descending necrotizing mediastinitis: surgical …€¦ · descending necrotizing medistinitis...
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Descending Necrotizing Mediastinitis: Surgical management and results C.Aránzazu Pérez, PhD1; J.D. Contreras, MD1; CA. Rómbola, MD2 , M.I Rodríguez MD1; F.J. Diaz, MD1 T. García, MD; JC. Ceballos, MD3
ENT Department1 , Thoracic Surgery Department2 , Pulmonology Department3
Complejo Hospitalario Universitario de Albacete. Spain
Descending necrotizing medistinitis (DNM), is
commonly caused by odontogenic infection,
peritonsillar abscess or retropharyngeal
abscess. The diagnosis must be stablished
rapidily. Because mortality rates are too high,
aggressive surgical treatment is indicated. This
investigation reviews the effects of surgical
drainage on the survival of patients with DNM.
PATIENTS AND METHOD
A retrospective review of patients from 2003
through 2010 with a diagnosis of DNM was
performed. Their records were abstracted for
personal demographics, hospital course,
surgical treatment, morbility and mortality. The
records of all patients were statistically analyzed
for the impact of several clinical factors on
survival.
RESULTS:
We treated 15 patients (13 men, 2 woman) in
whom DNM was identified. DNM was consecutive
to dental abscess (6 cases), pharingitis (6 cases),
foreign body infection (2 case) and after
tracheotomy (1 case). The mean age of the
patients was 56 years (range, 27 to 85 years).
Surgical treatment consisted : in 8 patients
combined transthoracic mediastinal and cervical
drainage and 7 with a less aggressive surgical
approach, such as cervical drainage and
transcervical mediastinal drainage. Four patients
required reoperation. Traqueotomy was
performed in 6 patients. Three deaths occurred.
The mean duration of hospitalitation was 29
days.
CONCLUSION
Descending necrotizing mediastinitis must be
detected as soon as possible by computer
tomography scanning in patients with persistent
symptomatologia after treatment for pharyngeal
infections. It´s important an early diagnosis and
aggressive treatment. Ample cervicotomy
associated with mediastinal drainage is essential
in managing these critical ill patients and can
significantly reduce the mortality rate.
ABSTRACT
Descending necrotizing mediastinitis (DNM), is a life-
threatening disease originating from odontogenic,
pharyngeal or cervical infections that spreads along
fascial planes into the mediastinum. The infection is
usually polymicrobic or mixed aerobic/anaerobic.
Because delayed diagnosis and treatment lead to
mortality and because the validity of antibiotics is
limited, radical debridement of all affected tissue is
required for DNM. The optimal management of DMN
remains controversial, in particular the question of
whether cervical drainage alone or routine
thoracotomy should be performed.
We reported about our experience with 15 patients
affected by DNM and its surgical management.
INTRODUCTION
METHODS AND MATERIAL
RESULTS
Between 2003 and 2010, 15 patients (13 males and 2
woman) were diagnosed and treated for DNM. The
mean age was 56 (range 27-85). All cases met the
criteria stablished by Estrera for the diagnosis (Figure
1). In addition to demographic data, we recorded the
original pathology, the length of time between the
initial symphtoms and hospitalitation, mediastinal
involvement, the type of pathogen, the type of surgery,
the length of hospital stay and the result.
1. Clinical manifestation of severe oropharyngeal infection.
2. Demostration of characteristic imaging features of mediastinitis (CT)
3. Documentation of necrotizing mediastinal infection at operation.
4. Stablishment of a relationship between oropharyngeal infection and
developement of necrotizing process.
Figure 1.The criteria of Estrera
A cervical infection was clinically obvious in all cases. The delay between onset symptoms and admission to our hospital was 8 days (range from 3 to 18) . Of the 15
patients, 8 had mediastinitis at admission and 7 developed mediastinitis during admission (despite antibiotic treatment and surgical drainage in some cases 3). The
primary focus of infection was odontogenic and pharyngeal in 12 patients (Table 1).
A cervicothoracic Computed Tomography (CT) scan results facilitated diagnosis in all cases and revealed heterogeneous infiltration, gas effusion, abscesses and fluid
collections (Figure 2).
After clinical diagnosis, urgent surgical drainage was performed and empirical broad-spectrum intravenous antibiotic was initiated.
In all cases a collar bilateral incision was carried out, involved cervical spaces were opened, debridement of necrotic tissue and drainage were performed (in two cases we
did a thoracoscopic drainage by cervical approach too) . In seven patients the infection was resolved.
In the remaining eight patients we made a drainage of the mediastinal collection by a thoracic approach with a posterolateral thoracotomy (right in 7 and left in one) .
(Figures 3-5) .A temporary tracheotomy was performed in 6 patients . Mediastinal drains were inserted and used for irrigation following surgery . CT was performed 2 or 3
days after surgery
All the patients were admitted to the intensive unit care after surgery. The mean duration of intensive care stay was 14 (range 2-40) days. Three patients died, one in the
unit care by multiorganic failure and the other two in the hospital by pulmonary hemorrhage once and exacerbation of cardiac pathology the other.
Abbreviattions: M-man; W- woman.
* Diagnosis of mediastinitis at the same time of admission at hospital
Table 1: Personal data and source of infection
DISCUSSION
CONCLUSIONS
REFERENCES
1. DNM is caused by downward spread of neck infections an constitutes a
hight lethal complication of oropharyngeal lesions.
2. It´s necessary an early diagnosis using cervicothoracic CT and
inmediate multidisciplinary medical and surgical therapy.
3. The primary treatment of DNM includes intravenous broadspectrum
antibiotics .
