Descending necrotizing mediastinitis – a surgical view

Česká verze

Authors: J. Šafránek
Authors place of work: Chirurgická klinika LF UK a FN Plzeň
Published in the journal: Rozhl. Chir., 2024, roč. 103, č. 12, s. 502-507.
Category: Souhrnné sdělení
doi: https://doi.org/10.48095/ccrvch2024502

Summary

Introduction: Descending necrotizing mediastinitis (DNM) is a relatively uncommon but serious type of inflammation. Even today, the mortality is around 20%. An overview of DNM issues, recent literature and clinical practice of our department is presented.

Anatomy and etiology: The cause is the descent of an originally oropharyngeal infection from the deep neck space into the mediastinum.

Therapy: Treatment takes place in an intensive care department, with a combination of antibiotics. Elimination of the neck source of inflammation is a prerequisite. The type of surgical drainage depends on the stage and extent of mediastinal involvement. Cervicomediastinal, mediastinothoracic, or cervicomediastinothoracic “Rendezvous” drainage are options.

Conclusion: The basis of DNM treatment is adequate surgical drainage, but interdisciplinary care (surgeon, anesthesiologist, ENT and dental surgeon) is a necessary condition.

Keywords:

surgical treatment – descending necrotizing mediastinitis – types of drainage

Zdroje

1. Kocher GJ, Hoksch B, Caversaccio M et al. Diffuse descending necrotizing mediastinitis: surgical therapy and outcome in a single-centre series. Eur J Cardiothorac Surg 2012; 42(4): e66–e72. doi: 10.1093/ejcts/ezs385.

2. Ridder GJ, Maier W, Kinzer S et al. Descending necrotizing mediastinitis: contemporary trends in etiology, diagnosis, management, and outcome. Ann Surg 2010; 251(3): 528–534. doi: 10. 1097/SLA.0b013e3181c1b0d1.

3. Prado-Calleros HM, Jiménez-Fuentes E, Jiménez-Escobar I. Descending necrotizing mediastinitis: systematic review on its treatment in the last 6 years, 75 years after its description. Head Neck 2016; 38(Suppl 1): E2275–E2283. doi: 10.1002/ hed.24183.

4. Freeman RK, Vallieres E, Verrier ED et al. Descending necrotizing mediastinitis: an analysis of the effects of serial surgical debridement on patient mortality. J Thorac Cardiovasc Surg 2000; 119(2): 260–267. doi: 10.1016/S0022-5223(00)70181-4.

5. Liptay MJ, Kim AW. Acute and chronic mediastinal infections. In: Shields TW, Licicero III J, Reed CE et al. (eds.). General thoracic surgery. Philadelphia: Lippincott Williams & Wilkins 2009 : 2181–2186.

6. Šmat V. Akutní a chronická mediastinitis. In: Řehák F, Šmat V (eds.). Chirurgie plic a mediastina. Praha: Avicenum 1986 : 207–208.

7. Qu L, Xu H, Liang X et al. A retrospective cohort study of risk factors for descending necrotizing mediastinitis caused by multispace infection in the maxillofacial region. J Oral Maxillofac Surg 2020; 78(3): 386–393. doi: 10.1016/j.joms. 2019.11.017.

8. Wheatley MJ, Stirling MC, Kirsh MM et al. Descending necrotizing mediastinitis: transcervical drainage is not enough. Ann Thorac Surg 1990; 49(5): 780–784. doi: 10.1016/0003 -⁠ 4975(90) 90022-x.

9. Taylor M, Patel H, Khwaja S et al. Descending cervical mediastinitis: the multidisciplinary surgical approach. Eur Arch Otorhinolaryngol 2019; 276(7): 2075–2079. doi: 10.1007/s00405-019-05471-z.

10. Pearse HE. Mediastinitis following cervical suppuration. Ann Surg 1938; 108(4): 588–611. doi: 10.1097/00000658-193810000-00009.

11. Dajer-Fadel WL, Ibarra-Pérez C, Sánchez-Velázquez LD et al. Descending necrotizing mediastinitis below the tracheal carina. Asian Cardiovasc Thorac Ann 2014; 22(2): 176–182. doi: 10.1177/0218492313485589.

