Descending Cervical Mediastinitis

doi:10.1016/S0003-4975(98)00142-8

The Annals of Thoracic Surgery

Volume 65, Issue 5, May 1998, Pages 1483-1488

https://doi.org/10.1016/S0003-4975(98)00142-8 Get rights and content

Abstract

Descending cervical mediastinitis is an uncommonly reported presentation of infection originating in the head or neck and descending into the mediastinum, which is fraught with impressive morbidity and mortality rates of 30% to 40% or more. We present the INOVA–Fairfax–Alexandria Hospital experience with descending cervical mediastinitis, January 1, 1986, to April 1, 1997; in addition we review the English-language medical and surgical literature with regard to this entity. Computed tomography and magnetic resonance imaging serve to aid both diagnosis and management. The application of broad-spectrum antibiotics should initially be empiric, with an eye to coverage of mixed aerobic and anaerobic infections. Definitive treatment mandates early and aggressive surgical intervention. All affected tissue planes, cervical and mediastinal, must be widely debrided, often leaving them open for frequent packing and irrigation. The treating physician must remain always alert to the further extension of infection, which, if it occurs, must be further debrided and drained. Tracheostomy serves a dual role of further opening cervical fascial planes and securing an often compromised airway.

Section snippets

Patient 1

A 38-year-old female addict was admitted, after injecting herself over the previous 3 months through the left internal jugular vein, with fever, left neck swelling, dyspnea, and trismus. Broad-spectrum antibiotics were initiated. A computed tomographic (CT) scan of the neck and chest revealed deep cervical and superior mediastinal fascial edema and possible microabscess formation. Spiking temperatures, dyspnea, and neck and mandibular rigidity resolved quite rapidly after deep left neck and

Comment

Descending cervical mediastinitis refers to mediastinal infections that begin at the cervical region and spread through deep fascial planes into the mediastinum. The 5 cases reviewed represent the full and morbid spectrum of the disease, yet without the high mortality (Table 1) usually reported 20, 28.

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Cited by (130)

