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December 1996, Vol 122, No. 12 >
ARTICLE | December 1996

Descending Necrotizing Mediastinitis: Title and subTitle BreakSurgical Drainage and Tracheostomy FREE

Alessandro Brunelli, MD; Armando Sabbatini, MD; Gianbattista Catalini, MD; Aroldo Fianchini, MD
Arch Otolaryngol Head Neck Surg. 1996;122(12):1326-1329. doi:10.1001/archotol.1996.01890240034008
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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.Arch Otolaryngol Head Neck Surg. 1996;122:1326-1329

REFERENCES

1 +
Pearse HE.  Mediastinitis following cervical suppuration . Ann Surg . 1938;:108: 588-611.
2 +
Estrera AS, Landay MJ, Grisham JM, et al.  Descending necrotizing mediastinitis . Surg Gynecol Obstet . 1983;;157:545-552.
3 +
Wheately MJ, Stirling MC, Kirsh MM.  Descending necrotizing mediastinitis: trans-cervical drainage is not enough . Ann Thorac Surg . 1990;;49:780-784.
4 +
Payne WS, Larson RH.  Acute mediastinitis . Surg Clin North Am . 1969;;49:999-1009.
5 +
Cameron JL, Kieffer RF, Hendrix TR, Mehigan DG, Baker RR.  Selective nonoperative management of contained intrathoracic esophageal disruptions . Ann Thorac Surg . 1979;;27:404-408.
6 +
Santos GH, Frater RW.  Trans-esophageal irrigation for the treatment of mediastinitis produced by esophageal rupture . J Thorac Cardiovasc Surg . 1986;; 91:57-62.
7 +
Moncada R, Warpeha R, Pickleman J, et al.  Mediastinitis from odontogenic and deep cervical infection . Chest . 1978;;73:497-500.
8 +
Hawkins DB, Seltzer DC, Barnett TE, Stoneman GB.  Endotracheal tube perforation of the hypopharynx . West J Med . 1974;;120:282-286.
9 +
Manheim A, Perez RE, Nevin JE.  A rare complication from a not-so-rare occurence (endotracheal intubation) . South Med J . 1971;;64:814-819.
10 +
Marty-Ane CH, Alauen M, Alric P, Serres-Cousine O, Mary H.  Descending necrotizing mediastinitis: advantage of mediastinal drainage with thoracotomy . J Thorac Cardiovasc Surg . 1994;;107:55-61.
11 +
Santos GH, Shapiro BM, Komisar A.  Role of transoral irrigation in mediastinitis due to hypopharyngel perforation . Head Neck Surg . 1986;;9:116-121.
12 +
Watanabe M, Ohshica Y, Aoki T, Takagi K, Tanaka S, Ogata T.  Empyema and mediastinitis complicating retropharyngeal abscess . Thorax . 1994;;49:1179-1180.
13 +
Takao M, Ido M, Hamaguchi K, Chikusa H, Namikawa S, Kusagawa M.  Descending necrotizing mediastinitis secondary to a retroparyngeal abscess . Eur Respir J . 1994;;7:1716-1718.
14 +
Nakajima H, Sega H, Yokota T, et al.  Two cases of mediastinitis as a complication of odontogenic infection and tonsillitis . Nippon Kyobu Shikkan Gakkai Zasshi . 1993;;31:754-759.
15 +
Ogiso A, Tamura M, Minemura T, Kurashina K, Kotani A.  Mediastinitis caused by odontogenic infection associated with adult respiratory distress syndrome . Oral Surg Oral Med Oral Pathol . 1992;;74:15-18.
16 +
Van Straalen HCM, Jansveld KA, Michels LF, Tjon A, Tam R.  Mediastinitis with fistula formation to the left main bronchus . Chest . 1994;;106:623-624.
17 +
al Ebrahim KE.  Descending necrotising mediastinitis: a case report and review of the literature . Eur J Cardiothorac Surg . 1995;;9:161-162.
18 +
Bounds GA.  Subphrenic and mediastinal abscess formation: a complication of Ludwig's angina . Br J Oral Maxillofac Surg . 1985;;23:313-321.
19 +
Rubin MM, Cozzi GM.  Fatal necrotizing mediastinitis as a complication of an odontogenic infection . J Oral Maxillofac Surg . 1987;;45:529-533.
20 +
Levine TM, Wurster CF, Krespi YP.  Mediastinitis occurring as a complication of odontogenic infection . Laryngoscope . 1986;;96:747-750.
21 +
Zachariades N, Mezitis M, Stavrinidis P, Konsolaki-Agouridaki E.  Mediastinitis, thoracic empyema and pericarditis and complications of a dental abscess . J Oral Maxillofac Surg . 1988;;46:493-495.
22 +
Allen D, Loughnan TE, Ord RA.  A reevaluation of the role of tracheostomy in Ludwig's angina . J Oral Maxillofac Surg . 1985;;43:436-439.

