taiwan
- Department of Otorhinolaryngology-Head and Neck Surgery, New Taipei Municipal Tucheng Hospital, New Taipei City, Taiwan
| | - Shy-Chyi Chin
- School of Medicine, Chang Gung University, Taoyuan, Taiwan
- Department of Medical Imaging and Intervention, Chang Gung Memorial Hospital, Linkou, Taiwan
| | - Shih-Lung Chen
- School of Medicine, Chang Gung University, Taoyuan, Taiwan
- Department of Otorhinolaryngology-Head and Neck Surgery, Chang Gung Memorial Hospital, Linkou, Taiwan
| |
Collapse
|
3
|
Yun JS, Lee CH, Na KJ, Song SY, Oh SG, Jeong IS. Surgical Experience with Descending Necrotizing Mediastinitis: A Retrospective Analysis at a Single Center. J Chest Surg 2023; 56:35-41. [PMID: 36575811 PMCID: PMC9845862 DOI: 10.5090/jcs.22.110] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2022] [Revised: 11/04/2022] [Accepted: 11/07/2022] [Indexed: 12/29/2022] Open
Abstract
Background We analyzed our experience with descending necrotizing mediastinitis (DNM) treatment and investigated the efficacy of video-assisted thoracoscopic surgery (VATS) for mediastinal drainage. Methods This retrospective analysis included patients who underwent surgical drainage for DNM at our hospital from 2005 to 2020. We analyzed patients' baseline characteristics, surgical data, and perioperative outcomes and compared them according to the mediastinal drainage approach among patients with type II DNM. Results Twenty-five patients (male-to-female ratio, 18:7) with a mean age of 54.0±12.9 years were enrolled in this study. The most common infection sources were pharyngeal infections (60%). Most patients had significantly increased white blood cell counts, elevated C-reactive protein levels, and decreased albumin levels on admission. The most common DNM type was type IIB (n=16, 64%), while 5 and 4 patients had types I and IIA, respectively. For mediastinal drainage, the transcervical approach was used in 15 patients and the transthoracic approach (VATS) in 10 patients. The mean length of hospital stay was 26.5±23.8 days, and the postoperative morbidity and in-hospital mortality rates were 24% and 12%, respectively. No statistically significant differences were found among patients with type II DNM between the transcervical and VATS groups. However, the VATS group showed shorter mean antibiotic therapy duration, drainage duration, and hospital stay length than the transcervical group. Conclusion DNM manifested as severe infection requiring long-term inpatient treatment, with a mortality rate of 12%. Thus, active treatment with a multidisciplinary approach is crucial, and mediastinal drainage using VATS is considered relatively safe and effective.
Collapse
Affiliation(s)
- Ju Sik Yun
- Department of Thoracic and Cardiovascular Surgery, Chonnam National University Hwasun Hospital, Chonnam National University Medical School, Hwasun, Korea
| | - Cho Hee Lee
- Department of Thoracic and Cardiovascular Surgery, Chonnam National University Hospital, Chonnam National University Medical School, Gwangju, Korea
| | - Kook Joo Na
- Department of Thoracic and Cardiovascular Surgery, Chonnam National University Hwasun Hospital, Chonnam National University Medical School, Hwasun, Korea,Corresponding author Kook Joo Na Tel 82-61-379-7662 Fax 82-61-379-7665 E-mailORCIDhttps://orcid.org/0000-0003-0923-1414
| | - Sang Yun Song
- Department of Thoracic and Cardiovascular Surgery, Chonnam National University Hwasun Hospital, Chonnam National University Medical School, Hwasun, Korea
| | - Sang Gi Oh
- Department of Thoracic and Cardiovascular Surgery, Chonnam National University Hospital, Chonnam National University Medical School, Gwangju, Korea
| | - In Seok Jeong
- Department of Thoracic and Cardiovascular Surgery, Chonnam National University Hospital, Chonnam National University Medical School, Gwangju, Korea
| |
Collapse
|
4
|
Oruc M, Oruc K, Meteroglu F, Sahin A. Descending Necrotizing Mediastinitis: Evaluation of 30 Cases. Indian J Surg 2022. [DOI: 10.1007/s12262-022-03651-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
|
5
|
Congedo MT, Nachira D, Pennisi MA, Chiappetta M, Calabrese G, Bello G, Parrilla C, Franza L, Covino M, Petracca Ciavarella L, Porziella V, Vita ML, Lococo F, Margaritora S, Meacci E. Risk Factors Associated with Post-Operative Complications in Multidisciplinary Treatment of Descending Necrotizing Mediastinitis. J Clin Med 2022; 11:6364. [PMID: 36362592 PMCID: PMC9659166 DOI: 10.3390/jcm11216364] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2022] [Revised: 10/08/2022] [Accepted: 10/26/2022] [Indexed: 12/24/2023] Open
Abstract
BACKGROUND Descending necrotizing mediastinitis (DNM) is a severe, life-threatening complication of oropharyngeal infections with cervical necrotizing fasciitis. In this study, we aimed to identify any possible factors that correlate with favorable outcomes. METHODS We retrospectively analyzed our series of 18 patients who underwent surgical treatment for DNM from a cervical abscess. Gender, age, symptoms, etiopathogenesis, comorbidities, time to surgery from diagnosis, degree of diffusion, identified microorganisms, surgical procedure, days in the intensive care unit, need for tracheostomy, complications, and surgical outcomes were reviewed. RESULTS The main type of surgery was thoracotomy + cervicotomy in eight cases (50.0%), followed by cervicotomy +VATS in four (22.2%). Seven patients (38.9%) had two or more surgeries; a bilateral operation was necessary for four patients. Evaluating the risk factors associated with post-operative complications, age ≥ 60 years (p:0.031), cervicotomy alone as surgical approach (p = 0.040), and the bilateral approach (p = 0.048) resulted in significance in terms of the univariate analysis; age ≥ 60 years (p = 0.04) and cervical approach (p = 0.05) maintained their significance in terms of the multivariate analysis. CONCLUSIONS The low mortality of our series emphasizes the importance of an extensive and immediate surgical drainage of both the neck and the mediastinum. Mediastinal drainage from cervicotomy seems to be a risk factor for post-operative complications. Minimally invasive surgery on the chest cavity, such as with Uniportal-VATS, could be a good approach above all in elderly patients and all those cases where bilateral access is required.
