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Early open thoracotomy and mediastinopleural irrigation for severe descending necrotizing mediastinitis
Takekazu Iwata1, Yasuo Sekine, Kiyoshi Shibuya
1Department of Thoracic Surgery, Chiba University Graduate School of Medicine, 1-8-1 Inohana, Chuo-ku, Chiba 260-8670, Japan.
Objective:
Descending necrotizing mediastinitis (DNM) is a severe infection spreading from the cervical region to the mediastinal connective tissue. The mortality rate was reported as 40% until the 1980s. Since DNM is uncommon, few reports of large series of patients with DNM (i.e. more than 10 cases) have been published. The present aim was to evaluate our treatment strategy for DNM by retrospective chart review.
Methods:
Retrospective chart review was performed in 10 patients with DNM between 1991 and 2003. The mean age was 53.8+/-23.3 years (median 58, range 16-82). The causes of DNM were primary peritonsillar or parapharyngeal abscess in 5 patients, post-extraction odontogenic abscess in 3, cervical abscess of post-tracheostomy in 1, and unknown in 1 patient. In nine cases, the abscess extended from the cervical region to the lower mediastinum. Immediately after the diagnosis of DNM, broad-spectrum antibiotics were administered empirically, and surgical treatments consisting of cervical drainage, thoracotomy with radical surgical debridement of the mediastinum and excision of necrotic tissue, decortication, and irrigation were performed in all cases. Post-operatively, mediastinopleural irrigation with saline was performed once or twice a day until a culture of pleural effusion became negative.
Results:
The mean duration of chest tube retention was 26.7+/-17.0 days, and the mean hospital stay was 62.3+/-33.9 days. Five patients suffered from severe complications including septic shock, acute respiratory distress syndrome, disseminated intravascular coagulation, and pan-peritonitis due to duodenal perforation. The outcome was favorable in 8 patients. Of those with severe complications, two patients, who were older than 75 and had diabetes, died of multiple organ failure due to septic shock. Therefore, the mortality rate was 20%.
Conclusion:
Our treatment strategy for severe DNM was efficacious for early treatment and reduced the mortality rate. Early detection of DNM, and immediate thoracotomy and irrigation of the mediastinum and thoracic cavity, are recommended.
Insights
This study evaluated a treatment strategy for descending necrotizing mediastinitis (DNM), a severe neck-to-mediastinum infection. Early detection, thoracotomy, and mediastinal irrigation significantly reduced the mortality rate from 40% to 20%.
Area of Science:
- Thoracic Surgery
- Infectious Diseases
- Critical Care Medicine
Background:
- Descending necrotizing mediastinitis (DNM) is a rare but severe infection with high historical mortality rates.
- Few large patient series have been published due to its uncommon nature.
- Previous mortality rates approached 40% before the 1980s.
Purpose of the Study:
- To evaluate the efficacy of a specific treatment strategy for descending necrotizing mediastinitis.
- To assess the impact of early intervention on patient outcomes.
- To analyze complications and mortality associated with DNM.
Main Methods:
- Retrospective chart review of 10 patients diagnosed with DNM between 1991 and 2003.
- Patients received broad-spectrum antibiotics and underwent surgical treatment including cervical drainage and thoracotomy with mediastinal debridement.
- Post-operative mediastinopleural irrigation with saline was administered until pleural effusion cultures were negative.
Main Results:
- The study involved 10 patients with a mean age of 53.8 years, with causes including peritonsillar abscess and post-extraction infections.
- Eight out of ten patients had a favorable outcome, resulting in a mortality rate of 20%.
- Severe complications occurred in five patients, including septic shock and acute respiratory distress syndrome.
Conclusions:
- The implemented treatment strategy for severe DNM proved efficacious in reducing mortality.
- Early detection and prompt surgical intervention, including thoracotomy and mediastinal irrigation, are crucial.
- This approach significantly lowered the mortality rate compared to historical data.
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