title: [Surgical treatment of acute descending necrotising mediastinitis].
abstract: BACKGROUND
  Acute descending necrotizing mediastinitis (DNM) is a severe septic inflammation of the mediastinum with necrosis, which progrediates rapidly and leads to death without adequate surgical treatment in 80% of cases.
  
  
  METHODS
  17 patients were treated with acute DNM between 1999 and 2012 at the Thoracic Surgical Department of Koranyi National Institute and Semmelweis University of Hungary. The infection source was primarily in the head-neck region with dental infections in eight cases, retro/parapharyngeal abscess in four patients, primary collar phlegmone and abscess in one case and two retrotonsillar abscesses. Further, in one case there was a previous operation (mediastinoscopy) in the history and in another case there was "difficult intubation process" (not recognized trachea-laesion) mentioned during abdominal operation. Primary exploration was performed from the neck in nine cases, thoracotomies plus collar incisions were carried out in four cases, athoracotomy only was done in one and orofacial exploration in further three patients. Disease progression could be evaluated by computer tomography which had to be followed by immediate surgery.
  
  
  RESULTS
  Four patients needed two operations, five patients underwent exploration three times, while three patients needed 4 interventions four times. More than one anatomical region was explored in 70% of the cases. Based on our experience prognosis is affected by the time elapsed between detection and surgical intervention, age of the patient and comorbidites such as diabetes mellitus. We lost nine patients (53%), eight patients recovered and symptom free (47%).
  
  
  CONCLUSIONS
  Successful treatment is based on early diagnosis, urgent elimination of the primary source, adequate exploration of the cervico-facial region, debridement, collar and upper mediastinal drainage. If the inflammation spreads below the azygos vein or the aortic arch, a right thoracotomy should be performed with wide mediastinal exploration, debridement, and thoracic suction-lavage drainage. Treatment should be completed with broad spectrum and targeted antibiotics as well as organ support. Mortality and morbidity can be reduced with prompt and aggressive therapy.
authors.affiliation: Országos Korányi Tbc és Pulmonológiai Intézet, Mellkassebészeti Osztály és Semmelweis Egyetem, Általános Orvostudományi Kar, Mellkassebészeti Tanszéki Csoport Budapest. vagvolgyiattila@koranyi.hu
authors.forename: Attila
authors.initials: A
authors.lastname: Vágvölgyi
authors.forename: Pál
authors.initials: P
authors.lastname: Vadász
authors.forename: Zoltán
authors.initials: Z
authors.lastname: Heiler
authors.forename: József
authors.initials: J
authors.lastname: Kas
authors.forename: Csaba
authors.initials: C
authors.lastname: Fehér
authors.forename: Attila
authors.initials: A
authors.lastname: Csekeő
authors.forename: Katalin
authors.initials: K
authors.lastname: Zsikla
authors.forename: Zsolt
authors.initials: Z
authors.lastname: Rozgonyi
mesh_terms: D000208:Acute Disease; D000328:Adult; D000368:Aged; D001424:Bacterial Infections / Q000150:complications; D003646:Debridement; D004322:Drainage; D005260:Female; D006801:Humans; D006814:Hungary / Q000453:epidemiology; D008297:Male; D008480:Mediastinitis / Q000175:diagnosis* / Q000000981:diagnostic imaging / Q000209:etiology / Q000401:mortality / Q000473:pathology / Q000601:surgery*; D008875:Middle Aged; D009026:Mortality / Q000639:trends; D009336:Necrosis; D010508:Periodontal Abscess / Q000150:complications; D000039:Peritonsillar Abscess / Q000150:complications; D012189:Retrospective Studies; D013396:Suction; D007507:Therapeutic Irrigation; D013908:Thoracotomy / Q000379:methods*; D014057:Tomography, X-Ray Computed; D016896:Treatment Outcome