Infectious Mediastinitis: A Retrospective Cohort Study

Background

This study aimed to characterize the demographics, microbiology, management and treatment outcomes of mediastinitis according to the origin of the infection.

Methods

This retrospective observational study enrolled patients who had mediastinitis diagnosed according to the criteria defined by the Centers for Disease Control and Prevention and were treated in Strasbourg University Hospital, France, between 1 January 2010 and 31 December 2020.

Results

We investigated 151 cases, including 63 cases of poststernotomy mediastinitis (PSM), 60 cases of mediastinitis due to esophageal perforation (MEP) and 17 cases of descending necrotizing mediastinitis (DNM). The mean patient age (standard deviation) was 63 (14.5) years, and 109 of 151 patients were male. Microbiological documentation varied according to the origin of the infection. When documented, PSM cases were mostly monomicrobial (36 of 53 cases [67.9%]) and involved staphylococci (36 of 53 [67.9%]), whereas MEP and DNM cases were mostly plurimicrobial (38 of 48 [79.2%] and 8 of 12 [66.7%], respectively) and involved digestive or oral flora microorganisms, respectively. The median duration of anti-infective treatment was 41 days (interquartile range, 21-56 days), and 122 of 151 patients (80.8%) benefited from early surgical management. The overall 1-year survival rate was estimated to be 64.8% (95% confidence interval, 56.6%-74.3%), but varied from 80.1% for DNM to 61.5% for MEP.

Conclusions

Mediastinitis represents a rare yet deadly infection. The present cohort study exhibited the different patterns observed according to the origin of the infection. Greater insight and knowledge on these differences may help guide the management of these complex infections, especially with respect to empirical anti-infective treatments.

Surgical therapy and outcome of descending necrotizing mediastinitis in Chinese: a single-center series

Background

Descending Necrotizing Mediastinitis (DNM) is an acute and often fatal infection that affects the neck and mediastinum. DNM treatment consists of broad-spectrum antibiotics, early diagnosis, and surgical debridement with multidisciplinary cooperation. However, owing to the rarity and complexity of this disease, the mortality rate is high. This retrospective study analyzed a single-center experience of managing DNM in Chinese patients over the last 10 years.

Methods

A single-center, retrospective, observational, and descriptive study was conducted on 31 patients with DNM at Peking Union Medical College Hospital from 2012 to 2022. Case report forms were used to collect data which were then analyzed with a focus on surgical management and outcomes.

Results

This study examined the outcomes of 31 patients diagnosed with DNM at our hospital. The most common comorbidities on admission were hypertension (48%) and diabetes mellitus (42%). The degree of diffusion of DNM according to Endo's classification was classified as follows: type I in 7 patients (22.6%), type IIA in 5 (16.1%), and type IIB in 19 patients (61.3%). Among these patients, 13 (41.9%) were found to have a single microbial infection, while 16 (51.6%) were found to have polymicrobial infections. In all cases, neck drainage was performed via cervicotomy, with multiple drains (64.5%) and vacuum sealing drainage (VSD) (35.5%). Mediastinal drainage was performed via a cervical mediastinotomy (51.6%), video-assisted thoracic surgery (VATS) (41.9%), or thoracotomy (6.5%). The 30-day mortality rate was 25.8% and 24.0 days of the average length of hospital stay.

Conclusion

Early accurate diagnosis and timely intervention have been shown to be correlated with a positive prognosis. Cervicothoracic CT (computed tomography) is essential for the diagnosis, staging, and evaluation of the optimal surgical treatment. Cervicotomy and video-assisted thoracoscopic surgery with percutaneous drainage is effective, even in advanced cases. Additionally, the application of VSD in cervical incision did not improve prognosis but may shorten the length of ICU (intensive care unit) and hospital stays.

Demographic, clinical, and paraclinical features of patients operated with the diagnosis of acute descending necrotizing mediastinitis: a retrospective study in Southern Iran

INTRODUCTION

Descending necrotizing mediastinitis (DNM) is a type of acute mediastinitis that is rarely reported but is regarded as a fatal disease despite improvements in technological methods and antibiotic therapies. We aimed to determine the demographic, clinical, and paraclinical features of patients diagnosed with acute DNM.

METHODS

In this retrospective study, patients' hospital records with a diagnosis of DNM admitted to the Namazi hospital in southern Iran during 18 years (2002-2019) were reviewed. Demographic and clinical features were recorded and subsequently analyzed via SPSS 22.

RESULTS

Out of 67 mediastinitis patients, 25 (37.3%) were diagnosed as DNM with an average age of 37.2 ± 16.7 years, and 68% were male. Regarding etiology, 52.0% were due to neck infection. Based on the technique of surgery, 52% of the patients underwent the combined method, which was mostly among type I and IIA DNM, while thoracotomy was mostly performed on type IIB DNM (P = 0.08). Based on the incision, type IIA and IIB had the highest frequency of thoracotomy and cervicothoracic incisions (P = 0.02 and 0.002). Puss discharge was significantly lower in type I DNM (P = 0.01). Based on the presenting symptoms of our patients, the majority (72.0%) had a chief complaint of neck pain, followed by chills and fever (48%). There were no reports of mortality during our short-term follow-up.

