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Ann Thorac Surg 1996;62:1650-1654
© 1996 The Society of Thoracic Surgeons

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Original Articles: General Thoracic

Descending Necrotizing Mediastinitis: Surgical Treatment Via Clamshell Approach

Departments of Thoracic and Cardiovascular Surgery, Plastic and Reconstructive Surgery, Otorhinolaryngology Head and Neck Surgery, and Internal Medicine, University of Berne, Berne, Switzerland

Accepted for publication July 12, 1996.

	Abstract

Top Footnotes Abstract Introduction Patients, Methods, and Results Comment References

 
Background. Descending necrotizing mediastinitis requires an early and aggressive surgical approach to reduce the high morbidity and mortality associated with this disease. The clamshell incision has provided excellent exposure of the entire mediastinum and both pleural cavities and was assessed in patients suffering from descending necrotizing mediastinitis.

Methods. Three patients with descending necrotizing mediastinitis and bilateral pleural empyema due to invasive streptococcal infections were operated on with this method. Radical debridement of the mediastinum and bilateral decortication was performed through a clamshell incision, including pericardiectomy in 2 patients. All patients received initially a high dose of antibiotic regimen, 2 had bilateral chest tube drainage, and 1 had mediastinal drainage and pleural debridement via cervical mediastinotomy and thoracoscopy, respectively. All these measures alone, however, failed to control the disease.

Results. The clamshell incision offered an excellent exposure for bilateral decortication and debridement of the entire mediastinum including pericardiectomy. One patient, who was referred in critically ill condition, died of multiorgan failure in the postoperative period. The remaining 2 patients recovered without further interventions and without evidence of phrenic nerve palsy, sternum osteomyelitis, or sternal override.

Conclusions. The clamshell approach offers an excellent exposure for a complete one-stage surgical treatment with mediastinal debridement and bilateral decortication in patients suffering from descending necrotizing mediastinitis in the absence of profound septic shock.

	Introduction

Top Footnotes Abstract Introduction Patients, Methods, and Results Comment References

 
Descending necrotizing mediastinitis is a rare disease and is mainly related to the spread of oropharyngeal and odontogenic infections into the mediastinum [1]. It is associated with high mortality, mainly due to rapid spread of infection and a delay in diagnosis and onset of treatment [2]. Antibiotics, cervical exploration with debridement, and mediastinal drainage are the cornerstones of treatment, but mortality remains as high as 40% due to the persistence of infection with empyema, pericarditis, and blood vessel erosion [3]. It seems that necrotizing infections require radical debridement of all affected tissues and not only simple drainage of collections [4]. Median sternotomy has a potential risk of dehiscence and osteomyelitis of the sternum if performed for treatment of mediastinal infections. Furthermore, conventional thoracotomy does not sufficiently expose both chest cavities. In contrast, the clamshell incision provides excellent exposure of both thoracic cavities and of all mediastinal structures with minimal morbidity [5]. We report our experience in 3 patients with descending necrotizing mediastinitis treated with radical debridement of the mediastinum and both pleural cavities by this "old-fashioned" and recently rediscovered approach.

	Patients, Methods, and Results

Top Footnotes Abstract Introduction Patients, Methods, and Results Comment References

 
Since January 1995, three patients with necrotizing descending mediastinitis were referred to our institution and were treated by mediastinal debridement through a clamshell approach.

Patient 1
A 32-year-old woman with an uneventful medical history presented to her general practitioner with a sore throat and fever of 38°C. A bilateral tonsillitis was found and treated with penicillin. Over the next 4 days shortness of breath, chest pain, and disorientation developed. Subsequently she was admitted to our institution.

On admission the patient presented a severe respiratory distress, was somnolent, and had inspiratory and expiratory stridor. Intubation was performed in the emergency room. Her blood pressure was 100/65 mm Hg with a pulse rate of 110 beats/min. The skin of the neck and upper thorax was erythematous, and a subcutaneous emphysema was present. Initial laboratory results revealed a white blood cell count of 23 x 10⁹/L with 81% bands and toxic granules and an arterial pH of 7.23 with a base excess of -4.3 mmol/L. Chest roentgenography revealed bilateral pleural effusion; chest tubes were inserted and drained 2 L of purulent pleural effusion. A gram stain showed gram-negative rods and gram-positive cocci (Streptococcus anginosus). Endoscopy revealed a paratonsillar abscess with perforation of the left vallecula epiglottica. Computed tomographic scan showed a parapharyngeal abscess descending into the mediastinum, as well as pericardial and bilateral pleural effusions (Figs 1A, 1B). The antibiotic regimen included ceftriaxone, gentamycin, vancomycin, and ornidazole. Cervical debridement and drainage of the retrosternal mediastinal space and pleural debridement were performed by use of an anterior cervical mediastinotomy and thoracoscopy, respectively. However, the patient's condition did not improve over the next few days, and repeated computed tomographic scan revealed persistent fluid and air accumulation within the mediastinum and both pleural spaces.

