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Nhat LX, Vinh VH, Thi CP, Van Khoi N. Surgical management of descending necrotizing mediastinitis: strategy for thoracic interference. J Cardiothorac Surg 2023; 18:229. [PMID: 37438726 DOI: 10.1186/s13019-023-02321-2] [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: 12/01/2022] [Accepted: 06/28/2023] [Indexed: 07/14/2023] Open
Abstract
BACKGROUND The present descriptive study shares the overall experience of treating all these patients where different surgical process was adopted depending on the treatment required after carefully evaluating the risk factors and comorbidities. METHODS The present study was conducted at the Department of Thoracic Surgery, Choray Hospital, Vietnam between the period of 2010 to 2020. We have treated 95 patients altogether in this duration. RESULTS We were able to save most of the patients by applying thoracotomy and thoracic irrigation for most of the patients based on the observed indications that were identified immediately after the compulsory standard cervicotomy. The indication for thoracic interference was considered when the infection was deeply spread into the mediastinum and cannot get out through cervicotomy, although the most effective method of drainage was applied. CONCLUSION Our statistical investigation of the patient data suggested the possible association and influence of comorbidity such as diabetes. Therefore, we recommend that in specific cases thoracotomy along with thoracic irrigation and repetitive surgical draining could be a better option to reduce the infection and the mortality rate. TRIAL REGISTRATION Retrospectively registered.
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Affiliation(s)
- Lam Xuan Nhat
- Department of Thoracic Surgery, Cho Ray Hospital, Ho Chi Minh City, Vietnam
| | - Vu Huu Vinh
- Department of Thoracic Surgery, Cho Ray Hospital, Ho Chi Minh City, Vietnam.
| | - Chau Phu Thi
- Department of Thoracic Surgery, Cho Ray Hospital, Ho Chi Minh City, Vietnam
| | - Nguyen Van Khoi
- Department of Thoracic Surgery, Cho Ray Hospital, Ho Chi Minh City, Vietnam
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Descending necrotizing mediastinitis: etiopathogenesis, diagnosis, treatment and long-term consequences-a retrospective follow-up study. Eur Arch Otorhinolaryngol 2023; 280:1983-1990. [PMID: 36478116 PMCID: PMC9988808 DOI: 10.1007/s00405-022-07769-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2022] [Accepted: 11/29/2022] [Indexed: 12/13/2022]
Abstract
PURPOSE The primary aim of this retrospective study was to analyze the progression of descending necrotizing mediastinitis (DNM), evaluate the impact of comorbidities on complications and mortality and to observe long-term consequences of DNM on dysphagia and measurements quality of life. DNM is a serious infectious disease that requires multimodal treatment. Current literature varies in conclusions of risk factors, management and outcome of DNM. In addition, little is known about persisting effects on quality of life. METHODS Retrospective data analysis of 88 patients with DNM representing the largest single-center study. Recording data of patients and diseases as well as clinical progression from 1997 to 2018. Two questionnaires were sent to the participants to measure quality of life and to detect dysphagia. RESULTS 88 patients were included. The most frequently found pathogen were Streptococcus spp. (52%). 75% of the patients underwent multiple surgeries, mean count of surgical procedures was 4.3 times. 84% received intensive care treatment. Median length of stay on the intensive care unit was 7 days. 51% had pre-existing comorbidities associated with reduced tissue oxygenation (e.g., diabetes). The most common complication was pleural effusion (45%). During the observation period, the mortality rate was 9%. 12 questionnaires could be evaluated. 67% of the participants were affected by dysphagia at the time of the survey. CONCLUSIONS Descending necrotizing mediastinitis (DNM) is a severe disease requiring an immediate initiation of multimodal treatment. Although quality of life usually isn´t impaired permanently, dysphagia may often persist in patients after DNM.
