Ann Thorac Surg 2000;69:1249-1251
© 2000 The Society of Thoracic Surgeons
CASE REPORTS
Spontaneous closure of a large tracheal fistula due to descending necrotizing mediastinitis
Hiroshi Kato, MDa,
Nobukazu Ohkubo, MDa,
Kenji Akazawa, MDa,
Hiroyoshi Iseki, MDa,
Masaki Haruna, MDa
a Divisions of Cardiovascular Surgery, Surgery, Otolaryngology, and Anesthesia, Toyonaka Municipal Hospital, Osaka, Japan
Address reprint requests to Dr Kato, Division of Cardiovascular Surgery, Toyonaka Municipal Hospital, 14-1, 4-chome, Shibahara-cho, Toyonaka, Osaka 560-8565, Japan
 |
Abstract
|
|---|
We present a case of a 77-year-old man who had a large tracheal fistula due to descending necrotizing mediastinitis. He underwent long-term care with a respirator after mediastinal drainage operations. The fistula was covered spontaneously with the anterior wall of the esophagus 1.5 months postoperatively.
|
Introduction
|
|---|
Descending necrotizing mediastinitis (DNM) is generally lethal, although aggressive mediastinal drainage is recommended. Moreover, it is very rare for a atient with a large fistula to the trachea caused by DNM to survive. We present the case of a 77-year-old man with a large fistula to the trachea who did survive.
A 77-year-old man with untreated carious teeth complained of high fever, chills, right mandibular swelling, and pain. Four days after onset, treatment with broad-spectrum antibiotics was initiated by a general physician. Ten days later, the patient presented as a surgical outpatient at our hospital and underwent an incision of the swollen upper part of the neck. Culture of the pus obtained revealed Streptococcus intermedius. On February 14, 1998, 22 days after onset, he was admitted as an emergency patient to our hospital with dyspnea, dysphagia, and septic shock. A chest roentgenogram showed a widened mediastinum and a computed tomographic (CT) scan demonstrated the neck and mediastinal abscess with gas collections (Fig 1). Transcervical drainage of the neck and superior mediastinum was performed by surgeons. The patient required respiratory care with volume-limited ventilation (Puritan Bennett 7200 series), and inotropic drugs for circulatory support in the intensive care unit. Flomoxef and clindamycin were also administered. On hospital day 2, an echocardiogram showed no pericardial abscess, but the second CT scan revealed that the transcervical drainage was not sufficient for the abscess in the inferior mediastinum. After we, the cardiovascular surgeons, had been consulted, it was decided that the patient required another mediastinal drainage through the subxiphoid approach and a right minithoracotomy with placement of two drainage tubes for irrigation. At the same time, the transcervical drainage tube needed to be positioned appropriately in the right superior mediastinum. Continuous mediastinal and pleural irrigation with 0.5% povidone-iodine solution diluted in normal saline solution was initiated and the pus obtained again showed S intermedius. On hospital day 4, total parenteral nutrition was commenced and oral surgeons removed two teeth, the second and the third right mandibular molars, which caused DNM, when an air leak was recognized. On hospital day 12, bronchoscopy confirmed a 3-cm-long defect of the membranous portion of the distal part of the trachea, extending from approximately 3 cm above the carina tracheae to the upper trachea (Fig 2A). The anterior wall of the esophagus could be seen through the large fistula (Fig 2B). The tip of the orotracheal tube was cut so that the cuff balloon could be placed so as to cover the large fistula. The pressure of the balloon was approximately 20 cm H2O, which was unlikely to cause pressure necrosis of the remaining membranous portion of the trachea yet the air leak was nearly eliminated. The patient received pressure-limited ventilation (Puritan Bennett 7200 series), with positive end-expiratory pressure of 6 cm H2O and end-inspiratory pressure of 23 cm H2O, which were the minimal requirements for maintenance of the tidal volume in lungs with poor compliance. On hospital day 19, methicillin-resistant S aureus was cultured from arterial blood and from the drainage solution, and administration of vancomycin was started. On hospital day 40, enteric feeding with a nasogastric tube was started. The air leak was reduced gradually and on hospital day 47, another bronchoscopy revealed closure of the tracheal fistula, ie, it was covered by the anterior wall of the esophagus (Fig 3). The patient was placed on continuous positive airway pressure of 6 cm H2O. On hospital day 49, a follow-up CT scan showed that the abscess cavity had disappeared. The continuous drainage was discontinued on hospital day 61 after three negative surveillance cultures. On hospital day 82, the patient required a tracheostomy with an especially long tube and on the next day he was weaned off ventilatory support. The patient was transferred to the general ward on hospital day 87. On hospital day 94, a gastrostomy was performed because of paralysis of both vocal cords. Oral intake was started on hospital day 131 because the patient had recovered from left vocal cord paralysis. The patient was discharged home on hospital day 244. At the last follow-up 7 months later, the patient was leading a healthy life without any disability.