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1 +
Pearse HE.  Mediastinitis following cervical suppuration . Ann Surg . 1938;:108: 588-611.
2 +
Estrera AS, Landay MJ, Grisham JM, et al.  Descending necrotizing mediastinitis . Surg Gynecol Obstet . 1983;;157:545-552.
3 +
Wheately MJ, Stirling MC, Kirsh MM.  Descending necrotizing mediastinitis: trans-cervical drainage is not enough . Ann Thorac Surg . 1990;;49:780-784.
4 +
Payne WS, Larson RH.  Acute mediastinitis . Surg Clin North Am . 1969;;49:999-1009.
5 +
Cameron JL, Kieffer RF, Hendrix TR, Mehigan DG, Baker RR.  Selective nonoperative management of contained intrathoracic esophageal disruptions . Ann Thorac Surg . 1979;;27:404-408.
6 +
Santos GH, Frater RW.  Trans-esophageal irrigation for the treatment of mediastinitis produced by esophageal rupture . J Thorac Cardiovasc Surg . 1986;; 91:57-62.
7 +
Moncada R, Warpeha R, Pickleman J, et al.  Mediastinitis from odontogenic and deep cervical infection . Chest . 1978;;73:497-500.
8 +
Hawkins DB, Seltzer DC, Barnett TE, Stoneman GB.  Endotracheal tube perforation of the hypopharynx . West J Med . 1974;;120:282-286.
9 +
Manheim A, Perez RE, Nevin JE.  A rare complication from a not-so-rare occurence (endotracheal intubation) . South Med J . 1971;;64:814-819.
10 +
Marty-Ane CH, Alauen M, Alric P, Serres-Cousine O, Mary H.  Descending necrotizing mediastinitis: advantage of mediastinal drainage with thoracotomy . J Thorac Cardiovasc Surg . 1994;;107:55-61.
11 +
Santos GH, Shapiro BM, Komisar A.  Role of transoral irrigation in mediastinitis due to hypopharyngel perforation . Head Neck Surg . 1986;;9:116-121.
12 +
Watanabe M, Ohshica Y, Aoki T, Takagi K, Tanaka S, Ogata T.  Empyema and mediastinitis complicating retropharyngeal abscess . Thorax . 1994;;49:1179-1180.
13 +
Takao M, Ido M, Hamaguchi K, Chikusa H, Namikawa S, Kusagawa M.  Descending necrotizing mediastinitis secondary to a retroparyngeal abscess . Eur Respir J . 1994;;7:1716-1718.
14 +
Nakajima H, Sega H, Yokota T, et al.  Two cases of mediastinitis as a complication of odontogenic infection and tonsillitis . Nippon Kyobu Shikkan Gakkai Zasshi . 1993;;31:754-759.
15 +
Ogiso A, Tamura M, Minemura T, Kurashina K, Kotani A.  Mediastinitis caused by odontogenic infection associated with adult respiratory distress syndrome . Oral Surg Oral Med Oral Pathol . 1992;;74:15-18.
16 +
Van Straalen HCM, Jansveld KA, Michels LF, Tjon A, Tam R.  Mediastinitis with fistula formation to the left main bronchus . Chest . 1994;;106:623-624.
17 +
al Ebrahim KE.  Descending necrotising mediastinitis: a case report and review of the literature . Eur J Cardiothorac Surg . 1995;;9:161-162.
18 +
Bounds GA.  Subphrenic and mediastinal abscess formation: a complication of Ludwig's angina . Br J Oral Maxillofac Surg . 1985;;23:313-321.
19 +
Rubin MM, Cozzi GM.  Fatal necrotizing mediastinitis as a complication of an odontogenic infection . J Oral Maxillofac Surg . 1987;;45:529-533.
20 +
Levine TM, Wurster CF, Krespi YP.  Mediastinitis occurring as a complication of odontogenic infection . Laryngoscope . 1986;;96:747-750.
21 +
Zachariades N, Mezitis M, Stavrinidis P, Konsolaki-Agouridaki E.  Mediastinitis, thoracic empyema and pericarditis and complications of a dental abscess . J Oral Maxillofac Surg . 1988;;46:493-495.
22 +
Allen D, Loughnan TE, Ord RA.  A reevaluation of the role of tracheostomy in Ludwig's angina . J Oral Maxillofac Surg . 1985;;43:436-439.

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