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Case Reports
. 2023 Dec 24:8:8.
doi: 10.21037/med-23-32. eCollection 2024.

Descending necrotizing mediastinitis: key points to reduce the high associated mortality in a consecutive case series

María Del Prado Venegas Pizarro  1   2 , Elisabeth Martínez Téllez  2 , Xavier León Vintró  1 , Miquel Quer Agustí  1 , Juan Carlos Trujillo-Reyes  3 , Alejandra Libreros-Niño  3 , Georgina Planas Cánovas  3 , Josep Belda-Sanchis  3
Affiliations
Case Reports

Descending necrotizing mediastinitis: key points to reduce the high associated mortality in a consecutive case series

María Del Prado Venegas Pizarro et al. Mediastinum. .

Abstract

Background: Descending necrotizing mediastinitis (DNM) is an acute life-threatening infection that originates in the oropharyngeal region. It is an uncommon disease with a mortality rate of about 20-40%. This high mortality is mainly attributed to delays in diagnosis and treatment and poor drainage of the mediastinum. We highlight key points that may help reduce mortality.

Case description: We analyze a retrospective case series of seven patients diagnosed with DNM between March 2019 and July 2022 at Hospital de la Santa Creu i Sant Pau. The primary oropharyngeal infection was peritonsillar abscess in three cases and odontogenic abscess in four. All patients showed symptoms of severe cervical infection and symptoms suggestive of mediastinitis. A cervicothoracic computed tomography (CT) scan confirmed the presence of cervical and mediastinal collections and emphysema in all cases. All patients were simultaneously evaluated by the otorhinolaryngology and thoracic surgery teams. Broad-spectrum antibiotic therapy was instituted pending culture. All the patients underwent urgent surgery, consisting of cervicotomy to control the cervical focus and unilateral or bilateral video-assisted thoracoscopic debridement and drain of the pleural cavities and mediastinum. Regarding the outcomes, no patients died, one patient (14.2%) underwent transcervical mediastino-thoracoscopy drainage only. In six patients (85.8%) we performed a combined transcervical and transthoracic approach. Reoperation was required in 3 (43%) cases. The parameter that indicated a poor clinical evolution in these patients was an increase in C-reactive protein and the infection extension on the cervicothoracic CT scan. The follow-up was 30 days from last surgery; there were no losses.

Conclusions: Based on our experience, the key points that can help reduce the high mortality associated with DNM are a rapid multidisciplinary assessment and a combined surgical procedure, considering the minimally invasive approach as the first option to drain the pleural cavities and mediastinum.

Keywords: Oropharyngeal infection; case series; descending necrotizing mediastinitis (DNM); transcervical drainage; video-assisted thoracoscopy.

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Conflict of interest statement

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://med.amegroups.com/article/view/10.21037/med-23-32/coif). The authors have no conflicts of interest to declare.

Figures

Figure 1
Figure 1
Endo’s classification. Degree of extension of DNM based on the CT scan. DNM, descending necrotizing mediastinitis; CT, computed tomography.
Figure 2
Figure 2
Chest CT scan (axial and coronal sections) showing mediastinal gas and fluid collections involving anterior, middle, and posterior compartments of the mediastinum. CT, computed tomography.
Figure 3
Figure 3
Ports placement for the VATS approach. VATS, video-assisted thoracic surgery.
Figure 4
Figure 4
Ports placement for the combined intercostal and subxiphoid VATS approach (left); endoscopic view of the mediastinum (right). VATS, video-assisted thoracic surgery.
Figure 5
Figure 5
CRP levels on the day IQ and on the POD1, POD3, POD5 and POD7. CRP, C-reactive protein; day IQ, day of surgery; POD, postoperative day.
See this image and copyright information in PMC

References

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