12. Deu-Martín M, Saez-Barba M, Sanz IL et al. Mortality risk factors in descending necrotising mediastinitis. Arch Bronconeumol 2010; 46(4): 182–187. doi: 10.1016/j.arbres.2010. 01.008.

13. Vieira F, Allen SM, Stocks RMS et al. Deep neck infection. Otolaryngol Clin N Am 2008; 41(3): 459–483. doi: 10.1016/j.otc.2008.01.002.

14. Pulst-Korenberg A, Morris SC. Descending necrotizing mediastinitis resulting from pharyngitis with perforation of the aryepiglottic fold. Case Rep Emerg Med 2020; 2020 : 4963493. doi: 10.1155/2020/4963493.

15. Marioni G, Staferi A, Parisi S et al. Rational diagnostic and therapeutic management of deep neck infections: analysis of 233 consecutive cases. Ann Otol Rhinol Laryngol 2010; 119(3): 181–187. doi: 10.1177/000348941011900306.

16. Huang T-T, Liu T-C, Chen P-R et al. Deep neck infection: analysis of 185 cases. Head Neck 2004; 26(10): 854–860. doi: 10.1002/hed.20014.

17. Estrera AS, Landy MJ, Grisham JM et al. Descending necrotizing mediastinitis. Surg Gynecol Obstet 1983; 157(6): 545–552.

18. Sugio K, Okamoto T, Maniwa Y et al. Descending necrotizing mediastinitis and the proposal of a new classification. JTCVS Open 2021; 8 : 633–647. doi: 10.1016/j.xjon.2021.08.001.

19. Endo S, Murayama F, Hasegawa T et al. Guideline of surgical management based on diffusion of descending necrotizing mediastinitis. Jpn J Thorac Caridovasc Surg 1999; 47(1): 14–19. doi: 10.1007/BF03217934.

20. Reuter TC, Korell V, Pfeiffer J et al. Descending necrotizing mediastinitis: etiopathogenesis, diagnosis, treatment and long-term consequences –⁠ a retrospective follow-up study. Eur Arch Otorhinolaryngol 2023; 280(4): 1983–1990. doi: 10.1007/s00405-022-07769-x.

21. Brunelli A, Sabbatini A, Catalini G et al. Descending necrotizing mediastinitis: cervicotomy or thoracotomy? J Thorac Cardiovasc Surg 1996; 111(2): 485–486. doi: 10.1016/s0022-5223(96)70460-9.

22. Marty-Ane CH, Alauzen M, Alric P et al. Descending necrotizing mediastinitis advantage of mediastinal drainage with thoracotomy. J Thorac Cardiovasc Surg 1994; 107(1): 55–61.

23. Ris HB, Banic A, Furrer M et al. Descending necrotizing mediastinitis: surgical treatment via clamshell approach. Ann Thorac Surg 1996; 62(6): 1650–1654. doi: 10.1016/s0003-4975(96)00683-2.

24. Izumoto H, Komoda K, Okada O et al. Successful utilization of the median sternotomy approach in the management of descending necrotizing: report of a case. Surg Today 1996; 26(4): 286–288. doi: 10.1007/BF00311590.

25. Stella F, Petrella F. Transseptal transpericardial approach for acute descending necrotizing mediastinitis. J Thorac Cardiovasc Surg 2005; 129(1): 212–214. doi: 10.1016/j.jtcvs.2004.04.020.

26. Kiernan PD, Hernandez A, Byrne WD et al. Descending cervical mediastinitis. Ann Thorac Surg 1998; 65(5): 1483–1488. doi: 10.1016/s0003-4975(98)00142-8.

27. Misthos P, Katsaragakis S, Kakaris S et al. Descending necrotizing anterior mediastinitis: analysis of survival and surgical treatment modalities. J Oral Maxillofac Surg 2007; 65(4): 635–639. doi: 10.1016/j.joms.2006.06.287.

28. Marty-Ané C-H, Berthet J-P, Alric P et al. Management of descending necrotizing mediastinitis: an aggressive treatment for an aggressive disease. Ann Thorac Surg 1999; 68(1): 212–217. doi: 10.1016/s0003-4975(99)00453-1.

