Nikolaos Nikolaos D, Apostolakis Efstratios E, Marangos Markos N, Koletsis Efstratios N, Zampakis Petros, Panagopoulos Konstantinos, Dougenis Dimitrios
Department of Cardiothoracic Surgery, Patras University School of Medicine, Patras, Greece.
Med Sci Monit. 2007 Jul;13(7):CS83-7.
Descending necrotizing mediastinitis (DNM) is a life-threatening complication secondary to oropharyngeal abscesses, esophageal perforation, or neck infections spreading into the mediastium, but very uncommon after thyroidectomy. Early diagnosis and close clinical and laboratory monitoring are crucial for patient survival. CT scanning of the cervical and thoracic area is a useful tool for diagnosis and follow-up. Different surgical approaches in the management of DNM have been proposed, the most widely accepted being a combined cervicotomy with lateral thoracotomy procedure.
A rare case of DNM with group A ss-hemolytic streptococci, in a 47-year-old patient developing after thyroidectomy for multinodular goiter is presented. A more conservative approach through a cervical incision was followed and thoracic drains for pleural effusion evacuation were inserted. After re-operation, repeated CT scanning for disease progression and prompt surgical wound cleaning were performed. Antibiotic therapy was continued up to one month after release. The patient's recovery was uneventful and continues well.
To the best of the authors' knowledge this is the second case of post-thyroidectomy DNM reported. According to present data it is recommend that a less invasive approach could be satisfactory when prompt diagnosis is established and the thoracic drainage is effective. This case suggests that repeated postoperative CT scanning and close clinical and laboratory monitoring could make an additional thoracotomy a second-line procedure. Moreover, due to the fact that only two cases of post-thyroidectomy DNM are reported worldwide, therapy of this condition remains an open question.
下行性坏死性纵隔炎（DNM）是口咽脓肿、食管穿孔或颈部感染蔓延至纵隔继发的一种危及生命的并发症，但在甲状腺切除术后非常罕见。早期诊断以及密切的临床和实验室监测对患者存活至关重要。颈部和胸部CT扫描是诊断和随访的有用工具。对于DNM的治疗已提出了不同的手术方法，最广泛接受的是颈切开术联合侧胸切开术。
本文介绍了一例罕见的甲状腺切除术后发生的由A组β溶血性链球菌引起的DNM病例，患者为47岁，因结节性甲状腺肿接受了甲状腺切除术。采用了更为保守的经颈部切口的方法，并插入胸腔引流管以排出胸腔积液。再次手术后，进行了重复CT扫描以观察疾病进展，并及时清理手术伤口。抗生素治疗持续至出院后一个月。患者恢复顺利且情况良好。
据作者所知，这是报告的第二例甲状腺切除术后DNM病例。根据现有数据，建议在确诊后及时采取侵入性较小的方法且胸腔引流有效的情况下可能会令人满意。该病例表明，术后重复CT扫描以及密切的临床和实验室监测可能会使再次开胸手术成为二线手术。此外，由于全球仅报告了两例甲状腺切除术后DNM病例，这种疾病的治疗仍然是一个悬而未决的问题。
