Ann Thorac Surg 2004;77:1834-1837
© 2004 The Society of Thoracic Surgeons
Case report
Successful thoracoscopic debridement of descending necrotizing mediastinitis
Noritaka Isowa, MDa,
Tetsu Yamada, MDa,
Takeshi Kijima, DDSb,
Kazuki Hasegawa, DDSb,
Koji Chihara, MD*a
a Division of Thoracic Surgery, Shizuoka City Hospital, Shizuoka, Japan
b Division of Oral and Maxillofacial Surgery, Shizuoka City Hospital, Shizuoka, Japan
Accepted for publication June 5, 2003.
* Address reprint requests to Dr Chihara, Division of Thoracic Surgery, Shizuoka City Hospital, 10-93 Ohtemachi, Shizuoka 420-8630, Japan
e-mail: echihara{at}mb.infoweb.ne.jp
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Abstract
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Descending necrotizing mediastinitis results from odontogenic, deep neck infection that spreads along fascial planes into the mediastinum. Although the optimal surgical approach remains controversial, nearly half of the cases require mediastinal debridement by thoracotomy. We report a case of successful thoracoscopic debridement for descending necrotizing mediastinitis due to odontogenic infection that failed to be drained by transcervical approach. Because of less invasiveness as compared with standard thoracotomy, the thoracoscopic approach should be used as early as possible in case of unsuccessful transcervical approach.
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Introduction
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Descending necrotizing mediastinitis (DNM) is a highly fatal disease originating from odontogenic, pharyngeal, or cervical infectious sources that descend along fascial planes into the mediastinum. Because delayed diagnosis and treatment lead to mortality and because the validity of antibiotics is limited, radical debridement of all affected tissue is required for DNM [1]. However, the optimal surgical approach is controversial [1–4]. We report a case of successfully treated DNM due to odontogenic infection through the thoracoscopic approach.
We report the case of a 57-year-old man who had his left lower third molar tooth extracted by a local dentist 2 days prior to consulting with his family doctor for left mandibular pain and swelling. Although oral antibiotics were prescribed for 2 days, the swelling persisted. He was then admitted to the division of oral surgery in the local hospital. Intravenous antibiotics for 11 days did not improve his condition, and he was then referred to our hospital. Chest radiograph demonstrated widened mediastinum and bilateral pleural fluids. Cervicothoracic computed tomographic scan showed the abscess in the bilateral pharyngeal space as well as in the anterior and posterior mediastinum (Fig 1).
We immediately performed drainage and debridement of the cervix and anterior mediastinum through a cervical incision. Although we also tried to drain the abscess from the posterior mediastinum, a computed tomographic scan on the following day revealed that the posterior mediastinal abscess still existed, although the pharyngeal lesions were resolved (Fig 2).
On hospital day 2, the patient was taken to the operating room again for thoracoscopic drainage of posterior mediastinal abscess. A right thoracoscopic approach revealed serous pleural effusion and a bulged mass with pus by peeling off the pleural adhesion in the mediastinal area (Figs 3A, B).
The lateral wall of the abscess cavity was excised, and the pus and necrotic tissue were removed from the paratracheal space (Fig 3C). Because the computed tomographic scan showed left pleural effusion (Fig 2), we subsequently performed a left thoracoscopic exploration. The effusion was also serous in the left thoracic cavity. Although we dissected the mediastinal pleura, the pus did not spill out. Cultures obtained at the time of the cervical and thoracoscopic drainage were sterile. Postoperatively the mediastinal lesion quickly resolved (Fig 4).
The left and right chest tubes were removed on days 6 and 8 after the thoracoscopic surgery, respectively. Antibiotic treatment was discontinued, and the cervical drainage tubes were taken out on postoperative days 16 and 23, respectively. The patient was discharged home on postoperative day 27.
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Fig 1. Cervicothoracic computed tomographic scan on admission showed pharyngeal (top) and mediastinal (bottom) abscess.
