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Ann Thorac Surg 2004;77:306-310
© 2004 The Society of Thoracic Surgeons

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Original article: general thoracic

Descending necrotizing mediastinitis: a minimally invasive approach using video-assisted thoracoscopic surgery

^a Department of General Thoracic Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
^b Department of Head and Neck Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea

Accepted for publication July 21, 2003.

^* Address reprint requests to Dr Kim, Department of Thoracic and Cardiovascular Surgery, Samsung Medical Center, 50 Ilwon-Dong, Kangnam-Ku, Seoul 135-710, South Korea.
e-mail: jkim{at}smc.samsung.co.kr

	Abstract

Top Abstract Introduction Patients and methods Results Comment Conclusion References

 
BACKGROUND: Descending necrotizing mediastinitis is a rare but serious disease. Aggressive surgical approaches have been emphasized rather than simple medical treatment.

METHODS: Four patients with descending necrotizing mediastinitis were treated surgically in our institution between January 2001 and August 2002. Three had peritonsilar abscesses and one had an odontogenic abscess. Operative procedures included drainage and debridement through a Chamberlain incision and neck incision using video-assisted thoracic surgery.

RESULTS: The mean duration from symptoms to operation was 5.3 days (range, 3 to 7) and mean hospital stay was 28.8 days (range, 14 to 47). There was no perioperative mortality. Postoperative complications were found in three patents: two with localized pleural effusion and one with a hydropneumothorax.

CONCLUSIONS: Video-assisted thoracic surgery is feasible and effective as a less invasive method for the surgical management of patients with descending necrotizing mediastinitis, especially when applied early.

	Introduction

Top Abstract Introduction Patients and methods Results Comment Conclusion References

 
Acute mediastinitis is a severe infection of the mediastinal connective tissue that fills the interpleural mediastinal space and its thoracic structures. It is most often caused by perforation of the esophagus or infection after sternotomy in patients receiving cardiac surgery. However, it can also occur as a complication of primary oropharyngeal infection progressing to the cervical region and spreading through the fascia to the mediastinum. In the latter case, the disease is termed descending necrotizing mediastinitis (DNM) [1]. The diagnostic criteria of DNM were defined by Estrera in 1983 [1, 2]: clinical manifestations of severe infection [2]; characteristic roentgenographic features (mediastinal widening on simple Roentgenogram and noncapsulated fluid collections or abscesses with gas bubbles on chest CT) [3]; documentation of necrotizing mediastinal infection at operation or postmortem examination, or both [4]; establishment of the involvement of the necrotizing mediastinal process. DNM is a serious disease and its reported mortality rate is as high as 40%–50% [1, 7, 8, 12]. Many have recommended early diagnosis, adequate antibiotics, and early effective surgical drainage—especially early aggressive surgical intervention—for the management of patients with DNM, and a variety of surgical incision techniques such as sternotomy or clamshell incisions have been used for effective drainage. However, we believe that such extensive surgery is not essential. Indeed, the prolonged procedure times and serious tissue destruction caused by extensive surgery may induce debilitated patients to worsen and progress to sepsis. In this situation, we consider that video-assisted thoracic surgery (VATS) may be better for the management of DNM because it is effective in producing drainage while being minimally invasive. Therefore we report our results using VATS for the management of DNM.

	Patients and methods

Top Abstract Introduction Patients and methods Results Comment Conclusion References

 
Between January 2001 and August 2002, four patients (three men and one woman) were referred to our institution for suspected DNM. Their mean age was 36 years (range 23 to 43). The origins of infection included peritonsilar abscesses in three patients and a submandibular abscess in one following a tooth extraction. DNM was diagnosed by preoperative cervico-thoracic computed tomography (CT) scans. These demonstrated soft tissue infections in the neck and mediastinal infections (noncapsulated fluid collections or abscesses with gas bubbles). Three patients had pleural effusions (bilateral in two) and one patient had pericardial effusion on preoperative chest CT scans. Empirical broad-spectrum antibiotics were initiated for all patients as soon as DNM was suspected. These antibiotic regimens were modified according to the results of culture and sensitivity tests of materials obtained from the neck, pleura, mediastinum, and blood (less than operative procedures more than).

