Descending necrotizing mediastinitis: contemporary trends in etiology, diagnosis, management, and outcome.
OBJECTIVE
To evaluate contemporary trends in etiology, diagnosis, management, and outcome of descending necrotizing mediastinitis (DNM) and to draw the clinician's attention on this probably underappreciated disease.


BACKGROUND
An uncommon but one of the most serious forms of mediastinitis is DNM which is caused by downward spread of deep neck infections and arises as a major complication of "banal" odontogenic, pharyngeal, or cervicofacial foci. As most studies are based on small patient populations, current data on risk factors, etiology, and outcome vary significantly. Also, the optimal form of treatment remains controversial.


METHODS
This retrospective study, which is the largest single-center study since 1960, is based on the management of 45 patients with DNM treated over a period of 12 years. Additionally, a meta-analysis of 26 studies on DNM published between 1999 and 2008 was performed and compared with own data and 2 previous meta-analyses covering the interval from 1960 to 1998.


CONCLUSIONS
Today DNM most commonly arises from pharyngeal foci and mixed polymicrobial aerobic and anaerobic infections. Reduced tissue oxygenation and impaired immune function promotes its development. Most cases of DNM are limited to the upper mediastinum and can be adequately drained by a transcervical approach. Formal thoracotomy should be reserved for cases extending below the plane of the tracheal bifurcation. Although DNM remains an aggressive infection with high morbidity, a favorable outcome can now be obtained in 85% of patients, even with this selective approach. Early diagnosis and surgical intervention are crucial.
Department of Otorhinolaryngology-Head and Neck Surgery, University of Freiburg, Freiburg, Germany. gerd.ridder@uniklinik-freiburg.de
Gerd J
GJ
Ridder
Wolfgang
W
Maier
Susanne
S
Kinzer
Christian B
CB
Teszler
Carsten C
CC
Boedeker
Jens
J
Pfeiffer
D000293:Adolescent; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D002648:Child; D002675:Child, Preschool; D005260:Female; D006801:Humans; D008297:Male; D008480:Mediastinitis / Q000175:diagnosis / Q000209:etiology / Q000628:therapy; D008875:Middle Aged; D009336:Necrosis; D012189:Retrospective Studies; D016896:Treatment Outcome; D055815:Young Adult