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Asian Cardiovascular and Thoracic Annals
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DOI: 10.1177/0218492311408641
2011 19: 228 Asian Cardiovascular and Thoracic Annals
Teppei Wakahara, Yugo Tanaka, Yoshimasa Maniwa, Wataru Nishio and Masahiro Yoshimura
Successful management of descending necrotizing mediastinitis

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Original Article
Successful management of descending
necrotizing mediastinitis
Teppei Wakahara, Yugo Tanaka, Yoshimasa Maniwa,
Wataru Nishio and Masahiro Yoshimura
Abstract
Descending necrotizing mediastinitis is a critical infection and the mortality rate remains high. Early aggressive surgical
drainage and antibiotic therapy are essential for treatment. We evaluated the efficiency of transthoracic drainage using a
minimally invasive technique in 11 cases of descending necrotizing mediastinitis between May 2002 and March 2008.
We performed a right-side minithoracotomy with thoracoscopic assistance, and the mediastinum was thoroughly
drained. The length of hospitalization ranged from 30 to 117 days. The postoperative course was good in all patients,
and the outcome was favorable. All patients were discharged without major complications. We recommend employing a
minithoracotomy with thoracoscopic assistance for aggressive treatment of descending necrotizing mediastinitis.
Keywords
bacterial infections, drainage, mediastinitis, otorhinolaryngologic diseases, thoracoscopy
Introduction
Descending necrotizing mediastinitis (DNM) is a criti-
cal infection that develops when an infection arises in
the neck region, such as the mouth or pharynx, and
descends to the mediastinum because of the anatomical
connection. Although the mortality rate has improved
in recent years, it still remains high at 14%23%.
1,2
We
treated 11 cases of DNM, and all were healed without
major complications. Herein, we describe our proce-
dures and discuss their advantages.
Patients and methods
From May 2002 to March 2008, we treated 11 consecu-
tive patients with DNM in Kobe University Hospital.
All patients underwent preoperative cervicothoracic
computed tomography (CT). Inclusion criteria for the
study population were those previously dened by
Estrera and colleagues:
3
clinical manifestations of a
severe infection, establishment of a relationship between
an oropharyngeal or cervical infection and subsequent
mediastinitis, radiographic features characteristic of
DNM (Figures 1 and 2), and documentation of a necro-
tizing mediastinal infection at the time of operative
debridement.
For entry into the thoracic cavity, a minithoracot-
omy with the assistance of thoracoscopy was performed
in all cases. Ten patients had a thoracotomy thorough
the right triangle of auscultation, and one had a right
para-mediastinal incision.
4
At the same time, cervical
open drainage was carried out by an otolaryngologist in
10 patients, and 9 underwent a tracheotomy in antici-
pation of laryngeal edema. The mediastinal pleura were
opened widely longitudinally in 3 areas: the anterior
mediastinum, paratracheal space, and posterior space
of the trachea including the subcarinal space (Figure 3).
Drainage of pus was followed by debridement of necro-
tic tissues. Silicon drains and tubes for postoperative
irrigation were positioned at all opened areas, and an
additional drain was placed in the inferior thoracic
cavity, just above the diaphragm (Figure 4).
Asian Cardiovascular & Thoracic Annals
19(3/4) 228231
The Author(s) 2011
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DOI: 10.1177/0218492311408641
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Division of Thoracic Surgery, Kobe University Graduate School of
Medicine, Kobe, Japan.
Corresponding author:
Yoshimasa Maniwa, Division of Thoracic Surgery, Kobe University
Graduate School of Medicine, 7-5-2 Kusunoki-cho, Chuo-ku, Kobe
650-001, Japan
Email: maniwa@med.kobe-u.ac.jp
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Postoperatively, we irrigated the mediastinum and
thoracic cavity continuously with warm physiologic
saline at 100 mLh
1
for 24 h. Subsequently, we per-
formed the irrigation with 1 L of physiologic saline
for 1 h twice daily. The duration of drainage and irri-
gation was dependent on clinical ndings and the
results of bacterial culture.