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Klug TE, Greve T, Hentze M. Complications of peritonsillar abscess. Ann Clin Microbiol Antimicrob 2020; 19:32. [PMID: 32731900 PMCID: PMC7391705 DOI: 10.1186/s12941-020-00375-x] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2020] [Accepted: 07/24/2020] [Indexed: 12/12/2022] Open
Abstract
Background The vast majority of patients with peritonsillar abscess (PTA) recover uneventfully on abscess drainage and antibiotic therapy. However, occasionally patient´s condition deteriorates as the infection spread in the upper airway mucosa, through cervical tissues, or hematogenously. The bacterial etiology of PTA is unclarified and the preferred antimicrobial regimen remains controversial. The current narrative review was carried out with an aim to (1) describe the spectrum of complications previously recognized in patients with peritonsillar abscess (PTA), (2) describe the bacterial findings in PTA-associated complications, and (3) describe the time relation between PTA and complications. Methods Systematic searches in the Medline and EMBASE databases were conducted and data on cases with PTA and one or more complications were elicited. Results Seventeen different complications of PTA were reported. The most frequently described complications were descending mediastinitis (n = 113), para- and retropharyngeal abscess (n = 96), necrotizing fasciitis (n = 38), and Lemierre´s syndrome (n = 35). Males constituted 70% of cases and 49% of patients were > 40 years of age. The overall mortality rate was 10%. The most prevalent bacteria were viridans group streptococci (n = 41, 25%), beta-hemolytic streptococci (n = 32, 20%), F. necrophorum (n = 21, 13%), S. aureus (n = 18, 11%), Prevotella species (n = 17, 10%), and Bacteroides species (n = 14, 9%). Simultaneous diagnosis of PTA and complication was more common (59%) than development of complication after PTA treatment (36%) or recognition of complication prior to PTA (6%). Conclusion Clinicians involved in the management of PTA patients should be aware of the wide range of complications, which may arise in association with PTA development. Especially males and patients > 40 years of age seem to be at an increased risk of complicated disease. In addition to Group A streptococci and F. necrophorum, the current findings suggest that viridans group streptococci, S. aureus, Prevotella, and Bacteroides may also play occasional roles in the development of PTA as well as spread of infection. Complications occasionally develop in PTA patients, who are treated with antibiotics and surgical drainage.
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Affiliation(s)
- Tejs Ehlers Klug
- Department of Otorhinolaryngology, Head and Neck Surgery, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99 Aarhus N, Aarhus, 8200, Denmark.
| | - Thomas Greve
- Department of Clinical Microbiology, Aarhus University Hospital, Aarhus, Denmark
| | - Malene Hentze
- Department of Otorhinolaryngology, Head and Neck Surgery, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99 Aarhus N, Aarhus, 8200, Denmark
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Descending Necrotizing Mediastinitis Resulting from Pharyngitis with Perforation of the Aryepiglottic Fold. Case Rep Emerg Med 2020; 2020:4963493. [PMID: 32099689 PMCID: PMC7040390 DOI: 10.1155/2020/4963493] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2019] [Accepted: 01/13/2020] [Indexed: 11/17/2022] Open
Abstract
Descending necrotizing mediastinitis and pharyngeal perforation are uncommon complications of pharyngitis that are associated with high morbidity and mortality. This case report describes a previously healthy 18-year-old male who presented to the emergency room with 5 days of severe sore throat, intermittent fevers, and vomiting and was found to have extensive posterior pharyngeal and mediastinal air along with extravasation of contrast on computed tomography, consistent with perforation of the left aryepiglottic fold as well as descending necrotizing mediastinitis. The patient had a complicated hospital course including multiple operative interventions, abscess formation, and development of pericardial and pleural effusions. Successful treatment required swift resuscitation including broad-spectrum antibiotics and significant coordination of emergent operative intervention between otolaryngology and cardiothoracic surgery. It is important to recognize descending necrotizing mediastinitis as a clinical entity that may result from oropharyngeal infections as early intervention significantly decreases subsequent complications and mortality. Furthermore, pharyngeal perforation is an extremely rare complication which requires either CT with oral contrast or esophagram for diagnosis.
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Ye RH, Yang JC, Hong HH, Mao YP, Zhu YH, Cao Y, Wang Z. Descending necrotizing mediastinitis caused by Streptococcus constellatus in an immunocompetent patient: case report and review of the literature. BMC Pulm Med 2020; 20:43. [PMID: 32066414 PMCID: PMC7027095 DOI: 10.1186/s12890-020-1068-3] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2019] [Accepted: 01/29/2020] [Indexed: 11/10/2022] Open
Abstract
Descending necrotizing mediastinitis is a severe infection of the mediastinum. This syndrome manifests as fever and chest pain following cough and sputum production. A 49-year-old woman presented with fever and a 14-day history of pneumonia. CT showed mediastinal abscesses with a giant calcified mediastinal lymph node (21 × 18 mm) and pneumonia. Bronchoscopy by EBUS-TBNA under general anesthesia was performed. The pathogen found in the puncture culture was Streptococcus constellatus, and antibiotics (mezlocillin/sulbactam 3.375 IVGTT q8h) was administered. A proximal right main bronchial neoplasm, suspected lung cancer, was found and conformed to inflammatory granuloma. A total of 22 months post-discharge the patient was clinically stable. We also conducted a review of the literature for all Streptococcus constellatus descending necrotizing mediastinitis infections between 2011 and 2017.
