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Seventy-nine-year-old man presents with tongue and neck swelling, inspiratory stridor, dyspnea, and fever. (A) Contrast-enhanced 16-section CT axial source image of the neck shows a fluid collection in the right submandibular space (white arrow), pretracheal space (black arrow), and retropharyngeal space (arrowheads). (B) CT scan at the level of the sterno-manubrial junction shows a fluid collection in the posterior mediastinum (asterisks). (C) The fluid collection extends caudally to the diaphragmatic crura (asterisks). (D) Parasagittal reformatted CT images provide optimal depiction of spread of odontogenic infection through the retrovisceral space (asterisks). This is an example of a posterior route of spreading of the infection. Note that the involvement of the anterior visceral space (arrowheads) is limited to the thoracic inlet and does not concern the anterior mediastinum. (Reprinted with permission from Scaglione et al. 21 )
Source publication
Descending necrotizing mediastinitis (DNM) is an uncommon disease and may be lethal if not treated adequately and promptly. In all settings, multidetector row computed tomography (MDCT) is the most valuable tool to assess the presence and extension of the disease when DNM is clinically suspected. The key point for an accurate diagnosis of descendin...
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Citations
... Among the imaging examinations, contiguous cervicothoracic CT is considered as the most reliable and accurate method for diagnosis. Fluid density, the presence of gas bubbles in soft tissue, and increased density of the fat and cellulitis are typical signs of infection (19). CT can not only detect infections and abscesses at an early stage but can also guide surgical approaches. ...
Background
Acute necrotizing mediastinitis (ANM) is a severe infection of the mediastinal loose connective tissue. Traditionally, it has been treated with thoracotomy, but video-assisted thoracic surgery (VATS) is been increasingly used in patients with this condition. This study aimed to compare the outcomes of VATS and open thoracotomy in treating ANM.
Methods
The medical records of patients with ANM who underwent surgery between March 2012 and April 2021 were retrieved. A retrospective screening was conducted based on clinical characteristics, bacterial pathogens, surgical approach, and outcomes. The patients were divided into a VATS group and an open thoracotomy (Open) group. The patient characteristics and surgical outcomes of the two groups were summarized and compared.
Results
A total of 64 cases were enrolled in this study, including 48 in the VATS group (75%) and 16 in the Open group (25%). The most common site of infection was the neck (n=26, 40.6%). Streptococcus constellatus and Acinetobacter baumannii (A. baumannii) were the most frequently found pathogens in secretion culture. In sputum culture, the most common pathogens were Klebsiella pneumonia and A. baumannii. Postoperative outcomes, including blood transfusion (33.3% vs. 43.8%; P=0.45), duration of postoperative drainage {14 [1–47] vs. 17 [4–54] days; P=0.15}, length of antibiotic medication {14.5 [1–54] vs. 18 [4–54] days; P=0.29}, admission to intensive care unit (ICU) (87.5% vs. 75.0%; P=0.43), length of ICU stay {5 [1–58] vs. 8.5 [1–37] days; P=0.20}, postoperative hospital stay {17 [2–61] vs. 21 [5–56] days; P=0.22}, reoperation rate (12.5% vs. 6.25%; P=0.82), and mortality rate (14.6% vs. 12.5%; P>0.99) were comparable between the two groups.
Conclusions
ANM treated by both the VATS and open approach had comparable outcomes. Therefore, VATS is a viable option for patients with ANM.
... In patients with AM secondary to esophageal perforation the main findings are thickening of the esophageal wall, periesophageal collections, pneumomediastinum and extravasation of the contrast medium into the mediastinum (19,20). In patients with NDM, alterations in imaging studies correspond to basal infection (collections in the neck compartments), with caudal extension to the mediastinum, subcutaneous emphysema, subcutaneous cellular tissue edema, and manifestations related to mediastinitis 6,21,22 . ...
Background:
Acute mediastinitis is the inflammation of the connective tissue and fat surrounding the mediastinal structures. It is a high-mortality entity and its most frequent causes include sternotomy infections from cardiovascular surgery, esophageal perforation and extension of head and neck infections. Isolated cases of acute mediastinitis from hematogenous spread are described in the literature.
Case presentation:
58 year-old man, with history of gouty arthritis managed with steroids, diagnosed with acute mediastinitis by S. aureus, secondary to septic arthritis of the ankle, managed with drainage of mediastinal collections by thoracoscopy and antibiotic therapy, with satisfactory evolution.