Collapse
Affiliation(s)
- Maria Teresa Congedo
- Unit of Thoracic Surgery, Fondazione Policlinico Universitario A. Gemelli IRCCS, 00168 Rome, Italy
- Facoltà di Medicina e Chirurgia, Università Cattolica del Sacro Cuore, 00168 Rome, Italy
| | - Dania Nachira
- Unit of Thoracic Surgery, Fondazione Policlinico Universitario A. Gemelli IRCCS, 00168 Rome, Italy
- Facoltà di Medicina e Chirurgia, Università Cattolica del Sacro Cuore, 00168 Rome, Italy
| | - Mariano Alberto Pennisi
- Facoltà di Medicina e Chirurgia, Università Cattolica del Sacro Cuore, 00168 Rome, Italy
- Department of Intensive Care Medicine and Anesthesiology, Fondazione Policlinico Universitario A. Gemelli IRCCS, 00168 Rome, Italy
| | - Marco Chiappetta
- Unit of Thoracic Surgery, Fondazione Policlinico Universitario A. Gemelli IRCCS, 00168 Rome, Italy
- Facoltà di Medicina e Chirurgia, Università Cattolica del Sacro Cuore, 00168 Rome, Italy
| | - Giuseppe Calabrese
- Unit of Thoracic Surgery, Fondazione Policlinico Universitario A. Gemelli IRCCS, 00168 Rome, Italy
- Facoltà di Medicina e Chirurgia, Università Cattolica del Sacro Cuore, 00168 Rome, Italy
| | - Giuseppe Bello
- Facoltà di Medicina e Chirurgia, Università Cattolica del Sacro Cuore, 00168 Rome, Italy
- Department of Intensive Care Medicine and Anesthesiology, Fondazione Policlinico Universitario A. Gemelli IRCCS, 00168 Rome, Italy
| | - Claudio Parrilla
- Facoltà di Medicina e Chirurgia, Università Cattolica del Sacro Cuore, 00168 Rome, Italy
- Unit of Otorhinolaryngology, Head and Neck Department, Fondazione Policlinico Universitario A. Gemelli IRCCS, 00168 Rome, Italy
| | - Laura Franza
- Facoltà di Medicina e Chirurgia, Università Cattolica del Sacro Cuore, 00168 Rome, Italy
- Emergency Department, Fondazione Policlinico Universitario A. Gemelli IRCCS, 00168 Rome, Italy
| | - Marcello Covino
- Facoltà di Medicina e Chirurgia, Università Cattolica del Sacro Cuore, 00168 Rome, Italy
- Emergency Department, Fondazione Policlinico Universitario A. Gemelli IRCCS, 00168 Rome, Italy
| | - Leonardo Petracca Ciavarella
- Unit of Thoracic Surgery, Fondazione Policlinico Universitario A. Gemelli IRCCS, 00168 Rome, Italy
- Facoltà di Medicina e Chirurgia, Università Cattolica del Sacro Cuore, 00168 Rome, Italy
| | - Venanzio Porziella
- Unit of Thoracic Surgery, Fondazione Policlinico Universitario A. Gemelli IRCCS, 00168 Rome, Italy
- Facoltà di Medicina e Chirurgia, Università Cattolica del Sacro Cuore, 00168 Rome, Italy
| | - Maria Letizia Vita
- Unit of Thoracic Surgery, Fondazione Policlinico Universitario A. Gemelli IRCCS, 00168 Rome, Italy
- Facoltà di Medicina e Chirurgia, Università Cattolica del Sacro Cuore, 00168 Rome, Italy
| | - Filippo Lococo
- Unit of Thoracic Surgery, Fondazione Policlinico Universitario A. Gemelli IRCCS, 00168 Rome, Italy
- Facoltà di Medicina e Chirurgia, Università Cattolica del Sacro Cuore, 00168 Rome, Italy
| | - Stefano Margaritora
- Unit of Thoracic Surgery, Fondazione Policlinico Universitario A. Gemelli IRCCS, 00168 Rome, Italy
- Facoltà di Medicina e Chirurgia, Università Cattolica del Sacro Cuore, 00168 Rome, Italy
| | - Elisa Meacci
- Unit of Thoracic Surgery, Fondazione Policlinico Universitario A. Gemelli IRCCS, 00168 Rome, Italy
- Facoltà di Medicina e Chirurgia, Università Cattolica del Sacro Cuore, 00168 Rome, Italy
| |
Collapse
|
6
|
Cavernous Sinus Involvement and Near Miss Mediastinitis following Mandibular Tooth Infection Treated during the COVID-19 Pandemic: Clinical Diagnosis and Treatment. Case Rep Dent 2022; 2022:8650099. [PMID: 35865553 PMCID: PMC9296300 DOI: 10.1155/2022/8650099] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2021] [Revised: 05/03/2022] [Accepted: 06/07/2022] [Indexed: 11/17/2022] Open
Abstract
Odontogenic infections represent a frequent condition that in some cases, if not treated promptly, can spread quickly to the rest of the body and turn into life-threatening infections. In this work, the case is reported of a 59-year-old woman, diabetic and overweight, who presented to the Odontostomatology and Otolaryngology Section of the Policlinic of Bari with mandibular tooth infection that had developed into a deep neck space infection leading to the involvement of cavernous sinuses and near mediastinum. The diagnosis, the surgical drainage of the phlegmon and removal of infection foci, appropriate control of the airways, and a correct antibiotic therapy made it possible to avoid a potentially fatal condition. Prompt management and early diagnosis of deep space neck infections, such as phlegmon and/or necrotizing fasciitis, with the auxilium of CT scans and tools such as LRINEC (Laboratory Risk Indicator for Necrotizing Fasciitis), NLR (Neutrophil-to-Lymphocyte Ratio), and LRINECxNLR scores (Laboratory Risk Indicator for Necrotizing Fasciitis and Neutrophil to Lymphocyte Ratio), are advised to evade delays and complications that could potentially worsen the patient’s outcome.
Collapse
|
7
|
Ho CY, Chin SC, Wang YC, Chen SL. Factors affecting patients with concurrent deep neck infection and aspiration pneumonia. Am J Otolaryngol 2022; 43:103463. [PMID: 35417839 DOI: 10.1016/j.amjoto.2022.103463] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2022] [Accepted: 04/04/2022] [Indexed: 11/27/2022]
Abstract
BACKGROUND Deep neck infection (DNI) is a life-threatening condition of the deep neck spaces with potential to obstruct the airway. Aspiration pneumonia (AP), which results from aspiration of colonized oropharyngeal or upper gastrointestinal contents, is a respiratory infection that affects the lungs, wherein the air sacs are filled with purulent fluid. The cooccurrence of these two diseases can cause severe damage to the respiratory system, leading to morbidity and mortality. However, the risk factors for concurrent DNI and AP have not yet been investigated. This study aimed to address this issue. METHODS A total of 561 DNI patients were enrolled in this study between June 2016 and December 2021. Among these patients, 26 had concurrent DNI and AP at the time of diagnosis. Relevant clinical variables were assessed. RESULTS In the univariate analysis, age > 60 years (OR = 3.593, 95% CI: 1.534-8.414, p = 0.002), C-reactive protein (OR = 1.005, 95% CI: 1.001-1.008, p = 0.003), involvement of ≥3 spaces (OR = 4.969, 95% CI: 2.051-12.03, p < 0.001), and retropharyngeal space involvement (OR = 4.546, 95% CI: 1.878-11.00, p < 0.001) were significant risk factors for concurrent DNI and AP. In the multivariate analysis, age > 60 years (OR = 2.766, 95% CI: 1.142-6.696, p = 0.024) and retropharyngeal space involvement (OR = 3.006, 95% CI: 1.175-7.693, p = 0.021) were independent risk factors for concurrent DNI and AP. The group with concurrent DNI and AP had longer hospital stays (p < 0.001) and lower rates of incision and drainage (I&D) open surgery (p = 0.020) than the group with DNI alone. There were no significant differences in pathogens (p > 0.05) between the groups. CONCLUSIONS Both DNI and AP can independently compromise the airway, and the concurrence of these two conditions makes airway protection more difficult. Age > 60 years and retropharyngeal space involvement were independent risk factors for the concurrence of DNI and AP. The group with concurrent DNI and AP had longer hospital stays and lower rates of I&D open surgery than the group with DNI alone. There were no differences in DNI pathogens according to concurrent AP status.
Collapse
|
8
|
Chen SL, Chin SC, Wang YC, Ho CY. Factors Affecting Patients with Concurrent Deep Neck Infection and Cervical Necrotizing Fasciitis. Diagnostics (Basel) 2022; 12:diagnostics12020443. [PMID: 35204533 PMCID: PMC8870768 DOI: 10.3390/diagnostics12020443] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2022] [Revised: 01/28/2022] [Accepted: 02/07/2022] [Indexed: 11/16/2022] Open
Abstract
Deep neck infection (DNI) is a severe disease of the deep neck spaces, which has the potential for airway obstruction. Cervical necrotizing fasciitis (CNF) is a fatal infection of the diffuse soft tissues and fascia with a high mortality rate. This study investigated risk factors in patients with concurrent DNI and CNF. A total of 556 patients with DNI were included in this study between August 2016 and December 2021. Among these patients, 31 had concurrent DNI and CNF. The relevant clinical variables were assessed. In univariate analysis, age (> 60 years, odds ratio (OR) = 2.491, p = 0.014), C-reactive protein (CRP, OR = 1.007, p < 0.001), blood sugar (OR = 1.007, p < 0.001), and diabetes mellitus (DM, OR = 4.017, p < 0.001) were significant risk factors for concurrent DNI and CNF. In multivariate analysis, CRP (OR = 1.006, p < 0.001) and blood sugar (OR = 1.006, p = 0.002) were independent risk factors in patients with concurrent DNI and CNF. There were significant differences in the length of hospital stay and therapeutic management (intubation, tracheostomy, incision and drainage) between DNI patients with and without CNF (all p < 0.05). While there were no differences in pathogens between the DNI alone and concurrent DNI and CNF groups (all p > 0.05), the rate of specific pathogen non-growth from blood cultures was 16.95% (89/525) in the DNI alone group, in contrast to 0% (0/31) in the concurrent DNI and CNF group (p = 0.008). Higher CRP and blood sugar levels were independent risk factors for the concurrence of DNI and CNF. With regard to prognosis, there were significant differences in the length of hospital stay and therapeutic management between the groups with and without CNF. While there were no significant differences in pathogens (all p > 0.05), no cases in the concurrent DNI and CNF group showed specific pathogen non-growth, in contrast to 89/525 patients in the group with DNI alone.
Collapse
Affiliation(s)
- Shih-Lung Chen
- Department of Otorhinolaryngology & Head and Neck Surgery, Chang Gung Memorial Hospital, Linkou 333, Taiwan;
- School of Medicine, Chang Gung University, Taoyuan 333, Taiwan; (S.-C.C.); (C.-Y.H.)