Results
The characteristics of each patient are shown in
Table 1. Their mean age was 65.9 years (range, 54
78), and 6 were male. Diabetes was observed in 4
patients. Two patients had injury to the pharynx as a
result of urgent tracheal intubation. No cases were
caused by odontogenic infection. The period from
detection of neck infection to thoracotomy for medias-
tinal drainage ranged from 3 to 22 days (mean, 7.7
days). In 3 cases (nos. 1, 2, 6), surgical treatment was
performed more than 10 days after the diagnosis of
cervical infection. In these patients, antibiotic therapy
had been given initially by general practitioners, but the
symptoms became worse, and they consulted us.
Bacteriological examination was carried out in all 11
patients, which revealed aerobic Streptococci in 6, aer-
obic Propionibacterium acnes in 1, and mixed aerobic
Figure 1. Chest radiograph showing enlargement
of the mediastinum.
Figure 3. The mediastinal pleura were opened wide,
longitudinally, in at least 3 areas: anterior mediastinum,
paratracheal space, and posterior space of the trachea to the
space of the subcarina. SVC=superior vena cava.
Figure 4. Postoperative chest radiograph showing thoracic
drains positioned in all opened areas, and an additional drain in
the inferior thoracic cavity, just above the diaphragm.
Figure 2. Chest computed tomography showing an abscess
extending from the upper mediastinum, with gas collections.
Wakahara et al. 229
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and anaerobic organisms (Streptococcus and Prevotella)
in 1; the pathogens could not be identied in the other 3
cases. The postoperative duration of mediastinal irri-
gation ranged from 5 to 30 days (mean, 12.3 days),
and the duration of drainage ranged from 9 to 56 days
(mean, 21.3 days). CT gave useful information on any
remaining abscess cavities. In one case, thoracotomy
was repeated to manage residual abscess cavities.
Duration of hospitalization ranged from 30 to 117
days (mean, 67.6 days). The mediastinitis resolved
well postoperatively in all patients, and the outcome
was favorable: all patients were discharged without
major complications.
Discussion
Because the cervical space contains loose areolar tissue
and continues into the pericardium, parietal pleura, and
mediastinum, any oropharyngeal or cervical infection
can easily move into the chest. Generally, the spread of
infection is very rapid. For example, it is said that infec-
tion from a cervical abscess can often progress to the
mediastinum within 48 h, and may result in pyothorax
and pericarditis as well as sepsis, disseminated intravas-
cular coagulation, and multiple organ failure.
3
In the
1980 s, the mortality from DNM was reported to be as
high as 30%40%. Although, early diagnosis by
improved CT imaging and the availability of broad-
spectrum antibiotics has reduced the mortality rate to
14%23%, it is still high compared to other infectious
diseases. Delay of treatment is one reason for the high
mortality rate in DNM; therefore, early aggressive
surgical drainage and antibiotic therapy are essential.
4
The therapeutic principle in our institution is to
perform emergency surgery soon after the diagnosis
of DNM.
It is very dicult to select the optimal antibiotic
therapy because identication of bacteria and antibiotic
sensitivity takes time. It is reported that mixed infec-
tions including both aerobic and anaerobic bacteria
were detected in >50% of DNM patients, and polymi-
crobial infections in 88%.
5,6
In our cases, aerobic bac-
teria in 7 patients and mixed aerobic and anaerobic
bacteria in one were detected by bacteriological exam-
ination, but no bacterium was detected in 3 because
previous medication masked the responsible bacteria.
We consider that intravenous broad-spectrum antibi-
otic therapy is essential in the primary treatment of
DNM because various bacteria may be responsible,
and the spread of infection is very rapid.
The indication for transthoracic drainage of the
mediastinum in patients with DNM is controversial.
