Descending Necrotizing Mediastinitis After Thyroidectomy

Thyroidectomy is a commonly performed endocrine procedure with generally low complication rates. Descending necrotizing mediastinitis (DNM) is an exceptionally rare but life-threatening complication resulting from cervical infections that spread into the mediastinum. DNM following thyroid surgery has been reported only rarely.

We analyzed retrospectively five patients who developed DNM following thyroid surgery between 2023 and 2025 at two tertiary centers. The patients' demographics, comorbidities, surgical procedures, clinical presentation, imaging, microbiology, treatment, complications, and outcomes were reviewed. The diagnosis was based on clinical and radiological evidence of cervicomediastinal infection, with operative confirmation in the four patients who underwent surgical drainage. A literature review was conducted using PubMed, MEDLINE, and Embase.

The case series included four women and one man (age 35-68, mean 53.8 years). All patients had at least one comorbidity, including obesity, cardiovascular or respiratory disease, immune compromise, and chronic nicotine use. Surgical procedures included total thyroidectomy (n = 3) and hemithyroidectomy (n = 2). Symptoms developed 2-10 days postoperatively, including cervical pain, swelling, fever, dysphagia, dyspnea, tachycardia, and subcutaneous emphysema. Contrast-enhanced (CT) of the neck and chest demonstrated findings consistent with DNM in all patients, with operative confirmation in the four patients requiring surgical drainage. Microbiological analyses identified Streptococcus pyogenes in three patients and Streptococcus pneumoniae in one patient. Concomitant methicillin-susceptible Staphylococcus aureus (MSSA) was isolated in one of the patients with S. pyogenes, while an additional patient had a positive rapid Group A Streptococcus test without confirmatory culture. Treatment included cervical drainage (n = 4), thoracic intervention (n = 2), tracheal repair (n = 1), and ICU admission (n = 4). Complications included acute kidney failure, septic shock, pleural/pericardial effusions, pulmonary embolism, and cardiac arrest. All patients survived with hospital stays ranging 7 to 42 days (median 21). Although the acute infectious process resolved in all patients, some required rehabilitation and one experienced long-term disability affecting daily activities and work capacity.

DNM after thyroidectomy is rare but potentially life-threatening. Early recognition, contrast-enhanced CT, prompt surgical drainage, and broad-spectrum antibiotics are essential. Awareness of predisposing factors and vigilant postoperative monitoring improves outcomes.