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

Multidisciplinary Management of Descending Necrotizing Mediastinitis: Is Thoracoscopic Treatment Feasible?

Background: Descending necrotizing mediastinitis (DNM) is a life-threatening condition, generally caused by downward dissemination of oropharyngeal infections through cervical fascial planes. Mediastinal drainage is conventionally achieved by thoracotomy, but a Video-Assisted Thoracoscopic Surgery (VATS) approach is gaining interest due to the reduced invasiveness of procedure. We aimed to evaluate the effectiveness of VATS treatment in patients with DNM. Methods: We conducted a retrospective multicenter study including patients with descending mediastinitis that underwent mediastinal drainage through VATS (VATS group) or thoracotomy (thoracotomy group), both in association with cervical drainage. Patients with mediastinitis secondary to cardiac, pulmonary, or esophageal surgery were excluded. The intergroup differences regarding surgical outcome and postoperative morbidity and mortality were compared. Results: A total of 21 patients were treated for descending mediastinitis during the study period. Cervicotomy and thoracotomy were performed in 15 patients (71%), while cervicotomy and VATS were performed in 6 patients (29%). There were no significant differences in surgical outcome, postoperative morbidity, and mortality between groups. VATS treatment was not associated with a higher complication rate. Patients in the VATS group had a shorter operative time (p = 0.016) and shorter ICU stay (p = 0.026). Conclusions: VATS treatment of DNM is safe and effective. The comparison with thoracotomy showed no significant differences in postoperative morbidity and mortality. The VATS approach is associated with a shorter operative time and ICU stay than thoracotomy.

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.

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.

Distribution of descending necrotizing mediastinitis and efficacy of distribution-specific drainage

Background

Descending necrotizing mediastinitis (DNM) resulting from oropharyngeal and cervical abscess is a life-threatening condition. This study attempted to improve our recognition of the extension and distribution of the abscess for ideal thoracic drainage.

Methods

We performed a retrospective clinical analysis of seven patients who underwent thoracic drainage for DNM with available clinical data. For mapping and classification of the distribution of the abscess, computed tomography and intraoperative findings were utilized.

Results

To cure patients, cervical drainage and thoracic drainage were performed 14 and 11 times, respectively. The operation time for thoracic drainage and intraoperative blood loss were 141±77 min and 103±103 g, respectively. The mean hospital stay was 66±41 days. All patients are alive without recurrence. We divided the abscess distribution into nine categories including the anterior thoracic wall, according to the computed tomography and intraoperative findings. The rate of abscess descended gradually toward the lower mediastinum. Abscesses were not necessarily continuous, and skipped lesions were occasionally noted.

Conclusions

We were able to cure all seven patients with DNM. It might be helpful to recognize the exact distribution of the abscess and distribution-specific drainage using a new map and classification of thoracic abscess.

Descending necrotizing mediastinitis after a trigger point injection

Descending necrotizing mediastinitis (DNM) is a rare form of mediastinal infection. Most cases are associated with esophageal rupture. DNM after a trigger point injection in the upper trapezius has not been described previously. We present a case of DNM after a trigger point injection in the upper trapezius. A 70-year-old man visited the emergency department with chest discomfort and fever after a trigger point injection in the left upper trapezius. Chest computed tomography showed evidence of DNM, and antibiotic therapy was immediately administered intravenously. Because of the risk of sudden death, poor prognosis due to underlying disease, and his age, he declined surgical treatment and died of septic shock. Although trigger point injections are generally considered safe, caution should be used in patients with an underlying disease or in the elderly. Early diagnosis, broad-spectrum antibiotics, and aggressive surgical management are essential to improve the prognosis.

Less invasive management of deep neck infection and descending necrotizing mediastinitis: A single-center retrospective study

By a 7-year retrospective review, we reported our experience in management of descending necrotizing mediastinitis (DNM) and deep neck infection (DNI). A retrospective design was used to reveal the clinical characteristics of DNI and DNM. The clinical outcome was analyzed to validate less invasive management. We reviewed 82 patients between 2009 and 2016, 12 of which were diagnosed as DNM by clinical and computed tomography findings. A total of 35 patients had relevant systemic conditions, mainly diabetes mellitus (19 patients). Most cases were secondary to oropharyngeal or dental infections. All patients underwent transcervical drainage, and 10 DNM patients were treated with additional closed thoracic drainage simultaneously. Twenty patients accepted more than 1 operation. Seven patients died as a result of sepsis and/or multiple organ failure. The mortality rate in our study was similar to that in other studies. In our opinion, less invasive therapies are useful to most patients. Transcervical drainage alone is optimal management for all DNI cases and some DNM cases. Additional closed thoracic drainage is enough for type I and IIA DNM with pleural effusion or empyema.

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.

