Descending Necrotizing Mediastinitis Research Articles

Descending necrotizing mediastinitis caused by a minor whiplash injury.

We describe a case of descending necrotizing mediastinitis (DNM) from a very unusual origin, caused by cervical oesophageal perforation by osteophytes after an apparently minor whiplash injury. Diagnosis was delayed by atypical and predominantly neurological clinical presentation. Despite late presentation, minimally invasive access surgical debridement of mediastinum and cervical injury site lead to full recovery.

Infectious Mediastinitis: A Retrospective Cohort Study.

This study aimed to characterize the demographics, microbiology, management and treatment outcomes of mediastinitis according to the origin of the infection. This retrospective observational study enrolled patients who had mediastinitis diagnosed according to the criteria defined by the Centers for Disease Control and Prevention and were treated in Strasbourg University Hospital, France, between 1 January 2010 and 31 December 2020. We investigated 151 cases, including 63 cases of poststernotomy mediastinitis (PSM), 60 cases of mediastinitis due to esophageal perforation (MEP) and 17 cases of descending necrotizing mediastinitis (DNM). The mean patient age (standard deviation) was 63 (14.5) years, and 109 of 151 patients were male. Microbiological documentation varied according to the origin of the infection. When documented, PSM cases were mostly monomicrobial (36 of 53 cases [67.9%]) and involved staphylococci (36 of 53 [67.9%]), whereas MEP and DNM cases were mostly plurimicrobial (38 of 48 [79.2%] and 8 of 12 [66.7%], respectively) and involved digestive or oral flora microorganisms, respectively. The median duration of anti-infective treatment was 41 days (interquartile range, 21-56 days), and 122 of 151 patients (80.8%) benefited from early surgical management. The overall 1-year survival rate was estimated to be 64.8% (95% confidence interval, 56.6%-74.3%), but varied from 80.1% for DNM to 61.5% for MEP. Mediastinitis represents a rare yet deadly infection. The present cohort study exhibited the different patterns observed according to the origin of the infection. Greater insight and knowledge on these differences may help guide the management of these complex infections, especially with respect to empirical anti-infective treatments.

Multidisciplinary Management of Descending Necrotizing Mediastinitis: Is Thoracoscopic Treatment Feasible?

Background: Descending necrotizing mediastinitis (DNM) is a life-threatening condition, generally caused by downward dissemination of oropharyngeal infections through cervical fascial planes. Mediastinal drainage is conventionally achieved by thoracotomy, but a Video-Assisted Thoracoscopic Surgery (VATS) approach is gaining interest due to the reduced invasiveness of procedure. We aimed to evaluate the effectiveness of VATS treatment in patients with DNM. Methods: We conducted a retrospective multicenter study including patients with descending mediastinitis that underwent mediastinal drainage through VATS (VATS group) or thoracotomy (thoracotomy group), both in association with cervical drainage. Patients with mediastinitis secondary to cardiac, pulmonary, or esophageal surgery were excluded. The intergroup differences regarding surgical outcome and postoperative morbidity and mortality were compared. Results: A total of 21 patients were treated for descending mediastinitis during the study period. Cervicotomy and thoracotomy were performed in 15 patients (71%), while cervicotomy and VATS were performed in 6 patients (29%). There were no significant differences in surgical outcome, postoperative morbidity, and mortality between groups. VATS treatment was not associated with a higher complication rate. Patients in the VATS group had a shorter operative time (p = 0.016) and shorter ICU stay (p = 0.026). Conclusions: VATS treatment of DNM is safe and effective. The comparison with thoracotomy showed no significant differences in postoperative morbidity and mortality. The VATS approach is associated with a shorter operative time and ICU stay than thoracotomy.

Descending necrotizing mediastinitis secondary to retropharyngeal abscess

We report a case of descending necrotizing mediastinitis (DNM) in a 68-year-old male who presented in acute respiratory distress accompanied with anterior cervical neck swelling and pain with swallowing. Contrast enhanced computed tomography (CECT) of the neck demonstrated a large, peripherally enhancing retropharyngeal fluid and air collection that appeared to communicate with a fluid and air collection within the mediastinum. CECT of the chest demonstrated punctate foci of air and fat stranding along the anterior and superior mediastinum. Radiological evidence and the presence of necrosis on surgical debridement of the retropharyngeal abscess established the diagnosis of DNM. This case emphasizes the role of computed tomography (CT) in the diagnosis of DNM and demonstrates the utility of chest imaging in a high-risk patient who presents with a retropharyngeal abscess.

