Advertisement

Guideline of surgical management based on diffusion of descending necrotizing mediastinitis

  • Shunsuke Endo
  • Fumio Murayama
  • Tsuyoshi Hasegawa
  • Shinichi Yamamoto
  • Tsutomu Yamaguchi
  • Yasunori Sohara
  • Katsuo Fuse
  • Mamoru Miyata
  • Hiroshi Nishino
Original Article

Abstract

Background: Descending necrotizing mediastinitis resulting from oropharyngeal abscess, is a serious, life-threatening infection. Exisiting strategies for surgical management, such as transcervical mediastinal drainage or aggressive thoracotomic drainage, remain controversial.Methods: Four patients, (three males and one female) were treated for descending necrotizing mediastinitis resulting from oropharyngeal infection. Two had peritonsillar abscesses, while the others experienced dental abscess and submaxillaritis. Descending necrotizing mediastinitis received its classification according to the degree of diffusion of infection diagnosed by computed tomography. Mediastinitis in two cases, (Localized descending necrotizing mediastinitis-Type I), was localized to the upper mediastinal space above the carina. In the others, infection extended to the lower anterior mediastinum (Diffuse descending necrotizing mediastinitis-Type IIA), and to both anterior and posterior lower mediastinum (Diffuse descending necrotizing mediastinitis-Type IIB). The spread of infection to the pleural cavity occurred in three cases.Results: The surgical outcome concerning each of the patients was successful. Radical cervicotomy (unilateral in three patients, bilateral in the other) in conjunction with mechanical ventilation with continuous postoperative positive airway pressure, was performed in all cases. Tracheostomy was established in three patients and pharyngostomy in two. The two descending necrotizing mediastinitis-Type I cases were successfully managed with transcervical mediastinal drainage. The descending necrotizing mediastinitis-Type IIA case received treatment through transcervicotomy and anterior mediastinal drainage through a subxiphoidal incision. The patient with descending necrotizing mediastinitis-Type IIB required posterior mediastinal drainage through a right standard thoracotomy followed by left minimal thoracotomy.Conclusions: The mediastinal infection, the extent of which has been accurately determined by computed tomograms, necessitates radical cervicotomy followed by pleuromediastinal drainage. Situations where infection has spread to posterior mediastinum, particularly when it reaches in the level of the carina (descending necrotizing mediastinitis-type I), may not always require aggressive mediastinal drainage. In comparison, diffuse descending necrotizing mediastinitis-Type IIB demands complete mediastinal drainage with debridement via thoracotomy. Subxiphoidal mediastinal drainage without sternotomy may provide adequate drainage in diffuse descending necrotizing mediastinitis-Type IIA.

Index words

descending necrotizing mediastinitis surgical management diffusion of infection 

Preview

Unable to display preview. Download preview PDF.

Unable to display preview. Download preview PDF.

References

  1. 1.
    Estrera AS, Landy MJ, Grisham JM, Sinn DP, Platt MR. Descending necrotizing mediastinitis. Surg Gynecol Obstet 1983; 157: 545–52.PubMedGoogle Scholar
  2. 2.
    Wheatley MJ, Stirling MC, Kirsh MM, Gago O, Orringer MB. Descending necrotizing mediastinitis: transcervical drainage is not enough. Ann Thorac Surg 1990; 49: 780–4.PubMedCrossRefGoogle Scholar
  3. 3.
    Marty-Ane C-H, Alauzen M, Alric P, Serres-Cousine O, Mary H. Descending necrotizing mediastinitis. Advantage of mediastinal drainage with thoracotomy. J Thorac Cardiovasc Surg 1994; 107: 55–61.PubMedGoogle Scholar
  4. 4.
    Takao M, Ido M, Hamaguchi K, Chikusa H, Namikawa S, Kusagawa M. Descending necrotizing mediastinitis secondary to a reteropharyngeal abscess. Eur Respir J 1994; 7: 1716–8.PubMedCrossRefGoogle Scholar
  5. 5.
    Izumoto H, Komada K, Okada O, Kamata J, Kawazoe K. Successful utilization of the median sternotomy approach in the management of descending necrotizing mediastinitis: report of a case. Jpn J Surg 1996; 26: 286–8.CrossRefGoogle Scholar
  6. 6.
    Ris H-B, Banic A, Furrer M, Caversaccio M, Cerny A, Zbaren P. Descending necrotizing mediastinitis: surgical treatment via clamshell approach. Ann Thorac Surg 1996; 62: 1650–4.PubMedCrossRefGoogle Scholar
  7. 7.
    Kruyt PM, Boonstra A, Fockens P, Reeders JWAJ, Lanschot JJB. Descending necrotizing mediastinitis causing pleuroesophageal fistula. Successful treatment by combined transcervical and pleural drainage. Chest 1996; 109: 404–7.CrossRefGoogle Scholar
  8. 8.
    Howell HS, Prinz RA, Pickleman JR. Anaerobic mediastinitis. Surg Gynecol Obstet 1976; 143: 353–9.PubMedGoogle Scholar
  9. 9.
    de Marie S, Tjon A, Tham RT, van der Mey AG, Meerdink G, van Furth R, van der Meer JW. Clinical infection and nonsurgical treatment of para-pharyngeal space infections complicating throat infection. Rev Infect Dis 1989; 11: 975–82.PubMedCrossRefGoogle Scholar
  10. 10.
    Economopoulos GC, Scherzer HH, Gryboski WA. Successful management of mediastinitis, pleural empyema and aorto-pulmonary fistula from odontogenic infection. Ann Thorac Surg 1983; 35: 184–7.PubMedCrossRefGoogle Scholar
  11. 11.
    Stone HH, Martin JD. Synergistic necrotizing cellulitis. Ann Surg 1972; 175: 702–11.PubMedCrossRefGoogle Scholar
  12. 12.
    Pearse HE: Mediastinitis following cervical suppuration. Ann Surg 1938; 108: 588–611.PubMedCrossRefGoogle Scholar
  13. 13.
    Rubin MM, Cozzi GM. Fatal necrotizing mediastinitis as complication of an odontogenic infection. J Oral Maxillofac Surg 1987; 45: 529–33.PubMedCrossRefGoogle Scholar

Copyright information

© The Japanese Society of Thoracic and Cadiovascular Surgery 1999

Authors and Affiliations

  • Shunsuke Endo
    • 1
    • 2
  • Fumio Murayama
    • 1
    • 2
  • Tsuyoshi Hasegawa
    • 1
    • 2
  • Shinichi Yamamoto
    • 1
    • 2
  • Tsutomu Yamaguchi
    • 1
    • 2
  • Yasunori Sohara
    • 1
    • 2
  • Katsuo Fuse
    • 1
    • 2
  • Mamoru Miyata
    • 1
    • 2
  • Hiroshi Nishino
    • 1
    • 2
  1. 1.Department of Thoracic SurgeryJichi Medical SchoolTochigiJapan
  2. 2.Department of OtorhinolaryngologyJichi Medical SchoolTochigiJapan

Personalised recommendations