Determining optimum management of descending necrotizing mediastinitis with CT; experience with 32 cases

Detection of aerobe-anaerobe mixed infection by metagenomic next-generation sequencing in an adult suffering from descending necrotizing mediastinitis

BACKGROUND

Descending necrotizing mediastinitis (DNM) is one of the most virulent forms of mediastinitis. The main causes of high mortality in DNM are believed to stem from difficulty and delay in the diagnosis. Fast and accurate identification of pathogens is important for the treatment of these patients. Metagenomics next-generation sequencing (mNGS) is a powerful tool to identify all kinds of pathogens, especially for rare and complex infections.

CASE PRESENTATION

A 64-year-old male patient was admitted to the intensive care unit (ICU) with unconsciousness, dyspnea, and swelling in the mandible and neck. Computed tomography (CT) scan results combined with clinical laboratory examination indicated DNM. Vancomycin and imipenem were used, and vacuum sealing drainage was applied for debridement and drainage of the infected area. The positive mNGS results of drainage fluid confirmed the presence of mixed infection caused by Streptococcus anginosus, Prevotella oris, and several other anaerobes. The antibiotics were adjusted to piperacillin/tazobactam and tinidazole according to the mNGS results and antimicrobial susceptibility testing of cultured pathogens. After 11 days of antibiotic therapy, the infection symptoms of the neck and mediastinum improved, and the patient was transferred out of the ICU on the 26th day after negative result of drainage fluid culture.

CONCLUSION

This case suggested that mNGS is a promising technology for precise and fast pathogens identification with high sensitivity, which may guide the diagnosis of infectious diseases in the future trend.

Rare case of postoperative mediastinitis following thyroidectomy

Descending necrotizing mediastinitis (DNM) is a life-threatening complication secondary to oropharyngeal abscesses, cervical esophageal perforation, or neck infections spreading along the fascial planes into the mediastinum. Post-thyroidectomy surgical site infection is a highly unusual complication that is typically localized around the incision, but may be propagated into the mediastinum, causing DNM. We encountered a case of this rare complication after thyroidectomy. The patient was a 33-year-old woman who was admitted to our center for left hemithyroidectomy. The surgery was performed without any intraoperative events. However, she later developed fever, hypotension, and tachycardia. Imaging revealed deep neck emphysema and focal pneumomediastinum with infiltration in the anterior neck and mediastinum with abscess formation. Additional imaging at 7 days postoperatively revealed reduced fluid collection deep in the neck with minimal changes in fluid collection in the mediastinum. Esophageal perforation was excluded via an esophagogram, which lead to the conclusion that the infection may have been caused by open thyroidectomy. The patient was treated with prompt medical and surgical intervention. After treatment, she was discharged from the hospital with no further complications. We present our case report as well as a literature review of the diagnosis and treatment of this disease.

Associated Pleural and Pericardial Effusions: An Extensive Differential Explored

Concurrent pleural and pericardial effusions are not an unusual finding, but their differential diagnosis remains uncertain. Medline-based review identified an extensive list of infectious, inflammatory, neoplastic, iatrogenic, and myriad other etiologies. A single retrospective study had addressed this presentation. Several principles of a diagnostic workup are suggested, acknowledging that a significant minority of patients may not require a comprehensive workup and remain 'idiopathic'.

Catastrophic descending necrotizing mediastinitis of the anterior and posterior compartments: A case report

Descending necrotizing mediastinitis (DNM) is a medical emergency with a high associated morbidity and mortality.

DNM may arise secondary to primary odontogenic or neck infection in susceptible patients and it may spread contiguously via the “danger” space to the mediastinum. This case report is focused on complications following an odontogenic infection in a healthy 48-year-old male that led to a massive inflammation associated an extensive empyema.

After chest and neck computed tomographic scan a diagnosis of cervical necrotizing fasciitis with DNM was made. A multidisciplinary approach with an urgent surgical intervention and the finding of the right antibiotic therapy resulted to be successful. After 2 weeks the patient was dismissed in better health condition.

Acute purulent mediastinitis with sequential bilateral pleural empyema caused by neck trauma: A unique occurrence, a case report

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The lesson we took from this case is that: 1- blunt neck trauma rarely leads to descending necrotizing mediastinitis and late sequential empyema (after 18 days).