Estrera and colleagues
3
stated that open drainage
should be performed when the abscess cannot be con-
trolled by transcervical mediastinal drainage. Kruyt
and colleagues
7
argued that transcervical drainage is
adequate for draining the mediastinum in patients
who do not have septic conditions. Endo and col-
leagues
8
classied DNM into 3 types, according to
the degree of spread of DNM diagnosed by CT, and
proposed dierent surgical management strategies
according to this classication. On the other hand, sev-
eral reports demonstrated that aggressive mediastinal
drainage by a thoracotomy approach is required for
treatment of DNM, regardless of the level of mediasti-
nal involvement.
9,10
Marty-Ane and colleagues
11
rec-
ommended the thoracotomy approach because it
allows comprehensive access to a hemithorax including
the ipsilateral mediastinum and pericardium. Corsten
and colleagues
12
noted that the mortality rate in cases
of transcervical drainage only was 47%, whereas it was
19% after thoracotomy drainage.
Table 1. Characteristics of 11 patients with descending necrotizing mediastinitis
Case Age (years)/ Underlying Duration* Drainage Hospital
No. Sex Disease Source of infection (days) Time (days) Stay (days) Outcome
1 57/M AF Retropharyngeal abscess 22 Unknown 62 Discharged
2 60/F - Unknown 11 11 64 Discharged
3 67/F AMI Pharyngeal intubation injury 5 56 64 Discharged
4 58/M DM/gout Acute epiglottitis 3 15 30 Discharged
5 74/F Dementia Acute epiglottitis 5 12 103 Discharged
6 63/M Basedow disease Cervical cellulitis 13 23 30 Discharged
7 74/M AMI Pharyngeal intubation injury 5 16 60 Discharged
8 78/M RA/DM Unknown 6 17 117 Discharged
9 54/M - Cervical cellulitis 5 40 110 Discharged
10 69/F - Pharyngeal injury 7 14 61 Discharged
11 71/F DM Unknown 3 9 43 Discharged
*From onset of primary infection to operation. AF =atrial fibrillation, AM=acute myocardial infarction, DM=diabetes mellitus,
RA=rheumatoid arthritis.
230 Asian Cardiovascular & Thoracic Annals 19(3/4)
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It seems that previous debate concerned whether the
adequacy of drainage or avoidance of the stress of
surgery was given priority in the treatment of DNM.
We consider that minimally invasive surgery and accu-
rate drainage are both important. Therefore, we
performed a minithoracotomy with thoracoscopic assis-
tance in all 11 cases, to achieve minimally invasive and
ecient drainage. Compared to the conventional thora-
cotomy, our approach provided a smaller surgical
wound and less invasive treatment. Moreover, with the
aid of thoracoscopy, we were able to get good visualiza-
tion of the entire thoracic cavity and ensure ecient
drainage. Although we recognize that some of our
cases might have been controllable by a transcervical
approach only, avoidance of the transthoracic approach
might have resulted in failure of treatment in some cases.
Furthermore, emergency cervical and mediastinal drain-
age was performed at the same time in all cases, even
if the patients condition was poor, because prompt
treatment is also necessary for DNM. Our treatment
approach was successful in all 11 patients. In recent
case reports, mediastinal drainage using video-assisted
thoracoscopic surgery has been described as a much less
invasive approach.
13,14
The progress in thoracoscopic
techniques has reduced the degree of surgical stress,
and transthoracic drainage can be employed without
constraint. It is expected that treatment for DNM will
develop with less invasive and more ecient drainage.
