Suppurative Cervicomediastinitis From the Perspective of the Head and Neck Surgeon in a Tertiary Treatment Unit

Abstract

Introduction Cervical suppurations represent an emergency pathology, with a dramatic evolution in the absence of adequate treatment. It frequently affects young people, hence the medico-legal implications of these cases. The anatomical substrate for the development of these deep cervical suppurations is represented by the cervical fascia and spaces. A distinct and extremely serious sub-chapter within diffuse cervical suppurations is necrotic cervical fasciitis, a polymicrobial infection with the most common oropharyngeal or odontogenic starting point, with rapidly progressive, destructive evolution in the deep fascial planes of the neck. Materials and method We will present a retrospective clinical study carried out on 26 cases diagnosed and treated between September 2013 and September 2018 in the ENT Clinic Department of the Bucharest University Emergency Hospital. Results Our retrospective analysis of a cohort of 26 patients in a tertiary referral center showed that deep cervical suppurations are slightly more common in men than in women. The most affected age groups were 50-59 years, followed by 20-29 years, representing a percentage of 53.84% of all cases. Also, 53.84% of the studied patients with deep cervical suppurations had a precarious and modest status. The most common clinical signs at presentation were malaise, cervical swelling, neck pain, dysphagia, fever, dysphonia, dyspnea, and cervical erythema. More than 60% of suppurations were odontogenic and 23% were caused by a traumatic element. Diabetes mellitus represents a comorbidity in 30.8% of patients, while 42.3% of patients had no personal pathological history, and thus this pathology has a lethal potential also in a patient in full health. In the study group, 46 (15%) had cervicomediastinitis, and 61.53% developed necrotizing fasciitis. One-third (34.61%) of our patients had undergone previous drainage surgery. Bacteriological examinations of the wound were with group C, D, G betahemolytic streptococcus, while 61.53% of the cultures were negative. Most patients required at least two cervicotomies. The average duration of hospitalization was 28.26 days, and the mortality rate was 23.07%; therefore, practically, one out of four cases resulted in death. In the studied group, no direct relationship can be established between the length of hospitalization and the favorable and unfavorable evolution of the patient. We propose a 10-step management protocol for the management of a cervical suppuration. Conclusion The multidisciplinary approach to these suppurations by the head and neck surgeon, the thoracic surgeon, the oromaxillofacial surgeon, anesthetist, imagist, specialist in infectious diseases, pathologist, psychologist, and so on, is the key to success in a patient who presents not only a suppuration in the throat but also a disease with systemic resonance and significant lethal potential.

Keywords: deep neck spaces; infection; mediastinitis; multidisciplinary approach; surgery.

Figure 1. Chart depicting the distribution of the study group by age.

Figure 2. Chart depicting the distribution of the study group by social status.

Figure 3. Chart depicting the distribution of the study group according to clinical symptoms.

Figure 4. Chart depicting the distribution of the study group by etiology of the suppuration.

Figure 5. Chart depicting the distribution of the cases with traumatic etiology.

IJV, internal jugular vein

Figure 6. Chart depicting the distribution of the study group according to comorbidities/risk factors.

Figure 7. Chart depicting the distribution of the study group by type of suppuration.

NCF, necrotizing fasciitis; DNM, descending necrotizing mediastinitis

Figure 8. Chart depicting the distribution of the study group by time interval between clinical onset and admission/cervicotomy.

Figure 9. Chart depicting the distribution of the bacteriology results from the supuration swabs.

ESBL, extended-spectrum β-lactamase; MRSA, methicillin-resistant Staphylococcus aureus

Figure 10. Distribution of the study group by the number of surgeries performed during hospital stay.

Figure 11. Chart depicting the distribution of the study group according to the length of hospitalization.

Figure 12. Chart depicting the distribution of the study group according to the final prognosis.

NCF, necrotizing fasciitis; DNM, descending necrotizing mediastinitis

Figure 13. Deep cervical suppuration in a 17-year-old female patient after a viral episode of acute pharyngitis, with an altered immune terrain of autoimmune type. (a) Clinical picture. (b) MRI presurgical imaging. (c) Intraoperative appearance with right cervicotomy. (d) Final aspect at two weeks after discharge (our case).

Figure 14. Intraoperative aspects of NCF of odontogenic origin with drainage cervicotomy (a) in the shape of the letter H and extensive debriding (b).

NCF, necrotizing fasciitis

Figure 15. Intraoperative aspects, with drainage systems with rubber tubes in a diffuse phlegmon of the floor of the mouth (a) and in case of NCF (b).

NCF, necrotizing fasciitis

Figure 16. Appearance of vicious scarring, with integumentary substance defect and granulation appearance of the healing wound in a case with diffuse cervical suppuration on the 26th day of hospitalization.

Figure 17. Cervical and thoracic CT appearance and intraoperative findings in a 32-year-old female patient with left cervical hematoma due to aggression, complicated with cervicomediastinitis. (a) Axial CT scan of the neck. (b) Axial CT scan of the thorax. (c) Surgical aspect from the neck. (d) Surgical aspect from the thorax. (e) Final aspect two weeks after discharge.