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Ann Thorac Surg 1998;65:1483-1488
© 1998 The Society of Thoracic Surgeons

Current Review

Descending Cervical Mediastinitis

Paul D. Kiernan, MDa, Adam Hernandeza, William D. Byrne, MDa, Robert Bloom, MDb, Barry Dicicco, MDb, Vivian Hetrick, RNa, Paula Graling, RNa, Betty Vaughan, RNa

a Section of Thoracic Surgery, INOVA Health Systems, Fairfax, Virginia, USA
b Section of Pulmonary Medicine, INOVA Health Systems, Annandale, Virginia, USA

Address reprint requests to Dr Kiernan, Cardiovascular & Thoracic Surgery Associates, PC, Suite 301, 3301 Woodburn Rd, Annandale, VA 22003


   Abstract
Top
 Abstract
Introduction
 Case reports
 Comment
 References
 
Descending cervical mediastinitis is an uncommonly reported presentation of infection originating in the head or neck and descending into the mediastinum, which is fraught with impressive morbidity and mortality rates of 30% to 40% or more. We present the INOVA–Fairfax–Alexandria Hospital experience with descending cervical mediastinitis, January 1, 1986, to April 1, 1997; in addition we review the English-language medical and surgical literature with regard to this entity. Computed tomography and magnetic resonance imaging serve to aid both diagnosis and management. The application of broad-spectrum antibiotics should initially be empiric, with an eye to coverage of mixed aerobic and anaerobic infections. Definitive treatment mandates early and aggressive surgical intervention. All affected tissue planes, cervical and mediastinal, must be widely debrided, often leaving them open for frequent packing and irrigation. The treating physician must remain always alert to the further extension of infection, which, if it occurs, must be further debrided and drained. Tracheostomy serves a dual role of further opening cervical fascial planes and securing an often compromised airway.


   Introduction
Top
 Abstract
 Introduction
Case reports
 Comment
 References
 
Descending cervical mediastinitis (DCM) is an underreported and virulent presentation of infection that may arise from odontogenic or cervicofacial infection, esophageal perforation, or trauma. Our experience with DCM (1986 through 1997) is presented for physician education; in the past this entity, many times affecting young and healthy individuals, too often has been belatedly recognized and awkwardly treated, with oftentimes deservedly poor results.

As infection spreads along deep cervical planes into the mediastinum, widespread cellulitis, necrosis, abscess formation, and sepsis may occur. Five widely varying clinical presentations we have encountered are presented. These five cases are drawn from our successful experience with seven cases over the past decade. Pertinent literature, as reported to date, is reviewed and discussed, suggesting a range of therapeutic options to be considered in management.


   Case reports
Top
 Abstract
 Introduction
 Case reports
Comment
 References
 
Patient 1
A 38-year-old female addict was admitted, after injecting herself over the previous 3 months through the left internal jugular vein, with fever, left neck swelling, dyspnea, and trismus. Broad-spectrum antibiotics were initiated. A computed tomographic (CT) scan of the neck and chest revealed deep cervical and superior mediastinal fascial edema and possible microabscess formation. Spiking temperatures, dyspnea, and neck and mandibular rigidity resolved quite rapidly after deep left neck and superior mediastinal exploration and drainage with prophylactic tracheostomy. No frank abscesses were noted at operation, but the tissues were inflamed and indurated. Over several days the tissue granulated in nicely in response to open packing, irrigation, and drainage. The patient’s wound was allowed to close by secondary intention, and she was dismissed home on her 20th postoperative day.

Patient 2
A 72-year-old woman was admitted to an outlying facility with congestive heart failure necessitating emergent intubation. Thereafter, subcutaneous emphysema was noted, which was explained when on her sixth postoperative day a pyriform sinus and paratracheal collection (secondary to traumatic intubation) were diagnosed on Gastrogafin (E.R. Squibb & Sons, Princeton, NJ) swallow. Broad-spectrum antibiotics were initiated, with subsequent cervical fascial cultures positive for Enterococcus and Candida organisms.

On the patient’s 17th hospital day, she was transferred to our hospital because of steady clinical deterioration. Computed tomography revealed a large cervical and mediastinal abscess extending from the pyriform sinus to the carina, which emanated from a pyriform sinus fistula visualized at pharyngoscopy. The abscess was evacuated and drained through an anterolateral cervical–superior mediastinal approach, after which tracheostomy was performed to secure the airway. The patient ultimately required closure of the pyriform sinus fistula with mobilized sternocleidomastoid muscle.