Head and Neck Necrotizing Fasciitis: Abbreviated SOFA Score Associated With Death and Infection Spread.

Describe features unique to head and neck (H&N) necrotizing fasciitis (NF) compared to other anatomic regions and specify a prognostic score associated with death and descending necrotizing mediastinitis (DNM). Retrospective cohort. Tertiary care, level 1 trauma center. A single-institution database identified 399 confirmed cases of NF between 2006 and 2021, 33 of which involved the H&N. Patients with confirmed H&N NF were sorted into cohorts based on clinical outcomes, with the "poor" outcomes group defined by death and/or DNM. Thirty-three patients with H&N NF were included. Compared to NF of other regions, patients with H&N NF had a significantly lower mortality rate (6.06% vs 20.8%, p = .041) and significantly lower rates of obesity (27.3% vs 63.7%, p < .001) and hypertension (42.4% vs 60.9%, p = .038). Within the H&N group, there were 2 deaths (6.06%) and 8 cases of DNM (24.2%). Diabetes was associated with poor outcomes (p = .047), as was an abbreviated sequential organ failure assessment score for necrotizing fasciitis (nfSOFA) of 2 or greater (p = .015). H&N NF is unique among other forms of NF, with a lower mortality rate and lower rates of obesity and hypertension in affected patients. Within the H&N cohort, worse outcomes were associated with diabetes as well as a nfSOFA score of 2 or greater. Timely surgical debridement alongside broad-spectrum antibiotics remains the mainstay of treatment for NF; however, this simple prognostic score may play a role during the early stages of care for patients with H&N NF.

Efficacy of Continuous Saline Irrigation Therapy for Descending Necrotizing Mediastinitis.

Objectives Descending necrotizing mediastinitis (DNM) is a poor prognosis disease. This study aims to examine the patient background and treatment of DNM and to identify more effective treatments for DNM. Methods The patient background and treatment of 11 patients who underwent surgery for DNM between November 2010 and June 2021 were studied. The patients were divided into six patients who underwent continuous saline irrigation (group I) and five patients who did not (group N). The differences in the drainage duration and length of hospital stay between the two groups were retrospectively investigated. Results Eleven patients were treated for DNM: six male and five female, with a median age of 61 years (35-79). Comorbidities included diabetes mellitus in three cases; one patient was administered steroids. The pathways of occurrence were anterior tracheal gap/vascular visceral gap/posterior visceral gap in group I (2/1/2) and group N (0/2/4). Progression was I/IIA/IIB according to Endo's classification in group I (1/1/4) and group N (3/1/1). The mean duration of irrigation was 9.0 ± 3.7 days, and the drainage duration in group I was 17.5 ± 8.2 days, which was significantly shorter than 31 ± 13.6 days in group N ( p < 0.048). The hospital stays in group I was 29.3 ± 8.4 days, which was significantly shorter than that in group N (68 ± 27.1 days; p < 0.015). Conclusions Irrigation therapy significantly shortened the drainage duration and hospital stay. Irrigation is a useful treatment for DNM.

