The importance of individualized surgical treatment of descending necrotizing mediastinitis
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ABSTRACT:
SUBMITTER: Coltro P
PROVIDER: S-EPMC9442214 | biostudies-literature | 2022 Aug
REPOSITORIES: biostudies-literature
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Project description:BackgroundDescending necrotizing mediastinitis (DNM) is an inflammation occurring in the oropharynx and descending to the deep cervical space and mediastinum, which is a serious infectious disease. The investigation of a new classification system and treatment methods for DNM is still necessary.MethodsA total of 139 patients with DNM caused by odontogenic or pharyngeal infection were retrospectively analyzed in last 20 years in the Ninth People's Hospital Affiliated to Shanghai Jiao Tong University School of Medicine. The patients were divided into the traditional treatment Group T (Group T: 43 patients) and the new classification Group N (Group N: 96 patients). A new DNM classification was developed based on the progression of mediastinal infection as follows: type Ia: infection in the anterosuperior mediastinum; type I: infection in the anterior mediastinum; type II: infection in the posterior mediastinum; and type III: infection of the whole mediastinum.ResultsThere were 49, 8, 10, and 29 patients classified as type Ia, I, II, and III, respectively in the Group N. The type Ia DNM patients were managed with transcervical mediastinal drainage, and the patients with types I and II DNM underwent open (thoracoscopic) surgery, 1 patient within types I died. The 29 patients with type III were managed with unilateral or bilateral open (thoracoscopic) surgery, among them, 8 patients died. The mortality rate for patients with type III DNM was 27.6%. The overall mortality rate in Group N was 9.4%. The mortality rate for patients in the Group T was 25.6%. The mortality rate of Group N was significantly lower than that of Group T (P<0.05).ConclusionsWe have carried out a new clinical classification of DNM, and selected the appropriate treatment method according to the classification, and achieved a better effect than the traditional treatment method.
| S-EPMC7944333 | biostudies-literature
Project description:BackgroundDescending necrotizing mediastinitis (DNM), a severe infection with a high fatality rate, develops in mediastinal spaces due mainly to deep cervical abscesses. The majority of causative microbes of DNM are Streptococci and oral anaerobes. DNM associated with Lactobacillus-infection is rather rare.Case presentationA 69-year-old male with an unremarkable past medical history was referred to our hospital for surgical resection of advanced laryngeal cancer. Full examination revealed a neck abscess and DNM with a background of untreated diabetes mellitus. Initially, he was treated with meropenem. However, Lactobacillus plantarum was isolated from surgical drainage of a mediastinal abscess. Despite using antibiotics capable of eradicating all isolates with susceptibilities not differing significantly from those of the neck and mediastinal abscesses, we attributed DNM to the L. plantarum detected only in the mediastinal abscess. After DNM treatment, he underwent total pharyngolaryngectomy with bilateral neck dissection followed by reconstruction using free jejunum. He was discharged fully recovered.ConclusionWe concluded that L. plantarum as the sole cause of the mediastinal abscess in the present case cannot be ruled out. As the number of immunocompromised patients increases, we should be cautious regarding this "familiar" microbe.
| S-EPMC3847138 | biostudies-literature
Project description:ObjectivesThoracotomy is a reliable approach for descending necrotizing mediastinitis (DNM), and the use of video-assisted thoracic surgery (VATS), a minimally invasive procedure, has been increasing. However, which approach is more effective for DNM treatment is controversial.MethodsWe analysed patients who underwent mediastinal drainage via VATS or thoracotomy, using a database with DNM from 2012 to 2016 in Japan, which was constructed by the Japanese Association for Chest Surgery and the Japan Broncho-esophagological Society. The primary outcome was 90-day mortality, and the adjusted risk difference between the VATS and thoracotomy groups using a regression model, which incorporated the propensity score, was estimated.ResultsVATS was performed on 83 patients and thoracotomy on 58 patients. Patients with a poor performance status commonly underwent VATS. Meanwhile, patients with infection extending to both the anterior and posterior lower mediastinum frequently underwent thoracotomy. Although the postoperative 90-day mortality was different between the VATS and thoracotomy groups (4.8% vs 8.6%), the adjusted risk difference was almost the same, -0.0077 with 95% confidence interval of -0.0959 to 0.0805 (P = 0.8649). Moreover, we could not find any clinical and statistical differences between the 2 groups in terms of postoperative 30-day and 1-year mortality. Although patients who underwent VATS had higher postoperative complication (53.0% vs 24.1%) and reoperation (37.9% vs 15.5%) rates than those who underwent thoracotomy, the complications were not serious and most could be treated with reoperation and intensive care.ConclusionsThe outcome of DNM treatment does not depend on thoracotomy or VATS.