View larger version (40K):
[in this window]
[in a new window]
|
Fig 2. (A) The oval area indicates the defect of the membranous portion of the trachea (large tracheal fistula). (B) Bronchoscopic scheme showing a large tracheal fistula. (1 = left main bronchus; 2 = right main bronchus; 3 = edge of large tracheal fistula; 4 = esophagus; 5 = mediastinal space.)
|
|
View larger version (135K):
[in this window]
[in a new window]
|
Fig 3. Bronchoscopic photograph showing closure of the tracheal fistula. The arrow denotes the border between the tracheal epithelium and the anterior wall of the esophagus.
|
|
|
Comment
|
|---|
Our case matched the criteria for DMN, which were defined by Estrera and associates [1]. In our case, there was a risk of the odontogenic abscess rupturing into the submandibular and parapharyngeal space, which extended into the retropharyngeal space. This space is the major pathway for spread of infection from the oral cavity to the posterior mediastinum [1]. Tracheal or bronchial fistula following DNM is a life-threatening complication. Marty-Ane and associates [2] reported 6 patients with DMN. In their series, 1 patient died on postoperative day 18 of tracheal fistula and respiratory distress syndrome. It is very rare for a patient with a large fistula to the trachea caused by DNM to survive. The tracheal fistula in our case may have existed on admission, so that supposedly the air leak could be recognized only after sufficient drainage had removed the pus around the tracheal fistula.
Niwa and colleagues [3] treated defects in the membranous portion of the trachea by tracheoplasty with the esophageal wall. The abundant blood supply to the esophageal wall made it superior to an isolated graft. In our case, the anterior esophageal wall fortunately covered the large fistula. That is, spontaneous "tracheoplasty" with the esophageal anterior wall occurred as a result of not only sufficient drainage but also of covering the large fistula with the balloon of the endotracheal tube as well as of meticulous respiratory care. Our conservative therapy for tracheal fistula could be a choice of management. Careful and close follow-up is required to ascertain the outcome and prevent complications.
|
Acknowledgments
|
|---|
The authors acknowledge the help and support of various anesthetists, oral surgeons, and surgeons. We are indebted to Dr Mitsunori Ohta, Division of Thoracic Surgery, Toneyama National Hospital, Osaka, and Dr Akira Masaoka, Emeritus Professor, Second Department of Surgery, Nagoya City University, Medical School, Nagoya, Japan, for their contributions to this publication.
|
References
|
|---|
-
Estrera A.S., Landay M.J., Grisham J.M., Sinn D.P., Platt M.R. Descending necrotizing mediastinitis. Surg Gynecol Obstet 1983;157:545-552.[Medline]
-
Marty-Ane C.H., Alauzen M., Alric P., Serres-Cousine O., Mary H. Descending necrotizing mediastinitis. Advantage of mediastinal drainages with thoracotomy. J Thorac Cardiovasc Surg 1994;107:55-61.[Abstract/Free Full Text]
-
Niwa H., Masaoka A., Yamanaka Y., et al. Esophageal tracheobronchoplasty for disease of the central airway. J Thorac Cardiovasc Surg 1996;112:124-129.[Abstract/Free Full Text]
Accepted for publication August 3, 1999.
This article has been cited by other articles:
|
|
|
|
 
M. R. Aerni, J. G. Parambil, M. S. Allen, and J. P. Utz
Nontraumatic disruption of the fibrocartilaginous trachea: causes and clinical outcomes.
Chest,
October 1, 2006;
130(4):
1143 - 1149.
[Abstract]
[Full Text]
[PDF]
|
|
|
Top
Abstract
Introduction