Clinical management and prognosis for descending necrotizing mediastinitis

Objective: To investigate the clinical characteristics, treatment experiences and prognostic factors for descending necrotizing mediastinitis (DNM). Methods: A retrospective analysis was performed on the data of 22 patients with DNM diagnosed and treated in Henan Provincial People's Hospital from January 2016 to August 2022, including 16 males and 6 females, aged 29-79 years. After admission, all patients underwent CT scanning of the maxillofacial, cervical, and thoracic regions to confirm their diagnoses. Emergency incision and drainage were performed. The neck incision was treated with continuous vacuum sealing drainage. According to the prognoses, the patients were divided into cure group and death group, and the prognostic factors were analyzed. SPSS 25.0 software was used to analyze the clinical data. Rusults: The main complaints were dysphagia (45.5%, 10/22) and dyspnea (50.0%, 11/22). Odontogenic infection accounted for 45.5% (10/22) and oropharyngeal infection accounted for 54.5% (12/22). There were 16 cases in the cured group and 6 cases in the death group, with a total mortality rate of 27.3%. The mortality rates of DNM typeⅠand typeⅡwere respectively 16.7% and 40%. Compared with the cured group, the death group had higher incidences for diabetes, coronary heart disease and septic shock (all P<0.05). There were statistically significant differences between the cure group and the death group in procalcitonin level (50.43 (137.64) ng/ml vs 2.92 (6.33) ng/ml, M(IQR), Z=3.023, P<0.05) and acute physiology and chronic health evaluation Ⅱ(APACHEⅡ) score (16.10±2.40 vs 6.75±3.19, t=6.524, P<0.05). Conclution: DNM is rare, with high mortality, high incidence of septic shock, and the increased procalcitonin level and APACHE Ⅱ score combined diabetes and coronary heart disease are the poor prognostic factors for DNM. Early incision and drainage combined with continuous vacuum sealing drainage technique is a better way to treat DNM.

The efficacy of thoracoscopic surgery for descending necrotizing mediastinitis.

Thoracotomy is a reliable approach for descending necrotizing mediastinitis (DNM), and the use of video-assisted thoracic surgery (VATS), a minimally invasive procedure, has been increasing. However, which approach is more effective for DNM treatment is controversial. We analysed patients who underwent mediastinal drainage via VATS or thoracotomy, using a database with DNM from 2012 to 2016 in Japan, which was constructed by the Japanese Association for Chest Surgery and the Japan Broncho-esophagological Society. The primary outcome was 90-day mortality, and the adjusted risk difference between the VATS and thoracotomy groups using a regression model, which incorporated the propensity score, was estimated. VATS was performed on 83 patients and thoracotomy on 58 patients. Patients with a poor performance status commonly underwent VATS. Meanwhile, patients with infection extending to both the anterior and posterior lower mediastinum frequently underwent thoracotomy. Although the postoperative 90-day mortality was different between the VATS and thoracotomy groups (4.8% vs 8.6%), the adjusted risk difference was almost the same, -0.0077 with 95% confidence interval of -0.0959 to 0.0805 (P = 0.8649). Moreover, we could not find any clinical and statistical differences between the 2 groups in terms of postoperative 30-day and 1-year mortality. Although patients who underwent VATS had higher postoperative complication (53.0% vs 24.1%) and reoperation (37.9% vs 15.5%) rates than those who underwent thoracotomy, the complications were not serious and most could be treated with reoperation and intensive care. The outcome of DNM treatment does not depend on thoracotomy or VATS.

Surgical Experience with Descending Necrotizing Mediastinitis: A Retrospective Analysis at a Single Center.

We analyzed our experience with descending necrotizing mediastinitis (DNM) treatment and investigated the efficacy of video-assisted thoracoscopic surgery (VATS) for mediastinal drainage. This retrospective analysis included patients who underwent surgical drainage for DNM at our hospital from 2005 to 2020. We analyzed patients' baseline characteristics, surgical data, and perioperative outcomes and compared them according to the mediastinal drainage approach among patients with type II DNM. Twenty-five patients (male-to-female ratio, 18:7) with a mean age of 54.0±12.9 years were enrolled in this study. The most common infection sources were pharyngeal infections (60%). Most patients had significantly increased white blood cell counts, elevated C-reactive protein levels, and decreased albumin levels on admission. The most common DNM type was type IIB (n=16, 64%), while 5 and 4 patients had types I and IIA, respectively. For mediastinal drainage, the transcervical approach was used in 15 patients and the transthoracic approach (VATS) in 10 patients. The mean length of hospital stay was 26.5±23.8 days, and the postoperative morbidity and in-hospital mortality rates were 24% and 12%, respectively. No statistically significant differences were found among patients with type II DNM between the transcervical and VATS groups. However, the VATS group showed shorter mean antibiotic therapy duration, drainage duration, and hospital stay length than the transcervical group. DNM manifested as severe infection requiring long-term inpatient treatment, with a mortality rate of 12%. Thus, active treatment with a multidisciplinary approach is crucial, and mediastinal drainage using VATS is considered relatively safe and effective.