CONCLUSION

We report one of the largest retrospective studies of DNM patients in our referral center, with a high prevalence of the disease among younger populations, especially under 40 years. The method of treatment should be chosen based on the extent of infection and can be limited to neck exploration in upper mediastinal infections, though thoracic or combined approach in more broad infections.

Descending Necrotizing Mediastinitis by Streptococcus anginosus and Prevotella buccae in an Intensive Care Unit Patient: A Case Report

Necrotizing infections of deep neck spaces are a group of life-threatening infectious diseases acquired through trauma or as a descending infection from an odontogenic source. The isolation of pathogens is unusual because of the anaerobic nature of the infection; however, one way to achieve this is through the use of automated microbiological methods like matrix-assisted laser desorption/ionization and time-of-flight (MALDI-TOF) following standard microbiology protocols for analyzing samples from potential anaerobic infections. We present a case of a patient without risk factors for descending necrotizing mediastinitis with isolation of Streptococcus anginosus and Prevotella​​​​​​​ buccae managed at the intensive care unit with a multidisciplinary team. We present our approach and how we successfully treat this complicated infection.

Descending necrotizing mediastinitis: etiopathogenesis, diagnosis, treatment and long-term consequences-a retrospective follow-up study

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.

Surgical Experience with Descending Necrotizing Mediastinitis: A Retrospective Analysis at a Single Center

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.

Risk Factors of Descending Necrotizing Mediastinitis in Deep Neck Abscesses

Background and Objectives: Cervical space infection could also extend to the mediastinum due to the anatomical vicinity. The mortality rate of descending necrotizing mediastinitis is 85% if untreated. The aim of this study was to identify risk factors for the progression of deep neck abscesses to descending necrotizing mediastinitis. Materials and Methods: We retrospectively reviewed the medical records of patients undergoing surgical treatment of deep neck abscesses from August 2017 to July 2022. Computed tomography (CT) was performed in all patients. Before surgery, lab data including hemoglobulin (Hb), white blood cell count, neutrophil percentage, C-reactive protein (CRP) level, and blood glucose were recorded. Patients' characteristics including gender, age, etiology, and presenting symptoms were collected. Hospitalization duration and bacterial cultures from the wound were also analyzed. Results: The C-reactive protein (CRP) level was higher in patients with a mediastinal abscess than in patients without a mediastinal abscess (340.9 ± 33.0 mg/L vs. 190.1 ± 72.7 mg/L) (p = 0.000). The submandibular space was more commonly affected in patients without a mediastinal abscess (p = 0.048). The retropharyngeal (p = 0.003) and anterior visceral (p = 0.006) spaces were more commonly affected in patients with a mediastinal abscess. Conclusions: Descending necrtotizing mediastinitis results in mortality and longer hospitalization times. Early detection of a mediastinal abscess on CT is crucial for treatment. Excluding abscesses of the anterior superior mediastinum for which transcervical drainage is sufficient, other mediastinal abscesses require multimodal treatment including ENT and thoracic surgery to achieve a good outcome.

Evaluation of clinical parameters affecting the prognosis in surgically treated patients with descending necrotizing mediastinitis - A retrospective study

OBJECTIVES

Descending necrotizing mediastinitis (DNM) is the most serious complication of maxillofacial infections followed with high mortality. The objective of this retrospective study was to evaluate possible prognostic clinical factors for survival of patients with DNM based on single center clinical data.

METHODS

The study enrolled patients admitted to the Emergency Center of Vojvodina with the diagnosis of DNM either as the primary diagnosis or with discharged diagnosis after surgical treatment during 11-years period. The data were obtained from patient medical records.

RESULTS

After final analysis total of 28 charts were randomized for statystical analysis, 19 charts in survivors and 9 in non-survivors group. The most common cause of infection in survivors group was odontogenic and in non-survivors group pharyngeal infection. On multivariate regression analysis of collected data results of control computed tomography, preoperative Endo status, early postoperative C-reactive protein (CRP) and procalcitonine (PCT) values and postoperative complications were statistically significant predictors for mortality.

CONCLUSIONS

Based on results of this study, extent of infection in the mediastinum based on Endo's criteria, progression of infection on control cervicothoracic CT, increase of CRP and PCT values in immediate postoperative period and presence of postoperative complications and septic shock provide poor prognosis for patients with DNM.

Risk Factors Associated with Post-Operative Complications in Multidisciplinary Treatment of Descending Necrotizing Mediastinitis

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.

Four Different Reasons of Subcutaneous Emphysema With or Without Pneumomediastinum and Pneumothorax After Facial Bone Surgery

ABSTRACT

In the present study, the authors report rare case series with subcutaneous emphysema with or without pneumomediastinum and pneumothorax after orthognathic and facial bone contouring surgery, compare their clinical and radiologic findings, and suggest precautions. Four patients who showed subcutaneous emphysema on follow up chest X-ray and computed tomography after orthognathic and facial bone contouring surgery were included in the study. In all cases post-op subcutaneous emphysema were detected, however, the aspect and mechanisms of post-op air spread were all different. After the conservative management with administering the O2 by nasal cannula or endotracheal tube, the symptoms were relieved except 1 patient who needed chest tube insertion and further supra-sternal incision. In conclusion, subcutaneous emphysema with or without pneumomediastinum and pneumothorax after orthognathic and facial bone contouring surgery can be occurred by cervical fascia injury or alveolar ruptures. To preventing those complications, traumatic naso-tracheal intubation, excessive positive pressure ventilation, intermaxillary fixation immediate after the surgery, and increase of intra-alveolar pressure of the patients should be avoided.

