Management of descending necrotizing mediastinitis.

PURPOSE

One of the most dreaded and the most lethal form of mediastinitis is descending necrotizing mediastinitis (DNM).

PATIENTS AND METHODS

Between January 1990 and June 2001, 6 patients (mean age, 54.5 years; age range, 19 to 72 years) with DNM were treated in the Department of Thoracic Surgery of General Hospital of Attica "K.A.T." The primary etiology was odontogenic abscess in 3 patients and peritonsillar abscess in the other 3. Diagnosis was confirmed by computed tomography of the neck and chest. All patients underwent surgical drainage of the involved cervical region and mediastinum by monolateral cervicotomy and left thoracotomy.

RESULTS

The delay between the occurrence of thoracic symptoms and mediastinal drainage varied from 1 to 4 days. The thoracic approach and the side of the thoracotomy depended on the involved mediastinal compartments and side of pleural effusion. The duration of mediastinal drainage varied from 8 to 22 days (mean, 12.5 days). One patient died of multiorgan failure related to postoperative septic shock.

CONCLUSION

Delayed diagnosis and inadequate drainage are the main causes of the high mortality rate of DNM. Routine use of the computed tomography scan is highly recommended in patients with a deep cervical infection for early detection of mediastinitis at a time when the chest roentgenogram is still normal. If one realistically hopes to avoid the high mortality rate, aggressive surgical drainage and debridement of the neck and drainage of the mediastinum via a posterolateral thoracotomy by a multidisciplinary team of surgeons are required.