Conclusions:
In patients with acute mediastinitis, hematogenous dissemination should be considered when the etiologies most frequently associated with the entity are ruled out. Early surgical treatment derived from a multidisciplinary diagnostic approach improves the prognosis of these patients.
... -endobuccal drainage by retropharyngeal puncture; -cervical drainage with a large cervicotomy and placement of large drains a little distance from the vessels -possibly thoracic drainage by anterolateral thoracotomy in case of pyothorax Estrera, et al. [4] and Scaglione et al [6,14] emphasized the interest of cervicothoracic CT for diagnosis, For many authors, an exclusive cervical approach is sufficient if the process does not descend beyond a plane passing through the tracheal bifurcation [4,19,20]. Beyond this plane, a complementary thoracic approach is essential. ...
... Chest X-ray generally shows widened mediastinum, subcutaneous emphysema, and sometimes a mediastinal hydroaeric level. Cervicothoracic CT is gold key for early stage diagnosis [5,9,14,15] ...
Objective : compare a less aggressive descending necrotizing mediastinitis management with equivalent results to those of the actual series which use an aggressive approach.
Methods: a five years retrospective study of five patients (three men and two women) treated in our departement for descending
necrotizing mediastinitis.
Results: the infection origin was a dental abscess in all cases. All the patients have had a transcervical approach associated to a thoracic
one in all cases. These incisions permitted evacuation of the pus collections and debridement of necrosis.Systematically, the incisions
were closed up. Tubes for draining were placed in neck and mediatinum. An irrigation system was putted in throw the draining tubes for three patients.Post operatively, we aknowledge good recovery for all patients.
Conclusion: closing up the incisions after surgical treatment of descending necrotizing mediastinitis and irrigation throw draining tubes
... DNM occurs as the deep cervical infection descends through the paratracheal, prevascular and retropharyngeal spaces and reaches the mediastinum. This descend is thought to be facilitated by gravity, respiration, intrathoracic negative pressure and the destructive effects of the enzymes of the bacteria involved [4]. We identified that our case had DNM secondary to a deep cervical infection started at retropharyngeal space as well. ...
... Typical CT features of DNM are increased density of the adipose tissues (>25 Hounsfield units), cervical lymphadenopathy, mediastinal fluid collections and pleural and/or pericardial fluid collections (Fig. 2). Furthermore, myositis and vascular thrombosis can be seen [194]. ...
... Comorbidities, especially of immunosuppressive character, i.e. diabetes, alcoholism, malnutrition, corticosteroid therapy and prior chemotherapy, might not only predispose to development of DNM but also lead to more complicated courses of the disease [45,188,190,[192][193][194]. ...
Mediastinitis continues to be an important and life-threatening complication after median sternotomy despite advances in prevention and treatment strategies, with an incidence of 0.25-5%. It can also occur as extension of infection from adjacent structures such as the oesophagus, airways and lungs, or as descending necrotizing infection from the head and neck. In addition, there is a chronic form of 'chronic fibrosing mediastinitis' usually caused by granulomatous infections. In this expert consensus, the evidence for strategies for treatment and prevention of mediatinitis is reviewed in detail aiming at reducing the incidence and optimizing the management of this serious condition.
... Neck abscesses are still commonly encountered in the era of widespread antibiotic usage. Neck abscesses are usually sequelae of upper respiratory tract infection, odontogenic infection, or even direct trauma [1][2][3][4][5]. These abscesses may spread into adjacent compartments of the neck or into the mediastinum via the retropharyngeal, parapharyngeal, carotid, or prevertebral spaces [1,2]. ...
... Neck abscesses are usually sequelae of upper respiratory tract infection, odontogenic infection, or even direct trauma [1][2][3][4][5]. These abscesses may spread into adjacent compartments of the neck or into the mediastinum via the retropharyngeal, parapharyngeal, carotid, or prevertebral spaces [1,2]. The potentially life-threatening complications associated with neck abscess include respiratory embarrassment, mediastinitis, internal jugular vein thrombosis, pseudoaneurysm, fulminant sepsis, and even death. ...