Patients were intubated using double-lumen endotracheal tubes (Broncho-Cath, Mallinckrodt, Ireland) under general anesthesia. They were positioned supine with their necks extended and the right side tilted about 30°. For patients with left pleural effusions on preoperative workup, a left closed thoracostomy was initially performed before the main procedures because the collapsed left lung could not be oxygenated. After the anesthetist had collapsed the right lung, a 2-cm long skin incision was performed at the level of the eighth intercostal space at the anterior axillary line; then a 10 mm trocar (Karl Storz-Endoskope, Tuttlingen, Germany) was inserted through the incision. A thoracoscope (Endoskope Karl-Storz) was inserted through the trocar for evaluation of the right pleural cavity. If pleural effusion or pus was present, it was evacuated and evaluated microbiologically. A unilateral oblique neck incision along the medial border of the sternocleidomastoid muscle or a collar incision was then performed. Neck and superior mediastinum were explored. Blunt dissection was continued through the pre- or retro-tracheal, periesophageal, and perivascular spaces (especially along the superior vena cava). Abscess pockets were drained and necrotic materials were debrided through the neck incision without difficulty. Under the direct vision of the thoracoscope, the nearest right mediastinal pleura was opened longitudinally (from thoracic inlet to the level of azygos vein). Further debridement of necrotic materials and drainage of pus were performed through the opening of the mediastinal pleura, which was assisted by opening the right third sternocostal junction (Chamberlain incision). If reactive pericardial effusion was present on preoperative CT scans or two-dimensional (2D) echocardiography, pericardial window formation was performed posterior to the phrenic nerve for drainage of pericardial effusions. A chest tube was inserted via the pleural space and placed in the mediastinum through the opening of the mediastinal pleura for drainage of mediastinal pus, while another drainage device was placed in the mediastinum through the neck wound. After the wound had been closed, the operation was completed and patients were transferred to the intensive care unit.

Case 1
A 23-year-old man had an uneventful medical history when admitted. His second molar had been extracted ten days previously at an outside dental clinic and he developed a submandibular abscess seven days later. Incision and drainage of the abscess was performed at an outside hospital, but progressive odynophagia, fever, neck swelling with subcutaneous emphysema, and chest pain on inspiration persisted. At the time of admission, his vital signs showed a temperature of 38.2°C and a respiration rate of 24 per minute. His blood pressure was 140/80 mm Hg with a pulse rate of 97 beats/min. Initial laboratory results revealed a white blood cell count of 37.9 x 10³/µL with 90% neutrophils and a C-reactive protein (CRP) concentration of 21.64 mg/dL. He was diagnosed as having DNM with bilateral pleural effusions and a moderate amount of pericardial effusion by chest radiographs and cervico-thoracic CT scans. We performed emergency surgery. From the second postoperative day, cyclic irrigation of the mediastinum was performed three times per day using 0.5% Betadine solution through the chest tube. Gram staining and culture of materials obtained from the mediastinum showed gram-positive cocci (Streptococcus bovis) and the antibiotic regime was modified accordingly. The patient's condition and laboratory findings improved over the next few days. A cervico-thoracic CT scan was repeated on the 10^th postoperative day. This revealed that the anterior mediastinal abscess had disappeared but that localized pleural fluid remained in the right pleural cavity. This was drained using a CT-guided percutaneous drainage catheter. He recovered without specific problems and was transferred to a neighboring outside hospital for additional antibiotics on the 15^th postoperative day.

Case 2
A 43-year-old man was transferred from an outside hospital to our emergency room and was admitted with fever, odynophagia, neck swelling, chest pains on inspiration, dyspnea, and myalgia after developing a sore throat 10 days previously. At the time of admission, his vital signs showed a temperature of 37.9°C and a respiration rate of 26 per minute. His blood pressure was 152/89 mm Hg with a pulse rate of 110 beats/min. Initial laboratory results revealed a white blood cell count of 19.1 x 10³/µL with 76% neutrophils and a CRP concentration of 24.18 mg/dL. He was diagnosed as having DNM with right side pleural effusions from chest radiographs and cervico-thoracic CT scans (Figure 1). We performed emergency surgery. After the operation, the patient's condition and laboratory findings improved progressively over the next few days. A gram stain and culture showed gram-positive cocci (Streptococcus viridans) and his antibiotic regimen was modified accordingly. On chest radiography, there was small amount of localized pleural effusion in the interlobar fissure. With intravenous antibiotics, he was afebrile and laboratory findings (WBC and serum CRP) were within normal range for three weeks. However, after discontinuation of antibiotics, he became febrile with elevated serum CRP concentrations. A cervico-thoracic CT scan was performed on the 33rd postoperative day. This revealed that the anterior mediastinal abscess had almost disappeared (Figure 2) but undrained localized pleural fluid was present in the right major interlobar fissure. This localized effusion, thought to be a febrile focus, was drained using CT-guided percutaneous needle aspiration. He became afebrile and was discharged on the 47th postoperative day after an additional three weeks of antibiotics.