| S-EPMC10133401 | biostudies-literature
Project description:BackgroundDescending necrotizing mediastinitis (DNM) is a severe, life-threatening complication of oropharyngeal infections with cervical necrotizing fasciitis. In this study, we aimed to identify any possible factors that correlate with favorable outcomes.MethodsWe retrospectively analyzed our series of 18 patients who underwent surgical treatment for DNM from a cervical abscess. Gender, age, symptoms, etiopathogenesis, comorbidities, time to surgery from diagnosis, degree of diffusion, identified microorganisms, surgical procedure, days in the intensive care unit, need for tracheostomy, complications, and surgical outcomes were reviewed.ResultsThe main type of surgery was thoracotomy + cervicotomy in eight cases (50.0%), followed by cervicotomy +VATS in four (22.2%). Seven patients (38.9%) had two or more surgeries; a bilateral operation was necessary for four patients. Evaluating the risk factors associated with post-operative complications, age ≥ 60 years (p:0.031), cervicotomy alone as surgical approach (p = 0.040), and the bilateral approach (p = 0.048) resulted in significance in terms of the univariate analysis; age ≥ 60 years (p = 0.04) and cervical approach (p = 0.05) maintained their significance in terms of the multivariate analysis.ConclusionsThe low mortality of our series emphasizes the importance of an extensive and immediate surgical drainage of both the neck and the mediastinum. Mediastinal drainage from cervicotomy seems to be a risk factor for post-operative complications. Minimally invasive surgery on the chest cavity, such as with Uniportal-VATS, could be a good approach above all in elderly patients and all those cases where bilateral access is required.
| S-EPMC9659166 | biostudies-literature
Project description:ObjectiveWe aimed to clarify the clinical features and surgical outcomes of descending necrotizing mediastinitis (DNM) to provide a guide for its surgical treatment, focusing on the type of extension and the deployed procedures.MethodsAs a joint study of the Japan Broncho-esophagological Society and the Japanese Association for Chest Surgery (JBES1703/JACS1806 study), the clinical data of consecutive patients with DNM who underwent surgical drainage between 2012 and 2016 were collected from 131 participating institutions. The infection limited to the area superior to the carina level was defined as type I; while spreading to the lower mediastinum (LM) as type II. The LM infection limited to the anterior LM, that spread to both the anterior and posterior LM and that limited the posterior LM (type IIC) were further categorized as type IIA, IIB, and IIC, respectively.ResultsA total of 225 patients were ultimately eligible. One hundred patients (44.4%) were categorized as type I, whereas 125 patients were type II (56.6%); The number of type IIA, IIB, and IIC cases was 20 (16%), 62 (49.6%) and 43 (34.4%), respectively. Patients with type I and IIC infections more commonly underwent cervical drainage than patients with type IIA and IIB infections (34.3% and 13.4%, respectively). A total of 8 patients died within 30 days (3.6%, type I/II: 1/7). The 5-year overall survival rate was 68.6%. Type II infection was associated with the 90-day mortality (odds ratio, 5.18; P = .045).ConclusionsThis study demonstrated a previously unclassified group of lower mediastinal extent that is localized within the posterior mediastinum (type IIC). We proposed a new DNM classification including type IIC mediastinitis.
| S-EPMC9390273 | biostudies-literature
Project description:BackgroundDescending necrotizing mediastinitis (DNM) resulting from oropharyngeal and cervical abscess is a life-threatening condition. This study attempted to improve our recognition of the extension and distribution of the abscess for ideal thoracic drainage.MethodsWe performed a retrospective clinical analysis of seven patients who underwent thoracic drainage for DNM with available clinical data. For mapping and classification of the distribution of the abscess, computed tomography and intraoperative findings were utilized.ResultsTo cure patients, cervical drainage and thoracic drainage were performed 14 and 11 times, respectively. The operation time for thoracic drainage and intraoperative blood loss were 141±77 min and 103±103 g, respectively. The mean hospital stay was 66±41 days. All patients are alive without recurrence. We divided the abscess distribution into nine categories including the anterior thoracic wall, according to the computed tomography and intraoperative findings. The rate of abscess descended gradually toward the lower mediastinum. Abscesses were not necessarily continuous, and skipped lesions were occasionally noted.ConclusionsWe were able to cure all seven patients with DNM. It might be helpful to recognize the exact distribution of the abscess and distribution-specific drainage using a new map and classification of thoracic abscess.
