- Research article
- Open Access
Unusual case of exacerbation of sub-acute descending necrotizing mediastinitis
© Di Crescenzo et al; licensee BioMed Central Ltd. 2013
- Published: 8 October 2013
Descending necrotizing mediastinitis is a life-threatening complication of an oropharyngeal infection that requires prompt and aggressive medical and surgical therapy. Herein, we report unusual case of man suffering of sub-acute mediastinal infection due to odontoiatric abscess which exacerbated at 3 months after its first presentation. Chest X-ray and CT scan demonstrated soft-tissue swelling of the neck and encapsulated fluid collections with gas bubbles within anterior mediastinum, especially on the right side. Bilateral anterior neck dissections were performed and blunt dissection, irrigation and debridement were carried out to several centimetres below the sternal manubrium. Then, right standard thoracotomy was performed with debridement of the anterior mediastinum. Four tubes were placed in the mediastinum and pleural cavity on the right side, and two tubes were placed in the left thoracic cavity. Follow-up CT scans of neck and chest showed the resolution of infection.
Descending necrotizing mediastinitis (DNM) is a life-threatening complication of an oropharyngeal infection that requires prompt and aggressive medical and surgical therapy. Delay of diagnosis and inappropriate drainage of the mediastinum are the main causes of mortality in this life threatening condition [1, 2]. Herein, we report a case of man suffering of sub-acute mediastinal infection due to odontoiatric abscess which exacerbated at 3 months after its first presentation. Aggressive surgical treatment with left in mediastinum multiple drainage allowed the resolution of the infection.
The most dreaded and probably lethal form of mediastinitis is the diffuse necrotizing variety that occurs as a complication of infection of the oropharynx. The best term of such mediastinitis is DNM; descending because the infection uses fascial planes in the neck to gain access to the mediastinum, and necrotising because the infection is often polymicrobial and gas-producing . Infections originating in the fascial planes of the head and neck spread downward into the mediastinum along the cervical fascias, facilitated by gravity, breathing, negative intrathoracic pressure, and the absence of barriers in the contiguous fascial planes of neck and mediastinum. DNM diagnosis implies the established relationship between mediastinitis, oropharyngeal infection, and radiological findings of mediastinitis. Delay of diagnosis is one of the primary reasons for the high mortality in DNM which ranging from 16% to 40% according to the most series [5, 6].
Intravenous broad-spectrum antibiotic therapy alone is not efficient without adequate surgical drainage of the cervical and mediastinal collections, extensive debridement and excision of necrotic tissue, and wide mediastinopleural irrigation [6–14].
The most interesting aspect of the present case, not been reported before, is that our patient suffered of sub-acute mediastinal infection due to odontogen abscess treated with antibiotic therapy for three months. Then, an exacerbation of mediastinal infection is observed with concomitant presence of infected foot ulcer. In theory, the infection of foot ulcer may lead to septicemia which in addition with other risk factors as diabetes, and obesity may then cause the exacerbation of mediastinal infection.
In the present case, diagnosis of cervical infection with increasing infectious symptoms, and respiratory insufficiency is clinically obvious; yet, radiological studies show the presence of cervical abscess with diffuse mediastinal collections. Thus, the diagnosis of DNM is confirmed in agreement of diagnostic criteria of Estrera et al. . These criteria include: (1] clinical manifestation of severe oropharyngeal infection;  demonstration of characteristic roentgenographic features of mediastinitis;  documentation of necrotizing mediastinal infection at operation or post-mortem examination or both; and  establishment of relationship between oropharyngeal infection and development of necrotizing mediastinal process.
In reported cases of DNM, successful surgical management involves a combination of cervical and mediastinal drainage with or without open thoracotomy. Endo et al.  proposed a classification scheme to facilitate management of DNM based on CT assessment of the extent of infection as follows: 1) Type I (or localized DNM) is an infection localised to the upper mediastinum above the tracheal bifurcation; 2) Type II A is defined an infection which involves the lower anterior mediastinum; 3) Type II B if the anterior and posterior lower mediastinum is involved. On the basis of CT findings, our case should be considered as Type II B; thus we support the use of an aggressive surgical treatment as combined cervicotomy and thoracotomy approach in order to evacuate all infected and necrotic tissue.