View larger version (95K): [in this window] [in a new window]   Fig 1. A preoperative computed tomography scan (case 2) showing mediastinal abscess with gas pockets formation (white arrows) around the trachea.

View larger version (83K): [in this window] [in a new window]   Fig 2. A postoperative computed tomography scan of the same patient (case 2) showing disappearance of mediastinal abscess. White arrowhead indicates the chest tube at mediastinal pleura, where the abscess pocket was observed.

Case 4
A 42-year-old man was transferred to the emergency room with fever, odynophagia, neck tenderness, hoarseness, and dyspnea after developing a sore throat three days previously. At the time of admission, his vital signs showed a temperature of 38.9°C and a respiration rate of 20 per minute. His blood pressure was 155/80 mm Hg with a pulse rate of 135 beats/min. Initial laboratory results revealed a white blood cell count of 13.9 x 10³/µL with 88.7% neutrophils and a CRP concentration of 37.28 mg/dL. He was admitted to the department for head and neck surgery under the impression that he had a peritonsilar abscess and empiric broad-spectrum antibiotics were initiated. Over the next six days, his condition worsened with the development of spiking fevers and chest pain on inspiration. A repeat CT scan was performed and revealed that the peritonsilar abscess had progressed to the mediastinum and that he had developed DNM with no pleural effusion. An emergency operation was performed on the seventh day after admission. A gram stain and culture showed no organisms, and he became afebrile and laboratory findings improved progressively. Empirical broad-spectrum antibiotics were continued. After three weeks of administration of intravenous antibiotics—including preoperative usage—he was discharged on the 16th postoperative day.

	Results

Top Abstract Introduction Patients and methods Results Comment Conclusion References

 
The mean time from onset of chest symptoms until surgery was 5.3 days (range 3 to 7) and mean hospital length of stay for patients in our series was 28.8 days (range 14 to 47). There was no perioperative mortality. The postoperative complications were localized pleural effusions in two patients and hydropneumothorax in the right pleural cavity in one, caused by a communicating neck wound. The patients were followed up in our outpatient department or by telephone interviews for 15, 12, six, and five months (Cases 1 to 4, respectively). All patients became well and had no recurrences or infections.

	Comment

Top Abstract Introduction Patients and methods Results Comment Conclusion References

 
DNM is an uncommon form of mediastinitis, which is usually caused by primary oropharyngeal infection and can rapidly progress to sepsis. Although its general incidence is low, the mortality is as high as 40% to 50% despite the development of antibiotics, early diagnosis through the invention and development of CT scanning, and the improvement of anesthetic and intensive care protocols [12]. Oropharyngeal infection spreads to the mediastinum thorough the loose anatomical structure of the pretracheal, perivascular, and retropharyngeal spaces [9]. Assisted by gravity, respiration, and the negative pressure in the mediastinum and pleural cavities during inspiration, pus in the cervical space readily descends into these cavities and the pericardial space [3, 4].

The management of DNM includes early diagnosis, adequate antibiotics, and effective drainage of pus. Endo et al [4] classified DNM into diffuse and localized types according to the degree of diffusion of infection diagnosed by CT and suggested differential surgical management according to this classification. In the DNM type I, in which infection is localized to the upper mediastinal space above the tracheal bifurcation, transcervical drainage is sufficient to drain mediastinal pus. They reclassified diffuse DNM into types II A (infection in the lower anterior mediastinum) and II B (infection in the lower posterior mediastinum). The more extensive DNM type II A, affecting the anterior mediastinum, was successfully managed with irrigation through subxiphoidal and cervical incisions with additional percutaneous thoracic drainage when necessary. In DNM type II B, complete irrigation and debridement of the entire mediastinum through a right standard thoracotomy, followed by left minimal thoracotomy, was demonstrated as effective based on the degree of DNM expansion ascertained by initial thoracoscopic exploration.