Despite further development of a deep cervical seroma requiring further drainage and associated with an ipsilateral, unilateral vocal cord paralysis, the patient steadily progressed to be dismissed from the hospital on her 126th hospital day. One year later she underwent successful surgical coronary revascularization at our facility.

Patient 3
A 66-year-old man was admitted with stridor, sore throat for 48 hours, leukocytosis of 24,000/µL, and a negative chest roentgenogram. Diagnosis of acute epiglottitis was confirmed at laryngoscopy. Tracheostomy was performed to secure the airway, and broad-spectrum antibiotics were initiated.

Repeat CT scanning several days thereafter revealed abscess extension from the base of the skull to the diaphragm with bilateral pleural effusions. Repeated cervical and superior mediastinal explorations and drainages were effected, the last time leaving the incision open for thrice daily packing and irrigation, with additional multiple tube thoracostomies placed for drainage of bilateral empyemas. Despite interval cardiac arrest requiring cardiopulmonary resuscitation, arterial hemorrhage from infection eroding a branch of the right external carotid artery, and transient right vocal cord paresis, with open wound packings, irrigation, and drainage as detailed, the patient improved to be dismissed on his 53rd hospital day.

Patient 4
A 34-year-old man was admitted with pleuritic chest pain, myalgia, and fever during the previous 2 weeks. Pharyngolaryngoscopy and CT revealed, respectively, epiglottitis and right retropharyngeal abscess. The latter was evacuated through a right cervical approach with closed system drainage. Despite the use of broad-spectrum antibiotics postoperatively, the patient deteriorated and follow-up CT revealed extension of the abscess to the level of the diaphragm. Evacuation and open packing and drainage of the neck and superior mediastinum was effected, followed by bilateral tube thoracostomies for drainage of developing, bilateral pleural empyemas.

The patient continued to deteriorate. Repeat CT scans delineated anterior and middle mediastinal collections, treated with mediansternotomy, longitudinal pericardiotomy, and open packing and irrigations. After further mediastinal debridement and rectus muscle flap closure, this patient was dismissed home on his 101st hospital day.

Patient 5
A 69-year-old woman was admitted within 48 hours of outpatient general anesthesia for facial cosmetic surgery with fever and generalized subcutaneous emphysema. Computed tomography (Fig 1) revealed the subcutaneous cervicothoracic emphysema as well as bilateral pleural effusions. Suspecting that the cause of the patient’s predicament was false passage esophageal injury secondary to intubation at the time of her outpatient operation, a cervical esophagogram (Fig 2) was ordered, illustrating well contrast extravasation into the superior mediastinum.



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  		Fig 1. Computed tomography provides complementary information to other studies, such as noted in Figure 2; In addition it may be used to dynamically track craniocaudad extent of the inflammatory or infections process. In this figure is well illustrated the extent of infection in patient 5, with subcutaneous emphysema, mediastinal engorgement (particularly along the superior mediastinum), and bilateral pleural effusions.

 


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  		Fig 2. Esophagogram from patient 5, an individual who while undergoing outpatient, cosmetic "face-lift" operation suffered occult posterior cervical esophageal injury, with resultant cervical esophageal perforation, subcutaneous empyema (refer to Fig 1), and descending cervical mediastinitis with bilateral pleural effusions. The esophagogram illustrates well (A) the contrast extravasation from the cervical esophagus into the prevertebral space and the superior mediastinum and (B) the absence of extravasation after surgical repair of the esophageal rent, cervical and mediastinal drainage, and subsequent healing of the wound.

 
Administration of broad-spectrum antibiotics was initiated, and the patient was emergently operated on, with right cervical–superior mediastinal exploration, primary esophageal perforation closure, and exploration of the superior mediastinum from a cervical approach with insertion of bilateral pleural tubes, culturing all secretions and leaving the cervical-mediastinal wound open for thrice daily irrigation and packing. No tracheostomy was performed as the patient had been breathing comfortably before the operation and we believed in this instance tracheostomy would more likely contaminate the adjacent wound than protect the patient’s airway.

After 4 days’ intubation and mechanical ventilation, the patient was discharged home on her 20th postoperative day receiving ciprofloxacin, clindamycin, and flucanazole; all cultured organisms were sensitive to at least one of those antibiotics. The wound had fully healed at the final postoperative office visit 3 weeks after discharge, and the patient was partaking of a regular diet.


   Comment
Top
 Abstract
 Introduction
 Case reports
 Comment
References
 
Descending cervical mediastinitis refers to mediastinal infections that begin at the cervical region and spread through deep fascial planes into the mediastinum. The 5 cases reviewed represent the full and morbid spectrum of the disease, yet without the high mortality (Table 1) usually reported [20, 28].