Unveiling the Pathogenic Bacteria Causing Descending Necrotizing Mediastinitis

The combination of maxillofacial infections (MI) with descending necrotizing mediastinitis (DNM) is a complex disease characterized by rapid development and high mortality. Here, we performed metagenomic next-generation sequencing (mNGS) using samples from 21 patients with MI and eight patients with DNM. In this study, we found that the species richness of the DNM group was higher than that of the MI group, and the species diversity of the DNM group was higher than that of the MI group, with no statistically significant differences between groups (P > 0.05). LefSE analysis revealed that the main species differing between groups were Bacillus, Lactobacillus, Streptococcaceae, and Streptococcus (S. constellatus and S. anginosus). In addition, the PLS-DA analysis revealed that the dominant groups in the DNM group at the species level were S. constellatus, S. anginosus, Streptococcus intermedius, Prevotella oris, Mogibacterium timidum, and Eubacterium nodatum. Next, we correlated the clinical characteristics of the patients with the relative abundance of the pathogens identified in the LefSe and PLS-DA analyses. The relative abundance of S. anginosus was positively correlated with C-reactive protein (CRP) and calcitoninogen (PCT) but negatively correlated with the percentage of lymphocytes (Lymph%) (P < 0.05). On the other hand, M. timidum was positively correlated with the percentage of neutrophils (Neut%) and glycated hemoglobin (GLU) (P < 0.05), and Parvimonas micra was positively correlated with CRP (P < 0.05).

Multidisciplinary Approach in the Treatment of Descending Necrotizing Mediastinitis: Twenty-Year Single-Center Experience

Descending necrotizing mediastinitis (DNM) is an acute, rare, severe condition with high mortality, but the optimal management protocol is still controversial. We retrospectively analyzed the results of multidisciplinary management in patients treated for DNM at our center over the last twenty years. Fifteen male patients, mean age 49.07 ± 14.92 years, were treated: 9 with cervico-pharyngeal etiopathogenesis, 3 peri-tonsillar/tonsillar, 2 odontogenic, 1 post-surgical; 6 with DNM type I, 6 with type IIA, and 3 with type IIB (Endo’s classification). Mean time between diagnosis and treatment was 2.24 ± 1.61 days. In all cases, mediastinum drainage via thoracotomy was performed after neck drainage via cervicotomy, associated with tooth treatment in two; one required re-operation; tracheostomy was necessary in 9, temporary intensive care unit stay in 4; 6 developed complications, without post-operative mortality. Main isolated germs were Staphylococci and Candida; 7 had polymicrobial infection. The most used antibiotics were meropenem, metronidazole, teicoplanin, third-generation cephalosporins and clyndamicin; anti-fungal drugs were fluconazole, caspofungin and anidulafungin. On multivariate analysis, presence of cardiovascular disease was statistically significantly associated with longer chest tube duration and hospital stay. DNM requires early diagnosis and treatment to reduce mortality and morbidity. The most effective treatment should provide a multidisciplinary approach, combining cervicotomy and thoracotomy to drain all infectious collections with administration and monitoring of the proper antimicrobial therapy.

Acute Mediastinitis - Outcomes and Prognostic Factors of Surgical Therapy (A Single-Center Experience)

Purpose: The aims of this work were the retrospective analysis of a cohort of patients with acute mediastinitis treated at the authors’ worksite over a 15-year period and the identification of factors that significantly affect the outcomes of the therapy.

Methods: During the period 2006–2020, 80 patients with acute mediastinitis were treated. Within the cohort, the following were observed: the causes and the type of acute mediastinitis, length of anamnesis, comorbidities, diagnostic methods, time from the diagnosis to surgery, types and number of surgical procedures, results of microbiological tests, complications, and outcomes of the treatment.

Results: The most common type of acute mediastinitis was descending mediastinitis (48.75%). A total of 116 surgical procedures were performed. Ten patients in the cohort died (12.5%). Patients older than 60 years were at a 6.8 times higher risk of death. Patients with more than two comorbidities were at a 14.3 times higher risk of death. The presence of yeasts in the culture material increased the risk of death by 4.4 times.

Conclusion: Early diagnosis, removal of the cause of mediastinitis, sufficient mediastinal debridement, and multiple drainage thereof with the possibility of continual postoperative lavage are essential for the successful treatment of acute mediastinitis.

Descending necrotizing mediastinitis and the proposal of a new classification

Objective

Methods

Results

Conclusions

Prognostic factors for descending necrotizing mediastinitis development in deep space neck infections-a retrospective study

OBJECTIVES

Descending necrotizing mediastinitis (DNM) is the most serious complication of deep neck infections (DNI). The objective of this retrospective study was to evaluate prognostic factors for DNM development in deep space neck infections.

