Hindawi Publishing Corporation
Case Reports in Otolaryngology
Volume 2012, Article ID 504219, 4 pages
doi:10.1155/2012/504219
Case Report
Descending Necrotising Mediastinitis:
A Case Report Illustrating a Trend in Conservative Management
B. A. P. Jayasekera,1, 2 O. T. Dale,3 and R. C. Corbridge3
1 Department
of General Surgery, Royal Berkshire Hospital, Reading RG1 5AN, UK
West Wing, The John Radcliffe Hospital, Oxford OX3 9DU, UK
3 Department of ENT, Royal Berkshire Hospital, Reading RG1 5AN, UK
2 The
Correspondence should be addressed to B. A. P. Jayasekera, ashanoncall@gmail.com
Received 25 November 2011; Accepted 25 December 2011
Academic Editors: L. J. DiNardo and M. B. Naguib
Copyright © 2012 B. A. P. Jayasekera et al. This is an open access article distributed under the Creative Commons Attribution
License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly
cited.
The mortality rate from descending necrotising mediastinitis (DNM) has declined since its first description in 1938. The decline
in mortality has been attributed to earlier diagnosis by way of contrast-enhanced computed tomographic (CT) scanning and
aggressive surgical intervention in the form of transthoracic drainage. We describe a case of DNM with involvement of anterior
and posterior mediastinum down to the diaphragm, managed by cervicotomy and transverse cervical drainage with placement
of corrugated drains and a pleural chest drain, with a delayed mediastinoscopy and mediastinal drain placement. We advocate a
conservative approach with limited debridement and emphasis on drainage of infection in line with published case series.
1. Introduction
Descending necrotising mediastinitis describes a necrotising
fasciitis from an oropharyngeal or primary neck origin, with
spread along cervical tissue planes into the mediastinum.
Since its first description in 1938 [1], the mortality rate has
declined with prompt diagnosis by way of contrast-enhanced
computed tomographic (CT) scanning and aggressive surgical intervention. Whilst most reports support combined
cervical and transthoracic drainage and debridement, the
optimal method of drainage is contended. We describe the
management of a young man with DNM with cervicotomy
and transcervical mediastinal drainage with a pleural chest
drain and subsequent mediastinal drain.
2. Case Report
A 47-year-old man presented on the general medical take
with a 2-day history of sore throat, right sided pleuritic
chest pain, and neck swelling. On examination this patient
was systemically unwell and septic with diffuse anterior neck
swelling and subcutaneous crepitations. There was, however,
no discolouration of the overlying skin. There was evidence
of severe periodontal and gingival disease, with reduced
breath sounds on the right side of the chest, and a dull
percussion note at the right lung base.
Flexible nasolaryngoscopy demonstrated marked oedema of the supraglottis. The patient was intubated, and
a spiral CT of the neck and chest performed (Figure 1).
This showed free gas extending from retropharyngeal tissue
at the skull base, through subcutaneous/intermuscular fat
planes of the neck and around the larynx into the anterior
and posterior mediastinum to the level of the diaphragm,
with bilateral pleural effusions. No evidence of oesophageal
rupture was noted.
The patient was transferred directly to the operating
theatre. A bucket handle mastoid to mastoid incision was
made, and subplatysmal flaps raised. This revealed a necrotic
appearance of the strap muscles, thyroid tissue, and carotid
sheath, with discrete pockets of pus between the tissue
planes. The superficial strap muscles were debrided, and the
retropharyngeal space opened, expressing more pus. Swabs
2
Case Reports in Otolaryngology
(a)
(b)
(c)
Figure 1: Coronal and sagittal CT scans demonstrating free gas from the skull base through the neck and into the anterior and posterior
mediastinum.
were taken for microbiological culture, and all neck spaces
were washed out with betadine and hydrogen peroxide solution. Corrugated drains were placed in the retropharyngeal
space up to the skull base and down into the mediastinum,
and the skin loosely closed.
A right-sided chest drain was inserted in the fifth intercostal space, immediately draining a litre of frank pus. The
patient was then transferred to ITU.
