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Ann Thorac Surg 1999;68:212-217
© 1999 The Society of Thoracic Surgeons

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Original Articles

Management of descending necrotizing mediastinitis: an aggressive treatment for an aggressive disease

^a Service de Chirurgie Thoracique et Vasculaire, Hôpital Arnaud de Villeneuve, Montpellier, France

Address reprint requests to Dr Marty-Ané, Service de Chirurgie Thoracique et Vasculaire, Hôpital Arnaud de Villeneuve, Centre Hospitalier Universitaire, 34295 Montpellier Cedex, France

	Abstract

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Background. Descending necrotizing mediastinitis represent a virulent form of mediastinal infection requiring prompt diagnosis and treatment to reduce the high mortality associated with this disease. Surgical management and a particularly optimal form of mediastinal drainage remain controversial.

Methods. Over a 10-year period, 12 patients were treated at our institution. Surgical treatment consisted of 1 or several cervical drainages, associated with drainage of the mediastinum through a thoracic approach in 11 patients. Thoracic procedures included radical surgical debridement of the mediastinum with complete excision of the tissue necrosis, decortication, and pleural drainage with adequate placement of chest tubes for mediastino-pleural irrigation. Transcervical mediastinal drainage was performed in only 1 patient.

Results. The outcome was favorable in 10 patients, 9 of whom had mediastinal drainage through thoracotomy. Two patients were initially drained through a minor thoracic approach; the first died of tracheal fistula and the second required new drainage through a thoracotomy. The patient who had transcervical mediastinal drainage without a thoracic approach presented an abscess limited to the anterior and superior mediastinum. In 3 patients, ongoing mediastinal sepsis required a second thoracotomy.

Conclusion. A stepwise approach with transcervical mediastinal drainage is first justified in patients with very limited disease to the upper mediastinum. However, ongoing mediastinal sepsis requires new drainage, through a major thoracic approach, without delay. Extensive mediastinitis can not be adequately treated without mediastinal drainage including a thoracotomy. This aggressive surgical policy has allowed us to maintain a low mortality rate (16.5%) in a series of 12 patients with this highly lethal disease.

	Introduction

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The majority of acute mediastinal infections result from esophageal perforation or infection following a trans-sternal cardiac procedure. Occasionally, acute mediastinitis results from oropharyngeal abscesses with severe cervical infection spreading along the fascial planes into the mediastinum. This is a particularly virulent form of mediastinal infection, described as Descending Necrotizing Mediastinitis (DNM). The criteria for diagnosis of DNM were accurately defined by Estrera and associates [1]. The delay of diagnosis and delayed or inappropriate drainage of the mediastinum are the main causes for the high mortality in this life threatening condition, which requires prompt diagnosis and treatment. Surgical management, and particularly the optimal form of mediastinal drainage, remains controversial with support ranging from cervical drainage alone, to cervical drainage and routine thoracotomy. We report our experience with 12 patients with DNM, and stress the importance of early and large surgical mediastinal drainage for improving a mortality rate that ranges in the literature from 30% to 40% [1, 2]. Routine use of an aggressive surgical approach allowed us to confirm the results of our initial report [3] with a low mortality rate of 16.5%.