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2- If the patient does not recover from sepsis despite optimal surgical management, contra lateral empyema or pericarditis should be considered.

Background

Descending necrotizing mediastinitis (DNM) due to blunt trauma is very rare form of mediastinitis that can rapidly progress to septicemia and multi organ failure, in spite of optimal surgical management.

Case presentation

We report a 28-year-old patient, previously healthy man, with acute descending necrotizing mediastinitis and late sequential bilateral pleural empyema, caused by blunt neck trauma. Although after admission, the course of his illness was complicated with septic shock, homodynamic instability, renal and pulmonary insufficiency, however he survived with on time diagnosis, aggressive surgical intervention, appropriate antibiotics administration and optimal management in the intensive care unit (ICU).

Conclusions

Descending necrotizing mediastinitis due to blunt neck trauma is a rare occurrence, but can lead to late sequential bilateral empyema even after 18 days. With early diagnosis, aggressive drainage and antibiotic therapy, the patient life can be saved.

The lesson we took from this case is that: 1- blunt neck trauma rarely leads to descending necrotizing mediastinitis and late sequential empyema (even after 18 days).

2- If the patient does not recover from sepsis, despite optimal surgical management, contra lateral empyema or pericarditis should be considered.

Pharyngeal Emergencies

Pharyngeal emergencies, which can be subdivided into traumatic versus nontraumatic, are a common cause of Emergency Department visits. Patients often present to Emergency Department with a wide variety of pharyngeal symptoms, for which computed tomography imaging has become the first line imaging modality. Familiarity with these conditions enables a radiologist to make a prompt diagnosis, assess the extent of disease, and evaluate for potential complications. In this chapter, we present a brief overview of nontraumatic pharyngeal emergencies based on anatomic subdivisions (nasopharynx, oropharynx, and hypopharynx), discuss their etiologies, clinical presentations, computed tomography imaging findings, and management options. We will also discuss differential diagnoses based on imaging findings.

Taking heed of the 'danger space': acute descending necrotising mediastinitis secondary to primary odontogenic infection

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.

Imaging of Oncologic Emergencies

Oncologic emergencies can be either the result of the primary tumor, its metastasis, a paraneoplastic syndrome or reaction to the chemotherapy. Imaging plays a crucial role in ensuring a prompt diagnosis as well as assisting in the therapeutic management. In this article, we discuss the common thoracic and abdominal oncological emergencies that may be encountered in an emergency department.

Clinical features and outcome of patients with descending necrotizing mediastinitis: prospective analysis of 34 cases

PURPOSE

We aimed to investigate clinical features of patients with descending necrotizing mediastinitis (DNM) in order to improve management and outcome.

METHODS

We prospectively examined all patients with DNM admitted to the Intensive Care Unit (ICU) during the period from April 2007 to December 2013. Demographics, clinical features, microbiology, medical and surgical treatment data were recorded. Survivor and nonsurvivor groups were analyzed to identify factors associated with mortality.

RESULTS

Overall, 34 patients with DNM have been included. The mean age was 46.8 ± 11.2 years (range 24-70). The male/female ratio was 3.25. DNM arose from odontogenic infection in 22 (65%) patients; from peritonsillar abscess in 9 (26%) patients and from paranasal sinus in 3 (9%) patients. Microbiological cultures revealed a high percentage of aerobic/anaerobic coinfection. Nonsurvivors were statistically more likely to have higher SAPS II score (mean difference 19.1, 95% CI 12.3-25.9 P < 0.01) and more severe disease (P < 0.01) than survivors. Positive correlation was found between time to ICU admission after head or neck infection diagnosis and SAPS II score (ρ = 0.5, P = 0.03). The same was true for ICU length of stay and time to ICU admission (ρ = 0.6, P < 0.01) and time to surgery (ρ = 0.5, P = 0.03). Surgical treatments consisted in: transcervical drainage in 14 cases, (42%); irrigation through subxiphoid and cervical incisions of the anterior mediastinum with additional percutaneous thoracic drainage when necessary in ten cases, (29 %); thoracotomy with radical mediastinal surgical debridement, excision of necrotic tissue and decortication in ten cases, (29%). We have found a mortality rate of 12%. Patients with DNM type IIB were admitted to the ICU later than patients with DNM type I and type IIA (mean difference 3.2 days, 95% CI 1.2-5.1, P 0.02).

