Best practice for the treatment of descending mediastinitis: A review of review articles and studies looking at cause, diagnosis, treatment and outcomes of head and neck descending necrotizing mediastinitis

Abstract

Introduction: Descending necrotizing mediastinitis (DNM) is a rare but serious infection. The aim of this review is to highlight the common pathogens and risk factors associated with DNM as well as depicting both the medical and surgical treatments. Methods: A literature search of the Cochrane libraries and PubMed libraries for articles published between January 2000 and December 2020 reporting on DNM were reviewed. The key words used: descending necrotizing mediastinitis, odontogenic infection, cervical infection. 3 surgeons evaluated 40 abstracts. Only literature reviews and studies were included. Results: The total number of papers included were 14, 8 articles were reviews of the literature and 6 articles were original studies. Patient outcomes are better the earlier that the condition is diagnosed and treated. CT neck and thorax was the best imaging modality. Odontogenic with streptococcal species is most common cause and the most effective antibiotic sensitivity is a third-generation cephalosporin or clindamycin combined with metronidazole. An alternative is a penicillin with metronidazole. Prompt surgical management is required to effectively debride necrotic tissue. Airway management is an important consideration. Hyperbaric oxygen can be an useful adjunct to treatment. Conclusions: Early treatment of descending mediastinits is imperative for best outcome. Imaging of choice is a CT neck and thorax. Early broad-spectrum antibiotics and surgical intervention is key. Introduction: Descending necrotizing mediastinitis (DNM) is a rare but serious infection. The aim of this review is to highlight the common pathogens and risk factors associated with DNM as well as depicting both the medical and surgical treatments. Methods: A literature search of the Cochrane libraries and PubMed libraries for articles published between January 2000 and December 2020 reporting on DNM were reviewed. The key words used: descending necrotizing mediastinitis, odontogenic infection, cervical infection. 3 surgeons evaluated 40 abstracts. Only literature reviews and studies were included. Results: The total number of papers included were 14, 8 articles were reviews of the literature and 6 articles were original studies. Patient outcomes are better the earlier that the condition is diagnosed and treated. CT neck and thorax was the best imaging modality. Odontogenic with streptococcal species is most common cause and the most effective antibiotic sensitivity is a third-generation cephalosporin or clindamycin combined with metronidazole. An alternative is a penicillin with metronidazole. Prompt surgical management is required to effectively debride necrotic tissue. Airway management is an important consideration. Hyperbaric oxygen can be an useful adjunct to treatment. Conclusions: Early treatment of descending mediastinits is imperative for best outcome. Imaging of choice is a CT neck and thorax. Early broad-spectrum antibiotics and surgical intervention is key.