- Correspondence: ; Tel.: +886-3-3281200 (ext. 3972); Fax: +886-3-3979361
| | - Shy-Chyi Chin
- School of Medicine, Chang Gung University, Taoyuan 333, Taiwan; (S.-C.C.); (C.-Y.H.)
- Department of Medical Imaging and Intervention, Chang Gung Memorial Hospital, Linkou 333, Taiwan
| | - Yu-Chien Wang
- Department of Otorhinolaryngology & Head and Neck Surgery, Chang Gung Memorial Hospital, Linkou 333, Taiwan;
- School of Medicine, Chang Gung University, Taoyuan 333, Taiwan; (S.-C.C.); (C.-Y.H.)
- Department of Otorhinolaryngology & Head and Neck Surgery, New Taipei Municipal Tucheng Hospital, New Taipei City 236, Taiwan
| | - Chia-Ying Ho
- School of Medicine, Chang Gung University, Taoyuan 333, Taiwan; (S.-C.C.); (C.-Y.H.)
- Division of Chinese Internal Medicine, Center for Traditional Chinese Medicine, Chang Gung Memorial Hospital, Taoyuan 333, Taiwan
| |
Collapse
|
9
|
Kim Y, Han S, Cho DG, Jung WS, Cho JH. Optimal Airway Management in the Treatment of Descending Necrotizing Mediastinitis Secondary to Deep Neck Infection. J Oral Maxillofac Surg 2021; 80:223-230. [PMID: 34582808 DOI: 10.1016/j.joms.2021.08.159] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2021] [Revised: 08/13/2021] [Accepted: 08/17/2021] [Indexed: 10/20/2022]
Abstract
PURPOSE To review our experiences of descending necrotizing mediastinitis (DNM) secondary to deep neck infection (DNI) and determine appropriate airway management for decreasing mortality and morbidity of patients with DNM. METHODS Medical records of 20 patients (8 women and 12 men) who had been managed for DNM secondary to DNI between March 2006 and December 2019 were analyzed. Diagnosis and extent of infection were confirmed by computed tomography of the neck and chest. The upper airway was closely monitored with a fiberoptic laryngoscope. Complications were evaluated according to various types of airway management in our serial cases. RESULTS Five (25%) out of 20 patients died as a result of septic shock and multiorgan failure. None of these patients died of accidental airway obstruction or airway management mishaps. Keeping short-term orotracheal intubation was safe and adequate after the initial surgery. Early tracheotomy was performed for 4 patients and it was significantly associated with mortality (P = .032). Three patients who underwent late tracheotomy had no mortality. Patients with tracheotomy had longer duration of overall hospital stay than those without tracheotomy. CONCLUSIONS Well-controlled airway management might decrease mortality, hospitalization, and airway complications in patients with DNM secondary to DNI. Keeping orotracheal intubation rather than upfront tracheotomy should be first considered when managing airway along with examination of the upper airway with a fiberoptic laryngoscope.
Collapse
Affiliation(s)
- Yoonho Kim
- Resident, Department of Otorhinolaryngology-Head and Neck Surgery, The Catholic University of Korea, Seoul, Republic of Korea
| | - Sungjun Han
- Clinical Assistant Professor, Department of Otorhinolaryngology-Head and Neck Surgery, The Catholic University of Korea, Seoul, Republic of Korea
| | - Deog Gon Cho
- Professor, Department of Thoracic and Cardiovascular Surgery, The Catholic University of Korea, Seoul, Republic of Korea
| | - Won-Sang Jung
- Clinical Associate Professor, Department of Radiology, The Catholic University of Korea, Seoul, Republic of Korea
| | - Jung-Hae Cho
- Assistant Professor, Department of Otorhinolaryngology-Head and Neck Surgery, The Catholic University of Korea, Seoul, Republic of Korea.
| |
Collapse
|
10
|
Fiorella ML, Greco P, Madami LM, Giannico OV, Pontillo V, Quaranta N. New laboratory predictive tools in deep neck space infections. ACTA ACUST UNITED AC 2021; 40:332-337. [PMID: 33299222 PMCID: PMC7726647 DOI: 10.14639/0392-100x-n0790] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2020] [Accepted: 05/20/2020] [Indexed: 02/06/2023]
Abstract
Introduction Deep neck space infections (DNSIs) are a group of infective suppurative diseases involving deep neck spaces and cervical fascia. Necrotising and septic evolutions are rare, but severe complications can dramatically affect the prognosis and should be promptly managed. Clinical examination often has low sensitivity, although instrumental diagnosis may delay te treatment. We investigated two laboratory tools, LRINEC (Laboratory Risk Indicator for the Necrotizing fasciitis) and NLR (neutrophil to lymphocyte ratio), in the expectation to find a rapidly available predictive indicator that may help in distinguishing necrotising complications and/or systemic septic involvement. Methods A retrospective observational cohort study was performed on 118 patients who had underwent surgical treatment for DNSIs at our Surgical Unit. LRINEC, NLR and the product LRINEC x NLR were calculated. Results Statistical analysis showed that these scores may have utility in rapidly predicting the risk of necrotising fasciitis and systemic involvement at an early diagnostic stage. Conclusions Further studies with a larger cohort may be necessary in order to increase the sensitivity and specificity.
Collapse
Affiliation(s)
- Maria Luisa Fiorella
- Unit of Otorhinolaryngology, Department of Biomedical Sciences, Neurosciences and Sense Organs, University of Bari, Italy
| | - Paolo Greco
- Unit of Otorhinolaryngology, Department of Biomedical Sciences, Neurosciences and Sense Organs, University of Bari, Italy
| | - Luigi Maria Madami
- Unit of Otorhinolaryngology, Department of Biomedical Sciences, Neurosciences and Sense Organs, University of Bari, Italy
| | - Orazio Valerio Giannico
- Section of Hygiene, Department of Biomedical Sciences and Human Oncology, University of Bari "Aldo Moro", Bari, Italy
| | - Vito Pontillo
- Unit of Otorhinolaryngology, Department of Biomedical Sciences, Neurosciences and Sense Organs, University of Bari, Italy
| | - Nicola Quaranta
- Unit of Otorhinolaryngology, Department of Biomedical Sciences, Neurosciences and Sense Organs, University of Bari, Italy
| |
Collapse
|
11
|
Sizer B, Yılmaz Ü, Kınış V, Yorgancılar AE. Comparison of death and survival cervical necrotizing fasciits cases. J Cosmet Dermatol 2021; 21:1635-1641. [PMID: 34038027 DOI: 10.1111/jocd.14254] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2021] [Accepted: 05/19/2021] [Indexed: 11/27/2022]
Abstract
BACKGROUND Cervical Necrotizing Fasciitis (CNF) is associated with a high mortality rate. The occurrence of mediastinitis with CNF may increase mortality up to 70%. AIMS We aimed to identify the differences between surviving and deceased cases. METHODS The present study was conducted retrospectively by scanning the files of 16 patients between the ages of 19-71 who were diagnosed with CNF. Patients were divided into two groups as the surviving patient group (SPG) and the deceased patient group (DPG). Both groups were compared in terms of age, gender, Laboratory Risk Indicator for Necrotizing Fasciitis (LRİNEC) score, duration of symptom onset to hospital admission, use of antibiotherapy prior to admission, duration of hospitalization, presence of diabetes mellitus (DM), presence of dental etiology, mediastinitis, and respiratory distress at the time of admission. RESULTS Diabetes mellitus was the most common comorbid disease. 5 out of 7 deceased patients had DM. Dental events were the most common etiology. Rapid surgical debridement and airway management was the first treatment method. The most frequently isolated species in the culture was Streptococcus. 6 of 11 patients who developed mediastinitis deceased at the end of the process. CONCLUSION Dental pathologies mostly play a role in the etiology. It is obvious that dentists, another occupational group that frequently encounters this patient group, have a critical role in this process. Therefore, precise attention should be given to dental problems in patients with diabetes, and hospitalization and initiation of broad-spectrum antibiotherapy should be considered in case of suspicion of deep neck infection.