Methicillin-resistant staphylococcus aureus descending necrotizing mediastinitis in an infant
2023, Journal of Pediatric Surgery Case Reports
Citation Excerpt :
Descending necrotizing mediastinitis (DNM) is a medical emergency that is not well described in pediatric patients. The mortality rate can reach as high as 40% and management of a patient with DNM can be difficult, especially when complicated by the rising incidence of methicillin-resistant Staphylococcus aureus (MRSA) infection [1,2]. We present a rare case of DNM, one of the youngest patients in the literature, that stemmed from a complicated MRSA oropharyngeal infection.
Descending necrotizing mediastinitis (DNM) can be a deadly medical emergency that is not well described in pediatric patients. Usually stemming from an oropharyngeal infection, it can spread rapidly to the mediastinum through the alar fascia known as the “danger space.”
We describe a rare case of a 4-month-old female who was found to have a complicated oropharyngeal MRSA infection leading to DNM. Contrast-enhanced computed tomography showed an extensive oropharyngeal abscess that spanned from her skull base to the mediastinum, encasing her the neurovascular bundle of the carotid sheath, as well as the great vessels of the aorta. An associated large right pleural effusion also complicated her case.
The patient was treated with antibiotic therapy, multiple operative drainages of her supraclavicular abscesses, and tube thoracostomy. She was able to make a full recovery and was discharged with a course of antibiotics.
DNM is a rare, but potentially deadly, complication of oropharyngeal infection. Surgical intervention, along with antibiotic therapy, must be considered if the severity of DNM is extensive. Clinicians must have a high index of suspicion for DNM when pediatric patients present with a severe oropharyngeal infection, especially with the rise of MRSA associated infections.
A global science mapping analysis on odontogenic infections
2023, Journal of Stomatology, Oral and Maxillofacial Surgery
Odontogenic infections are common and a topic of core interest for dentists, and maxillofacial surgeons. The aim of this study was to conduct a bibliometric analysis of the global literature on odontogenic infection and explore the top 100 most cited papers to identify the common causes, sequelae and management trends.
Following a comprehensive literature search, a list of top 100 most cited papers was created. The VOSviewer software (Leiden University, The Netherlands) was used to create a graphical representation of the data, and statistical analyses were performed to analyze the characteristics of the top 100 most cited papers.
A total of 1,661 articles were retrieved with the first article published in 1947. There is an exponential upward trend on the number of publications (R² = 0.919) and a majority of papers are in English language (n = 1,577, 94.94%). A total of 22,041 citations were found with a mean of 13.27 per article. The highest number of publications were recorded from developed countries. There was a male predilection in the reported cases and the most common sites included the submandibular and parapharyngeal spaces. Diabetes mellitus was identified as the commonest co-morbidity. Surgical drainage was ascertained to be the preferred method of management.
Odontogenic infections remain prevalent and have a global distribution. Although prevention of odontogenic infection through meticulous dental care is ideal, early diagnosis and prompt management of established odontogenic infections is important to avoid morbidities and mortality. Surgical drainage is the most effective management strategy. There is lack of consensus regarding the role of antibiotics in the management of odontogenic infections.
Descending necrotizing mediastinitis and the proposal of a new classification
2021, JTCVS Open
We aimed to clarify the clinical features and surgical outcomes of descending necrotizing mediastinitis (DNM) to provide a guide for its surgical treatment, focusing on the type of extension and the deployed procedures.
As a joint study of the Japan Broncho-esophagological Society and the Japanese Association for Chest Surgery (JBES1703/JACS1806 study), the clinical data of consecutive patients with DNM who underwent surgical drainage between 2012 and 2016 were collected from 131 participating institutions. The infection limited to the area superior to the carina level was defined as type I; while spreading to the lower mediastinum (LM) as type II. The LM infection limited to the anterior LM, that spread to both the anterior and posterior LM and that limited the posterior LM (type IIC) were further categorized as type IIA, IIB, and IIC, respectively.
A total of 225 patients were ultimately eligible. One hundred patients (44.4%) were categorized as type I, whereas 125 patients were type II (56.6%); The number of type IIA, IIB, and IIC cases was 20 (16%), 62 (49.6%) and 43 (34.4%), respectively. Patients with type I and IIC infections more commonly underwent cervical drainage than patients with type IIA and IIB infections (34.3% and 13.4%, respectively). A total of 8 patients died within 30 days (3.6%, type I/II: 1/7). The 5-year overall survival rate was 68.6%. Type II infection was associated with the 90-day mortality (odds ratio, 5.18; P = .045).
This study demonstrated a previously unclassified group of lower mediastinal extent that is localized within the posterior mediastinum (type IIC). We proposed a new DNM classification including type IIC mediastinitis.
Descending necrotizing mediastinitis: Case report and literature review
2021, Cirugia Cardiovascular
La mediastinitis necrosante descendente es una forma de mediastinitis originada a partir de una infección orofaríngea u odontogénica. Se caracteriza por una infección polimicrobiana aguda con necrosis fascial extensa que puede afectar músculos y piel contigua.
Se trata de una patología poco frecuente con gran relevancia dentro de la cirugía torácica por su elevada mortalidad (cercana al 40%). Las decisiones del equipo médico responsable del manejo de estos pacientes son decisivas, ya que el retraso en el diagnóstico y el tratamiento inapropiado o insuficiente son los principales factores asociados a la alta mortalidad.
Se presenta caso de paciente hombre de 63 años de edad que acude al servicio de urgencias posterior a manejo conservador de un absceso cervical, sin respuesta a tratamiento y deterioro clínico. A su ingreso se realizó tomografía simple y contrastada, donde se observó proceso inflamatorio con extensión desde el piso de la boca hasta mediastino anterior. Se realizó procedimiento quirúrgico con abordaje transcervical y esternotomía media. Cursó con adecuada evolución posterior a manejo.
Esta revisión aborda desde las consideraciones anatómicas y vías de diseminación de la infección en una mediastinitis necrosante descendente, hasta el diagnóstico y tratamiento de elección en esta patología.
La importancia de este trabajo radica en la presentación de un caso clínico que ejemplifica el manejo adecuado y escalonado en un paciente con mediastinitis necrosante descendente, asociado a una revisión actual de la literatura.
Descending necrotizing mediastinitis is a mediastinitis’ form that has its origin in an oropharyngeal or dental infection. It is presented as a multibacterial infection that causes fascial necrosis and may affect muscles and nearby skin.
It is a rare entity that is considered very important among thoracic surgery because it has a high mortality rate (close to 40%). Medical team's decisions are decisive because diagnosis and treatment's delay are the main factors related to mortality.
We present a clinical case of a male patient, 63 years old. He entered emergency room after being treated medically for a neck infection, without improvement. Immediately after arrival, he was taken for a CT cervical and thoracic scan, where we found an inflammatory process that extended from mouth's floor to anterior mediastinum. He was operated using a transcervical and medial sternotomy approach, with abscess drainage. He recovered without any complication.
This review includes descending necrotizing mediastinitis’ anatomical considerations and dissemination pathways, as well as its diagnosis and treatment.
The importance of this work is the presentation of a well-treated patient as an example of how management has to be done when this entity is suspected. We also did a literature review in order to present the most relevant knowledge.
Nontraumatic head and neck injuries: a clinical approach. Part 2
2017, Radiologia
Las urgencias no traumáticas de cabeza y cuello son un reto en el campo neurorradiológico por los motivos referidos en la primera parte: su área de afectación, en la encrucijada del tórax y la cavidad craneal, y su baja incidencia en la urgencia, lo que supone que sean poco conocidas.
Manteniendo el mismo enfoque que en la actualización previa, a partir de las formas clínicas de presentación en el ámbito de la urgencia, en lugar de la división por regiones anatómicas estudiaremos las entidades que se presentan con patrones que combinan tumefacción cervical, disfagia y disnea, y los déficits agudos de los sentidos. Dentro de este último grupo, el síntoma al que haremos referencia específica será el déficit visual, puesto que es el que de forma más frecuente requiere estudio radiológico urgente.
Nontraumatic emergencies of the head and neck represent a challenge in the field of neuroradiology for two reasons. As explained in the first part of this update, these entities affect an area where the thorax joins the cranial cavity and can thus compromise both structures; second, they are uncommon, so they are not well known.
Maintaining the same approach as in the first part, focusing on the clinical presentations in the emergency department rather than on the anatomic regions affected, we will study the entities that present with two patterns: those that present with a combination of cervical numbness, dysphagia, and dyspnea and those that present with acute sensory deficits. In the latter group, we will specifically focus on visual deficits, because this is the most common symptom that calls for urgent imaging studies.
A Case of Extensive Descending Necrotizing Mediastinitis Requiring Repeated Drainage
2024, Practica Oto-Rhino-Laryngologica