Subsequently, a total dental clearance was performed.
On ITU persistent ST elevation was noted in his ECG,
with a raised troponin reflecting on going mediastinal
sepsis. A further CT scan was performed showing ongoing
mediastinal collections. He underwent mediastinoscopy and
insertion of mediastinal drains to drain his persisting mediastinal collections. The microbiology swabs taken at the time
of his initial neck debridement showed prevotella species
and anaerobes. The patient was started on a long course
of intravenous coamoxiclav. After 30 days intubated and
ventilated on ITU, he was extubated and transferred to the
ward to complete a 6-week course of IV antibiotics. At the
time of writing the patient is GCS 15 with no residual deficits
from his hospital episode.
3. Discussion
Various terms have been in use to describe deep spreading
infections in the neck and mediastinum. The first series
describing necrotising mediastinitis as a consequence of cervical suppuration was by Pearse in 1938 [1]. Of 110 patient
with necrotising mediastinitis (99 from the literature and 11
from Pearse’s own experience), 21 cases were oropharyngeal
in origin (retropharyngeal abscess n = 11, peritonsillar
Case Reports in Otolaryngology
abscess n = 8, Ludwigs angina n = 2). The majority of
cases were from perforated cervical oesophagus (n = 64).
Other aetiologies included supportive cervical lymphadenitis
n = 13, tracheotomies n = 6, spondylitis of the cervical spine
n = 3, and postthyroidectomy n = 3.
Estrera et al. [2] drew the distinction between descending
necrotising mediastinitis (DNM) originating from oropharyngeal/deep neck infections and necrotising mediastinitis from nonoropharyngeal/cervical sources, for example,
oesophagus, lung, and spine [2, 3]. They used the following
criteria for diagnosis of descending necrotising mediastinitis:
(1) clinical markers of severe infection, (2) characteristic
radiological appearances, (3) evidence of necrotising mediastinal infection during operation or postmortem, and (4)
oropharyngeal or cervical origin of descending necrotising
mediastinitis.
Spread of infection is thought to occur via three principle
cervical tissue spaces, namely, retropharyngeal, perivascular,
and pretracheal planes, facilitated by the absence of barriers
along such planes, negative intrathoracic pressure during
respiration, tissue necrosis, and gas-forming organisms [3].
Wheatley et al. [4], examining all case reports published from
1960 to 1990, reported predominantly odontogenic sources
of DNM. Recent meta-analyses of case series have suggested
that the aetiology of DNM is predominantly from pharyngeal
infections as opposed to odontogenic infections [3]. Other
causes include pharyngeal perforations from foreign bodies,
iatrogenic perforation, and primary neck infections. In
the case described the initial infection was thought to
be odontogenic in origin. The majority of infections are
polymicrobial with aerobic and anaerobic bacterial species.
Ridder et al. [3] identified Streptococcus species (pyogenes,
intermedius, constellatus), as the most prevalent aerobic
species in their series, with bacteroides species as the most
prevalent anaerobic species.
The mortality rate has declined from 49% in the first
reported case series by Pearse [1], with figures as low
as 11% in some series [3]. Earlier identification with CT
and more aggressive surgical drainage are thought to have
contributed to the decline in mortality. Estrera et al. [2]
first highlighted the value of contrast CT scans in timely
identification of DNM in a patient population with often
nonspecific clinical presentations. Contrast-enhanced CT
scans are considered the gold standard in investigation,
permitting accurate anatomical delineation of disease to
guide surgical intervention. After drawing the distinction
of descending necrotising mediastinitis from necrotising
mediastinitis from other sources, Estrera et al. [2] questioned the adequacy of transcervical mediastinal drainage,
suggesting transthoracic drainage in cases where necrosis
extended below the level of the fourth thoracic vertebrae
posteriorly or tracheal bifurcation. Marty-Ane et al. [5]
suggested systematic transthoracic drainage in cases of
DNM, irrespective of the level of mediastinal involvement.
