Ann Thorac Surg 2006;81:2279-2281
© 2006 The Society of Thoracic Surgeons
Case report
Successful Video-Assisted Mediastinoscopic Drainage of Descending Necrotizing Mediastinitis
Kimihiro Shimizu, MD
a
,
*
,
Yoshimi Otani, MD
a
,
Tetuhiro Nakano, MD
a
,
Yukihiro Takayasu, MD
b
,
Yoshihito Yasuoka, MD
b
,
Yasuo Morishita, MD
a
a Division of Thoracic and Visceral Organ Surgery, Gunma University Faculty of Medicine, Gunma, Japan
b Division of Head and Neck Surgery, Gunma University Faculty of Medicine, Gunma, Japan
Accepted for publication July 25, 2005.
* Address correspondence to Dr Shimizu, Division of Thoracic and Visceral Organ Surgery, Gunma University Faculty of Medicine, 3-39-15 Showa-machi, Maebashi, Gunma, 371-8511 Japan (Email: kmshimiz{at}showa.gunma-u.ac.jp).
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Abstract
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Descending necrotizing mediastinitis is an uncommon form of mediastinitis that can rapidly progress to septacemia. To date, the optimal surgical approach has remained controversial. We report a case of descending necrotizing mediastinitis that was treated successfully through a transcervical approach with video-assisted mediastinoscopy. In our case, because the abscess was separated into small compartments, especially in the paratracheal space, the abscess was drained using video-assisted mediastinoscopy. This less-invasive approach may be an option in the treatment of descending necrotizing mediastinitis, especially when the abscess in the paratracheal space is separated into small compartments.
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Introduction
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Descending necrotizing mediastinitis (DNM) is a highly fatal disease originating from odontogenic, pharyngeal, or cervical infections that descend along fascial planes into the mediastinum [1]. Only a small series of DNM has been reported in recent literature, with mortality rates between 25% and 40% [1]. Debridement, drainage of infected fluid collections, and necrotic tissue excision are the surgical gold standard therapies. However, the best surgical approach for this disease remains controversial. We report a case of DNM treated successfully using video-assisted mediastinoscopy (VAM).
A 70-year-old woman was referred to our hospital for fever, odynophagia, neck swelling, and dyspnea after having a sore throat develop 8 days previously. Initial laboratory data showed a white blood cell count of 18.9 x 103/mL and a C-reactive protein concentration of 20.77 mg/dL. A cervicothoracic computed tomographic scan showed abscesses in the pharyngeal space bilaterally, as well as in the anterior and middle mediastinum. The abscess in the middle mediastinum was localized above the tracheal bifurcation. The abscess in the paratracheal space was separated into small compartments (Figs 1A, 1B).
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Fig 1. (A) Computed tomographic chest scan on admission. The abscess in the paratracheal space is separated into small compartments. (B) Computed tomographic chest scan on admission showing paratracheal and anterior mediastinal abscesses. (C) Computed tomographic chest scan on postoperative day 9. The paratracheal and anterior mediastinal abscesses have resolved. The white arrowhead indicates mediastinal drainage tubes.
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In an emergency operation, the patient was placed in the dorsal decubitus position. Drainage and debridement of the cervix and anterior mediastinum were performed by the blunt dissection method through a transcervical incision. After cervical and anterior mediastinal drainage, paratracheal fascia opening, and blunt finger dissection along the trachea, a video-assisted mediastinoscope (model 10970MV [Karl Storz-Endoskope, Tuttlingen, Germany]) was inserted through the same transcervical incision. A metal blunt-tipped coagulation suction device and an endoscopic grasp were used to dissect the abscess wall. The abscess, which was separated into small compartments, was repeatedly punctured and dissected (Fig 2). After washing the paratracheal space, two mediastinal drainage tubes were placed in the middle mediastinum space with VAM. Finally, a tracheostomy was added with two cervical drainage tubes in the cervical space. Her postoperative course was uneventful. The mediastinal drainage tubes were removed on postoperative days 13 and 16, respectively. The mediastinal abscess lesion had resolved (Fig 1C), and the patient was discharged on postoperative day 49.