METHODS

The study enrolled patients admitted to the Emergency Center of Vojvodina with the diagnosis of multispace DNI with or without DNM either as the primary diagnosis or with discharged diagnosis after surgical treatment during 7-year period. The data were obtained from patient medical records.

RESULTS

After final analysis total of 141 charts were randomized for statystical analysis, 124 charts in DNI and 17 in DNI + DNM groups. The most common cause of infection in both groups was odontogenic. On multivariate regression analysis of collected data infection of retropharyngeal, pretracheal and carotid space, C-reactive protein and procalcitonine values were statistically significant predictors for DNM development.

CONCLUSIONS

Treatment and diagnosis of DNM requires multidisciplinary approach, with prompt clinical and radiological examinations, empirical broad spectrum antibiotic therapy and radical surgical debridement. Multispace neck infection and especially infection of retropharyngeal, carotid and pretracheal spaces are the most sensitive predictors for DNM development in deep space neck infections.

CLINICAL RELEVANCE

If the infection from deep neck spaces reach retropharyngeal, carotid or pretracheal space, the DNM is probable to occur.

TRIAL REGISTRATION

ClinicalTrials.gov ID NCT04865003. Date of registration 27.4.2021.

Deep neck infections with and without mediastinal involvement: treatment and outcome in 218 patients

Purpose

Infections of the deep neck, although becoming scarcer due to the widespread use of antibiotics, still represent a dangerous and possibly deadly disease, especially when descending into the mediastinum. Due to the different specialities involved in the treatment and the heterogenous presentation of the disease, therapeutic standard is still controversial. This study analyzes treatment and outcome in these patients based on a large retrospective review and proposes a therapeutic algorithm.

Methods

The cases of 218 adult patients treated with deep neck abscesses over a 10-year period at a tertiary university hospital were analyzed retrospectively. Clinical, radiological, microbiological and laboratory findings were compared between patients with and without mediastinal involvement.

Results

Forty-five patients (20.64%) presented with abscess formation descending into the mediastinum. Those patients had significantly (all items p < 0.0001) higher rates of surgical interventions (4.27 vs. 1.11) and tracheotomies (82% vs. 3.4%), higher markers of inflammation (CRP 26.09 vs. 10.41 mg/dl), required more CT-scans (3.58 vs. 0.85), longer hospitalization (39.78 vs 9.79 days) and more frequently needed a change in antibiotic therapy (44.44% vs. 6.40%). Multi-resistant pathogens were found in 6.67% vs. 1.16%. Overall mortality rate was low with 1.83%.

Conclusion

Despite of the high percentage of mediastinal involvement in the present patient collective, the proposed therapeutic algorithm resulted in a low mortality rate. Frequent CT-scans, regular planned surgical revisions with local drainage and lavage, as well as an early tracheotomy seem to be most beneficial regarding the outcome.

Acute mediastinitis, mediastinal granuloma, and chronic fibrosing mediastinitis: A review

Acute mediastinitis is a rare infection that carries high morbidity and mortality. They are complications seen most often with deep sternal wound infections from surgeries with median sternotomies, oropharyngeal and odontogenic infections and esophageal perforations. These conditions should be promptly recognized and treated. Mediastinal granulomas are focal, mass-like lesions commonly resulting from prior granulomatous infections. They are regarded as benign, self-resolving lesions however can cause complications by compression of adjacent mediastinal structures. Chronic fibrosing mediastinitis is a rare, diffuse fibroinflammatory process most often seen with granulomatous infections and carries a worse prognosis than mediastinal granulomas especially when adjacent mediastinal structures are compromised. In this review, we discuss the epidemiology, etiology, clinical presentation, treatment and prognosis of acute mediastinitis, mediastinal granulomas, and chronic fibrosing mediastinitis.

Identification of risk factors for mortality and delayed oral dietary intake in patients with open drainage due to deep neck infections: Nationwide study using a Japanese inpatient database

BACKGROUNDS

Data on risk factors for deep neck infection including descending necrotizing mediastinitis (DNM) have been limited. Using a nationwide database, the aim was identifying the factors related to patient death and delay in recovering oral intake.

METHODS

Data of 4949 patients were extracted from a Japanese inpatient database between 2012 and 2017. The main outcome was survival at discharge. In a subgroup analysis of the 4949 patients with survival, the second outcome was delay in the interval between admission and full recovery of oral intake.

RESULTS

Only a few factors (advanced-age, ventilation) were associated with both mortality and delayed oral dietary intake by logistic regression analyses. Conversely, several factors including DNM (adjusted-odds ratio [OR] 1.41) and repeated surgery (adjusted-OR 1.70) were significantly related only to delayed oral dietary intake.

CONCLUSIONS

Although DNM was not necessarily related to mortality, patients with DNM should receive careful attention to avoid delayed oral dietary intake.

[Descending Necrotising Mediastinitis: the Choice of Drainage]

INTRODUCTION

Descending necrotising mediastinitis (DNM) is a rare, but very severe, septic condition, caused by the spread of infection from the neck to the mediastinum. Delay in diagnosis and inadequate surgical procedures may lead to a life-threatening situation.