CONCLUSIONS

Prompt ICU admission in order to manage severe sepsis and/or septic shock, along with early and aggressive surgery and adequate antimicrobial therapy, could be key factors in reducing DNM mortality.

Clinical features of deep neck infections and predisposing factors for mediastinal extension

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.

A pain in the neck--imaging in neck sepsis

Deep neck infection has a high morbidity and mortality and the extent of infection is often difficult to estimate clinically. The complex anatomy and the communication between neck spaces means that infection can spread along fascial planes leading to life-threatening complications such as airway compromise, vascular erosion/thrombosis, neural dysfunction, and ultimately descending necrotizing mediastinitis. Imaging has an important role to play in identifying the extent of infection and the presence of complications.

Descending necrotizing mediastinitis as a complication of odontogenic infection

Descending necrotizing mediastinitis (DNM) is a serious, life threatening complication that can occur from a common odontogenic infection. Even with advancements in antibiotics, diagnostic imaging, and surgical management, the mortality rate remains between 20 and 40%. It is imperative that the practitioner taking care of patients with odontogenic infections be sensitized to this potentially fatal complication. We report the successful management of a case of mediastinitis complicating an odontogenic infection in a 39-year-old male.

Successful treatment for descending necrotizing mediastinitis with severe thoracic emphysema using video-assisted thoracoscopic surgery

Descending necrotizing mediastinitis (DNM) is a rare, highly fatal disease that occurs as a complication of a cervical or odontogenic infection spreading into the mediastinum. We herein report of a 50-year-old man with DNM and severe thoracic emphysema who was successfully treated using surgical drainage by video-assisted thoracoscopic surgery (VATS) and a transcervical approach. Chest enhanced computed tomography on admission revealed massive left pleural effusion, pneumothorax, absolute collapse of the left lung, and a mediastinal shift to the right side with emphysema. We urgently performed left thoracic and mediastinal drainage using VATS. Retropharyngeal and upper mediastinal drainage was performed transcervically on the third hospital day. He recovered and was discharged on hospital day 57. Surgical drainage is the most important therapy in the treatment of DNM, but there is no standard surgical approach. We believe that VATS is a less invasive, effective modality for draining the posterior mediastinum.

[Mortality risk factors in descending necrotizing mediastinitis]

INTRODUCTION

The term descending necrotizing mediastinitis (MND) refers to an infection that begins in the oropharyngeal region and spreads through the fascial planes into the mediastinum. This study aims to estimate the incidence of MND in our centre, the epidemiology and clinical features of the disease and to evaluate prognostic factors influencing mortality.

PATIENTS AND METHODS

We performed a retrospective study on 43 consecutive patients diagnosed at the Hospital Universitari Vall d'Hebron in Barcelona from January 1996 to December 2006. We performed a descriptive study and a bivariate and a multivariate analysis of variables collected.

RESULTS

Overall mortality was 21%, but when we subdivided the study into two periods (1996-2000 and 2001-2006) it shows a significant decrease (40% versus 4.3%). Risk factors identified in the bivariate analysis were: diagnosis period 1996-2000, diabetes mellitus, comorbidity, number of surgeries, left lateral surgery, postoperative morbidity and septic shock. In multivariate analysis, only the presence of septic shock proved to be an independent predictor of mortality.

CONCLUSIONS

MND is a disease of low incidence and should be suspected clinically and confirmed immediately with a computed tomography (CT). Multidisciplinary and early treatment has allowed us to reduce mortality by 40% in the first initial period to 4.3% today.

Optimal treatment of cervical necrotizing fasciitis associated with descending necrotizing mediastinitis

Background

Cervical necrotizing fasciitis (CNF) associated with descending necrotizing mediastinitis (DNM) is a rapidly evolving and life-threatening condition. The aim of this retrospective study was to describe a treatment strategy for CNF with DNM and present a management algorithm for mediastinal extensions of CNF.

Methods

Patients diagnosed and treated for CNF with DNM over 14 years in a tertiary referral centre were included.

