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Ann Thorac Surg 1997;64:887-888
© 1997 The Society of Thoracic Surgeons

Correspondence

Appropriate Exposure and Drainage for Descending Necrotizing Mediastinitis

Fritz J. Baumgartner, MD, Bassam O. Omari, MD, Stanley R. Klein, MD

Divisions of Cardiothoracic Surgery General Surgery, Harbor-UCLA Medical Center, 1000 W Carson St, Torrance, Ca 90509

To the Editor:

The interesting article by Ris and colleagues [1] suggests a clamshell thoracotomy for patients with descending necrotizing mediastinitis who may require mediastinal debridement, bilateral decortication, and pericardial drainage. The inadequacy of a cervical approach to drain the mediastinum in descending necrotizing mediastinitis below the level of the fourth thoracic vertebra was outlined previously by Wheatley and coworkers [2]. A transthoracic approach to the mediastinum is necessary below this level.

These issues are illustrated in the fatal case of a 47-year-old male patient at our institution who presented with Ludwig's angina from a dental abscess. He underwent removal of teeth 17 and 32, incision and drainage of a submental abscess, and tracheostomy. Cultures grew multiple streptococcal species, Escherichia coli, and anaerobes. His clinical condition worsened and on day 4 a computed tomographic scan showed a retropharyngeal and prevertebral abscess with air extending to the superior and posterior mediastinum. The patient returned to the operating room for cervical drainage and left posterolateral thoracotomy by a general surgeon for mediastinal debridement. On day 5, an echocardiogram showed a pericardial effusion and a cardiothoracic surgeon was consulted. A subxiphoid pericardial window was done, draining 200 mL of pus growing E coli. A repeat computed tomographic scan showed persistent mediastinal fluid and a new right pleural effusion (Fig 1Go), which was drained and grew E coli. On day 7, he underwent repeat transcervical drainage of the mediastinum and drainage of the right pleural effusion, growing E coli. He continued to deteriorate and was taken back to the operating room for repeat transcervical and transthoracic abscess drainage on day 14, but died that day of overwhelming sepsis.



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  		Fig 1. . Computed tomographic scan at the level of the carina (T4 vertebral body) revealing persistent mediastinal inflammation and a new right pleural effusion in a patient with descending necrotizing mediastinitis. This was despite submental and transcervical mediastinal drainage, left thoracotomy, and subxiphoid pericardial drainage.

 
In the report of Ris and colleagues, multiple inadequate procedures were performed for descending necrotizing mediastinitis before definitive clamshell thoracotomy. These included chest tube drainage, thoracoscopy, and transcervical debridement of the mediastinum and pleura. In our patient additional submental abscess and subxiphoid pericardial drainage procedures were done. We believe that early cardiothoracic consultation and use of a clamshell thoracotomy combined with cervical drainage would have obviated most of the procedures ultimately done in our patient, and may have led to a more gratifying outcome.

References

  1. Ris H-B, Banic A, Furrer M, Caversaccio M, Cerny A, Zbaren P. Descending necrotizing mediastinitis: surgical treatment via clamshell approach. Ann Thorac Surg 1996;62:1650–4.[Abstract/Free Full Text]
  2. Wheatley MJ, Stirling MC, Kirsh NM, Gago O, Orringer MB. Descending necrotizing mediastinitis: transcervical drainage is not enough. Ann Thorac Surg 1990;49:780–4.[Abstract]
 

Reply

Hans-Beat Ris, MD

Department of Thoracic Cardiovascular Surgery, University of Berne, Inselspital 3010 Berne, Switzerland

To the Editor:

My colleagues and I appreciate Dr Baumgartner and associates' comments and are pleased to recognize their concurrence in the importance of early and complete debridement for necrotizing descending mediastinitis, including the mediastinum and both pleural cavities. The clamshell procedure is a useful approach to gain simultaneous access to the mediastinum and both thoracic cavities for various diseases, including necrotizing mediastinitis. It is an excellent approach with minimal morbidity and results in appropriate functional and cosmetic outcome.




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