MATERIAL

We retrospectively evaluated a group of patients who suffered from DNM and were treated in our department by mediastinal drainage in the last 10 years (2010 - 2019). All patients required one of the following methods of drainage: cervicomediastinal, mediastinothoracic or cervicomediastinothoracic "Rendevouz" drainage (MTC-D). In the group, we evaluated the source of infection, microbiologic findings, method of mediastinal drainage, length of hospitalisation, ventilation duration and inflammatory laboratory parameters.

RESULTS

In total, we treated 22 patients with DNM, including 14 men and 8 women, aged 23 - 85 years, with a mean age of 54.1 years. After the spread of infection, in 8 cases the initial cervicomediastinal type of drainage had to be followed by one of the types of thoracic drainage. As the final method, in 8 patients we chose irrigation drainage from the cervical approach, from thoracotomy in 6 cases and in 8 cases irrigation CMT-D. The method of mediastinal drainage was chosen according to the initial CT findings, and further intervention was chosen according to CT signs during the treatment. Four patients died of DNM (mortality 18.2%). Pharyngeal focus was responsible for 15 cases of DNM; odontogenic infection caused 6 DNM cases; in 1 case the origin was unclear. Although we always chose the method individually and CMT-D for the most difficult cases, there were no statistically significant (p < 0.05) differences between the evaluated parameters. For CMT-D, there was even a shorter hospital stay (not significant) and ventilation duration.

CONCLUSION

In cases of DNM with severe inflammation of caudal and distal compartments of the mediastinum we consider CMT-D as an ideal method of treatment. This appraoch is radical enough and in our group of patients, despite the severity of this illness, both the length of treatment and mortality were sufficient.

A new classification of descending necrotizing mediastinitis and surgical strategies

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.

Mediastinitis of odontogenic origin. A serious complication with 80 years of history

We performed a systematic review of the literature about descending necrotising mediastinitis (DNM) of odontogenic origin. In parallel, a retrospective review of this pathology was carried out in an Oral and Maxillofacial Surgery Service of a reference hospital for a population of 1,100,000 inhabitants. The main objectives were to determine changes in mortality and prevalence of this serious complication. The systematic review included 51 articles with 89 patients and our study comprised seven patients. The period of time with the highest number of cases was between 2000-2009 (38 patients). The percentage of mortality observed was 20.2% in diffuse DNM and 4.9% in localised DNM. Thirty-one patients with DNM in our review were admitted for more than 41 days. Despite evidence of a decrease in DNM cases, publications have increased over the years, but it does not appear to be due to an increase in those of odontogenic origin. The survival of DNM has improved since 1998 and remained stable since then. Despite the low prevalence of this disease, multicentre control studies are needed to achieve better evidence about this entity.

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.

Descending Necrotizing Mediastinitis: Analysis of 9 Cases in Our Hospital

OBJECTIVES

Descending necrotizing mediastinitis (DNM) is a serious and progressive infection involving the neck and chest and with high mortality if not treated quickly and properly. The aim of this study is to share our practices for managing this condition.

METHODS

We retrospectively evaluated 9 patients diagnosed with DNM in our hospital between January 2006 and October 2019. Age, gender, origin of infection, length of hospital stay, microorganisms present, type of surgical treatment, and clinical outcomes were reviewed.

RESULTS

All patients underwent surgery to drain neck and mediastinal secretions and collections. Three (33.3%) patients were treated with transcervical drainage alone, and 6 (66.7%) patients were treated with combined transcervical and transthoracic drainage. Reoperations were reported in 3 (33.3%) cases. The average length of hospital stay was 22.78 ± 10.05 days (range: 9-40 days). The average length of intensive care unit stay was 6.44 ± 10.10 days (range: 0-25 days). There were no in-hospital deaths, and all patients were discharged home with good outcomes.

CONCLUSIONS

To improve the prognosis of DNM, we suggest early and adequate debridement of all affected areas along with the proper use of antibiotics. A multidisciplinary approach involving both cardiothoracic and ENT surgeons is also required.

Descending Necrotizing Mediastinitis Resulting from Pharyngitis with Perforation of the Aryepiglottic Fold

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.

Assessment of Prognosis in Odontogenic Descending Necrotizing Mediastinitis: A Longitudinal Retrospective Study

Background: Descending necrotizing mediastinitis [DNM] is a serious complication of odontogenic infections, being associated with a high mortality rate. The diagnosis, classification, and management depend on computed tomography [CT] findings. Incision, drainage, and debridement represent the principal management. This study aimed to assess the prognosis in odontogenic DNM. Methods: The DNM type I was managed by transcervical mediastinal drainage, while in DNM type II, a right or left posterolateral thoracotomy was used. Data were compared among survivors and deceased to detect the risk factors affecting the prognosis. Results: This study included 63 patients. Transcervical mediastinal drainage was performed in 57 patients with Endo Type I while drainage through a right posterolateral thoracotomy was performed in the other five patients with Endo Type I and one patient with Endo Type IIA. Of patients in the study, 82.5% survived while 17.5% died because of multiple organ failure. Multiple complications and severe sepsis or septic shock as risk factors were statistically significant. Conclusion: A CT scan is the modality of choice for diagnosis and classification of DNM. Incision and drainage of the maxillofacial infection with mediastinal drainage and debridement represent the main management. Multiple complications and severe sepsis or septic shock were associated with poor prognosis.