Collapse
Affiliation(s)
- Bilal Sizer
- Department of Ear, Nose and Throat, Memorial Diyarbakır Hospital, Diyarbakır, Turkey
| | - Ümit Yılmaz
- Department of Ear, Nose and Throat, Selahaddin Eyyubi Public Hospital, Diyarbakır, Turkey
| | - Vefa Kınış
- Department of Ear Nose and Throat, Dicle University Medicine Faculty, Diyarbakır, Turkey
| | | |
Collapse
|
12
|
Guan X, Liang X, Liang X, Wang F, Qian W, Zhang W. A new classification of descending necrotizing mediastinitis and surgical strategies. ANNALS OF TRANSLATIONAL MEDICINE 2021; 9:356. [PMID: 33708983 PMCID: PMC7944333 DOI: 10.21037/atm-21-121] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Background Descending necrotizing mediastinitis (DNM) is an inflammation occurring in the oropharynx and descending to the deep cervical space and mediastinum, which is a serious infectious disease. The investigation of a new classification system and treatment methods for DNM is still necessary. Methods A total of 139 patients with DNM caused by odontogenic or pharyngeal infection were retrospectively analyzed in last 20 years in the Ninth People's Hospital Affiliated to Shanghai Jiao Tong University School of Medicine. The patients were divided into the traditional treatment Group T (Group T: 43 patients) and the new classification Group N (Group N: 96 patients). A new DNM classification was developed based on the progression of mediastinal infection as follows: type Ia: infection in the anterosuperior mediastinum; type I: infection in the anterior mediastinum; type II: infection in the posterior mediastinum; and type III: infection of the whole mediastinum. Results There were 49, 8, 10, and 29 patients classified as type Ia, I, II, and III, respectively in the Group N. The type Ia DNM patients were managed with transcervical mediastinal drainage, and the patients with types I and II DNM underwent open (thoracoscopic) surgery, 1 patient within types I died. The 29 patients with type III were managed with unilateral or bilateral open (thoracoscopic) surgery, among them, 8 patients died. The mortality rate for patients with type III DNM was 27.6%. The overall mortality rate in Group N was 9.4%. The mortality rate for patients in the Group T was 25.6%. The mortality rate of Group N was significantly lower than that of Group T (P<0.05). Conclusions We have carried out a new clinical classification of DNM, and selected the appropriate treatment method according to the classification, and achieved a better effect than the traditional treatment method.
Collapse
Affiliation(s)
- Xin Guan
- Department of Thoracic Surgery, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Xiang Liang
- Department of Thoracic Surgery, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Xi Liang
- Department of Thoracic Surgery, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Feng Wang
- Department of Thoracic Surgery, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Wentao Qian
- Department of Oral Surgery, Shanghai Ninth People's Hospital, College of Clinical Medicine, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Weijie Zhang
- Department of Oral Surgery, Shanghai Ninth People's Hospital, College of Clinical Medicine, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| |
Collapse
|
13
|
Ma C, Zhou L, Zhao JZ, Lin RT, Zhang T, Yu LJ, Shi TY, Wang M. Multidisciplinary treatment of deep neck infection associated with descending necrotizing mediastinitis: a single-centre experience. J Int Med Res 2019; 47:6027-6040. [PMID: 31640429 PMCID: PMC7045650 DOI: 10.1177/0300060519879308] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
Objective Deep neck infection (DNI) associated with descending necrotizing mediastinitis (DNM) is a highly lethal condition. This retrospective review was performed to share our experience performing multidisciplinary management of DNI associated with DNM during a 7-year period. Methods We reviewed 16 patients who had been surgically treated for DNM at Peking Union Medical College Hospital from April 2010 to July 2017. The clinical outcomes were analysed to determine the most appropriate therapeutic strategy. Results Five women and 11 men were included in this study. Their mean age was 54.9 ± 14.3 years. DNM-associated infections most commonly occurred secondary to odontogenic infections (n = 10). Thirteen patients required tracheotomy because of tracheal compression. All patients underwent unilateral or bilateral cervicotomy. Six patients with DNM localized in the upper mediastinal space underwent transcervical mediastinal drainage, while 10 patients with DNM extending to the lower mediastinum were treated by cervicotomy and video-assisted thoracoscopic surgery. Three patients died of multiple organ failure. Conclusion Multidisciplinary treatment can achieve favourable outcomes in >80% of patients with DNM. Early diagnosis, proper airway management, and adequate surgical drainage are crucial for reducing mortality in patients with DNM, and minimally invasive procedures also play an important role.
Collapse
Affiliation(s)
- Chao Ma
- Department of Stomatology, Peking Union Medical College Hospital (PUMCH), Chinese Academy of Medical Science (CAMS) and Peking Union Medical College (PUMC), Beijing, China
| | - Lian Zhou
- Department of Stomatology, Peking Union Medical College Hospital (PUMCH), Chinese Academy of Medical Science (CAMS) and Peking Union Medical College (PUMC), Beijing, China
| | - Ji-Zhi Zhao
- Department of Stomatology, Peking Union Medical College Hospital (PUMCH), Chinese Academy of Medical Science (CAMS) and Peking Union Medical College (PUMC), Beijing, China
| | - Run-Tai Lin
- Department of Stomatology, Peking Union Medical College Hospital (PUMCH), Chinese Academy of Medical Science (CAMS) and Peking Union Medical College (PUMC), Beijing, China
| | - Tao Zhang
- Department of Stomatology, Peking Union Medical College Hospital (PUMCH), Chinese Academy of Medical Science (CAMS) and Peking Union Medical College (PUMC), Beijing, China
| | - Li-Jiang Yu
- Department of Stomatology, Peking Union Medical College Hospital (PUMCH), Chinese Academy of Medical Science (CAMS) and Peking Union Medical College (PUMC), Beijing, China
| | - Tian-Yin Shi
- Department of Stomatology, Peking Union Medical College Hospital (PUMCH), Chinese Academy of Medical Science (CAMS) and Peking Union Medical College (PUMC), Beijing, China
| | - Mu Wang
- Department of Stomatology, Peking Union Medical College Hospital (PUMCH), Chinese Academy of Medical Science (CAMS) and Peking Union Medical College (PUMC), Beijing, China
| |
Collapse
|
14
|
Abbasi Z, Inam H, Das S, Neel S, Fatimi SH. Fungal Cervical Abscess Complicated by Necrotizing Fasciitis Leading to Descending Necrotizing Mediastinitis: A Case Report. Cureus 2019; 11:e5369. [PMID: 31612097 PMCID: PMC6784916 DOI: 10.7759/cureus.5369] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Cervical necrotizing fasciitis (CNF) is a rapidly spreading deep neck infection with a high mortality rate if left untreated. The occurrence of necrotizing infections in the head and neck region is uncommon; therefore, it is a rare cause of chest pain presenting to the emergency department. Here, we present an interesting case of fungal cervical skin abscess complicated by necrotizing fasciitis that progressed to involve the mediastinum, causing necrotizing mediastinitis with pneumomediastinum in an elderly female. The patient presented to the emergency department with chest pain, shortness of breath, and fever. She had a 10-day history of a mass in the anterior midline of her neck with odynophagia. After radiologic confirmation, she was taken to the operating room where she underwent incision and drainage with debridement and washout. Postoperatively, she was given broad-spectrum antibiotics empirically, which were later replaced with intravenous (I/V) fluconazole after culture reports. Prompt diagnosis and treatment lead to the early recovery of the patient and subsequent discharge without any complications. We report this case to draw the attention of emergency medicine physicians and clinicians to this rare and life-threatening but treatable condition. Expeditious diagnosis and treatment lead to early recovery and fewer postoperative complications.
Collapse
Affiliation(s)
- Zainab Abbasi
- Internal Medicine, Liaquat University of Medical and Health Sciences, Jamshoro, PAK
| | - Hina Inam
- Cardiothoracic Surgery, The Aga Khan University, Karachi, PAK
| | - Sajan Das
- Emergency Medicine, Sindh Government Lyari General Hospital, Karachi, PAK
| | - Sejal Neel
- Pediatrics, Sindh Government Children Hospital, Karachi, PAK
| | - Saulat H Fatimi
- Cardiothoracic Surgery, The Aga Khan University, Karachi, PAK
| |
Collapse
|
15
|
Risk factors of synchronous multifocal necrotizing fasciitis: a case control study in comparison with monofocal necrotizing fasciitis in Taiwan. BMC Infect Dis 2019; 19:513. [PMID: 31185920 PMCID: PMC6558844 DOI: 10.1186/s12879-019-4103-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2018] [Accepted: 05/16/2019] [Indexed: 11/23/2022] Open
Abstract
Background Monofocal necrotizing fasciitis (MONF) involves a single site in a rapidly progressing infection and necrosis of the fascia and surrounding soft tissue. Synchronous multifocal necrotizing fasciitis (SMNF), the simultaneous development of NF in multiple noncontiguous sites, is rarely reported. This study aimed to compare the clinical characteristics and outcomes between patients with SMNF and MONF, and to determine the risk factors of SMNF. Methods Our retrospective case-control study compared the clinical characteristics and outcomes, between January 2006 and January 2013, of patients with SMNF and of patients with MONF of the extremities. Results We enrolled 144 patients with NF of the extremities: 19 with SMNF and 125 with MONF. The duration of symptoms before admission was significantly shorter for the former than for the latter (1.7 days vs. 3.3 days, p = 0.001); the prevalence of shock at the initial visit significantly higher (73.7% vs. 36%, p = 0.002); and the total-case postoperative mortality rate significantly higher (68.4% vs. 14.4%, p < 0.001). In further analysis of the total-case mortality, 9 in 13 SMNF deaths (69.2%) within 7 days after fasciotomy were in the majority while 13 with 28-day mortality (72.2%) was the majority of MONF deaths (p < 0.001). SMNF was significantly more likely to involve bacteremia (89.5% vs. 36%, p < 0.001). Independent risk factors for SMNF were liver cirrhosis (LC) (odds ratio [OR] 6.0, p = 0.001) and end-stage renal disease (ESRD) (OR 7.1, p = 0.035). Gram-negative bacteria were most common in SMNF, and Gram-positive bacteria in MONF (83.3% vs. 53.3%, p = 0.005). Vibrio species were the most common single microbial cause (35.4%) of all NF patients and were the overwhelming cause (73.7%) of SMNF. Staphylococcus aureus and group A β-hemolytic streptococcus (45.6%) were the other predominant causes of MONF while both (10.5%) rarely caused multifocal NF. Conclusions SMNF was more fulminant than was MONF. SMNF was attributable primarily to marine Gram-negative bacteria. Physicians should be aware of SMNF because of its extremely high mortality rate.