	Material and methods

Top Abstract Introduction Material and methods Results Comment References

 
Over a 10-year period, 12 patients with DNM were treated at our institution. In all cases the criteria of Estrera were fulfilled. These criteria include: (1) clinical manifestation of severe oropharyngeal infection; (2) demonstration of characteristic roentgenographic features of mediastinitis; (3) documentation of necrotizing mediastinal infection at operation or postmortem examination or both; and (4) establishment of relationship between oropharyngeal infection and development of necrotizing mediastinal process. In each case, this relationship was clearly established. The patients included 11 men and 1 woman, with ages ranging from 19 to 67 years (mean: 42 years). The primary oropharyngeal infection was a peritonsillar abscess in 7 patients and an odontogenic abscess in 5 patients. All patients had received previous antibiotic therapy and in 8 of these the antibiotic therapy had been associated with corticotherapy. Three of our patients were alcoholics and had a history of heavy smoking, 2 patients had diabetes and chronic obstructive pulmonary disease and 1 patient had AIDS. The delay between onset of primary infection and hospitalization varied from 5 to 15 days (mean: 7 days). Pre- and postoperative cervicothoracic computed tomographic (CT) scanning was performed in all patients, and follow-up CT was performed to assess the adequacy of therapy. Signs of mediastinal infection demonstrated by CT included: (1) mediastinal soft-tissue infiltration with gas bubbles (Fig 1 ); (2) mediastinal uncapsulated fluid collections (Fig 1); and (3) mediastinal abscess (Figs 2, 3). In each case, surgical treatment consisted of 1 or more cervical drainages. This was followed by drainage of the mediastinum through a thoracic approach in 11 patients. Transcervical mediastinal drainage was performed in only 1 patient. The neck is usually approached through an incision anterior to the sternomastoïd muscle or a collar bilateral incision. The involved cervical spaces are opened, drained, and debrided of necrotic tissue and the cervical wound is left open. Thoracic procedure included radical surgical debridement of the mediastinum with complete excision of tissue necrosis, decortication, and pleural and in some cases pericardial drainage with adequate placement of chest tubes for mediastino-pleural irrigation. Open drainage of the mediastinum was performed with multiple large-bore chest tubes (Argyle 28 or 32; Sherwood Medical Company, St. Louis, MO) allowing irrigation. The duration of irrigation and drainage was dependent on clinical progress, a return to normal CT scanning aspects, and the results of the cultures of fluids aspirated from the mediastinal tubes.

View larger version (113K): [in this window] [in a new window]   Fig 1. CT scan appearance of anterior mediastinitis with unencapsulated fluid collections and gas bubbles.

View larger version (95K): [in this window] [in a new window]   Fig 2. CT scan disclosing mediastinal abscess in the right paratracheal area and posterior mediastinum extending below the carena associated with mediastinal emphysema in the upper and anterior mediastinum.

View larger version (105K): [in this window] [in a new window]   Fig 3. Post-operative chest CT scan demonstrating persistence of voluminous anterior mediastinal abscess requiring new surgical drainage.

	Results

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The outcome was favorable in 10 patients, 9 of whom had mediastinal drainage through a thoracotomy. The first patient of this series, who had mediastinal drainage through a minor thoracic approach (anterior mediastinotomy) without thoracotomy, died on postoperative day 18 of tracheal fistula and respiratory failure. In another patient (case 2), insufficiently treated through a posterior mediastinotomy, CT scan control showed persistent posterior mediastinal abscess requiring thoracotomy for new mediastinal drainage. In cases 6, 8, and 10, further mediastinal drainage through a second thoracotomy on postoperative days 7, 3, and 12, respectively, was indicated on CT scan control showing persistent mediastinitis. Ten patients were discharged from the hospital without major sequelae. The mortality rate in this series was 16.5%. Control thoracic CT scan done before discharge displayed normal aspect with return to water density of the mediastinal fat or persistence of increased soft tissue attenuation in the mediasinal fat planes, but without widening of the mediastinum.

	Comment

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The most dreaded and probably the most lethal form of mediastinitis is the diffuse necrotizing variety that occurs as a complication of infection of the oropharynx, best termed descending necrotizing mediastinitis. DNM is an uncommon clinical entity of the suppurative mediastinitis group. Brunelli and associates [5] recorded 58 cases and Corsten and associates [6] 69 cases from 1960 to 1995. In the preantibiotic era, Pearse [2] recorded 110 patients with mediastinitis from cervical infections; 21 of these cases resulted from oropharyngeal infections. Although rare, this variety of mediastinitis is a highly lethal disease according to the review of Estrera and associates [1], who reported a 40% mortality rate in the antibiotic era. The 6 initial patients of our series were previously reported on [3] with a 17% mortality rate. With the addition of 6 other patients, we now report the largest series in the literature without increasing the mortality rate of our initial experience.