Deep cervical and paratracheal drainage for descending necrotizing mediastinitis

Background

Descending necrotizing mediastinitis is life-threatening and extends into the deep cervical fascia including the pretracheal, perivascular and retrovisceral, and prevertebral spaces. Deep cervical and paratracheal drainage via a transcervical approach prevents the spread of infection into the deep mediastinum. It is effective for local neck drainage and important in the primary treatment of descending necrotizing mediastinitis. Transthoracic mediastinal drainage is also effective for treating this condition.

Methods

Nine patients with descending necrotizing mediastinitis were treated by deep cervical and paratracheal drainage via a transcervical approach at our institution from April 2007 to December 2017. Four patients with diagnoses of extensive descending necrotizing mediastinitis had progressive extension of abscesses into the lower mediastinum, below the level of the carina. The other five had localized descending necrotizing mediastinitis with infection in the upper mediastinum above the level of the carina.

Results

All 9 patients (4 with extensive and 5 with localized descending necrotizing mediastinitis) initially underwent deep cervical and paratracheal drainage via a transcervical approach, and all recovered. Two of the patients with extensive infection required no additional surgical intervention.

Conclusions

Fluid collections in the deep cervical fascia must be drained urgently. Deep cervical and paratracheal drainage via a transcervical approach effectively controls all types of descending necrotizing mediastinitis, and it is less invasive than transthoracic approaches via thoracotomy. However, a thoracotomy for mediastinal drainage must be considered if infection is not controlled by transcervical drainage. Thoracic surgeons and otolaryngologists must plan efficacious treatment before surgical procedures for descending necrotizing mediastinitis.

Multidisciplinary treatment of deep neck infection associated with descending necrotizing mediastinitis: a single-centre experience

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.

Continuous venovenous hemodiafiltration using cytokine-adsorbing hemofilters as adjuvant therapy for anaerobic descending necrotizing mediastinitis: a case report

Background

We describe a combinatorial intensive care approach and discuss the critical factors that allowed us to successfully manage a life-threatening case of acute anaerobic septic shock triggered by descending necrotizing mediastinitis.

Case presentation

We admitted a 38-year-old critically ill Kosovar Albanian man to our intensive care unit because of clinical manifestations of severe sepsis. His condition had worsened in the previous 2 weeks following unsuccessful antibiotic therapy for tonsillitis complicated by retropharyngeal abscesses. Computed tomography and intraoperative observations identified abscesses in the anterior and middle mediastinum regions and the distal part of the neck, directly on the border with the left lobe of the thyroid gland. Cultures indicated infections with α-hemolytic Streptococcus and Clostridium species: High procalcitonin and lactate levels, blood gas analysis, poor peripheral capillary oxygen saturation, and severe hemodynamic instability pointed to a case of acute septic shock. The entire treatment consisted of an aggressive antibiotic regimen, transthoracic and mediastinal surgical evacuation of the abscess, vacuum sealing drainage with a pleural chest tube, continuous venovenous hemodiafiltration using cytokine-adsorbing hemofilters, and extracorporeal blood hyperoxygenation.

Conclusions

Efficient treatment of severe anaerobic sepsis resulting from descending necrotizing mediastinitis should build on a multidisciplinary approach. In support of first-line therapies with targeted antibiotics and surgical debridement, clinicians should consider alternative therapies such as continuous venovenous hemodiafiltration with cytokine-adsorbing hemofilters and hyperoxygenation.

Electronic supplementary material

The online version of this article (10.1186/s13256-019-2123-7) contains supplementary material, which is available to authorized users.

Septic shock from descending necrotizing mediastinitis - combined treatment with IgM-enriched immunoglobulin preparation and direct polymyxin B hemoperfusion: a case report

Background

Descending necrotizing mediastinitis is a common and progressive polymicrobial infection involving the neck and chest with a high death rate (10 to 40%). From a microbiological point of view, descending necrotizing mediastinitis is sustained by Gram-positive bacteria (43–62%), anaerobes (46–78%), and, rarely, Gram-negative bacteria. Data collected during the Antibiotic Resistance-Istituto Superiore di Sanità project confirmed that Italy is positioned among the countries with the highest levels of resistance in most pathogenic species under surveillance. In particular, 32.9% of Klebsiella pneumoniae isolates were resistant to carbapenem, 33.6% of Staphylococcus aureus to methicillin, and 28.7% and 43.9% of Escherichia coli isolates to third-generation cephalosporins and fluoroquinolones, respectively.

Case presentation

We describe the case of a 38-year-old white man with septic shock due to descending necrotizing mediastinitis sustained by multidrug-resistant Gram-negative and Gram-positive bacteria treated after surgery with an IgM-enriched immunoglobulin preparation and polymyxin B hemoperfusion therapy.

Conclusion

Despite the contrasting data on the use of immunoglobulins and polymyxin B hemoperfusion in septic shock and the lack of literature in cases of acute mediastinitis caused by both Gram-negative and Gram-positive multidrug-resistant bacteria, we obtained an improvement in clinical conditions and the survival of our patient, against all odds.

[Descending necrotizing mediastinitis : Treatment concept with focus on thoracic surgery]

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.