29. Roccia F, Pecorari GC, Oliaro A et al. Ten years of descending necrotizing mediastinitis: management of 23 cases. J Oral Maxillofac Surg 2007; 65(9): 1716–1724. doi: 10. 1016/j.joms.2006.10.060.

30. Tanaka Y, Maniwa Y, Sugio K et al. The efficacy of thoracoscopic surgery for descending necrotizing mediastinitis. Interdiscip Cardiovasc Thorac Surg 2023; 36(4): ivad053. doi: 10.1093/icvts/ivad053.

31. Marty-Ané CH, Berthet JP, Alric P et al. Management of descending necrotizing mediastinitis: an aggressive treatment for an aggressive disease. Ann Thorac Surg 1999; 68(1): 212–217. doi: 10.1016/s0003-4975(99)00453-1.

32. Iwata T, Sekine Y, Shibuya K et al. Early open thoracotomy and mediastinopleural irrigation for severe descending necrotizing mediastinitis. Eur J Cardiothorac Surg 2005; 28(3): 384–388. doi: 10.1016/j.ejcts.2005.05.018.

33. Lavini C, Natali P, Morandi U et al. Descending necrotizing mediastinitis. Diagnosis and surgical treatment. J Cardiovasc Surg (Torino) 2003; 44(5): 655–660.

34. Mikušová K, Hamžík J, Statelová D et al. Descendetná nekrotizujúca mediastinitída odontogenného povodu –⁠ naše skúsenosti. Stud Pneumol Phthiseol 2012; 72(5): 255–259.

35. Šafránek J, Špidlen V, Skalický T et al. Descendentní nekrotizující mediastitinitida –⁠ chirurgická léčba. Rozhl Chir 2012; 91(7): 362–367.

36. Wiesemann S, Schmid B, Haager B. Mediastinitis: clinical presentation and therapy. Zentralbl Chir 2015; 140(Suppl 1): S8–S15. doi: 10.1055/s-0035-1557779.

37. Palma DM, Giuliano S, Cracchiolo AN et al. Clinical features and outcome of patients with descending necrotizing mediastinitis: prospective analysis of 34 cases. Infection 2016; 44(1): 77–84. doi: 10.1007/s15010-015-0838-y.

38. Kimura A, Miyamoto S, Yamashita T. Clinical predictors of descending necrotizing mediastinitis after deep neck infections. Laryngoscope 2020; 130(11): E567–E572. doi: 10.1002/lary. 28406.

39. Weaver E, Nguyen X, Brooks MA. Descending necrotising mediastinitis: two case reports and review of the literature. Eur Resp Rev 2010; 19(116): 141–149. doi: 10.1183/09059180.00001110.

40. Bottin R, Marioni G, Rinaldi R et al. Deep neck infection: a present-day complication. A retrospective review of 83 cases (1998–2001). Eur Arch Otorhinolaryngol 2003; 260(10): 576–579. doi: 10.1007/s00405-003-0634-7.

41. Byers J, Lowe T, Goodall CA. Acute cervico-facial infection in Scotland 2010: patterns of presentation, patient demographics and recording of systemic involvement. Br J Oral Maxillofac Surg 2012; 50(7): 626–630. doi: 10.1016/j.bjoms.2011. 11.013.

42. Glen P, Morrison J. Diffuse descending necrotising mediastinitis and pleural empyema secondary to acute odontogenic infection resulting in severe dysphagia. BMJ Case Rep 2016; 2016: bcr2015212145. doi: 10.1136/bcr-2015-212145.

43. Safranek J, Skala M, Vejvodova S et al. Descending necrotising mediastinitis: the choice of drainage. Zentralbl Chir 2021; 146(Suppl 1): S19–S25. doi: 10.1055/a-1346-0210.

44. de Freitas RP, Fahy CP, Brooker DS et al. Descending necrotising mediastinitis: a safe treatment algorithm. Eur Arch Otorhinolaryngol 2007; 264(2): 181–187. doi: 10.1007/ s00405-006-0174-z.

doc. MUDr. Jarmil Šafránek, Ph.D.

Chirurgická klinika

LF UK a FN Plzeň

alej Svobody 80

304 60 Plzeň-Lochotín

safranek@fnplzen.cz