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Current ReviewDescending Cervical Mediastinitis

Abstract

Section snippets

Patient 1

Comment

Oral Surg

Chest

J Oral Maxillofac Surg

Ann Thorac Surg

Br J Oral Maxillofac Surg

J Oral Maxillofac Surg

J Oral Maxillofac Surg

Ann Thorac Surg

Ann Thorac Surg

J Oral Maxillofac Surg

Am J Med

Chest

J Thorac Cardiovasc Surg

J Oral Maxillofac Surg

J Oral Maxillofac Surg

Ann Thorac Surg

Chest

Surg Clin North Am

Surg Clin N Am

Suppurative soft tissue infection of the head and neck

West Ind Med J

Nonclostaidial deep gas-producing infection in the neck

Arch Otolaryngol

Fatal mediastinitis following retropharyngeal abscess

Arch Otolaryngol

Pharyngeal-esophageal perforations associated with rapid oral endotracheal intubation

Ann Otol Rhinol Laryngol

Endotracheal tube perforation of the hypopharynx

West J Med

Necrotizing fascitis of the necka complication of dental extraction

Tex Med

Mediastinitis in a child caused by perforation of pharynx

Am J Dis Child

Nontraumatic mediastinitis

JAMA

Current Review
Descending Cervical Mediastinitis