Neck abscesses are difficult to diagnose and treat. Currently, contrast-enhanced computed tomography (CECT) is the imaging modality of choice. The study aims to determine the predictive value of CECT findings in diagnosing neck abscess, causes of neck abscess and the most common neck space involved in the local population. 84 consecutive patients clinically suspected to have neck abscess who underwent CECT and surgical confirmation of pus were included. Demographic and clinical data were recorded. 75 patients were diagnosed as having neck abscess on CECT; out of those 71 patients were found to have pus. Overall CECT findings were found to have a high sensitivity (98.6%) and positive predictive value (PPV) (94.7%) but lower specificity (67.2%) in diagnosing neck abscess. The CECT diagnostic criterion with the highest PPV is the presence of rim irregularity (96%). The most common deep neck space involved is the submandibular compartment, which correlates with the finding that odontogenic cause was the most common identifiable cause of abscess in the study population. Thus, in a patient clinically suspected of having neck abscess, CECT findings of a hypodense mass with rim irregularity are helpful in confirming the diagnosis and guiding clinical management.
... The median duration of mediastinal tube retention was 10 days (QR: [6][7][8][9][10][11][12][13][14][15][16][17], and the median hospital stay was 21 days (QR: 11.5-30). ...
... Recent meta-analyses of case series have suggested that the etiology of DNM is predominantly arising from pharyngeal infections as opposed to odontogenic infections (13,14,15); in our series 16 out of 45 cases. Other potential causes of DNM, besides dental infections and common oropharyngeal infections such as tonsillitis, include pharyngitis, primary neck infections (including posttraumatic ones), cervical lymphadenitis, suppurative thyroi ditis, traumatic endotracheal intubation (with DNM usually manifested in the early postopera ti ve period) and intravenous drug use (3,16). None of the articles reviewed presented more than 3 cases of DNM of osteoarticular origin, as with our series (cases 9, 16, 35). ...
... However, these signs often appear too late in the course of the disease (6,14). A liberal use of a contrastenhanced cervicothoracic CT scan is essential for the early detection of DNM and for follow-up (15,16). In all cases CT scan immediately confirmed the diagnosis with high accuracy, showing soft tis sue infiltration or collection of fluid density with or without the presence of gas bubbles. ...
Objectives. Descending necrotizing mediastinitis is a severe infection spreading from the cervical region to the mediastinum. Since this pathology is uncommon, only a few reports of large series of patients with descending necrotizing mediastinitis have been published. The present aim was to evaluate our treatment strategy and survival for this disease by a retrospective chart review.
Methods. Retrospective analysis of 45 cases with descending necrotizing mediastinitis was performed between 2002 and 2011. The mean age was 55.3 ± 15.4 years. The primary oropharyngeal infection was found in 16 (35.6%), an odontogenic abscess in 17 (37.7%) and other causes in 12 (26.7%) patients. Endo type I mediastinitis was assessed in 25 (56%) patients, Endo type IIA in 10 (22%) and Endo type IIB in 10 (22%) patients. Broad spectrum antibiotics were administered empirically and surgical treatment consisting of cervical drainage, thoracotomy with radical surgical debridement of the mediastinum and placement of permanent mediastinal irrigation were performed in all the cases.
Results. Collar incision and drainage only were performed in 16 (35.6%) patients, whereas only transthoracic approach was used in five cases (11%). In the remaining 24 (53.4%) patients cervical drainage and thoracic operation were performed. Fifteen patients had severe complications: septic shock, multiple organ failure and haemorrhage from mediastinal vessels. The median hospital stay was 21 days. The outcome was favourable in 35 patients. Ten patients died (overall mortality 22.2%).
There was a negative correlation between the time from the onset of symptoms till the first admittance to hospital and hospitalization time (Pearson correlation coefficient 0.357, p = 0.016). That allows us to suggest that time of illness spent at home without appropriate treatment plays a crucial role on the survival. It was found that younger age, Endo type I, negative bacterial culture and longer hospital stay are true precursors of favourable outcome.
Conclusions. For descending necrotizing mediastinitis limited to the upper part of the mediastinum a transcervical approach and drainage may be sufficient. However, in advanced cases an immediate and more aggressive surgical approach is required to combat a much higher morbidity and mortality in this subset of patients.
... The extension of the retropharyngeal abscess may spread to adjacent spaces and down to the thorax via the mediastinum [12,13]. It is critical to include the posterior cranial fossa and upper mediastinum in the CT scan. ...
