Sudden Death: A Practical Autopsy Approach to Unexplained Mediastinitis Due to Fatal Untreated Neck Infections-A Systematic Review

Abstract

Neck infections are often prone to being underestimated and can manifest insidiously. The spread of infection can lead to translocation into thoracic areas, causing descending necrotizing mediastinitis (DNM). However, the application of the post-mortem approach in such cases is not well-described in the literature. A literature review was carried out according to the PRISMA methods. Nine papers were included in the final review, revealing different levels of involvement of neck layers that can be linked to different causes. Expertise with respect to the anatomy of the fasciae and spaces of the neck enables an understanding of the pathogenesis of DNM. However, a clear autoptic description was not provided in any of the articles. Therefore, we also employed a practical post-mortem approach to cases of death due to DNM. It is fundamental for pathologists to identify the exact head and neck structures involved. Providing dissectors with support from an otolaryngologist could be useful. This paper could help address such difficult cases.

Keywords: autopsy; forensic; mediastinitis; neck surgery; postmortem.

Figure 1

The process of selecting papers according to the PRISMA protocol.

Figure 2

External examination often reveals a green discoloration on the anterior surface of the neck, indicating that putrefactive phenomena are enhanced in this region.

Figure 3

(A) Skin dissection approach must be conducted carefully, with platysma exposure. (B) Layer-by-layer neck dissection. Yellow: site of dissection.

Figure 4

(A). The dissection of the neck in a case of DNM. A thick layer of purulent and necrotic material with greenish color is visible on and within the muscle’s fibers of the infrahyoid muscles (yellow arrows). Skin dissection approach must be conducted carefully, with platysma exposure and layer-by-layer neck dissection. (A,B) shows purulent exudate distribution. (C,D) show pus surrounding the aditus ad laringem.

Figure 5

Hematoxylin and eosin stain of infrahyoid muscles (A,B) show a great degree of infiltration of neutrophils (CD15+). (C,D) present the same sample with greater magnification (100×).