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  		Table 1. Mortality and Morbidity (Length of Stay)

 
Etiology
The most common cause of DCM is odontogenic infection. Mediastinitis from an odontogenic source is rare but accounts for 58% of DCM cases reported in the literature since 1960 [28]. Other causes include retropharyngeal abscess, peritonsillar abscess, cervical lymphadenitis, parotitis, thyroiditis, trauma, traumatic endotracheal intubation, and intravenous drug use, as well as a variety of other iatrogenic causes [12, 27, 28]. The causative organism varies depending upon the origin, but in the majority of cases flora are mixed between aerobic and anaerobic bacteria. ß-Hemolytic streptococcus is most commonly found because of the high incidence of odontogenic infections.

Anatomy and pathophysiology
The deep cervical fascia are arranged in three layers [54]: (1) a superficial (pretracheal) layer, (2) a visceral layer, and (3) a prevertebral layer. These layers effectively partition the deep neck into three spaces: (1) pretracheal, (2) perivascular, and (3) retrovisceral or prevertebral. The pretracheal space is the space anterior to the trachea and posterior to the strap muscles and pretracheal fascia. Its upper limit is bound by the thyroid cartilage and below in the mediastinum by the pericardium and parietal pleura at the level of the carina, explaining the findings of purulent pericarditis and empyema seen in patient 4. The perivascular space is surrounded by the carotid sheath. It is formed by the fusion of the major layers of cervical fascia and contains the carotid artery, internal jugular vein, and vagus nerve, and descends into the chest with these structures. The prevertebral space is anterior to the prevertebral fascia and posterior to the pharynx and esophagus (ie, retrovisceral). Its upper limit is bound by the skull base and descends inferiorly to the level of the diaphragm. Through these spaces cervical infections can easily spread. Of course infection may also spread across fascial planes, thus cross-contaminating into the anterior, middle, and posterior mediastinum and pleural spaces.

Once cervical infection is established, caudad spread is facilitated by gravity as well by negative intrathoracic pressures. The effects of infection are dependent on the organisms involved, the timeliness and appropriateness of medical treatment and surgical intervention, the origin and extent of infection, and the preinfection host health status.

It has been estimated that 8% of mediastinitis cases originating in the neck spread through the pretracheal space [50]. The pretracheal space is the usual route of spread of infections originating at the thyroid gland or tracheostomy site. This space provides no direct access for odontogenic infections but may become involved if violated in the process of draining other spaces or even by contiguity with necrotizing organisms. Dental infections may originate and spread through the pterygomandibular or infratemporal spaces, depending on whether the inciting pathology originates in the mandible or maxilla, respectively. When more caudad extension occurs, in greater than 70% of cases spread occurs through the prevertebral space [50]. Perivascular spread occurs in the remainder of cases, often producing complicating arterial hemorrhage as noted in patient 3.

Suppurative complications within the neck include the systemic effects of any undrained abscess: fever, pain, and sepsis. Cranial nerve deficits are common, as is trismus and stridor. Erosion into adjacent hypopharynx, esophagus, or vascular structures may occur. As infection spreads, systemic ill effects are more likely to predominate, particularly as the mediastinum becomes involved. Capillary leak occurs with possible consequences of dehydration, adult respiratory distress syndrome, cardiac tamponade, and empyema. The latter serves to further embarrass respiratory function on the basis of restriction of normal alveolar aeration as well as arteriovenous shunting.

Diagnosis
For the most part early diagnosis can be made with the fundamentals of patient history and physical examination. Fever, local discomfort, and respiratory distress are common presenting complaints. Respiratory distress necessitates emergency evaluation and intervention, as epiglottitis may rapidly occlude the airway; adult respiratory distress syndrome usually indicates belated diagnosis.

Laryngoscopy, CT (Fig 1), and esophagography (Fig 2) may be helpful in identifying upper aerodigestive tract pathology, particularly involving the pyriform sinus and epiglottis. Simple roentgenography may be helpful (eg, to detect disturbance of usual fascial planes by air, edema, or fluid), but is all too often nondiagnostic until late in the course of the disease process, when airway compromise may have already developed. Sonography may be helpful but is more often limited to evaluation of the more superficial anatomic planes. Cross-sectional CT (Fig 1) or magnetic resonance imaging is indispensable in the detection of deep neck infections and the evaluation of their craniocaudad spread. As such they may be useful in directing and serially evaluating therapeutic intervention.

Treatment
Descending cervical mediastinitis is an uncommonly reported but potentially highly lethal entity. Despite improvements in diagnostic imaging and antibiotics, the mortality reported for DCM since 1960 has been stated to be 36% [28]. The latter figure is all the more impressive when one notes the average age of patients afflicted since 1960 is only 32 years (59 years in our series).