Descending Necrotizing Mediastinitis Caused by Streptococcus pyogenes in a Child with Primary Epstein–Barr Virus Infection

Descending necrotizing mediastinitis (DNM) is a severe, life-threatening disease with a high mortality rate resulting from sepsis or other complications. DNM can also be a rare and severe complication of Epstein-Barr virus (EBV) infection in adolescents and young adults but has never been reported in a pre-school child. A 4-year-old girl was admitted to our hospital with a 2-day history of fever and chest pain. Computed tomography (CT) revealed a right sided pleural effusion, fluid collection in the retropharyngeal and mediastinal areas, cervical lymphadenopathy, and marked hepatosplenomegaly. She was diagnosed with empyema, retropharyngeal abscess, and mediastinitis. To improve her dyspnea, a chest tube was inserted, and antibiotic treatment was initiated. Her condition improved temporarily, but on day 5 in our hospital, she developed a fever again. A repeat CT scan showed exacerbation of fluid retention in the retropharyngeal area and the mediastinum, for which she underwent drainage and debridement of necrotic tissue in the retropharynx and mediastinum. The presence of cervical lymphadenopathy and marked hepatosplenomegaly suggested the involvement of EBV. Serological tests for EBV revealed primary EBV infection at the time of the DNM onset. Finally, she was diagnosed with DNM following primary EBV infection. At follow-up 1 year later, she was doing well. The risk of DNM should be recognized in patients, even pre-school aged children, with primary EBV infection.

Descending necrotizing mediastinitis: etiopathogenesis, diagnosis, treatment and long-term consequences—a retrospective follow-up study

PurposeThe primary aim of this retrospective study was to analyze the progression of descending necrotizing mediastinitis (DNM), evaluate the impact of comorbidities on complications and mortality and to observe long-term consequences of DNM on dysphagia and measurements quality of life. DNM is a serious infectious disease that requires multimodal treatment. Current literature varies in conclusions of risk factors, management and outcome of DNM. In addition, little is known about persisting effects on quality of life.MethodsRetrospective data analysis of 88 patients with DNM representing the largest single-center study. Recording data of patients and diseases as well as clinical progression from 1997 to 2018. Two questionnaires were sent to the participants to measure quality of life and to detect dysphagia.Results88 patients were included. The most frequently found pathogen were Streptococcus spp. (52%). 75% of the patients underwent multiple surgeries, mean count of surgical procedures was 4.3 times. 84% received intensive care treatment. Median length of stay on the intensive care unit was 7 days. 51% had pre-existing comorbidities associated with reduced tissue oxygenation (e.g., diabetes). The most common complication was pleural effusion (45%). During the observation period, the mortality rate was 9%. 12 questionnaires could be evaluated. 67% of the participants were affected by dysphagia at the time of the survey.ConclusionsDescending necrotizing mediastinitis (DNM) is a severe disease requiring an immediate initiation of multimodal treatment. Although quality of life usually isn´t impaired permanently, dysphagia may often persist in patients after DNM.

Risk Factors Associated with Post-Operative Complications in Multidisciplinary Treatment of Descending Necrotizing Mediastinitis.

Descending necrotizing mediastinitis (DNM) is a severe, life-threatening complication of oropharyngeal infections with cervical necrotizing fasciitis. In this study, we aimed to identify any possible factors that correlate with favorable outcomes. We retrospectively analyzed our series of 18 patients who underwent surgical treatment for DNM from a cervical abscess. Gender, age, symptoms, etiopathogenesis, comorbidities, time to surgery from diagnosis, degree of diffusion, identified microorganisms, surgical procedure, days in the intensive care unit, need for tracheostomy, complications, and surgical outcomes were reviewed. The main type of surgery was thoracotomy + cervicotomy in eight cases (50.0%), followed by cervicotomy +VATS in four (22.2%). Seven patients (38.9%) had two or more surgeries; a bilateral operation was necessary for four patients. Evaluating the risk factors associated with post-operative complications, age ≥ 60 years (p:0.031), cervicotomy alone as surgical approach (p = 0.040), and the bilateral approach (p = 0.048) resulted in significance in terms of the univariate analysis; age ≥ 60 years (p = 0.04) and cervical approach (p = 0.05) maintained their significance in terms of the multivariate analysis. The low mortality of our series emphasizes the importance of an extensive and immediate surgical drainage of both the neck and the mediastinum. Mediastinal drainage from cervicotomy seems to be a risk factor for post-operative complications. Minimally invasive surgery on the chest cavity, such as with Uniportal-VATS, could be a good approach above all in elderly patients and all those cases where bilateral access is required.