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Affiliation(s)
- Rui-Hai Ye
- Department of Respiratory Medicine, Zhejiang Province Hospital of Traditional Chinese Medical, Hangzhou, China
| | - Jun-Chao Yang
- Department of Respiratory Medicine, Zhejiang Province Hospital of Traditional Chinese Medical, Hangzhou, China
| | - Hui-Hua Hong
- Department of Respiratory Medicine, Zhejiang Province Hospital of Traditional Chinese Medical, Hangzhou, China
| | - Yu-Ping Mao
- Department of Laboratory, Zhejiang Province Traditional Chinese Medical Hospital, Hangzhou, China
| | - Yuan-Hong Zhu
- Department of Respiratory Medicine, Zhejiang Province Hospital of Traditional Chinese Medical, Hangzhou, China
| | - Yu Cao
- Department of Respiratory Medicine, Zhejiang Province Hospital of Traditional Chinese Medical, Hangzhou, China
| | - Zhen Wang
- Department of Respiratory Medicine, Zhejiang Province Hospital of Traditional Chinese Medical, Hangzhou, China.
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Fujiwara K, Koyama S, Fukuhara T, Takeuchi H. Successful Surgical Treatment for Dysphagia Secondary to Descending Necrotizing Mediastinitis. Yonago Acta Med 2019; 62:253-257. [PMID: 31582891 DOI: 10.33160/yam.2019.09.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2019] [Accepted: 06/27/2019] [Indexed: 11/05/2022]
Abstract
Descending necrotizing mediastinitis (DNM) is a life-threatening disease with a high fatality rate that occurs as a complication of deep neck abscess. DNM complicated by severe dysphagia during the postoperative period has been previously reported, but there have been no published cases of surgical treatment for severe dysphagia secondary to DNM. A 63-year-old man was diagnosed with a deep neck abscess followed by DNM. The patient had dysphagia after incision and drainage of the abscess and drainage for DNM with video-assisted thoracic surgery (VATS). A comprehensive long-term physiotherapy program with a speech and language therapist did not reduce his dysphagia. Thus, the patient underwent laryngeal elevation and cricopharyngeal myotomy, which enabled oral intake. Surgery should be considered for prolonged severe restriction of laryngeal elevation and esophageal introitus opening that is unresponsive to physiotherapy with a speech and language therapist.
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Affiliation(s)
- Kazunori Fujiwara
- Division of Otolaryngology, Head and Neck Surgery, Department of Sensory and Motor Organs, School of Medicine, Tottori University Faculty of Medicine, Yonago 683-8504, Japan
| | - Satoshi Koyama
- Division of Otolaryngology, Head and Neck Surgery, Department of Sensory and Motor Organs, School of Medicine, Tottori University Faculty of Medicine, Yonago 683-8504, Japan
| | - Takahiro Fukuhara
- Division of Otolaryngology, Head and Neck Surgery, Department of Sensory and Motor Organs, School of Medicine, Tottori University Faculty of Medicine, Yonago 683-8504, Japan
| | - Hiromi Takeuchi
- Division of Otolaryngology, Head and Neck Surgery, Department of Sensory and Motor Organs, School of Medicine, Tottori University Faculty of Medicine, Yonago 683-8504, Japan
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Mark R, Song S, Mark P. Taking heed of the 'danger space': acute descending necrotising mediastinitis secondary to primary odontogenic infection. BMJ Case Rep 2018; 2018:bcr-2018-225019. [PMID: 29848536 DOI: 10.1136/bcr-2018-225019] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Descending necrotising mediastinitis (DNM) is an uncommon clinical entity which may arise secondary to primary odontogenic or neck infection in susceptible patients. Infection may spread contiguously via the alar or 'danger' space, a potential anatomical space posterior to the true retropharyngeal space.1 Spread of infection to the mediastinum almost always necessitates urgent cardiothoracic surgical intervention.2-4 This case report describes a male patient whose clinical deterioration following the diagnosis of submandibular abscess was investigated with CT imaging of the chest, where a diagnosis of DNM was made. Diagnosis was confirmed following surgical intervention and aspiration of pus from the mediastinum.
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Affiliation(s)
- Rose Mark
- Radiology, Royal Perth Hospital, Perth, Western Australia, Australia
| | - Swithin Song
- Radiology, Royal Perth Hospital, Perth, Western Australia, Australia
| | - Peter Mark
- Radiology, Fiona Stanley Hospital, Murdoch, Australia
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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.
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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.