Collapse
|
16
|
Yang X, Yang YF, Zhu ZC, Xu TS, Cheng YN, Sun ZY. Senile Lemierre syndrome complicated with descending necrotizing mediastinitis: A case report. Medicine (Baltimore) 2018; 97:e11903. [PMID: 30170383 PMCID: PMC6392631 DOI: 10.1097/md.0000000000011903] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
RATIONALE Senile patients with LS complicated with DNM are rarely seen in clinical practice, and extensive cervical incision and drainage plus administration of effective antibiotics are the basis for treatment. Currently, the treatment controversy mainly has focused on whether mediastinal incision and drainage is necessary for patients with type I DNM, and whether anticoagulation therapy is required for jugular venous emboli and distant metastatic emboli induced by LS. PATIENT CONCERNS A female, 76 years old, developed pain of tonsil on right side 5 days ago, and felt that the pain aggravated complicated with dysphagia and swelling pain of neck on both sides since then. DIAGNOSES She was diagnosed with LS complicated with type I DNM. INTERVENTIONS Tazobactam and Piperacillin 4.5 q8h and Ornidazole 100 ml q6h ivgtt were administered empirically,and secondary extensive cervical incision and drainage was performed under general anesthesia, after which low molecular weight heparin 4250 U q12h SC was administered. G test was performed 3 days later, which showed (1,3)-β-D-glucan >1000 pg/ml. Bridging anticoagulation therapy, low molecular weight heparin 4250 U q12h SC, and Warfarin 2.5 mg qd po were given one week later. Low molecular weight heparin SC was discontinued and only Warfarin po was administered after treatment of bridging therapy for 3 days. OUTCOMES CT of head and neck was reexamined on post-admission d24 and revealed that neck infection was improved on both sides, jugular vein distension on right side was restored to normal, abscess and pneumatosis of superior mediastinum were improved, distension of pulmonary artery on both sides was normalized, WBC was 9.94×109/L, neutrophil count was 4.43×109/L, CRP level was 9.8mg/L, D-D level was 0.81mg/L, PCT level was 0.800ng/mL and G test suggested (1,3)-β-D-glucan pf 27.1 pg/mL. LESSONS Concomitant use of anticoagulants on the basis of repeated cervical incision and drainage + administration of effective antibiotics can obtain excellent therapeutic efficacy in the treatment of patient with LS complicated with type I DNM.
Collapse
|
17
|
Smith AKK, Sokdavy T, Gollogly JG, Bhutta MF. Fatal cervicomediastinal necrotising fasciitis due to cholesteatoma. ANZ J Surg 2018; 89:E350-E351. [PMID: 29651799 DOI: 10.1111/ans.14466] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2017] [Revised: 02/04/2018] [Accepted: 02/11/2018] [Indexed: 11/29/2022]
Affiliation(s)
- Aaron K K Smith
- Gold Coast University Hospital, Gold Coast, Queensland, Australia
| | | | | | - Mahmood F Bhutta
- Brighton and Sussex University Hospitals NHS Trust, Brighton, UK
| |
Collapse
|
18
|
Abstract
BACKGROUND Descending necrotizing mediastinitis (DNM) originates from odontogenic or oropharyngeal infections which spread along preformed cervicothoracic spaces into the mediastinum and requires emergency multidisciplinary treatment. MATERIAL AND METHODS A total of seven patients were diagnosed with DNM based on typical radiological features in a cervicothoracic computed tomography (CT) scan and subsequently underwent standardized transcervical and open transthoracic radical debridement. RESULTS The initially detected polymicrobial spectrum of pathogens was dominated by streptococci followed by enterobacteriae. After calculated antibiotic treatment a shift in the spectrum of pathogens was noted and in particular a mycotic superinfection occurred in 43 % of the cases. Anterolateral thoracotomy was performed for radical removal of tissue necrosis and mediastinothoracic drainage extending to the posterior mediastinum was placed. In selected cases, cervico-mediastino-thoracic tubes were transmediastinally placed by the rendevouz technique either in the previsceral or retrovisceral mediastinal space. Despite predominantly advanced mediastinitis (Endo classification type II B) in this patient cohort, the mortality only reached 14 %. CONCLUSION Rapid diagnosis, anatomical knowledge, understanding of the progression of infections as well as critical care, antimicrobial treatment and multidisciplinary radical surgical therapy are paramount for successful treatment of DNM. We favor anterolateral thoracotomy as the standard open transthoracic approach to the mediastinum. Placement of cervico-mediastino-thoracic irrigation drains can help to limit DNM.
Collapse
|
19
|
Krüger M, Decker S, Schneider JP, Haverich A, Schega O. [Surgical treatment of acute mediastinitis]. Chirurg 2018; 87:478-85. [PMID: 27106240 DOI: 10.1007/s00104-016-0171-8] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Despite modern intensive care management, acute mediastinitis is still associated with a high morbidity and mortality (up to approximately 40 %). Effective antibiotic therapy, intensive care management, elimination of the causative sources of infection and drainage of the affected mediastinal compartments are the cornerstones of therapy in a multidisciplinary treatment concept. Early diagnosis, prompt and uncompromising initial therapy and planned computed tomography (CT) control after the first stages of therapy in order to decide on the necessity for surgical re-interventions are essential for achieving optimal results. Knowledge of the specific anatomical characteristics is crucial for the understanding of this disease and its treatment; therefore, the current knowledge on fascial layers and interstitial spaces from the neck to the mediastinum is described and discussed. A possible foudroyant spread of the infection, especially within the posterior mediastinum, has to be anticipated. The approach to the mediastinum depends on the mediastinal compartments affected, on the causative disease and on the patient's clinical situation. The surgical approach should be adapted to the particular clinical situation of the individual patient and to the surgical experience of the surgeon. When in doubt, the more invasive approach to the mediastinum, such as bilateral thoracotomy, is recommended. An ascending mediastinitis due to pancreatitis is a very rare condition; however, as chest pains are often the main clinical sign surgeons should be aware of this differential diagnosis. An intraoperative brown-black serous fluid in the mediastinal tissue is virtually pathognomonic. The treatment results of esophageal perforation as the most frequent cause of mediastinitis have been improved by integration of various interventional procedures. Hyperbaric oxygen therapy or immunoglobulin treatment can play an auxiliary role in selected patients with acute mediastinitis.