Cervical necrotizing fasciitis complicated by sepsis case report

Cervical necrotizing fasciitis (CNF) is uncommon, difficult to diagnose, and rapidly progressive severe infection causing necrosis of subcutaneous tissue and fascial compartments, associated with high mortality; early recognition and surgical intervention are crucial. In most cases of nercrotizing fasciitis in the head and neck region the origin is odontogenic or pharyngolaryngeal; predominantly identified bacteria are Streptococci and Staphylococci. A characteristic CT finding is gas demonstration. The main complication is descending necrotizing mediastinitis (DNM), unfrequently vascular entities: internal jugular vein thrombosis, carotid sheath necrosis, carotid artery aneurysm and rupture, and other arterial hemorrhages. A fulminant CNF course requires timely implementation of appropriate treatment. Broad-spectrum antibiotic therapy and repeated surgical interventions with the removal of necrotic tissues constitute the most common treatment. Open wound treatment increases the risk of additional coinfection and sepsis; a modern approach is the use of negative pressure wound therapy or percutaneous catheter drainage. Tracheostomy may be helpful in need of further, repetitive debridement. Loss of soft tissues and skin of the neck may require reconstruction with full- or split-thickness free flap, local flap, or biodegradable dermal substitute. The authors describe the case of a patient with CNF complicated by sepsis. The necrosis resulted in a 10x20-cm defect in the front of the neck, which was covered with a split-thickness graft harvested from the anterolateral surface of the thigh. No complications occurred during the healing of the graft.

Descending Necrotizing Mediastinitis as a Complication of Dental Cervical Cellulitis: A Case Report and Review

Descending necrotizing mediastinitis remains a serious condition with a high mortality rate due to its often fulminant clinical presentation. An early diagnosis and a well conducted multidisciplinary therapeutic management are essential to reduce morbi-mortality. Delayed diagnosis, inappropriate antibiotic therapy, non-optimal surgical drainage or lack of surveillance may increase morbidity and mortality. We report the case of a descending necrotizing mediastinitis complicating a dental cervical cellulitis in a 27 year old female patient with a successful outcome.

Unveiling the Pathogenic Bacteria Causing Descending Necrotizing Mediastinitis.

The combination of maxillofacial infections (MI) with descending necrotizing mediastinitis (DNM) is a complex disease characterized by rapid development and high mortality. Here, we performed metagenomic next-generation sequencing (mNGS) using samples from 21 patients with MI and eight patients with DNM. In this study, we found that the species richness of the DNM group was higher than that of the MI group, and the species diversity of the DNM group was higher than that of the MI group, with no statistically significant differences between groups (P > 0.05). LefSE analysis revealed that the main species differing between groups were Bacillus, Lactobacillus, Streptococcaceae, and Streptococcus (S. constellatus and S. anginosus). In addition, the PLS-DA analysis revealed that the dominant groups in the DNM group at the species level were S. constellatus, S. anginosus, Streptococcus intermedius, Prevotella oris, Mogibacterium timidum, and Eubacterium nodatum. Next, we correlated the clinical characteristics of the patients with the relative abundance of the pathogens identified in the LefSe and PLS-DA analyses. The relative abundance of S. anginosus was positively correlated with C-reactive protein (CRP) and calcitoninogen (PCT) but negatively correlated with the percentage of lymphocytes (Lymph%) (P < 0.05). On the other hand, M. timidum was positively correlated with the percentage of neutrophils (Neut%) and glycated hemoglobin (GLU) (P < 0.05), and Parvimonas micra was positively correlated with CRP (P < 0.05).

