Descending necrotizing mediastinitis: 5 years of published data in Japan

Abstract

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.

Keywords: Airway emergency; cervical necrotizing fasciitis; descending necrotizing mediastinitis; percutaneous catheter drainage; video‐assisted thoracoscopic drainage.

Figure 1

Cervical spaces important for mediastinal progression (reproduced from Sumi (2013),53 “Current treatment for burn injury”). A, Axial schematic view: parapharyngeal space (sp.) is the hub for deep space infections, which communicates with the major spaces: submandibular space, retropharyngeal space, and carotid space. B, Sagittal schematic view: submandibular space to anterior mediastinum (anterior visceral space), retropharyngeal space to the posterior mediastinum via danger space.

Figure 2

Contrasted computed tomography of neck and chest: anterior mediastinitis due to odontogenic source (reproduced from Sumi (2013),53 “Current treatment for burn injury”). A, Gas collections in left masticator, parapharyngeal, and carotid spaces. B, C, Diffuse thickening of the subcutis, reticular enhancement of s.c. fat, and gas collections in submandibular space. D, Reticular enhancement of s.c. fat, and gas collections in pretracheal and anterior visceral space. E, Thickening and enhancement of anterior mediastinal fat and fluid collections.

Figure 3

Contrasted computed tomography of neck and chest showing posterior mediastinitis due to tonsillar abscess (reproduced from Sumi (2013),53 “Current treatment for burn injury”). A, Diffuse thickening and gas collection in retropharyngeal space. B, C, Diffuse thickening and gas collection in carotid and danger space. D, Diffuse thickening of mediastinal fat and gas collection in posterior mediastinum.