Descending necrotizing mediastinitis (DNM) is a severe infection spreading from cervical region to mediastinal connective tissue. The mortality rates have been reported between 25 and 40 % in the literature. Since DNM is uncommon, few reports of large series (more than 10 cases) of patients with DNM have been published. The aim was to evaluate our treatment strategy for DNM by retrospective chart review.
Retrospective chart review was performed in 10 patients with DNM between 1991 and 2003. 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, odontogenic abscess of post-extraction in 3, cervical abscess of post-tracheostomy in 1 and unknown in 1 patient. In 9 cases, the abscess extended from cervical region to the lower mediastinum, while in another case the abscess localized in the upper mediastinum above carina. Immediately after the diagnosis of DNM, broad spectrum antibiotics were administrated empirically and surgical treatments consisting of cervical drainage, thoracotomy with radical surgical debridement of the mediastinum with complete excision of the tissue necrosis, decortication and irrigation were performed in all cases. Postoperatively, mediastinopleural irrigation with saline was performed once or twice a day until culture of pleural effusion became negative.
The mean duration of chest tube detention was 26.7±17.0 days, and their 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. In patients with severe complications, two patients, who were older than 75 and had diabetes, died of multiple organ failure due to septic shock. (The mortality rate was 20 %).
Our treatment strategy for severe DNM was feasible and reduced the mortality rate.
Early detection of DNM and immediate thoracotomy and irrigation of mediastinum and thoracic cavity should be recommended.
T. Iwata, None.