[Acute and chronic mediastinitis]

BACKGROUND

A systematic approach to the etiology and possible course of acute mediastinitis is a prerequisite for adequate diagnostics and therapy. Chronic mediastinitis represents a rarity in the clinical practice.

MATERIAL AND METHOD

A selective literature search was carried out.

RESULTS

An acute infection of the mediastinum occurs after perforation of mediastinal structures, such as the esophagus and trachea mostly of iatrogenic origin and as descending necrotizing mediastinitis (DNM) from oropharyngeal foci. The mortality rate of esophageal injuries, irrespective of the cause is currently given as 12 %. A DNM results from an unobstructed spread along the cervicothoracic spaces and is a severe infection which manifests as a clinical picture of sepsis. The mortality rate given in the currently available literature is 14 %. Chronic mediastinitis is a very rare condition which is characterized by the proliferation of fibrous and collagenous tissue in the mediastinum. Whereas the pathogenesis remains unclear, there are indications for a Histoplasma capsulatum infection as the causal link. The prognosis is good.

CONCLUSION

After perforation of the esophagus or trachea there is always the risk of an infection of the mediastinum; therefore, the diagnosis is followed by further evaluation and early therapy. The DNM can cause unspecific symptoms of sepsis without an obvious focal point. It is important to be aware of a possible correlation between an oropharyngeal center of infection and mediastinitis in order to initiate appropriate diagnostic imaging in cases with the slightest suspicion. Chronic mediastinitis is a rare condition with varying courses and can be difficult to diagnose. An histological clarification for distinction from malignant diseases appears to be a sensible approach.

[Surgical treatment of acute mediastinitis]

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.

Endoscopic Treatment of Transesophageal Echocardiography-Induced Esophageal Perforation

BACKGROUND

Perforation of the esophagus is the most severe complication of transesophageal echocardiography (TEE) and can lead to mediastinitis, pleural empyema, or peritonitis. Currently, the majority of patients receive operative treatment with only 6% treated endoscopically. We report our experience with endoscopic and conservative approaches.

METHODS

We retrospectively reviewed all patients treated for esophageal perforation and included all patients with perforation caused by TEE. All patients with perforation of the esophagus by TEE probe underwent conservative or endoscopic treatment, drainage of pleural and mediastinal retentions, and adjusted to antibiotic therapy.

RESULTS

From January 2004 to December 2014 a total of 109 patients were treated for esophageal perforation in our department. In 6 patients (5.5%) the perforation was caused by TEE. Location was cervical and midthoracic in 2 and 4 cases, respectively. All patients underwent successful endoscopic treatment and no further surgical procedure, such as esophageal suture or resection was necessary. The mean time between TEE and therapy of the perforation was 7.3 days. In all patients closure of the leakage could be achieved within 30 days. Mortality rate was 0%.

CONCLUSIONS

Esophageal perforations caused by TEE are typically small, in the cervical and mid esophagus, and minimally contaminated. These are good prognostic factors for successful endoscopic treatment with preservation of the esophagus. Operative treatment should only be considered in cases of failed endoscopic treatment.

European Association for Cardio-Thoracic Surgery expert consensus statement on the prevention and management of mediastinitis

Mediastinitis continues to be an important and life-threatening complication after median sternotomy despite advances in prevention and treatment strategies, with an incidence of 0.25-5%. It can also occur as extension of infection from adjacent structures such as the oesophagus, airways and lungs, or as descending necrotizing infection from the head and neck. In addition, there is a chronic form of 'chronic fibrosing mediastinitis' usually caused by granulomatous infections. In this expert consensus, the evidence for strategies for treatment and prevention of mediatinitis is reviewed in detail aiming at reducing the incidence and optimizing the management of this serious condition.

Descending necrotizing mediastinitis in the elderly patients

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.

Diffuse descending necrotising mediastinitis and pleural empyema secondary to acute odontogenic infection resulting in severe dysphagia

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.

Retrospective Review of Management and Outcomes of Pediatric Descending Mediastinitis

Objectives

To review the management and outcomes of pediatric patients treated for descending mediastinitis at a single institution and contribute to an updated mortality rate.

Study Design

Case series with chart review.

Setting

Tertiary care pediatric hospital.

Subjects and Methods

This study is a 19-patient case series of all patients treated for descending mediastinitis at a tertiary pediatric hospital from 1997 to 2015, and it serves as an update to the case series published from this institution in 2008. Review of management included time to diagnosis, time to surgery, surgical procedures performed, and antibiotics administered. The primary outcomes measured were length of hospitalization and mortality.

Results

In addition to 8 previously reported patients, we identified 11 pediatric patients treated for descending mediastinitis in the period of review. All 19 patients were <18 months old, and all survived their hospitalization. Fourteen patients underwent surgical drainage at least twice. The median length of hospital stay was 15 days. Retropharyngeal abscess was the source of infection in 16 of 19 patients, and methicillin-resistant Staphylococcus aureus (MRSA) was the isolated organism in 14 of 15 positive cultures.

Conclusion

This review represents the largest reported series of pediatric patients with descending mediastinitis. With 100% survival, our results suggest that pediatric descending mediastinitis can be safely managed by prompt surgical drainage. Broad-spectrum antibiotics covering MRSA and a low threshold for repeat surgical intervention have been an important part of our successful approach and may decrease length of stay.