| S-EPMC7330360 | biostudies-literature
Project description:Descending necrotizing mediastinitis and pharyngeal perforation are uncommon complications of pharyngitis that are associated with high morbidity and mortality. This case report describes a previously healthy 18-year-old male who presented to the emergency room with 5 days of severe sore throat, intermittent fevers, and vomiting and was found to have extensive posterior pharyngeal and mediastinal air along with extravasation of contrast on computed tomography, consistent with perforation of the left aryepiglottic fold as well as descending necrotizing mediastinitis. The patient had a complicated hospital course including multiple operative interventions, abscess formation, and development of pericardial and pleural effusions. Successful treatment required swift resuscitation including broad-spectrum antibiotics and significant coordination of emergent operative intervention between otolaryngology and cardiothoracic surgery. It is important to recognize descending necrotizing mediastinitis as a clinical entity that may result from oropharyngeal infections as early intervention significantly decreases subsequent complications and mortality. Furthermore, pharyngeal perforation is an extremely rare complication which requires either CT with oral contrast or esophagram for diagnosis.
| S-EPMC7040390 | biostudies-literature
Project description: Not available
| S-EPMC9561517 | biostudies-literature
Project description:BackgroundDescending necrotizing mediastinitis (DNM) is an acute life-threatening infection that originates in the oropharyngeal region. It is an uncommon disease with a mortality rate of about 20-40%. This high mortality is mainly attributed to delays in diagnosis and treatment and poor drainage of the mediastinum. We highlight key points that may help reduce mortality.Case descriptionWe analyze a retrospective case series of seven patients diagnosed with DNM between March 2019 and July 2022 at Hospital de la Santa Creu i Sant Pau. The primary oropharyngeal infection was peritonsillar abscess in three cases and odontogenic abscess in four. All patients showed symptoms of severe cervical infection and symptoms suggestive of mediastinitis. A cervicothoracic computed tomography (CT) scan confirmed the presence of cervical and mediastinal collections and emphysema in all cases. All patients were simultaneously evaluated by the otorhinolaryngology and thoracic surgery teams. Broad-spectrum antibiotic therapy was instituted pending culture. All the patients underwent urgent surgery, consisting of cervicotomy to control the cervical focus and unilateral or bilateral video-assisted thoracoscopic debridement and drain of the pleural cavities and mediastinum. Regarding the outcomes, no patients died, one patient (14.2%) underwent transcervical mediastino-thoracoscopy drainage only. In six patients (85.8%) we performed a combined transcervical and transthoracic approach. Reoperation was required in 3 (43%) cases. The parameter that indicated a poor clinical evolution in these patients was an increase in C-reactive protein and the infection extension on the cervicothoracic CT scan. The follow-up was 30 days from last surgery; there were no losses.ConclusionsBased on our experience, the key points that can help reduce the high mortality associated with DNM are a rapid multidisciplinary assessment and a combined surgical procedure, considering the minimally invasive approach as the first option to drain the pleural cavities and mediastinum.
| S-EPMC10839519 | biostudies-literature
Project description:BackgroundWe describe a combinatorial intensive care approach and discuss the critical factors that allowed us to successfully manage a life-threatening case of acute anaerobic septic shock triggered by descending necrotizing mediastinitis.Case presentationWe admitted a 38-year-old critically ill Kosovar Albanian man to our intensive care unit because of clinical manifestations of severe sepsis. His condition had worsened in the previous 2 weeks following unsuccessful antibiotic therapy for tonsillitis complicated by retropharyngeal abscesses. Computed tomography and intraoperative observations identified abscesses in the anterior and middle mediastinum regions and the distal part of the neck, directly on the border with the left lobe of the thyroid gland. Cultures indicated infections with α-hemolytic Streptococcus and Clostridium species: High procalcitonin and lactate levels, blood gas analysis, poor peripheral capillary oxygen saturation, and severe hemodynamic instability pointed to a case of acute septic shock. The entire treatment consisted of an aggressive antibiotic regimen, transthoracic and mediastinal surgical evacuation of the abscess, vacuum sealing drainage with a pleural chest tube, continuous venovenous hemodiafiltration using cytokine-adsorbing hemofilters, and extracorporeal blood hyperoxygenation.ConclusionsEfficient treatment of severe anaerobic sepsis resulting from descending necrotizing mediastinitis should build on a multidisciplinary approach. In support of first-line therapies with targeted antibiotics and surgical debridement, clinicians should consider alternative therapies such as continuous venovenous hemodiafiltration with cytokine-adsorbing hemofilters and hyperoxygenation.
| S-EPMC6610986 | biostudies-literature