Descending mediastinal infections are usually associated with acute fulminant processes. Origins of infection include odontogenic, pharyngeal or cervical infections. Disease spreads into the mediastinum via fascial planes. Delays in diagnosis and management are frequent and may be associated with poorer outcomes. Ideal management varies according to acuity of presentation.
A retrospective review of all patients treated by thoracic surgeons at two teaching hospitals over an 18 month period was performed. The group was analysed for referral pattern, etiology of infection, clinical presentation, management approaches and outcome.
Over the study period, 4 patients were treated surgically for descending mediastinal infections. All patients were referred after initial treatment with intravenous antibiotics at outside facilities resulted in progression of disease or failure of management. There were 3 males and 1 female. One patient presented with a fulminant course, one presented with an acute but stable course, and two patients were symptomatic but clinically stable. The two acute presentations resulted from presumed odontogenic infections. The other two patients had underlying pharyngeal infections. Those patients with odontogenic sources required more aggressive surgical debridement due to greater mediastinal involvement. These two patients underwent extensive mediastinal debridement via thoracotomies. The two patients with underlying pharyngeal infections were managed with mediastinal drainage via cervical approaches. There were no deaths. Patients were discharged on post-operative days 5, 6, 7, and 49 in the most acute case. All patients were discharged on intravenous or oral antibiotics. No patients had recurence of their disease process.
Descending mediastinal infections may not present as acute descending mediastinitis. However, once the mediastinum is involved in the disease process, conservative management with intravenous antibiotics will fail. A high index of suspicion is needed in patients with the underlying etiological processes who fail to improve with conservative care. Surgical management is necessary but varies according to severity of disease.
Appropriate initial management of descending mediastinal infections will decrease morbidity and mortality including the use of less invasive approaches when appropriate.
A. Wohler, None.