Descending necrotizing mediastinitis. Surgical drainage and tracheostomy

Abstract

Objective: To outline the most appropriate treatment of descending necrotizing mediastinitis.

Design: Case series.

Setting: General community, institutional practice, hospitalized care.

Patients: Five consecutive cases of descending necrotizing mediastinitis that were treated at our institution from 1983 to 1995. Selection criteria included clinical manifestations of severe cervical infection, characteristic radiographic features, documentation of the mediastinal infection at operation, and establishment of the relationship of the oropharingeal infection with the mediastinal process. Cases of mediastinitis due to perforation of the cervical esophagus were excluded. A cervicothoracic computed tomographic scan was obtained in the last 4 patients on admission. In the first case, computed tomographic scanning was not yet available at our institution.

Interventions: All patients underwent drainage of the cervical infection through a cervical incision. Mediastinitis was drained by thoracotomy in 2 patients, since the lower mediastinum was involved, whereas 3 patients underwent cervicomediastinal drainage alone. Tracheostomy was performed in 2 patients.

Results: All patients survived, with a short hospital stay (mean, 35 days).

Conclusions: Cervicomediastinal drainage is adequate when the descending mediastinitis is limited to the upper mediastinum. Thoracotomy has to be performed only when the process has diffusely spread below the carina. Early diagnosis is crucial, and we strongly recommend a cervicothoracic computed tomographic scan in every patient with deep cervical infection. We consider tracheostomy not always necessary. Adequate early drainage, with the cervical wounds left open, and antibiotic and anti-inflammatory therapy should prevent upper airway obstruction.