Collapse
Affiliation(s)
- M Krüger
- Klinik für Herz-, Thorax-, Transplantations- und Gefäßchirurgie, Medizinische Hochschule Hannover, Carl-Neuberg-Straße 1, 30625, Hannover, Deutschland.
| | - S Decker
- Klinik für Thoraxchirurgie, Heinrich-Braun-Klinikum Zwickau, Zwickau, Deutschland
| | - J P Schneider
- Institut für Funktionelle und Angewandte Anatomie, Medizinische Hochschule Hannover, Hannover, Deutschland
| | - A Haverich
- Klinik für Herz-, Thorax-, Transplantations- und Gefäßchirurgie, Medizinische Hochschule Hannover, Carl-Neuberg-Straße 1, 30625, Hannover, Deutschland
| | - O Schega
- Klinik für Thoraxchirurgie, Johanniter-Krankenhaus im Fläming, Treuenbrietzen, Deutschland
| |
Collapse
|
20
|
Faunø Thrane J, Pikelis A, Ovesen T. Hyperbaric oxygen may only be optional in head and neck necrotizing fasciitis: a retrospective analysis of 43 cases and review of the literature. Infect Dis (Lond) 2017. [PMID: 28644692 DOI: 10.1080/23744235.2017.1342142] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/29/2023] Open
Abstract
BACKGROUND Necrotizing fasciitis in the head and neck (NF-HN) is a rare and potentially life-threatening condition. The use of hyperbaric oxygen therapy (HBOT) in the acute regimen is disputed and there is a lack of evidence of therapeutic effect. This study aims to describe a retrospective cohort of patients with NF-HN and investigate the use of HBOT and consequences thereof. METHODS All patients treated for NF-HN at Aarhus University Hospital (AUH) between 2002 and 2014 were included in this retrospective cohort. Data regarding demographics, treatment and a one-year follow-up was registered. A review of the literature on NF-HN and HBOT was performed. RESULTS Forty-three patients were consecutively treated for NF-HN during the period. All patients were treated in accordance with current guidelines with HBOT as a variable. Thirty patients received HBOT, and 13 patients were omitted from HBOT for different reasons. In the HBOT group were no mortalities vs. three mortalities in the non-HBOT group two late deaths due to precursory underlying cancer of the head and neck, and one early death shortly after admittance. We found higher rates of complications (63% vs. 25%) and sequelae (77% vs. 40%) among the HBOT group compared to the non-HBOT group. CONCLUSIONS Our findings suggest that HBOT for NF-HN may only be optional and that the decision relies on an individual assessment of each patient. Further research is needed concerning the evidence of HBOT and towards selecting the patients benefitting from HBOT.
Collapse
Affiliation(s)
- Jens Faunø Thrane
- a Department of Otorhinolaryngology Head and Neck Surgery , Aarhus University Hospital , Aarhus , Denmark
| | - Arunas Pikelis
- a Department of Otorhinolaryngology Head and Neck Surgery , Aarhus University Hospital , Aarhus , Denmark
| | - Therese Ovesen
- b Department of Otorhinolaryngology Head and Neck Surgery , Regionshospitalet Holstebro HEV , Holstebro , Denmark.,c Department of Clinical Medicine , Aarhus University Health , Aarhus , Denmark
| |
Collapse
|
21
|
Lareyre F, Cohen C, Declemy S, Raffort J, Quintard H. A Fatal Aortic Arch Rupture Due to Descending Necrotizing Mediastinitis in a 24-year-old Woman. Vasc Endovascular Surg 2017; 51:408-412. [PMID: 28618847 DOI: 10.1177/1538574417715193] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Descending necrotizing mediastinitis (DNM) is a life-threatening disease which often develops from a purulent infection of the oral cavity and is associated with high rates of mortality. Here we report the case of a young patient who died from an aortic arch rupture in context of DNM developed from an odontogenic infection caused by Prevotella buccae. Based on the current knowledge on this very rare vascular complication, we discuss factors that may have contributed to this fatal issue and future issues to optimize care provided to patients.
Collapse
Affiliation(s)
- Fabien Lareyre
- 1 Department of Vascular Surgery, University Hospital of Nice, Nice, France.,2 CNRS, Inserm, IRCAN, University of Côte d'Azur, Nice, France
| | - Charlotte Cohen
- 3 Department of Thoracic Surgery, University Hospital of Nice, Nice, France.,4 University of Côte d'Azur, Nice, France
| | - Serge Declemy
- 1 Department of Vascular Surgery, University Hospital of Nice, Nice, France
| | - Juliette Raffort
- 2 CNRS, Inserm, IRCAN, University of Côte d'Azur, Nice, France.,5 Clinical Chemistry Laboratory, University Hospital of Nice, Nice, France
| | - Hervé Quintard
- 6 Intensive Care Unit, University Hospital of Nice, Nice, France
| |
Collapse
|
22
|
Wei D, Bi L, Zhu H, He J, Wang H. Less invasive management of deep neck infection and descending necrotizing mediastinitis: A single-center retrospective study. Medicine (Baltimore) 2017; 96:e6590. [PMID: 28403094 PMCID: PMC5403091 DOI: 10.1097/md.0000000000006590] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
By a 7-year retrospective review, we reported our experience in management of descending necrotizing mediastinitis (DNM) and deep neck infection (DNI). A retrospective design was used to reveal the clinical characteristics of DNI and DNM. The clinical outcome was analyzed to validate less invasive management. We reviewed 82 patients between 2009 and 2016, 12 of which were diagnosed as DNM by clinical and computed tomography findings. A total of 35 patients had relevant systemic conditions, mainly diabetes mellitus (19 patients). Most cases were secondary to oropharyngeal or dental infections. All patients underwent transcervical drainage, and 10 DNM patients were treated with additional closed thoracic drainage simultaneously. Twenty patients accepted more than 1 operation. Seven patients died as a result of sepsis and/or multiple organ failure. The mortality rate in our study was similar to that in other studies. In our opinion, less invasive therapies are useful to most patients. Transcervical drainage alone is optimal management for all DNI cases and some DNM cases. Additional closed thoracic drainage is enough for type I and IIA DNM with pleural effusion or empyema.
Collapse
|
23
|
Cortese A, Pantaleo G, Borri A, Amato M, Claudio PP. Necrotizing odontogenic fasciitis of head and neck extending to anterior mediastinum in elderly patients: innovative treatment with a review of the literature. Aging Clin Exp Res 2017; 29:159-165. [PMID: 27798811 DOI: 10.1007/s40520-016-0650-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2016] [Accepted: 10/12/2016] [Indexed: 12/01/2022]
Abstract
BACKGROUND Necrotizing fasciitis (NF) of odontogenic origin affecting the head and neck region is a rare but serious clinical condition, which, if diagnosed late, can lead to a fatal outcome. The early diagnosis of necrotizing fasciitis can be difficult. Delay in diagnosis leads to increase in the area of necrosis with a resulting increase in cosmetic deformity and life-threatening complication. In this study, we present two cases of elderly patients with aggressive NF affecting the neck and anterior mediastinum, which were of odontogenic origin. METHODS In the two patients selected necrotic skin and soft tissue were removed and wide exposure was achieved with debridement of the neck at the level of the affected layer of superficial cervical fascia. Saline solution was used as irrigation to treat the patients with acute necrotizing fasciitis. Difficulties in managing this condition with NF extent to deep anterior mediastinum is related to clavicle osteotomy or thoracotomy need with high surgical risks. In our technique, by gentle suction in anterior mediastinum, necrotic tissue resection was possible without any osteotomy need. CONCLUSIONS Suctioning resection technique associated with hyperbaric, metabolic rebalance, and amino acid support in association with three types antibiotic therapy are fundamental points for correct therapy strategy, leading to full recovery and healing of NF patients even if in very unfavorable conditions. Multidisciplinary approach is paramount for proper treatment of this disease.
Collapse
Affiliation(s)
- Antonio Cortese
- Unit of Maxillofacial Surgery, Department of Medicine and Surgery, University of Salerno, Via S. Allende, 84081, Baronissi, SA, Italy.
| | - Giuseppe Pantaleo
- Department of Neurosciences, Reproductive and Odontostomatological Sciences, University of Naples Federico II, Naples, Italy
| | - Antonio Borri
- Unit of Maxillofacial Surgery, Department of Medicine and Surgery, University of Salerno, Via S. Allende, 84081, Baronissi, SA, Italy
| | - Massimo Amato
- Department of Medicine and Surgery, University of Salerno, Baronissi, SA, Italy
| | - Pier Paolo Claudio
- Department of BioMolecular Sciences, School of Pharmacy, National Center for Natural Products Research, University of Mississippi, Oxford, MS, USA
| |
Collapse
|
24
|
Mazzella A, Santagata M, Cecere A, La Mart E, Fiorelli A, Tartaro G, Tafuri D, Testa D, Grella E, Perrotta F, Bianco A, Mazzarella G, Santini M. Descending necrotizing mediastinitis in the elderly patients. Open Med (Wars) 2016; 11:449-460. [PMID: 28352835 PMCID: PMC5329867 DOI: 10.1515/med-2016-0080] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2016] [Accepted: 08/19/2016] [Indexed: 12/20/2022] Open
Abstract
Descending Necrotizing Mediastinitis (DNM) is a polymicrobic, dangerous and often fatal process, arising from head or neck infections and spreading along the deep fascial cervical planes, descending into the mediastinum. It can rapidly progress to sepsis and can frequently lead to death. It has a high mortality rate, up to 40% in the different series, as described in the literature. Surgical and therapeutic management has been discussed for long time especially in an elderly patient population. The literature has been reviewed in order to evaluate different pathogenesis and evolution and to recognise a correct therapeutic management.