The prophylactic indication for postoperative tra-
cheotomy is controversial. We consider that tracheot-
omy should be performed in patients whose
preoperative respiratory condition is severe, because
pharyngeal edema and airway constriction are frequent
symptoms of DNM. In 9 of our 11 patients, strict respi-
ratory care was needed for long periods because the
preoperative respiratory condition was severe. Thus
we performed tracheotomy without hesitation in these
cases, and obtained good results. Because the tracheot-
omy site is near the cervical drainage wound, cervical
infection could spread to the tracheotomy wound,
resulting in a longer hospital stay. However, we con-
sider that airway management is more important than
wound infections. We recommend that a minithoracot-
omy with thoracoscopic assistance should be employed
for aggressive treatment of patients with DNM.
Funding
This research received no specic grant from any funding
agency in the public, commercial, or not-for-prot sectors.
Conflict of interest statement
None declared.
References
1. Sancho LM, Minamoto H, Fernandez A, Sennes LU and
Jatene FB. Descending necrotizing mediastinitis: a
retrospective surgical experience. Eur J Cardiothorac
Surg 1999; 16: 200205.
2. Papalia E, Rena O, Oliaro A, Cavallo A, Giobbe R,
Casadio C, et al. Descending necrotizing mediastinitis:
surgical management. Eur J Cardiothorac Surg 2001;
20: 739742.
3. Estrera AS, Landay MJ, Grisham JM, Sinn DP and Platt
MR. Descending necrotizing mediastinitis. Surg Gynecol
Obstet 1983; 157: 545552.
4. Tanaka Y, Maniwa Y, Yoshimura M and Okita Y.
Successful treatment of descending necrotizing mediasti-
nitis. Gen Thorac Cardiovasc Surg 2007; 55: 366369.
5. Wheatley MJ, Stirling MC, Kirsh MM, Gago O and
Orringer MB. Descending necrotizing mediastinitis:
transcervical drainage is not enough. Ann Thorac Surg
1990; 49: 780784.
6. Chow AW, Roser SM and Brady FA. Orofacial odonto-
genic infections [Review]. Ann Intern Med 1978; 88:
392402.
7. Kruyt PM, Boonstra A, Fockens P, Reeders JW and van
Lanschot JJ. Descending necrotizing mediastinitis caus-
ing pleuroesophageal fistula: successful treatment by
combined transcervical and pleural drainage. Chest
1996; 109: 14041407.
8. Endo S, Murayama F, Hasegawa T, Yamamoto S,
Yamaguchi T, Sohara Y, et al. Guideline of surgical man-
agement based on diffusion of descending necrotizing
mediastinitis. Jpn J Thorac Cardiovasc Surg 1999; 47:
1419.
9. Marty-Ane CH, Alauzen M, Alric P, Serres-Cousine O
and Mary H. Descending necrotizing mediastinitis:
advantage of mediastinal drainage with thoracotomy.
J Thorac Cardiovasc Surg 1994; 107: 5561.
10. Freeman RK, Vallieres E, Verrier ED, Karmy-Jones R
and Wood DE. Descending necrotizing mediastinitis: an
analysis of the effects of serial surgical debridement on
patient mortality. J Thorac Cardiovasc Surg 2000; 119:
260267.
11. Marty-Ane CH, Berthet JP, Alric P, Pegis JD, Rouvie` re P
and Mary H. Management of descending necrotizing
mediastinitis: an aggressive treatment for an aggressive
disease. Ann Thorac Surg 1999; 68: 212217.
12. Corsten MJ, Shamji FM, Odell PF, Frederico JA,
Laframboise GG, Reid KR, et al. Optimal treatment of
descending necrotizing mediastinitis. Thorax 1997; 52:
702708.
13. Roberts JR, Smythe WR, Weber RW, Lanutti M,
Rosengard BR and Kaiser LR. Thoracoscopic manage-
ment of descending necrotizing mediastinitis. Chest 1997;
112: 850854.
14. Nagayasu T, Akamine S, Oka T and Muraoka M.
Thoracoscopic drainage with wound edge protector for
descending necrotizing mediastinitis. Interact Cardiovasc
Thorac Surg 2003; 2: 5860.
Wakahara et al. 231
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