Results

Seventeen adult patients were included. The origin of infection was mainly oropharyngeal. The diagnosis of CNF/DNM was based on clinical and computed tomography findings. All patients underwent cervicotomy for CNF. In ten patients, DNM was located above the carina and could be accessed by a cervical approach. In seven patients, DNM was below the carina, and necessitated sternotomy for anteroinferior mediastinal involvement and posterolateral thoracotomy for posteroinferior mediastinal involvement. All patients received broad-spectrum antibiotics. One patient died 3 days after surgery. The median hospital stay was 30 days. There was no recurrence during long-term follow-up.

Conclusion

Prompt diagnosis and early surgical treatment are essential for reducing mortality in CNF/DNM. All patients should undergo extensive cervicotomy. The surgical approach to the mediastinum depends on the supracarinal or infracarinal location of the disease.

Necrotizing fasciitis of the face: a life-threatening condition

Necrotizing fasciitis (NF) is a highly aggressive infectious process, polymicrobial in nature, involving soft tissues with a high risk of rapid spread through superficial and deep fascial planes and muscular layers. Cervical NF is quite rare, is mostly of odontogenic origin, and may be complicated by descendant mediastinitis with a very high mortality rate. Systemic conditions impairing the patient's immune competence, such as diabetes, may play a predisposing role. An effective treatment strategy includes prompt diagnosis (clinical findings, local microbiological tests, blood culture and, if deemed necessary, histopathology), broad-spectrum antibiotic therapy as early as possible which should be later adjusted according to antibiogram results, stabilization of vital functions and, if possible, elimination/ treatment of predisposing factors. This paper describes a complex and emblematic case.

[Diffuse cervical cellulites and descending necrotizing mediastinitis]

OBJECTIVES

To give a report on the progress in physical examination, investigations and treatment of diffuse cervical cellulites (DCC) associated with descending necrotizing mediastinitis.

MATERIALS AND METHODS

A Retrospective study (1995-2005) of patients presenting DCC with mediastinitis was made. All had a cervical and thoracic Computed tomography (CT) scan. The references were collected by a Medline search.

RESULTS

Six men and 2 women, average ages 53 years were treated. Four had an immunodeficient status. Two had had an anti-inflammatory drug treatment without antibiotic treatment. The average for diagnosis and treatment was 4 days. In 2 cases we found a dental origin and in 6 cases a pharyngeal origin. The most frequently identified germs were streptococcus beta haemolytic group A and Prevotella. In 4 cases, no physical sign of mediastinitis was noted. The diagnosis of mediastinitis was made thanks to the thoracic CT scan. All the patients were treated by broad-spectrum antibiotic therapy. All had cervical and thoracic surgical drainage. Mediastinal drainage was made by cervical way in 3 cases and by thoracotomy in 5 cases. One patient died.

CONCLUSIONS

The DCC with mediastinum extension are serious infectious emergencies with a high mortality rate. Clinical diagnosis of mediastinitis is difficult. A thoracic CT scan should be performed systematically. Performing thoracotomy best controls mediastinal drainage.

CT features of descending necrotizing mediastinitis—a pictorial essay

Descending necrotizing mediastinitis (DNM) is a relatively rare condition caused by downward spread of neck infections into the mediastinum. This infection previously had a much worse prognosis. In recent years, prompt computer topography (CT) diagnosis has been recommended. CT scan provides the earliest means of detecting DNM for optimal management and early surgical intervention. This paper provides an illustrated summary of our extensive clinical experience with DNM, involving 36 documented cases with CT over a 5-year period.

Descending Necrotizing Anterior Mediastinitis: Analysis of Survival and Surgical Treatment Modalities

PURPOSE

Descending necrotizing anterior mediastinitis (DNAM) is a severe infectious disease with a very high mortality rate. The aim of this study was to define the impact of several clinical factors on survival.

PATIENTS AND METHODS

Between 1985 and 2002, 27 patients were managed for DNAM, 11 with combined transthoracic mediastinal and cervical drainage (group A) and 16 with a less aggressive surgical approach, such as cervical drainage and transcervical mediastinal drainage (group B). The records of all patients were statistically analyzed for the impact of several clinical factors on survival.

RESULTS

Although patients in group A were admitted to the hospital faster, treated with antibiotics as outpatients earlier, and operated on much sooner after hospital admission compared with the patients in group B, multivariate analysis revealed that early combined transthoracic mediastinal and cervical debridement and drainage was the only favorable factor for survival in patients DNAM patients (odds ratio = 9.99; 95% confidence interval = 1.02 to 97.49).