Collapse
Affiliation(s)
| | - Mario Santagata
- Maxillo-Facial Surgery Unit, Second University of Naples, Italy
| | - Atirge Cecere
- Maxillo-Facial Surgery Unit, Second University of Naples, Italy
| | - Ettore La Mart
- Maxillo-Facial Surgery Unit, Second University of Naples, Italy
| | | | | | - Domenico Tafuri
- Department of Sport Sciences and Wellness, University of Naples "Parthenope", Naples, Italy
| | - Domenico Testa
- Department of Anesthesiologic, Surgical and Emergency Sciences, Otolaryngology, Head and Neck Surgery Unit, Second University of Naples, Naples, Italy
| | - Edoardo Grella
- Department of Cardiothoracic and Respiratory Sciences, Second University of Naples/Hosp. Monaldi, Italy
| | - Fabio Perrotta
- Department of Cardiothoracic and Respiratory Sciences, Second University of Naples/Hosp. Monaldi, Italy
| | - Andrea Bianco
- Department of Cardiothoracic and Respiratory Sciences, Second University of Naples/Hosp. Monaldi, Piazza Miraglia, 2, 80138 Naples, Italy
| | - Gennaro Mazzarella
- Department of Cardiothoracic and Respiratory Sciences, Second University of Naples/Hosp. Monaldi, Italy
| | - Mario Santini
- Thoracic Surgery Unit, Second University of Naples, Italy
| |
Collapse
|
25
|
Glen P, Morrison J. Diffuse descending necrotising mediastinitis and pleural empyema secondary to acute odontogenic infection resulting in severe dysphagia. BMJ Case Rep 2016; 2016:bcr-2015-212145. [PMID: 27013653 DOI: 10.1136/bcr-2015-212145] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
We report a case of acute odontogenic sepsis in a 59-year-old man, presenting with diffuse, descending necrotising mediastinitis complicated by pleural empyema. Despite surviving the odds, his recovery was complicated by severe dysphagia, resulting in gastrostomy feeding for 6 months. Until now, severe dysphagia following descending necrotising mediastinitis has been unreported.
Collapse
Affiliation(s)
- Peter Glen
- Department of Oral and Maxillofacial Surgery, St John's Hospital, Edinburgh, UK
| | - James Morrison
- Department of Oral and Maxillofacial Surgery, St John's Hospital, Edinburgh, UK
| |
Collapse
|
26
|
Prado-Calleros HM, Jiménez-Fuentes E, Jiménez-Escobar I. Descending necrotizing mediastinitis: Systematic review on its treatment in the last 6 years, 75 years after its description. Head Neck 2016; 38 Suppl 1:E2275-83. [DOI: 10.1002/hed.24183] [Citation(s) in RCA: 63] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/02/2015] [Indexed: 12/12/2022] Open
Affiliation(s)
- Héctor M. Prado-Calleros
- Division of Otolaryngology and Head and Neck Surgery; General Hospital “Dr. Manuel Gea González,”; México City México
| | | | - Irma Jiménez-Escobar
- Medical Director; General Hospital “Dr. Manuel Gea González,”; México City México
| |
Collapse
|
27
|
Guan X, Zhang WJ, Liang X, Liang X, Wang F, Guo X, Zhou Y. Optimal surgical options for descending necrotizing mediastinitis of the anterior mediastinum. Cell Biochem Biophys 2015; 70:109-14. [PMID: 24696071 DOI: 10.1007/s12013-014-9865-z] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
The mortality rates from descending necrotizing mediastinitis (DNM) are between 25 and 40 % mainly because of delayed diagnosis and inappropriate surgical treatment. This study was undertaken to examine two surgical options for DNM and determine the optimal surgical option for DNM of the anterior mediastinum. Fifteen cases of DNM of the anterior mediastinum, January 2001 and October 2010, were retrospectively reviewed. Eleven were anterosuperior mediastinitis, with infection located above the tracheal bifurcation and four had infections involving the entire anterior mediastinum. Depending on the location of mediastinitis, open drainage of the submandibular and neck abscesses, in addition to other surgical treatments, was performed. If the infection was anterosuperior, transcervical mediastinal drainage or thoracotomy was performed. If the entire anterior mediastinum was involved, necrotic tissue was removed with thoracoscopic via subxiphoid incision, the bilateral pleurae were opened for drainage, and a tunnel connecting the neck incision and the subxiphoid incision through the whole anterior mediastinum was made for drainage. The anterosuperior mediastinitis cases were treated with either transcervical mediastinal drainage (n = 8) or thoracotomy (n = 3). Patients healed after an average of 24.5 and 20.0 days in the hospital, respectively. For the four other cases, one patient died of septic shock, while the other three patients were healed after and an average of 43.3 days in the hospital. Mortality rate was 6.7 %. The surgical procedure used to treat DNM should be selected according to the location of the infection. DNM involving the anterosuperior mediastinum can be treated by transcervical mediastinal drainage. If anterosuperior mediastinitis spreads to the side of the trachea, open thoracotomy is a suitable therapy. If the entire anterior mediastinum is involved, debridement and drainage of the anterior mediastinum should be performed with a thoracoscope via the subxiphoid incision.
Collapse
Affiliation(s)
- Xin Guan
- Department of Thoracic Surgery, Ninth People's Hospital, Shanghai Jiaotong University School of Medicine, 5th Building 4 Flour, 639 Zhi Zao Ju Road, Shanghai, 200011, People's Republic of China,
| | | | | | | | | | | | | |
Collapse
|
28
|
Gausepohl JS, Wagner JG. Survival from cervical necrotizing fasciitis. West J Emerg Med 2015; 16:172-4. [PMID: 25671035 PMCID: PMC4307710 DOI: 10.5811/westjem.2014.12.21553] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2014] [Revised: 12/03/2014] [Accepted: 12/15/2014] [Indexed: 11/29/2022] Open
Abstract
Cervical necrotizing fasciitis (CNF) is an uncommon, yet clinically significant infection that rapidly progresses to involve the deep neck spaces. Early recognition and aggressive surgical intervention and debridement are important, as this disease is associated with a high morbidity and mortality. In this report, we present a case of CNF and descending mediastinitis from a non-odontogenic source in a patient presenting with neck swelling and odynophagia.
Collapse
Affiliation(s)
- Jeniffer S Gausepohl
- Los Angeles County + University of Southern California Health Network, Department of Emergency Medicine, Los Angeles, California
| | - Jonathan G Wagner
- Los Angeles County + University of Southern California Health Network, Department of Emergency Medicine, Los Angeles, California
| |
Collapse
|
29
|
Cruz Toro P, Callejo Castillo À, Tornero Saltó J, González Compta X, Farré A, Maños M. Cervical necrotizing fasciitis: Report of 6 cases and review of literature. Eur Ann Otorhinolaryngol Head Neck Dis 2014; 131:357-359. [DOI: 10.1016/j.anorl.2013.08.006] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2012] [Revised: 08/02/2013] [Accepted: 08/08/2013] [Indexed: 10/25/2022]
|
30
|
Blanchard A, Garza Garcia L, Palacios E, Bordlee B, Neitzschman H. Ludwig angina progressing to fatal necrotizing fasciitis. EAR, NOSE & THROAT JOURNAL 2013; 92:102-4. [PMID: 23532644 DOI: 10.1177/014556131309200306] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Affiliation(s)
- Adam Blanchard
- Department of Radiology, Tulane University Hospital and Clinics, New Orleans, LA, USA
| | | | | | | | | |
Collapse
|
31
|
Righini CA, Karkas A, Tourniaire R, N'Gouan JM, Schmerber S, Reyt E, Atallah I. Lemierre syndrome: study of 11 cases and literature review. Head Neck 2013; 36:1044-51. [PMID: 23784917 DOI: 10.1002/hed.23410] [Citation(s) in RCA: 47] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2013] [Accepted: 06/05/2013] [Indexed: 11/09/2022] Open
Abstract
BACKGROUND Lemierre syndrome is a rare but serious illness that associates throat infection and thrombosis of the internal jugular vein (IJV) or one of its tributaries with subsequent distant septic emboli. The purpose of our study was to review the pathogenesis, clinical presentation, and treatment of this disease. METHODS Patients with confirmed Lemierre syndrome were included in our retrospective monocentric study. All patients had bacteriologic analyses as well as radiologic imaging. RESULTS There were 11 patients in our study (from 1998-2012). Fusobacterium necrophorum was responsible for the infection in 45% of cases. Surgical drainage of pharyngeal, cervical, or mediastinal abscesses was carried out in 8 cases. All patients received broad-spectrum antibiotics. Six patients were admitted to the intensive care unit (ICU). One patient (9%) died. CONCLUSION Treatment with broad-spectrum antibiotics is the primary choice of treatment of Lemierre syndrome. Surgery is indicated in case of abscess formation.