In the meta-analysis by Corsten et al , patients that receive combined cervicotomy and thoracotomy have a mortality of 19% versus 47% in patients receiving cervicotomy alone, which is a statistically significant difference. Marty-Ane et al.  achieve a relatively low mortality rate of 16.5% in their series of 12 patients by aggressively utilising thoracotomy. In their series, all patients that undergo both cervicotomy and thoracotomy survive. More recently, less invasive approaches successfully employing thoracoscopic or mediastinoscopic drainage have been reported.
Roberts et al  report the thoracoscopic management of a case of DNM with encapsulated mediastinal abscess; Gobien et al  propose CT-guided percutaneous drainage as a valuable alternative to surgical intervention in selected patients with mediastinal abscesses. However, in our case these procedures are inadequate for the spread of disease; thus, we attended an aggressive surgical treatment with left in place multiple drainage within mediastinum. They permitted the complete drainage of infection with resolution of disease.
PL: Resident in Department of Medicine and Surgery - University of Salerno. FN: Resident in Department of Medicine and Surgery - University of Salerno. CC: Resident in Department of Clinical Medicine and Surgery - University of Naples. MD: Aggregate Professor of Surgery in Department of Clinical Medicine and Surgery - University of Naples Federico II. BA: Associate Professor of Surgery in Department of Clinical Medicine and Surgery - University of Naples Federico II. AG: Assistant Professor of Pediatric Surgery - University of Salerno. MV: Associate Professor of Endocrinology - University of Salerno. VDC: Assistant Professor of Thoracic Surgery - University of Salerno.
This article has been published as part of BMC Surgery Volume 13 Supplement 2, 2013: Proceedings from the 26th National Congress of the Italian Society of Geriatric Surgery. The full contents of the supplement are available online at http://www.biomedcentral.com/bmcsurg/supplements/13/S2
- Weaver E, Nguyen X, Brooks MA: Descending necrotising mediastinitis: two case reports and review of the literature. Eur Respir Rev. 2010, 19: 116-141-149View ArticleGoogle Scholar
- Santini M, Fiorello A, Cappabianca S, Vicidomini G: Unusual case of Boerhaave syndrome, diagnosed late and successfully treated by Abbott's T-tube. J Thorac Cardiovasc Surg. 2007, 134: 539-40. 10.1016/j.jtcvs.2007.04.033.View ArticlePubMedGoogle Scholar
- Fiorelli A, Morgillo F, Fasano M, Vicidomini G, Di Crescenzo V, Di Domenico M, Accardo M, Santini M: The value of matrix metalloproteinase-9 and vascular endothelial growth factor receptor 1 pathway in diagnosing indeterminate pleural effusion. Interact Cardiovasc Thorac Surg. 2013, 16 (3): 263-9. 10.1093/icvts/ivs466.PubMed CentralView ArticlePubMedGoogle Scholar
- Santini M, Fiorelli A, Vicidomini G, Di Crescenzo V, Messina G, Laperuta P: Endobronchial treatment of giant emphysematous bullae with one-way valves: a new approach for surgically unfit patients. Eur J Cardiothorac Surg. 2011, 40 (6): 1425-31. 10.1016/j.ejcts.2011.03.046.View ArticlePubMedGoogle Scholar
- Rispoli C, Rocco N, Iannone L, Amato B: Developing guidelines in geriatric surgery: role of the grade system. BMC Geriatrics. 2009, 9 (SUPPL.1): A99-Google Scholar
