Descending necrotizing mediastinitis. Diagnosis and surgical treatment.
OBJECTIVE
Descending necrotizing mediastinitis (DNM) is an unusual and severe disease with a high mortality rate. Surgical management remains controversial. Our investigations reviews the most effective surgical treatment in the management of this rare pathology.


METHODS
Seven patients with DNM and treated over a 20-year period are reported. All patients were evaluated according to the classification suggested by Endo et al. of the degree of mediastinal diffusion, based on CT scan findings. Five patients underwent combined cervical drainage and thoracotomy, 2 patients were treated with cervical drainage alone.


RESULTS
The outcome was favorable in 5 patients, 4 treated with a combined cervical and thoracic approach and 1 with a cervical approach alone. Two patients that underwent a combinated cervical and thoracic approach alone, died of septic shock. Overall mortality rate was 28.5%.


CONCLUSIONS
Early diagnosis and early, aggressive surgical treatment are required to improve the poor prognosis of DNM. Although a unique surgical management is still not completely accepted, we state, in agreement with other authors, a wide approach consisting of a cervical drainage and mediastinotomy in case of upper mediastinitis and a combined cervical and thoracic approach in case of lower mediastinitis. In the course of thoracotomy a wide excision of necrotic and particularly fat mediastinal tissue is needed, to avoid a recurrent infection. A continuous cervico-mediastinal irrigation system is suggested during the postoperative period.
Lavini
C
C
Department of Thoracic Surgery, University of Modena and Reggio Emilia, Modena, Italy. c.lavini@unimo.it
Natali
P
P
Morandi
U
U
Dallari
S
S
Bergamini
G
G
D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D000900:Anti-Bacterial Agents / Q000627:therapeutic use; D002648:Child; D004322:Drainage / Q000379:methods; D005260:Female; D006801:Humans; D008297:Male; D008480:Mediastinitis / Q000000981:diagnostic imaging* / Q000473:pathology / Q000601:surgery*; D008875:Middle Aged; D009336:Necrosis; D011379:Prognosis; D009057:Stomatognathic Diseases / Q000150:complications / Q000175:diagnosis / Q000628:therapy; D013908:Thoracotomy / Q000379:methods; D014057:Tomography, X-Ray Computed
D000900:Anti-Bacterial Agents