Infections originating in the fascial planes of the head and neck spread downward into the mediastinum along the cervical fascias, facilitated by gravity, breathing, and negative intrathoracic pressure. The anatomic relationship between the cervical fascias, consisting of the superficial fascia and three layers of the deep cervical fascia (superficial, visceral, prevertebral), is essential to an understanding of the anatomy of infections in the deep neck and mediastinum. These layers partition the neck into several potential spaces (pretracheal space, retropharyngeal space, perivascular space, and parapharyngeal space) that can all serve as portals of entry into the mediastinum (Fig 4 ). The most common anatomic pathway is the lateral pharyngeal space through the retrovisceral space, inferiorly into the mediastinum [7].

View larger version (20K): [in this window] [in a new window]   Fig 4. Pathways of extension of oropharyngeal infections into the mediastinum.

Intravenous broad-spectrum antibiotic therapy alone is not efficient without adequate surgical drainage of the cervical and mediastinal collections, extensive debridement and excision of necrotic tissue, and wide mediastino-pleural irrigation. Preoperative CT scanning can provide accurate information on the mediastinal compartments involved in the necrotizing process and determine the optimal thoracic approach for efficient surgical drainage. In most cases of our experience, several cervical operations were necessary because of persistent seeding infection related to residual necrosis, undrained or recurrent abscess or occlusion of drains. The anterior mediastinum can be entered transcervically through the pretracheal space and opened by blunt finger dissection to the level of the tracheal bifurcation; the posterior mediastinum is entered by extending the dissection of the retropharyngeal space downward. This transcervical mediastinal drainage was the most commonly used approach in DNM before 1990 [8]. Drainage of the mediastinum can be done through minimal thoracic approach (in addition to cervical drainage) on the basis of predominance of infection as determined in the CT scans (anterior mediastinotomy or subxiphoid drainage in anterior mediastinitis, posterior mediastinotomy in posterior mediastinitis). Standard posterolateral thoracotomy provides very good exposure to the pleural cavity, the pericardium, and all compartments of the mediastinum, which can be opened widely from the upper chest to the diaphragm. For most authors, the optimal surgical approach for mediastinal drainage in patients with DNM is dependent on the level of diffusion of the necrotizing process [1, 3, 4, 9, 10]. If infection reaches only the superior mediastinum above the level of the carina, standard transcervical mediastinal drainage may be adequate. A more extensive disease requires a subxiphoid or thoracic incision. In the case of mediastinitis spreading below the tracheal bifurcation anteriorly or the fourth thoracic vertebra posteriorly, Estrera and colleagues [1] recommends a mediastinal drainage through a transthoracic approach. In our experience, adequate mediastinal drainage in DNM required an aggressive surgical approach, including in most cases a transthoracic approach through a standard thoracotomy. Two patients were drained through a less invasive thoracic approach (parasternal and subxiphoid incision in one case, posterior mediastinotomy in the other case); the first died on postoperative day 18 of tracheal fistula and the second required a new drainage through a thoracotomy on day 20 because the initial procedure was inadequate. The only patient (case 11) who had transcervical mediastinal drainage without a thoracic approach presented a mediastinitis limited to the anterior and superior mediastinum. In three patients (cases 6, 8, 10), a seeding process with persistent or diffuse mediastinitis with bilateral empyema required a second thoracotomy 7, 3, and 12 days, respectively, after the first thoracotomy. In patient 10, second thoracotomy was performed on the opposite side because of contralateral spreading of the infection. In this patient the second thoracotomy was probably performed too late and he died on day 13 in a state of septic shock and multiorgan failure.

Transcervical mediastinal drainage and other minor thoracic approaches provide only narrow access to the mediastinum, thus excluding complete excision of the tissue necrosis. Thoracotomy provides better access to all mediastinal compartments, allowing radical surgical debridement, complete excision of tissue necrosis, drainage of the pericardial and pleural cavities, and adequate placement of multiple large-bore chest tubes for mediastino-pleural irrigation. The risk of pleural contamination resulting from transpleural drainage [4, 8] is theoretical because empyema is often associated with DNM, as it was in nine patients of our series. Corsten and associates [6] reported successful treatment of 7 of 8 patients with DNM and 6 of them underwent mediastinal drainage through thoracotomy. This author states that the mediastinum cannot be adequately drained by a limited approach through subxiphoid or anterior mediastinotomy, and he supports the use of early thoracotomy for the best control of mediastinal sepsis. In a review of the subject, Corsten and associates [6] reported a significant difference in mortality in patients who received neck and thoracic drainage (19%) compared with neck drainage alone (47%) (p < 0.05). Wheatley and colleagues [8] emphasized the inadequacy of transcervical drainage and his review of the literature revealed that transcervical mediastinal drainage was inadequate in 80% of the patients; in these cases, the patients died or required thoracotomy for further drainage. Esteva [11] reported 3 deaths in 4 patients with DNM of dental origin treated without aggressive surgery. He recommends the use of thoracotomy for complete mediastinal drainage, pleural cleansing, and early decortication.