View larger version (232K): [in this window] [in a new window]   Fig 1. . Computed tomographic scan of patient 1 with descending necrotizing mediastinitis revealing a fluid- and air-containing mediastinum with enlarged mediastinal lymph nodes (A), and bilateral empyema (B). (C) Intraoperative situs after bilateral decortication, mediastinal debridement, and pericardectomy via clamshell incision.

Patient 2
A 16-year-old female patient presented with signs of tonsillitis a few days after her father was treated for necrotizing cervical fasciitis. The initial evaluation confirmed group A Streptococcus-related angina, and she was treated with penicillin. Despite that, her clinical condition deteriorated and she was referred to our institution. On admission she presented with renal and respiratory insufficiency and was in septic shock, requiring emergency intubation and circulatory support with fluids and pressors. Initial laboratory results revealed a normal white blood cell count with 67% bands, toxic granules, and vacuoles, a normal arterial pH with a base excess of -7.4 mmol/L, and a hypoalbuminemia (12 g/L). The initial chest roentgenogram revealed bilateral effusions requiring bilateral chest tubes, which drained 500 mL of pus on both sides. Computed tomographic scan confirmed bilateral empyema, pneumonia, and mediastinitis.

Mediastinal debridement and bilateral decortication were performed via a clamshell incision 48 hours after admission. Recovery was uneventful, with extubation on day 10 and release home on day 21 after the operation. The antibiotic regimen was stopped 3 weeks after the operation. A clinical and radiologic assessment 3 months after the operation showed a normal chest roentgenogram and primary wound healing without sign of sternal nonunion or override.

Patient 3
A 58-year-old man with a history of tuberculosis of his right lung and immunosuppressive treatment for chronic polyarthritis underwent dental repair of the left second lower molar; subsequently, a periodontal abscess developed on the same side. He was referred to a district hospital, where a phlegmonous infection of the neck with subcutaneous emphysema was diagnosed and an antibiotic regimen was instituted. The patient's condition rapidly deteriorated, and he was referred in critically ill condition with respiratory insufficiency and severe septic-toxic shock requiring emergent fiberoptic intubation, high doses of adrenalin and fluids to maintain the blood pressure. The neck skin and upper part of the thorax was erythematous and edematous (Fig 2B). Initial laboratory results revealed fewer than 5,000 thrombocytes per liter due to disseminated intravasal coagulation with overwhelming sepsis. Computed tomographic scan demonstrated a large parapharyngeal abscess descending into the mediastinum with bilateral empyema and pericardial effusion (Figs 2C, 2D).

View larger version (460K): [in this window] [in a new window]   Fig 2. . (A) Descending necrotizing mediastinitis in patient 3 due to a periodontal abscess of the second lower molar with communication between the oral cavity and the neck (arrow). (B) Erythematous and edematous skin of the neck and upper part of the thorax at admission. (C, D) Computed tomographic scan revealing a large abscess of the neck with displacement of the larynx to the right side (C), descending into the anterior and visceral compartment of the mediastinum, and bilateral empyema (D).

	Comment

Top Footnotes Abstract Introduction Patients, Methods, and Results Comment References

 
Descending necrotizing mediastinitis is a rare but life-threatening complication of oropharyngeal and odontogenic infections [1, 6, 7]. Necrotizing infections are increasingly observed in recent time and are mainly related to group A Streptococcus, although similar pathologic processes are also observed after infections with other streptococci, Clostridium perfringens, and Staphylococcus aureus. Many terms have been proposed in the literature to describe necrotizing infections of the soft tissue depending on the location, clinical presentation, and causative organisms [8, 9]. The characteristic features of the streptococcal toxic shock syndrome include deep-seated necrotizing infections such as necrotizing fasciitis and myositis associated with shock and multiorgan failure [4]. Clinically, necrotizing fasciitis usually begins with a painful local swelling and erythema. Within 24 to 48 hours, frank necrosis of fascia and subcutaneous fat develops, while the overlying skin is not necrosed. If it is associated with myositis the prognosis is extremely poor, with a mortality rate of 80% to 100%. Fever, mental confusion, arterial hypotension, elevated serum creatinine values, hypoalbuminemia, and usually mild leukocytosis with a high percentage of immature neutrophils are other typical findings of this disease. Symptoms are often not recognized at the time, leading to a deleterious delay in treatment. This is illustrated by the case of patients 1 and 2, who presented with a throat infection, which treated with penicillin and evolved rapidly to a life-threatening illness. In spite of the fact that in both cases the organisms were fully susceptible to penicillin, the drug may have failed to clear the infection in the presence of an already large inoculum ("Eagle" effect) [10]. Early diagnosis is crucial for starting adequate treatment without delay, thus decreasing the very high morbidity and mortality [2]. The initial treatment consists of early administration of antibiotics, fluids, and pressors, followed by generous resection of all affected tissues as soon as possible after an initial phase of stabilization of vital functions [4]. Aggressive surgical debridement is of great importance because of the limited efficacy of antibiotics alone in humans [11–13].

