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Ann Thorac Surg 2007;83:393-396
© 2007 The Society of Thoracic Surgeons

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Original Articles: General Thoracic

Descending Necrotizing Mediastinitis Treated With Rapid Sternotomy Followed by Vacuum-Assisted Therapy

^a Department of Cardiovascular Surgery, Hospital Hietzing, Vienna, Austria
^b Department of Otorhinolaryngology, Hospital Hietzing, Vienna, Austria
^c Department of Anaesthesiology, Hospital Hietzing, Vienna, Austria

Accepted for publication September 18, 2006.

^_* Address correspondence to Dr Gorlitzer, Hospital Hietzing, Wolkersbergenstr. 1, A-1130 Vienna, Austria. (Email: michael.gorlitzer{at}wienkav.at).

	Abstract

Top Abstract Introduction Patients and Methods Results Comment References

 
BACKGROUND: Descending necrotizing mediastinitis (DNM) is a life-threatening emergency after oropharyngeal infection. The diagnosis must be established rapidly. DNM is associated with septic shock and respiratory insufficiency. Because mortality rates may be as high as 60%, aggressive surgical treatment is indicated.

METHODS: Between December 2001 and December 2005, 5 patients (3 men, 2 women) with DNM, average age of 69 years (range, 24 to 72 years), were treated at our department. Surgical treatment consisted of one or more cervical drainages and drainage of the mediastinum through sternotomy after mediastinitis had been confirmed by computed tomography. The latter investigation also revealed mediastinal abscess and empyema. After radical debridement, a vacuum-assisted closure device was inserted.

RESULTS: The outcome was favorable in 4 patients. A 72-year-old woman died of prolonged septic shock and subsequent multiple organ failure. Tracheotomy was performed in all patients to create an airway. The duration of the intensive care unit stay was 51 ± 24.2 days.

CONCLUSIONS: Rapid and extensive cervical and mediastinal debridement is mandatory in patients with DNM. A vacuum-assisted closure device is useful because it promotes tissue approximation and stimulates the ingrowth of granulation tissue.

	Introduction

Top Abstract Introduction Patients and Methods Results Comment References

 
Necrotizing fasciitis is a rare tissue infection and a life-threatening emergency. The most common sites of occurrence are the abdomen, lower and upper limbs, and the perineum. Published reports of descending necrotizing mediastinitis (DNM) are rare. We discuss five cases that occurred immediately after a primary oropharyngeal infection such as a peritonsillar abscess. The concept of treatment and pathophysiology reported in the medical literature are reviewed. We emphasize the need for early diagnosis and urgent and effective surgical debridement, thoracotomy, and the use of a vacuum-assisted closure device.

	Patients and Methods

Top Abstract Introduction Patients and Methods Results Comment References

 
Between 2001 and 2005, 5 patients (3 men, 2 women) with DNM were treated at our institution. Because the study involved acute intervention in intubated patients, patient consent was deemed unnecessary by the local ethics committee.

All patients fulfilled Estrera and colleagues’ criteria [1] for clinical manifestation of severe oropharyngeal infection and were assigned to type IIB on the basis of computed tomography (CT) scans [2]. Type IIB DNM extends to the anterior and lower posterior mediastinum below the tracheal bifurcation (Fig 1).

View larger version (107K): [in this window] [in a new window]   Fig 1. A computed tomography scan shows a large descending abscess (arrows) in the visceral fascia, the carotid sheath, and the mediastinum.

The mean delay between the onset of primary infection and hospitalization was 2.5 days (range, 1 to 5 days). Preoperative and postoperative CT scans of the cervical and thoracic region were obtained in all patients.

Surgical treatment consisted of one or several cervical debridements and sternotomy, followed by mediastinal necrosectomy (Fig 2). The wounds were sealed with a vacuum-assisted closure device (V.A.C. Therapy System, KCI Austria GmbH, Vienna, Austria), which was exchanged every 2 to 3 days. Before the V.A.C. system was wrapped into the mediastinum, the adjacent parts of the heart were covered with a soft silicone wound contact layer, which is an elastic, transparent polyamide net (Mepitel, Mölnlycke Health Care, Goeteborg, Sweden), to avoid injury to the right ventricle. If necessary, partial debridement was performed when the closure device was exchanged (Fig 3).

View larger version (128K): [in this window] [in a new window]   Fig 2. Descending necrotizing mediastinitis with communication between the neck and the upper part of thorax after excessive debridement of the neck and sternotomy.

View larger version (110K): [in this window] [in a new window]   Fig 3. Wound sealed with the vacuum-assisted closure system.

	Results

Top Abstract Introduction Patients and Methods Results Comment References

 
Necrotizing fasciitis starts with characteristic skin changes. The physical examination of cervical infection revealed a diffusely painful erythematous cervical swelling accompanied by subcutaneous emphysema and fever. Leukocytosis with a left shift was present in most patients. Respiratory insufficiency was noted in all patients; intubation was performed the same day the patients showed signs and symptoms of sepsis. Chest roentgenograms showed widening of the mediastinal shadow. The CT scans confirmed mediastinitis, mediastinal abscess, and empyema (Fig 4).

View larger version (79K): [in this window] [in a new window]   Fig 4. Chest computed tomography scan shows gas collections (arrows) in the anterior and middle compartments of the mediastinum and the aortic wall.

The bacteriologic investigation revealed polymicrobial infection in all cases. The most frequent isolated organisms were aerobic Streptococcus, Staphylococcus, which was multi-resistant in 2 patients, Enterococcus faecalis, and Prevotella. Escherichia coli and Acinetobacter were found in 1 patient.