Many authors have reported the advantages of drainage and debridement through the thorax in the management of patients with DNM. Corsten et al [5] reported the successful treatment of seven out of eight patients with DNM and six of these received mediastinal drainage via thoracotomy. They stated that the mediastinum cannot be adequately drained by a limited approach through subxiphoid or anterior mediastinotomy, and supported the use of early thoracotomy for the best control of mediastinal sepsis. They reported a significant difference in mortality in patients who received neck and thoracic drainage (19%) compared with neck drainage alone (47%) and suggested the early use of thoracotomy in the management of DNM. However, for posterolateral thoracotomy there is a need to change the patient's operative position to perform transcervical mediastinal drainage and thus manage the DNM: this approach is cumbersome and tedious. However, our approach (supine with necks extended and right side tilted up about 30°) enabled us to carry out a neck incision and to drain the pleural effusion simultaneously and thus resolve this problem. Izumoto et al [6] reported successful management through median sternotomy for patients with DNM and suggested this approach as an alternative to cervicotomy and thoracotomy. However, median sternotomy also seems inadequate in patients with DNM, because subsequent osteomyelitis and dehiscence of the sternum may occur, and access to the posterobasal compartments of the chest cavity is difficult, especially on the left side. Ris et al [7] reported the successful treatment of two out of three patients with DNM and bilateral empyema who had mediastinal drainage via clamshell incisions. Although the exposure of the entire mediastinum and both chest cavities is excellent with the advantage of a one-stage operation, this approach is particularly invasive in critically ill patients and exposes them to the risk of phrenic nerve palsy and osteomyelitis of the sternum. Aggressive surgical approaches would thus worsen patients with sepsis. These aggressive approaches would also increase the length of hospital stay, morbidity, and mortality. Roberts et al [8] recently reported on thoracoscopic drainage management as a valuable alternative to surgical intervention in selected patients with mediastinal abscesses resulting from esophageal perforation or postoperative complications. Pericardial effusions were drained simultaneously using thoracoscopic procedures. These procedures produce less pain due to smaller skin incisions and lead to lower morbidity; thus they are recommended for drainage of posterior mediastinal abscesses.

Gobien and associates [12] proposed CT-guided percutaneous drainage as a valuable alternative to surgical intervention in selected patients with mediastinal abscesses. They performed percutaneous catheter drainage in six patients, facilitating elective surgery in one and proving curative in five, but all patients presented with isolated mediastinal abscesses following thoracic or abdominal surgery.

There are several questions regarding our approach. These include (1) whether the left thoracic cavity should be evaluated when left pleural effusion is present on preoperative CT scans, and (2) how to drain a pericardial effusion when detected on preoperative evaluation. As to the first problem, we experienced two instances among the four patients. In our experience, this was not empyema but probably reactive pleural effusions. We believe that the aortic arch on the left side protected the thoracic cavity on that side against the progression of DNM. Thus simple closed thoracostomy or thoracoscopic explorations were satisfactory for drainage but drainage through extensive surgical incisions such as bilateral thoracotomy or clamshell incisions was not necessary. For the second problem, we experienced one patient with a pericardial effusion accompanying DNM. In this case, the serous effusion was drained to the right thoracic cavity through a pericardial window performed using VATS. In this situation, simultaneous pericardial window formation via the right side VATS was sufficient for the drainage of pericardial effusion even in the infected state.

	Conclusion

Top Abstract Introduction Patients and methods Results Comment Conclusion References

 
In conclusion, minimally invasive video-assisted thoracic surgery is a feasible and effective method for the surgical management of patients with DNM. This less invasive approach would be an option of the treatment in DNM, especially when applied early. [10, 11]

	References

Top Abstract Introduction Patients and methods Results Comment Conclusion References

 

1. Sancho L.M.M., Minamoto H., Fernandez A., et al. Descending necrotizing mediastinitis: a retrospective surgical experience. Eur J Cardiovasc Surg 1999;16:200-205.
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4. 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.[Medline]
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6. Izumoto H., Komoda K., Okada O., et al. Successful utilization of the median sternotomy approach in the management of descending necrotizing mediastinitis: report of case. Surg Today 1996;26:286-288.[Medline]
7. Ris H.B., Banic A., Furrer M., et al. Descending necrotizing mediastinitis: surgical treatment via clamshell approach. Ann Thorac Surg 1996;62:1650-1654.[Abstract/Free Full Text]
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9. Kiernan P.D., Hernandez A., Byrn W.D., et al. Descending cervical mediastinitis. Ann Thorac Surg 1998;65:1483-1488.[Abstract/Free Full Text]
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