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Fig 2. Cervicothoracic computed tomographic scan 1 day after transcervical drainage was performed showed satisfying drainage in cervical lesion (top). Note the abscess is left in the right paratracheal area (bottom).
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Fig 3. (A) Right thoracoscopic view revealed a bulged mediastinal abscess after peeling off the pleural adhesion. (B) By incising the cavity wall by cautery, the pus was spilled out. (C) The pus and necrotic tissue were removed from the paratracheal area. (Tr = trachea.)
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Fig 4. (A) Chest computed tomographic scan showed the paratracheal abscess was quickly resolved until 3 days after the thoracoscopic surgery. (B) Anterior mediastinal abscess was resolved until 15 days after the thoracoscopic surgery. (C) Nearly normal mediastinal structure was demonstrated on postoperative day 45.
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Comment
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A 36% mortality for DNM was described according to a report in 1990 [4]. The recent reports in the era that computed tomography can be used as a routine diagnostic tool demonstrated that the mortality of the disease was 16% [3] to 23% [2]. Because of the limited efficacy of antibiotics alone, there is no argument that adequate surgical drainage is required as soon as possible. Based on the findings of computed tomographic scans, many authors recommended that superior mediastinal abscess above the level of carina can be treated by transcervical incision and that thoracotomy or subxiphoid incision should be used when the abscess extends below the level of carina [1, 3, 4]. According to a review by Wheatley and coworkers [4], 12 of 43 patients (28%) underwent only transcervical drainage for DNM, whereas 20 of 43 patients (46%) required subsequent thoracotomy in addition to previous transcervical drainage, suggesting that many of the cases considered to be controlled by cervical approach subsequently extended to the lower level of mediastinum. However, thoracotomy by posterolateral or clamshell incision [1] is clearly invasive compared with the transcervical or thoracoscopic approach. Late decision due to a hesitation in using such an aggressive operation may lead the patients to a critical situation. Although thoracoscopic surgery to the mediastinal mass is well established, few reports on thoracoscopic drainage or debridement for mediastinitis have been published. Roberts and colleagues [5] first described the efficacy of thoracoscopic drainage for DNM.
In the present case, although the effusions existed in both thoracic cavities, the abscess was limited to above the level of carina. Therefore, we first tried to perform transcervical debridement of the abscess in the paratracheal space. However, because the abscess especially in the right paratracheal space was separated into the small partition, effective debridement could not be accomplished by transcervical approach. The administered long-term antibiotic therapy may result in producing avascular collagen matrix that walls off the insulting fluid in the abscess. Based on our patient's computed tomographic scan on day 2, we quickly decided to perform thoracoscopic exploration of both thoracic cavities and complete debridement. We believe that thoracoscopic debridement should be used as early as possible in cases in which the transcervical approach fails to clean up the mediastinal abscess.
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References
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- 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;62:1650-1654.[Abstract/Free Full Text]
- Kiernan P.D., Hernandez A., Byrne W.D., et al. Descending cervical mediastinitis. Ann Thorac Surg 1998;65:1483-1488.[Abstract/Free Full Text]
- Marty-Ane C.H., Berthet J.P., Alric P., Pegis J.D., Rouviere P., Mary H. Management of descending necrotizing mediastinitis: an aggressive treatment for an aggressive disease. Ann Thorac Surg 1999;68:212-217.[Abstract/Free Full Text]
- Wheatley M.J., Stirling M.C., Kirsh M.M., Gago O., Orringer M.B. Descending necrotizing mediastinitis: transcervical drainage is not enough. Ann Thorac Surg 1990;49:780-784.[Abstract]
- Roberts J.R., Smythe W.R., Weber R.W., Lanutti M., Rosengard B.R., Kaiser L.R. Thoracoscopic management of descending necrotizing mediastinitis. Chest 1997;112:850-854.[Abstract/Free Full Text]
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Abstract
Introduction