A novel treatment for inferior mediastinal abscess via abdominal laparoscopy

Mediastinal abscess can be managed through a variety of both invasive and minimally invasive methods, as determined by location and spread of infection. Thoracotomy remains the gold standard in treatment and is often employed. In the present case, a 54-year-old female with chronic pancreatitis presented with a 1-week history of severe epigastric pain, nausea and vomiting. On CT scan, a large abscess was discovered in the anterior inferior mediastinum. She was taken to the operating room and underwent laparoscopic drainage of the abscess. Laparoscopy represents a novel approach in management of anterior inferior mediastinal abscess.

Descending necrotizing mediastinitis: minimally invasive thoracic surgical treatment

OBJECTIVE

To report a case series of patients with descending necrotizing mediastinitis (DNM) who were treated with minimally invasive thoracic surgery.

METHODS

We report three cases of male patients with DNM who underwent mediastinal debridement by video-assisted thoracic surgery at the Hospital São Paulo, located in the city of São Paulo, Brazil, from admission to the final outcome.

RESULTS

The postoperative evolution was favorable in all three cases. The mean length of hospital stay was 16.7 days.

CONCLUSIONS

We conclude that video-assisted thoracoscopy is an effective technique for mediastinal drainage in the treatment of DNM, with the benefits common to minimally invasive surgery: less postoperative pain, lower production of inflammatory factors, earlier return to activities of daily living, and better aesthetic results.

Transcervical drainage for descending necrotizing mediastinitis may be sufficient

OBJECTIVE

Descending necrotizing mediastinitis (DNM) is a serious form of mediastinitis with a high mortality rate. It is caused by the downward spread of an oropharyngeal or cervicofascial infection. The optimal surgical approach for this often fatal disease is controversial. This article describes the authors' experience and characterizes the surgical strategies and treatment outcomes of patients with DNM.

STUDY DESIGN

Case series with chart review.

SETTING

A tertiary referral medical center.

SUBJECTS AND METHODS

This study conducted a retrospective chart review of patients with deep neck infections treated at a medical center from 1994 to 2007 and identified 29 patients with DNM. The clinical characteristics and outcomes were compared between patients treated with transcervical drainage alone (group I) and those with both cervical and thoracic drainage (group II).

RESULTS

There were 20 patients in group I and 9 patients in group II. The overall mortality rate was 10.3%. The mean duration of the hospital stay was 29.3 ± 15.5 days. There was no statistically significant difference in age, sex distribution, or duration from the appearance of symptoms to hospital admission between the 2 groups. The duration of hospital stay, tracheotomy rate, and mortality rate also did not differ significantly between the 2 groups. However, the numbers of surgeries were significantly higher in group II than in group I.

CONCLUSION

Transthoracic mediastinal drainage is not a compulsory therapy, but timely, aggressive, transcervical mediastinal drainage with extensive debridement is very important for a good outcome when treating DNM patients.

Descending deep neck infection in a liver transplant patient

Descending deep neck space infections are serious conditions that appear as a complication of cervical and odontogenic infections. Infecting bacteria descend into the mediastinum causing systemic toxicity and septic shock. Liver transplant patients are at increased risk of developing life-threatening infections, but reports about descending deep neck space infections in these patients are scarce. Here, we report a case of deep neck infection resulting in mediastinitis in a liver transplant patient. Streptococcus anginosus was isolated in blood cultures.

Descending necrotizing mediastinitis: a 10-year surgical experience in a single institution

OBJECTIVE

Early diagnosis and aggressive surgical drainage are very important for successful treatment of descending necrotizing mediastinitis. However, the surgical techniques used for this condition remain controversial. We report our 10-year experience of managing this devastating disease, focusing on the multidisciplinary, minimally invasive operative procedures and the unique bacteriologic factors in Taiwan.

METHODS

Between January 1997 and January 2007, we retrospectively reviewed 18 patients with descending necrotizing mediastinitis who were treated in the National Taiwan University Hospital. Diagnosis and Endo classification were confirmed by computed tomography of the neck and chest.

RESULTS

Eight women and 10 men were included in this study. The mean age was 57.8 +/- 15.2 years. Cervical drainage was performed in the involved area in all patients. The methods for mediastinal drainage included transcervical (n = 10), video-assisted thoracic surgical drainage (n = 6), subxiphoid drainage (n = 1), and mediastinoscopy-assisted drainage (n = 1). We could not rescue 3 patients because of uncontrolled sepsis before surgery, for a mortality rate of 16.7%. Klebsiella pneumoniae uniquely represents the most common pathogen in diabetic patients (P = .01), leading to more complicated courses in older patients (P =.04) and requiring more surgical interventions (P =.05) than other pathogens.

CONCLUSION

Transcervical mediastinal drainage is first justified in patients with limited disease in the upper mediastinum. For those with involvement of the lower anterior mediastinum, an additional subxiphoid approach is suggested. Cervicotomy with video-assisted mediastinal drainage is an excellent combination for involvement of the posterior mediastinum and pleural space. Klebsiella pneumoniae uniquely represents the most important and threatening causative pathogen for diabetic patients with descending necrotizing mediastinitis.