CONCLUSIONS

Less extensive surgical approaches (ie, thoracic drainage without cervical drainage or combined cervical and subxiphoid thoracic drainage) led to unsatisfactory results and high reoperation rates. In contrast, early, aggressive combined cervical and thoracic drainage proved to be an effective method for managing DNAM.

Cervical complications following routine tonsillectomy and adenoidectomy

PURPOSE OF REVIEW

Fortunately, patients undergoing adenotonsillectomies have far more complaints than complications. Sore throats, dysphagia, and neck pain are frequent and expected symptoms after surgery. Differentiating these symptoms from early signs of severe cervical complications can be difficult. Such complications are rare but include atlanto-axial subluxation (Grisel's syndrome), cervical necrotizing fasciitis, cervical emphysema and cervical oseteomyelitis. Due to the frequency with which adenotonsillectomies are performed, most otolaryngologists will encounter these events during their career. This article is thereby intended to elucidate the early warnings, appropriate diagnostic workup, and therapeutic modalities for cervical complications following adenotonsillectomies.

RECENT FINDINGS

Early recognition and intervention can prevent devastating morbidity and mortality described with cervical complications. Computed tomography scanning remains the gold standard for diagnosing cervical complications after adenotonsillectomy. Although a range of severity exists in cervical complications, most cases can be managed conservatively with broad spectrum antibiotics, observation, bedrest and immobilization in cases of Grisel's syndrome. Cervical necrotizing fasciitis requires a high index of suspicion and urgent management to avoid fatal consequences.

SUMMARY

This is a review of the most frequently encountered, although rare, cervical complications following adenotonsillectomies. It gives the reader an insight into the efficient diagnosis and management of these complications.

Management of Descending Necrotizing Mediastinitis Using Minimally Invasive Video-assisted Thoracoscopic Surgery

Early diagnosis and aggressive surgical drainage are very important for successful treatment of descending necrotizing mediastinitis (DNM). However, the surgical techniques used for DNM treatment remain controversial. The purpose of this study was to evaluate the effectiveness of video-assisted thoracoscopic surgery (VATS) and cervical drainage for the management of DNM. Nine patients diagnosed with DNM were treated from May 2001 to April 2004. The mean age of the patients was 51.1+/-15.0 years. VATS and cervical drainage, including debridement and drainage of the mediastinum and pleura, were performed simultaneously. The mean postoperative hospital stay was 20.6+/-6.6 days. One patient (11%) died of sepsis and renal failure on the 15th postoperative day. Minimal mastication difficulty developed in 2 patients (22%). The mean postoperative follow-up period was 28.7+/-14.7(5 to 52) months. All the survivors are in good health with no recurrences. VATS was safe, effective, and a less invasive surgical option for the management of DNM and should be considered as a good alternative therapeutic modality.

Descending mediastinitis: a review

CONTEXT

Mediastinitis is an inflammation of connective tissue that involves mediastinal structures. When the condition has an infectious origin located in the cervical or oral region, it is termed "descending mediastinitis" (DM).

DATA SOURCES

The subject was examined in the light of the authors' own experiences and by reviewing the literature available on the subject. The Medline, Lilacs and Cochrane databases were searched for articles, without time limits, screening for the term "descending mediastinitis". The languages used were English and Spanish.

DATA SYNTHESIS

There are three main fascial pathways by which oral or cervical infections can reach the mediastinum: pretracheal, lateropharyngeal and retropharyngeal. About 70% of DM cases occur via the retropharyngeal pathway. The mortality rate is about 50%. According to infection extent, as seen using computed tomography, DM can be classified as focal (type I) or diffuse (type II). The clinical manifestations are nonspecific and resemble other systemic infections or septic conditions. The primary treatment for DM consists of antibiotics and surgical drainage. There are several approaches to treating DM; the choice of approach depends on the DM type and the surgeon's experience. In spite of all the improvements in knowledge of the microbiology and physiopathology of the disease, controversies still exist regarding the ideal duration of antibiotic therapy and whether tracheostomy is really a necessary procedure.

CONCLUSION

Since DM is a lethal condition if not promptly treated, it must always be considered to represent an emergency situation.