DESCENDING NECROTIZING MEDIASTINITIS IN COVID-19 ERA

TYPE: Late Breaking Abstract TOPIC: Chest Infections PURPOSE: Descending Necrotizing Mediastinitis (DNM) is the fatal form of mediastinitis and mostly develops as a complication of peritonsillar abscesses or dental- odontogenic infections. The aim of this study is to evaluate clinical and surgical feature of the patients with DNM who were managed in during the period of general lockdown , between March 2020 and Sept. 2021, due the Covid 19. METHODS: During the period of general lockdown, 18 patients, mean age 46, 25 years ( 39-59), with DNM treated to our Department . Primary odontogenic abscess occurred to 10 patients and peritonsillar abscess to other 8 of them. Diagnosis was confirmed by computed tomography (CT) of the neck and chest. All patients underwent surgical drainage of abscesses of the involved cervical region and mediastinum by lateral cervicotomy and left thoracotomy , and cervicotomy , and bilateral thoracotomy in one patient. RESULTS: The delay between the occurrence of thoracic symptoms and mediastinal drainage varied from 1 to 3 days. The side of the thoracotomy depended on the involved mediastinal compartments and side of pleural effusion. The duration of mediastinal drainage varied from 12 to 20 days (mean: 17 days). One patient died of multiorgan failure related to post-op septic shock. CONCLUSIONS: We concluded that the patients delay for dentistry recourse because of covid-19, result in the increased number of patients with DNM in the above period. Aggressive surgical drainage and debridement of the neck and drainage of the mediastinum via a posterolateral thoracotomy by a multidisciplinary team of surgeons is a must. CLINICAL IMPLICATIONS: Chest infections DISCLOSURE: Nothing to declare. KEYWORD: Descending Necrotizing Mediastinitis

Multidisciplinary Approach in the Treatment of Descending Necrotizing Mediastinitis: Twenty-Year Single-Center Experience.

Descending necrotizing mediastinitis (DNM) is an acute, rare, severe condition with high mortality, but the optimal management protocol is still controversial. We retrospectively analyzed the results of multidisciplinary management in patients treated for DNM at our center over the last twenty years. Fifteen male patients, mean age 49.07 ± 14.92 years, were treated: 9 with cervico-pharyngeal etiopathogenesis, 3 peri-tonsillar/tonsillar, 2 odontogenic, 1 post-surgical; 6 with DNM type I, 6 with type IIA, and 3 with type IIB (Endo’s classification). Mean time between diagnosis and treatment was 2.24 ± 1.61 days. In all cases, mediastinum drainage via thoracotomy was performed after neck drainage via cervicotomy, associated with tooth treatment in two; one required re-operation; tracheostomy was necessary in 9, temporary intensive care unit stay in 4; 6 developed complications, without post-operative mortality. Main isolated germs were Staphylococci and Candida; 7 had polymicrobial infection. The most used antibiotics were meropenem, metronidazole, teicoplanin, third-generation cephalosporins and clyndamicin; anti-fungal drugs were fluconazole, caspofungin and anidulafungin. On multivariate analysis, presence of cardiovascular disease was statistically significantly associated with longer chest tube duration and hospital stay. DNM requires early diagnosis and treatment to reduce mortality and morbidity. The most effective treatment should provide a multidisciplinary approach, combining cervicotomy and thoracotomy to drain all infectious collections with administration and monitoring of the proper antimicrobial therapy.

Management of Descending Necrotizing Mediastinitis, a Severe Complication of Deep Neck Infection, Based on Multidisciplinary Approaches and Departmental Co-Ordination.