Comparing English case reports/series from 1960 to 1995,
Corsten et al. [6] highlighted the favourable mortality rate
in patients treated with combined surgical neck and thorax
drainage compared to neck drainage alone (19% versus
47%, P < 0.05). They commented that thoracic drainage
3
was often for patients who were more ill and had not
responded to initial neck drainage, highlighting the merit
of thoracic drainage. Brunelli et al. [7] contended the view
of Marty-Ane, suggesting that transcervical drainage was
adequate in cases limited to the superior mediastinum. In
their series of 10 patients, Freeman et al. [8] attributed the
0% mortality rate to early diagnosis and surveillance for
disease progression either by clinical suspicion or empirically
at 48 to 72 hours after each operation. Any undrained
collections or progression of necrosis prompted repeat
surgical intervention. Mean operations per patient were
higher in Freemans series than in published case reports
from 1970 to 1999 (n = 102 patients), with more mean
transcervical (4 versus 2) and transthoracic procedures (2
versus 0.7), per patient.
Endo et al. [9] classified DNM on the basis of mediastinal
involvement as follows: type 1 no involvement beyond the
fourth thoracic vertebrae posteriorly, and type 2a involving
the anterior mediastinum, type 2b involving the anterior
and posterior mediastinum. They managed type 1 cases with
transcervical drainage alone (n = 2), type 2a cases with
combined transcervicotomy and subxiphoid mediastinal
drainage (n = 1), and type 2b cases with combined transcervicotomy and thoracotomy (n = 1). Karkas et al. [10], using a
similar algorithm, treated 17 patients successfully depending
on the level, and extent of mediastinal involvement with
cervicotomy for disease limited to the above carina, and
combined cervicotomy and sternotomy for anterior inferior mediastinal disease or cervicotomy and posterolateral
thoracotomy for posteroinferior mediastinal disease. The
transthoracic approach used to drain the mediastinal disease
varies, and some groups report favourable results with videoassisted thorascopic drainage for all classes of DNM [11].
Nakamori et al. [12] felt in their experience that the
principal goal of surgical intervention in cervical necrotising
fasciitis, and DNM was drainage of pus, rather than surgical
debridement. With this mind, they opted for percutaneous
drainage of cervical necrotising fasciitis and DNM under
radiological control. 6 cases of cervical necrotising fasciitis
complicated by DNM were successfully managed with percutaneous mediastinal drainage.
In our case we opted for limited surgical debridement
with cervicotomy and transcervical mediastinal drainage,
with corrugated drain placed into the superior mediastinum.
Despite the presence of posterior mediastinal involvement,
we felt that a pleural chest drain would provide adequate
drainage given the likely contiguity with the mediastinum.
However, the patient required subsequent mediastinoscopy
and insertion of a mediastinal drain for a persistent collection, highlighting the need to review the patient for
persistent/spreading infection clinically or for surveillance
with CT scans to identify unanticipated collections/spread of
disease. We advocate a conservative approach in managing
DNM and in this regard agree with Nakamori et al. that
surgical drainage rather than debridement should be the
principal aim of surgical intervention though the short
interval from presentation to surgery would have contributed
to the patient’s survival.
4
In summary DNM is an uncommon entity with an
often nonspecific clinical presentation. A high index of
suspicion when managing patients with deep neck infections
should prompt timely investigation in the form of contrastenhanced CT scanning to identify DNM. Management
priorities should include securing the patients airway, initiating broad-spectrum antibiotics to cover aerobic and
anaerobic species, and surgical intervention with minimal
delay. A multidisciplinary approach is necessary, with ENT
and cardiothoracic input, and maxillofacial surgery if an
odontogenic infection is suspected. If transthoracic drainage
is required the choice of percutaneous, thoracoscopic, or
open surgery should be guided by the facilities available
and the experience of the surgical teams involved, however,
where possible we advocate conservative intervention with
the emphasis on ensuring adequate drainage. Postoperative
surveillance for clinical signs of persistent infection or
empirical CT scans should be considered.
References
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