The standard surgical treatment advocated for descending necrotizing mediastinitis consists of mediastinal drainage through an anterior cervical mediastinotomy followed by a tracheotomy [3]. However, when the inflammatory process extends below the level of the fourth thoracic vertebra, a thoracotomy is recommended for adequate debridement and drainage of the mediastinum in addition to the cervical approach [14, 15]. Therefore, our first patient did not improve after bilateral chest tube insertion, mediastinal drainage, and pleural debridement by use of cervical mediastinotomy and thoracoscopy alone. The infection persisted within the anterior and the visceral compartments of the mediastinum and in both pleural cavities. Several methods of access have been proposed to obtain additional surgical control of the necrotizing inflammation involving the mediastinum after transcervical drainage, including subxiphoid drainage, anterior mediastinotomy, and thoracotomy [14–19]. All authors agree, however, that complete and early mediastinal exploration is of crucial importance. Because the 3 patients of our series suffered from extensive mediastinal involvement as well as bilateral empyema, we thought that simultaneous exploration of the mediastinum and both chest cavities would be the appropriate surgical treatment. Median sternotomy is increasingly used for removal of mediastinal tumors and resection of bilateral pulmonary disease. However, mediastinal infections should not be accessed through a median sternotomy because subsequent osteomyelitis and dehiscence of the sternum may occur, especially if no additional muscle or omental flap are interposed between the debrided mediastinum and the transected sternum [20]. Moreover, the access to the posterobasal aspects of the chest cavity is difficult through a median sternotomy, especially on the left side. The clamshell incision that includes a bilateral anterior thoracotomy and a transverse sternotomy has recently shown to constitute an improved surgical approach for the management of bilateral pulmonary or combined pulmonary and mediastinal diseases [5].

Based on this we have used this approach in 3 patients with necrotizing mediastinitis and have found it to offer an excellent exposure of the entire mediastinum and both chest cavities. Bilateral decortication and radical debridement of the entire mediastinum including pericardiectomy was performed while both phrenic nerves were identified and preserved. However, caution is indicated while opening the chest to prevent overstretching of the phrenic nerves. A tracheotomy, which is recommended after mediastinal drainage [3], was not found to be necessary in our patients. Early tracheostomy bears the potential risk of blood vessel erosion [3], and we thought that this life threatening complication might be promoted by debriding the anterior cervicomediastinal compartment with consecutive dissection of vessels. Early airway control was therefore obtained in our patients by prompt endotracheal intubation followed by the liberal use of a percutaneously inserted minitracheostomy after extubation. No airway complications were observed in the surviving patients during follow-up, and primary wound healing with a good aesthetic result was achieved without any evidence of sternal dehiscence or override. Because 1 patient referred in critical condition succumbed after the operation, we would not advise this approach for critically ill patients suffering from overwhelming sepsis with profound shock and disseminated intravascular coagulopathy. It might be preferable in these unstable situations to drain both pleural cavities by chest tubes and the mediastinum through an anterior cervical mediastinotomy. Debridement of the mediastinum and the chest cavities by use of a clamshell incision should be postponed until the patient's condition has been stabilized.

In summary, we present 3 cases of descending necrotizing mediastinitis with bilateral empyema. The surgical treatment included debridement of the mediastinum and bilateral decortication through a clamshell incision. The clamshell incision offers an excellent exposure for a complete one-stage operation with debridement of all affected tissues with the mediastinum and both pleural cavities, but it should be used with caution in unstable, critically ill patients.

	Footnotes

Top Footnotes Abstract Introduction Patients, Methods, and Results Comment References

 
Address reprint requests to Dr Ris, Department of Thoracic and Cardiovascular Surgery, Inselspital, 3010 Berne, Switzerland.

	References

Top Footnotes Abstract Introduction Patients, Methods, and Results Comment References

 

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