Descending necrotizing mediastinitis : Treatment concept with focus on thoracic surgery

Abstract

Descending necrotizing mediastinitis (DNM) originates from odontogenic or oropharyngeal infections which spread along preformed cervicothoracic spaces into the mediastinum and requires emergency multidisciplinary treatment. A total of seven patients were diagnosed with DNM based on typical radiological features in a cervicothoracic computed tomography (CT) scan and subsequently underwent standardized transcervical and open transthoracic radical debridement. The initially detected polymicrobial spectrum of pathogens was dominated by streptococci followed by enterobacteriae. After calculated antibiotic treatment a shift in the spectrum of pathogens was noted and in particular a mycotic superinfection occurred in 43 % of the cases. Anterolateral thoracotomy was performed for radical removal of tissue necrosis and mediastinothoracic drainage extending to the posterior mediastinum was placed. In selected cases, cervico-mediastino-thoracic tubes were transmediastinally placed by the rendevouz technique either in the previsceral or retrovisceral mediastinal space. Despite predominantly advanced mediastinitis (Endo classification type II B) in this patient cohort, the mortality only reached 14 %. Rapid diagnosis, anatomical knowledge, understanding of the progression of infections as well as critical care, antimicrobial treatment and multidisciplinary radical surgical therapy are paramount for successful treatment of DNM. We favor anterolateral thoracotomy as the standard open transthoracic approach to the mediastinum. Placement of cervico-mediastino-thoracic irrigation drains can help to limit DNM.