... [3]), reflecting the process of oral bacteria entering through disruptions of mucosal and tissue barriers and spreading from a head or neck source, along the deep fascial planes, downward into the mediastinum. The different anatomic neck spaces from which infection spreads to the mediastinum are well described in the literature [2,[9][10][11][12]: The pretracheal space, that ends inferiorly at the pericardium and parietal pleura at carinal height, represents a possible pathway in 8% of cases of DNM for infections of the airways, i.e. epiglottitis/laryngitis and the thyroidea to the anterior and middle mediastinum. Odontogenic infections tend to spread posteriorly towards the vascular space (Fig. 1) and from there, in 12% of cases of DNM, further to the anterior mediastinum (Fig. 2). ...
... Besides oropharyngeal examination, a liberal use of a contrastenhanced cervicothoracic CT scan [11] is essential for the early detection of DNM in patients scan can also be a helpful tool in identifying any clinically suspected progression or persistence of infection in the postoperative period [12]. ...
Descending necrotizing mediastinitis (DNM) is a rare but rapidly progressing disease with a potentially fatal outcome, originating from odontogenical or cervical infections. The aim of this article was to give an up-to-date overview on this still underestimated disease, to draw the clinician's attention and particularly to highlight the need for rapid diagnosis and adequate surgical treatment.
We present a retrospective analysis of 17 patients diagnosed and treated for advanced DNM between 1999 and 2011 in a tertiary referral medical centre. Hence, this is one of the largest single-centre studies in recent years concerning the diffuse form (i.e. extending into the lower mediastinum) of DNM. Subsequently, we analysed and compared the international literature with our data, with the focus on surgical management and outcome.
In our series of 17 adult patients, 16 were surgically treated by median sternotomy (n = 8) or the clamshell (n = 8) approach for diffuse DNM. One patient, referred with septic shock, died 2 days after surgery. The median interval from diagnosis of DNM by cervicothoracic computed tomography scan and thoracic surgery was 6 h (range 1-24 h) in all but the one patient with fatal outcome (48 h). Concomitant cervicotomy was performed in 11 patients (65%) and tracheotomy in 9 (53%). The median duration of hospitalization was 16 days (range 4-50 days), including an intensive care unit stay of 4 days (range 1-50 days).
For DNM limited to the upper part of the mediastinum, which applies to the majority of cases, a transcervical approach and drainage may be sufficient. In advanced disease, extending below the tracheal carina, an immediate and more aggressive surgical approach is required to combat a much higher morbidity and mortality in this subset of patients. A timely situational approach via median sternotomy or a clamshell incision allowed us to maintain a very low morbidity, mortality and rate of reoperations, without major complications due to the surgical approach itself.
... In addition to mediastinal air and fluid collections, neck CT findings of DNM include thickening of the subcutaneous tissues in the neck, thickening or enhancement of cervical fascia and muscles, fluid collections, and enlarged lymph nodes (Fig 6) (16,20). Establishing pathways for the spread of infection from soft tissues in the neck to the mediastinum is key in diagnosing DNM (21). On the basis of CT findings, Endo et al (22) proposed a classification system to define the extent of disease and aid patient management. ...
Given their high frequency, mediastinal emergencies are often perceived as being a result of external trauma or vascular conditions. However, there is a group of nonvascular, nontraumatic mediastinal emergencies that are less common in clinical practice, are less recognized, and that represent an important source of morbidity and mortality in patients. Nonvascular, nontraumatic mediastinal emergencies have several causes and result from different pathophysiologic mechanisms including infection, internal trauma, malignancy, and postoperative complications, and some may be idiopathic. Some conditions that lead to nonvascular, nontraumatic mediastinal emergencies include acute mediastinitis; esophageal emergencies such as intramural hematoma of the esophagus, Boerhaave syndrome, and acquired esophagorespiratory fistulas; spontaneous mediastinal hematoma; tension pneumomediastinum; and tension pneumopericardium. Although clinical findings of nonvascular, nontraumatic mediastinal emergencies may be nonspecific, imaging findings are often definitive. Awareness of various nonvascular, nontraumatic mediastinal emergencies and their clinical manifestations and imaging findings is crucial for making an accurate and timely diagnosis to facilitate appropriate patient management.