Collapse
Affiliation(s)
- Christian Adrien Righini
- Department of Otolaryngology, Grenoble University Hospital, Boulevard de la Chantourne, BP 217, 38043, Grenoble Cedex 09, France
| | | | | | | | | | | | | |
Collapse
|
32
|
Benito J, Espinoza S, Gutiérrez-Fonseca R, Bagan P, Laccourreye O. Descending mediastinitis with mediastinal abscess after supracricoid partial laryngectomy. Ann Otol Rhinol Laryngol 2013; 122:369-73. [PMID: 23837388 DOI: 10.1177/000348941312200604] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
We document a rare and not-yet-reported condition after supracricoid partial laryngectomy: the development of descending mediastinitis with mediastinal abscess. We present a case in which early diagnosis and team management allowed for a successful outcome. The pathophysiology of this severe complication, as well as its diagnosis, management, and prevention, is discussed, together with a review of the medical scientific literature.
Collapse
Affiliation(s)
- José Benito
- Department of Otorhinolaryngology-Head and Neck Surgery, Université Paris Descartes Sorbonne Paris Cité, HEGP, APHP, Paris, France
| | | | | | | | | |
Collapse
|
33
|
Propolis-Induced Descending Necrotizing Mediastinitis and Aspiration Pneumonia. Ann Thorac Surg 2013; 95:e87-9. [DOI: 10.1016/j.athoracsur.2012.09.086] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2012] [Revised: 09/15/2012] [Accepted: 09/28/2012] [Indexed: 01/19/2023]
|
34
|
Chung V, Scott A. Cervical necrotizing fasciitis in children under two years of age. Int J Pediatr Otorhinolaryngol 2012; 76:1857-60. [PMID: 23068314 DOI: 10.1016/j.ijporl.2012.09.012] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2012] [Revised: 06/16/2012] [Accepted: 09/03/2012] [Indexed: 10/27/2022]
Abstract
We present two cases of life-threatening, necrotizing infections of the head and neck region, a rare infectious process in young children, that progressed to bacteremia and sepsis in two toddlers. To date there have been no reports of cervical necrotizing fasciitis in toddlers under two years of age. Immunocompromised children may be at higher risk for developing fulminent infections. Optimal management requires a combination of medical and surgical interventions. An aggressive surgical approach may be required to adequately clear the infection.
Collapse
Affiliation(s)
- Victor Chung
- Department of Otolaryngology and Head & Neck Surgery, Tufts Medical Center, Boston, MA, USA.
| | | |
Collapse
|
35
|
Descending necrotising mediastinitis: a case report illustrating a trend in conservative management. Case Rep Otolaryngol 2012; 2012:504219. [PMID: 22953116 PMCID: PMC3420637 DOI: 10.1155/2012/504219] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2011] [Accepted: 12/25/2011] [Indexed: 11/23/2022] Open
Abstract
The mortality rate from descending necrotising mediastinitis (DNM) has declined since its first description in 1938. The decline in mortality has been attributed to earlier diagnosis by way of contrast-enhanced computed tomographic (CT) scanning and aggressive surgical intervention in the form of transthoracic drainage. We describe a case of DNM with involvement of anterior and posterior mediastinum down to the diaphragm, managed by cervicotomy and transverse cervical drainage with placement of corrugated drains and a pleural chest drain, with a delayed mediastinoscopy and mediastinal drain placement. We advocate a conservative approach with limited debridement and emphasis on drainage of infection in line with published case series.
Collapse
|
36
|
Kocher GJ, Hoksch B, Caversaccio M, Wiegand J, Schmid RA. Diffuse descending necrotizing mediastinitis: surgical therapy and outcome in a single-centre series. Eur J Cardiothorac Surg 2012; 42:e66-72. [DOI: 10.1093/ejcts/ezs385] [Citation(s) in RCA: 55] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
|
37
|
Erkmen CP, Wang H, Czum J, Paydarfar JA. Use of cervicothoracic anatomy as a guide for directed drainage of descending necrotizing mediastinitis. Ann Thorac Surg 2012; 93:1293-4. [PMID: 22450079 DOI: 10.1016/j.athoracsur.2011.08.081] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2011] [Revised: 08/18/2011] [Accepted: 08/30/2011] [Indexed: 11/30/2022]
Abstract
Descending necrotizing mediastinitis is a potentially lethal infection originating from the oropharynx. Adequate abscess drainage is crucial to successful treatment. We present novel management of descending necrotizing mediastinitis using a series of anterior mediastinal incisions adjoined by Penrose drains. The success of this treatment was dependent on radiographic documentation of infection confined to the anterior cervicothoracic plane.
Collapse
Affiliation(s)
- Cherie Parungo Erkmen
- Division of Cardiothoracic Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire 03756-0001, USA.
| | | | | | | |
Collapse
|
38
|
Sarna T, Sengupta T, Miloro M, Kolokythas A. Cervical Necrotizing Fasciitis With Descending Mediastinitis: Literature Review and Case Report. J Oral Maxillofac Surg 2012; 70:1342-50. [DOI: 10.1016/j.joms.2011.05.007] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2011] [Revised: 05/03/2011] [Accepted: 05/04/2011] [Indexed: 10/17/2022]
|
39
|
Danic Hadzibegovic A, Sauerborn D, Grabovac S, Matic I, Danic D. Necrotizing fasciitis of the neck after total laryngectomy. Eur Arch Otorhinolaryngol 2012; 270:277-80. [PMID: 22430034 DOI: 10.1007/s00405-012-1992-9] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2010] [Accepted: 03/02/2012] [Indexed: 11/30/2022]
Abstract
Necrotizing fasciitis (NF) is an unusual, life threatening, rapidly advancing infection characterized by widespread fascial and subcutaneous tissue necrosis and gangrene of the skin. It most commonly affects the extremities, abdominal wall and perineum, whereas cervical NF is rare. NF of the head and neck is often caused by both aerobic and anaerobic microorganisms found in the upper aerodigestive tract. Usually, cervical NF originates from odontogenic, tonsillar and pharyngeal infection, and it is very rarely a complication of surgical procedure. Without immediate surgical treatment, cervical NF leads to mediastinitis and fatal sepsis. There is only one case of cervical NF after total laryngectomy described in the literature. We report two cases of cervical NF after total laryngectomy, selective neck dissection and primary vocal prosthesis insertion. In both cases, the infection spreads to thoracic region and in one of them NF was associated with Lemierre's syndrome, i.e., thrombosis of the internal jugular vein. In both patients, vocal prosthesis was inserted during the infection and did not influence the healing process.
Collapse
Affiliation(s)
- Ana Danic Hadzibegovic
- Department of ENT, Head and Neck Surgery, General Hospital Dr. Josip Bencevic, Osijek School of Medicine, Josip Juraj Strossmayer University, Andrije Stampara 42, 35000, Slavonski Brod, Croatia
| | | | | | | | | |
Collapse
|
40
|
Gonlugur U, Guclu O, Karatag O, Mirici A, Derekoy S. Cervical necrotizing fasciitis associated with descending necrotizing mediastinitis. Multidiscip Respir Med 2011; 6:387-9. [PMID: 22958302 PMCID: PMC3436625 DOI: 10.1186/2049-6958-6-6-387] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2011] [Accepted: 10/12/2011] [Indexed: 11/10/2022] Open
Abstract
We report a case of potentially fatal cervical necrotizing fasciitis and descending necrotizing mediastinitis due to deep neck infection in a 66-year-old male patient with no history or evidence of immunocompromising disorders. On admission, he had painful neck movements and the skin over his neck was red, hot and tender. A computerized tomography (CT) scan of his neck and chest showed evidence of air collection in soft tissues. He was treated with broad-spectrum intravenous antibiotics and early massive cervical drainage. Prompt diagnosis by CT of the neck and chest enabled an early surgical treatment of cervical necrotizing fasciitis. Although acute mediastinitis is a fatal infection involving the connective tissues that fill the interpleural spaces and surround the median thoracic organs, an extensive cervicotomy combined with appropriate antibiotics can prevent the need for mediastinal drainage.
Collapse
Affiliation(s)
- Ugur Gonlugur
- Department of Chest Diseases, School of Medicine, Canakkale Onsekiz Mart University, Canakkale, Turkey.
| | | | | | | | | |
Collapse
|
41
|
Sandner A, Börgermann J. Update on necrotizing mediastinitis: causes, approaches to management, and outcomes. Curr Infect Dis Rep 2011; 13:278-86. [PMID: 21369879 DOI: 10.1007/s11908-011-0174-z] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
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.
Collapse
Affiliation(s)
- Annett Sandner
- Department of Otorhinolaryngology, Head and Neck Surgery, Martin Luther University Halle-Wittenberg, Magdeburger Strasse 12, 06097, Halle/Saale, Germany,
| | | |
Collapse
|