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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.
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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
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Cardiac Tamponade Due to Group A Streptococcus Descending Necrotizing Mediastinitis: Case Report of an Unusual Presentation. J Emerg Med 2014; 47:12-4. [DOI: 10.1016/j.jemermed.2014.01.024] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2013] [Revised: 11/02/2013] [Accepted: 01/30/2014] [Indexed: 01/16/2023]
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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.
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Affiliation(s)
- José Benito
- Department of Otorhinolaryngology-Head and Neck Surgery, Université Paris Descartes Sorbonne Paris Cité, HEGP, APHP, Paris, France
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Yoshimura N, Mukaida H, Mimura T, Iwata K, Amioka A, Hirabayashi N, Takiyama W. A case of an acute cervicomediastinal hematoma secondary to the spontaneous rupture of a parathyroid adenoma. Ann Thorac Cardiovasc Surg 2013; 20 Suppl:816-20. [PMID: 23445790 DOI: 10.5761/atcs.cr.12.02060] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
We herein report the case of a patient with an acute cervicomediastinal hematoma secondary to the spontaneous rupture of a parathyroid adenoma. A 47-year-old female presented with swelling and pain in the neck. She had no history of trauma or of having undergone any medical or odontological procedures. An ultrasound examination revealed the presence of an obscure mass located behind the right lobe of the thyroid gland. A computed tomography scan showed the presence of a low-density lesion extending from the retropharynx to the mediastinum, a high-density lesion located behind the right lobe of the thyroid gland and a right pleural effusion. Because the patient's neck swelling and anemia gradually worsened, she underwent emergency surgery. The neck was found to be swollen due to a hematoma; however, no abscesses were detected in the operative field.Thoracoscopy of the right chest showed no active bleeding. The fragmented mass was histopathologically diagnosed as a parathyroid adenoma with acute hemorrhage, which is quite rare. Our experience suggests that, in patients with severe cervicomediastinal hematomas without any trauma or trigger, a diagnosis of spontaneous rupture of a parathyroid gland lesion should be considered.
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Affiliation(s)
- Noriko Yoshimura
- Department of Surgery, Hiroshima City Asa Hospital, Hiroshima, Japan
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Ishinaga H, Otsu K, Sakaida H, Miyamura T, Nakamura S, Kitano M, Tenpaku H, Takao M, Kobayashi M, Takeuchi K. Descending necrotizing mediastinitis from deep neck infection. Eur Arch Otorhinolaryngol 2012; 270:1463-6. [DOI: 10.1007/s00405-012-2182-5] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2012] [Accepted: 09/06/2012] [Indexed: 11/30/2022]
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Kang SK, Lee S, Oh HK, Kang MW, Na MH, Yu JH, Koo BS, Lim SP. Clinical features of deep neck infections and predisposing factors for mediastinal extension. THE KOREAN JOURNAL OF THORACIC AND CARDIOVASCULAR SURGERY 2012; 45:171-6. [PMID: 22708085 PMCID: PMC3373973 DOI: 10.5090/kjtcs.2012.45.3.171] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/14/2011] [Revised: 10/20/2011] [Accepted: 10/22/2011] [Indexed: 11/16/2022]
Abstract
BACKGROUND Deep neck infections (DNI) can originate from infection in the potential spaces and fascial planes of the neck. DNI can be managed without surgery, but there are cases that need surgical treatment, especially in the case of mediastinal involvement. The aim of this study is to identify clinical features of DNI and analyze the predisposing factors for mediastinal extension. MATERIALS AND METHODS We reviewed medical records of 56 patients suffering from DNI who underwent cervical drainage only (CD group) and those who underwent cervical drainage combined with mediastinal drainage for descending necrotizing mediastinitis (MD group) from August 2003 to May 2009 and compared the clinical features of each group and the predisposing factors for mediastinal extension. RESULTS Forty-four out of the 56 patients underwent cervical drainage only (79%) and 12 patients needed both cervical and mediastinal drainage (21%). There were no differences between the two groups in gender (p=0.28), but the MD group was older than the CD group (CD group, 44.2±23.2 years; MD group, 55.6±12.1 years; p=0.03). The MD group had a higher rate of co-morbidity than the CD group (p=0.04). The CD group involved more than two spaces in 14 cases (32%) and retropharyngeal involvement in 12 cases (27%). The MD group involved more than two spaces in 11 cases (92%) and retropharyngeal involvement in 12 cases (100%). Organism identification took place in 28 cases (64%) of the CD group and 3 cases of (25%) the MD group (p=0.02). The mean hospital stay of the CD group was 21.5±15.9 days and that of the MD group was 41.4±29.4 days (p=0.04). CONCLUSION The predisposing factors of mediastinal extension in DNI were older age, involvement of two or more spaces, especially including the retropharyngeal space, and more comorbidities. The MD group had a longer hospital stay, higher mortality, and more failure to identify causative organisms of causative organisms than the CD group.