	Comment

Top Abstract Introduction Patients and Methods Results Comment References

 
DNM is a life-threatening form of mediastinitis that occurs as a complication of oropharyngeal infection. Clinical reports are few, and most have been published in otolaryngology journals [3–5]. Because the condition is rare, the series of investigated patients are usually small.

The importance of early and extensive surgical drainage is obvious in view of the reported mortality rate of 30% to 40% [6]. Aggressive treatment, as described by Marty-Anè and associates [7], reduced the mortality rate to 16.5% in a series of 11 patients. Freeman and colleagues [8] registered no surgical deaths in 10 patients.

Several surgical approaches have been described, including the subxiphoid approach, the clamshell incision, thoracoscopic approach, or sternotomy [9–12]. Sternotomy, in our opinion, is the best means of accessing all thoracic compartments and the extensive necrotic areas that exist in the presence of the disease. A vacuum-assisted closure device can then be easily inserted through the cervical and mediastinal wounds.

A CT scan should be obtained as early as possible when DNM is suspected on clinical investigation. CT scanning is an accurate and specific diagnostic tool to identify the presence of mediastinitis and provides information about the extent of the necrotizing process [13]. It reveals the density of fluids, collections of gas in mediastinal compartments, and soft tissue infiltration with loss of normal fat planes [14].

It may prove difficult to establish the diagnosis of mediastinitis. Physical examination shows unspecific cervical swelling and an erythematous and tender hot area of cellulitis accompanied by local pain and fever. Fascial necrosis is more widespread than changes in the overlying skin. Leukocytosis with a left shift is usually present. Hypocalcemia may develop due to extensive fat necrosis [15].

As bacteria and toxins are released into the bloodstream, signs and symptoms of sepsis soon develop. Most patients are admitted to the hospital with dyspnea, necessitating a tracheal intubation. Chest roentgenograms show widening of the mediastinal shadow in a few instances. In all of our patients, DNM appeared within 24 hours. Death secondary to DNM remains high if patients do not receive mediastinal drainage immediately after a CT scan has confirmed the condition.

A postoperative CT scan is a useful tool to assess persisting necrotic areas and the need for further surgical debridement. Several cervical and mediastinal explorations are often required because of persistent seeding of infection related to residual necrosis. This is performed to achieve normal blood circulation and healthy edges of soft tissue at each replacement of the vacuum-assisted closure system every 2 or 3 days. In all of our patients, soft tissue necrosis was still in progress after the initial debridement.

Knowledge of the topography of cardiomediastinal fascial spaces is important to monitor the spread of infection. The deep cervical fascia is arranged in three layers that divide the neck into three spaces: a superficial layer, a visceral layer, and a prevertebral layer. All of these layers can serve as portals of entry into the mediastinum. The visceral layer was identified in 70% of cases of DNM [16] as the source of descending infection. The potential space in front of the trachea, beyond the sternohyoid and sternothyroid muscles, is attached to the pericardium and the parietal pleura at the level of the carina; therefore, purulent pericarditis and empyema are often observed in the presence of DNM. In all of our patients, the perivascular compartment, which is surrounded by the carotid sheath, was affected. Infection may spread to the mediastinal and the pleural space by this route. In addition to cranial nerve deficits and potential rupture of vessels, perforation of the trachea may occur. Thus, infection of this space is an extremely dangerous condition.

Intubation was required in all patients within a few hours after hospitalization because of respiratory insufficiency. We recommend tracheotomy because the pharyngeal inflammation predisposes the patient for upper airway obstruction and necessitates repeated aspiration. Furthermore, massive edema of the upper airway can be fatal because of the nearly impossible task of reintubation.

DNM is a soft-tissue infection caused by ß-hemolytic group A Streptococcus strains, frequently combined with polymicrobial and mixed aerobic and anaerobic bacteria. Recently, Hidalgo-Grass and colleagues [17] isolated ß-hemolytic group A Streptococcus strains from necrotic tissue. A trypsin-like protease released by these strains reduced counts of human interleukin 8 and its mouse homologue macrophage inflammatory protein-2 and impaired its the function. When inoculated subcutaneously in mice, these strains produced a fatal, necrotic soft-tissue infection that was marked by poor neutrophil recruitment at the site of injection. All of our patients had a streptococcal infection. Further investigation of this issue will be necessary to understand the pathomechanism of this severe infection.

The V.A.C. system (vacuum-assisted wound closure) is an active and noninvasive device to promote healing in difficult wounds that do not respond to established treatments. The system is based on the application of negative pressure by controlled suction to the wound surface. The V.A.C. system was introduced into clinical practice in 1996, and numerous studies since then have proved its effectiveness on microcirculation and the promotion of granulation tissue [18, 19].

In conclusion, rapid and extensive cervical and mediastinal debridement is mandatory in patients with DNM. A vacuum-assisted closure device is useful to promote tissue approximation and stimulate ingrowth of granulation tissue.

	References

Top Abstract Introduction Patients and Methods Results Comment References

 

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				M. Lanuti Invited commentary Ann. Thorac. Surg., February 1, 2007; 83(2): 396 - 396. [Full Text] [PDF]

This Article Abstract Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Michael Gorlitzer Ferdinand Waldenberger Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Gorlitzer, M. Articles by Waldenberger, F. Search for Related Content PubMed PubMed Citation Articles by Gorlitzer, M. Articles by Waldenberger, F. Related Collections Mediastinum Related Article