Transcervical mediastinal drainage is justified in mediastinal abscess limited to the upper mediastinum but inefficient in the diffuse and necrotizing form with unencapsulated collections, which was the most usual presentation of mediastinitis in our experience [11, 12] and requires wide debridement and excision of the necrotic tissues. Failure of an initial limited surgical drainage with ongoing mediastinal sepsis is an indication for a major thoracic approach without delay before the onset of fatal events such as vessel erosion and exsanguination, or cardiac and respiratory complications. Ris and associates [12], in a recent publication, reported the successful treatment of 2 of 3 patients with DNM who had mediastinal drainage via the Clamshell approach, which includes a bilateral anterior thoracotomy and a transverse sternotomy. If the exposure of the entire mediastinum and both chest cavities is excellent with the advantage of a one-stage operation, this approach is particularly invasive in these critically ill patients and exposes them to the risk of phrenic nerve palsy and sternum osteomyelitis. However, the authors using this approach did not observe these complications in their series. Median sternotomy also seems inadequate in DNM, because subsequent osteomyelitis and dehiscence of the sternum may occur and the access to the posterobasal compartments of the chest cavity is difficult, especially on the left side [13]. Roberts and associates [14] recently reported the thoracoscopic management of a case of DNM with encapsulated mediastinal abscess and Gobien and associates [15] proposed CT-guided percutaneous drainage as a valuable alternative to surgical intervention in selected patients with mediastinal abscesses. This author performed percutaneous catheter drainage in 6 patients, facilitating elective surgery in one and proving curative in 5, but all patients presented isolated mediastinal abscess following thoracic or abdominal surgery. Isolated mediastinal abscesses usually result from esophageal perforation, postoperative complication, or posttraumatic infected mediastinal hematoma. In contrast, DNM is a diffuse infection involving the neck and mediastinum, making thoracoscopic and percutaneous drainage inadequate in most cases because the unencapsulated fluid collections associated with extensive necrotizing cellulitis require radical surgical debridement and not merely simple drainage of the collections.

The CT scan is a useful tool in postoperative follow-up for assessing the results of surgical drainage, determining the duration of irrigation and drainage, and establishing the timing of possible reoperation in patients with continued sepsis, as was the case in 4 patients (cases 2, 6, 8, 10) in this series.

Delayed diagnosis and inadequate drainage are the main causes of the high mortality rate in DNM. Routine use of the CT scan is highly recommended in patients with a deep cervical infection for early detection of mediastinitis at a time when the chest roentgenogram is still normal. The CT scan accurately defines the extent of spread of the septic process and is a valuable guide to plan adequate surgical drainage. A stepwise approach with transcervical mediastinal drainage first is justified in patients with disease limited to the upper mediastinum, but ongoing mediastinal sepsis requires without delay new drainage through a major thoracic approach. Extensive mediastinitis cannot be adequately treated without mediastinal drainage including a thoracotomy. With Corsten and associates [6] we support the use of early thoracotomy in DNM, an infection process that requires treatment to be as aggressive as the disease itself. This aggressive surgical policy has allowed us to confirm our initial results [3] and to maintain a low mortality rate of 16.5% in a series of 12 patients with this highly lethal disease.

	References

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This Article Abstract Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Marty-Ané, C.-H. Articles by Mary, H. Search for Related Content PubMed PubMed Citation Articles by Marty-Ané, C.-H. Articles by Mary, H.