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.

Descending necrotizing mediastinitis: 5 years of published data in Japan

Descending necrotizing mediastinitis implies infection originating from the neck, most commonly an oropharyngeal or odontogenic focus, that spreads in the cervical fascial spaces and descends into the mediastinum. Early diagnosis is essential because descending necrotizing mediastinitis can rapidly progress to septic shock and organ failure. A comprehensive review of the current data of descending necrotizing mediastinitis in Japan was carried out using PubMed and ICHUSHI from the last 5 years. The symptoms, origins, comorbid conditions, treatment modalities, complications, and survival rates were analyzed. Tonsillar and pharyngeal origin was more identified compared to odontogenic origin. More than one-third of patients were diabetic and 28% of them were not identified as having any comorbidity. Streptococcus sp. and anaerobes were most isolated, reflecting the microflora of the oral cavity. Of the broad antibiotics, carbapenem was the most used as treatment, and clindamycin was the most co-given. Mediastinal drainage approach varied widely and the optimal approach is controversial. Twenty-one patients were treated with video-assisted thoracic surgical drainage and 15 cases by percutaneous catheter drainage, whereas transcervical approach was applied in 25 patients and thoracotomy was carried out in 21 patients. The overall mortality was 5.6%. Many authors advocated that the most effective management tool is a high degree of clinical suspicion followed by prompt and adequate drainage with intensive care including hemodynamic and nutritional support and repeat computer tomographic monitoring.

Descending necrotizing mediastinitis: a modified algorithmic approach to define a new standard of care

BACKGROUND

Descending necrotizing mediastinitis (DNM) is a highly morbid infectious process. This uncommon disease process has carried historically a substantial burden of morbidity and mortality. In this study we hypothesized that application of a prospective modified management algorithm would decrease the morbidity and mortality from this highly destructive process.

METHODS

We developed a systematic approach for managing DNM, focusing on serial debridement guided by imaging, in conjunction with the use of broad-spectrum antibiotics and modern principles of critical care. We reviewed all patients admitted with this disease process from 2007-2012. Data collected included demographic information, co-morbidities, laboratory data including culture results, operative details, imaging frequency and findings, complications, and survival. Continuous variables were reported as median values and ranges.

RESULTS

From 2007-2010, we treated eight patients with DNM. The median age of the patients was 33 y (range 28-63 y), and 63% were male. In accordance with our algorithm, the patients underwent serial imaging at regular intervals following operative debridement. The median number of imaging studies was 11 (range 4-19). The patients required a median of five operative debridements (range 1-15). In five patients, drainage was necessary through a cervical exploration. A thoracic approach was required in six patients (two thoracoscopic, four via thoracotomy). Additional procedures included thymectomy (n=2), anterior mediastinotomy, carotid sheath exploration and resections of the clavicle, first rib, manubrium, pectoralis major muscle, and sternocleidomastoid muscle. The most common etiologic agents were Peptostreptococcus spp. and Streptococcus anginosus. Study patients received a median of six different antibiotics (range 2-10) for a total of 42 d (range 34-55 d). These patients were hospitalized for a median of 29 days (range 16-56 d), with 15 d (range 7-48 d) spent in the intensive care unit. Remarkably, the rate of survival was 100% (median follow-up of 33 mo). The patients developed no major complications, required no re-admissions, and had no re-infections.

CONCLUSIONS

We applied an algorithmic approach to the treatment of DNM, consisting of aggressive operative debridement and enhanced by equally aggressive imaging. Our patients had excellent outcomes despite the widely known lethality of DNM. An aggressive approach may decrease complications and improve survival in this devastating disease process. Furthermore, our prospective experience with DNM suggests that this algorithm used in the present study should be the standard for managing patients with this challenging condition.

Descending necrotizing mediastinitis below the tracheal carina

BACKGROUND

Descending necrotizing mediastinitis is a dreadful disease with a high mortality rate, particularly when below the tracheal carina. This study describes the epidemiologic, clinical, and paraclinical features of patients treated for this condition.

METHODS

We performed a single-center retrospective descriptive review of 60 patients with descending necrotizing mediastinitis below the tracheal carina, who were treated during a 7-year period, the largest study in the last 50 years. Demographic, clinical, paraclinical, and therapeutic variables were analyzed.

RESULTS

43 (71.7%) patients were male. The mean age was 41.2 ± 14.7 years. Mean hospital length of stay was 25.0 ± 19.8 days. Comorbidities were present in 46.7% of patients, diabetes mellitus being the most common. Odontogenic infections (45%) were the most frequent source of descending necrotizing mediastinitis. Cultures showed Gram-negative bacilli in 68.3%, Gram-positive cocci in 38.3%, and fungi in 6.7%. Mortality was 35% (21 patients); risk factors for mortality were age (>35 years), diabetes mellitus among other comorbidities, and associated complications.

CONCLUSIONS

In this low socioeconomic status patient population, descending necrotizing mediastinitis below the carina causes high morbidity and mortality, the latter particularly associated with age, complications, diabetes mellitus and other comorbidities.