4. Aggressive cervical and mediastinal drainage will be performed. A
cervical approach is adequate when the mediastinitis is limited to the
upper mediastinum and transthoracic drainage when the mediastinitis
has spread below the carina.
1. Estrera AS, Landay MJ, Grisham JM et al.Descending necrotizing mediastinitis. Surg
Gynecol Obstet 1983;157:545-52.
2. Endo S, Murayama F, Hasegawa T et al. Guideline of surgical management based on
diffusion of descending necrotizing mediastinitis. Jpn J Thorac Cardiovasc Surg 1999;
47:14-9.
3. Roccia F, Pecorari GC, Oliaro A et al. Ten years of descending necrotizing mediastinitis:
management of 23 cases. J Oral Maxillofac Surg 2007; 65:1716-1724.
4. Deu-Martin M, Saez-Barba M, López Sanz I et al. Mortality risk factors in descending
necrotizing mediastintis. Arch Bronconeumol 2010; 46:182-187
Odontogenic and pharyngeal infections are the most common cause
of DNM. The majority of DNM are mixed polymicrobial aerobic and
anaerobic reflecting its pharyngeal or odontogenic nature. It can affect all
age groups but it´s more frequent in the fourth and fifth decade.
Early diagnosis of DNM will be done. It´s easy the diagnosis of cervical
infection but the diagnosis of mediastinitis is often difficult. CT of the
neck and thorax is mandatory if the process is suspected and it´s used
preoperatively to asses the extent of the necrotising process and
stablished the optimal approach for efficient drainage.
Inmediate surgical drainage though wide neck exposure and
exploration of fascial compartments with extensive debridement is
essential. The cervical wounds are not closed until the pathologic
changes regress completly.
According to several investigator, superior mediastinal drainage
through a cervical approach is adequate when the mediastinitis is limited
to upper mediastinum and transthoracic drainage (thoracotomy) has to
be performed when the mediastinitis has spread below the carina. And
when more than one mediastinal space is envolved, the standard
treatment should be a combined cervical and thoracic approach in the
same operation. The need for tracheotomy should be assessed on an
individual basis.
In addition to surgical treatment, postoperative intensive care
management is an essential determinant for outcome.
Figure 5
Vision through open thoracotomy for mediastinal abscess.
Drainage from the neck to posterior mediastinum for washing.
Figure 4
Cervical necrotizing fasciitis of odontogenic origin (patient
5). Tissue necrosis and acumulation of seropurulent content
between the facias and spaces.
Figure 3
Status post wound revision and incision and drainage of
collection of patient 8. Vision drains inserted at level of the
anterior mediastinum for irrigating.
C. Aránzazu Pérez Fernández
ENT Department. General Hospital of
Albacete. Spain
Email: [email protected]
Website: www.chospab.es
CONTACT
Abbreviations:S- Supracarinal; I-Infracarinal; C- Cervicotomy drainage; CVAM- Cervicotomy And Video-assisted
mediastinoscopic drainage; RT- right posterolateral thoracotomy; LT- left Posterolateral thoracotomy; T- tracheotomy.
Figure 2
A. Axial CT scan shows fluid collection containing
gas in the visceral space, the left cervical space. B. The fluid
Collection spreads to the anterior mediastinum .
Patient 8 A B
Table 2. Description of treatment and outcome
Case
Type of surgery No of
tubes Postoperatory complications Bacteria Length of stay Outcome
1 C 2 Toxic shock None 17 Died
2 C + RT + T 4 None alpha hemolytic streptococci 28 Hospital discharge
3 CVAM 1 None Enterobacter coaclae 11 Hospital discharge
4 C + RT 2 Pneumony Streptococcus viridans 35 Hospital discharge
5 C + RT + T 4 Toxic shock Streptcoccus viridans 47 Died
6 C 2 None None 28 Hospital discharge
7 C + T 2 None Streptococcus viridans 28 Hospital discharge
8 CVAM 1 Pneumony None 59 Died
9 C + RT 3 None None 16 Hospital discharge
10 C + RT 4 Cerebral ischemic stroke Streptococcus viridans 22 Hospital discharge
11 C + T 2 Pneumony Prevotella sp 15 Hospital discharge
12 C + T 2 None Streptococcus viridans 28 Hospital discharge
13 C + RT 4 Toxix shock Streptococcus viridans 34 Hospital discharge
14 C + RT 4 Pleural effusion Streptococcus viridans 30 Hospital discharge
Case
Age
/Gender Past history Cause
Time from symptoms
to admission
Clinical diagnosis
Development of
Mediastinitis (days)
1 63/M No Odontogenic
Infection 4 Cervical necrotizing fascitis 0 *
2 46/M Alcoholism Pharyngeal infection 3 Parapharyngeal abscess 13
3 46/M No Foreign infection body 7 Parapharyngeal abscess 0
4 45/M No Pharyngeal infection 5 Parapharyngeal abscess 0
5 36/M DM type I
Alcoholism Odontogenic infection 15 Cervical necrotizing fascitis 0
6 72/M NO Odontogenic infection 18 Cervical necrotizing fascitis 0
7 59/M No Odontogenic infection 15 Ludwig´s angina 6
8 85/M No Odontogenic infection 10 Parapharyngeal abscess 9
9 60/M DM type II Pharyngeal Infection 7 Retropharyngeal abscess 0
10 69/M NO Pharyngeal infection 4 Parapharyngeal abscess 2
11 80/M No After tracheotomy 8 Parapharyngeal abscess 7
12 43/M Obesity Pharyngeal infection 4 Parapharyngeal abscess 0
13 44/W Obesity Foreign infection body 3 Cervical necrotizing fascitis 0
14 27/W No Odontogenic infection 10 Ludwig´s angina 6