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Affiliation(s)
- Shin Kwang Kang
- Department of Thoracic and Cardiovascular Surgery, Chungnam National University Hospital, Chungnam National University School of Medicine, Korea
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Ho KL, Chen HL, Lin CM. Acute descending mediastinitis secondary to an odontogenic infection in a patient initially suspected of having acute thyroiditis: A case report. J Acute Med 2011. [DOI: 10.1016/j.jacme.2011.10.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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17
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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.
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Affiliation(s)
- Annett Sandner
- Department of Otorhinolaryngology, Head and Neck Surgery, Martin Luther University Halle-Wittenberg, Magdeburger Strasse 12, 06097, Halle/Saale, Germany,
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González-García R, Risco-Rojas R, Román-Romero L, Moreno-García C, López García C. Descending necrotizing mediastinitis following dental extraction. Radiological features and surgical treatment considerations. J Craniomaxillofac Surg 2011; 39:335-9. [DOI: 10.1016/j.jcms.2010.10.001] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2010] [Revised: 08/21/2010] [Accepted: 10/04/2010] [Indexed: 11/16/2022] Open
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Inaba Y, Tokano H, Ohtsu A, Kitamura K. A Case of Descending Necrotizing MediastinitisPenetrating to the Esophagus. J Rural Med 2010; 5:190-3. [PMID: 25648975 PMCID: PMC4309356 DOI: 10.2185/jrm.5.190] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
Here, we present the case of a 78-year-old man with a deep neck infection that caused
descending necrotizing mediastinitis that extended from the pharynx to the stomach and was
accompanied by two large esophageal fistulas and multiple gastric ulcers. We believe that
the series of lesions were the signs of a hidden carcinoma.
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Affiliation(s)
- Yuichiro Inaba
- Department of Otolaryngology, Toride Kyodo General Hospital, Japan
| | - Hisashi Tokano
- Department of Otolaryngology, Toride Kyodo General Hospital, Japan ; Department of Otolaryngology, Tokyo Medical and Dental University, Japan
| | - Atsushi Ohtsu
- Department of Internal Medicine, National Cancer Center East Hospital, Japan
| | - Ken Kitamura
- Department of Otolaryngology, Tokyo Medical and Dental University, Japan
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Sokouti M, Nezafati S. Descending necrotizing mediastinitis of oropharyngeal infections. J Dent Res Dent Clin Dent Prospects 2009; 3:82-5. [PMID: 23230490 PMCID: PMC3517278 DOI: 10.5681/joddd.2009.021] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2009] [Accepted: 07/14/2009] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND AND AIMS Descending necrotizing mediastinitis (DNM) is a rare and life-threatening infection. Management of this condition is very difficult and before 1990s, DNM had a mortality rate of 40% despite the use of antibiotics. One of the etiologies of this condition is rapid downward spread of oropharyngeal infection along the cervical fascia planes into the medi-astinum. MATERIALS AND METHODS Patients with DNM from odontogenic, peritonsillar and retropharyngeal origins, who underwent surgical treatment from 1990 to 2007, were reviewed. Data extracted from medical records of the patients included age, gender, origin of the infection, surgical approaches, and the cause of mortality. Descriptive data were expressed as a Mean ± SE. RESULTS Thirteen patients aged 15 to 56 (mean, 34.5 years old; 8 males and 5 females) were studied. The origins of infection included odontogenic abscess in 10 cases and peritonsillar and retropharyngeal abscess in 3 patients. The mean duration from onset of symptoms to the surgery was 12.18 ± 0.98 days (range 3 to 24 days) and the mean duration from initial surgery to dis-charges was 28.51 ± 3.25 days (range 5 to 92 days). Post-operative mortality was seen in three patients. CONCLUSION Descending necrotizing mediastinitis can arise from odontogenic abscesses and must be detected as early as possible, as it is a life-threatening infection.
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Affiliation(s)
- Mohsen Sokouti
- Associate Professor, Department of Thoracic Surgery, Faculty of Medicine and Imam Reza Hospital, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Saeed Nezafati
- Assistant Professor, Department of Oral and Maxillofacial Surgery, Faculty of Dentistry, Tabriz University of Medical Sciences, Tabriz, Iran
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