Descending necrotizing mediastinitis (DNM) developing after deep neck infection (DNI) is a potentially lethal disease of the mediastinum with a mortality rate as high as 40% prior to the 1990s. No standard treatment protocol is available. Here, we present the outcomes of our multidisciplinary approaches for treating DNM originating from a DNI. Between June 2016 and July 2021, there were 390 patients with DNIs admitting to our tertiary hospital. A total 21 patients with DNIs complicated with DNM were enrolled. The multidisciplinary approaches included establishment of airway security, appropriate surgery and antibiotics, extracorporeal membrane oxygenation, and intensive care unit management. The clinical variables were analyzed. Two patients died and 19 survived (mortality 9.5%). The patients who died had a higher mean C-reactive protein (CRP) level than did those who survived (420.0 ± 110.3 vs 221.8 ± 100.6mg/L) (P = .038). The most common pathogens were Streptococcus constellatus and Streptococcus anginosus. From 2001 to 2021, the average mortality rate of studies enrolling more than 10 patients was 16.1%. Multidisciplinary approaches, early comprehensive medical treatment, and co-ordination among departments significantly reduce mortality. Patients with severe inflammation and high CRP levels require intensive and aggressive interventions.

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

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.

SORE THROAT GONE BAD: DESCENDING NECROTIZING MEDIASTINITIS

TOPIC: Chest Infections TYPE: Fellow Case Reports INTRODUCTION: Descending necrotizing mediastinitis (DNM) is a rare yet dangerous complication of oropharyngeal infections with mortality rates up to 50%. DNM was first described in 1983 and it clinically manifests as a sequalae of a primary odontogenic or pharyngeal infectious focus with supporting radiological features of mediastinitis. Due to its high mortality rates, prompt imaging and initiation of antibiotics remains cornerstone of management. CASE PRESENTATION: A 42 year old male came to our emergency department with complaints of sore throat, fever, chills, odynophagia and hoarseness for 2 days. He reported having a sore throat for a few weeks for which he did not seek treatment. He was septic on arrival with WBC count of 17.9 and CT scan of the neck showing extensive right peritonsillar abscess extending to the retropharynx and uvula. The patient was initially started on Clindamycin and subsequently switched to Unasyn and Azithromycin. Repeat CT neck on day 4 showed improvement in the abscess but the patient continued to spike fevers and developed recurrent hemoptysis. Antibiotics were changed to Vancomycin + Piperacilin/Tazobactam and he underwent a laryngoscopy with subsequent right tonsillectomy and parapharyngeal space exploration. The patient clinically improved but repeat CT scan on day 12 showed paratracheal mediastinal abscesses, extending into the posterior mediastinum behind the esophagus concerning for descending necrotizing mediastinal abscess. A multidisciplinary team meeting was conducted with the thoracic surgeon and consensus was to continue antibiotics and perform periodic imaging with prompt surgery if he deteriorates. Antibiotics were narrowed when tonsillar cultures reported S.Viridans sensitive to Piperacilin/Tazobactam. The patient completed a 24 day antibiotic regimen and was discharged home to complete 2 weeks of Augmentin therapy. On follow up in clinic 2 weeks later the patient made a complete recovery. DISCUSSION: DNM can be a fatal complication of mediastinitis. Our patient was previously healthy who progressed through the full spectrum of pharyngitis; ranging from simple infection to peritonsillar abscess to mediastinitis and eventually DNM. Due to its rare incidence, there was diagnostic and therapeutic delay patient in our patient. However due to a multi disciplinary team approach comprising of a hospitalist, critical care physician, radiologist, ENT and cardiothoracic surgeon our patient made a complete recovery without having to undergo surgical intervention. Awareness of DNM should be addressed so that timely intervention is performed. CONCLUSIONS: We recommend physicians keep DNM high in the differential when routine management for pharyngeal/odontogenic infections fails. REFERENCE #1: Sancho LM, Minamoto H, Fernandez A, et al. Descending necrotizing mediastinitis: a retrospective surgical experience. Eur J Cardiothorac Surg 1999; 16: 200–205 REFERENCE #2: Scaglione M, Pinto A, Romano S, et al. Determining optimum management of descending necrotizing mediastinitis with CT; experience with 32 cases. Emerg Radiol 2005; 11: 275–2 REFERENCE #3: Mihos P, Potaris K, Gakidis I, et al. Management of descending necrotizing mediastinitis. J Oral Maxillofac Surg 2004; 62: 966–972. DISCLOSURES: No relevant relationships by carol epstein, source=Web Response No relevant relationships by Steven Epstein, source=Web Response No relevant relationships by Huzaifah Salat, source=Web Response