Aggressive surgical drainage is recommended as the preferred treatment of DCM. Estrera and colleagues [20] recommend transthoracic drainage of any mediastinitis extending below the fourth thoracic vertebral plane posteriorly (ie, the plane of the tracheal bifurcation anteriorly) as mediastinitis caudad to such levels has been shown to be complicated by an increased incidence of pleural empyema. Wheatley and associates [28] also condemn simple cervical drainage, preferring the combination of cervical drainage and anterior mediastinal drainage through the subxyphoid approach, along with tracheostomy to secure the airway. Their approach is supported by published data replete with a 70% to 80% failure rate with cervical drainage alone, attendant multiple reoperations, prolonged hospital stays, and a mortality rate achieved with all approaches of nearly 40% since 1983 [28].

Our own recommendations are based on our own small but uniformly successful experience (7 cases during the past decade), as well as that published in the literature. We advocate broad-spectrum antibiotics in combination with early and aggressive cervical and superior mediastinal drainage, often leaving the cervical incision open for multiple daily packings and irrigations. We do not support a minimalist approach as recommended by de Marie and coworkers [27]. Late diagnosis and anything less than aggressive drainage may delay more appropriate treatment, leading to the high morbidity and mortality so often reported. Liberal use of CT scanning along with a high level of suspicion, thorough history, and repeated physical examinations provide the fundamental means of diagnosis and surveillance.

Whenever the neck and superior mediastinum are explored, all three deep cervical spaces are dissected and drained. Subxyphoid anterior mediastinal and pericardial drainage may be supplemented, but when mediastinitis persists, whether by lack of clinical improvement or persistent collection(s) by CT scan, thoracotomy or median sternotomy, including longitudinal pericardiotomy or other "open" procedures, should be considered along with other open procedures, such as bilateral thoracotomy through the so-called clamshell approach [44], allowing for multiple daily wound packing and irrigations. When the infectious process preferentially involves the posterior mediastinum, this must be drained by multiple tube thoracostomies, often guided by thoracotomy for thorough evacuation, evaluation, debridement, and establishment of continuing drainage, packing, or irrigation.

Finally, airway compromise, though not occurring in every case, is a common development and should always be anticipated. Thus it seems appropriate to abide by the adage, "if tracheostomy is to be reasonably considered, it should probably be performed," our own patient 5 illustrating that exceptions do exist.

Appropriate antibiotics are an essential component of treatment; empiric therapy should be directed toward mixed aerobic and anaerobic infections, pending specific cultures and sensitivities. Particular attention should be given to the usual oral pharyngeal flora, including Candida and Aspergillus organisms, especially in the deteriorating or debilitated patient.

Summary
With reasonable suggestion and documentation of deep cervical infection, aggressive and definitive surgical exposure and drainage must be effected. Similar to treatment of abscesses elsewhere, infected deep cervical planes must be opened adequately for thorough debridement, irrigation, and drainage. So too, the mediastinum, if contaminated, should be opened, packed, or drained, whatever it takes to "unroof" the planes of infection.

We prefer exposure of DCM through an incision along the anterior border of the sternocleidomastoid muscle, deepening down medial to the carotid sheath and into the prevertebral space, dissecting the planes bluntly and in a thorough manner, and leaving them open for three to four times daily wound irrigation and packing changes. Supplemental maneuvers available to expose extension of the infection into the mediastinum include (1) subxyphoid and substernal dissection and drainage of the anterior mediastinum and pericardium, (2) mediansternotomy with full longitudinal pericardiotomy (patient 4), and (3) multiple tube thoracostomies that may, on occasion, be supplemented by thoracotomy for wider dissection, debridement, and accurate placement of multiply perforated catheters for subsequent irrigations and continuing suction.

We have been impressed that awaiting the definition of abscess by CT can be misleading in the detection of DCM, as the latter is often early characterized by pure fascitis and cellulitis. If one realistically hopes to avoid the high mortality rate as reported in the literature (Table 1), aggressive surgical exploration, exposure, debridement, and drainage of infected anatomic planes is a must. Initial complementary antibiotic selection should be empiric, anticipating mixed anaerobic and aerobic involvement. When Candida organisms are to be anticipated, fluconazole is a reasonable, initial complement. Similarly, Aspergillus organisms, as well as numerous other complicating pathogens, must be assiduously looked for, delineated, and, if cultured, treated.


   References
Top
 Abstract
 Introduction
 Case reports
 Comment
 References
 

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