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Eur J Cardiothorac Surg 2005;28:384-388
© 2005 Elsevier Science NL

Original articles

Early open thoracotomy and mediastinopleural irrigation for severe descending necrotizing mediastinitis

Department of Thoracic Surgery, Chiba University Graduate School of Medicine, 1-8-1, Inohana, Chuo-ku, Chiba 260-8670, Japan

Received 8 March 2005; received in revised form 15 May 2005; accepted 16 May 2005.

^* Corresponding author. Tel.: +81 43 222 7171x5464; fax: +81 43 226 2172. (Email: sekine{at}faculty.chiba-u.jp).

Abstract

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.

Key Words: Descending necrotizing mediastinitis • Thoracotomy • Pleural irrigation

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