- Marty-Ane´ CH, Berthet JP, Alric P, Pegis JD, Rouviere P, Mary H: Management of Descending Necrotizing Mediastinitis: An Aggressive Treatment for an Aggressive Disease. Ann Thorac Surg. 1999, 68: 212-7. 10.1016/S0003-4975(99)00453-1.View ArticlePubMedGoogle Scholar
- Santini M, Fiorelli A, Vicidomini G, Laperuta P, Di Crescenzo V: Iatrogenic air leak successfully treated by bronchoscopic placement of unidirectional endobronchial valves. Ann Thorac Surg. 2010, 89 (6): 2007-10. 10.1016/j.athoracsur.2009.10.015.View ArticlePubMedGoogle Scholar
- Santini M, Fiorello A, Di Crescenzo V, Vicidomini G, Busiello L, Laperuta P: Use of unidirectional endobronchial valves for the treatment of giant emphysematous bulla. J Thorac Cardiovasc Surg. 2010, 139 (1): 224-6. 10.1016/j.jtcvs.2008.05.069.View ArticlePubMedGoogle Scholar
- Baldi A, Mottolese M, Vincenzi B, Campioni M, Mellone P, Di Marino M, Di Crescenzo V, Visca P, Menegozzo S, Spugnini EP, Citro G, Ceribelli A, Mirri A, Chien J, Shridhar V, Ehrmann M, Santini M, Facciolo F: The serine protease HtrA1 is a novel prognostic factor for human mesothelioma. Pharmacogenomics. 2008, 9 (8): 1069-77. 10.2217/146224188.8.131.529.View ArticlePubMedGoogle Scholar
- Santini M, Fiorello A, Vicidomini G, Di Crescenzo V, Laperuta P: Role of diffusing capacity in predicting complications after lung resection for cancer. Thorac Cardiovasc Surg. 2007, 55 (6): 391-4. 10.1055/s-2007-965326.View ArticlePubMedGoogle Scholar
- Santini M, Fiorello A, Di Lieto E, Di Crescenzo V, D'aniello G, Vicidomini G, Perrone A, Pastore V: Surgical strategies in cervico-mediastinal goiters. Minerva Chir. 2006, 26 (4): 221-229.Google Scholar
- Napolitano V, Pezzullo AM, Zeppa P, Schettino P, D'Armiento M, Palazzo A, Della Pietra C, Napolitano S, Conzo G: Foregut duplication of the stomach diagnosed by endoscopic ultrasound guided fine-needle aspiration cytology: case report and literature review. World J Surg Oncol. 2013, 11: 33-10.1186/1477-7819-11-33. Feb 2PubMed CentralView ArticlePubMedGoogle Scholar
- Cipullo C, Amato B, Vigliar E, Di Crescenzo V, Zeppa P: lymph node fine needle cytology in the diagnosis of infectious diseases and reactive unspecific processes. Infez Med. 2012, 20 (Suppl 3): 30-3. Oct 1PubMedGoogle Scholar
- Falleti J, Vigliar E, Zeppa P, Schettino P, Napolitano V, D'Armiento M: Gastric duplication cyst: a rare congenital disease often misdiagnosed in adults. Case Rep Gastrointest Med. 2013, 2013: 850967-doi: 10.1155/2013/850967PubMed CentralPubMedGoogle Scholar
- Estrera AS, Lanay MJ, Grisham JM, et al: Descending necrotizing mediastinitis. Surg Gynecol Obstet. 1983, 157: 545-52.PubMedGoogle Scholar
- Endo S, Murayama F, Hasegawa T, et al: Guideline of surgical management based on diffusion of descending necrotizing mediastinitis. Jpn J Thorac Cardiovasc Surg. 1999, 47: 14-19.View ArticlePubMedGoogle Scholar
- Roberts JR, Smythe WR, Weber RW, Lanutti M, Rosengard BR, Kaiser LR: Thoracoscopic management of descending necrotizing mediastinitis. Chest. 1997, 112: 850-4. 10.1378/chest.112.3.850.View ArticlePubMedGoogle Scholar
- Gobien RP, Stanley JH, Gobien BS, Vujic I, Pass HI: Percutaneous catheter aspiration and drainage of suspected mediastinal abscesses. Radiology. 1984, 151: 69-71. 10.1148/radiology.151.1.6701339.View ArticlePubMedGoogle Scholar
This article is published under license to BioMed Central Ltd. This is an open access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.