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Eur J Cardiothorac Surg 2005;28:384-388
© 2005 Elsevier Science NL
Original articles |
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
1. Introduction
Acute mediastinitis is a serious infection involving the connective tissue that fills the interpleural spaces and surrounds the median thoracic organs. The most common causes of mediastinitis are esophageal perforations and infections after operations through sternotomy incisions. Occasionally, acute mediastinitis occurs as a complication of infections that may arise from odontogenic or cervicofascial infections or cervical trauma. This is a particularly virulent form of mediastinal infection, described as Descending Necrotizing Mediastinitis (DNM).
The criteria for diagnosing DNM were defined by Estrera and associates in 1983 [1]. These are: (1) clinical manifestations of severe infection; (2) demonstration of characteristic roentgenographic features; (3) documentation of the necrotizing mediastinal infection at operation or post-mortem examination, or both; (4) establishment of the relationship of oropharyngeal or cervical infection with the development of the necrotizing mediastinal process.
Delay of diagnosis and inappropriate drainage of the mediastinum are the main causes of mortality in this life-threatening condition. Until the 1980s, the mortality rates have been reported as 40% [1]. Since DNM is uncommon, few reports of large series of patients with DNM (that is, more than 10 cases) have been published [2–4]. We report our experience of 10 patients with DNM and discuss the surgical management.
2. Patients and methods
A retrospective chart review of 10 patients (7 male and 3 female) with DNM between 1991 and 2003 was performed. The mean age was 53.8±23.3 (median 58, range 16–82) years.
Diagnosis was made by clinical findings and cervicothoracic computed tomography (CT) in all patients. Preoperative CT demonstrated soft-tissue swelling of the neck and encapsulated fluid collections (with gas bubbles in some cases) or abscess of the mediastinum (Fig. 1 ).
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We retained 2–7 silicon tubes at the operation. In the most severe cases, one or two tubes were placed in mediastinum, one or two in the thoracic cavity (apical or dorsal) and one on the diaphragm (Figs. 3 and 4 ).
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Cervicothoracic CT was performed frequently to confirm the disappearance of abscess. Where abscess remained, re-operation was performed.
In this study, we evaluated the effectiveness of our management strategy in terms of surgical complications and survival rate.
3. Results
The patient characteristics are shown in Table 1 . Symptoms at hospitalization included pyrexia (n=8), neck or mandibular swelling (n=5), dyspnea (n=4), sore throat (n=4), dysphagia (n=2), and back pain (n=1). The foci of the inciting infections were 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. The interval between onset of symptoms and the first hospitalization varied from 0 to 12 days (mean 5.6 days).
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The clinical findings are shown in Table 2 . There was one case of Endo's type I, two cases of type IIA, and seven of type IIB. The white blood cell count or C-reactive protein (CRP) was elevated in the blood of all patients. Bacterial infection was determined by fluid culture from the neck or mediastinum in nine cases. The original organisms were Streptococci in seven cases, Peptostreptococci in four cases, Bacteroides in two cases, and Prevotella in two cases. In seven cases, aerobic and anaerobic organisms were mixed.
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Post-operatively, mechanical ventilation was provided in all cases, and continuous hemodialysis filtration (CHDF) was performed in a shock case (case 9).
Five patients suffered severe complications. Disseminated intravascular coagulation (DIC) or pre DIC occurred in 3 patients. Septic shock occurred in three cases. Acute respiratory distress syndrome (ARDS) occurred in two cases. Pan-peritonitis due to duodenal perforation occurred in 1 patient (case 9).
In case 8, we performed a second thoracotomy on post-operative day 3, because mediastinal residual abscess was found after the first thoracotomy by post-operative CT.
The mean duration of chest tube retention was 26.7±17.0 days, and the mean hospital stay was 62.3±33.9 days. Comparing the types of DNM, the mean duration of drainage was 18.3 days in types I and IIA and 37.6 days in type IIB (P=0.05), while the hospital stay was 51.7 days in types I and IIA and 73.4 days in type IIB (P=0.30).
The outcome was favorable in 8 patients who were less than 78-year-old, were without severe concomitant diseases, and were able to receive prompt treatment. Two patients (cases 7 and 9) died (overall mortality: 20%); they were an 82-year-old female and a 79-year-old female, both with severe diabetes and in an exacerbated condition at the time of operation.
4. Discussions
In 1938, Pearse [6] described 110 patients with DNM and reported a 55% mortality rate (86% mortality in non-operative patients and 35% in surgical patients). Even after induction of antibiotics, the mortality was still 40%, as reported by Estrera et al. [1] in 1983. Since the end of the 1990s, a few reports of large series (more than 10 cases) of patients with DNM have been published, which demonstrated a reduced mortality rate. In Table 4 , we compare previous reports to our study. The mortality rates vary from 0 to 23% [2–4].
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In terms of the thoracotomy approach, Freeman et al. [3] and Marty-Ane et al. [2,9] insisted that standard posterolateral thoracotomy was the best approach because it allows comprehensive access to a hemithorax including the ipsilateral mediastinum and pericardium. Successful management through median sternotomy [13,14] or clamshell incisions [15] has been reported. However, the risk of subsequent osteomyelitis of the sternum should be considered. Several authors have reported using video-assisted thoracoscopic surgery (VATS) [16,17]. However, it is controversial whether VATS obtains sufficient drainage and irrigation for severe cases. We used VATS for one case (case 9), but we could not rescue this case.
For effective post-operative irrigation, we retain several tubes and infuse saline from various tubes in order to irrigate a wide area of the thoracic cavity and mediastinum. Frequent culture of pleural effusion is employed to monitor post-operative infection.
5. Conclusion
Our treatment strategy for DNM is as follows. (1) If DNM is suspected, we perform cervicothoracic CT immediately for diagnosis and for evaluating the extent of infection and necrosis. (2) We initiate empirical broad-spectrum antibiotics as soon as DNM is suspected. We select antibiotics in consideration of anaerobic bacteria, which are present in 70% of cases. (3) We perform cervical and mediastinal debridement, drainage, and irrigation. The standard approach for mediastinal drainage is thoracotomy. (4) We repeat cervical and mediastinal-thoracic irrigation with copious saline, post-operatively, until the culture of pleural effusion becomes negative. (5) We perform CT frequently after operation for assessing the results of surgical drainage and irrigation.
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