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Fig 2. (A) Mediastinoscopic view showing bulging mediastinal abscesses. (B) On incising the cavity wall, pus spilled out. (C) A metal blunt-tipped coagulation suction device was used to dissect the abscess wall, which is separated into small compartments. (Ab = abscess; Tr = trachea).
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Comment
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A number of surgical approaches for DNM have been described, including a transcervical approach, a subxiphoid approach, a median sternotomy, a thoracotomy, and a thoracoscopic approach. However, the optimal surgical approach remains controversial. Based on computed tomographic findings, many authors recommend that a superior mediastinal abscess above the level of the carina should be treated using a transcervical incision, and that a thoracotomy or a subxiphoid incision should be used for an abscess extending below the level of the carina [2, 3]. In our case, abscess formation was limited to above the level of the carina. Therefore we selected transcervical drainage of the abscess in the cervix and anterior mediastinum and abscess drainage in the paratracheal space using VAM. Isowa and colleagues [4] reported successful thoracoscopic debridement of DNM that had been treated unsuccessfully by drainage through a transcervical approach. They stated that effective debridement could not be accomplished by a transcervical approach because the abscess was separated into small compartments, especially in the paratracheal space. In our patient, the abscess in the paratracheal space was also separated into small compartments. Therefore, the abscess in the paratracheal space was drained using VAM. Many cases with surgical treatment using a transcervical approach probably failed as a result of insufficient drainage or debridement of an abscess in the paratracheal space that was separated into small compartments.
We believe that this is the first successful case using video-assisted mediastinoscopic drainage for DNM. Video-assisted mediastinoscopy allows bi-manual handling, the insertion of several instruments, and better visualization, which facilitates sufficient drainage or debridement of mediastinal abscesses. Furthermore, the VAM procedure is easy and convenient. As the patient's operative position for VAM is the same as for transcervical drainage, and the VAM can be inserted through the same transcervical incision, changing the operative position is unnecessary, unlike what is needed for a thoracotomy or VATS procedure. Furthermore, because the VAM drainage procedure does not require lung deflation, unlike a thoracotomy or the VATS procedure, intubation with a double-lumen tracheal tube is unnecessary.
Some authors have reported the advantages of drainage and debridement through the thorax for the management of DNM, regardless of whether the mediastinal abscess extends below the level of the carina [5, 6]. A thoracotomy or VATS is an excellent option for managing DNM if the infection involves the lower and posterior mediastinum. However, it is unclear whether a thoracotomy or VATS is the optimal choice for DNM localized to the superior mediastinum. When the mediastinal pleura is opened, empyema may induce cervical pus, which readily descends into the pleural cavity through the mediastinum [7]. Therefore, transcervical drainage with VAM may be the management of choice for DNM localized to the superior mediastinum.
In conclusion, video-assisted mediastinoscopic drainage may be an option in the treatment of DNM, especially when the abscess is localized above the tracheal bifurcation and the abscess in the paratracheal space is separated into small compartments.
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References
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- Freeman RK, Vallieres E, Verrier ED, Karmy-Jones R, Wood DE. Descending necrotizing mediastinitisan analysis of the effects of serial surgical debridement on patient mortality. J Thorac Cardiovasc Surg 2000;119:260-267.[Abstract/Free Full Text]
- Marty-Ane CH, Berthet JP, Alric P, Pegis JD, Rouvière P, Mary H. Management of descending necrotizing mediastinitisan aggressive treatment for an aggressive disease. Ann Thorac Surg 1999;68:212-217.[Abstract/Free Full Text]
- Endo S, Murayama F, Hasegawa T, et al. Guideline of surgical management based on diffusion of descending necrotizing mediastinitis Jpn J Thorac Cardiovasc Surg 1999;47:14-19.[Medline]
- Isowa N, Yamada T, Kijima T, Hasegawa K, Chihara K. Successful thoracoscopic debridement of descending necrotizing mediastinitis Ann Thorac Surg 2004;77:1834-1837.[Abstract/Free Full Text]
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Abstract
Introduction
